Walking a fine line Science, public pressure at play in health policy decisions By: Sarah Lawrynuik Posted: 3:00 AM CDT Saturday, Apr. 25, 2020

Hey there, time traveller!
This article was published 25/04/2020 (2291 days ago), so information in it may no longer be current.

If you’ve been paying attention to the COVID-19 policy response across the country, you may have noticed a trend — a trend towards the (somewhat) inconsistent.

Every health policy has been laid out by politicians stating that it is based on the best science available, in the express interest of protecting the public. And yet, in nearly all jurisdictions, that looks different. Take, for example, the size of groups allowed to gather. In Manitoba, 10 people can gather under provincial guidelines. In Alberta, it’s 15. In Quebec, all public gatherings are banned.

This pandemic has made it abundantly clear that while health policy is underpinned by science, it also is heavily influenced by a multitude of other factors.

“The intersection of public health guidance, civil liberties and human behaviour is a really tricky intersection to navigate. It’s Portage and Main during rush hour,” said Ian Culbert, the executive director of the Canadian Public Health Association.

To start, health policy isn’t solely based on the advice of expert physicians, Culbert explains. It’s also epidemiologists, sociologists, and others — all coming together to offer perspectives from different realms of science.

Then, there are the other less-scientific factors.

Alan Katz, the director of the Manitoba Centre for Health Policy at the University of Manitoba, teaches medical students to expect and anticipate these factors when they watch health policy develop over the course of their careers.

“Particularly in a public health system, we elect people and they make decisions around policy. We haven’t elected the scientists. We’ve elected the politicians,” Katz said. “So it’s not a simple matter of there being one study, or three studies, that say X and as a result that’s what happens. It’s not that simple.”

Katz adds that nearly all science is also in need of interpretation, as raw scientific findings don’t necessarily indicate what action should be taken. And interpretation can vary a great deal depending on who the translator is.

Economic implications

On April 6, Manitoba’s premier pulled the chair out from the long table set up to face the broadcast cameras. Brian Pallister sat, shuffled his papers and said, “Money pays for health care. So, let’s talk about money today.”

Culbert says economic implications and the reality of finite resources are a part of the discussion in Canada, but generally speaking he thinks Canadian leaders have done a better job at keeping the focus on health priorities than, say, our neighbours to the south.

There are two primary ways money and economics influence health policy. First, how health policies influence the economy writ large. That is: what does virtually closing down cities mean for the economy? Second, evaluating what kind of policies can be implemented within the jurisdiction’s spending constraints.

There are two primary ways money and economics influence health policy.

In the case of the latter, this isn’t specific to a pandemic. This is a constant balancing act. Katz points to waitlists for various tests and procedures in the province as a prime example.

“For example, we could, if the government decided, build 20 more MRI machines at a huge cost, staff them, and when you need an MRI test it could be done the next day. Would that be a smart thing to do? Absolutely not, it would be a really inappropriate decision, and one that’s not going to be made because the politicians know it would be inappropriate.”

Thus the policy decisions we are watching unfold must also be viewed with that in mind. We cannot afford everything, but it is politicians who are tasked with defining the tradeoff between cost and the benefit that spending would provide to the population.

Public perception

Ultimately, every decision made by politicians will also take into account the public’s reaction. Perhaps because of the political democracy we live in and politicians are always vying for votes, Culbert says, but from a good policy perspective, it’s also important because public acceptance plays into whether or not people will follow the rules.

“f you can’t justify a response to the public, you probably won’t get significant buy-in.” – Executive director of the Canadian Public Health Association Ian Culbert

To Culbert, closing the borders is an excellent example. Principally, because the science noting the effectiveness of closing borders is weak. The World Health Organization (WHO) has pointed this out and has continuously advised against implementing travel and trade restrictions.

“In general, evidence shows that restricting the movement of people and goods during public health emergencies is ineffective in most situations and may divert resources from other interventions. Furthermore, restrictions may interrupt needed aid and technical support, may disrupt businesses, and may have negative social and economic effects on the affected countries,” the WHO advisory reads.

But the Canadian public cried out and demanded action, and so action was taken, with the borders closing to all non-essential travel starting on March 21. But Culbert suspects that if that move had been made any earlier, politicians wouldn’t have had that critical buy-in from Canadians.

“It’s easy to look back and say, ‘Oh, well on Jan. 15 we had the first travel-related case of COVID-19 in Canada, we should have closed our borders,’” Culbert said. “But the reality is, that wouldn’t have been a proportionate response at the time. And if you can’t justify a response to the public, you probably won’t get significant buy-in. Then the public will start to question future directives.”

“By the time Canada made the decision to close its borders, that was less about containing the spread of COVID-19, and more about the political sense that Canadians were demanding this.”

Media has role

Katz points out that in the way people react, it is also important to examine the role of the media. While reporters are informing the public of all that is happening at breakneck spreads, they are also shaping the messages and the narrative of the crisis. And this is all circulated back to politicians.

Earlier this month, the government of Manitoba announced its plan to invest $5 million for research projects associated with the novel coronavirus. Within that plan, $700,000 is set aside to investigate the benefits of hydroxychloroquine — the same drug that’s gained international notoriety because U.S. President Donald Trump endorsed it as a “miracle” treatment of COVID-19, despite a lack of evidence to support that statement at this time.

While this drug could one day prove to be a successful treatment, there are certainly many bigger players investigating this already. So to Katz, this is a good example of how media can influence health policy.

“Is there strong science that suggests that’s the best way of spending that money? There may not be. But that doesn’t mean that it isn’t a politically smart thing for this government to do at this time,” Katz said.

Pressure to conform

Masks and projection numbers have been the two latest health policy areas that have gotten the public and media in a bit of a tizzy.

After days of relentless questions about whether or not Canadians should be wearing masks, the country’s chief public health officer, Dr. Theresa Tam, gave in — sort of.

“A non-medical mask can reduce the chance of your respiratory droplets coming into contact with others or landing on surfaces,” Tam said. “The science is not certain but we need to do everything that we can and it seems a sensible thing to do.”

“One of the ways that public health authorities and politicians need to walk a fine line, is between giving too much information and too little information to the public. ” – Alan Katz, the director of the Manitoba Centre for Health Policy at the University of Manitoba

Culbert says a number of factors might have contributed to Tam being hesitant to offer advice on masks, including cultural acceptance of wearing them, but ultimately after the Centers for Disease Control and Protection in the United States advised people to wear masks, the pressure to conform likely pressed Tam to issue her permissive statement.

That pressure to conform has also been felt when it comes to disclosing possible projection numbers. And Katz for one wishes the emphasis on these numbers was relaxed.

“I’m not a great fan of sharing those numbers, I don’t think it’s useful,” Katz said. “The modelling that provinces are doing is to try and plan. They’re not there to be shared with the public and interpreted in their own way.”

In the end, all of these types of policy decisions might be based in science, but to say that’s all that is at play would simply be naive.

“One of the ways that public health authorities and politicians need to walk a fine line, is between giving too much information and too little information to the public. If you give the public too little information, there’s a sense that you’re hiding something and then the public doesn’t believe you, and then you’ve lost their faith, and then they’re not following your instruction,” Katz said.

Both Katz and Culbert come to this point: through all of these balancing acts, maintaining the health authority’s credibility is critical to public safety.

“It is the constant challenge of public health. If we get it right, nothing happens,” Culbert said. “If we get it wrong at all, the bad thing happens.” This can be particularly cruel in retrospect, Culbert adds, when decisions are evaluated with far more information than was available at the time the decision was made.

“It is this dance that we do. The classic definition of public health refers to it as the art and the science of preventing disease and promoting health. And that art piece is what we’re talking about here.”

sarah.lawrynuik@freepress.mb.ca

Twitter: @SarahLawrynuik