More Public health paradoxes


Establishing a means for assessing and engaging genuine public opinion can also help, for some options can be put up for decision in a public forum.

Feedback on a recent post (https://gammiris.lk/public-health-paradoxes/), on Covid 19 cremation versus burial, encouraged me to raise a further question – as to whether our other preventive responses too should be examined more critically. Enforced treatment in designated hospitals can serve as an example.

If I were found ‘PCR positive’ the law allows the authorities to force me into accepting treatment at places not of my choice. I have heard that I can be imprisoned for breaking the law, should I refuse. This sort of enforcement response will, I guess, find support among most of the global public. My preference to risk dying at home rather than being subject to treatment in a prison-like setting can easily be overruled, on the basis that it is for the public good.

The simple logic is clear: forcibly incarcerate infected people and they will transmit less. But we can see how the implementation of this seemingly obvious response can lead to unexpected or paradoxical outcomes. Some individuals may choose to resist hospitalization. I too will refuse, at least initially. But, given that making the authorities move me forcibly will lead to unfair risk to the people who will then be tasked to bundle me up and carry me away, I will eventually comply – for their sake.

I am sure that secluding me at home will pose less risk than moving me to a treatment centre, even with my full cooperation.  Should I die at home the remains can be disposed of as safely as from hospital. By the way, I believe that the risk of my dying at home of asymptomatic Covid 19 infection, with no medical care at all, is still miniscule – even though I am in my 70s.

Some citizens may forcefully resist hospitalization, as we saw on television. Others may hide signs of infection. The proportion of such individuals will affect the eventual outcome of whether enforced treatment helps or hinders the spread of Covid. In the absence of settled science as to what is better, how should we decide?

We can start by seeking simple ways to improve our proposed and current approaches.

One possibility is to conduct virtual experiments. Potential positive and negative outcomes of a planned step can be assessed on a ‘best reasonable guess’ basis. An example is soon allowing tourists in, within protective bubbles. We should right away conduct the experiment in imagination. This is not a very clever solution and is full of pitfalls. But it is better than putting things to the test in real life, without the preceding virtual experiment. We can in this way work out systematically the potential positive and negative results of any current or proposed measure.

If people of different opinions can be engaged to project different outcomes, we can generate informed and wide-ranging dialogue among them – free of rancor or debating-point-scoring. Three of four informed individuals deliberating for one hour may alone provide invaluable insights. Our proposed approach will as a result be strengthened, or may even be rejected on the basis of the virtual experiment alone. That forestalls a much greater setback than what would have happened had negative outcomes led to things collapsing in the face of real -life difficulties that were not even considered initially.  

Another approach is to pursue any given action for a predetermined period only, after which results have to be reviewed compulsorily. If we can set out beforehand the criteria that will lead us to abandon a particular action or modify it in agreed ways, correctives will automatically kick in. Criteria for stopping the intervention before the agreed time can also be decided beforehand. Such a review process can be applied to ongoing measures too.

A rapid assessment of any anticipated fears or problems that will likely result from a given measure should also be helpful. A good way to elicit these is to seek public responses. Unforeseen difficulties, which lead to ad-hoc changes can be reduced in this way. There can of course be misconceived or mischievous objections to very productive interventions. But such tactics will become evident in open discussion, if conducted free of mass media and social media amplification of differences of opinion.

Establishing a means for assessing and engaging genuine public opinion can also help, for some options can be put up for decision in a public forum. This applies for example to actions whose expected effectiveness is not established on the basis of scientific evidence. Ways to assess public opinion, free of distortion by interested intermediaries, can readily be worked out.

We can collectively come up with lots of ideas such as the foregoing and pick some among them to put to the test. Suggestions listed above are not spelt out in enough detail to meet even the immediate objections that they are easier said than done. Details of how each proposed action can flexibly be implemented and guided have not been provided.

Creating forums, within decision making circles, for rapid and dispassionate critical analysis and for truly representative public engagement will be a step in the right direction.  

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