The Rationale -- Towards the end of March 2020, I sent out a call to the members of the European Health Policy Group and the Anglo-American Health Policy Network, inviting people to write 1,200 words on the response of their region or country thus far to the coronavirus pandemic.
Within ten days, I had received approximately forty such reports and they were uploaded by Cambridge University Press onto the Cambridge Core blog shortly after that. We wanted these reports to be genuinely useful, not just to those who are having to deal at a policy level with this pandemic now, but also to those who will soon have to deal with the virus, and perhaps to those who will be forced to face similar challenges in the future. To be of use, the reports of course must be read, and in order to be read I felt that they had to be short and they had to be timely. All authors acted so quickly not for credit but due to a genuine desire to try to help, but I thank them for their remarkable efforts regardless.
The authors were asked to write their reports such that the first 800 words or so detailed their country/region’s response to the pandemic up to the beginning of April, offering an indication of the justification given for the response (e.g. was it expert-informed, was the response immediate or delayed, was it informed by the experiences of other countries etc.?). In the final third of their reports, the authors were asked to offer a reflection on the response thus far. They were asked to consider what they think has been done well, and what could have been done better. The emphasis was on balance; I wanted no polemics, because I think the situation is too serious for that.
At the beginning of each month, until the crisis has passed, the authors will be given the opportunity to offer short updates, of 600-800 words, on their country/region’s continuing response to this worldwide catastrophe and their further reflections on those responses. It probably goes without saying that for the sake of us all, I hope that there will not be too many of these updates.
A common country experience with the virus was that it was spread first by Chinese tourists and by people returning from China, and that the spread was greatly exacerbated by people returning to their own countries from winter skiing holidays in the Austrian or Italian alps. Most countries have introduced similar policies, albeit at somewhat different times and extents, with the intention, informed by the experiences of northern Italy, of ‘flattening the curve’ (i.e. smoothing the incidence of new infections in the population over time so that health care services can cope). These policies included the closing of borders, the banning of large and then even small gatherings, lockdowns and social distancing, financial support packages for loss of earnings, and testing for the virus. Of those countries considered in this series, Sweden is a slight outlier at the time of writing, adopting a relatively soft approach by placing more emphasis on voluntary cooperation. Other countries had adopted the softer approach earlier in the pandemic, but came to the conclusion that insufficient numbers of people could be trusted to cooperate without stricter interventions. It ought to be noted, however, that it will be a long time before anyone knows what the best approach is/was for dealing with this pandemic (indeed, it may never be known, due to the multifarious factors that have to be balanced against each other). Academics, the media and the public are already pouring forth an almost endless stream of commentary on why a particular country did not do this or that, and that it would have been better if they had done that than this (and that there should be hearings and reckonings on why they did not do this – or that). These commentaries are informed by hindsight bias, but without the benefit of any actual hindsight. That said, on the basis of the reports written in this series, I am able to offer a few tentative observations.
The multifarious factors that have to be balanced against each other are the health and mortality consequences of the virus, the financial consequences of locking down an economy (which in itself will have long-term health consequences), public opinion on what ought to be done (particularly in the liberal democracies), public willingness to comply with strict measures over long time periods, and the values and ideologies that underpin each individual society (e.g. whether or not a heavy weight is attached to the notion of freedom). These trade-offs are of course difficult to make, and whether a lockdown (for example) occurs almost immediately or is relatively delayed are both potentially well-informed expert-driven strategies, depending on the relative weight attached to the different considerations. A responsible media should, in my view, be highlighting that various considerations have to be balanced against each other in informing policy, because any policy direction can be criticised if any one or more of these various considerations are not acknowledged.
Strong interventionist policies, such as lockdowns, are probably easier to implement quickly in countries with authoritarian governments (authoritarian governments can more easily suppress information and action also, of course), but authoritarianism is something that a great many people will want to avoid. Many of the countries included in this series had authoritarian governments in living memory; some have even had them in recent memory, and will be keen to avoid a return to that type of system (some countries have written constitutions that are designed to prevent authoritarian rule, which is a reason why they cannot immediately impose draconian interventions, even in the face of a serious public health threat – see the Japan report). In this light, it is understandable that people consider very seriously the possible implications of restricting individual freedoms even in the face of the public health challenge that we now face, and even when there is public criticism for supposedly not acting quickly enough. It is also important that these restrictions are relaxed as soon as it is safe to do so. I do not think I am alone in feeling that it would be a tragedy if the forces of anti-liberalism were to benefit from the situation that we now all face.
Some democracies locked down quickly for fear that their (perhaps relatively lean) health care system would otherwise be very quickly overrun (e.g. India, Greece), but quick lockdowns came with their own unintended negative consequences. In several countries, the announcement of an impending lockdown led to significant human movement (e.g. people returning to their hometowns) – e.g. Italy, Spain – exacerbated if financial support packages to compensate for loss of wages were unclear or unannounced – e.g. India. These movements of people likely caused a spreading of the virus within several countries.
There have been recriminations within several countries that there is shortage of facemasks and other personal protective equipment (PPE). These shortages are almost inevitable – it is what happens when there is a sudden sharp increase in demand for a product across almost the whole of the world. But an important lesson here is that when normality returns, and resources permitting, it would be a good idea for every health care system to build up gradually a stockpile of durable PPE, as an insurance against future new infectious diseases.
There have also been concerns relating to a shortage of respirators and ICU beds. Respirators can be stockpiled to some degree, but the situation with ICU beds is a little trickier. In normal circumstances, some countries have followed the path of taking a less interventionist approach to health care than others. For example, in some jurisdictions, health care resources are directed towards providing good palliative end of life care rather than acute specialist care that is intended to keep a sometimes very elderly person alive, even for a short time, at high cost. If the former approach is taken, then almost inevitably resources will be directed towards general rather than ICU care, but in normal circumstances, this might be the better approach, given constrained health care resources. A question that many countries might now face is whether to keep their provision of ICU high, even if this is considered suboptimal for the general provision of health care in normal circumstances, because of the benefits ICU offers if there is a major global pandemic (perhaps once every 50 or 100 years) – see the Belgium report. This balancing of health care considerations sits aside that which is present while the pandemic is ongoing – namely, to what extent do we trade-off consideration of those with non-covid-19 related conditions in order to focus attention on treating those with this virus?
A further observation is that in countries with substantial devolved decision-making (the US, Canada, Spain, Italy), tensions between the national and local levels have hindered a nationally-coordinated response (incidentally, more could have been done, and could still be done, on an internationally coordinated response, without sinking into recriminations over who could have done what to stop the spread of the virus to begin with). On the flipside, it may have been the case that in some jurisdictions local decision-makers were more sensitive to local circumstances, suggesting that devolved decision-making has been beneficial (e.g. Germany and Switzerland, perhaps).
The authors of several of the reports have highlighted that there has been concern with the transparency of government messaging regarding the pandemic in their countries (e.g. US, Australia, Belgium), and that in most countries there is poor knowledge regarding how many people have been infected with the virus, and how many have died in care homes and the community from covid-19. There have been some positive developments, also, however. For instance, effective public-private partnerships in attempting to deal with the pandemic have been forged in some countries (e.g. Ireland).
To reiterate, given the complexity of the challenges that the pandemic poses, we cannot yet know – and we may never know – what is/was the most effective strategy for dealing with it. But we might speculate that it might have been most beneficial to very quickly close the borders to those coming from high risk countries, and to implement aggressive contact tracing/digital tracking (e.g. South Korea, Taiwan). Following these actions, a lockdown of businesses/schools etc. might then be unnecessary, and the economy is relatively protected. The countries that adopted this strategy may have learned useful lessons from previous SARS and MERS outbreaks, but there are also plausible negative implications of such a strategy. Aggressive contact tracing, for instance, risks creeping authoritarianism and a surveillance culture that may be unpalatable in other contexts, and if realised could, over the long term, be more damaging to people’s lives than a coronavirus.
To finish, it appears that all countries that have implemented a lockdown are now struggling to work out an exit strategy. Economies need to be kickstarted again, and the need for people to live their lives unmolested may soon outweigh the risks of catching and spreading the virus. But when the lockdowns cease, it is possible, even probable, that there will be a new spike in cases, given that there is unlikely as yet to be sufficient immunity within the population, and a vaccine is perhaps a year away – and it may be the case that those countries that locked down relatively early might be particularly threatened with a resurgence of the virus.
However, just as no-one really knows what the best strategy was to tackle this pandemic, so no one can be sure how things will transpire. The updates in this series will hopefully offer some clarity.