Senior Fellow and former Fulbright Research Chair in Science and Society, ISSP uOttawa
President Emeritus of the Center for Policy on Emerging Technologies, Washington, DC
Managing risk, one year on
When Dr. Anthony Fauci was asked some weeks back when he thought a semblance of normality would return, he replied Q3 or Q4 of 2021; now he’s less sure, as the emergence of new variants bringing increased transmissibility and/or vaccine resistance has thrown a series of spanners in the works. But his remarks offer us a ballpark expectation from the expert best-placed to judge; all being well, we’re around half-way through. UK Prime Minister Boris Johnson’s slick assertion that it will be “over by Easter” looks like just another mendacious crowd-pleaser.
Hard to believe it’s been nearly a year since I wrote my last ISSP blog on the challenges Covid-19 posed to governments. As the virus continues to snake around the planet and forcibly seize our attention, time has seemed both to stand still and slip past at an unnerving pace. Our lives have been radically re-focused by the interplay of three forces: the virus itself, this deadly thing with its tricky transmission and myriad symptoms; the efforts of governments, from shrewd to bumbling and worse, to manage its impact; and our personal and familial assessments of risk, informed by our coping resources, financial and psychological.
It’s an especially curious experience for those of us professionally engaged in discussing science and technology and policy. We’re rats in our own lab. As the gantries proclaim over US freeways, we want to Arrive Alive!
Like you, perhaps, I keep turning to Fauci for vaccine prognostications but also news of his personal approach to risk management—which includes 6,000 IUs of Vitamin D, and entertaining guests outside. (In case you did not know, this exemplary human being has been working 16-hour days, every day, since January. Death threats mean he has a 24-hour security detail. On Christmas Eve he celebrated his 80th birthday.)
Like you, perhaps, also, I’ve been tracking the personal responses of people I know and admire, like storied Harvard geneticist George Church, who has “hardly left his home” since last March. I’ve been particularly interested by the survey of hundreds of epidemiologists and virologists conducted by The New York Times, which asked them some pretty direct questions about their behaviours and expectations. Here’s a sampling from December:
“I am optimistic that the encouraging vaccine results mean we’ll be back on track by or during summer 2021,” said Kelly Strutz, an assistant professor at Michigan State University.
But epidemiologists are a very cautious group. Most said that even with vaccines, it would probably take a year or more for many activities to safely restart, and that some parts of their lives may never return to the way they were.
Karin Michels, professor of epidemiology at UCLA, said it would probably be many years until it was safe enough to “return to approximately the lifestyle we had… We have to settle to live with the virus.”
I’m not quite as risk averse as George, but close. In the meantime, I’m sending my kids and their families goody bags of medical-grade PPE and HEPA filters—and more good advice than they have appreciated!
An astonishing variety of responses – to the same thing
In their speedy and incisive new book The Wake-up Call Adrian Wooldridge (of The Economist) and John Micklethwait (Editor-in-chief of Bloomberg) set our pandemic management in the context of the long-term decline of the West and its institutions. The blundering response of most western nations to the crisis stands in stark contrast to the competence of China and Singapore and other Asian spowers, and also to two “Western” nations, Australia and New Zealand. They are both island states, which is quite a plus for border control. But there again so is the UK. Both Canada and the US share these advantages of distance and potential isolation. It looks like Belgium, with 1,847 deaths per million, (where I now live) and the UK, with 1,632/million (where I was born), are at the top of the death table (with tiny Slovenia squeezed between them), even if the United States, with 1,366/million (and where I lived for 30 years) has been the most anarchic.
While the US (until January 20) has been conspicuous for its lack of policy, the UK plainly takes the biscuit for too much, and ensuing chaos. Some kind person recently calculated that since the pandemic started the UK government has shifted its Covid policy no less than 64 times. Add the revelation that the Prime Minister missed the first five Covid meetings of his COBRA emergency committee, and then backed a key advisor who had shamelessly broken the Covid rules, and you begin to see why things quickly went south. In a public health crisis simplicity, consistency of messaging, and trust are the vital currencies.
Canada has fared better, at 541 deaths per million, despite hard-hit outlier Quebec (1,155/million). But the antipodean contrast with Europe and North America is extraordinary. Australia? 35.84/million. New Zealand? A mere 5.08/million. (Most of these figures from Statista, February 4, 2021.) The differences across the Five Eyes, which have so very much in common, are rather remarkable.
There’s been a shocking lack of interest in Europe and North America in how countries that have handled Covid best are faring. Our governments have been happy to shelter behind the notion that if they’ve done badly it’s because everyone has done badly. Yet some countries have done extraordinarily well. Greater press interest in how they have managed things would have put pressure on western governments to shift their approach, as they have struggled with mass infections and fatalities, including the scandal of the slaughter in care homes (here’s a Canadian perspective).
It’s worth a quick look at some success stories before we look ahead. Since China’s claims may be suspect, what about Singapore and South Korea? Using deaths/million as our guidepost, Singapore is at 5.08 (identical to NZ), and South Korea at 28. As others have pointed out, these Asian societies may be more conformist with better-behaved citizenry, and of course Singapore tends toward heavy-handed government. Yet the foresight and competence of these governments are striking. As Micklethwait and Wooldridge point out, Singapore began taking the temperatures of passengers arriving from China on January 22 of last year. By the middle of February, South Korea had closed airports, schools and military bases and advised quarantines in two major cities. Italy announced a lockdown on March 9. France finally imposed a lockdown on March 17. The UK, where PM Johnson insisted on shaking hands with everyone when he visited a hospital, waited one further week—a deadly delay that caused thousands of deaths. In the first three months of 2020, more than 18 million people flew into the UK, including on hundreds of flights from Wuhan. In Hong Kong, despite its integration into mainland China, there have been only 185 deaths to date; fewer than 25/million.
Back to the Five Eyes, and in particular the antipodean pair. How has Australia, with 25 million people, managed to keep total fatalities below 1,000? And New Zealand, with 5 million, to suffer just 25? As we have noted, they are islands. The key difference between them and the UK has been their capacity for agile policy development, a focus on data, and trust-building across political divides and the national/federal levels (for which Australia convened a “National Cabinet”), per a McKinsey review. Together with these competencies has gone a commitment to eliminate the virus. This is the core issue. Not merely, as in the UK and most western nations, merely to “contain” it—and control the flow of victims into hospitals, ICUs, and graves—but to get rid of it.
Science and policy choices
Policymakers and scientists engage with one another continually. The special issue for us is the role of science and scientists at a time of crisis, where governments face urgent policy choices. The climate crisis offers a partial parallel, though it’s a slow burn. Our once-in-a-century pandemic is shining bright light on the proper role of science and its practitioners, and it’s plainly not simple. Since the Second World War, when Vannevar Bush in the US and Churchill’s friend Frederick Lindemann played outsize roles in advising their respective leaders, it’s been plain that science has a key role in government.
But what? At one extreme, in Sweden, policy leadership on the Covid front seems to have been placed in the hands of epidemiologist Anders Tegnell—who according to a recent article in Foreign Policy “botched” the response, which even the King has declared a “failure.” According to the article, from the start he and colleagues took the fatalistic view that the virus would sweep the population and eventually establish herd immunity, so Sweden’s restrictions were among the lightest in the developed world. As a result, they suffered many more casualties than the other Nordic countries (1,160/million compared with 372/million in Denmark, 124/million in Finland and 107/million in Norway). The big surprise is that the Swedes also suffered a greater drop in GDP than either Finland or Norway.
At the other extreme is the United States. The Trump administration was engaged in an almighty tussle with scientists like Fauci and the CDC while the President touted crank cures, and alternated between “declaring war” on Covid and describing it as fake.
Somewhere in between, Boris Johnson has well illustrated a clear problem by constantly claiming to be “following the science” while actually hiding behind it as a cover for dithering, U-turns, and cherry-picking. (Micklethwait and Wooldridge dismiss him summarily as “incompetent.”) Small surprise that this chaos has given rise to an act of rebellion by the government’s former Chief Scientific Advisor, the formidable Sir David King. The official government advisory committee is referred to by the cringe-worthy acronym SAGE (“Scientific Advisory Group for Emergencies”). Sir David has called together a distinguished alternative group of scientists and named it “Independent SAGE”. They write their own reports, and host a weekly 90-minute Zoom call, open to the press and public, where they review the latest data, and critique the government. Their core recommendation? That the UK needs a “zero Covid” policy. In other words, in the language of epidemiology, a strategy of “elimination” or “suppression”, rather than “containment”, much like Australia, New Zealand, and the Asian nations.
With all of this in mind, some facts have become increasingly clear.
- Sweden has demonstrated two useful data points. First, their “light” approach to restriction has not brought any economic advantages. This shows that policymakers are not confronted with a competition between public health and the economy. The two will sink or swim together. Secondly, the idea that “herd immunity” can be built by permitting the circulation of the virus through the population is a dangerous fallacy. Sweden sought to do this, and early on the UK flirted with the idea. But at what cost? According to WHO, while the figure for Covid is not yet known, measles requires 95% and polio 80% population exposure. Plainly, for Covid, the costs in terms of infection and death of achieving immunity in this way would be very high. In any case, we don’t know how long immunity acquired in this way will last. The evidence increasingly suggests not long.
- The general “containment” strategy adopted in Western Europe and North America, with a focus on aligning disease prevalence with available healthcare resources, has—entirely predictably—led to the emergence of variant strains of the virus with increased transmissibility, which makes it far harder to keep the R0 below 1. It also imperils vaccine effectiveness. The less circulation, the less opportunity for the emergence of variants. As I write this, South Africa is abandoning its use of the AstraZeneca vaccine in light of a study pegging its effectiveness against the “South African” variant at just 10%.
- The competence of governments in applying a “containment” strategy has varied, with the worst-affected countries (notably Belgium and the UK, as we have seen) experiencing very high fatality levels. Political pressure on governments to lessen the impact of restrictions has led to constant shifts in policy, with loosening of rules continually leading to an upping of R0 and their being tightened again. We have noted the UK’s 64 policy shifts. In Belgium, where infections remain very high, the government is re-opening of hairdressers and tattoo parlours—against the advice of its expert committee. Even within the European Union there is wide divergence. In Germany, which has a lower incidence of infection, all schools remain closed. In Belgium, not only are schools open but parents have been threatened with expulsion or worse if children do not attend.
- The global economic impact has plainly been enormous, though far from uniform. As a recent report from the Brookings Institution points out, Covid has devastated sectors focused on the movement of people, while leaving largely unscathed those focused on the movement of information. According to a recent review in Forbes, developed economies contracted in 2020 by 4.7%; developing economies (excluding China) by 8.1%. China, remarkably, has kept growing.
What lies ahead? Until the emergence of the new variants it seemed likely that—as in the movie Contagion—vaccines would end the crisis. But the combination of more transmissible variants and vaccine-resistant variants (Moderna and Pfizer are working on updates), with the vacillations of government policy in country after country, increasingly suggest otherwise. As leading expert Ali Mokdad has put it: “It’s a grim projection, unfortunately…. This virus is here to stay…. We’re not going to reach herd immunity… It’s going to be seasonal, and it’s going to be like the flu, and we’re going to need to be ready for it,” he said. If he’s right, it will indeed be like the flu—except with a higher case fatality rate (for which there are many estimates; a complex issue, well discussed here).
As we approach halftime, five points stand out for policy-makers.
- It’s not too early to start post-mortems. The botched responses of many governments to the pandemic need to be scrutinized as a matter of urgency. In due course many nations will wheel out cumbersome Royal Commissions and Judicial Inquiries and whatnot. This process should start now, and ask searching questions of decision-makers whose decisions, starting in the early weeks of 2020, have got us where we are now. We need to shine light on poor choices and poor decision-makers precisely because we are not out of the woods. I’d like to know, for example, how many heads of government and health ministers have actually read, cover-to-cover, John Barry’s definitive study of The Great Influenza. Anyone who has not should be summarily fired. How many have called on the governments of Australia and NZ for aid in their decision-making? And, of course, how many have claimed, like Boris Johnson, to be “following the science” at every twist and turn, when that plainly has been dishonest? The inquiries need to begin in parallel with our management of the continuing pandemic.
- What policies have our governments have actually been pursuing? insofar as there has been any policy beyond seeking to avoid the overwhelming of health systems, for which “containment” is a polite term. After initial lockdowns and travel restrictions, last summer saw the disease on the ropes in many places; so—surprise!—policy-makers decided to open everything up again. The lessons from the Spanish flu are not that complicated.
- As the cautionary tale of Sweden shows, handing science advisors the actual policy-making role may not be a good idea, since scientists have highly particular expertise and their views on anything beyond it can be as good or bad as anyone else’s (the classic case is that of James Watson, of Watson-and-Crick fame; his racism and eugenicism have long been well-known). A post-mortem of the UK’s experience here may prove instructive. The “SAGE” group’s work has been secretive, and occasionally leaked. Early on the PM’s top advisor, Dominic Cummings, attended their meetings. At every stage, the PM has put the Chief Scientific and Chief Medical Advisors on the podium beside him as he has issued constantly shifting pronouncements. There may be no ideal model. But the gross politicizing of “the science” as cover needs to be outed. One would have hoped that senior scientists would step away publicly from leaders who are incompetent and seeking political cover. Yet Whitty and Vallance, Johnson’s press conference props in the UK, are still in post.
- With the EU and UK at unseemly loggerheads, vaccine wars are already breaking out. This is just the beginning. The developed economies are banking on re-opening as vaccines are rolled out. Poorer nations? WHO is urging vaccine sharing with the developing world. But it’s hard to see the UK holding off on vaccinating 30-year-olds in the summer so they can send the precious shots to old folk in Malawi. Of course, such a move would not simply be an act of charity. If Covid is to be suppressed, and ultimately eradicated, the effort must be global, or the resurgence of fresh contagion will be a constant threat. The eradication of smallpox took an enormous effort.
- While our attention is focused, this is the time for policy-makers to revisit the question of pandemic and wider disaster-preparedness, not simply by building proper stocks of PPE but addressing asymmetric threats of other kinds. Chief among them is the coming antimicrobial crisis as the world heads toward what former WHO director Margaret Chan has called a “post-antibiotic era.” Meanwhile, there will likely be other zoonotic diseases. Covid-19 could be followed by Covid-21. But nothing will come close to the end of antibiotics. Just perhaps, the terrible cost of this pandemic could leave us better prepared to head that off.