Monthly Archives: November 2020

Coronavirus Primer, Part 4: Coronavirus and Society

COVID-19 is much more than a medical issue. The virus, and human response to the virus, have made 2020 feel like a time of war. 1

What is guiding us — the fear of contagion or the contagion of fear?

About This Primer

I am researching and writing this series to take a big-picture look at COVID-19.  I’m taking a step back from the daily news information overload and fact-checking the (even larger) load of misinformation.  I announced this project in June and invited questions from my friends. It is now a series of indefinite duration.  Part 1 covered the basics of viruses and coronaviruses.  Part 2 dealt with SARS-CoV-2 on the level of individual health.  Part 3 discussed the epidemiology.

In today’s installment, I take a turn from the biological to the social realm.  The pandemic is much more than a medical issue.  It has come to define the environment of 2020 in all aspects of our lives.  Part 4 is “Coronavirus and Society.”  I begin with the coronavirus recession.  I then discuss the psychology and politics of how we think, feel, and communicate about this pandemic.  What guides us – the fear of contagion or the contagion of fear?  Why do different segments of society have such divergent outlooks on this event?   

I. The Coronavirus Recession

II. National and Partisan Differences in Attitude

III. The Psychology of Uncertainty

IV. Conclusions

V. Citations

I. The Coronavirus Recession

COVID-19 as a social and economic crisis is arguably more momentous than as a medical crisis.  The only way to slow the contagion for now is to regulate travel and population density.  As you well know, this keeps employees from work, it slows down consumer spending, and it shutters factories – in short, it is an economic wrecking ball.  While the virus itself has harmed about 1% of 1% of us, our response to it has impacted us all.    

A recession is defined as a period of at least two consecutive quarters of economic contraction.  By that standard, the US and 18 other nations were already in recession by the 3rd quarter. 2 The forecast for the year is that the global economy will shrink by 4 – 5%, the deepest plunge since WWII.  This is the first recession to slow down the growth of developing nations.  Some economists predict that over 90% of all national economies will contract this year, a metric that makes this downturn even worse than the Great Depression. 3 The loss of jobs in the second quarter of 2020 alone was equivalent to almost 200 million full-time workers. 4 

When economists describe this recession, a recurring theme is that demand and supply are both down. 5 This double-whammy impact is felt most strongly in travel and inessential establishments like bars and massage parlors.  Not only are these businesses unable to provide their full range of services, but the customers have less discretionary money on hand.  This will make recovery difficult, as there will not be an excess of demand waiting to meet recovering supply or vice versa.   

Another significant effect is a transfer of economic activity from one sector to another.  While restaurant dining is down, food delivery is up; TV on demand has taken over the movie theater industry.  Online shopping has exploded.  Many of today’s hot sectors (like nursing and webcasting) are hiring vigorously.  However, it will take a while for employees to train and find jobs, and by then the short-term surge may have ended.

Some sectors are unequivocally depressed.  Oil prices have tanked as people have driven less and airlines have slashed flights.  This helps consumers but harms many of the poorest countries, which derive a large portion of their income from oil exports. 

In some ways, the coronavirus recession is a tipping point for existing crises.  There was already a major debt crisis in the 2010s.  Now, government spending is breaking records.  There have been numerous high-profile stimulus packages in the US and Europe.  Small governments that are not accustomed to such bailouts are strained to the limits and are borrowing heavily. 6 Lockdowns are also exacerbating famines that were already alarming last year. 7

The two faces of the coronavirus – the disease and the depression – have us between a rock and a hard place.  In the short term, we cannot ameliorate one without aggravating the other.  Concerns about public health and the economy are all legitimate, and it seems politically impossible to find a balance satisfactory to everyone. 

II. National And Partisan Differences In Attitude

An anonymous person on a forum asked,Why do conservatives downplay the pandemic compared to liberals?

A.  Conservative and Liberal Attitudes

B.  Political Parties and Leaders

C.  National Differences

A. Conservative and Liberal Attitudes

The tension between public health and the economy is ages old, and political parties were already positioned on opposite sides of the divide.  Conservatism might be described as an “economy first” philosophy.  Conservatives resist spending money or changing behavior for new or uncertain threats.  Liberal-minded thinkers are more receptive to accepting new problems and solutions, 8 and to paying for those solutions with government funds.  These positions have been consistent at least since the 18th century, when economists sounded alarms about overpopulation.  The same theme has played out with nutritional and medicinal advice, wildlife conservation, pollution, and climate change. 

There is an important commonality to these modern liberal concerns.  They are all “invisible” to the individual.  When it comes to cosmic questions, conservatives feel more comfortable with traditional sources like religion.  Otherwise, reality is conservatively defined by tangible direct personal experience.  The conservative part of our mind is apt to think, “I burn gasoline in my car every day.  My neighborhood is clean, and it snowed here last night.  You can’t tell me that fossil fuels cause pollution or climate change!”  It’s easy to conclude that warnings about fossil fuels are a fiction spun by someone with an agenda. 

The liberal part of our mind may have an easier time seeing, believing, or caring about aggregate effects.  However, liberal parties can take their concerns to extremes that are not clearly necessary.  Public health threats are often detected in their early phases.  We can’t really know the scope of the problem without predicting the future – and predictions often lead to worst-case-scenario anxiety.  Furthermore, aggregate solutions do not always require rapid, radical changes for all persons.   

The political divide is exaggerated by urban / rural differences.  Viral contagion, like many other societal hazards, is most rampant in densely populated cities.  Urban areas also happen to be more liberal in character than small towns and the countryside.  Since ruralites don’t face the same infectious risk as urbanites, they often feel that city-made precautions do not apply to them. 9

B. Political Parties and Leaders

Most people are probably not conscious of why each attitude is associated with a different political party, but it doesn’t matter why.  Once those associations are made, they become self-perpetuating.  Well before the pandemic, the Republican and Democratic parties of the United States had already become hyper-partisan to the point of feeling contemptuous and prejudiced toward each other.  Sociologists actually have a name for this state: affective polarization. 10 It has become more important to each party to defeat the other than to think in terms of a common interest.          

Political leaders and the party rank-and-file reinforce each other.  Politicians know and say what their constituents want to hear.  Their behavior clarifies the party standard, which crystallizes quickly throughout the party.  On the right, presidents such as Trump 11 and Bolsonaro 12 resist wearing masks, downplay the public health threat, and scoff at safety measures.  Trump has said that wearing a mask “would send the wrong message” to his voters by making it seem like he is preoccupied with health instead of the economy. 13 In turn, 84% of Republicans trust the president more than they trust scientists. 14

Political parties can co-exist peacefully even when they have different values.  They may self-segregate or irritate each other.  The differences become more salient when one party imposes its values on the other, or even when one perceives an imposition.  This year, generically speaking, conservatives feel that governments, corporations, and even judgmental neighbors are imposing “liberal” rules and restrictions upon them.  Liberals feel violated when conservatives invade their space without safety precautions.  In this quibble, the stakes are high.   

C. National Differences

Some political leaders feel embarrassed about natural disasters getting out of their control, so they deny the problem or shift blame.  The Chinese and US governments point the finger at each other, sometimes with completely unfounded accusations. 15 President Trump has alternately argued that his opponents are making a mountain out of a molehill 16 or, if it is a bad problem, it’s their fault. 17

The United States and western Europe, the homeland of the 18th century Enlightenment, are unique among the world in their esteem of individual liberty. 18 The rest of the world places higher value on being “protective of the collective” (to coin a phrase) even if it demands personal sacrifice.  As I discussed in Part 3, Asians have a much easier time accepting government recommendations, and they wear face masks in the highest proportions. 

Westerners, on the other extreme, feel threatened when the government tells them what to do, even if it is for the public good.  This sentiment increases toward the right.  Many conservatives deny that there is a public threat at all.  The words that they associate most often with face mask mandates and social lockdowns are not even entirely economical; they include “freedom” and “rights”. 

III. The Psychology of Uncertainty

Karen K. commented, “The speed at which guidance changes based on ‘emerging understanding’ of the virus is enough to make me trust no one.”

Mitzi M-H rhetorized, “How can we possibly know what it’s doing when the numbers are changing or inaccurate to start with?”

William B. rhetorized, “What’s going on with the WHO and the CDC?  Why are there so many disparate studies and conflicting information?”

A. Dealing with Unknowns

B. Whom can we Trust?

C. How Do we Feel?

D. How Should we Feel?

A. Dealing with Unknowns

When it comes to the coronavirus, it’s important to remember a key issue:

There are many unknowns.

This butts heads with a universal law of human nature:

We hate unknowns.

As 21st century web addicts, we demand answers, and we demand them now!  Unfortunately, clear answers are usually hard to find in the early stages of any sudden crisis.  We ask, “How many infections are harmless and undetected?  What causes more harm – the disease or the lockdowns?  Will immunity last forever?  When will vaccines be available?”  We expect textbook right-and-wrong answers.  Although many such questions are mathematically modeled, they usually have answers like, “We don’t know,” or “It depends.” 

These are emotionally unsatisfying answers, especially coming from experts, and doubly so for people who are not accustomed to nuance.  Unresolved anxiety then tempts us to conclude, “There is a simple answer, and someone knows, but they’re not telling me!” Then our imagination fills in the voids.  We are highly prone to believing the next “satisfying” answer that comes along. 1 19

It’s okay to accept that knowledge has boundaries, often blurry ones.  That’s especially true for a moment of panic like this year.  Even honest scientists, doctors, politicians, and public officials don’t have all the answers.  But their bounded answers are much better than conspiratorial guesswork.  Give doubt a chance.

B. Whom can we Trust?

Most Americans say that they trust major health agencies first 20 and that they are skeptical of their social media news feeds. 21 Are these intuitions justified?     

My standard is to consider the sources’ incentives and capabilities: 

Who is most willing and able to find the truth, the whole truth, and nothing but the truth?

By my values, research scientists must be at the top of this list, for at least two reasons.  First, they are the only people with direct first-hand knowledge and expertise in the medical issues.  Second, scientists are judged by how well they find truth, whether it’s beautiful or ugly. 

There is a broad spectrum of media bias and credibility.  I strongly recommend sites such as All Sides and Media Bias / Fact Check , which rank news sources on several criteria.  Still, news outlets produce content for mass consumption, which requires them to simplify and / or sensationalize information.  In an event like this pandemic, most news channels can only present a surface-level account – but it’s an essential first source.   

I do not turn to politics for answers.  This goes somewhat for office holders, but especially for party activists and armchair politicians.  Partisans get emotionally attached to their parties’ preconceived notions.  They then devote most of their time and energy to trash-talking each other and defending themselves.  Truth takes a back seat to “who’s right” or, even more trivially, “who’s righteous”. 

Social media rumors and word of mouth place lowest in my trust hierarchy.  There are large but highly vocal segments of the population that lack the capacity or the incentive to manage voluminous, nuanced, complex information.  Office holders, in turn, must pander to those folks for re-election. 

Unelected government agencies in free countries are generally more trustworthy, as they are ideally sheltered from the partisan winds of emotionality.  Agencies also have money for effective scientific and statistical research.  Unfortunately, there is mounting evidence that President Trump has politicized US agencies like the FDA 22 , CDC 23 , and HHS 24 .  Federal agencies have sent mixed signals as they have vacillated between public health advice and the president’s preferred messaging. 25

C. How Do We Feel?

“People are tired of COVID.  People are saying, ‘Whatever, just leave us alone.‘ ” …

You turn on CNN, that’s all they cover. ‘COVID, COVID, pandemic’ …

People aren’t buying it, CNN, you dumb bastards.”

President Trump, 10/19/20 26

President Trump is describing crisis fatigue, aka chronic stress response.  Whether we are stressed out about the virus itself, the economic impact, impositions on our lifestyle, or simply the unending arguments, most of us have felt stressed all year.  Long-term stress is not natural, and it takes a toll on physical and emotional health.  Nine out of ten Americans reported feeling emotional distress due to the pandemic, and that was already in May. 27

While a crisis can help unite people against a common enemy, in the long term it can aggravate political differences in addressing the problem.  Other effects of chronic stress response include negative emotions and reckless behavior. 28 Substance abuse, crime, and suicide are running high in 2020. 29

Experts advise that knowledge is empowering to cope with stress.  It is easier to confront facts than fears and rumors.  It is also important to be aware of our own feelings.  Only by identifying the sources and nature of our emotions can we ever hope to address them.  Finally, look for solutions when you are in your best state.  Let your “adult self” make your choices, not your “overwhelmed self” or your “survival self”. 30

Historians compare this pandemic to a depression or even a war that has potential to leave lasting changes in society.  We know that billions of people have lived through such crises before – plagues, wars, tyrannies, and more.  Most of us thought that we wouldn’t see such a catastrophe in our own lifetimes, but here we are.  The classic stages of grief are denial, anger, bargaining, depression, and acceptance.  History inspires us by proving that people can get through any tragedy when they learn to accept their new world.     

D. How Should We Feel?

“Nobody panics when things go ‘according to plan’ even if the plan is horrifying! 

Upset the established order, and everything becomes chaos.”

— The Joker, as written by Jonathan and Christopher Nolan, “Dark Knight” (2008)

In the politicized public discourse about coronavirus, one of the major through-lines has been the question, “How serious is this?”  Should we feel afraid of the virus?  Or is it no big deal?  This deceptively simple question is difficult to answer even without the political complications. 

One challenge is that we have to think as individuals and as a society at the same time.  For you, as just one person, chances are slim (so far) that you’ll catch coronavirus, and slimmer still that it will make you seriously ill.  But if we multiplied those small probabilities by the whole human population, we’d end up with tens of millions of preventable deaths.  It comes down to a question of what you care about and what “we” care about. 

Many people illustrate their perspectives by comparing the coronavirus pandemic to other causes of death.  Other respiratory tract infections are a natural comparison.  Diseases like tuberculosis, pneumonia, influenza, and COPD prematurely kill millions of people every year. 31 Why haven’t we been on red alert about them for decades?  This is probably the hardest question I’ve encountered in my research.  I posed this question to my Facebook friends early this year, and I still haven’t found a satisfactory answer. The only explanation I can conjure is the Joker’s principle, a psychological irrationality.  Those diseases have reached equilibrium; they are part of the plan.  They are known background noise, and it is the unknown that we fear.  We don’t know how far or fast coronavirus will spread.  Other dangers that alarm us and boil over in the streets, like terrorism or errant police brutality, kill miniscule numbers compared to any infectious disease.  Our emotions are clearly not linked to the numbers. 

When math nerds like me talk about uncertain events, we describe them with at least three components:  Probability, costs, and benefits.  You have to consider all three to arrive at the most rational way to quantify an event, its “expected value”:

E = P(BC)

In a potentially dangerous situation, sometimes our mind exaggerates the probability P (like plane crashes).  Sometimes we recklessly ignore a high cost or probability because we enjoy the benefit (like drugs).  In the coronavirus situation, some people fixate on probabilities while others focus on the cost of death.  This is why both sides can argue endlessly and both be partly right.  A nuanced understanding must account for the whole formula.

In order to transcend irrational, emotional judgments, most regulatory agencies have adopted numerical limits to acceptable risks.  The value of “one in a million” has become a widely accepted standard. 32 That is, if the probability of death is less than one in a million, a government will usually consider it unnecessary to commit further resources to controlling the risk.  In a world of 8 billion people, this standard would set the acceptable threshold at 8,000 preventable deaths. We reached that point in March, less than a week after COVID-19 was recognized as a pandemic.  

The premise that “coronavirus is just like the flu” is pretty accurate in terms of death toll so far.  It’s the resulting conclusion that’s backward.  This comparison does not demonstrate that the coronavirus is innocuous, but that influenza, like COVID-19, is vastly unacceptable.     

IV. Conclusions

I am finishing this essay in the first week of November 2020, right in the middle of the Biden / Trump presidential election.  I can’t imagine a more apt background.  The coronavirus pandemic has loomed large in this election, both as an issue and as the environment in which we vote.  Each party has a completely different vision of what the problems are and how to address them.  Where Democrats see a serious public health threat, Republicans are not as concerned because it has not affected most of their personal lives.  So far, preventive responses have been much more disruptive than the disease itself.  Then again, it’s impossible to know how much worse the pandemic would have been without such measures. 

Our perception of this pandemic is informed by politics and psychology as much as by facts.  In complex controversies, one side rarely has all the answers.  It’s not a matter of right or wrong but of emotional resonance.  Different groups of people have different cares and concerns.  It’s important to realize this, not only to manage your own thoughts but also to vet information and to understand your neighbors.       

My next article will discuss solutions and a path forward. 

V. Citations

                

  1. Image by Elchinator / CC BY-SA (https://creativecommons.org/licenses/by-sa/4.0), https://pixabay.com/illustrations/recession-economic-crisis-economy-5124813/ (accessed and saved 11/04/20).
  2. Staff writers, “Recession watch: which nations’ GDP is still going down?” The Guardian, https://www.theguardian.com/news/datablog/2009/aug/13/global-economy-globalrecession (updated regularly; accessed and data saved 8/29/20).
  3. M. Ayhan Kose et al., Global Economic Prospects, World Bank (June, 2020), https://www.worldbank.org/en/publication/global-economic-prospects (accessed, saved, and archived 8/28/20).
  4. Staff writers, “COVID-19 and the world of work”, International Labour Organization (2ed, 4/07/2020), https://www.ilo.org/wcmsp5/groups/public/—dgreports/—dcomm/documents/briefingnote/wcms_740877.pdf (accessed, saved, and archived 8/29/20).
  5. See e.g. Peter S. Goodman, “Why the Global Recession Could Last a Long Time”, New York Times (4/01/2020), https://www.nytimes.com/2020/04/01/business/economy/coronavirus-recession.html (accessed, saved, and archived 8/29/20).
  6. Fred Imbert, “Half of the world has asked the IMF for a bailout, chief says”, CNBC (4/15/2020), https://www.cnbc.com/2020/04/15/half-of-the-world-has-asked-the-imf-for-a-bailout-chief-says.html (accessed, saved, and archived 9/11/20).
  7. Staff writers, 2020 – Global Report on Food Crises, UN World Food Programme (4/20/2020), https://www.wfp.org/publications/2020-global-report-food-crises (accessed 9/11/20).
  8. See e.g. Staff writers, “The Politics of Climate”, Pew Research Center (10/04/2016), https://www.pewresearch.org/science/2016/10/04/the-politics-of-climate/ (accessed, saved, and archived 9/23/20).
  9. Sara Burnett and Brian Slodysko, “Pro-Trump protesters push back on stay-at-home orders”, Associated Press (4/17/2020), https://apnews.com/ea4c17f541c7c63fac52941a6f43b885 (accessed, saved, and archived 9/23/20).
  10. Shanto Iyengar et al., “The Origins and Consequences of Affective Polarization in the United States”, Annual Review of Political Science 22:129-146 (May, 2019), https://www.annualreviews.org/doi/full/10.1146/annurev-polisci-051117-073034 (accessed and saved 9/28/20).
  11. Will Steakin and Ben Gittleson, “Trump heads into flu season amid pandemic mocking masks, holding packed campaign rallies”, ABC News (9/11/2020), https://abcnews.go.com/Politics/trump-heads-flu-season-amid-pandemic-mocking-masks/story?id=72950584 (accessed, saved, and archived 9/23/20).
  12. Tom Phillips, “Brazil: Bolsonaro reportedly uses homophobic slur to mock masks”, The Guardian (7/08/2020), https://www.theguardian.com/world/2020/jul/08/bolsonaro-masks-slur-brazil-coronavirus (accessed, saved, and archived 9/23/20).
  13. Will Weissert and Jonathan Lemire, “Face masks make a political statement in era of coronavirus”, Associated Press (5/07/2020),  https://apnews.com/7dce310db6e85b31d735e81d0af6769c (accessed, saved, and archived 9/23/20).
  14. Laura Wronski, “Axios | SurveyMonkey Poll: coronavirus and trust”, Axios (March, 2020), https://www.surveymonkey.com/curiosity/axios-coronavirus-trust/ (accessed, saved, and archived 9/23/20).
  15. Conor Finnegan, “False claims about sources of coronavirus cause spat between the US, China”, ABC News (3/13/2020), https://abcnews.go.com/Politics/false-claims-sources-coronavirus-spat-us-china/story?id=69580990 (accessed, saved, and archived 10/12/20).
  16. Brett Samuels, “Trump hits Democrats over coronavirus criticism: ‘This is their new hoax’”, The Hill (2/28/2020), https://thehill.com/homenews/campaign/485245-trump-hits-democrats-over-coronavirus-criticism-this-is-their-new-hoax (accessed, saved, and archived 10/12/20).
  17. John Fritze and David Jackson, “Trump blames ‘blue states’ for increasing nation’s coronavirus death rates, ignores high rates in red states”, USA Today (9/17/2020), https://www.usatoday.com/story/news/politics/elections/2020/09/16/trump-blames-blue-states-covid-19-death-rates/5819120002/ (accessed, saved, and archived 10/12/20).
  18. Jonathan Haidt, The Righteous Mind: Why Good People are Divided by Politics and Religion, Pantheon (2012), Kindle edition around location 418
  19. See e.g. V. Swami et al., “Putting the stress on conspiracy theories: Examining associations between psychological stress, anxiety, and belief in conspiracy theories”, Personality and Individual Differences vol. 99, pp. 72-76 (Sep., 2016), https://www.sciencedirect.com/science/article/abs/pii/S0191886916303440?via%3Dihub (accessed and saved 9/12/20).
  20. Wronski, op. cit.
  21. Mark Jurkowitz and Amy Mitchell, “An oasis of bipartisanship: Republicans and Democrats distrust social media sites for political and election news”, Pew Research Center (1/29/2020), https://www.journalism.org/2020/01/29/an-oasis-of-bipartisanship-republicans-and-democrats-distrust-social-media-sites-for-political-and-election-news/ (accessed, saved, and archived 9/29/20).
  22. See e.g. The Editors, “Dying in a Leadership Vacuum”, The New England Journal of Medicine 383(15):1479-80 (10/08/2020), https://www.nejm.org/doi/full/10.1056/NEJMe2029812 (accessed and saved 10/10/20).
  23. Brett Murphy and Letitia Stein, “’It is a Slaughter’: Public health champion asks CDC director to expose White House, orchestrate his own firing”, USA Today (10/06/2020), https://www.usatoday.com/story/news/investigations/2020/10/06/expert-cdcs-redfield-should-expose-trump-covid-failures-leave-post/5899724002/ (accessed and saved 10/12/20).  This article includes a link to the letter that former CDC director Foege wrote to current director Redfield.
  24. Staff writers, “Political pressure Inside HHS Policy Shop To Tailor Facts To Fit Trump’s Message Unprecedented, Staffers Say,” Kaiser Family Foundation (7/30/2018), https://khn.org/morning-breakout/political-pressure-inside-hhs-policy-shop-to-tailor-facts-to-fit-trumps-message-unprecedented-staffers-say/ (accessed, saved, and archived 10/12/20); note that this article well predates the pandemic.
  25. Mike Stobbe, “CDC drops controversial testing advice that caused backlash”, Associated Press (9/18/2020), https://apnews.com/article/virus-outbreak-pandemics-public-health-22e7ac15e8d622b12bf784295e4b5266 (accessed, saved, and archived 10/12/20).
  26. Brett Samuels, “Trump calls CNN ‘Dumb bastards’ for covering coronavirus”, The Hill (10/19/2020), https://thehill.com/homenews/administration/521741-trump-calls-cnn-dumb-bastards-for-covering-coronavirus (accessed, saved, and archived 10/22/20).
  27. Olafur S. Palsson, Sarah Ballou, and Sarah Gray, “The U.S. National Pandemic Emotional Impact Report”, UNC and Harvard Schools of Medicine (6/29/2020), http://pandemicimpactreport.com/ (accessed, saved, and archived 11/03/20).
  28. Tony Schwartz and Emily Pines, “Coping with Fatigue, Fear, and Panic During a Crisis”, Harvard Business Review (3/23/2020), https://hbr.org/2020/03/coping-with-fatigue-fear-and-panic-during-a-crisis (accessed, saved, and archived 11/04/20).
  29. Jayne O’Donnell, “’Deaths of despair’: Coronavirus pandemic could push suicide, drug deaths as high as 150K, study says”, USA Today (5/08/20), https://www.usatoday.com/story/news/health/2020/05/08/coronavirus-pandemic-boosts-suicide-alcohol-drug-death-predictions/3081706001/ (accessed, saved, and archived 11/04/20).
  30. Schwartz and Pines, op. cit.
  31. Staff writers, Global Impact of Respiratory Disease, 2ed, Forum of International Respiratory Societies (2017), https://www.who.int/gard/publications/The_Global_Impact_of_Respiratory_Disease.pdf (accessed 10/22/20).
  32. Paul R. Hunter and Lorna Fewtrell, “Ch. 10: Acceptable risk”, Water Quality: Guidelines, Standards, and Health, WHO (London, 2001), https://www.who.int/water_sanitation_health/dwq/iwachap10.pdf?ua=1 (accessed and saved 10/09/20).
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