Covid 19 and Evidence-Based Policy
The Covid pandemic has challenged us in ways that are unprecedented in modern society. Currently we sit at a pivot point in the national response to mitigating the virus and its health and economic impacts. Given the seriousness of the crisis and the implications for national physical and economic well-being, it is worth reflecting at this point on which strategies are working and which are having unintended adverse impacts. After all such agility is a prerequisite in successfully dealing with challenges of this scale and complexity.
The response to Covid 19 had initially brought a welcome return to the reliance on expertise. Experts from epidemiology and public health were clearly critical in determining the early strategy in what was evidently a public health emergency. However as the scale of the problem became apparent, there appeared a significant divergence in how individual countries were responding and that those differences were leading to dramatically different outcomes. Like a series of trials run in tandem across complex environments but with the same outcome in mind, these differences illuminated success factors in dealing with the pandemic. What was it that South Korea, Singapore, Taiwan and China were doing differently that allowed them to isolated and minimise the impact of the virus, avoid the catastrophic consequences of near total economic shut down and critically avoid the indiscriminate and blanket restrictions that are currently testing the limits of public compliance? The differences appear to be focused around the volume of testing, the scope of testing beyond the virus to include temperature, sophisticated tracking mechanisms that isolated disease outbreaks and all who may have had contact with them combined with targeted isolation and quarantine for those exposed. So we have the “what” that was done differently, clearly different tactics were much more effective at least in suppression the incidence of the initial phase of the disease but to understand why these methods were effective, we need to draw on the wisdom of health psychology that has been studying and modelling health behaviour for decades.
Health psychology includes a number of models that are relevant and pertinent to the current pandemic including the theory of planned behaviour, locus of health control and the transtheoretical model of behaviour change but it’s the health belief model (HBM) that I think offers the most profound insights into the trans-national differential rates of success that we are currently seeing.
The HBM focuses largely on the beliefs and assumptions that individuals have about the susceptibility and severity of the illness, with these assumptions then providing a cost benefit analysis that predicts the probability of compliance behaviour. It has been used extensively in behavioural medicine and significantly predicts compliance with diabetic regimes, coronary care and other significant health issues where substantial behavioural change is required. This at least partially explains the success of the Asian model – greater clarity around susceptibility came from mass testing and targeted isolation for those known to have been in close proximity to the infection. There appears to have been a much greater compliance with such restrictions because the rational was clear and the application targeted and finite. The risk we currently have in Australia and Europe is that the general focus on daily incidence increases and indiscriminate restrictions that are independent of individual risk, can lead to the unintended consequence of perceived invulnerability in sub-groups who see themselves as the wrong age or stage or misunderstand their susceptibility by focusing on individual rather than collective risk. Finally the cost-benefit analysis performed on these perceived risks predicts ultimate compliance. There is a public intuition here increasingly voiced in the media, that at some point (and that point needs to be articulated) the economic damage and its subsequent negative impacts on health and well-being by the current tactics will be greater than the impacts of the virus. The adverse health impacts of prolonged austerity are just as tangible and debilitating as those resulting from the pandemic.
This is where I think a change of tactics based on the evidence is due. Evidence-based decision-making is critical is successfully navigating wicked problems as is the courage and agility to recognise where strategies are not working and course correction is necessary. The UK’s behavioural insights team suggest behavioural change policy needs to follow the EAST acronym – easy, attractive, social and timely. Punitive and coercive measures are unlikely to work especially in cultures that value individual freedom over the common good. The WHO has explicitly asserted there is no value in border closure at this stage in the pandemic and yet Australians are currently unable to leave their state or country. Research suggests policy that emphasises peer compliance is far more effective in encouraging others to get behind the containment methods than those that emphasise and stigmatise exceptionalism. In addition we need a strategy like the excellent document just published by Utah State, that provides a framework, rationale and most importantly a timeline for any restrictions. The Utah Leads Together plan divides dealing with Corona into the urgent, stabilization and recovery phases with clear timelines and goals for each segment. In addition it’s inclusive in its goals of both flattening the curve and remaining engaged in the economy. This is a great example of positive rather than punitive goal setting that unites individuals around a common purpose, explains the rational for temporary changes in individual liberties and is selective and discriminating about compliance predicated on individual risk.
In addition to a strategy we need to change the way the data is reported. The daily incidence is only meaningful if put in the context of percentage of the population tested and differentiated by those coping at home, those requiring hospital admission and those in intensive care. This data mediates a more accurate calculation of severity and susceptibility. Secondly we need some ambitious and meaningful collective goal setting around containment. Incidence is not an effective criterion as it inevitably goes up as testing increases but Ro or the rate of transmission is a good candidate. If we collectively get this below 1 we stabilize the pandemic and can then move to the recovery phase. Finally as the corporate sector, especially finance, rediscovers its purpose beyond shareholder value, it would be inspiring to see other businesses leading the way in the selective implementation of evidence-based techniques, especially those derived from the Asian experience.