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.
If you want to move a successful intervention from here (where it was first identified) to there (a plurality of new settings), spend your time understanding the context of the intervention. Understand the context of success. Implementation Science—the science of moving successful interventions from here to there—assumes a real (in the world effect) that can be generalised to new settings. In our latest (open access) article, recently published in Social Science and Medicine, we re-imagine that presumption.