Towards a science of infectious disease negative externalities

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This piece by Sanjeev Sabhlok, an economist with counter-narrative covid books already to his name (see here and here), is a lay summary of a first-principles review of public health that he commenced in early 2023. Among other things, hisreview identifies the “market failures” in infectious disease and asks whether the preferred remedy of public health – quarantine of the healthy – is efficient from an economic standpoint

Sabhlok reports that nearly 200 years ago, the Sanitarians (a movement prompted by the work of Charles Maclean) intended sanitation to be a complete replacement for quarantine, which they sought to abolish. Quarantine was found by those in this movement to be “little short of willfulmurder” as it always failed because of human factors, and in fact increased harms.  At the same time, he notes, the discipline of public health has downplayed the fact that the hospital system is the main multiplier of serious infectious disease. 

The piece concludes by agreeing with the Sanitarians that quarantine should be abolished and suggesting that an independent health stream be established for serious infections, from the pre-triage stage onwards.

The ongoing work underpinning this piece, of approximately 80,000 words at time of writing, is available in the public domain. Sanjeev expects his ongoing research to take two to four years.

Some of us think that lockdowns were a bad idea, but astoundingly, the majority of public health professionals have long believed otherwise.

Anders Tegnell exclaimed on 24 June 2020 about lockdowns that “[i]t was as if the world had gone mad, and everything we had discussed was forgotten”. I have searched hard for evidence regarding those who might have “forgotten” what they had discussed. I have found that the three co-authors of Donald Henderson’s 2006 paper (that was critical of lockdowns) have backed off from their paper and supported covid lockdowns. And the Hong Kong academic who led the WHO’s 2019 pandemic guidelines (that opposed mass-quarantine) supported Hong Kong’s restrictive covid policies.These people indeed seem to have “forgotten”, in the madness of the covid panic, what they once knew.

Yet more broadly, anti-quarantine views have for generations remained at the fringe of the public health profession. My research has identified only 25-odd public health practitioners who ever expressed scepticism about quarantine between the years 1900 and 2019, i.e., probably 0.1% of all such practitioners. The overwhelming majority were directly or implicitly supportive of quarantine. Textbooks, journal articles, books and the media have long provided extensive lip-service support for quarantine, always citing previous “successful” quarantines. Indeed, I believe that no public health textbook sceptical of quarantine effectiveness has ever existed. Over the recent decades, mathematical models too have asserted that quarantine works.

It doesn’t surprise me, therefore, that the ABC, Australia’s public broadcaster, slandered and attacked me in 2021 while justifying Xi Jinping’s Wuhan lockdowns. The ABC cited the alleged success of the lockdowns instituted to control the 1665 London plague and the early 21st century outbreak of SARS. That quarantines work is, indeed, the conventional opinion in the public health literature.

But here’s the problem with all this.  The many comments made over the past 120 years (either in favour of or against quarantine) have almost always been throw-away lines, casual and unsupported, and based on poorly analysed historical, anecdotal accounts. No one – whether supporter or opponent of quarantine – has attempted a systemic, scientific study of the topic. 

And, of course, the claim that quarantines and lockdowns worked in the past is a big lie. I have drafted a paper which collates extensive empirical evidence of the failure of previous quarantines. Moreover, it would not matter whether quarantine worked, if its harms undermine its benefits. It is the net effect on health and wellbeing of any health intervention that matters. We have robust evidence that quarantine does not create a net benefit for society for any disease. Medical isolation is important for serious infectious disease such as SARS, and in such cases is likely to pass the cost-benefit test, but quarantine of the healthy harms society.

Public health has strayed very far from its foundations

Public health did not start in this fuzzy, chaotic manner. It had a glorious beginning, in which truth and the scientific method mattered. With Bentham’s interest in expanding human welfare and the pathbreaking scientific discoveries of Dr Charles Maclean and the Sanitarians, public health was the biggest large-scale rational advance in medical science. While some perceptive people had commented over the centuries about the failure of quarantine (e.g., US President Thomas Jefferson wanted a review of this policy), it took three decades of work by Charles Maclean to bring the empirical and theoretical scientific work together to support this view that quarantines don’t work.

Everything that we have come to expect today from science and rationality was part of Maclean’s analytical framework. His books informed us, based on empirical evidence, that quarantines have never worked for the non-contagious diseases of plague, cholera, yellow fever and typhus (for which medieval quarantines were imposed), and cannot work even for any contagious disease because of the failure of humans, including corruption. His books are replete with examples.

He then carefully identified the endless “adventious”(collateral) harms to human wellbeing from quarantine. He proved that “the Quarantine Laws are … invariably found to increase sickness and mortality”. He then conducted the first-ever cost-benefit analysis (CBA) of quarantine to prove that harms grossly exceed any benefit. Not until 200 years later was anyone to even consider such an undertaking.

In my opinion, there is nothing in our basic theoretical and empirical toolkit today for examining quarantines’ value that was not already identified and made use of by Charles McLean. Moreover, his work is far superior in many ways even to the work of those who have conducted CBAs of lockdowns in recent years, since he provided not just a theoretical foundation and detailed calculations, but also extensive empirical proofs of previously failed quarantines.

Maclean’s work pivotally influenced Dr Southwood Smith and Edwin Chadwick who led the demand for sanitary reforms and helped create the first Public Health Act (of 1848). In 1883, Chadwick reported that “quarantine had everywhere failed to check the advance of the pestilence. Quarantines … were of as little avail as they would be against the east wind” and that “cordons sanitaires, internal as well as external … aggravates instead of mitigating the evils”. Around 1850, Dr Southwood Smith wrote: “Substitution of sanitary measures for quarantine restrictions would render the importation of any disease from one country into another in the highest degree improbable.” These latter two men were the lead members of the first General Board of Health established under the Public Health Act of 1848, which “proposed the dissolution of the existing quarantine establishments, and their replacement by sanitary regulations.”

Yet public health has completely hidden these amazing facts from our view. No public health textbook tells its students that the founders of the discipline repeatedly insisted, with extensive proofs, on the abolition of quarantine. Or that its founders had undertaken mammoth empirical work and a CBA on this topic. Instead, modern public health rejects empiricism and the idea of a CBA, in favour of models, speculation and “expert” assertion.

Maclean wanted continuing research on the topic

Being an empiricist and scientist, Maclean called for “continued practical investigation” of quarantine. Did public health follow through? You bet not. Instead of following the scientific journey started by the Sanitarians, the modern practitioners of public health insist on mediaeval quarantines that were created by superstitious, ignorant quacks during a dark period when the scientific method itself did not exist.

The reason for this ongoing support for quack quarantines isobvious. Vested interests gain enormously from quarantine: jobs for mates, public resources, enormous political power. Such interests have managed not only to scuttle all talk of the abolition of quarantine but also to cancel the scientific breakthroughs of Maclean and the Sanitarians which continue to threaten their livelihood. My research has shown that the sporadic, rare references to Maclean in the public health literature are, without exception, slanderous.

The need for a first-principles review of public health

Today’s discipline of public health has not only re-written the entire failed history of quarantine, it rewards those with anability to create mass hysteria through models, thereby “proving” that quarantine works. The most obvious and self-evident truths are turned on their head. Anyone with open eyes can see that covid lockdowns failed to stop the virus anywhere in the world. Even Australia’s attempts failed. Restrictions imposed on the elderly in aged care centres across the world failed. But Imperial College claims that covid lockdowns have saved 3 million lives in Europe alone. Goebbels would have been proud.

There is some good news in the midst of this medieval darkness. Since 2020, a few public health practitioners and economists have commenced a critical examination ofquarantine. Such work is good but needs to significantly up the anteMany decades of work lie ahead in order to advance the frontier of science from where Maclean and the Sanitarians left it – with their blaze of broad-based, empirical, scientific analysis.

Not aware of this pathbreaking work already done 200 years ago, a few months ago I started a first-principles review of public health to identify the market failures in public health and consider options to address these failures. Maclean’s extensive analysis has acted as a booster rocket and launched my work into orbit: I’m far further ahead in my journey than I had anticipated, because he has done practically 75% of my work.

Apart from confirming Maclean’s conclusion that quarantine must be abolished, my tentative conclusions are that in order to promote the health of the public, we need (a) more sanitation, (b) more international air travel, (c) a two-category hospital system featuring a stark separation of non-infectious from infectious disease, and (d) a new social compact. Regarding (c), there is extensive empirical evidence that hospitals are the main super-spreaders of infectious disease (a phenomenon termed “nosocomial spread”). Around 30-80% of the patients who enter hospitals will catch one or another infectious disease. The problem starts with Emergency Room triage, which is not fit for purpose. Options to fix this include drive-in triage and triage that picks up infectious patients from home, plus the establishment of a separate Isolation Hospital. I have detailed all these proposals in my 80,000 word-plus draft paper. I invite feedback and suggestions.

An outcome that I hope will emerge ultimately from this work is the creation of a full-fledged branch of public health and economics to study the science of infectious disease negative externalities. I’m not referring here to modelling, but to the empirical analysis of social distancing, quarantine and isolation. Further, future generations of health professionals will need to be educated in the reasons why quarantine has failed and causes great harm. That requires the writing of new textbooks. Young professionals must also be encouraged to focus their energy on re-designing our hospital systems. Doing this won’t eliminate negative externalities from infectious diseases – which will always be with us – but, unlike quarantine, carry the potential to reduce them at a tolerable cost.

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