What is the optimal number of broken jaws?

I was chatting with a friend recently about the COVID-19 response in different countries. Reflecting on her own country, she said, “It is so hard to know what is right!”; that is, it is so hard to know what the right response to COVID-19 should be.

The variation, for instance, in countries’ lockdown responses is substantial, but which country is doing the right thing? In some countries, there has been no lockdown. The government asked the people to be sensible. In other countries, the government legally confined people to their homes — only one person was allowed out at very specific (restricted) times to buy essentials. Given these two policy extremes (be sensible and house arrest), which one is the right one, and how do you know?

An economist, I have forgotten who once asked tongue-in-cheek, what is the optimal number of dead babies? The very purpose of such a crass question is to make you stop and think. What tradeoffs are you prepared to make to save the lives of babies? Sure, you could be lazy, condemn the questioner as immoral (for even asking you to think), and declare zero dead babies to be the right number. As a simple policy proposition, if zero dead babies is the right number, then all the resources of society should be aimed at preventing neonatal deaths. ALL RESOURCES! Until the policy goal has been achieved, there is more work to be done to reduce the number. One dead baby is too many!!! Farmers may farm, but only to produce the food that supports the workforce that is striving to reduce baby deaths to zero. Teachers may teach, but only to educate the people to fill the jobs to support the policy goal to reduce baby deaths to zero. There is very limited use for art, music, cinema, sport, fashion, restaurants, etc. They will all have to go! If five-year-old deaths increase, that is something to live with, just as long as we can save another baby.

At this point, you’re probably thinking, well that’s stupid. That’s not what I meant when I said the optimal number of dead babies is zero. What I meant was something more along the lines of, “In an ideal world there would be zero dead babies”. Equally, if you were asked about poverty or crime, or amazing works of art, you presumably would have stated the ideals in terms of zero poverty, zero crime, and lots more wonderful art. And this is quite a different proposition. An ideal world is not ideal in virtue of its achievement of a single goal. It is ideal in having achieved all sorts of different outcomes. And that is why the real and the ideal do not intersect. In the real world, we do not achieve the ideal anything. We seek to achieve many ideals, and realistically, we hope to make progress against them, knowing that there is always more to be done. In striving to improve the societal position against a basket of goals, we allocate limited resources and make trade-offs.

This is one part of the COVID-19 problem, and, as my friend observed, why it is so hard to know what is right. What is the right number of COVID-19 deaths? There are lots of important, rational debates to be had around this topic because it is about the tradeoffs we are prepared to make against a basket of societal goals against the myopic achievement of one. Muscular public health responses — effective house arrest — are very good at reducing the number of new COVID-19 cases. They are also very effective at increasing domestic violence, increasing depression, lowering child immunisation rates, degrading child education, increasing poverty and increasing unemployment. If the societal goal should be zero COVID-19 deaths, what is the optimal number of broken jaws, suicide attempts, measles encephalitis cases, illiterate and enumerate children, beggars, and soup kitchens?

All these issues, under normal circumstances, are things of concern to Public Health and maybe, one day, they will be again.

Another part of the COVID-19 problem is that, whether a government “did the right thing” will be determined in hindsight, and by making (inadequate) historical comparisons between the outcomes across countries’. In democracies, at least in the short-term, “did the government do the right thing?” will often be decided at the ballot box. This will surely get the answer wrong. In less-than-democracies, astute rulers will write the history books themselves ensuring that, without regard to the outcome, the government did the right thing.

One of the main reasons that “it is so hard to know what is right!” is that we rarely have a societal view about the long term goals we wish to achieve and the tradeoffs we are prepared to make. Furthermore, we are reluctant to accept the fact that one can do the right thing and still fail. We assume that the right course of action will, by definition, result in success. We are prospective Kantians and retrospective Utilitarians.

Relativity in a pandemic

A busy McDonalds is like a well-greased machine. A coordinated team of short-order cooks; staff behind the counter ready to take your order. Queues of people waiting impatiently to pick up their triple burger, hold the onions, no cheese and a flurry of fries. A Manager hovers. Joel, someone’s vomited in the toilets. Sarah, supersize the “meal”. Dinesh, where’s the lady’s McMac?

Time is money. The faster people move through, the greater turnover. The greater the turnover, the greater the profit. It is not just time that is money, space is money too. The more space you have, the more seats you can fit; the more customers you can welcome; the more deep-fryers you can install; the more fries you can produce. Space is money on both sides of the ledger. You have to pay for space, so the space you have needs to be efficiently packed with people.

This is the space-time continuum of business profits. To increase profits, increase trades per unit time and increase customers per unit space.

And then came lockdown! Sand was poured into the cogs of the well-greased machine.

Fortunately, governments have promised a return to “the new normal”. It will be like coming back to a restaurant you have never visited before. When you do return, the McDonalds has changed. Behind the counter, there are fewer people. There are half the numbers of Dineshs to take your order, and fewer short order cooks called Sarah. (The unemployment queues are a little longer. Joel is there.)

No more walking through the front door – there is a limit on the number of people allowed in – but I’m sure it will be worth the wait. Once in, the restaurant feels familiar but somehow more spacious. The bustle and the impatience at the counter are gone. People are standing a prescribed two meters apart. Everything moves a little slower. When you pick up your order and turn to find a table, there is a “wow!” moment. Tables are no longer packed together. There are fewer people seated, and the seating is further apart. You were surprised, however, when you paid – those prices had really gone up. It was no longer a cheap, thoughtless bite-to-eat.

The whole thing takes much longer than you expected, which means you will be late back to the office. Maybe you will think twice, or three times, before coming back, and as you leave, you notice the “To Let” sign in the window.

The neighbourhood has also changed. The cheap but cheerful family restaurant is gone. It survived on volume trade. A well-spaced, sit-down service on melamine plates is too incongruous and too expensive to survive. The “all you can eat” buffets of carbs and fat have also disappeared – too many opportunities for “a Covey” to lick all the serving spoons or sneeze on the mac and cheese.

Fortunately, the internet will save us. Thank you, Google!

Without ever having to see or talk to another human being, you can do it all. You can sit, safe and alone in your bed-sit enjoying a lukewarm meal delivered in takeaway containers. There is an obligatory under-growth of warm, wilted lettuce nestling the spring-rolls; the fries have a flaccidity reminiscent of a moment you’d rather forget; the oils have begun to congeal. The whole experience is perfumed with cardboard and polystyrene. Delicious!

Who speaks for whom in Global Health?

Speakers’ corner [Source: Wikimedia]

I had an interesting experience the other day when a friend, Mark Cheong, and I submitted a letter to one of the leading health journals.

Mark, a Malaysian academic, had done his PhD on palliative care with a particular focus on the delivery of palliative care in low- and middle-income countries (LMICs). For about six months, he and I had been discussing the ethical challenge of delivering palliative care in LMICs. It is a pillar of Universal Health Coverage. Still, there is a possibility that in weak health systems, governments could avoid their obligations to deliver curative care by choosing, instead, to deliver palliative care.

With the development of the COVID-19 pandemic, our conversation had taken a slightly different path. The modelling suggested that many LMICs would have their hospitals and clinics overwhelmed with COVID patients. The basic management tools of oxygen and ventilators, which were being rationed in High-Income Countries, would be a rare resource in poorer ones, leaving many people to die without any care at all. Our thinking returned to the palliative care question. The ethical dilemma, however, had shifted. The issue now was, how do LMICs deliver palliative care at a massive scale?

This was the subject of the letter, “Manage suffering when you cannot manage treatment”. The letter didn’t say anything earth-shattering, but it was necessary, and it had been crafted into a pithy 600 words. We had not seen anyone else raise the issue in the COVID-19 literature, which was (and still is) overwhelmingly focused on the provision of clinical care. We submitted the letter and crossed out fingers.

In terms of an academic career, a letter in a high profile journal does not amount to much. But it is a nice affirmation of one’s relevance in a global conversation. As a mentor, I have certainly encouraged colleagues to use letters as a vehicle for sharing and developing ideas. It also strikes me as important that it is academics and health professionals in LMICs who are the ones highlighting the issues that are important in LMICs. Now, you might take issue with whether I have a legitimate place in that conversation or not, but there is no doubt that Mark does.

I was surprised when, 9 days after the letter was submitted, an editorial appeared in the journal developing similar ideas. It was written by the Editor-in-Chief, a well-known advocate for many worthy causes, who lives in a high-income country. He regularly uses the pages of the journal to discuss challenging global health issues about health equity and human rights. He had more words available to develop the ideas and, in truth, he writes much better than we do. Six days after the editorial was published (15 days after submission), we received the rejection letter.

Thank you for submitting your Letter. Having discussed your Letter with the Editor-in-Chief, and weighing it up against other submissions we have under consideration, I am sorry to say that we are unable to accept it for publication. Please be assured that your Letter has been carefully read and discussed by the Editors.

I did not feel assured at all. It would have been impossible for the journal to publish the letter once the editorial was published. It was redundant. Instead, it made me wonder about whose voice gets heard? Whose voice has enough legitimacy even to have the possibility of being heard? And the reality is that power matters.

Nothing nefarious happened. Ideas are cheap, and the Editor-in-Chief had a similar idea to our’s — and he has a privileged platform from which to deliver it. The message is important, and ultimately it was delivered. Does it matter who delivered it? I think it does. Having the right to say something does not mean it is right that you say it. Comedians are very aware of this. A powerful joke from one person’s mouth falls flat when delivered from another’s. Who tells “a Jewish joke” and who uses the “N” word can shift comedy from hilarious to tone-deaf to the offensive.

To have a platform from which to advocate for justice is a great thing. It is often more important to use that platform to enable, empower and legitimise other voices (and add your voice to theirs) than to be the voice.

Es ist ernst! [It is serious]

Chancellor Angela Merkel, 2019 (source: wikimedia)

There are truly great, rousing political speeches. President John F Kennedy’s Inaugural Address on 29 January 1961 comes to mind: “ask not what your country can do for you — ask what you can do for your country.” Prime Minister Winston Churchill’s, “We shall fight them on the beaches” speech, during World War II.

The defining political speech of the COVID-age will surely be that of the German Chancellor, Angela Merkel: “Es is ernst!” It’s in German. There are subtitles. Watch it!!

The power of the speech lies in no single phrase and no single idea. The power lies in the gestalt. It lies in the thoughtful, measured, and compassionate speech to a nation from someone who holds the idea of democracy dearly, and needs to ask 83.1 Million people for patience, sacrifice, and forbearance; for a great community good — because no one is expendable.

In her speech, brilliantly, she thanks the forgotten cash register staff and shelf packers for their tireless efforts, as well as the easily remembered healthcare and public health workforce for theirs. She suggests that people might even consider writing a letter to a friend or loved one because, of course, the German postal service continues to work. She constantly plays between the culture of the German people (what it is to be a German), their expectations of Government, and the task of managing SARS-CoV-2.

Like many countries, Germany has instituted measures that are anathema to democracy, but necessary to slow the spread of the virus. As she explains, all we are doing now is buying time. Stretching it out. The longer we stretch it out, the more time researchers and healthcare workers have to find measures of prevention, management, and cure. The longer we stretch it out, the more person-ventilator-time (PVT) and person-ICU-time (PICUT) there will be to allocate. If you are acutely ill, PVT and PICUT are the most precious commodities available at the moment (excepting toilet paper), and the best way to make more of this commodity is to stretch out the length of the pandemic.

Do not watch or listen to the blather and buffoonery of the likes of Trump and Johnson. Whether they do not understand or do not care is irrelevant. Their “ideas”, their politics and their speeches will be lost in the waste-paper basket of history, to be picked over by pimply, undergraduate students in response to the essay topic: “Political leadership is important in times of crisis. Discuss”

Merkel’s speech is the most hopeful, rational and caring political message I have heard since the outbreak of the SARS-CoV-2 pandemic. Sitting at my desk in Dhaka, I found it enormously comforting to know that there was leadership like Angela Merkel’s out there. There has been considerable discussion about the lack of global political leadership. It is there. Turn your eyes and face the light.

This is serious.