www.merit.unu.edu

number 4, 2020

Overview The COVID-19 pandemic is not Hammer or nudge? Science- only confronting the world with a new and deadly virus – it has also based policy advice in the brought ‘science’ back into the lead of policymaking. One can only welcome this dramatic recognition of the value COVID-19 pandemic and role of science to society amid the COVID-19 public health challenge. However, the science-based policy he COVID-19 pandemic is not only confronting the world with a new advice for measures to combat COVID- and deadly virus – it has also brought ‘science’ back into the lead of 19 has also some worrying features. T Three are being discussed here. They policymaking. The global science community is busier than ever and open have led to a strong national bias in science is becoming the norm as researchers routinely share their data. both science-based policy advice and Meanwhile, the vaccine research community, both in public and private in the national policies implemented research labs, is working together day and night in developing, experiment- to combat COVID-19. Alternative ing and testing possible new vaccines. One can only welcome this dramatic approaches are discussed focusing in recognition of the value and role of science to society amid the COVID-19 particular on the European Union. public health challenge. As if scientists wake up in a new world of facts and evidence-based policy.

Written by Luc Soete1. Edited by However, the science-based policy advice for measures to combat Howard Hudson, UNU-MERIT COVID-19 has also some worrying features. First, a certain degree of arro- gance of disciplinary knowledge with the rejection of any debate coming © United Nations University 2020 from researchers outside of the virology and epidemiological professions. ISBN 978-92-808-5015-4 Second, the imposition of confinement restrictions independently of other Licensed under the Creative Commons behavioural or social sciences insights on the broader impact of such unique Deed ‘Attribution-NonCommercial- societal experimentation. And third, the way current science-based policy NoDerivs 2.5’ advice combatting COVID-19 appears imprisoned in national data, leading to a strong national bias in policymaking. The views expressed in this publication are those of the authors and do not necessarily reflect the views of United It leads us to present some alternative, more speculative views on the Nations University. regional impact of the COVID-19 outbreak. These views are presented as illustrations of the need to remain in science-based policy advice, even when confronted with a dramatic pandemic such as COVID-19, open to alterna- tive views. They start from the wide disparity in COVID-19 contamina- tion, hospitalisation and fatalities. To what extent can the study of the local environments which became breeding grounds not just of COVID-19 con- tamination but also of COVID-19 illness and mortality, provide additional insights. And in the same vein, to what extent are regions confronted with www.unu.edu

the differential impact of COVID- That variable will also be very differ- 19 not in a better position to design ent over time. Thus, historical com- appropriate exit policies. parisons with previous pandemics such as the ‘Spanish Flu’ in the early Crush the virus? 20th century, apart from the major differences in the characteristics of Viruses know no borders the infection with the Spanish Flu and in our globalised world, the – affecting more young people and undetected virus in pre- or asymp- having a shorter incubation period tomatic carriers – individuals not – ignore the very different social exhibiting any symptoms of the dis- and economic environments within ease (yet) – appears to have led to an which individuals interacted 100 unusually fast ‘super-propagation’ of years ago. COVID-19 across the world. Hence the calls for a radical ‘hammer The theoretical effectiveness approach’2 in the policy response of lockdown in these SIR models to the COVID-19 outbreak. combined with the limited medi- Such a policy response is based cal, and in particular intensive care on the well-known, so-called SIR facilities in most countries, even (Susceptible-Infectious-Removed) the most developed ones, has led model3. Susceptible population one naturally to focus on immedi- runs into infected population and ate policies to reduce the degree of gets infected at a rate β which is contact within a population leading the contact rate leading exponen- ultimately to various forms of con- tially to new infections minus the finement. And based on the histori- rate γ of the infected population cal evidence from the Spanish Flu 5 recovering or passing away. Policy pandemic in the USA, highlighting will be focused on reducing the so- the fact that states with the tightest called basic reproduction number restrictions fared best economically (R0=β/γ) indicating how many subsequently, strict confinement new cases one infected person gen- appears the best policy to imple- erates. Quite naturally, lockdown ment. Hence the standard policy will be considered the most effective view proposed and endorsed by the way of reducing this reproduction World Health Organization on the number because doing so reduces need for testing and the fast imposi- tion of strict confinement policies. About the Author both the number of susceptible and infected populations. However, and Luc Soete (born 15 September as pointed out by Daron Acemoglu4, ‘The hammer’ is there- 1950, Sint-Jans-Molenbeek) is the there is a lot of uncertainty about fore the preferred policy approach former director of UNU-MERIT, for virologists and epidemiolo- former Rector Magnificus of the parameters used in these epide- Maastricht University, and miological SIR models. Ultimately, gists. Through extreme measures now Dean of the Institute for the contact rate β is an economic like social distancing, confinement, European Studies and Vesalius and social variable which will reflect lockdown and travel restrictions, College, VUB (Free University very different types of interactions the ‘hammer’ crushes the spread of of Brussels). Correspondence to: between parts of the population the virus and brings the R0 value [email protected] with as a result different infection, quickly well below 1. From this per- hospitalisation and fatality rates. spective, all measures contributing

2 Policy Brief www.merit.unu.edu

“ For the social scientist and social science-based policy adviser, a hammer represents anything but a useful tool. The focus will be rather on ‘nudging’. ”

to such an immediate reduction are leading to continuous questioning welcome, and the stricter the con- by citizens of the internal logic of finement measures the better. individual measures. It also under- mines the organisational innova- Hammer or nudge? tion potential of entrepreneurs in personal service delivery coming up For the social scientist and with potentially safe alternatives6 to social science-based policy adviser, physical distancing. It will provide a hammer represents anything but a poor information on appropriate useful tool. The focus will be rather exit strategies as all major policy on ‘nudging’. In the face of a new measures have been introduced at virus like SARS-CoV-2 it would the same time, implying that it will consist of making sure that each be impossible to identify which incremental policy measure builds deconfinement policies are likely to up to ‘societal’ behavioural change. be the most effective. From this perspective, authorities should carefully weigh the addi- A national bias? tional, marginal impact of each mea- sure as it contributes to the overall The current virology and reduction in transmission of the epidemiological based approaches all virus, starting from simple behav- focus on the contamination and ioural changes such as routine hand- spreading of the virus within a washing to social distancing – and national setting. For years now, epi- then assess the impact of each. All demiological studies have taken indi- this within a framework of transpar- vidual countries as ‘containers’ for ency and consistency. Thus, imple- data collection and data analysis. menting physical (rather than social) The national setting also provides distancing will automatically prevent the framework for estimating the the occurrence of a large number capacity of medical facilities, espe- of social events (like public football cially the total number of available matches) or smaller social gather- intensive care units needed to handle ings in pubs or restaurants without COVID-19 patients. authorities having to specify exactly this or that set of new rules. The measurement of the pandemic and capacity of medical A ‘hammer policy’ approach infrastructure are therefore organ- combining all measures from social ised within the boundaries of indi- distancing to lockdown at once, is vidual states. In the case of Europe, from this perspective double up this explains why national health

Hammer or nudge? Science-based policy advice in the COVID-19 pandemic 3 www.unu.edu

prerogatives became so dominant, in the focus will be on the particular line with the national funding of regional environmental characteris- social and health security. It was the tics for ‘welcoming’ a COVID-19 national scarcity of intensive care outbreak. Thus, and limiting the facilities that became the red line for analysis to Europe, in the Northern introducing various national con- Italy case it is likely that it is not the finement policies and scientific first hospitalised case in Codogno expertise7 organised by taking the that is relevant, but rather the state as a measurement unit. ‘super-spreading’ event: the Champions League game between As an indirect result, the Atalanta against Seville in Milan the Footnotes internal borders of the EU, which day before with more than 40,000 1) I am particularly grateful to critical had ‘disappeared’ 25 years ago under Atalanta supporters from Bergamo. comments from Jean-Marie Beckers, the Schengen Accord, were quickly Similarly, the French outbreak had Jean-Claude Burgelman, Joep Geraedts, closed, and often unilaterally, for less to do with the first case identi- Jos Kleinjans, Pierre Mohnen, Eleonara fear of cross-border contamination. fied in Bordeaux but with a religious Nillesen, Jo Ritzen, Sven Van Kerckhoven, A policy called elsewhere a form of event in Mulhouse at the Christian Luk Van Langenhove and Bart Verspagen. Views and errors remain, however, my own. ‘beggar-thy-neighbour’ corona pol- Open Door from 17th to 21st icy.8 Doing so, COVID-19 under- February 2020. Carnival also played 2) See in particular the various publications mined the notion of European values a significant role in the spreading of of Thomas Pueyo Brochard who refers to the measures to be taken as to “the in favour of primarily national COVID-19 in the Dutch region of hammer and the dance” (see Medium expert advice and values: a first col- Noord-Brabant. In Belgium, the https://medium.com/@tomaspueyo). lateral damage of COVID-19 in highest contamination figures Martin Paul pointed this out in his latest Europe. appeared regionally clustered in par- blog on COVID-19 (https://www. ticular localities in Limburg having maastrichtuniversity.nl/blog/2020/04/ celebrated particular events9. dealing-covid-19-hammer-and-dance). Does location matter?

3) First used by W.O. Kermack and One may wonder, of course, Through such large social A.G. McKendrick, A contribution to whether there are not also other events, an unnoticed virus which had the mathematical theory of epidemics, Communicated by Sir Gilbert Walker, possible approaches to the outbreak already infected a number of indi- F.R.S.—Received May 13, 1927, of COVID-19. Might for example viduals could spread locally very Proceedings of the Royal Society A, the study of the local environments quickly. Most surprising from this Volume 115, Issue 772 and applied to that became breeding grounds not perspective is the observation that a variety of diseases, especially airborne just of COVID-19 contamination nursing homes became ideal breed- childhood diseases with lifelong immunity but also of COVID-19 illness and ing grounds for COVID-19 illness upon recovery, such as measles, mumps, rubella, and pertussis. mortality, provide additional and mortality. The elderly residents insights? And if so, might such in these homes had not travelled to 4) Daron Acemoglu, 2020, Unknowns, insights be relevant to policymaking? Northern Italy or been to large Challenges and Opportunities in the Time of COVID-19, April 9th https://www. social events, but still represented an youtube.com/watch?v=PmKsuAsJjm4 From a geographic point of ideal ‘breeding ground’ for COVID- view, it seems logical to focus on the 19. Old age, and in particular men 5) Sergio Correia & Stephan Luck & Emil Verner, 2020. “Fight the Pandemic, Save specific regions where COVID-19 having suffered or suffering from the Economy: Lessons from the 1918 found a particularly welcoming lung and heart diseases such as Flu” Liberty Street Economics 20200327, ‘breeding ground’. Virology or epi- COPD, diabetes and high blood Federal Reserve Bank of New York. demiological microanalysis will be pressure appeared to be the most on the physical contact stream of ‘susceptible population’ for becom- infected individuals; at a macro level, ing ill because of COVID-19. In

4 Policy Brief www.merit.unu.edu

other words, while COVID-19 substantially between countries but spread in particular locations in also between regions. Europe because of random social

events in February and March 2020, Does air quality matter? a clear relationship emerged between the incidence of COVID-19 The second more specula- patients and the overall health of tive question is the extent to which a local populations, and especially the second local factor: air quality, may health of elderly populations in par- have been of influence in explaining ticular regions. the clustering of COVID-19 illness and casualties in some regions and The ‘openness’ to interna- not in others. The amount of fine tional contacts: a major characteris- dust in the air is a typical local, often tic of European society, laid the regional phenomenon. It would not basis for the rapid spread of explain the location of the outbreak COVID-19 across Europe. The of COVID-19 contamination in health risk of COVID-19: the num- Lombardy, Mulhouse, Heinsberg or ber of hospital patients with Tilburg, but it might help explain COVID-19 and the mortality rate the high degree of COVID-19 ill- became regionally clustered. Yet the ness and mortality in some of these ‘hammer’ policy response remained regions such as Northern Italy10. national. The latter ignored how the Encircled by the Alps, the latter has concentration of more susceptible an extreme concentration of both groups in society differed not only traffic and industrial production

Hammer or nudge? Science-based policy advice in the COVID-19 pandemic 5 www.unu.edu

between the cities of Turin, Milan and case incidence is robust in the and Genoa and a Po Valley inten- presence of data on health-related sively cultivated. Northern Italy is preconditions, proxies for symptom currently the worst area for air pol- severity, and demographic control lution in Europe with high levels of variables.” However, as Andrée ozone, nitrogen oxides, and fine himself stresses: “The findings call particles, as illustrated in the figure for further investigation into the above. The figure illustrates the association between air pollution on high levels of air pollution in SARS-CoV-2 infection risk. If par- Northern Italy, large cities such as ticulate matter plays a significant Madrid, Barcelona, Paris, London, role in the incidence of COVID-19 Brussels and the regions of disease, it has strong implications Flanders, the Southern part of The for the mitigation strategies Footnotes Netherlands and the German Ruhr required to prevent spreading, par- 6) A point well-recognised in the area. All regions which have been ticularly in areas that have high lev- legislation on environmental standards: heavily impacted by COVID-19 ill- els of pollution.” does one require for example that all cars ness and mortality. of a company each have only a maximum It is not the purpose of the amount of emissions or does one set From a public health point present policy brief to substantiate standards at the firm level for the height of the overall emissions. The latter has of view, it is not surprising that the further the claim that regions with proven much more efficient and cheaper, strong clustering of COVID-19 high air pollution have provided a as one firm might work towards bringing mortality rates would be closely more ‘welcoming’ breeding ground the emissions of its trucks down, whereas related to places with poor air qual- for COVID-19 contamination13 but another might focus on its overall car park. ity11. Air pollution may well be cor- rather to illustrate how research in In the end, one can all share best practices, related with respiratory disease. such other research areas might pro- making a much larger overall impact. The smallest particles of fine dust of vide new insights on the health 7) Within each country different national, 2.5 micrograms tend to lodge deep impact of COVID-19. Thus, one scientific media heroes. in the lungs, making citizens of may wonder whether the various 8) Corvers, F. en L.Soete, Zet de grens met those regions more vulnerable to national COVID-19 confinement België op een kier, NRC, 17 april, 2020. COVID-19 infection. A recent policies based on purely national 12 9) Such as in Alken (the so-called Monty World Bank study by Andrée virology and epidemiological scien- Reunion on 6th March) or Sint-Truiden: investigated the statistical relation- tific advice, have missed the geo- carnival and the football match against Standard ship between COVID-19 incidence graphical dimensions in which Liège on 7th March 2020. and air pollution in 355 municipali- COVID-19 impacted local popula- 10) A recent convincing scientific paper ties in the Netherlands. Andrée’s tions differently in terms of the pointing to such a relationship can be found in results are interesting in showing need for hospitalisation and risks of Conticini, E et al., Can atmospheric pollution that so-called ‘atmospheric particu- mortality. Doing so, they inadver- be considered a co-factor in extremely high level of SARS-CoV-2 lethality in Northern late matter with a diameter less than tently led to the ‘lockdown’ of entire Italy?, Environmental Pollution, https://doi. ₂․₅ (PM₂․₅)’ is a highly significant national economies, whereas more org/10.1016/j.envpol.2020.114465 predictor of the number of con- focused regional confinements may

11) As also reported in the NYT, A Harvard firmed COVID-19 cases and have represented a more appropriate study found correlation between air pollution related hospital admissions: “The policy response to COVID-19. and COVID-19 deaths in the USA. See NYT, estimates suggest that expected https://www.nytimes.com/2020/04/07/ COVID-19 cases increase by nearly climate/air-pollution-coronavirus-covid. 100 percent when pollution concen- html trations increase by 20 percent. The association between air pollution

6 Policy Brief www.merit.unu.edu

Conclusions effective European way, exploiting now also more fully the notion of Healthwise, a regional ‘subsidiarity’ in addressing COVID- COVID-19 policy focus will natu- 19. Doing so, it would bring back rally focus on the most vulnerable, the notion of solidarity between susceptible parts of the local popu- regions, as opposed to the current lation in combatting the pandemic; lack of solidarity between individual the opposite as it were of the smart European Member States. specialisation development strate- Solidarity between regions in the gies typically pursued in European EU as actually encapsulated in the Footnotes

regions, namely weak regional vul- European Treaties and reflected in 12) Andrée, B.P.J. (2020), Incidence of nerabilities specialisation. the particular attention given to the COVID-19 and Connections with Air Implementing regional confinement so-called cohesion funds in Pollution Exposure Evidence from the or quarantine raises of course com- European integration would possi- Netherlands, Policy Research Working Paper plex implementation and mainte- bly be the best response to rebuild 9221, April. nance issues. How to prevent people European values at this time of 13) A recent paper by Martelletti, L and from being mobile between a con- COVID -19 crisis, contributing not Martelletti, P., Air Pollution and the Novel fined region and other regions just to economic convergence across Covid-19 Disease: a Putative Disease Risk within a country?14 For sure, it is Europe but also to health and social Factor, SN Compr. Clin. Med, https://doi. org/10.1007/s42399-020-00274-4 claims easier to close a national border convergence. that the “SARS virus and other respiratory than to confine a particular region, diseases such as COPD (chronic obstructive as Italy witnessed when it attempted pulmonary disease) find fertile ‘territory’ in air to do so in the early stages of the pollutant particles and, in a linear relationship, COVID-19 outbreak. But lessons they survive longer and become more aggressive could be learned. Ultimately, it in an immune system already aggravated by these harmful substances.” In another recent raises similar practical problems of study of Yaron Ogen, Assessing nitrogen immediate, sudden closure and dioxide (NO2) levels as a contributing factor to restricting the mobility of individu- coronavirus (COVID-19), Science of the Total als to what are considered essential Environment 726 (2020) 138605 https://doi. activities. The main point is that org/10.1016/j.scitotenv.2020.138605, a putting a region into quarantine is regional spatial analysis has been conducted for 66 administrative regions in Italy, Spain, likely to have a more limited impact France and Germany. Results show that the on the overall economy than concentration of COVID-19 fatality cases national confinement policies. It was in five regions with the highest NO2 will also enable one to introduce concentrations combined with downwards deconfinement policies more gradu- airflow preventing an efficient dispersion of ally, taking into account regional air pollution. As the paper highlights: “These results indicate that the long-term exposure to differences in contamination levels. this pollutant may be one of the most important Here too more targeted responses in contributors to fatality caused by the COVID- the exit strategy in line with the 19 virus in these regions and maybe across the geographical characteristics will be whole world.” more effective. 14) Of course it can be argued that many European countries have had experience And from a European per- in cross-border regions with such regional spective, such regional approach confinement policies having closed their would open up the policy window of borders. addressing COVID-19 in a more

Hammer or nudge? Science-based policy advice in the COVID-19 pandemic 7 www.unu.edu www.merit.unu.edu

INSIDE: Policy Brief

The United Nations University – Maastricht Economic and Social Hammer or nudge? Research Institute on Innovation and Technology (UNU-MERIT) is a research and training institute of United Nations University based Science-based in Maastricht in the south of the Netherlands. The institute, which collaborates closely with Maastricht University, carries out research and policy advice in the training on a range of social, political and economic factors that drive COVID-19 pandemic economic development in a global perspective. Overall the institute functions as a unique research centre and graduate school for around Some 25 years after 100 PhD fellows and 140 Master’s students. It is also a UN think tank the Schengen Accord, addressing a broad range of policy questions on science, innovation and democratic governance. COVID-19 has undermined the notion of European values in favour of primarily national expert advice and values: a first collateral damage of

COVID-19 in Europe.

The Netherlands The

6211 AX Maastricht AX 6211

Boschstraat 24 Boschstraat

Innovation and Technology and Innovation

social Research institute on institute Research social

Maastricht Economic and Economic Maastricht Uniter Nations University - University Nations Uniter