Hindsight is always 20/20, as the adage goes. The takeaway from COVID-19 is: How can foresight be improved to minimize health risks by taking aggressive, early actions? I am writing this not to be critical of governments in Canada or abroad (though I am), as much as to explain the reasons why humans are inherently reluctant to invoke strong measures that are in our own long-term self-interest.
Much has been written on making decisions in the face of risk and uncertainty. All kinds of academic journals publish scholarly papers on risk assessment, risk management, risk policy and risk communications. Others look specifically at the link between science and policy. When evaluating risk and appropriate response to risk, one of the longest-running debates among academics and policymakers can be summed up as: “When do we have enough information to take action?” This pithy statement is at the heart of some of the most protracted, political, legal and corporate clashes of the past 100 years. And it is highly relevant to the actions, and consequences of inaction, and of the varying COVID-19 responses by Canada and other countries.
For example, when did we know enough about lung cancer to blame smoking and sue tobacco companies? When did we know enough about the link between lead and brain damage to ban lead in gasoline and paint? When did we know enough about asbestos causing mesothelioma to ban asbestos products and compensate the victims and their families who died from the disease? And, most recently, when did we have scientific evidence showing that burning fossil fuels increases the risks of climate change such that we needed to take action to regulate emissions to prevent irreversible catastrophe?
In every one of these examples, the science was known decades before any serious actions were taken, causing millions of needless deaths globally. There is a similar pattern with COVID-19, only rather than human death and disaster unfolding slowly over decades; with COVID-19, the timeframe is highly compressed — measured in days and weeks, not decades. This provides useful insights into the decision processes of governments and the extent to which science informs policy. Which happens to be at the heart of my work for the past 20 years.
Appreciating the complexity of COVID-19 and the rapidly evolving global situation, it is hard to criticize the actions of governments around the world, although we are now seeing that different stringencies and timing of responses have led to very different outcomes. Countries that determined the risk to be serious, acted faster, and invoked tougher measures; Taiwan, China and South Korea, for example, have fared much better than countries that delayed serious actions to curb the pandemic. Countries that employed early, rigorous and widespread testing were able to better contain the spread of the disease.
The U.S, even with the benefit of clear evidence from the successful approaches in South Korea and Taiwan, and the rampant spread in Italy, chose the pathway of Italy. And to be clear, this was an explicit decision to ignore science and evidence, resulting in the U.S. rapidly overtaking Italy in the case count and catapulting it into the No. 1 spot for the COVID-19 outbreak globally.
All of this is linked to the social and political backdrop of jurisdictions where factors such as trust in science, trust in government and respect for the common good versus personal freedom alter the ability of a country to respond to external health or environmental risks. (Noting that there is a distinction between responding to fabricated fears versus measurable risks.) It is not surprising that the U.S., a country that would probably score lower on those trust measures than any other in the OECD, has one of the least adequate responses to COVID-19.
It is fair to argue that a country is free to prioritize actions based on the values of that country. Many Americans, the president included, seem to value the preservation of wealth among the wealthy over the protection of public health. Politicians in the U.S. openly discussed their preference of having some old people die if it meant keeping the stock market healthy. This alone should have encouraged Canada to shut our borders with the U.S. sooner and to require self-quarantining of all returning travellers from that country long before we did. Fear of economic reprisal from our largest trading partner seems to be the cause for the delays --public health was secondary.
As with most things it seems, Canada, being reasonable, lies somewhere in between the aggressive actions of Asian countries and the lackadaisical U.S. response: Taking reasonably serious measures in a reasonable timeframe resulting in middling levels of infection. As decisions were unfolding in Canada, colleagues and I had conversations questioning what seemed to be arduously slow and insufficient measures over the critical two-week period of March 13 to March 26. Poor advice from the World Health Organization (WHO), including opposition to travel bans, appears to be at the root of some of the delay and confusion.
For example, why on March 13, did Canada, according to the health minister, believe closing borders was “ineffective” when that seemed to be an essential ingredient in the success of Taiwan, South Korea and China for stemming the spread of COVID? These countries adopted strict travel and border restrictions a month previously with clear results. And why did we have virtually no border controls in place when people returned many weeks into the pandemic from their vacations abroad? Anecdotally, every person I spoke to returning from the U.S., Europe and Asia commented on the total lack of border screening at Canadian airports.
Throughout most of March, Canadians were given very soft advice and told to “avoid non-essential travel.”There were no restrictions on travellers during what was almost certainly the period where the virus was actively spreading in Canada. More than a month earlier, Taiwan began restricting passenger travel and requiring 14-day quarantines, and despite being highly integrated with China and having confirmed cases much earlier than Canada -- with two-thirds Canada’s population -- Taiwan has fewer than five per cent of the confirmed cases that Canada has.
"First there’s denial (“a hoax”), then downplaying the risk, followed by questioning the measures to fight it as too risky to the economy, followed finally by meaningful but slow response once the threat is seen to be immediate."
On March 16, Canada did an about-face announcing that effective March 18, foreign nationals from all countries, save the U.S., would be barred entry to Canada and tighter international flight restrictions were announced. Why not include the U.S. in the travel restrictions? Excluding the country where 60 per cent of Canada’s foreign travel takes place didn’t make sense, other than it being an economic decision versus an evidence-based public health decision. The next day, Canada announced a ban on non-essential movement between Canada and the U.S.
And it was not until March 24 that Canadians returning from abroad were told they must self-isolate, versus softer recommendations from the previous week “recommending” self-isolation. Again, the WHO took the unusual stance of discouraging self-isolation, perhaps contributing to delays and increased spread of the virus in many regions of the world. And then not until March 28 were Canadians told not to fly or take trains inside Canada. Most of my colleagues had stopped all domestic and international travel by March 18, when Canada had 730 cases. Why did it take the government an additional 10 days and 6,000 confirmed cases to make this common-sense announcement? Other countries had instituted domestic travel restrictions two months earlier.
Testing also seemed slow and counter to expert advice, as well as the evidence coming out of Asia. Why did parts of Canada refuse to test people at risk who were showing symptoms of COVID-19 in the first two weeks of confirmed cases in Canada? Why were statistics then used to show that all confirmed cases in Canada were related to people who had contracted it abroad versus community spread, when the testing criteria left out anybody who had not been abroad, excluding any possible evidence of community spread?
Finally, in a glaring example of misunderstanding risk: Why were elementary schools closed days ahead of the lockdown of long term care homes, where the population is in the high-risk group? Up until March 30, seniors in nursing homes in Ontario were free to come and go, even though there were 16 nursing home outbreaks in the province. It took nine deaths in Bobcaygeon for more stringent action, yet I was having conversations two weeks earlier with colleagues wondering why governments had not put in place more stringent conditions on nursing homes in early March.
To answer some of these, we can go back to the question I frequently ask myself when working on sustainability and human health: “Given what we know about (fill in the blank here: coronavirus pandemics, climate change, mercury poisoning, asbestos, etc.) why do humans not take meaningful actions sooner”?
One answer is that when there are multiple experts providing conflicting advice, politicians freeze in their tracks; hence why the oil industry has spent millions over the past three decades skewing climate research to confuse and delay political action (based on the successful strategies of the tobacco industry over the previous three decades).
For example, on Feb. 24, Canada’s Chief Public Health Officer Dr. Theresa Tamissued this warning: “The window of opportunity for containment ... for stopping the global spread of the virus, is closing." She seemed to be on the right track for early and decisive action related to travel restrictions. However, advice from the WHO a week later was specifically opposing the implementation of travel bans, advice that to this day has not been updated. Another confusing article appeared March 5, by a past-president of the Ontario Medical Association, advising people to keep their March vacation plans, saying: “Healthy people should be fine.” These are the kinds of conflicting pieces of advice that stymie political action.
There are ways to get past this. I began noting that hindsight is 20/20 and what we need is foresight. This brings us to the precautionary principle (originally a German concept called the foresight principle), which provides instructive insights into how COVID-19 may have been contained quicker in Canada.
Four factors tend to undermine the ability of governments to act fast when facing a combination of a threat to the public together with a degree of uncertainty regarding the likelihood of the threat and the potential severity of the threat, these essentially being the definition of risk. First is economic concern. Second is legitimate uncertainty regarding evidence of the risk, often construed as the need for absolute causal association between an activity and a harm. Third is the cost of the measures that need to be adopted (another economic consideration). Fourth is not having public support with respect to either understanding the severity of the risk or accepting the societal implications of the control measures. In the other cases of political delay I mentioned, the major force preventing action was almost exclusively economic, with the other three factors as “supporting excuses,” often fomented and exaggerated by the business interests that stood to lose from measures designed to protect public health and the environment.
The precautionary approach was designed to address these shortcomings in political decision making by introducing several important concepts. One of the most significant being “weight of evidence,” which means that if 1,000 scientists find that asbestos causes mesothelioma and five say it doesn’t, you ignore the five and proceed to ban asbestos. In the case of COVID-19, if the evidence of travel restrictions suggests it works, then it should be adopted quickly, regardless of advice from WHO or the opinions of economic advisers. If we know the virus is deadly for seniors, clamp down on nursing homes ASAP. And if we believe in evidence-based approaches, then use the evidence we have and gather all the evidence we can by ramping up testing. Canada has been behind the curve in many of these areas.
The precautionary approach makes protection of public health the default, by acting sooner rather than later – it is the classic “ounce of prevention is worth a pound of cure.” The idea is to overcome the sequence of human response that we see with almost any threat, whether COVID-19 or climate change. First there’s denial (“a hoax”), then downplaying the risk, followed by questioning the measures to fight it as too risky to the economy, followed finally by meaningful but slow response once the threat is seen to be immediate. Precautionary thinking short circuits decision processes.
The bottom line is that there are five main things we can learn from our history of slow response:
1. Use science, evidence and history to inform decisions.
2. Analyse specific responses and results carefully and act accordingly.
3. Gather the information needed to assist rapid response.
4. Act quickly and stringently in the face of rapidly advancing threats.
5. Most importantly, do not let short-term economic thinking impair or delay judgment on long-term public health and economic health considerations.