Month: April 2020

Politics and economics explained

Like many others, our family has started meeting by VTC for a catch-up once a week. The agenda requires one or more of us to lead discussion on a topic of interest.  I was recently required to open discussion on changes to the world’s political economy from the second war to 2020 – a jolly little assignment, I’m sure you will agree.

Some of my children communicate best using the language and vocabulary of films and TV shows, having no experience with the simile and metaphor of economics – the dismal science. It therefore seemed helpful to couch my background contribution in language and terms they would relate to more easily. The story is mostly based in the UK.

This is Part 1 of the piece: 1940-1960. Part 2 is Dr Strangelove to coronavirus.

Part 1:  1940-1960

It is 1940. The Second World War has started. The two sides appear to be fairly evenly matched until the third quarter when (7 December 1941) the United States comes off the bench. Japan sinks seven US battleships at Pearl Harbour but not their primary target – the American aircraft carriers. Yamamoto concludes: “I fear all we have done is to awaken a sleeping giant and fill him with a terrible resolve.” [Tora! Tora! Tora! 1970]

A shy steel factory worker in Russia surpasses his production quota and receives the order of Lenin. His town is attacked by the Germans who move forward to reach the gates of Moscow. Hitler is furious when he hears that Moscow has not fallen, and the Russians also successfully defend Stalingrad. The Soviet armies then close in on Berlin. [The Fall of Berlin (Падение Берлина). 1949]

Both sides attempt to destroy the other’s manufacturing and heavy industries including, in the case of the Allies, with a cunning bouncing bomb dropped by Lancaster bombers flying at 60 feet. [The Dam Busters. 1955] Even submarines do not escape destruction, including U-96, a German U-boat hunting British freighters in the north Atlantic. [Das Boot. 1976] There was also significant destruction of infrastructure effected by Alec Guinness in Thailand. [The Bridge on the River Kwai. 1957]

Many people flee from Europe to the U.S. when the war begins, some of them via North Africa. Exit visas are not easy to come by, even for people as important as Czech resistance leaders, except in Rick’s Cafe.  Some of the European intellegentsia who make their way to the U.S. play a part in the Manhattan project to develop a nuclear bomb.  [Casablanca. 1942.] [The Day After Trinity: J. Robert Oppenheimer and the Atomic Bomb. 1980]

US President Roosevelt is determined to prevent a retreat into isolationism once the war is over. In 1941 he and Churchill announce the formation of the United Nations. In 1945 fifty nations sign the charter for a permanent United Nations, an alliance “with power adequate to establish and to maintain a just and lasting peace.” [Scary Movie 4. 2006]

In 1944 the World Bank and the International Monetary Fund are created in the hope of preventing a return of the cut-throat economic nationalism that had prevailed before the war. One of the architects of the post-war financial system agreed at the Bretton Woods Conference was John Maynard Keynes. He died in 1946 so wouldn’t have known that governments everywhere soon adopted his idea from the 1930s, when unemployment reached 20 per cent. He thought increased government spending could make up for a slowdown in business activity and so prevent recession and the loss of jobs.  At the time, balanced budgets were standard practice with governments, based on Mr Micawber’s recipe for happiness. [David Copperfield. 1935]

The pattern of the political economy for forty years is set by the fact that, in winning the war, Russia bore down on Berlin from the East while the Allies approached, fashionably late,  from the west.

Western nations fear that the poverty, unemployment and dislocation which exists across Europe  immediately after the war would strengthen the appeal of communism. The political situation begins to unravel in Greece and Turkey so US President Truman (Roosevelt having died suddenly) announces his eponymous Doctrine, to provide countries with support to prevent them from turning to communism.

In Eastern Europe (Poland, Hungary, Czechoslovakia and places further to the right) Russia is doing the same sort of thing to shore up communism. Berlin is divided and becomes the symbol of the division between East and West and of the Cold War that results. This provides the background for lots of James Bond movies. [Goldfinger 1964. Thunderball 1965.]

The Truman Doctrine is the foundation of the greatest foreign-aid program in world history: the Marshall Plan or European Recovery Program. The U.S. spends $13 billion to rehabilitate the economies of 17 western and southern European countries. Assistance was offered to Eastern-bloc countries as well, but Stalin gave them better offers.

The Marshall Plan helped to restore industrial and agricultural production, establish financial stability, and expand trade. The countries involved experienced a rise in their gross national products of 15 to 25 percent during this period. The plan contributed greatly to the rapid renewal of the western European chemical, engineering, and steel industries.

People in London and Coventry were finding it particularly tough, with rubble in their gardens and leaking roofs. Therefore, to help them out, in 1948 William Beveridge invented the welfare state. This saw the government protecting the economic and social well-being of citizens by taking responsibility for people unable to find for themselves the minimal provisions for a good life.

The welfare state is a good idea and it spread to many countries.

Firms of consultants are established to help smaller firms to combat the rapaciousness and pillaging of large multi-national corporations. The consultants begin by providing direct help and then move to a community development paradigm, passing to the managers of smaller enterprises the skills and self-confidence needed for the ongoing challenge of sustainability. [1960. The Magnificent Seven] 

– to be continued

Explaining the COVID-19 modelling

Modelling the transmission of infectious disease

Mathematical models of disease transmission can be used to estimate the potential impact of public health responses to infectious diseases. Recently (7 April) some details of the particular model that is being used as the basis for the decisions of Australian governments on the COVID-19 crisis have been published.

How do such models work? How can we be sure they are accurate? What do they tell us?

The headline findings from the modelling are the ones that have been delivered to us consistently in governments’ media conferences and other information activities:  

An uncontrolled COVID-19 epidemic would result in a situation dramatically exceeding the capacity of the Australian health system over a prolonged period, notwithstanding the increases in that capacity that are possible. 
A combination of case-targeted isolation measures with general
social measures will substantially reduce transmission and result in a more prolonged epidemic with lower peak incidence, fewer overall infections and fewer deaths.

As we all know, we have to stay home.

How it works

These general prescriptions from the modelling are clear and largely unchallenged. But as time passes it will be good  if there is closer scrutiny of this and other modelling. This will result in better understanding of both the general applicability of such modelling and the specific work being done on the Australian government’s preferred model.

The key variables on which mathematical models of infection are based are the latent period (i.e. the interval following exposure before an individual becomes infectious and transmits the disease), the infectious period (i.e. the period during which an infected person can transmit a pathogen to a susceptible host), and transmissibility. Transmissibility is described by the reproduction number – the number of secondary cases generated by a single infected case introduced into a susceptible population.

If the transmissibility number is less than 1, infection is receding. If it’s greater than 1, infection is spreading.

For models of this kind it is useful to know the extent to which outputs (in effect, the model’s  predictions) change in response to a given amount of variation in its inputs, and the particular input to which altered outputs can be attributed. The inputs include both the assumptions made about the structure of the entity being modelled and the data fed in.

This is the business of uncertainty and sensitivity analysis. In effect they provide information about the robustness of the model – the probability of the model and its predictions being accurate reflections of reality. The greater the model’s uncertainty or sensitivity, the more its outputs change with a given amount of variation of its inputs – and the less useful it will be.

Such analyses can help check the accuracy of a model’s structure or specification by assessing the individual contribution of a variable and the need to include it or not.

They can also help interpret the results of a model by identifying thresholds for certain variables that trigger outcomes of interest.

The value of  any such modelling is limited if the model’s structure is imperfect (that is, if it makes false assumptions about the relationships between elements of the model) or if incomplete or inaccurate data are fed into it. The modelling can be run again and again with greater confidence about its accuracy as, each time, more is known about the characteristics of thepathogen and more local (Australian) data are added in.

Critically, accurate estimation of the transmissibility of a disease requires reliable data on its incidence in the total population. As we have been told time and time again, this requires “testing, testing and testing”.

In addition to the latent period, the infectious period and transmissibility, more specific variables can be included in the model, such as the structure of the population and its mobility patterns, demographic variables, risk factors and age profiles. But with every new variable included the risk of false assumptions or imperfect data is likely to increase.

The preferred Australian model for use with COVID-19

There are a number of mathematical models doing their stuff around the world on the spread of infectious diseases and the impact of various public health responses. The one that has been, and remains, the basis for the decisions of Australian governments on the COVID-19 crisis is managed by the Peter Doherty Institute for Infection and Immunity, a joint collaboration of  the University of Melbourne and the Royal Melbourne Hospital.

The Doherty team released to the public a paper on 7 April 2020 about their modelling work on COVID-19.

The paper is quite open about potential weaknesses of the model that stem from unavoidable uncertainties about the assumptions made and imperfect or incomplete data relating specifically to the progress of the disease in Australia. Since it is a new pathogen there are uncertainties about the true disease ‘pyramid’ for COVID-19, and a lack of information about determinants of severe (as distinct from mild) disease. In the modelling done so far, age has been used as a best proxy for the probability of symptoms becoming severe.

There are other uncertainties. The model being used has been converted from one used for influenza and there are great differences between that pathogen and COVID-19. The assumptions about reducing transmission of influenza through a combination of distancing measures come not from Australian data but from Hong Kong. The relative contributions of different measures, such as the cancellation of mass gatherings, distance working, closure of schools or cessation of non-essential services, are not yet clear.

More will be learned about these particular strategies from real time data now being collected by various Australian agencies. In turn this will enable the more precise estimation of transmissibility for COVID-19 in Australia. This will be used to update forecast trajectories of the epidemic. These will no doubt be among the key pieces of information used by governments to manage the ongoing responses to the pandemic.

Some critical unknowns

Perhaps the most serious and alarming reminder in the published paper is that low and middle-income countries will find it even harder – potentially quite impossible – to deal with the COVID-19 crisis. Their health systems are already weaker, with limited access to high level care.

Given the massive impact on world trade and damage  to the budgets of all countries, including those that are affluent that have been donors of international aid, the impact of the COVID-19 emergency on the people and governments of poorer countries may become quite unmanageable.   

Much will depend on the role played by international aid and trade in the new order.

One of the most critical omissions from Australia’s modelling to date is that it has not as yet accounted for the loss of health care workers due to illness, carer responsibilities or burnout. Nor has it accounted for shortages of critical medical supplies, because the true extent of these shortages and their likely future impacts on service provision are apparently still unknown. 

These are two aspects of the issue to which governments and others must continue to give urgent attention. Apart from anything else it reminds us of the very special place of health care workers and the risks they face. Let’s continue to applaud, thank and support them.

Uncertainty and sensitivity analyses may perhaps already have been used by the team in Melbourne to investigate any number of aspects of the modelling. For example the published paper reports that in the simulation of a case-targeted public health intervention it was assumed that 80% of the identified contacts adhered to quarantine measures. It would be useful to know how many additional ICU beds would be required if the compliance rate was 78% or 82%, for example.

With the publication of the Institute’s paper a start has been made down the track of ensuring that the public becomes more familiar with, and more trusting of, the basis of many of the decisions affecting them. It will help to equip the Australian people for the kinds of generous and determined responses that will be needed for global recovery.

“Hi-Yo Silver!”

It seems odd that there has been no clear and unequivocal advice about whether or not it would help if we all wore face masks. This piece considers the many different aspects of the question which, between them, explain its complexity and why there has not yet been a single clear recommendation. Instead the matter has been left to individuals to decide.

This organic approach to an issue in which every one of us is potentially involved has at least two advantages. It lets the authorities off the hook of accountability for any sort of uniform advice. And it cedes responsibility to the people, which is widely considered a desirable principle. But if and when there is a clear technical (health or clinical) case for a particular protocol relating to masks, it will be an important challenge for the authorities to spread the word and obtain widespread community compliance.     

“Who was that masked man?”

School closures

Two weeks ago the question of whether or not schools should be closed seemed to be the most critical on which there was no clear advice. The experts had discussed the matter. We were told that schools would remain open but it would be good if parents who were able to do so would keep their kids at home.

The solidarity of the National Cabinet seemed to be fractured. Different jurisdictions provided different advice, based not just on medical views but on logistical matters such as when school terms were ending. Very soon it became apparent that the matter was apparently too complex for uniform national action to be agreed and it fell to parents to bear responsibility for the decision.

This cannot be seen necessarily as a criticism or failure of ‘the powers that be’. It may well be that the mixed mode that emerged about schools was in fact optimal given all the relevant circumstances and considerations.

The characteristics of that decision on schools which made it so complex seem now to relate to the question of whether or not to recommend or potentially even to mandate the wearing of masks. Is it to be Tonto or the Lone Ranger?[1]

Aspects of the question

Where the wearing of masks is concerned, the aspects to be considered include the following.

1. Does the wearing of masks reduce rates of transmission? This might appear to be the simplest and most important question but, even without scientific knowledge, one can understand its complexity. It obviously depends on the number, type and location of mask deployed. Does the effectiveness of masks depend on the proportion of the population who wear them? Why does the evidence from other countries seem to be conflicting? One thing that is clear is that masks are effective only when used in combination with other measures, most particularly frequent hand-washing with soap and water. The efficacy of masks is impacted by their supply; in short supply, the risks multiply of having them used in an unhygienic fashion.  

2. Does the wearing of masks have desirable or undesirable effect on the extent to which the population, or particular groups within the population, are compliant with critical measures like self-isolating and social-distancing? Some have argued that people wearing masks, or seeing others wear them, instils over-confidence and a lack of the required discipline on other fronts. The widespread use of masks could conceivably increase the public’s pessimism and propensity for ‘catastrophisation’. This could have adverse effects for mental well-being.

3. There is clearly a hierarchy of need relating to the wearing of masks and other personal protective equipment. Clinicians and others ‘on the frontline’ must be given first dibs, both for their own safety and for the effectiveness of the health and related systems. Any increase in the encouragement of others in the population to wear masks would therefore have to be moderated by accurate knowledge about the supply of masks.

4. “A mask is not a mask.” All sorts of products exist, including surgical masks and cloth or fabric face coverings. Surgical masks and respirators are essential for practitioners dealing with COVID-19 patients and those suspected of having it. Even if a uniform decision was possible on other fronts, there would be questions about what types of mask is useful in particular circumstances. We have seen and heard much about ingenuity of individual people and retooled companies making masks, but the  efficacy of various models and their uses has to be considered.

5. Consideration needs to be given to the cultural aspects of wearing masks. In Australia we look to countries to our north to see community/political entities (Singapore and the like) which are more accustomed both to wearing masks and to being told what to do on such matters. To the rugged individualists we are supposed to be, being told to wear masks may be a bridge too far, jeopardising a national consensus.

6. Some will argue that the question of mandating the wearing of masks is a legitimate battleground on the ‘personal freedom v. government control’ front.

7. There may be implications relating to the effect of a uniform approach on particular subgroups of the population. If wearing masks has cost indications not covered by governments, mandating their wearing would contribute to further inequality between rich and poor, employed and unemployed. The same might be said for urban-rural differences and equity. If there are national shortages of masks and other personal protective equipment they are certain to be greater and to have more impact in rural and remote areas than in the major cities.

8. Wearing a mask needs to be done properly. Any mandatory use of masks would need to be accompanied by detailed practical advice about what to do before putting it on, when to change it, how take it off and how to discard it. The WHO and many other organisations provide essential information about such matters which should be consulted by potential users. There is a recent article on the issue at https://insidestory.org.au/so-you-want-to-wear-a-mask-in-public/

It might be that, in their wisdom, governments and their advisers have tacitly agreed that it would be best if the decision about wearing masks remained organic – something to be owned and narrated by the community itself, evolving at the pace determined by people themselves. This would have some of the characteristics of the responses to the COVID-19 situation advocated by those who trust in citizen engagement and community development. I belong to that group but also crave information and advice from technicians about matters that can be subject to technical certainty.

And the Lone Ranger? Every week after he and his trusty friend Tonto had saved the world in 30 minutes, they would ride off into the distance, silhouetted against the skyline. Someone turns to the sheriff to ask who that masked man was. The sheriff responds that it was the Lone Ranger, who is then heard yelling “Hi-Yo Silver, away!” as he and Tonto ride away. We could do with him back again.

Information and disclaimer: this article has been written in the belief that policies relating to the wearing of masks are complex and illustrative of the great difficulties posed for decision makers by the current COVID-19 situation. It is not my intention to make or promote judgements about the clinical, social or economic aspects of the matter and it is certainly not my intention to provide advice to individuals. There is a mass of information online about the wearing of masks in the current situation and people making a personal decision should consider that information.

Some circumstances make the wearing of a mask essential. They include the situation in which a patient is suspected of having infection or when someone is coughing or sneezing such that a physical barrier between them and another is of obvious value. But based on the majority views in Australia at present it seems that in other circumstances most people will not benefit from wearing a surgical mask.

General practitioners should be able to access surgical masks through their local Primary Health Network.

For the latest advice, information and resources, go to www.health.gov.au

The National Coronavirus Health Information Line on 1800 020 080 operates 24 hours a day, seven days a week. If you require translating or interpreting services, call 131 450. 

[1] Those of you old enough to get this joke are hopefully self-isolating at home and getting your grandchildren to drop groceries at the door.

COVID-19: Models and emotions

What is the right thing to do? And how is it best to encourage us all to do it?

An emotive appeal may well have greater impact than a weight of statistics and numbers. I was inspired by something Amy Remeikis, journalist with the Guardian Australia, said on ABC TV’s The Drum last week:

“I just hope that when people are walking around and they’re seeing what they’re calling apocalyptic scenes and everyone’s seeing how negative it is; I look at an empty space and I see that as an act of love or of giving, because it’s people trying to save the lives of people they may never meet and that includes my father. – – I know there are people all over the country who are terrified for their relatives and that’s why l really do hope so many people are taking this as seriously as it needs to be taken.”

The Prime Minister and others have consistently attributed decisions they have made about the virus to the health advice from the Federal and State/Territory Chief Medical Officers. “Don’t blame or credit us governments; we are simply following independent, world’s best scientific advice.”

In turn, the Chief Medical Officers have referred to (or deferred to?) the modelling of COVID-19 transmission and infection done both here and in other countries.

We have been promised an open-book approach to the modelling being relied upon, but have yet to get it. This is perhaps because complete openness would lead to more distraction from the central task. Those who are already frantic providing health advice to the National Cabinet can do without debate about their preferred judgements, including because they differ from those of some other experts.

These ‘others’ include a team from Australia’s leading research universities, asked for advice by Professor Brendan Murphy, Commonwealth CMO. Their view was not unanimous but the majority of them called two weeks ago for “a rapid, sweeping and costly lockdown to pave the way for a national recovery once the crisis abates”.

Even with open access to the health modelling still more would be needed in order to understand – and evaluate – the decisions made in response to the pandemic. Presumably the economic impacts of various potential decisions have also been modelled, with the inputs being potential decisions about restrictions on businesses and movement, and the outputs such things as business turnover, the number of jobs lost and investor confidence.

The third part of the equation, and the most outrageously difficult, has been to make judgements about the relative value of different outcomes from the health and economy models. Put simply, it has in effect been a question of how much economic cost is justified to save a life.

When we have a chance to scrutinise the health and economic modelling that has been relied upon there will still be disagreement about whether or not the decisions made have been optimal. One thing we can be sure will be agreed is that all such modelling consistently displays great sensitivity – meaning that small changes in the assumptions and inputs at the front end have resulted in huge variations in outputs. Sensitivity must be even greater where the phenomenon being modelled is subject to exponential growth.

The Prime Minister has spoken often of the importance of preserving “life as we know it” – a euphemism for protecting the economy. For some people it has been impossible to shake the belief that his and his government’s embarrassment about their premature ‘back in black’ celebrations made them attribute, for some time, more weight to the economic crisis than to the virus.    

In the earliest discussions with my eldest son – rational and risk-averse – I had taken the (disgraceful?) line that if there is a new virus in the world we might as well get used to it and develop immunity as well as we can. On the last weekend before the 500 threshold was declared I was in Bathurst with about a thousand others at the NSW over-65s hockey championships. Just in the nick of time.

Soon after that I was a convert to what I think of as The Norman Swan Line: the government should go hard and early, to maximise the probability of halting the spread. As Dr Swan has been saying for several weeks, the only potential down-side of this approach is that if spread is prevented and nothing happens, the nay-sayers would be able to say that the government had over-reached. That would be a great outcome!

I have been doing my bit for the Swan line. A sort of epiphany was at the Parkinson’s singing group on the Monday of the week after the hockey tournament. As soon as I sat down with the small group of us in the church hall I realised what we were doing. Given our small number and our recent history of travel, the probability of our meeting increasing the rate of transmission of the virus was close to zero. But my decision to attend had contributed to a meeting – and gatherings of 10 or 500 are occasioned by the individual decisions of 10 or 500 individuals. The desired outcome cannot be achieved without my compliance.

We each need to commit to that act of love or giving in order to save the lives of people we will never meet.

Thus disposed, the staged or gradualist approach adopted by the National Cabinet “as a result of the medical advice”, never seemed to me to make sense. If we know that a total lockdown will work, and that we will probably need that eventually, why wait?

Which brings us back to the modelling of health and economic impacts. In the case of school closures, the modelling would require assumptions about different transmission rates with various proportions of school children at school, based on even more basic assumptions about the behaviour of school children, parents and the virus itself. The decision to keep schools open while encouraging parents to keep their kids at home seemed to indicate a lack of confidence in the modelling and the Federal Government’s unwillingness to be held accountable for a decision on the matter. The hard decision rested with the States and Territories.

The Federation seems to have come to the view that the States and Territories are responsible for action consequent on the belief that overcoming the health crisis is a pre-requisite to beating the economic crisis, while the national government acts through its taxing and spending powers to engage in preparations for economic bounce-back.

The generosity of the national government on economic matters has been astonishing, although it is people not governments who will inherit the debt. And it is fervently to be hoped that the cart and the horse are lined up in the right order.