Practicing Corona – Towards a research agenda of health policies

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Pleasecitethisarticleinpressas:BalR,etal.PracticingCorona–Towardsaresearchagendaofhealthpolicies.HealthPolicy(2020), https://doi.org/10.1016/j.healthpol.2020.05.010

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ContentslistsavailableatScienceDirect

Health

Policy

jo u rn al h om ep a g e :w w w . e l s e v i e r . c o m / l o c a t e / h e a l t h p o l

Practicing

Corona

–

Towards

a

research

agenda

of

health

policies

Roland

Bal

∗

,

Bert

de

Graaff,

Hester

van

de

Bovenkamp,

Iris

Wallenburg

ErasmusSchoolofHealthPolicyandManagement,ErasmusUniversityRotterdam,theNetherlands

a

r

t

i

c

l

e

i

n

f

o

Articlehistory: Received8April2020

Receivedinrevisedform6May2020 Accepted7May2020 Keywords: Coronavirus Covid-19 Researchofpolicy Pandemicpolicy Researchagenda

a

b

s

t

r

a

c

t

AsCoronavirusisputtingahugestressonhealthcaresystemsaroundtheworld,analystsofhealth

policywillhavetorespondwithstartingupresearchontheconsequencesofcurrentpolicies.Inthis

paper,weproposeanagendaforresearchofhealthpolicyfromagovernanceperspective,focussingon

theconsequencesofdecision-makingstructuresandpractices,themediatisationofthepandemic,the

organisationofhealthcaresystemsandtheroleofexpertise.

BY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction

Coronavirusisputtinganenormousstressontheworld,andon healthcaresystemsinparticular.Massiveeffortsarebeingtakenas tothepreventionoffurtheroutbreaks,thetreatmentofpatients, andthetrainingandprotectionofhealthprofessionals.Healthcare providersaroundtheworldareeitheroverwhelmedbypatients, makingplansfornewwavesofthevirus,oranticipatingwavesof delayedcare.Callsfortheproductionanddistributionofpersonal protectiveequipment(PPE),drugsandintensivecaretechnology areloud.Atthesametime,manycountriesareinlockdown,with economies slowlycomingtoa haltand only vitalservices(e.g. healthcare,police)operationalandothers(e.g.education)moving intothevirtualworld.

Researchcanandshouldhelpindealingwiththiscrisis.Whilst much researcheffortsare currentlyand understandably under-takenforpolicy(e.g.predictingthespreadofinfection,courseof diseaseand planningcapacity)thestudyof preventiveandcare policieswithregard toepidemiccrises (e.g.how policiescome about,how they are implemented and towhat effects and for whom)isequallyimportant.Coronaisheretostayforawhile—as avirusandasanissueonthepoliticalagenda—andresearchersof healthpolicyshouldstartdoingresearchonhowourpolicymakers andinstitutionsdealwiththiscrisisandtowhatconsequences.

Inthisshortpaperwethereforesuggestanagendaforpolicy research.We dothis largelyfromourbackgroundinhealthcare

∗ Correspondingauthor.

E-mailaddress:r.bal@eshpm.eur.nl(R.Bal).

governance,realizingthat otherfieldsand disciplineswillhave otherthemes and valuablecontributions tomake. Health plan-ningstudiesonhowtocalculatenecessarycapacities[1];economic studieson thecost-benefitsof specificstrategies towards early warning[2]and remediationstrategies, socialpsychology stud-iesonrisk perspectivesand communications[3]—thosewill all benecessary,butlie outsidethescopeofthisagenda. Herewe focusmainlyondecision-makingstructuresandpractices,the orga-nizationofhealthcareandwelfaresystemsandtheirunderlying values,mediatizationandtheimportanceoflanguage,andtherole ofexpertise.

2. Decision-makingstructuresandpractices

One of thequestions that willno doubtﬁgure prominently in theevaluation ofthe Coronacrisis is if‘we’ were prepared. Thiswillhave atleasttwo components;capacity and decision-making.Whilstthiswilltakedifferentformsindifferentcountries, all of them now have to deal with scarcity; e.g. with regards to PPEs, beds, professionals, and medication. The crisis makes clearhowdependentthefunctioningof ourhealth systemshas becomeonglobaltradeandthatforexampleproduction capac-ityinEuropeisverylimited.Protectivemasksandrawmaterials fordrugshavetobeshippedinfromChina,lung-machinesfrom the US. Given the global and political character of the crisis, production and distribution lines have come understress. Dis-cussions willnodoubtriseonbecoming less dependent,but it wouldalsobeinterestingtoanalyzethedifferentwaysinwhich countries—policymakers,healthcareproviders,professionals—deal withscarcityandwhatthismeansfortheresilienceofour health-https://doi.org/10.1016/j.healthpol.2020.05.010

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caresystems.Onaglobalscalethiswillleadtodiscussionsabout protectivemeasuresversusinternationalsolidarity,andthe func-tioningofinternationalorganizations.Butalsowithincountries, distribution and rationing will become important themes. The extenttowhich‘scalingup’(ofproduction,training)canoccur,and howinnovation(e.g.insterilizationofprotectivemasks)is stim-ulatedwillbecomeimportantquestions,aswillquestionsabout rationing.WhoistogetPPEs,whoistested,which patientsare allowedintothehospitalandtheICU?Countrieswilldifferinthe answerstothesequestionsand itwillbenecessarytocompare differencesastheywill havelargeconsequences for healthcare systems.

Thewaysinwhichdecision-makingaboutpreventionandcare arestructuredalsoseemstobeofcrucialimportancetothe devel-opmentofthecrisis.Withinthepublichealthliterature,thereare somevoicessayingautocraticregimesfair‘better’astheycanmore easilytakedirectivemeasuresandscaleup[4].Howsuchsystems workoutis notpredetermined though.TheChinesereaction is acaseinpoint:theauthoritarianregimewasabletotakeﬁerce measures,but onlyafterweeksof denialand scapegoatingthat mighthavecontributedtotheglobalspreadofthevirus. Decentral-izedsystems,likemostWesternEuropeancountries,mighthavea hardertimetodesignandimplementprotectivemeasures. How-ever,theymayalsogivemoreroomforactorsatthesharpend toactonemergingissuesandexperimentallylearnwhatworks. Also,previousexperienceswithinfectiousoutbreaksmightbeof importance—e.g.theexperienceofAsiancountrieswithSARSor ofAfricancountrieswithEbola.Atleastthestrategiesofintensive testingcombinedwithimmediatecontainmentversuscontrolled scalinguptowards‘lockdown’mightbeexplainedbythose expe-riences.

Institutionalizedresponsescanalsobeseeninthewaysinwhich publichealth services are organized acrosscountries and how theyrelatetohealthcareservices.Manyhealthcaresystemshave decentralized—‘market-based’—structuresthatareatleastpartly sidelinedincrisisdecision-making.Thisraisesthequestionhow ‘normal’and‘crisis’governanceandmanagementrelateandunder whatconditionscentralizationordecentralizationoccurs,a ques-tionthatisespecially pertinentnow Coronaviruswilllikelybe amongusforsomeyearstocome.Thesequestionsincludeissues ofﬁnancinghealthcareandpreparingfor(newwavesof)the epi-demic.

Moreover,structuresonly tellussomuch;it is theways in whichtheyarepracticedthatmakesthedifference.Data collec-tionshouldthereforenotonlyfocusontheformalorganizationof decision-makingstructures,butalsoonhowtheseareused(ornot), bypassed,reinvented,etc.Towhatextentdosuchstructuresand practiceshelpinmakingcountriesmoreresilientand‘managethe unexpected’[5]?

3. Healthcaresystemsandvalues

OnethingthattheCoronacrisismakesclearisthedifferent wayswehaveorganizedourhealthcaresystems.Takefor exam-pletherelativeamountofICUbeds:whereastheEuropeanmean is11ICUbedsper100,000inhabitants,differencesarehuge,with theNetherlandsat6,4andGermanyatalmost30(source:https:// www.covid-19.no/critical-care-bed-numbers-in-europe,visited4 May2020).Somecountrieshaveinvestedmoreinprimarycare thanothers.Thesedifferencesreﬂectunderlyingchoicesandvalues intheorganizationofcare.TheDutch,forexample,havealonger traditionofpreventingunnecessaryandburdeningclinical treat-ment,andalikewise longertraditionofpalliativecarethanthe Germans,butasaconsequencefacedaneedtoatleastdoubleICU capacityina matterofweeks.Likewise,differencesexistinthe

organization(andquality)ofthelong-termcaresectorthat mat-tergreatlyfortheprotectionofvulnerablepopulationsintimesof pandemicthreat.

Theorganizationofhealthcare andtheprinciplesand values thatguidethewaysinwhichhistoricalchoiceshavebecome insti-tutionalizedinﬂuencetheresilienceofhealthcaresystemsintimes ofapandemicthreat.Thisisnotonlythecaseforhospitalcare,but alsoforelderlycarefacilities,homecareandcareforvulnerable groupssuchasthehomelessandmentalhealthpatients.Howare trade-offsmadebetweenfreedomandsafety,betweenhealthand well-being,atdifferentlevelsofthehealthcaresystem,andhow dotheseworkoutinpractice?Suchquestionsincludethe distribu-tionofPPEsthatinmostcountrieshavefavoredhospitalsoversay elderlycare.Nodoubt,theseissueswillallbeonpoliticalagendas fortheyearstocomeandresearchingtheconsequencesofthe orga-nizationofhealthcarefordealingwithsuchvalueswillbecrucial forthequalityoffuturedebates.

4. Mediatizationandtheimportanceoflanguage

Corona-diseaseisthefirstpandemicintimesofsocialmedia. Whilstmediatizationhasbeenimportantinearliercrises,the enor-mousflowofinformation bynewsmedia,ontwitterandother platformsisunprecedented.Nodoubtwehaveallnoticedthe hor-ridimagesfromItalywithpilled-upcoffinsanddoctorsandnurses speakingaboutthepainfulchoicestheyhadtomakeindailycare. Suchpowerfulimageshaveahugeimpactonpeople—andon poli-tics.IntheNetherlands,everydayat2pmwegetanupdateonthe numberofpeoplethathavediedfromorhospitalizedwithCorona disease(175and722respectivelyatthetimeofwritingthefirst ver-sionofthispaper,26and42whilerevisingit).Thereisnoescaping thedreadfulnewsthatcomesineverydayfromallovertheworld. Howismediareportinginfluencingthedecisionsthatpeopleonthe streets(orrather:intheirhomes)make,andhowdoesitinfluence politics?

Framing[6]playsacrucialroleinpandemicdecision-making, both in relation tomeasures taken and to the issues at hand. Whether the Corona crisis is depicted as a public health, an economic or a social crisis has huge implications, not only in terms of decisionsto scale-upprotective measures, but alsoin thefocusofpolicies.I.e. whilstthemediaisfullwithICU beds, thereis verylittleattentionfor primarycare.Also, theframing ofbehavior iscrucial. Inhisspeechintroducingthe‘intelligent’ lockdownintheNetherlands,PrimeMinisterRuttereferredto peo-plegoingtothebeachas‘anti-social’.Such framingslegitimize morefar-reachingpolicymeasuresanddelineatetheexperience oftheproblemathand.Framingscanalsobackﬁre,however. Ear-lierreferencesby BorisJohnson tobuildup‘herdimmunity’by preventingalockdownback-ﬁredundermediaandexpert criti-cism.

Whatkindsofmetaphorsareusedtodescribethediseaseor preventivemeasuresalsomatters.SusanSontagalreadypointed at the endemic use of war-talk in relation to infectious dis-eases[7],with‘foreign’bodies ‘invading’ourown,thuseliciting militaristic reactions. Whilst such metaphors might be helpful in developing speciﬁcresponses,theyare alsohighly problem-atic.For example,the metaphor of the‘lockdown’ might seem tomake sense,but what about populationsthat can hardlybe ‘locked down’ (e.g. slumsin South-Africa,or theimpoverished communitiesinSyria)orforwhomlockdown mightactuallybe bad, suchas the homeless or refugees,or children in problem families?Thereisaneedtostudythewaysinwhichpolicy mea-sures areframed and towhat consequences. Again,differences betweencountriesareinterestingtostudytounderstandsuch con-sequences.

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5. Organizingexpertiseintimesofcrises

Everypubliccrisisisalsoacrisisofexpertise.Asexpertsare necessarily drawn in toadvice politics, expertisealso becomes politicized [8]. Not only is this visible in the huge amount of misinformation—there is a whole infodemiology of Corona out there—butlegitimateexpertsthemselvesdisagreeonkeyissues whilstresearchisbeingexecutedandpublishedatrecord-speeds, making it more difficult to value. Disciplinary backgrounds of coursematter—virologistswillhaveadifferenttakeonthingsthat saysociologistsoreconomists.Thepressuresputonexpertsalso enlargesdifferenceswithindisciplinarycircles.Discussionsthatare usuallyplayedout‘behindthescenes’ofscientificcommittees[9] nowcomeoutintotheopenasexpertsareallovertheplaceinthe media,anddifferencesareexposedandmagnified.Callsfortrust in‘theexperts’thenbecomesomewhatemptyasthequestionis ratherwhomwillbegrantedthepositionofexpert.Therolethat canbeplayedbycertifiedexpertbodies—inSwedenforexample thePublicHealthAgency—thenbecomesdependentontheways inwhichotherexpertsaregivenastageinthemedia.

Again,therearedifferencesbetweencountries,bothinthe voic-ingofexpertopinionsandinthestageexpertsgetatthepolitical level.Clearly,thisisalsoinfluencedbythemedia,butthe insti-tutionalizationofexpertiseprobablyalsomatters.Countrieswith astrongtraditionofcertifiedexpertbodiesprobablydodifferent thancountriesthathaveamorefragmentedorganizationof exper-tise.Therecentriseof‘factfreepolitics’insomecountriesofcourse alsoinfluencesthewaysinwhichexpertscannowsettheagenda. Whatexpertsgetavoiceandhowtheycaninfluencepandemic decision-makingisclearlyamatterthatneedsscholarlyattention.

6. Conclusion

TheCoronacrisiscallsforresearchbyandinsightsfromhealth policyanalysists,todealwiththe(unfolding)crisisnowbutalso tolearnforfuturecrises.Handlingthiscrisiswilltakeconsiderable time,andwecananticipatemanyevaluationsofcurrentpolicies.

Theissuesmentionedaboveareonlyafewofpossibleimportant ones.Theyareallissuesthatwecan(andshould)startcollecting dataonnow,byobservingdecision-makinginaction,by analyz-ingpolicydocumentsand(social)mediaandbyinterviewingkey actors.Comparativeresearchbetweencountriesandregionswill beparticularlyhelpfulinevaluatingtheeffects ofdifferent pre-ventionpoliciesandpractices.Atthemoment,bothnationaland international(i.e.EU)callsforresearcharebeingissuedandallow foropportunitiestoactuallystartdoingcomparativeresearch.We lookforwardforyoutojoininthiseffort.

DeclarationofCompetingInterest

Therearenocompetingintereststodeclare.Nobodyhaspaid forororderedthispublicationinanywayexceptfortheauthors.

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