Allocation of Responsibility

 I have seen this attributed to Augustine[1], but verified it only in Liguori: "Nothing is more certain than death, but nothing is more uncertain than the hour of death".

I've seen many, many recriminations recently over the timings of various governments' decisions to take steps regarding the Covid-19 outbreak. I've seen fewer recriminations over poorly-executed "pandemic preparedness", such as the Ontario government investing in protective equipment after the SARS scare but failing to invest in maintenance.

 

I've seen almost nothing about what is, from a rational point of view, the most culpable failure of all: the systemic failure to govern for a world where pandemics - and other medical disasters - exist.

 

Although it was poor policy, politics interfering with what expert advice said to do, the failure of governments to gear up at the earliest possible time is understandable. Unlike classic "medicine", which runs on evidence, double-blind tests, and the like, epidemiology and public health is about probabilities and risk assessment. And although standard risk rules say that you should spend a hundred million dollars to forestall a crisis which will cost you ten billion dollars if the probability of the crisis is over 1%, it's difficult to persuade a politician to do something expensive - like the imposition of moderate restrictions on economic activity - to avoid later extensive damage to health and economic outcomes if the probabilities are low.

 

But the probability of an eventual pandemic is unity. Not even approaching unity, unity. There are no questions of probability: the only question is when, not if. And it is far more serious that the health care system has been not only allowed to bump along at a level which can be swamped by an slightly heavy flu season, but has actually been gradually bled of resources.  Beds in hospitals were consistently not ramped up to match population growth and changing age profiles. Staffing levels have been reduced to minimize costs.

 

And this didn't just mean that hospitals were poorly equipped to handle a pandemic; they were barely equipped to handle anything more than an average load. There were continual reports of emergency rooms with patients stashed in hallways, ambulances which had to be rerouted because the closest emergency room was at capacity, and overstressed staff in other wards because staffing levels had been cut in the name of efficiency.

 

(For all of Doug Ford's promises to end "hallway healthcare", the changes they were putting in place were designed to reduce the costs of the system, not to add large numbers of beds and staff in a sustainable way. And the Liberals before them were little better.)

 

There are interim benefits to running a system which is generally pandemic-ready, even if we discount the costs of a rushed ramp-up when a pandemic dies arrive: general care is better.

 

The same applies, doubled, redoubled, and in spades to seniors' residences, with the additional factor that because many if not most are private the allocation of resources is made worse by the extraction of profits.  (Much of the growth rate locally, at least, has been in seniors' residences which, if better designed with an eventual pandemic in mind, would have a much lower transmission rate.)

 

This is not a public policy decision made juggling probabilities and timing. This is a straightforward decision regarding inevitable threats on a large scale to the population. And even economically, the costs of inaction outweigh the benefits: an epidemiologically robust health-care system would require far less in the way of suppression of economic activity to reduce growth rates to a level the system will handle, and would be in a position to protect front-line staff, without mad panic buying of supplies of protective equipment and ventilators.

 

It is this failure to respond to an inevitable need simply because the response is expensive and possibly mildly disruptive in transition (higher taxes, different allocation of resources) which displays the real failure of governments here, and unlike the failures around communications and timing which are heavily affected by personalities this failure is long-term and systemic. It is here that a real reassessment of how our society operates has to begin.

 

[1] By Donald Howard, in his biography of Chaucer, but with no citation given. Liguori quotes it in the context of a different Augustinian saying: "All other goods and evils are uncertain; death only is certain." Either way, it has a history.