Health policy making in times of virus (1) - Trends and context

In early April, Márk Molnár and I gave a quick & dirty estimate of the incremental cost-effectiveness ratio (ICER) of ‘flattening the curve’ of Covid-19 (~260K euro/QALY), and in late April I wrote an emotionally more loaded piece on the opportunity costs of subordinating health care resources to Covid-19, taking measles as the comparator. Things have been evolving rapidly, and we have been asked by policymakers and colleagues from the pharma industry what we have learnt so far from Covid-19, and what health care systems will look like after Covid-19. This article summarizes what we have learnt in the past 2-3 months, and the next piece (coming soon) will sketch five scenarios for the future of health care.

Interestingly, most of the things we have been musing over lately have pretty much nothing to do with health economics. There is a simple explanation to that: health economics have become invisible, at least for the general public, since the start of the Covid-19 pandemic and the related firefighting. Where have you seen any health economist in any prominent public role, influencing the course of things, in the past few months? We haven’t seen any, at least in the countries that we know well. But there are some underlying trends and observations that are worth exploring first.

We are going to raise five points here: 1) a slow return to consistency in policymaking, 2) the renaissance of bi- and multilateralism in foreign relations, 3) the politicization of Covid-19, 4) the question of fear and fearmongering and, finally, 5) the invisibility of health economics.

1. Return to consistency in policymaking

Governments in developed countries have been starting to act more consistently within the (narrow) manoeuvring room they left for themselves after Covid-19 had knocked in. As if there were fewer contradictions between policies on Monday and policies on Tuesday. We still meet a lot of dumb, disproportionate or unrealistic regulations or proposed rules (like talk to only one parent at a time [UK], walk on the beach but don’t swim [some places in Australia], social distancing for typhoon evacuees [India], two-week quarantine with a negative Covid-19 test [many countries], closing parks while urging people to exercise [many countries]), but messages are more consistent regarding what to do, what not to do, what to be careful with. Several countries are opening up, or searching for viable ‘exit strategies’. Governments are more receptive now than a month ago to the collateral societal and economic damage of lockdowns. Paradoxically, the lifting or easing of lockdowns may be premature according to public health considerations, i.e. the original, unidimensional strategy of ‘flattening the curve’. It rather appears to be an acknowledgement that lockdowns are simply not sustainable. (Some countries even seem to use some liberally interpreted scientific data to rationalize their actions. Funnily, politicians in countries with quite different traditions and trajectories such as the UK, the US and Russia have shown a liking for creative data interpretation.)

No matter what drives the lifting of lockdowns, it is good news from a policy perspective as it reflects a cautious drift away from the unidimensional policies of the past months. A return to rationality, at least partially.

2. The renaissance of bi- and multilateralism

But the return to rationality is taking place at national levels or in ‘bubbles’ only. International relations are dominated by bi- or multilateral actions of sovereign states, which we had thought to be a thing of the ‘70s and ‘80s. The ‘ideal’ of globalization is being challenged fundamentally. Countries are lifting travel restrictions and re-launching tourism based on bi- or multilateral agreements (‘travel bubbles’), repatriation efforts and medical assistance missions are enabled by bilateral diplomacy. These agreements are nominally based on success in virus containment and data reliability. In actual fact, they depend on geopolitics, historical ties and even personal relations between chief diplomats. We may face a situation where you can travel from Slovakia to Italy via Austria but not through Hungary and Slovenia. Or you may be quarantined if you return through one country, but you are free to return through another. Or take the case of Czechia (Czech Rep.) where the government has opened up borders (excuse them saying as little as three weeks ago that Czech citizens should be banned from going abroad for one more year at least), but there is nowhere to go as surrounding countries are closed. (To be fair, they will open up in a few days.)

Formal ‘supranational’ structures are not exactly thriving. Our feeling is that the World Health Organisation (WHO) will come out of this crisis much weaker than before, regardless of the US decision about withdrawing funding or not (emphatic note: no US-China politics here). Its scientific opinion leader status has suffered a blow, and its future role may be more limited to poorer countries. WHO may have fallen victim to international politics, but they have been doing quite a job to end up so. The European Union is in stupor: apart from the closure of external borders, some guidelines and pleas to member states to maintain internal movements, some apologies to Italy, we haven’t seen too much. Despite the latest French-German plans, we consider European disintegration more probable than reinvigoration (emphatic note: absolutely no Hungarian or Italian or any EU-periphery politics here).

Based on what we are seeing now, we simply cannot imagine any future scenario in and outside health care where globalization and wider international interdependence would become stronger. We only see scenarios with increased isolationism, regionalism and self-dependence.

3. Politicization of Covid-19

No-one fully understands yet why Covid-19 is hitting some regions harder than others, whether it poses a higher risk to some ethnicities or it’s just about ethnicity correlating with wealth in Europe and the US, and why some countries have better results than others. Most questions surrounding elderly homes, and possible focused strategies in the case of a second wave are debated but unanswered. The lack of facts and understanding has led to the (unfortunate) politicization of the Covid-19 phenomenon. If someone believes that the economy should open up, they are a rightist (or Trumpist, if they live in the US). If someone asks people to keep social-distancing voluntarily when restrictions are opened up, they will probably be pigeonholed as a ‘moralising leftist’. If someone argues that Sweden’s eventual shortcomings with elderly homes should be discussed within the paradigm Sweden has chosen, there will be someone to call them inhumane ‘utilitarians’. On a loosely related note, Anthony Fauci and Anders Tegnell deserve all respect, but it is perhaps not healthy of any society to build cults around them (and print T-shirts with their portraits). To continue, if someone says there may be a correlation between success in overcoming Covid-19 and underlying societal and political institutions, they risk being labelled a ‘racist’ or ‘supremacist’. And if we say (what we actually believe) that Central Europe (Poland, Czechia, Slovakia, Austria, Hungary, Slovenia, Croatia, Baltic countries) has in many regards been more successful (quicker, more pragmatic, more considerate and luckier…) to contain the virus than many countries in Western or Southern Europe, then there will be some bitter soul to say they are on a path to abandon Europe.

This politicization makes it sometimes (very) challenging to conduct meaningful and value-neutral dialogue about Covid-19.

4. Fear and fearmongering

For us, by far the most interesting lesson learnt from the ‘Covid-19 months’ is how deeply existential fear permeates society, and how this fear and media interact in a vicious cycle. We would never have imagined people, old and young, urban and rural, educated or not, single or with families, to be so much paralyzed by the ‘invisible enemy’. We have neighbours whom Facebook wisdom has convinced about the existence of hidden, secret Covid-19 hospitals where people are taken to die, but their families are ordered not to talk about it. We have neighbours who know that cucumbers are lethal unless treated with chlorine, peeled in disinfected plastic gloves after they have spent at least 72 hours on the balcony. (Perfect child food, isn’t it?) Only one third of all kids come to our recently re-opened kindergarten because parents are afraid that they will get infected (in Hungary, where there has essentially not been any epidemic, with mass screening by medical universities showing an infection rate between 0.1 and 1.1 per cent). In the small Sicilian town where one of us has friends and relatives, streets are half-empty after months of quarantine because people are afraid to go out. Paradoxically, they wanted to go out while they couldn’t; now they can but are not so keen.

There may be a deeper reason here. Most of the population in the developed world has been extremely lucky not to have experienced any war, destruction or existential crisis for long decades. There have been financial crises and structural adjustments, the Soviet bloc collapsed (in some countries without pain, in others with pain), industries and professions have gone down, there has been some insane, sick terror, and that’s it. Tragedies have mostly been personal rather than societal, the really painful conflicts have been exported to proxy regions. Most of us living in Europe, the US, Australia etc. have been facing typically postmodern problems, sometimes artificially fed by the clash of postmodern and conservative activism, but no real existential threat. (With due respect, the cycle vs car debate, the over-tourism debate, body positivism, free-range chicken, fair trade coffee, the chances of democracy in Afghanistan, various quotas based on positive discrimination, the French burka debate, questions of non-binary identity, Tea Party-type movements etc. are all interesting stuff but pretty insignificant when we are all bound to die…). Now, the first time that a seemingly real existential threat has emerged, we don’t have any frames of reference, nor experience, nor ability to make founded judgments, we don’t understand what’s going on, and we have reverted to primordial fear.

Social networks and mass media, which excel at discussing postmodern problems, seem to be overwhelmed by the same fear. They have developed an addiction to the virus, a perpetuated state of psychological emergency, as if it were impossible to live without Covid-19. Maintaining the tension and ‘crunching the virus’ all the time gives an outlet to fear. Self-restraint and consideration are missing from news channels. When people could be told some reassuring news (or they would be better off with simply nothing), they are told instead that quarantine fatigue may compromise alertness, cases may be on the rise again, Covid-19 possibly causes Kawasaki-syndrome in children and may lead to stroke in young adults. This may be driven by the click economy, by the erroneous interpretation of the social responsibility of media, or by a simple psychological addiction. We don’t know but it is dangerous, as this obsession exerts pressure on governments to design their policies to attend to primordial existential fear. Fearmongering prompts vote-maximising politicians in democratic societies to succumb to irrationality when Covid-19 cases start to rise again (they will) or when people start coughing next winter (they will).

We are probably experiencing the most striking example ever of the power of social networks, self-appointed bloggers and influencers, and the news economy. Instead of being autonomous actors, governments are being governed by those whom they are supposed to govern. Covid-19 shows that modern democratic states have lost quite a chunk of their power in the era of continuous newsfeeds and social networks, and the existential fear they help maintain.

A lot of things have recently been mentioned as success factors in coping with Covid-19: social patterns, demographics, general health status, health care competences and capacities, willingness to test, etc. We speculate that resilience to existential fear will also be a mid- and long-term success factor at national level, especially when the total health, economic and societal impact of Covid-19 is analysed. Strong states will be partly defined through their resilience to existential fear (and their capability to reassure their populations in a credible way), and it will be an interesting test of democracy whether strong states will be able to develop this resilience without autocratic tendencies.

5. The invisibility of health economists

In a world characterised by existential fear and irrationality, in a crisis with health care origins, and in a situation where perhaps the most important trade-offs of our societal existence have to be made, it would be logical that health economists help resolve trade-offs, stand up to share their perspective, discuss with policymakers, give interviews, try to provide reassuring reason to the public, etc. Well, not in the case of Covid-19. Our strange overall impression is that Covid-19 is going by without health economists, at least in Europe. They have not stood up, nor have they been asked. We are not talking here about health economists speaking to other health economists, but rather about having visible, external impact. Unlike epidemiologists and public health scientists, who have essentially brought back their discipline from insignificance and increased its recognition dramatically, health economists and our profession have stayed invisible. We truly wonder why: is it the ethical component (human life) where an economist has a good chance of becoming unpopular/controversial? Is it simply a lack of thoughts to share? Is it a dull language which does not come through? (Personal remark: epidemiology is hardly more exciting, at least for the general public.) Is it the lack of access to decision-makers? Is it the focus on efficiency and cost-cutting throughout the past decades, which prevents out-of-the-box thinking needed in a catastrophic situation?

We don’t know but we do have a guess: Covid-19 is the first time in recent history when governments have said: ‘let’s save these lives regardless of cost, age, gender, health status and life expectancy’. Once such a decision is taken, there is not much demand for health economists, frankly. Who needs a fairly annoying, punctilious character lecturing about trade-offs, cost-effectiveness and value-for-money when it’s all about human lives (add: war and sacrifice)? Covid-19 gives us the impression as though health economics were confined to budget cuts and second-grade prioritisation problems such as choices between drugs A and B, or assessing the effectiveness of straightforward interventions on relatively smaller populations, where governments don’t want to spend unlimited money on a patient.

We see this as a problem. As we wrote above, when perhaps the most important trade-offs of our societal existence have to be made and inter-generational fund transfers will be taking place, we would like to see the economic viewpoint influence policymaking. Health economics should not be limited to guiding simple choices (provided there is sufficient time) or legitimating cost-cutting interventions. It should have a role in establishing the frames and guiding key health policy decisions. Instead of being a passive branch of science which can reliably and reasonably rattle along within the playground defined by politics, it should be a more active field which wants to influence the evolution of health care (the size and shape of the playground).

We believe that health care structures and funding should look different after Covid-19 than before, at least for a number of services and therapy areas. Whether they will look positively different is another question. One thing is quite sure, though: once the rain is over and health economists come out of their shelters, if they start to play again the old chords of efficiency and cost-cutting (where they had stopped), it will be a historical mistake. At a time when health care has a chance, albeit weak and fickle, of being regarded as a strategic asset instead of a money pit, messages from health economists should be focused on its strategic reinforcement and the necessary resources, and not on technical efficiency and cost-effectiveness.

Dávid Dankó and Márk Péter Molnár

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Questions for boring evenings:

• How do you think Winston Churchill would have coped with social networks during the Battle of London? (Our assumption: he would have shut them down.)
• How would European governments have reacted to the trickling news about the Chernobyl nuclear disaster if there had been social media in 1986? (Our assumption: complete lockdown, with half of Europe bunkering in nuclear shelters.)
• Would you like to travel on a cost-effective airplane or on a safe airplane?
• Would you support armed forces that have cost-effective weapons, or armed forces that operate at the available technological maximum?