Question of Scale

7 min read March 13, 2020 at 5:17pm

It's been a crazy busy couple of weeks, for obvious reasons.  I'm going to briefly come out of my coronavirus cave to try and simply address the incredible unhinging that has happened in response to the COAG announcement yesterday afternoon that gatherings would be banned from Monday.

For future context, here's this week's timeline.

Thursday 12th March: PM Scott Morrison told the nation we were well prepared and everything was fine.

Friday 13th March, morning:  There were widespread leaks and grand-standing from the AMA, suggesting there was about to be or should be a ban on mass gatherings.

Friday 13th, ~1400: Media conference following the COAG meeting, at which the PM announced that gatherings of >500 people will be banned from Monday 16th March, on advice from the Chief Health Officer, and the Australian Health Protection Principle Committee

Friday 13th, ~ 1401: Twitter goes nuts about how completely nuts the advice is and WHY HAVEN'T THEY BANNED GATHERINGS RIGHT NOW??!?!?!?!??1?

As much as I dislike the PM - and that's plenty - and despite the fact I think his messaging hasn't been very good so far, I think this is a justifiable and sensible decision.

(Less sensible was his insistence on going to watch the Sharkies until the media told him what a terrible idea that would be in light of the potato blight (hat tip to the indefatigable Allen Cheng for that one.) 

So wait, why do I think this is reasonable?

I'm an infectious diseases physician. Our job is the prevention, diagnosis and treatment of individuals with infections. Our "unit of care" is primarily an individual patient. We'd like you to get vaccinated for things you can, and to wash your hands because it reduces your personal risk of getting an infection.

There is another group of professionals called public health physicians. (I'm almost one of them too, but I need to stop putting off finishing my training.) They are interested in many things, including  the prevention of the spread of infections in the population. Their "unit of care" is the entire population. They'd like to cancel mass gatherings because it stops lots of people getting exposed all at once and helps slow the spread of the disease through the community.

We do work together - although perhaps not as well as might be ideal - but our different perspectives lead to different goals and different methods of achieving these goals. It looks different for the patient I see in fever clinic vs the population overview taken by the public health team.

At a clinical level, the question is : Is condition A bad enough to warrant the side-effects of the treatment?  I'm fond of using the example of antibiotics for a cold. It's either due to a virus, or a mild bacterial infection which will resolve without treatment. Since there are no benefits to antibiotic treatment, there are only risks, so clearly it's a bad idea.

Alternatively, you could ask yourself if the risk that coronavirus poses to your own health worth this disruption of working from home for a few weeks? If you are young and fit, this is a difficult question. For people who are at higher risk, like people living with chronic lung disease or immunosuppression, the answer is much more likely to be "yes".

At the population level, the question my public health colleagues are asking: will this disease control measure work well enough to justify the down-sides?

The benefits of cancelling gatherings might at first glance seem obvious, but stay with me here.

The tangible risks of cancelling social gatherings like the football are that it will dramatically reduce spending.

Think of your Uber/taxi/bus/train to the stadium, buying a pie and a VB. Maybe deciding to have a few drinks or dinner before or after the game.  Multiply that by however many people go to NRL games these days, and you can pretty easily see that cancelling just one footy game will have significant economic impacts. Cancelling the rest of the season for all the codes and all the other theatres, gigs, conferences is going to be a huge economic hit. It also means that the casual employees who staff venues, hospitality, entertainment will have no job and no income. This is far from a trivial risk. 

There is no shortage of tweets declaring we should LISTEN TO THE MEDICAL EXPERTS or JUST APPLY THE SCIENCE. But the economic and social costs mean that this is a political decision.

It's worth stepping back for a moment to remember that politicians also have to assess these balances. They don't deal only with health, but with defence, the economy, education, and all the other things the government does here or overseas. Australia has been teetering on the brink of a recession for many months now, the government has just announced a stimulus package to try and prevent it from developing.


These are the risks. Now, we also have to assess - how clear are the potential benefits?

As far as we know, there is not (yet) widespread community transmission of coronavirus in Australia. So the benefits of cancelling the game right now, today, this afternoon as opposed to Monday is... what, exactly?

We are expecting that there will be community transmission, and soon. But as of yesterday afternoon, there was not. Almost all of the identified cases have had known exposures - mostly overseas, or a known positive contact.  An immediate cancellation would have the economic harms, possibly create (more) panic and still probably not have much impact on slowing the spread, because it's not spreading that much right now.

What we want right now from government is a careful assessment of the risks and benefits of their decisions. Not taking action in a panic because parts of the community are yelling that it's "NOT DOING ENOUGH RIGHT NOW".

Panic makes for bad policy and ugly politics.

In terms of what you can personally do to reduce your own risks, it's still pretty simple - washing your hands, trying not to stick your fingers near your face. Practicing social distancing - by not going to the footy, for example - won't necessarily do much to reduce your risk right now, but it's probably a good skill to start developing before it becomes really strictly necessary.

In terms of what the population response needs to be, it isn't necessarily about stopping people from getting sick altogether. It's about stopping lots of people from getting sick all at the same time, which will create  a surge in demand for health services and result in the whole system falling over.

This is what is meant when you see people talking about "flattening the curve" - rather than a huge spike in services all at the same time, we want a lower peak, which will probably mean it's spread out over a longer time. That's right - successful control will mean the outbreak will go for longer, but will be less intense.


#FlattenTheCurve - by Toby Morris and Siousie Wilks

There is now growing discussion that it may not be enough to merely flatten the curve, but that it may be necessary to #StopTheSpread - and this will require both individual action (wash your damn hands and #StayTheFuckHome ) and public health responses - including gathering cancellations and school closures.

#StopTheSpread - by Toby Morris and Siousie Wilks

While I'm sure it's even more frustrating for you than it is for me that the guidelines keep changing every five minutes, and we are at the all-time low ebb of trust in politicians, I don't think it's going to help terribly much if our first instinct is to rip our politicians apart for following advice that doesn't make sense to you.

Maybe - just maybe - we should be open to the fact that there might just be a reason that isn't yet immediately obvious?



Image credit:  "Flatten the Curve" via SMH Online - believed fair use.

[Revised 15th March following review by Daniel Reeders who is a comms professional and who has also written an excellent blog post on the need to communicate effectively but without panic. I'd be enormously pleased if the people tweeting all stop right now and go and read it, thanks]