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07 Apr 2020

COVID-19 presents problems and dilemmas, not clear solutions

This article originally appeared in The Canberra Times' Public Sector Informant, written by University of Melbourne Professor Jodie McVernon, Director of Doherty Epidemiology and Dr Erik Baekkeskov, Senior Lecturer in Public Policy at the University of Melbourne.

COVID-19 is challenging public health systems and governments in Australia and abroad. However, meeting those challenges involves navigating several dilemmas rather than identifying clear solutions.

What sets COVID-19 apart from other crises is its scale and the longevity of measures needed to mitigate its impact. Whether in tsunamis, bushfires, or epidemics, responders face similar management challenges. They struggle with uncertainty about the situation and how to handle it, yet action is urgently needed. They face torrents of new and often disjointed information but must make rapid sense of it. All the while, governments and experts need to communicate with each other and the public, preferably in clear, frequent, and consistent messages that avoid confusion and cross-purposes. Managing this is difficult in ‘normal’ emergencies. When every level of government, public health authorities, businesses, health care providers, and households are involved, these management problems are augmented.

As Australia’s and all other governments act, there are difficult dilemmas rather than clear solutions. Most starkly, what cost of saving a human life should we bear? The answer to this question has cascading effects rippling outward into businesses, jobs, schools, beyond borders, and even into social and civil rights. Whole of government and society public health action to reduce disease spread has some consequences that are immediate and others that will continue to unfold over many months or even years. Though most of us dismiss as callous any alternatives to saving life that can be saved, high costs to the economy damages lives and threatens the resource foundations for innumerable public goods including universal health care now and in the future. In addition, restrictions on assembly and movement can be odds with civil or human rights and liberties. Hence, if health and economic or other priorities do point in different policy directions, governments and all other decision-makers down the line are choosing between them, whether they like it or not.

Health care responders are grappling with conflicts between essential values. While Australia has not yet seen severe effects of scarcity in health care capacity, hospitals and doctors in some of the richest regions on Earth – such as Lombardy (Italy) and New York and Seattle (USA) – have been overwhelmed by essential resource shortages. Basic protective gear like gloves and face masks are at critical supply levels, exposing health care workers to increased risk of infection. Policy-makers and physicians are now making hard choices about access to limited intensive care beds. Values in conflict include strongest need, prospects of survival, life years or quality lost, and opportunity cost. Another key value is increasingly in play in some settings: who can pay most. In a dramatic and (so far) unique move, Ireland recently announced nationalisation of private hospitals, in the name of levelling access to care. Inequalities are on display in health care decisions, as are now some reactions to them.

Critical social dilemmas face many households. When people self-isolate at home many face stark choices between their domestic priorities. To name some: working from home in unfamiliar ways, managing child care and schooling, managing social connections virtually, managing shopping and related essentials without risking infection, keeping up with domestic chores. There are steep learning curves and hard choices between these values, all at once, across the world’s homes. In addition, several adverse effects have emerged in this space. Old gender roles may be re-asserting themselves, reversing decades of attempts to homogenise domestic divisions of labour. Abusive relationships are exacerbated. Mental health can suffer. Purse strings are tightening and uncertainty about future payments and prospects are increasing for many. Behaving responsibly is clearly about keeping yourself and dependents healthy, but it is also about peace and stability.

The presence of these dilemmas and the absence of single clear solutions may partly explain why governments are responding differently to COVID-19. Most have moved toward increasing restrictions on social assembly to reduce the rate of epidemic growth and maintain health system functions. Australia’s population distribution and diversity creates  local considerations for  decision makers. While the national government broadly harmonises our approach to COVID-19, jurisdictions have implemented different specific measures such as border and behavioural restrictions. One example is the concerted focus on preventing introduction of COVID-19 through stringent movement controls in northern Australia’s remote communities.

Further afield, social scientists often study Scandinavia’s politically and socially similar and highly integrated countries (Denmark, Norway, and Sweden) to understand how government policy differences develop. The countries had similarly minimal policies during the months after the Wuhan outbreak (e.g., unlike Australia, none restricted travel from China). This changed when community spread was confirmed in the region in mid-March. Denmark and Norway rapidly closed schools and ‘non-essential’ public organisations, public venues, national borders, and asked all residents to stay at home. In contrast, Sweden restricted the size of public assemblies, but most schools and many public venues remain open, borders can be crossed, and stay-home recommendations focus on people with symptoms or in risk groups. Some of Sweden’s leading public health experts are now in very public disagreement about this course. But generally, Denmark’s and Norway’s leaders are explicitly applying the ‘precautionary principle’ while Sweden’s endorse a ‘proportional’ approach.

Dilemmas make choices difficult and we are seeing this difficulty as every country and location works to mitigate the pandemic. The stakes are high, and people increasingly understand what they are. No solution will satisfy everyone when societies face trade-offs between core values. Hard choices make dissent unavoidable and quite often public. Public health scientists advising governments in Australia and elsewhere assess alternative choices and effects on population health based on decades of research and experience. As COVID-19 shows, governments can still act differently even in very similar countries or in different locations within a country. Partly, context such as disease characteristics, health care capacity, social resources, and legal options shape such divergences. And partly, as we have suggested here, experts and governments settle COVID-19’s many dilemmas in different ways as they take action.

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