Health Expertise and Covid-19: Managing the Fear Factor
No amount of expert evidence will [as a rule] point logically and unambiguously to a given conclusion.
Peter Self, 1977, p. 2051
As Covid-19 raced across the globe, the leaders of almost every country were forced to rely on their health experts to advise them on the sudden threat. Of course, the degree of that reliance and the nature of the leader's relationship with their advisers varied.
US President Donald Trump notoriously fought with the health professionals, as he sought to downplay the virus. In contrast, both Australia's federal and state governments were at pains from the start to stress that policy prescriptions were evidence-based, driven by the expert advice.
Prime Minister Scott Morrison adopted the mantra of protecting “lives and livelihoods”, and wanted a balance between the two, which often led to his believing some jurisdictions were being too restrictive, at a high cost to the economy. The counter argument was that health outcomes would drive, positively or negatively, the economic outcomes.
Not only has the health advice been pivotal to the crafting of policy responses, but Australian leaders have used the presence of their health officials – in person, regularly at the news conferences of the prime minister and premiers – to buttress their political authority.
Professor Brendan Murphy, Commonwealth Chief Medical Officer in the early months of the pandemic, quickly became a nationally-known figure. Because of the respect he attracted, the Morrison government continued to use him publicly after he assumed the usually less high profile position of Secretary of the Department of Health. Chief health officers in the states also became well known to their local publics.
The purpose of this article is to tell the story of the role of health expertise in the evolution of responses by the Australian governments to the Covid-19 pandemic. This evolving story is organised into three parts.
We begin by defining what we mean by expertise in the Covid-19 context and reviewing what the pre-covid-19 evidence tells us about the role of expertise in Australian public policy. We explore key issues of continuity and change in the evidence base during the pandemic. And we examine key areas of contestation between experts to highlight the dominant ideas informing government policy.
Defining The Role Of Experts
Edward Page observes that expertise is best understood as “a high level of familiarity with a body of knowledge and/or experience that is neither widely shared nor simply acquired”.
This is a useful definition because, in keeping with the multi-dimensional impacts of Covid-19, it allows for four different types of knowledge as “expertise”.
Scientific Expertise, Policy Expertise, Public Health Professional Expertise and Instrument Expertise
First: SCIENTIFIC expertise attempts to understand the why, how and control of the spread. Here expertise comes to the fore across the full spectrum of natural and social sciences; from medicine and pharmacy, through to economics and psychology; from genetics and data science, through to sociology and communication.
Second: POLICY expertise refers to knowledge of the range of policies and instruments, past and present, informing the public policy response. For example, types of lockdown, social distancing, masks, quarantine regimes, contact tracing, economic stimulus etc.
Third: PUBLIC HEALTH PROFESSIONAL expertise refers to broad interdisciplinary, experiential and practical knowledge of the nature of similar problems and the complex processes to be followed to ensure a sensible response can be found and put into effect. This would include the creation of new agencies such as the National Cabinet, Emergency Relief National
Coordination Group, and Covid-19 Quarantine Victoria, as well as the elevation of the Australian Health Protection Principal Committee (AHPPC) – the primary national health advisory body.
Fourth: INSTRUMENT expertise refers to knowledge of how to put a law into effect, what is permissible and what is not, what could be challenged and what is likely to stand – for example, the Emergency Powers Act, which empowers or disempowers elected and non-elected officials (depending on the state) or the implications of Covid-19 response for the Biosecurity Act 2015.
Governments create longstanding and durable epistemic (knowledge) communities comprised of elite natural and social scientists and/or experts from any discipline or profession with authoritative claims to scientific, policy, process or instrument expertise.
The discussion that follows draws on interviews conducted with key protagonists derived from these four types of expertise found within and outside the Covid-19 epistemic community.
What The Evidence Tells Us About The Role Of Experts
Privileged experts tend to dominate policy advice by virtue of their knowledge capital, strong interpersonal relationships with key political and/or bureaucratic actors and shared policy norms and values.
Expert advice, particularly in areas where the government lacks knowledge, can be formally granted a privileged position in the policy process in the form of expert bodies that exercise a veto over policy proposals and specialist committees that can require bureaucracies to develop policies.
However, over fifty years of policy research also demonstrates that evidence is not a sufficient criterion for policy action as it is nearly always contested and the nature of the contestation often reflects competing social values.
Studies of the role of natural scientists in policy-making tend to suggest that when there is a clash of policy values between experts with competing views on the evidence-base – as, for example, in the case of the Murray Darling Basin Plan – the role of science in settling the conflict is limited.
This is because, as Peter Self puts it: “scientific training often makes an expert scrupulously objective about the policy implications of his knowledge” and it is not unusual for pure scientists to adopt rigid positions when the political settings are compelling political elites towards a compromise. Natural scientists find it difficult to accept that evidence is not a sufficient criterion for policy action in a liberal democracy.
EVIDENCE IS NOT A SUFFICIENT CRITERION FOR POLICY ACTION AS IT IS NEARLY ALWAYS CONTESTED AND THE NATURE OF THE CONTESTATION OFTEN REFLECTS COMPETING SOCIAL VALUES.
Continuity And Change
Nonetheless, the evidence also suggests that scientists have benefitted from exceptional trends in Australia both pre and during the pandemic.
Prior to the pandemic there was strong evidence, particularly in the USA and the United Kingdom, of anti-intellectualism – the generalised distrust of intellectuals and experts.
International evidence shows that anti-intellectualism is connected to populism, a worldview that sees political conflict as primarily between ordinary citizens and a privileged societal elite.
However, this pattern of opinion has not been shared by the Australian public either before or during the pandemic. This is largely explained by Australia being able to evade the economic and social dislocation caused by the Global Financial Crisis and partly by Australia's main political parties absorbing certain populist agendas into the mainstream. For example, Labor and anti-immigration and the Coalition and climate scepticism.
The Wellcome Global Monitor ran a survey in 2018 on trust in science and scientists in over 140 countries, which also included a question on trust in national government. Australia ranked just 85th out of 134 countries for its level of political trust, but 14th out of 144 for trust in scientists, suggesting that in relative terms it has a high level of trust in technocratic elites.
In times of coronavirus, for the first time since 1993, Australians are exhibiting relatively high levels of trust in federal government (from 29% in 2019 to 54% in 2020), and the Australian Public Service (from 38% in 2019 to 54% in 2020) while continuing to exhibit high levels of trust in scientists and experts (77% in 2020).
Trust has been vital to dealing with the crisis. In the lockdowns, Australians were asked to accept extraordinary curbs on their activities and freedoms. They did so with a high level of compliance, encouraged by the message that the measures were based on expert advice.
A key feature of the 2021 campaign to encourage people to get vaccinated is public reassurance from experts of its safety. As the vaccine arrived in Australia, the federal government said not only would Prime Minister Scott Morrison and Health Minister Greg Hunt be setting an example by taking it immediately (each getting a separate type) but so would the Secretary of the Health Department, Brendan Murphy, and the Commonwealth Chief Medical Officer, Paul Kelly.
Australians have comparatively high levels of political trust in Prime Minister Morrison because he is perceived as being competent and efficient in his handling of the outbreak. The process
For the first time since 1993, Australians are exhibiting relatively high levels of trust in federal government
of judging the competence of political elites in the context of Covid-19 is more than a crude judgment about threats and outcomes. It reflects how the leader is perceived to have managed the process and their relationships with other stakeholders and interests. Do they consult with experts, express themselves clearly, work across governmental and political divides? The leader that citizens seem to be looking for in the age of the coronavirus is not a blustering populist, but a decisive, reflective, and even technocratic type (SEE FIGURE 1).
On the issue of populism, it is also noteworthy that the polarisation of politics that characterises many liberal democracies with a penchant for populism, continues to be absent in Australia (SEE FIGURE 2) where citizens want to see more collaborative, evidence-based politics.
So how has the story of the health experts unfolded during the pandemic?
The Contest Of Ideas And Its Intersection With Politics
In Australia, much of the contestation between federal and state governments has not been based upon the material nature of the health advice but on the balance between health and economic imperatives, and the wider context of political and economic circumstances, which has allowed for differences in
The information landscape of a sudden pandemic is dynamic and unpredictable, resulting in experts having to accelerate the slow, deliberate processes of research.
the measures pursued at each level of government.
While we are concentrating this article on health expertise, it should be remembered the economic experts have also been crucial. The Morrison government went as far as it did in its fiscal stimulus because it accepted the advice of Treasury when it argued strongly for a massive injection of funds that included the Jobkeeper wage subsidy program.
The story of the “experts” is, however, more complex than it might first appear. Who is a health “expert” in a pandemic can be, and has been, contested because – as outlined earlier – multiple specialties and skills are relevant. Compounding this issue of ‘multiple voices' is the fact that the information landscape of a sudden pandemic is dynamic and unpredictable, resulting in experts having to accelerate the slow, deliberate processes of research.
Individual experts, and whole fields of science, sometimes changed their minds and argued with each other about appropriate responses. Differences emerged among those “in the tent” of officialdom, as well as between insiders and some outsiders in academia.
As more information and data emerged, the experts around the country espoused a range of views. Arguments about how the virus was transmitted – mostly via “droplets” or with a big aerosol component – led to an intense debate about the efficacy of masks.
Murphy did not favour recommending the widespread use of masks early on (this was informed by doubt about their usefulness in the absence of much community transmission, but he also had in mind the need to conserve the local supply, given most masks were imported).
The head of the Infection Control Expert Group (ICEG), Lyn Gilbert, was sceptical on masks. But Raina Macintyre, head of the UNSW'S Biosecurity Program, and many health professionals were outspoken, especially in urging the safer variety of masks for health professionals.
In August 2020, a group of doctors wrote to health minister Greg Hunt, with a stinging attack on Gilbert and her group. “The assertion by the Chair of the ICEG that a higher level of protection in the form of the respirator is unnecessary in the worst pandemic of our lifetimes is irresponsible”, they declared.
One notable split at the pandemic's beginning was between the Australian health advice, which led to a quick closure of Australia's border with China, and that coming from the World Health Organisation, which recommended against shutting borders.
The advice to close the border to people travelling from China (apart from Australian returnees), which was done on February 1 (a prelude to later full closure), was endorsed by the AHPPC, based on a recommendation from Murphy, who was studying the epidemiological evidence from China, from where Australia's cases were originating.
It was a bold step by the Morrison government, given the importance to the economy of Chinese students and tourists, and Morrison put the decision squarely on the health advice. “Up until today it has not been the advice of the Chief Medical Officer, and our medical experts that this has been necessary,” Morrison said. But now the advice had changed.
Murphy also commissioned modelling of scenarios for the future course of the virus from Melbourne's Doherty Institute. Experts from that institute, and elsewhere from inside and outside officialdom were invited into the broad orbit of the AHPPC, which included federal and state health officers and would advise the National Cabinet when it was formed by Morrison in March 2020 to bring together federal, state and territory leaders.
A central imperative over the months was managing the politics of fear.
A central imperative over the months was managing the politics of fear. Key decisions (on state borders, the toughness of restrictions imposed, the nature of the quarantine system) involved assessing how much risk to take. It quickly became clear the Australian public were very fearful of the virus. In April, the Essential poll found 88% concerned “about the threat of Covid-19 (coronavirus) in Australia”.
17 The fear factor was reinforced by the reports of the horrific situation in many comparable countries abroad.
Over the months, Morrison and the NSW government tilted towards being willing to tolerate a higher level of risk than most states. Yet voters seemed to welcome the most risk-averse strategies, despite their high economic and social costs.
The official national policy was one of “suppressing” the virus – stopping community transmission – rather than “eliminating” it. Yet some experts were arguing for elimination. On the AHPPC Murphy and his deputy (later successor) Paul Kelly, mindful of the stand of Morrison and the position of National Cabinet (one of “living with the virus”) guided the language away from “elimination” (which was New Zealand's policy).
As the numbers fell towards zero in various jurisdictions (excluding quarantine cases), the mindset of some leaders and their publics was clearly to move beyond suppression. The language shifted to a goal of “aggressive suppression”, defined as no community transmission. This was “elimination” on any ordinary measure.
Throughout 2020, there were differences between the federal government and some states, and among states, over what they considered appropriate responses. Leaders would usually justify these divergences by referencing their own health experts. Victoria's Daniel Andrews in October said: “the whole way through this, we have been guided by our public health experts and their advice”.
Queensland's Annastacia Palaszczuk said: “We think it's important to listen to the health experts. Their advice keeps Queensland safe.”
The perception that the politicians were looking to the health experts undoubtedly boosted public confidence, and was key in the high level of compliance with restrictions, especially in the Victorian lockdown of more than 100 days in its second wave.
But for both the politicians and the experts in officialdom, it was a two-edged sword. The Morrison government was critical of what it considered some states' overreactions,
The experts found themselves operating in an environment where not only was the ground constantly shifting but the proper responses were contested.
especially their border closures and Victoria's harsh, long lockdown. But later it backed off criticisms, because clearly the states' actions were very popular with their own constituencies. Even when flaws in its hotel quarantine and contact tracing arrangements shut down Victoria, Premier Andrews retained what, on the face of it, seemed a surprising level of support.
The experts found themselves operating in an environment where not only was the ground constantly shifting but the proper responses were contested. Some counterparts abroad were advocating radically different approaches. In Sweden, for example, Anders Tegnell, the chief epidemiologist at the Public Health Agency, drove what was dubbed “a light touch” policy of minimum restrictions, which resulted in a death toll approaching 13,000 at the end of February 2021 for a population of 10 million people. The mirage of herd
immunity, with its prospective huge death toll, was never a serious option for Australia.
The Australian health officials found their advice criticised by some peers from academia. As the pandemic escalated in March, Murphy commissioned the Group of Eight Universities to convene experts to propose options. They came up with two perspectives. The clearly dominant one advocated going hard with a “comprehensive, simultaneous ban” across the country; the second was for a more “proportionate response”.
Murphy, questioned at a news conference with the Prime Minister, indicated he did not favour the majority view. Another paper circulating at the time, authored by Macintyre and others, also argued for “a short, sharp lockdown”.
Within the AHPPC, the operating mode was consensus and that was mostly the outcome. But Victoria's chief health officer Brett Sutton was a dissident voice on the need, early on, for a tougher lockdown than others favoured. The restrictions announced by Morrison on March 22 were a compromise between the hardline Victorian approach, supported by NSW, and a more limited response favoured by the Prime Minister and other jurisdictions.
What the AHPPC did not deal with was also notable. It eschewed the domestic border question, on the grounds this was an area of state responsibility, but equally because consensus would never be reached. The states, which were driving much of the response, were not going to agree to measures they didn't favour. They went their own way on borders, citing their local advisers.
On the key question of schools, the federal government and Murphy believed in keeping them open, but states took their own, usually more conservative, decisions.
The health officers inevitably found themselves becoming political figures. The public identified with them, sometimes to an extraordinary degree. Sutton became a cult figure, featured on t-shirts, pillows and even socks (the same happened with New Zealand's Director-general of Health, Ashley Bloomfield, whose image featured in artworks and across a suite of merchandise). But they also increasingly became targets.
Queensland's Jeannette Young, who under state legislation had extensive direct power over decisions such as border exemptions, came under immense pressure as the Queensland election approached, and the federal government highlighted decisions that had gone against mercy cases.
Sutton especially was in the sights of hard-right critics – labelled “Bambi-eyes” by the Institute of Public Affairs' Gideon Rozner; these critics argued the Victorian government was reacting excessively with lockdowns and ignoring the costs.
The Western Australian Chief Health Officer, Andrew Robertson, was caught in the middle of the debate over the state's hard border policy. After it was suggested he had contradicted the claims his premier, Mark Mcgowan, had made about the health advice, Robertson issued an October statement highlighting changing information, saying his advice had been “consistent about maintaining current border
The public identified with them, sometimes to an extraordinary degree.
controls since border restrictions were implemented”, and had merely raised “possible future options if the epidemiology and national control measures were to change.”
The presence of health officials, federal and state, at leaders' regular news conferences introduced a new real-time bureaucratic accountability. They had to defend their advice, and in some cases answer for controversial decisions (especially Young) and weaknesses in a state's system (especially Sutton).
Implications For Future Health Governance
Health experts have been used to politically manage the community fear factor during Covid-19, as well as provide the foundation for the policy responses. The Morrison government has built on the high levels of trust that Australians possess for experts, to share and absorb the risk of failure.
A range of expertise has been necessary to combat the virus but given the few absolute scientific truths about the pandemic, policy and process expertise has been preeminent and scientific expertise has been harvested from tried and trusted experts within the Government's epistemic community, the AHPPC, which draws on knowledge from wider sources.
The determination of insider and outsider expert status depends on the quality/objectivity of the scientific evidence on offer, the reputation of the expert in the epistemic community and the ability of the expert to translate the evidence in a meaningful way for policy.
In the case of Covid-19, it is the status of the expert, the content of their expertise and their institutional affiliation that accounts for their influence. There has also been an element of ‘who knows who'; some identify a Melbourne circle, which Sydney experts believe has a special ‘insider status'.
Contestation between health experts has proved inevitable given that no one has all the answers, but two broad communities of health experts have featured strongly – one that follows the international evidence in the worst hit countries e.g. the USA and the UK (the outsiders) and one that is responsive to the national context (the insiders).
As a parting shot, we asked our informants whether Covid-19 would lead to a new marriage between politicians and experts or default to business as usual. Most thought health experts crucial to the success of the Morrison Government's management of the pandemic and saw significant gains in terms of fostering stronger trust systems between the public service, insider heath experts and the political class and augmenting a new dawn for Government strategic communications with departments playing a more visible role. However, few were optimistic that it would last into the future as technocracy is a challenge to representative democracy and dependent on political will.
“It will survive while the public have memory but it will fizzle out.”
“The pandemic is unique. It won't give more agency to experts in other areas.”
“We will backslide as the fear level goes down.”
But then again, winter is coming.
The presence of health officials, federal and state, at leaders’ regular news conferences introduced a new real-time bureaucratic accountability.