Political medicine on a grand scale: the roadmap as the least worst option

Rudolf Virchow, a 19th century physician and public health pioneer, once wrote that “medicine is a social science, and politics is nothing more than medicine on a grand scale”.

He was among the first to appreciate the profound influence of political decisions and public policy on health.

Virchow’s words resonate strongly as we see elected officials grapple with COVID-19. After all, medicine is a balancing act aiming to ameliorate illness without unduly harming the patient in the process.

The latest instalment is Victoria’s roadmap to reopening, which seeks to balance the need to reduce the second wave of the virus with the growing frustration and pressure to remove restrictions. 

Reactions have ranged from criticism to praise and everything in between.

I think that the roadmap is a bad plan — except for the alternatives. The curfew aside, it’s the “least bad” strategy to get the state back on track. But the chance of success relies on improving testing and contact tracing and on additional financial support.

Elimination is best for health and the economy

COVID-19 is a nasty, highly contagious illness. Rather than being a binary decision, going for zero is the optimal way to: 

1. Minimise mortality, illness, and costs driven by greater demand for intensive care as well as costs incurred by non-COVID patients being denied or avoiding treatment;
2. Enable a faster economic rebound on the other side.

Eliminating local transmission is eminently possible, as demonstrated in other states and territories. And let’s not forget that Victoria may have avoided this situation had the government not continued to ease restrictions during smaller surges throughout April, May and June (and had they better managed the quarantine process).

Having near-zero cases is especially important in Victoria, where the public health system is ill-equipped to manage a baseline infection rate and where targeted restrictions were unsuccessful. But maintaining near-zero levels will need more testing (including wastewater sampling) and better contact tracing.

On the economic side, forget spurious claims that low mortality correlates with higher growth (and the even more spurious implication of a causal relationship).

But the fact is that people are demonstrably cautious when a deadly virus is circulating in their community. Declines in economic activity occurs irrespective of official restrictions, and I’m yet to see convincing evidence suggesting that a mandated lockdown creates worse health and social problems than a self-imposed one.

This recession is due to a slump in demand driven by an exogenous reason: the virus. The economic slowdown caused by “letting it rip” (and going for herd immunity) is likely to go on for much longer than the slowdown caused by eliminating the virus altogether. 

Reasons for economic optimism are emerging. Also, the recent national accounts show household savings increased three-fold as a proportion of income (from 6% to 19.8%) in the June quarter and are now up by a whopping A$42 billion to A$59.5 billion.

This reservoir was created by decreased consumer spending, an increase in income and recent benefits like JobKeeper. A decent proportion of this is likely to reside in Victoria.

That’s quite an amount of cash sitting on the sidelines for when things reopen. While not all of it will be spent on discretionary goods and services, of course, the more confident people are that the virus is under control and that ongoing risks are managed, the more likely they are to spend that money.

Based on the current timeline, the floodgates could open just in time for Christmas, while, for some, they already have.

But businesses and low-income households will need ongoing financial assistance to survive the coming months. Victoria’s new business support package is a positive signal, but state and federal co-operation will be critical, making the political shouting match between Canberra and Melbourne very unhelpful and, frankly, quite dangerous.

Hope without hype

Politically, the roadmap is important because it gives Victorians a light at the end of a tunnel — a tunnel that must be getting very dark indeed.

A key role of political leaders is to provide hope in difficult times. I think the roadmap does this but does it sensibly (curfew aside), managing expectations and not over-promising.

The use of dates has been criticised, and some feel that they are too conservative. I disagree. 

First, a date is more tangible than a rolling average to the normal punter. The underlying message is clear: if things go to plan, we could be back to normal by Christmas. 

Second, making the dates conditional on infection numbers is smart. It provides wiggle room if things take longer than expected. As to the proposed lengths of each stage, surely it’s sensible to under-promise? 

The roadmap has also been criticised for being too complex. But this as a complex problem to which there are no simple solutions. Yes, perhaps the information could be displayed in simpler terms, with better-designed visuals, for example. But dumbing it down is not only patronising, it may well create a perception that the road is easier than it is. Over-simplifying it would also remove the rationale for amending the plan if the circumstances change.

The grim alternative

Opening up prematurely would see COVID-19 cases rise, resulting not only in many more deaths and the associated costs of contagion, but also in a prolonged economic slump through ongoing restrictions and consumer caution. That’s a grim alternative.

Elimination is the least-bad option and the right way to go. The Victorian roadmap is tough but it does the job of signalling that there is a plan, that it is realistic, that the restrictions are not indefinite, and that yes, there is a light at the end of the tunnel.

As a social medicine, it’s the one with the highest chance of success and the least ongoing side effects.