Never let a crisis go to waste: covid-19 and democracy (Guest post from Luke Slawomirski)

Dear Troppodillians, please welcome Luke Slawomirski to Troppo. I first met Luke at the OECD where I gave a paper on public-private digital partnerships with a particular focus on health policy. Luke was an Australian health economist working there and he’s recently returned to COVID free Perth. Anyway, I said I’d welcome a guest post from him and here it is. Nicholas

A few years ago, I had the opportunity to observe several groups of citizens deliberate on how their local health services should be managed in terms of provision and access. This approach could help policymakers navigate some upcoming challenges of COVID-19 crisis.

At the time, I was sceptical that a citizens’ jury could produce more than a wish-list of costly services and interventions. I was wrong. The 20-or-so jurors, randomly selected from the electoral roll and led by a strong, well-versed facilitator, quickly grasped the economic concepts at play: resource scarcity, opportunity cost, diminishing returns and even vertical equity – the unequal but equitable treatment of unequals.

In this way, the jury helped local policymakers define concepts such as health ‘need’, provided guidance for setting priorities that require value judgements and inevitable trade-offs when trying to do the most with limited resources.

Citizens’ juries date back to the ancient Athenian practice of sortition, a practice that involved citizens in the executive functions of government.  More recently, they have gained traction in health and other areas of public policy.

The unique challenges of covid-19 illustrate its potential advantage and signals that perhaps their time may have truly arrived.

A SARS-Cov-2 vaccine is uncharted policy territory

While the COVID-19 curve has been flattened in most places for now, it is clear that the virus will be with us for some time.

A vaccine is expected in 2021.[1] Beyond the first hurdle of negotiating prices and access internationally,[2] its arrival on Australian shores will present major policy and political challenges. Demand for the vaccine will be unprecedented – and will vastly the outnumber supply for the foreseeable future.[3]

How should Australia select those who are to be vaccinated as a priority … and those who should miss out? What will be considered fair? And who should pay for immunisation?

These are actually not unusual questions and can apply to any new or existing health technology. What’s unique in this case is (a) the urgent need for answers, and (b) that outcomes will play out quickly – in full view of the public.

Ask the people, as well as the experts

Most would agree that important decisions like these should be based, at least in part, on what the citizenry prefers. But who can know this given the current context? Abstractions like ‘need’ must be defined to be useful but can mean a range of things depending on one’s principles and priorities. Who is nest placed to do it? The government? Doctors? Policy makers, bureaucrats?

Fighting a pandemic was not an election issue and even the most diligent MP will be hard-pressed to know their constituents’ views on vaccine access. Doctors – we love and respect them – but they are trained to treat the patient in front of them. Policymakers may have the public interest at heart. But it would be presumptuous to assume they have meaningful knowledge of social preferences in this case.

In fact, the technocrat’s advice may well be informed by the concept of health utility – represented by the QALY,[4] the expected longevity gain from an intervention adjusted for quality of life. Many medical therapies are rationed this way. But it is easy to see how this would disadvantage the frail and elderly, especially those in care homes.

Would such a cold, utilitarian calculus be palatable? Perhaps, but it’s difficult to say without asking.

But this isn’t a yes / no question. It’s also too complex for a survey. The questions need considered deliberation, with participants first gaining a basic understanding of the underlying issues (how the vaccine works) and the trade-offs involved (X amount of people in Y age bracket will likely die if we pursue option Z).

Citizens’ juries are the best available approach. A handful of juries of appropriate size, expertly facilitated, could easily be conducted across the country in the December quarter of this year. The financial outlay would be negligible considering what is at stake. Follow-up juries could be convened soon after to sort out any conflicting preferences from the first round.[5]

The resulting information can complement expert advice to help the national cabinet decide what to do with limited number of vaccines. The decisions will be controversial regardless. But it will have more legitimacy if based on meaningful consultation with the most important stakeholders of all. It can also minimise unbecoming political squabbles, vacillation and the perception of influence by vested interests. There’s much potential gain for relatively little pain.

A healthier democracy

Most would agree that democracy demands more than simply voting. John Dewey said that elections are just the apex of a much larger structure that relies on inclusion, education and participation. Citizens’ juries represent a practical mechanism to promote a vibrant, deliberative democracy. Managing the public health aspect of the covid-19 crisis is a good opportunity to prove their worth. Let’s not waste it.

[1] This is not guaranteed. Safe, effective vaccines are difficult to develop (we’re still waiting for an HIV vaccine) but given the amount of resources thrown and a few early promising developments, we can expect something.

[2] A highly difficult task (worthy of its own post)… one that international institutions are hopefully up to.

[3] Manufacturing vaccines is more complex and time-consuming than manufacturing drugs, and global supply chains are not geared to produce the number of units required.

[4] Quality-Adjusted Life Year

[5] In my experience, juries tend to reach agreement once an issue is deliberated on. The force of the better argument prevails (to paraphrase Habermas), especially if the output is framed as guidance as opposed to a yes/no decision that requires ex ante agreement on unanimity or majority.

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8 Responses to Never let a crisis go to waste: covid-19 and democracy (Guest post from Luke Slawomirski)

  1. paul frijters says:

    Hi Luke,

    welcome!

    I totally agree with the notion that the allocation of a scarce number of vaccines is something eminently suitable for a citizen’s jury, even if it would be a hypothetical future vaccine (because there are many different types of vaccines and its hard to know beforehand which ones will emerge at which price).

    I totally disagree with how you subtly assumed 99% of the overall Australian strategy to be set in stone, which is “bunker down in a quarantine until the magic vaccine comes along”. That default presumption, which is the presumption under which it makes sense to talk about December citizen juries, is almost everything. The question of how to allocate scarce vaccines is minor in comparison to your policy-by-default.

    Why not a vastly more ambitious citizens jury on the whole strategy Australia is taking to covid-19? Why not include things like whether or not to have quarantines, social distancing rules, border controls, social distancing, involuntary lock downs, etc.? Why not ask it to consider alternatives like going for engineered herd immunity (as I have described in various posts here on Troppo) or the approaches taken in various European and American states?

    • Luke says:

      Thanks Paul – I agree and would go further that a standing citizens’ jury (council or senate?) on health policy would be a good idea – both nationally and within states/territories which manage their own hospitals. I thought, as a single issue, the vaccine question would be a opportune and quick way to prove the value of CJs.

      • paul frijters says:

        standing citizen juries on long-running policies are an interesting idea. Are there examples from around the world as to how it might work? One worry is that the next bynch in a citizen’s jury would want a major change from a previous lot, and with a system wherein all major change is difficult and costly, that could be a problem. But maybe some system of limited or rolling policy considerations has been developed with citizen juries?
        I am sympathetic to the idea we should be bold enough to give this route a serious try. We need more citizen engagement in democracy.

        • Nicholas Gruen says:

          There’s now standing citizens’ juries in a province of Belgium and in Madrid.

          More generally, it struck me that a standing citizens’ jury would be a handy thing for Daniel Andrews to have in Victoria right now as he’s trying to make decisions about lockdowns etc, whether one should be able to make testing compulsory and so on. Abstracting from your view that he shouldn’t do any of this, as a general rule what’s going to happen is that if rules that reasonable people would agree to are imposed, in our political system the rulers have little legitimacy against activists who will grab hold of any argument from ‘freedom’ to community responsibility that suits them.

          If Andrews had a standing council of 25 citizens, he could run policies past them and say that he’s hoping for a super majority of the group to support it and if they don’t he won’t go ahead with it.

  2. Conrad says:

    You are basically implying that vaccine production is slow and hard — that’s true of older vaccines and some of the Covid ones being tested (the most advanced Chinese one uses an entire deactivated dead virus, which presumably will also be sickening to get too), but there are some now that can potentially be made vastly more quickly.

    For example, if you look at Vaxart — which was one of the the companies added to the US Warp Speed program recently, they claim they could make 1 billion doses a year. I believe some other companies have similar technology (although not in tablet form). Of course, this is new technology and may well fail, although one of their current drugs in the pipeline for influenza appears to work better than the injectable form. So it might only take a few months.

    You could also be in a position where you would have slower and faster vaccines available (some should be stackable for higher efficacy given they target slightly different things).

    • murph the surf says:

      An adjuvanted killed virus product primarily produces side effects from the adjuvant.
      That is a mix of chemicals designed to stimulate inflammation at the injection site and this induces a greater response from the immune system
      2 or 3 shots are often needed to fet a solid response.
      Modified live biologicals have an attenuated ( achieved by being bred through 100 + generations ) potency due to being mutated sufficiently to be non pathogenic but being capable of reproduction.This can knock you about as the virus replicates but this exposes the host immune system to the virus and this to produce a protective response.

    • Luke says:

      Thanks Conrad – that’s really interesting. Let’s hope something safe and effective is developed quickly. Then we will have the nice problem of allocating it across and within countries … even a billion doses in one year world-wide will require some tough decisions.

  3. Pingback: Covid19 Reflections #41

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