Home Tuberculosis Epidemic Costs And Responses: Coronavirus And Tuberculosis

Epidemic Costs And Responses: Coronavirus And Tuberculosis

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Early Identification and Action

We are now
learning, from Covid19, one thing above all else. With
epidemics, it is early
identification and action that matters. When our Prime
Minister, Jacinda Ardern, says that New Zealand’s government
approach is to “go hard and go early”, she is only partly
correct. What matters is that by going early you may not
have to go hard; and that having (and understanding)
information both enables early responses to outbreaks, and
makes it possible to go no harder than is
necessary.

Radio New Zealand ran a story this morning
(9:20am) “Is business support shifting away from government
elimination goal?”. As is often the case, the headline
missed the nuanced point being made by the interviewee,
Auckland Chamber of Commerce CEO Michael Barnett. The point
being made was that, to avoid repeated hard and disruptive
responses to each epidemic outbreak, early and precise
action was required – in particular, through smart-testing
and smart-confinement.

Smart testing means:
symptomatic testing of people whose lives involve
significant close contact with other people, sample
asymptomatic testing of people who work at or travel through
international or quarantine borders, and follow-up genomic
testing (for positive cases) and sample antibody testing
(serology). This is the information component of a
smart-response strategy.

Smart confinement means
focussing on restricting the pathogen rather than
restricting the people; in the case of Covid19, the pathogen
is the coronavirus SARS-Cov2. The major tools here are
contact tracing, the temporary mandatory use of face
masks in sensitive environments until an outbreak is
contained
, and the temporary closures of
sensitive environments for which mask use is not always
possible (such as premises that involve eating or drinking,
or singing). The general idea is that speedy containment
should minimise the time for which such temporary mandates
and closures are required.

With regard to contact
tracing, having a smart public health app and a smart public
health card are complementary. A public health card (a
‘Covid Card’, kept in the same place as one’s drivers
licence or ‘hop card’), which logs offline records of
contacts can complement an app that, when deployed, can
trigger a notification of a casual contact or a place
recently frequented by a possibly infectious
person.

Bureaucratic Bungles

There is much
chatter this month about the failures of managers to keep
critical facilities safe; facilities such as ‘managed
isolation and quarantine’ (MIQ), ports of entry into New
Zealand, rest homes, and medical facilities.

This is a
systemic problem that is due in large part to a
tone-deaf management culture which
emphasises financial/accounting ‘costs’ over economic costs,
and largely underestimates benefits; indeed, economic costs
include the foregone benefits of cost-cutting measures. (See
RNZ’s Doctors
pen warning to Christchurch over DHB
, and my Counting
the Cost of Government Action and Inaction
.)

This
management culture in New Zealand goes back to the 1987
Treasure Briefing to government, called ‘Government
Management’. (This policy briefing of course reflected
management practices that were already fashionable in some
other countries.) By and large, all government in New
Zealand since 1987 have been responsible for the creation of
a bureaucratic culture that overemphasises financial and
accounting costs, and deemphasises societal benefits. David
Clark was a Minister of Health who epitomised and reinforced
this culture.

In practice, it means that if a
government asks its officials to implement a policy, but
makes some aspects of that policy ‘optional’, then these
bureaucrats will choose to save costs by not implementing
those parts of the policy, or by implementing a scaled down
version of the policy. Further, such managers in charge of
stockpiled resources – such as personal protective
equipment (PPE) – will be reluctant to deploy or relocate
such resources; much as misers who ‘save for a rainy day’
refuse to spend their savings when it rains on the grounds
that it might rain even harder tomorrow.

The problem
is compounded by management structures, where Ministries act
as intermediaries between ministers and operational
managers, and where ‘spending ministers’ – such as the
Ministers of Health and Education – are intermediaries
between their ministries and the Treasury ministers. If the
Prime Minister mandates some policy, it has to pass through
a whole bureaucratic chain – a chain which may have
multiple points of resistance. The chain is from Prime
Minister, to Treasury Ministers (who authorise a pot
of money
, even when there may be no practical reason for
capped funding), to spending Minister, to the Ministry, to
– in the case of public health – the District Health
Boards (DHBs).

DHBs’ managers may interpret and
respond to the mandate they receive in different ways,
depending on the different extents of culturation present in
each institution. A good manager will have heard the mandate
from the top, and will question any discrepancies between
the spirit and the letter of their instructions. Tone-deaf
managers will take their filtered instructions literally,
and will try to comply by spending as little money as
possible. One result which we are familiar with is the
grudging minimalist approach by managers towards upholding
the safety of clinical staff.

Economic
Principle

The general economic principle that should
guide action is that of economic efficiency, which enters
public policy as cost-benefit analysis.

The principle
is that, if the marginal benefit of a policy action
exceeds the marginal cost of that action, then that
action should be undertaken (albeit with the possibility
that parties who would bear that cost should receive
appropriate compensation). By marginal, we mean
‘additional’. For example, in our present context, there may
be a proposal to add a restriction to a society which is
currently at New Zealand’s epidemic alert Level Two. If the
best estimate of the benefit of the additional measure is
that it outweighs the (best estimate) cost of that measure,
then the measure should be implemented. And if the
marginal cost outweighs the marginal benefit, then the
additional policy measure should not be
implemented
.

(This process of analysis also
applies to proposals to remove a measure that is currently
in force.)

The most difficult part of this process is
to produce unbiased estimates of these benefits and costs.
And, within that, the difficulty exists in both estimating
and discounting long term benefits and costs. By
‘discounting’, we mean weighting immediate benefits and
costs against expected future benefits and costs. What
matters is that the cost calculus used to make such a policy
decision is transparent – publicly available, and able to
be challenged. It does not mean that policy action must wait
until challenges are exhausted. Rather, the process of
challenge is a process of learning, and refinement of the
analysis in light of new information.

One way that we
can attempt to estimate long run benefits and costs is to
evaluate past comparable episodes. The past episode that I
find to be interesting here, is that of tuberculosis. We
note here that the classic tuberculosis ‘pandemic’ began in
the eighteenth century and only ended in the mid-twentieth
century with the development of an antibiotic effective in
treating the tuberculosis bacteria. (With ongoing global
poverty and antibiotic resistance, it has been argued – by
Frank Snowden – that the world is already in a second
tuberculosis pandemic.)

Pandemics and Society: the
Long Term

Yesterday I read They
say, ‘learn to live with Covid-19. Here’s what I say
back
, by scientist Siouxsie Wiles. The most interesting
part of Dr Wiles’ article was its discussion of the harmful
aspects of Covid19 infection other than the possibility of
imminent death. In this regard, Covid19 can be usefully
compared with tuberculosis.

In Frank Snowden’s 2019
book Epidemics and Society, the emphasis is on the
social causes and social consequences of epidemic
diseases. Tuberculosis was a reality of life for two
centuries that people had to live with knowing there was no
cure. An interesting story – told by Margaret Heffernan in
Uncharted, how to Map the Future Together – is one
about the history of economic forecasting. The three
pioneers of this statistical art – Irving Fisher, Roger
Babson and Warren Persons – were all diagnosed with
tuberculosis. (Two of these lived beyond the age of 80, and
may have been false positives.) It meant that they lived
their lives under the cloud of considerable personal
uncertainty, and that circumstance most likely contributed
to their quests to minimise economic
uncertainty.

Until the end of the nineteenth century
– when Robert Koch proved that tuberculosis was an
infectious disease – the disease had ‘romantic’
connotations. (Indeed, the pale and drawn appearance of
women with tuberculosis seems to have been the precursor for
the widespread twentieth century preference for skinny
models in the fashion industry.) In the ‘Romantic era’,
tuberculosis was seen as an inherited condition that
particularly affected creative white people (it was called
the ‘white plague’). So, while suffering from tuberculosis
would usually lead to an early death, there was no stigma
attached to it. Tuberculosis escaped the attentions of the
‘sanitary movement’ of the 1830s to 1850s; the movement that
attributed most other diseases to ‘filth’. (In fact,
tuberculosis existed in poor and non-white communities, but
was largely undiagnosed and unnoticed.)

After the
1880s, tuberculosis gradually came to be understood as a
contagion – typically but not only passed from person to
person – that caused substantial damage (scarring) to a
person’s lungs and could also damage other organs. It was
revealed to be a ‘tricky’ disease of remissions rather than
cure; an ailment that might activate at any time in an
infected person’s life, and an ailment that would typically
and substantially reduce both quantity and quality of life.
It was discovered that fresh air – preferably dry mountain
air – and minimal stress could substantially extend
tuberculosis remissions. More generally, it came to be
understood that people benefited from remission from work.
Tuberculosis may have played a large part in the perception
from the 1880s to the 1930s that the most important
improvements to living standards were increased leisure
rather than increased household incomes; in those years
productivity growth did not mean economic
growth.

These points are very pertinent today, because
the bodily damage created by SARS2 (Covid19) and SARS1 may
be similar to that created by tuberculosis; ongoing though
intermittent, and requiring affected people to lead less
stressful and less precarious lives than the lives they
might have been anticipating in 2019. We no longer live in a
world – as we did in the later decades of the twentieth
century – where young adults could believe that they could
get infectious diseases with impunity, knowing that their
diseases would either self-cure or be cured with drugs such
as antibiotics.

Conclusion

Covid19 is taking
us – in a way that cannot pass unnoticed (as SARS1 did)
– into a new era of changing estimations of long-run costs
and benefits. It is a disease that, while survivable for
most, is a disease that nobody wants to get. Nevertheless
– like tuberculosis in the nineteenth century – a
substantial minority of the world’s population will have it,
and will have their whole lives physically and
psychologically affected by it. At the very least, this
experience will modify the future economic choices that most
of us
make.

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https://www.scoop.co.nz/stories/HL2008/S00158/epidemic-costs-and-responses-coronavirus-and-tuberculosis.htm

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