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A bylaw enforcement officer patrols the Eastern Beaches boardwalk in Toronto on April 10, 2020. (Shutterstock)

How governments can make public health decisions when some information about coronavirus is missing

The COVID-19 pandemic continues to be a rapidly evolving crisis. The implications of the virus were at first seen in terms of the need to flatten the curve on the number of cases. It is now evident that we need to address the other impacts of the virus on our lives.

From economic difficulties to mental health, mobility and surveillance concerns to gendered, racialized and class disparities, the public health measures taken in response to the novel coronavirus are taking their toll. And as public health officials and governments begin to plan for transitioning out of these measures, there are many lessons to be learned from how things have been handled thus far.

A primary lesson that should come out of what has transpired is the value of the precautionary principle.

An ounce of prevention

The precautionary principle states that “when an activity raises threats of harm to human health or the environment, precautionary measures should be taken even if some cause and effect relationships are not fully established scientifically.” It’s a population-based approach and its adoption is fundamental to public health.

The British physician John Snow reduced the number of fatalities from cholera in London in the mid-1800s by convincing authorities that it was being transmitted in the water supply. (Wellcome Collection), CC BY

The approach is illustrated in the classic story of Dr. John Snow’s recommendation to officials in London, U.K., in 1854 to remove the Broad Street water pump handle to stem a cholera outbreak. The conventional view at that time was that cholera was spread in the air, but Snow was of the opinion that it was being spread through contaminated drinking water. At the time, scientists were unaware of the existence of pathogens.

When the pump handle was removed, the number of new cholera cases dropped dramatically. The lesson of removing the pump handle — taking a population-based approach with prevention in mind — is important to remember now.

Lessons from the environment

Environmental health advocates have long argued for the application of the precautionary principle in the face of threats to human health stemming from exposure to pollution and toxins.

“The precautionary principle is meant to represent the public good in all decisions made under scientific uncertainty. When there is substantial scientific uncertainty about the risks and benefits of a proposed activity, policy decisions should be made to err on the side of caution with respect to the environment and the health of the public”.

Regulations on air pollution, chemicals in industrial and consumer products and workplace exposures to environmental toxins have often taken the precautionary principle into account.

Government adoption

Governments at all levels, institutions and even businesses and individuals should be adopting the precautionary principle as we continue to move through the COVID-19 pandemic and prepare for life afterwards.

The SARS outbreak of 2003 provided a road map for dealing with future outbreaks. An independent commission conducted hearings to explore how things were handled, and a key recommendation to emerge was for the implementation of the precautionary principle:

“That in any future infectious disease crisis, the precautionary principle guide the development, implementation and monitoring of procedures, guidelines, processes and systems for the early detection and treatment of possible cases … [and] worker safety procedures, guidelines, processes and systems.”

Public health measures and transitions towards returning to work, school and normal operations should include policies that both anticipate possibilities and mitigate effects as the virus continues to be felt. Individual-level behaviours are important for slowing the spread of COVID-19. Yet they are insufficient from a systems or population perspective.

Disproportionate impacts

The premise of individual responsibility dominates policies for many health issues. It’s true of obesity, breast cancer, violence against women and poverty. Individualized arguments fail to capture that health exists in a nested set of relationships. Individual health is a product of the conditions of families, workplaces, communities, nations and global environments. The precautionary principle can serve as a guideline to capture these complexities.

Governments should take a systemic approach to protect the health of the population as a whole, rather than placing the responsibility on the individual. (Shutterstock)

Going forward, government directives and responses should implement systemic protections and policies in a timely fashion, especially where they impact vulnerable populations. There are a number of examples of what could be implemented:

Rapid, barrier-free, provision of economic supports for people living in poverty and those whose employment conditions have shifted would mitigate impacts. So would alternative networks of transportation or goods and services provision for those with limited mobility.

Protections need to be applied for vulnerable sectors of the workforce such as those in health care who lack proper personal protective equipment and others on the front lines providing necessities.

Health care could be improved through widespread testing and contact tracing, and the collection of data through self-identification and consent by racialized peoples including Indigenous people.

Strategies should account for diversities of experiences and conditions of the population and developed through consultation with impacted populations and groups.

Decision-making for the public good

The actions taken to mitigate the effects of the COVID-19 virus highlight the flaws of our health-care system and public health approaches.

As governments and public health officials prepare for a return to normal, the precautionary principle should be front and centre. All policy decisions should be made with the public good as the foremost consideration, even in the face of continuing uncertainties. Health, as has been made clear as we have endured the lockdown of COVID-19, must take into account not only the role of this novel coronavirus but also its implications.

The uneven impacts of COVID-19 across communities must be considered as risk mitigation strategies are constructed. These policies must address intersectional factors such as gender, racialization, mobility, housing, transportation and other health issues.

The way forward for overall health needs to apply the precautionary principle and focus on primary prevention of illness and disease.

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