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Introduction
Introduction
The summer of 2020 saw countries around the world loosen precautionary COVID-19 restrictions. Now, with cases on the rise again, hospitals are overwhelmed, and widespread shutdowns need to be re-enacted. How do public policymakers go about making these decisions and communicating them to their constituents? We have seen closure and reopening policies based primarily on political affiliation. This polarization makes enacting closures difficult to justify to the public, further deepening already intense political divide. To subvert political narratives, are there deeper guiding principles that can be used to inform such decisions? How might we conceptualize these principles and apply them to public policy decisions?
We discuss three main frameworks in making such decisions — a harm reduction framework, an economic framework, and an ethical framework. Each offers a unique perspective on the shutdown and reopening decision-making process. We will explore each of these frameworks and examples of their applications in public health decisions. Finally, we argue that complex decisions about closings and re-openings must be made using multiple frameworks in mind in an attempt to depoliticize public health policies. It is imperative that decisions be objective, fair, and justifiable to the general public.
Harm Reduction
Harm Reduction
The initial framework we will discuss is that of harm reduction. Harm reduction was generated through collaboration of activists, physicians and public health officials in the 1990s, which aimed to better provide better support to people struggling with drug addiction (Roe, 2005). The goal of harm reduction is not to prevent people from participating in certain behaviors, but to encourage them to do it in a way that minimizes risks (Lesli, 2008).
Harm reduction as a response to COVID-19 begins as an attempt to shift normal behavior in order to limit viral spread. Mandating that masks be worn and redesigning outdoor spaces to reduce crowding are both examples of harm reduction strategies. They allow people to live their lives as normally as possible, while mitigating the risk of COVID-19 transmission (Weinstock, 2020). There is not an absolute public health message that dictates survival as predicated on any one behavior, but rather focuses on the reduction of overall risk (Holmes, 2020). Harm reduction promotes best practices and safety measures. In the end, it gives autonomy to individuals to make an informed choice, and trust that they will choose the safer option (Marcus, 2020).
When it comes to informing policy on closures and reopenings, harm reduction would not necessitate complete lockdowns. It would instead offer strategies of risk reduction that are specific to location and context. For a restaurant, this may mean a closure of indoor dining spaces, yet permitting restaurants to provide outdoor dine-in and take-out services, exemplified by New York governor Andrew Cuomo recently reinstated ban on indoor dining services amid rising cases (Gold, 2020). In the harm reduction framework, rather than banning certain behaviors and businesses entirely, we simply modify them to reduce risk as much as we can.
Fig 1. A table ranking activities with level of COVID spread. This is an example of an intervention in the ethic of harm reduction, via Vox
Economics
Economics
The second framework we will discuss is the economic framework which prioritizes a cost-benefit analysis in its approach to implementing closures. In this framework, we look to the economy as a marker of how well the general population is doing.
The COVID-19 pandemic has put national economies at a standstill. Over the course of 2020 we have seen a 5.2 percent contraction in global GDP, suggesting one of the deepest global recessionary periods we have experienced in decades (World Bank, 2020). Human capital, or the economic value of workers, has been greatly impacted by the pandemic, making the need more urgent to get people back to work (Bremen and Mhatre, 2020).
The economic framework uses a cost-benefit analysis to inform closures and reopenings during the COVID-19 pandemic. It weighs cost, or lives lost to COVID-19, against livelihoods, or economic well-being. In this framework, policymakers must consider several important questions: Which businesses are the most reasonable and economically valuable to keep open? How many lives is it reasonable to sacrifice to keep the economy afloat, businesses open, and citizens employed? (Puyvallée, 2020)
The economic framework has been used often by right wing legislators, who tend to prioritize the economy and allow businesses to remain open. Although the state of South Dakota ranks second in the US for coronavirus cases per capita, governor Kristi Noem has resisted shutdowns, defending her decision with the argument that the state expects “8.7% more money” in this fiscal year (Noem, 2020). While this example is perhaps extreme interpretation, generally speaking the economic framework provides a method of weighing lives negatively affected by the economic effects of closures against lives lost if those measures aren’t taken.
Fig 2. South Dakota governor, Kristi Noem, defends COVID strategy amid rising cases, via NBC
Ethics
Ethics
The third and final framework in closure/reopening decisions is based on ethical considerations. We ask ourselves the question: how much should society sacrifice in order to save lives? Some argue there is a balance to be struck — whether the sacrifices made are harming more than they’re helping (Fisher, 2020). For instance, how many individuals should sacrifice their sources of income to save a life, given the negative association between unemployment and life expectancy? If an individual is at an increased risk of suicide, might their psychologist opt to assess them in person to intervene? (Schwartz-Mette et. al., 2020) These are difficult questions to answer, given that we will likely never know how many lives are saved or lost due to our actions. By and large, the ethical framework argues that we as a society, especially those who are able, have an obligation to sacrifice to whatever degree is necessary to protect those of us who are particularly vulnerable to COVID-19 (Crawford, 2020).
This fall, many colleges made a difficult, but ethically sound decision — to make classes majority or entirely virtual. This choice was made with the well-being of not just college students in mind, but the surrounding community, which would be significantly more at risk by an influx of students traveling from other parts of the world (Crawford, 2020). At Cornell University, this decision was made with staff and faculty in mind, as well. BIPOC comprise a majority percentage of campus staff and essential workers, and we know that BIPOC communities have been the hardest hit by the pandemic. The median age of faculty is 55, and we know that older age groups have an increased risk of severe illness and death from COVID-19 (CDC, 2020). Despite the potential financial and logistical consequences, the university, like many others, elected to protect those who are most vulnerable. Following the same ethical framework, we have an obligation to continue to make difficult sacrifices to protect the most vulnerable, whose lives depend on our choices.
Fig 3. Cornell Health staff urge students and community members to stay at home to prevent COVID-19 spread in their communities, via Cornell Chronicle
Conclusion
Conclusion
Fig 4. Protesters of a proposed citywide mask ordinance in Tulsa, via Ian Maule (Tulsa World).
Each of the aforementioned frameworks provides a valuable perspective to re-opening and closure decisions. It is possible to use just one framework to inform COVID-19 policy decisions. However, we argue that the best and most just policies regarding re-openings and closings will be made when multiple frameworks are applied to the decision at hand. Perhaps we first assess whether we can prevent closures by reducing risk through increased safety measures. If the reduction of risk and spread is not sufficient, we then consider a cost-benefit analysis to decide what locations should close, as well as the ethical implications of our options. This may end in shutdowns of some businesses or locations to ensure that the most vulnerable individuals are protected. We also argue that a method of decision making that incorporates all three frameworks will be more objective and easier to justify to the general public.
We have seen around the world and firsthand in the US that COVID closure decisions are profoundly impacted by politics. In the US, left leaning leadership prioritizes closures on the basis of ethics, while right leaning states act with hesitancy, prioritizing economic benefit over the cost of lives (Gollwitzer, Martel, Brady et al., 2020). Amid political controversy, it is difficult for policymakers to make closure decisions that aren’t inherently tied to their political affiliation. The consideration of multiple frameworks and inclusion of multiple perspectives may provide the objective analysis that is lacking in US COVID-19 policy decisions today.
An objective analysis supported by multiple frameworks may also make closure and reopening decisions easier to justify to the general public. The same political divide we see in local and state government response is reflected in public attitudes toward COVID-19 safety measures. A multiple-framework justification will allow public officials to communicate and rationalize COVID-19 safety measures in a manner that is independent of political party. Ideally, this depoliticized response would lessen the political divide and promote a productive discourse in response to the global COVID-19 pandemic.
References
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Centers for Disease Control and Prevention. (2020, December 7). Older Adults and COVID-19. CDC.
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Schwartz-Mette, R., Brown, K., Childress-Beatty, L., & Skillings, J. (2020, June 5) COVID-19: What the Ethics Code says about reopening your practice now. American Psychological Association.
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