Keith Rankin Analysis – Covid19 Premier League: Spectrum of Public Health Choices

Analysis by Keith Rankin.

Now is as good a time as any to evaluate and reflect on the public health policy choices made in the period from February to April 2020, re the Covid19 pandemic. Here I have postulated a ‘league’ of 12 economically advanced countries which have made different choices which loosely fit onto a spectrum.

The choices made reflect a full spectrum from ‘herd immunity’ to pushing for ‘elimination’. The immediate context, in making those choices in February 2020, was twofold:

• memories of recent influenzas outbreaks (2009 Swine Flu, and the more recent Avian Flu outbreaks), combined with a recent centenary of the 1917-19 influenza pandemic
• experience of twenty-first century coronavirus epidemics; MERS and, especially, SARS in 2003

One big surprise is that western governments were most conscious of the need to prepare for influenza, while, despite the recent and highly lethal coronavirus outbreaks, only a few Asian governments had the coronavirus scenario at the forefront of their pre-pandemic preparedness.

At the two extreme ends of the spectrum of responses were Sweden and New Zealand; and, in 2020, the world noticed. Both responses were led by public health professionals – the bureaucrats of Sweden and the technocrats of New Zealand. In both countries there were dissenting views; views which were denied media ‘oxygen’ as the each dominant response narrative emerged. Sweden made its choice in late February 2020. New Zealand, which seemed initially to be going for the middle of the spectrum, was panicked into making its extreme and opposite ‘fortress’ choice, in the third week of March 2020. For both countries, the choices were made from an abundance of ignorance; especially a somewhat wilful ignorance about coronaviruses.

The United Kingdom, dealing with Brexit, initially made the Swedish choice, but ‘switched horses’ towards the New Zealand choice. However, the Johnson-led United Kingdom government was never able to erect a fortress, and was never as ideologically inclined towards fortress solutions as was a New Zealand government that was already feeling its way into an immigration policy based on labour-market nationalism. (We may note this week’s UK commission report, which also was an implicit critique of Sweden’s choice; refer to this story on RNZ on 13 October.)

So, the United Kingdom ended up with a policy hotch-potch; as did the United States under the circumstances of jealously-held federalism, and a nationalist exceptionalism that was driving the Trump administration. Denmark held to a much more coherent position (than UK or USA) on the centre of the spectrum; so did South Korea, with its prior advantage of coronavirus awareness and its early Covid19 outbreak. Japan took a position towards the Sweden end of the covid response spectrum. Australia and Germany, both federal countries, were able to take positions closer to New Zealand’s than was the United States. Of the Scandinavian countries, Finland’s response was closest to New Zealand’s. Israel took a position similar to United Kingdom, knowing that its traditions were not conducive to people being asked to take a ‘voluntary physical distancing’ approach. (Sweden and Japan were culturally much better suited to such ‘voluntarism’.)

Ireland took a coherent position between New Zealand and United Kingdom. Ireland had to respond quickly; it caught covid very early, in February 2020, and had worrying numbers of covid deaths by the end of March 2020.

Sweden versus New Zealand: the Trade-Offs

A (human) pandemic represents a relationship between a pathogen and a human host population. In essence Sweden’s approach, in March 2020, fully emphasised host immunity (ie it emphasised people over pathogen; people living with this a new virus that would soon become like viruses already in circulation); whereas New Zealand’s approach emphasised forward defence, keeping the pathogen out.

This passage from The coronavirus is here to stay (Nature, 16 Feb 2021) summarises Sweden’s position: “Flu pandemics occur when populations are naive [my emphasis] to a virus; by the time a pandemic virus becomes seasonal, much of the population has some immunity to it. … Jesse Bloom, an evolutionary biologist at the Fred Hutchinson Cancer Research Center in Seattle, thinks the coronavirus might follow a similar path.”

So Sweden opted to take an early hit; and to try to recover, stronger for the experience. New Zealand did the opposite, to shut out the pathogen indefinitely, knowing that host weakness (‘naivety’) would result, in the hope that the pathogen would disappear – as SARS and MERS appear to have disappeared – and in the hope that host strength could be restored by a yet-to-be-developed vaccine. New Zealand’s approach was critically dependent on a quick global elimination of the pathogen, or of a comparatively quick and comprehensive vaccine solution; New Zealand’s approach was clearly a gamble, and not the ‘cautious’ approach presented by the government.

With today’s hindsight, both Sweden’s and New Zealand’s approaches have been proved valid, and in the wider context of economic cost. Sweden made some bad mistakes early on, however, in its failure to adopt a Covid19 testing programme (until far too late) and in its failure to protect its elderly population.

New Zealand’s ‘public health solution as the best economic solution’ held until mid-2021, and by then effective mass-produced vaccinations were fully available. Sweden had a bad year in 2020, and was hit again as the alpha strain of covid spread through Europe a year after the spread of the original Wuhan strain. Nevertheless, Sweden seems to have had all its bad news in its first 12 months, with considerable host immunity present as the alpha-strain swept through Europe early this year; further, excess deaths in Sweden so far in the pandemic are close to zero (New Zealand’s excess deaths at present are negative). Sweden has had its pain, and New Zealand has had its gain. The future, however, points to gain to Sweden and pain to New Zealand. (An unfinished game of two halves; Sweden played into the wind in the first half.)

Japan’s position in October 2021 now looks much like Sweden’s, with both host immunity and a degree of voluntary physical distancing playing roles. In Japan’s case, the host immunity appears to have derived from ongoing exposure to seasonal endemic viruses, and not so much to Covid19 itself. In 2020, Japan largely eschewed lockdowns and facemask mandates.

In the meantime, the mish-mash countries (especially UK and USA) had a tough time, and have no ongoing surety that their tough times are over. Of the countries in the middle of the spectrum, Denmark and Ireland are now the poster-children for success. (We don’t dare mention yet, in polite circles, the successes of Sweden or Japan.) Of the other countries mentioned here, as well as New Zealand, only Australia – and possibly Finland and Ireland – have naïve populations; Australia’s naivety is least in Sydney, and (thanks to record-long lockdowns) greatest in Melbourne. Viral naivety results from lockdowns, facemasks, and enforced distancing of young people. And induced-naivety to one covid-like or flu-like pathogen means, to a large extent, acquired naivety to all such pathogens.

Vaccination

The big questions, relating to this pandemic, for the remainder of the 2020s are whether vaccination-acquired immunity is sufficient to remove viral naivety, how frequently immunity to coronaviruses and influenzas needs to be boosted, and how effective global supply chains will be at sustaining global mass-vaccination programmes.

It is pertinent to review vaccination percentages to date, for the ‘premier league’ countries mentioned here. The numbers provided give half-weight to people with partial vaccination.

The current leaders are Denmark and Ireland. Japan and South Korea are among the best of the rest, having been – like New Zealand and Australia – very slow to get started. The initial vaccination leaders, Israel and United Kingdom, have stalled somewhat, as has Germany. The United States has also stalled, now overtaken by the vaccination laggards, New Zealand and Australia.

Evaluation of Strategies

The logic of Sweden’s strategy was to emphasise natural immunity, especially among the non-vulnerable population. While having a shocking year in 2020, Sweden looks very well-placed to have a very good year in 2022; I am not aware that problems relating to long-covid are worse in Sweden than elsewhere, though I stand to be corrected. Sweden has been ‘middle-of-the-league’ on vaccination, treating it as a complement to its wider immunisation strategy, rather than as the strategy’s central focus. Sweden’s headline statistics are stable at present, at 400 weekly cases per million people [and 20 deaths] (equivalent to 290 daily cases in New Zealand [and 10 weekly deaths]).

The best-performing mid-spectrum countries have been Denmark and Ireland. Denmark has taken a coherent position in the centre of the spectrum. It is now open, and has a well-immunised population, though with greater reliance than Sweden on vaccination. Denmark’s ‘delta outbreak’ has been significantly more severe than Sweden’s, and seemed to be largely over until last week. Denmark’s cases increased 36% over the last seven days, and, per capita, are nearly double Sweden’s. Finland, this month, is on a par with Denmark.

Ireland is also seeing a small resurgence at present. It’s currently five times worse than Sweden, and three times worse than Denmark.

At the New Zealand end of the covid policy spectrum, the logic was an extreme reliance on vaccinations in the likely event that global elimination did not occur. There was a process of cognitive dissonance however, in that, despite New Zealand’s obvious strategic dependence on vaccinations, New Zealand’s political leaders had thought that New Zealand could afford to be a vaccination laggard. Like Australia, New Zealand is still near the bottom of the league vaccination table; both Australasian countries have only just overtaken that other recent laggard, the United States. (While not in the ‘premier league’ that I have constructed, Canada was an early vaccination leader, and its latest statistics fall just below Ireland’s.)

An interesting ‘local derby’ match is that of Japan versus South Korea. Both countries were slow starters with vaccination. Japan is much closer to the Sweden end of the covid policy spectrum, whereas South Korea is closer to Ireland or Denmark. Currently, South Korea’s case-incidence of Covid19 is five times that of Japan.

The country, of those considered here, that is currently worst for reported cases is the United Kingdom, with USA being easily the worst for deaths. Israel falls just short of USA for cases, and just short of United Kingdom for deaths.

So far, New Zealand is still clearly winning in the headline statistics’ – still the best of these countries on reported cases, recorded deaths; and, for that matter, on excess deaths.

The Sweden versus New Zealand match

But, let’s just consider – within the ‘covid stakes’ – the match contest between New Zealand and Sweden. We may treat it as a rugby test match (excuse the switch of metaphor from football to rugby) in a Wellington southerly storm. Sweden chose to play into the wind in the first half, and dropped the ball many times; New Zealand preferred to play with the wind in the first half, and got plenty of points on the board. So, the half-time score clearly favours New Zealand. It turns out, however, that New Zealand did not bother preparing for a second-half into the southerly; rather, New Zealand simply hoped that the wind would abate before half time. And Sweden’s first-half experience made the Swedish ‘team of 10 million’ more resilient. Now, in the second-half, with the southerly even stronger than it was at kick-off time, New Zealand is going into this phase of the match substantially and wilfully underprepared. We have no idea who will be the winner at fulltime (eg mid-2022); but if the fulltime result is a draw, then Sweden will almost certainly defeat New Zealand in extra-time.

Conclusion

New Zealand is currently leading the covid league tables, in terms of ‘points on the board’. And, despite missing a number of tackles early in the second-half, its half-time lead over Sweden is holding for now. But New Zealand is vulnerable, and underprepared; the match could easily turn out like France versus New Zealand in the 1999 Rugby World Cup. Sweden, after a torrid time, may now be ‘out of the woods’ and getting points on the board.

Of the other countries in the covid premier league, only Japan looks to be ‘out of the covid woods’. If New Zealand loses to Sweden, it may not have the resilience to avoid a steady decline towards the bottom of the league table. Even if New Zealand eventually defeats Sweden on its headline covid statistics, it may prove to be a Pyrrhic victory. New Zealand will not be the covid league champion that New Zealanders thought it could be.

It is possible that Sweden will win my Covid Premier League, with Japan as runner up. That’s not how a betting person would have seen it in January this year.

Keith Rankin (keith at rankin dot nz), trained as an economic historian, is a retired lecturer in Economics and Statistics. He lives in Auckland, New Zealand.