Wednesday, 1 April 2020
COVID-19: The public health emergency and the disproportionately disadvantaged
Disproportionate disadvantage in the campaign to arrest COVID-19
Professor Shamit Saggar
In common with others, Australia is facing a first order public health crisis, the scale and contours of which are both unprecedented and hard to navigate. At the time of writing, it seems that European-style restrictions on people’s everyday lives are now inevitable as the country’s south-eastern states have begun to implement large elements of a lockdown.
There can be arguments about the route taken and opportunities missed on the way but it is clear that a massive curbing of human interaction is the only way to proceed given the limitations of testing for community transmission at this stage in the crisis.
How have we got here? We can expect many follow-up inquiries which will want to know why, by mid-March, the country was left wholly reliant on population-wide policy instruments. As state and national governments have ramped up their control measures, formulating public policy responses at large has had to balance many counter-veiling pressures. Lives versus livelihoods is the most acute example as the economic impacts have begun to crystallise. Overseas, the White House has openly questioned whether the costs of the cure (in terms of economic dislocation) could end up outweighing the problem to begin with.
One size fits all?
Most such measures veer towards treating people on the basis of averages. On average we model that each infected person will infect about 2.3 others without significant interventions, and those models are designed implicitly to recognise variation around that. We can then see the likely implications of 70 versus 80 versus 90 per cent compliance with each round of ever-severe restrictions on people’s daily lives. The Australian approach has been to bear down on social interaction as successive surges of infection appear.
The approach can and has been criticised because of its reactive nature and because it is not intelligence-led in the way that say Singapore, Taiwan and South Korea have had success through concentrating on isolating those very likely to become infected through contact tracing. In their approach it matters little whether these individuals meet notional averages based on their characteristics, since their movement (and capacity to harm others) per force is being squeezed at the source.
A population-wide strategy is reflected in Australian administrations urging people to stay at home, albeit not consistently across states and territories. The policy intervention’s benefits can be seen but the socio-economic circumstances of poorer, less supported Australians means that some people’s ability to meet this objective varies, sometimes considerably. Take the example of a woman facing the daily threat of domestic violence and abuse. We are asking her to run towards the source of danger since her version of self-isolation comes at a price. For others a lack of daily structure and routine looks like a modest burden in comparison.
There are many others who do not begin the task of protecting themselves (and others) on a level playing field. The homeless are an obvious example, but equally those with certain mental health conditions are likely to struggle with social isolation that will most likely make them worse. There are countless other illustrations that highlight the fact that a single policy lever, when pulled, impacts us in very different ways. At a larger level, CEDA has reported that more than 140,000 temporary skills workers in Australia are exposed to premature removal in the economic downturn and has called for a flexible response by Canberra in how these workers can contribute to other sectors.
In fact, public policy formulation deals with this problem regularly by assessing whether, or how far, a policy measure can be sensitised so that implementation does not result in a ‘one size fits all’ outcome. In the case of disability, consultation and engagement, when done well, ensures that policy formulation has been influenced so as to take account of the known facts about the limitations faced by those with different disabilities in navigating public services and modern markets. Assisted hearing and braille, for example, have become commonplace in dealing with public service providers who recognise that these structural impediments will not melt away of their own accord. The rationale is twofold: to ensure efficiencies and improvements for those directly affected and to enhance societal fairness as a goal in itself.
A similar set of principles applies in so many other cases: requiring firms and providers to offer non-digital services for older people who may lack particular skills and experience; allowing people to use telephone hotlines to complete forms for public services as a means of tackling poor literacy; offering dosage information for prescription medications in different languages to cope with non-native English readers; and so forth.
Policy sensitisation has been an incremental art practiced over many years. The idea is to be as well informed as possible about the realities of people’s lives and the obstacles to good outcomes they routinely face, and to be alive to adjusting and tweaking implementation in a way that can meet those circumstances. Obviously we cannot take a de minimis approach to this and try to identify and remove every obstacle no matter how small; but we can and should actively tackle the big, known barriers that have been extensively documented.
What can be done going forward? The general population measures now taken cannot and should not be reversed as these are driven by the approach taken much earlier, and it is clear that dramatic escalation is impending. But we can gear up to look for how these will impact unevenly and use this information to inform priorities if and when a lockdown strategy persists over several months.
The larger story is that a rapidly deteriorating public health picture can leave some people considerably less able to cope than others. Some without decent homes and diets will be exposed to infection as colder, damper weather arrives. Their precarious finances mean that their reliance on direct aid from government will become acute.
At some point an economic recovery will take shape. If the infectivity curve is successfully stretched out for a longer period, this implies not only a longer recession but also greater scarring effects on those out of work during that period. The hope is that, with government support, some skills can be reactivated and deployed quickly, and that workers can begin to repair the damage they have endured from a standing start. The notable gap in this assessment is that many businesses will not re-appear and whole sectors will be recast in a post-crisis economy that will look and feel very different. This is because the economy will experience a sudden structural shock rather than a conventional recession, in which case the demand for particular workers may just vanish.
The public health emergency has been communicated in terms of the potential for harm to spiral beyond control with measures adopted to slow and disrupt that trajectory. This is only half the story once we take account of existing inequalities and fragilities in our society. Prioritising the vulnerable is now critical and speaks to the sensitisation of modern public policy formulation and implementation that, in part, we already practice.
- UWA Public Policy Institute