Ulli Diemer — Radical Digressions

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Thinking Clearly in a Time of Crisis

By Ulli Diemer

A crisis like this pandemic is not a time to stop thinking. It is a time when critical thinking and public discussion are more important than ever.

A small number of officials and politicians are taking decisions with enormous and far-reaching implications for the lives of many people, not just for the duration of this pandemic, but far into the future. The time to have serious discussions about what they are doing, and the direction we are heading in, is now, not some day in the future when it will be difficult, or too late, to change course.

To be clear: I believe that public health officials, the people who are taking a leading role in shaping our response to COVID-19, are doing their best to deal with a very real crisis. I respect their dedication, and I know that it is very difficult to respond to a rapidly changing situation with imperfect information and limited resources. And I certainly have no stomach for the rapidly spreading pandemic of conspiracy theories, let alone the disgusting racist attacks on Canada’s Chief Public Health Officer.

Nevertheless, we need to be asking questions about the public health response. And in fact, there isn’t one single public health response: different jurisdictions, all of which have access to the same science and the same models about spread, have reacted to COVID-19 in significantly different ways.

This is not surprising. The fields of epidemiology and public health are like any other scientific endeavour: there are debates and disagreements among the specialists in the field about what the evidence is, how good the evidence is, what conclusions can be drawn from the evidence, and what measures ought to be taken. There is nothing wrong with this. In fact, it’s good, because that is the nature of any living science.

The problem is that public health agencies are structured as top-down bureaucracies, with a CEO at the top who is the only one authorized to speak for or make decisions for the agency. The senior official makes a statement, and that statement is taken as the last word on the science of the pandemic. That may be inevitable in a government agency, but it is also a recipe for making serious mistakes. There is little or no room for the critical weighing of evidence and conclusions that healthy science requires. It is also in the nature of top-down organizations, whether private or public, that they find it almost impossible to admit to uncertainty, let alone acknowledge mistakes.

So it falls to those who are outside the official decision-making bodies to ask critical questions.

One crucial set of questions concerns the nature of the official projections about the spread of COVID-19 and the likely death rate:
What data and assumptions are these projections based on?
With what degree of certainty are these projections made?
Why do you consider this model to be more reliable than other models which lead to different projections?
What do scientists on the outside of the agency say about these projections?

Modelling uncertainty

These are not arcane questions. In February, a group of scientists from Imperial College led by Neil Ferguson projected more than 500,000 deaths from COVID-19 in Britain alone, and more than two million in the United States. They suggested Britain and the U.S. would have to essentially shut down for 18 months to avoid this. Their research was widely quoted, and relied on, by public health bodies in many countries. But then other studies appeared, notably one from Oxford, challenging their validity of their work, leading the Imperial College group to backtrack and drastically lower their projected death toll to a fraction of the original forecast.

Obviously epidemiology in the midst of a pandemic is not – cannot possibly be – an exact science. This is absolutely not a reason to dismiss epidemiology. But serious problems arise when public health officials and politicians speak and act as if it is an exact science, and then compound the problem by failing to explain how they arrived at their conclusions.

This became an issue in Canada on April 26, when it was revealed that the projections the federal government has been relying on to forecast the spread of COVID-19 are not based on an actual model at all, but on an attempt to create a synopsis of widely differing forecasts, based on different assumptions, both from Canada and from other countries.

Outside experts were quick to point to the unscientific nature of this approach. For example, if, as was the case, one model projects a 60% infection rate, and another model projects a 10% infection rate, it is scientifically absurd to average them out and create a ‘synopsis.’ At least one of the models must be wrong.

Compounding the problem is the inadequacy of the data. For example, the Ontario government regularly releases information about what it says are the number of COVID-19 cases in the province. The media reports them, and local governments and various institutions take decisions based on these figures.

The only thing we know for certain about these numbers is that they are wrong. In Ontario people who have symptoms of COVID-19 are instructed to stay home until they recover, unless they get so sick that they need urgent medical care. Since there is no treatment, this makes sense. There is no suggestion they report their illness to anyone, and even if they were to show up at a testing site and ask to be tested, most of them will be turned away because Ontario doesn’t have the capacity to test large numbers of people. Since most people who get infected with COVID-19 get better on their own (in fact, a sizeable minority, perhaps a majority, show no noticeable symptoms at all) it is certain that the number of cases is considerably higher than the official figures show. Which also means that the death rate is lower, and the recovery rate higher, than the official figures indicate.

Yet governments take these flawed numbers, plug them into speculative models, and produce projections that are then used to make far-reaching decisions. It is possible, of course, that decisions based on flawed data and flawed models can nonetheless be the right decisions. It is also very possible that they are the wrong decisions. That is why we need to be asking more questions, demanding more information, and encouraging more informed public discussion.

Unfortunately, discussion is often the last thing politicians and public health officials want to encourage. Theirs is a top-down approach: the appointed expert or the leader decides what needs to be done and issues directives telling people what they may or may not do. Questions are not needed or wanted. If there is any suggestion of uncertainty or room for discussion, official thinking seems to go, the public will be confused and fail to follow the rules around self-isolation and social distancing.

One problem with this is that official unwillingness to admit that there is a degree of uncertainty and room for debate creates a vacuum which is inevitably filled by those who are already predisposed to distrust both science and government. They quickly pounce on unacknowledged discrepancies and disagreements as ‘proof’ that people in positions of authority are hiding information because they are acting on a hidden agenda.

Cancelling surgeries and treatments

Questions about models, and the assumptions on which they are based, are not abstract or trivial matters. For example, Ontario, the province I live in, decided in the middle of March to cancel all so-called “elective” surgeries, as well as a wide range of other treatments. The stated purpose was to free up hospital beds for an anticipated surge of COVID-19 patients.

It’s now eight weeks later, and the surge hasn’t happened. We learned a few days ago that ICU usage is about half of the best-case scenario that the model projected, while hospitals that are usually full are now running at less than 70% of normal occupancy. Of course, it’s good that we are doing better than the most optimistic scenario. But obviously the model on which these projections were based was flawed. Once again, we see that when we short-circuit the scientific method (which includes transparency about data and methodology, and peer review by others in the field) we are likely to end up with bad science and bad decisions.

The decision to cancel elective surgeries and other treatments has had grave repercussions: preventable deaths, suffering, and terrible worry for those denied treatment for debilitating or potentially fatal conditions. One has to ask: What were they thinking? For a large proportion of elective surgeries, the patient arrives in the morning, and is discharged either the same day, or the next morning. It would have been quite possible to continue performing elective surgeries (at a somewhat slower pace to allow time for donning personal protective equipment) until the anticipated surge actually started to materialize. If a surge of COVID-19 patients did start turning up, that would have been the point to start cancelling surgeries. In the meantime, even if the number of ‘non-urgent’ procedures had been cut in half, rather than cancelled, thousands of vitally necessary operations could have been performed.

It’s true that another reason for cancelling surgeries and treatments was to have fewer people circulating in hospitals, thereby lessening the risk of exposure to someone who may have undiagnosed COVID-19. This is not a trivial consideration, but it is worth remembering that when hospitals resume these surgeries and treatments, COVID-19 will still be around. The virus isn’t going to be eradicated, not in a month from now, not three months from now. The virus will still be circulating, and the same precautions will still be necessary. Postponing surgeries hasn’t eliminated the problem; it has magnified the problem.

Whatever the political and practical considerations may have been, it is important to remember that the cancelled surgeries we are talking about are vital procedures such as mastectomies, heart surgery, cataract surgery, gall-bladder removal, and joint replacements. These are life-altering, and in many cases, life-saving procedures. To that, add cancelled treatments like chemotherapy and physiotherapy. There is an enormous human cost to these cancellations.

In Ontario alone, the backlog of cancelled/postponed surgeries is now above 60,000. Even if it is possible to catch up, it will be too late for more than a few. The first studies are now starting to appear showing that people have died, and more people almost certainly will die, because of these cancellations. Others will have suffered irreversible damage to their health. It would have been good to have had more informed consideration of these foreseeable outcomes before the decision to cancel.

Shutdowns and social distancing

Shutdowns and social distancing directives are another area crying out for critical discussion and evidence-based decision-making rather than arbitrary rules. There is no question that social distancing and targeted shutdowns can be important tools in preventing the spread of the virus. However, what the rules and guidelines should be is far from clear. Public health officials make authoritative assertions, it is true – but it is also true that what they say, and the policies they adopt, vary substantially from one jurisdiction to another.

Schools have remained open in Sweden and Taiwan with social distancing measures; in many other jurisdictions they are closed. In some cities, like Ottawa, sitting on the grass in a park can net you a stiff fine. In Berlin, it’s OK for people to do so, as long as they keep a meter apart. (The World Health Organization and the European Union both recommend keeping one meter distant from other people; Canada says two meters, with no explanation for the difference.) The British Columbia Medical Officer of Health encourages people to go outside and enjoy the parks, adding that there is very little chance of getting COVID-19 by, for example, walking past someone on a path. Ontario’s Medical Officer of Health, meanwhile, urges people to “Stay Home” while the Prime Minister continually advises people not to go outside “unless you absolutely have to.”

Elite panic and abusive enforcement

It’s difficult to escape the feeling that some of what is driving the sometimes arbitrary rules around social distancing is “elite panic.” Elite panic refers to the fear that strikes those in positions of authority during an emergency when they fear that they will lose control. Essentially, it’s a fear that people, ordinary people, will run amuck and do crazy things. The solution is invariably seen as strict rules and punitive enforcement.

In reality – and this has been seen it many situations, not just with this pandemic – it is often the authorities, and those charged with enforcing the rules, who run amuck. The truth is that there is no social problem for which police are a good solution. Arbitrary interpretation of the law, coupled with mindless rigidity in enforcing it, are characteristic of those who work in law enforcement.

This has certainly been evident during COVID-19. In fact, the Canadian Civil Liberties Association has described what is going on as a “policing pandemic.” This is true internationally as well as in Canada.

It Italy and France, among other places, no sooner were lockdown measures put into effect than police were out on the streets issuing tickets to homeless people. In Paris, the police herded them into packed gymnasiums to get them off the street. In India, police harassment and violence directed at the poor have been endemic; migrant workers and their families have been forced into packed trucks, driven out of town, and dumped by the side of the road.

In Canada, the City of Ottawa has been repeatedly in the news for announcing rules which make no sense whatever in terms of actual health risks, and for its abusive enforcement practices. It was Ottawa where a public health official said that two people sitting on chairs in a driveway, 10 feet apart, were breaking the rules. Why? Apparently because the mere sight of them sitting there might encourage other people to rush over and congregate around them. It was in Ottawa too where a man received an $880 ticket because he sat down on the grass in a park, away from other people, to take a phone call. The bylaw enforcement officer interpreted his behaviour as ‘having a picnic.’ In Montreal, a woman faces a $1546 fine because some of her friends drove by her home and honked their horns to wish her happy birthday. In Aurora, Ontario, a woman walking in a park with her baby was fined $880 for standing more than two minutes in one place. She had stopped to answer a text on her cell phone; no one else was near her. In Toronto, the city I live in, a man jogging alone through a wooded park was pounced on by a lurking bylaw enforcement officer who gave him a $700 fine, even though jogging on park paths is permitted. The officer claimed that this particular path was an ‘amenity’ used for dog-walking (though there was no sign to indicate this was the case), and therefore verboten because ‘amenities’ are off limits. (See ccla.org and policingthepandemic.ca for many more Canadian instances.)

What is apparent in a large number of reported ‘infractions’ is that there was in fact no infraction of social distancing guidelines at all.

What is also apparent is that the vast majority of people are behaving responsibly and doing their best to follow the guidelines and avoid risky behaviour. The appropriate way of dealing with the small minority who are failing to do so, either deliberately or inadvertently, would be speak to them and tell them what they should or shouldn’t be doing. Instead, the approach adopted by public health officials and politicians is to treat everyone as if they can’t be trusted, and to impose huge fines on those who inadvertently transgress an arbitrary interpretation of a rule that often makes no sense in the first place.

It is worth considering how the approach to COVID-19 differs from the way we approach other potentially risky behaviour. In Canada, alcohol is a factor in three or four fatal car crashes per day, as well as a significant number of injuries. About 2,700 people die of alcohol-related illness, such as cirrhosis, in an average year. Yet we don’t stop selling alcohol because some people might abuse it. We target education and enforcement at problem drinkers, trusting that most people will use alcohol responsibly. With COVID, the authorities act as if everyone will act irresponsibly unless they are forced to stay home.

Assessing degrees of risk

The goal of social distancing and shutdowns is – or should be – to prevent transmission of the virus. It is clear that most instances of transmission occur during close or prolonged contact. By far the most dangerous situations are health care and other care settings, such as nursing homes, where prolonged close contact is unavoidable. Other high-risk setting include shelters, group homes, jails, public transit, and workplaces where workers are in close proximity, such as meat packing plants. Elevated risk also occurs in jobs which involve coming in close proximity to a large number of people, e.g. cashiers, bus drivers, and taxi drivers.

Outdoor settings, such as parks and paths, involve minimal levels of risk, as Bonnie Henry, B.C.’s Provincial Officer of Health, has noted. Yet some jurisdictions, Toronto and Ottawa for example, have prioritized keeping people out of parks to the point of obsessiveness. In Toronto, even cemeteries and community gardens have been closed, for reasons that no one can explain.

The constant messaging that ‘everyone’ should ‘stay home’ has served not only to confuse the population about what kinds of situation are high-risk and which are low-risk; it seemingly clouded the judgment of the decision-makers themselves. When it became clear that ‘community transmission’ (that is, cases of COVID-19 not linked to returning travelers) was occurring, the policies put in place, and the messaging around them, seemed to be based on the assumption that all situations were equally risky, and that the solution was to get everyone to stay in their homes.

The first problem with this is that for society to function, large numbers of people have to go to work. If everyone were to stay home, we’d have no drinking water, no electricity, no food, no hospitals, no Internet. Of course, public health officials and politicians are perfectly aware of this. But with their focus on preventing community transmission generally, as if it was equally likely to occur in a park, a bus, and a nursing home, they failed to take action that needed to be taken in essential workplaces and other high-risk settings. While solitary joggers and people sitting on the grass were being ticketed, staff in nursing homes and hospitals, and transit workers, had to beg for the most basic personal protective equipment like masks, and other workers had to walk out to get basic protections and precautions put in place.

The nursing home disaster

In Canada, these misjudgments and misplaced priorities helped to create the still-unfolding disaster in nursing homes. More than 80% of Canada's COVID-19 deaths have been in long-term care settings; most of them in Quebec and Ontario.

Given the endless warnings to “stay home” there is a certain bitter irony in the fact that in Ontario, more than 80% of those who died were exposed to the virus in their homes – the government-supervised nursing homes in which they lived.

While there were serious mistakes and delays in the public health response to the situation in nursing homes, the real problems are structural and ongoing. Neoliberal policies of tax cuts for the rich, coupled with austerity in social services and health care, have produced chronic understaffing and inadequate care.

Privatization has made the situation worse. An analysis of COVID-19 infections in care homes published by the Toronto Star on May 9 showed that residents in privately owned nursing homes were four times as likely to die as residents of municipally owned homes. The numbers are new, but the picture they paint is not. Advocates for the elderly have been documenting appalling conditions in homes, especially but not exclusively in private facilities, for years. The situation in the majority of privately owned facilities is actually worse than the figures suggest, because they include a minority of posh facilities for the well-off. In privately owned homes for poor people, residents are often warehoused, two or four to a room, with staffing levels inadequate for providing essential care, let alone recreation and personal contact.

In these kinds of circumstances, proper infection control procedures are impossible. With four people to a room, social distancing is out of the question. Add to that the factor of part-time staff who work in multiple homes, and who were told not to wear masks, and the recipe for the disaster that took place is clear. And yet, as the nursing home tragedies were unfolding inside the homes, the City of Ottawa’s director of long-term care found time issue an edict banning window visits, in which family members (no longer allowed to enter the homes where their loved ones live) would stand outside their windows and shout and wave to them.

Negligence and short-sighted decision-making

Long-term structural problems are not something that affects only long-term care. They are part of a broader picture of negligence, greed, and short-sightedness. In countries infected by the plague of neo-liberal austerity, including Canada, health care, including public health preparedness, has been gravely compromised by years of cutbacks and short-sighted decision-making.

One of the messages we have heard over and over again is that the purpose of shutdowns and social distancing is to “flatten the curve.” In other words, the goal is not to keep people from being infected with the coronavirus, but to spread out the rate of infection over a longer period of time, to keep from overwhelming the capacities of the health care system. Something that never seems to be mentioned in this discourse is that the capacity of the health care system is not some immutable fact of nature. The limited capacity of the system today is a result of systematic neglect over a period of years. If the health care system had been properly funded, we would have been better prepared, and our capacity to handle a crisis such as COVID-19 would be significantly greater.

Another area of neglect relates to the failure to learn and apply the lessons of previous outbreaks. In the last two decades, the world has experienced SARS, H5N1, H1N1 (swine flu), MERS, and Zika. Epidemiologists and public health experts knew, and repeatedly said, that further outbreaks were inevitable. Detailed studies and reports were produced outlining what needed to be done to be prepared for the next one. Ensuring that abundant supplies of personal protective equipment were on hand was identified as one of the most obvious and straightforward requirements. Hospitals, and health care systems generally, did the opposite. They increasingly moved to ‘just in time’ procurement, on the assumption that supplies could always be purchased if they were needed. This proved to be a disastrous miscalculation.

The lessons of SARS

In the wake of the SARS coronavirus outbreak in 2002, we were told that it was important to draw the lessons of SARS so that we would be better prepared when future outbreaks took place. Ontario set up a commission of inquiry, chaired by Justice Archie Campbell, which in 2006 produced a comprehensive report outlining health system failings and recommending urgent changes. Among the failings the report identified were inadequate worker safety protocols in hospitals and failure to provide hospital staff with N95 respirators. “SARS may be the last wake-up call we get before the next major outbreak of infection, whether it turns out to be an influenza pandemic or some other health crisis,” the Commission said.

Fast-forward to 2020, and it turns out that the lesson of SARS is that those in charge of the health care system didn’t learn the lessons of SARS.

What kind of exit strategies?

There is now increasing discussion of “exit strategies” and re-opening businesses and schools. This will involve far-reaching decisions which will impact not only the future course of this and other pandemics, but the future of the environment, the economy, and how people lead their lives. We have to insist that there be public discussion and public input on these critical decisions. Government leaders and their corporate friends will try to persuade us that everything needs to go back to ‘normal.’ On the contrary: the normal functioning of industrial agriculture, the globalized economy, and a down-sized public sector, brought us to where we are today. We need to do much better than normal. We need fundamental change.

One area in which governments are considering changes to the normal way of doing things concerns public health measures. The fundamental dilemma is that shutdowns have to end sooner or later. Schools have to reopen, businesses have to reopen, people have to go back to work, cancelled surgeries have to be rescheduled, large numbers of people have to use public transit, international travel will resume. And the virus will still be present in the population, in this country, and in most other countries, and it will still be highly contagious. Even if it could be eradicated in this country – and no one has been suggesting this is possible – it will still be present in many other places. International travel and global supply chains are how it spread from one country to another in the first place, and they will keep spreading this and other viruses. A vaccine is believed to be 18 months away, and, as we know, the growing plague of anti-vaxxers will ensure that many people will not be vaccinated even when a vaccine has become available and has been shown to work.

One idea that has been proposed is that of “immunity passports,” that is, allowing those who have been exposed to COVID-19 and have recovered, to go back to work and move about freely. The absurdity of regarding this as a viable option becomes apparent as soon as you consider the numbers. In Canada, there have been an estimated 70,000 cases as of May 11; of those, about 5,000 individuals have died. That leaves about 65,000 people who would be eligible for an “immunity passport” out of a population of more than 37 million. In other words, out of every 100,000 people, 65 would be eligible for an immunity passport and 99,935, more than 99.9% of the population, would not be. Would they be required to stay at home for the next 18 months to two years until a vaccine is developed? This is not a serious option.

There is also a push from the usual suspects, that is, the digital mega-corporations like Google and Facebook, backed by the ‘national security’ apparatus, to roll out various kinds of spyware to track the movements of entire populations, ostensibly to identify individuals who may have come into close proximity to someone carrying the virus. Assuming for a moment that those pushing this idea actually believe this makes sense, it needs to be pointed out that existing mobile phone tracking technology is not capable of locating phones accurately enough to make this workable. If the danger of transmission occurs within a range of one or two meters, then knowing that someone came within 50 meters of someone carrying the virus is useless. (According to Wikipedia, mobile phone geo-location data is accurate to within 50 meters in urban areas, less in rural areas.) We also know that a very large percentage of those who are carrying the virus don’t know they are carrying it, which means the tracking software won’t know it either.

But we can safely assume that those pushing this techno-fix have other reasons for promoting it. This is seen as a golden opportunity to suck up the personal data of entire populations. You would have to be very gullible indeed to believe that it won’t quickly end up in the hands of the U.S. National Security Agency, as well as corporations wanting ever-more-detailed information about those they want to target with their advertising.

The future must be different – or there will be no future

The very concept of an “exit strategy” can serve to mislead us about what the future is likely to hold, and what choices we need to make. Exiting this stage of the coronavirus crisis means that we will be entering a different stage, in which the virus will still be present among us. And, what is perhaps even more important: there will be more viruses, and more pandemics. This is not the last one, and probably not the worst one, that we will face.

This makes it imperative that this time around, we work harder to draw the lessons of this pandemic, and act accordingly.

One of the most important lessons, one that biologists have been stressing for years, is that the spread of industrial agriculture, and the unsustainable practices associated with industrial livestock operations in particular, are driving the emergence of new and extremely dangerous viruses. These practices are enormously destructive of traditional farming communities, the ecology of our planet, and human health and life. They cannot continue if we hope to survive.

Another huge problem is the so-called “global supply chain” that neo-liberal capitalism has tried to convince us is normal, desirable, and inevitable. Those who have been mapping the COVID-19 pandemic have shown that its spread has closely followed global supply chains. Efficient as they are in spreading viruses, the global supply chains are even more efficient at spreading environmental destruction. The real meaning behind the lazy rhetoric of globalization is that the individual components which are assembled into products that corporations produce, are manufactured in many different locations around the world, wherever labour costs are lowest. This is what “efficiency” means to capitalists: wherever labour costs are lowest.

This has devastating effects on the living standards of workers around the world, and on their human rights, as repressive governments crush attempts to unionize in order to impose rock-bottom wages. It is also hugely harmful for the environment, as ships criss-cross the oceans burning enormous quantities of fossil fuel, and degrading marine ecosystems, as they carry components, back and forth, from one low-wage location to another. Trucking and air transport of goods and components are also part of the unsustainable economy that has been built up around us. This too cannot continue.

There is another important lesson that this pandemic has taught us. After decades of austerity and cutbacks to health care, education, social services and environmental protection – basically everything except the military – it turns out that the money we need to do what is necessary is there after all. Cupboards that were said to be bare are suddenly found to have billions and billions of dollars in them, available to spend. This is a lesson we must remember.

This is hugely important to our prospects for shifting our economy off the track to catastrophic climate change. If millions of people can be paid to stay home, then it is certainly possible to shut down the most environmentally damaging parts of our economy and pay the laid-off workers to do socially useful work. We just have to find the will to do it, and muster the political power to make it happen.

May 12, 2020

Ulli Diemer is a writer who has been socially distancing in Toronto during the COVID-19 pandemic of 2020.

Related:

Morality in an Amoral World – A crisis like the novel coronavirus COVID-19 shows us – if we have the courage to see – who we are as individuals and as a society (March 2020)

Abandoning the Public Interest – Exploring the costs of austerity and cutbacks to public health and safety (October 2000)

Contamination: The Poisonous Legacy of Ontario’s Environmental Cutbacks – On the Walkerton water contamination disaster (May 2000)

References:

Capitalist Agriculture and Covid-19: A Deadly Combination

How "Just-in-Time" Capitalism Spread COVID-19

Pandemic Insolvency: Why This Economic Crisis Will Be Different

“Diarrhea, Dehydration, Hunger, Exhaustion”: India’s Rural Poor Suffer Most Under Lockdown

Keywords: Critical Thinking – Health Care – Public Safety