Why It Could Be Disastrous To Outsource Lockdown Decisions To Public Health Experts
Should a health expert’s opinion on lockdown extension count any more than a migrant worker stranded on a highway?
As a postdoctoral research scientist, I cannot emphasise enough on the importance of expertise and evidence-driven science at this time of Covid-19 related crisis.
Yet, I am becoming increasingly uncomfortable with the perceived role of public health experts in some quarters of the public policy debate around the world.
Some people believe we should listen to ‘experts’ more than politicians (see, here, and here, here).
Opening up the economy by loosening up restrictions on social distancing is a public policy decision with valid arguments on both sides of the aisle.
The ongoing tension between the two camps, which can be crudely described as "do not extend lockdown" and "be careful about opening up too soon", is demonstrated in this lively interaction between Dr Anthony Fauci, director of the United States National Institute of Allergy and Infectious Diseases (a household name in US now) and Dr Rand Paul, a conservative senator who is also a medical doctor.
What should be the role of public health experts in this lockdown debate and to what extent should they influence public policy around lockdowns?
Should an epidemiologist or virologist or a doctor treating Covid-19 patients have more say in the lockdown decision than other stakeholders (affected parties) like migrants or small business owners or farmers?
These are important questions which have profound implications in countries under attack from the Covid-19 pandemic.
As India is planning to decide on what to do after 18 May, it is vital to understand that there is a lot of uncertainty around critical Covid-19-related knowledge just from a public health perspective.
We do not know when a Covid-19 vaccine or medicine is going to be available and how effective it will be.
We are not even sure about how much social distancing is safe from Covid-19 transmission risk perspective.
While the World Health Organization (WHO) suggests "at least 1 metre" distance, United States Centers for Disease Control and Prevention suggests 1.8 metres ("6 feet"), a recent paper by a team from Massachusetts Institute of Technology (MIT) suggests even that may be insufficient.
Hence, we should recognise that politicians have to take decisions partially in the dark. We don’t even know for sure how much will be the mortality if lockdown is lifted — there are too many assumptions in these mortality models which lead to wide ranges. It is absolutely not the fault of health experts that we know so little right now.
While we have hundreds of scientists toiling hard for the last few months to answer these questions with generous funding flows, it will take some more time due to the basic nature of robust science. (Ethical science requires following the ‘do no harm’ principles, which inevitably slows down the process as the focus is on minimising negative effects of any new treatment at every step).
But let us, for the sake of argument, assume that a 100 per cent effective vaccine will come to market within the next three months and if the lockdown is fully lifted on 18 May 2020, about 100,000 Indians will die from Covid-19 in the next three months.
Let's also assume there is no public health downside to extending the lockdown. (In reality, lockdown has weakened India’s fight against tuberculosis and increased risk of mental health problems).
In such a scenario, should public health experts recommend extension of lockdown by another three months or green light society to function as “business as normal”. (Allowing a business, say a restaurant, to open up will not automatically lead to a full house, the consumers have to feel safe to come back, but that is beside the point).
Lockdown decisions (when to open, how much to open) involve questions spanning a range of fields from social sciences, to behavioural economics, to political science, to law to supply chain management.
How many Food Corporation of India (FCI) employees and contractors should be asked to break lockdown (ie, report to work as essential workers) to ensure sufficient supply of food grains to poor people without cash so that they don’t die of hunger?
How many hours restaurants should be open to remain viable financially?
How many people desperate for alcohol commit crimes?
Will extension of lockdown announcements frustrate people and lead to rioting?
How many trains should be run to alleviate this human tragedy of migrants desperate to return home?
Say, if Apple decides to shift manufacturing from China to India, giving an immediate boost to 'Atmanirbhar Bharat Abhiyan', but only if it is allowed to resume operations immediately and not wait for another three months, should the government latch on to that opportunity?
Ultimately, what is the value of 100,000 human lives?
Is it more than the financial loss to citizens and government if lockdown is extended by another three months? (Morally, any human life is invaluable and irreplaceable especially to their family and friends, so we should not put a price on it; in reality, policymakers routinely announce compensation amounts for accidents, ie, put a price on death).
I would argue that health experts — be it epidemiologists or clinicians — are not trained to answer these questions.
Health experts are free to opine on it, but their answer will come from the perspective of a singular objective: minimise mortality from Covid-19.
Policymakers, on the other hand, have to deal with competing priorities-save lives from Covid-19, prevent riots, keep up the morale of police, manage the migrant crisis and the unemployment crisis.
In a must-read essay on public policy and evidence, economist Jean Dreze says "policy decisions would... require values and objectives, which are political by nature".
While evidence-driven policy, data-driven governance, informed policy-making are noble ideals, in an imperfect world this means dealing with taking (literally) life-and-death decisions with low information flows, and loads of uncertainty.
The final decision of lockdown will depend on political values, risk-taking ability, and instincts of democratically elected prime minister and chief ministers (assuming Centre will give discretion to states on lockdown easing guidelines).
Whatever may be the decision, if it does not go well, political fortunes will take a massive hit.
Can you imagine what will happen to the ‘popularity’ of politicians if the lockdown is eased, and within a month, hundreds of people are helpless when children and parents die in their arms without treatment, and India is forced into another lockdown?
What will happen when lockdown is extended for another three months, and thousands of businesses permanently shut shops and millions become unemployed (not temporary salary cuts) with no recovery in near future?
You can replace ‘three month’ time scale in the aforementioned questions with three weeks or six months, or, 100,000 deaths with 10,000 or 10 lakh deaths, the problem fundamentally remains the same — taking extremely consequential decisions with very limited information.
Answering these questions is not the responsibility of public health experts, nor do they have any specialised training for it.
In that case, why should a migrant or small business owner’s opinion on lockdown matter less?
The job of public health experts is to gather reliable and detailed data, and communicate it to policymakers.
It is a matter of shame that in ‘digital’ India, data on daily excess mortality at national and state level is not available for March and April 2020 (compared to previous years).
There is no easily accessible data on positivity rate (Covid-19 positive result to the total number of tests) at ward level in the worst affected urban centres, which can enable administration to decide on resource allocation and priority areas.
Data on quality control tests results for sensitivity and specificity of myriad testing kits in use across India is also sparse. Politicians should give health experts free-hand (without trying to suppress information) and resources to tackle these challenges while they focus on lockdown decisions.
This is perhaps the first time in life, I feel sympathetic to the politicians in power — who have to take a hard decision. If it boomerangs will cost them power in the next elections, darken their legacy, and lead to deaths and misery — Covid-19 or otherwise.
Pray that it works for the sake of the people of India. But please don’t complain that politicians should do what health experts recommend regarding lockdown. That would be outsourcing politics to a singular domain of expertise — and it is neither smart, nor courageous, nor desirable in healthy democratic societies.
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