Reflections on the Skegg report

By Dr Martin Lally

Director, Capital Financial Consultants Ltd

The government has recently released a report from the Covid-19 Public Health Advisory Group chaired by Prof David Skegg (the “Group”), relating to future Covid-19 policy, and intended to answer various questions.

The first of these questions was: “Is an elimination strategy still viable as international travel resumes and/or are we going to need to accept a higher level of risk and more incidence of COVID in the community”?  Viability is a very low bar for any strategy to cross.  More important is whether continued use of the elimination strategy is optimal.  The Group recognised this deficiency in the question and proceeded to answer both questions.

In para 16, the Group concluded that continued recourse to elimination as international travel resumes is “the best option at this stage”.  In para 10, they defined elimination as “zero tolerance towards new cases”.  In para 15 they recognised that occasional large outbreaks may still occur, and proposed eliminating them by physical distancing, mask wearing, testing, contact tracing, and “localised elevations of alert levels”.  The latter words are a euphemism for lockdowns.  In para 5, they acknowledged that “no-one knows what the outcome of this pandemic will be in say 3-5 years’ time”, and that more dangerous covid variants may emerge.  Lockdowns may then be even more frequent and severe than they have been to date.

In describing elimination as the “best option at this stage”, the Group implies that there are at least two alternatives to it.  However, the only specific alternative mentioned by them involves ongoing “pronounced physical distancing, wearing masks in most indoor places, and separating high risk individuals from family and friends during winter months” (para 19).  This is an extreme alternative to an elimination strategy.  Governments do not in general adopt either of these extreme approaches to other contagious diseases, such as the flu, but instead adopt other approaches that impose no requirements upon the entire population.  Such an approach might be appropriate for covid, but the Group does not even contemplate that possibility, let alone analyse it.  Acting as if there is only one (extreme) alternative to one’s preferred policy when this is not the case is not analysis but marketing.

In support of its conclusion that continued recourse to elimination is optimal, the Group presented three arguments (in paras 17-21):

  1. Doing so ensures that “our health system is not overwhelmed by large numbers of patients requiring care.”
  2. Doing so will obviate the need for “pronounced physical distancing, wearing masks in most indoor places, and separating high risk individuals from family and friends during winter months”.
  3. Doing so preserves the option to later switch to the alternative strategy.

No disadvantages of the elimination strategy were mentioned.  This cannot be because the Group believes there are none because it acknowledges their existence in its para 21, where it refers to the possibility that “the costs of elimination outweighed the benefits”.  The Group does not identify these costs, but they include the GDP losses from lockdowns, the behavioural problems emanating from the attendant unemployment, and disruption to the education of students, and the Group accepts that future lockdowns are possible under an elimination strategy.  As with acting as if there is only one (extreme) alternative to elimination, listing its advantages but not its disadvantages is marketing rather than analysis.

The normal practice in assessing health interventions in this country and elsewhere is to estimate the Quality Adjusted Life Years (QALYs) saved by an intervention net of its costs, and to favour it only if this difference is positive.  The Group carries out no such analysis.  It cannot be unaware of this standard practice, because every member is an expert in health policy (most at Otago University), and the University runs a program (BODE3) to identify the health interventions that satisfy this QALY test:

Furthermore, in respect of point 1, there is a clear implication that our health system is not currently overwhelmed.  The contrary is true, and manifested in long queues for many operations, with some patients dying from the ailment in question (or another one) before they reach the head of the queue.  Moreover, even if our health system sans covid were able to accommodate all demands on it, the emotive verb “overwhelmed” would cover every excess demand scenario down to only a handful of covid patient not being catered for.  An analysis should estimate the extent to which the system would be “overwhelmed”, and the deaths that would result from that.  An emotive verb is not a substitute for analysis.

Point 1 also implies that the capacity of our health system is an immutable feature of nature.  However, its capacity can be increased, and should have been in response to the pandemic because the benefits of capacity increases (in the form of lives saved and/or lockdowns avoided or mitigated) dwarf the costs up to some point.  Lack of time is not a viable excuse.  The Chinese built a hospital in a week, and even the UK managed in the course of a few weeks to convert several existing buildings into hospitals with the capacity for thousands of patients (“Nightingale” hospitals).  Our response over the 18 months since the pandemic arrived has been virtually imperceptible.

Finally, in respect of point 3, the Group states in its para 21 that “if it became clear over the next few years that the costs of elimination outweighed the benefits, it would be a simple matter to follow the example of other countries.”  However, the Group’s report consisted only of listing the advantages of elimination, ignoring the disadvantages, and then declaring elimination to be the winner. The Group then favours something being done in the future by somebody else (in the form of recognising the costs of elimination and comparing them to its benefits) that it entirely fails to perform itself.