key: cord- -zvb bxix authors: connolly, john title: the “wicked problems” of governing uk health security disaster prevention: the case of pandemic influenza date: - - journal: disaster prev manag doi: . /dpm- - - sha: doc_id: cord_uid: zvb bxix purpose: the purpose of this paper is to examine the governance and policy-making challenges in the context of “wicked problems” based on the case of pandemic influenza. design/methodology/approach: the case study research is based on an analysis of official documentation and interviews with policy elites at multiple levels of uk governance. findings: results of this study show that policy actors regard risk communication, the dynamics of international public policy and uk territorial governance as the main governance challenges in the management of influenza at a macro-level. the paper also serves to identify that although contingencies management for epidemiological issues require technical and scientific considerations to feature in governance arrangements, equally there are key “wicked problems” in the context public policy that pervade the health security sector. practical implications: the study indicates the need to build in resources at a national level to plan for policy coordination challenges in areas that might at first be seen as devoid of political machinations (such as technical areas of public policy that might be underpinned by epidemiological processes). the identification of the major governance challenges that emerge from the pandemic influenza case study is a springboard for a research agenda in relation to the analysis of the parallels and paradoxes of governance challenges for health security across eu member states. originality/value: this paper provides a novel interrogation of the pandemic influenza case study in the context of uk governance and public policy by providing a strategic policy lens from perspective of elites. in april the british public were reminded that pandemic influenza (flu), in the context of health security, continues to be a major concern for uk policy-makers. there is recognition by the uk government that a pandemic remains the top health risk for the population (nhs england, ) . the risk of pandemic flu has come into the spotlight recently due to the fact that key measures to prevent such a diseaseinduced disaster may not be effective. a review of the effectiveness of tamiflu [ ] (the main contingencies measure to manage a pandemic) produced by the cochrane collaboration ( jefferson et al., ) , referred to in the rest of this paper as "cochrane review", in the uk concluded that tamiflu had no significant impact on reducing hospital admissions and does not serve to prevent the person to person spread of influenza. this led to pharmaceutical companies retorting by questioning the reliability and validity of the review. uk health authorities responded by insisting that investing in tamiflu remained "a good insurance policy for the population" . the debates around the cochrane review (which are often scientific and epidemiological in nature) also served to highlight the public policy-orientated challenges to managing health security threats such as a pandemic. this paper seeks to delve into the public policy aspects of contingencies management for disease threats from the perspective of policy elites based on the case study of the influenza pandemic in the uk. the paper addresses a lacuna in uk disaster and crisis management literature by contributing to the "governance" aspects managing health security. there are studies which consider crisis management, resilience and risk in the context of uk public policy (e.g. mcconnell, ; drennan and mcconnell, ; brassett et al., ) , however, there are very few case-based research studies which illustrate crisis and disaster governance challenges from the perspective of those institutions and policy actors that are responsible for managing such "wicked problems" from a macro-level policy position. from a public policy point of view, pandemics represent challenges that are unstructured, relentless and cross-cuttingall hallmarks of a wicked problem (weber and khademian, , p. ) . first, as weber and khademian ( , p. ) note, issues that can be viewed in this way are unstructured given that there are high informational demands, there is not always a clear solution to the problem and they have multiple ripple effects. second, the relentlessness of such problems emerges as a result of the fact that the fight is never over and a line cannot be drawn under themthere is no finality. third, cross-cutting refers to the fact that wicked problems involve multiple stakeholders who have a range of views and knowledge within a complex political and economic context. the complexities of disease threats and their transcendence of systems elucidates the fact that health security and pandemic prevention involves trade-offs, require flexibility, resource sharing and collaboration to ensure policy success (durant and legge, ) . other examples of wicked problems include responding and managing climate change, social justice, drug trafficking, immigration, and epidemics. pandemic influenza fits with the notion of a wicked problem given that they call for multi-level and multi-actor responses across territories requiring a high degree of resilience to deal with the contours of the disease (unstructured and cross-cutting). at a population level the risk of a pandemic endures over time as a result of the mutation of disease strains and the impact of pandemics can traced over many years (relentless). indeed, policy-makers are well aware that in the last century alone the , and influenza pandemics have contributed to millions of fatalities as well as vast economic and social disruption (kamradt-scott and mcinnes, , pp. - ) . the case of pandemic influenza is a "way in" to understanding the policy dynamics of the health security sector in the context of disaster research. the issues to emerge from pandemic influenza are likely to have consequences for the governance of other diseases (and, naturally, reference to other diseases will be made in this paper given policy responses to specific diseases do not exist in a vacuum). the question that underpins the paper, therefore, is: what does the case study of pandemic influenza tell us about what policy elites regard as the key "wicked problems" of contingencies management in the context of uk governance? the case study has been interrogated by deploying mixed qualitative methods. the case study method is effective in public policy research for exploring, assessing, conceptualising, and refining explanations for the characteristics and dynamics of social realities or events (lowi, , p. ; eckstein, , pp. - ; flyvbjerg, , p. ) . the approach included a thematic analysis of secondary sources and official government documentationincluding the and house of lords reports into pandemic influenza (hl- , ; hl- , ), the department of health (doh) national framework for responding to an influenza pandemic (doh, ) , the independent review of the influenza pandemic (cabinet office, ), the uk influenza pandemic preparedness strategy (doh, ) and reports of the european commission. the research also involved undertaking in-depth semi-structured elite interviews with policy actors who occupy strategic-level governmental positions in scotland, the uk and in the european commission (the commission being the main policy initiator at the eu level). the analysis of documentation served to support the identification of interviewees and contributed to the themes that structured interview schedules. the interviewees were purposely sampled due to their positions at different tiers of government in the health security policy area. the interview breakdown is as follows: scottish government ¼ interviews (subnational/devolved level); uk government (national) level: public health england (phe) (agency of the uk civil service) ¼ ; westminster/uk parliament ¼ ; uk cabinet office (central ministerial department/headquarters for government) ¼ ; and european commission (health threats unit: ). interviews lasted on average . to hours in length. the scottish and uk level interviews were face-to-face in governmental or parliamentary premises and the interviews with european commission officials took place via teleconference facilities (with the interviewer being present on university premises). there were inconsistencies in terms of the medium by which the interviews were conducted and the necessity for teleconference interviewing was borne out of resource limitations for travel (particularly the high costs for travel between scotland and luxembourg -where the officials were based in the commission). however, these inconsistencies should not necessarily been seen as limitations given that the interviews conducted via teleconference were equally rich in depth and exploratory. interviews were also sought from individuals who work in the area of public health and disease risk management in the doh, however, there was a lack of preparation by such individuals to engage with this research via an interview. the position of the department was that their institutional approach had been detailed sufficiently in strategy documentation (cited earlier in this paper). digital recordings of all the interviews were fully transcribed within hours of the interviews taking place. the interview data was thematically coded around the most significant strategic policy challenges to emerge from the data. it should be noted that the majority of the interviewees felt it to be impossible to "rank" the extent of whether one challenge outweighs another but regarded these challenges to be equally placed on a continuum of policy challenges that were present in the case of pandemic influenza. the quality of the interviews is borne out of the fact that the individuals are situated in strategic-level positions within the institutional environment under investigation (less senior officials, of which there would likely be higher numbers, would be less able to discuss strategic relations across territories). in this respect the quality of the interviews outweighs the need for quantity given the low number of individuals that are in such senior positions in this policy sector (i.e. ten interviews represents a strong sample from a small pool of available data). this approach also serves to highlight the uk health security contribution that emerges from the study in that the interviewees where able to discuss matters of macro, strategic level concern from their perspectives. the interviewees were made up of a senior uk parliamentarian (with a remit for health security) and senior officials working within the areas of contingencies and crisis management for public health at multiple levels of governance (the european commission, uk government departments/agencies and in the scottish government). in short, the paper seeks to identify where the "politics" fits in the area of contingencies and crises management from the perspective of elites in relation to health security within a multilevel governance context. the study accommodates all study protocols which were approved by the author's university ethics committee and by the funding body for the research (carnegie trust, scotland). viewing health security in the context of "disaster" in a similar vein to "crisis", no definition of disaster has been agreed upon in the literature (hood and jackson, ; perry and quarantelli, ) . alexander ( , p. ) has described disaster research as being embedded in a "definitional minefield". analyses have ranged from explaining disasters as the collapse of cultural protections (carr, ) , unique events (rubin and popkin, ), a form of collective stress (barton, ) , systemic events, and a form of a social catalyst (kreps, ) . disasters tend to be events which lead to large-scale damage to human life, damage to the physical environment and have vast economic and social costs. there is a considerable body of literature that has focused on the impact that physical (sometimes expressed as environmental) disasters have had on human activities (alexander, ; steinberg, ) . indeed, human vulnerabilities have been an important defining factor in the classification of an event as a disaster (smith, ) . again, however, there is an analytical grey area between what constitutes a crisis or disaster due to shifting identities and contextual change. for example, analyses have described a shift from threats to disasters (rijpma and van duin, ) and from crises to disasters (davies and walters, ) . the definition(s) applied to analyses seem to be dependent on the discipline using the term and the aims of the researcher because "actors create a definition with different ends in mind" (perry, , p. ) . in this respect, the "securitisation" of health, particularly around pandemic disaster prevention and management in the context of global governance, is now generally accepted by key supranational authorities (who, ; european commission, ) and in the academic literature in the context of global governance (kay and williams, ; connolly, ) . it is argued that health security can be studied and framed in the context of disaster research given that if threats of disease pandemics are not managed effectively, and safeguards are weakened, then a pandemic, and thus pandemonium, will ensueleading to far-reaching damage to human life and produce vast economic social and environmental costs on a global scale. the case of pandemic influenza in the uk the implications of pandemic influenza are "feared by politicians, health practitioners and security experts alike" (kamradt-scott and mcinnes, , p. ). significant concern of a pandemic occurring was heightened as a result of the threat of the avian flu virus in asian countries (h n virus) in and . more recently, fear about human to human transmission of influenza was particularly acute as a result of the h n "swine flu" virus. the threat emerged when the world health organisation (who) declared that there was an outbreak of swine flu following confirmation of human cases in the usa and mexico in april . two confirmed cases of pandemic influenza subsequently emerged which involved a couple who had returned to scotland from mexico (connolly, ) . this led the uk government to increase their stockpile of antivirals (tamiflu) to million (from million). the government's approach was to maintain the policy of containment e.g. through contract tracing and antiviral treatment (cabinet office, , pp. - ) . by june/july the cases of swine flu has reached almost , in countries. the cases of swine flu in the uk reached , and there were pockets of concentration of the disease in birmingham and greater glasgow (cabinet office, , p. ). the who declared the outbreak had moved to pandemic levels which triggered the uk government to procure vaccines to cover per cent of the population. in late november modellers concluded that the pandemic had peaked and a gradual reduction in cases followed (cabinet office, , p. ) . the pandemic led to [ ] deaths during the pandemic in the uk (cabinet office, , p. ). the uk response to the pandemic relied on cooperation between supranational, national and subnational jurisdictions (with uk state level being the "core" crisis management actor through the department of health phe and the uk cabinet office). following the pandemic the government produced a uk influenza pandemic preparedness strategy (doh, ) which, building on the "national framework" for responding to an influenza pandemic (doh, ) , sets out in some detail the key planning assumptions and presumptions for planning for a pandemicincluding a summary of the key roles of government departments and agencies as well as the control strategies in order to mitigate against the impact of a pandemic influenza crisis. an important point, made rather passively in the strategy, is that preparedness and response to the threat is coordinated at local, national and international levels (doh, , pp. - ; connolly, ) . the case of pandemic influenza in highlighted that disease threats, such as pandemic influenza are trans-boundary which can penetrate integrated political and economic systems (such as the european union) and, therefore, call for a large number of organisational actors, at different governance levels, to be engaged in crisis management processes (allison, ; 't hart et al., ) . the resilience literature recognises the importance of considering the implications of when crises outweigh local capacity and there is a need for a multi-level response across borders and tiers of governance (see, e.g. brassett et al., ) . there is general agreement in the literature that local-or state-centric studies of crisis, emergency management, security and risk ('t hart et al., ) need to adapt their analytical frames to consider multi-level systems (coaffee, , p. ). the study "resilience" is characterised by its inexactitude given that, as anderson ( , p. ) , notes it has been referred to in academic circles, amongst other things, as "ethos", "programme", "ideology", "concept", "term", "governing rationality", "doctrine", "discourse", "epistemic field", "logic", "buzzword", "normative or ideal concept", and "strategy of power". however, in the context of health security, we are reminded by the - global ebola outbreaks of the need for international systems to be resilient in terms of being flexible and multi-partnership focused whilst, at the same time, having clarity over institutional roles and responsibilities. this is in order to avoid disorganised and belated responses (as demonstrated by the global response to ebola). in this regard, successful resilience is dependent on being able to navigate complexity given the context of interdependences between governmental and non-state actors across multi-level uk health security and cross-cutting jurisdictional boundaries (bevir, , p. ) which necessitate inter-organisational coordination (perry and lindell, ) . as a result, this warrants the need for contingency planning needs to take place at multiple levels of governance given that internal failures can have implications for the integrated system and have disastrous consequences (see turner and pidgeon, ; boin and mcconnell, ) . these requirements are not always matched by the characteristics of bureaucratic contexts which are known for their conservatism when it comes to institutional change. what is more, conflictual and political behaviours can manifest at different levels or governance and, as a result, a lack of contestation between political and bureaucratic actors cannot be assumed (rosenthal et al., , pp. - ) . yet evidence of this is often masked by the tendency of official governmental documents (such as strategies and contingency planning documents) to be read as if contingency processes (particularly for scientific or epidemiological issues) are in some way non-political in that such documents tend to focus on a range of "manual-like" sequential steps that should be taken in the event of an incident. clarke ( ) discusses the symbolic and political nature of such crisis contingency planning by the use of "fantasy documents". it is the contention that governmental documents that attempt to tame crises or disasters are "little more than vague hopes for remote futures and have virtually no known connection with human capacity or will" (clarke, , p. ) . it is within this context that questions about the "politics" of contingencies and crisis management functions across multiple levels of governance are pursued and, specifically, how this relates to the issue of health security. the case study data indicates that balancing the activities of risk communication with pharmaceutical interests is a major governance challenge in policy-making for pandemic flu (and, arguably, for other diseases). the conclusions of the aforementioned cochrane review questioned whether government investment in a stockpile of "tamiflu" as a contingency measure to safeguard the population matched any potential benefits of taking the medication. the evidence presented by jefferson et al. ( ) suggested that tamiflu moderately reduced the period that individuals would have flu symptoms. this led to pointed media reporting of the issue which included headlines such as "drugs given for swine flu were waste of £ million" (knapton, ) and "what the tamiflu saga tells us about drug trials and big pharmaceuticals" (goldacre, ) . the response from the industry was that the review underestimated the benefits of tamiflu and that they disagreed with the statistical analyses and therefore disagreed with all of the conclusions (gallagher, ) . the uk department of health confirmed that they would not change their public health advice in relation to the use of tamiflu as part of its preparedness planning despite the findings of the cochrane review. it is with key reference to the issue of tamiflu that elite actors suggest that there are challenges with regards to risk communication and, revealingly, the chief medical officer (cmo) for scotland pointed out that "we are not very good in government at conveying the full arguments and why we have decided to continue with the current policy" (keel, ) . for policy-makers the former secretary of state for health, and latterly the chair of the uk parliamentary committee for health, highlighted the difficulties in "communicating the subtleties" of scientific evidence (dorrell, ) . this chimes with the perspectives of the cmo for scotland and the chair of phe who considered that the challenges of "coordinating and digesting advice" (keel, ) that is "unadulterated, clear, properly analysed and packaged for the policy-makers" ) are significant. the wider point here is that scientific evidence is just one consideration by policy-makers and it would almost be impossible for this to not be the case in a politically driven society . a further challenge in terms of risk communication is getting across the message that it will take at least four to six months after a novel virus has been identified and isolated before pharmaceutical manufacturers can make an effective vaccine available (doh, , p. ) . although it could be said that the provision of scientific products by pharmaceutical companies are essential, because they are the only place where new drugs and vaccines and biotechnologies are being developed, the risk for many politicians is that because they are profit-making organisations "it is easy to be accused of favouring a pharmaceutical company because of vested interests" . however, contingency planning for health security requires the need for a stockpile of drugs and vaccines but this undoubtedly remains a political decision because the opportunity cost would be that policy-makers could be accused, in the event of a crisis, of not having appropriate measures in place thus endangering the health of the public (dorrell, ) . pandemic flu served to highlight that risk communication, coupled with industry interests, need to be taken into account when it comes to the management of science-or medical-based areas of public policy. political leaders can have their fate determined by how they respond to crises (boin et al., ) , and investing in a stockpile (even if they are never used), symbolises government readiness ('t hart, ) . the uk department of health has highlighted that in a globalised world it is not possible to prevent, manage and eradicate a new virus in neither the country of origin nor when it penetrates uk borders (doh, , p. ) . it is for this reason that the current chair of ohe, writing back in , noted that reporting and responding to infectious diseases requires collaboration across territories (heymann, , p. ) . heymann ( , p. ) suggested that "[t]his phenomenon is a potential infringement on national sovereignty that compromises the concept that states reign supreme over their territories and peoples". the twin threats of sars and avian influenza served to seal a new approach to health security for disease threats within a globalised world whereby the norms to responding to public health threats are such that reporting is much more the norm in order to eradicate diseases as efficiently and effectively as possible. the rise of surveillance using the internet and international standards and agreements, such as the global influenza surveillance network (of which there are member states), overseen organisations such as the who, has now replaced a situation whereby individual states provide information on disease threats and outbreaks on a voluntary basis (heymann, , p. ) . the relationship between state actors and international policy regimes in the process of contingencies management for health security becomes ever more apparent in the context of eu public policy. the legislative competence of the eu in coordinating contingencies and crisis management arrangements for public health threats has increased after a series of serious disease episodes, such as sars, avian flu and pandemic influenza, which have presented opportunities for closer policy integration and europeanisation (ryan, ) . health security within the eu is coordinated by the directorate general for health and consumer protection of the european commission. the role of the commission has become legally enshrined since the sars outbreak which ended the voluntary arrangement in place for member states to provide data to supranational institutions uk health security (as was the case in terms of providing national level information to the who). there is now a system in place for eu level surveillance in that member states are legally required to statistically report on cases of communicable diseases through the eu health security committee on an annual basis and second, states are obliged to inform each other using an electronic system of outbreaks of one of these communicable disease which could have effects on other member states. yet, enthusiasm for closer integration between states cannot be taken for granted given that given that larger member states (such as the uk, france and germany) have their own systems of contingencies management that have strengthened over time and, therefore, "carrying smaller member states" can be a distraction (phe official, ) . there have also been difficult tensions (which is a key hallmark of "wicked problem") when it comes of the sharing of what some member states would describe as "sensitive data" with each other through the route of the health security committee when it comes to contingency planning. the reason for this is articulated by a senior european commission official: we have member states that plan to vaccinate percent of their population in the event of a pandemic. in other words, percent will not be vaccinated and then you have countries that are providing for percent. clearly if this information becomes public the citizens of the concerned countries -the percent who won't get the vaccine might have some questions to ask of their politicians. the health security committee does not oblige member states to vaccinate everybodythat's not the purpose of the exercisethis is a national decision for how many people they consider suitable or requiring a vaccination. for example it could be public service workers, it could be medical personnel, the armed services, it could be the security services. in germany it was the politicians for some reason. so this is a very political and national decision. what we have done is to take the figures from each member state and formulate a joint tender. so we now have the figures for the different member states which are quite confidential i can tell you and we will make a tender to industry and the industry will be able to apply to supply this vaccine. for senior policy-makers, the governance challenges are grouped around managing public policy dynamics around ensuring closer integration and europeanisation in the knowledge that diseases transcend borders and therefore requires collaboration across territories. however, the complexities come from the politics of using resources to support "weaker" member states and the sensitivities around sharing classified information about who will be prioritised when it comes to implementing a vaccination programme in the event of a pandemic. the wicked problem of uk territorial governance uk policy actors (i.e. in scottish and uk governments) in the area of health security have highlighted the domestic state-level challenges of managing planning for pandemic disease within uk borders and the political dimensions to this process. the uk constitutional arrangements are such that we have devolved governments (with limited powers) in scotland, wales and northern ireland. the governance challenges are complex and this is partly due to the fact that control over health policy in the uk is not straightforward. for example, in the case of scotland public health (i.e. nhs and wider healthcare) is a devolved matter, however, matters of health security that have public health implications (such as bio-terrorism) are reserved matters for the uk government. such challenges are exacerbated when administrations are headed by different political parties at different tiers of governance. for example, the scottish government is headed up by a different political administration to the uk level (the scottish nationalist party) and the case study data has shown there to be evidence that nationalist politics has impacted on approaches to multi-level contingencies management for health security (although, for pandemic influenza specifically, both uk and scottish level elites highlighted that there were strong relationships between public health officials). a scottish government official indicated how the nationalist public health minister, michael matheson, was concerned that documentation on cross-border contingencies management pertaining to health (such as radiation protection and nuclear monitoring) had the word "england" in the title as a result of the creation of "phe" as an executive agency of the uk department of health at uk level in april . this had serious implications for civil servants in scotland in that they had to research and scope out the reasons why there is not the capacity to undertake this type of work at the subnational level in scotland: the current policy arrangements are such that the devolved administrations in the uk contribute to national strategies for preparedness planning and crisis simulations, however, as one senior scottish government official noted, "it is not always the case that the devolved administrations are there and creating plans with the uk government" (scottish government official, ). interviewees from different triers of uk governance agreed that there is mutual interest in maintaining strong relationships across levels of governance both in terms of managing the spread of diseases and ensuring that clear communication channels are in place. this is not to say, however, that there are no political tensions when it comes to multi-level contingencies management for national health and security. a senior official in scottish government gives the example of counterterrorism efforts as part of the operations of the commonwealth games in glasgow . as noted above although counter-terrorism measures have implications for public health, contingencies management arrangements for terrorism are a reserved issue for westminster. this leads to multi-level tensions in terms of information sharing (even to the officials of the host country of the games) given the sensitivities around responses to terrorism: we had an exercise for the commonwealth games and cobra [of the uk cabinet office] was involved. one of the issues that people mentioned quite a lot was the counter-terrorism aspect as that is a big issue. there is an issue in terms of sharing information between parts of the administration. it is clear from such insider perspectives that there are political interests that infiltrate the approach of policy-makers even when it comes to so-called "technical" areas of contingencies and crisis management. the cmo was clear about the fact that there are interests on both sides of the border between scotland and england in terms of maintaining the current arrangements even if the devolution of more powers continues given that diseases and organisms do not stop at the border (keel, ) . in terms of the experience of managing the influenza pandemic the independent review of crisis noted that strong sub-national and national relations were not taken for granted given that "the h n pandemic was the first uk-wide crisis in a devolved policy area, and therefore there could have been inconsistencies and disagreements between the four uk nations during the response" (cabinet office, , p. ). yet the report concluded that "the willingness of the devolved administrations and the department of health to work closely together within a common uk framework was fundamental to the overall success of the response" (cabinet office, , p. ). notwithstanding this encouraging narrative, as noted above, there have been examples of nationalist fervour impacting on the public policy process in scotland which have placed demands on civil servants north of the border. there are also intriguing inter-institutional dynamics here if one considers the fact that reserved areas of public policy (which have health security implications) are legislated for in england (such as counter-terrorism policy which include measures to manage biosecurity) and the uk government can become protectionist when it comes to sharing information with subnational government despite public health being fully devolved to scotland. this serves to demonstrate that the case of public health threats fit with the perspectives of those who consider there to be an "unequal plurality" and a "predominantly asymmetric imbalance" (marsh et al., , p. ) in uk governance. this is certainly the case for the context of contingencies management processes for uk health security. the paper has provided key insights into strategic-level relationships across multiple levels of governance in relation to contingencies management policy-making for health security. it has sought to unpack some of the political multi-level policy complexities associated with managing pandemic influenza as a "wicked problem". contingency management processes in relation to this case study highlights the considerable public policy and political challenges, articulated by for policy elites, in terms of risk communication, the internationalisation and europeanisation of national contingencies management processes and uk national-subnational relations. the lens adopted by this paper, in terms of identifying the perspectives of policy elites, has emerged out of the desire to address a lacuna in uk disaster and crisis research in that there is a dearth of case-based analyses of the challenges and paradoxes of contingencies management processes from a "macro" governance position. by interrogating the case of pandemic influenza the paper highlights that the recent high profile debates over the efficacy of tamiflu instigated by the cochrane review is but one example of the governance challenges that face policy elites. from a practical point of view it is important that risk management registers (i.e. organisational systems for identifying levels of risks and countermeasures) at different tiers of governance address the management of policy and political relations across such levels and that this is continually evaluated as a result of bureaucratic coordination and conflict challenges (which are likely to emerge, in part, by constitutional reforms). this research also presents opportunities for comparative research in terms of the multi-level governance processes for contingencies management in the context of health security. this includes whether the findings of the uk experience are translatable to other state contexts with 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new answers to old questions from accident to disaster: the response to the hercules crash the bureau-politics of crisis management disaster recovery after hurricane hugo in south carolina, natural hazards research and applications information center interview with the author in the eyes of the beholder? making sense of the systems(s) of disaster(s) acts of god: the unusual history of natural disasters in america man-made disasters wicked problems, knowledge challenges, and collaborative capacity builders in network settings foreign policy and health security an economic theory of democracy uk devolution and the european union: a tale of cooperative asymmetry pandemic influenza preparedness in the asia-pacific region serious cross-border threats to health risk and crisis management in the public sector crises and crisis management: toward comprehensive government decision making the changing world of crises and crisis management about the author the project, funded by the economic and social research council, concerned analysing the dynamics of policy and organisational change in relation to the uk animal health security sector (with particular emphasis on foot and mouth disease and avian flu). the doctoral thesis was awarded the sir walter bagehot prize by the uk political studies association for its contribution to research in public policy and administration. after completing his phd dr connolly worked as a policy adviser in the scottish public sector (nhs health scotland) and returned to academia on a full-time basis in for instructions on how to order reprints of this article, please visit our website: www.emeraldgrouppublishing.com/licensing/reprints.htm or contact us for further details: permissions@emeraldinsight key: cord- - kz kvdm authors: miller, henry i title: vox populi and public policy: why should we care? date: journal: nat biotechnol doi: . /nbt - sha: doc_id: cord_uid: kz kvdm nan in , the indiana house of representatives unanimously passed house bill , a measure that redefined the calculation of the value of π, the ratio of the circumference of a circle to its diameter . fortunately, the bill died in the state senate. although this anecdote might appear a historical curiosity to scientists today, nonexperts are becoming more and more prominent in formulating public policy decisions that require an understanding of subtle and complex scientific and technological phenomena. britons had their say last summer, for example, on whether they want biotechnologyderived, that is, recombinant dna-modified (known widely as genetically modified or gm) products in their fields and their food. to gauge public opinion in advance of a decision scheduled for late in the year on whether to allow commercial planting of gm crops, at great expense the uk government sponsored a series of public discussions (ironically termed 'gm nation') around the country, as well as using more conventional methods, such as focus groups. local authorities and various organizations held hundreds of additional public meetings on the subject. the head of the united kingdom's debates' organizing committee, malcolm grant, called them a "unique experiment to find out what ordinary people really think once they've heard all the arguments" . but the reality argues otherwise. mark henderson, science correspondent for the times (london) newspaper, offered this view of the half-millionpound initiative: "the exercise has been farce from start to finish. i'm not sure i want the man in the street to set britain's science, technology and agriculture policy. one of the six meetings. . .spent much of its time discussing whether the sars virus might come from gm cotton in china. it's more likely to have come from outer space" . henderson went on to say that the meetings were dominated by anti-technology zealots, the only faction that was well enough organized and cared enough about the issue to attend. jan bowman attended three of the eventsincluding one in stourbridge, "where both invited speakers opposed biotechnology"and offered an assessment similar to henderson's. "at all of them, the audience numbered no more than , and was overwhelmingly middle class, white and already anti-biotech" . the urge not only to sample, but also to respond to, public opinion flourishes on the other side of the atlantic as well. the us national science foundation (nsf; washington, dc, usa), whose primary mission is to support laboratory research across many disciplines, is funding a series of "citizens technology forums," at which average, previously uninformed americans come together to solve a thorny question of technology policy. according to the nsf's abstract of the project, being carried out by researchers at north carolina state university under a grant, participants "receive information about that issue from a range of content-area experts, experts on social implications of science and technology, and representatives of special interest groups"; this is supposed to enable them to reach consensus "and ultimately generate recommendations" . the project, first funded in to support two panels and expanded this year under a continuing grant, calls for eight more panels, each comprising citizens (who are "representative of the local population") . their deliberations will be overseen by a research team "composed of faculty in rhetoric of science, group decision-making, and political science" that will test both "an innovative measure of democratic deliberation" and "also political science theory, by investigating relationships between gender, ethnicity, lower socioeconomic status and increases in efficacy and trust in regulators" . at a time when federal budgets are under pressure and laboratory research funding is tight, the nsf has seen fit to spend almost half a million us taxpayer dollars on this politically correct, but dubious, project. getting policy recommendations on an obscure and complex technical question from groups of citizen nonexperts (who are recruited through newspaper ads) is similar to going from your cardiologist's office to a café, explaining to the waitress the therapeutic options for your chest pain, and asking her whether you should have the angioplasty or just take medication. the first of these nsf-funded groups tackled regulatory policy toward agricultural biotechnology, and recommended that the government tighten regulations for growing gm crops, including adding a new requirement that the foods from these crops be labeled to identify them for consumers. both of these proposals are unwarranted, inappropriate and contrary to the recommendations of experts, including those within the government and in the scientific community , . the output of the citizens' panel illustrates that such undertakings have limitations both in theory and practice: nonexperts are too much subject both to their own prejudices and to the specific choice of materials and advocates to whom they are exposed. although involvement of the public is critical to their understanding of government policy, it is less useful for the formulation of policy. this is particularly true when complex issues of science and technology are involved. science is not democratic. the citizenry do not get to vote on whether a whale is a mammal or a fish, or on the temperature at which water boils, and legislatures cannot repeal the laws of nature. however, on questions to which there is no scientifically 'right' answer (e.g., at what age can persons drive and vote, or whether we should carry out more manned exploration of the moon), public opinion can play a critical role. thus, one should be wary of the attempts in various countries-in recent years, these have included the netherlands, new zealand, the united states and the united kingdomto sample public opinion as a prelude to setting policy on biotechnology. even if such opinion-sampling exercises were better organized, widely attended and more representative, their purpose should not be to translate the vox populi into policy on subjects highly dependent on an understanding of the subtleties of science and technology. such undertakings would founder on the principle that something not worth doing at all is not worth doing well. the goal of policy formulation should be to get the right answers. for biotechnology, just as for critical decisions about medical interventions and the design of airplanes and bridges, the best insights are likely to come from experts. and although it may be useful, as well as politic, for governments to consult broadly on high-profile public policy issues, after the consultations and deliberations have been completed, government leaders are supposed to lead. if democracy must eventually take public opinion into account, good government must also discount heuristic errors and prejudices. the th century irish statesman and writer edmund burke emphasized the government's responsibility to make such determinations. he observed that in republics, "your representative owes you, not only his industry, but his judgment; and he betrays, instead of serving you, if he sacrifices it to your opinion" . this commentary is modified from an article first published in the washington times on october , . institute of food technologists the writings and speeches of edmund burke-volume iii: party, parliament, and the american war - pp key: cord- -pqy bikp authors: hayes, adrian c.; jupp, james; tsuya, noriko o.; brandon, peter title: book reviews date: journal: j popul res (canberra) doi: . /bf sha: doc_id: cord_uid: pqy bikp nan the common picture of the health of populations around the world today is confusing. on the one hand, death rates in most developing countries have declined dramatically over the past years and people live longer; on the other hand, infectious diseases once thought to have been conquered are making a comeback and hiv/aids could become the worst epidemic in history. in this book mcmichael argues that the way to make sense of this paradox is to use a broad human ecological perspective on population health. he gives a masterful and engaging account of the 'long history of the changing patterns of human ecology and disease' from the pleistocene to the dawn of the twenty-first century. patterns of health and disease are examined as the product of ever-changing interactions between human biology and the social and physical environments. new patterns of disease emerging today may reflect the fact that humans are stressing ecological life support systems beyond the limits of their tolerance. in the space of this review i can only mention a few of the many topics mcmichael skilfully weaves into the story. biology establishes some fundamental parameters for population health. mcmichael's first three chapters discuss relevant aspects of human evolution. human and chimpanzee genuses diverged in africa - million years ago as the cooling of the pliocene produced an ecological niche 'for an ape able to survive mostly out of the forest' (p. ). then the enhanced cooling of the pleistocene (beginning about million years ago) led to rapid speciation of the homo genus. it is now generally agreed that a succession of homo species migrated out of africa, with extensive periods of co-existence among different homo species. homo sapiens and homo neanderthalis, for instance, shared much of western eurasia for thousands of years before the latter species became extinct around , years ago. since then homo sapiens has been the sole survivor of the homo genus -and, as mcmichael poignantly points out, if the current anthropogenic decline of species continues, it could become the sole representative of the whole great ape family. many distinctive characteristics of human biology were established as adaptations to environmental conditions of the pleistocene. as conditions changed, some of those adaptive responses became no longer so 'adaptive', and the resulting imbalances between biology and environment can manifest themselves as a tendency to disease. one example discussed by mcmichael is adaptations in insulin metabolism. insulin is an 'ancient vertebrate hormone' (p. ) that plays a vital role in the way the human body processes ingested carbohydrates and fats and converts them into energy for cell metabolism. the australopithecines (our pre-homo ancestors, including the celebrated 'lucy') appear to have been mostly vegetarian. as the tropical vegetation thinned during the global cooling of the pliocene, however, 'the survival benefit gained from supplementary high-quality meat protein would have increased ' (p. ) . certainly the hominines (species of the homo genus) emerging during 'the even cooler pleistocene … took to meat-scavenging and hunting … the product of an evolutionary branch that invested in cognition rather than mastication ' (pp. - ) . we would expect natural selection to have a corresponding effect on the way the body uses insulin. mcmichael, drawing on the work of j.v. neel and others, hypothesizes that 'meat-dependent hunter-gatherers may have reached the end of the pleistocene, around , years ago, with a reduced insulin sensitivity by comparison with their australopithecine ancestors ' (p. ) . this sets the stage for mcmichael to advance a 'provisional thesis' (p. ) to account for the prevalence pattern of 'type ii' (non-insulin-dependent) diabetes in the world today. the prevalence of type ii among major population groups varies by more than a factor of ten, and the variation is still striking even after controlling for obesity. europeans have low rates. assuming that reduced insulin sensitivity was the 'background' genotypic condition , years ago mcmichael speculates that a few neolithic populations might have diverged from this condition and developed a more insulin sensitive metabolism. moreover those few populations could well have included the proto-europeans, who were after all among the first to develop settled agriculture, implying a diet with more carbohydrates again. middle eastern farmers domesticated not only plants, but also goats, sheep, and later cattle. 'from around , - , years ago these agrarian communities began consuming milk and milk products. the result, today, is that genetically based tolerance of lactose (milk sugar) is much more prevalent in european than in most non-european populations' (p. ). genetic adaptation of populations to diets with differing glycaemic loads could help account (in conjunction with dietary changes and obesity levels) for their different levels of glucose intolerance and frank diabetes. mcmichael's line of reasoning takes more twists and turns than i can repeat here, and lack of direct confirmatory evidence means much of it remains speculative. as the late stephen jay gould ( : ) remarked, paleoanthropology has 'more minds at work than bones to study'. but his account shows how mismatches between biology and environment can affect population health. 'patterns of health and disease are the product of antecedent biological evolution interacting with current social and physicalenvironmental conditions' (p. ). other selection pressures he discusses, aside from food availability, are climate (leading to adaptations in skin pigmentation and the immune system) and infection (chapter includes a fascinating account of the co-evolution of parasite and host in the case of malaria). chapters - explore how a succession of changes in human ecology during the period of recorded history have affected patterns of health and disease by virtue of their impact on the co-evolutionary interplay between microbes and humans. this interplay is ubiquitous wherever there are human populations and is older than 'history' itself. when early humans became meat-eaters they exposed themselves to various animal parasites; when they migrated out of africa they encountered unfamiliar microbes. in these chapters, however, mcmichael emphasizes three broad historical transitions. the first corresponds to the rise of settled agriculture and the concentration of population in the early civilizations of the middle east, egypt, south asia, east asia and central and south america. this created a new web of relationships among animals, humans and microbes, facilitating the migration of microbes from animal to human populations. 'smallpox arose via a mutant pox virus from cattle. measles is thought to have come from the virus that causes dis-temper in dogs, leprosy from water buffalo, the common cold from horses, and so on' (p. ). most of the well-known infectious 'crowd' diseases appear to have developed during this transition; although the 'leap' from animal species to humans can still occur today, of course, as hiv and sars attest: writing before the recent sars outbreak mcmichael notes: 'in southern china, the intimate pig/duck farming culture creates a particularly efficient environment in which multiple strains of avian viruses infect pigs. the pigs act as "mixing vessels", yielding new recombinant-dna strains of virus which may then infect the pig-tending humans ' (pp. - ) . each of the ancient civilizations acquired its own repertoire of locally evolving infectious diseases. the second transition corresponds to the era of fluctuating contact among the eurasian civilizations through trade and warfare from around bc to ad . mcmichael builds on mcneill's ( ) thesis that this contact resulted in the transmission and swapping of microbes, leading to episodic epidemics followed by periods of gradual re-equilibration between the infectious agent and human host population. the complex aetiology of the black death in mid-fourteenth century europe, for example, seems to include an outbreak of bubonic plague in china during the s. 'after many turbulent centuries, this transcontinental pooling resulted in an uneasy eurasian equilibration of at least some of the major infectious diseases' (p. ). the third great historical transition refers to europe's exploration and conquest of distant lands, and (using language reminiscent of diamond ) the export of 'its lethal, empire-winning, germs to the americas and later to the south pacific, australia and africa' (p. ). the large aztec and inca populations had no herds of wild animals they could domesticate and remained relatively free of 'crowd' infectious diseases until they were decimated by smallpox, measles and influenza introduced by europeans. falciparum malaria and yellow fever were brought to the americas in the seventeenth century by the trans-atlantic slave-trade. in similar fashion the aborigines of australia suffered deadly epidemics following the arrival of europeans on that continent. and within years of captain cook's first visit to hawaii in the native population declined from around , to less than , . mcmichael points out that the third transition was more a 'dissemination' of microbes that had co-evolved with the eurasian population to other parts of the world than an 'exchange'; and he is sceptical that syphilis was really introduced to europeans from the amerindians, as is often claimed. in any event the third transition represents another major process re-equilibrating the balance between microbes and humans, this time across transoceanic populations. are we experiencing a fourth major historical transition today? around many experts thought that tuberculosis, cholera and malaria would soon be conquered; it was time 'to close the book on infectious diseases', declared the us surgeon-general (p. ). but now these diseases are increasing again, and a host of other diseases or their pathogens have been newly identified; they include lyme disease, hepatitis c and e, human herpes viruses and , ebola virus and legionnaires' disease. something 'unusual' seems to be happening to patterns of infectious diseases (p. ). to explain this mcmichael suggests we must look at contemporary human-induced social-environmental changes which provide new opportunities for microbes to invade and colonize the human body: worldwide urbanization, intravenous drug use, changing sexual practices, changes in medical practice (blood transfusion, organ transplants), intensive food production, poverty and inequality, irrigation, deforestation, eutrophication of rivers, and so on. in the last three chapters mcmichael draws together these themes in a more prospective view, detailing the risks to population health inherent in the way we are currently 'depleting or disrupting many of the ecological and geophysical systems that provide lifesupport' (p. ). chapter includes a discussion of the health impact of climate change. as in his earlier work ( ) mcmichael adds his voice, with eloquence and authority, to the imperative of establishing more sustainable ways of living. mcmichael's book is impressive in the way it marshals research findings from diverse fields, and even more important for the way it clarifies our contemporary situation. however, in telling the story about population health from a social ecological perspective his narrative is ahead of his analytics. he criticizes the conventional epidemiological approach (taking the individual as the unit of analysis) for its reductionism, but gives no systematic exposition of his own more holistic conceptual framework detailing precisely how it is 'some important health-determining factors operate essentially at the population level' (p. ). similarly his conceptualization of anthropogenic environmental change (building on peter vitousek and others) is pretty all-embracing and not yet structured to help us focus on those parts or processes most relevant for population health. the persuasive force of this book comes more from the weight of its examples of social-ecological processes influencing patterns of health and disease in populations than from any systematic theory describing these relationships. mcmichael is clearly aware of these limitations; we hope he can address them in future work. a more explicit analytics will facilitate a more felicitous telling of the story. experts and advanced students from any number of population-and healthrelated disciplines will find this book useful and stimulating. demographers will especially like the way it clearly positions 'population' centre stage; and the book's central thesis is certainly a boost to those of us who like to see demography in a strategic position at the intersection of the human and natural sciences. for those working in family planning, there is a challenging section on the health consequences of modern reproductive interventions ( pp. - ). institutions which have supported this fine work deserve some credit too. mcmichael was professor of epidemiology at the london school of hygiene and tropical medicine when he wrote this book; he is now with the national centre for epidemiology and population health (nceph) at the australian national university. the disciplinary structure of modern universities is not always conducive to bold synthetic research like mcmichael's. this book shows how important it can be: in fact the future health of human populations could well depend on it. the basic proposition of this interesting and timely book is that 'irregular migration occurs because states make rules about who can legally cross their borders. under conditions of globalization, these rules promote transnational economic activity, but limit who can work and stay ' (p. ) . in other words, there is a contradiction between increasing globalization and a declining willingness to accept mobility of labour as opposed to capital and goods. this contradiction is especially apparent in the european union and the united kingdom, with which much of this book is concerned. britain, france and the netherlands had a long tradition of free entry for imperial subjects, which they eventually found politically embarrassing. they now have the practice of free entry for european union subjects, which they may also find embarrassing as the eu extends to eastern europe and even turkey. with its focus on britain, this study sees irregulars as mainly those who arrive through legal means but then work, which they are forbidden to do. peoplesmuggling, which has become so controversial, is not central to their analysis. because the majority entering britain do not need visas, it is easy to get in. because there is no national identity card, it is easier to work illegally than in most european states. serious criminal activity is a matter for the police, who are relatively indifferent to breaches of immigration rules. the basic problem remains that britain, like several other european states, does not really have an immigration program. those who wish to remain permanently and to become citizens must either be closely related to those already there, or make a successful asylum application, or gain access to the very restricted working-visa or business-visa system. only recently, and since the publication of this study, has the government moved towards developing a coherent system allowing a quota of permanent residents; it has done so in response to widespread hysteria, worked up by the populist media, against asylum seekers. one weakness of this study is that it concentrates on economic motivations; yet the recent surge of asylum seekers, as in australia, includes many who are genuinely fleeing wars in afghanistan and iraq. the british situation is made more acute by many from collapsing african states, or balkan romanies, making well-based claims of ethnic persecution. these latter will probably have full access to britain once their states have joined the european union. at the core of this study is an analysis in depth of irregular migrants living and working in london. the groups chosen are brazilians, who have no strong historic connections with england; poles, who have stronger links; and kurdish turks, the only ones who can make plausible claims to be asylum seekers. other than some of the kurds -who are highly politicized -the irregulars simply come to make more money than at home, have no real desire to settle permanently and are ready to work for low wages and below their level of qualification. one interesting feature of these irregulars, which may well apply generally, is that they are young and well educated. they may come from poor countries but they are not peasants or labourers. what little we know about asylum seekers suggests that they are also well educated and skilled. the difference is that they have few places left to go, whereas many of the openly 'economic irregulars' have every intention of returning home in due course. because they are relatively well-qualified, many of those studied here have access to the variety of non-government organizations which have sprung up to help them and represent them to the authorities. they are certainly not voiceless even if inclined to avoid direct contact with government for fear of deportation. because london has a long history of immigrant labour in service industries, there does not seem to be much concern with the present situation. as host to millions of tourists it needs a mobile labour force, and it does not have a serious unemployment problem except in some declining enclaves in the east end. many of those interviewed have worked illegally for years and have rarely encountered any attempt to discourage or remove them. there is a contrast between this liberal approach to casual labour and the much stricter attempts to discourage permanent settlement. however, the flood of asylum seekers in recent years is changing this. the book's publication was too early to account for the recent moves in britain towards a regime reminiscent of that in place in australia. as presented here the british authorities do not really mind people coming to work in low-wage industries because they do not expect them to settle. london is now so cosmopolitan that racial tensions are less politically significant than in some smaller cities which have recently experienced violent reactions. as is regrettably common in texts published in europe and north america, there are only passing references to australia. this reflects our isolation, which also makes the 'dilemmas' of irregular migration less pressing than for states with long land boundaries or short sea crossings. however, australia does have a complex, planned and longstanding immigration program, with some principles and practices extending back for over a century. this is in contrast to the united kingdom situation studied at the heart of the book. some issues which are of interest to australian scholars and addressed by this book include: will irregular immigration increase despite increasingly rigorous attempts to prevent it? does the admission of large numbers of students, tourists and working-holiday temporary migrants make this more likely to happen? is flexibility needed in assessing asylum seekers as against 'economic migrants'? how can immigration policy be insulated against populist agitations and political expedience? can sydney hope to be a 'world city' without a degree of 'irregular migration' to supply transient labour in services? does our expanding relationship with the island states of the south pacific make regularization of immigration on a more generous basis more likely? does it really matter if there are thousands of 'irregular migrants' working in the economy? how can people-smuggling, trafficking in women, drug-smuggling and terrorism best be controlled without draconian restrictions on legitimate movement? this is an interesting and useful book. its tendency to see all movement as essentially motivated by economic inequality is of prime importance, even if that is only part of the story. globalization without liberal migration regimes, on this view, could be oppressive. but are the rich societies ready to modify this? this study ends on the note that 'globalisation has consisted in the development of the world economy under conditions most favourable for capital and the first world countries, and under terms that discriminated against the developing countries in the liberalisation of trade. … for these reasons, it is doubtful whether an international regime for managing migration, would be a step towards international justice' (p. ). australian national university this volume offers anthropological accounts of the evolution, production, and consumption of various social policies in contemporary japan. consisting of nine chapters, it is a collection of papers prepared originally for an international conference. chapter , by goodman, discusses the evolution of applied anthropology, and explains what anthropology can offer to the studies of social policy. the anthropology of social policy is not only the study of meanings ascribed to slogans and symbols associated with the policy but also that of its production and consumption. as goodman argues, social policies not only emerge from a particular socio-cultural context, but they also provide important clues to how social values are constructed and altered. chapter , by bestor, attempts to sketch a 'cultural biography' of civil society in contemporary japan. it first traces the postwar development of the notion of civil society; it next examines the multiple uses of related terms such as civil society, volunteerism, npo, and ngo; and then provides an example of the development of civil society by describing a sudden rise in volunteer activities and the enactment of the npo law following the hanshin earthquake in . instead of devoting many pages to explanations of the meanings of different terms, the chapter would have been more interesting if it were focused more on the processes that gave rise to volunteerism and the ensuing legislation by illustrating the interaction between volunteer activities and the policy responses. in chapter , roberts analyses the problems associated with low fertility, by examining programs within the angel plan -the comprehensive policy to increase the rapidly falling birthrate -and public discourse associated with its implementation. roberts demonstrates that the policy initiatives are not consistent with, therefore not effective in altering, the prevailing gender division of labour. by identifying some of the voices influencing the production and implementation of the policy, she also illustrates the nature of changing social norms and the roles of policy in bringing about such changes. although some demographic facts are misrepresented, the chapter nevertheless offers vivid information regarding how the plan is produced and consumed, therefore furthering our understanding of the importance and difficulties of balancing work and family in contemporary japanese society. in chapter , stevens and lee analyse how two sets of government policies, those of the ministry of health and welfare and the others of the ministry of justice, influence the provision of maternal and child healthcare for foreigners in japan. they argue that legal and cultural stresses, exerted by the way the policies determine the eligibility and provisional guidance for healthcare, make it difficult for foreign women to have the care they need, and that in turn leads to higher-risk pregnancies. public policies and laws are influenced by the perception of ethnicity, and the lack of policies to deal specifically with health problems of foreign mothers suggests a dual reality of health and welfare in different segments of the population. however, their arguments are not fully supported by empirical evidence, according to which the mothers who suffer higher health risks are those from developing countries in southeast asia whereas the risks for other foreign mothers are similar to, or significantly lower than, those for japanese mothers. providing that foreigners comprise vastly different groups, it seems necessary to account for their differences in socio-economic status, demographic features, and legal status before we determine whether foreign mothers indeed suffer higher health risks. chapter , by ben-ari, examines the interrelation between the organizational features of japanese preschools and the way by which they are predicated on notions of normal development of children. based on participant observations, visits to childcare institutions, and secondary analyses of administrative documents used by these institutions, ben-ari shows how organizational arrangements of institutions of early childhood education are related to the ways that children are socialized according to a uniform set of ideas that the state deems normal and ideal. this chapter is, like chapter , an example of practical anthropology at its best. it offers useful and interesting information based on two primary methods of applied anthropology: field work and content analysis of documents. in chapter , goodman analyses the 'discovery' of child abuse in japan and the development of social policy to deal with the problem. his view is that the upsurge of reported cases of child abuse in the s was largely a result of the campaigns by the media and child-welfare institutions. mothers are found to be the main abusers of children, and these groups viewed the increasing child abuse as a consequence of nuclearization of the family, combined with the prevalent myth of motherhood. goodman shows that through the implementations of regulations and policies, this discovery altered the relationship between the state and parents by giving greater powers to authorities to intervene in what had previously been seen as the exclusive and private domain of the family. chapter , by thang, offers an overview of programs to promote interaction between the elderly and school-aged children and teenagers in japan. through an attempt to interpret intergenerational interactions in the context of the japanesestyle welfare society, thang seeks to show the needs for and significance of intergenerational interaction programs. although we cannot deny the need for programs to promote intergenerational interactions, i cannot help feeling that such programs are supplementary in an array of policies designed to support and care for the elderly. given the rapidity of population ageing and the pervasiveness of its socio-economic, demographic, and political consequences, more attention should be paid to how these programs are related to mainstream elderly policies such as the golden plan and the long-term care insurance, and to how these policies and programs together alter the perceptions and treatment of the elderly in contemporary japan. in chapter , tsuji examines the evolution of death-related policies in japan over the last years. tsuji shows that mortuary practice is shaped by interplay among policies, individual actors, and traditions, being conditioned by wider socio-economic and demographic changes. though it is a little too long on explanations of prewar development, i found the chapter interesting and informative, illustrating skilfully that since meiji the government has used death policies to exert control over the family and individuals, and that mortuary practices have changed in recent decades in the face of constraints driven by low fertility. chapter , by mackie, discusses some of the ways in which social policy affects individuals differently. it argues that the archetypal citizen in the contemporary japanese political system is a male, heterosexual, able-bodied, fertile, white-collar worker. this in turn suggests that our understanding of citizenship can be broadened if we view citizens as embodied individuals whose positions are situated somewhere in a spectrum, shaped and constrained by legal and institutional structures. while the typology of citizens provided by this chapter is useful in understanding how citizenship is defined by the society, it falls short of explaining how changes in social policy are related to changes in the notion of citizenship in contemporary japan. there are general weaknesses in the volume, stemming largely from the very nature of the enterprise. in all, however, the volume provides useful insights into how problems and policy issues shared by many industrialized countries are tackled in japan. thus it will be of interest not only to japan specialists but also to those who are interested in social policy in industrialized societies in general. is an ambitious book. the first book in a series on the australian economy and society, it provides informative analyses about education, work, and welfare in australia over the last decades of the twentieth century. this important work on contemporary australia creatively presents data on shared and divergent attitudes among australians, social trends over time, comparisons among social groups, and comparisons with other nations. the book is distinctive in using large, representative samples of australians and persons from other nations to make conclusions and inferences. three principal sources of data are used: the international social science surveys/australia, the international social survey program, and the international survey of economic attitudes. combined, the three surveys yield a sample numbering over , individuals. the surveys are nationally representative and, depending upon the topic under investigation, permit the authors to make generalizations to the populations as a whole. with the improvements in measurement theory and survey questionnaire design, the authors can provide authoritative statements about people's attitudes and behaviours within countries and compare australians' attitudes and behaviours to those of persons in other nations. with some exceptions, the nations with which australia is most often compared are english-speaking or european. two chapters that provide interesting applications of the comparative analysis approach using survey data are chapter , 'conflict between the unemployed and workers in nations' and chapter , 'participation in the labour force'. the tabulations in each chapter develop the authors' stories as eloquently as the accompanying narratives. furthermore, the large amounts of data collected from the surveys permit the authors to exploit more advanced multivariate techniques. throughout the book, various multivariate modelling strategies are used to better understand relationships between such topics as education and earnings; job complexity and earnings; upbringing and attitudes about trade unions; and risky lifestyles and ideals about societal responsibility for diseases. obviously, in the interests of science and effective policy development, debate should surround the methods used and the conclusions reached. notwithstanding the need for such debate, the book carefully documents its methods and justifies the statistical approaches taken. readers concerned about empirical social science will welcome the multivariate models featured in the book, especially since most of its predecessors, which aimed for the same grand scale and scope, often omitted multivariate models. that omission was rarely made by choice, but was usually due to data constraints. attention to methods, creative use of surveys, and strategically placing findings in national and international contexts produce some fascinating findings in the book. some of the more notable findings include workers' desires for job security, even if it means less pay; stronger support for trade unionism among public service employees than among blue-collar workers; australians' desires to see the influence of unions no further weakened after many years of sustained government efforts to do so; a tension between australians' feeling sorry for their fellow australians who have suffered from diseases as outcomes of risky health behaviours on the one hand, yet also feeling one must take responsibility for one's own life-style choices on the other hand. and, lastly, a finding that australians do more complex jobs than their counterparts in five european nations, but that complexity is not the most important determinant of salaries. rather, the apparent determinants of australian salaries are status and maleness. the book accomplishes its goal of clearly and concisely presenting its findings and interpreting what they mean for contemporary australian life. topic vi, 'retirement', which contains three chapters, is a good example of the clarity and compactness of the writing style and presentation of facts. however, readers may sometimes find the book too dense and the huge number of graphs, figures, statistics, replicated survey questions, and technical notes distracting instead of illuminating. perhaps the commendable effort to document rigorous scientific analyses is occasionally counterproductive. overall, the work is essential reading and it offers researchers, policymakers, and others concerned about australia's future a myriad of social and economic data in one source. if this book is indicative of future volumes in the series, then the series will have great utility. guns, germs and steel: the fates of human societies planetary overload: global environmental change and the health of the human species plagues and people key: cord- -ldkjqco authors: nan title: news date: - - journal: aust vet j doi: . /avj. sha: doc_id: cord_uid: ldkjqco nan r eports of psychological distress, occupational stress and burnout and an increased risk of suicide in the veterinary profession are urgent reminders that veterinary schools, professional organisations and also employers should continue to address these issues. , managerial aspects of the job, long working hours, heavy workload, poor work-life balance, difficult client relations and performing euthanasias have been consistently associated with increased levels of occupational stress. chronic work stress can lead to emotional exhaustion and burnout. female veterinarians, younger veterinarians and those working on their own are at greatest risk of stress and mental health difficulties. , results from a recent observational study conducted at veterinary practices in canada suggest that team effectiveness can improve an individual team member's job satisfaction and offer protection against stress and burnout. the study found that % of veterinary team members were considered to be at a high risk of burnout. the study recommendations are that practice managers: • ensure all team members are kept abreast of changes in the clinic and given opportunities to provide suggestions to improve patient care and client service • recognise team members for their contributions • provide all staff with adequate resources and guidance to complete their jobs in a meaningful fashion and provide opportunities for growth and professional development • ensure all team members have clearly defined roles and are given autonomy to make decisions consistent with their position in the practice • encourage colleagues and supervisors to provide guidance and social support to help team members develop coping skills • take steps to create and maintain a positive work environment -this may include addressing conflicts among co-workers, ensuring all employees are treated equally and fairly, promoting civility and collegiality • consider current staff numbers and individual workloads to prevent excessive workload. providing communication and coping skills training and improving cognitive skills for young professionals may also help to decrease depression, anxiety, stress and burnout. if you are concerned that a colleague, close friend or family member is experiencing mental health difficulties, try talking to them in a supportive manner and encourage them to consult their gp or mental health professional. a -hour telephone counselling service is available for ava members on . this service can also arrange a counsellor to attend veterinary workplaces to help support staff after a traumatic incident. lifeline is another excellent support option: . dogs suffering from osteoarthritis need proven relief from pain and infl ammation. julia nicholls, president a s i write, our policy advisory council (pac) is voting on policies that are under review or newly drafted. so it may be a good time to reflect on why we have these polices and how they are written, as there has also been some debate about the function and process of the pac. ava policies are used as a reference point for the public, the media and members. many of our members sit on external boards and committees and the policies are key documents in these forums. i recently had to respond to a good question as to why our policy on equine dentistry did not completely align with the recommended key principles for veterinary practice acts in australia, which were recently circulated to members (www.ava.com.au/node/ ). the crux of this is that the policy reflects an ideal world, but the veterinary practice acts, which are written for the protection of the public, reflect current reality. we have other policies that do not align with those of key stakeholders or with current legislation. this is healthy and reflects our independence and the democratic process. the ava has approximately policies and position statements. subjects range from live animal export to genetic defects in domestic animals, and from puppy socialisation to cane toad euthanasia. position statements replace policies where there is a significant diversity of opinion among members. many policies reflect our stance on animal welfare issues and this is something to be proud of. the pac consists of a representative from every division and special interest group and meets once a year face-to-face but engages in healthy debate online all year. the full process of policy development may seem long-winded to an outsider. an initial draft is created by a working group and is then discussed by all the councillors until the majority are happy that the policy is suitable to go to all members for comment. members have a chance to comment on draft policies twice each year. the councillors work very hard to gain consensus from the members and to work with each other to get a policy ready for the vote. the october voting round is an electronic vote for policies that have been discussed online or have been out for general member comment. councillors vote whether to move each policy to the next stage in the process, send it back to a working group or abandon it altogether. anything requiring more debate is referred to the face-to-face meeting in may. the final sign off is by the ava board. the structure of the ava's policies is important. they should start with a short statement suitable for a media release or sound bite and then have a section on the underlying philosophy, the evidence and some scientific references. operational matters or procedures linked to the policy are usually included as guidelines. each policy undergoes regular review to maintain currency. some are deleted and others added as the environment changes. the policy compendium is a living document and something that is the envy of other veterinary associations. it is hard to see any shortcuts that would improve the process for member involvement. yet situations occur where we have no policy to fall back on. in the world of the -hour news cycle, topics arise that require an immediate response or at least one faster than the formal policy development process. the changes to higher education funding are a case in point. we do not have a policy on this, but it was clear that the proposed changes pose a threat to the future viability of our profession. we believe that we have to oppose this government policy shift, so we are, hopefully with your support. another example is where we have a policy but it is silent on the particular aspect of the topic under debate. in these circumstances, the board or a consultative group delegated by the board will arrive at an official position in keeping with the spirit of our policies. ideally, a policy will eventually flow from experiences like these. members and board directors have asked a range of questions about our policy development process in recent years: • should there be more scanning and identification of futureproofing policies? pet insurance is an increasingly important element of economic sustainability for many members. it means that clinical veterinarians can provide the best care for their patients and clients, regardless of the cost. unfortunately, there have been a number of teething problems with policies and claims, which led us to form a pet insurance taskforce in . the taskforce's role is to work with the profession and pet insurance companies to identify and then address issues of concern for veterinarians, pet owners and the insurance companies. our ultimate goal is to ensure that pet owners and veterinarians have confidence in pet insurance as a trustworthy and valuable element of pet care. one of the key activities the taskforce has undertaken is to develop a veterinarians guide to pet health insurance. the guide includes: • general information on what pet insurance is (and isn't) • useful facts about the australian market • reasons why more clients don't use pet insurance • techniques for making pet insurance work in your practice and for your clients. it also includes our guidelines for promoting pet insurance, your legal obligations, and what you can and can't say when talking to clients. we've heard from many members who are confused about this area, and the guidelines provide some much needed clarity. a veterinarians guide to pet health insurance is available for download now from the ava website: www.ava.com.au/node/ . on the back of member a survey conducted earlier this year, the taskforce is now gathering more detailed feedback including case studies from members at conferences and other forums. the feedback highlights several areas we believe could be addressed to remove barriers to take-up of pet insurance in australia, including: • the need for a cooling off period so that the pet owner can withdraw from an insurance policy if they are dissatisfied with the exclusions • the need for clearer terms and conditions, and explanations of any exclusions at the time of policy uptake • removing policy exclusions for pre-existing conditions based on entire body systems and unrelated to previous conditions -for example, removal of a toe lump cannot be considered a pre-existing condition just because a dog had a superficial skin infection a year before • making it easier for clients to know if their policy provides cover for particular treatments and diagnostic tests • an improved review of disputed claims by australianregistered veterinarians -we think that an industry review panel of ava members would offer an alternative pathway for appeal to the financial industry ombudsman • moving to electronic submission of claims, and making interactions with the insurers more efficient for veterinarians. we're looking forward to engaging with the insurance companies over these and other issues in the coming weeks. we'll keep you up-to-date with any new developments, and we also plan to develop some more educational resources for veterinarians shortly. with changes to the way the insurance policies and claims process works, we anticipate that more and more pet owners will choose to insure their pets, resulting in more treatment options. it will also mean that veterinarians are working with a system that supports good outcomes for all involved -pets, owners and veterinarians. fun is like life insurance; the older you get, the more it costs. international veterinary, biomedical and business journals at your fingertips vet ed library: www.ava.com.au/library as a vet, you are used to handling your patients with care and understanding, (especially if their bite is worse than their bark). at boq specialist, we adopt the same approach. we've spent nearly years working closely with vets and we've come to know your world as well as we do our own. we know your idiosyncrasies and we can anticipate your needs. so, unlike a conventional bank, we've developed products and services that are carefully designed to meet your business and personal banking requirements. when you call us, you'll always feel you are dealing with one of your own breed. crayfish plague is caused by a water mould, aphanomyces astaci. its native hosts are north american freshwater crayfish and although it produces some minor pathology, does not usually cause death. however, in naïve crayfish (never exposed to the pathogen), the disease causes death and effectively exterminates native crayfish from infected waters in as little as a couple of weeks. historically, north american crayfish were first introduced into europe in the late s for culture and fishery purposes. they carried crayfish plague with them. crayfish plague travelled around europe, with american crayfish that were translocated into european waterways. however, once crayfish plague was introduced to a country, it would also spread rapidly via contaminated fishing gear and water. crayfish plague continues to spread to previously unaffected areas of europe. the effect was severe in areas with a culture of consuming crayfish, particularly scandinavia. national declines in crayfish populations vary from % to % and lakes where crayfish were eliminated became overgrown with aquatic plants. in finland, the estimated cumulative direct loss from crayfish plague over the past years is € million. australia's freshwater crayfish fauna is diverse, with over described species, including a large number that are rare and endangered. crayfish play a crucial role as predators, herbivores and in breaking down detritus in freshwater ecosystems, and are often the largest animals in australian mountain streams. australian crayfish can be split into two broad groups: spiny and smooth-shelled crayfish. spiny crayfish are slow growing, have very large claws and usually prefer clear, cool water. because of their low meat yield and slow growth, they are not farmed. they are important fauna of streams where habitat is suitable, and many have highly restricted distributions, low fecundity and are listed as endangered. the best known of the spiny crayfish is the murray river cray (euastacus armatus). smooth-shelled crayfish include commercially and recreationally important species such as marron (cherax cainii), redclaw crayfish (cherax quadricarinatus), and the ubiquitous 'yabby' (cherax spp.). marron, redclaw and yabbies are farmed in queensland, new south wales, south australia and western australia. marron are primarily farmed in western australia and south australia. annual production varies, but in - it was valued at a$ . million and a$ , , respectively. redclaw production in queensland has declined over the past years and is now valued at a$ , . yabby production for food is limited, mainly from farms in western australia ($ , ) and new south wales ($ , ). redclaw and yabbies have been translocated (legally and illegally) for recreational fishing. many species have substantial cultural importance, and have been a source of food for indigenous people for millennia. crayfish are 'keystone species' in aquatic environments, acting as major processors of organic materials, facilitating the release of energy and nutrients, turning over substrates and aerating soil, and can reach very high biomasses in some systems. some smooth-shelled crayfish are remarkably persistent in dry environments and can survive drought in deep burrows for extended periods. aphanomyces astaci spreads by means of motile zoospores released from mature filaments in infected crayfish. the zoospores are attracted to crayfish cuticle, and the filaments penetrate immediately. zoospores can remain motile for up to days and cysts can survive for weeks (in distilled water). zoospores can re-encyst three times if they do not encounter a host. it is recommended to wait months before attempting to re-stock waters in which crayfish have been killed by crayfish plague, to allow all zoospores to die out. crayfish plague is also spread via contaminated fishing equipment or zoospores in water. american crayfish, including red swamp crawfish (procambarus clarkii) and signal crayfish (pacifastacus leniusculus) are tolerant of infection. they can remain carriers for life, and may exhibit little or no sign of infection. until recently, crayfish plague was only known in temperate to cool climates, but a spanish strain is active at temperatures of - °c. the strain that affects the invasive red swamp crawfish can sporulate at temperatures up to . °c. red swamp crawfish have established in japan, china and taiwan, and populations are sometimes maintained in ornamental fish outlets in the region. thus there is potential for spread of the pathogen throughout the region, either in contaminated water or with live or dead crayfish. freshwater crabs are susceptible to crayfish plague and may act as reservoirs for the pathogen. the chinese mitten crab (eriocheir sinensis) and the european crab (potamon potamios) are both susceptible to infection with crayfish plague. the chinese mitten crab is listed as one of the most invasive species on the planet and has established successfully in europe and north america. australia has very rich and diverse freshwater crab fauna. if infected chinese mitten crabs established in australia, their extensive migration habits (migrating upstream from estuary spawning grounds) could spread crayfish plague inland to crayfish and crab populations. australian crayfish are known to be highly susceptible to crayfish plague. eight species of four genera (including yabbies, cherax destructor) of australian crayfish were experimentally exposed to zoospores of a. astaci. they showed limited or little effective host response to invading filaments. the usual response of crayfish to infection is encapsulation and melanisation of invading filaments. redclaw crayfish and marron have been introduced into many countries for farming purposes. in late , crayfish plague was detected in farmed redclaw crayfish in taiwan. it was detected in five widely spread locations, four of which experienced % mortality, while one experienced % mortality and % morbidity. pathology was not described in the report. as demonstrated by its ability to infect multiple crayfish species, chinese mitten crabs and european crabs, crayfish plague is not very species-specific and could potentially infect most or all australian freshwater crayfish and crab species. it can cause disease and death in crabs, although the effects are not as immediate or dramatic as in crayfish. often the first sign of crayfish plague is the sudden mass death of crayfish in a water body. however, some symptoms do appear, including behavioural changes and external signs. affected crayfish may become active in the day and appear uncoordinated and lethargic. whitish areas in the muscle may be visible through the cuticle under the tail. at very low temperatures (< °c) effects may be slower to emerge, and the disease may be chronic rather than lethal in susceptible species. when american crayfish species (i.e. tolerant of infection but carry it) become infected, the shell may develop dark patches, as the reaction by crayfish to damage is to lay down melanin around the pathogen. these patches are easiest to see on the underside along the abdomen. the identification field guide to aquatic animal diseases of significance to australia provides details of clinical signs and diagnosis for crayfish plague. the aquavetplan disease strategy manual for crayfish plague provides details on gross and clinical signs of the disease. crayfish plague should be differentiated from other possible causes of mass death, such as insecticide poisoning. pcr techniques for detection of the pathogen have been developed. there is an australian and new zealand standard diagnostic procedure detailing methods for diagnosing crayfish plague. the oie manual of diagnostic tests for aquatic animals also provides details on diagnostics to confirm the presence of the pathogen. australian freshwater crayfish are known to be susceptible to crayfish plague fungus. freshwater crayfish are important and dominate in many australian ecosystems, and many species are rare or threatened. many species have restricted distributions, so could become extinct very rapidly if exposed to the disease. crayfish are the basis of an aquaculture industry, as well as supporting recreational and cultural fisheries. the potential consequences of entry of this disease into australia could be severe. the outbreak in taiwan is the first reported case of australian native crayfish being naturally infected by a. astaci and demonstrates the high susceptibility of this tropical crayfish to the pathogen. it caused very high mortalities, suggesting that a similar outbreak in australia could have devastating consequences. some strains of crayfish plague fungus are temperate but others transmit in temperatures up to . °c, suggesting that crayfish plague could infect large areas of australia. american crayfish are widespread in asia. they are regarded as pests in some countries, and until recently crayfish plague had not been reported from asia. the report from taiwan indicates that plague is present and could, potentially, be widespread in the region in feral populations of north american crayfish or chinese mitten crabs. australia has import conditions to restrict the entry of freshwater crayfish or crabs for both environmental and biosecurity reasons. these conditions limit the risk of entry of crayfish plague into australia. however, vigilance for diseases should always be maintained. if an exotic disease is suspected, please call the disease watch hotline for advice and assistance. brett herbert australian government department of agriculture comment on this article at www.ava.com.au/ r abies is present in more than countries across the world, causing more than , human deaths each year, almost all of them in africa and asia and many of them young children. although rabies can infect all warm-blooded animals, the most important source of human infection around the world is an infected dog bite or scratch. australia is one of the few countries that claims freedom from the disease, but as the rabies virus spreads in nearby countries, it is becoming more likely that it will eventually reach our shores. honorary associate professor at the university of sydney, dr helen scott-orr, has been involved in rabies programs in flores, as well as early response and control programs when rabies was first diagnosed in bali in . "rabies is a terrible and terrifying disease when it occurs. it exists in canine populations on several indonesian islands close to our northern shores. in recent years there have been outbreaks on eastern islands, including bali, flores, ambon and the tanimbar islands, which have increased the risk of the disease entering australia. "if it were to reach our border, the most likely place for an incursion is northern australia and the most likely scenario is an illegally imported, infected animal arriving by boat, " dr scott-orr said. dr ted donelan is president of animal management in rural and remote indigenous communities (amrric), which delivers animal health programs in rural and remote aboriginal and torres strait islander communities. dr donelan says that people in isolated indigenous communities are most at threat from a rabies outbreak. "large portions of the northern australian coastline are very sparsely populated. there are significant populations of semi-free-ranging camp dogs, dingos and other wild dogs in and around these communities. if these dogs became infected, they would pose a huge threat to the health and safety of the aboriginal and torres strait islander people living in those areas, " dr donelan said. the australian government has been active in rabies preparedness and prevention. the minister for agriculture, barnaby joyce, recently said, "the work offshore, at our borders and on shore -including the department's engagement with indigenous communities in northern australia as part of the northern australia quarantine strategy (naqs) -is vitally important to ensuring australia maintains its freedom from rabies and other exotic diseases. " since , the department of agriculture has been working in partnership with the indonesian ministry of agriculture to improve the management of emerging infectious diseases. the australia indonesia partnership for emerging infectious diseases is funded by the australian government, with a$ million allocated to developing a more integrated veterinary service capable of preventing, detecting and controlling important endemic and emerging infectious diseases. dr scott-orr and dr donelan agree that the naqs is doing a great deal of work on rabies surveillance, education and preparedness to prevent its introduction to australia. they also believe that australia's ongoing work with neighbouring countries is playing an important part in our protection from the deadly disease. "spending resources on helping our neighbours control rabies helps reduce the risk to australia. it also helps build the pool of professionals with experience in fighting an outbreak, " dr donelan said. preventing the spread of rabies is best achieved through vaccination. dr scott-orr says the most universal knee-jerk reaction from authorities is to kill dogs, but this has proven to be ineffective in containing the virus. "in new incursions, it often spreads insidiously for several months in the dog population before one or more human deaths occur, causing panic. the way to control rabies is to vaccinate dogs. the target for control is at least % of dogs vaccinated every year with a vaccine that has a -year duration of immunity. in addition to this, preventing rapid turnover of the dog population by fertility control is strongly advisable, " dr scott-orr said. • rabies is a vaccine-preventable viral disease that occurs in more than countries and territories. • infection causes tens of thousands of deaths every year, mostly in asia and africa. • % of people who are bitten by suspect rabid animals are children under years of age. • dogs are the source of the vast majority of human rabies deaths. • immediate wound cleansing and immunisation within a few hours after contact with a suspect rabid animal can prevent the onset of rabies and death. • every year, more than million people worldwide receive a post-exposure vaccination to prevent the disease -this is estimated to prevent hundreds of thousands of rabies deaths annually. within australia, dr donelan is encouraging veterinary practitioners who regularly visit remote communities to provide dog health programs to be more proactive in rabies preparedness. "relationships are everything in working with indigenous communities and people who are known, trusted and respected by the locals are far more likely to be given information about sick dogs and gain their cooperation with control measures and vaccination programs, than are outsiders. there is often a healthy mistrust of authority, stemming from experience that usually the prime goal of dog 'management' is to kill the dogs, " dr donelan said. both dr scott-orr and dr donelan advise veterinarians to consider getting vaccinated against rabies for personal protection and to enable them to assist in an outbreak if one was to occur. amrric is currently establishing a register of rabies-vaccinated practitioner members currently servicing or prepared to volunteer in northern australia. "the prevalence of the closely related australian bat lyssavirus (ablv) in both flying foxes and some insectivorous bats, with three human and two equine fatalities recorded, presents another reason for australian vets to consider being vaccinated against rabies. ablv has been found in all states except tasmania and the act, " dr scott-orr said. the media space is becoming more competitive, with more pressure on fewer journalists to file stories in a shorter space of time and when big stories overtake the news, such as the recent terrorist threat, these pressures intensify. total times the ava and its spokespeople feature in the media each year. ava news is not only covered in print, radio and television but increasingly online as well. in fact, between january and september this year, % of our media coverage appeared in online news sites. this reflects people's demand for immediate, up-to-date news and growing preferences to receive information from online sources. you can view some of the online news coverage we've received on the ava website at www.ava.com.au/news- . the ava media program involves identifying and telling positive stories to raise the ava's profile and promote the veterinary profession. the topics we cover include topical policies, response to disease outbreaks and the advocacy work the ava does to support our five strategic priorities. an example of coverage from our advocacy work is the higher education reforms campaign where media coverage has supported our efforts to communicate our position to decision makers in person. significant media coverage was received on this issue. julia nicholls conducted several interviews about the impact the reforms would have on veterinary students and the profession. the story was covered in the sun herald, the sunday age and the sunday canberra times. flow on coverage included wsfm, ue in sydney, ec bega and pr perth, as well as the rural report on abc online. a successful program of stories throughout the year for many of our special interest groups has helped maintain our media profile. these stories have covered heat waves, tick paralysis, parvovirus, behavioural issues, farm safety, dental health, distemper, heartworm, parvovirus, horse heart murmurs, hendra virus, bvdv, pollen, snake bites and swooping magpies. you can view all the ava media releases on the website at www.ava.com.au/mediareleases. ava members also have regular pet advice columns in the west australian and the adelaide advertiser, and a weekly pet radio segment on nm muswellbrook. although stories focussing on companion animals tend to be popular with the media, we continue to increase our influence in the rural media and promote the great work veterinarians do with producers and livestock.  % pets  % livestock  % equine  % legislation / advocacy  % other media releases have been distributed throughout the year to promote sig and division conferences. the publicity program for the ava annual conference was a great success this year and generated media hits. one of the biggest drawcards was the media conference on antimicrobial resistance, which generated more than media hits alone, including radio national and abc radio stations around australia. a panel of experts, who presented papers on the topic at the conference, spoke at the media conference about the facts on antimicrobial resistance in animals and the potential impact on people. although the situation in australia is better than in many other parts of the world, the take home message was that we can't be complacent. australia needs a long-term national surveillance program of antibiotic resistance before any problems get out of hand. you can view some of the coverage at yahoo news (aap) and abc rural. this year's asava conference resulted in a tv news piece on nbn and an interview with david neck on abc brisbane. several media releases to support the world buiatrics congress delivered media impressions in queensland country life, abc rural, the veterinarian and southern cross radio among others. every year the ava conducts media training sessions using professional media trainers to ensure we have a pool of spokespeople to cover every division, sig and potential topic of media interest. we have been very fortunate with the calibre of ava volunteer spokespeople over the years and they have been instrumental in helping us to achieve such excellent exposure for the profession and the ava in the media. comment on this article at www.ava.com.au/ protection against hendra at equestrian events e quine veterinarians australia (eva) has recently advised members on the best-practice approach to managing hendra risk at equestrian events. "managing hendra biosecurity risk at events is extremely challenging due to the nature of the disease and the large number of horses and people intensively interacting, " said nathan anthony, president of eva. "event organisers have a responsibility to ensure a safe environment for horses and people. however, not all event organisers are willing or able to implement and adhere to hendra biosecurity essentials during an equestrian event, " dr anthony said. veterinarians providing services at equestrian events have obligations in relation to work health and safety, and they are expected to provide accurate advice on biosecurity threats. eva has provided recommendations and resources to help veterinarians meet these obligations. "for events in queensland and new south wales, eva advises organisers to implement a mandatory hendra vaccination requirement for all event participants. this is to protect both people and horses from the extremely serious effects of an outbreak at an event, " dr anthony said. "for events in other states and territories, we advise event organisers to require horses travelling from queensland or new south wales to be vaccinated against hendra virus. "eva has developed resources to help vets communicate this advice and to ensure that event organisers acknowledge their responsibility to manage the risk of a hendra outbreak, " he said. a ntimicrobial resistance threatens human and animal health worldwide. antibiotic awareness week australia ( - november) forms part of a global campaign to increase awareness of antimicrobial resistance and to promote responsible use of antimicrobials. the veterinary profession is involved this year through the ava's strategic priority program 'fighting antimicrobial resistance' . the veterinary profession has adopted the one health concept of expanding interdisciplinary collaboration and communications in all aspects of health care for humans and animals. veterinarians are seen by other health professions and the public as key players in the responsible use of antimicrobials, because of our stewardship over a considerable amount of antimicrobial use in companion and food animal species. participating in antibiotic awareness week alongside human health professionals is a key way for veterinarians to demonstrate their commitment to working with others to help solve this global crisis. the focus on antimicrobial resistance and use in humans and animals is increasing around the world, and both the world health organization and world organisation for animal health (oie) are leading policy to extend the useful life of antimicrobials. here in australia, the departments of agriculture and health are developing a national strategy on antimicrobial resistance similar to canada, the united states and the united kingdom. resistance to antibiotics is found in australian hospitals and increasingly in the community. multidrug-resistant bacterial pathogens are becoming more prevalent. patients with resistant infections experience delayed recovery and treatment failure and are more likely to die than patients with non-resistant infections. the profession and the ava have been proactive in addressing antimicrobial resistance concerns, naming 'fighting antimicrobial resistance' as one of the ava's five strategic priorities. recent new resources have included simple one-page guidelines on the principles of responsible prescribing of antimicrobials by veterinarians and a client fact sheet on safe handling of animals being treated with antibiotics. the ava is also currently exploring options to develop new national guidelines to help veterinarians ensure they're making the best decisions when prescribing antibiotics. the australian veterinary journal has recently published several articles on antimicrobial resistance and its effect on our patients and ourselves, including articles on methicillin-resistant staphylococcus aureus (mrsa) in horses, vet hospitals and its carriage by veterinarians. australia is in an enviable position with regard to antimicrobial resistance -we have never allowed the use of fluoroquinolones in food-producing animals, and a recent survey by meat and livestock australia showed low levels of resistance in australian beef. over time, the one health focus on antimicrobial resistance will increase and it's important that veterinarians are proactively involved and informed of their responsibilities when using antimicrobials in all areas of practice, both companion and food animals. in the future, veterinarians may well be more involved in human cases of antimicrobial resistance. for example, family pets may be identified as reservoirs of infection. veterinarians may have to make decisions on whether to use the newest 'big gun' antimicrobial or more conservative treatment. off-label prescribing and compounding practices in food-producing animals may also come under increasing scrutiny. these challenges will provide an opportunity to underscore the importance of veterinary science to the overall health of both humans and animals. veterinarians are not unique in facing this challenge. more than health professionals have already taken a pledge to support the mind me principles: microbiology guides therapy wherever possible indications should be evidence based narrowest spectrum required dosage appropriate to the site and type of infection minimise duration of therapy ensure monotherapy in most cases. indeed, clients may come to expect this approach from all health professions, veterinarians included. jonathan taylor amrric is an independent group of veterinarians, academics and health professionals, both indigenous and non-indigenous, working in the one health framework to improve the health and well-being of companion animals and their communities. since its inception, amrric has focused on developing and implementing sustainable, culturally-sensitive programs in rural and remote aboriginal and torres strait islander communities. this program has seen dozens of veterinarians, nurses and other volunteers from around australia and overseas donate their time and skills in desexing, worming and treating animals in some of the country's most remote communities. the conference, held in darwin in conjunction with the international fund for animal welfare (ifaw), attracted over delegates from australia and around the world. following a welcome to country by larrakia elder bilawara lee, amrric president ted donelan and ifaw regional director, isabel mccrea, opened proceedings. keynote speakers included kate nattrass atema, ifaw's program director companion animals, who discussed the logistics of animal welfare programs in countries ranging from bosnia to bali. dr frank ascione, from the university of denver, has performed extensive research on the link between animal abuse and interpersonal violence. he discussed the relationship between mental health and animal abuse, as well as animal abuse as an indicator of family violence. he also discussed initiatives that had been developed as a result of this research, including pet-friendly shelters for victims of domestic violence. with the threat of a rabies incursion into northern australia presenting a real risk to remote communities, the topic of rabies detection and control was a key theme of the conference. a panel of experts, including nt chief veterinary officer dr malcolm anderson, nt centre for disease control public health physician dr charles douglas, northern australia quarantine strategy veterinary officer joe schmidt and former nsw chief veterinary officer helen scott-orr, participated in a simulated rabies incursion to assess australia's preparedness for such an outbreak. issues raised included the number of vaccinated veterinarians available to assist in such an event, the need for existing relationships with and experience with communities, and understanding of dog population dynamics in remote communities. above all, the conference provided an opportunity for those working at the coalface to connect with others in academia and government and ensure that community animal health and welfare are on the agenda. "what i have learnt there was very motivating and made me see my community from another perspective, " said torres strait island regional council animal management worker, william bero. "it has motivated me to continue in promoting healthy and happy animals equals healthy and safe community. " the study reaffirms much of what we already know, but it is an australian study -which is important, as we don't have much local data, " said dr andrew carter, ava sa division president. "interestingly, the study also noted that two-thirds of incidents involved the dog being provoked. this is significant, as it again points to the need for children to be taught about appropriate interaction with pets, but also highlights the need for adults to step in, " dr carter said. in regard to breed, the study finds that breed-specific legislation is not necessarily effective and proposes the development of a set of well-defined criteria that enables early identification of dangerous dogs on an individual basis. "this is very much in line with our own ava research, which emphasises the importance of education coupled with identification and control of individual 'potentially dangerous' dogs along with 'dangerous' dogs, " dr carter said. the results mirror another recent study of dog bite-related fatalities in the united states. that study, released late last year, looked at fatalities from to . although calculated risk factors could not be specified by the study, the key factors that were found to be present in fatal attacks were: • absence of someone to intervene • the dog and victim were unknown to each other • the dog was not desexed • compromised ability of victims to interact appropriately with dogs • the dogs were isolated from regular positive human interactions (possibly kept outside) • owners' prior mismanagement of dogs • owners' history of abuse or neglect of dogs. importantly, in the majority of fatalities at least four of these factors were in place. the study reinforced other findings relating to breed, stating that dog bite-related fatalities "were characterized by coincident, preventable factors; breed was not one of these. " the paper also notes that although desexing appeared to be a factor, it is uncertain whether this is causal or coincidental. they note that past research "…suggests that owner failure to have their dog spayed or castrated may co-occur with other factors that more directly influence a dog's social competence. " executive officer -sa and nt division comment on this article at www.ava.com.au/ the results support the existing understanding of dog bite incidents: dog bites are most likely to involve children aged - years, who are bitten on the face by a familiar dog and in a familiar environment. esutures is a discount distributor of ethicon, covidien, synthes, bard and arthrex suture, mesh and surgical devices. we specialize in selling brand name products at below market prices in quantities you decide. we stock thousands of surgical devices available by the box or by the individual item, and ready to ship today! no contracts. no minimum orders. fast shipping. all orders ship global priority from the u.s. at a flat rate. order today: info@esutures.com www.esutures.com use promo code: avj for $ off your next order of $ or more.* a ccording to the food and agriculture organisation of the united nations (fao), a recent strain of avian influenza virus in poultry in southeast asia needs to be closely monitored. known as a(h n ), the fao says it represents a new threat to animal health, with recent detection in poultry in the lao pdr and vietnam after first being reported in poultry in china in april . it also represents a threat to the poultry-related livelihoods that contribute to the incomes of hundreds of millions of people in the region. fao's chief veterinary officer, dr juan lubroth, said that influenza viruses are constantly mixing and recombining to form new threats. "h n is particularly worrisome as it's been detected in several places so far from one another. and because it's so highly pathogenic, meaning infected poultry become sick and, within hours, death rates are very high, " dr lubroth said. the world health organisation for animal health (oie), which works together with the fao and the world health organization (who) to support countries' responses to animal and human disease threats, is also monitoring the situation closely. only one case of h n has been reported in humans after contact with exposure to poultry shortly after its detection in china. the person later died. according to the who, although the dynamics of the new strain are still not fully understood, it's unlikely that h n represents an immediate and significant threat to human health. both the who and fao have advised that even if the public health risks posed by h n currently appears to be low, it is still of concern and they recommend that consumers follow appropriate hygiene, food preparation and food safety guidelines. these include washing hands often, cleaning utensils and surfaces used during food preparation and eating only well-cooked poultry meat products. people should also avoid handling sick birds or those that have died of illness. the fao is also urging countries to remain vigilant to prevent further spread of the virus and is recommending that governments in the area support poultry producers in following essential biosecurity measures and standard hygiene precautions. this includes early detection, immediate reporting and rapid response. comment on this article at www.ava.com.au/ d r russell dickens oam is a trailblazer and mentor to countless young and now a bit older veterinarians. dr robert johnson suggested we shine the avj member spotlight on his mentor, dr dickens, so we can share his story with ava members. dr dickens started a veterinary practice in western sydney in and has been protecting australian wildlife and caring for animals, farmers and pet owners ever since. he has seen western sydney transition from a rural, farming community to a burgeoning, densely-populated metropolis and has evolved his practice to meet the changing needs of his community. beyond his practice and research work, dr dickens is a primary producer of angus beef at cullen bullen and has also placed his considerable energy into community activities. he has been a councillor at blacktown council for over years, served as mayor and is currently deputy mayor, while still working at his practice. he is a foundation member of the animal ethics committee at westmead hospital and millennium institute, a rotary paul harris fellow, on the salvation army's advisory board and this year was lauded with the university of sydney's alumni award, which places him among some of the sharpest minds in australia. dr johnson recounted a recent saturday afternoon, when he thought he'd done a stellar day's work after a full week. he finished by pm and thought he'd pop in to visit dr dickens' practice. "i found a packed waiting room with russ methodically managing the clients by himself. when he saw the look on my face, he smiled and said, 'i'm also acting mayor today' , " dr johnson recalled. he also still -almost exclusively -runs his practice's out-of-hours service and has done so since the s. "age is a matter of mind. if you don't mind it doesn't matter, " he quipped. when asked to recall a time he had shared with his mentor that had a particular effect on him, robert chose to share the aftermath of being sent to help a friesian cow with a dislocated hip, some years ago. "russ sent me out to attend to a large heifer and i managed to sedate her, get her to lie down and with the farmer's help and some impressive force, to reduce the dislocation. triumphant, i headed back to the practice where russ looked at me with some surprise. i asked, "why the funny look?" russ said that he had expected me to be covered from head to toe in mud and to provide him with his entertainment for the afternoon. like most other days, we laughed. "russ has taught me the two most important things in my career: that it's fun to be a veterinarian and you should always be prepared to laugh at yourself, " dr johnson said. e ach year the ava recognises those who contribute to and serve the veterinary profession or the association. nominations are now open for the following prizes and awards: this is the ava's most prestigious award for outstanding service by a member or a non-member to veterinary science in australia. nominees who were unsuccessful from the previous two years are automatically included. issued jointly with the australian college of veterinary scientists, the kesteven medal is awarded to members for distinguished contributions to international veterinary science through technical and scientific assistance to developing countries. nominees who were unsuccessful from the previous two years are automatically included. awarded to members for outstanding service to the association. the award is given either to members who have rendered meritorious service to the association, regional divisions, branches or special interest groups, or to persons who are not eligible for membership of the association but have clearly provided meritorious service to those bodies. awarded to eminent non-veterinarians for services to the ava or the veterinary profession. animal health australia, the australian veterinary association and guild insurance have put together a unique framework to cover private practising vets like you to assist in an emergency animal disease response. no other insurer offers this unique cover. for leading veterinary business insurance and professional indemnity insurance call us today for a quote. insurance issued by guild insurance ltd (gil) abn , afsl and subject to terms, conditions and exclusions. gil supports your association through the payment of referral fees. gil will assess an eadr outbreak and make a decision to provide cover on a case by case basis. gil will need to be contacted for the cover to be activated. additional premiums may apply depending on existing cover with gil. for information on the guild veterinary business insurance policy, refer to the product disclosure statement (pds) and policy wording. you can get a copy of the pds by calling . gld avj eadr ad / while you're taking care of an emergency, who's taking care of you? make the right choice. freecall guildinsurance.com.au/eadr d r alex rosenwax from waterloo in sydney, reports that he has had five unrelated unusual cases of rabbit deaths over the past few weeks. all presented with gastrointestinal stasis and were febrile with anorexia. the signs appeared to be consistent with calicivirus and all died within - hours, despite intensive treatment. all came from one general area of sydney, and they had been vaccinated in the past. "i have contacted the dpi and they have confirmed that a new strain of calicivirus has been documented in sydney by elizabeth macarthur agricultural institute (emai) in the past year. that strain is resistant to the vaccine. their signs were similar to the ones in the rabbits we have seen, " said dr rosenwax. rabbit haemorrhagic disease virus (rhdv) is a calicivirus that usually kills % of susceptible adult rabbits within hours, but the molecular mechanisms for this virulence are unknown. it has been used in australia as a biological control agent to reduce rabbit numbers since it was released in . there is also an endemic non-pathogenic australian rabbit calicivirus, rcv-a , that is known to provide some cross-protection to lethal infection with rhdv, and pet rabbits are usually vaccinated against the endemic strain to protect them. australia's chief veterinary officer, dr mark schipp, notified oie of the new strain in january this year. the notification related to the outbreak in sydney where sudden deaths occurred in show rabbits of various ages and both sexes. there were very few clinical signs prior to death. the rabbits had previously been in good health and were vaccinated against the endemic strain of rabbit calicivirus. of the susceptible rabbits, there were cases, and deaths, equating to an apparent morbidity rate of . %, mortality rate of . %, and case fatality rate of . %. gross necropsy findings showed little signs of the heavy haemorrhage usually seen with rhdv. they had more cranial changes. emai reported that the normal elisa test for calicivirus was negative whereas pcr was positive. some of the rabbits were presented to dr rosenwax because they were apparently having seizures. he noted that although his cases were highly suspicious of calicivirus, as the appropriate samples had not been taken, the cases could not be confirmed. a nonformalin-fixed, frozen -g liver sample is required for submission to emai to confirm the presence of the virus. tracing and surveillance of the new strain is underway to determine how many rabbits have been exposed and how widespread the virus is. this may have implications for pet rabbits, as evidence suggests the current vaccine may not be effective against this new strain. this new strain also has implications for rabbit control. the invasive animal cooperative research centre (ia crc) research shows that australian native vegetation is very sensitive to rabbit damage, and as few as . rabbits per hectare can remove all seedlings of the more palatable native trees and shrubs, so delaying natural regeneration. rabbits are australian agriculture's most costly pest animal with the annual cost of over $ million. according to the ia crc, the use of myxomatosis and calicivirus is still limiting rabbit numbers and without them, the annual cost to agriculture from the imported pest would exceed $ billion. however, they report that rabbit numbers are increasing, with research also showing there are a number of rabbit colonies that are immune to the calicivirus. without this virus, other control techniques would need to be tried, including warren ripping, fumigating, shooting and baiting. the ia crc is now involved in studies to evaluate other rhdv strains, mainly because there is increasing genetic resistance in the rabbits to current rhdv strains and young rabbits are acquiring immunity. dr rosenwax reports that in the absence of a definitive diagnosis, his practice has instituted quarantine for all rabbits with suspicious clinical signs. we heard about the contrasting aspects of rural practice in three different areas of australia. all seemed to share similar problems of beef and dairy profitability, increased numbers of graduating veterinarians, competition from paraprofessionals, the cost of travel and the loss of populations from rural towns. david petersen from deniliquin, told us about his practice in the dairy area of the riverina in victoria. there is no water except for irrigation -the gates on the channels are opened at the top levels, and the water 'wooshes' down for about hours per day. they see american holstein cattle, which are big cows with lots of milk, that have poor reproductive function, in an area where daytime temperatures are regularly between and ºc, and ºc at am. the veterinarians keep temperature logs in their cars, and have to throw away medications if they get too hot. sam mcmahon told us of her experiences in setting up the northern territory veterinary services in katherine. with an area of . million km , slightly bigger than nz, uk, ireland and france combined, but with a population of only , , they need a fleet of wd to cover the area. their practice includes going out to stations and indigenous communities and their new branch in alice springs is a . hour road trip away from their main centre. brahman cattle are most common in the humid katherine, and british cattle breeds in the drier alice springs area. comment on this article at www.ava.com.au/ workshop host bill tranter's practice covers km to the north, south and west, with two small animal and equine practices in mareeba. they cover extensive beef in the west of the region as well as herd health management for the more intensive dairy industry. the practice is an integral part of clinical training at james cook university. our first visit was to a relatively small feedlot, with heat-tolerant brahman-cross cattle. the property has . metres of rain annually, and also produces silage. the next stop was at a dairy of between and holstein cows. the tropical grasses grow very slowly except for a flush when it rains in december. they have a year-round calving pattern, and have to produce the same amount of milk throughout the year. their best conception rates are in the cooler winter months, and they also produce silage and grow ryegrass to boost production at that time. bull and heifer reproductive examination was next, with andrew hoare demonstrating the ultrasound probe and showing us ovarian anatomy, and enoch bergman demonstrating the intimacies of bull examination. andrew hoare multitasking i wasn't the only one taking photos communicationthe essential ingredient w ith the increasing amount of technology changing the way we communicate, it can be difficult to find the best medium to engage with all of your stakeholders. despite all these advancements, in particular the role of the internet, text messaging and social media in our lives, there is still no replacement for verbal communication in a work environment. it is verbal communication that is the essential ingredient in building an efficient and harmonious workplace. the key to an efficient workplace is to create an environment that is conducive to open and honest communication. this creates a positive relationship between employee and employer and while this relationship remains positive, then the workplace will usually stay productive. most issues with employees can be resolved through a face-to-face discussion where both parties are able to voice concerns, resolve misunderstandings and get a clear understanding of each party's motivations and the solutions required to overcome any grievances. communication is a two-way process. it involves both the dissemination of information, but even more importantly, the receipt of information through genuine listening. both are equally important for the employee and the employer. firstly, managers need to explain to employees what is expected of them and not simply rely on job descriptions to explain this. employees also have an obligation to ask questions if they are unsure about work requirements and advise managers of any changes that may affect the way they perform the job, or improve the process to deliver expected outcomes. it has often been said that the employment relationship is similar to a marriage. both parties enter into the relationship with the best of intentions, but throughout the relationship there will be good and bad times, which put the relationship to the test. once communication becomes difficult, or either party looks for ways to avoid verbal communication, it is a strong sign that there is a problem. the only way to resolve these problems is to address them as soon as the issue is identified and do this face-to-face. just because an employee chooses to communicate via text, it is never a good idea for a manager to start texting anything more than confirming receipt of the message. it is always best to make a phone call and talk to the employee directly. there can never be too much communication. managers do not have to wait for that annual review, or monthly meeting, to raise a concern or discuss a matter with their employees on any matter. frequent communication on any matter will assist in building relationships. communication must be kept simple and relevant with employees -don't start communicating information that does not affect the employee. importantly, effective communication does not mean gossiping about an employee's personal life; it simply means communicating what is expected of employees and issues that might be affecting their performance and the effect on other stakeholders. in summary, there are three things that are critical to build an efficient workplace ... communication, communication, communication. if you do this well, you will reduce and avoid most workplace relations issues. michelle eamer ava hr advisory service comment on this article at www.ava.com.au/ the material contained in this article is general comment and is not intended as advice on any particular matter. no reader should act or fail to act on the basis of any material contained herein. the material contained in this publication should not be relied on as a substitute for legal or professional advice on any particular matter. suicidal behaviour and psychosocial problems in veterinary surgeons: a systematic review veterinary surgeons and suicide: a structured review of possible influences on increased risk the role of veterinary team effectiveness in job satisfaction and burnout in companion animal veterinary clinics references . nobanis. invasive alien species fact sheet: -aphanomyces astaci. www.nobanis.org the effects of crayfish plague on finland's crayfish economy australian fisheries statistics manual of diagnostic tests for aquatic animals cultured aquatic species information programme: procambarus clarkii (girard, ) the crayfish plague pathogen can infect freshwater-inhabiting crabs defence reactions in and susceptibility of australian and new guinean freshwater crayfish to european-crayfish-plague fungus event summary: crayfish plague (aphanomyces astaci) australian government department of agriculture, fisheries and forestry. identification field guide to aquatic animal diseases of significance to australia. th edn. www.daff.gov.au/animal-plant-health/pests-diseases-weeds/ aquatic-animal-diseases-significant-to-australia-identification-field-guide australian government department of agriculture, fisheries and forestry. aquavetplan disease strategy manual for crayfish plague world organisation for animal health. oie manual of diagnostic tests for aquatic animals. www.oie.int/international-standard-setting/aquaticmanual/access-online/ accessed conservation of freshwater crayfish in australia australian commission on safety and quality of health care. antibiotic awareness week australian veterinary association. fighting antimicrobial resistance international organisation for animal health, oie. managing antimicrobials use in animals emergence of multi-resistant pseudomonas aeruginosa in a western australian hospital methicillin-resistant staphylococcus aureus in a population of horses in australia methicillin-resistant staphylococcus aureus: an issue for veterinary hospitals carriage of methicillin-resistant staphylococcus aureus by veterinarians in australia antimicrobials and the cattle industry methicillin-resistant staphylococcus aureus in a family and its pet cat nps medicinewise: resistance fighter pledge first-time study of women's and children's hospital bite victims shows that nine in attacks is by a familiar dog retrospective review of dog bite injuries in children presenting to a south australian tertiary children's hospital emergency department policy and model legislative framework co-occurrence of potentially preventable factors in dog bite-related fatalities in the united states rabbit haemorrhagic disease invasive animals cooperative research centre. landscape control -rabbits prices include delivery of print journals to the recipient's address. delivery terms are delivered at place (dap); the recipient is responsible for paying any import duty or taxes. title to all issues transfers fob our shipping point, freight prepaid. we will endeavour to fulfil claims for missing or damaged copies within six months of 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association limited. key: cord- - fcac aw authors: srisai, patinya; phaiyarom, mathudara; suphanchaimat, rapeepong title: perspectives of migrants and employers on the national insurance policy (health insurance card scheme) for migrants: a case study in ranong, thailand date: - - journal: risk manag healthc policy doi: . /rmhp.s sha: doc_id: cord_uid: fcac aw background and purposes: thailand has implemented a nationwide insurance policy for migrants, namely the health insurance card scheme (hics), for a long time. however, numerous implementation challenges remain and migrant perspectives on the policy are rarely known. the aim of this study was to examine migrant service users’ perspectives and their consequent response towards the hics. methods: a qualitative case-study approach was employed. in-depth interviews with ten local migrants and four employers were conducted in one of the most densely migrant-populated provinces in thailand. document review was used as a means for data triangulation. inductive thematic analysis was exercised on interview data. results: the findings revealed that most migrants were not aware of the benefit, they are entitled to receive from the hics due to unclear communication and inadequate announcements about the policy. the registration costs needed for legalising migrants’ precarious status were a major concern. adequate support from employers was a key determining factor that encouraged migrants to participate in the registration process and purchase the insurance card. some employers sought assistance from private intermediaries or brokers to facilitate the registration process for migrants. conclusion: proper communication and promotion regarding the benefits of the hics and local authorities taking action to expedite the registration process for migrants are recommended. the policy should also establish a mechanism to receive feedback from migrants. this will help resolve implementation challenges and lead to further improvement of the policy. migrant health has become a major global policy discourse due to a high health burden, especially infectious diseases-related mortality in a large number of migrants. it is believed that nearly million people or . % of the global population resides outside their own country of origin. this number is predicted to increase and exceed million people in next three decades. it is due to the rapid growth of human mobility which has several contributing factors, such as economic opportunity, convenient transportation, political conflict, violence, and human trafficking. the issue of migrant health protection has been considered globally at many high-level meetings, such as the united nations general assembly meeting in , the world health assembly (wha) with resolutions wha . , wha . , and wha . , and the global compact for safe, orderly and regular migration adopted by member states of the united nations in . [ ] [ ] [ ] [ ] [ ] in , migrant health received increased global attention when the sustainable development goals (sdgs) included migrant health as fundamental in achieving universal health coverage (uhc) under the principle of "leave no one behind" the pathway to achieve such a goal requires huge effort from all sectors including immigration control, the security sector, labour authorities, and the public health arena as well as the implementation of migration laws and citizenship regulations in each individual country. thailand is a major migration hub as its location is suitable as a centre of transition and destination among countries in southeast asia. due to the country's rapid economic growth, it receives a huge number of migrants from neighbouring populations especially cambodia, lao pdr, myanmar, and vietnam (clmv nations). in , the cumulative volume of non-thai people in thailand was about . million. among these, . million were clmv migrant workers and dependants. over half of them entered the country without valid travel documents, and are recognised as undocumented migrants. a recent report by the international labour organization suggested that migrants contributed about . - . % of thai gross domestic product in . this situation, among other aspects, leads the thai government to exercise lenient measures to legalize and register these undocumented migrants rather than a deportation policy. one key measure is nationality verification (nv). with nv, undocumented migrants are able to reside and work in the country lawfully. the nv policy is implemented alongside a measure to protect the health of migrants. the most distinct health policy for migrants is the "health insurance card scheme" (hics), a national insurance scheme for clmv migrants managed by the ministry of public health (moph). the hics benefit package is comprehensive, covering all types of care including health promotion and disease prevention activities. the hics is financed by an annual premium. the hics revenues are pooled at the central moph and later redistributed in a decentralized manner to the local health facilities. an insuree does not need to pay for any cost upfront, except a us$ administrative fee. the card price gradually increased over a period of years from baht (us$ ) between and to baht (us$ ) in . this was because in the moph expanded the hics benefit to include hiv/aids treatment and certain high-cost treatments. migrants who enter the country lawfully and work in the formal sector (like firms, factories or enterprises) need not buy the hics as they are covered by the social security scheme (sss), which is the same social insurance for thai formal workers. the sss is financed by tri-partite contributions, equally shared between employer and employee ( % of the employee's salary and % subsidies of employer) as well as . % from the government. the sss is managed by the ministry of labour (mol). the benefit packages of the hics are quite similar to the sss. one of the most remarkable differences between the two schemes is that the sss provides additional non-health benefits for its beneficiaries (such as a pension and unemployment allowance). in mid- , after the military coup in thailand, the military government launched a "one stop service" (oss) policy to facilitate the registration of undocumented migrants and to expedite the nv process. the policy message at that time was quite strong that those failing to register with the oss would be deported. at the same time, the hics premium was reduced in order to attract more migrants to enrol in the scheme. from , the moph reduced the hics premium to baht (us$ ) for a migrant adult, plus baht (us$ ) for a health check-up before being enrolled in the scheme, and baht (us$ ) for a migrant child aged less than seven years. , despite these numerous proactive measures, evidence suggests that implementation gaps remain as a result of inadequate communication between related authorities particularly the ministry of interior, the minister of labour, and the minister of public health, and unclear policy implementation guidelines. for example, whether migrant employees or thai employers are responsible for the hics payment, and if migrants failing to register with the oss are still able to buy the hics. although policy implementation challenges from providers' perspectives were mentioned in some literature, little is known about the perceptions and practices of migrant service users and their employers. though it was previously discovered that hics contributed to increased service utilization among migrants, the rate of service utilization was still lower than the main insurance scheme of thai citizens (universal coverage scheme). as the ultimate goal of universal health coverage is to "leave no one behind" and to assure that everyone receives quality healthcare without incurring excessive healthcare spending, it is necessary to submit your manuscript | www.dovepress.com risk management and healthcare policy : explore the possible challenges of using the hics from both migrants' and employers' perspectives. therefore, this study aimed to examine the migrants' and employers' perspectives and their responses to the hics as part of the oss. it is hoped that findings from this study will not only extend the value and academic richness of public health research on migrant health in thailand, but also help inform policy makers in other countries, especially lower-and middle-income nations, to further improve migrant health policy implementation. moreover, this study may contribute to a better understanding of the hics and lead to the improvement of the hics on the ground. policy makers and frontline implementers may use these findings to tailor health services for migrants by making the insurance scheme more responsive to the health behaviour and perspectives of migrants. a qualitative case-study approach was employed. ranong, a province in the southern region of thailand, was selected as a study site. this is because it is an area with the highest ratio of insured migrants to thai citizens ( figure ). within the province, the research team focused on two districts with the highest number of migrants namely mueang and kraburi districts. mueang is the headquarter district of the province. it is geographically located next to victoria point, one of the major business cities of south myanmar. common occupations for migrants in mueang district lie within fishing industries, construction, and the service sector. by contrast, kraburi is more rural and most migrants are involved in the agricultural sector (rubber farming and rice planting). in order to examine the degree to which the migrant health policy is fulfilling migrant health needs, ten households with at least one member in the family with severe or chronic disease were purposively recruited. the family members' insurance status and household characteristics were taken into consideration to assure a good mix of migrants' background. since some migrants were in precarious legal status, the researchers faced many challenges in identifying them. thus, the researchers started identifying potential interviewees by discussing with local healthcare officers at the health centres and local nongovernment organizations (ngos) and asked them to facilitate the research team's entry into the field. additionally, the research team conducted the interviews with the employers of these migrants (n= ) in order to seek a comprehensive view from both migrants and their (thai) employers. the selection of employers was done through purposive sampling method, taking a variety of work characteristics into account. table demonstrates the characteristics dovepress of the ten selected migrants and four employers who agreed to participate in this study. data collection was performed by in-depth interviews with ten local migrants and four employers during october to september , the period right after the implementation of the oss. each informant was interviewed for about two to three rounds until the data were saturated. the first interview started with an informal discussion to enhance rapport. the following interviews then went into more depth and followed emerging discussion points. the interviews were conducted in either thai or myanmar or any preferred language of the informants. in order to mitigate a sense of coercion (unintentionally originated by the research team), the interview group was kept as small as possible (normally only the main interviewer and a note taker). each interview lasted about - minutes and took place at the interviewees' household. telephone interview was used instead for some interviewees who were uncomfortable to undergo a face-to-face interview. it is also important to note that some interviews preferred to participate in a group interview rather than an individual interview because some informants reported that they felt more secure to have their family members around while being interviewed. verbal consent from interviewees was requested before audio recording. all interviews were transcribed verbatim. tone of voice and laughter were all noted. the following additional procedures were included in order to safeguard the reliability of the translation. professional interpreters were asked to verify the correctness of the translation between audio records and transcripts. for the question guides, key informants were asked to describe their experiences of obtaining health-care services as well as their perception and relationship with hics and other policies concerned with migrant health. the question sets built upon a notion that the health-seeking behaviour of migrants and perceptions of the policy is vastly affected by factors such as the cost of services, and support from peers and family members. this does not necessarily align with the policy's initial objectives. the study's framework recognized two stages of policy including policy formulation and policy implementation phases; but for this study, the latter phase is the main focus. the agenda setting phase during policy formulation was explained in kingdon's model that when the agenda is set, the objectives of the policy are then translated to the policy implementation stage. in this phase, the street-level bureaucracy theory of lipsky elucidates that policy adaptation is inevitable at all levels of implementation. the adjustment is made to suit the policy users' circumstances which can unintentionally twist the original policy intention. additionally, health seeking behaviour among service users also plays a critical role in determining whether the health insurance policy has reached its ultimate goal. health seeking behaviour determinants as adapted from maxwell et al include three themes: namely (i) individual factors such as current health status and demographic profiles; (ii) system factors which refer to the existing health-care system and health policy; and (iii) societal factors referring to the physical and social environment and support. all mentioned theories were captured and modified in the conceptual framework ( figure ). data were imported into the nvivo v and coded manually. inductive thematic analysis was applied. the researcher performed data cleansing of the transcripts using audio records. condensed meaning units were then labelled by grouping paragraphs and sentences with the same content. similar meaning units were given preliminary codes and then alike codes were assembled to identify emerging categories. lastly, the researcher highlighted a higher construct/theme that was demonstrated throughout all categories. the interview data were triangulated with the document review, field notes and memos. since international health policy program (ihpp) is a smallsized organization, the commitments do not cover ethical consideration to avoid any possible conflict of interest. thus, the process for obtaining ethical approval requires an external institution with a high credibility. the institute for development of human research protection in thailand is a recognized institution that aims to protect rights, dignity, safety and well-being of participants in a research which is complied with international standards including declaration of helsinki, who gcp guidelines and so on. this study received ethics approval from the institute for development of human research protection in thailand (ihrp letter head: / ) which is complied with the declaration of helsinki. all data remained anonymous including transcripts, data entry and publications. the research team assured total confidentiality of the data to interviewees and advised that it is understandable and acceptable to withdraw from the study at any time or decline to answer any questions. verbal consent including consent to quote the participants was received instead of the gold standard of written consent since the written consent might cause migrants (particularly those with precarious legal status) to feel distress. all verbal consents were informed verbal consents and approved by the institute for development of human research protection a total of five themes emerged from the interviews with ten migrant service users and four employers. the headings of each theme were: (i) individual factor: different recognition of the insurance card's function; (ii) individual factor: equivocality of employment status; (iii) societal factor: support of family members, employers and peers; (iv) system factor: impression of the insurance card and related-health policies; (v) system factor: struggles in managing the insurance for migrant employees. note that, when mapping the above conceptual framework, some themes were classified as individual factors, while some were classified as either societal factors or system factors. details of all five themes were as follows. of the ten migrants being interviewed, seven were insured with the hics. there were various reasons for acquiring the insurance card. one interviewee (mm ), who was a translator at the health facility, informed that she recognized the benefit of the card and she strived to buy the card every year. two interviewees (mk and mk ) informed that they received the health card through the assistance of intermediaries (brokers), who helped them during the registration as part of the "registration package". one interviewee (mm ) stated that the health card could save her from being deported by the officials. she also joined the oss with a belief that the military might arrest her if she was uninsured. two interviewees (mm and mm ) misunderstood that traffic accidents were not covered by the health card despite the fact that they are actually covered. two out of seven insured interviewees obtained the card after they were sick (mm and mm ). the oss was designed to support all unregistered migrants within the country by providing them with the nv and issuing a work permit for migrant workers who had solid employer. however, some migrant workers in the province were involved with the informal sector and some were even self-employed. thus, the employment status of a migrant was often unclear, and their job description was not always straightforward or in line with the information provided during the registration. mm was a -year-old unlawful immigrant who had been through the oss registration and lived in thailand for more than years. while being a shop owner was not listed as legally permitted work for him and his work permit stated that he was a labourer, he worked as a karaoke shop owner in mueang district. technically, the shop was under the thai employer's name who charged him a monthly rent of us$ and allowed him to run the shop on behalf of the real owner. another complicated scenario was demonstrated through mm 's story who was a -year-old migrant and had been living in thailand for more than years. she did not possess a legitimate residence permit (tor ror / ). her hometown was in myanmar. she travelled into ranong by boat and every time she came she acquired a "border pass" ( figure ) from the sea border control. the border pass was an authorized travelling document between border towns with a permission of stay for not more than two weeks. it served as a relaxed border control between two adjacent countries and was issued for tourists or local people only for short business purposes. however, in reality, the interviewee (mm ) stayed in thailand almost all the time. she always renewed her border pass by crossing back to myanmar and getting it stamped by border control every two weeks. she earned a living by selling goods to her neighbours. in her opinion, the health card was pricey since she was still healthy and had no need for health-care services. she also considered the process cumbersome since a broker would need to help her acquire a passport and work permit before she could obtain the health card. the last example of an intricate employment status case was a mismatch between a work permit document and actual work status. one interviewee (mm ) had already possessed all necessary documents (a work permit, health card and residence permit). all documents were obtained with the assistance of a broker. however, the name of employer listed in her work permit was not the real employer who hired her to peel shrimps on a daily basis. it was noticeable that migrants living in kraburi could earn a greater amount of income, had bigger houses and received better support from family members and peers compared with migrants living in mueang. the nv had already been achieved in three out of four migrant interviewees in kraburi (mk , mk , and mk ). additionally, all of these three remained in contact with their family and cousins in myanmar. in contrast, most interviewees from mueang did not keep in touch with their relatives. an explanation (stated by the interviewees) was that migrants in kraburi could easily and economically cross a river back to myanmar (around us$ per head per trip by an unofficial local speedboat). thus, they travelled back and forth for numerous significant family events. one interviewee (mk ) stated that her employer, a rubber field owner, provided accommodation for her free of charge (except electricity bills). she was not residing with her husband and her one-month-old baby. her baby was taken care of with support from her cousin who crossed a river from myanmar to help her almost every day. support from employers was also distinct in kraburi district as most rubber owners offered not only higher salaries than in other districts, but also assistance for oss registration. all insured interviewees expressed that they were pleased with the health services and decent care from a hospital. two interviewees (mm and mm ) also stated that the frontline workers and nurses were less friendly than most doctors they had encountered. since the doctors at a hospital were always available, the migrants interviewed preferred to go to a hospital rather than a health centre where the services were mostly provided by nurses. they were all impressed with how the hics could save them healthcare costs substantially. however, their health-seeking behaviour was affected by a waiting time especially among uninsured migrants with minor diseases. thus, most of them chose to visit a private clinic as a first solution when becoming ill. one interviewee (mk ) explained that she was willing to pay an extra cost at a private clinic (about us$ per visit) to reduce her waiting time for treatment. as a hics insuree, she commented that it would be better if the card could cover all of her family members. it is also important to note that her background was unique. she had risk management and healthcare policy : submit your manuscript | www.dovepress.com dovepress been unofficially married to a thai man for over ten years and she was registered as the housemaid of her husband in her work permit. she had not obtained thai nationality yet and this was the reason she bought the hics instead. though all interviewees expressed that the card could significantly reduce their health expenditure, most of them were still doubtful about the benefit of the card and the reasons behind the change of the card price and related regulations over time. all information about the card was received from discussions with neighbours and peers rather than official announcements. the advantage of the card is if we have surgery or if we are giving birth, we pay only a little (uss ) . . . but the policy changed very quickly. we even informed the villagers (about the card), and then the policy changed again, and the villagers came to blame us (for giving wrong information). [mm ] mk also shared her views that most of her migrant peers preferred the hics to the sss. a migrant could (and should) switch his/her insured status from the hics to the sss when their nv process is completed and/or when he/she changed jobs from the informal to the formal sector. however, in reality, very few migrants and employers wished to change their insurance schemes. they stated that it was because the monthly payment for sss was much greater than the hics premium despite the fact that the sss provided additional benefits to healthcare treatment. additionally, they also expressed that the reimbursement process was complicated and not suitable for their needs. the social security office (the governing body of the sss) told that they will give us the money back when we reach years of age, and also when we die. who will guarantee that we will receive that money? and they say they will give us baht (us$ ) when we leave for our homeland. but you must send notice (to the social security office) in advance . . . who will know that their cousin will die by next month? just baht! i can collect it by myself. [mm ] all the four employers (rn_e , rn_e , rn_e , and rn_b ) expressed their unfavourable attitude toward hics that it should not be a compulsory policy since it was impractical to purchase their migrant employees a service that they could rarely use as their routine jobs was mobile. specifically, when migrant workers were working with fishery company where they were mostly offshore. additionally, they mentioned how legalisation of migrant workers could potentially cause them to lose their employees. when migrant workers passed the nv process, they were allowed to move outside their registered area, and this meant that the employers might lose the employees after the registration process was completed. thus, paying for the insurance and going through all the registration processes when their employees could leave anytime was not a preferred choice for the employers. i am always against the hics. i will be ok with it if it is for migrant who works on land and fish docks. i think those seasiders do not have an opportunity to enjoy the service since they are always in other countries. i spent over a million for this insurance while some migrants only worked for me for some time and then they left. i did not even have a chance to collect the fees from them. i think the policy makers did not understand this context . . . [rn_e ] two employers (rn_b and rn_e ) also mentioned the red tape of the registration process which drive them to rely on brokers to attain the registration though extra charges incurred. nowadays, there emerge new jobs that try to assist employers in the registration process for migrants. though i had to pay more but it is less burdensome (laugh!). i got charged for baht per migrant but the registration required various steps and very tedious since there are many people . . ..that's why i am ok with paying for brokers. [rn_e ] overall, this study provides perspectives from and adaptive behaviour of myanmar beneficiaries towards the hics, the main insurance policy for cross-border migrants in thailand. based on the researchers' knowledge, this study is probably among the first of studies to comprehensively explore the perception and behaviour of migrants towards the hics (and related registration policies including the oss and the work permit issuance). although the hics is well recognized in many international platforms as one of a best practices for providing access to health for vulnerable populations, its actual implementation still faces several challenges. submit your manuscript | www.dovepress.com risk management and healthcare policy : one of the clear discoveries from this study is that not all migrants conform to the hics regulation or the oss registration policy. as presented above, some migrants did not recognise the existence of the hics and the majority of the interviewees had little knowledge about it. phaiyarom et al conducted research in two border hospitals in thailand, which are located in migrant-populated areas. the findings highlighted that service utilization of hics between and was significantly lower than usage of the universal coverage scheme (ucs), the main insurance scheme for thai citizens, for both inpatient (ip) and outpatient (op) visits. phaiyarom et al also suggested that the hics only increased overall op visit by . %, compared with uninsured migrants; but this effect size was still smaller than the ucs patients (+ . %) (see supplementary file). maxwell et al pointed that knowledge on the existing healthcare system was an important factor that determined the use of healthcare service (and for this research determines the likelihood of obtaining the insurance). it was also discovered that migrants in france underutilized health services due to an unawareness of their existence and a lack of familiarity with the health-care system. this research also identifies a more sophisticated point, which is that access to the insurance is not merely determined by an individual's knowledge or perception. it also depends on the design of the system. a clear instance of this is that most migrants (seven from ten interviewees) realized that the hics was part of the nv registration package and to obtain the hics, the most common practice is to rely on private intermediaries (or in their language, "brokers"). this preference also occurred among employers to overcome a strenuous effort to complete the registration for migrant employees. the interference of brokers causes the registration cost to soar tremendously. it was noted that some brokers engaged in all employment processes from faking desirable working conditions to producing counterfeit entry documents, and this led to a higher cost during registration processes than through the official route. the migrants' exploitation was an alarming issue, especially when migrants choose to receive brokers' services regardless of price and do not appreciate how their labour rights are actually better protected by official registration processes. this phenomenon clearly contradicts the primary objective of the policy that intends to enrol as many migrants as possible in the insurance. when the process of obtaining the insurance was not smooth, some migrants opted to leave themselves uninsured and willingly dropped out the system. in contrast, those who acknowledged the benefit of the hics always found a loophole in the system in order to access the insurance. for example, this study depicts the story of a woman (mm ) who did not possess a legitimate residence permit but somehow was able to access the insurance. the only proof of residence was the travel pass which she renewed from time to time. another example is a woman (mm ) who did not know the name of the employer listed on her work permit, but for some reason she was able to complete the whole registration process and acquire the work permit as well as the insurance card. in other words, the process for service users to acquire the insurance card is distorted from the initial policy intention. this policy adaptation occurs not only among migrants and employers, but also among service providers. suphanchaimat et al highlighted that local providers involved with the hics also adapted their routine practice in a way that matched their work burden and individual perception. for example, some providers decided not to sell the insurance card to migrants who were "seemingly" sick despite a lack of guidelines from the moph that ratifies such an action. some healthcare providers introduced this internal policy because they deemed that insuring "seemingly sick" migrants might create a financial risk to them (adverse selection phenomenon). however, some evidence shows that the hics has generated a positive balance for some health facilities, especially those in bangkok. these incidents are consistent with the street-level bureaucracy (slb) theory by lipsky, which suggests that policy modification can appear at all levels along the implementation line. erasmus elaborates more on this point, suggesting that the adaptation of policy is part of the coping mechanisms of the people involved in the policy. there were also a deadlock situation which is not merely confined to the slb, but is linked to a larger conceptual dilemma about whether migrants with chronic diseases are unable to appreciate the card benefits as equally as healthy migrants. although most of the interviewees who were insured agreed that hics insurance could save them health expenditure, some migrants with chronic conditions could not obtain the work permit as they were too weak to be re-hired by an employer. suphanchaimat et al dovepress uninsured migrants. it was also observed that uninsured migrants had to pay tremendously more than the hics insured migrants ( baht or us$ ) when they got severe conditions that required a hospital admission. in , when the hics included high-cost care in the benefit package, the oop among hics beneficiaries became even lower than the previous year and the gaps in the oop between insured and uninsured migrants became more remarkable as well. as a result, service utilization from hics in and soared higher to the point where it was even marginally higher than the ucs. this highlighted not only the hics's success, but also a policy gap that occurred when an unhealthy migrant could not obtain a work permit and thus, the care they needed. as highlighted in an earlier study, the government ties the health insurance (hics) with a work permit to promote both work rights and health protection at the same time. yet this mechanism comes with an unintended consequence in that it practically creates a dead-end circumstance for vulnerable migrants. leaving unhealthy migrants uninsured is more likely to bring about serious negative consequences than insuring them from the outset. the negative consequences are not just the impact on the balance sheet of a health facility but also the impact on health security for the whole of society, which might be particularly apparent during an outbreak. the world economic forum has recently expressed concern over the world's migrants who have no financial resources and supportive health insurance as this could be devastating if countries are unable to take precautionary measures with an entire population during a pandemic. stimpson et al also marked that it was necessary to protect public health from uncontrolled pandemics with a feasible option for unauthorized migrants to obtain health insurance that provides prevention and treatment of infectious diseases. in germany, health insurance for migrants is tied with work and residence status. this means undocumented migrants need to apply for a health card first before enjoying the right to health-care services. in germany a law of infectious disease allows undocumented migrants to obtain free screening and counseling for certain diseases without a requirement to disclose their identity and working status to health-care providers. in france, emergency care is freely offered to all migrants regardless of their immigration status for the first three months of their stay. in the meantime, the french government established a special fund to cover unpaid debts of health facilities caused by providing emergency care for uninsured migrants. the adaptive behaviours of migrants appear not only among migrant populations. suphanchaimat and napaumporn report that there was a laotian immigrant who undertook a registration more than five times and possessed five passports despite the fact that she only needed to complete the registration once. this sort of policy adaptive behaviour also appeared among users of other health policies. it is also interesting to explore further whether these challenges in policy implementation are reported back to the central authorities (particularly the moph) so it can fine-tune and improve the hics; and this point can serve as a recommended topic for further studies. the case stories above (indirectly) indicate the incoherence between ministries, especially the moph and the mol. it means that the data between both ministries are not synchronized. in theory, those obtaining a work permit should be insured for their health concurrently. in other words, it means that that health and labour protection does not go in tandem. in terms of policy implication, the hics design should be reviewed to capture all the dynamics of migrant policies and behaviour of migrants in thailand. hics registration (as well as the oss) should be simplified and free from unnecessary interference by private intermediaries in order to reduce financial barriers that hinder access to care and the nv process. in addition, this study points to a larger question of whether the thai government is ready and willing to take care of undocumented migrants who do not have equivocal employment status or who fail to take part in the nv process. if so, the hics alone might not be able to fully address this problem as it is still linked to the registration process, where in reality there will be always people who slip out of the system. in this respect, the thai government may consider introducing a parallel health service system which allows (unregistered) undocumented migrants to enjoy services. however, this proposal creates a circular logic concerning who will bear the cost of care, and innovative financing systems need to be considered and perhaps such measures go beyond the responsibility of a single country. all these recommendations should be seriously considered and all concerned parties (the government, migrants, employers and academics to name but a few) should be able to take part in the policy design from the outset. there remain some limitations in this study. firstly, the study site was only performed in one province, which is the main residential area for most myanmar migrants in thailand. although myanmar migrants constitute the largest share of all non-thai nationals, it is still questionable if the findings can be generalized to all migrants in other areas in thailand. however, the discovery shown in this study might be, to some extent, transferable to other countries with a relatively similar context to ranong. secondly, implications from the findings were made from the interview results rather than actual behaviour observed by the investigators. the interviewers attempted to triangulate the study validity by various means such as informal discussions with local providers or community leaders. thirdly, the small number of respondents could limit the ability of the study to capture all possible challenges in implementing the policy. it is likely that the investigators missed "the most vulnerable of the vulnerable" such as a totally undocumented migrant with chronic diseases living in faraway village that cannot be identified by the local health staff or ngos. lastly, this study focuses on the views and behaviours of the migrant service users only. to gain a better understanding on the hics in all dimensions, it is necessary to take a thorough view from all stakeholders' perspectives including policy makers, service providers, donors, civic group representatives and academics. therefore, the interpretation of the findings should be made with caution and if there are points to be considered for policy for recommendations, the views from other stakeholders should be seriously taken into consideration. health insurance for migrants allows them to enjoy their human right to access essential care regardless of ethnicity. the migrants' and employers' perspectives on and responses to the health insurance card scheme (hics) in this study reflect the challenges faced in policy implementation. due to the lack of familiarity with the policy, migrants were unaware of the benefit they could claim in obtaining the health card. this reflects how their rights were not clearly communicated and promoted. migrant exploitation is another alarming issue, and it is evident that brokers create opportunities during confusing registration process resulting in a costlier process than necessary. policy intention distortion and adaptation to suit actual situations and individual justifications appeared among both service providers and user's responses as part of the policy engagement mechanism. unhealthy migrants are possibly unable to benefit from the policy as much as healthy migrants due to the lack of alternative pathways for them to obtain the service economically. public health concerns over a control of infectious diseases among unauthorized migrants who have no access to health services are flagged as a threat that need to be resolved strategically. policy recommendations emerging from the findings can be summarised into four main points. firstly, the benefits of hics and official registration processes for migrants should be vividly and correctly communicated and promoted by local authorities to avoid both underuse of health insurance and broker interference. secondly, cumbersome and time-consuming registration processes could be resolved in order to close gaps for broker interference. thirdly, migrants with chronic conditions and unauthorized migrants should be taken into policy design considerations in order to protect public health. lastly, feedback channels from the ground to central levels are also indispensable in order to accumulate and resolve implementation dilemmas and this should be further examined. global patterns of mortality in international migrants: a systematic review and meta-analysis a/ ) united nations world migration report : the future of migration: building capacities for change. geneva: international organization for migration world health organization. th assembly. resolution wha . -workers' health: global plan of action. resolution wha . geneva: who risk management and healthcare policy : submit your manuscript | www world health organization. st assembly. resolution wha . -health of migrants. resolution wha . geneva: who health and foreign policy: influences of migration and population mobility global compact for migration united nations world health organization. nd assembly. resolution wha . -promoting the health of refugees and migrants. resolution wha . geneva: who accelerating health equity: the key role of universal health coverage in the sustainable development goals the devil is in the detail-understanding divergence between intention and implementation of health policy for undocumented migrants in thailand how immigrants contribute to thailand's economy, oecd development pathways evolution and complexity of government policies to protect the health of undocumented/illegal migrants in thailand -the unsolved challenges seminar on measures and protocols of medical examination, insuring migrants and protecting maternal and child health gdp per capita (current us$): the world bank national council for peace and order. temporary measures to problems of migrant workers and human trafficking (order no. / ) outcomes of the health insurance card scheme on migrants' use of health services in ranong province, thailand overview of migrant utilisation in ranong hospital. province svobohair, editor. ranong, thailand: ranong hospital marginalization, morbidity and mortality: a case study of myanmar migrants in ranong province agendas, alternatives, and public policies street-level bureaucracy: dilemmas of the individual in public services developing theoretically based and culturally appropriate interventions to promote hepatitis b testing in asian american populations the ministry of foreign affairs. the rd global compact for safe, orderly and regular migration stakeholder workshop good practice in health care for migrants: views and experiences of care professionals in european countries extreme exploitation in southeast asia waters: challenges in progressing towards universal health coverage for migrant workers financing healthcare for migrants: a case study from thailand. nonthaburi, thailand: health insurance system research office/ health systems research institute the use of street-level bureaucracy theory in health policy analysis in low-and middle-income countries: a meta-ethnographic synthesis the effects of the health insurance card scheme on out-of-pocket expenditure among migrants in ranong province, thailand. risk manag healthc policy covid- surge exposes ugly truth about singapore's treatment of migrant workers the coronavirus pandemic could be devastating for the world's migrants: world economic forum unauthorized immigrants spend less than other immigrants and us natives on health care health care for undocumented migrants: european approaches well-being development program for alien health populations in thailand (phase i). nonthaburi: hisro/ihpp/ the graphico systems co open access funding provided by the qatar national library. all authors would like to express great appreciation toward local workers, migrants' interviewees and ihpp members who accommodated the data collection process. there is also a high appreciation toward some data from the doctoral thesis of dr suphanchaimat. it is noted that the analysis and writing style was not uniquely the same as presented in the thesis. for instance, some more references that were not contained in the thesis were included. enlightening guidance and advice from lshtm staff, especially prof. anne mills, are immensely thankful. the authors declare no conflict of interest. risk management and healthcare policy is an international, peerreviewed, open access journal focusing on all aspects of public health, policy, and preventative measures to promote good health and improve morbidity and mortality in the population. the journal welcomes submitted papers covering original research, basic science, clinical & epidemiological studies, reviews and evaluations, guidelines, expert opinion and commentary, case reports and extended reports. the manuscript management system is completely online and includes a very quick and fair peer-review system, which is all easy to use. visit http://www.dovepress.com/testimonials.php to read real quotes from published authors. key: cord- -uwzgbpeo authors: naumann, elias; möhring, katja; reifenscheid, maximiliane; wenz, alexander; rettig, tobias; lehrer, roni; krieger, ulrich; juhl, sebastian; friedel, sabine; fikel, marina; cornesse, carina; blom, annelies g. title: covid‐ policies in germany and their social, political, and psychological consequences date: - - journal: nan doi: . /epa . sha: doc_id: cord_uid: uwzgbpeo many policy analyses on covid‐ have been focusing on what kind of policies are implemented to contain the spread of covid‐ . what seems equally important to explore are the social and political consequences of the confinement policies. does the public support strict confinement policies? what are the social, political, and psychological consequences of the confinement policies? the question of how legitimate a policy is among the public is at the core of democratic theory. its relevance also stems from the expected consequences of public support on behavior: the more someone supports a policy, the more someone is likely to follow the policy even if the policy is not strictly enforced. in this paper, we will focus on germany, briefly summarize the main policies during the first weeks of confinement and then explore political attitudes, risk perceptions, and the social consequences of the lockdown. many policy analyses of the covid- pandemic have focused on what kind of policies are implemented to contain the spread of the disease and on how effective these policies are in reducing the number of new infections and deaths. what seems equally important to explore are the political, social, and psychological consequences of the containment policies. in this paper, we focus on germany and provide an overview of the main policies that were implemented in an attempt to halt the spread of covid- during the first weeks of confinement. we complement this with results of a daily survey, the german internet panel (gip), which allows us to capture the immediate political, social, and psychological consequences of the confinement. first, does the public support strict confinement policies, and how does this support change over time? the question of how legitimate a policy is among the public and how public opinion and policies are linked is a prominent and widely researched topic in political and social sciences. theoretical and empirical research support the claim that it is, in fact, an interrelationship: public opinion affects policy-making (brooks & manza, ; burstein, ; page & shapiro, ) and policies affect public opinion (ebbinghaus & naumann, ; mettler & soss, ; pierson, ) . these policy feedback effects then, in turn, alter attitudes (kumlin & stadelmann-steffen, ) . as lockdown policies have been so quickly introduced and as the public most likely did not have any attitude regarding these policies before the onset of the covid- pandemic, this seems to be one of the few examples where policies were clearly enacted before the emergence of public opinion. hence, we focus rather on how the lockdown policies might have affected public attitudes. skocpol ( : ) refers to policy feedback as the ways "policies, once enacted, restructure subsequent political processes," and pierson ( ) distinguishes two main types of feedback effects. first, resource and incentive effects link policies to the self-interest of people since they determine how resources are distributed, provide incentives, and thus shape the costs and benefits of actors. hence, we would expect that the more threatened people feel by the pandemic, the higher they perceive the risk of being infected to be, and the lower their support is. moreover, the more apparent the economic costs of the lockdown become over time, the lower the support should be. second, interpretative effects provide a mechanism to link policies and attitudes via values since they serve as sources of information and meaning. for example, policies "frame the meaning and origins of societal problems by identifying target groups for government action and defining solutions" (mettler & soss, : ) . let us take the labor market and possible reasons for unemployment as an example. when the government promotes job-training programs, the focus is on a lack of skills, and when wage subsidies are introduced, the focus is on the structural limitations of the labor market and potential consequences of globalization, whereas strict regulations of the access to unemployment benefits shifts the focus to individual behavior and self-discipline (gusmano, schlesinger, & thomas, ) . so, policies can alter frames and the way people think about an issue (chong & druckman, ) and we expect that policies themselves shape the framing and perception of the pandemic and should have an effect on reform preferences but also on risk perceptions. second, we explore the social consequences of the lockdown and particularly focus on the labor market. the closure of non-essential businesses but also macro-economic consequences of the global covid- crisis had an immediate effect on the labor market and led to lay-offs and short-time work (see for example fuchs-schündeln, kuhn, & tertilt, ) . moreover, many employers extended possibilities for remote work and flexible work arrangements so that employees had the opportunity to work and to stay at home. at the same time, employees in essential areas of the economy who are not able to work remotely face an increased risk of being infected. do these negative consequences affect everyone equally? we would rather expect the opposite. germany's labor market is characterized by a pronounced "insider-outsider" divide and has a considerable amount of low wage and fixed-term employment, while the core workforce in standard employment is well protected by labor regulations (emmenegger, häusermann, palier, seeleib-kaiser, ) . hence, immediate lay-offs, for example, are not possible for those in regular employment. furthermore, labor market measures to buffer the negative crisis consequences for employees and companies are mostly targeted at the core workforce. as for the possibilities to work remotely, most jobs in which this is a viable option are in well-paid occupations that require a high level of education (dingel & neiman, ) . in summary, we expect that existing social inequalities will rather be increased by the confinement policies. third, we examine the psychological consequences of the lockdown. we explore the extent to which people feel threatened by covid- . feelings of threat play an important role in shaping attitudes and behavior. if threat perceptions are too low, people might not support confinement policies or might not follow them if they are not strictly enforced. too strong threat perceptions might impair people in their daily lives if, for example, they do not leave their home any more. moreover, there is a growing political economy literature that argues that subjective (mis-)perceptions of societal trends are very important in explaining political attitudes and behavior. for example, alesina, miano, and stantcheva ( ) show that natives' usually overestimate the share of migrants and underestimate their labor market integration. these misperceptions are then one important factor in understanding anti-migrant attitudes. similarly, we would expect that people rather overestimate their own infection risk (overestimation of small probabilities) but over time they might adapt their perceptions to reality (see breznau, ) . in what follows, we will first provide a brief overview of how the covid- pandemic unfolded in germany and how the government reacted to it. this provides the background against which we will then present our results and will show how public attitudes and perceptions changed during this period. in figure , we provide a summary of the first half of and show daily case numbers and the cumulative numbers of deaths in germany. moreover, the government response index shows the reaction of the german government to the pandemic aggregating containment and closure policies, economic policies, and health system policies (hale, webster, phillips, & kira, ) . the initial period of the covid- pandemic in germany resembles very much the experience of many other european countries. the government knew about covid- in china and its potential threat also for europe already in late december . yet, the first confirmed case in germany was found on january , . the government response to this was the introduction of contact tracing systems, the mandated isolation of the few infected people, and a first information campaign mainly recommending good hand hygiene and reassuring the population that the isolation of the infected worked well in keeping the virus at bay. the situation did not change until the end of february when the number of confirmed infections started to increase, in particular in some local hotspots. moreover, the italian experience with the pandemic led to doubts that it would be possible to contain the virus in germany by the initial measures that had been taken. "the situation in italy also changes our assessment of the situation: corona has arrived in europe as a pandemic" german health minister jens spahn remarked on february th. yet, the government was still reticent to introduce strict lockdown measures. it was recommended to cancel big public events of more than , participants, and it was also recommended to close schools and childcare if confirmed infections were established. at the same time, large public events like the carnival in cologne took place as planned with several thousand attendees. this changed very quickly in mid-march, when the number of daily cases increased within weeks from less than to , (see figure ) and as also the first covid- -related deaths were recorded. on march , schools and childcare facilities were closed and the government issued recommendations regarding social distancing. on march th, the borders were closed, and on march th, chancellor angela merkel announced the general lockdown with stay-at-home orders. "this is serious," she remarked in her speech to the nation "please, take it seriously, too." these measures went into effect on march st and were then further extended twice until the beginning of may. at the same time, the government reassured the population that they would do everything necessary to buffer the negative consequences of the lockdown. the debt brake was suspended, and the government announced an extra federal budget of billion euros. short-time work ("kurzarbeit") was introduced which allows firms to temporarily reduce hours worked while providing employees with income support from the state for the hours not worked. on april nd, the subsidy was increased to up to % of the regular salary. in mid-april, some states started to make the wearing of face coverings obligatory in public transportation and shops. by april th, face masks were obligatory in public transportation and shops in all german states. germany reached its peak of the first wave in terms of daily infections in early april when the -day moving average of new infections per day reached almost , . yet, the lockdown and stayat-home orders which had gone into effect on march st seem to have been very effective since case numbers decreased quickly in the second half of april, and also, the increase in the number of deaths slowed down in the beginning of may when it has reached about , deaths. the government (and the public) started to discuss re-opening plans at the end of march, and the first restrictions were lifted in may. as we are mainly interested in the public reactions to the lockdown, we restrict the following analysis to the time between march (i.e. from when survey data is available) and may when the first re-openings occurred (marked in gray in figure ). in summary, having a high performing medical system but little past experience with pandemics, germany tended to show a later, slower, and weaker policy response compared to some other countries (capano, howlett, jarvis, ramesh, & goyal, ) . to capture public reactions of the german population, we use data from the german internet panel (gip). the gip is based on a random probability sample of the general population in germany aged to . the study started in and was supplemented with additional participants in and . the panel participants were recruited offline using strict statistical procedures (blom, gathmann, & krieger, ) . every other month, panel participants are invited to take part in a voluntary online survey. for the mannheim corona study (mcs), the gip launched a special survey on march th. the sample was divided into eight random subsamples. the subsamples - were assigned to a specific day of the week, while the eighth subsample serves as control group and is not surveyed. within one week, the questionnaire remains exactly the same for all participants. between and (on average ) respondents take part in the study every day, allowing for the analysis of daily but also weekly changes in attitudes and behavior. in our analysis, we use a response propensity weight, which projects the characteristics of the msc participants to the general gip study using data on employment status and occupational sector. moreover, a raking weight was used to extrapolate the characteristics of msc participants to those of the general population of germany based on age, gender, marital status, level of education, household size, and federal state. we use two survey questions as indicators for the "public support for" and "evaluation of" the lockdown policies. respondents are asked whether they think that the societal benefits of the current policies outweigh their economic costs. answer categories ranged from , the societal benefits are greater than the economic costs to , and the economic costs are greater than the societal benefits. we also provided respondents with a list of lockdown policies, and respondents should choose all the policy measures they think are appropriate to deal with the covid- pandemic (see appendix for the exact wording of questions). to examine the economic consequences of the lockdown, we explore how the employment situation changes over time. we distinguish four different employment status (employed, short-time work, furloughed with and without pay, and unemployed) and also whether the employed work on-site or remotely. finally, we explore the psychological reactions of the public focusing on how threatened people feel by the covid- pandemic, how they rate their individual infection risk and their ability to control an infection, and the perceived likelihood of severe illness if infected (see appendix for the exact wording of questions and response scale). daily data on policies are available from january , , and the survey data are available on a daily basis starting on march , . as we are primarily interested in the lockdown policies and their effect on the public, we restrict our analysis to the period between march , , to may , . in mid-may, germany began to gradually lift some of the lockdown measures and started to re-open the country. how did the public react to the lockdown measures? we first look at political reactions and distinguish between performance evaluations and support for specific policies. figure shows how the public evaluates the consequences of the lockdown policies. we reversed the scale in the questionnaire so that higher values on the -point scale mean that the population thinks that the societal benefits are greater than the economic costs. we see that at the beginning of our period of observation, at the peak of the first wave and briefly after strict lockdown measures had been introduced, that the public evaluates the policies quite positively and in general supports the evaluation that the societal benefits of the lockdown outweigh its economic costs. this evaluation remains stable at around . during the first two weeks but then begins to steadily decline already in early april and continues to drop weekon-week until the beginning of may. at the end of our period of observation, the evaluation dropped below on the -point scale as around % of the population in germany felt that the lockdown had more negative than positive consequences. in figure , we move from the general performance evaluation to support for specific lockdown measures. the graph shows which share of the population supported each of six different policies. we see that most of the policies receive tremendous support in the first weeks of the lockdown. more than % of the population supported closing public facilities (like schools and universities), closing borders, and prohibiting public gatherings with more than participants. a lockdown and strict stay-at-home order also received majority support. the public was more critical toward closing public transportation and also toward tracking mobile phones of infected people without their consent, although notably about a third did support such a policy. over time, with declining case numbers and higher awareness for the economic costs of the lockdown measures, support steadily declined for all policies. we observe the steepest decline in support for closing public facilities which fell from % support in week to around % support at the beginning of may. the population in germany became equally critical toward a stay-at-home order and slightly less than % of the population supported a stay-at-home order in may. other measures lost support, including banning international travel (− percentage points) and prohibiting gatherings of more than participants (− percentage points). briefly before the first re-opening started, a majority still supported these two measures. also, only very few people (around %) did not support any of the lockdown measures. overall, during the lockdown, the public in germany became most critical about those policies which had the strongest | negative impact on their daily lives, such as the measures regarding the closures of public facilities and stay-at-home orders, whereas banning international travel or prohibiting larger public events were still supported by a majority. although our empirical data only provide evidence on one very strict version of a tracking and tracing policy, the results suggest that the public sees a benefit in these kinds of measures as support did not decline very much over time. in addition to the political consequences, the lockdown also had negative effects on the economy and the labor market in particular. here, we focus on the workforce and explore who is affected most by the negative consequences of the lockdown. does the covid- crisis increase existing social inequalities? our results suggest that it does. figure shows the employment situation depending on the level of school education, and we distinguish between low (without or with basic school-leaving qualifications-hauptschulabschluss), middle (intermediate school-leaving qualification-mittlere reife), and high (with higher education entrance qualification (fach-hochschulreife) education) levels. we restrict our analysis to those respondents who were employed before the lockdown (i.e., in january ). hence, our results show which groups were able to keep their jobs, who switched to remote work, but who lost their job, were furloughed or were sent on short-time work. overall, our results show that the lower the level of education, the higher the proportion of people who changed to short-time work, to furlough without pay, or who were laid off (figure ). job loss for someone with a low or middle education is twice as likely as for someone with a high level of education. among those who kept their jobs and were able to work about the same hours as in january , employees with a high level of school education are more often working remotely (more than percent in march and april) than employees with a lower level of education. the majority of those with a low or medium school education work on-site (between - percent in march). in summary, high education reduces the risk of job loss and at the same time provides the privilege to work remotely. the negative consequences of the covid- lockdown hence increase existing social inequalities along two dimensions. the lower educated lost their jobs, were suspended without pay, or experienced a partial income loss by short-time work to a much higher degree than higher educated workers. what's more, if they were able to keep their jobs, they tended have to work on-site, facing higher risks of infection. these social inequalities are linked to political attitudes and policy evaluations. additional analyses (not shown here) confirm that the lower educated are much more critical of the lockdown policies and rather tend to say that the economic costs are higher than the societal benefits. to better understand public reactions to the lockdown in germany, we argue that it is crucial to look more specifically at public perceptions. in figure , we show how threatened the public felt by the covid- pandemic and how the population rated its own infection risk (both on the left y-scale). moreover, we explore whether people thought that they were at risk of a severe illness if infected and whether they felt in control of their own infection risk. in the first two weeks, shortly after the lockdown had been introduced but before the peak of the first wave of infections, threat perceptions were highest and the population rated the degree they felt personally threatened above on the -point scale ranging from (indicating no perceived threat at all) to (indicating an extreme perceived threat to me). also, the population thinks that almost out of people will get infected in the next days. this is a very major overestimation of the actual infection risk. both the threat perception and the individual infection risk then steadily decreased over time. in contrast, the subjective risk assessment of having a severe illness in case of infection and also the feeling of having control over an infection remains more stable over time. in summary, the steady decrease of feelings of threat and perceived risk might be one explanation for why the lockdown slowly lost public support over time. additional analyses show that such a correlation also exists at the individual level, as the more someone felt threatened, the higher degree of support they indicated for lockdown policies and the more positive was their overall evaluation of the benefits of the lockdown. in this paper, we have summarized the political response to the covid- pandemic in germany and focused on the period between the occurrence of the first case in january to the end of the lockdown in mid-may . our analysis shows that germany followed a containment strategy for the first months until mid-march, focusing on isolation of the infected and on contact tracing but refraining from stricter policy measures which would affect the daily life of those not infected. this changed very quickly during the first two weeks of march when the daily new cases increased from below to around , . in response, germany very quickly moved from a containment strategy to a strategy focused on delaying the spread of the virus and within weeks moved from prohibiting large events with more than , participants to a lockdown with a national stay-at-home order. our analysis of survey data starting at the peak of the first wave briefly after the lockdown was introduced shows very high approval rates of these policy measures which might explain their success in effectively delaying the spread and reducing new infections to below , per day by mid-may. also, germany managed to keep the number of deaths at a very low level throughout the crisis (see contributions by malandrino ( ) on italy and by colfer ( ) , covering the uk, in this issue). yet, our analysis also shows that the widespread support for the containment and delay policy measures steadily decreased over time as did feelings of threat and subjective risk perceptions. moreover, the negative economic consequences of becoming unemployed or of moving to short-time work did not affect everyone equally but did track existing social inequalities. while economic and social policies provided support to buffer these negative consequences in the short run, it is unclear whether the policies will also be able to adequately address medium-and long-term consequences of the lockdown. hence, the conclusions and policy implications drawn from our analysis are clearly limited to these short-term effects and are clearly hampered by the fact that we are trying to explore an ongoing phenomenon. the external validity of our findings for other countries and institutional settings is of course also hampered by the specificities of the german case. germany has a strong economy and labor market, a comparably well-functioning welfare state, and a stable government that has been in office for several years. this might explain both the success but also the high approval of the lockdown policies in the country (breznau, ) . in summary, our analysis clearly shows that the lockdown policies feed back into the political process by altering political attitudes and public risk perceptions (pierson, ; skocpol, ) . this raises some doubts that the acceptance of policies and the willingness of citizens to comply with lockdown measures during a potential second wave would be as widespread and as strong as they were during the first wave of the pandemic. information campaigns, a societal discussion reflecting on the experiences of the lockdown, but also social policies that address some of the social inequalities the pandemic has exposed (see for example lynch, ) might help to prepare the population for subsequent waves and for subsequent pandemics. how to cite this article: naumann e, möhring k, reifenscheid m, et al. covid- policies in germany and their social, political, and psychological consequences. eur policy anal. ; : - . https://doi.org/ . /epa . question text (english translation) what do you think about the consequences of the current confinement policies in germany: are the economic costs greater than the societal benefits, or are the societal benefits greater than the economic costs? -the societal benefits are greater than the economic costs. … -the economic costs are greater than the societal benefits. policy support which of the following policy measures do you think are appropriate for dealing with the current situation? please tick all that apply. -closing public facilities (e.g., universities, schools, and nursery schools) -closing boarders -prohibit events and public gatherings with more than participants -general stay-at-home order -closing of public transportation -tracking of mobile phones of infected persons for contact tracing (without consent) -i do not support any of these measures. to what degree do you feel personally threatened by the coronavirus pandemic? no threat at all to me … extreme threat to me we would like to know how likely you think it is that you or someone like you will be infected with covid in the next days. please think of persons who are very similar to you, that is, they have a similar age, a similar health, live in your neighborhood, have a similar occupation and a similar lifestyle. what do you think, how many of these persons will be infected with covid in the next days? immigration and redistribution (no. w ) setting up an online panel representative of the general population: the german internet panel the welfare state and risk perceptions: the novel coronavirus pandemic and public concern in countries social policy responsiveness in developed democracies the impact of public opinion on public policy: a review and an agenda mobilizing policy (in)capacity to fight covid- : understanding variations in state responses framing theory herd-immunity across intangible borders: public policy responses to covid- in ireland and the uk. european policy analysis. forthcoming how many jobs can be done at home? welfare state reforms seen from below: comparing public attitudes and organized interests in britain and germany the age of dualization: the changing face of inequality in deindustrializing societies the short-run macro implications of school and child-care closures policy feedback and public opinion: the role of employer responsibility in social policy oxford covid- government response tracker health equity, social policy, and promoting recovery from covid- conflict in decision-making and variation in public administration outcomes in italy during the covid- crisis the consequences of public policy for democratic citizenship: bridging policy studies and mass politics effects of public opinion on policy when effect becomes cause protecting soldiers and mothers https://orcid.org/ - - - roni lehrer https://orcid.org/ - - - key: cord- - gopftv authors: park, kisoo; lim, jeongsub title: institutional rules for framing healthcare policy issues in national, financial, and specialized newspapers date: - - journal: nan doi: . /s - - -y sha: doc_id: cord_uid: gopftv by considering the role of institutional rules for news making, this study examines news frames embedded in stories from national, financial, and specialized newspapers with respect to four healthcare policy issues: “the decrease in pharmaceutical prices,” “the comprehensive medical payment system,” “swine flu,” and “humidifier-related lung disease.” conflict, economy, crisis, and policy execution are dominant frames in stories about the policy issues, and these four frames are also major frames used by the newspapers. this phenomenon is understood as “concentration of healthcare frames.” we conducted in-depth interviews with news reporters to identify institutional rules that might influence the formation of news frames. in-depth interviews revealed that similar types of frames resulted from institutional rules (e.g., journalist’s autonomy, news value, newspaper’s mission statement, and characteristics of readers). the findings suggest that health journalists follow institutional rules that govern the creation of news frames. to provide diverse perspectives on healthcare policy issues, newspapers need to reconsider their institutional rules. the media tend to focus on aspects of a perceived reality and emphasize those aspects in news stories. this helps them to facilitate certain types of problem definitions, causal interpretations, or moral evaluations (entman ) . these types of frames do not always provide accurate information to the reader. rather, they tend to promote apathetic and cynical attitudes toward social realities (gamson ) . these inaccurate framings of health issues frequently appear in media coverage, which could induce false perceptions or attitudes toward health issues. for instance, television coverage of diet-related issues might cause health problems by encouraging excessive weight loss (harrison ) . this mechanism is grounded in the media framing process, which relates to the coverage of health issues. the news framing of health issues may affect health examinations and treatment decisions (viswanath and emmons ) , because news frames serve as frameworks for readers to organize and understand particular phenomena (gamson and modigliani ) . newspapers develop generic and specific frames in response to health issues and diseases. generic frames are highly abstract frames such as human interest, conflict, morality, or cost, which are applicable to diverse research (matthes ). researchers use generic frames to analyze many different issues rather than a single issue . specific frames are less abstract than generic frames, because they originate from a particular research setting (gamson ) . we have to distinguish between framing and second-level agenda setting in order to clarify our focus on framing rather than attribute agendas. these two theories look at aspects of the public's cognitive processing. framing focuses on attributing aspect by highlighting certain expressions or deleting certain words. for instance, when news media emphasize negative perspectives on smoking, the public who are repeatedly exposed to this type of frame view the issue negatively, blaming smokers for causing health risks to nonsmokers (e.g., housewives, schoolchildren, or babies). in other words, the public connects the frame to the blaming of smokers. by contrast, second-level agenda setting examines the accessibility of issues covered by the news media. when newspapers and television networks cover the negative aspects of smoking over time, the public who are exposed to the coverage are likely to recall the attribute and consider it to be an important problem. in other words, agenda setting refers to a process by which the news media influence the accessibility of an issue or an attribute in the public mind, whereas framing indicates a process by which the news media affect the public's perception of an issue, which varies with the presentation of the issue (scheufele ) . the new york times portrayed mad cow disease, bird flu, and west nile fever in terms of generic frames such as results, action, uncertainty, conflict, and evidence of disease (shih et al. ) . analyses of aids-related news that appeared in two indian newspapers revealed that news frames emphasized the seriousness of aids, the causes of aids, the importance of treatment, and the vulnerability of poor people infected with aids (souza ) . news coverage of sars virus outbreaks in the united states and china relied on other types of generic frames: economy, accountability, conflict, leadership, and human interest (luther and zhou ) . korea's national daily newspapers (e.g., chosun ilbo, joongang ilbo, and hankyoreh) framed stories about h n in terms of bare statistics, followed by consequences, new evidence, and attribution of responsibility, while u.s. national daily newspapers (e.g., new york times, washington post, and usa today) focused on attribution of responsibility, followed by bare statistics, new evidence, and action (oh et al. ) . bare statistics showed ''the current epidemic situation using statistics such as the number of patients and fatalities caused by h n , but without giving further interpretation or implications'' (oh et al. , p ) . healthcare policy issues contain a complex structure of information and often face opposition from interested groups. however, few researchers have investigated specific mechanisms and structural factors that explain how national, financial, and specialized newspapers frame healthcare policy issues (e.g., drugs or medical practices). these three types of newspaper are major participants in constructing healthcare policy issues because they produce a large number of stories and their journalists cover press releases and events originating from the ministry of health & welfare in korea. in other words, they are major actors in the news market with regard to healthcare policy issues. the news value of healthcare policy issues and the type of newspaper can lead health journalists to take different approaches to coverage of the issues, because their understanding can vary according to their experience of reporting and the mission of their newspaper. the news value of an issue and the organization features of newspapers are part of institutional rules that allow for efficient production of news. the institutional rules provide detailed guidelines as to how journalists decide the direction of reporting. institutional rules include constitutive rules and regulative rules (ryfe b ). constitutive rules define what news is, and regulative rules help journalists to write stories according to this definition of news. we are interested in the implications of the institutional rules for news framing of healthcare policy issues in national, financial, and specialized newspapers. this study focuses on four healthcare-related issues: ''the decrease in pharmaceutical prices,'' ''the comprehensive medical payment system,'' ''swine flu,'' and ''humidifierrelated lung disease.'' the four issues were chosen in terms of two criteria. the first criterion was whether the issue concerns a policy or a disease. the second criterion was whether the issue has large-scale or limited effects on the public. given these two criteria, the decrease in pharmaceutical prices is a policy-related issue that influences the entire public. the comprehensive medical payment system is a policy-related issue that affects only the patients having any of seven specified ailments, including appendicitis and cataract. swine flu is a disease-related issue that influences the whole public because it is a highly contagious disease. humidifier-related lung disease is a disease-related issue that affects only people who have used a sterilizing substance over time to clean a humidifier. more details about the four issues are presented below. the issue of ''the decrease in pharmaceutical prices'' is related to the korean government's decision to reduce medication prices by an average of % in july . the government operates the national health insurance system. therefore, the health authority controls negotiations with pharmaceutical companies and decides the sales prices of new medicines. the issue of ''the comprehensive medical payment system'' refers to the medical treatment payment system by which total treatment costs are determined before services start. the opposite type of system would be a ''fee for service'' or ''retrospective payment'' system in which the total cost varies depending on the number of services provided, length of hospital stay, and so on. the korean government prefers the comprehensive medical payment system to reduce national insurance costs. ''swine flu'' is an infection caused by several types of swine influenza virus. swine flu was first detected in a human body in in mexico. since that time, swine flu infections institutional rules for framing healthcare policy issues... have terrified citizens, particularly korean citizens, because the flu was described as a ''new type of flu'' in korea until the world health organization declared that the swine flu pandemic officially ended in august . ''humidifier-related lung disease'' is a deadly respiratory disease that affects people who use humidifier-sterilizers inside buildings for long periods (e.g., during the winter). the health authority announced that humidifier-related lung disease had not been reported in other countries because users of humidifiers had not used toxic chemical products to sterilize them. previous researchers have focused on news production (cohen and young ; gamson and modigliani ; gans ; kim and lee ; shoemaker and reese ; tuchman ) . these studies identify the factors that influence news content: journalists, internal organizations, and external organizations. these factors can affect the ways in which newspapers develop frames, because news content relies on frames for the construction of reality. researchers understand frames as constructing our reality in communication by focusing on how content producers create messages (lim and jones ) . at the journalist level, influential factors for news content include individual characteristics; personal values, beliefs, attitudes; and reporters' roles and ethics (shoemaker and reese ) . personal values affect news stories (gans ) . the u.s. media frequently place blame for disease and poverty issues at the individual level, rather than at the societal level. this reflects the individual opinions of journalists (wallack et al. ) . experiences based on internal power relationships and practice can affect journalists' autonomy (son ) . such characteristics of journalists as age, gender, minority status, and political leaning influence the types of stories that the journalists produce and respect (beam ) . for instance, male journalists consider sports stories to be the best work more frequently than female journalists, and conservative journalists view stories about accidents, disasters, and religion as the best work (beam ) . the internal organizational level involves the importance of learning by doing through internal routines (tuchman ) . media practices affect the media's determination of news value, gatekeeping, organizational structures, and points of view (shoemaker and reese ) . differences in international news staff, deployment of foreign correspondents, and average number of pages per week predict the differing quantities of international news stories (kim ) . health journalists working for newspapers and magazines consider potential for public impact, new information, human angle, local angle, and supervisor interest when developing a story (viswanath et al. ) . in other words, these organizational rules influence the development of a health story. the type of newspaper belongs to this internal organizational factor. regarding the korean government's policies related to adolescent online gaming, national newspapers emphasized the positive effects of policy execution, and financial newspapers contained frames that focused on negative effects (yu et al. ) . financial newspapers attached importance to the industrial aspects of online gaming. alternatively, national newspapers supported the positions of consumers who highlighted problems related to game addictions. the news media employed frames consistent with their political and economic interests (alger ) . in this sense, individual, organizational, and ideological factors transformed content related to social conflict (kim ) . in addition, media owners and executives who engage in editorial interference can affect the news production process, even though these types of intervention during news formation might not be explicit. as evidence, broadcast stations owned by an independent network produce more local news than those stations within one television market that are owned by the same firm or those stations that are owned and operated by such a network as abc, nbc, and cbs (yanich ). at the external organizational level, factors that affect news content include advertisers, political pressure, government regulations, information sources, civic organizations, and sociocultural norms (shoemaker and reese ; tuchman ) . profitability is an important factor because the media is made up of private companies that pursue publicness. korea's national newspapers rely on advertisements for - % of their total revenues. this may account for advertisers' increasing influence on news content (pae ) . political pressure can include advertisements funded by government. similarly, u.s. newspapers generate more than % of their revenue from advertisements. the proportion of a newspaper that is dedicated to advertisements has increased to % (picard ) . political pressure can consist of official factors (e.g., control through law) and unofficial factors (e.g., indirect pressure from the government). the government's political leverage can be highly influential. a country's healthcare system, the news value of policy issues, and the public attitude toward healthcare issues are external organizational factors. korea operates a singlegovernment system known as the national health insurance system, which requires every citizen to obtain this health insurance and provides equal benefit payments to subscribers (ministry of health and welfare ). thus, healthcare policies related to drugs and medical practices operate in the regulatory dimension. a major issue that affected domestic healthcare policy in korea was the separation of prescribed and dispensed pharmaceuticals that occurred in . newspapers assign more legitimacy to the government than to doctors, and newspapers describe doctors as an immoral and unethical group of people who prioritize their personal financial interests (yang ) . the public sensitivity to healthcare issues is rather high in comparison with social and political issues. the spread of swine flu in exerted a direct impact on national preventive policies related to disease and individual health regulations. a frame analysis of news related to swine flu (ju and you ) revealed that both the public's and the media's anxiety increased because swine flu was recognized as a new disease with the same name when it was first discovered in mexico in april . on the basis of reviewing previous research (beam ; kim ; pae ; shoemaker and reese ) , it is reasonable to expect that these three factors (i.e., journalists, internal organizational, and external organizational) can influence newspapers and journalists in developing frames. however, the previous research did not consider the factors as being incorporated into institutional rules that could affect the formation of news frames. institutional rules are internalized by journalists and induce them to prefer certain frames over other frames. this is the contribution that this study makes to an understanding of news framing. in other words, the factors are institutionalized into the process of framing healthcare news. institutions are defined as ''regulative, normative and culturalcognitive elements that, together with associated activities and resources, provide stability and meaning to social life'' (scott , p. ) . news organizations respect rules, practices, or routines, which emerge from diverse categories of organization (cook ; ehrlich ehrlich , ryfe a) . thus, institutional rules with regard to news-making processes are a set of underlying rules shared and respected by journalists and news organizations when they make specific news decisions, such as applying certain types of frame to healthcare-related issues. this institutional perspective allows researchers to focus on the role of news rules in guiding specific coverage (ryfe b ). in other words, researchers can use the concept of institutional rules to understand how journalists frame healthcare policy issues, because institutions control news production and journalists' attitudes. the institutional rules allow journalists to develop specific reporting styles such as objectivity, balance, or fairness (ryfe a) . we suggest that these factors at multiple levels contribute to the formation of institutional rules when news organizations deal with these factors. if we apply these institutional rules to understanding news frames of healthcare policy issues, we can find that newspaper journalists could demonstrate their particular styles in the choice of frames. the styles guide framing patterns of the issues. the healthcare policy issues studied here are ''the decrease in pharmaceutical prices,'' ''the comprehensive medical payment system,'' ''swine flu,'' and ''humidifier-related lung disease.'' it is unclear whether national, financial, and specialized newspapers develop similar or different frames to describe these four issues. therefore, this study proposes research questions instead of hypotheses. a content analysis of relevant newspaper stories will answer the first and second questions, and indepth interviews will answer the third question. rq how do news frames of four selected healthcare policy issues vary based on the nature of each issue? rq how do news frames of four selected healthcare policy issues vary based on the type of newspaper (national, financial, or specialized)? rq what institutional rules guide the formation of news frames? this study combined a quantitative content analysis and in-depth interviews. the four issues selected were ''the decrease in pharmaceutical prices,'' ''the comprehensive medical payment system,'' ''swine flu,'' and ''humidifier-related lung disease.'' we analyzed news stories selected from newspapers. daily national and financial newspapers were selected on the basis of the power (i.e., circulation) of the newspaper in the news market. five influential major daily newspapers in korea were chosen: kyunghyang, donga ilbo, chosun ilbo, joongang ilbo, and hankyoreh. this study considered these newspapers as one entity: daily national newspapers. this study did not further examine political affiliations of each newspaper because political stance was not a focus of the study. the national newspapers were likely to cover the four issues in terms of more a comprehensive perspective than other types of newspaper because they targeted national news readers. four daily financial newspapers were selected: mk business news, seoul economic daily, financial news, and the korea economic daily. financial newspapers attached greater importance to industrial aspects than did national newspapers (yu et al. ). thus, their coverage of issues was likely to consider industrial viewpoints such as pharmaceutical companies, hospitals, or relevant associations because the industrial actors were among their major advertisers. finally, four specialized newspapers were included in the study: daily medi, daily pharm, medipana, and medical time. the specialized newspapers were chosen on the basis of the number of staff reporters and the publication's power within the group of specialized newspapers. most specialized newspapers employed three or four reporters, but the four specialized newspapers chosen each had reporters dedicated to coverage of the ministry of health & welfare, national health insurance service, health insurance review & assessment service, hospitals and clinics, pharmaceutical companies, doctors association, pharmacists association, korean medicine association, and nurses association. reporters for the specialized newspapers have years of experience in covering healthcarerelated issues, which gives them significant advantages over the reporters for national and financial newspapers. data collection periods varied based on the nature of each issue. with respect to ''the decrease in pharmaceutical prices,'' the period ranged from july , , when the korean government announced its policy, and june , , two months after the actual decrease in pharmaceutical prices occurred. with respect to ''the comprehensive medical payment system,'' the period ranged from august , , when the issue became a controversy, and the last day of the month after the policy was announced on july , (i.e., july , ). the ''swine flu'' period ranged from may , , when it first became an issue in korea, and may , . the ''humidifier-related lung disease'' period began on may , , when the first patient was identified, and ended on july , , when the government announced the cause of the disease. this study assumed that newspapers were likely to publish relevant stories during the selected time period for each issue. accordingly, an issue was put under a public spotlight when the newspapers started to cover it. the current study collected stories by the use of search strings on newspaper websites: stories related to ''swine flu'' ( . %), stories related to ''the comprehensive medical payment system'' ( . %), stories related to ''the decrease in pharmaceutical prices'' ( . %), and stories related to ''humidifier-related lung disease'' ( . %). one of the researchers and two independent coders inductively extracted frames by reading each article. labeling of extracted frames was determined on the basis of relevant prior framing research, because the research provided useful guidelines for finalizing frames. one reason for not applying previous frames to this study is that the nature of the four issues differs from that of issues in previous research. given this caution, previous researchers provided prototypes of frames, such as conflict (shih et al. ) , economy, and individual rights (rogers and peterson ) , educational prevention (jung ) , and morality (park ) . some articles contain multiple frames because we focused on the paragraph as a unit of analysis. a paragraph is a minimum unit for producing a meaning, and the relationship between a sentence and a paragraph reveals a meaning of the sentence (jasperson et al. ) . we discussed disagreements during specific sessions. this study estimated the intercoder reliability based on randomly selected articles. the scott's pi for the types of frames was . . the operational definitions determined for frames identified in this study are listed below. institutional rules for framing healthcare policy issues... differing interests among the various actors in a conflict structure frequently emerged as major topics of articles. examples included ''consumer groups dispute over humidifier disinfectants'' and ''department of health and human services versus pharmaceutical companies, second round of litigation.'' these articles focused on government policy enforcement, countermeasures, and so on. examples included ''department of health and human services enforces planned decrease in pharmaceutical prices'' and ''department of health and human services applies the comprehensive medical payment system on seven diseases beginning on july .'' this term refers to a crisis that will occur in the future or a crisis that has already occurred and serves as the subject of an article, such as ''woman in her s from the city of daegu is also infected with swine flu'' and '' cases of humidifier disinfectant-related lung diseases discovered.'' this frame appeared in news published from an economic or commercial perspective, such as ''pharmaceutical industry: loss is expected in the first quarter'' and ''comprehensive medical payment system does not even meet the costs of medical services.'' these articles criticized policy failures and the spread of diseases, as well as the government's incompetence. examples included ''decrease in pharmaceutical price is an example of a rough-and-ready policy'' and ''causes of pregnant women's lung diseases are unknown. this increases citizens' confusion.'' these articles highlighted the government's efforts to minimize public anxiety by engaging in swift policy management. they also focused on the government's ability to manage situations related to particular issues. examples included ''high-speed and high-intensity quarantine countermeasures put in operation'' and ''the government prepares an effective countermeasure.'' these articles emphasized the importance of decision making through consensus between parties involved in conflicts related to an issue. examples included ''pre-announcement of legislation in progress after in-depth discussions held with pharmaceutical companies'' and ''communication must occur prior to enforcement of comprehensive medical payment system.'' these articles emphasized patients' medical options and quality of care. examples included ''comprehensive payment system negatively affects the quality of medical services'' and ''comprehensive payment system hurts patients' choices for medical services.'' these articles focused on the medical and scientific aspects of diseases. examples included ''why is swine flu rampant despite the heat?'' and ''how does petrified lung occur?''. these articles emphasized actors' moral and ethical problems. examples included ''the government should not confront hospitals by using patients as hostages'' and ''doctor's group refuses to perform cataract surgeries.'' these articles described disease prevention factors such as diet, exercise, the importance of becoming a nonsmoker, and taking a positive view of life. examples included ''get a flu checkup days after traveling abroad,'' ''wash your hands frequently outside the home,'' and ''individuals who cough must wear masks.'' in-depth interviews allow researchers to understand news-making processes by identifying particular incidents, experiences, and internal understanding (jankowski and jensen ) . the interviews also provide researchers with the opportunity to observe what interviewees have experienced and what they thought (mccracken ) . to obtain a diverse group of health journalists, we selected no more than three health reporters from each of the newspapers (national, financial, and specialized). the journalists included beat reporters, assistant editors, and editors who produced news stories about the four healthcare policy issues. we chose experienced reporters who covered the policy issues and conducted interviews with them between july , , and august , . before each interview, we sent an email to or met with the interviewee to explain the purpose of the interview and obtain their cooperation. we conducted the interview at the health journalist's beat or at the news organization. each interview lasted from min to hr, and the average time was . min. we allowed the interviewees to respond to the questions at their pace and created transcripts with the consent of the interviewees. the prepared questions were guiding questions, so they were revised during the interviews in order to find any new meaningful information. we developed four guiding questions. the first question referred to what individual, organizational, and external factors influenced the formation of frames with regard to healthcare-related news as compared with other issues. the second question referred to how news frames varied among the four issues. the institutional rules for framing healthcare policy issues... third question referred to how news frames varied with newspaper type. the fourth question concerned how to improve the frame-making process. because these questions aimed to let the journalists reveal what they thought, we provided them with contexts and reasons for the guiding questions rather than asking the questions directly. after the interviews, we called or sent emails to interviewees to clarify any confusing statements that appeared in their answers. table describes the characteristics of the interviewees. the health journalists in the study sample included females aged - and males aged - . the number of years worked at newspapers ranged from to years, and the total length of journalistic work experience ranged from to years. the first research question focused on the variability of news frames of the four selected healthcare issues based on the nature of each issue. in table , this study identified five frames related to ''the decrease in pharmaceutical prices'' (i.e., conflict, policy execution, economy, blame, and democratic consensus), and two frames related to ''the comprehensive medical payment system'' (i.e., patients' choice and morality). news stories focused on ''swine flu'' relied on frames, including policy execution, crisis, economy, blame, and government efforts. news stories concerning ''humidifier-related lung disease'' relied on eight frames, including conflict, policy execution, crisis, and prevention. coverage of all four issues relied on the following common frames: policy execution, economy, and blame. the policy execution frame appeared more frequently in articles focused on ''the comprehensive medical payment system'' ( . %) than in articles focused on ''the decrease in pharmaceutical prices'' ( . %). the policy execution frame was also found in articles related to ''swine flu'' and ''humidifier-related lung disease.'' the proportion of policy execution was . % for ''swine flu'' issues. the proportion was . % for ''humidifier-related lung disease.'' the economy frame was commonly found in all four issues. out of all policy-related issues, the proportion of the economy frame was higher in articles related to ''the decrease in pharmaceutical prices'' ( . %) than for articles related to ''the comprehensive medical payment system'' because many articles covered the pharmaceutical pricing issue from an economic point of view. the proportion of the conflict frame predominated for the two policy-related issues because interest groups were linked with functions for these healthcare issues. the government, interest groups, and the internal voices of interest groups engaged in conflict led to the conflict frame. the conflict frame for articles on ''humidifier-related lung disease'' differed from the conflict frame that focused on interest groups with respect to policy-related issues. these articles attempted to investigate the truth and verify damages that affected the families of humidifier-related lung disease victims. with respect to ''humidifier-related lung disease,'' the proportion of the blame frame ( . %) was high. these stories revealed that the government did not actively recall humidifier disinfectants. the government received limited positive recognition for its efforts to identify the relationship between lung damage and disinfectants. the patients' choice and morality frames were solely extracted from stories focused on ''the comprehensive medical payment system.'' the patients' choice frame was a unique frame that solely appeared in stories related to the medical services system, as well as in articles concerning claims by the medical association that the system infringed on patients' right to choose treatments. the morality frame highlighted problems related to doctors' morality because doctors' refusals to perform surgeries as protests against the comprehensive medical payment system threatened many patients' lives. these articles also stated that the implementation of the comprehensive medical payment system increased the proportion of treatments determined solely by doctors' consciences. the second research question focused on the variability of news frames related to the four healthcare issues with respect to newspaper type. table shows relationships between news frames and newspaper type with regard to the decrease in pharmaceutical prices. this study compared rankings of the frequency of each news frame across national, financial, and specialized newspapers and calculated kendall's tau_b correlation. this correlation coefficient investigates relationships better than spearman's rho (clark-carter ) , and researchers use the correlation when the sample size is small (dimmick and mcdonald ) . as a result, there was a significant high correlation between different types of newspaper. the rankings of news frames used by national newspapers were significantly correlated with those used by financial newspapers (r = . , p = . , n = ). both types of newspaper applied the frames of policy execution, conflict, and economy to portraying the issue of the decrease in pharmaceutical prices, while they did not use the frames of crisis, government effort, patient's choice, medicine, morality, and prevention. the rankings of news frames used by national newspapers were also significantly correlated with the rankings of news frames used by specialized newspapers (r = . , institutional rules for framing healthcare policy issues... p = . , n = ). that is, the frames of policy execution, economy, and conflict were most frequently used by specialized newspapers as well as national newspapers. the same patterns were found in financial and specialized newspapers. thus, there was a significant correlation between the rankings of news frames used by financial newspapers and those used by specialized newspapers (r = . , p = . , n = ). table shows relationships between news frames and newspaper type with regard to the comprehensive medical payment system. as in table , the rankings of news frames used by national newspapers were significantly correlated with those used by financial newspapers (r = . , p \ . , n = ). the former were also significantly correlated with the rankings of news frames used by specialized newspapers (r = . , p \ . , n = ). there was a significant correlation between the rankings of news frames used by financial newspapers and those used by specialized newspapers (r = . , p \ . , n = ). conflict, economy, patient's choice, government effort, and morality were the most dominant frames used by the three types of newspaper with regard to the issue of the comprehensive medical payment system. by contrast, the frames of policy execution, crisis, medicine, and prevention were not used. table shows relationships between news frames and newspaper type with regard to swine flu. the rankings of news frames used by national newspapers were significantly correlated with those used by financial newspapers (r = . , p \ . , n = ). the former were also significantly correlated with the rankings of news frames used by specialized newspapers (r = . , p = . , n = ). there was a significant correlation between the rankings of news frames used by financial newspapers and those used by specialized newspapers (r = . , p = . , n = ). the three types of newspaper focused on the frames of patient's choice, democratic consensus, crisis, and government effort in portraying the issue of swine flu. but they did not use the frames of conflict, blame, policy execution, and medicine. table shows relationships between news frames and newspaper type with regard to humidifier-related lung disease. the rankings of news frames used by national newspapers were significantly correlated with those used by financial newspapers (r = . , p \ . , n = ). the former were also significantly correlated with the rankings of news frames used by specialized newspapers (r = . , p = . , n = ). there was a significant correlation between the rankings of news frames used by financial newspapers and those used by specialized newspapers (r = . , p \ . , n = ). the three types policy execution . . . crisis . . . medicine . . . prevention . . . total institutional rules for framing healthcare policy issues... of newspaper applied the frames of democratic consensus, prevention, crisis, and patient's choice to portraying the issue of humidifier-related lung disease. by contrast, they did not use the frames of economy, conflict, and policy execution. a comparison of the framing patterns across the four issues shows two interesting perspectives. first, national, financial, and specialized newspapers show strikingly similar framing patterns when portraying the issues, which indicates that some underlying rules guide the newspapers' decisions. this implies that institutional rules play a role in newsmaking processes. second, the nature of an issue is an important factor in the formation of news frames by national, financial, and specialized newspapers. for instance, the policy execution frame did not appear in coverage of the comprehensive medical payment system, swine flu, and humidifier-related lung disease. the medicine frame was absent from coverage of the decrease in pharmaceutical prices, the comprehensive medical payment system, and swine flu. some frames frequently used by the newspapers for one issue disappeared in the coverage of other issues. the newspapers relied on the conflict frame for describing the decrease in pharmaceutical prices and the comprehensive medical payment system, but the frame was absent from the coverage of swine flu and humidifier-related lung disease. by contrast, the newspapers framed swine flu and humidifier-related lung disease in terms of crisis, but they did not apply the crisis frame to portraying the decrease in pharmaceutical prices and the comprehensive medical payment system. these diverse framing patterns were likely to be related to institutional rules governing the news-making processes of national, financial, and specialized newspapers. the third research question addressed this point. the question focused on institutional rules that would guide the formation of news frames. in-depth interviews with health journalists revealed five informative rules that affected how the journalists develop frames in covering healthcare policy issues: ( ) diversity of interest groups; ( ) complexities of issues and terminologies; ( ) journalists' autonomy; news value; ( ) characteristics of readers; and ( ) news organizations' mission statements. a very wide variety of interest groups operate within the national health insurance system based on the principles of the nation's social insurance policies. doctors, pharmacists, nurses, nursing assistants, acupuncturists, and physical therapists are bound to consult with one another on matters related to drugs and the reclassification of medicines. i have been covering many government departments. however, i have never seen the type of major conflict of interest between related parties as i have seen in the healthcare industry. the number of related parties is the largest i have ever seen. (journalist i) journalists' initial reaction to the healthcare industry was ''the content is too difficult.'' when they addressed general political or social issues, a few unfamiliar terminologies were detected. in the healthcare field, most terms were initially unfamiliar. for instance, terms such as the combination of services industry, discretionary grants, and medical insurance fees were not commonly used in everyday life. the healthcare delivery system contained professional content. it took the longest time to adapt to my newsbeat. i had to become familiar with the terms. because most of the content, such as medical practices and health insurance, requires expertise, i had to put considerable efforts into publishing the material in articles. (journalist c) generally, healthcare issues are professional and immune to political tendencies. in this respect, when deciding on the direction for a new story, journalists' autonomy was more secure in the healthcare sector than in other sectors related to general politics or social issues. unlike issues such as the relationship between south korea and the united states, or the four rivers project, healthcare issues are not ideologically controversial issues. in fact, if a political agenda exists, journalists are allowed less autonomy in their coverage. in those cases, most political journalists write articles based on company expectations. however, in the healthcare field, all directions are mostly open to journalists. (journalist d) most of the news desks already maintained significant amounts of information related to these issues within their own chains of command. they determined the importance of these cases based on these standards. however, given their expertise with issues in the healthcare sector, journalist's decisions became more important. in cases related to issues such as the comprehensive medical payment system or humidifier-related lung disease, it can be hard to determine the importance of these issues unless you understand the entire content available in the field. journalists' judgment is important because the desk does not have the room to take commonsense approaches to professional content. (journalist b) journalists felt that policy issues did not contain sufficient newsworthy content to deserve stories because, traditionally, readers do not consider healthcare issues subjects of interest. therefore, the stories were based on ''angles.'' they also contained story structures that interested readers: disagreement, conflict, and confrontation. for instance, stories that focused on the comprehensive medical payment system were based on the conflict structure that developed between the government and the medical industry. when journalists write articles, they think about ways to choose angles, and ways to tell stories. in the case of healthcare issues, the main interests are conflicting situations. (journalist a) on the other hand, issues related to disease exerted direct impact on people's lives. health crises that could develop because of illnesses were the factor with the greatest news value. the implications of stories related to ''swine flu'' or ''humidifier-related lung disease'' revolved around whether these diseases threatened people's health or could be prevented. however, highlights of the crises were readers' main interest. because of increasing health concerns, a disease is a good element to cover in the news. however, inevitably, we emphasize the crisis or the risk of disease because, if the disease is not dangerous, there is no reason to cover it in articles. for the same reason, journalists get more dramatic when they write articles. in the process, crisis is highlighted. (journalist m) most journalists mentioned readers as the reason as news frames varied based on media type. journalists stated that the nature of the person who reads a newspaper is important. with respect to national newspapers, readers who possessed multidisciplinary interests (e.g., political, social, economic, and cultural interests) were the target readership. readers interested mainly in the economy subscribed to financial newspapers. specialized newspapers were targeted at readers who worked in industries related to their specialties. ranges of readers can differ according to whether they read national newspapers, financial newspapers, and specialized newspapers. journalists from national newspapers tend to write more articles from a variety of perspectives. in contrast, financial newspapers focus on economic issues from an economic perspective. specialized newspapers faithfully address what readers wonder about. (journalist q) news frames varied according to newspaper type because newspapers or specialized newspapers had mission statements that focused on particular issues. mission statements are statements that outline the objectives of media companies. national newspapers' mission statements focused on general readers' points of view. financial newspapers highlighted the market economy or wealth in their mission statements. specialized newspapers emphasized healthcare, new drugs, and medical and pharmaceutical developments. mission statements are also connected to the corporate culture. when a journalist enters the media and goes through three to six months of training sessions, he or she learns the mission statement of the news production organization. in other words, journalists learn how to create news that meets the expectations of the news desk and the company. (journalist f) many journalists may not be aware of the mission statements of their own companies. however, they unconsciously learn which stories and frames work well when they write articles and interact with news desks. (journalist k) this study investigates the ways national, financial, and specialized newspapers frame healthcare policy issues. it also attempts to determine the institutional rules that may affect the formation of these frames. news frames vary according to newspaper type, and multiple institutional rules influence framing of healthcare news. the three types of newspaper apply remarkably similar frames to describing each of the four issues: ''the decrease in pharmaceutical prices,'' ''the comprehensive medical payment system,'' ''swine flu,'' and ''humidifier-related lung disease.'' this indicates that certain underlying rules are working in the application of news frames with regard to healthcare policy issues. health journalists believe that the characteristics of readers tend to influence framing patterns in national newspapers, financial newspapers, and specialized newspapers. further, as institutional rules, they mention interest groups, complexities related to issues and their related terminologies, and journalists' autonomy as reasons to apply the frames to healthcare issues. this study's findings provide interesting interpretations about the framing of healthcare policy issues. first, health journalists identify several institutional rules at their own level, the internal organizational level, and the external organizational level. at the journalist level, the journalist's autonomy guides the coverage of healthcare policy issues, because journalists have expertise in relevant issues in the healthcare field and their newspapers rely on this expertise. this autonomy explains why the conflict frame dominated coverage of the decrease in pharmaceutical prices, but was absent from articles on swine flu and humidifier-related lung disease. journalists decide on the application of certain frames to some issues according to their independent viewpoints and expertise. at the internal organizational level, news value and the newspaper's mission statement govern the production of healthcare news. health journalists focus on how to deliver significant stories for readers, including conflicting events, and they are educated to learn the ways of producing news consistent with their newspapers' mission statements. therefore, news value and the mission statement guide journalists in determining how to frame healthcare policy issues. for instance, with regard to the issue of swine flu, national newspapers, financial newspapers, and specialized newspapers focused on the aspects of patient's choice because they agreed with the value of the frame for coverage of the issue. a focus on patient's choice well serves a mission statement such as protecting the interests of underprivileged groups. the conflict frame is used frequently by the media because it plays an important role in creating valuable news, in that conflict is frequently used to attract audience attention (neuman et al. ) . therefore, the news value factor causes newspapers to prefer the conflict frame for healthcare issues, so as to attract readers' attention. at the external organizational level, the diversity of interest groups and the characteristics of readers regulate how health journalists write stories. when covering the issue of humidifier-related lung disease, the three types of newspaper highlighted the democratic consensus because the issue involved opposing groups (victims versus manufacturing companies). by considering the diversity of the groups, the newspapers framed the issue in terms of consensus: the groups needed to agree upon some plausible solutions to the problem. the economy frame reflects the interests of readers, in particular for financial newspapers. because financial newspapers secure industrial associations, hospitals, or pharmaceutical companies as their readers, they needed to describe the decrease in pharmaceutical prices and the comprehensive medical payment system in terms of their economic aspects and impact on the healthcare industry and hospitals. previous research (yu et al. ) states that financial newspapers cover stories from financial or industrial perspectives. this study determined that the economy frame was used similarly in national newspapers, financial newspapers, and specialized newspapers. individuals employed in those industries are the main readers of specialized newspapers. second, institutional rules at multiple levels guide the production of news frames for healthcare policy issues, because the rules reside in the news-making process and journalists follow the rules (cook ; ryfe a) . the manifest outcome is the emergence of dominant frames. conflict and economy are major frames for the issue of ''the decrease in pharmaceutical prices,'' and conflict and policy execution are dominant frames for the issue of ''the comprehensive medical payment system.'' the frame of conflict is salient in the stories about these two issues. this means that health journalists approached these two issues by focusing on oppositional relationships between the government and interest groups. the ministry of health & welfare in korea negotiated with pharmaceutical companies to determine the prices of new medicines. in response to the decrease in prices, pharmaceutical companies filed a lawsuit, arguing that the policy of the decrease would weaken their revenue structure (jung ) . the introduction of a comprehensive medical payment system caused the korean medical association to cancel surgery schedules for patients (song ) . this conflict inherent within the issues was part of the news value on which health journalists relied to develop frames for relevant stories. the stories on ''swine flu'' are framed from the crisis perspective, because the disease had quickly spread to europe, asia, and other countries and patients had been found in korea. this situation promoted a fear of infection by the disease among the public. health journalists responded to the issue of swine flu by focusing on the danger and the possibility of infection. the stories on ''humidifier-related lung disease'' are framed from the policy execution perspective. this issue is different from the swine flu case, because victims were limited to those who used a humidifier. however, the korean government did not issue an immediate recall of the product because there was no causal connection between the humidifier and the lung damage. given this context, we can speculate that newspapers' institutional rules for the production of healthcare news prompt health journalists to focus on a limited number of frames with regard to the four healthcare policy issues. overall, national newspapers employed the frames of crisis, policy execution, and conflict, and financial newspapers used the frames of crisis, conflict, economy, and policy execution. specialized newspapers relied on the frames of conflict, policy execution, and economy. of the frames, the three types of newspaper applied three or four frames to covering the selected healthcare policy issues. we call this phenomenon ''concentration of healthcare frames.'' the concentration can have negative effects on readers' understanding of healthcare policy issues. when health journalists prefer a limited number of frames to diverse frames, readers who need a wide range of information can consume unbalanced or even biased sets of news stories. the preference for dominant frames can contradict health journalists' stated consideration of the characteristics of readers. this suggests that health journalists and newspapers need to reconsider their institutional rules for development of diverse frames. reader profiles, news management, and newspapers' mission statements may contribute to the concentration of healthcare frames. from the policy-maker perspective, the problem of the use of similar types of frames needs to be resolved so that diverse frames can mobilize the public to support healthcare policies. by conducting in-depth interviews with health journalists, this study finds that health journalists need to deliver comprehensive and appropriate health information because many internal or external obstacles can affect coverage. the journalists interviewed for this study admitted that the excessively biased frames could cause readers stress and chaos or manipulate social reality. for instance, newspapers frame healthcare policies from the conflict perspective and describe diseases from the crisis perspective. with respect to the issue of disease, a crisis frame that highlights excessive concerns can increase social stress levels, distort policy procedures, and increase costs. during the swine flu epidemic in korea, newspapers emphasized the disease's many negative consequences and encouraged the public's concern, even though the disease was not very dangerous. these tendencies can distort social reality for readers who want balanced information related to healthcare policies and diseases. this study had some limitations. it failed to examine broadcast news. future research on healthcare issues needs to include broadcast news as well as print media. if an analysis of the media's efforts to portray the influences of the healthcare industry can be performed, the levels of frame research will be enriched. in-depth interviews are subject to supplementation. it is not acceptable to identify factors that affect frame formation in news organizations by listening to the voices of journalists. however, interviews conducted with high-ranking journalists, such as editors and managing editors, would be meaningful. in summary, this study examined the implications of institutional rules for news framing of healthcare policy issues. national, financial, and specialized newspapers adopt similar institutional rules, despite the differences in their organizations. these newspapers rely on three or four frames for covering complicated healthcare policy issues. accordingly, newspapers frequently fail to provide balanced 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epidemics: linking framing and issue attention cycle toward an integrated theory of print news coverage of epidemics mediating the message what really affects campaign reporters?: campaign reporters' perceptions of structural constraints and autonomy korean medical association opposes the comprehensive medical payment system the construction of hiv/aids in indian newspapers: a frame analysis. health communication making news: a study in the construction of reality occupational practices and the making of health news: a national survey of u.s. health and medical science journalists message effects and social determinants of health: its application to cancer disparity media advocacy and public health: power for prevention media framing of social conflict: a case study of medical doctors' strikes in korea does ownership matter? localism, content, and the federal communications commission the frame analysis of the adolescent online game regulation policy: focused on shutdown system news report key: cord- -nwnk q authors: ascari, guido; florio, anna; gobbi, alessandro title: monetary-fiscal interactions under price level targeting date: - - journal: nan doi: nan sha: doc_id: cord_uid: nwnk q the adoption of a"makeup"strategy is one of the proposals in the ongoing review of the fed's monetary policy framework. another suggestion, to avoid the zero lower bound, is a more active role for fiscal policy. we put together these ideas to study monetary-fiscal interactions under price level targeting. under price level targeting and a fiscally-led regime, we find that following a deflationary demand shock: (i) the central bank increases (rather than decreases) the policy rate; (ii) the central bank, thus, avoids the zero lower bound; (iii) price level targeting is generally welfare improving if compared to inflation targeting. after more than a decade from the outburst of the great recession that made the policy rate hit the lower limit of zero, the outbreak of the covid- pandemic has revitalized the never faded debate on how to avoid the zero lower bound (zlb). central bankers are worried that the low level of the equilibrium real interest rates could make the zlb a binding constraint, making it harder in the future to react to a deflationary shock. one of the most discussed suggestions, especially in the u.s., has been the adoption of a (temporary) price level targeting (plt) (bernanke, (bernanke, , . according to this proposal, whenever the economy is in the proximity of the zlb, the central bank should commit to a lower-for-longer rate to fully offset any shortfalls of inflation from target. at the jackson hole symposium, jay powell announced a change in the fed's monetary procedure towards an average inflation target, which is a kind of plt with a finite time window for measuring inflation. therefore, there will be periods when inflation will overshoot the stated inflation target to make up for its previous undershooting. in addition to the adoption of new monetary procedures, even before the outbreak of the coronavirus, many observers suggested to use fiscal measures to stimulate aggregate demand in presence of adverse shocks. evans et al. ( ) claimed that aggressive monetary policy could not be sufficient to avoid deflationary spirals whereas it should be combined with aggressive fiscal policy. draghi ( ) invoked a more active role for fiscal policy since he imputed the slide into disinflation to an unbalanced macroeconomic policy mix (in favor of monetary policy). lagarde ( ) called for euro area fiscal support claiming that monetary policy could not be the only game in town. to mitigate the negative effects of the pandemic, in most countries governments actually adopted unprecedented fiscal stimulus. especially in difficult times, then, monetary and fiscal policy interactions becomes crucial. bernanke ( ) , talking about plt, states that central bank independence should be protected without "ruling out temporary periods of monetary-fiscal coordination that may be essential for achieving key policy goals." when interest rates (are about to) hit zero and the price level is falling, monetary policy can completely lose control on inflation and, according to sims ( ) , an note that the neutral rate might further decline due to the long-lasting effects of the pandemic, see jorda et al. ( ) . see on this point even williams ( ), evans ( ) and yellen ( ) . note that another often cited option to avoid the zlb is increasing the inflation target. however, andrade et al. ( ) find that the case for increasing the inflation target is much reduced when the central bank adopts a price level targeting approach. plt was adopted in the s by the sweden's riksbank that, in the more recent past, has re-pondered that option, as the bank of canada did. active fiscal policy could be beneficial. according to sims ( ) , two dynamics are at work during a deflation episode: an accelerationist dynamic that makes prices decrease further, and real balance effects that instead increase prices. "for real balance effects to rule out or prevent deflationary spirals, fiscal policy must be seen not to be committed to keeping the real value of primary surpluses in line with the current outstanding real value of government debt so that this will not be backed by increased future real taxation. policy-makers should understand that under some circumstances budget balancing can become bad policy." the implications of adopting a plt for different monetary and fiscal policy regimes are, however, not studied so far in the literature. on the one hand, several studies have discussed the potential advantages of price-level stabilization over inflation stabilization in terms of improved welfare, lower inflation variability and a more favorable inflation-output gap trade-off (see, among the others, giannoni, ; svensson, ; vestin, ) . other studies theoretically justify a plt approach to address the zero lower bound problem and to escape deflationary traps (see evans, ; eggertsson and woodford, ; billi, ) . all these studies, however, either abstract from fiscal policy or consider a passive fiscal policy (or a monetary-led regime). on the other hand, a large literature analyses the effects of different monetary-fiscal mixes (both monetary-and fiscally-led regimes) to counteract recessions and deflationary traps in an inflation targeting (it) context (see, among the others, davig and leeper, ; bianchi and melosi, ; ascari et al., ) . there is no such an analysis, however, under plt. we aim to fill this gap. to our knowledge, this paper is the first attempt to merge the literature on monetary-fiscal interactions with the plt proposal, while previous papers on plt consider only a monetary-led regime framework. we investigate the dynamics of the model under plt and a fiscally-led regime (i.e., active fiscal policy) and how the adoption of a plt rule modifies leeper's analysis of equilibrium uniqueness under rational expectations. in this respect, our paper could be considered as the counterpart under plt of the analysis in bhattarai et al. ( ) under it. our main result is that under price level targeting and a fiscally-led regime, the central bank increases (rather than decreases) the policy rate after a negative demand shock. this leads the economy out of the deflationary trap and allows the central bank to avoid the zero lower bound. this result resonates with the neo-fisherian recipe to increase the interest rates in order to increase inflation, as argued by e.g., uribe ( ) . however, here the logic is very different from the neo-fisherian perspective. first, the nominal interest rate increases under plt and active fiscal policy because determinacy implies that the price level coefficient in the interest rate rule should be lower than zero. hence, the nominal interest rate increases if the price gap is negative. second, after a demand shock, this "inverse" reaction of the policy rate to inflation amplifies the wealth effects due to the fiscal theory of the price level. despite there is nothing normative in our plt rule, we show that plt is generally welfare improving if compared to it after a demand shock, under both a monetary and a fiscally-led regime. the paper is organized as follows. section introduces two of the main proposals-namely price level targeting and active fiscal policies-put forth to adjust the actual policy framework to face the current and future recessions. section shows how leeper's ( ) results change when the central bank adopts a plt rule. section extends the determinacy analysis to a simple dsge model and shows the effects of structural shocks both in the monetary-and in the fiscally-led regimes, comparing the impulse response functions under a plt rule to those under a it rule. this section includes a welfare analysis of the two approaches in case of a demand shock and it is closed with a description of the effects of that shock when the zlb is a potentially binding constraint. section concludes. before the coronavirus crisis, the federal reserve was discussing how to review its inflation-targeting framework. the reasons for this choice were low inflation, that had run below the % inflation target for much of the - expansion, falling inflation expectations and low interest rates that increased the risk of falling back into a zlb episode, which readily occurred when the u.s. was hit by the covid- shock. this last shock has speeded up the fed's framework review leading the u.s. central bank to adopt, since august , an average inflation target. a central bank under it aims to reach % inflation every period and commits to correct the inflation deviations from the intended target. under a makeup strategy, like plt or average inflation targeting, instead, the central bank should reverse previous shocks to the price level, abandoning the "bygones are bygones" approach. in particular, under plt, the monetary authority defines a target path for the price level (p * t , in logs) and tries to correct deviations of the price level (p t ) from this path. the corresponding log-linear monetary policy rule has the form: where r t is the nominal interest rate (in deviations from the steady state) and θ t is a monetary policy shock. using the fact that p * t = p * t− + π * , where π * is the inflation target, one gets the following wicksellian rule: we will employ this rule throughout the paper when referring to plt. the main traditional argument in favour of plt is the long-run predictability of the price level, while the major disadvantage is the increase in the short-run variability of both inflation and output (e.g., lebow et al., ; haldane and salmon, ) . if the plt is credible, the history-dependence introduced by this approach could achieve better economic outcomes thanks to the management of market expectations. after a deflationary shock, the central bank adopting a plt approach commits to keep rates lower for longer to tackle deflationary expectations. this increases inflation expectations that, in turn, reduce real rates and scale down the risk of hitting the zlb. the current situation, with low inflation (e.g., blanchard, ) , huge fiscal stimulus and central banks that accommodate increased fiscal spending, could be akin to a period of fiscal dominance. what would happen if, in the presence of an active fiscal policy, the proposal of a plt approach would be put forth? at the moment there is not a framework that links plt and fiscally-led regimes. in the next section we introduce plt in leeper ( ) leeper's ( ) with plt leeper ( ) employs a flexible-price model to analyse the determinacy and the properties of equilibria produced by monetary and fiscal policy rules according to whether policy authorities behave actively or passively. we extend his model to consider a monetary rule that responds to the price level, rather than to inflation. the main reason to consider this simple leeper's ( ) . despite that, we were able to get the analytical solution of the model to gain some insights throughout the paper, we assume central bank credibility and we do not cope with the time inconsistency problems that could well undermine it. the only exception is the so-called "going direct" approach (see bartsch et al., ) that advocates a more explicit coordination between monetary and fiscal policy to be undertaken just in some defined circumstances, with an explicit exit strategy and with an explicit inflation objective for which both monetary and fiscal authorities are held accountable. the inflation target should be met through a monetary financing of a fiscal expansion (a fiscally-led regime) and the central bank should make up for past inflation shortfalls (a make-up strategy in line with plt). that carry over to the sticky price model. beside the monetary policy rule, the original model by leeper ( ) is composed of the following linearized equations: r equation ( ) is a fisher equation, relating the gross nominal interest rate to inflation, keeping the real rate fixed at its steady state value β − . equations ( ) and ( ) are a money demand relation and the government budget constraint expressed in real terms, wherem t are real money balances,b t is the real level of debt,τ t are real lump-sum taxes net of transfers, and c represents real consumption expenditure. finally, equation ( ) is a fiscal policy rule: the government adjusts lump-sum taxes in response to lagged debt according to the parameter γ and to a fiscal policy shock, ψ t . we generalize leeper's monetary policy rule witĥ where θ t is a monetary policy shock. such a rule returns the traditional it case, i.e.,r t = φπ ππ t + θ t , when δ = and φ p = . it reduces to the case of strict plt (or superinertial) rule when δ = and which corresponds to equation ( ) in the previous section. note that both ψ t and θ t follow a stationary ar( ) with autoregressive parameter equal to ρ ψ and ρ θ , respectively. substituting the fiscal rule, the plt rule, and the money demand equation into the government budget constraint we obtain an expression for real debt: where the coefficients ϕ , ϕ and ϕ are reported in table . see appendix a. for all the derivations. following leeper ( ) , the model is linearized rather than loglinearized. hence, in this section hatted variables indicate deviations rather that log-deviations from the steady state, while variables without subscript indicate steady state values. therefore, to derive both the determinacy conditions and the solution of the rational expectation equilibrium when the central bank adopts a plt approach, we consider the system formed by equations ( ), ( ) and ( ). under passive fiscal policy, i.e., when |β − − γ| < , determinacy requires φ p to be positive. this parametric region defines the am/pf regime, so active monetary policy corresponds to φ p > . conversely, under active fiscal policy, i.e., when |β − − γ| > , determinacy is achieved if φ p is negative. this parametric region defines the pm/af regime, so passive monetary policy corresponds similarly to the analysis of leeper ( ) under it, when both authorities behave passively the system returns indeterminacy, while in case of jointly active fiscal and monetary policies the system has no stable solutions. note that, differently from the standard it case, under plt monetary policy is active when the inflation coefficient in the monetary rule ( ) is positive and it is passive when that coefficient is negative. we defer further comments on this to the following section where we analyse a sticky price model. we use the method by bhattarai et al. ( ) to find the rational expectation solution for inflation under plt (see appendix a. ). table compares the solutions under plt and it in the two determinate regimes. as under it, the solution for inflation under plt depends just on monetary shocks in an am/pf regime, while it depends also on government debt and fiscal shocks in a pm/af regime. differently from the it case, however, a super-inertial interest rate rule implies that the nominal interest rate is an endogenous state variable. therefore, inflation depends on the lagged interest rate (r t− ) under both regimes. in the am/pf regime we have that φ p > , so the coefficient relating past interest rate to current inflation (− π φp ) is negative. the intuition goes as follows. imagine that π t− increases, so that the central bank increases the interest rater t− . however, given that plt introduces history dependence in monetary policy, the policymaker should compensate the positive shock to inflation occurred in the past by reducing current inflation (bygones are not bygones). as a consequence,π t will be negatively affected by a surge inr t− . in the pm/af regime, inflation also depends on lagged debt (positively, as it can be shown) while the coefficient on past interest rate is more involved. its sign will depend on the chosen calibration. we now depart from leeper's ( ) flexible price model and illustrate the key properties of plt adapting a basic new-keynesian model. we augment the model with a fiscal block and replace the traditional it rule with a that nests both it and plt. the resulting model is composed of four equations: ŷ the model contains three exogenous variables: the demand shock ε t , the monetary policy shock θ t , and the fiscal policy shock ψ t . section . contains the determinacy analysis of this simple nk model for which we provide analytical results. however, it is not possible to solve the model analytically, so section . present the simulated impulse responses to a demand and a fiscal shock under both the monetary and the fiscally-led regime. section . compares the welfare losses under it and plt rules after a demand shock, while section . includes impulse response following the same demand shock in the presence of a zero lower bound. the determinacy properties of this simple dsge model trace the findings obtained previously in the flexible price model. proposition . determinacy requires either: • an am/pf mix such that γ < b τ ( + β) and φ p > , • or a pm/af mix such that γ > b τ ( + β) and φ p < . proof. see appendix a. . giannoni ( ) undertakes the same analysis considering just the case of a passive fiscal policy. we confirm his finding that under plt the determinacy condition for monetary policy is less restrictive than the taylor principle. interest rate reaction to an increase in inflation should be positive but, in case of price-level stabilization, it could even be lower than one. the new result here pertains to the active fiscal policy case. there is determinacy whenever the nominal interest rate moves in opposite direction with respect to inflation (φ p < ): if inflation decreases, the central bank must increase the nominal interest rate so that the real interest rate increases unambiguously. uribe ( ) suggests, to exit a liquidity trap, to permanently raise nominal interest rates as this would increase inflation, according to the so-called neo-fisherian effect. interestingly, in case of adoption of a plt combined with a pm/af regime, the same would happen: whenever inflation decreases the central bank must increase the interest rate. as explained below, however, the economic mechanism is very different here and it is due to the wealth effect induced by the fiscal theory of the price level. we now want to study the dynamics of economic variables when hit by a demand shock and by a fiscal shock. we analyse both the monetary-led regime (with γ = . ) and the fiscally-led one (with γ = ) and we compare impulse response functions under it (when δ = and φ p = in ( ) to those under plt (when δ = , φ π = ). results in the literature for the plt case are limited to the study of the monetary-led regime, while here we enrich the explanation of the dynamics in the fiscally-led regime. consider a negative demand shock, as shown in figure . therefore, in an am/pf regime, there are advantages from the adoption of a plt approach. pm/af. figure b shows that a negative demand shock decreases inflation less under plt. output decreases more on impact, but it exhibits a less persistent dynamics, returning to equilibrium after periods. to have an intuition of what is going on, consider the government debt valuation equation: where b t− is nominal debt (predetermined), p t is the price level, s is government surplus and r is the real interest rate (from the fisher equation: r t = r t − e t π t+ ). the real value of government debt (lhs) must be backed by the present value of future primary surpluses (rhs). active fiscal policy implies that unbacked fiscal expansions -an increase in government expenditures not combined to a tax rise to cover the deficit -induce wealth effects: agents will substitute out of debt holdings and this would raise consumption demand and increase current prices to a level that restores balance between the lhs and the rhs. under it, output decreases and so does inflation creating a negative inflation tax on government's nominal liabilities which increases real government debt (lhs increases). since fiscal policy does not adjust taxes or public expenditures, the lhs is larger than the rhs so wealth effects kick in and these make inflation increase (inflation reversal) and output too. the inflation increase helps to keep the government budget constrain satisfied. output and inflation decrease under plt too. however, as a response to the inflation reduction, the central bank increases the nominal interest rate, r, under plt and this, in turn, raises the real interest rate, r. this has two consequences. first, there is a much larger reduction in output on impact. second, a rise in r enlarges the difference between the lhs (which increases on impact) and the rhs of ( ), because r is at the denominator on the rhs. hence, wealth effects are now larger, inducing a much quicker rebound of both inflation and output. after a decrease in inflation the central bank raises the interest rate and this, in turn, creates wealth effects that spur inflation. as previously stressed, here the recipe to go out from a deflationary trap is similar to the one proposed exploiting the neo-fisherian effect: increase interest rates to increase inflation. however, here the logic is very different from the neo-fisherian perspective, and it is based on the wealth effects due to the fiscal theory of the price level. furthermore, note that, contrary to what happens under it, if the central bank is adopting a plt approach, such a shock does not make the nominal interest rate decrease. in this case, plt also serves the purpose of preventing the economy from hitting the zero lower bound. figure shows the effects of an expansionary fiscal shock brought about by a tax reduction. am/pf. because of ricardian equivalence, a fiscal policy shock with lump-sum taxes in the am/pf regime turns out to be ineffective on inflation, output and nominal interest rates (see figure a ). if the government decreases taxes, rational agents anticipate a future fiscal adjustment and so they save today to pay for higher taxes tomorrow: there are no wealth effects and economic variables do not move. this is true both under it and under plt. pm/af. figure b shows the dynamics after an expansionary fiscal shock in a pm/af regime under both it and plt. under it, a tax reduction decreases the present discounted value of surpluses (rhs of ( )). the government debt owned by households exceeds the present discounted value of surpluses (lhs > rhs), and this represents a positive wealth effect. agents anticipate that surpluses will not be covered by future fiscal adjustments and thus they convert bonds into current consumption goods, spending increases and inflation surges. this inflation increase is accommodated by the central bank that raises r but less than one-for-one with the increase in inflation. this stimulates output and makes the debt over gdp ratio decrease. under plt dynamics are different. as before, a tax reduction decreases the present discounted value of surpluses and the government debt owned by households exceeds the present discounted value of surpluses (lhs > rhs) engineering a positive wealth effect: spending increases and inflation too. however, now, following the increase in the price level, the central bank decreases r. thus, the real interest rate r goes down by a greater extent than under it. since r appears at the denominator on the rhs of ( ), the more it decreases, the more it offsets the reduction in the fiscal surplus; therefore, the less the lhs will be higher than the rhs, and the lower the wealth effect will be, the lower the increase in inflation and in the debt/gdp ratio. furthermore, the largest decrease in r stimulates output. following gorodnichenko and shapiro ( ), we undertake a welfare analysis to evaluate the performance of it and plt rules following a demand shock. in order to do so we employ the following loss function: where ω π , ω x and ω r are the weights on inflation, the output gap and the deviation of the interest rate from its target path. as gorodnichenko and shapiro ( ) , we bias the findings against plt by not including a possible term on the price-level gap and by associating a relatively large weight to the output gap (ω x = ), since plt usually increases output volatility with respect to it. in the am/pf case (white background), we find the well-known result, e.g., schmitt-grohe and uribe ( ) , that monetary policy can completely stabilize the output gap and inflation facing a demand shock by making the inflation coefficient (or the price level one) tend to infinity. this would be the overall preferred policy combination after a demand shock. note that both the output gap and the inflation gap components decreases with φ π . here, we are more interested int he shaded area, that is, the pm/af regime. in the it case, the overall loss function (blue line) increases as it approaches the cut-off value of , so a very passive monetary policy would be preferred. as monetary policy becomes more active, the output gap volatility (red line) decreases, while the inflation gap one (yellow line) increases sharply. the latter effect dominates in determining the overall loss. the opposite happens in the plt case. the overall loss is decreasing in φ p , so that a less passive policy is preferred. while, as for the it case, as monetary policy becomes more active, the output gap volatility decreases and the inflation gap one increases, under plt it is the former effect to dominate in determining the overall loss. as expected, plt determines a larger output gap volatility and a smaller inflation gap volatility than it. however, the overall welfare loss function is much smaller under plt, so that, conditional on a demand shock, plt generally outperforms it. following eggertsson and woodford ( ) , we now assume a demand shock that hits the economy depressing output and inflation and we introduce a zlb that prevents the central bank to provide the appropriate stimulus to offset the recession. also in this case we consider both the it and the the nominal interest rate increases if the price gap is negative. whenever there is a demand shock, this "inverse" reaction of the policy rate to inflation exacerbates wealth effects; while, if a shock hits the government surplus (see the tax shock above), it dampens them. analysing the social loss function, we find that plt generally dominates it even from a social welfare point of view. bernanke ( ) proposal of a temporary price-level targeting entails a switch from it to plt whenever the economy is about to approach the zlb. according to this (preliminary) analysis, adopting a plt approach could be beneficial, whatever the monetary/fiscal policy mix. future work should address this topic employing a markov-switching approach that analyses both the switch from it to plt and that from a monetary-to a fiscally-led regime. the markov switching framework would, among the other things, stress the role of the expectation effects and, since expectations on future policy moves affect the present value of primary surplus, this would shade more light on wealth effects too. leeper ( ) is formed by the following equations: a fisher equation, where π t = p t /p t− and r t is the gross nominal interest rate; a money demand relation, where m t are real money balances; a government budget constraint, where b t is the level of real government debt, consisting in one-period bonds, τ t are real lump-sum taxes net of transfers, while c and g are real consumption and government expenditures, which are assumed to be constant. the model is closed by two feedback rules: one for fiscal policy and one for monetary policy. lump-sum taxes react to lagged debt where ψ t is a fiscal policy shock. with respect to leeper ( ) , we generalize the monetary policy rule letting the central bank react both to the deviations of the price level and of the inflation rate from their targets wherep t = p t /p * t andπ t = π t /π * . note that the steady state level of inflation is equal to the inflation target, so we can substitute π * = π. following gorodnichenko and shapiro ( ) , we define the law of motion of the target price level as using the identity p t = π t p t− , we obtain that the price level gap evolves as to get a linearized version of the model, let's first consider the monetary policy rule. from (a ) we obtainr where hatted variables are definedr t = r t − r and the likes, while from (a ) we get after quasi-differencing equation (a ) and using (a ) to substitute the price deviations, we obtain the expressionr which corresponds to equation ( ) in the text. note that for δ = and φ p = we are back to the usual case of it, while for δ = and φ π = we obtain the strict plt rule. the other equations of the model, that is, equations (a )-(a ), can be linearized to obtain equations ( )-( ) in the text, which we report here for convenience: we can substitute the linearized money demand relation, the fiscal rule and the monetary policy rule (a ) inside the government budget constraint to obtain if we now impose the parametrization for the plt rule (φ π = and δ = ) we get which corresponds to equation ( ) in the text. instead, if we use the parametrization for the it rule (φ p = and δ = ) we obtaiñ parameters ϕ , ϕ , ϕ ,φ ,φ , andφ are all reported in table in the text. we study the determinacy properties of the system formed by equations ( ), ( ) and ( ) in the text, which we report again for convenience: in matrix form this system becomes the matrix on the left hand side can be inverted to obtain to satisfy the blanchard-kahn conditions for determinacy, the matrix a must have two eigenvalues inside and one outside the unit circle. the eigenvalues of a are , β − γ and + βφp π . therefore, if β − γ is inside the unit circle, that is if we have a passive fiscal policy, the other two eigenvalues should be one inside and the other outside. this happens when φ p > , which denotes an active monetary policy. if β − γ is outside the unit circle, that is if we have an active fiscal policy, the other two eigenvalues should be both inside. this happens when φ p < , that denotes a passive monetary policy. therefore, summarizing, determinacy requires either: • φ p > and β − γ < , the am/pf case, or • φ p < and β − γ > , the pm/af case. we now solve our model to find the solution for inflation both in the monetary-led (am/pf) regime and in the fiscally-led (pm/af) regime. to find the solutions, we follow the procedure of bhattarai et al. ( ) , which is based on the spectral decomposition of matrix a = v dv − , where d and v are the matrices with the eigenvalues and the eigenvectors of a. in particular, we obtain by multiplying both sides of (a ) by v − , we can diagonalize the system as where we defined note that in the last equality we used the fact that βq + q = e q . to find the rational expectation solution, we solve forward the first difference equation associated to the explosive eigenvalue. we distinguish two cases, corresponding to the am/pf and the pm/af parametrizations. in the am/pf regime, the eigenvalue e is outside the unit circle. we thus use the second row of (a ) to draw linear restrictions between model variables. let's rewrite the equation as substituting recursively the future values of x , we obtain the monetary policy shock θ t follows a stationary ar( ) process so we have that which we can plug into (a ) to get after some manipulations, we can obtain and using the definition x ,t = q πt + q rt− we arrive tô finally, after substituting e = + βφp π and noting that q q = π φp , we obtain the solution for inflation in the am/pf regime:π in the pm/af regime, the eigenvalue e is outside the unit circle and we need to solve forward the third equation of system (a ). in this case we obtain the fiscal policy shock ψ t also follows an ar( ) process, so we have that substituting this results in (a ) and following the same steps of the the am/pf case, we arrive to the relation then, we use the definition x ,t = q πt + q rt− +b t− to rewrite the last equation aŝ we can now define the coefficients so that q = e k h and q = e j h . using these relations, together with e = β − γ, the rational expectation solution for inflation in the pm/af regime can be rewritten aŝ the dsge model in the text is given by equations ( )-( ) which, disregarding expectations errors, can be written in matrix form as: inverting the matrix on the left hand side, we obtain one of the four eigenvalues of the matrix a is − β τ b γ − . to study determinacy we have to analyse the other three eigenvalues of the top-left submatrix: if − β τ b γ − is inside the unit circle, that is, in case of passive fiscal policy (γ τ < b τ ( + β)), given the presence of two jump variables, to respect blanchard-khan conditions for determinacy,Ã should have one eigenvalue inside and two outside of the unit circle. woodford ( , appendix c) states these conditions in terms of the determinant, the trace and the sum of the principal minors ofÃ, whose values are the following: det(Ã) = β , tr(Ã) = + β + κ β , m (Ã) = β ( + κ + β + κφ p ) . in order to have two eigenvalues outside and one inside, one of the following three cases must hold. • case : two restrictions should be satisfied simultaneously: the first is verified for φ p < , but the second is never verified, so this case does not hold. the first condition is satisfied for φ p > , the second is always true while the third holds for φ p > β − . • case : in this last case four conditions are required: the first is satisfied for φ p > , the second and the fourth are always satisfied, the third holds true for φ p < β − . in conclusion, from cases and we get the sole condition is φ p > . therefore, when fiscal policy is passive, determinacy can be achieved for φ p > . if − β τ b γ − is outside the unit circle, that is in case of active fiscal policy (γ > b τ ( + β)), given the presence of two jump variables, to respect blanchard-khan conditions for determinacy,Ã should have two eigenvalues inside and one outside of the unit circle or, equivalently, we would ask for two eigenvalues outside and one inside in the following: for this matrix we have det(Ã − ) = β tr(Ã − ) = κ + β + κφ p + m (Ã − ) = β + + κ. as before, we should consider the three cases above. we can exclude case since the second condition is never verified. from case we find that the first condition gives φ p < , the second is always true and the third is verified for φ p < β − (that is a less stringent condition than φ p < ). the optimal inflation target and the natural rate of interest controlling inflation with timid monetary-fiscal regime changes dealing with the next downturn: from unconventional monetary policy to unprecedented policy coordination temporary price-level targeting: an alternative framework for monetary policy inflation dynamics: the role of public debt and policy regimes escaping the great recession price-level targeting and risk management in a low-inflation economy is there deflation or inflation in our future monetary-fiscal policy interactions and fiscal stimulus twenty years of the ecb's monetary policy the zero bound on interest rates and optimal monetary policy monetary policy in a low-inflation environment: developing a state-contingent price-level target liquidity traps, learning and stagnation optimal interest-rate rules and inflation stabilization versus price-level stabilization monetary policy when potential output is uncertain: understanding the growth gamble of the s three issues on inflation targets longer-run economic consequences of pandemics the future of the euro area economy economic performance under price stability equilibria under 'active' and 'passive' monetary and fiscal policies asymmetric expectation effects of regime shifts in monetary policy optimal simple and implementable monetary and fiscal rules comment on three lessons for monetary policy in a low-inflation era price-level targeting versus inflation targeting: a free lunch? the neo-fisher effect: econometric evidence from empirical and optimizing models key: cord- - mxkfvvu authors: de leeuw, evelyne title: from urban projects to healthy city policies date: - - journal: healthy cities doi: . / - - - - _ sha: doc_id: cord_uid: mxkfvvu a definition of projectitis (also known as ‘projectism’) is proposed to describe a key barrier to full deployment of a healthy city vision and values. this chapter argues that to put health high on local social and political agendas necessarily means to transcend project-based work, and move into lasting programme and policy development. the conditions for such approaches are favourable in healthy cities, as a number of glocal (global and local) developments invest and sustain longer term perspectives. these conditions include emphases on policy diffusion, social justice, a better understanding of complex systems, and global commitments to the development and implementation of health in all policies. these efforts, in turn, are grounded in renewed and tangible support from universal health coverage and primary health care, asset-based community health development, and better insights into what drives (health) equity and economic development. in describing these elements of policy development for value-based healthy cities the chapter also gives a firm argument for a broad range of stakeholders to engage successfully in longer term policy change. the urban health world is rife with projects-to alleviate poverty, empower communities, provide better roads, increase access to education, secure primary care, etc. many of these initiatives, rightly, have a fixed life. a new school needs to be built; upon completion it requires staff and maintenance: these are entirely different things that can be managed well on a project basis. but a proper policy would take a longer term perspective that includes not just the building and maintenance of the infrastructure. such a policy would set parameters to how infrastructure relates to continued access, how both of these relate to the delivery of a curriculum, and how to undertake regular reviews of accomplishments. goumans and springett ( ) have identified that many healthy cities suffer from projectism. interestingly, although this term (alternated with 'projectitis') has become an integral part of the vernacular of the-critical-government bureaucrat, we have been unable to ascertain an authoritative definition for it. in development studies, pareschi ( ) and little ( ) refer to projectism when they describe the tendency of the international development community (the 'do-gooders' (christensen ) in development aid) to impose a project format with defined beginning and end, contained resources (money, people) in time and space, on daily activities undertaken by indigenous communities that by their very nature are organic and ongoing, e.g. the defence of territory, production of food, and political organization. such project 'containment', they assert, can provoke major changes in cultural values, leadership patterns, time conceptions, organizational structure, and political relations in affected indigenous communities. true as this may be, the popularity of projectism/itis suggests that the phenomenon may have detrimental effects in high-income, industrialized nations as well. a definition that reaches beyond indigenous culture into (western) bureaucratic and political values might read 'the reflex, intention and action to contain organisational and community efforts in terms of resource allocation, time, space and conceptualisation purely for the sake of accountability and management purposes, not because the effort at hand necessarily lends itself to such limitation'. goumans and springett ( ) have investigated the potential of healthy cities to move beyond projects and projectism, and found that ample opportunities exist to move into longer term programmes or policies that embed the value base and strategic outlook of the approach. in this chapter we take a look at the conditions that may facilitate such a longer term endeavour. some research suggests that achieving policy innovation, which is required for introducing systemic and sustainable intersectoral perspectives across society, cannot be achieved at the national level, or not at that level alone. policy diffusion researchers (e.g. shipan and volden ) argue that local governments drive policy innovation and diffusion of novel policies horizontally to other local governments, and vertically to regional and national governments. for example, policy diffusion facilitated the netherlands' efforts to develop a broad healthy public policy in the s (de leeuw and polman ) . global commitments, such as the kyoto protocol for climate change adaptation and mitigation or the framework convention for tobacco control, can be seen as crucial benchmarks for the need to develop new policy types. policy innovation does not happen exclusively bottom-up or top-down, but must be characterized as happening through a process called 'mixed scanning' (etzioni (etzioni , in which systems of incremental and reciprocal checks and balances between governance levels create opportunities for change. a key term that has been encountered throughout this book is 'glocal'. 'glocal health' (de leeuw ; de leeuw et al. ; kickbusch ) is a term used to recognize and appreciate the intricate and inseparable interface between global developments (e.g. climate change or trade) and local responses (e.g. councils adopting building codes that account for the increased risks of flooding and heat islands, or offering favourable opportunities for local entrepreneurship to engage in international forums). this glocalization dynamic is reciprocal. less likely or desirable global developments may be mitigated-or exacerbated-by local action. for instance, the increasing number of local governments around the world adopting 'zero-carbon emission' policies (e.g. koehn ) not only contribute to possible reductions in climate change risks, but also send signals to their colleagues, at local as well as higher government levels, that such actions are feasible and effective. through policy diffusion these local policies impact on global change. in fact, analyses of local government efficacies in the late s and early s led to the introduction of the terms 'glocal' and 'glocalization' into our vocabularies (swyngedouw ) . virtually every development and phenomenon in healthy cities has glocal dimensions. so why would we make policy at all? healthy people are an important resource for society. healthy communities are thriving communities, not just in economic terms (because they may more comprehensively contribute to building their common resources) but certainly also in terms of social development and the resilience to cope with shifts and challenges in their social and natural environments. societies and communities with high levels of positive health are resilient. they can face adversity better. a firm expression of the nature of such a health perspective is often found in its definition as engrained in the constitution of the world health organization ( ): health is a state of complete physical, mental, social [and spiritual, larson ] wellbeing and not merely the absence of disease or infirmity. in spite of this broad framing of health, in many countries the health service delivery (or 'sick care') sector is not fully embracing these views and their consequences. most healthcare establishments focus on individual treatment and disease prevention, and are challenged to adopt a full social model of health. around the world, the health delivery industry has become a dominant economic sector in its own right and efforts to involve it in actions to promote community health (rather than cure and prevention of disease) face strong beliefs that individual-focused interventions are better, quicker, or more effective. the microbiologist-philosopher dubos ( ) recognized the profound interface between individual and social health and defined health as the expression of the extent to which the individual and the social body maintain in readiness the resources required to meet the exigencies of the future. the key to appreciating this definition is the notion of 'the social body': it refers to community as well as society and its institutions. the institutions can be seen as tangible 'hardware' (hospitals, transport services, bodies of government) but also in a more sociological sense. the formidable ahrendt ( ) saw an institution as 'a body of people and thought that endeavours to make good on common expressions of human purpose'. this idea of an institution (as in 'the institution of marriage' rather than 'the hospital institution') has intimate relations to concepts of government and governance. the ways in which local governments are shaped are functions of both the philosophical and structural views of institutions. in democratic traditions, the assumption is that local government can directly represent constituents and respond to individual, family, community, and neighbourhood needs. but that assumption is firmly based in other assumptions about representation and eligibility of people to partake in the communal and political processes leading to the values that pervade governance, and the resulting shape of government. a key aspiration of modern glocal government is to deliver justice. as spinoza ( ) said, the ultimate end of the state is not dominion, nor restraint by fear, nor the exaction of obedience; on the contrary, its end is to free every man from fear, so that he may live securely. contrast this with ronald reagan's definition of government as like a big baby-an alimentary canal with a big appetite at one end and no sense of responsibility at the other (adler , p. ) and the clash of political ideologies will be clear. governments can secure and facilitate different forms of justice (e.g. ruger ): • procedural justice-decision-making about policy, programme, service design, and delivery-making the composition of decision-making bodies more descriptively representative of the community (in cultural, socioeconomic, gender, etc. senses); and strengthening communities' power to define 'agenda' items independently of the 'dominant culture' • substantive justice-influence-putting items on the agenda, influencing discussion and debate on all agenda items, and influencing the outcomes of decision • distributive justice-ensuring that the population has equitable opportunities to access social resources including high-quality health care, but also preventive services and education, employment, transport, etc. we assert that local government is an expression and instrument of priority setting for shaping the resources for health that dubos describes, and creating the forms of justice that allow people to fully participate. this happens through policy development and the management of social and environmental assets. the growing body of evidence, over recent decades, on the social, political, and commercial determinants of health may well enable local government better than other levels of government and governance to take decisive action. evidence from the other chapters in this book shows that local governments (and especially healthy city ones) are in closer contact with their constituents and would purportedly be able to respond more effectively and quickly to needs expressed. clearly this is an idealtype description: not all local governments are transparent and accountable, and not all people may be, or may feel, represented. this is particularly true for slum dwellers. sometimes urban inequities are literally hidden-in many third world cities the slums and their informal populations are located in gullies and ravines. but in others, the favelas rise up high on the slopes surrounding affluence. it appears that technology can come to a degree of rescue, whether it is enabling social connectedness in nairobi slums (corburn and karanja ) or physical connectedness through novel public transportation solutions in medellin, colombia (díez et al. ) . local government also has the potential to address the wider determinants of health and health equity. the determinants of health extend far beyond the workings of the health care system, and include the provision and levels of education, the availability of work and employment and standards, the quality of the built and natural environment, the existence of intangible things like a sense of community and solidarity expressed in 'social capital', and the apparent immutability presence of general social gradients between those at the highest and lowest ends of the socioeconomic spectrum. families and communities, and their elected representations in local governments, most directly suffer and enjoy the negative and positive consequences of their decisions on how their lives are shaped in all these domains. complex and connected issues require complex and integral responses. local government does not stand alone in this-it can respond (and has responded, e.g., through the healthy communities and healthy cities networks) more efficaciously to population needs; but at the same time it is bound by regional (provincial, state) and (inter)national contexts. horizontal and vertical collaboration and synergy can and should be sought. analyses of the workings of modern society and its institutional structures (governance, democracy, leadership, etc.) have shown that traditional sectoral and vertical (top-down) responses may yield short-term success but may not address the systemic and complex causes of problems. the consequence of such analyses has been a call for better integration of (and within) problem formulation, policy development, and comprehensive action. such integration would assume equitable access of highly heterogeneous stakeholders to all elements of enormously multifaceted systems (anyone should have access at any time wielding the same influence over the process, no matter who and where they are-a utopian ideal). it is no wonder that solving this issue has eluded politicians, scholars, practitioners, and communities. at an abstract level, the solution has been found in concepts such as 'systems thinking', 'complexity science', and identification of problems as being 'wicked', 'messy', or 'fuzzy'. for policy-making, those terms have translated into perspectives on 'whole of government', 'joined-up government', 'integral government', and 'horizontal government' (carey ; carey and crammond ; pollitt ) . there is a strong argument to be made that these perspectives play out best at the local level because it is there that cooperation between state, market, and civil society actors is considered most likely to produce coordinated planning and action (christensen and laegreid ) . the search for whole, joined-up, integral, or horizontal local government approaches achieved momentum, some scholars and politicians claim, since the (perhaps overly zealous) adoption of 'new public management' (npm) principles from the s. in npm citizens are viewed as customers, and public servers/administrators are considered managers of product and service delivery. the assumption of npm was that marketization of public goods would yield greater efficiencies. however, vulnerable, socially excluded, marginal, and under-represented populations in particular often cannot claim a voice of influence and power in this pseudo-economic discourse. governments have tried to repair the resulting gaps in the system with the application of (often cunningly rhetorical) tools that go by monikers such as 'new social partnerships' and 'empowered clients'. in many cases a new balance between complete state control (the 'nanny state' caring for everyone 'from cradle to grave', cf. rivett ) and full dissolution of services to commercial sectors is yet to be struck. in the health field, the recognition of 'health' as an issue across social and government sectors has led to the launch of policy perspectives such as 'healthy public policy' and 'health in all policies'. in action terms (that is, for specific intervention development) we have seen the emergence of terms like 'strategic', 'comprehensive', 'multisectoral', or 'intersectoral' action. in the scientific literature we see important efforts to distinguish between all these terms. analysts also suggest ways in which they interrelate. a canadian publication (gagnon and kouri ) starts this discussion with a description stemming from australia of 'integrated governance': the structure of formal and informal relations to manage affairs through collaborative (joined-up) approaches which may be between government agencies, or across levels of government (local, state and commonwealth) and/or the nongovernment sector. this describes the overarching principles driving both policy and intervention responses to complex systems issues in health development: managing health, health development, and health equity through collaborative approaches. the current perspective on health in all policies (hiap) finds a basis in the call to develop healthy public policies in the ottawa charter ( ). around the world, governments at all levels have experimented with integrated health policies. some of these actually inspired the pronouncements of the ottawa charter, e.g. the norwegian farm-food-nutrition policy, the chinese 'barefoot doctors' programme, and women's health initiatives in the americas. two initiatives from opposite ends of the world started the developmental process of what now is called hiap. one came from finland during its presidency of the european union in : finland, building on its experience in the long-running north karelia project (labelled a 'horizontal health policy'), urged other members of the union to engage in a horizontal, complementary policy-related strategy contributing to improved population health. the core of hiap is to examine determinants of health that can be altered to improve health but are mainly controlled by the policies of sectors other than health. (ståhl et al. ) the other came almost simultaneously from the government of the state of south australia, which identified opportunities for a broad policy programme to invest in the health of its people: health in all policies aims to improve the health of the population through increasing the positive impacts of policy initiatives across all sectors of government and at the same time contributing to the achievement of other sectors' core goals (ståhl et al. , quoted in baum et al. rudolph et al. ). these provided impetus for the organization of the eight global conference on health promotion where a statement and framework were adopted that expressed hiap as follows: health in all policies is an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts in order to improve population health and health equity. it improves accountability of policymakers for health impacts at all levels of policy-making. it includes an emphasis on the consequences of public policies on health systems, determinants of health and well-being. (world health organization a, b) in different countries and jurisdictions the emphases of the different dimensions of hiap vary. consistently, values (in bold) associated with the concept centre around the importance of collaboration between sectors of public policy-making in good partnership. other aspects where less coherence exists between the different jurisdictions include health equity, the attainment of synergy, hiap leading to or driven by accountability, the character of innovation, ways of integration, and the very nature of policy, e.g.: health in all policies is a collaborative approach that integrates and articulates health considerations into policy making across sectors, and at all levels, to improve the health of all communities and people. health in all policies is a collaborative approach to improving the health of all people by incorporating health considerations into decision-making across sectors and policy areas. (california health in all policies task force) health in all policies is the policy practice of including, integrating or internalizing health in other policies that shape or influence the [social determinants of health (sdoh)] … health in all policies is a policy practice adopted by leaders and policy makers to integrate consideration of health, well-being and equity during the development, implementation and evaluation of policies. (european observatory on health systems and policies) health in all policies is an innovative, systems change approach to the processes through which policies are created and implemented. (national association of county and city health officials) (from rudolph et al. ) shifts like these don't just happen. they are the result of, and embedded in, intricately connected webs (kickbusch ( ) identified those for the health promotion endeavour as rhizomes) that grow, dissolve, reconnect, and interact between people, agents, and events. callon ( ) and latour ( ) based their actor-network theory (ant) on such a view of social, policy, and technology development. this is not the place to engage in a fully fledged ant analysis; instead we will list six keystone developments that made the current momentum for hiap possible. one foundation and lasting contribution to our thinking about health in all policies has been the drive towards primary health care (phc). at the who/unicef conference on primary health care in alma ata in , the concept was defined (unicef and who ) as essential health care based on practical, scientific and socially acceptable methods and technology. it is made universally accessible to individuals and families in the community through their full participation and at an affordable cost to the community and country. in its further development, phc became more fine grained, and two perspectives emerged. one was a horizontal (comprehensive, systems-driven) approach aligned with a set of strong values around equity, participation, and community-driven bottom-up action for health and well-being, and the other a vertical (disease and health care-driven) approach aligned with the need to address specific (burdens of) disease in many countries, and grounded in existing institutions and patterns in the delivery of clinical interventions. ideology-inspired debates have raged, contrasting the superiority of each approach. reviews show that vertical programmes, particularly those targeting infectious disease morbidity, may yield short-term and specific health gains (e.g. from vaccination campaigns), but that long-term population health development (e.g. aiming at the reduction of the incidence of non-communicable disease [ncd]) does not unequivocally benefit from such selective approaches (e.g. magnussen et al. ) . vertical programmes work for particular threats, and horizontal programmes contribute to general well-being. in particular, addressing health equity and ncds does not align well with a selective, vertical approach. evidence has emerged that, depending on the existing health profile and management of (social) determinants of health in different communities and countries, an appropriate balance between the two should be struck. building on a mix between vertical and horizontal primary health care, the aspiration should be to engage in the development of comprehensive health strategies accessible to all (rasanathan et al. ). in north america, planning emerged as a discipline early in the twentieth century. initially the planning professional focused on urban development, but soon social planning and other areas such as health and environmental planning were added to the repertoire of the planner. considering the 'best' ways of planning, experts before long found that the full participation of people in planning considerations was important. what 'full participation' entailed was (and perhaps continues to be) a matter of debate, and arnstein's 'ladder of participation' as well as davidson's 'wheel of participation' have contributed significantly to insights into the circumstances and degrees of public participation in the planning endeavour. these views have also made a significant contribution to public health and health promotion practice around the world (wallerstein ) , in the americas (wallerstein and duran ) , and in european healthy cities (boulos et al. ; green and tsouros ) . a second tradition in this arena was driven by paulo freire's work in the area of community development through new forms of education, famously called 'the pedagogy of the oppressed' (originally published in in portuguese, translated into english in ; his politics of education ( ) gives a good reflective overview). the views espoused by freire and others in this tradition hinge on a philosophy that all in society should be able to engage with personal and social development equitably, through open forms of democracy and decision-making. in order to attain such a capacity, empowerment was, and remains, a key strategy in (local) (health) development. others have taken this important work as a starting point for, for instance, assetbased community development (recognizing that the people in particular social contexts are an important resource for change), deliberative democracy, and a particular form of the latter, participatory budgeting. the 'father of asset-based community development' is john mcknight. he sees community assets as all the potential resources in a community-not only financial, but also the talents and skills of individuals, organizational capacity, political connections, buildings and facilities, and so on (kretzmann and mcknight ) . some authors (e.g. page-adams and sherraden ) criticize such a broad conceptualization as assets might be taken to mean 'all good things', and in order to make assets more tangible they prefer to frame them in a more economic manner. such a view denies, in our view, the fact that social and health equity both depend on much more than financial and resource capability, and also involve culture, history and heritage, and context (wilkinson and pickett ) . the asset model presented by morgan et al. ( ) aims to redress the balance between evidence derived from the identification of problems to that which accentuates the positive capability to identify problems jointly and activate solutions, and so promotes the self-esteem of individuals and communities and leads to less dependency on professional services. this can lead to an increase in the number and distribution of protective/promoting factors that are assets for individual-and community-level health. the asset approach should be seen as the 'shiny' side of the coin. the deficit approach remains valuable in responding to acute crises (at individual, community or societal levels), but in evidence terms at least, the asset model may help to further explain the persistence of health and well-being inequities despite increased efforts to do something about it. harrison et al. ( ) have defined health assets as resources that individuals and communities have at their disposal and that protect against negative health outcomes, or promote health status. these assets can be social, financial, physical, environmental, or human resources (e.g. education, employment skills, supportive social networks, natural resources) (harrison et al. ). as such, a health asset can be defined as any factor or resource which enhances the ability of individuals, groups, communities, populations, social systems, or institutions to maintain and sustain health and well-being and to help to reduce health inequities. these assets can operate at the level of the individual, group, community, or population as protective (or promoting) factors to buffer against life's stresses. obviously a balance needs to be struck between the intangible assets (skills, knowledge, intents, and aspirations) and the hardware assets of a community (schools, work, infrastructure, etc.). even when both are available there may still be a disconnect between the two: individuals, families, and communities may want to improve their health, but insidious factors such as (health) literacy, culture, sexism, and racism may stand in the way of full and equitable access and use. an asset-based health approach should carefully take into account all elements of a complex individual, social and ecological environment. effectively mobilizing and empowering communities for their health, health equity, wealth, and well-being is an inherently political enterprise and may upset the status quo. not all governments, locally or nationally, may see the full benefits of participation and empowerment. the maturity of government and governance styles as well as patterns of accountability, transparency, and responsiveness to need may not always allow for the full mobilization of community assets. we will return to these challenges later in this chapter. due to a growing recognition that health lifestyle change through traditional behavioural (health education) interventions had limited efficacy, and needed to be embedded in broader social change, the world health organization with health canada and the canadian public health association organized the first international conference on 'the move toward a new public health' in ottawa, in . the conference, followed by a series of global health promotion conferences, culminated in the adoption of the ottawa charter (world health organization et al. ). the charter defined health promotion as 'the process to enable individuals, groups and communities to increase control over the determinants of health and thereby improve their health'. the conference and its charter saw a responsibility to enable, mediate, and advocate a broad view of health and health action in four areas: • to reorient health services towards a broader, participatory, and health-promoting position in society at any level • to create supportive social, economic, natural, and built environments to create and sustain health promotion and to address the determinants of health equitably • to invest in personal skills and community action to drive and complement these actions • to build healthy public policy, recognizing that health is created across many sectors in society that all have the potential to enhance institutional, community, and personal health reviews of the accomplishments of the ottawa charter have found that substantial progress has been made in our understanding of the drivers of success in each of these fields. our understanding of the complex nature of natural, social, political, and commercial determinants of health has increased, as has our appreciation of the impact of policies on all of these. great advance has been documented in linking ('enabling, mediating, and advocating') individual and community health potential with systemic action on environments for health. the only area where success has been lagging is the reorientation of health services (ziglio et al. ) . the global community of health promoters continues to work on the basis of these principles and advances, and implements these especially in the context of 'healthy settings'-a concept that the charter launched: health is created and lived by people within the settings of their everyday life; where they learn, work, play and love. health is created by caring for oneself and others, by being able to take decisions and have control over one's life circumstances, and by ensuring that the society one lives in creates conditions that allow the attainment of health by all its members. health and economic development go hand in hand, although the interface between the two can best be described as 'fuzzy', or in terms of complex systems policy development 'wicked'. the fact that investment in health is a sound economic strategy started to gain traction from the late s and achieved prominence for the first time in the world bank's world development report investing in health. a strong case was made of the importance to national economies and local communities of addressing health and disease factors that impeded full economic development (jamison ) . the report was criticized for espousing new public management and neoliberal principles of outsourcing and privatizing health as a public good (including, e.g., the supply of safe drinking water) and quantifying the impact of disability on economic development through a measure called the 'disability-adjusted life year' (daly) (e.g. navarro ). however, it succeeded in placing health promotion and public health management on global and local agendas as legitimate strategies for development. the argument for hiap, also at the global level between international bodies, has evolved in the past years with the family of un agencies, including world bank, undp, and who, now mobilized for ncd action. the argument has been developed and refined over the years; for instance, in the jeffrey sachs-led who commission on macro-economics and health. more recently the who commission on social determinants of health (the marmot commission, who commission on social determinants of health ( )) forcefully indicted unequal economic conditions and pervasive poverty as one of the most critical drivers of health inequity around the world. impressively, the global marmot report has had a number of regional (europe), national (e.g. brazil, england), and local (malmø) reincarnations, highlighting the opportunities and benefits of political action on the social determinants of health. in recent years there has also been a move to take the discourse further, with some starting to address commercial and political determinants of health. recently who and undp issued guidance note on the integration of noncommunicable diseases into the united nations development assistance framework ( ), an expression of the joint-agency work that was an outcome of the high-level meeting at the un in which ncds were given utmost priority. in the guidance note the vicious cycle of poverty and health is described with great insight into the implications of this perspective for local government action. the recognition that health is unequally distributed across populations is not new to the twenty-first century. the terminology used for this phenomenon is possibly as political as its causes and consequences. various terms are pertinent to this discourse, including 'health disparities' and 'health differences' (scholars of the unfair distribution of resources and its consequences in society claim that these are deliberately 'value-free' functional descriptors to obscure the political nature of the issue) and 'the social gradient' (the statistical slope between those at the top of a socioeconomic spectrum and those at the bottom) upon which most health and disease expressions can be mapped. (in)equality, some say, is purely a description of that social health gradient, whereas (in)equity conveys a view of the moral and social injustice of such differences in society. wilkinson and pickett ( ) describe how equitable societies provide and create better opportunities for health for all, including enhanced economic development, sustainability, and educational attainment. striving for equity is not necessarily a requirement or prerogative of national government alone-it depends and thrives on a vibrant civil society and its political representation, extending from local action to global policy and the other way around. equity is a driving concept in various global strategies, including those on climate change, sustainable development, and gender. particularly in the health domain, the work by the marmot commission has been instrumental. its report reviews the causes and consequences of health inequity, and demonstrates that it is possible to close the gap within a generation. policy and action at every level are required to mitigate the possible negative influences of globalization on equity; some authors, however, also allude to the significant potential that global connectedness through new social media may have on an equity agenda. the idea that we live in a globalized world has become a mainstream perspective in the twenty-first century. goods, capital, and knowledge travel, sometimes with the speed of light, around the world. globalization goes beyond the bounded role of the traditional nation-state. indeed, although countries continue to collaborate and expand their vision in the globalized world, the phenomenon to no small extent is driven by commercial interests-but also by a new global civil society. the latter includes ngos like greenpeace, médecins sans frontières, amnesty international, human rights watch, and the peoples' health movement. the actions of this variety of actors on the global scene have made the traditional borders of sovereign states more permeable. no country can thrive without interaction, not just with its neighbours but across the globe, and not just with other countries but with such 'non-state actors'. in discussions about global health governance, experts agree that a new architecture for managing health and health systems in this context is very important. at the same time, new technologies and social media offer new opportunities for knowledge development and community mobilization . local governments around the world see the dissolving integrity of the nationstate as an opportunity to take action. the challenges to the sovereign nature of the nation-state have become prominent during (and in the aftermath of) the sars epidemic; authors such as fidler ( ) argue for a new architecture of global health governance (de leeuw ). ncd control, ebola, hiv/aids, the zika and chikungunya viruses, and other health issues have become a global health concern, and new options for policy development at the interface between global and local need to be developed. this has happened through the creation of networks of cities around themes such as climate change and sustainability, age-friendly cities, and knowledge and creativity. assessments of these networks show that such contacts benefit the quality of policy development and actions to improve the quality of life of their citizens. these developments interface with a current discourse about governance. geidne et al. comprehensively review the emergence of the concept of governance as relevant for local health development. they explain that a focus on governance, as complementary to studies of government, derives from a more refined understanding of the scope and nature of the welfare state. this understanding has led to a convergence of ideas that 'government directed by sovereign politicians is not necessarily the most rational arrangement' (geidne et al. , p. ) . stoker ( ) argues that, despite there being no unequivocal definition of governance, a consensus exists that it refers to the development of governing styles that blur the boundaries between, and within, the public and private sectors. this makes governance a multidimensional and contextually relevant approach to local arrangements for health development, but also a phenomenon that can be construed as a messy research problem (e.g. sinkovics and alfoldi ), and 'evidence' for it must be generated in ways beyond the epidemiological paradigm of (quasi-)experimental studies. there is a profound connection between governance and health (e.g. marmot et al. ; plochg et al. ; vlahov et al. ). in a foundation report for the who european region health strategy, kickbusch and gleicher ( ) build on this evidence and argue that there is a difference between health governance and governance for health: ( ) the governance of the health system and the strengthening of health systems is called health governance; and ( ) the joint action of health and non-health sectors, of the public and private sectors, and of citizens for a common interest is called governance for health. the definition of the latter they propose is the attempts of governments or other actors to steer communities, countries, or groups of countries in the pursuit of health as integral to well-being through both whole-of-government and whole-of-society approaches. in many reports and pronouncements the concepts of health governance, health policy, and health action are used interchangeably, especially when they deal with complex intersectoral endeavours. it is useful to distinguish between these, particularly as there is value in seeing an overlapping. intersectoral governance can be defined as the sum of the many ways individuals and institutions, public and private, manage the connections of their common affairs. it is a continuing process through which conflicting or diverse interests may be accommodated and cooperative action may be taken. it includes formal institutions and regimes empowered to enforce compliance, as well as informal arrangements that people and institutions either have agreed to or perceive to be in their interest. (commission on global governance ) in the european region of who, from the early stages of the programme, a commitment to intersectoral governance has been a criterion for designation as a healthy city. from phase ii onwards, cities needed to submit evidence that they had established an intersectoral steering committee (isc) that would oversee policy and intervention development (heritage and green ; lipp et al. ). there are no specific requirements to the design or architecture of such iscs, as they are often driven by unique local contexts and requirements. whether cities lived up to the expectation beyond their formal application commitments was ascertained via annual reporting templates. virtually all members of the network reported that they did establish an isc, although the frequency with which this body met was variable. in some cities it met only once a year, and in others more regularly, up to monthly. in cities where the isc met annually, the role of the body was more at a systems and regulatory level, such as driving and approving policy development and monitoring of intersectoral deliverables; iscs that met more regularly tended to engage more directly in the operational aspects of partnership development, such as allocation of resources and direct supervision of working relationships. both the strategic and the operational aspects of intersectoral governance are important. in their multiple governance framework, hill and hupe ( ) show these different dimensions of governance as complementary requirements for effective and transparent policy development and implementation (fig. . ) . intersectoral governance moves between, and encompasses, an architecture in which implicit and explicit rules at a systems level ('institutional design' in fig. . ) explicitly connect to the way in which individuals in collaborative pro-cesses manage their contacts. since healthy cities in europe have been deliberately considered a natural laboratory of health policy innovation at the local level (tsouros ) , in hindsight it has been appropriate that the specific terms of reference of iscs have never been spelt out in great detail. this flexibility has allowed the emergence of all types of governance, and an evolution of praxis in which these different levels and types of governance have been tried, tested, and connected. regarding the actual architecture of intersectoral governance arrangements in healthy cities, all designated cities are required to have a coordinating office. similar to the flexibility in terms of reference for the iscs, who has not set specific expectations regarding the organizational positioning of this office. there has been an ongoing debate whether this coordinating body should be directly associated with the local government executive office, that is, as a staff unit appended to the mayor's office (fig. . , model a) , or should be a line unit at a relatively high hierarchical level able to coordinate efforts within government (fig. . , model b) . both models can serve a distinctive purpose, depending on the nature and maturity of the healthy city. the evaluation of phase v revealed another type of governance architecture whereby healthy cities increasingly integrate and devolve the responsibility for intersectoral action for health throughout both the government and civil society. intersectoral action is the engagement of relevant sectors, both within and outside the public policy arena, in the implementation of activities, programmes, and projects that have a multidimensional nature. obesity, for instance, has lifestyle-choice dimensions but must also be addressed through structural interventions in the obesogenic environment (kirk et al. ), e.g. in public transport, food security, and community development. ideally this requires a policy and managerial context that embraces the values of hiap described below, and it is important that different sectoral stakeholders collaborate effectively. lipp et al. ( ) show that from phase ii through phase iv of the european healthy cities programme, intersectoral action has expanded and strengthened. for example, the cities participating in both phase iii and phase iv increased the extent of partnership working in all sector studies: health services, social services, education, urban planning, voluntary, environmental protection, transport, and economic development. for phase v, farrington et al. ( ) show that healthy cities, in trying to address the prevention of non-communicable disease, also make explicit efforts to work intersectorally in distal determinants of health. european healthy cities, they find, recognize that to make healthier choices easier requires appropriate structuring of the upstream determinants of health. for example, interventions in the built environment to make active living an easier choice include investment in city sports and exercise facilities, investment in cycling infrastructure, and redesignating streets for pedestrians only. successive european healthy cities evaluations therefore show that local governments are not only embracing intersectoral work through the creation and maintenance of appropriate governance architectures, but are also increasingly deploying resources in terms of operational action to deal with complex problems in dynamic partnerships. following the programme logic of realist synthesis, this suggests that the social determinants of health are being addressed more effectively and sustainably. elsewhere i have argued, with clavier and breton, that 'policy' can mean different things to different actors at the same time. a bureaucrat may use the word 'policy' to indicate 'standard operation procedures', a community activist may mean by it 'a dictate coming from above', and a politician may use the term to denote 'an intention to change'. not surprisingly, the same diversity is found in the field of political science. for the purpose of this chapter, and to distinguish meaningfully between governance, action, and policy, we define the latter as the expressed intent of government to allocate resources and capacities to resolve an expressly identified issue within a certain timeframe (de leeuw et al. ). such an approach clearly distinguishes between the policy issue, its resolution, and the tools or policy instruments that should be dedicated to attaining that resolution. thinking about intersectoral health policy has evolved over the years. healthy cities engage enthusiastically-and beyond mere rhetoric-in the development of health and health equity in all policies. building on a strong foundation in the various political statements on healthy cities over the years and most recently in the athens declaration (tsouros ) , local governments work with diverse stakeholders from the public and civil society sectors to develop such policies. the nearly three decades of healthy city development are clearly leaving a legacy, in that healthy cities manage the politics and logistics of interorganizational work effectively. this is clearly dependent on strong yet flexible governance arrangements and demonstrated commitments to the action component of intersectorality (mcqueen et al. a, b) in the evidence on intersectoral policy development and implementation compiled for european healthy cities (de leeuw et al. ) , there was an interesting mix between more traditional health approaches, such as a programme on active living in izhevsk, russian federation, and initiatives where the health sector has more peripheral ownership, such as a programme on sustainability in amaroussion, greece. this is precisely the message for effective hiap development-that the health sector has the capacity to share, redistribute, and even disavow ownership of policy initiatives beyond its traditional remit. healthy cities show that such actions do not compromise but strengthen the integrity of health sector policy-making capacity. the above developments have created a strong historical footing for the development of health in all policies. they are, however, often seen as abstract global concepts and aspirations rather than operational local inspirations. in this second decade of the third millennium there are, nevertheless, many reasons why local governments and their communities in particular should be inspired to make a real difference. we compile five themes that drive further action. it is important for society and its communities to spend their resources where they matter. although it can be easily contested what 'where it matters' actually means in different contexts (for instance, a national re-election campaign of a politician based in a megacity would probably not recognize the needs of rural and remote communities to their fullest magnitude), this idea has driven the development of evidence-based (health) policy. substantial impact on this broader aspiration was made by the evidence-based medicine mantra that has its foundation in the work of archibald cochrane. he found that many medical practices were not firmly rooted in evidence of effectiveness (whether something produces the intended result) or efficiency (how well it produces that result). the consequence of this position was that decision-makers, both in policy and in practice, invested in approaches to demonstrate the effectiveness of medical procedures. this effort has had its influence on policies that espouse a broad social model of health and health promotion, both globally and locally. the methods to generate evidence of effectiveness on this arena are, naturally, different from the often controlled circumstances under which clinical procedures can be tried and tested. where in clinical environments an assumption is that an experimental group can be matched with a control group, is it much harder in reality to find the perfect experimental match for, for example, a barrio in medellin, in order to test the effectiveness of social investment. yet very good progress is being made in demonstrating the effectiveness and efficiency of health policy and health promotion. evaluation efforts around healthy cities show that it is easier to achieve public participation and good governance for health at the local level. equity is a concept close to the heart of many local politicians. international research shows that health and health equity impact assessments are not just highly effective tools for measuring the consequences for population health of broad social, environmental, and economic change, but also have a significant impact on the quality and sustainability of policy development and implementation. concepts like healthy urban planning that embrace a wider view of transport and mobility show not just health, but far broader social improvement. the ottawa charter for health promotion also launched the ideas of settings for health ('where people live, love, work and play') as a critical aspect of health development. significant evidence has been accumulated on the efficacy and health impacts of initiatives beyond healthy cities, for instance in health promoting schools (globally the most significant network of settings for health with tens of thousands of participating primary and secondary schools, currently expanding into kindergarten environments), health promoting market places, healthy islands (notably in the pacific through the yanuca declaration, linked to the barbados programme of action), health promoting universities, health promoting prisons, and healthy transport. this evidence continues to be compiled by international organizations like who, undp, iuhpe (the international union for health promotion and education), and other global agencies, but also through networks of civil society like international city networks (e.g. c and healthy cities) and academia. there is, in fact, 'metaevidence' that networking for evidence generation enhances the quality, relevance, and responsiveness for glocal action. the enthusiasm and vigour that were originally part of the alma ata declaration on primary health care were rekindled a few years ago when the world health assembly formally re-endorsed the broad social nature of the declaration. it was further sustained by a global campaign to work towards universal health coverage (uhc) at all levels of governance and health system operation. it is defined as ensuring that all people can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship (world health organization ). in some instances uhc is conceived as an exclusively financial issue that requires fiscal programmes and discipline to redistribute key social resources. the evidence shows that, in fact, the monetary dimension is maybe the least problematic to address. moving from divisive health (delivery) services towards inclusive ones requires much more than the reallocation of resources. uhc has many benefits and creates ample win-win situations, apart from the obvious health gain. they secure a (human) rights-based perspective on population health, have the potential to organize and rally communities for social and economic development, and have the strong potential for higher quality health information collection and management, thus adding to more bespoke evidence-based local health policy. local governments may not always have control over fiscal opportunities and the management of health facilities and professionals. often these are organized and financed at higher levels of governance, and partly for good reason: not every town needs highly specialized neurosurgeons and expensive fmri scanners. but the essential population-based 'first point of contact' with the health system, i.e. primary care, is by its very nature integrated in local communities-even where there may be no doctor. community health workers and local health posts play critical roles in maintaining and integrating universally accessible and appropriate health and social support; they are also the natural champions of (local) community development. even when there are no formal governance arrangements for local government institutions (and in slum areas may even have an informal nature), these professionals and their operational bases are very much part of the social and political landscape of local government. uhc at point of delivery is therefore a concern for local action, whether it has been formalized as a local government remit or not. experiences from the americas, e.g. of people-centred programmes in mexico and brazil, show that uhc is possible and yields significant dividends, not just for population health but more broadly for social development (quick et al. ). evidence suggests that success of uhc schemes depends on the presence of ( ) the strength of organized progressive groups in local communities; ( ) the potential of mobilizing adequate economic resources; ( ) the absence of significant societal divisions; ( ) a weakness of institutions that might oppose it (such as for-profit hospital enterprises); and ( ) a skilful identification and opening up of windows of opportunity by (local) policy entrepreneurs (mckee et al. ). the description of the social gradient in health (that is, the fact that health parameters like mortality, morbidity, and life expectancy follow the patterns of the distribution of wealth, prestige, status, and education in society) has moved from a mere epidemiological curiosity to a political issue. increasing numbers of governments endeavour to place health equity and its causes high on their political agendas. this happens with varying degrees of success. there have been arenas of governance with such a strong belief in their equitable nature that a debate around the sheer existence of health inequity in those societies and communities has been unimaginable. there are also cases where existing inequity is attributed to personal lifestyle choice rather than to broader determinants of health. this so-called lifestyle drift can be inspired either by uninformed behaviourist tendencies (assuming that all human behaviour is entirely within the control of the individual) or by political ideologies like conservative liberalism (assuming that the fate of societies can be entirely attributed to the resourcefulness of its individual members). the evidence, however, demonstrates that individual choice is determined by social, environmental, cultural, economic, natural, and built environments. clearly these interact in extremely intricate ways. they are also the result of political preference, and of commercial interest. both england's report fair society healthy lives and the swedish socially sustainable malmö stress the interrelation between policies that aim to • give every child the best start in life • enable all children, young people, and adults to maximize their capabilities and have control over their lives • create fair employment and good work for all • ensure a healthy standard of living for all • create and develop healthy and sustainable places and communities • strengthen the role and impact of ill-health prevention one of the most prominent challenges in establishing cross-cutting policies and actions is to move outside traditional disciplinary and sectoral boundaries-silos. how did we end up with, and in, those silos? the classic ideal of a good citizen was that of the renaissance man, of whom perhaps the best example is leonardo da vinci ( - ), the italian polymath, painter, sculptor, architect, musician, mathematician, engineer, inventor, anatomist, geologist, cartographer, botanist, and writer . typically da vinci would not regard himself as any of these 'professions'-he accomplished all of this without silos. and certainly he was not unique-many advances to modern society have been made by men and women who branched out across scientific disciplines and the arts. this comprehensive integration of the sciences and the arts, not just in one person but in a world view, was challenged in the period of enlightenment, in the sixteenth and seventeenth centuries when the world view evolved towards one of a separation of body and mind, and of distinctly different disciplines arguing that the observed world could be understood mainly through rigorous analysis, that is, deconstructing it into its unique parts. scholars started to focus on particular bodies of knowledge and developed strong theories for each. when in the nineteenth century medicine, as one of these disciplines, became highly professionalized (influenced by the industrial revolution and a growing upwardly mobile middle class) these disciplines started to specialize even further. the process is sometimes called 'hyperspecialization' and today can be witnessed in the proliferation of academic journals focusing on quite particular areas of interest. hyperspecialization is one reason that modern societies operate in management and policy silos. professionalization is another. this is the process of establishing acceptable qualifications, a professional body or association to oversee the conduct of members of the profession, and some degree of demarcation of the qualified from unqualified amateurs. the process creates a hierarchical divide between the knowledge authorities in the professions and a deferential citizenry and creates strong patterns of inclusion and exclusion: building a bridge requires an engineering professional, taking someone to court needs legal professionals, and treating disease must involve qualified medical professionals. specialist and professional segregation are continuously challenged. in the early twentieth century, for instance, debate raged in north america whether public health was within the remit of the medical profession. the matter was resolved with the publication of the flexner report (flexner et al. ) , urging a proper 'scientific' approach to clinical medicine teaching, thus excluding public health. in europe-and in countries that followed a european model of health professionalization-medical education continued to include public health matters under the banner of 'social medicine'. specialization and professionalization created formidable commercial and political forces to maintain and protect their status quo. even when the evidence base concerning social determinants of health rationally dictates collaboration and integration of efforts, these forces often prevent successful and effective action and policy development. there is a growing body of rhetorical and evidence-based knowledge that addresses these problems. effective partnering for health starts with the recognition that the capacities of a discipline or specialty in isolation are insufficient to make a difference. the process that enables such a recognition requires the presence of leadership, communication and analytical skills, and something that can be called social entrepreneurship (the capacity to advocate, mediate, and manage opportunities and differences in diverse communities of policy and practice). firm pronouncements by executive offices (e.g. a mayor, ceo, or spiritual leader) in support of reaching out to other sectors are indispensable. reliable and sustainable grounding of such positions in community action helps maintain momentum. such approaches to removing the walls of silos play out at a relatively high level of abstraction; a workforce that is receptive to interdisciplinary work and has been trained to reach out to others is, of course, vital, too. increasingly we see programmes and curricula across primary, secondary, and tertiary education that do in fact embrace such values. the terms intersectoral action (sometimes intersectorial action) and multisectoral action have been part of the rhetorical repertoire of public health and health promotion since the mid- s. the terms achieved credence through the alma ata declaration, the ottawa charter, and a series of other pronouncements by global bodies including who. the international discourse has also included arguments and evidence around variations of ideas about working together for health on the spectrum networking-coordinating-cooperating-collaborating (see lipp et al. for a brief discussion). although there may be conceptual shades of grey around the interpretation of these terms, this focus of public health and health promotion clearly hinges on the noun action. agencies, individuals, groups, and communities may come together to jointly act on health concerns or determinants of health-but this does not necessarily mean that these actions are either driven by policy or result in policy. a series of case studies, however, are starting to build an evidence base that demonstrates that successful intersectoral action may inspire the need for hiap. hiap, however, may not necessarily lead to intersectoral action: for instance, policies to limit lead (pb) content in paints and gasoline are singularly industrial-economic in nature, and apart from commitments required by industry do not necessitate the deep involvement of other government sectors. considering the importance of successful intersectoral action for the development of hiap, it may be worthwhile to reflect on the reasons why it appears such a challenge to break the walls of the silos and move beyond pithy interests. irwin and scali ( ) , at the request of who, assessed the reasons for the failure of intersectoral action and policy to become an 'easy', 'mainstream' effort. they show that intersectoral action for health failed because ( ) it was driven by the health sector alone; ( ) the intersectoral rhetoric was effectively challenged by the absence of supporting empirical evidence and research programmes to establish such evidence; ( ) public health was 'messed up' by new public management ideologies that moved health responsibilities out of government into private and civil society spheres and complicated matters; and ( ) international donors and healthcare agencies achieved rapid success with single disease-focused vertical delivery programmes. it appears that, with the resurgence of primary health care, the strengthening of uhc, and an increasing commitment to equity around the world, the seesaw with neoliberalism and free market principles on one side and deeper human values on the other have become balanced again, and that the political climate for successful intersectoral action initiatives is more positive. this is expressed in the commitment to hiap formation and implementation, but the limitations and challenges in the comprehensive embrace of integral action will remain and need to be addressed. this discussion on the critical connection between action and policy raises the question of what the process to attain and sustain health in all policies will entail, and which actors need to be engaged. mcqueen et al. ( a, b) describe various governance models for hiap. these have been mapped onto the different elements of the policy process ( fig. . ) and hinge on seven best practice models for hiap implementation. different (groups of) government and non-government agencies can play different roles during the hiap process. figure . describes some of the governance parameters for positioning hiap development within government structures. in addition to this, we have also identified eight institutionally different structural interaction patterns (fig. . ) that describe the linkages between the health care system and its public policy agencies (e.g. a ministry of health at the national or provincial level; or a public servant within a local government agency with a public health remit), other public sector agencies and executives (the office eight ways to coordinate between sectors, and implement hiap in integrated or separate action of the president or mayor, for instance), and the shape that intersectoral action for health and health equity may take. it would be an illusion to think that inter-agency integration or collaboration will automatically lead to integrated action. there are many cases where collaboration still leads to a multitude of singular projects without a lot of systemic and synergy consequences. an example might be inter-agency collaboration on road safety: even where there may be agreement on the nature of a road safety issue (e.g. child fatalities) and action is taken, those actions may not be coordinated and sometimes may be counterproductive. road design, improvements, trauma response, safety communications (signage), and behaviour communications (promoting seatbelts and helmets) should be jointly assessed and developed. if they are not, the whole of the roadscape may be messy and confusing and the total effectiveness of interventions significantly decreased. on the other hand, we know examples where the health sector successfully drives systemic and sustainable intersectoral action in cases where the sector is given the opportunity to engage with local communities. an example would be the integration of health checks, childcare, and (health) literacy training in 'casas de cultura' (latin america) or community hubs. key to the success of any approach is the assessment of win-win opportunities, playing to the strengths of each sector and community, 'going with the flow' rather than against it, demonstrating co-benefits to those involved (and that goes beyond government sectors), avoiding turf wars, and a more comprehensive appreciation of different forms of evidence that are generated and applied beyond the health system alone. this includes the exploitation of successful inter/multisectoral action driven by stakeholders outside the health and public sectors. intersectoral action and hiap must not happen for their own sake. collaboration without joint ownership and outcomes, and integrated policy addressing onedimensional issues, is senseless. many lessons have been learned from the integrated partnership agenda in health promotion, particularly in healthy cities (e.g. lipp et al. ) . planned action to connect, integrate, and scope the integral policy agenda needs to address the following evidence-based stages: • map and recognize organizational mission and resource capacities and acknowledge the boundaries of the traditional organizational footprint. • describe organizational challenges in addressing issues and populations that permeate and move beyond the organization's legitimate area of concern. • map and include organizations that cover the same, similar, or different issues and populations, or share the same, similar, or different approaches and interventions to deal with these. • recognize the legitimate potential of other stakeholders to be involved in intersectoral action or integral policy development and strive for transparency in sharing these views. • scope the dimensions of probable and possible collaboration and factors that may stand in the way of respectful joint action. • involve real authorities and decision-makers, including organization executives as well as street-level bureaucrats (frontline implementation personnel who deal with inter-sectoral action challenges on an everyday basis), in shaping the joint agenda. • formalize and celebrate each of these stages, as far as possible including individuals, communities, and neighbourhoods that are at the 'pointy end' of the implementation of action and policy outputs. • make all stakeholders in these processes, as far as is culturally and organizationally possible, accountable for their actions, but apply the 'chatham house rule' (full confidentiality of sensitive and strategic considerations) wherever necessary. in this book we have seen that in many local government areas there are already effective structures and processes that would further facilitate the development of inter-sectoral action for health and a strongly associated integral policy development potential. such structures and processes include • an engaged and empowered community • successful experience in deliberative democratic and participatory processes • successful experience in partnerships and collaboration for health and well-being • a broad recognition of the urgency of ncd strategies, supported at executive and council levels • a broad recognition of the 'causes of the causes' of ill health, supported at executive and council levels • an existing agenda to strengthen or move towards universal health coverage • existing role models and examples of inter-sectoral action and hiap in other local governments in the countries, for instance, connected through healthy communities networks • vertical integration of governance models for inter-sectoral action and hiap between different levels of government • existing evidence of social, economic, and sustainability win-win situations, and ongoing connections with local and national agencies and structures that may support the creation and maintenance of such evidence (e.g. local and national universities and ngos) addressing the complexity of modern health and health equity issues requires a lasting, continuous process. the establishment and implementation of one health in all policy in one place cannot be considered the end point. it is a stage in an evolutionary practice: the policy needs to be reviewed, adapted, and renewed to meet the exigencies that it has created. the context, and local stakeholders, in which this happens will constantly change. political shifts may require a renewal of executive commitment; evolving community concerns will dictate ongoing participatory consultative action; and technological advances may inspire new solutions. the local government apparatus will require a firm grounding in flexible understanding of the foundations of inter-sectoral action and hiap, and the processes required to maintain and develop its potential and impact. the above steps, when documented and conscientiously applied, form a local basis for sustained capacity to address new complex health issues through hiap and inter-sectoral action. a form of 'corporate memory' is required to keep such lessons on the radar, and a public repository (virtual or real) can be such a resource. various organizations, often at the interface of policy and practice, offer capacitybuilding programmes that engage with real-life environments and aim to integrate new understanding and improved potential for sustained change in local health development. one example is the learning by doing programme (harris-roxas and harris ; pennington et al. ) that makes local government agents across sectors engage in, and reflect on, health impact assessments. another example is the efforts of the victoria health promotion foundation (australia) to build capacity for local operators to include broad determinants of health thinking (environments for health) in actual processes towards the development of compulsory municipal public health plans through its 'leading the way' programme (vichealth ). we started this chapter by asserting that many local initiatives merit a project approach with dedicated temporal and resource dimensions. but to drive those projects in an integrated vision they should transcend themselves, transforming into a perspective that connects an overall vision for the future of a glocal issue or environment. we have described how such vision has been given momentum by developments both local and global, firmly grounded in a set of coherent values including equity, participation, sustainability, and accountability. it is not just preferable to work towards policy for health: it is the only thing to do to respond to the needs of communities, and through integrated connections between sectors, in health in all policies. the reagan wit on violence new norms new policies: did the adelaide thinkers in residence scheme encourage new thinking 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international business policy date: - - journal: j int bus policy doi: . /s - - - sha: doc_id: cord_uid: y ii r u we introduce a special collection of papers on covid- and international business policy that looks at the global policy challenge from different perspectives. the combination of confinement and protectionist measures including export bans, import tariffs and border closures that were introduced in response to the covid- pandemic affect mnes by increasing trade costs and amplifying the costs of communicating tacit knowledge. in this editorial, we draw specific attention to how these policies impact the heart of mnes’ activities – the knowledge-intensive intangibles. physical distancing limits the face-to-face meetings that undergird the production of intangibles in large urban hotspots. at the same time, travel restrictions constrain mnes’ abilities to connect to and source knowledge from their foreign partners. virtual conferencing has helped mnes to cope with these challenges but it remains an imperfect substitute. a protracted public health crisis that would require limiting social interactions in the medium term might push mnes to reconfigure their knowledge management strategies both locally and globally. in , the academy of international business launched the ambitious project of adding a public policy journal to its line of publications -the journal of international business policy. the rationale was that international business scholars have a deep knowledge about how the economic landscape influences firm behavior and vice versa, and this knowledge can be highly valuable in policy discussions (lundan, ) . the goal of the journal was therefore to promote a policy turn in international business research by pushing scholars to not only reflect on the implications of their research for managers, but also to investigate the societal implications of their studies (van assche, ) . the timing of the launch was auspicious as it coincided with a period where international business policy mounted to the forefront of public policy discussions. populism had been rising on both sides of the atlantic in the wake of the great recession of [ ] [ ] , which fed a wave of antitrade sentiment (rodrik, ) . several government leaders jumped on the populist bandwagon by throwing their support behind export mercantilism (evenett, ) , renegotiating or leaving trade agreements, and initiating trade wars (bown & irwin, ) . international business (ib) scholars were quick to seize the moment and have in ten jibp journal issues put their own stamp on ib policy debates in an era of ''slowbalization''. the ''great lockdown'' related to the covid- pandemic is yet another policy challenge that can benefit from insights from ib scholarship. the instigator of the acute economic downturns across the globe is not the health crisis as such, but rather the policy response that has been remarkable in its suddenness, magnitude and synchronicity across countries. to halt the spread of the disease, governments have adopted extraordinary containment policies to flatten the epidemiological curve, that is, to slow the rate of new covid- infections in order to ease the burden on local health facilities. when the epidemic initially hit, governments put a hard stop on economic activity by suspending operations of non-essential businesses, by closing international borders to nonessential traffic, and by implementing stringent stay-at-home orders. once the initial outbreak was contained, countries have gradually loosened restrictions on those non-essential businesses where virus transmission can be more easily controlled. lockdown exit strategies have varied substantially across countries and regions, but a common element is that physical distancing measures will need to remain in place until a vaccine or treatment becomes available. policy is also central to countries' efforts to cope with the resulting economic crisis. governments have adopted a mix of fiscal, monetary and financial policies to avoid economic collapse related to the ''hard stop'' containment policies (baldwin, ) . as of april , japan and the united states have committed to fiscal stimulus packages that already exceed percent of their annual gross domestic products (elgin, basbug, & yalaman, ) . international business policies have been part of the mix. past experiences have shown that governments turn to protectionism during economic downturns (evenett, ) , and this time is no different. when the epidemic initially hit, several countries reacted to global shortfalls of personal protective equipment and testing kits by banning or limiting the export of medical equipment and medicines (evenett, ) . once the attention turned from infection containment to economic recovery, several governments have switched to more traditional mercantilist policies by imposing import tariffs, putting into place ''buy domestic'' measures and adopting export subsidies (bown, ) . most countries in the world have imposed partial or complete border closures to foreign nationals during the coronavirus outbreak (chugh, ) . businesses -including multinational enterprises (mnes) -have been left scrambling trying to respond to the new policy reality. much has been written about distilleries, textile companies and automotive firms that have ventured into the production of hand sanitizers, masks and ventilators (fleming, ) . other studies have pointed out that firms are reorganizing their global value chains by reshoring production, diversifying their supplier base and adopting industry . technologies (javorcik, ; kilic & marin, ; seric & winkler, ) . while these initial insights are valuable, it is fair to say that extant studies have only scratched the surface. our understanding of the complex twoway interaction between covid- -related policies and ib remains murky and can benefit from fresh insights originating from ib scholarship. for this reason, we in early april contacted several leading scholars in ib and adjacent fields and asked them to provide their thoughts on the impact of the covid- pandemic on international business both in the short and medium run. our aim is to publish these articles in a jibp special collection on covid- and international business policy that will span the next two issues of the journal. in this editorial, we introduce the special collection by drawing the attention of jibp readers to the impact of covid- -related policies that strike at the heart of mnes -the knowledge-intensive intangibles -as their managers rush to cope with local physical distancing measures, non-essential travel restrictions and stringent immigration policies. at the end of the article, we also provide an overview of the first four papers that are included in the special collection. of intangibles in a recent book, baldwin ( ) divided the history of globalization into three periods: the pre-globalization period (before ) when both trade and communication costs were high, the first unbundling period ( - ) when trade costs dropped but communication costs remained high, and the second unbundling period ( -present) when both trade and communication costs became low (see figure ) . he argued that each period has organized production and consumption in a different way, affecting trade and foreign investment flows. the pre-globalized period was effectively a phase of autarky. high trade and communication costs isolated production and consumption to such a degree that the global economy was little more than a patchwork of local ecosystems that took care of themselves. while there was some international business (e.g., china's silk road trade), it had only a limited impact on a country's aggregate performance. the arrival of steamships and railroads in the nineteenth century substantially lowered the cost of long-distance transportation. with cheaper international shipping, more consumers started buying faraway goods, allowing for the gradual separation of production and consumption. this first unbundling period led to a spurt in international business, but the high communication costs across borders confined production processes within countries. globalization accelerated again at the end of the twentieth century, when the ict revolution slashed the cost of communicating codifiable information at a distance. this instigated globalization's second unbundling period, which involved the international fragmentation of production. improvements in communication technology now made it feasible and profitable to coordinate production activities across different countries, allowing for the emergence of global value chains. ib scholarship has brought to the table several refinements that have enriched this depiction of globalization. first, it has highlighted the central role that mnes have played in driving change over the two unbundling periods. as mne managers observed shifts in the costs and risks of doing business abroad, they reassessed how to compete, where to extend their geographical footprint and which activities to conduct within firm boundaries (buckley & strange, ; verbeke, coeurderoy, & matt, ) . it is mnes' adoption of new forms of intra-and inter-organizational arrangements on the micro-level that instigated shifts in macro trade and investment flows. second, ib scholarship has emphasized that mnes not only adapt the tangible parts of their activities -the production, trade and sale of physical goods -but also the intangibles which are at the heart of mne operations. intangibles are those claims to future benefits that do not have a physical or financial embodiment (lev, ) . highly knowledge-intensive in nature, they include the intellectual property, brand equity and other economic competencies that provide mnes the economic power to set product strategy, place orders, and take financial responsibility for the goods and services that their supply chains turn out (sturgeon, ; teece, ) . the drop in communication costs during the second unbundling period has pushed mnes to not only fragment production internationally but also to globalize the production of intangibles. a highly influential ib literature describes the complex global knowledge management strategies that mnes adopt to transfer and exploit existing repositories of knowledge around the world and to engage in the exploration of new knowledge (alcácer, cantwell & piscitello, ; cantwell, ; kogut & zander, ) . one of the reasons these knowledge management strategies are complex is that mnes need to consider the paradoxical geography of knowledge creation which is both concentrated in few local hotspots and increasingly global (lorenzen, mudambi & schotter, ) . the tacit nature of much of the knowledge that is embedded in intangibles implies that there are significant agglomeration economies in the production of intangibles (glaeser & gottlieb, ). one reason for this is that complex forms of knowledge are difficult to communicate over distance and require direct and repeated face-to-face contact for their exchange (storper & venables, ; d'este, guy, & iammarino, ) . for firms, co-locating with similar and related companies thus can boost collective learning processes through frequent opportunities for formal and informal knowledge exchanges. several recent studies provide strong evidence that the production of intangibles concentrates disproportionately in a few urban hotspots (crescenzi et al., ; moretti, ; balland et al., ) . a complementary feature is that lead firms have developed sophisticated strategies to allow teams of people in different global cities to collaborate in the production of intangibles. many lead firms nowadays deliberately establish linkages to other global knowledge hotspots to tap into pockets of complementary knowledge and resources that are unavailable or more expensive locally (bathelt, malmberg, & maskell, ) . they do so by setting up intrafirm linkages to competence-creating subsidiaries or by developing inter-firm partnerships (bathelt, cantwell, & mudambi, ) . once new knowledge combinations are created, these can then be transferred to the home country or other locations to enhance the parent firm's innovation performance (cano-kollmann et al., ) . regardless of the governance structure adopted, and the knowledge exchanges facilitated by ict, the mobility of key personnel is a key factor that keeps these ''pipelines'' open. several scholars have voiced their concern that the current covid- pandemic may have a lasting impact on globalization in general and more specifically on the ways in which mnes configure their cross-border activities (altman, ; irwin, ; kobrin, in this issue) . the combination of covid- -related confinement and protectionist measures is effectively a policy mix that affects mnes by ( ) increasing trade costs and ( ) amplifying the costs of communicating tacit knowledge (see figure ). the increase in trade costs reflects in part the struggle to adapt the international transportation system to the covid- -related policy measures. the unprecedented grounding of passenger planes has disrupted air transport since a significant portion of air cargo is transported in the hold of passenger planes (van assche, ). many ports' restrictions on vessels and crew changes have led to similar disruptions in sea freight (heiland & ulltveit-moe, ) . protectionist measures have added to these trade cost increases. with governments trying to limit the health and economic impact on their people, some countries have restricted their exports of hundreds of products, ranging from antibiotics to cotton face masks and medical ventilators (evenett, ) . the united states has reignited its trade war with china. japan has promised subsidies to japanese companies that are willing to reshore production from china to japan. the policy response to covid- has also amplified the costs of communicating tacit knowledge. locally, the physical distancing rules have severely limited both the planned and unplanned face-toface meetings that undergird the buzz of local innovation ecosystems. internationally, the closing of borders to non-essential travel and limits to immigration have limited firms' abilities to collaborate and exchange tacit knowledge with their foreign partners. the availability of digital infrastructure has allowed firms to limit the scope of disruptions related to the reduction in face-to-face interactions and may well have a permanent impact on global knowledge management practices in the post-pandemic period. for many office workers, telework and virtual conferencing have become the new norm. some companies such as twitter have even announced that staff can continue to work from home permanently. despite vast improvements in virtual conferencing capabilities, they nonetheless remain imperfect substitutes to face-to-face meetings. the effect of covid- on the development of intangibles will depend on both the duration of the health crisis and the extent to which the economy can return to normal once the pandemic itself is behind us. a relatively short crisis with a swift relaxing of physical distancing rules, an opening up of international borders and elimination of protectionist measures will likely lead to the return of established practices. a protracted public health pandemic, then again, that continues to limit social interactions in the medium term and potentially leads to a global descent into protectionism will require firms to reconfigure their business models on both the tangible and intangible side. in the special collection in this editorial we have highlighted just one topic area where international business scholarship can be instrumental in understanding the link between covid- and eventual economic recovery. the jibp special collection on covid- and international business policy includes several other original papers, including four that are published in this issue. we hope that these papers stimulate members of the ib community and beyond to engage in conversations about the ongoing policy challenges facing the global economy, and to place these issues on their research agenda alongside other ongoing sources of disruption such as climate change and rising inequality within and between countries. the collection opens with steve kobrin's thoughts on the impact of covid- on globalization. he argues that the pandemic has for the second time in little more than a decade laid bare the very real social, political and economic dangers of high specialization and connectedness between markets. after acting as a potent vehicle for the transmission of a global financial crisis during the great recession of - , the globalized system has during the covid- pandemic of acted as a virulent medium for the spread of a health calamity that continues to wreak havoc across the globe. according to kobrin, these events further undermine the longstanding belief that globalization is an indicator of progress and they have reinforced fears of ''the other'' that are all too easy to exploit for political gain. he points out three major changes that need to occur to restore a positive view of globalization: restoring the balance between sovereignty and integration; making globalization more inclusive; and insuring some degree of resilience in global supply chains. however, kobrin is skeptical that the current geopolitical climate is conducive to these changes. in a second paper, gary gereffi digs deeper into one of the ''choke points'' that have been uncovered by the covid- pandemic, namely the global shortages of medical supplies in the early months of the health crisis. he questions the oftenheard assertion that these shortages were due to structural flaws in medical equipment supply chains and conducts a detailed case study of the face mask value chain in the united states to evaluate this claim. according to gereffi, the shortage of masks in this case was much more a policy failure than a market failure. while just-intime production techniques could make supply chains fragile in times of crisis, they did not stop the american company m from quadrupling its u.s. supply of n masks from just over million in january to million per month in may. rather, the critical bottleneck appeared to be the limited government stockpiling of n masks before the crisis and the regulatory constraints that in early prevented m and its competitors from scaling up local production. in a third paper, rajneesh narula turns to the other side of these global value chains and focuses on the impact of the covid- pandemic on the informal economy in developing countries. according to narula, informal workers and enterprises have been especially vulnerable to the pandemicinduced economic shock. for decades, global value chains have used the informal sector in developing countries as a valve that takes on extra tasks during periods of peak demand. unfortunately, the reverse side of the coin is that informal workers and firms have also been the first to be cut from the roster when the valve is turned off during economic downturns. often living from hand to mouth, and with limited government rescue packages to help them, covid- has thus condemned millions of workers in the informal economy to poverty. narula nonetheless sees a (faint) silver lining: the severity of the economic shock and the precariousness of the informal sector may finally convince governments to actively engage with informal actors without pushing for their formalization, for example by placing them on par with formal firms when implementing industrial policy. in a fourth paper, peter buckley reflects on the impact of covid- for china's highly ambitious infrastructure-building belt road initiative (bri) that spans a large number of developing economies across asia. even before the current pandemic, there were concerns in several bri countries that the high costs of the investment projects were leading to unprecedented levels of debt. buckley points out that these apprehensions have only increased in the wake of the covid- pandemic as governments face severe revenue shortfalls, as they embrace new budgetary priorities in light of the health crisis, and as china faces growing geopolitical tensions with the united states. he nonetheless suggests that china's need to address its own domestic overcapacity combined with the amorphous nature of bri provides the chinese government with the means to flexibly rethink its bri strategy in the face of the covid- -related setbacks. this classification is similar to that presented by jones ( ) with the exception that the (policy-induced) collapse of international trade in the interwar years is not considered separately. internationalization in the information age: a new era for places, firms, and international business networks will covid- have a lasting impact on globalization the great convergence the supply side matters: guns versus butter, covid-style complex economic activities concentrate in large cities clusters and knowledge: local buzz, global pipelines and the process of knowledge creation overcoming frictions in transnational knowledge flows: challenges of connecting, sense-making and integrating covid- could bring down the trading system trump's assault on the global trading system: and why decoupling from china will change everything the governance of the global factory: location and control of world economic activity knowledge connectivity: an agenda for innovation research in international business technological innovation and multinational corporations will covid- change how we think about migration and migrant workers? the geography of innovation: local hotspots and global innovation networks shaping the formation of university-industry research collaborations: what type of proximity does really matter economic policy responses to a pandemic: developing the covid- economic stimulus index protectionism, state discrimination, and international business since the onset of the global financial crisis sicken thy neighbour: the initial trade policy response to covid- how big business is joining the fight against covid- the wealth of cities: agglomeration economies and spatial equilibrium in the united states an unintended crisis: covid- restrictions hit sea transportation the pandemic adds momentum to the deglobalization trend the greater trade collapse of : learnings from the - great trade collapse multinationals and global capitalism: from the nineteenth to the twenty first century how covid- is transforming the world economy how globalization became a thing that goes bump into the night knowledge of the firm and the evolutionary theory of the multinational corporation intangibles: management, measurement, and reporting international connectedness and local disconnectedness: mne strategy, city-regions and disruption from the editor: engaging international business scholars with public policy issues the effect of high-tech clusters on the productivity of top inventors populism and the economics of globalization covid- could spur automation and reverse globalisation -to some extent buzz: face-to-face contact and the urban economy from commodity chains to value chains: interdisciplinary theory building in an age of globalization business models and dynamic capabilities from the editor: steering a policy turn in international business-opportunities and challenges trade is among the casualties in the covid- pandemic the future of international business research on corporate globalization that never was… ari van assche is professor of international business at hec montréal and deputy editor of the journal of international business policy. his research focuses on the organization of global value chains and their implications for international trade sarianna lundan holds the chair in international management and governance at the university of bremen and she is the editor-in-chief of the journal of international business policy key: cord- - khx c authors: liu, fengchen; enanoria, wayne t. a.; ray, kathryn j.; coffee, megan p.; gordon, aubree; aragón, tomás j.; yu, guowei; cowling, benjamin j.; porco, travis c. title: effect of the one-child policy on influenza transmission in china: a stochastic transmission model date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: khx c background: china's one-child-per-couple policy, introduced in , led to profound demographic changes for nearly a quarter of the world's population. several decades later, the consequences include decreased fertility rates, population aging, decreased household sizes, changes in family structure, and imbalanced sex ratios. the epidemiology of communicable diseases may have been affected by these changes since the transmission dynamics of infectious diseases depend on demographic characteristics of the population. of particular interest is influenza because china and southeast asia lie at the center of a global transmission network of influenza. moreover, changes in household structure may affect influenza transmission. is it possible that the pronounced demographic changes that have occurred in china have affected influenza transmission? methods and findings: to address this question, we developed a continuous-time, stochastic, individual-based simulation model for influenza transmission. with this model, we simulated years of influenza transmission and compared influenza transmission rates in populations with and without the one-child policy control. we found that the average annual attack rate is reduced by . % (sd . %) in the presence of the one-child policy compared to a population in which no demographic changes occurred. there was no discernible difference in the secondary attack rate, − . % (sd . %), between the populations with and without a one-child policy. we also forecasted influenza transmission over a ten-year time period in a population with a two-child policy under a hypothesis that a two-child-per-couple policy will be carried out in , and found a negligible difference in the average annual attack rate compared to the population with the one-child policy. conclusions: this study found that the average annual attack rate is slightly lowered in a population with a one-child policy, which may have resulted from a decrease in household size and the proportion of children in the population. the one-child-per-couple policy in china was introduced in in an effort to raise living standards by slowing population growth. subsequently, the policy reduced fertility rates [ , ] and household sizes, with only one dependent child found in most households. the total birth rate dropped from . , before the policy was introduced, to . among women over years of age, and to . among women under years old in . women's preferences for smaller families have changed ( % prefer one child and % prefer two children according to a study in ) [ ] . the total fertility rate decreased from . in to . in , with a rate of . in urban areas and less than . in rural areas. this trend has created a distinct demographic pattern for nearly a quarter of the world's population, resulting in chinese urban families with predominantly one child and rural families with predominantly two children [ ] . the spread of infectious diseases may depend on demographic characteristics, environmental changes, consumption behaviors (eating, drinking, culinary culture, etc.), other behaviors (sexual contacts, drug use, hospital procedures, etc.), and host conditions (malnutrition, diabetes, immune status, etc.) [ ] . while the one child policy has had economic, demographic, and sociological ramifications far beyond the scope of infectious disease transmission, it is important to understand the consequences for influenza dynamics, in part because china and southeast asia lie at the center of a global transmission network of influenza [ ] . demographic changes may affect influenza transmission dynamics because children have an increased susceptibility due to lower immunity. moreover, increased viral shedding and longer infectious periods in children lead to more influenza among susceptible populations [ ] . demographic characteristics have been incorporated into many modeling studies [ , , ] to help understand the effects on transmission of influenza or the socioeconomic impact of mitigation strategies [ , ] . household composition is an important determinant of the transmission of respiratory pathogens including influenza [ , , , , , , ] and remains an important feature of recent transmission models [ , , , , , ] . this paper presents a study focusing on the indirect effects of demographic changes on influenza transmission. we developed a continuous-time, event-driven, individual-based stochastic simulation model for influenza transmission in a dynamic population. we used this model to simulate transmission while assuming different demographic control policies: the one-child policy, the absence of any control policy, and a strict one-child policy. the strict onechild policy was introduced to compare influenza transmission rates with a hypothetical one-child policy to rates with an actual one-child policy, since two or more children are often allowed in rural areas and for ethnic minorities [ ] ; the existing census data do not reflect the effects of truly restricting families to one child. the model was used to simulate years of influenza transmission in a dynamic population as follows: ( ) we initialized the population using demographic data (four years before a one-child policy was fully launched in china); ( ) we calibrated the population projections by fitting the simulated population with the one-child policy to the census and compared the simulated population without the one-child policy with projections from previous literature [ , ] in which population growth was predicted under different demographic control policies; ( ) we calibrated the influenza-specific parameters by fitting the annual attack rate and secondary attack rate from the reported literature [ , , , , , , ] ; and ( ) we compared the simulated annual attack rate and secondary attack rate in simulated populations with and without the one-child policy. in the plenary sessions of the chinese people's political consultative conference and the national people's congress, a two-child policy was proposed to start as early as [ ] . experts suggested that the one-child policy may threaten china's economic growth due to the increase in the number of older people, a decrease in the number of younger workers, as well as a sex-ratio imbalance [ ] . because a two-child policy was proposed to start as early as [ ] , we also forecasted influenza transmission over a ten-year period ( to ) in a population with a two-child policy. our model has three main features: ( ) influenza transmission, ( ) population demographics, and ( ) dynamic network structure. we used a susceptible-exposed-infectious-recovered (seir) model which included waning immunity and seasonality of influenza transmission. we used census data [ , , , , ] (table ) from china, to construct a population with demographic changes under a one-child policy. a simple dynamic network structure was used to group people with household links, school links and social links, allowing influenza to be transmitted along these links in the network while changing the state of each individual (s, e, i and r). the model structure is described in the section titled model structure (and in the text s and figure s ). influenza transmission parameters were calibrated using approximate bayesian computation (abc) [ , ] as described in the calibration section (we chose parameters' ranges based on both the english and chinese literature [ ] ). the computation section briefly discusses the implementation and computations based on calibrated parameters (table ) ; a more detailed description can be found in the text s . natural history of influenza. individuals infected with the influenza virus first pass through a latent period when they are asymptomatic and not infectious. we assumed that viral shedding does not take place during the latent period, and that the mean duration of the latent period is to days [ , , ] . for influenza, the infectious period is assumed to begin about one day before the symptomatic period [ ] . in general, individuals infected with influenza may be asymptomatic, and yet still shed the virus. the proportion of transmission by asymptomatic individuals is assumed to be one-third to one-half that of influenza-infected symptomatic individuals [ , , , ] . the mean period during which a person may be asymptomatic but infectious is assumed to be day [ ] . individuals are assumed to become symptomatic and infectious with an average duration of . to . days [ , , , , ] . mathematically, we represent the course of influenza according to the diagram shown in figure (and figure s ). in this model, we classified influenza as being mild or not being mild; individuals in each severity type progress to different stages. mild cases and non-mild cases are classified as infected prior to all symptoms and infectiousness (e and e ), infectious but asymptomatic (i and i ), or recovered with strain specific immunity (r). the non-mild cases may be symptomatic and infectious as well (i ), which occurs after asymptomatic infectiousness (i ). table lists the durations between stages. a recovered individual loses immunity with rate m, reverting to the uninfected susceptible (s) stage. we assume that individuals have age-specific death rate d, and a birth rate b; these dynamic population demographic features which are represented by the death and birth of each individual, will be described in the demographic description section given below. for a specific individual, we assume that the duration time between two stages is randomly chosen from an exponential distribution with a given rate. immune escape and seasonality. to model antigenic drift, our model is designed such that every individual has a maximum immunity level immediately following recovery from infection by a particular strain of influenza, but this immunity gradually wanes to zero over to years [ , ] . following reinfection, the immunity level is restored to the maximum value and declines at the same rate thereafter. the underlying causes of influenza seasonality remain unclear [ , , ] , despite many studies postulating possible causes. suggested causes have included changes in human mixing patterns or fluctuations in human immunity and environmental humidity [ ] . the transmission of seasonal influenza tends to increase substantially from november to february in the northern hemisphere and from may to august in the southern hemisphere [ ] . to incorporate seasonality of influenza transmission into our model, we modeled the transmission probability per contact as a sinusoidal function of time [ ] according to p trans (t)~p base ze cos( p( z t{h d )), so that the transmission probability, p trans , varies during the course of the epidemic. here, p base is the baseline transmission probability, t is time, and e (where we assume p base ,e,p base ) characterizes the degree of seasonality (e = corresponds to no seasonal variation at all). we let d denote the total duration of an epidemic season (for instance, days in this model) and h (an offset from time ) is the peak time of an epidemic season. our model adopted h as november , corresponding to northern china where influenza peaks in the winter [ ] . in this model, the probability of infection for each individual depends on the immunity level, seasonality, and the contact rates (please see the text s for more details). china's demographic data. the demographic data were taken from the population statistics yearbooks for china, and from five censuses carried out in , , , and [ , , , , ] . some demographic data sources were extracted from previous articles [ , , , , ] in which the population growth under different population control policies were predicted. key demographic parameters used in our simulation included age, household size, age-specific death rates, and age-specific fertility rates, as shown in table . initially, we stochastically sampled age and household size from distributions fitted to the demographic data [ , , ] . we used dynamic age-specific fertility rates and death rates from year to to simulate the population growth under conditions of the one-child policy; calibration details of the age-specific fertility rates can be found in text. population projections without the control of a one-child policy were implemented by assuming a static age-specific fertility rate (from ) and fixing the birth rate to the same value that it was in (which, of course, corresponds to an unrealistic population trajectory). we also analyzed the assumption of a very strict onechild policy that allows one female to have only one child in her life-this is stricter than the one-child policy as actually implemented. finally, we conducted a simple projection of the population with a proposed two-child policy (from to ), which allows one female to have two children. it was implemented by increasing the fertility rate for nulliparous females. to calibrate the population, we fit the age-specific population number of each year and the average household size of each year to the census data, then compared the population projections of our model with the census data and projections described in other studies [ , , ] . dynamic network structure. we simulated the transmission of influenza using a simple dynamic network structure shown in figure . specifically, we assumed that each individual is located in a household and links to other household members, and we assumed that each individual has several links to other individuals outside of his/her household. these links outside the household represent contacts in the community and an individual has a lower relative contact rate with outside links than with household links. for school-aged individuals, we assume that they are in primary and middle schools, and have school links to all of their schoolmates. the contact network of this model consists of each individual's household contacts, school contacts and casual contacts, and its dynamic is reflected by updating each individual's household, school and casual contacts which will be discussed in turn. household contacts. each individual in the model has household links that are initialized by grouping individuals into households based on the household size distribution data of china in , and linking all household members of each household. during simulation, each individual's household links are updated dynamically ( ) when the individual leaves his/her household between his/her age and years as a household with onemember, ( ) when the single individual over years of age has found (with a partnership searching rate per year) another single over years of age to live with as a two-member household, ( ) at the time the individual dies (with a dynamic age-dependent . individual b has two household members (c and d), two visible casual contacts (a and e), and three visible schoolmates (f, i and j), other social contacts and schoolmates of b are not shown in this small part of contact network. if b was an index case, the household contacts would be at highest risk of being infected due to the higher contact rates among household members than the casual and school contacts (for the contact rates of different link types, please see table ). doi: . /journal.pone. .g effect of one-child policy on flu transmission plos one | www.plosone.org mortality rate), or ( ) at the time the individual or one of the other family members gives birth to a baby (with a dynamic agedependent fertility rate). the dynamic age-dependent mortality rate and the dynamic age-dependent fertility rate are from the population data of china from to . during the simulation, an individual's mortality rate and fertility rate depend on the current simulated year and the individual's current age. the partnership searching rate per year is calibrated to fit to the observed household size from to . the dynamic agedependent fertility rates under the other three scenarios are assumed to be zero if the individual already has more than one child for the strict-one-child-policy, the same as the fertility rates in for the absence of one-child policy, and doubled from to for the two-child-policy. school contacts. each individual whose age is between the primary-school-age of and years or between the middleschool-age of and years has school links that are initialized using the primary and middle schools' statistical data of gansu province in china in , and are updated annually by reassigning all individuals with school ages into primary or middle schools according to year-dependent average school size from to , or are updated at the time the individual dies with the dynamic age-dependent mortality rate. casual contacts. each individual may have several random contacts per day with a daily contact rate contact casual = . once an individual becomes infectious, all of his/her casual contacts during the infectious period are randomly chosen from the population and their contacting times are predicted and scheduled using an exponential distribution with the casual contact rate per day, contact casual . transmission via the network. once an individual becomes infectious, an infectious period will be generated using an exponential distribution with recovery rate. during the individual's infectious period, the contact times between he/she and each of his/her household members are stochastically scheduled using an exponential distribution with the contact rate per household member per day, contact house = ; transmission between the infectious individual and the susceptible household contacts will take place at the scheduled contact times. similarly, the casual contacts of the infectious individual during the infectious period are randomly chosen from the entire population, and the contact times between the infectious individual and his/ her casual contacts are scheduled using an exponential distribution with a casual contact rate per day, contact casual = . transmission between the infectious individuals and the susceptible casual contacts will be active at the scheduled times. in addition, the contacts between the infectious individual and his/her schoolmates during his/her infectious period are randomly picked from the individual's school links and are scheduled by an exponential distribution with school contact rate per day, contact school = . the transmission between the infectious individual and the susceptible school contacts will be active at the scheduled times. once a scheduled transmissible contact takes place between the infectious individual and one of his/her susceptible household members, schoolmates, or casual contacts, a successful transmission will be completed with a transmission opportunity which is a product of the seasonal transmission probability per contact, p trans , and the chance of immune escape, -m i (t), where m i (t) (defined in the text s ) is a dynamic immunity level of a susceptible individual i at time t. the dynamic immunity level of an individual depends on his/her infection history, the immunity waning rate per year and the current time. the model is initialized with , individuals whose ages are generated from the age distribution of china in . the household links for each individual are initialized with household size distribution of china in , and the school links for each school age individual are initialized with the average school size of gansu province in china in . casual contacts of each individual are randomly selected from the population with a casual contact rate per day contact casual = . five exogenous infectious cases with the same influenza strain are introduced into the population on november th in to start influenza transmissions via the contact networks of all individuals. at the beginning of the simulation, we assume that all individuals are completely susceptible. once an individual recovered from an infection, he/she will have a % immunity level which wanes with % immunity loss rate per year (m = . ). the demographydependent dynamic network of the population is reflected by updating household links and school links of each individual as stated above, which also depends on the scenario of population control policy for the current simulation. as a base scenario, we assume that the one-child policy is active, thus the mortality rates for ages to years and the fertility rates for ages existing census data reflect those demographic changes caused by the one-child policy as actually implemented. in order to assess what would have occurred in the absence of such a policy or other demographic changes, we assumed a static fertility rate of that in for females. however, a strict one-child policy includes the assumption that there is no chance for a female who already has a child to give birth to a second child, an assumption that does not hold in practice. to calibrate the demographic component of our model, we first fitted the population projection with the available demographic data, as well as with other population projections [ , ] in which they predicted population with a one-child policy and other control measures (see figure s (a)). then, we fitted the population age distribution of each year to demographic data in the years from to , (see figure s (b)). finally, we required that the average household size (see figure s (c)) corresponded to the census data in , , and , which reported average household sizes of . , . , . and . in these years, respectively [ ] . we calibrated the model using eight influenza transmission parameters: ( ) mean duration of the latent period, ( ) mean duration of the asymptomatic infectious period, ( ) mean duration of the symptomatic infectious period, ( ) probability that a case will be mild, ( ) immunity waning rate, ( ) the degree of immunity following infection, ( ) transmission probability per contact, and ( ) contact rate between two household members ( table ) . parameters ( ), ( ), ( ) and ( ) are age-dependent parameters with age categories: to , to , to , to , and + years. to calibrate these parameters, we chose parameter sets randomly from a uniform distribution with given upper and lower bounds (assuming independence among parameters). the annual attack rate (averaged over years) and the simulated household secondary attack rate (averaged over years, and the rate of each year was averaged over all households with index cases) were computed from each set of parameters. simulations yielding average annual attack rate (ar) within the range ( . , . ) [ , , , ] , and secondary attack rate (sar) inside the range ( . , . ) [ , , , , , ] , were considered plausible; calibration was done by approximate bayesian computation [ , ] . for details of the ar and sar we cited, please see tables s and s . for each household with an index case, we calculated the secondary attack rate based on the proportion of household contacts who were infected by the index case in the household during the infectious period of the index case [ , ] . the sar was averaged by using the secondary attack rates of all households with index cases. this calculation of the sar includes partially immune household contacts [ , , , , , ] . simulations were run for sets of parameters, resulting in parameter sets that fit the acceptable ar and sar ranges stated above. parameter sets having higher or lower values of ar or sar were excluded. finally, we used the fitted (non-excluded) parameter sets and used them in the model to predict and study influenza transmission in the population under three scenarios: the one-child policy, the absence of a one-child policy, and the strict one-child policy. the individual-based model was implemented and programmed in c++ [ ] and r [ ] following our previously published agent-based transmission models [ , ] . c++ was used for the main simulation program and r for the analysis of data generated by the main simulation program. to add scalability for simulations of large population sizes, we used an agent-based platform abm++ [ ] which supports parallel and cluster computing. simulations were performed on the rti midas cluster, a cluster with compute nodes with a total of compute cores and gb of distributed memory, running linux distribution of centos v . . the running time for a single run of the model varied with input parameters in tables and . given a fitted set of parameters with the one-child policy and an initial population size of , it took about to seconds for a single run on one compute core with a speed of . ghz in the cluster. we simulated years of influenza transmission in a representative population of initial size under three different scenarios: a population with a one-child policy (), a population without a one-child policy (), and a population with a strict onechild policy (), (following ''one-child policy'' represents ). under each of the scenarios, we used fitted sets of parameters (described in the calibration section) to simulate influenza transmission. each scenario was simulated times and the annual and secondary attack rates were averaged among simulated ars and sars. we then computed the partial rank correlation coefficients (prcc) [ , ] for each input parameter and the annual attack rate under the three different policy scenarios using the sets. when the prcc is close to zero, the value of the parameter has little relation to the simulation output (see the text s ). the prcc values of key parameters are listed in table . finally, we calculated the annual and secondary attack rates experienced by the population under the three policy scenarios. to explore the influenza transmission factors that are likely affected by the one-child policy, we estimated the average differences in the annual attack rate (dar) and the secondary attack rates (dsar) in the populations without and with the onechild policy control. we found that the population without the . ar and sar differences between populations without the one-child policy and with the one-child policy. (a) average difference in annual attack rate (dar: . % (sd . %)) between populations without the one-child policy and with the one-child policy, based on calibrated parameter sets which yielded the annual attack rates between % and %, and secondary attack rates between % and %. for each parameter set, we simulated the influenza trajectories under two demographic control policies, and then computed the difference in average annual attack rates over years between two policies. (b) difference in secondary attack rates (dsar: . % (sd . %)) between populations without one-child policy and with the child-policy, based on calibrated parameter sets which yielded the annual attack rates between % and %, and the secondary attack rates between % and %. for each parameter set, we simulated the influenza trajectories under two demographic control policies, and then computed the difference in average secondary attack rates over years between two policies. doi: . /journal.pone. .g one-child policy had an average annual attack rate that was slightly higher than the population with the one-child policy. the distribution of the difference of annual attack rates with a mean of . % per year (with standard deviation (sd) . %) using fitted sets of parameters, in figure (a) , shows that all the values reflecting the dars between population without one-child policy and population with one-child policy are positive for all sets of parameters. here, each value of dar is the difference of the average annual attack rates over years between two different policies. this supports the notion that the one-child policy gradually reduced the annual attack rate. the decrease in annual attack rates may be caused by the smaller household sizes and the decreased proportion of children in the population resulting from the one-child policy. the distribution of dsar, in figure (b), shows that the expectation of the dsar is . % per household per year (sd . %) and there is no significant difference of secondary attack rates with the one-child policy introduced. however, the one-child policy had little to no discernible effect on the secondary attack rates. a larger population size gave similar results as stated above. we performed the same comparisons of the dar and dsar, comparing populations with the existing one-child policy with a hypothetical two-child policy. we assumed the two-child policy from to ; the simulations for a -year transmission period ( figure ) did not show significant differences of dar and dsar ( . % per year (sd . %) and . % per household per year (sd . %), respectively). in addition, we conducted sensitivity analyses by increasing the contact rate per day within household and the immunity loss rate per year and varying their values from to for the contact rate and from % to % for the immunity loss rate in order to compare the difference in ar and the difference in sar between populations without and with the one-child policy ( figures (a) and (b)). changes in household structure and the proportion of children in the population as a result of the one-child policy could have more effects on the ar, and the difference in ar could be as high as % under a scenario of very high immunity loss rate per year ( figures (a) ). however, the results showed that the difference in sar was not very sensitive to the contact rate in the household and the immunity loss rate (figures (b) ). the one-child policy has been applied in china for over years, causing great changes in the demographic composition of the chinese population. to address the impact of demographic changes caused by the one-child policy (or similar changes which may have arisen for other reasons) on influenza transmission, we developed a continuous-time individual-based, stochastic, simulation model for influenza transmission in dynamic populations with the support of available demographic data. after calibrating the simulated population with available demographic data and published attack rates, we simulated years of influenza transmission under three assumptions: a population with a onechild policy, a population without a one-child policy, and a population with a strict one-child policy. this study provides some evidence that demographic changes caused by demographic policy may slightly affect influenza transmission in populations. simulated results from this model show that populations without childbearing policies have slightly higher annual attack rates than populations with a one-child policy. we did not find significant differences in the secondary attack rates between populations with a one-child policy and populations without it. we predicted influenza transmission over years ( to ) in a population with a hypothetical two-child policy, and found negligible differences of the average annual attack rates and secondary attack rates compared to the population with a onechild policy. one limitation of our findings is that it is impossible to know what would have happened in the absence of the one-child policy. because our goal was to highlight the role of household size and other related demographic changes, we simply assumed an extrapolation from s trends. in reality, demographic changes may have occurred for other reasons in the absence of a one-child policy. moreover, this model did not distinguish contacts other than household and school (for example workplace [ , , ] , or community [ ] ). containment measures, such as different vaccine strategies [ , ] and travel restrictions [ , ] , were not considered in this model, allowing for a focus on the relationship between child policies and influenza transmission. we did not distinguish antigenic diversity [ ] ; because aging populations have more cross-immunity for similar strains [ ] . this limitation may underestimate an aging effect on influenza transmission. all parameters used in this model were defined from existing published literature. we did not assess the differences between pandemic years versus inter-pandemic years because of the assumption that there are no changes in influenza natural history parameters during the course of over years. we did not use this model to answer an important question that whether or not the demographic changes affect pathogen emergence in china because of lacking sufficient data, and this question is beyond the scope of this paper. this study found that the average annual attack rate is slightly lower in a population with a one-child policy, which may result from a decreased household size (from . in to . in in the model) and the decreased proportion of children (who are more vulnerable to infection than adults) in the population because of the dramatically reduced fertility rates from . in to . in . however there is no discernible difference in the sar. a possible reason for the absence of a discernible difference is that the decrease of average household size (from . to . ) might not be large and fast enough to obviously reflect the change in the secondary attack rate. we compared the results of this study with other recent studies [ , , , , ] about the relation between household size and sar, household size and the overall attack rate. the lower annual attack rate with smaller household size is consistent with the results from fraser et al. [ ] and kwok et al. [ ] , but carcione et al. [ ] found that individual risk was not associated with the household size. the absence of a discernible difference in the sar observed in this study is similar to the findings in [ ] in which the sar remained stable as household size increased, while the sar increased with larger household size . ar and sar differences between one-child policy and two-child policy ( years: to ). (a) dar ( . % (sd . %)) between one-child and two-child policies based on calibrated parameter sets which yielded the annual attack rates between % and % and the secondary attack rates between % and %. for each parameter set, we simulated the influenza trajectories under two demographic control policies, and then computed the difference in average annual attack rates over years ( to ) between two policies. (b) dsar ( . % (sd . %)) between one-child and two-child policies based on calibrated parameter sets which yielded the annual attack rates between % and % and the secondary attack rates between % and %. for each parameter set, we simulated the influenza trajectories under two demographic control policies, and then computed the difference in average secondary attack rates over years ( to ) between two policies. doi: . /journal.pone. .g in other studies [ , , ] . the above comparisons included some studies in which the sar was measured empirically, though the relation between the simulated sar and household size may be controlled by the model structure. in this model, the sar was estimated by the proportion of household contacts of an index case who subsequently became infected [ , ] , so that the simulated sar stands in relation to the simulated epidemic, which is in the same way the real-world empirical sar and its relation to the true unobserved epidemic. author contributions figure . ar and sar differences under assumptions of different contact and immunity loss rates. (a) varying the value of contact rate per day between any two members in a household (from to ) and the value of immunity loss rate per year (from % to %) yielded that under the scenario of of household contact rate and % of immunity loss per year, the ar in the population without the one-child policy could be % higher than the ar in the population with the one-child policy. (b) by varying the values of contact rate per day between any two members in a household (from to ) and the immunity loss rate per year (from % to %), the sar in the population without one-child policy could be % higher than the sar in the population without the one-child policy, when the contact rate per day in household is and the immunity loss rate per year is %. doi: . /journal.pone. .g has china outgrown the one-child policy? demography. of population projections and projectiles family size, fertility preferences, and sex ratio in china in the era of the one child family policy: results from national family planning and reproductive health survey the effect of china's one-child family policy after years environmental and social influences on emerging infectious diseases: past, present and future global migration dynamics underlie evolution and persistence of human influenza a (h n ) risk factors of influenza transmission in households the shifting demographic landscape of pandemic 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restrictions predicting the epidemic sizes of influenza a/h n , a/h n , and b: a statistical method avian influenza h n transmission in households secondary attack rate of pandemic influenza a(h n ) in western australian households influenza transmission in a community during a seasonal influenza a(h n ) outbreak ( - ) in mongolia: a community-based prospective cohort study modelling the proportion of influenza infections within households during pandemic and non-pandemic years serial intervals and the temporal distribution of secondary infections within households of pandemic influenza a (h n ): implications for influenza control recommendations the transmissibility and control of pandemic influenza a (h n ) virus key: cord- - lfmqzmc authors: chandrasekhar, arun g.; goldsmith-pinkham, paul; jackson, matthew o.; thau, samuel title: interacting regional policies in containing a disease date: - - journal: nan doi: nan sha: doc_id: cord_uid: lfmqzmc regional quarantine policies, in which a portion of a population surrounding infections are locked down, are an important tool to contain disease. however, jurisdictional governments -- such as cities, counties, states, and countries -- act with minimal coordination across borders. we show that a regional quarantine policy's effectiveness depends upon whether (i) the network of interactions satisfies a balanced-growth condition, (ii) infections have a short delay in detection, and (iii) the government has control over and knowledge of the necessary parts of the network (no leakage of behaviors). as these conditions generally fail to be satisfied, especially when interactions cross borders, we show that substantial improvements are possible if governments are proactive: triggering quarantines in reaction to neighbors' infection rates, in some cases even before infections are detected internally. we also show that even a few lax governments -- those that wait for nontrivial internal infection rates before quarantining -- impose substantial costs on the whole system. our results illustrate the importance of understanding contagion across policy borders and offer a starting point in designing proactive policies for decentralized jurisdictions. global problems, from climate change to disease control, are hard to address without policy coordination across borders. in particular, pandemics, like covid- , are challenging to contain because governments fail to coordinate efforts. without vaccines or herd immunity, governments have responded to infections by limiting constituents' interactions in areas where an outbreak exceeds a threshold of infections. such regional quarantine policies are used by towns, cities, counties, states, and countries, and trace to the days of the black plague. over the past years, regional quarantines have been used to combat cholera, diphtheria, typhoid, flus, polio, ebola, and covid- [ , , , ] , but rarely with coordination across borders. decentralized policies across jurisdictions have two major shortcomings. first, governments care primarily about their own citizens and do not account for how their infections impact other jurisdictions: the resulting lack of coordination can lead to worse overall outcomes than a global policy [ , , ] . second, some governments only pay attention to what goes on within their borders, which leads them to under-forecast their own infection rates. we examine three types of quarantine policies to understand the impact of non-coordination: (i) those controlled by one actor with control of the whole society -"single regime policies," (ii) those controlled by separate jurisdictions that only react to internal infection rates -"myopic jurisdictional policies," and (iii) those controlled by separate jurisdictions that are proactive and track infections outside of their jurisdiction as well as within when deciding on when to quarantine -"proactive jurisdictional policies. " we use a general model of contagion through a network to study these policies. we first consider single regime policies. a government can quarantine everyone at once under a "global quarantine," but those are very costly (e.g., lost days of work). less costly (in the short run), and hence more common, alternatives are "regional quarantines" in which only people within some distance of observed infections are quarantined. regional quarantines, however, face two challenges. first, many diseases are difficult to detect, because individuals are either asymptomatically contagious (e.g., hiv, covid- ) [ , , ] , or a government lacks resources to quickly identify infections [ , ] . second, it may be infeasible to fully quarantine a part of the network, because of difficulties in identifying whom to quarantine or non-compliance by some people -by choice or necessity [ , , , , , , ] . either way, tiny leakages can spread the disease. we show that regional quarantines curb the spread of a disease if and only if: (i) there is limited delay in observing infections, (ii) there is sufficient knowledge and control of the network to prevent leakage of infection, and (iii) the network has a certain "balanced-growth" structure. the failure of any of these conditions substantially limits quarantine effectiveness. we then examine jurisdictional policies, which are regional quarantine policies conducted by multiple, uncoordinated regimes. the regions that need to be quarantined cross borders, leading to leakage that limits their effectiveness. as we show, myopic policies do much worse than proactive ones, as they do not forecast the impact of neighboring infection rates on their own population. moreover, a few lax jurisdictions, which wait for higher infection rates before quarantining, substantially worsen outcomes for all jurisdictions. consider a large network of nodes (individuals). our theory is asymptotic, applying as the population grows (details in the si). an infectious disease begins with an infection of a node i , the location of which is known, and expands via (directed) paths from i . in each discrete time period, the infection spreads from each currently infected node to each of its susceptible contacts independently with probability p. a node is infectious for θ periods, after which it recovers and is no longer susceptible, though our results extend to the case in which a node can become susceptible again. the disease may exhibit a delay of τ ≤ θ periods during which an infected and contagious person does not test positive. this can be a period of asymptomatic infectiousness, a delay in testing, or healthcare access [ , , , , , ] . after that delay, the each infected node's infection is detected with probability α < (for simplicity, in the first period after the delay). α incorporates testing accuracy, availability, and decisions to test. this framework nests the susceptible-infected-recovered (sir) model and its variations including exposure, multiple infectious stages, and death [ , , , , ] , agent-based models [ , , ] , and others. we begin by analyzing a single jurisdiction with complete control. a (k, x)-regional policy is triggered once x or more infections are observed within distance k from the seed node i ; at which point it quarantines all nodes within distance k + of the seed for θ periods. this captures a commonly used policy where regions that are exposed to the disease are shut down in response to detection. we give the policymaker the advantage of knowing which node is the seed and study subsequent containment efforts. in practice, the estimation of the infection origin is an additional challenge. whether a regional policy halts infection in this setting is fully characterized by what we call growth-balance (formally defined in the si). this requires that the network have large enough expansion properties and that the expansion rate not drop too low in any part of the network. to better understand growth-balance, consider an example of a disease that is beginning to spread with a reproduction number of . and such that one in ten cases are detected in a timely manner (α = . ). first, consider a part of the network in which each infected person infects . others on average. if we monitor nodes within distance k = of an infected node, a "typical" chain of infection would lead to roughly . + . + . = . expected cases. the chance that this goes undetected is tiny: . . = . . next, suppose the infection starts in part of the network where each infected person infects just one other, on average. now a chain of depth leads to + + = infections. the chance that this spread remains undetected is very high: . = . . many different networks can lead to the same average reproduction number, but have very different structures. if the distribution of reproduction numbers around the network has no pockets in which it is too low, then it is highly likely that any early infection will be detected before it goes beyond a distance of three away from the first infected node. if instead, the distribution of reproduction numbers gives a nontrivial chance that the disease starts out on a chain with lower reproduction numbers, like the , , , chain, then there is a high chance that it can travel several steps before being detected. given the short distances in many networks [ , , ] , this allows it to be almost anywhere. supplementary figure c. in the si pictures a network that has a high average reproduction number, but is not growth-balanced and allows the infection to travel far from the initially infected node without detection. in the si (theorem ) we prove that, with no delays in detection and no leakage, a (k, x)regional policy halts infection among all nodes beyond distance k + from i with probability approaching (as the population grows) if and only if the network satisfies growth-balance. growth-balance is satisfied by many, but not all, sequences of random graph models, provided that the average degree d satisfies d k → ∞ (corollary , si). without growth balance, a regional policy fails non-trivially even under idealized conditions. the effectiveness of a regional policy breaks down, even if a network is growth-balanced, once there is leakage (due to imperfect information, enforcement, or jurisdictional boundaries) or sufficient delay in detection. to understand how delays in detection affect a regional policy, consider two extremes. if the delay is short relative to the infectious period, the policymaker can still anticipate the disease and adjust by enlarging the area of the quarantine to include a buffer. an easy extension of the above theorem is that a regional policy with a buffer works if and only if the network is growth-balanced and the delay in detection is shorter than the diameter of the network (theorem , si). given that real-world networks have short average distances between nodes [ ], non-trivial delays in detection allow the disease to escape a regional quarantine. next, we consider how leakage -inability to limit interactions [ ] or mistakes in identifying portions of a network to quarantine [ , ] -diminishes the effectiveness of regional policies. although minimizing leakage increases the chance that a regional quarantine will be successful, we show (theorem , si) that even a small amount of leakage leads to a nontrivial probability that a regional policy will fail. we can use the results from regional quarantines as a starting point to understand jurisdictional policies. for instance, leakage generally applies when interactions cross jurisdictions. figure pictures two jurisdictions that fail to nicely tessellate the network. given leakage across jurisdictional borders, unless policies are fully coordinated across jurisdictions, our theoretical results indicate that they will fail to contain infections. the theory provides insights into the various hurdles that quarantine policies face, but does not provide insight into how well different types policies will fare in slowing infection and at what costs. to explore this, we simulate a contagion on a network of nodes that mimics realworld data [ , , , ] . these simulations illustrate our theoretical results and also show the improvements that proactive policies provide relative to myopic ones. the results are robust to choices of parameters (si). the network is divided into locations, each with a population of . we generate the network using a geographic stochastic block model (si). the probability of interacting declines with distance. the average degree is . and nodes have . % of their interactions within their own locations and . % outside of their location (calibrated to data from india and the united states, including data collected during covid- [ , , , ], si). we set the basic reproduction rate r = . to mimic covid- [ ], and θ = and α = . ([ , , ] , si). the simulated network is fairly symmetric in degree and therefore approximates satisfying growth-balance, and thus the attention in our simulations is focused on leakage and detection delay. before introducing jurisdictions, we first illustrate the effects of leakage as well as delays in detection. in figure , the entire network is governed by a single policymaker using a (k, x) = ( , )-regional quarantine. figure a shows the outcomes for no delay in detection nor any leakage. consistent with theorem the policy is effective: on average nodes per million are infected ( . % of the population), with node-days of quarantine per million nodes. figure b introduces a delay in detection. with a delay of τ = , infections increase, with nodes per million eventually infected ( . % of the population) and node-days of quarantine per million nodes. adding a buffer to correspond to the detection delay effectively makes the regional policy global, as the buffered region contains . % of the population on average. figure c adds leakage to the setup of figure b , making only % of the intended nodes quarantined. the number of cumulative infections per million nodes increases to ( . % of the population). the leakage increases the number of quarantined node-days to per million nodes. we now introduce jurisdictions to the same network as before, and each location becomes its own jurisdiction. we compare two types of jurisdictional policies. in myopic policies each jurisdiction quarantines based entirely on internal infections. in proactive policies, jurisdictions track infections in other jurisdictions and predict their own -possibly undetected -infections and base their quarantines off of predicted infections (calculation details in si). in both cases, if a jurisdiction enters quarantine, all links within and to the jurisdiction are removed. figure illustrates the improvement a proactive policy offers relative to myopic internal jurisdictional policies. in figure a finally, we also add a few "lax" jurisdictions to the setting. these are jurisdictions that are myopic and have a high threshold of internal infections before quarantining. we examine how these few lax jurisdictions worsen the outcomes for all jurisdictions. in figures c and d , four lax jurisdictions react only to infections within their own borders and wait until they have detected five infections before quarantining (simulation details, si). figure global quarantines (closing the entire network at once) and single-jurisdiction regional quarantines (with leakage) do the best on both dimensions. once jurisdictions are introduced, proactive jurisdictions quarantine earlier and have fewer recurrences than myopic jurisdictions. lax jurisdictions cause an overall higher number of quarantines, over a longer time. the proactive jurisdictional policy trades off more quarantine days for substantially fewer infection days compared to the myopic internal policy, but proactive policies do significantly better than myopic policies on both dimensions when mixed with jurisdictions using lax policies. figure b plots the number of person-day infections (per million) against the number of personday quarantines (per million) for six key policy scenarios. the global policy does the best on both dimensions, and the second best is the single-jurisdiction myopic strategy (which does worse than the global because of leakage). with jurisdictions, both proactive policies outperform the internal, myopic policies. by far the worst, on both dimensions, is the internal, myopic policy with some lax jurisdictions. these results come from the same solutions that produce figures and . we have shown that regional quarantine policies are likely to fail unless leakage and delays in detection are limited. multiple jurisdictions using independent policies are even less effective, as leakage occurs across jurisdictional borders. we have also shown that there are substantial improvements from proactive policies, and that a few lax jurisdictions greatly worsen the outcomes for all jurisdictions. jurisdictional policies tend to be aimed at the welfare of their internal populations, yet the external effects are large. our results underscore the importance of timely information sharing and coordination in both the design and execution of policies across jurisdictional boundaries [ ] . the results also underscore the global importance of aiding poor jurisdictions. indeed, there is mounting evidence that a lack of coordination across boundaries has been damaging in the case of covid- [ ] . the use of masks (decreasing p), social distancing (decreasing d), and increasing testing (increasing α), all help attenuate contagion, but unless they maintain the reproduction number below one, the problems identified here remain. even tiny fractions of interactions across boundaries are enough to lead to spreading in large populations. with modern interand intranational trade being a sizable portion of all economies, such interaction is difficult to avoid. nonetheless, our analysis offers insights into managing infections at smaller scales; e.g., within schools, sports, and businesses. by creating a network of interactions that is highly modular, keeping cross-modular interactions to a minimum and making sure that they are highly traceable, together with aggressive testing (especially of cross-module actors), one can come close to satisfying the conditions of our first theorem. our results also suggest caution in using statistical models to identify regions to quarantine. although contagion models are helpful for informing policy about the magnitude of an epidemic and broad dynamics, the models can give false comfort in our ability to engage in highly targeted policies, whose results can be influenced by small deviations from idealized assumptions. our growth-balance condition also points out that not all parts of a network are equal in their potential for undetected transmission. in places where the reproduction number is lower, so is the probability of observing outbreaks, enabling undetected leakage of infections. [ ] watts, d. j. small worlds: the dynamics of networks between order and randomness (princeton university press, ). supplementary material interacting regional policies in containing a disease by chandrasekhar, goldsmith-pinkham, jackson, thau the model there are n > nodes (individuals) in an unweighted, and possibly directed, network. we study the course of a disease through the network. time is discrete, with periods indexed by t ∈ n. an initial infected node, indexed by i ∈ v , is the only node infected at time . we call this node the seed. we track the network via neighborhoods that expand outwards via (directed) paths from i . let n k be all the nodes who are at (directed) distance k from node i . we use n k to denote the cardinality of n k . for any node in j ∈ n k , for k < k, let n j be the number of its direct descendants and n j k be the number of its (possibly indirect) descendants in n k that are reached by never passing beyond distance k from i . all unweighted network models are admitted here. additionally, all results extend directly to any weighted model in which weights are bounded above and below (e.g., probabilities of interaction). note also, that the network can be directed or undirected. the infection process proceeds as follows. in every time period t ∈ { , , . . .}, an infected node i transmits the disease to each of i's neighbors independently with probability p. a newly infected node is infectious for θ ≥ periods after which the node recovers and is never again infectious. the model can easily be extended to accommodate renewed susceptibility. there may be a delay in the ability to detect the disease. the number of periods of delay is given by τ with ≤ τ ≤ θ. delay is a general term that can capture many things. for example, it can correspond to (a) asymptomatic infectiousness, (b) a delay in accessing health care given the onset of an infectious period, (c) any delay in the administration of testing, and so on. in the first period of an infected node's infectious period -after delay -there is a probability α that the policymaker detects it as being infected. so, potential detection happens exactly once during the first period in which the node can be detected. detection is independently and identically distributed. our results are easily extended to have a random period for detection after the delay. finally, the policymaker may face some error in their knowledge of the network. this can come from their inability to enforce exactly the interactions they wish to allow or limit, this can come from random variation in data collected to estimate interaction networks, or this can come from misspecification. if there is error, we will track a share of nodes that are within a k-neighborhood of the seed but are estimated by the policymaker to be outside the k-neighborhood. let regional policy of distance k and threshold x be such that once there are at least x infections (other than the seed) detected within distance k from the initial seed, then all nodes within distance k + of i are quarantined for at least θ periods. a quarantine implies all connections between nodes are severed to avoid any further transmission and the infection waits out its duration θ and dies out. implicit in this definition is that a quarantine is not instantaneous, but that infected people could have infected their friends before being shut down, which is why the nodes at distance k + are quarantined. all the results below extend if we assume that it is instantaneous, but with quarantines moved back one step and path lengths in definitions correspondingly adjusted. we have assumed the policymaker knows the "seed," for simplicity -and which may take some time in reality. this provides an advantage to the policymaker, but we see substantial. containment failures despite this advantage. in order to conduct asymptotic analysis, a useful device to study the probabilities of events in question in large networks, we study a sequence of networks g(n) with n → ∞ and an associated sequence of parameters (α, p, τ, θ, k) = (α(n), p(n), τ (n), θ(n), k(n)). in what follows when we drop the index n, and it is implied unless otherwise stated. consider a network and a distance k from the initially infected node i . a path of potential infection to k + is a sequence of nodes i , i , . . . i with i ∈ n k+ , i j+ being a direct descendant of i j for each j ∈ { , . . . , − }, and for which i has a descendant in n k+ . consider a sequence of networks and k(n)s. we say that there are bounded paths of potential infection to k(n) + if there exists some finite m and for each n there is a path of potential infection to k(n) + , i , i , . . . i of length less than m , with n j < m for every j ∈ { , . . . , − }. we say that a sequence of networks is growth-balanced relative to some k(n) if there are no bounded paths of potential infection to k(n) + . growth balance is essentially a condition that requires a minimum bound of expansion along all paths from some initial infection. the intuition behind the condition is clear: in order to be sure to detect an infection, within distance k of the seed, it has to be that many of the nodes within distance k have been exposed to the disease by the time it reaches distance k. what is ruled out is a relatively short path that gets directly to that distance without having many nodes be exposed along that path. supplementary figure , it is much more likely to be detected. however, that only happens with some moderate probability in this network, and so growth balance fails. we begin with a benchmark case in which there is no delay in detection (τ = ) and the policymaker can completely enforce a quarantine at some distance k + . we allow the size of the quarantine region k to depend on n in any way, as the theorem still applies. we work with an arbitrary but fixed threshold x, in order to allow infections to be detected. what is important is that x not grow too rapidly, as otherwise there is no chance of observing that many infections within some distance of the seed. theorem . consider any sequence of networks and associated k(n) < k(n) − where k(n) is the maximum k for which n k > ; , such that each node in n k(n)+ has at least one descendent at distance k(n) + , and let x be any fixed positive integer. let the sequence of associated diseases have α(n) and p(n) bounded away from and , no delay in detection, and any θ(n) ≥ . a regional quarantining policy of distance k(n) and threshold x halts all infections past distance k(n) + with a probability tending to if and only if the sequence is growth-balanced with respect to k(n). note that the growth-balance condition implies that the number of nodes within distance k(n) from i must be growing without bound. theorem thus implies that in order for a regional policy to work, the region must be growing without bound, and also must satisfy a particular balance condition. proof of theorem . to prove the first part, note that if the infection never reaches distance k then the result holds directly since it can then not go beyond k + . we show that if the sequence of networks is growth-balanced relative to k, then conditional upon an infection reaching level k with the possibility of reaching k + within two periods, the probability that it infects more than x nodes within distance k before any nodes beyond k tends to . suppose that infection reaches some node at distance k that can reach a node in n k+ . consider the corresponding sequence of paths of infected nodes i , i , . . . i with i ∈ n k+ , i j+ being a direct descendant of i j for each j ∈ { , . . . , − }, and note that by assumption i has a descendant in n k+ . by the growth-balance condition, for any m , there is a large enough n for which either the length of the path is longer than m or else there is at least one i j with j ≤ − along the path that has more than m descendants. in the latter case, the probability that i j has more than x descendants who become infected and are detected is at least − f m,m (x) where f m,m is the binomial distribution with m draws each with probability m, where pα > m for some fixed m. given that x and m are fixed, this tends to probability as m grows. in the former case, the sequence exceeds length m , all of which are infected and so given that α is bounded below, the probability that at least x of them are detected goes to as m grows. in both cases, as n grows, the minimal m across such paths of potential infection to k + grows without bound, and so the probability that there are at least x infections that are detected by the time that i − is reached tends to as n grows. to prove the converse, suppose that the network is not growth-balanced. consider a sequence of bounded paths of potential infection to k + , with associated sequences of nodes i , i , . . . i of length less than m with i ∈ n k+ , i j+ being a direct descendant of i j for each j ∈ { , . . . , − }, with n j < m for every j ∈ { , . . . , − }, and for which i has a descendant in n k+ . the probability that each of the nodes i , . . . i − becomes infected and growth-balance condition becomes more complicated, as the m in that definition adjusts with the rate of growth of x. otherwise, it is actually a global policy. the cases of p or α equal to are degenerate. no other nodes are infected within distance k − , and that all infected nodes are undetected is at least (p( − α)( − p) m ) m . this is fixed and so bounded away from . this implies that probability that the infection gets to nodes at distance k, and i − in particular, without any detections is bounded below. thus, there is a probability bounded below of reaching i before any detections, and then by the time the quarantine is enacted, there is at least a p times this probability that it escapes past n k+ , which is thus also bounded away from . we note that theorem admits essentially all sequences of (unweighted) networks. thus, for every type of network, one can determine whether a regional policy of some k, x will succeed or fail. the only thing that one needs to check is growth-balance. if it is satisfied, a regional policy works, and otherwise it will fail with nontrivial probability. the following corollary details the implications of the theorem for some prominent random network models. . for a sequence of block models (with erdos-renyi as a special case), a regional policy with a bounded k has a probability going to of halting the disease on the randomly realized network if and only if the seed node's expected out degree d is such that d k → ∞. . for a regular expander graph with outdegree d, a regional policy works if and only if the expansion rate d k → ∞. . for a regular lattice of degree d, a regional policy works if and only if d k → ∞. . for a rewired lattice with a fraction links that are randomly rewired, a regional policy with a bounded k has a probability going to of halting the disease on the randomly realized network if and only if d k → ∞. for a sequence of random networks with a scale-free degree distribution, a regional policy works (with probability ) if and only if k → ∞. thus, whether a regional policy works in almost any network model requires that either the degree of almost all nodes grows without bound, or else the size of the quarantine grows without bound. for a scale free distribution, there is always a nontrivial probability on small degrees, and hence in order for a regional policy to work, the size of the neighborhood must grow without bound. in practice, even very sparse networks will have a large d k (e.g., if people have hundreds of contacts, is already a million and even with a very low α many infections will be detected within a few steps of the initial node). what the growth-balance condition rules out is that some nontrivial part of the network have neighborhoods with many fewer contacts -so there cannot be people who have just a few contacts, since that will allow for a nontrivial probability of undetected escape (e.g., = and so with only infections, it is possible that none are detected and the disease escapes beyond steps). as many realworld network structures have substantial heterogeneity, with some people having very low numbers of interactions, such an escape becomes possible even under idealized assumptions of no delay in detection and no leakage [ , , , , ] . the detection delay, τ , is distributed over the support { , . . . , τ max }. this includes degenerate distributions with τ max being the maximal value of the support with positive mass. the policymaker may or may not know τ max and we study both cases. the latter is important as in practice we estimate delay periods so there is bound to be uncertainty. when τ is known, we can simply say τ = τ max . let a regional policy with trigger k and threshold x and buffer h be such that once there are at least x infections detected within distance k + h from the initial seed, then all nodes within distance k + h + of i are quarantined/locked down for at least θ periods. there are two differences between this definition of regional policy from the one considered before. first, it is triggered by infections within distance k + h (not within distance k), and it also has a buffer in how far the quarantine extends beyond the k-th neighborhood. we extend the definition of growth balance to account for buffers. consider a network and a distance k from the initially infected node i and an h ≥ . a path of potential infection to k + h + is a sequence of nodes i , i , . . . i with i ∈ n k+h+ , i j+ being a direct descendant of i j for each j ∈ { , . . . , − }. consider a sequence of networks, n, and associated k(n), h(n). we say that there are bounded paths of potential infection to k(n) + h(n) + if there exists some finite m and for each n there is a path of potential infection to k + h + , i , i , . . . i of length less than m , with n j < m for every j ∈ { , . . . , − h − }. we say that a sequence of networks is growth-balanced relative to some k(n) and buffers h(n) if there are no bounded paths of potential infection to k(n) + h(n) + . theorem . consider any sequence of networks and k(n) < k(n) − h − where k(n) is the maximum k for which n k > , such that each node in n k for k > k has at least one descendent at distance k + , and let x be any fixed positive integer. let the sequence of associated diseases have α(n) and p(n) bounded away from and , θ(n) ≥ , and have a detection delay distributed over some set { , . . . , τ max } with τ max > (with probability on τ max bounded away from ). a regional policy with trigger k(n), threshold x, and buffer τ max halts all infections past distance k(n) + τ max + with a probability tending to if and only if the sequence is growth-balanced with respect to k(n). the proof of theorem is a straightforward extension of the previous proof and so it is omitted. this result shows several things. first, if the detection delay is small relative to the diameter of the graph, one can use a regional quarantine policy -adjusted for the detection delay -along the lines of that from theorem and ensure no further spread. this is true even if the period is stochastic as long as the upper bound is known to be small. second, and in contrast, if the detection delay is large compared to the diameter of the graph, then a regional policy is insufficient. by the time infections are observed, it is too late to quarantine a subset of the graph. this condition will tend to bind in the case of real world networks, as they exhibit small world properties and have small diameters [ , ]. as a result, even short detection delays may correspond to rapidly moving wavefronts that spread undetected. next we turn to the case of in which there is some leakage in the quarantine, which may come for a variety of reasons. the policymaker may have measurement error in knowing the network structure of the network and who should be quarantined. second, and distinctly, the policymaker may be unable to control some nodes or interactions. third, the network may leak across jurisdictions and some nodes within distance k of i may be outside of the policymaker's jurisdiction. to keep the analysis uncluttered, we assume no detection delay, but the arguments extend directly to the delay case with the appropriate buffer. theorem . consider any sequence of networks. let the sequence of associated diseases have α and p bounded away from and , and be such that θ ≥ , with no detection delay. consider any k(n) < k − where k is the maximum k for which n k > , suppose that each node in n k(n) has at least one descendent at distance k(n) + , and let x be any positive integer. suppose that a random share of ε n of nodes within distance k of i are not included in a regional quarantine policy and connected to nodes of distance greater than k + -because of a lack of jurisdiction, misclassification by a policymaker, or lack of complete control over people's behaviors. then: . if ε n = o(( k ≤k n k ) − ) and the network is growth-balanced, then a regional policy of distance k and threshold x halts all infections past distance k + with a probability tending to . . if ε n ≥ min[ /x, η] for all n for some η > or the network is not growth-balanced, then a regional policy of distance k(n) and threshold x fails to halt all infections past distance k(n) + with a probability bounded away from . proof of theorem . part follows from the fact that if ε n = o(( k ≤k n k ) − ) then the probability of having all nodes in n k correctly identified as being in n k tends to , and then theorem can be applied. for part , suppose that some x infections are detected. the probability that at least one of them is misclassified is at least − ( − ε n ) x . given that ε n ≥ min[ /x, η] for any η > , it follows that ( − ε n ) x is bounded away from . there is a probability bounded away from that at least one of the infected nodes is misclassified, and not subject to the quarantine, and connected to a node outside of distance k + . the theorem implies that the effectiveness of a regional policy is sensitive to any small fixed ε amount of leakage. to illustrate the processes described in the main text, we run several simulations. first, we construct a large network with many jurisdictions. we directly study the content of the theorems with several versions of (k, x) quarantines with an sir infection process on a network. we use the same process and network to show the issues with regional containment, studying regional and adaptive policies. we model real world network structure as follows. . there are l locations distributed uniformly at random on the unit sphere. each location has a population of m nodes with a total of n = ml nodes in the network. . the linking rates across locations are given as in a spatial model [ , ] . the probability of nodes i ∈ and j ∈ for locations = linking depends only on the locations of the two nodes and declines in distance: where dist( , ) is the distance between the two locations on the sphere and a, b < . every interaction between every pair of nodes is drawn independently from the observed spatial distribution, with distances being along the surface of the unit sphere. . the linking patterns within a location are given as in a mixture of random geometric (rgg) [ ] and erdos-renyi (er) random graphs [ ] . specifically, as spheres are locally euclidean, we model nodes in a location (e.g., in a city) as residing in a square in the tangent space to the location. the probability that two nodes within a location link declines in their distance in this square. we set d rgg as the desired degree from the the rgg. nodes are uniformly distributed on the unit square [ , ] , and links are formed between nodes within radius r [ ]. to obtain the desired degree we set: the remaining links within location are drawn identically and independently with probability where d is the desired average degree for all nodes within location . . next, we uniformly add links to create a small world effect, with identical and independently distributed probability s = cn , where c is an arbitrary constant and n is the total number of nodes in the network [ ]. . finally, we designate a single location as a "hub," to emulate the idea that certain metro areas may have more connections to all other regions. to do so, we select a hub uniformly at random and add links independently and identically distributed with probability h from the hub location to every other location. we first take l = and m = for all locations. we set a = − and b = − . next, we set d = . , and d rgg = . for all locations. next, we set c = . finally, we set h = . × − . this process results in a graph that emulates real world networks in the united states and india [ , , , ] . this includes data from india during the covid- lockdowns about interactions within six feet, meaning that it is conservative [ ] . we fix a graph to use in all versions of the simulations. the network we generate is sparse, clustered, and has small average distances, as in real world data. finally, we recalculate the connection probability matrix to accurately reflect rates of connection across regions, which we call q. we set parameters as follows: the duration of infection is θ = , detection delay (when incorporated) is τ = , and set thresholds x for quarantine based on the simulation type. we set transmission probability p as whered is the mean degree. we take r = . , based on estimates of covid- [ ]. cases are detected i.i.d. with rate α, which we define as α = p(symptomatic) · p(tested) · p(test positive|truly positive) we take the symptomatic rate as . % [ ] , and the power of the test as % [ ] . following estimates from the literature ( - %), we set α = . [ , ] . so, the detection rate is roughly in . in the simulations, each node is either detected or not during the first period in which it can be detected, and no information comes after that. when τ = , any detection occurs as soon as they are infected and when τ > this happens in the τ + th period of infection. as outlined in the main text, we begin by using θ = and τ = [ , , , ]. each time period in the simulation progresses in four parts, which happen sequentially. the simulations run as follows: . the policy maker sees the detected infections from the previous period, and calculates if a quarantine is necessary in the next period. . the disease progresses for a period. this includes new infections and recoveries. . infected nodes that have just finished their detection delay of τ periods are independently detected with probability α. . new quarantines are enacted based on decisions made in part one of the process. quarantines that have taken place for θ periods end. a node that becomes infected in period t with a detection delay of τ and total disease length θ, is tested in period t + τ , results are processed in t + τ + , and they will be quarantined (if necessary) starting at the end of t + τ + (under the fourth item above). this means that they have τ + time periods during which they can infect other nodes. for instance, if τ = this allows a node that becomes infected but (that was not already under quarantine for other reasons) one opportunity to infect others. this process reflects that neither detection nor quarantining of individuals (or jurisdictions) happens instantaneously. in addition, we stipulate that the seed node, i is not counted in the quarantining testing and calculations. this is meant to reflect that it may be unclear whether the disease is spreading or not. nodes that are detected are marked as such until recovery. a random node i is selected and the epidemic begins there. we study the epidemic curve, the number total node-days of infection, and the number of node-days of quarantine for a variety of containment strategies. we examine a number of scenarios using the (k, x) policy model outlined in theorems - . in the case that the quarantine fails, but there are infections outside of the quarantine radius, the policy maker deals with them individually. the policy maker treats each detected case outside of the initial quarantine as a new seed, and immediately quarantines all nodes with the same radius as the initial quarantine. begin by using a simple objective function to find the optimal threshold for triggering the initial quarantine. we minimize a linear combination of the number of infected person periods and quarantined person periods. for all linear combinations where some weight is given to both terms, the optimal threshold is x = . the logic is as follows: if the initial quarantine is successful, the number of quarantined person periods will be fixed and also the minimum number of quarantined person periods. therefore, the problem reduces to minimizing the number of infections, which is done by setting x = . we study three versions of a (k, x) policy. first, we simulate (k, x) = ( , ) with no detection delay. then, we incorporate a detection delay of τ = , still using a policy of (k, x) = ( , ) with no buffer. lastly, we study a ( , ) policy with no buffer and enforcement failures. in this case, a fraction = . of nodes do not ever quarantine. a global quarantine policy imagines the state as an actor which quarantines every node for θ periods when more than x = infections are detected globally. we study this in the case with a detection delay, to compare to the (k, x), regional, jurisdiction based, and proactive policies. for both the myopic-internal and proactive policies, we take each location as a single jurisdiction. myopic internal quarantine policies. jurisdictions respond only to detections within their own borders, setting x independently of one another. in addition, states act independently: jurisdictions do not take detected infections outside of their borders into account. we set x = for all jurisdictions, the most conservative possible threshold unless otherwise specified. proactive quarantine policies. we examine a more sophisticated approach to deciding when to quarantine. with this policy, each jurisdiction decides to quarantine based on not only defections within their borders, but within neighboring jurisdictions as well. in each period, each jurisdiction calculates their expected detected infections w as follows: w ,t = max{w ,t− + y ,t − r ,t , z ,t } we use y ,t to denote the number of expected new infections in region at time t, and use r ,t to denote the number of expected recoveries in at t. each state calculates y ,t as: not quarantined at t- m q , w ,t− the summation includes the term for spread from to still within . if is quarantined at time t, then y ,t = . expected recovery at each period r ,t is calculated as: finally, we set w ,t < . to be zero, to avoid implementation issues with floating point calculations. setting a lower value to truncate at would improve the performance of the proactive jurisdiction policies, as they would be more sensitive to detected cases in other jurisdictions. uniform and lax policies we run two simulation variants for both the proactive and internally-based policy: one in which all states are as conservative as possible, setting x = and a second in which four regions set a higher threshold of x = ; in the proactive case, these lax regions also act myopically, following the internal jurisdiction-based policy. we choose x = to simulate lax thresholds. in the united states, new york state issued a stay at home order when . % of the state population was infected, which scaled to our populations of that is equivalent to a threshold of . [ , ] . when scaled to match our population of , florida began re-opening with a threshold of . , and some countries never locked down [ , , ] . in our stylized model, quarantines are more aggressive as they cut contact completely. we include the results of the simulations detailed in the main text in the tables below. in addition, we run simulations with two sets of varied parameters: first, we take α = . , second we take θ = and τ = . within the united states, estimates for the detection rate range from % to %, and in countries with less developed testing infrastructure, the detection rate is undoubtedly lower [ ] . because disease parameters are estimated, we use a different estimated of the disease lifespan of covid- [ ] . for all simulations, we fix r = . . [ ] penrose, m. random geometric graphs, vol. (oxford university press, ). cholera, quarantine and the english preventive system the concept of quarantine in history: from plague to sars lessons from the history of quarantine, from plague to influenza a. emerging infectious diseases diffusion and contagion in networks with heterogeneous agents and homophily interdependence and the cost of uncoordinated responses to covid- variations in governmental responses to and the diffusion of covid- : the role of political decentralization transmission of influenza: implications for control in health care settings contributions from the silent majority dominate dengue virus transmission presumed asymptomatic carrier transmission of covid- characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention failing the test: waiting times for covid diagnostic tests across the u.s. the state of the nation: a -state covid- survey covid- the law and limits of quarantine can we contain the covid- outbreak with the same measures as for sars? the role of sexual partnership networks in the epidemiology of gonorrhea gonorrhoea and chlamydia core groups and sexual networks in manitoba containing bioterrorist smallpox statistical properties of community structure in large social and information networks diffusion of microfinance a network formation model based on subgraphs classes of small-world networks the average distances in random graphs with given expected degrees using aggregated relational data to feasibly identify network structure without network data on random graphs collective dynamics of small-world networks how many people do you know?: efficiently estimating personal network size changes in social network structure in response to exposure to formal credit markets can network theory-based targeting increase technology adoption? messages on covid- prevention in india increased symptoms reporting and adherence to preventive behaviors among million recipients with similar effects on non-recipient members of their communities reconstruction of the full transmission dynamics of covid- in wuhan suppression of covid- outbreak in the municipality of vo variation in false-negative rate of reverse transcriptase polymerase chain reaction-based sars-cov- tests by time since exposure the incubation period of coronavirus disease (covid- ) from publicly reported confirmed cases: estimation and application estimating the fraction of unreported infections in epidemics with a known epicenter: an application to covid- substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (sars-cov- ) evidence supporting transmission of severe acute respiratory syndrome coronavirus while presymptomatic or asymptomatic continuing temporary suspension and modification of laws relating to the disaster emergency the covid tracking project. totals by state phase : safe. smart. step-by-step. plan for florida's recovery emergency information from swedish authorities. restrictions and prohibitions key: cord- - nuhvs authors: attorp, adrienne; mcareavey, ruth title: muck, brass and smoke: policy post-exceptionalism in the agri-food sector() date: - - journal: j rural stud doi: . /j.jrurstud. . . sha: doc_id: cord_uid: nuhvs governance is well recognized as shifting boundaries of responsibilities for doing things among key partners. what is less clear is how exactly power relations are altered and where power is concentrated as new forms of governance emerge. in our article we use the concept of policy post-exceptionalism to critically assess ‘going for growth’, a strategic action plan that, until the recent past, underpinned the northern ireland agri-food industry. the agri-food sector has an important and prominent role in the northern ireland economy. the going for growth strategy illustrates how particular interests within the sector are supported by government, as demonstrated through the renewable heat initiative and a scheme promoting anaerobic digestors. using policy post-exceptionalism to scrutinize the strategy, our research shows what can go wrong when a transition to post-exceptionalism occurs. while going for growth purported to represent the wider interests that one might expect to find in a post-exceptionalist approach to agri-food governance, in fact the concentration of power with corporate actors left little space for the inclusion of wider interests. we conclude that this strategy represented a move towards tense post-exceptionalism, creating at least one political scandal, raising questions of legitimacy and transparency and fundamentally undermining political viability of wider government. it is an extreme case of what can happen when post-exceptionalist policymaking goes wrong. european agriculture has for a long time enjoyed special economic treatment, whereby the rules that generally apply to other major sectors of the economy do not apply to it (greer, ) . this means that it is protected from market forces and receives extensive state intervention (see, for instance, cox et al., ; daugbjerg and swinbank, ; daugbjerg and feindt, ) . consequently, tariffs, subsidies and payments are terms that permeate the agri-food policy domain. however, in recent decades, this special status has been eroded. opposition to the high cost of subsidizing agricultural goods comes from different interest groups including consumers, taxpayers and environmental groups and influences the actions of policymakers and food producers (skogstad, ; carolan, ; hinrichs, ; alons, ; greer, ; daugbjerg and feindt, ) . as a result, farmers increasingly need to attend to issues beyond food production, including the creation of environmental and other public goods, if they are to enjoy financial compensations that were traditionally aligned with food production (marsden and sonnino, ) . the involvement of stakeholders beyond government in the policymaking process is reflective of a wider shift from government to governance across many different sectors including health, education and agriculture. at its simplest, governance is characterized by the erosion of traditional boundaries, relying on new partners including the community, public and private sector, and based on devolved power as a way of 'getting things done' (stoker, ; jessop, ) . the outcomes of governance do not differ from that of government, which is about making decisions and enforcing them, but the way of achieving this is different and it suggests greater power for a wider range of stakeholders (rhodes, ; stoker, ) . the perception of process becomes as important as the policy itself and it is important for stakeholders to feel that they are closer to decision making. effective governance relies on attention towards positive and negative consequences, while also achieving a fine balance between the appropriate and legitimate involvement of different interest groups, often operating at different levels (jessop, ; stephenson, ; westerink et al., ) . gerry stoker pointed out twenty years ago that "[t]ensions and difficulties with the institutions of civil society, as well as inadequacies in the organizations that bridge the gaps between public, private and voluntary sectors may lead to governance failure" ( , p. ) . governance ☆ research conducted for this article was part-funded by teagasc, the enviresearch foundation and friends of the earth (northern ireland). failure arises where institutions are not capable of evolution, learning, adaptation and public defence (goodin, ) . this can result in failures of leadership, lack of shared aspirations and social conflict among key partners (stoker, ) . accordingly, we want to analyse the extent to which modes of governing within the agri-food sector in northern ireland (ni) have led to governance failure. specifically, we use the concept of policy (post-)exceptionalism to critically assess the role of 'going for growth' (gfg) (afsb, ), a strategic action plan underpinning the ni agri-food sector for five years from . it set out a series of priorities and recommendations for that sector and was led by a board which was appointed by government. fundamentally, growth and job creation were major priorities, with an anticipated expansion of turnover by percent to £ bn in and an increase in employment by percent within the sector. this was to be achieved through seven wide-ranging themes, including regulation; market share; and innovation and entrepreneurship. emphasis was placed on growth within specific sectors, notably the pig and poultry sectors, the latter being held up as a "role model of a highly integrated and successful sector" (gfg, p. ) . crucially, the strategy identified the need to overcome barriers to expansion of that sector, namely poultry waste. we return to this important factor later when we also elaborate on the strategy. our analysis contributes to wider debates on policy postexceptionalism that analyse a shift away from agricultural exceptionalism towards what daugbjerg and feindt ( ) have termed 'post-exceptionalism', by illustrating the complexity of post-exceptionalist governance dynamics. agricultural exceptionalism refers to a socio-political climate in which national food security and farmers' economic interests prevail, and farmers receive 'special' political treatment in the form of favourable policies and subsidies (skogstad, ; daugbjerg and feidnt, ; alons, ) . post-exceptionalism is not a straightforward concept and there is no consensus in the literature on exactly what it is. while it involves new actors; shifting roles for the state, with emphasis on market-based solutions; expanded policy issues and policy innovation, ambiguity remains. for instance, is the shift of concentration of power away from primary producers towards food retailers and processors exceptionalism or post-exceptionalism, or is some government intervention likely? neither is there consensus in the literature on whether or not european agriculture has fully transitioned to post-exceptionalism. while some argue that a clear transition to post-exceptionalism has indeed been made (repplinger, ) , particularly within specific arenas such as farm animal welfare (vogeler, ) , others suggest that there has been only a partial transition from exceptionalism to post-exceptionalism, as manifest within the common agriculture policy (cap) (alons, ; greer, ) . in our analysis, we find a transition from exceptionalism, where power remains concentrated in the hands of a few but has shifted away from primary producers towards the corporate sector, namely large food processing companies. this shift is strategically important as these advantageously-placed individuals can manipulate policymaking to realize their own interests (goldstein and keohane, ; in skogstad, ) . not only is this an insidious and hidden form of power (lukes, ) , but we argue that it is a form of post-exceptionalism more akin to what daugbjerg and feindt ( ) identify as 'tense post-exceptionalism' (p. ), where political viability is undermined due to unbalanced involvement of different interests. in doing so, we seek to add clarity to debates on what constitutes post-exceptionalism and what the implications of problematic transitions are. the article is structured as follows: we begin with a general overview of governance and power in food systems, including analysis of the concept of policy (post-)exceptionalism. the gfg strategy is then presented before we critically examine its environmental implications. our analysis moves on to use two schemes that emerged out of the strategy to illustrate asymmetric power relations within the agri-food sector. we show how the sector represents a form of tense post-exceptionalism, effectively limiting the wider interests of society and prioritizing a privileged few. examining the processes of governance and policymaking is critical in understanding relationships between the state and other stakeholders in the agri-food industry. it has been shown how conceding disproportionate power to certain interest groups can lower the effectiveness of policies, not least because those policies may ignore the embeddedness of markets in wider social structures and so omit broader societal interests such as concern for the environment or animal welfare (foord, ; benoit and patsias, ; richardson, ) . in recent years, scrutiny has been directed towards a range of issues within agri-food, including relationships between industry and the state; environmental degradation; the position of more vulnerable groups; and the capacity and sustainability of the system overall (barling et al., ; angus et al., ; clapp and fuchs, ; hinrichs, ; bui et al., ; kirwan et al., ; lang, ) . to investigate this more fully, we examine the overarching approach to governance within the agri-food sector. the european agri-food sector remains a special case in governance terms. exceptionalist policy approaches tend to occur where a sector is perceived to deliver significant benefits to the public good, e.g. health or education (daugbjerg and feindt, ) . it occurs in farming because of the belief that disproportionate state intervention is warranted due to its difference from most other economic sectors. in short, agricultural producers face unpredictable natural and economic risks, and the agricultural sector is seen to contribute to wider national interests such as food security (skogstad, ; daugbjerg and swinbank, ; daugbjerg and feindt, ) . this has long been the case. for instance, in , the selborne committee in the uk recognized the need for "increasing home-grown food supplies in the interest of national security, to consider and report upon the methods of effecting such increase" (cited in cox et al., , p. ) . post-second world war, agricultural exceptionalism was also central to the state-assisted policy paradigm that arose in both europe and the united states (skogstad, ) . the european union's common agricultural policy was a key element of this post-war paradigm, originally using a combination of protectionist tariffs and price supports to support european food security (harvey, ) . in terms of policymaking, the agriculture sector therefore long benefitted from special treatment, or 'agricultural exceptionalism' (cox et al., ; grant, ; skogstad, ) , where farmers were viewed as the sole legitimate 'custodians of the countryside', and a relatively closed network of farm ministries and farm groups were traditionally responsible for developing agriculture policies (clunies-ross et al., ; daugbjerg and swinbank, ; daugbjerg and feindt, ) . historically-close ties between the agriculture sectorfarmers' unions in particularand government prevailed (jordan et al., ; woods, ) . while other groups such as suppliers of agricultural inputs, financial institutions and food processors benefitted from this policy approach, the intention was to support agricultural producers (clunies-ross et al., ) . in recent years there has been evidence of a transition away from traditional agricultural exceptionalism: food processors and retail corporations increasingly assume a privileged position at a global level as they integrate food systems and occupy political and economic leadership roles (lang et al., ; clapp and fuchs, ) , and the idea of agriculture as 'multifunctional' -not just about food productionhas become a central research and policy focus (marsden and sonnino, ; renting et al., ). there has also been a broad "participative turn" in western public policies (benoit and patsias, , p. ), whereby community involvement and participatory approaches to decision-making have been encouraged (prager et al., ; benoit and patsias, ) . this shift has been reflected in the cap, which, under ongoing pressure from the world trade organisation, moved away from legislating protectionist tariffs and price supports towards offering farmers support via less market-distorting measures (harvey, ) . additionally, in response to the release of a seminal eu report on rural society (european communities commission, ) , support for environmental and rural development measures was included in recognition of the multi-functional nature of the countryside. alongside this evidence of a shifting trajectory of agricultural policy in europe, there was much interest in what a paradigm shift away from exceptionalist policymaking would look like (skogstad, ; persson, ) . significant debate and analysis preceded the labelling of agricultural policy as post-exceptionalist in (daugbjerg and feindt, ) . skogstad argues that a shift away from exceptionalism is characterized by deregulation of agricultural markets and "the termination or substantial restraint of government expenditures for agriculture, and a discourse antithetical to government intervention" ( , p. ) . meanwhile, in considering agricultural policy beyond exceptionalism, persson ( ) underlines the importance of policymaking moving away from a productivist discourse to one of environmental concerns as economic and environmental interests are balanced. according to greer ( greer ( , p. , the shift towards post-exceptionalism occurs when new actors and interests are incorporated into the policymaking arena, effectively extending the boundaries of inclusion beyond primary producers. "messy" policy issues such as the environment or climate change become also increasingly important, and the highly interventionist role of government becomes weakened, as reflected in changing policy instruments and programmes. however, post-exceptionalism retains the idea that a sector is special. feindt ( , p. ) articulate how the move away from a "compartmentalized policy arena" is combined with the idea that the agriculture sector still warrants special treatment, albeit with an "updated set of policy ideas" (such as those related to sustainability). they argue that this results in policy innovation. however, a full transition to market orientation does not occur and there remains room for government intervention (daugbjerg and feindt, ) . some maintain that a neat transition to post-exceptionalism has not been made, rejecting the notion that policy instruments have been "reframed" (persson, (persson, , p. to address wider environmental interests (alons, ; greer, ) . writing about the cap, greer ( ) argues that, even though some of the policy mechanisms have changed, agricultural policy retains a key focus on propping up farm income. he argues that a form of "shallow exceptionalism" has emerged instead, with the inclusion of new actors and intuitions alongside changes to policy instruments representing change, but the ideas around redistribution and farm subsidies remaining intact (greer, (greer, , p. . clearly, the transition is not straightforward, and the literature suggests that there are circumstances which fall between the two policy approaches. benoit and patsias ( ), tosun ( ) and mccarthy et al. ( ) highlight how actors who were formerly marginalized within agri-food politics, including processors, suppliers, retailers, ngos and consumers/consumer organizations, have begun to play an increasingly active role in the policy area. similarly, lawrence et al. ( ) argue that increased financialization and corporatization of the agriculture industry have brought various upstream (e.g. financial institutions, input producers) and downstream interests and agencies (e.g. processors, distributors, retailers) into the food value chain. daugbjerg and feindt ( ) state thatin europe, at leastrelatively little is known about the degree to which these players influence policy around food and agriculture but that "post-exceptionalist actor constellations are more complex and contain players from a wider range of backgrounds" ( , p. ). this does not necessarily result is equal power sharing across those new players, but is typically manifest in "strategic positioning" of individuals or partners (skogstad, ) , such as a concentrated role for multi-national food corporations in food systems spanning the local and the global (barling et al., ; clapp and fuchs, ; foord, ) . as a result of this concentration of control, there is wide recognition that prevailing food governance systems are no longer fit for purpose due to questions of legitimacy, power, resources and interactions of relevant actors within agri-food governance (hinrichs, ) . further unease exists over a range of issues including climate change; food safety and quality; and wider systemic inequalities (angus et al., ; clapp and fuchs, ; hinrichs, ) . policy decisions rely heavily on lengthy debates on the nature of the 'problem' to be addressed, and corporate actors are key influencers in how this is framed in public discourse (clapp and fuchs, ; sacks et al., ) . in light of these issues, contemporary research on food systems is concerned with different forms of change (see hinrichs ( ) for an overview), specifically, transition, which "implies a gradual, pervasive shift from one state or condition to something different" (hinrichs, , p. ) and involves adjusting imbalances and addressing "design faults" (richardson, , p. ) . before considering the case of the ni agri-food sector as a means of scrutinizing current transitions, we provide an overview of our approach to the research. language may be used by those in power to advance or impede the way a particular social issue is dealt with in society (fairclough, ; van dijk, ) . we wanted to probe beneath the official policy documents employed in the gfg strategy to get beyond the '''well-intentioned' passive construction of words and sentences" (evans-agnew et al., , p. ) . accordingly, our study is based on a critical discourse analysis of the gfg strategy. rather than traditional discourse analysis found in linguistics, we employed fairclough's ( ) popular approach which has been used to analyse social policy and practice (hastings, ; taylor, ; richardson, ; evans-agnew et al., ) . used in this way, it takes account of language and social practices, the latter referring to behaviour and action. it relates to the complex interactions that occur in everyday life and the way in which people advance their interests. thus, our aim was to employ a simple approach to evaluate the claim made in the gfg strategy and compare these to practice on the ground in terms of what actually occurs within farming and the agri-food sector in ni. our data collection involved scrutiny of policy documents relating to gfg, including the final printed strategy; review of the website that was used to promote that strategy; examination of emerging policy initiatives (namely promotion of anaerobic digestors and the renewable heat initiative), and fourteen semi-structured interviews with individuals involved in the agri-food sector. interviews were necessary to give us insight into the social practices of different actors in the sector. six preliminary interviews were conducted in and , and a further eight were conducted in and . we sought to achieve a range of perspectives and interviewed primary producers, individuals involved in retail, food processing and policymaking, as well as a few academics. some of our respondents wore 'two hats', for instance, being primary producers but also having involvement in food processing. generally, we found that few respondents were universally critical of the strategy, and that most identified most found some good points. for reasons of confidentiality, the interviewees' identities remain anonymous, but between them they represent a poultry farmer, two academics, three environmental ngo employees, four government agency employees and four individuals who are employed in different aspects of the food chain (three of whom are also part-time farmers). interviews explored many different themes relating to food security and safety; export markets; environment; poultry waste; and family farms. not all interviewees agreed to being recorded, but where this was agreed, interviews were transcribed. thematic analysis was undertaken through reading and re-reading transcripts and interview notes, and coding them according to the key themes that arose. consideration was given to discourse, style and genre to show how language and rhetoric are used to advance a particular position. with its focus on text and talk, this approach evaluates how language is used. specifically, it examines what is being said about the strategy and how it is presented, along with opinions about its context, rationale and expected outcomes. ni lies within the jurisdiction of the united kingdom (uk) and enjoys devolved powers on several issues. generally, it maintains a peculiar position within the uk, not only because government in ni is elected under the single transferable vote (a power sharing government), but also because of a history of civil unrest and fractured relations with great britain during the latter part of the th century. connected to this difficult legacy, ni relies heavily on subvention from westminster to a degree that many ailing english regions would welcome. the power sharing government was thwarted in and was not fully restored until january , having been brought down by the renewable heating incentive, a scheme directly connected to the agri-food sector in ni and to which we return later in our analysis. like the rest of the uk, agricultural policy here has been governed by the cap, and although the importance of ni's agri-food industry has declined in recent decades, it remains a significant contributor to the region's economy, accounting for £ . billion ( . percent) of gross value added (gva), and employing . percent of the region's population in ( . percent in agriculture, forestry and fishing; . percent in food and drink processing) (daera, ). the estimated contribution of agriculture and food and drink is significant for the regional economy, each with employment multipliers of . ; over two jobs are generated elsewhere in the regional economy for every job in those sectors (nisra, ). the industry is roughly twice as important for the ni economy as it is for the uk economy as a whole; gva from agri-food is only percent nationally, and only . percent of the uk population is employed in the sector (daera, ). farming in ni is characterized by small, usually family-owned, farms units: the average size is ha compared to ha in the uk ( in europe) (daera, ). nearly percent of the land is categorized as less-favoured and most farms are cattle and sheep ( percent) (daera, ). however, this structure is being eroded with the policy drive to intensify farms and expand production. this shift is evident in the trend of growth within the intensive dairy, pig and poultry sectors and concurrent decline of the (mainly) extensive drystock sector. between and , there was a seven percent increase in the already-significant dairy herd, a percent increase in pig numbers, a percent increase in broiler numbers, and an percent increase in the commercial laying flock. during the same period, sheep numbers increased by only percent, while the beef herd declined by percent (daera, ). gfg is an agri-food strategy that encapsulates the future desired direction for the sector in ni. the strategy has now run its course, having achieved much of what it set out to do (we return to this below). it is unknown what, if anything, will take its place given the disruption arising from covid- and the uncertainty surrounding ongoing brexit negotiations, which continue to make new policy decisions nearly impossible. however, gfg does provide valuable lessons for policymaking more generally, both within ni and more broadly, some of which we consider here. in its - programme for government, the ni executive committed to developing a strategy for expanding the region's agri-food sector in response to what was perceived as a growth in demand for ni's food products. following this commitment, the ni department of agriculture and rural development (dard -now the department of agriculture, environment and rural affairs), the ni department of trade and investment (deti -now the department for the economy), and invest ni (ni's economic development agency) worked together to set up a bespoke agri-food strategy board (afsb) responsible for developing this strategy, now called 'going for growth' (afsb, a). the board was appointed for an initial tenure of three years from . this was extended for an additional two years in february . tony o'neill, then a director at moy park -at the time ni's largest private sector business and one of europe's largest poultry producerswas appointed chair of the board. other members were subsequently appointed via an ostensibly open application process: board positions were advertised widely and applicants from a range of backgrounds were interviewed. in the end, members were appointed: six representatives from some of ni's biggest agri-food businesses; two independent dairy farmers, both former presidents of the ulster farmers union (ufu); one representative from invest ni; three government officials; and one accountant (afsb, b). conspicuous in their absence were representatives from academia, ngos, the environmental lobby and other community interest groups. a quote from one of our interview respondents illuminates this: "i and others of an [environmental] bent applied, and some at least of us were interviewed, but no go. they wanted an 'industry representative' board, no science or [environmental] knowledge required." despite the apparent 'big industry' focus of the board, according to the afsb's now archived website, efforts were made to engage with stakeholders outside of the agricultural industry, as well as with the smaller players within it. the board established nine sectoral sub-groups tasked with considering specific challenges and opportunities faced by each of ni's key agri-food sub-sectors. the afsb reports that more than stakeholders from industry and relevant government agencies were consulted through this process. it also states that further stakeholders were engaged via a public call for evidence, which received approximately responses from individuals representing a range of interests, including farming, food, forestry, and the environment. as well as meeting with wider agencies loosely associated with government, some of this status is derived from the legacy of the ethno-nationalist conflict known as 'the troubles', which began in the late s and ended with the good friday agreement (gfa) in . the gfa set up a series of government institutions between ni and the republic of ireland and between the republic of ireland and the uk. significant funds have been injected into the region by the uk government and the eu to ensure that conflict remains firmly in the past. here, taken to include primary agriculture as well as food and drink processing. in areas designated as "less-favoured", agricultural production or activity is considered more difficult because of challenges such as difficult climatic conditions, steep slopes, or low soil productivity (european commission, nd (carroll, a) . it currently has a network of poultry farms and processes around million chickens each week. including the northern ireland tourist board and the environment agency, the board "engaged with major retail multiples and environmental interest groups" (afsb, , p. ). feedback received from said stakeholders was then "considered by the main board" and it "influenced the strategic action plan" (afsb, a, p. ). although it could be argued that this demonstrates the policymaking arena now includes more players, a key feature of post-exceptionalism, the degree to which the extra players impacted the final report could be contested given the vagueness with which their input is described, their absence on the actual board and the fact that the majority of the report's recommendations benefit big industry while paying little regard to small family farmers, small food companies or the environment. we elaborate on the latter assertion in detail below. the key features of the gfg strategy are described in the report 'going for growth: a strategic action plan in support of the northern ireland agri-food industry' (afsb, ). gfg's premise is to expand supply, secure global markets and reduce costs and it aims to do so by "industry, government and the wider stakeholder base, working together" (p. ). it seeks to bring about a wholesale re-orientation of ni towards an export-dependent strategy based on large-scale industrial agriculture. the executive summary describes how "[t]he industry, moreover, has continued to grow … and to display tremendous potential for sustainable growth through its sharp focus on export sales, innovation and productivity. we have been immensely encouraged by the appetite for growth outside northern ireland…" (p. ). although intensive farming was the order of the day, reference is made to some environmental activities as the strategy describes how the growth of woodlands "would complement intensive agricultural production by providing improvements in soil, water and air quality" (p. ). this reflects many of the features of post-exceptionalism given that "[p] ost-exceptionalism denotes a partial departure from compartmentalized, exclusive and exceptionalist policies and politics which, however, preserves some exceptionalist features and has not led to a complete transformation to market-oriented and performance-based policies" feindt, , p. ) . while the role of markets is recognized in the gfg narrative, overall there is a limited shift towards market-oriented policies and a continued reliance on government intervention. recommendations made under beef and sheep illustrate: the supply chain must seek to deliver greater economies of scale with a particular opportunity to improve communication, technical input and efficiencies through a higher number of larger scale beef finishing units working in partnership with processors. industry and government must develop an action plan to double the number of beef and sheep farms actively engaged in physical and financial performance recording over the next five years. (afsb, , p. ). the document deems economic scale and efficiency to be critical, and identifies government-led incentives as being important in encouraging economies of scale at producer and processor levels. in other words, support bigger farms and agri-food processing businesses. figures are ambitious: grow sales by percent to over £ billion, create , new jobs, grow sales outside ni by percent to £ . billion, and increase value added to £ billion by . the report also references the value of consolidating working and calls for greater integration of the supply chain, including farm producers, food processors, wholesalers, retailers and export businesses. according to gfg, significant government action, along with input from academia, will stimulate an export-oriented strategy geared towards meeting consumer demand in emerging markets, including in the usa, europe, asia and the middle east (agri-food strategy board, ) . of a total of recommendations (p. ), only ( percent) are the sole responsibility of industry. the remaining recommendations ( percent) are directed towards government, either to be delivered in partnership with industry ( recommendations), or by government alone ( recommendations). proposed government commitments were not insubstantial and include a proposed government investment of £ million over three years (to lever an industry investment of £ . million). the shared government-industry recommendations sometimes seemed to be heavily geared towards government. for example, number (p. ) relates to government-commissioned research. the ni executive approved the board's proposed plans as published in april by responding formally in october (ni executive, ) . many of the benefits of gfg are directed towards large corporations in the form of increased sales, rather than towards primary producers, while costs are borne by taxpayers in the form of subsidized grants and other interventions. the strategy offers little tangible support to small business, be they family farms, processors or retailers. indeed, although the report states that family farms are "a major element of our economy", it goes on to say "they also present a significant challenge in terms of long term sustainability" (p. ). the ufu was critical of the gfg chair's position on family farms, publicly registering disappointment with his statement to the agriculture and environment committee that only farmers are needed in ni for food production (macauley, ) . this constellation of actors beyond primary producers, as well as the free market language alongside government intervention, all fit with post-exceptionalist policy. importantly, while the rhetoric refers to the role of markets, gfg actually denotes a shift away from market-based policies, with justification of excessive state intervention. as mentioned earlier, many of the recommendations require government action. rather than the strategy benefiting primary producers, significant benefits are directed towards large scale partners such as meat processors. we contend that gfg does not neatly fit with post-exceptionalism because, although there are more actors in the policymaking process, there is significant tension as the constellation of ideas, institutions, interests and policy "co-exists in an unbalanced way, which undermines its political viability" feidnt, , p. ) . further, there is little evidence of a shift in the nature of policy tools employed, a key feature in the transition to post-exceptionalism but obvious signs of continued reliance on traditional grants and financial incentives coming from government. so, if not a neat form of post-exceptionalism, what does gfg represent? to shed further light on this, we analyse what gfg implies from a sustainability perspective as a means of considering the extent of an evolving policy arena which is a key feature of post-exceptionalism. according to greer ( ) , a shift to post-exceptionalism should include the emergence of "'issue-network' type" actors, including those from backgrounds such as consumer, environmental and animal welfare groups, and slow food activists" (p. ), and broader policy issues such as the environment are brought to the fore (p. ). the ni government adopted gfg wholesale, without conducting any environmental impact assessment (leroux, ) and with very limited involvement of environmental interests in developing the strategy overall, as is discussed earlier. normal rules were not applicable. further, decades of intensive farming have had a significant negative impact on biodiversity and has resulted in degradation of water systems globally, a pattern that is evident in northern ireland (government office for science, ; campbell et al., ; committee on climate change, ; daera, ; friends of the earth, ) . within the eu, introduction of legislation such as the nitrates directive and the water framework directive has begun to somewhat limited agriculture's impact on the environment (van grinsven et al., ) , and recent cap reforms demonstrate a partial attempt to "green" agriculture (harvey, ) . however, gfg's focus on expanding intensive industrial farming in ni runs counter to these efforts and has a range of negative implications. as highlighted above, growth within the ni agriculture industry has, in the past decade, come mainly from poultry and pig production (daera, ). both operate under extremely intensive, integrated models of the kind gfg actively advocates. this is a logical economic model, as growers share costs and risks with the integrator, i.e. the corporate food processor (fao, ) . however, the fao ( ) warns that careful regulation of this model is required to avoid negative externalities such as physical and chemical pollution impacting on growers, employees and wider society. indeed, numerous concerns have been raised about the negative environmental impacts of these kinds of operations, mainly related to the high levels of animal waste they produce and the subsequent release of ammonia (brennen et al., ; friends of the earth, ) . ammonia can have a significant negative impact on both aquatic and terrestrial biodiversity and on human health (apis, ) . ammonia pollution is a particular problem in ni; the region is responsible for percent of the uk's ammonia emissions, despite accounting for only percent of its population. ammonia has contaminated nearly all ni's national protected sites and in some of its ancient woodlands, more than percent of native lichen species have disappeared as a result (carroll, a; friends of the earth, ; leroux, ) . while cattle farming currently accounts for the majority of ni's agricultural ammonia emissions, the poultry industry is responsible for half of the increase since (carroll, a) . thus, it can be argued that further development of these industries is incompatible with delivery of the public goods that are mentioned in the strategy (p. ). greater numbers of intensive chicken and pig production units not only put significant pressure on both ni's water supply and on the biodiversity of its farmland and protected sites, but also change the physical appearance of the countryside due to the visibility of the buildings (blackwood, ; committee on climate change, ; friends of the earth, ; gladkova, ) . this policy outcome favours privileged interests. in the past, in the 'normal' course of exceptionalism, that would have comprised farmers as primary producers (smith, ) , but here we see the interests of the food processing and retail sectors taking precedence. environmental interests were evidently not a major priority for the agri-food strategy. having explained how export-oriented the agri-food sector is, one of our (government agency) interviewees stated: " [gfg] was largely targeted at one particular sector, largely because of the individual who chaired that. so the poultry got a disproportionate focus, and the environment was completely left out of it …. in terms of air quality, in terms of carbon, in terms of biodiversity […] those things were never ever talked about in that going for growth. it was just about pure economics." we pick up this issue of disproportionate focus on the poultry sector, moving on to give concrete examples of how large food processors, particularly within this sector, received special or exceptional treatment. the development of schemes to incentivise particular practices within agriculture demonstrates clear cases of exceptional treatment that allowed large players in the poultry sector to advance their interests. two significant initiatives that led to recent political scandals in ni emerged from the gfg strategy and reflect the central role of agri-food in policymaking in ni. these cases demonstrate the degree to which private interests have benefitted from public subsidy. the (currently) higher profile scandal, dubbed 'cash for ash', surrounds the renewable heat incentive (rhi). the more recent scandal, 'muck for brass', is still developing, but is apparently set to "dwarf" the cash for ash scandal (leroux, ; gannon, ) . more than just evidencing the special treatment that the ni agriculture industry receives from the government, both appear to demonstrate how key industry players directly influenced policymaking to their benefit, using the gfg strategy as a lever. we elaborate on the schemes below. recommendation number of the gfg strategy is that "government must review incentives for renewable energy and ensure policies are complementary to the agri-food industry rather than in competition with it" (p. ). the rhi, which began in , was a ni government-led initiative to encourage businesses and individuals to switch from fossil fuels to renewable energy technologies such as wood-burning boilers (coghlin et al., ) . in line with the gfg recommendation, this scheme was heavily promoted to the agriculture industry. however, due to deep flaws in the scheme, not only did the government make subsidies worth more than the cost of wood pellets used to heat boilers, it did not cap the total subsidy available (brennan et al., ; coghlin et al., ) . thus, what began as a bid to reduce carbon emissions, quickly evolved into a profit-making scheme for many in the agriculture industry. people reportedly scrambled to install boilers and began to run them / . some farmers even heated empty sheds to turn a profit (carroll, b; mcbride, ) . different accounts have emerged about what happened and who was responsible. however, the prevailing narrative is that, despite allegedly being notified by a whistleblower in and again in , ni deti did nothing to stop the scheme, which was in fact continued and extended (bbc, ; carroll, b; coghlin et al., ) . the scheme eventually ended in , but not before £ million in taxpayer money was spent (brennan et al., ; carroll, b; gannon, ) . when the scandal surfaced, it led to the collapse of ni's power-sharing government in january , which, as noted above, was not reinstated until january . a full public inquiry into the scandal was set up in january and its findings were released in march , delivering a scathing assessment of the governance failures related to delivery of the scheme, citing poor leadership, lack of transparency and little evidence of critical scrutiny of material (coghlin et al., ) . more recently, investigative journalists uncovered another renewable energy scandal -'muck for brass' -this time involving government subsidy of anaerobic digesters (ads) (carroll, a; leroux, ; gannon, ) . the expansion of intensive animal farming in ni lies at the core of gfg, particularly through expansion of the pig and poultry sectors, but animal waste was a key limiting factor, as discussed above. one of gfg's key recommendations was that government must "fast track a solution for poultry waste into energy, recognizing the environmental benefits and remove a key uncertainty over the growth of the agri-food industry in northern ireland" (afsb, , p. ) . the solution that industry put forward was ads, and in , the ni government implemented an £ million taxpayer-funded scheme to support the installation of ads on ni farms. ads can turn animal waste into biogas, which is considered a 'green energy'. animal waste processed via an ad before being spread on fields has not historically been subject to detailed scrutiny in terms of its impact on sensitive habitats, thus allowing the agricultural industry to effectively bypass nutrient application limits as set out in the eu nitrate directive (carroll, a; leroux, ) . notably, the ad process does not appreciably change the amount of ammonia (or other nutrients) present in waste (malamis et al., ) , which, once passed through an ad, is still spread on the fields as fertilizer, funnelling ammonia back into the environment (carroll, a; leroux, ) . the ni government was aware of this prior to allowing the scheme to proceed; in a report, the ni agriculture and environment department specifically acknowledged that anaerobic digestion "does not address the fundamental issue of excess nutrients in the manure, as it requires land spreading of the digestate. therefore, it is not an alternative to land spreading" (daera, , p. , in leroux, . despite these reservations, ads were promoted, and big industry players were able to pay contractorsusing taxpayer moneyto install large ads across the countryside . as a result, the poultry industry experienced huge growth, as it was able to 'overcome' the problem of how to dispose of hundreds of thousands of tons of chicken litter and still meet nitrates directive limits (carroll, a; leroux, ) . the ad scheme in ni allowed large agribusinesses to fuel the expansion of intensive practices, and the solution found for one problem led to another: environmental degradation (leroux, ) . brennan et al. ( ) point to the problem of the dominant perception among some of ni's politicians that environmental costs are merely overheads in the business of promoting or supporting economic development and that funding schemes and policies are there to be manipulated for financial gain, something that is clearly demonstrated in the two schemes described above. moreover, both cases exemplify how disproportionate power and government support was afforded the poultry industry. one of the major poultry producers in the region, indeed, in europe, moy park is a powerful actor in the policymaking process and it has enjoyed exceptional treatment from government on more than one occasion. as already discussed, one of its then directors was the chair of the gfg board for a time, and a freedom of information request revealed that, between and , moy park representatives held meetings with officials from ni's agriculture ministry, during which anaerobic digestion was a main focus (leroux, ) . moreover, the ni government approved a £ million loan scheme to build two large ads: one in ni and one in donegal across the border in the republic of ireland. the former was specifically designated for poultry waste from moy park; no other processor was afforded this treatment (carroll, a; leroux, ) . all this despite the fact that the ministry clearly understood that ads would do nothing to mitigate the pollution problems associated with animal waste. more recently, privileged senior moy park executives were apparently given advance notice of the government's plan to end rhi subsidies, and as a result, nearly poultry farmers signed up to the scheme in its final months, most of whom supply moy park (mcbride, ; mcdowell, ; coghlin et al., ) . indeed, moy park has been singled out as acting and being treated differently than other processors. unlike other processors, it is mentioned times across the report's pages (coghlin et al., ) . it has been linked to approximately £ million pounds in rhi claims (mcdowell, ) , and the bbc reports that it was actively pushing its producers to take up the subsidy as it ultimately lowered the price it had to pay them for the chickens they produced (macauley, ) , thus increasing profit for the company. the interests served in the development of the initiatives emerging from and/or supported by the gfg strategy contributed to an unstable post-exceptional process, as one powerful stakeholder wielded undue influence within the agriculture industry. the problem in ni is that, while there are many more interest groups, they have not been properly included in the policymaking arena. there is little evidence of "institutional layering" feindt, , p. ). foord's work with key stakeholders on the challenges facing the ni food system further illuminates this gap in the policymaking process: policy making is viewed as too closed, with some industry stakeholders having disproportionate influence. there is excellent input from a few environmental champions, but there is a perception that the wider environmental sector is marginalized and excluded. one interviewee suggested that policy decisions are often, in effect, made prior to public consultation. there are numerous working groups and fora addressing different food issues (e.g. climate change; food poverty, food waste; etc.) but no holistic, strategic approach that allows joined-up thinking (foord, , p. , p. ) . including interest groups in policymaking is important, for if this is not done, policies tend to be ineffective (richardson, ) and lacking innovation (daugbjerg and feindt, ). as our case shows, post-exceptional policymaking is a delicate balancing act between appropriate inclusion and excessive power. environmental groups were included along the margins, but not in any meaningful way. attempts to involve them were rather shallow; they were given the opportunity to engage through consultation but were not embedded into institutional processes. that is to say, they were not actually part of the decision-making realm. the afsb responsible for the development of the gfg strategy comprised a limited range of industry stakeholders, and little action was taken by this board and the government department to obtain legitimacy across a wider range of stakeholders by inviting new policy actors into the policy arena. further, it seems the ni government encountered another problem: when governments grant interest groups excessive power, policy effectiveness can be compromised (peters, ; richardson, ) . richardson ( ) calls this "a central paradox in government/interest group relations" (p. ). as both the rhi and 'muck for brass' scandals illustrate, the policymaking process facilitated, and to some extent, sought to legitimate the disproportionate benefits and influence afforded a few powerful interests. this was to the detriment of the taxpaying public and ni's natural environment. gfg creates the illusion of a smooth transition to a postexceptionalist policy agenda where we might expect significant representation from 'new' actors such as consumer and environmental groups; greater consideration of issues such as water pollution and climate change; and a shift away from interventionist government policies towards market solutions (greer, ) . the reality is that it creates the conditions that support a concentration of power by a few key actors. rather than power resting with primary producers and other groups that have traditionally benefited from exceptionalist policies, corporate business assumes a privileged position and government remains heavily involved in supporting the industry. further, the strategy fails to identify practical measures for reducing the environmental impact of the agri-food sector. a clear paradox exists as gfg language is in line with change to 'ideational structure' -with consideration of market influences, environmental protection and preservation of the rural fabricwhereas its recommendations are firmly exceptionalist. we therefore argue that gfg represents an incomplete transition to post-exceptionalism, which is in line with other authors' interpretation of recent changes to european agriculture policy (alons, ; greer, ) . while it would be easy to assume that what occurred through the development of the gfg strategy represents a shift back towards exceptionalism, we contend that this is an over-simplification of what has happened. the bottom line is that post-exceptionalism retains the underpinning idea that the sector is special and so warrants some intervention (daugbjerg and feindt, ) . therefore, the fact that the ni agri-food sector has continued to receive 'special treatment' does not necessarily denote exceptionalism. moreover, we argue that there was a desire to make the shift from exceptionalism towards a post-exceptionalist approach, that is, away from the dominant closed policy communities focused on primary producers towards a more open style that involves a wider range of actors with competing interests authors note that a limited number of ad plants are now employing innovative processing techniques to remove a significant percentage of the nutrients present in digestate. however, it will be some time before this is a universal practice (if ever). (greer, ) . however, this article shows that where gfg falls short is that despite intentions to do so, it failed to extend power to a range of stakeholders; it did not succeed in updating the policy agenda, i.e. it did not sufficiently address emerging environmental issues; reliance on government intervention remained strong; and it failed to initiate novel policy solutions. this created at least one political scandal, bringing down the devolved government while also raising questions of legitimacy and transparency. it is an extreme example of what can happen when post-exceptionalist policymaking goes wrong. the shift of emphasis away from primary producers towards large-scale industry and the way in which political viability was undermined due to unbalanced power held by different actors constitutes what feindt term "tense post-exceptionalism" ( , p. ) . this is in line with other literature, which clearly identifies iterations of post-exceptionalism, with varying emphasis on the environment, productivity and the power afforded different stakeholders (alons, ; greer, ) . peters suggests that, where sub-optimal policies have developed, "the role of government then becomes providing the leadership to shape the debate and move decisions away from the lowest common denominator realm into a more socially desirable space" ( , p. ) . this would seem to be very pertinent for ni. already, the gfg strategy is outdated as market circumstances have radically altered since the time the strategy was first envisaged. back then, markets were buoyant, but in the intervening years global prices have fallen. meanwhile, the brexit vote has initiated a significant period of uncertainty as politicians figure out the future agri-food landscape. this is not likely to be sorted quickly (hubbard et al., ) . more widely, the role of the state is critical if progressive, postexceptionalist agricultural policies are to emerge. it has an important function from the outset in ensuring a 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coordinated agri-environmental management contesting rurality: politics in the british countryside the authors acknowledge the very helpful comments provided on an earlier version of this article by participants at the trans-atlantic rural research meeting in aberdeen ( ) and at the european society of rural sociology in trondheim ( ). supplementary data to this article can be found online at https://doi. org/ . /j.jrurstud. . . . key: cord- - ucqp uz authors: chorus, caspar; sandorf, erlend dancke; mouter, niek title: diabolical dilemmas of covid- : an empirical study into dutch society’s trade-offs between health impacts and other effects of the lockdown date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: ucqp uz we report and interpret preferences of a sample of the dutch adult population for different strategies to end the so-called ‘intelligent lockdown’ which their government had put in place in response to the covid- pandemic. using a discrete choice experiment, we invited participants to make a series of choices between policy scenarios aimed at relaxing the lockdown, which were specified not in terms of their nature (e.g. whether or not to allow schools to re-open) but in terms of their effects along seven dimensions. these included health-related effects, but also impacts on the economy, education, and personal income. from the observed choices, we were able to infer the implicit trade-offs made by the dutch between these policy effects. for example, we find that the average citizen, in order to avoid one fatality directly or indirectly related to covid- , is willing to accept a lasting lag in the educational performance of children, or a lasting (> years) and substantial (> %) reduction in net income of households. we explore heterogeneity across individuals in terms of these trade-offs by means of latent class analysis. our results suggest that most citizens are willing to trade-off health-related and other effects of the lockdown, implying a consequentialist ethical perspective. somewhat surprisingly, we find that the elderly, known to be at relatively high risk of being affected by the virus, are relatively reluctant to sacrifice economic pain and educational disadvantages for the younger generation, to avoid fatalities. we also identify a so-called taboo trade-off aversion amongst a substantial share of our sample, being an aversion to accept morally problematic policies that simultaneously imply higher fatality numbers and lower taxes. we explain various ways in which our results can be of value to policy makers in the context of the covid- and future pandemics. the outbreak of covid- in the netherlands, as in many other countries, was followed by an unprecedented package of measures, summarized by the dutch government under the name "intelligent lockdown". as of mid-march, schools closed, as did bars and restaurants and countless other service providers (the so-called 'contact professions' such as barbers). working from home became the norm, large scale events such as professional football matches were banned, and a variety of other commandments and urgent stipulations were issued [ ] . in this first, acute phase of the crisis, there was a sense of unanimity and focus in dutch society: the goals (i.e., delaying and limiting the spread of covid- , protecting the vulnerable, preventing the collapse of the healthcare system) justified the means (i.e., a lockdown that in effect crippled large parts of society). in this acute and early phase of the crisis, deontological ethics were dominant in the public debate: most agreed that everything had to be done to keep the healthcare sector afloat and to keep the loss of human lives at an absolute minimum. about a month and a half after the lockdown was put in place, pressure on the healthcare system started to gradually decrease, accompanied by a downward trend in the number of covid- related fatalities. this signaled a gradual transition into the chronic phase of the crisis, with public attention shifting to the question of how the country should deal with the lurking threat of a virus that can always re-emerge until a vaccine or medicine is found, while at the same time keeping society functioning at a reasonable level. in the public debate it is becoming clear that this chronic phase also entails a different-consequentialist-ethical perspective in which all possible effects of government policy are taken into account. in addition to health related effects, this includes, for example, the impacts of the lockdown on the economy at large and one's personal income, as well as possible educational disadvantages due to distance learning. during this transition to the chronic phase of the crisis, the call for further opening up society has been getting louder and louder. the dutch government-like many other ones-as a result found itself in a position where diabolic dilemmas had to be faced; these were the words uttered by prime minister mark rutte, during an april press conference watched by almost half of the dutch population [ ] . the morning after this press conference, our survey including a choice experiment went live. our aim was to explore the preferences of the dutch population in terms of the weights they assigned to various effects of policies aimed at relaxing the lockdown. specifically, we wanted to know if the dutch were willing to trade health effects (such as avoiding fatalities) against other effects (e.g. on the economy), and if so, what would be their willingness to sacrifice economy-and education-related suffering for a reduction in fatalities and in pressure on the national healthcare system be. their choices in the experiment would also allow us to learn to what extent the transition from a deontological ethics perspective (requesting a full focus on saving human lives) was indeed gradually being replaced by a consequentialist one which puts weight on all foreseeable consequences of government policy. this paper reports the outcomes of this choice experiment. to be sure, the main contribution of this paper is not a methodological one: the use of choice experiments to study citizens' preferences and trade-offs involving fatalities and injuries has a long tradition in health economics [ ] , traffic safety analysis [ ] and environmental and climate change economics [ ] . more related to the topic of our study, choice experiments have been deployed for measuring preferences for a covid- contact tracing app in the netherlands [ , ] , in the united kingdom [ ] and in the united states (e.g. [ ] ); as well as to measure preferences for attributes of a covid- vaccine among australian citizens [ ] . in addition, related survey techniques have been used to study beliefs about the effectiveness of covid- policies [ ] , public sentiment toward covid- policies [ ] and willingness to be vaccinated against covid- [ ] . what makes our study unique is that it is the first one, to the best of our knowledge, that applies this tool to survey and investigate a society's willingness to make the highly salient and morally troubling trade-offs associated with policies aimed at relaxing a lockdown that was imposed in the wake of the covid- crisis. while our study is confined to the dutch society, and we acknowledge that countries differ widely in terms of their culture, the actions taken by their governments and preferences towards covid- policies [ , ] , we nonetheless observe that in many other countries, debates are raging that are similar to the one being held in the netherlands; take for example the heated exchange in the united states of america (e.g., [ ] ) between governor cuomo of new york who emphasizes that avoiding fatalities takes priority and that one cannot weigh a human live against the economic impact of the lockdown, versus president trump who is keen to re-open the economy and professes that the cure cannot be worse than the disease. given the similarities between various countries in terms of the societal tension between health-and economy-related effects of lockdowns, we expect our results to hold lessons well beyond the dutch context. the remainder of this paper is organized as follows: section presents the method of discrete choice experiments and the econometric methodology used to analyze the obtained choice data. section elaborates the data collection effort, followed by section where we present and interpret our results. section concludes by discussing the main conclusions and policy recommendations that can be drawn from our study. the method of using discrete choice experiments (dces) to elicit latent preferences and tradeoffs of citizens regarding the effects of government policies has a long pedigree in domains as diverse as transport (e.g. [ ] ), environment and climate adaptation [ , ] , immigration [ ] and health care [ ] [ ] [ ] . also when it comes to morally challenging trade-offs involving human lives, dces have been widely used in these contexts (e.g. [ , ] ). the core idea behind using dces is that choices made by respondents between policy scenarios specified in terms of their outcomes on various dimensions, can be used to identify the weights that respondents assign to each of these dimensions. these weights may then be used to: i) learn about the relative importance attached by society to various policy-impact dimensions, ii) predict levels of support for and opposition against specific policies, and iii) convert various policy dimensions into monetary terms in order to allow for a cost-benefit assessment. in this paper, the emphasis is on the first of these three potential uses of dces. compared to other approaches to identify citizens' preferences and trade-offs, such as directly asking respondents to assign a weight to various policy-impact dimensions, the dce methodology has important advantages. for example, it is well known that people find it very difficult to make explicit their preferences and decision making processes [ ] , especially in the context of morally sensitive topics such as the one we study [ ] . that is, people have great difficulty in reliably answering questions such as "how many cases of lasting mental health effects are you willing to tolerate, to avoid one covid- related fatality?". the dce approach circumvents such difficulties, by asking respondents to choose between policy scenarios specified in terms of these and other impacts; based on choices made, the implied relative weights attached to different dimensions can then be inferred by the analyst. furthermore, in contrast to standard opinion polls which typically ask questions that are too generic to be of much policy relevance ("should lockdown policies be focused more on reducing health effects or economic effects?"), the dce approach presents very specific policy scenarios (e.g. in terms of numerically expressed policy effects), allowing for the assessment of particular policies based on the estimated weights. it is important to note however, that despite its advantages and the resulting widespread use of dces, there is a continuing debate about their reliability [ , ] . important insights from this debate can be put as follows: i) if available, the analysis of choices observed in real life (e.g. during referenda) is to be preferred over the analysis of choices made in hypothetical conditions such as a dce; ii) if a dce is used, care must be exercised to ensure 'consequentiality', i.e. respondents must feel that their choices will have consequences in real life [ ] ; iii) the choice situations presented in the dce must be realistic and must align with experiences and considerations held by respondents (see e.g. [ , ] ). a recent study in the context of immigration policies in switzerland, which compared the outcomes of a dce with those obtained by an actual referendum, shows that a properly designed dce is likely to generate reliable insights into the weights assigned by the population to various policy dimensions, also in morally salient contexts [ ] . translating these generic lessons to our specific dce, we are confident that the policy scenarios presented to respondents were well aligned with the current public debate in the netherlands; in fact, the dimensions covered in our study were widely discussed in the media during the weeks preceding the data collection. furthermore, we made a substantial effort to ensure consequentiality, by (truthfully) informing respondents that the outcomes of this study would be shared with high-ranking policy makers at relevant ministries and the netherlands institute of public health (rivm). qualitative statements provided by respondents after having completed our survey (not reported here) strengthen our belief that most took the experiment very seriously. in the absence of an actual referendum on the topic, we believe that given these precautions our dce provides a useful and reliable alternative to collect choice data. in our dce, we vary policy scenarios along seven dimensions, covering those impacts of the lockdown that received the most attention in the public debate during the weeks preceding the data collection effort. table shows the different policy dimensions ('attributes') and the ranges of their scores ('attribute levels'). note that these attributes and their levels were selected in an iterative process of pilot testing and discussions with colleagues at other dutch universities as well as analysts at relevant ministries and the netherlands institute of public health (rivm). for instance, we decided in consultation with analysts from the dutch government to select the three health dimensions ('increase in the number of deaths caused by the coronavirus', 'increase in the number of lasting physical injuries caused by the coronavirus', 'increase in the number of lasting mental injuries caused by the coronavirus') instead of using the concept of quality adjusted life years (qaly) which is popular in health economics studies [ , ] . the reason being that the public debate in the netherlands focused on these three dimensions and not on qalys. moreover, in a draft version of the dce we made a distinction between increases in the number of deaths in different age groups (younger than years, - years, older than years); however, policy makers and analysts from the rivm argued that this was not a relevant variable for the trade-offs they faced in their decision-making. hence, we decided not to distinguish between different age-groups in our final experiment. more generally speaking, we constructed the attribute levels in three stages. firstly, we analyzed studies which provided projections of the impacts of the corona crisis on the seven policy impact dimensions. for instance, we analyzed rough estimates on the increase in the number of deaths [ ] , projections regarding the increase in the number of people with lasting physical injuries caused by postponed operations [ ] , data on the increase in domestic violence caused by the corona crisis in the united kingdom [ ] , data regarding domestic violence in the netherlands prior to the corona crisis [ ] , data on the number of children with educational disadvantages prior to the crisis [ ] and projections about bankruptcies, unemployment and income loss [ ] [ ] [ ] . secondly, we discussed the realism of these figures with epidemiologists and policy makers. the epidemiologists warned us to lower our predictions on the number of deaths and gave suggestions for determining the levels for 'number of people with lasting physical injuries'. moreover, we asked policy makers from the ministry of finance to provide a prediction of the one-off corona tax per household in . thirdly, we tested in a pilot survey whether the levels that we constructed were salient and relevant in the eyes of participants. based on the results of the pilot survey we decided to increase the difference between the levels of 'increase in number of deaths'. we chose to execute a so-called unlabeled dce, which did not specify policies in terms of their nature (e.g. reopening schools, or sport clubs) but rather focused on the impact of policies on a range of dimensions. the advantage of such an unlabeled approach is that it allows policy makers to use our results for the assessment of (combinations of policies), including those that are currently not on the table but might be considered in later phases of the crisis. the experiment was designed using statistical techniques which ensure that every choice task contains a maximum amount of information on the weights assigned by respondents to different policy impacts [ ] . more specifically, respondents were asked to choose between two policy packages described by seven attributes or policy impacts. the attributes and their levels (note that each attribute had three possible levels) were combined into choice tasks using a d-efficient design with priors obtained from a pilot study [ ] . the choice tasks were blocked into two blocks of choice tasks and respondents were randomly allocated to a block when entering the survey. we show a sample choice task and the text shown to respondents in fig . to see the relation between the exit strategies presented in the choice task exhibited in fig with the attribute levels presented in table , note that the left-hand side strategy in the choice task ("exit strategy ") consists of level of attribute deaths, level of attribute injuries, level of attribute mental injuries, level of attribute educational disadvantages, level of attribute income losses, level of attribute corona tax, and level of attribute work pressure in health sector. our econometric approach for analyzing the choices collected in the discrete choice experiment involves three model types. first, we estimate a classical linear in parameters binary logit model, where each attribute is assigned a corresponding parameter (its weight) in a process of maximum likelihood estimation; see ben-akiva and lerman [ ] for details of this model and how it is estimated. second, we estimate a latent class model where we identify different classes in the population with people assigned to the same class have the same weight-parameter, i.e., have the same preferences [ , ] . third, acknowledging the moral salience of the choice context, we estimate a so-called taboo trade-off aversion model [ ] . this model estimates a penalty parameter for each policy scenario that involves higher numbers of fatalities and lower taxes. such a policy may be considered taboo by some respondents, as it in effect assigns a monetary value to a human life. the taboo trade-off aversion effect has a rich tradition in moral psychology [ ] ), and in the context of a dce analysis it can be captured by means of an interaction effect, which indicates a potential dislike for a combination of particular attribute values beyond the separate direct effects of those attributes. following chorus et al. [ ] we implement the taboo trade-off by constructing a dummy variable which equals if a policy scenario presented in a choice task featured lower taxes and more fatalities than the other scenario that was presented in the same choice task. the accompanying parameter estimate represents the level of taboo trade-off aversion (we estimate such a parameter for each latent class, to explore heterogeneity in terms of taboo trade-off aversion). to introduce notation, let respondent n's utility from choosing alternative i in choice situation s be described by the linear-in-the-parameters random utility function in eq . here, β is a row-vector of parameters to be estimated, column vector x nis contains the levels of the attributes of the alternative and ε nis represents an extreme value type i distributed error term. under these standard assumptions, the probability that respondent n chooses alternative i in choice situation s can be expressed by the multinomial logit model [ ] . the multinomial logit model (mnl) is the workhorse in discrete choice analysis, but is limited by its inability to describe unobserved preference heterogeneity and its inability to accommodate for the fact that each respondent made a series of choices (panel effect). a latent class model allows for capturing such unobserved preference heterogeneity and panel effects. let π qn be the probability that respondent n's preferences can be described by the q th vector (class). here, α q is a class specific constant, γ q a vector of parameters to be estimated, and z n a vector of respondent specific variables. we set the qth constant and parameter vector to zero for identification. every class q has a unique vector of attribute weights β q which describes the behavioral preferences of respondents assigned to the specific class. this enables us to take the panel structure of the data into account by allowing parameter weights to vary across classes while at the same time ensuring that they are constant across choices made by the same individual. now, we can express the probability that respondent n chooses alternative i in a particular choice task s as: likewise, for example, we can express the choice probability that respondent n chooses alternative i in every choice task s as: given our linear treatment of attributes, society's willingness-to-sacrifice a particular attribute (e.g. a certain number of households facing an enduring and substantial reduction in net income) in order to avoid one fatality which is directly or indirectly related to covid- can be calculated straightforwardly: it is given by the ratio between the fatality parameter and the parameter associated with the other policy effect (e.g. the parameter associated with the number of households facing income reductions). in the context of the latent class models, the sample level willingness to sacrifice is the weighted sum of the willingness to sacrifice per latent class, where the weights are the unconditional class probabilities. the data were gathered on april, the day following a widely watched press conference by prime minister mark rutte ( april) during which he emphasized that most of the lockdown-policies and regulations would remain in place until further notice, while some others were slightly relaxed. in hindsight, the days surrounding this press conference can be considered the height of the public debate in the netherlands about how to weigh the health-related effects of the lockdown with other societal impacts such as economic standstill, educational problems and mental health crises, among others. note that early may, after our data were collected, another press conference was held in which the government-quite unexpectedly in the eyes of many-announced a series of lockdown relaxations to take place in the months of may through september (also in this, the netherlands was not alone, as various other countries were contemplating and deciding for relaxations of lockdowns in this same time period). respondents were sampled from the online kantar public panel, with a view to be representative with respect to the dutch population in terms of age, gender and education level. kantar public approached members of their panel by e-mail to take part in our online survey. sampled respondents were informed about the purpose of the study, the methods employed and the specific policy impacts that were part of the choice experiment. our data collection effort was approved by the ethics board of the delft university of technology. a total of respondents of the panel were invited to participate. of these, respondents started the survey and we received , completed and usable surveys (implying a drop-out rate of %). for our analysis, we excluded two respondents who stated 'other' gender because parameters associated with this socio-demographic variable could not be identified empirically due to insufficient variation in the data. all models are run with these respondents excluded for comparability. table compares the sociodemographics of our sample with those of the population, and finds a close correspondence in terms of gender and age, but an over-representation of highly educated respondents. in the next section, we will explore what this means in terms of the general applicability of our findings. table shows the estimation results of our final model specifications. the binary logit model is our point of departure; note that the outcomes of this base model have been published in a dutch-language economics journal [ ] . also note that in order to ensure that all obtained parameters were within the same order of magnitude (which helps guaranteeing parameter stability in latent class models), we rescaled our attributes; see table for the resulting units. signs are as expected: people dislike increases in: the number of fatalities related (directly or indirectly) to covid- ; the number of people with lasting physical and mental injuries; the number of children left with an educational disadvantage; the number of households with persistent income loss; personal income taxes; and work pressure in the health care sector. all parameters are highly significant. the implied average (in the dutch society) willingness to sacrifice in order to avoid one fatality directly or indirectly related to covid- equals (rounded to the nearest integer): • cases of lasting physical injuries; • cases of lasting mental health problems; • children with lasting educational disadvantage; • households with long term decline in net income. in terms of the relative importance of working pressure in the health care system, we find that a one-step increase in the working pressure corresponds (in terms of disutility to dutch society) to , additional fatalities, underscoring the dominant role this variable has been playing in the public debate. in terms of the willingness to accept a higher (one-off) tax to help avoid fatalities, we find that the average dutch citizen weighs an additional , fatalities as heavily as a one-off tax increase per household of , euro. this implies that dutch society as a whole (which consists of approximately eight million households) is willing to sacrifice a total additional one-off tax burden of approximately . million euros. this 'value of life' estimate allows us to indirectly validate our dce: the dutch road authority [ ] employs a value of life metric of . million euro in the context of road safety analysis, which is in line with our results. note that the average life lost in road accidents is likely to be that of a younger person than the average life lost due to covid- directly or indirectly, e.g. due to postponed treatment-this may partially explain that our estimate is lower than the official number used by dutch authorities. a meta-study done by the oecd [ ] reports a median (across studies) value of life of . million euros, which also is of the same order of magnitude as our result. as a final indirect validation of our estimates, it is worth pointing out that the factor ten which we obtain between the weight of a fatality versus the weight of a lasting physical injury is about the same as the factor used for dutch road safety analysis [ ] . before moving to the more sophisticated latent class model, we briefly illustrate how the basic binary logit model can be used to forecast support for policy scenarios. take the choice between the two policy scenarios depicted in fig . based on the parameter estimates (and applying eqs and given in the previous section), the model predicts that % of dutch society would prefer exit strategy , while the remaining % would prefer exit strategy . if the government would be able to reduce the impact of strategy on mental health problems (e.g. by means of aggressively increasing funding in mental health care programs), in effect reducing the number of effected individuals from thousand to thousand (i.e., the same number as in strategy ), the model predicts that support would rise to %. of course, such a mental health program would come with a cost. if the government decides to increase the oneoff corona tax in strategy from , euro to , euro (which would generate approximately billion euro in taxes) to achieve these mental health benefits, our model predicts that that would still imply a % preference level for strategy over strategy . the latent class (lc) model with three classes fits the data significantly better than the binary logit model, even when adjusting for additional parameters; this is to be expected, given that opinions expressed in the public debate on this topic vary widely. the latent class model with four classes did fit the data even better, but we are of the opinion that reasonable class sizes and interpretability are important factors to consider in model selection when the purpose is to generate behavioral insights for policy analysis. we tested a wide range of alternative models and specifications; these are available from the corresponding author upon request. it should be noted, however, that the improvement in fit cannot be entirely attributed to the model describing unobserved heterogeneity, since the lc model also takes the panel structure of the data into account whereas the binary logit model does not. we see that all parameters in all classes are of the expected sign and significant at the % level, except for the increase in the number of deaths in class , which is insignificant, and income loss (number of households facing a loss in income) in class , which is only significant at the % level. looking at the weights obtained per class, the classes can be interpreted as follows: class , in which older people are over-represented, is not sensitive to changes in the number of fatalities, but it does care about the other policy-impacts and in particular puts a very high negative weight on tax increases. this finding is interesting and somewhat surprising in light of the fact that individuals in this class are known to be much more likely to die when contracting the virus, compared to younger people. this class contains about % of the sample. class , in which higher educated people are over-represented, is highly sensitive to each policy-impact, except for the tax increase (to which they are equally sensitive as the average respondent). this class contains about % of our sample. class (containing about % of our sample) is as sensitive as the average respondent to fatality numbers and working pressure in the healthcare sector, while being considerably less sensitive to the other policy effects. in terms of ethical perspectives, class can be described as a typical consequentialist class, weighing every single impact of the exit strategies. class weighs most impacts, but not the one which moral psychologists call the sacred attribute (human life), while class can be considered to combine the consequentialist and deontological perspectives as it weighs all effects, but puts less (compared to the average respondent) weight on effects other than the increase in fatalities and the working pressure in the healthcare system. in table , we show the sample level willingness-to-sacrifice estimates for each sub-group (segment) of respondents implied by our class probability functions, as well as the associated % confidence intervals. standard errors were calculated using the delta method [ ] . in terms of willingness to accept an increase in the number of people with lasting physical injuries to avoid one fatality directly or indirectly related to covid- , we find several differences between subgroups of respondents. for example, highly educated women between and years old are only willing to accept an increase of people with lasting physical injuries for each avoided fatality, whereas men between and with low education are willing to accept an increase of more than people with lasting physical injuries for each avoided fatality. looking at the other policy dimensions, we see the same general trend: older and more highly educated people in general, and women in particular, are willing to sacrifice (per fatality avoided) fewer people with mental injuries, fewer children at an educational disadvantage and fewer households with an income loss, compared to younger people with lower education, and younger men in particular. in many cases the differences in willingness to sacrifice between segments of the population are large and significant judging by the non-overlapping confidence intervals. returning to the fact that our sample, while representative in terms of gender and age, is somewhat skewed towards highly educated people (see table ), these segment-specific estimation results imply that our aggregate level estimates for society's weighing of various policy impacts of exit strategies is likely to somewhat underestimate the weight attached to fatalities and to somewhat overestimate the weight attached to other policy impacts such as physical and mental injuries, educational advantage, and income loss. more generally, these results suggest that segmentation along socio-demographic lines is needed to obtain a nuanced view of society's preferences related to covid- policies. with a view to exploring potential causes behind differences in weights attached to fatalities and other policy impacts, we estimated a series of two-class latent class models, where class membership was determined by respondents' perceived risk that they or a relative would contract covid- , would become severely ill if having contracted the virus, would be hospitalized if contracting the virus, or would die if contracting the virus. none of these variables, which were all measured using five-point likert-scales, turned out to have a significant effect on class membership (and hence, on respondents' weighing of the policy impacts). we also tested a model where class membership was a function of whether or not one or more of a respondent' relatives had contracted the virus; respondents indicated that this was the case. (note: only two respondents indicated that they had contracted the virus themselves, this number being too low to use in our analyses) using this variable as a predictor of class membership, table shows that respondents whose relative(s) had been infected by the virus were significantly less likely to belong to class which does not put a significant weight on fatalities. this is in line with intuition. our results for taboo trade-off aversion (see table for the full estimation results) can be summarized as follows: in a three class model where we allowed all parameters, including the taboo trade off aversion parameter, to vary between classes, we find two classes with a significant and negative taboo-penalty associated with policies that involve (simultaneously) a lower tax and a higher number of fatalities than the alternative policy. for one of these classes, containing % of our sample, the taboo penalty is large (- . ) whereas in the other class, containing % of our sample, the taboo penalty is of moderate size (- . ). a third class (containing a minority of % of our sample), surprisingly features a large and positive taboo parameter ( . ) , implying that individuals in this class actually favor the combination of lower taxes and higher fatality rates. some caution is in place though, when interpreting these taboo aversion-related outcomes: correlations between the taboo penalty-parameters on the one hand, and the tax-and fatalityrelated parameters on the other hand, were quite high (> . ). this indicates, that the model struggles to disentangle the direct effects of the tax-and fatality-variables on the one hand, and their joint indirect effect through the taboo-dummy variable on the other hand. this is not surprising, given that the experiment was not designed specifically to pick up these two separate but subtly related effects in an econometrically efficient way. we performed additional analysis to verify our results, including a three class model where the taboo parameter was allowed to vary across classes while the attribute weights were constrained to be the same across classes, as well as a three class model where the taboo parameter was allowed to vary across classes while the attribute weights were fixed to their binary logit sample-level estimates. estimation results for these models (which can be obtained from the corresponding author) showed that, as expected, they had a much lower model fit than the original taboo trade off aversion model which allowed the taboo parameter and the attribute weights to vary across classes, but they avoid high correlations between parameters. these models identified a taboo aversion for only about % of the sample. this indicates that more research is needed to draw definite conclusions about the role of taboo trade off aversion in the context of lockdown relaxation policies. this paper presented the results of an empirical study into dutch society's preferences of covid- related government policies, specifically in terms of the weights attached to various impact-dimensions of such policies. at the aggregate level-i.e., combining choices made by all respondents-as well as for particular segments of the population, we obtain estimates for society's willingness to accept or sacrifice fatalities in order to avoid physical, mental, educational, and economic impacts of lock-downs. the fact that the implied 'value of life' estimate obtained on our sample is close to the value that is used by the dutch government in other contexts, lends credibility to our results. what is perhaps the most striking finding of our study, is the large heterogeneity within the population in terms of the weights attached to various policy impacts: first, while some groups appear to weigh all impacts in line with what would be prescribed by consequentialist ethics, other groups appear to put much weight on some impacts while ignoring other impacts. second, while a majority dislikes policies that imply a taboo trade-off between lives and taxes, a sizeable minority in fact favors such policies. third, also within each group, there appears to be a substantial variation in terms of the weights attached to various policy impacts. some of this heterogeneity can be traced back to whether one has a relative that has contracted the virus (this leads to a higher weight on avoiding fatalities), but classical sociodemographic differences (gender, age, education level) appear to play an important role as well. this high level of preference heterogeneity should come as no surprise to those who have been following the heated debates about covid- policies in various countries including the netherlands; this result is also in line with the high levels of heterogeneity found in several other covid- choice experiments and surveys (see papers cited in the introduction). in the face of the covid- crisis, policy makers worldwide need to make choices with far-reaching consequences, based on a wide variety of considerations and limited by a high degree of uncertainty. the results of our research are no more than a small piece of this immense puzzle, and are subject to a number of limitations: first, while great care was exercised to develop a choice experiment aimed at obtaining trustworthy responses, it must be acknowledged that the choices made by respondents were made between hypothetical policies. as such, care must be exercised when interpreting and applying our estimation results. second, although our sample was representative in terms of gender and age, and despite having a high response rate among members of a representative panel, we did obtain an over-representation of highly educated people. combining this notion with our estimation results, this implies that our aggregate level results are slightly overestimating society's willingness to accept a fatality in order to reduce negative impact on educational disadvantage, economic impacts and other policy impacts. third, our data were collected at a specific point in time in a specific geographical and cultural context, which in itself limits the generic applicability of our results. notwithstanding these limitations, we believe that our results can be useful in four ways in developing policies with regard to a possible (further) relaxation of the intelligent lockdown in the netherlands as well as in other countries. first, upon inspection of our estimation results, including the latent class models, we find that most of our respondents appear to have an eye for both the direct health-related effects of relaxation policies and their indirect impacts on mental health, the economy, education and their personal financial situation. although health impacts are of great importance to our respondents, most seem to employ a consequentialist ethical perspective by balancing various dimensions of policies. this suggests that an open view of policy makers, taking into account the broad range of effects of policies, would be appreciated by citizens. nonetheless, our result that about three quarters of our sample have a moderate to high aversion against making 'taboo tradeoffs', suggest that governments need to be careful in their decision-making and in how policies and their effects are communicated to the public. secondly, our results enable policy makers to determine whether the net valuation in society is positive or negative for particular combinations of policy effects. take, for example, the situation in which a certain policy measure leads to an expected reduction in deaths, but also to an increase in the number of people who will suffer from lasting mental health problems such as depression. our results indicate that, if the number of people who experience such problems as a result of the policy is fewer than about fifteen per avoided death, the policy is assessed positively by the average dutch person. however, if the number is higher, the net valuation is negative. thirdly, our results enable policy makers to identify levels of support and opposition among dutch citizens for different policy packages. for example, the binary logit model, fed by the estimated parameters, can be used to determine the percentage of dutch people who support a certain policy package over another one, as was illustrated in section . for this, the effects of the policy package must of course be within the scope of those presented in table . and fourthly, our model can be used to determine whether the average adult citizen prefers a proposed policy package over a particular reference case. this reference case can be "a continuation of current policy" or "no restrictive measures". for this, it is important that the reference case can be specified in terms of the impacts on (a selection of) the policy impacts included in our experiment. in terms of avenues for further research, we believe that assessing the spatial and temporal transferability of our results is important, before conclusions for other countries, and for future situations, can be derived. regarding geography, given the considerable differences across countries in terms of culture, covid- policies and the effects of the virus on society, we expect that weights for various policy effects will differ across countries. moreover, some effects included in our experiment might be less relevant in other countries, while factors excluded in our study may be highly relevant in different geographical contexts. regarding timing, we expect that as the situation changes in terms of the threat of the virus and the visibility of e.g. economic effects, societal preferences and trade-offs will change, too. it would be interesting to test for this, by repeating our experiment in due time. nonetheless, we feel that having these timely estimates available helps (local) policy makers in the short term. a final suggested avenue for further research relates to the hypothetical nature of our experiment: if, as seems likely, one or more countries will in due time ask their citizens to vote for particular covid- policies in a referendum style voting process, such 'real' data could be used to make a comparison with data obtained by means of hypothetical choice experiments such as ours; see hainmueller et al. [ ] for an example of such a comparison. in general, we hope that future study efforts aimed at measuring citizens' tradeoffs and preferences concerning the policy impacts of lockdowns in different countries (triggered by covid- or another pandemic) can use our study as a stepping stone. supporting information s appendix. description of the policy impacts. 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value of different qaly types valuing qalys in relation to equity considerations using a discrete choice experiment kans op . tot . doden heropstart van zorg: eenvoudige rekensommetjes, maar lastige afwegingen revealed: surge in domestic violence during covid- crisis over , dutch domestic violence victims in years facts and figures scenario's corona crisis dutch economy to contract this year more than in een vijfde van de nederlanders ervaart inkomensterugval applied choice analysis: a primer design efficiency for non-market valuation with choice modelling: how to measure it, what to report and why* discrete choice analysis: theory and application to travel demand a latent class model for discrete choice analysis: contrasts with mixed logit discrete choice methods with simulation taboo trade-off aversion: a discrete choice model and empirical analysis taboo trade-offs: reactions to transactions that transgress the spheres of justice conditional logit analysis of qualitative choice behavior nederlanders maken een brede afweging bij afbouw coronamaatregelen mortality risk valuation in environment, health and transport policies calculating errors for measures derived from choice modelling estimates we received valuable input from the following individuals during the development and implementation of the experiment: marion collewet, shannon spruit, anatol itten, ardine de wit, key: cord- -g esbbrr authors: fargnoli, raffaele title: adapting the eu economic governance to new macroeconomic and political realities date: - - journal: inter econ doi: . /s - - - sha: doc_id: cord_uid: g esbbrr there was a widespread consensus on the need to modify fiscal rules in the eu even before the covid- crisis. the aim of this article is to reflect on the reform of fiscal rules from a broader perspective, looking at three different dimensions: the political economy of fiscal rules in the current political and economic environment, the renewed debate about fiscal policy roles and objectives, as well as the current incomplete nature of the european monetary union and the prospects for its completion. the main contribution of this paper is to analyse emu fiscal policy and the related governance modes from a broader perspective. furthermore, the article briefly discusses ideas for a new model of fiscal and economc surveillance based on a cooperative governance system in order to better fit with with current macroeconomic and political realities. even before the covid- crisis, which has led to the suspension of the stability and growth pact (sgp) through the activation of the general escape clause to be invoked in a severe economic downturn, there was a widespread consensus on the need to modify fi scal rules confi guration. current rules are criticised for complexity, procyclicality bias and scarce adaptability to macroeconomic circumstances not driven by very exceptional events. this article is based on fargnoli ( ) and discusses the reform of fi scal rules across three different dimensions: i) the political economy of fi scal rules in the current political and economic environment; ii) the renewed debate about fi scal policy roles and objectives; iii) the current incomplete nature of the european monetary union (emu) and the prospects for its completion. the refl ection over the fi rst two dimensions emphasises that fi scal policy prescriptions stemming from the sgp framework are now suffering from a gap of legitimacy both in terms of ownership (being capable of achieving a synthesis of bold and diverging national preferences) and regarding their output (capacity to deliver on multiple goals). the third dimension highlights the need to rethink the analytical relation between the incomplete nature of the emu, which is likely to persist in the near future, and the implications for fi scal and economic policy coordination, in particular regarding the need to recover from the coronavirus crisis and to manage its long-term consequences. the literature on fi scal rules emphasises that their infl uence on national governments' behaviour stems from (formal enforcement aside) the reputational cost suffered by non-compliant governments. this assumption is based on the ability of external pressure groups -i.e. the public and the market -to offer national policymakers proper incentives (schuknecht, ) . in this respect, simpler fi scal rules increase the probability of compliance by facilitating their understanding and monitoring. however, if infl uential groups fail to exert genuine pressure on national authorities, both simple and better designed rules are just as likely to be neglected as more complex rules. today, eu fi scal rules have to cope with increasing scepticism about the benefi ts of strict fi scal discipline as a key principle for sound policymaking. for instance, in some of the countries hardest hit by the pandemic, people have been strongly touched by the often evoked argument pointing to the link between the overwhelmed health care system and previous years' budgetary cuts. in this respect, it is likely that the unprecedented economic fallout triggered by covid- , coupled with the political and economic costs inherited from the last fi nancial and sovereign debt crisis, will cement negative feelings towards fi scal consolidation for a long time. the great recession also showed that the market's ability to correctly price the risks related to national economy fundamentals suffers from several fl aws. to this extent, the public's confi dence in market assessment is also eroding. thus, sudden increases in sovereign spreads, among other effects, are also likely to cause frustration in relation to the fiscal policy rising demand for balancing fi scal discipline with other policy goals, in particular supporting growth and economic recovery, increasing public investment and reducing unemployment and inequalities. in high-debt countries, because of subdued growth and infl ation, the permanent increase in the primary surplus needed to put the evolution of the debt-to-gdp ratio on a convergence path towards the % sgp target, ranged, before covid- , from % of gdp in belgium and portugal to - % of gdp in italy, spain and france. while the huge stress to which public fi nances are currently subject will increase these requirements, greater fi scal corrections risk being politically unattainable in the future. indeed, the social and political backlash, partly triggered by the great recession and its policy response, coupled with more recent protests related to relatively modest tax hikes, e.g. by the gilets jaunes movement in france, suggest that in a number of countries, the political limits for fi scal consolidation have already been reached. the so-called period of great moderation, characterised by infl ation under control, decreasing unemployment and lower output volatility, cemented a widely accepted consensus over fi scal policy functions. most economists used to agree that fi scal policy should focus mainly on the long-term sustainability of public fi nances, while leaving stabilisation goals to the mere functioning of automatic stabilisers. this consensus was the basis for the design of the sgp. the limits of monetary policy effectiveness in an environment characterised by interest rates at the zero lower bound hit this conventional wisdom. a general shift in thinking advocates a more active role for discretionary fi scal policy for different purposes such as: i) to cope with present and future stabilisation needs, especially in the presence of hysteresis implying lasting lower output levels (draghi, ) ; ii) to address defl ationary tendencies and the persistent gap in aggregate demand (rachel and summers, ) ; iii) to stimulate long-term output through growth-enhancing expenditure (deleidi and mazzucato, ) . if the persistent 'liquidity trap' started to erode the old consensus, covid- is fully abating it, leading to a profound revolution with regard to the set of macroeconomic tools to be used in this new environment. first of all, there is an almost unanimous agreement on the fact that massive public intervention is needed to cope with the mix of strong supply and demand shocks caused by the pandemic in order to keep the economy afl oat. income support for households, extended unemployment benefi ts, tax reliefs, government capital injections and guarantees for fi rms besides health-related costs to contain the pandemic will lead to skyrocketing budget defi cits. the diffi cult challenge of managing the resulting high levels of government debt is also affecting the almost sacred prohibition of monetary fi nancing. some economists are suggesting radical solutions, such as direct central bank mon-ey injections into the economy through so-called helicopter money (gali, ) . without going so far, proposals like perpetual bond issuances with central bank backstops (tabellini and giavazzi, ) or massive asset purchases undertaken in particular by the federal reserve blur the lines between unconventional monetary policy and monetary fi nancing. in any case, once the pandemic is fi nally under control, fi scal policy should be loosened futher to support economic recovery. before covid- , many prominent voices called for profiting from the low interest rate environment to prioritise, over other policy objectives, a powerful investment policy to spur gdp growth both in the short and in the long term (blanchard, ) . this debate, reinvigorated proponents of some sort of golden rule to be included in the eu governance framework. however, given the heterogeneity of spending programmes with positive economic returns, ranging from expenditure in education, training, human capital investment, health, climate mitigation, infrastructure and the broad set of innovation policies, it is diffi cult to conceive an investment clause capable of covering all these items effectively and without creating distortions in the allocation of public expenditure. figure shows that a number of countries present a suboptimal expenditure composition. countries with low potential growth rates such as italy and spain have expenditures below the eu average in all the growth-enhancing items displayed in the fi gure, with a gap accounting for almost % of gdp. the fi gure also shows that the expenditure gap widened in recent years, in particular in those countries hit hardest by the sovereign debt crisis. decisions on the size and the time extension of counter-cyclical measures as well as the more structural increase in investment will face the limit imposed by debt sustainability concerns. however, since much higher debt levels will become permanent in the future, the debate on how to manage such a high debt burden will intensify. the views will likely diverge between those asking for achieving a larger primary surplus for a long period of time in order to seek reducing the debt ratio and those calling for a strategy aimed at keeping the debt under control in the short term while undertaking well-designed growth-enhancing spending programmes to strengthen the recovery and raise potential growth. in the future passive debt deleveraging based on higher nominal growth and prudent fi scal policy in good times could result in a more substantial and politically sustainable debt reduction (rawdanowicz, ) . at the same time, the inherent vulnerability of high-debt countries will raise the question of whether short-term fi nancial market turmoil, causing dangerous increases in sovereign borrowing costs, can be managed by the european stability mechanism (esm) or if, alternatively, either a more active central bank intervention or some form of debt restructuring will become inevitable. against this backdrop, the debate on fi scal policy choices and debt management interacts with the political economy issues discussed above. indeed, irrespective of the merit of the different views, this fragile environment will widen the existing divergences about the optimal conduct of fi scal policy, making the current architecture of the european eco-nomic governance, in particular the current rules-based fi scal framework, rather unsuitable to the post-pandemic world. figure displays the main trade-off characterising the prospects for the future evolution in the emu institutional architecture. on the vertical axes, there are types of common institutions and resources that are typically found in fully fl edged monetary unions (federations and confederations). on the horizontal axes, fi scal policy moves from tight fi scal controls exerted by the federal government to larger discretion for lower levels of government. the emu is now situated in the bottom left quadrant where political tensions and the risk of fi nancial instability are not excluded. this is true despite the creation of the esm and the fact that the possible completion of the banking union could allow for the reduction of the most extreme consequences of a fi nancial crisis. the emu, at present, shares some features of centralised models of federations based on the relatively strict fi scal rules often associated with administrative sanctions and mild market discipline since member state bailout is de facto no longer excluded. however, the emu lacks the central instruments needed to make this model fully sustainable and resilient. common schemes to address a common real economy shock are absent. national governments remain reluctant to move towards a minimal fi scal union with stronger spending responsibilities and coercive powers at the emu level (moving to the upper left quadrant). the resources that will be mobilised at the eu level through the next generation eu instrument could push the emu (eu) towards the upper quadrants, especially if new eu own budget sources are to be set up and at least part of the common debt is rolled over, to attain a permanent increase in the size of the eu budget. against this background, it is crucial to highlight a basic principle emerging from present macroeconomic realities and the emu experience: the larger the common countercyclical and investment instruments permanently available, the stricter the oversight and the constraints on national public fi nances, also by means of stringent fi scal rules. however, although the agreement on the recovery facility represents a polar step in the right direction by providing crucial support to national budgets, they will continue to play a key role in order to achieve the goals of attaining full recovery and ensuring a proper level of growth-enhancing spending. the temporary nature of the recovery instrument will also require, in the future, that national budgets are able to keep ensuring the fi nancing of some of the main long-term investment programmes activated today by common borrowing. all these considerations support the case for conceiving the future economic governance in a way that guarantees greater room for manoeuvres at the national level, while promoting high quality policymaking and preserving debt sustainability. against this background, it has been argued that the peculiar features of the emu would fi t better with a decentralised system based on larger discretion and more cooperation on setting fi scal targets (wyplosz, ) . in fact, despite diffi culties in the optimal design of fi scal rules and limited transfers fl owing from the eu level, full sovereignty on taxation remains a prerogative of member states, who are also likely to retain signifi cant divergences in fi scal policy preferences. moving towards a decentralised model would also reinforce market discipline to avoid the risk of fi scal profl igacy. these considerations contributed, before covid- , to a debate on the opportunity to strengthen the no-bailout rule found in article of the treaty on the functioning of the european union in order to: i) provide better incentives for sound policymaking and reduce moral hazard risks; ii) scale down the current rules-based system, providing space for tailoring fi scal policy to national preferences within the limits set by market assessments; iii) overcome political resistance towards building up needed common instruments, such as a european deposit insurance scheme. however, this bright theoretical environment confl icts with reality. indeed, market assessment is characterised by several fl aws, well observed during the great recession. markets' perceptions are pro-cyclically biased as they tend to overlook risks in good times and be inclined to panic in bad times. by overreacting during a crisis period, markets can trigger a vicious circle of continuous increases in interest rates and deterioration of sovereign debt solvency, generating self-fulfi lling prophecies, thus turning simple liquidity crises into solvency crises. this can occur more easily in a monetary union due to credit market integration and the free movement of capital across borders which increase the risk of sudden-stop crises, like that experienced by the emu in - . furthermore, the probability of ending in a bad equilibrium scenario will be bigger in the future, as it increases with a larger stock of existing debt. indeed, the post-pandemic world, characterised by the strong vulnerability of those emu countries with a high debt burden, will make the full enforcement of strong market discipline particularly risky. first, the prerequisite to minimise the impact of a sovereign debt default on the real economy and the fi nancial sector have not been created. in the us, the federal budget, besides dealing with stabilisation needs, accounts for key expenditure functions (investment, innovation, top-up of unemployment expenditure, social insurance). this will reduce the real economy cost of an eventual bail-in of a us state, thus increasing the political acceptance of the no-bailout rule and strengthening perceptions about its concrete application (kirkegaard, ) . financial spillovers are also circumscribed by the fact that state government debt is about % of gdp and the share of state securities in the portfolio of us banks is low. despite all of this, the high costs associated with any sort of subnational government default explain why federal governments (in the us and in other federations) often prefer some form of bailout of subnational entities (cordes et al., ) . furthermore, in the current context, in the emu, the political impact of debt restructuring risks being even more destructive than its economic costs. the pandemic has amplifi ed the request for recognising mutual interest and mutual support among eu countries. another reason why a debt restructuring will hardly be accepted is that it will be associated with the last episode of rising public debt, namely the covid- crisis, regarded as an exogenous shock with no government responsibilities involved. lastly, it should be considered that the downturn induced by a debt restructuring would represent the signifi cant third economic shock in only a few years, after the great recession and the current crisis. against this background, it is likely that strong market discipline will lack credibility in the emu due to the large economic and political consequences it involves. alternatively, in case it would entail sovereign debt restructuring, the risk of a political and social backlash triggered by the size of economic disorder that it would generate could jeopardise the eu integration process as a whole. these considerations suggest that neither a reform of fi scal rules nor pure fi scal policy decentralisation at the member state level (associated with strong market discipline) are mod-fiscal policy els capable of promoting high-quality fi scal policy and strong political ownership and legitimacy, while also minimising risks of political turmoil and fi nancial instability. in this respect, while these goals could be achieved by building up meaningful and permanent risk-sharing instruments at the eu level, supported by some embryonic form of political union, this scenario does not seem politically attainable for the time being. an alternative model of fi scal governance could be designed by reducing the role of quantitative fi scal rules and moving towards a cooperative system where fi scal targets and the medium-term macroeconomic strategy are periodically negotiated by a competent eu authority and the national government. the base for negotiations would be represented by a multi-annual plan submitted by the national government at the beginning of its mandate, setting a medium-term debt target and other concrete objectives in terms of fi scal variables and policies. a qualitative analysis of the plan should go hand in hand with the quantitative assessment of government targets. cooperation and negotiations would serve the purpose of increasing the focus on qualitative variables, e.g. the quality of public expenditure, while also taking into account national views and other policy objectives following an outcome-based assessment. this would increase national authorities' accountability and responsibility, besides providing a high degree of adaptability to macroeconomic circumstances. this cooperative governance principle could also fi t with the underlying governance framework of the next generation eu. the narrative and the concrete application of the monitoring system should aim at building up effective cooperation between national governments and eu institutions. for instance, the policy dialogue on the national reform programme could serve to: i) identify national policy priorities in need of support; ii) adopt high-quality practices for the design of the spending programmes; iii) monitor implementation and results. leaving aside the specifi c framework underlying the recovery instrument in exchange for more room to manoeuvre with regards to national fi scal policy conduct, a gradual and semi-automatic enforcement system should be put in place to avoid moral hazard. it would range from small penalties in case of simple divergences between eu recommended policies and the national policy strategy, to more serious deterrents for reiteration of ineffective policies and clear-cut gross policy errors. the enforcement tools could include a quasi-automatic contribution to a future stabilisation fund to be regarded as an insurance premium to (partly) cover the risk that the national policy strategy could weaken domestic and emu resilience. finally, in the post-covid- world, a proper management of high levels of public debt will be crucial to safeguard fi nancial stability. in this regard, one could question whether the current outright monetary transactions (omt) framework would remain fully credible to address sovereign market volatility, in light of the conditionalities attached to the instrument, in particular adhering to an esm programme (cohen-setton and vallee, ). thus, a broader scope for ecb involvement might be needed in the future. in this respect, avoiding gross policy errors in national budgetary plans could provide the basis for a form of softer conditionality, opening the way to more ordinary ecb intervention, outside a formal omt programme, to reduce short-term market tensions causing dangerous increases in sovereign borrowing costs. in general, this cooperative system of governance should be underpinned by an open and inclusive policy dialogue between the eu and national stakeholders. mutual respect and recognition of a larger range of preferences, views and objectives are the basis for high quality policies to increase input and output legitimacy of eu governance and to underpin trust and support in eu integration. this model could also be used to create an environment where the conditions for moving towards a more effi cient fi scal, fi nancial, economic and political union could fl ourish because it would seed a culture of confl ict resolution and would connect national spheres by channelling and mediating different policy conceptions. as john stuart mill ( ) asserted in its masterpiece on liberty: "it is only by the collision of adverse opinions that the remainder of the truth has any chance of being supplied" ( ). europe must fi x its fi scal rules euro area reform cannot ignore the monetary realm subnational fi scal crises from balance to confl ict: a new constitution for the eu putting austerity to bed: technical progress, aggregate demand and the supermultiplier farewell remarks, frankfurt am main adapting the eu fi scal framework to new macroeconomics and political realities, eui working paper helicopter money: the time is now a more perfect (fiscal) union: us experience in establishing continent-sized fiscal union and its key elements most relevant to the euro area on liberty on falling neutral real rates, fi scal policy, and the risk of secular stagnation choosing the pace of fi scal consolidation eu fiscal rules, issues and lessons from political economy covid perpetual eurobonds: jointly guaranteed and supported by the ecb, vox cepr policy portal europe's quest for fiscal discipline key: cord- -y iu hbc authors: straka, john w.; straka, brenda c. title: reframe policymaking dysfunction through bipartisan-inclusion leadership date: - - journal: policy sci doi: . /s - - - sha: doc_id: cord_uid: y iu hbc persistent policy failures have been examined in recent years with a focus on the role of political systems. we evaluate the growth of dysfunctional policymaking in the u.s. and propose a countering approach. policy failures often reflect partisan policy stalemate, errors or unintended consequences, polarized extremism or imbalance, or partisan reversals with changes in power. extremes in partisanship are not new historically, but growing policy failures due to negative partisanship have now severely damaged public trust. more “party blind” conditions in policy formulation may be able to renew a more productive social contract. we propose a disruptive presidential leadership approach of bipartisan inclusion to seek to reframe the partisan divides, counter negative partisanship and extremes, re-establish better policymaking interactions, and improve governance and policy outcomes. dysfunctional policymaking has been attributed to republicans and democrats in a prisoner’s dilemma. iterated prisoner’s dilemmas often lead to higher rates of cooperation, and similarly, historical policymaking included greater cooperation, but in recent decades the bipartisan norms of governance have substantially eroded. we describe three complementary explanations, which suggest that non-cooperative partisan policymaking has become self-reinforcing, and institutional changes to promote cooperation should focus on lowering the risk-adjusted cost–benefit ratio, making cooperation safer and more attractive for policymakers. persistent policy failures have been examined in recent years with a focus on the role of political systems (howlett et al. ; derwort et al. ; schultz ) . this paper evaluates the growth of dysfunctional policymaking in the u.s. compared with earlier history and proposes a countering approach. policy failures often reflect partisan policy stalemate with a drifting status quo, errors or unintended consequences, polarized extremism or imbalance, or partisan reversals with changes in power. extremes in partisanship are not new historically, but growing policy failures due to negative partisanship have now severely damaged public trust in institutions. we describe three complementary explanations, which suggest that non-cooperative partisan policymaking has become self-reinforcing, and institutional changes to promote cooperation should focus on lowering the risk-adjusted cost-benefit ratio, making cooperation safer and more attractive for policymakers. we propose a disruptive new form of presidential leadership joined with other approaches to improvement. government policymaking dysfunction from partisan polarization is generally seen as a corrosive failure of institutions (thurber and yoshinaka ) . much of it being reflected in a lost sense of governing trust (or social contract) and many deadlocked unmet policy needs. over % of americans have said the country is greatly divided about important values, with % saying they are dissatisfied with the state of politics (summers ) . about % to % have said they are very concerned with the deepened polarization, bitterness, disrespect, contempt, and even hatred between groups (brooks a . a december new hampshire poll found more voters viewing political dysfunction ( %) and disunity ( %) as a threat to america than any other major issue (troiano ) . after the midterm elections, the economist ( ) emphasized america's divisions and prospects for poor policymaking with both sides declaring victory. most of the public expected gridlock through (pew research ) , and, as in previous years, this has been a good general forecast. with many unaddressed policy tradeoffs and needs, political candidates can seek or rise to power through major policy failures, failures that are inflated, embellished, and aggrandized, or alignment with specific voter protest or identity groups. unmet needs in turn encourage more power-play policymaking or obstruction (e.g., laws passed or blocked along party-line votes) and more ominously, authoritarian tendencies. to counter these trends, we suggest that a new form of social contract between the dominant governing parties may be possible through a reframing of policymaking interactions to encourage better governing norms. a recent rand study (kavanagh and rich ) found that in earlier periods of turmoil, a revival of factual policy analysis and journalism and a focus on holding leaders accountable helped clarify the line between opinion and fact. a similar renewal today might re-orient policymaking to more fact-based rationality, assessment, and purpose (perl et al. ). our proposal requires leadership but no new laws. more "party blind" "auditioning" conditions in policy formulation may better balance and improve cooperative policymaking. we propose a new presidential administration with bipartisan leadership inclusion in policymaking. a broad analysis by gehl and porter ( ) finds over many years: ( ) a clear trend decline in the numbers of laws passed by congress; ( ) a clear trend increase in the number of "salient issues" deadlocked in congress; ( ) a sharp trend decline in the number of bipartisan conference committee reports; ( ) an increasing proportion of party-unity votes; ( ) much lower bipartisan vote support after the s for "landmark legislation;" ( ) a low recent share (about a third) of legislation introduced with bipartisan cosponsors; and ( ) a declining much lower share of moderates in congress, especially after the early s. from empirical studies showing policy stalemate trending upward along with party polarization, commentators have noted the growth of policy problems and failures mounting from "kicking the can down the road" and "drifting" outcomes that perpetuate the status-quo (lee ) . prior to , recent decades of legislative changes or corrections in policy have not appeared to systematically advantage either conservatives or liberals (curry and lee ; lee ) . with a few landmark exceptions generally realized through unilateral power, the limited laws that have passed have not included many potential larger or more difficult changes. more difficult policy improvements requiring broader bipartisan support persistently fail to succeed legislatively or even reach the floor of the senate or house for votes. in - , a stronger partisan tilt through unilateral power became prominent (with the gop president, senate, and house before ). new administration policies (several more extreme), judicial appointments, and legislation or legislative attempts, with congressional support or acquiescence, rescinded or reversed the directions of many previous obama administration policies and longstanding bipartisan approaches. the shift of the supreme court and judiciary to the right has grown as trump and the gop-controlled senate have enacted the long-term strategy of the federalist society and beyond with several doctrinaire judges appointed despite ratings of 'unqualified' by the american bar association. (in comparison, none of obama's judicial nominees were rated unqualified.) senate denials blocked many of obama's nominees, culminating in the unprecedented -month refusal to give obama's last high-court nominee a hearing. since the power shift in congress after the midterms, gop senate leader mcconnell has returned to his previous obstructive tactics, blocking from consideration nearly bills passed in the democraticcontrolled house (axelrod ; martin ) . policy failures from the pattern of non-cooperative partisan stalemate have led to recurrent tragedies or mounting issues from: ( ) gun violence and deaths, ( ) eroding infrastructure, ( ) failed immigration reform, ( ) growing climate and environmental risks, ( ) health threats and inefficiencies despite costly systems, ( ) failed trade-and technology-adjustment support causing uneven employment, ( ) unequal access to rights and opportunities with unshared economic growth and growing inequality, ( ) unsustainable entitlements, ( ) the general pattern of government shutdowns/threats and planning uncertainty, ( ) inconsistent foreign policies with mixed responses, ( ) unclear preparedness for growing cyber threats, and on and on. difficult policy problems have been made worse by government dysfunction with inabilities to address tradeoffs, plan appropriately, and devise more effective approaches. even the u.s.' severities of the - great recession and the coronavirus pandemic can be traced in considerable degree to the non-cooperative policymaking equilibrium. policy failures have multiple causes of course, which can interact, but at root, the costs of policy stalemates sooner or later have often been high and tragic. policymaking dysfunction in the u.s. has been described as the outcome of republicans and democrats in a prisoner's dilemma where mutual cooperation is generally better than divided non-cooperation, but each party is independently incented to not cooperate (atkins ; contrisciani ; desai ; kamer ; masket ; picardo ; easley et al. ; the economist ; sallet ) . the trump era has deepened these concerns (brooks a, b; bauman ; gammon ) . from each party's perspective "winning" is better than mutual cooperation while the "sucker" outcome (cooperating while opponents do not) is the worst, as shown in fig. . this reflects policy perceptions, not objective policy quality per se. such incentives between opposing policymakers have existed throughout america's history. this is an iterated prisoner's dilemma (ipd) repeated many times over, essentially in perpetuity. historically, policymakers were able to restrain and discipline themselves (e.g. through the rules of congress and general governing norms) to act more consistently with the ideal that democracy requires power sharing and compromise, not "win at all costs" (levitsky and ziblatt ) . in recent decades, instead, policymakers have increasingly failed to bridge significant differences. polarization has whipsawed policies over time with changes in power and left many festering problems with little to no sustainable progress on many policy needs. ironically, trump's electoral-college victory in was an exploitation of the noncooperative policymaking equilibrium. before election (and ever since), trump inflated, aggrandized, and branded a large share of past policy failures or shortcomings, along with any competing or opposing politician, as a "total failure," a "loser," and so on (a common tactic of demagogues with authoritarian ambitions). given the policy problems made worse by non-cooperative stalemate, and a groundswell of public mistrust and disgust, "establishment" politicians were vulnerable to this line of attack albeit crudely ill-informed fig. the policymaking prisoner's dilemma and often plainly and unabashedly dishonest. trump took an already established phenomenon to new heights, wherein renegade political behavior has paid individual political dividends to its purveyors (rauch ) . many voters took a protest-vote gamble on trump as a "disruptive outsider" (henriques ) who could "make sensible business-like deals" in washington (no matter that his actual business record, other than in branding his name, was very weak)-but almost exactly the opposite has occurred since his election. he has made the problems of political polarization-punctuated by the house impeachment of trump followed by senate "forgiveness"-and resulting policymaking stalemates much worse. many democrats now believe, in prisoner's dilemma terms, that their party must stop "playing the sucker" (cooperating while the other party does not) because america no longer has a rational political system (paur ; atkins ) . republicans have likewise accused democrats of refusing to cooperate in policymaking (chantrill ) , and trump attempts to do the same. nothing has really changed in the policymaking problem except for a highly energized opposition to trump. trump's divisive and authoritarian-leaning approach has been precisely the wrong kind of disruption needed to counter the non-cooperative equilibrium in policymaking stalemates. in view of the causes of persistent policymaking dysfunction, more "party blind" "auditioning" conditions in policy formulation may better balance and improve cooperative policymaking. we propose a leadership strategy of bipartisan inclusion in a presidential administration to encourage such a change. a bipartisan presidential candidacy has been variously proposed, advocated, and considered both recently and in the past (glover ; bowden ; troiano ; troiano and wheelan ) although this approach is arguably impractical. a late poll of new hampshire voters found that % said they would support their preferred candidate forming such a "unity ticket" of democratic and republican running mates ( % of democrats, % of independents, and % of republicans) (troiano ) . various observers, however, have argued against such proposals-or any form of unity in (shepard ; smith ) . many democrats now see the gop's leadership as incapable of meaningful compromise or "unity" (tomasky b), which calls for staunch political opposition and partisan elections, not "dreamy" calls for unity. for a candidate from either party, a unity ticket risks splitting party-line votes and handing easier victory to the opposingparty candidate (a large percentage of independent voters "lean" toward either republican or democrat based on gallup and pew research polling). the last unity ticket was seen in . thus, even centrist presidential candidates seem very likely to continue to avoid any bipartisan candidacy. bipartisan inclusion in a presidential administration after election does not require a unity ticket, however. a group of party candidates or a popular leading candidate can instead announce that if elected president, he or she will offer a policy-advising role to the losing-party candidate or other opposition-party leader(s) and include a diverse-party mixture of advisors overall in the new administration. this plan will seek a new form of governing social contract through presidential leadership, which requires no new laws. past administrations have retained in their leadership only a small number of opposing-party functionaries at times (typically holdovers). by including policy-experienced non-extremist leaders from both the winning and opposition parties on the same operational administration "team" with mutual interests in superordinate goals, this proximity in executive-branch policy formulation may lower the risk-adjusted costs and raise the mutual-party-leader payoffs of policymaking cooperation. resulting policy changes reflecting bipartisanship from the executive federalism of this new administrative state, and bipartisan-supported proposals from this new type of administration, could both enact more balanced and durable executive-branch policies and help change the public discourse to achieve more balanced and durable policymaking legislation. through this disruptive reframing, key national leaders could thus potentially be nudged (hallsworth and egan ) away from policy gridlock, toward greater trust, and into more productive and fact-based, effective and balanced policies and governance. the planned offer to losing opposition-party leadership should exclude any chronically uncivil, corrupt or untrustworthy, ruthlessly partisan, or aggressively extreme opposingparty candidate or leader (e.g., trump, or anyone with such a divisive approach)-who would not be suitable for any new bipartisan policymaking administration. the remaining democratic candidate, joe biden, could pursue this choice today, for example, excluding trump, but stating that if elected he will offer a policy-advising role to some of trump's past gop opponents, such as william weld, joe walsh, jeb bush, or john kasich. this general type of approach would: ( ) explicitly offer bipartisan policy-advising roles to trustworthy counterparties, ( ) isolate divisive leaders like trump (and other supportive enablers and noncooperators), ( ) encourage more preferred alternative non-divisive candidates and thinking in congress, and ( ) diminish the partisan reelection prospects of divisive leaders. a credibly unifying presidential candidate from either party could plan and pursue such an approach. under this approach, the election will still have policy consequences of course. while drawing on a more bipartisan diversity of viewpoints and advice, the elected president will still be the final decision maker within the new administration. the planned offer(s) to opposition-party leaders can most likely be advisory roles, or perhaps cabinet positions or similar suitable roles at times. (congress needs to confirm any opposition-party appointments but will likely do so after an election win for any candidate with such an announced bipartisan-leadership plan.) career subject matter experts across government who have historically served presidential administrations from both parties can be most effectively leveraged in teams with bipartisan leadership inclusion, although final decision makers at administrative levels (determining recommendations passed to higher-level leadership or smaller policy details in practice) may still be from the elected president's party or other leadership of the president's choosing. this new approach could begin a reframing of key party-leader interactions in policymaking. it does not require unity-ticket partners to join and campaign together, and it offers any new president flexibility in the offered policy-advising roles of opposing-party views. the approach signals a broader customizable commitment to bipartisanship. the general plan of offering a role after election to opposing-party leadership also does not waste potential "loyal opposition" leadership contributions in ideas and experience, as generally occurs in administrations following each winner-party-take-all election cycle. any new administration with bipartisan inclusion should be more than symbolic, and intelligently managed-the new president will be the final decision maker, but he or she should take clear steps to include bipartisan diverse views in decision making. ironically, given the common zero-sum views in policymaking circles today, a president leading in a disruptively bipartisan way could have more truly effective and lasting leadership power by sharing rather than hoarding the input flow through executive policymaking channels. policies and decisions formulated with bipartisan support are more likely to be politically robust and sustainable, and diversity and balance can avoid "group think," promote creativity, and achieve better decisions (janis ; tetlock ; mccauley ; whyte ; cialdini and goldstein ; paulus and nijstad ; hong and page ) . the most effective policymaking leverage of a new bipartisan-inclusion administration may be realized through two other pillars added to this approach. first, while bipartisan inclusion in executive-branch processes could help mend some of the systemic problems of public discourse today, breaking congressional stalemates for bipartisan-supported legislation may often require enough cooperative or centrist-bloc swing votes (wheelan (wheelan , . second, although it must be approached cautiously, the polluting effects of the rise of partisan media and spread of falsehoods may be countered with a re-establishment of some new modernized and carefully balanced form of the historical "fairness doctrine" in broadcasting (avlon ; matzko ; rendall ) . as with any disruptive organizational change (especially a cultural shift), bipartisan inclusion within the executive branch may face several transition and management challenges. nonetheless, american voters weary of dysfunctional divisions, trumpian-style antics, and the disturbing patterns and trends of poor policy and governance outcomes could come to support and generally prefer this type of electoral and governing approach in or some future year. although self-interest leads to mutual non-cooperation in a one-shot prisoner's dilemma game, if the game or situation is repeated many times over, or with collaboration or reputation effects with informational asymmetries, players typically cooperate conditionally, punishing defectors through tit-for-tat for example, and higher rates of cooperation tend to evolve and prevail contrary to the nash prediction (e.g. flood ; axelrod and hamilton ; axelrod ; axelrod and dion ; chong et al. ; kreps et al. ; stewart and plotkin ; seltzer ) . likewise, historical policymaking included greater cooperation. in recent decades the bipartisan norms of governance have substantially eroded as failures of cooperation have undermined or stymied the ability of policymakers to improve all of these approaches are complementary to further approaches to reducing the negative policymaking impacts from polarization and noncooperative governance. institutional remedies show promise despite being generally slow-moving changes or legislation (e.g., mann and ornstein ; weiser and bannon ; wheelan ). an important set of approaches seeks to address factors in the social psychology that sustain the sharp divisions and unwillingness or inability to effectively cooperate toward the advancement of larger common goals. these approaches focus on grass roots change in individual social responsibility, social activism, political activism, and social interactions to promote greater tolerance, fact-based assessments, and bipartisan dialogue (brooks ; hartle ; freedman ; haynes ). many governance outcomes-especially in larger or more significant and durable ways. a general explanation of cooperative failure, as suggested by stewart ( ) , is that cooperation fails when the ratio of costs to benefits becomes too high. conflict and debate can be productive within governing norms promoting cooperation. cooperation can draw on mutual tolerance of opposing political parties and perspectives as legitimate, searches for common ground, thoughtful tradeoffs, and trust under appropriate framing. disagreements, even with deep ideological divides (e.g. on the role of government), are vital to democracy and have tended toward compromise and balanced solutions throughout america's history. bitter partisanship and policymaking conflicts are not new, with historical precedents even from the nation's first decades that reflect through to present-day partisanship (heineman jr. ) . tensions between government policymakers became tempered through the traditions and norms of constitutional democracy and bipartisan procedural governance, which generally held following contentious elections. in recent decades this changed with the descent into "take-no-prisoners" politics (moss ; levitsky and ziblatt ) . the costly non-cooperative status-quo requires explanation, and many have been proposed. appeals to reason, unity, and patriotism have done little to assuage the divisive general pattern and its growth, despite the high policymaking and social costs. we describe explanations in three complementary views of an increased cost-benefit ratio of cooperation, which we call: unstable asymmetric zero-sum (the payoff structure has become more asymmetric, and republican leaders have adopted asymmetrically noncooperative initiatives), party-ideology polarization, and stag-hunt risk avoidance. non-cooperative outcomes have occurred more frequently due to more key participants treating this not as a repeated prisoner's dilemma (nonzero sum), but purely as a zerosum game centered around the election cycles, now reflected in nearly every policymaking choice. as relationships between leaders and the parties have become more adversarial, compromises-however rational and balanced-have tended to please no one from a political or policy perspective, making it very difficult to move compromise policies forward. policymaking choices conditional on "winning" or "losing" elections change over time, as shown in fig. . if republicans in power can push through their desired policies without any democratic ideas or votes, they generally don't need them, and they tend to view this as the best policy outcome for the country. democrats conversely and symmetrically believe that policies implemented in the democrats win/republicans lose box are the best achievable, with no balance or votes needed from republicans if that's what it takes while they are in power. the "sucker" payoff is different, reflecting who is in power and by how much; it corresponds in each case to the "lose" outcome for the party not in power and the "lose gain" outcome for the party in power, but the principle is the same. figure also includes a "cooperate-cooperate" outcome that occurs at times on "smaller" or less contested policy matters-some compromises where bipartisan governance does continue to reasonably function. the prisoner's dilemma payoff structure has become more asymmetric due to institutional, political, and societal changes, making the political policymaking process more like a zero-sum game, with higher incentives for "party domination." the prospect of election victory for president or a congressional majority offers the winner a considerable time for asymmetrically large payoffs from a dominant position. the growth over time of multiple policymaking powers concentrated in the "imperial presidency" and "executive federalism" has significantly enhanced the one-party-dominant policymaking potential gained through electoral victory of the presidency (schlesinger ; modie and curcy ; friedersdorf ; cost ; head a, b; blow ; thompson et al. ) . particularly when a party holds the white house and both houses of congress with sufficient party loyalty in votes, the losing party's acquiescent "cooperation" on opposed policy matters is guaranteed as the losing party can only "resist with insufficient power," e.g. in the recent-years' focus on political appointments to the judiciary. the incidence of cooperation depends significantly on the game's parameters. more asymmetric payoffs lower the likelihood and frequency of cooperation making cooperation unstable and less sustained (sheposh and gallo ; beckencamp et al. ; ahn et al ) . as the payoff structure has become more asymmetric, more combative non-cooperative strategies have emerged with political successes, further lowering cooperation. non-stop strategizing for electoral gains polarizes not just elections but the many processes of governance and policymaking, with countervailing unilateral obstructions, tit-for-tat non-cooperation, and power-play policymaking. repeated non-cooperation tends to follow any defection nearing the end of a finite game. trump's nonstop campaigning from the time of taking of office, for example, has heightened the reframing of governance as a nearing-end finite game. the general observation that "little gets done in an election year" now extends to almost every year. obstructions and power-play policymaking have long been tactics used by both parties; however, republican leaders, reflecting a larger extent of party polarization to the right (hacker ; thurber and yoshinaka ) and other factors, have taken such "hardball" or "win at all costs" tactics to new heights in systematic initiatives for the past years (barr ; lofgren lofgren , . before president obama even took office in , for example, republican leaders planned to continue a combative uncompromising approach begun by newt gingrich's gop-controlled house in the s-not just to politically pursue a november change in the congress, but to block nearly every policy proposal from the new white house, even an attempted "bipartisan" jobs bill in the depth of the great recession (lofgren (lofgren , coppin ) . before taking office in after a contested divisive election, president george w. bush pledged to be a "uniter not a divider," but he was subsequently told by gop house majority whip tom delay (a no republicans in the house and only three in the senate ultimately voted for a watered-down fiscal stimulus despite the ongoing severe recession. this ruthless political-strategizing intertemporal choice became more public in with mitch mcconnell's proclamation to make obama a one-term president and republican pledges for "no compromise" (barr ). footnote (continued) ( %), contrary to the nash prediction. the weaker party gained the most from the cooperation in the pattern that occurred. other tactics in congress and at the state level with gerrymandering strategies, etc. have been aggressively (and successfully) employed to enhance the prospects of longer-term overall one-party-dominant policymaking. unstable cooperation may also reflect other assumptions that have been challenged in ipd research and assessment, questioning the robustness of cooperative versus more ruthless strategies and raising doubts about the ipd as an explanation of cooperation in evolutionary outcomes, and questioning the usefulness of the prisoner's dilemma in empirical explanation (northcott and alexandrova ; arnold ; raihani and bshary ; linster ). gingrich ally), "we don't work with democrats. there'll be none of that uniter-divider stuff." advised by karl rove, bush largely abandoned bipartisanship and governed to satisfy the partisan right base, which was followed by tit-for-tat partisan democratic senate obstructions of bush's judicial nominees (levitsky and ziblatt ) . such actions have marked or made more visible a significant shift in the traditional social contract in policymaking that encouraged or allowed more bipartisanship. on the larger or more difficult policies or wherever strongly contested principles are involved, the party in power may choose procedural or effective non-cooperation (hold no hearings, no bipartisan fact finding, etc., or eventually proceed with unilateral preferences) in order to pass its most desired legislation using party-line votes. periods in which the same party has managed to win the presidency and both houses of congress have been limited, and party uniformity is not always a given. along with more modest bipartisan policy changes, only occasional enacted larger policy changes have escaped from legislative deadlock through unilaterally asserted power. counter policies or reversals when the political power balance shifts-as exemplified in the extreme by trump's reversals and undercutting of so many obama-era policies-result in non-cooperative deadlock in the longer term with whipsawing changes making it very difficult for longer-term public and private planners. policymaking in this repeated zero-sum context has resulted in polarized governance with a need for power-play policymaking to accomplish any major change or even basic governing functions. mann and corrado ( ) discuss the poor match of extreme polarization with the american constitutional system and separation of powers with constraints on majority rule. non-cooperative gop behavior persisted through obama's two presidential terms (compromises came close to passage in congress but could not move beyond obstructions from republican factions), leading to tit-for-tat presidential and democratic behavior. the general state of non-cooperative policy deadlocks and power plays has only grown through the trump years. gop-leader "successes" in obstructions and power-play policy changes have evolved the current gop-leadership strategy into refusing to allow democratic party leaders to effectively govern after they are elected, while waiting to aggressively pursue a power shift back to the gop for pursing gop-preferred policies. such "achievements" reinforce the asymmetry of the perceived payoff structure, with stronger incentives to obtain the dominant power-play policymaking position. many republicans, in addition to most democrats, have found the candidacy and presidency of donald trump "distasteful" at least, repulsive, or unacceptable (at least privately) in its incivility, divorce from facts, policymaking incompetence, and authoritarian extremism. in many ways, however, trump's tactics have been a grotesquely logical extension of the minority or non-dominant party can still have influence, where allowed, for example through legislative amendments (krehbiel et al. ) . the origins of the party-based asymmetry in policymaking behavior may reflect, for example: ( ) gop antipathy to "big government" (except for military spending) with a ruthless calculus that government dysfunction benefits republican as opposed to democratic policy preferences (lofgren ); ( ) policy problems creating more demands for government action, which republicans generally prefer to oppose; ( ) differences in personality-type and civics across the parties (including the styles of party leaders), e.g. more judging assertive or persistent types among republicans or conservatives and more agreeableness among those with left-wing orientation (drenth ; darrell ; furnham and fenton-o'creevy ) ; allgood et al ( ) found economics majors more likely to be republicans, while in prisoner's-dilemma experiments frank, et al ( ) found that studying economics as an undergrad may inhibit cooperation; ( ) gop party leaders anxious to "leave their mark" on history; and ( ) long-term urbanization, industrial shifts, and changing demographics and societal practices that have typically aligned more with the democratic party, threatening traditional republican societal preferences and comfort with the past. combative noncooperative strategies. the continued support of the gop party structure in addition to trumpian loyalists reveals both the strength of republican leaders' "win at all costs" policymaking resolve and the depths of "us-versus-them" party ideology. despite posturing about the needs for bipartisanship to address unmet policy needs, the incentives for party loyalty and adherence to party ideology add significantly to partisans' incentives to "win" uncompromisingly on policy views (thurber and yoshinaka ). the group behavior has ideological or identity driven battle-promoting characteristics that differ from a simple sum of individuals. the need to belong, affiliate, reinforce, and elevate one's group is a strong psychological motivation (baumeister and leary ) . social identities and the biology of groups (hornung et al. ; forsyth ) incline policymakers toward conformity with party policy views, party loyalty, party-affiliated campaign themes and public expressions, and party-line voting (bernheim ; cialdini and goldstein ; berns et al ; yu and sun ; close ; harell ; cherry ) . financial incentives in party-driven or inspired fundraising and ideological views within parties add strong practical constraints against centrist moderation (mann and corrado ; o'donnell ; gehl and porter ; tomasky a) . penalties for non-conformity make it difficult for independent candidates to compete. perceived needs to satisfy the "party base" to stay in power push political decision-makers to conform even where it contradicts a policymaker's principles. in this type of explanation, consistent with the first, polarization has reframed most policymaking discourse not around policy substance and tradeoffs but as a zero-sum game, with whatever policy gains or changes the left (right) achieves characterized as losses of the right (left) (easley et al. ) . polarized identities with intolerance of "others," mistrust, and lowered willingness to negotiate and compromise over opposing policy viewpoints have grown, as have more extreme and caustically expressed political views, elevated by accommodative media coverage of policymaking fights or "battles." trends of politicized evidence and willful ignorance (perl et al. ; paul and haddad ) have helped to fuel negative partisan views of the "other side" with their "bad people" and "dangerous ideas" (theodoridis ; hetherington and rudolph ) , strangely inventive conspiracy theories, and partisan denials and disagreements on simple facts (dunning ) . low turnout in party primaries and ideologically driven voters have advantaged more extremist candidates with a limited but more mobilized base of support, resulting in a hollowing out of lawmakers with more centrist views in congress (wheelan ; gehl and porter ; mann and ornstein ) . many potential improvements in policy today have effectively become held hostage to the extremes of both parties and a stifled competition of ideas for more creative balanced policy solutions (alberta ; brooks a, b, ). the trumpian presidential approach has joined with the other previous and ongoing strands of non-cooperative gop power assertion to further deepen the political divides and loss of trust in policymaking discourse, often justified through odd concoctions from right-wing media, fueling outrage on the left, and leaving a steady barrage of negative partisanship and "our story versus theirs" portrayals. over a decade ago, psychologists pointed to the importance of prominent repeated divisive communications in simplistic characterizations like "red and blue states," arguing this would exacerbate social divisions (seyle and newman ) . words, and especially repeated divisive words, matter, a factor central to trump's political messages and methods. the confluence of technology, media, social, business, political, and communication factors can now be described as a "perfect storm" amplifying today's political divisions (evans ). partisan media feeding, and feeding on, conflict has grown into a big business now symbiotically and ominously aligned on one side with trump's political interests (avlon ) . conformity has been found to lower perceptions of the truth (asch (asch , (asch , berns et al ) and increase polarization in attitudes (moscovici and zavalloni ) . neuro-cognitive inclinations and a more uncertain environment incline individuals toward a greater extent of views and decisions conforming with the common behavior of the group (henderson ; fox ; grene ) . many voters may care more about their social identities than the particulars of any ideology, affecting coalitional views within both parties (bacon jr. ) . a more uncertain environment may also tend to incline individuals toward preferring a dominant leader, even a polarizing one (kakkar and sivanathan ) . kavanagh and rich ( ) concluded that, compared with earlier historical periods of "truth decay" (the s- s, s- s, and s- s) , the last two decades have seen a similar blurring between opinion and fact, and similar growth and influence of opinion, but a deeper loss of confidence in major institutions, and more disagreement about facts and interpretations. with orwellian lies and counterattacks now regularly assaulting facts, truth, and the mainstream media from the highest office today ( in the excesses of the trump era, the marks of authoritarianism with power-play policymaking have become clear. enough votes against mainstream candidates empowered through the primaries and electoral college a new type of president even though he was viewed by many as a "deeply flawed and clearly unfit demagogue" (dionne et al. ). unlike past presidents, apart from occasional speeches scripted by others, trump has made no attempt and shown no capacity for uniting the country or actually "making policy deals," but instead has become a twitter-message divider in chief. nonetheless, he has retained strong percentage support within the republican base-although this firm base is not a particularly large share of all americans. past american demagogues such as stretched political and policy-outcome narratives have long played out in political "spin," especially during election years. in recent years, however, negative partisanship has dominated partisan media and policymaking practice, leading to trump's unprecedented falsehoods and obfuscation of facts. authoritarian tendencies are not just a u.s. phenomenon, as recent events in britain have shown, for example, with boris johnson's move seeking to suspend parliament at the critical september-october brexit juncture. protest voting against mainstream politicians has continued to emerge in many other countries as well. self-reported republicans and democrats have become minority groups in gallup polling, hovering generally around - % for republicans, and - % for democrats. problems from the iraq war, the financial crisis, other policy-related problems, and policy gridlock have been significant factors taking down the percentages of self-reported republicans since , and the percentages identifying as affiliated with either party. since and especially since , self-reported independents have clearly become the largest, hovering in recent years generally between and %, reflecting dissatisfaction with the two parties or party leaders. with independents asked how they "lean," toward democrat or republican, added in, a tendency toward party conformity is much higher, in recent years around - % toward the democratic party and about - % toward republican. these totals may be inflated by the nature of the gallup question (only two choices), however, and even the sum of these two totals has declined over time from about - % to - %. a striking example occurred in the opposed public views of republican and democratic leaders concerning trump's multiple actions in the ukranian arms-for-investigations-of-opponents shakedown culminating in his remaining in office despite impeachment. huey long in the s and george wallace in the s were effectively screened by party gatekeepers, but traditional party "guardrails" against demagogic autocratic extremism have failed to contain trump (levitsky and ziblatt ) . gop tolerance of trump has reflected "ideological collusion" (ermakoff ) through sufficient overlap with the mainstream gop's agenda. policy deadlock through stalemates and alternating parties in power has become widely recognized, but "winner take all" strategies for party dominance coupled with "illusory superiority bias" (ghose ) may cause "predictably irrational" expectational and confirmation biases (ariely ; jerit and barabas ; wason ) with leaders from both parties believing that they can, should and will win more policy changes through successive elections than they actually do win over time. a condition of a prisoner's dilemma may be violated-that the players should not find it better to "take turns" exploiting each other. the payoff for mutual cooperation should be greater than the approximate average of the payoff for the temptation and sucker (chong et al. , chp. ) . this condition is not satisfied if party leaders generally believe that, in a more-or-less alternating sequence, they can achieve more in power, and later lose less out of power. other cognitive biases conditioned by party loyalty may create 'noise' that interrupts behavioral signals of reciprocating cooperation and further lowers perceptions of potential routes to balance and compromise (jerit and barabas ; wason ; molander ) . by many measures, polarization has increased over time (boxell et al. ) , and it may be significantly more concentrated within the political leadership than in the public at large (stein ) . training and traditions in the law and legal representations have taught many policymakers to think in terms of zealous advocacy for the "client" (in this case, the party's policy position) and a zero-sum win-or-lose game. another reason for such concentrated polarization may reflect the basic neuropsychological need for party leaders to respond most, and answer to their more extreme party wings and dogmatic adherents (zmigrod ) when most mobilized, by cases of identified versus statistical lives (cohen et al. )-a key reason why political campaigns highlight identified-life cases rather than dry statistical policy tradeoffs. with concentrated leadership polarization, so long as partisan warfare continues, policymaking leaders may feel largely compelled to endlessly seek "zero-sum" dominance or the upper hand rather than striving for more productive bipartisan balance and compromise-even as the public continues to lose trust in this policymaking process. feldman and stenner ( ) and stenner ( ) , for example, describe the associated personality traits of a predisposition toward authoritarianism. rauch ( ) similarly describes 'politiphobes' who believe that meaningful policy disagreements don't even exist and obvious policy solutions (the sorts they prefer) are not enacted because politicians are corrupt, self-interested, or addicted to unnecessary partisan feuding. weiler ( ), macwilliams ( ) , taub ( ) and jacobs ( ) , for example, have described the associated factors as the rise of american authoritarianism, rooted in psychological tendencies desiring order and fearing outsiders or normative threat. pettigrew ( ) describes the corresponding and related social psychological perspectives on trump supporters, and ongstad ( ) describes trump's brand of uniquely "american authoritarian" actions. trump's brazenly asking for supportive election meddling by foreign governments and apparently "getting away with it" further encourages the gop's "win at any cost" partisan beliefs and behavior and incents democratic leaders and strategists to respond with noncooperation. political policymaking can alternatively be viewed as a stag hunt game, as illustrated in figs. and . in a group of hunters waiting quietly for the larger prize of stags, each hunter is incented individually to go after the hare, to obtain something to eat sooner and at lower risk, but also spoiling the stag hunt. in the non-cooperative nash equilibrium, the hunters subsist on rabbits, but they miss out on the stags for all to share ( each). this is an individually optimal but socially suboptimal state of nature, calling for a social contract. likewise, democrats and republicans do not know if or when the serious possibility of larger, meaningful, but very difficult progress on cooperation and compromise between their divergent policy preferences might show up in any particular large but neglected or problematic policy area, allowing more productive and lasting policy solutions, or if such possibility will ever truly appear. there is both a highly productive cooperative equilibrium ( , ), and a much less productive non-cooperative equilibrium ( , ). unlike the prisoner's dilemma, where the individual party's self-interest best outcome at each move is always in the defect or cheat strategy attempting to try to exploit the other party, in the stag hunt each party leader should tend to recognize that they may ultimately obtain an even larger payoff not just for the collective but for themselves individually over time if they can only somehow agree on cooperation that is enforceable. the best responses for each party leader are clearly to cooperate in response to cooperation, and cheat or defect in response to cheating. after recurring rounds of cheating (and alleged cheating) to try to exploit the other party (with the , or , payoff temporarily), however, each side finds that the non-cooperative equilibrium generally prevails with the illustrative ( , ) average payoffs for each party in the non-cooperative equilibrium. the better larger policy solutions from the alternative cooperative equilibrium remain largely unobtainable. mutual cooperation is an alternative nash equilibrium due to its potential larger gains for all. republican and democratic policymakers find this unobtainable, however, because they are risk averse and have become increasingly uncertain about the prospects for larger, meaningful, but very difficult progress on cooperation and compromise between their divergent policy views. even where risk aversion is lower, due to ambiguity effects policymakers avoid more prolonged negotiating choices with ambiguous or unknown outcomes (frisch and baron ) . untrustworthy and mercurial negotiating tactics, such as exhibited repeatedly by trump in congressional dealings, further forestall any cooperative policymaking progress. cooperative outcomes are "payoff dominant," but non-cooperative outcomes are "risk dominant" (harsanyi and selten ) . non-cooperation dominates by being the safer option (golman and page ) . without a reasonably successful social contract to encourage or enforce greater cooperation (skyrms (skyrms , , cooperative policy outcomes are persistently thwarted, especially on larger or more difficult issues. the traditional social contract, following partisan elections, encouraged more cooperation through bipartisan problem-solving and negotiation traditions and procedures in governance (foran ; rauch ; moss ; levitsky and ziblatt )-as resulted, for example, in the reagan-o'neill social security deal of (dallek ). although the stag hunt view allows for a stable equilibrium of policymaking cooperation, it does not solve the problem of cooperation since there is also the non-cooperative equilibrium (skyrms ) . a cooperative equilibrium requires that enough policymakers from both parties somehow agree to negotiate in good faith, agree to compromise, and agree to "hunt" the larger more lasting bipartisan policy improvements through consistent mutually practiced cooperation. learning is a complex topic in game theory social dilemmas, and fear of a greater loss in the "sucker" payoff may have risk aversion effects primarily through fear of large losses (macy and flache ; izquierdo et al ) . the avoided risks of cooperation may be less in the costs of thwarted policy gains and more in fear of larger "sucker" payoffs from compromise allowing policy changes that cannot later be undone, or from future electoral loss. this is a rational response to actual, perceived, or claimed partisan or extremist exercises of power. "win at all costs" non-cooperative partisanship as a strategy makes opposing party leaders ever more risk averse against loss, ever more inclined to avoid compromise. re-establishing trust between party leaders becomes increasingly difficult. ipd research by press and dyson ( a, b) , as described in edge.org ( ), implies that opposing players can maximize their mutual scores through a cooperative "treaty." cooperate versus defect in political dysfunction can be viewed as "peace or war." agreeing to compromise also requires a sense of humility on policy views and willingness to work very hard to reach acceptable tradeoffs, despite many unpredictable challenges. the complementary explanations described above imply that despite the high and growing social costs, the non-cooperative policymaking equilibrium has become self-reinforcing within and across the opposing party groups psychologically, politically, and financially (e.g. turner ; hornung et al. ; gehl and porter ; levitsky and ziblatt ) . it cannot be assumed that leaders simply acting rationally rather than emotionally will solve this problem-the problem is fundamentally a failure of rationality under the current conditions. the limits of rationality do not end with an intractable prisoner's dilemma, however, as suggested by the stag hunt view, which is an important conceptual shift. in the prisoner's dilemma, policy beliefs and incentives to "win" tend toward every actor defecting, and a winner-take-all mentality, while a re-establishment of cooperation requires a success of higher-order strategies, such as tit-for-tat or alternatives (axelrod ; wu and axelrod ) , which may not be possible or sustainable. in the stag hunt, players are incented to cooperate provided that enough others do so as well. the choice to not cooperate is clearly sub-optimal for all in the long run, with usually only shortterm gains, even though it dominates by being the safer option. party partisans differ of course on the large non-cooperative policy battles in recent years, but few can deny the sad state of overall affairs, as reflected on by departing senators in (foran ) . social suboptimality persists fundamentally because of the perceived high risk-adjusted cost-benefit ratio of cooperation. this implies that institutional changes to promote cooperation should focus on overcoming its risks, i.e. lowering the risk-adjusted cost-benefit ratio, making cooperation safer and more attractive for policymakers. new institutional conditions to encourage more trust and fewer divergent incentives in key political relationships, which can lower the perceived cost and raise the perceived benefit, are needed for greater policymaking cooperation to become individually rational for each party leader. the proposed new presidential administration with bipartisan leadership inclusion in policymaking takes this approach. reframing the partisan divides in this way would seek to counter negative partisanship and extremes, 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prisoner's dilemma to conform or not to conform: spontaneous conformity diminishes the sensitivity to monetary outcomes nancy pelosi is making a big mistake on impeachment the partisan brain: cognitive study suggests people on the left and right are more similar than they think. the conversation key: cord- -oaqqh e authors: georgalakis, james title: a disconnected policy network: the uk's response to the sierra leone ebola epidemic date: - - journal: soc sci med doi: . /j.socscimed. . sha: doc_id: cord_uid: oaqqh e this paper investigates whether the inclusion of social scientists in the uk policy network that responded to the ebola crisis in sierra leone ( – ) was a transformational moment in the use of interdisciplinary research. in contrast to the existing literature, that relies heavily on qualitative accounts of the epidemic and ethnography, this study tests the dynamics of the connections between critical actors with quantitative network analysis. this novel approach explores how individuals are embedded in social relationships and how this may affect the production and use of evidence. the meso-level analysis, conducted between march and june , is based on the traces of individuals' engagement found in secondary sources. source material includes policy and strategy documents, committee papers, meeting minutes and personal correspondence. social network analysis software, ucinet, was used to analyse the data and netdraw for the visualisation of the network. far from being one cohesive community of experts and government officials, the network of people was weakly held together by a handful of super-connectors. social scientists’ poor connections to the government embedded biomedical community may explain why they were most successful when they framed their expertise in terms of widely accepted concepts. the whole network was geographically and racially almost entirely isolated from those affected by or directly responding to the crisis in west africa. nonetheless, the case was made for interdisciplinarity and the value of social science in emergency preparedness and response. the challenge now is moving from the rhetoric to action on complex infectious disease outbreaks in ways that value all perspectives equally. global health governance is increasingly focused on epidemic and pandemic health emergencies that require an interdisciplinary approach to accessing scientific knowledge to guide preparedness and crisis response. of acute concern is zoonotic disease, that can spread from animals to humans and easily cross borders. the "grave situation" of the chinese coronavirus (covid- ) outbreak seems to have justified these fears and is currently the focus of an international mobilisation of scientific and state resources (wood, ) . covid- started in wuhan, the capital of china's hubei province and has been declared a public health emergency of international concern (pheic) by the world health organisation (who). the interactions currently taking place, nationally and internationally between evidence, policy and politics, are complex and relate to theories around the role of the researcher as broker or advocate and the form and function of research policy networks (pielk, ) and (ward et al., ) and (georgalakis and rose, ) . in this paper i seek to explore these areas further through the lens of the uk's response to ebola in west africa. this policy context has been selected in relation to the division of the affected countries between key donors. the british government assumed responsibility for sierra leone and sought guidance from health officials, academics, humanitarian agencies and clinicians. the ebola epidemic that struck west africa in has been described as a "transformative moment for global health" (kennedy and nisbett, , p. ) , particularly in relation to the creation of a transdisciplinary response that was meant to take into account cultural practices and the needs of communities. the mobilisation of anthropological perspectives towards enhancing the humanitarian intervention was celebrated as an example of research impact by the uk's economic and social research council (esrc) and department for international development (dfid) (esrc, ). an eminent group of social scientists called for future global emergency health interventions to learn from this critical moment of interdisciplinary cooperation and mutual understanding (s. a. abramowitz et al., ) . however, there has been much criticism of this narrative, ranging from the serious https://doi.org/ . /j.socscimed. . received august ; received in revised form february ; accepted february * director of communications and impact, institute of development studies university of sussex, library road, falmer, brighton, bn re, uk. e-mail addresses: j.georgalakis@ids.ac.uk, mjcg @bath.ac.uk. available online february - / crown copyright © published by elsevier ltd. all rights reserved. t doubts of some anthropologists themselves about their impact (martineau et al., ) , to denouncements of largely european and north american anthropologists' legitimacy and the utility of their advice (benton, ) . there are two questions i hope to address through a critical commentary on the events that unfolded and with social network analysis of the uk based research and policy network that emerged: i) how transformational was the uk policy response to ebola in relation to changes in evidence use patterns and behaviours? ii) how does the form and function of the uk policy network relate to epistemic community theory? the first question will explore the degree to which social scientists and specifically anthropologists and medical anthropologists, were incorporated into the uk policy network. the second question seeks to locate the dynamics of this network in the literature on network theory and the role of epistemic communities in influencing policy during emergencies. the paper does not attempt to evidence the impact of anthropology in the field or take sides in hotly debated issues such as support for home care. instead, it looks at how individuals are embedded in social relationships and how this may affect the production and use of evidence (victor et al., ) . the emerging field of network analysis around the generation and uptake of evidence in policy, recommends this critical realist constructivist methodology. it utilises interactive theories of evidence use, the study of whole networks and the analysis of the connections between individuals in policy and research communities (nightingale and cromby, ; oliver and faul, ) . although ebola related academic networks have been mapped, this methodological approach has never previously been applied to the policy networks that coalesced around the international response. hagel et al. show how research on the ebola virus rapidly increased during the crisis in west africa and identified a network of institutions affiliated through co-authorship. unfortunately, their data tell us very little about the type of research being published and how it was connected into policy processes (hagel et al., ) . in contrast, this paper seeks to inform the ongoing movements promoting interdisciplinarity as key to addressing global health challenges. zoonotic disease has been the subject of particular concerns around the, "connections and disconnections between social, political and ecological worlds" (bardosh, , p. ) . with the outbreak of covid- in china at the end of , its rapid spread overseas and predictions of more frequent and more deadly pandemics and epidemics in the future, the importance of breaking down barriers between policy actors, humanitarians, social scientists, doctors and medical scientists can only increase with time. before we look at detailed accounts of events relating to the uk policy network, first we must consider what the key policy issues were relating to an anthropological response versus a purely clinical one. anthropological literature exists, from previous outbreaks, documenting the cultural practices that affected the spread of ebola (hewlett and hewlett, ) . the main concerns relate to how local practices may accelerate the spread of the virus and the need to address these in order to lower infection rates. ebola is highly contagious, particularly from contamination by bodily fluids. in west africa, many local customs exist around burial practices that clinicians believe heighten the risk to communities. common characteristics of these are, the washing of bodies by family members, passing clothing belonging to the deceased to family and the touching of the body (richards, ) . another concern, as the crisis unfolded, was people attempting to provide home care to victims of the virus. the clinical response was to create isolation units or ebola treatment units (etus) in which to assess and treat suspected cases (west & von saint andré-von arnim, ) . community based care centres were championed by the uk government but their deployment came late and opinion was divided around their effectiveness. clinicians regarded etus as an essential part of the response and wanted to educate people to discourage them from engaging in what they regarded as deeply unsafe practices, including home care (walsh and johnson, ) and (msf, ) . anthropologists with expertise in the region focused instead on engaging communities more constructively, managing stigma and understanding local behaviours and customs (fairhead, ) , (richards, b) and (berghs, ) . anthropologist, paul richards, argues that agencies' and clinicians' lack of understanding of local customs worsened the crisis (richards, ) and that far from being ignorant and needing rescuing from themselves, communities had coping strategies of their own. his studies from sierra leone and liberia relate how some villages isolated themselves, created their own burial teams and successfully protected those who came in contact with suspected cases with makeshift protective garments (richards, a) . anthropologists working in west africa during the epidemic prioritised studies of social mobilisation and community engagement and worked with communities directly on ebola transmission. sharon abramowitz, in her review of the anthropological response across guinea, liberia and sierra leone, provides examples from the field work of chiekh niang (fleck, ) , sylvain faye, juliene anoko, almudena mari saez, fernanda falero, patricia omidian, several medicine sans frontiers (msf) anthropologists and others (s. abramowitz, ) . however, abramowitz argues that learning generated by these ethnographic studies was largely ignored by the mainstream response. however, not everyone has welcomed the intervention of the international anthropological community. some critics have argued that social scientists in mostly european and north american universities were poorly suited to providing sound advice given their lack of familiarity with field-based operations. adia benton suggests that predominantly white northern anthropologists have an "inflated sense of importance" that led them to exaggerate the relevance of their research. this in turn helped reinforce concepts of "superior northern knowledge" (benton, , p. ). this racial optic seems to contradict the portrayal of plucky anthropologists being the victims of knowledge hierarchies that favour other knowledges over their own. our focus here, on the mobilisation of knowledge from an international community of experts, recommends that we consider how this can be understood in relation to group dynamics as well as individual relationships. particularly relevant is peter haas' theory of epistemic communities. haas helped define epistemic communities and how they differ from other policy communities, such as interest groups and advocacy coalitions (haas, ) . they share common principles and analytical and normative beliefs (causal beliefs). they have an authoritative claim to policy relevant expertise in a particular domain and haas claims that policy actors will routinely place them above other interest groups in their level of expertise. he believes that epistemic communities and smaller more temporary collaborations within them, can influence policy. he observes that in times of crisis and acute uncertainty, policy actors often turn to them for advice. the emergence of an epistemic community focused on the uk policy response was framed by the division of the affected countries between key donors along historic colonial lines. namely, the uk was to lead in sierra leone, the united states in liberia and the french in guinea. this seems to have focused social scientists in the uk on engaging effectively with a government and wider scientific community who seemed to want to draw on their expertise. this was a relatively close-knit community of scholars who already worked together, co-published and cited each other's work and in many cases worked in the same academic institutions. crucially, their ranks were swelled by a small number of epidemiologists and medical anthropologists who shared their concerns. from the time msf first warned the international community of an unprecedented outbreak of ebola in guinea at the end of march , it was six months before an identifiable and organised movement of social scientists emerged (msf, ) . things began to happen quickly when the who announced in early september of that year that conventional biomedical responses to the outbreak were failing (who, a) . this acted like a siren call to social scientists incensed by the reported treatment of local communities and the way in which a narrative had emerged blaming local customs and ignorance for the rapid spread of the virus. british anthropologist, james fairhead, hastily organised a special panel on ebola at the african studies association (asa) annual conference, that was taking place at the university of sussex (uos) on the september , . amongst the panellists were: anthropologist melissa leach, director of the institute of development studies (ids); audrey gazepo, university of ghana, medical anthropologist melissa parker from the london school of hygiene and tropical medicine (lshtm); anthropologist and public health specialist, anne kelly from kings college london and stefan elbe, uos. informally, after the conference, this group discussed the idea of an online repository or platform for the supply of regionally relevant social science (f. martineau et al., ) . this would later become the ebola response anthropology platform (erap). in the days and weeks that followed it was the personal and professional connections of these individuals that shaped the network engaging with the uk's intervention. just two days after the emergency panel at the asa, jeremy farrar, director of the wellcome trust, convened a meeting of around public health specialists and researchers, including leach, on the uk's response to the epidemic. discussions took place on the funding and organisation of the anthropological response. the government was already drawing on the expertise and capacity of public health england (phe), the ministry of defence (mod) and the department of health (doh), to drive its response but social scientists had no seat at the table. the government's chief medical officer (cmo) sally davies called a meeting of the ebola scientific assessment and response group (esarg), on the th september, focused on issues which included community transmission of ebola. leach's inclusion as the sole anthropologist was largely thanks to farrar and chris whitty, dfid's chief scientific advisor (m leach, ). there was already broad acceptance of the need for the response to focus on community engagement and the who had been issuing guidance on how to engage and what kind of messaging to use for those living in the worst affected areas (who, c) . in their account of these events three of the central actors from the uk's anthropological community describe how momentum gathered quickly and that: "it felt as if we were pushing at an open door" (f. martineau et al., , ) . by the following month, the uk's coalition government was embracing its role as the leading bilateral donor in sierra leone and wanted to raise awareness and funds from other governments and foundations. a high level conference: defeating ebola in sierra leone, had been quickly organised, in partnership with the sierra leone government, at which an international call for assistance was issued (dfid, ) . it was shortly after this that the cmo, at the behest of the government's cabinet office briefing room (cobra), formed the scientific advisory group for emergencies on ebola (sage). by its first meeting on the october , , british troops were on the ground along with volunteers from the uk national health service (nhs) (stc, ). leach was pulled into this group along with most of the members of esarg that had met the previous month. it was decided in this initial meeting to set up a social science sub-group including whitty, leach and the entire steering group of the newly established erap (sage, a). this included not just british-based anthropologists but also paul richards and esther mokuwa from njala university, sierra leone. from this point anthropologists appeared plugged into the government's architecture for guiding their response. there were several modes for the interaction between social scientists and policy actors that focused on the uk led response. firstly, there were the formal meetings of committees or other bodies that were set up to directly advise the uk government in london. secondly, there were the multitude of ad-hoc interactions, conversations, meetings and briefings, some of which were supported with written reports. then, there was the distribution of briefings, reports and previously published works by erap which included use of the pre-existing health, education advice and resource team (heart) platform, which already provided bespoke services to dfid in the form of a helpdesk (heart, ). erap was up and running by the th october and during the crisis the platform published around open access reports which were accessed by over , users (erap, ). there were also a series of webinars and workshops and an online course (lshtm, ) . according to ids and lshtm's application to the esrc's celebrating impact awards (m. leach et al., ) , the policy actors that participated in these interactions included: uk government officials in dfid's london head quarters and its sierra leone country office, in the mod and the government's office for science (go-science). closest of all to the prime minister and the cabinet office was sage. they also communicated with international non-governmental organisations (ingos) like help aged international and christian aid who requested briefings or meetings. erap members advised the who via three core committees, as well as the united nations mission for ebola emergency response (unmeer) and the united nations food and agricultural organisation (unfao). by the end of the crisis members of erap had given written and oral evidence to three separate uk parliamentary inquiries. these interactions were not entirely limited to policy audiences. erap members also contributed to the design of training sessions and a handbook on psychosocial impact of ebola delivered to all the clinical volunteers from the nhs prior to their deployment from december onwards (redruk, ). the way in which anthropologists engaged in policy and practice seemed to reflect an underlying assumption that they would work remotely to the response and engage primarily with the uk government, multilaterals and ingos. a strength of this approach, apart from the obvious personal safety and logistical implications, was that anthropologists enjoyed a proximity to key actors in london. face to face meetings could be held and committees joined in person (f. martineau et al., ) . a good example of a close working relationship that required a personal interaction were the links built with two policy analysts working in the mod. not even dfid staff had made this connection and it was thanks to a member of the erap steering committee that one of these officials was able to join the sage social science subcommittee and provide a valuable connection back into the ministry (martineau et al., ) . with proximity to the uk government in london came distance from the policy professionals and humanitarians in sierra leone. just % of erap's initial funding was focused on field work. although, this later went up and comparative analysis on resistance in guinea and sierra leone and between ebola and lassa fever was undertaken (wilkinson and fairhead, ) , as well as a review of the disaster emergency committee (dec) crisis appeal response (oosterhoff, ) . there was also an evaluation of the community care centres and additional funding from dfid supported village-level fieldwork by erap researchers from njala university, leading to advice to social mobilisation teams. nonetheless, the network's priority was on giving advice to donors and multilaterals, albeit at a great distance from the action. this type of intervention has not escaped accusations of "armchair anthropology" (delpla and fassin, ) in (s. abramowitz, , p. ). rather than relying solely on this qualitative account, drawn largely from those directly involved in these events, social network analysis (sna) produces empirical data for exploring the connections between individuals and within groups (crossley and edwards, ) . it is a quantitative approach rooted in graph theory and covers a range of methods which are frequently combined with qualitative methods (s. p. borgatti et al., ) . in this case, the network comprises of nodes who are the individuals identified as being directly involved in some of the key events just described. a second set of nodes are the events or interactions themselves. content analysis of secondary sources linked to these events provides an unobtrusive method for identifying in some detail the actors who will have left traces of their involvement. sna allows us to establish these actors' ties to common nodes (they were part of the same committee or event or contributed to the same reports.) furthermore, we can assign non-network related attributes to each of our nodes such as gender, location, role and organisation affiliation type. not only does this approach provide a quantitative assessment of who was involved and through which channels but the mathematical foundations of sna allow for whole network analysis of cohesion across certain groups. you may calculate levels of homophily (the tendency of individuals to associate with similar others) between genders, disciplines and organisational type and identify sub-networks and the super-connectors that bridge them (s. p. borgatti et al., ) . the descriptive and statistical examination of graphs provides a means with which to test a hypothesis and associated network theory that is concerned with the entirety of the social relations in a network and how these affect the behaviour of individuals within them (stovel and shaw, ) and (ward et al., ) . the quantitative analysis of secondary sources was conducted between march and june , utilising content analysis of artefacts which included reports, committee papers, public statements, policy documentation and correspondence. sna software, ucinet, was used to analyse nodes and ties and netdraw for the visualisation of the network (s. and (s. . the source material is limited to artefacts relating to the uk government's response to the ebola outbreak in ii) the apparent prominence or influence of these groups on the uk's response to the crisis, iii) the remit of these groups to focus on the social response, as opposed to the purely clinical one. tracing the events and policy moments which reveal how individual social scientists engaged with the ebola crisis from mid- requires one to look well beyond academic literature. whilst some of this material is openly available, a degree of insider knowledge is required to identify who the key actors were and the modes of their engagement. this is partly a reflection of a sociological approach to policy research that treats networks, only partially visible in the public domain, as a social phenomenon (gaventa, ) . the calculation of network homogeneity (how interconnected the network is), the identification of cliques or sub-networks and the centrality of particular nodes, can be mathematically stable measures of the function of the network. however, the reliability of this study mainly resides on its validity. the assignment of attributes is in some cases fairly subjective. whereas gender and location are verifiable, the choice of whether an individual is an international policy actor or a national policy actor must be inferred from their official role during the crisis period. sometimes this can be based on the identity of their home institution. given dfid's central focus on overseas development assistance, its officials have been classified as internationals, rather than nationals. in some cases, individuals may be qualified clinicians or epidemiologists but their role in the crisis may have been primarily policy related and not medical or scientific. therefore, they are classified as policy actors not scientists. other demographic attributes could have been identified such as race and age which would have enabled more options for data analysis. a key factor here is the use of a two mode matrix that identifies connections via people participating in the same events or forums, rather than direct social relationships such as friendship. therefore, measurement validity is largely determined by whether connections of this type can be used to determine how knowledge and expertise flow between individuals. to mitigate the risk that this measurement fails to capture knowledge exchange toward policy processes, particular care was taken with the sampling of focal events used to generate the network. the majority of errors in sna relate to the omission of nodes or ties. fig. sets out the advantages and disadvantages of each of the selected events and the data artefacts used to identify associated individuals. i am aware that some critics might take exception to my choice of network. it is sometimes suggested that by focusing on northern dominated networks or the actions of bilaterals and multilaterals, you simply reinforce coloniality and a racist framing of development and aid (richardson et al., ) and (richardson, ) . however, there is a valid, even essential, purpose here. only by seeking to understand the politics of knowledge and the social and political dynamics of global health and humanitarian networks can we challenge injustice and historically reinforced narratives that favour some perspectives over others. the secondary sources identify unique individuals, all but five of whom can be identified by name. four types of attribute are assigned to these nodes: gender, location (global north or south), organisation type and organisational role. attributes have been identified through an internet search of institutional websites, linkedin and related online resources. role and organisation type are recorded for the period of the crisis. the total number of nodes given at the bottom of fig. is slightly lower due to the anonymity of five individuals whose gender and role could not be established. looking at this distribution of attributes across the whole network one can make the following observations in relation to how prominently different characteristics are represented: i. females slightly outnumber males in the social science category but there are twice as many male 'scientists other' than female. they are a combination of clinicians, virologists, epidemiologists and other biomedical expertise. ii. there are just nine southern based nodes out of a total of and none of these are policy makers or practitioners. this is racially and geographically a northern network with just a sliver of west african perspectives. these included, yvonne aki-sawyerr, veteran ebola campaigner and current mayor of freetown, four academics from njala university and development professionals working in the sierra leone offices of agencies such as the unfao. iii. although 'scientists other' only just outnumber social scientists this is heavily skewed by one of the eight interaction nodesthe lessons for development conferencewhich was primarily a learning event and not part of the advisory processes around the response. many individuals who participated in this event are not active in any of the other seven interactions. if we remove these non-active nodes from the network, you get just social scientists compared to 'scientist other'. the remaining core policy network of individuals appears to be weighted towards the biomedical sciences. netdraw's standardised graph layout algorithm has been used in fig. to optimise distances between nodes which helps to visualise cohesive sub-groups or sub-networks and produces a less cluttered picture (s. . however, it should be noted that graph layout algorithms provide aesthetic benefits at the expense of attribute based or values based accuracy. the exact length of ties between nodes and their position do not correspond exactly to the quantitative data. we can drag one of these nodes into another position to make it stand out more clearly without changing its mathematical or sociological properties (s. p. borgatti et al., ) . we can see in this graph layout the clustering of the eight interactive nodes or focal events and observe some patterns in the attributes of the nodes closest to them. the right-hand side is heavily populated with social scientists. as mentioned above, this is influenced by the lessons for development event. as you move to the left side fewer social scientists are represented and they are outnumbered by other disciplines. the state owned or driven interactions such as sage and parliamentary committees appear on this left side and the anthropological epistemic community driven or owned interactions, such as erap reports and lessons for development, appear on the right side. the apparent connectors or bridges are in the centre. these bridges can be conceptualised as both focal events, including the erap steering committee, the sage social science sub-committee and the asa ebola panel, or as the key individual nodes connected to these. we know that many informal interactions between researchers, officials and humanitarians are not captured here. we are only seeing a partial picture of the network, traces of which remain preserved in documents pertaining to the eight nodal events sampled. nonetheless, so far the quantitative data seem to correspond closely with the qualitative accounts of the crisis. also, of interest is the visual representation of organisation affiliation. all bar one of the social scientists (in the whole network - fig. ) are affiliated to a research organisation, whereas one third of the members of other scientific disciplines are attached to government institutions, donors or multilaterals. these are the public health officials and virologists working in the doh, phe and elsewhere. they appear predominantly on the left side with much stronger proximity to government led initiatives. however, it is also clear that whilst social scientists are a small minority in the government led events, the right side of the graph includes a significant number of practitioners, policy actors and clinicians. it is this part of the network that most closely resembles an inter-epistemic community. for the centrally located bridging nodes we can see a small number of social scientists and policy actors embedded in government. as accounts of the crisis have suggested these individuals appear to have been the super-connectors. a final point of clarification is that this is not a map showing the actual knowledge flow between actors during the crisis. each of the spider shaped sub-networks represent co-occurrence of individuals on committees, panels and other groups. we can infer from this some likelihood of knowledge exchange but we cannot measure this. one exception to these co-occurrence types of tie between nodes are the erap reports (bottom right), which reveals a cluster of nodes who contributed to reports along with those who requested them. even though this represents a knowledge flow of sorts we can still only record the interaction and make assumptions about the actual flow of knowledge. a variation of degree centrality, eigenvector centrality, counts the number of nodes adjacent to a given node and weighs each adjacent node by its centrality. the eigenvector equation, used by netdraw, calculates each node's centrality proportionally to the sum of centralities of the nodes it is adjacent to (s. . netdraw increases the size of nodes in relation to their popularity or eigenvector value. the better connected nodes are to others who are also well connected the larger the nodes appear (s. p. borgatti et al., ) . in order to focus on the key influencers or knowledge brokers in the network, we entirely remove nodes solely connected to the lessons for development conference. as mentioned earlier, this event is a poor proxy for research-policy interactions and unduly over-represents social scientists who were otherwise unconnected to advisory or knowledge exchange activities. this reduces the number of individuals in the network from to . we also utilise ucinet's transform function to convert the two-mode incidence matrix into a one mode adjacency matrix (s. . ties between nodes are now determined by connections through co-occurrence. we no longer need to see the events and committees themselves but can visualise the whole network as a social network of connected individuals. we can now observe and mathematically calculate, how inter-connected or homogeneous this research-policy network really is. we see in fig. a more exaggerated separation of social science and other sciences on the right and left of the graph than in fig. . we can also see three distinct sub-networks emerging, bridged by six key nodes with high centrality values. the highly interconnected sub-network on the right is shaped in part by erap and the production of briefings and their supply to a small number of policy actors. we can see here the visualisation of slightly higher centrality scores than for the government scientific advisors on the left. by treating this as a relational network we observe that interactions like the establishment of a sage sub-group for social scientists increased the homophily of the right side of the network and reduced its interconnectivity with the whole network. although, one must be cautious about assigning too much significance to the position of individual nodes in a whole network analysis, the central location of the two social scientists and a dfid official closely correspond to the accounts of the crisis. this heterogeneous brokerage demonstrates the tendency of certain types of actors to be the sole link between dissimilar nodes (hamilton et al., ) . likewise, some boundary nodes or outliers, such as one of the mod's advisors at the bottom of the network, are directly mentioned in the qualitative accounts. just four individuals in this whole network are based in africa, suggesting almost complete isolation from humanitarians operating on the ground and from african scholarship. both the qualitative accounts of the role of anthropologists in the crisis and the whole network analysis presented here largely, correspond with haas' definition of epistemic communities. the international community of anthropologists and medical anthropologists that mobilised in autumn do indeed share common principles and analytical and normative beliefs. debates around issues, such as the level to which communities could reduce transmission rates themselves, did not prevent this group from providing a coherent response to the key policy dilemmas. this community did indeed emerge or coalesce around the demand placed on their expertise by policy makers concerned with the community engagement dimensions of the response. in the area of burial practices, there does appear to be some indication of the knowledge of social scientists being incorporated into the response. various interactions between anthropologists, dfid and the who did provide the opportunity to raise the socio-political-economic significance of funerals. for example, it was explained that the funerals of high status individuals would be much more problematic in terms of the numbers of people exposed (f. martineau et al., ) . anthropologists contributed to the writing of the who's guidelines for safe and dignified burials (who, b). however, their advice was only partially incorporated into these guidelines and the wider policies of the who at the time. the suggestion for a radical decentralised approach to formal burial response that would require the creation of community-based burial teams was ignored until much later in the crisis and never fully implemented. as loblova and dunlop suggest in their critique of epistemic community theory, the extent to which anthropology could influence policy was bounded by the beliefs and understanding of policy communities themselves (löblová, ) and (dunlop, ) . olga loblova argues that there is a selection bias in the tendency to look at case studies where there has been a shift in policy along the lines of the experts' knowledge. likewise, claire dunlop suggests that haas' framework may exaggerate their influence on policy. she separates the power of experts to control the production of knowledge and engage with key policy actors from policy objectives themselves. she refers to adult education literature and its implications for what decision makers learn from epistemic communities, or to put it another way, the cognitive influence of research evidence (dunlop, ) . she argues that the more control that knowledge exchange processes place with the "learners" in terms of framing, content and the intended policy outcomes, the less influential epistemic communities will be (dunlop, ) . hence, in contested areas such as home care, it was the more embedded and credible clinical epistemic community that prevailed. from october , anthropologists were arguing that given limited access to etus, which were struggling at that time, home care was an inevitability and so should be supported. where they saw the provision of home care kits as an ethical necessity, many clinicians, humanitarians and global health professionals regarded home care as deeply unethical with the potential to lead to a two tier system of support (f. martineau et al., ) and (whitty et al., ) . in sierra leone, irish diplomat sinead walsh was baffled by what she saw as the blocking of the distribution of home care kits. an official from the us centres for disease control and protection (cdc) was quoted in an article in the new york times as saying that home care was: "admitting defeat" (nossiter, ) in (walsh and johnson, ) . home care was never prioritised in sierra leone whereas in liberia hundreds of thousands of kits were distributed (walsh and johnson, ) . in this area, clinicians, humanitarians and policy actors seemed to maintain a policy position directly opposed to anthropological based advice. network theory provides further evidence around why this may have been the case. in his study of uk think tanks, jordan tchilingirian suggests that policy think tanks operate on the periphery of more established networks and enjoy fluctuating levels of support and interest in their ideas. ideas and knowledge do not simply flow within the network, given that dominant paradigms and political, social and cultural norms privilege better established knowledge communities (tchilingirian, ) . this is reminiscent of meyer's work on the boundaries that exist between "amateurs" and "policy professionals" (meyer, ) . moira faul's research on global education policy networks proposes that far from being "flat," networks can augment existing power relations and knowledge hierarchies (faul, ) . this is worth considering when one observes how erap's supply of research knowledge and the sage sub-committee for anthropologists only increased the homophily of the social science sub-community, leaving it weakly connected to the core policy network (fig. .) . the positive influence of anthropological advice on the uk's response was cited by witnesses to the subsequent parliamentary committee inquiries in . however, there is some indication of different groups or networks favouring different narratives. the international development select committee (idc) was very clear in its final report that social science had been a force for good in the response and recommended that dfid grow its internal anthropological capacity (idc, a, b) . this contrasts to the report of the science and technology committee (stc), which despite including evidence from at least one anthropologist, does not make a direct reference to anthropology in its report (stc, ) . this is perhaps the public health officials in their core domain of infectious disease outbreaks reasserting their established authority. this sector has been described as the uk's "biomedical bubble" which benefits from much higher pubic support and funding than the social sciences (jones and wilsdon, ) . just the presence of anthropologists in an evidence session of the stc is a very rare event in contrast to the idc which regularly reaches out to social scientists. not everyone agrees that the threat of under-investing in social science was the primary issue. the stc's report highlights the view that there was a lack of front line clinicians represented on committees advising the uk government, particularly from aid organisations (stc, ) . regardless of assessments of how successfully anthropological knowledge influenced policy and practice during the epidemic, there has been a subsequent elevation of social science in global health preparedness and humanitarian response programmes. writing on behalf of the wellcome trust in , joão rangel de almeida says: "epidemics are a social phenomenon as much as a biological one, so understanding people's behaviours and fears, their cultural norms and values, and their political and economic realities is essential too." (rangel de almeida, ). the social science in humanitarian action platform, which involves many of the same researchers who were part of the sierra leone response, has subsequently been supported by unicef, usaid and joint initiative on epidemic preparedness (jiep) with funding from dfid and wellcome. its network of social science advisers have been producing briefings to assist with the ebola response in the democratic republic of congo (drc) (farrar, ) and have mobilised in response to the covid- respiratory illness epidemic. network theory provides a useful framework with which to explore the politics of knowledge in global health with its emphasis on individuals' social context. by analysing data pertaining to researchers' and policy professionals' participation in policy networks one can test assumptions around interdisciplinarity and identify powerful knowledge gatekeepers. detailed qualitative accounts of policy processes needn't be available, as they were in this case, to employ this methodology. assuming the researcher has access to meeting minutes and other records of who attended which events or who was a member of which committees and groups, similar analysis of network homophily and centrality will be possible. the greatest potential for learning, with significant policy and research implications, comes from mixed methods approaches. by combining qualitative research to populate your network with a further round of data gathering to understand it better, you can reveal the social and political dynamics truly driving evidence use and decision making (oliver and faul, ) . although this study lacked this scope, it has still successfully identified the shape of the research-policy network that emerged around the uk led response to ebola and the clustering of actors within it. the network was a diverse group of scientists, practitioners and policy professionals. however, it favoured the views of government scientists with their emphasis on epidemiology and the medical response. it was also almost entirely lacking in west african members. nonetheless, it was largely thanks to a strong political demand for anthropological knowledge, in response to perceived community violence and distrust, that social scientists got a seat at the table. this was brokered by a small group of individuals from both government and research organisations, who had prior relationships to build on. the emergent inter-epistemic community was only partially connected into the policy network and we should reject the description of the whole network as trans-disciplinary. social scientists were most successful in engaging when they framed their expertise in terms of already widely accepted concepts, such as the need for better communications with communities. they were least successful when their evidence countered strongly held beliefs in areas such as home care. their high level of homophily as a group, or sub network, only deepened the ability of decision makers to ignore them when it suited them to do so. the epistemic community's interactivity with uk policy did not significantly alter policy design or implementation and it did not challenge fundamentally eurocentric development knowledge hierarchies. it was transformative only in as much as it helped the epistemic community itself learn how to operate in this environment. the real achievement has been on influencing longer term evidence use behaviours. they made the case for interdisciplinarity and the value of social science in emergency preparedness and response. the challenge now is moving from the rhetoric to action on complex infectious disease outbreaks. as demonstrated by ebola in drc and covid- , every global health emergency we face will have its own unique social and political dimensions. we must remain cognisant of the learning arising from the international response to sierra leone's tragic ebola epidemic. it suggests that despite the increasing demand for interdisciplinarity, social science evidence is frequently contested and policy networks have a strong tendency to leave control over its production and use in the hands of others. credit authorship contribution statement james georgalakis: conceptualization, methodology, software, formal analysis, investigation, data curation, writing -original draft, visualization. epidemics (especially ebola) social science intelligence in the global ebola response one health : science, politics and zoonotic disease in africa ebola at a distance: a pathographic account of anthropology's relevance stigma and ebola: an anthropological approach to understanding and addressing stigma operationally in the ebola response ucinet for windows. analytic technologies cases, mechanisms and the real: the theory and methodology of mixed-method social network analysis une histoire morale du temps present policy transfer as learning: capturing variation in what decisionmakers learn from epistemic communities the irony of epistemic learning: epistemic communities, policy learning and the case of europe's hormones saga ebola response anthropology platform erap milestone achievements up until the global community must unite to intensify ebola response in the drc networks and power: why networks are hierarchical not flat and what can be done about it the human factor. world health organization finding the spaces for change: a power analysis introduction: identifying the qualities of research-policy partnerships in international development-a new analytical framework introduction: epistemic communities and international policy coordination analysing published global ebola virus disease research using social network analysis evaluating heterogeneous brokerage: new conceptual and methodological approaches and their application to multi-level environmental governance networks health. education advice and resource team ebola, culture and politics: the anthropology of an emerging disease responses to the ebola crisis ebola: responses to a public health emergency. house of commons the biomedical bubble: why uk research and innovation needs a greater diversity of priorities the ebola epidemic: a transformative moment for global health ebola: engaging long-term social science research to transform epidemic response when epistemic communities fail: exploring the mechanism of policy influence online course: ebola in context: understanding transmission, response and control epistemologies of ebola: reflections on the experience of the ebola response anthropology platform on the boundaries and partial connections between amateurs and professionals pushed to the limit and beyond social constructionism as ontology: exposition and example a hospital from hell networks and network analysis in evidence, policy and practice ebola crisis appeal response review social science research: a much-needed tool for epidemic control. wellcome. redruk, . pre-departure ebola response training burial/other cultural practices and risk of evd transmission in the mano river region burial/other cultural practices and risk of evd transmission in the mano river region ebola: how a people's science helped end an epidemic on the coloniality of global public health biosocial approaches to the - ebola pandemic. health hum. rights , . sage scientific advisory group for emergencies -ebola summary minute of nd meeting scientific advisory group for emergencies -ebola summary minute of rd meeting science in emergencies: uk lessons from ebola. house of commons. stovel producing knowledge, producing credibility: british think-tank researchers and the construction of policy reports the oxford handbook of political networks getting to zero: a doctor and a diplomat on the ebola frontline network analysis and political science clinical presentation and management of severe ebola virus disease infectious disease: tough choices to reduce ebola transmission key messages for social mobilization and community engagement in intense transmission areas comparison of social resistance to ebola response in sierra leone and guinea suggests explanations lie in political configurations not culture coronavirus: china president warns spread of disease 'accelerating', as canada confirms first case. the independent acknowledgements i thank dr jordan tchilingirian (university of western australia) for discussions and support on ucinet. i thank professor melissa leach and dr annie wilkinson (institute of development studies) for access to archival data. key: cord- - x f t authors: lin, feng; muthuraman, kumar; lawley, mark title: an optimal control theory approach to non-pharmaceutical interventions date: - - journal: bmc infect dis doi: . / - - - sha: doc_id: cord_uid: x f t background: non-pharmaceutical interventions (npi) are the first line of defense against pandemic influenza. these interventions dampen virus spread by reducing contact between infected and susceptible persons. because they curtail essential societal activities, they must be applied judiciously. optimal control theory is an approach for modeling and balancing competing objectives such as epidemic spread and npi cost. methods: we apply optimal control on an epidemiologic compartmental model to develop triggers for npi implementation. the objective is to minimize expected person-days lost from influenza related deaths and npi implementations for the model. we perform a multivariate sensitivity analysis based on latin hypercube sampling to study the effects of input parameters on the optimal control policy. additional studies investigated the effects of departures from the modeling assumptions, including exponential terminal time and linear npi implementation cost. results: an optimal policy is derived for the control model using a linear npi implementation cost. linear cost leads to a "bang-bang" policy in which npis are applied at maximum strength when certain state criteria are met. multivariate sensitivity analyses are presented which indicate that npi cost, death rate, and recovery rate are influential in determining the policy structure. further death rate, basic reproductive number and recovery rate are the most influential in determining the expected cumulative death. when applying the npi policy, the cumulative deaths under exponential and gamma terminal times are close, which implies that the outcome of applying the "bang-bang" policy is insensitive to the exponential assumption. quadratic cost leads to a multi-level policy in which npis are applied at varying strength levels, again based on certain state criteria. results indicate that linear cost leads to more costly implementation resulting in fewer deaths. conclusions: the application of optimal control theory can provide valuable insight to developing effective control strategies for pandemic. our findings highlight the importance of establishing a sensitive and timely surveillance system for pandemic preparedness. emerging influenza is threatening the world with the next pandemic [ ] . the current swine flu caused by a novel h n virus has infected a documented , humans, killing , from april to august [ ] . the world health organization (who) declared the outbreak to be a pandemic because of growing worldwide cases [ ] . currently, the severity of the outbreak is moderate as most people recover from infection without the need for medical care [ ] . however, if the virus mutates and achieves the ability to cause severe illness, it will kill more people and overwhelm the health system. vaccination is the most effective means of pandemic mitigation. vaccine production is a complex multi-step process which involves development, manufacturing, and delivery processes and current levels of vaccine production capacity are inadequate. thus many uncertainties exist in every step and effective vaccines are typically available well after the viral strain has emerged [ ] [ ] [ ] [ ] . for instance, vaccines against the h n strain are still under development and will remain in short supply by november [ ] . current stockpiling of antiviral drugs will also be in short supply and their efficiency will be limited once a pandemic occurs [ , ] . public health systems need to be prepared for cases when effective pharmaceutical interventions are unavailable. non-pharmaceutical interventions (npis) are necessary to delay and dampen the pandemic before pharmaceuticals become available [ ] . recommended npis include: ( ) social distancing: school closure, workplace distancing, restricted public gathering and travel; ( ) case containment measures: voluntary case isolation, voluntary quarantine of members of households with ill persons; and ( ) infection control measures: hand hygiene, cough etiquette, and mask/respirator usage [ , ] . npis were implemented during the pandemic and more recently during the severe acute respiratory syndrome (sars) outbreak of . although research on these events confirms the importance of npis, suboptimal triggering during the pandemic rendered npis only moderately effective at reducing mortality [ ] [ ] [ ] . during sars, sheltering and quarantine were found to be effective [ , ] , while border screening was not [ ] . during the current h n outbreak, infection control is recommended to prevent spread of the virus among humans. public health authorities are developing action plans which may request social distancing actions depending on the severity of the outbreak [ ] . mathematical models are often used to study disease spread, with the susceptible-infectious-recovered (sir) model being preferred for diseases spread via droplet and aerosol. the sir model has been used to study pandemic flu [ , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , seasonal flu [ ] [ ] [ ] , sars [ , [ ] [ ] [ ] , and smallpox [ ] [ ] [ ] [ ] . these papers use sir to simulate the disease outbreak and evaluate the effectiveness of selected control measures under various predefined scenarios. they do not provide optimal controls for initiating implementation, and thus we will not review them here. sir literature most directly relevant to this work includes [ ] [ ] [ ] [ ] [ ] [ ] . these authors use the sir model to study optimal controls, i.e., controls that minimize a prescribed objective function. most show "bangbang" controllers to be optimal (in the sense of minimizing a specified objective function). these policies apply no control until the occurrence of a triggering event and then apply controls at maximum strength. sethi derived optimal closed-form results for isolation and immunization policies [ , ] using an si model. with this model, the population is partitioned into two parts, susceptible and infectious. the control is to either isolate and vaccinate at a maximum rate or do nothing. infectious individuals who recover become susceptible once again, and thus immunity due to infection and subsequent recovery are not considered. clancy [ ] studied the properties of optimal policies for isolation and immunization assuming that all infectious individuals can be immediately isolated and all susceptible individuals can be immediately immunized. the policy takes no action when the number of infectious is below an optimal threshold and immediately isolates and/or immunizes when the number exceeds the threshold. however, they can only obtain optimal policies when the state space is small. morton and wickwire [ ] developed optimal control policies for immunization assuming an infinite pandemic terminal time. however their switching curve derivation has an error in the derivatives (eqs. a and b of [ ] ) and thus their results are unclear. behncke [ ] derived mathematical properties of optimal vaccination programs under the following assumptions: ) the time when vaccine becomes available is known; ) infectious individuals can be immediately and completely isolated; and ) the time horizon of the pandemic is infinite. overall, we think the underlying assumptions of currently published results are questionable. it is not the case that all infectious can be immediately identified and isolated. further, planners do not know when vaccines will become available, and even when available, it is not true that mass prophylaxis is instantaneous. finally, during a pandemic, people will die. the current models do not account for mortality, which could be significant for viral strains such as h n . in this work, we use an expanded sir model to develop triggers for npi implementation to minimize expected person-days lost resulting from influenza related deaths and npi implementation. npi policies are derived for a deterministic control model. results are compared with the most relevant optimal control papers discussed above. multivariate sensitivity analyses based on latin hypercube sampling are performed to investigate the effects of input parameters on the control policy structure and the mean cumulative deaths. additional studies investigate the effects of departures from the modeling assumptions, which include exponential terminal time and linear npi implementation cost. in this section, we formulate an optimal control problem with an expanded epidemic model to compute npi implementation strategy. to understand the following discussion, the reader is referred to figure , which illustrates the compartmental model, and to table , which provides a summary of notation. to construct the model, we make six assumptions: . at any time, t ≥ , the community is composed of s(t) susceptible, i(t) infectious, r(t) recovered, and d(t) deceased individuals. the population is closed, ignoring the demographic turnover or immigration, i.e. s(t) + i(t) + r(t) + d(t) = n. to make the analysis independent of population size, we normalize the model by letting s t . thus, any community can be described by state variable x(t) = (s(t), i(t), r(t), d(t)). . the population is homogeneously mixed and people make contact at random. . people susceptible are able to get infected when they contact infectious people. once infected, they move into the infectious compartment. people infected can either recover at a constant rate, g, or die at a constant rate, τ. people recovered are assumed to be immune within our study horizon. . npi implementation is modeled by the decision variable u(t), where ≤ u(t) ≤ b <b. npi implementation reduces the rate of contact between susceptible and infectious individuals, and thus dampens the infection rate from b to a lower level, bu(t). in this paper, we only consider npis that will disrupt the normal societal functions and result in significant economic impact, such as school closure, work space distancing and voluntary isolation and quarantine. we assume these npis have the same effect in reducing disease spread. . we let person-days lost due to death be unit cost, while c ≤ will be person-days lost due to npi implementation. the cost c is a weight of npi cost relative to death. it measures the loss of productivity (persondays) due to implementing npis. to determine the value of c, the public health officials need to consider many factors, such as culture of the community, perceptions to death, consequences of pandemic and of figure expands the classic susceptible-infectious-recovered (sir) model to capture the mortality. table model notation. provides a summary of notation. x(t) = (s (t), i(t), r(t), d(t)) state that describes the disease status of a community x( ) = (s ( ), i( ), r( ), d( )) initial disease state of a community proportion of the control space hamilton-jacobi-bellman equation the npis, economic constraints, and etc. we assume that cost of npi implementation increases with implementation strength. in particular, we consider two cost structures, a linear structure in which cost is proportional to npi strength, and a quadratic structure in which the change in cost with npi strength is more variable. this paper is focused most extensively on the linear structure. . the optimization horizon t is assumed to be the time when effective vaccine becomes available to the community. although the production of the first doses of vaccine is estimated to take - months once the virus strain can be identified, nobody knows exactly when circulating virus can be identified. along with vaccine development, there are issues regarding manufacturing, delivery, and deployment. to capture the uncertainty in vaccine arrival time, we let t follow an exponential distribution. we can derive a model with a more general vaccine arrival time, but the problem is not currently numerically tractable, that is, algorithms for the general terminal time case present significant challenges and yet to be developed and tested. the exponential assumption ensures we get the discounted value function, which allows for a solution and some insights about the policy. in later sections we tested the model sensitivity to the exponential assumption. the probability density function (pdf) of t is written as f(t, Φ) = Φe -Φt , where t ≥ . because npi implementation disrupts daily activities vital to a productive society, they should only be used when they will be effective. thus, in developing triggers, npi cost must be balanced with npi effectiveness. in this work, we use person-days lost to measure npi cost and effectiveness. npis cause person-day losses by shutting down vital activities, but mitigate person-day losses by reducing mortality. by capturing the dynamic relationship between npi implementation, mortality, and associated person-day losses, our model provides a mechanism for finding an npi triggering scheme that helps minimize total person-days lost during the time period before vaccines become available. the dynamics of the controlled epidemic are given by the non-linear differential equations (dots denote time the total person-days lost for a pandemic under a policy which prescribes an admissible control, u, will be denoted by the value function v (x, u), which is defined as: the objective is to minimize expected person-days lost over the time horizon, t, which is assumed to be the time when effective vaccine becomes available to the community. an admissible control, u*, which minimizes v (x, u) will be called optimal, and the corresponding value function is denoted by: from eqs. ( ) and ( ) we can see that the knowledge of the state variables s(t) and i(t) determines the other two, thus we focus our analysis on the susceptible and infectious compartments. this reduces the system to two dimensions, s and i. thus, we study the control system in the (s, i)-plane, defined as Ω = {(s, i), s, i ≥ , s + i ≤ }. we let (s, i) represent the initial state x( ) = (s( ), i( )), and v (x, u) = v ((s, i); u) be the associated value function, which captures total person-days lost starting in state (s, i) Ω and operating under control u. the expected value of v*(s, i) is calculated by integrating v ((s, i), u)·f(t; Φ) over the range of t: by changing the order of integration, the problem is converted to an infinite horizon discounted problem: based on pontryagin's maximum principle [ ] , which gives necessary conditions for optimal control, we can derive a first-order partial differential equation satisfied by the optimal value function, v*. this is called the hamilton-jacobi-bellman (hjb) equation: eq. ( ) is a linear function of u, thus the optimal control will be "bang-bang" control [ ] , i.e., the candidate control, u*, should satisfy: where the switching curve ψ (s, i) is the coefficient of u in eq. ( ), defined as: the optimal control u* is pushed to its lower/upper bound depending on the sign of its coefficient, the switching curve ψ (s, i), because the hjb equation, eq. ( ), is linear in the control, u. however, if the hjb is nonlinear in u, the optimal control will not be bangbang. an example will be the linear quadratic optimal control problem, where the optimal policy is a linear state feedback [ ] . by the bang-bang nature of candidate u*, the npis should be implemented at the maximum level when ψ (x) < . to understand this, assume the community is in state x a = (s, i) and consider exerting an instantaneous and small control, δ u , which will move the system to state x b = (s + δ u si, i-δ u si) instantaneously. the exertion will cost csδ u person-days lost. if v*(x a )-v* (x b ) exceeds csδ u , then it is cost-effective to implement the npis. hence, indicates that exerting control reduces person-days lost. we keep implementing npis until ψ (x) > . due to the complexity of the eq. ( ), the switching curve, ψ (x), has no closed form. to find ψ (x), we use an algorithm based on dynamic programming [ ] , which requires discretization over time and space. the uniqueness and convergence of the solution is guaranteed by the viscosity solution concept developed in [ ] . the optimal control, u*, is obtained by solving the hjb equation (eq. ( )). figure shows u* for two infection rates, . and . , given a recovery rate of . and a death rate of . (taken from [ ] ). person-days lost from npi implementation, c, is set to . ( % of the cost of a single death). the maximum impact of npis on the infection rate is assumed to be a % reduction. note that the basic reproductive number r without any control is given by figures (a) and (b) indicate when to trigger npi implementation. when the system state falls in region Ω , npis should be implemented at maximum strength; in contrast, npis should not be implemented when the state falls in Ω . for example, in the influenza scenario of figure (a), npis should be implemented when % remains susceptible and % of the population is infected. however, if % remains susceptible and % is infected, it is better not to trigger the npis. we compare our policy against the most relevant optimal isolation policies derived in [ ] . figures (c) and (d) show these isolation policies under the different infection rates. the control either isolates at a maximum rate when the number of infectious exceeds a threshold or does nothing. for a pandemic with b = . and r = . , figure (d) tells us not to act until the percent infectious exceeds %; while figure (b) tells us to implement npis at an earlier stage of the outbreak, for example % susceptible and % infectious. we illustrate cases for which r > , i.e., the uncontrolled infection spreads rather than dying out. figures (a) and (b) compare the epidemic curves with and without npis, starting from a state % susceptible and % infected. according to figures (a) and (b) , the npis should be triggered at this state. in figure (a) , npi implementation not only reduces the total death by %, but also eliminates the peak of the outbreak. overall, npi implementation saves % of the average person-days lost. in figure (b) , where a more severe pandemic is considered, the reduction in total deaths is % and npi implementation reduces and delays the peak of outbreak, which allows additional time for vaccine development. figures (c) and (d) compare the epidemic curves with and without npis starting from states that fall on the control thresholds of [ ] shown in figures (a) and (d) . the proportions of recovered and dead population were set to because they could not be differentiated from infectious people in an si model. it is still best to implement npis at these states but the impact is limited. we also computed control policies for systems assuming quadratic control cost instead of linear cost, i.e., the value function is written as , while the system dynamics still follow eq. ( ). based on pontryagin's maximum principle [ ] , we can derive the hamilton-jacobi-bellman (hjb) equation for the new problem: eq. ( ) is now a quadratic function of u, thus the optimal control will not be "bang-bang" control. the candidate control u* should satisfy: by solving eq. ( ), we obtained the npi policies for systems assuming quadratic control cost shown in figure shows the optimal control policies for two infection rates, . and . , given a recovery rate g = . and a death rate τ = . . (a) presents the optimal npi control for b = . and r = . . (b) presents the optimal npi control for b = . and r = . . (c) presents the optimal isolation policy derived in [ ] for b = . and r = . . (d) presents the optimal isolation policy derived in [ ] for b = . and r = . . influenza characterized by b = . and r = . . figure (a) shows a multi-level policy in which npis are applied at varying strength levels based on certain state criteria. note that "red" indicates > % npi strength, "yellow" indicates % npi strength, and so forth. the level of npi policy decreases from % of maximum npi level to % as system state traverses from the upper to the lower part and from the right corner to the interior region. the contour line at u* ≈ % of maximum impelmentation level is very similar in shape and location to the boundary between Ω and Ω in figure (a). as another demonstration, figures (b) and (b) show the control policies under both control costs with influenza characterized by b = . . the two boundaries between Ω and Ω in figure (b) resemble the contour lines u* ≈ % of maximum impelmentation level in figure (b). the two regions of high level of u* in the upper corner and lower right corner of figure (b) correspond to two control regions Ω in figure (b). in addition, table compares the means of the expected person-days lost per person due to death, d , and control intensity, u *, between the linear and quadratic models. the overall npi strength of the linear model is higher than that of the quadratic model, while the expected person-days lost due to death is lower. the linear model tends to implement npis more intensely and save more lives while having a higher overall cost. a multivariate uncertainty and sensitivity analysis was performed to study the effects of input parameters on the control policy for the linear cost model. this analysis investigated the effects of five inputs (r , g, τ, c, b) on a performance measure, ω, defined as the proportion of the control space to the total state space, i.e., . there is no well-defined performance measure to evaluate the npi policy, especially when the policy is defined in a -dimensional state space. we figure epidemic curves of infectious and dead population with and without npi implementation. figure shows the impact of optimal control on pandemic severity, peak, and total deaths, when npis are triggered at different initial states. (a) compares the epidemic curves with and without npis, starting from a state % susceptible and % infected when b = . . (b) compares the epidemic curves with and without npis, starting from a state % susceptible and % infected when b = . . (c) compares the epidemic curves with and without npis, starting from a state % susceptible and % infected when b = . . (d) compares the epidemic curves with and without npis, starting from a state % susceptible and % infected when b = . . chose ω because it captures the overall intensiveness of npi implementations. in addition, we investigated the effect of these parameters on the outcome of applying the control policy, defined as the mean cumulative death, d t . we simulated the sird system under the optimal policy starting from all state (s , i , r , d ), where s > %, i < %, and d = . the simulation was terminated at a randomly selected exponential terminal time, and we recorded and analyzed the cumulative number of deaths. the mean cumulative death was calculated by taking the average of cumulative deaths over all tested initial states. table summarizes the estimated probability distribution functions (pdfs) of five input parameters, assuming the input parameters are statistically independent. the pdfs of influenza transmission characteristics (r , /g, and /τ) are estimated based on the pandemic [ ] . note that the infection rate b can be written as r (g + τ). the effect of npis, b, was found to reduce the infection rate, b, by up to - % in and in many cases the effect of npis was very limited [ ] ; thus we assume the impact of npi implementation, b, follows uniform( , %). we are not able to find any empirical data on the cost of npi, c. this value is a relative cost, which depends on decision makers' perceptions of saving lives versus maintenance of daily societal functions. in our analysis we let c take the value from to . uniformly, which would imply that the cost of four sessions of maximal npi implementation is equivalent to the cost of one death. we sampled ranges of the parameters times using latin hypercube sampling (lhs) to generate scenarios [ ] [ ] [ ] . then we conducted multivariate uncertainty and sensitivity analysis to determine the uncertainty in the performance measure that was due to the uncertainty in estimating the input parameters. the descriptive statistics for ω and d t are given in table , which lists the mean, variance, median, minimum, and maximum of ω and d t . figure shows the empirical cumulative distribution functions (cdfs) of ω and d t obtained from lhs scenarios and table provides the partial rank correlation coefficients (prccs) for the performance measures and each parameter. the cdf of ω revealed a wide range of estimates due to the uncertainty in estimating the values of the five input parameters. sixty percent of ω estimates are less than . %, with a minimum of % and a maximum of . %. for ω, the prccs are all statistically significant, i.e. p < . . the cost of npi implementation, c, the time when a death occurs after infection, /τ, and the time for an infectious person to recover, /g, are the most statistically influential (|prcc| > . ). an increase in c or /τ corresponds to a decrease in ω; while an increase in the infection period /g corresponds to an increase in ω. the cdf of d t shows that the mean of cumulative death is . %, with a minimum of . % and a maximum of . %. for d t , the prccs are are all statistically significant, i.e. p < . . the most statistically influential inputs are /τ, r , and /g (|prcc| > . ) while the other two parameters are lessinfluential. a decrease in /τ corresponds to an increase in d t ; while an increase in r or /g corresponds to an increase in d t . to test the sensitivity of our control policy to the terminal time assumption, we simulated the disease propagation and studied the outcome of applying our npi policy to settings with an exponential and a gamma terminal time. for each flu scenario specified in the sensitivity analysis, a corresponding npi policy can be obtained. we randomly selected a value from exponential( . ) and a value gamma( , . ) as the vaccine arrival time (or simulation terminal time). the sampling was repeated times for each scenario. then, we simulated the sird system starting from an initial state applying the corresponding npi policy. the simulation was terminated at the sampled vaccine arrival times and the cumulative deaths were recorded. a total of initial states were selected, where s ≥ % and i ≤ %, for a total of , simulations. we studied the difference in cumulative deaths under these two vaccine arrival assumptions. table lists the descriptive statistics of percentage difference in cumulative deaths for the same initial states at two terminal times. overall, the difference in cumulative deaths under exponential and gamma terminal times is small (mean = . %). the distribution of difference in cumulative deaths is left-skewed, with . % of these differences being less than %. there are a few cases where the cumulative deaths differ significantly (≥ %). these cases all started from initial states where only a small table lists the partial rank correlation coefficients (prccs) for the performance measure ω and d t . table lists the summary statistics of difference in cumulative deaths at exponential and gamma terminal time. proportion people are infectious, i.e., i ≤ %, and the difference between the selected gamma and exponential terminal time exceeds % of the maximum of these two. for example, in a case where i = %, s = %, gamma terminal time = days and exponential terminal time = days, the difference in cumulative death is . %. effect of npi policies on the epidemic npis reduce and delay the spread of pandemic by moderating social contact between susceptible and infectious people. because npis disrupt daily societal functions, it is important that they be implemented judiciously. this requires identifying effective initiating triggers, which is a challenging research task. implementing npis will impede influenza spread; on the other hand, normal societal functions will be interrupted. the optimal control method takes both aspects into account and tries to find the best balance between them, given the decision makers relative weighting of the two. based on figures and , early implementation for moderate and severe pandemic is very important for npis to have impact on the outbreak and the impact is effective only if npis are implemented early. late npi implementation might still be optimal, but the impact is much less. for a severe pandemic, it is optimal to trigger npis at the beginning stage when susceptible population is large and infectious population is small. if we miss the beginning stage, it is not optimal to implement npis until the outbreak is significantly progressed. this is because once the pathogen achieves a certain level of infection, npis are not effective against it, and thus are not worth the cost. that is, the benefit of npis at a stage when the disease has progressed significantly is less than the cost of npi implementation. this finding supports the cdc pandemic mitigation guidelines, which state that when the pandemic is category or , all npis are recommended for early implementation [ ] . furthermore, earlier npi implementation reduces and delays the peak of the outbreak as illustrated figures (a) and (b), which allows additional time for vaccine development. if a severe pandemic occurs, hospitals will experience an overwhelming influx of patients and need to operate at their surge capacities. earlier npi implementation can reduce the magnitude of infectious at the peak, which relieves some of the burden on hospitals and other health care infrastructures. in contrast, npis are not nearly as effective if disease has already spread into the community as the cases shown in figures (c) and (d). in both cases, npis are triggered after the peak of the outbreak, where hospitals might have already been operating at their surge capacities for a few weeks. both cases start at states falling on the control thresholds recommended in figures (c) and (d) [ ] . this finding indicates that the additional complexity of our model is warranted when compared with the si model used in [ ] . timely and sensitive surveillance systems are key to successful application of the optimal control method as knowledge of both the pathogen characteristics and the community state are assumed. the surveillance systems should be able to identify the virus quickly and provide accurate estimates for parameters which characterize the severity of an influenza. the effectiveness of the control policy depends on the accuracy of these estimates, which include infection rate b, death rate τ and recovery rate g. once the control policy is computed, we also need to track the community state to determine if npis should be triggered. as early npi implementation is found to be much more effective, we do not want to miss the beginning stage of the outbreak. thus, the surveillance system should also estimate the community state, including the size of the infectious and susceptible populations. our sensitivity analysis identified three important input parameters for determining the overall npi intensity. the important parameters are the npi cost, death rate, and recovery rate. for high npi costs, it is not worthwhile implementing npis because the benefit is less than the cost. for higher death rates, the policy sacrifices daily societal functions to save lives. in contrast, when recovery rate is small, infected people recover more slowly and continue infecting susceptible people. thus, more npi implementation is required. these results suggest that an influenza virus with a high death rate and a small recovery rate requires early intensive npi implementation, particularly when the community places a high value on avoiding death. cumulative death was most affected by the death rate, the basic recovery number and the recovery rate. for higher death rates, a higher proportion of infected people will die. for higher basic reproductive number, more people will be infected, resulting in more deaths even when the death rate is smaller. for lower recovery rate, infected people recover at a slower rate, and thus more people will be infected. this suggests that an influenza virus with a high death rate, a high basic reproductive number and a small recovery rate is less affected by npi implementation. npi cost does not seem to affect the cumulative death. however, npi cost was identified as the most influential (prcc = - . ) in determining the intensity of npi implementation. different communities have different perspectives of death versus disruption of daily societal functions. the range of c should be determined by decision makers after carefully evaluating the demographic, cultural, and economic characteristics of the community. as a performance measure, ω does not capture the complete structure of the control policy. it only captures the overall control intensity, but subtle differences between control policies, such as distribution and shape of Ω in the state space, is missing. policies that have different structure in the state space might have same ω value. therefore, continued effort should be made in selecting more refined measures for the control policy performance. linear v.s. quadratic cost function if the cost function is linear, the control policy is bangbang, which suggests implementing npis at the maximum strength or not implementing at all as shown in figure . if the cost function is nonlinear, for example the quadratic cases presented in figure , the control policy has multiple levels, which requires varying the npi strengths as the system evolves from one state to another. it is easily shown from eqs. and that if the linear model indicates npi implementation for a state x, i.e., u* = b for state x, then the quadratic model also indicates some implementation in state x, i.e., u* > for state x. but the inverse is not true. this property can be proved easily. if u* = b in the linear model, we have ψ(s, i) < , for all (s, i) Ω according to eq. . so together with eq. , we have u* > for these states in the quadratic model. thus, a quadratic cost structure will require npis to be implemented in more states but with much lower intensity in those states. overall, a linear cost structure leads to higher average npi intensity than the quadratic cost. in the examples observed, the boundaries between control and non-control regions in linear model resemble the quadratic contour lines u* ≈ % of maximum implementation. moreover, the linear cost model appears to place more weight on death, thus implementing more control and saving more lives as shown in table . in cases with quadratic cost structure, using a linear model might result in over-control which would not be marginally effective. however, quadratic cost introduces additional complexity in parameter estimation, computation, and policy interpretation. for example, we must determine how to implement npis at x% of maximum. this requires determining which npis will be implemented for each control level. the bang-bang policy, on the other hand, has only two levels, which is easier to understand and implement. finally, it is not clear that a direct comparison between policies obtained under linear and qudratic cost structures is appropriate, because the value functions are defined differently. more research needs to be done to better define the npi levels and interpret the policy if a non-linear cost function is chosen. we are currently not able to derive an optimal control policy for a general terminal time assumption. although the exponential optimal policy will not be optimal for cases with general terminal time, results shown in table indicate that the expected cumulative deaths predicted by the exponential optimal policy will be close to those occurring in a more general terminal time case. this suggests that the impact of the optimal exponential policy on virus spread is not always sensitive to terminal time distribution. although the exponential assumption might not be completely realistic, making this assumption allows us to obtain the npi policy, which then seems to provide desirable impact for cases with nonexponential terminal times. our model was limited in several ways. first, although hjb can be derived for models assuming general terminal time (e.g., gamma), so far the control policy can only be computed assuming exponential terminal time. second, the present modeling framework does not capture uncertainty in parameter estimation, i.e. the model accuracy relies on accurate estimation of input parameters. in practice, collection of accurate data and estimation of input parameters from data can be challenging and time consuming. third, the present modeling framework assumes equal effect of various npis in a homogeneously-mixed population, while different npis will have distinct impacts for disparate population groups. finally, bang-bang control must be further refined since it is not clear that on/off implementation is realistic for larger communities. to better apply optimal control methods in disease control problems, continued efforts should be made to refine the present model and to better estimate the input parameters. to conclude, we have considered a problem of nonpharmaceutical intervention (npi) implementation for pandemic control using optimal control theory to develop triggers that minimize expected person-days lost associated with infection related death and npi implementation over an exponential time horizon. the best control strategy for the model depends on the transmission characteristics of the influenza virus, the state of the pandemic, and the cost and implementation levels of npis. we present the computed policies under different transmission characteristics, where it is optimal to activate all npis when the system state falls in the control region, Ω . the optimal policy can be calculated for any combination of flu and cost parameters. we compare the impacts of npis triggered at different states, which supports the idea of early containment. for comparison, we present the npi policies assuming quadratic control cost. the quadratic cost assumption introduces additional complexity into parameter estimation, computation and policy interpretation, thus more research needs to be done to better define the npi levels and interpret the policy. we perform multivariate sensitivity analysis, which identifies important parameters that affect the intensity of control and the outcome of applying the policy. the findings highlight the importance of establishing a sensitive and timely surveillance system. finally, we study the outcome of applying our npi policy under exponential and gamma terminal times, and find small difference in the cumulative death. many uncertainties exist in estimating flu parameters, future research directions include developing a model that allows using stochastic rather than deterministic inputs and updates the control polices in real time. since npi implementation is not mandatory, compliance to npi requirements is crucial for successful implementation. community engagement, job security, and disruption of daily life affect compliance to npi implementation [ ] . moreover, prolonged outbreak might result in compliance fatigue. thus, in future work, we will integrate time-based compliance models into the system dynamics. other important research directions include consideration of population heterogeneity, stochasticity and partial observability in disease outbreak, and developing methods for general terminal time distributions. world health organization (who): who strategic action plan for pandemic influenza situation updates -pandemic (h n ) current who phase of pandemic alert world now at the start of influenza pandemic will vaccines be available for the next influenza pandemic nonpharmaceutical interventions for pandemic influenza international measures centers for disease control and prevention: intreim pre-pandemic planning guidance: community strategy for pandemic influenza world health organization (who) writing group: non-pharmaceutical interventions: their role in 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epidemic models optimal quarantine programmes for controlling an epidemic spread optimal immunization rules for an epidemic with recovery on the optimal control of a deterministic epidemic optimal control of deterministic epidemics dynamic programming and optimal control athena scientific introduction to optimal control theory springer optimal control and viscosity solutions of hamilton-jacobi-bellman springer what is the best control strategy for multiple infectious disease outbreaks sensitivity and uncertainty analysis of complex models of disease transmission: an hiv model, as an example uncertainty and sensitivity analysis of the basic reproductive rate: tuberculosis as an example modelling an outbreak of an emerging pathogen pre-publication history the pre-publication history for this paper can be accessed here an optimal control theory approach to non-pharmaceutical interventions the authors thank the indiana state department of health for supporting several pandemic planning projects that led to this research. the authors are also grateful to the editors and referees for very insightful and helpful comments. authors' contributions lf conducted the research, including model design, acquisition of data, analysis and interpretation of data, and manuscript drafting. km provided important guidance in model design and methods. he also revised the manuscript critically for important intellectual content. ml supervised the study. he had actively involved in model design and interpretation of data. he also revised the manuscript critically for important intellectual content. all the authors have given approval of the version to be published. the authors declare that they have no competing interests. key: cord- -n gk xhb authors: kickbusch, ilona title: policy innovations for health date: - - journal: policy innovation for health doi: . / - - - - _ sha: doc_id: cord_uid: n gk xhb we are at a turning point in health policy. it has become increasingly clear that changes in the existing health care system will not be sufficient to maintain and improve our health at this historical juncture. both our extensive knowledge on what creates health as well as the exponentially rising rates of chronic disease obesity, and mental health problems indicate that we need to shift course and apply a radically new mind-set to health and health policy. this is what we mean by policy innovations for health. the boundaries of what we call the “health system” are becoming increasingly fluid and health has become integral to how we live our everyday life. health itself has become a major economic and social driving force in society. this shifts the pressure for policy innovation from a focus on the existing health system to a reorganization of how we approach health in st century societies. the dynamics of the health society challenge the way we conceptualize and locate health in the policy arena and the mechanisms through which we conduct health policy. they also redefine who should be involved in the policy process. this concern is beginning to be addressed within government through health in all policy approaches and beyond government through new partnerships for health. most importantly, the role of citizen and patient is being redefined – a development that will probably lead to the most significant of the policy innovations for health in the st century. innovation is something everyone wants more of, but nobody is too sure what it means exactly. john gapper [ ] innovation for the authors of this book is about applying a radically new mindset to health and health policy with the goal of addressing the determinants of health and involving citizens in their health in new ways. this explains our choice of terminology: policy innovations for health. we start from a perspective that considers both health and innovation to be central driving forces in st century societies, and we maintain that their prominent role reflects major societal shifts that are under way. the consequence is not only a changing role of health in modern societies but also a new perception of innovation in relation to health. as part of this change we see new mechanisms emerge which aim to address the seminal changes underway in health and society. the shift from the industrial society of the th and th centuries to the knowledge societies of the st century is as ground-breaking as was the shift from the agrarian to the industrial world -and they are similar in their deep impact on health, this increases the need for innovation. the changes in our way of life are shaping our lifestyles and have created a situation where many of the patterns of everyday life -for example, our eating and food shopping patterns -and new forms of social stratification -for example, new forms of social inclusion and exclusion -endanger our health. this means that we need to understand that the health challenges and the diseases that come with this change are of a larger societal, not an individual nature. it seems obvious that this development has two consequences: it changes the role of the health care sector significantly toward managing chronic disease rather than acute care and it moves many of the solutions for the most challenging health problems into other social and policy arenas. the authors of this book are focused on the second challenge and the policy mechanisms that are needed to address it. the need for change is vast. first, there is hardly a policy sector that can be excluded: health, education, agriculture, transport, industry, consumer affairs, and sports -all are essential to support health. second, in a consumer society the role of business is critical and consumers themselves must express their demand. finally, communities must act for their health interest and individuals are required to support their individual health and that of their families in new ways. to do so they need to be able to negotiate and navigate an increasingly complex health and care environment. a recent analysis concerned with innovation and high performing health systems [ ] underlines that there are two goals of innovation in relation to health: improving the affordability, quality, and efficiency of the health care system and improving the health of populations. ideally the two would be fully complementary -in the real world they are not. usually when we speak of innovation in the context of health the automatic assumption is that we mean the expansion of therapeutic possibilities -we associate new medicines, new technologies, and increasingly the potential of biomedicine and genetics. sometimes we think of new approaches to the organization and financing of the medical care system, then we typically speak of "health care reform" -a term that is now linked almost exclusively with efficiency, effectiveness, and cost saving. the words innovation and health policy do not by and large sit very well together because the notion of "newness" and "better" that is at the core of innovation has been overshadowed by many short-term reorganizations of health care systems that seem to lack in vision and long-term perspective. and, if innovation is considered in terms of radical innovation only then we experience a clear tension between the drive for innovation and the constant challenge to keep down health care expenditures. a recent health innovation survey by the oecd [ ] typically focuses on the "question how to encourage and foster innovation which addresses health needs and priorities, maximizes access to benefits, and manages challenges and risks in a way that is beneficial to both innovators and health systems." innovation in this case is also mainly related to innovations in biotechnology and the key challenge is how oecd countries are able to cope with introducing such technical and product-based innovations into their respective health care systems. this focus on financial pressure has led -through a range of new assessment mechanisms -to a reinforcement of a binary understanding of innovation as being either radical or incremental and a focus on medical rather than social value. over the last decade we have begun to witness a major shift with regard to health and its role in society. i argue that we now live in a health society which is characterized by two major social processes: the expansion of the territory of health and the expansion of the reflectivity of health [ ] . the creation of the health society of the st century has been a process long in the making, beginning from about the mid th century onward. health is integral to modernity and our modern societies would not be possible without the health gains achieved in this -year period [ ] . during this time the balance of power between the four domains of the health systempersonal health, public health, medical health, and the health market -has shifted continuously. the domains of personal health and public health dominated the th and th centuries, while during the th century the medical health domain gained increasing strength both in terms of its power over the social definition of health and the dominance of its organizational and governance infrastructure; this process of dominance has been referred to as medicalization. as a consequence, in both political and public perceptions, the social organization of health resides in what we have come to call the health care system and concerns over how to ensure the long-term financial sustainability of this system dominate the health policy debate. but today the boundaries of what we call the "health care system" are becoming increasingly fluid. health has become integral to how we live our everyday life. in this health is similar to innovation, which is also increasingly defined as being fluid, an issue that will be reflected upon later in this chapter. indeed the expansion and liquidity of boundaries is a major characteristic of what the sociologist zygmunt bauman calls "liquid modernity" [ ] . this changes the health policy debate because it means that health is everywhere: every policy decision a government makes also impacts on health and at the individual level every behavioral choice also has a health consequence. this was always the case -but now it is part of reflective modernity. most discussions on health policy do not yet take this deep seminal change into account -they still focus on tinkering with a well-defined functional system of health governance, where through a process of defining the evidence base, they aim to ensure clear boundaries, define interventions, and prioritize medical rather than social solutions. the authors of this book are of the opinion that we clearly need a policy approach that responds more adequately to the new environment of st century health. the dynamics of the health society not only challenge the way we conceptualize and locate health and how we conduct health policy but they also redefine who should be involved in policy making -together they constitute policy innovations for health. the chapters of the book further explore five key defining concepts: . health is more than disease and health outcomes need to be measured differently; . the system boundaries are shifting and organization of health in society is increasingly separated from the management of disease and illness; . health policy is more than health care policy and becomes a joined up process of health in all policies at all levels of governance; . the differentiation into a first and second health market is occurring rapidly and we are faced with new issues of financing both health and health care; . people themselves are major actors in the health arena and new technologies are allowing them to participate in completely new ways. many analysts make the point that the changes facing the health sector will be as phenomenal as those we have witnessed in information technology and communications. this is due to the fact that health itself has become a major economic and social driving force in society [ ] and that good health outcomes are increasingly important for a range of societal goals. the conference board of canada [ ] suggests understanding innovation "as a means by which societies, systems or organizations achieve social or economic value (e.g. increasing positive health outcomes)"; they maintain that innovation occurs only when new value is created. our focus in this book is to explore what kind of policy innovations for health are required to achieve better population health, in terms of both its social and economic value. we argue though that the issue at stake is not just another reorganization/improvement of the health care system or a better mechanism of integrating scientific progress into existing heath care systems but a reorganization of how we approach health in st century societies. in this we follow peter drucker's understanding of innovation as creating a new dimension of performance [ ] . in modern democracies health is considered a right. its doability is driven by the perception that health can be created, managed, and produced: more health is always possible. it is one of the characteristics of the health society that the notion of doability has expanded beyond the ever-rising expectations toward the curative medical care system to impact the determinants of health. the first conceptual starting point for the arguments in this book are the rapidly changing determinants of health. we build on the arguments for increasing the investment for health and well-being and for strengthening the connection between health and wealth which are beginning to be expressed far beyond the public health community. witness the similarity of the statements from the public health perspective as voiced by wilkinson and marmot [ ] , two of the most respected researchers on social determinants of health good health involves reducing levels of educational failure, reducing insecurity and unemployment and improving housing standards. societies that enable all citizens to play a full and useful role in the social, economic and cultural life of their society will be healthier than those where people face insecurity, exclusion and deprivation and as expressed in a recent publication commissioned by the european commission [ ] ...improving the health status of a population can be beneficial for economic outcomes at the individual and the national level. there is indeed much evidence to suggest that the association between economic wealth and health does not run solely from the former to the latter. an immediate, if general, policy implication that derives from this conclusion is that policy-makers who are interested in improving economic outcomes (e.g. on the labour market or for the entire economy) would have good reasons to consider investment in health as one of their options by which to meet their economic objectives. it follows that if societies are to prepare adequately for new health challengessuch as obesity -and if they are to take action on the changes already under way, they must completely rethink their approach to health policy. it is argued that health sustainability is as important as environmental sustainability and that our response must be understood to be the challenge of at least a generation [ ] . we need policy innovations for health that address the classic determinants of health, such as education, work, housing, transport, and particularly equity. some countries -such as sweden -have now done so and this is discussed in more detail in the chapters that follow [ ] . the "classic" determinants of health continue to influence our health. the determinants of health however, in the boundaryless health landscape of the st century policy innovations are called for that respond to the st century determinants of health. health is increasingly being shaped by forces such as the speed of modern societies, globalization of markets, the increasing mobility and insecurity of individuals, energy expenditure, and concerns regarding risk and safety, and the reach of the media. these forces cut across many of the acknowledged social, environmental, and economic determinants of health. an approach to visualize the many determinants and their interaction was developed by the well-being project, scotland, in a joint effort with members of the community [ ] . the second conceptual starting point for the authors of this book is an understanding of health which is social rather than a medical. health governance is now challenged by this conceptualization of health as "well being beyond the absence of disease" as first defined by the world health organization in its constitution [ ] . the ottawa charter of the who [ ] stated that "health is created in the context of everyday life -where people live, love, work, learn and play," and this has found its expression in a wealth of health promotion activities at organizational, community, and local level. the most well known are the many "settings projects," which aim to create supportive environments for health and encourage people to participate in shaping these settings for everyday life, examples include healthy cities, healthpromoting schools, and healthy workplaces [ ] . indeed they constitute social innovations that spread the new understanding of health into many different sectors and, as an activity in the space between the sectors, prepare the ground for policy innovations and their social acceptance [ ] . recent global happiness surveys have identified health next to wealth and education as one of the three key factors for societal well-being [ ] . health becomes more central for the aspiration of personal goals in life and social inequalities are increasingly measured in health terms, highlighting differences in health and life expectancy. this broader view of health also needs to be reflected in the way we measure the impact of policy innovation for health. hernandez-aguada, in his chapter, discusses the increasing relevance of new types of health intelligence for intersectoral health governance with a particular focus on transparency and accountability for all actors in society. one such example of measurement, the canadian index of well-being [ ] , clearly illustrates the dimensions of innovation that a new type of health policy needs to address: • build a foundation to articulate a shared vision of what really constitutes sustainable well-being; • measure national progress toward, or movement away from, achieving that vision; • understand and promote awareness of why society is moving in the direction it is moving; • stimulate discussion about the types of policies, programs, and activities that would move us closer and faster toward achieving well-being; • give canadians tools to promote well-being with policy shapers and decision makers; • inform policy by helping policy shapers and decision makers to understand the consequences of their actions for canadian well-being; • empower canadians to compare their well-being both with others within canada and those around the world; and, • add momentum to the global movement for a more holistic way of measuring societal progress. policies must come to terms with the new forces that act to create or compromise health -they must respond to what has been called "the new personal health ecology" where the individuals are subject to a broad range of influences over which they have very little control [ ] . just as cholera was symptomatic for all the dimensions of the rapid urbanization of the th century, obesity is the symbolic disease of our global consumer society. it will be a test case for the health governance of the st century as was the introduction of water and sewage systems at the end of the th century. such challenges can only be resolved through great political commitment, willingness to innovate, and social action -including social entrepreneurship -at all levels of society. health and innovation are both social constructs, defined by their time and context. just as the concept of health is changing, so is the concept of innovation. the social sciences began in the s to concern themselves with both health and innovation as distinct areas of social analysis. it was at this point that both medical sociology (later to become health and medical sociology) and the sociology of innovation began to advance -the one never far removed from medicine, the other never far from the sociological analysis of technological development. even today much of the literature on innovation still comes from a science and technology perspective. this is in sharp contrast to economics, where already at the beginning of the th century josef schumpeter drew attention to innovation as the engine of social and economic development, highlighting both its power of creation and of destruction [ ] . health has now become such an innovation engine -many investors see health as "the next big thing" and a rapidly growing health market attaches the added value "health" and well-being to an ever-growing set of products and services. the chapter by henke and martin in this book illustrates this process: not only do health innovations change society, but through the societal process of innovation in health the very nature and the characteristics of innovation change, a process that has been described as "the innovation of innovation." this leads further to the concepts of "open innovation" and "fluid innovation," which are discussed further below in relation to policy innovations for health [ ] . in switzerland a recent survey asked a group of health experts to identify the key technological and social drivers of innovation in health [ ] . in the first category the experts established a ranking in the following order: ( ) developments in biotechnology and genetics, ( ) medical technology, ( ) informatics and soft ware, ( ) organic chemistry, ( ) telecommunications and ( ) nano technology. in the second category they ranked ( ) demography, ( ) individual responsibility, ( ) nutrition, ( ) education, and ( ) income distribution. most interesting though -and symptomatic for the speed of social change -is that the experts ranked the social driving forces as more important and forceful than the technological ones. additionally they did not assign a high impact value to political driving forces -which reflects the assumption of the experts, that not much innovation is to be expected from traditional types of health policy. the sociology of innovation argues that innovation itself has become a leitmotif of st century society; this development is called "ubiquitous innovating" [ ] . indeed if one refers to some of the key documents -for example, of the european union or of the oecd -a strategy for innovation is considered essential in order to compete in a global environment [ , ] . it is interesting -with a view to liquid modernity -how similar the discussion of a new conceptualization of innovation is to the discussion on a new understanding of health. health in turn is increasingly seen as one of the cornerstones for competitiveness and innovation. and like innovation it is increasingly seen to be in need of a policy approach that is more concerned with sustainability and long-term effects. the key health sustainability challenges of st century societies are: . the demographic and financial pressure brought to bear on health and social systems through the ageing of societies -societies need to support an increase in healthy life expectancy and an independent life, despite disability and chronic disease; otherwise, we might witness a breakdown of support systems and social solidarities. . in view of new epidemiological developments -for example, the increase of overweight and obesity, early onset of diabetes, and an increase in mental health problems -the generation of children born at the turn of the st century could be the first to have a lower health and life expectancy than their parents. increased investment in the health of the next generation is critical. . health systems organization and financing is not sustainable without major reorientation away from acute care toward increased prevention, management of chronic disease, and community-based, integrated primary health care. . with globalization we are witnessing the rapid spread and emergence of new infectious diseases -such as sars and hiv aids -and the re-emergence of others, such as tuberculosis, there is increasing fear of a global influenza pandemic -increased preparedness is critical at all levels of health governance. . as st century societies are restructuring they are presently witnessing increasing health inequalities -addressing these widening gaps will be a key challenge for trust in modern democracies. . we are only just beginning to understand the health impacts of global warming and climate change -we must be more conscious of the interdependence of health sustainability and environmental sustainability [ ] . while the territory of the medical system can be relatively clearly circumscribed and framed in terms of delivery and utilization of health care services, the territory of health becomes ever less tangible and increasingly virtual. disease has boundaries; health does not. the new health challenges make this blatantly obvious. within government the stakeholders in the response to obesity are not only the health ministry, but, for example, the ministries of transport, education, agriculture, trade, and consumer affairs. outside of government the producers of unhealthy food and drink products are as much in focus as are the settings of everyday life where they are consumed (such as canteens), global marketing and advertising practices, the media messages, and the role model celebrities to name but a few. smoking acts regulate not only who can buy tobacco products, where, and at what price but they define where it is permitted to smoke; in consequence, owners of bars and restaurants, retailers, and the management of airports and railway lines to name but a few, all need to be concerned with health in ways they were not before. consumers and voters as well as a wide array of health action groups and patient organizations make their preferences heard. this infinite nature of health has consequences for all four domains of the health system. it is specific to the health society that all four domainspersonal health, public health, medical health,and the health market -not only continue to change and expand but -and this is critical -that the balance between the systems is shifting [ ] . the health sector -consisting of the public health domain and the medical health domain -struggles to include more health, in the form of strengthening public health, health promotion, and prevention. yet, this approach is falling short in many countries, in particular for lack of political support, except where the measures are clearly medical, such as expanding screening or strengthening predictive medicine. while the new paradigms in preventative medicine are gaining increasing acceptance, public health measures are considered unduly paternalistic and are seen to impinge on the individual freedom of choice. structural measures addressing the determinants are also not politically popular, as they usually impinge on one or the other economic interest. there have been excellent policy documents such as the wanless report in england [ ] that have proposed to embark on an organizational shift within the health sector toward public health, driven in particular by the fear generated by the relentless growth of the medical health domain. they argue that more money needs to be invested in prevention, health promotion, and public health; otherwise, our societies will not be able to afford the constant expansion of the medical health system. so far within the health sector very few policies, institutions, organizations, and funding streams have clearly differentiated between investing for health and the expenditures for providing medical care. durand-zalesky makes this point in great detail in the contribution to this book and she underlines how important the political innovation environment is for a public health agenda focused on determinants -in the case of policy innovation for health the different perceptions of the role of the state, the market and the individuals are critical. where an accounting for health -which is different from the proposed national health accounts -is attempted, countries rarely reach more than a . % average of the overall "health" budget for prevention, health promotion, and public health, as oecd data tell us [ ] . politically the pressure is strong to subject every penny of this paltry amount to critical evidence reviews based on a medical mind-set, while to this day most health service organizations are still not accountable for their health outcomes and demonstrate a severe lack of transparency for patients and consumers. it is therefore arguable whether the expansion of a traditional public health approach -for example, with more funding -will be sufficient. a new nordic initiative argues -as do the authors in this book -that fundamentally new perspectives are needed. they locate them at three levels: mind-set, partnerships, and platforms [ ] . policy innovations for health need to move beyond the established functional boundaries of both the medical health domain and the public health domain. the innovation debate can help in conceptualizing the necessary change. open innovation is a term initially developed for the private sector and championed the idea that companies cannot anymore rely on their own innovative capacity -they need to share and outsource [ ] . the perception of open innovation now means to involve a broad range of partners in order to find innovative solutions, particularly in the form of innovation clusters. as used to be the case in business, the functional and hierarchical approach in the medical and the public health domains do not usually allow for this. there are therefore very few policy mechanisms that allow decision makers to consider both health determinants and health impacts in an integrated manner and to approach the new health challenges with joined up policy responses, initiatives, and interventions. usually each policy (sub) domain works to its own logic and intentions without regard for the impact on other areas of society or its global impact. some exceptions can be found in the area of environmental policies. if -with health in mind -we are willing to see the glass as half full, we can identify a range of policy innovations emerging in health that could be summarized under the term network governance. examples are described in more detail in the chapter by warner in this book. in many countries a first step to engage a broad range of actors around common goals was the development of health targets [ ] , an approach that gained ground from the s onward. in order to achieve the targets it became clear that policies in the health sector needed to be complemented by other sectors of government and that they in turn needed to be supported by policy commitments at different levels of government and in the private and nongovernmental sector. the wanless report calls this the fully engaged scenario [ ] . in consequence a new type of policy mix is emerging between governmental measures, global initiatives, local action, consumer pressure and demand, and mechanisms -such as self-regulation or corporate social responsibility approaches -put into place by companies and the private sector. who would have imagined even a decade ago a range of the policy innovations for health we have witnessed recently: • that a country would base its health policy on the determinants of health as in sweden? • that a health minister would regulate the body mass index of fashion models as in spain? • that television advertising of fast foods to children would be severely restricted as in england? • that a country could accept a total ban on smoking in public places -including restaurants and bars as in ireland? the health society not only means that health is present in every dimension of life, it also implies that risk is everywhere. as every place, setting, product or message in society can support or endanger health the potential stakeholders in any health policy decision expand exponentially; transport policies relate to the obesity epidemic, the beer tax influences young people's alcohol consumption and low literacy increases health inequalities. three types of policy innovations for health that qualify as open innovations are briefly outlined in the following: health in all policies, innovation clusters, and platforms. a key policy innovation for health is the health in all policies approach put forward by the finnish presidency of the european union in [ ] and first developed in the ottawa charter with the term "healthy public policy" [ ] . health in all policies is now also one of the four principles of the european health strategy of the ec [ ] . i have described health in all policies as an innovative policy strategy that responds to the critical role that health plays in the economies and social lives of st century societies. it introduces better health (improved population health outcomes) and closing the health gap as shared goals across all parts of government and addresses complex health challenges through an integrated policy response across portfolios. by incorporating a concern with health impacts into the policy development process of all sectors and agencies, it allows government to address the key determinants of health in a more systematic manner, while taking into account the benefit of improved population health for the goals of other sectors [ ] . some countries have tried to reflect such an approach by creating a ministerial mechanism for the focus on health rather than disease; for example, canada for a while had a minister for public health with cabinet rank, and england and sweden both have junior ministers for health. many partnerships are emerging beyond the health sector and its narrow policy conception. increasingly we see a wide range of innovation clusters developing which create a new type of interface between many different actors following the open innovation model for companies but expanding it into public-private partnerships. one such example "berlin's health care market" is described in this book in more detail by henke and martin. another example is the "myheart" project -which brings partners from countries together to develop "intelligent textiles" in order to prevent heart disease [ ] or the innovations in the area of functional foods. of particular interest as a policy innovation for health is the proposal to establish "the nordic region as a global health lab" [ ] . it is proposed that the nordic countries form an innovation cluster so that the nordic region will become "a global market leader for prevention solutions." they further state that "the booming global market for health related products and services speaks in favor of joint initiatives, where knowledge and experiences produced within a research framework can be used to develop products and solutions attractive to the nordic as well as the global market." they then go on to define the nine components that will give such an initiative a global competitive edge: nine components for success: . a social model supporting equal access to health for all . prevention as a top nordic policy priority . access to valuable data . strong civil society organizations . strong conditions for collaboration . innovative science environments . strong industries . a competitive nordic region . demanding consumers provide a strong platform for user driven innovations this initiative is a clear example of the attempt to build an innovation on a supportive policy environment in order to create social and economic value through health not only locally, but globally. another move toward policy innovations for health based on open innovation approaches is the ever increasing number of platforms, coalitions, alliances, and networks built around health issues. a good example is the european platform on diet, physical activity and health initiated in by the dg sanco of the european commission, which allows the commission to work with a wide range of players across the public, private, and nongovernmental sectors [ ] . the stated intent is to create a platform for concrete actions designed to contain or reverse current trends, platform members must commit to action. as underlined in the white paper on strategy for europe on nutrition, overweight and obesity related health issues, the commission considers that the development of effective partnerships must be the cornerstone of europe's response to tackling nutrition, overweight and obesity, and their related health problems. in such platforms the members agree to monitor and evaluate the performance of commitments in a transparent, participative and accountable way; the eu platform, for example, works to a founding member's statement, has a monitoring framework and produces progress reports. the visibility and legitimacy conferred through such alliances is gaining increasing importance as a policy mechanism as are a myriad of public-private partnerships. actors and issues gain prominence through media presentation and public debate as the health society is also a media-driven society. these platforms constitute a new political space for health and network governance, particularly for very controversial issues. the european commission, for example, uses a multistakeholder platform to address alcohol issues through an "alcohol and health forum," bringing together civil society and businesses pledging to take action to reduce alcohol-related harm in europe [ ] . innovation and knowledge are interdependent. innovation can be defined as the process through which social and economic value is created through knowledge, an issue discussed in more detailed in the chapter by sakellarides. this is done by different forms of knowledge creation, diffusion, transformation, and application. both health and innovation are increasingly dependent on the inclusion of the user and challenged by the democratization of knowledge production. the sociology of innovation describes the innovation paradox, which postulates that in the knowledge society the role of the producer and the role of the consumer move ever closer together -health as well as innovation therefore need to be considered as coproduced goods [ ] . in the area of technological innovation this is often described with terms like open source, open content, lead user, open innovation, collective invention, user innovation, and creative commons [ ] . in health policy this participatory element has been neglected. on the one hand it is particularly difficult for the health care system to accept participation, because it has been defined by a very strong hierarchy between the professional physician, other health professionals, and the patient. yet the management of chronic disease and the adherence to prevention regimes can only be achieved with full participation of the individual concerned. the overlap of unmet medical needs and unmet social needs can only be addressed jointly between patients, providers, and the social support system -patient input is a prerequisite to developing the kind of integrated disease-management models that most health systems still do not provide because they are out of step with the epidemiological and social development. the unmet medical and social need has led to the creation of a wide range of highly active patient organizations and self-help groups who act as the experts on "their" disease. the same applies to prevention and health promotion -the active participation of the individual, social groups, and communities is needed to engage in successful initiatives [ ] . sakellarides in his chapter highlights to interdependence of the knowledge society with innovation in the health society. patients want information, participation, and choices -this is the result of the "european patient of the future" survey from [ ] . consumers want simplicity, convenience, speed, and a good price [ ] . increasingly the two expectations meet as health systems become increasingly market driven and as patients want more say and have higher expectations. new products and technologies can only develop their full potential if they meet processes and structures that allow them to do so. this implies new forms of information, communication, and integration processes. the conference board of canada in its recent analysis [ ] defines three dimensions of high performing health systems: people and culture, technologies, and structure and processes. this is also reflected in the more recent literature on innovation which speaks of a paradigm shift toward a "fluid identity of innovation" [ ] . this means the "old" debates as to what constitutes a radical innovation and an incremental innovation is considered less and less relevant. this is often much more obvious in other, less regulated areas than the health sector. a good example from information technology is the telephone: at what point in the long process from graham bell's machine to the tiny multifunctional mobile instruments we use today do we speak of radical or incremental innovation? when it turned wireless? when it could take photographs? when it became the iphone? whatever it will be in future? similar questions arise in relation to medicines and medical technology which with the rise of chronic disease fulfill more than their primary medical function -they cannot cure any more so they will seek to reduce pain and the progress of disease, lengthen life, improve mobility, ensure independence, be easy to use, etc. the innovation process around medicines for hiv/aids is a typical case in point -every small improvement in the lives of aids patients counts and it continues to be driven not only by medical innovation but a very strong demand from influential user and advocacy groups. probably one of the most important process innovations that needs to be achieved lies in the transparency and accountability of health policy and health systems. hernandez-aguado in his chapter indicates how new types of monitoring could provide transparency and accountability for the impact that other sectors have on health. sakellarides and his coauthors highlight the significance of patient-driven and patient-owned health information, also including the determinants of health. it is indeed worrying that in modern democracies, citizens -once they become patients -do not have access to data on the performance of the system that they enter or even to their own health data. this knowledge-based value creation willas sakellarides states -probably be the most relevant health policy innovation in the next decade. health consumer powerhouse regularly publishes a ranking which indicates in which countries consumers and patients have the most rights and the most opportunities for participation [ ] . a recent german survey showed that most citizens would like to see a ranking of physicians and would like to see their medical bills. [ ] . if health is a coproduced good, then all those that participate in its production have a right to transparency of all elements of the process. the issue of transparency also arises around propriety regulations. in the information technology field, there has been a move toward open access, open source, and open standards, and with the expansion of the internet it has led to new forms of information access and sharing -the exciting mix of social and technological innovation, as reflected in platforms such as myspace and second life. these demand-push innovations have in turn led to highly profitable companies. due to the structure of the proprietary industry and government regulations, much of this innovation process remains closed. it is regularly challenged, in particular, by nongovernmental organization in relation to global health issues innovations -and more recently by the establishment of government assessment agencies. this conflict is not the subject of this book -yet it is worth referring to an interesting experiment at the world economic forum in , which discussed how the break down of proprietary rights in the entertainment industry could be a signal for the pharmaceutical industry to reconsider its approaches with a new and proactive demand-push approach. in some cases this has succeeded at the global level where new forms of pricing, patent policies, and financing of pharmaceutical innovation for diseases of the developing world have been developed, and after much conflict a new cooperation between advocacy groups, the industry, governments, and modern philanthropy has emerged. for this book the key issue is that health is no longer a given; it is produced, maintained, and enhanced. the results of health research are rapidly transported through the media -a new cure, a new method of prevention, a new confirmation of old behaviors, all have high currency in the health society. what is considered healthy today might not be so tomorrow -new risks continuously emerge [ ] . as a consequence heath literacy plays a critical role [ ] . risks are frequently not visible or seem intangible and they need to be well communicated, and above all understood and translated into action. as more and new health information becomes available this can become a difficult challenge for ordinary citizens in particular if they are not well educated or even functionally illiterate, as about % of all citizens in the oecd countries are. the expansion of health choices and the complexity of health systems demand an ever higher degree of sophistication and participation, and as a consequence there is a growing offer and demand not only for health information but for advice and knowledge brokering. to be a passive and compliant patient who follows the physician's instructions is no longer sufficient -particularly when related to preventative issues. indeed the emerging model is one of active and critical consumers, an ideal that only few members of the population can aspire to achieve. already today -despite the universal access to health care -health inequalities abound even in the richest countries, and there is a clear danger that they will widen even further as the health society expands. the very presence of health in all areas of everyday life can also lead to a variety of reactions -either to attempts to reach an unrealistic body image or to conscious risk taking in opposition to an overpowering set of health messages and expectations. while the health society offers many opportunities of empowerment, it can also be prescriptive and exert social control through health [ ] . within a health society there has to be constant democratic dialog about the societal value we attach to health, a debate that has barely begun. providing access to information on health and new health products and services including e-health is only a small part of the issues at stake as sakellarides points out in his chapter. there is in general a big democratic deficit in relation to health and health policy, which needs to be addressed with urgency: the reorientation toward participation and user involvement will be one of the most important governance shifts in health. what will innovation in health policy imply in the st century? if innovation means a reorganization of how we approach health in st century societies, i propose that the following five dynamic processes will be critical. our societies will need to • develop a new understanding of health as an investment and productive force in society • develop separate governance mechanisms for health and for health care, with a strong focus on accountability for health gain • augment the concern for ethics and values with respect to health through a broad dialogue with citizens in order to increase democratic legitimacy and ensure solidarity • move beyond a narrow understanding of health outcomes in terms of only physical health measures to those that aim to include or even prioritize broader measures of wellbeing • engage in network governance, partnership and multi-stakeholder approaches in rder to achieve health goals. the big st century health challenges call for more courageous and democratic policy approaches than applied so far. while our societies have now learned to recognize the urgency of the environmental challenge in terms of long-term sustainability, we are only just beginning to grasp the consequences that our way of life has in terms of health sustainability. an example of developing such a change in mindset are the health in all policy principles developed in the south australian government in through a health in all polices process [ ]. a "health in all policies" approach reflects health as a shared goal of all of government. in particular, it . recognizes the value of health for the well-being of all citizens and for the overall social and economic development of south australia. health is a human right, a vital resource for everyday life and a key factor of sustainability. . recognizes that health is an outcome of a wide range of factors -such as changes to the natural and built environments or to social and work environments -many of which lie outside the activities of the health sector and require a shared responsibility and an integrated and sustained policy response across government. . acknowledges that all government policies can have positive or negative impacts on the determinants of health and such impacts are reflected both in the health status of the south australian population today and in the health prospects of future generations. . recognizes that the impacts of health determinants are not equally distributed among population groups in south australia and aims at closing the health gap, in particular for the aboriginal peoples. . recognizes that health is central to achieving the objectives of the south australian strategic plan -it requires both the identification of potential health impacts and the recognition that good health can contribute to achieving south australia strategic plan targets. . acknowledges that efforts to improve the health of all south australians will require sustainable mechanisms that support government agencies working collaboratively to develop integrated solutions to current and future policy challenges. . acknowledges that many of the most pressing health problems of population health require long-term policy and budgetary commitment as well as innovative budgetary approaches. . recognizes that indicators of success will be equally long term and that regular monitoring and intermediate measures of progress will need to be established and reported back to south australian citizens. . recognizes the need to regularly consult with citizens to link policy changes with wider social and cultural changes around health and wellbeing. . recognizes the potential of partnerships for policy implementation between government at all levels, science and academia, business, professional organizations, and nongovernmental organisations to bring about sustained change. an additional complexity is due to the fact that health in the st century is inherently global and many determinants of health are no longer in the control of nation states. global and regional agreements of an economic and political nature can seriously endanger health -as experienced in rising alcohol rates in finland and sweden when they joined the european union -or they can move the health agenda forward through transnational and global health agreements. the last years have seen the acceptance by the who member states of both the international health regulations and the framework convention on tobacco control. but other less binding approaches, such as the forceful move on a global strategy to combat chronic diseases, the policy by the european union to consider the health impacts of all policies of the eu, the discussions on health at the davos world economic forum, the new priority assigned to health in the oecd, and the product shift of many global companies, all illustrate the global driving force that health has become. concerns arise around the global pharmaceutical market as much as over the global spread of sugary soft drinks, the global movement of health professionals as much as over the rapid global spread of viruses [ ] . while the policy innovations for health required at the global level are not subject of this book, the authors are aware that this global nature of health is in itself one of the most significant driving forces of the reorganization of health in the st century. magazine daily summary. oecd forum innovation, growth and equity, paris france - exploring technological innovations in health systems. conference board of canada oecd health and innovation survey the consequences of modernity liquid life health and modernity leading for innovation: & organizing for results social determinants of health health and consumer protection directorate ( ) the contribution of health to the economy of the european union tackling obesity -future choices project report sweden's new health policy. stockholm . public health agency of canada: determinants of health world health organization (who) ( ) constitution settings' based health promotion: a review territorial innovation models: a critical survey canadian index of wellbeing the nordic region as a global health lab theorie der wirtschaftlichen entwicklungen ( . auflage, ursprünglich ) wandel im gesundheitsmarkt: strategische ausrichtung der pharma-und biotechindustrie auf künftige marktbedingungen und träventive therapien. dissertation, eth zürich ) lissabon strategie. ec.europa.eu/ growthandjobs/index de die gesundheitsgesellschaft securing good health for the whole population. hm treasury. www.hm-treasury.gov.uk/consultations and legislation/wanless/consult wanless final.cfm open innovation health targets in europe adelaide revisited: from healthy public policy to health in all policies health strategy white paper fighting cardio-vascular diseases by prevention and early diagnosis eu platform on action on diet, physical activity and health. ec.europa.eu/health/ph determinants/life style/nutrition/platform/platform en.htm . hippel e. von ( ) democratizing innovation the european patient of the future. picker institute europe sustainable innovation as a corporate strategy consumer power house health consumer powerhouse: euro health consumer index ( ) www.healthpowerhouse.com/media/rapport ehci die ambulante versorgung aus sicht von bevölkerung undÄrzteschaft health literacy. towards an active health citizenhip risk and socio cultural theory, new directions and perspectives. cambridge special theme: health and foreign policy some parts of this chapter are based on a working paper for the academic advisory group, which provided the guidance for the work on this publication. it was published as an editorial. ( key: cord- -qi dkcb authors: wilson, kumanan; graham, ian; ricketts, maura; dornan, christopher; laupacis, andreas; hebert, paul title: variant creutzfeldt–jakob disease and the canadian blood system after the tainted blood tragedy date: - - journal: soc sci med doi: . /j.socscimed. . . sha: doc_id: cord_uid: qi dkcb the transfusion transmission of hepatitis c and hiv to thousands of canadian blood recipients was one of this country's largest public health catastrophes. in response to this crisis, and in an effort to prevent such a tragedy from occurring again, the canadian blood system has undergone substantial reform. variant creutzfeldt–jakob (vcjd) disease was the first infectious threat faced by the blood system since undergoing reform. the response at the time to this risk provides insights into the canadian blood system's new approach to infectious threats. our analysis of the decision-making concerning vcjd identifies two dominant themes characterizing the new blood system's approach to safety: ( ).. the adoption of a precautionary approach to new risks which involves taking action in advance of definitive evidence, and ( ).. risk aversion amongst policy makers, which has contributed to the adoption of safety measures with comparatively high cost-effectiveness ratios. overall the principles governing the new blood system have contributed to the system both providing protection against emerging infectious risks and regaining the confidence of the public and recipients. however, the current set of policy factors will likely contribute to increasingly risk-averse policy making that will contribute to continued increases in the cost of the blood system. the challenge the blood system now faces is to find the appropriate balance between maximizing safety and ensuring the system remains affordable. the transfusion of individuals with products infected with hiv and hepatitis c was, arguably, the largest public health catastrophe in canada's history. estimates suggest that infected transfusions led to more than one thousand individuals acquiring hiv and up to individuals acquiring hepatitis c (krever, a) . a national inquiry into the functioning of the blood system and how it could have led to the tragedy, headed by justice horace krever, precipitated a transformation of the delivery of transfusion services in this country. this transformation involved the replacement of the canadian red cross as the operator of the blood system and the creation of new financial arrangements and operating principles (krever, b) . it has now been years since canada's blood system has undergone reform and the opportunity exists to reflect on how successful the transition to a new system has been. from the perspective of managing infectious threats, the new blood system would have to be viewed as a major success. canada has acted aggressively to protect the blood supply from real and theoretical risks such as variant cjd, west nile virus and severe acute respiratory syndrome (canadian blood services, ) . in this regard, the post-krever blood system has received high marks, including from hemophiliacs who were one of the primary groups affected by the tainted blood tragedy (canadian hemophilia society, ) . however, the blood system has not been without criticism, which has primarily been directed at the introduction of safety measures with prohibitive cost-effectiveness ratios that have contributed to escalating blood costs. there are several opportunities to learn from the canadian blood system's reform efforts and in many ways the blood system provides an important model for other public health sectors which are addressing new and emerging risks in an increasingly risk averse environment. to better understand how decisionmaking has been transformed in the post-krever era we provide a detailed examination of the canadian blood system's management of variant creutzfeldt--jakob disease, its first infectious threat since undergoing transition. while many faults could be found with how blood officials managed affairs leading to the tainted blood tragedy, one of the areas of particular concern was how scientific evidence was utilized to formulate policy. our analysis is therefore assisted by the use of a descriptive policy analysis framework that focuses on the role of information in the policy process. we review our findings in the context of subsequent blood policy decisions to arrive at general principles governing policy making in the post-krever environment. in the late s, the canadian blood system and health officials were confronted with a true policy dilemma: how to manage the theoretical risk of blood transmission of cjd. this challenge emerged just as justice krever was releasing his final report and federal/provincial/territorial officials were creating a new blood system in line with many of the recommendations of this report. the challenge also presented itself as the united kingdom was addressing the outbreak of bovine spongiform encephalopathy, which eventually led to the emergence of vcjd in humans, and dealing with criticism of their response to this crisis. thus, the potential transfusion transmission of cjd combined aspects of two of the highest profile public health controversies at the time. further contributing to the challenge of managing the infections risk posed by cjd to the blood supply was the unusual nature of the disease itself. cjd is a rare infectious condition that is believed to be caused by a new form of infectious agent, an infectious protein, known as a prion (prusiner, ) . the infection is devastating and affected patients suffer progressive neurological deterioration and dementia due to spongiform changes in the brains of the victims. patients inevitably die from the infection, usually within a year of the diagnosis. while extremely rare (o % of all cases), there have also been several documented cases of iatrogenic transmission of cjd. the documented iatrogenic transmission of cjd via human growth hormone, in particular, raised concerns in the united states and canada about whether the condition may also be transmissible via blood products. this concern arose in the canadian blood system, as it was recovering from the tragedy of hepatitis c and hiv blood transmission. as a consequence, the potential transfusion transmission of cjd was viewed as the first major test for the blood system after these infectious threats (vaughan, ) . the challenge of managing the potential transmission of cjd via blood products was further complicated by the discovery, in , of a variant form of cjd in the united kingdom . the condition was believed to have arisen from bovine spongiform encephalopathy (bse). while there was no epidemiological evidence of blood transmission of vcjd, the theoretical risk was considered higher than classical cjd for a variety of reasons (cashman, ) . policy makers in the united kingdom decided to reject donations from their citizens and import their plasma requirements due to concerns over the potential blood transmission of vcjd. this prompted decisionmakers in the united states and canada to evaluate whether they should accept donations from individuals who had traveled to the united kingdom. however, this would potentially reduce the blood supply and cause shortages. ultimately canadian policy makers decided to defer donations from individuals who had spent months in the united kingdom between the years and (the peak period of the bse epidemic). it was anticipated that this policy would reduce the risk of vcjd to the blood supply and ensure that the blood supply remained adequate (wilson et al., ) . these policies have been modified as further evidence has accumulated of the prevalence of bse and donor deferral policies have been instituted for individuals who have resided in france and all of western europe. most significantly, scientific evidence has accumulated which validates the institution of the precautionary policies, both from animal models demonstrating transfusion transmission and from case reports of transfusion transmission in humans (wilson & ricketts, ) . a framework for understanding decision-making on health risks to understand decision-making on issues of risk pertaining to the blood system, analytical tools that provide a comprehensive understanding of the multiplicity of factors that influence policy are required. descriptive policy analyses are well suited to analyzing policy making concerning risks by identifying the critical factors influencing decisionmaking as well as providing insights on where decision-making breaks down and, equally important, where it works effectively (hogwood & gunn, ) . descriptive policy analyses in health, however, have often been based on the assumption that rational decisions are made on the basis of complete information (pal, ) . given the uncertainty of scientific information on potential health risks, these information-based models may not be adequate. alternative models to evaluate decision-making have focused on the role of value systems or institutions. however, to be truly comprehensive, approaches to policy analysis integrating the impact of information, values and institutions are needed to ensure that both the policy makers and the public understand how decisions are made concerning health risks. paul sabatier has compiled some of the available frameworks for conducting descriptive policy analyses (sabatier, a) . one of the criteria used for selecting frameworks is that they address the roles of conflicting values and interests, information flows, institutional arrangements and variations in socioeconomic environment on the policy process. the following frameworks were identified as useful for describing decision-making within a given political system or set of institutional arrangements: the stages heuristic, institutional rational choice, multiple-streams framework, punctuated equilibrium framework and the advocacy coalition framework. the last framework, the advocacy coalition framework (acf), was proposed by sabatier and suggests that decision making occurs in a policy subsystem involving individuals from a variety of public and private organizations who are actively concerned with a policy problem. within this subsystem, individuals aggregate into advocacy coalitions based on shared ideologies and beliefs. the success of the coalitions in translating their beliefs into policy is dependent upon their resources (money, expertise, legal authority and size). policy brokers attempt to mediate the conflict between the various advocacy coalitions. this process of conflict and mediation eventually results in policy outputs by the governing structures in the subsystem (sabatier, ; sabatier, b ). the acf model has been identified as being effective in describing decision-making in a variety of policy sectors (jenkins-smith & sabatier, ) . a modification of the acf model has been put forward by jonathan lomas (fig. ) (lomas, ) . in this model individuals make policy in an ''institutional structure for decision-making''. this structure consists of ''formal'' actors, who actually participate directly in the decision-making process, and ''informal'' actors, who influence decisionmaking through other means. values in this model are divided into ideologies (views on how things ought to be), beliefs (causal assumptions on how things are), and interests (responses to incentives and rewards). in addition, this model pays greater attention to the role of information producers and purveyors. it specifically examines how information is produced and spread and how the value systems of those involved in the policy subsystem influence the interpretation and use of this information. our choice of the lomas framework was based on face and content validity parameters; i.e. the domains we felt would be important are appropriately captured in the framework. the vcjd decision was primarily characterized by how policy makers utilized scientific information. in this sense, the lomas framework is well suited to conducting the analysis given its focus on knowledge development and knowledge transfer. the framework's hypothesis that policy makers resolve conflicts between their various value systems through a process of cognitive dissonance reduction is also well suited to analyzing a policy problem where information is uncertain and value systems would necessarily play a particularly prominent role. the objective of our overall study was to understand and compare the decision-making processes concerning two creutzfeldt-jakob disease-related decisions: a withdrawal of blood products from a classical cjd donor and a decision to defer donations from individuals who had traveled to the united kingdom for months during the peak of the bse outbreak ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . we present, here, the full analysis of the second decision, with the first decision acting as important historical context. our study consisted of a literature review and semi-structured interviews. the literature review included a systematic review of the risk of transmission of cjd via blood products, a content analysis of newspaper reporting as well as a review of important policy documents. in total we conducted semi-structured interviews with key informants of all major decision-making organizations. individuals were asked to describe decision-making leading to the and decisions as well as other relevant decisions. individuals were also asked about the role of information, information purveyors, decision-making organizations and external factors in the decision-making process. all information from the interviews was coded using qsr nudist, a qualitative software program. findings of the study were fed back to decision-makers through member check sessions with key stakeholder organizations. our findings have been presented in a series of papers, initially focusing on information (wilson, code, & ricketts, ) and information purveyors , then institutions (wilson et al., ; wilson, mccrea-logie, & lazar, ) and finally the role of values and changes in ideology (wilson, wilson, hebert, & graham, ) . we synthesized the results of these studies using the lomas framework. based on this synthesis we isolate the key policy factors that are driving current decision-making in the canadian blood system. we then propose mechanisms by which acting on these policy factors could influence future decisions. factors influencing decision-making (table ) in canada three pieces of information played an important role in influencing the decision-making process leading to the donor deferral decision: ( ) the risk of transmission of vcjd via blood products, ( ) the impact of donor deferral on the blood supply, and ( ) the degree of reduction in the blood supply the blood system could sustain. all of these pieces of information had substantial levels of uncertainty associated with them. there were no epidemiological studies on risk of blood transmission of vcjd and an estimation of the risk was based primarily on biological models. based on these models the theoretical risk possibility of blood transmission of vcjd was considered for the following reasons: vcjd had been demonstrated to be transmissible through a peripheral route (gi tract) and thus peripheral transmission via blood products was believed to be possible, the prion concentration in affected tissues was high in vcjd and prions are found in the lymphoreticular system in vcjd which is intimately linked to the blood supply (cashman, ) . scientists argued that this evidence of risk based on biological models was substantial enough to warrant government action to protect the blood supply. given the uncertainty of information on risk of blood transmission of vcjd the impact of a policy on the blood supply needed to be considered before proceeding. this information was obtained from a survey that suggested that a % reduction in the blood supply would occur with a -month deferral policy. previous experience in the blood system indicated that a % reduction was sustainable, although there was considerable uncertainty over this estimate. in an attempt to integrate all of this information, as well as the likelihood of developing vcjd over different residency periods in the united kingdom, a risk modeling exercise was performed. this analysis also suggested that the risk of contracting vcjd increased after months residence in the united kingdom. however, this model was based on infectivity rates of bse that, to this date, remain unclear (elsaadany & giulivi, ) . three major information purveyors influenced the policy process leading to the donor deferral decision: scientists, the media and think tanks. the media's primary role was to disseminate the release of a report by a think tank advisory committee on bioethics, which advocated that the canadian blood (bayer advisory council on bioethics, ) . in combination, this report and the media coverage it received played an important agenda setting function by bringing the emerging issue to the public's attention . scientists also played an important role in communicating information on risk to policy makers. in particular, due to the lack of scientific expertise on the subject, one scientist came to play a prominent role in the decisionmaking process. this individual was a consultant on three separate sources of information that were supplied to the decision-makers. all of these recommended that the government take action to protect the blood supply from vcjd (bayer advisory council on bioethics, ; cashman, ; expert advisory committee on blood regulation, ) . we had a unique opportunity to assess the impact of institutions on decision-making by being able to compare the vcjd donor deferral decision to another cjd related decision that took place prior to institutional change in the blood system; the recall of blood from a classical cjd donor. the major structural changes to the blood system that took place over this time period was the replacement of the canadian red cross as sole operator of the blood system by two separate operators, he´ma-que´bec in the province of quebec, and canadian blood services in the rest of canada. we observed that the movement to a two-operator system had an important impact on the decision-making process. the presence of a second operator introduced a form of ''check and balance'' on the decisionmaking processes of the larger operator by proposing competing policy options to address the vcjd problem. however, it also increased the complexity of the decision-making process and initially produced some inter-institutional conflict (wilson et al., ) . distribution of regulatory authority and funding also played an important role in the decisionmaking process, specifically the separation of these two functions. in canada regulatory authority for blood products exists at a federal level. financing of the blood system is the responsibility of the provinces. in this system, the incentive exists for the regulator to introduce policies that maximize the safety of the blood supply, and the financial considerations of the decision play a secondary role (wilson, mccrea-logie et al., ) . other institutional effects include decisions made by institutions in parallel subsystems, in particular other countries' blood systems. the uk decision to ban plasma donation from its own citizens played a large role in initiating the decision-making process in both canada and the united states as to how to handle donations from individuals who had traveled to the united kingdom. of particular importance, canadian policy makers attempted to coordinate canada's donor deferral policy with that of the united states. this was largely a consequence of the fact that canada imports a substantial portion of its plasma requirements from the united states. in general, canadian policy makers are expected to meet international standards in protecting the blood supply (canadian blood services, ) . we observed that most individuals shared a common belief, defined as a ''causal assumption of what is'', on the risk of transmission of cjd; that transfusion transmission was a theoretical risk with no known documented cases of transmission. however, while the risk was viewed as theoretical, the type of risk which was presented is one to which the public and policy makers would be particularly averse. the factors contributing to this perception of risk include the potentially catastrophic, involuntary nature of the risk, the lack of knowledge of the risk and the lack of trust in the system's ability to manage the risk (slovic, ) . ideologies, defined as ''causal assumptions of how things ought to be'', played an important role in determining how information was interpreted and utilized to develop policy. two dominant ideologies on how decision-making should take place on issues of risk were at play: evidence-based decision-making and the precautionary principle. the precautionary principle came to play a particularly prominent role largely as a consequence of the krever inquiry into the blood system use. however, we observed a clear tension in which decision-makers struggled with the idea of introducing a policy that could create a health risk (blood shortages) to protect against a risk for which no epidemiological evidence existed . at the institutional level, we found competing interest systems at work. the regulator's primary responsibility was to protect the safety of the blood system. the operators, in contrast, were interested in balancing safety with adequacy of supply. however, all players in the blood system recognized the crucial need to reestablish public confidence in the blood system and their responsibility to protect the blood supply on behalf of the public. at the level of the policy-maker, the lasting effects of the krever inquiry played an important role in influencing individuals' actions. the spotlight that was placed on previous decision-makers in the blood system and the legal consequences of the subsequent criminal probe created a climate that encouraged implementation of a risk-averse policy (picard, ) . reconstructing the policy process from the factors we have analyzed presents us with the following explanation of why events unfolded as they did. agenda setting in canada primarily occurred due to policy decisions made in other countries (e.g. the uk blood system). public awareness was raised by the release of a think-tank report and the dissemination of the information from this report via the print media. the decision to introduce a partial measure to protect against the theoretical risk, in the absence of definitive evidence of the risk, was largely influenced by the knowledge that the united states would proceed with a similar decision. the canadian decision-making process was also shaped by the emergence of the precautionary principle as a dominant ideology in public health. however, perhaps the most important driving factors in the decision-making process were the past experience of the blood supply with hepatitis c and hiv, the general shadow cast by the recent krever inquiry, policy maker fiduciary duty to the pubic and their need to re-establish public trust by being seen to be acting pro-actively. the vcjd policy decision deserves closer examination for several reasons. it demonstrated how policy was made to address an, at the time, theoretical risk. the canadian vcjd donor deferral decision was also emblematic of how other nations addressed the vcjd threat. in addition to withdrawing blood products derived from individuals subsequently diagnosed with vcjd and importing fractionated products from abroad, the uk has recently decided to ban donations from individuals who had previously received a transfusion. france also has instituted precautionary policies including the introduction of leukoreduction, which theoretically would remove infectious material from donated blood (lee, ) . the us policy regarding vcjd was similar to canada's, choosing to introduce donor deferral policies for individuals who had traveled to countries in which bse was endemic (fda, january ) . the vcjd decision-making process in all of these countries reflected a paradigm shift in how to manage emerging risks. this new paradigm involved the institution of protective measures at an early stage of the risk identification process and reflected a conscious decision by policy makers to act in advance of complete scientific information. important lessons can be learned from the canadian vcjd policy-making process and the decision-making process stands in stark contrast to the decisions concerning hepatitis c and hiv in the pre-krever blood system. in particular, two key themes that have come to dominate decisionmaking in the post krever era deserve further analysis-the application of the precautionary principle to blood policy and the challenge of rising costs in a risk-averse blood system. blood policy makers, in addressing the potential threat of vcjd, ultimately embarked upon a strategy that they believed balanced the reduction in blood supply with reducing the risk of exposure of canadians to potentially infected blood products. this decision explicitly acknowledged the possibility of risk in the absence of epidemiological studies and represented a critical shift from the previous mechanism of policy making. many criticisms exist of blood policy making in several countries leading to the transfusion transmission of hepatitis c and hiv. particularly, in the instance of hiv, the criticisms surround unacceptable delays implementing policies recognized as providing some protection to blood recipients (gilmore & somerville, ; picard, ; weinberg et al., ) . however, one of the primary limitations of pre-krever decisionmaking in canada was the manner in which scientific information was utilized in the formulation of policy. this was perhaps most glaringly demonstrated when considering the decision-making process concerning the adoption of surrogate testing for hepatitis c. the details of the canadian decision regarding surrogate testing has been well described elsewhere (krever, c) . in summary, blood officials in the s were confronted with the threat of a new form of hepatitis referred to as nona-nonb hepatitis, later discovered to be hepatitis c. this form of hepatitis was known to be transfusion transmissible, however, the virus had not been identified and thus no specific test existed to identify contaminated blood. consideration was therefore given to the use of surrogate tests which could not only identify some infected donations but also would result in the discarding of some donations that were not infected (aach et al., ; alter, purcell, holland, alling, & koziol, ) . canadian officials awaited the results of a prospective trial that compared the rates of post transfusion hepatitis from individuals who received blood from donors who had surrogate testing compared to those who received blood from donors who had not undergone surrogate testing. unfortunately, by the time evidence demonstrating the efficacy of the surrogate testing strategy become available, thousands of individuals had become infected by hepatitis c through blood transfusions, many of which could potentially have been prevented (blajchman, bull, & feinman, ) . on reflection, it becomes apparent that a fundamental failing of the canadian blood system's management of hepatitis c was the adoption or perhaps misapplication of the evidence-based paradigm when developing policy concerning safety. the evidence-based paradigm is dominated with the belief in a hierarchy of evidence that asserts that randomized trials are the highest level of evidence (upshur, ) . in the tainted blood tragedy such an approach was found to be wanting in many respects, primarily related to the consequences of waiting for high quality evidence when the health of populations, as opposed to the health of individuals, is at risk. reflecting this recognition, the ''precautionary principle'' has emerged as a new paradigm governing the use of scientific information. the precautionary principle essentially states that complete evidence of risk does not have to exist before action is taken to protect against the risk, particularly when the risk is potentially catastrophic (wingspread conference participants, ). although there are numerous interpretations of the principle, applications generally advocate an-ticipatory action to protect against harm, prioritize protection of public health and the environment and promote public participation in decision-making (stoto, ) . while the principle has become highly influential in risk decision-making in the environment and in health, it also has been heavily criticized. opponents of the principle point to its lack of clarity, potential to create unnecessary fear and potentially denying the public the benefits of new technology (morris, ) . in addressing the theoretical risk of vcjd, the canadian blood system, and blood systems around the world, was guided by the precautionary principle. however, at the same time they also integrated components of evidence-based policy making in an attempt to find a middle ground between these potentially conflicting paradigms. specifically, they chose to introduce a measured response that would not cripple the blood supply. this response was then calibrated as new evidence emerged on risk of transmission. in doing so they succeeded in accomplishing several policy objectives including reestablishing confidence in the blood system and demonstrating to the public that policy makers were acting proactively to protect the public. most importantly, as evidence accumulated to demonstrate the probable transfusion transmissibility of vcjd, the policy decisions made by canada and other countries appear to have been warranted and likely prevented further spread of vcjd through transfusion (llewelyn et al., ; peden, head, ritchie, bell, & ironside, ) . in hindsight, the integration of precautionary policy making in the new blood system would have to be considered a major success (wilson & ricketts, ) . while the new blood system's precautionary approach to blood safety has received praise it also has not been without some criticism. in canada, over a three-year period since the blood system underwent structural reform, expenditures in the blood system have increased by % . these rising blood system costs have been attributed to several factors including the increase in use of blood products, and the increase in cost of specific blood products such as intravenous immunoglobulin (wilson, macdougall et al., ) . however, attention has particularly been focused on the introduction of new safety measures that have only marginally improved the safety of the blood supply. some transfusion policy analysts have described the introduction of these safety measures as ''irrational''. these individuals point to the normally prohibitive cost-effectiveness ratios of many of theses measures (bayer & feldman, ) . the cost-effectiveness ratios associated with several of the post-krever safety measures has far exceeded the generally accepted cost-effectiveness ratios of $ to $ per qaly (laupacis, feeny, detsky, & tugwell, ) . for example, the cost/quality adjusted life year of nucleic acid amplification testing for hepatitis c is $ million/ qaly and for solvent detergent plasma $ million/ qaly (aubuchon & petz, ) . these tests have also impacted upon the cost of blood. nucleic acid amplification testing for both hepatitis c and hiv has been estimated to contribute - % of the cost of a unit of blood in the united states (weinberg et al., ) . blood systems are also being confronted with the decision of adopting several expensive new safety measures, such as pathogen inactivation technologies (council of europe, ) . in the united states (us) the medicare payment advisory committee identified that blood-related costs have been increasing more rapidly than other hospital costs placing strains on the current diagnosis related group (drg) payment system (medicare payment advisory committee, ) . in canada, provinces, which are responsible for funding the blood system, have expressed unease about rising blood costs and asked for a reconsideration of how policy decisions concerning the introduction of safety measures are being made (ibm consulting, ) . the decision to introduce highly risk averse policies (i.e. the choice of policies with a high certainty of eliminating remote risks) does not appear to be driven by ''public hysteria'' but rather by incentive systems that act directly on the policymakers. evidence for the lack of public demand driving the policy process is provided by the introduction of other similar protective policies. for example leukoreduction, a process by which white blood cells are removed, was introduced to protect against transfusion reactions and potentially other immune mediated effects. the policy met some controversy over its necessity and could not be expected to have been a high agenda issue for the public who would have little understanding of the process and for whom transfusion reactions would not be a major health concern (goodnough, ) . the other explanation for the lack of public influence on blood policy is the absence of welldefined advocacy coalitions representing the public and the interests of consumers of blood products (orsini, ) . the majority of recipients of blood products are members of the general population who cannot necessarily be identified in advance. the canadian blood system has also explicitly involved representatives of various consumer groups in their policy making process which has reduced the need for public lobbying by these individuals. in contrast to the relative lack of risk aversion amongst the public, our analyses suggest that risk aversion on the part of policy makers is likely responsible for the introduction of several of the safety policies. canadian officials are eminently aware of the public health consequences of the transfusion transmission of hepatitis c and hiv. they also cannot help but be aware of the legal consequences of those who were involved in the decision-making processes at the time. the current incentive structure does little to protect against liability because the recommendation of the justice krever to introduce a no-fault compensation system for transfusion related injury was not implemented. such systems have been found to be effective in controlling litigation in pediatric vaccination, an analogous policy area (plotkin, ) . further contributing to risk-averse policy making is the separation of funding from decision-making in the blood system, with the federal government having the authority of introducing safety measures but not the responsibility for paying for them. the impact of this structural factor on blood system costs could have been mitigated if justice krever's recommendation to have hospitals pay for blood products had been introduced since the budget restrictions of the hospitals would have limited their ability to pay for expensive products. despite the growing cost pressures on the blood system, we would expect the canadian blood system's proactive response to threats to blood safety to continue, given the current set of operating principles and policy factors at play. consequently, so will the trend towards the adoption of risk-averse safety measures with marginal cost-effectiveness ratios. if individuals in the blood system are interested in continuing the current practice of ensuring a safe blood supply with cost being a secondary concern, little change needs to occur in the decision-making process. on the other hand, if blood system decisionmakers or provincial officials responsible for funding the blood system desire a change to this approach, it is unlikely that additional studies demonstrating the comparatively poor cost-effectiveness of safety measures alone will have much impact. the current set of institutional arrangements, in which the regulator can introduce safety regulations and not be held directly responsible for the costs of these regulations, will continue to encourage the implementation of safety measures to ensure a high level of blood safety. this is also encouraged by the arms length relationship between the blood system operator and the provincial funders that permits the operator to independently introduce safety measures. to combat the impact of these factors provincial governments will have to make efforts to regain control of the policy making process in the blood system, or perhaps require federal regulators to pay a component of the costs associated with their safety regulations. the scenario of such federal unfunded mandates imposing cost burdens on other orders of government has been observed in the us where it was partially addressed through legislative means (conlan, riggle, & schwartz, ) . a risk-averse approach to blood safety is further encouraged as long as decisionmakers are aware of their potential legal and public accountability and a no-fault compensation program for transfusion injured recipients that limits legal liability may help address this issue. our analysis also suggests that as long as the canadian blood supply is reliant upon importing plasma from the united states, canadian blood policy will be heavily influenced by us blood policy. the continued goal of the canadian blood system to achieve selfsufficiency may address this concern. nevertheless, in an increasingly integrated world, decisions made in parallel policy subsystems of other nations' will play a crucial role in determining policy. standard of care may be defined as the international response to a threat and a decision-maker who disagrees with this response may still be left with little option but to meet the international standard. despite the presence of these factors, the adoption of highly risk averse policies cannot continue endlessly and the opportunity costs of these policies will become increasingly evident. eventually, policymakers will have to decide at what level of uncertainty of risk or at what level of cost/qaly safety measures will not be introduced. the decision of whether to adopt pathogen inactivation technologies, which offer the promise to remove both known and unknown pathogens from transfusions although at a substantial cost, will present an interesting challenge to the continued adoption of new safety measures. in many ways, the canadian blood system serves as a model for a transformed system emerging from a crisis of confidence. vcjd represents the first infectious threat to this transformed system and important lessons can be learned from how this threat was managed. decision-making related to vcjd is representative of the new blood system's approach of aggressively addressing risk in a proactive manner and introducing policies in advance of clear evidence of risk. while this approach was essential in the first stages of reform, and has reestablished the confidence of the canadian public, it has contributed to rising costs. the challenge the blood system now faces is to find the appropriate balance between maximizing safety and ensuring the system remains affordable. serum alanine aminotransferase of donors in relation to the risk of non-a, non-b hepatitis in recipients: the transfusion-transmitted viruses study donor transaminase and recipient hepatitis. impact on blood transfusion services making decisions to improve transfusion safety creutzfeldt-jakob disease, blood and blood products: a bioethics framework understanding the blood feuds posttransfusion hepatitis: impact of non-a, non-b hepatitis surrogate tests. canadian post-transfusion hepatitis prevention study group cbs response and action plan-summary. in performance review of canadian blood services safety of products report card on canada's blood system years after the commission of inquiry on the blood system in canada new variant creutzfeldt-jakob disease and the canadian blood supply: scientific basis of risk deregulating federalism? the politics of mandate reform in the th congress expert committee in blood transfusion study group on pathogen inactivation of labile blood components comprehensive risk assessment for vcjd in france and other countries for canadians and the canadian blood supply. ottawa: division of blood borne pathogens, health canada. expert advisory committee on blood regulation item . ottawa: health protection branch, health canada revised preventive measures to reduce the possible risk of transmission of creutzfeldt-jakob disease (cjd) and variant creutzfeldt-jakob disease (vcjd) by blood and blood products. us department of health and human services from trust to tragedy: hiv/aids and the canadian blood system blood feuds. aids, blood and the politics of medical disaster the case against universal wbc reduction (and for the practice of evidence-based medicine) models of policy making. in policy analysis for the real world executive summary. in performance review of canadian blood services evaluating the advocacy coalition framework the consequences of the contamination of the blood supply the blood system for the future. chapter canada's rejection of surrogate testing how attractive does a new technology have to be to warrant adoption and utilization? tentative guidelines for using clinical and economic evaluations france acts on threat of bse transmission by blood. the french blood transfusion authorities are banning donors who might have become exposed to bse in the uk. the scientist possible transmission of variant creutzfeldt-jakob disease by blood transfusion connecting research and policy blood safety in hospitals and medicare inpatient payment rethinking risk and the precautionary principle the politics of naming, blaming and claiming: hiv, hepatitis c, and the emergence of blood activism in canada public policy analysis preclinical vcjd after blood transfusion in a prnp codon heterozygous patient the gift of death. confronting canada's taintedblood tragedy rcmp lay charges in tainted-blood case. globe and mail lessons learned concerning vaccine safety novel proteinaceous infectious particles cause scrapie knowledge, policy-oriented learning, and policy change. an advocacy coalition framework. knowledge: creation, diffusion, utilization the need for better theories policy change over a decade or more. in policy change and learning. an advocacy coalition approach perception of risk the precautionary principle and emerging biological risks: lessons from swine flu and hiv in blood products are all evidence-based practices alike? problems in the ranking of evidence creutzfeldt-jakob disease latest unknown in struggle to restore faith in blood supply legal, financial, and public health consequences of hiv contamination of blood and blood products in the s and s a new variant of creutzfeldt-jakob disease in the uk the reporting of theoretical health risks by the media: canadian newspaper reporting of potential blood transmission of creutzfeldt-jakob disease risk of acquiring creutzfeldt-jakob disease from blood transfusions: systematic review of case-control studies the challenge of an increasingly expensive blood system a policy analysis of major decisions relating to creutzfeldt-jakob disease and the blood supply how should canada fund the blood system? an evaluation of the chargeback proposal understanding the impact of intergovernmental relations on public health: lessons form reform initiatives in the blood system and health surveillance the success of precaution? managing the risk of transfusion transmission of variant creutzfeldt-jakob disease the application of the precautionary principle to the blood system: the canadian blood system's vcjd donor deferral policy wingspread statement on the precautionary principle this study was supported by a grant from the canadian institutes of health research. thanks also to cathy code and nadya ahmad. key: cord- -yoav b authors: kyriazis, dimosthenis; biran, ofer; bouras, thanassis; brisch, klaus; duzha, armend; del hoyo, rafael; kiourtis, athanasios; kranas, pavlos; maglogiannis, ilias; manias, george; meerkamp, marc; moutselos, konstantinos; mavrogiorgou, argyro; michael, panayiotis; munné, ricard; la rocca, giuseppe; nasias, kostas; pariente lobo, tomas; rodrigálvarez, vega; sgouros, nikitas m.; theodosiou, konstantinos; tsanakas, panayiotis title: policycloud: analytics as a service facilitating efficient data-driven public policy management date: - - journal: artificial intelligence applications and innovations doi: . / - - - - _ sha: doc_id: cord_uid: yoav b while several application domains are exploiting the added-value of analytics over various datasets to obtain actionable insights and drive decision making, the public policy management domain has not yet taken advantage of the full potential of the aforementioned analytics and data models. diverse and heterogeneous datasets are being generated from various sources, which could be utilized across the complete policies lifecycle (i.e. modelling, creation, evaluation and optimization) to realize efficient policy management. to this end, in this paper we present an overall architecture of a cloud-based environment that facilitates data retrieval and analytics, as well as policy modelling, creation and optimization. the environment enables data collection from heterogeneous sources, linking and aggregation, complemented with data cleaning and interoperability techniques in order to make the data ready for use. an innovative approach for analytics as a service is introduced and linked with a policy development toolkit, which is an integrated web-based environment to fulfil the requirements of the public policy ecosystem stakeholders. the ict advances as well as the increasing use of devices and networks, and the digitalisation of several processes is leading to the generation of vast quantities of data. these technological advances have made it possible to store, transmit and process large amounts of data more effectively than before in several domains of human activity of public interest [ ] . it is undeniable that we are inundated with more data than we can possibly analyse [ ] . this rich data environment affects decision and policy making: cloud environments, big data and other innovative data-driven approaches for policy making create opportunities for evidence-based policies, modernization of public sectors and assistance of local governance towards enhanced levels of trust [ ] . during the traditional policy cycle, which is divided into different stages (agenda setting, policy formulation, decision making, policy implementation and policy evaluation), data is a valuable tool for allowing policy choices to become more evidence-based and analytical [ ] . the discussion of data-driven approaches to support policy making can be distinguished between two main types of data. the first is the use of open data (administrative -open -data and statistics about populations, economic indicators, education, etc.) that typically contain descriptive statistics, which are used more intensively and in a linked way, shared through cloud environments [ ] . the second main type of data is from any source, including data related to social dynamics and behaviour that affect the engagement of citizens (e.g. online platforms, social media, crowd-sourcing, etc.). these data are analysed with novel methods such as sentiment analysis, location mapping or advanced social network mining. furthermore, one key challenge goes beyond using and analysing big data, towards the utilization of infrastructures for shared data in the scope of ethical constraints both for the citizens and for the policy makers. these ethical constraints include "data ownership" ones, which determine the data sharing rules, as well as data localisation constraints, which may unjustifiably interfere with the "free flow of data". as for policy makers, the dilemma, to what extent big data policy making is in accordance to values elected governments promote, is created. this is a problem deriving from the fact that it is difficult to point to the scope of the consent citizens may give to big data policy analysis [ ] . furthermore, such policies provide a broad framework for how decisions should be made regarding data, meaning that they are high-level statements and need more detail before they can be operationalized [ ] . big data enabled policy making should answer modern democratic challenges, considering facts about inequality and transparency both on national and local level, involving multi-disciplinary and multi-sectoral teams. in this context, this paper presents the main research challenges and proposes an architecture of an overall integrated cloud-based environment for data-driven policy management. the proposed environment (namely policycloud) provides decision support to public authorities for policy modelling, implementation and simulation through identified populations, as well as for policy enforcement and adaptation. additionally, a number of technologies are introduced that aim at optimizing policies across public sectors by utilizing the analysed inter-linked datasets and assessing the impact of policies, while considering different properties (i.e. area, regional, local, national) and population segmentations. one of the key aspects of the environment is its ability to trigger the execution of various analytics and machine learning models as a service. thus, the implemented and integrated service can be executed over different datasets, in order to obtain the results and compile the corresponding policies. in terms of managing diverse data sources, the evolution of varieties of data stores (i.e. sql and nosql), where each variety has different strengths and usage models, is linked with the notion of "polyglot persistence" [ ] . the latter emphasizes that each application and workload may need a different type of data store, tailored for its needs (e.g. graph, time series). moreover, the field of data warehousing addresses creating snapshots of online transactional processing (oltp) databases for the purposes of online analytical processing (olap). this often requires copying the data and preparing it for analytics by transforming its structure (i.e. extract transform load process) and building the relevant indexes for the analytical queries. this costly process is performed in order to achieve fast query times for analytical queries of interest, and in order to support data mining. however, there is an increasing trend to adopt a "just in time data warehouse" model, where data are federated on the fly according to runtime parameters and constraints [ ] . as a result, data analytics frameworks increasingly strive to cater for data regardless of the underlying data store. apache spark [ ] is an open source framework for analytics, which is designed to run in a distributed setting within a data centre. spark provides a framework for cluster computing and memory management, and invents the notion of a resilient distributed dataset (rdd) [ ] that can be stored persistently using any storage framework that implements the hadoop file system interface, including the hadoop distributed filesystem (hdfs), amazon s and openstack swift. the spark sql component additionally defines a dataframe as an rdd having a schema, and provides a sql interface over dataframes [ ] . built in support is provided for data sources with a jdbc interface, as well as for hive, and the avro, parquet, orc and json formats. moreover, there is an external data sources api, where new data sources can be added by implementing a driver for the data source that implements the api. many such drivers have been implemented, for example for cassandra, mongodb and cloudant. these data sources can be queried, joining data across them and thus provide the ability to run batch queries across multiple data sources and formats. spark also integrates batch processing with real time processing in the form of spark streaming [ ] that allows real-time processing using the same underlying framework and programming paradigm as for batch computations. in spark . , streaming spark sql computations are also planned [ ] . with the advent of iot and the increasing capabilities available at the edge, applications may store and process data locally [ ] . in the policycloud architecture, data are managed whether in flight or at rest and are federated across multiple frameworks, data sources, locations and formats. another key aspect is data interoperability given the diversity of the data sources. among the main value propositions of the policycloud environment and tools for policy development and management will be its ability to integrate, link and unify the datasets from diverse sources, while at the same time enabling analytics over the unified datasets. as a key prerequisite to providing this added-value, the interoperability of diverse datasets should be ensured. a wide array of data representation standards in various domains have emerged as a means of enabling data interoperability and data exchange between different systems. prominent examples of such standards in different policy areas include: (i) the inspire data specifications [ ] for the interoperability of spatial data sets and services, which specify common data models, code lists, map layers and additional metadata on the interoperability to be used when exchanging spatial datasets, (ii) the common european research information format (cerif) [ ] for representing research information and supporting research policies, (iii) the internet of things ontologies and schemas, such as the w c semantic sensor networks (ssn) ontology [ ] and data schemas developed by the open geospatial consortium (e.g., sensorml) [ ], (iv) the common reporting standard (crs) that specifies guidelines for obtaining information from financial institutions and automatically exchanging that information in an interoperable way, and (v) standards-based ontologies appropriate for describing social relationships between individuals or groups, such as the "the friend of a friend" (foaf) ontology [ ] and the socially interconnected online communities (sioc) ontology [ ] . these standards provide the means for common representation of domain specific datasets, towards data interoperability (including in several cases semantic interoperability) across diverse databases and datasets. nevertheless, these standards are insufficient for delivering what policycloud promises for a number of reasons. initially, there is a lack of semantic interoperability in the given domain. for example, compliance to ontologies about iot and sensor data fails to ensure a unified modelling of the physics and mathematics, which are at the core of any sensing task. hence, in several cases there is a need for extending existing models with capabilities for linking/relating various quantifiable and measurable (real-world) features to define, in a user understandable and machine-readable manner the processes behind single or combined tasks in the given domain. furthermore, there is a lack of semantic interoperability across datasets from different sectors. there is not easy way to link related information elements stemming from datasets in different sectors, which typically comprise different schemas. in this context, environmental datasets and transport datasets for instance contain many related elements, which cannot however be automatically identified and processed by a system due to the lack of common semantics. finally, one needs to consider the lack of process interoperability. policycloud deals with data-driven policy development and management, which entails the simulation and validation of entire processes. especially in the case of multi-sectoral considerations (e.g., interaction and trade-offs between different policies) process interoperability is required in order to assess the impact of one policy on another. policycloud proposes a multi-layer framework for interoperability across diverse policy related datasets, which will facilitate semantic interoperability across related datasets both within a single sector and across different policy sectors. within a specific sector of each use case, semantic interoperability will enable adhering to existing standards-based representations for the sector data and other auxiliary data (e.g. sensor data, social media data). across different use cases, policycloud proposes a linkeddata approach [ ] to enable linking of interrelated data across different ontologies. the challenge is to provide a scalable, flexible and dependable methodology and environment for facilitating the needs of data-driven policy modelling, making and evaluation. the methodology should aim at applying the properties of policy modelling, co-creation and implementation across the complete data path, including data modelling, representation and interoperability, metadata management, heterogeneous datasets linking and aggregation, analytics for knowledge extraction, and contextualization. moreover, the methodology should exploit the collective knowledge out of policy "collections"/clusters combined with the immense amounts of data from several sources (e.g. sensor readings, online platforms, etc.). these collections of policies should be analysed based on specific key performance indicators (kpis) in order to enable the correlation of these kpis with different potential determinants of policies impact within and across different sectors (e.g. environment, radicalisation, migration, goods and services, etc.). another challenge refers to holistic policy modelling, making and implementation in different sectors (e.g. environment, migration, goods and services, etc.), through the analysis and linking of kpis of different policies that may be inter-dependant and intercorrelated (e.g. environment). the goal is to identify (unexpected) patterns and relationships between policies (through their kpis) to improve policy making. moreover, the approach should enable evaluation and adaptation of policies by dynamically extracting information from various data sources, community knowledge out of the collections of policies, and outcomes of simulations and evidence-based approaches. policies should be evaluated to identify both their effective kpis to be re-used in new/other policies, and the non-effective ones (including the causes for not being effective) towards their improvement. thus, developed policies should consider the outcomes of strategies in other cases, such as policies addressing specific city conditions. data-driven policy making highlights the need for a set of mechanisms that address the data lifecycle, including data modelling, cleaning, interoperability, aggregation, incremental data analytics, opinion mining, sentiment analysis, social dynamics and behavioural data analytics. in order to address data heterogeneity from different sources, modelling and representation technologies should provide a "meta-interpretation" layer, enabling the semantic and syntactic capturing of data properties and their representation. another key aspect refers to techniques for data cleaning in order to ensure data quality, coherence and consistency including the adaptive selection of information sources based on evolving volatility levels (i.e. changing availability or engagement level of information sources). mechanisms to assess the precision and correctness of the data, correct errors and remove ambiguity beyond limitations for multidimensional processing should be incorporated in the overall environment, while taking into consideration legal, security and ethical aspects. the specific challenge refers to the design and implementation of a semantic layer that will address data heterogeneity. to this end, the challenge is to research on techniques and semantic models for the interoperable use of data in different scenarios (and thus policies), locations and contexts. techniques for interoperability (such as oslc -open services for lifecycle collaboration) with different ontologies (as placeholders for the corresponding information) should be combined with semantic annotations. semantic models for physical entities/devices (i.e. sensors related to different policy sectors), virtual entities (e.g. groupings of such physical entities according to intrinsic or extrinsic, permanent or temporary properties) and online platforms (e.g. social media, humans acting as providers) should be integrated in data-driven policy making environments. these models should be based on a set of transversal and domain-specific ontologies and could provide a foundation for high-level semantic interoperability and rich semantic annotations across policy sectors, online systems and platforms. these will be turned into rich metadata structures providing a paradigm shift towards content-based storage and retrieval of data instead of data-based, given that stakeholders and applications target and require such content based on different high-level concepts. content-based networks of data objects need to be developed, allowing retrieval of semantically similar contents. one of the main barriers to public bodies experimenting with big data to improve evidence-based policy making is citizens' participation since they are lacking awareness of the extend they may influence policy design and the ways these will be feasible. the challenge is to raise awareness about policy consultations and enable citizens to take direct action to participate, thus ensuring higher levels of acceptance and of trust. a potential solution could be to follow a living lab approach and implement an engagement strategy based on different incentives mechanisms. furthermore, a data-driven policy management environment should allow social dynamics and behaviour to be included in the policy lifecycle (creation, adaptation, enforcement, etc.) through the respective models and analytical tools. these will allow policy makers to obtain the relevant crowd-sourcing data and the knowledge created by the closed groups (i.e. communities evaluating proposed policies) and the engaged citizens to analyse and propose social requirements that will be turned into policy requirements. on top of this, incentives management techniques will identify, declare and manage incentives for citizens' engagement, supporting different types of incentives (e.g. social, cultural, political, etc.), with respect to information exchange, contributions and collaboration aspirations. the environment should also provide strategies and techniques for the alignment participation incentives, as well as protocols enabling citizens to establish their participation. machine and deep learning techniques, such as classification, regression, clustering and frequent pattern mining algorithms, should be realized in order to infer new data and knowledge. sentiment analysis and opinion mining techniques should determine whether the provided contributor's input is positive or negative about a policy, thus developing a "contributor graph" for the contributors of the opinions that happen to be themselves contributors to ongoing policy making projects. in the same context, social dynamics and behavioural data analytics should provide insights regarding which data needs to be collected and aggregated in a given case (e.g. time window addressed by the policy, location of populations, expected impact, etc.), taking into consideration the requirements of the engaged citizens to model the required policies. moreover, a main challenge refers to technologies that allow analytics tasks to be decoupled from specific datasets and thus be triggered as services and applied to various cases and datasets. a key challenge refers to an overall system, acting as an endpoint that will allow stakeholders (such as policy makers and public authorities) to trigger the execution of different models and analytical tools on their data (e.g. to identify trends, to mine opinion artefacts, to explore situational and context awareness information, to identify incentives, etc.) and obtain the results. based on these results, the modelled policies (through their kpis) will be realized/implemented and monitored against these kpis. moreover, the endpoint should allow stakeholders and public administration entities to express in a declarative way their analytical tasks and thus perform/ingest any kind of data processing. another need is for an adaptive visualization environment, enabling policy monitoring to be visualized in different ways while the visualization can be modified on the fly. the environment should also enable the specification of the assets to be visualized: which data sources and which meta-processed information. the goal is to enable the selection of sources based on the stakeholders' needs. incremental visualization of analytics outcomes should also be feasible enabling visualization of results as they are generated. as a complete environment, the proposed architectural approach includes a set of main building blocks to realize the corresponding functionality as depicted in the following figure (fig. ) . the overall flow is initiated from various data sources, as depicted in the figure through the respective data acquisition block. data sources can be data stores from public authorities or external data sources (e.g. mobile devices, iot sensors, etc.) that contribute data following the provision of incentives, facilitated through the incentives management mechanism. a set of apis incorporated in a gateway component, enables data collection by applying techniques to identify the reliable sources exploiting the sources reliability component and for these sources obtain the data and perform the required data quality assessment and cleaning. semantic and syntactic interoperability techniques are utilized over the cleaned data providing the respective interoperable datasets to the policy cloud datastore following the required data linking and aggregation processes. the datastore is accessible from a set of machine learning models represented through the data analytics building block. machine learning models incorporate opinion mining, sentiment and social dynamic analysis, behavioural analysis and situational/context knowledge acquisition. the data store and the analytics models are hosted and executed in a cloud-based environment that provides the respective services obtained from a catalogue of cloud infrastructure resources. furthermore, all the analytics models are realized as services, thus enabling their invocation through a proposed policy development toolkit -realized in the scope of the policies building block of the proposed architecture as a single point of entry into the policycloud platform. the toolkit allows the compilation of policies as data models, i.e. structural representations that include key performance indicators (kpis) as a means to set specific parameters (and their target values) and monitor the implementation of policies against these kpis along with the list of analytical tools to be used for their computation. according to these analytics outcomes, the values of the kpis are specified resulting to policies implementation/creation. it should be noted that policycloud also introduces the concept of policies clusters in order to interlink different policies, and identify the kpis and parameters that can be optimized in such policy collections. across the complete environment, an implemented data governance and compliance model is enforced, ranging from the provision of cloud resources regarding the storage and analysis of data to the management of policies across their lifecycle. the vast amounts of data that are being generated by different sources highlight an opportunity for public authorities and stakeholders to create, analyse, evaluate and optimize policies based on the "fresh" data, the information that can be continuously collected by citizens and other sensors. to this end, what is required refers to techniques and an overall integrated environment that will facilitate not only data collection but also assessment in terms of reliability of the data sources, homogenization of the datasets in order to make them interoperable (following the heterogeneity in terms of content and formats of the data sources), cleaning of the datasets and analytics. while several analytical models and mechanisms are being developed a key challenge relates to approaches that will enable analytics to be triggered as services and thus applied and utilized in different datasets and contexts. in this paper, we have presented the aforementioned challenges and the necessary steps to address them. we also introduced a conceptual architecture that depicts a holistic cloud-based environment integrating a set of techniques across the complete data and policy management lifecycles in order to enable data-driven policy management. it is within our next steps to implement the respective mechanisms and integrate them based on the presented architecture, thus realizing the presented environment. how can social media data be used to improve services? business opportunities, and the it imperatives cases in public policy-making setting data policies, standards, and processes data for policy: a study of big data and other innovative data-driven approaches for evidenceinformed policymaking big data: basics and dilemmas of big data use in policy-making time data warehouse platform with databricks resilient distributed datasets: a fault-tolerant abstraction for in-memory cluster computing spark sql: relational data processing in spark discretized streams: fault-tolerant streaming computation at scale structuring spark: dataframes, datasets and streaming fog computing and its role in the internet of things data specifications linked data: evolving the web into a global data space acknowledgment. the research leading to the results presented in this paper has received funding from the european union's funded project policycloud under grant agreement no . key: cord- -bnxczi t authors: pennington, mark title: hayek on complexity, uncertainty and pandemic response date: - - journal: rev austrian econ doi: . /s - - - sha: doc_id: cord_uid: bnxczi t this paper draws on hayek’s distinction between simple and complex phenomena to understand the nature of the challenge facing policymakers in responding to the new coronavirus pandemic. it shows that while government action is justifiable there may be few systemic mechanisms that enable policymakers to distinguish better from worse policy responses, or to make such distinctions in sufficient time. it then argues that this may be a more general characteristic of large-scale public policy making procedures and illustrates the importance of returning to a market-based political economy at the earliest convenience. the new coronavirus (covid ) pandemic that has engulfed the world in recent months has prompted unprecedented levels of government activism both in an attempt to control the virus and in attempts to curtail the economic damage arising from these policy measures. governments across many parts of the world have effectively 'closed down' economic systems in response to the health threat posed by the pandemic. in some countries meanwhile governments have also committed themselves to policy measures -such as paying the wages of private sectors employees -that have rarely if ever been seen before. this paper considers the challenge the pandemic presents to policy makers by drawing on f.a. hayek's distinction between simple and complex phenomena. it argues that while government action may be warranted, the complexities entailed in addressing the multiple socio-economic dimensions at stake mean that on many of these dimensions it may not be possible to discern the contours of an effective policy response. or, if such responses can be identified, to secure their implementation in a sufficiently timely manner. the paper then considers the implications of hayek's perspective for broader socio-economic challenges that policymakers are increasingly being urged to assume, with a focus on post-pandemic risk planning and arguments for post-pandemic industrial policy. the paper commences in section one by outlining hayek's distinction between simple and complex phenomena and how this is reflected in his critique of economic planning. it then proceeds in section two to consider some of the dimensions of complexity that underpin the coronavirus policy challenge. section three argues that while government action may be a justifiable response to the pandemic, there may be few systemic mechanisms that enable policymakers to avoid large scale errors and to assess the effectiveness of alternative policy measures. finally, section argues that a continuation of activist government in a post-pandemic political economy may work to perpetuate aspects of the knowledge poor environment that characterises the pandemic itself. a central aspect of hayek's social theory is the distinction he draws between simple and complex phenomena (for example hayek ) . simple phenomena are those where it may be possible from a given starting position to predict the outcomes that will be generated by the application of a stimulus into a system. scientific problems in some (though by no means all) parts of physics are of this type and they allow for the derivation of predictive, quantitative regularities by scientific analysts. complex phenomena by contrast, refer to systems where the elements that make up a greater whole do not interact in a linear fashion and where the number of elements and the character of their interaction may be too vast for them to be comprehended by scientific observers. while non-linear systems can be scientifically modelled the relevant relationships may not typically be characterised with sufficient quantitative precision. the most that analysts may do when faced with complex phenomena is to try to understand the general principles that allow an order to form between the various elements-not to predict successfully the precise form that the order will take. all that science may be able to achieve in the face of such phenomena is to predict a statistical range of possible outcomes. it is tempting to equate hayek's distinction between simple and complex phenomena with the difference between the subject matter of the natural and social sciences, but this would be mistaken (for a discussion see caldwell ) . while it is true that some natural sciences analyse simple systems, this is not always so. many of the phenomena analysed in biology or ecology for example, are closer to complex systems. in such cases natural scientists may discover the general principles such as the principles of ecological succession that drive processes of environmental change. typically, however, the scientists concerned may not be able to discern enough about the multiple contextual relationships between elements to predict successfully how ecosystems will evolve, given certain exogenous or endogenous changes to them (for example botkin ; scheiner and willig ) . turning to the socio-economic world, the challenge of scientific understanding relates to even more complex systems. knowledge of all the varied and changing economic and cultural conditions that confront multitudes of people may not be comprehended by any social scientist or group of such scientists. away from very basic forms of human society where the rhythms and routines of people might be observed and predicted with some accuracy by external observersin more complex social orders the most that social science may achieve is an understanding of the general principles of human interaction and the broad patterns they produce. what may not be predicted successfully are specific responses to specific events. economists may for example understand that if a good becomes scarcer in a market, various changes such as a rise in price and the search for new supplies or substitutes may be expected. they may not, however, predict successfully (other than by chance) what the specific responses will entail and the balance between the respective forces set in train (for a recent argument see kay and king ) . moreover, it may not even be possible to specify the range of likely responses because unlike the natural world the 'human elements' making up the social ecology are creative actors. on a hayekian view, it is for this reason that the modelling of social interaction in terms of the predicted behaviour of statistically 'representative agents' that characterises contemporary neo-classical economics is of questionable valuefor it is entrepreneurial outliers that drive processes of social change. while there may be 'orderliness' in society this does not equate to some static or fixed equilibrium state where change can only be accounted for through 'exogenous shocks' to an otherwise stable system. rather, social interaction should be understood as process of ceaseless and sometimes turbulent change brought about by the generation of new ideas, processes, and ways of doing things (for example, wagner ). this stance does not imply rejecting statistical modelling as a possible way to inform the day to day plans of individuals and organisations. since future decisions grow incrementally out of past decisions there are some regularities that people can rely on to navigate their way in the worldthough even here expectations will often be disappointed. longer term econometric forecasting may however be of little use because the building of reliable econometric models requires knowledge of the factors that will shape the future in advance of their emergence (parker and stacey : - ) . the key point that hayek takes from the distinction between simple and complex systems is that whereas the former can be subject to planning and control by a 'directive intelligence' the latter cannot be subject to such control owing to the overwhelming 'knowledge problem' that would face such an intelligence. whatever objectives people may have, whether pertaining to health, economic growth, environmental protection, or some combination of these, will to a large extent have to be achieved via indirect mechanisms. unless people choose a dramatically simpler form of social existence that might be more amenable to direction and control, then intelligent policy can only hope to find rules that allow for the many agents that make up complex social systems to adapt to the actions of others without having to know all of the factors that drive them. the mechanisms and rules that work most effectively in this regard will be those that provide relatively clear feedback to the agents and agencies concerned and enable relatively speedy adaptation to changing information about success and failure in reading situations at the local level. in brief, this analysis underlies hayek's case for a market economy based on rules of private property and contract, over a planned or centrally managed economy. a market economy should be understood as a complex adaptive system where property rights and freedom of contract provide rules that enable an intricate ecology of dispersed individuals and organisations to experiment in responding to their own circumstances and for the results of these experiments to be communicated to neighbouring actors via profit and loss accounting and market price signals. the resultant 'order' is an 'emergent' property of the constant interaction between the various elements in a context where no 'directive intelligence' could be aware of all the possible and continually changing margins for adjustment. contrary to some critical readings of hayek's ideas (for example, grossman and stiglitz ) , there is no suggestion that the relevant order in markets occurs instantaneously or that adaptations made are 'perfect'. rather, hayek's claim is a comparative one that market economies facilitate more learning and adjustment than would likely arise in a centrally managed alternative. neither is there any suggestion that prices communicate all necessary knowledge. hayek's argument is the more modest one that market prices communicate in an indirect way more knowledge than would be possible without them. price signals will always operate in a 'noisy' environment and given uncertainty about future states of the world entrepreneurs must try to understand whether shifts in prices reflect longer or shorter-term social trends and what the possible causes of these might be. part of hayek's case for the market economy is that competition operates as a discovery procedure where different social constructions of what prices mean, are tested against one another and the relative strength of these subjective readings revealed through the account of profit and loss (for example , hayek ; hayek a, b) . prices on this view are not 'given data' which are presented in their totality to actors. rather they present themselves as overlapping 'bits' of data that both affect and are affected by a process of social contestation and interaction where widely dispersed interpretations of economic possibilities continually tussle with one another. outside of such a rivalrous process the capacity to reveal the opportunity costs of alternative courses of action would be confined to the very limited imagination of a 'directive intelligence' or 'social planner'. it should be noted that none of these arguments are undermined by technological innovations such as for example the development of artificial intelligence or 'big data' gathering techniques which it is often suggested might allow for the replacement of market processes (for example cottrell and cockshott ; phillips and rozworski for a critique see hodgson ). on the one hand, these innovations increase the scope for decentralised agents -whether individuals, firms, or voluntary organisations, to increase the complexity of their own decision-making. this means that no matter how sophisticated the relevant technology becomes the complexity of the social system at the 'meta-level' will be higher than the cognitive capacities of any 'directive intelligence'. similarly, no matter how much data collection is facilitated by technology it will remain the case that the data at issue will not 'speak for themselves'. even if big data were to allow for a retrodictive understanding of the causes of socio-economic events this understanding will arrive 'too late' to act as a guide to effective decisionmaking. moreover, to the extent that it provides an understanding of the past different people will interpret the future implications of the relevant data in different ways. on a hayekian view, readings of data are no more than social constructions so the importance of competition in testing these different constructions against alternative readings remains paramount. absent competition there is likely to be an increased risk of large scale decision failure where should those empowered to make decisions err in their choices then the effects are likely to be felt across the whole of society, rather than being confined to a relatively smaller portion of the community in question. while the foregoing arguments are theoretical in nature, they are also empirically grounded claims that help to explain, at least in a qualitative sense, the superior performance of economies that rely on market processes relative to those that try to suppress them. though hayek develops a powerful case for the importance of market processes however, his perspective does not imply that there are market solutions to all socio-economic problems. in works such as the road to serfdom ( ) and the constitution of liberty ( ) hayek sets out an extensive range of government measures where public goods style challenges arise. dealing with infectious diseases such as the new coronavirus where these dynamics may be especially prevalent, may thus be a justifiable form of government action. nonetheless, understanding and evaluating any such action will require proper appreciation of the levels of complexity in play and whether there are effective feedback mechanisms available to policymakers to cope with the uncertainties at hand. on a hayekian view, the task is to find institutional configurations that allow for experimentation and feedback that is somewhat analogous to that provided by markets. with this challenge in mind this section sets out some of the complexities that may confront policymakers facing the coronavirus pandemic. the subsequent section turns to the existence or otherwise of mechanisms analogous to those in market processes that may enable decision-makers to avoid large scale errors and to learn from other decision-making nodes. as with other pandemics, a first layer of complexity that policymakers must contend with in addressing the new coronavirus concerns the epidemiology of the virus itself. epidemiological problems although involving natural science phenomena are not of the simple 'physics' type. while epidemiologists may discern the principles that govern how a virus spreads and perhaps simulate a range of possible outcomes -the precise manner of spread through a population will depend on a host of context specific variables that may not be accessible to the scientists or experts concerned. this challenge is seen most clearly perhaps in the problem of modelling the spread of the pandemic and the sometimes very different projections of the size and shape of the peak of the disease (for a discussion of this see ormerod ). will the pandemic peter out of its own accord without first having to affect a large percentage of the population? at what level of spread might 'herd immunity' be achieved? how is the spread of the virus affected by weather and geography? will there be a second wave of infections? and will the virus mutate into a weaker or stronger form? uncertainties surrounding answers to these and other such questions mean that modelling and data analysis will involve a good deal of subjective interpretation and scope for significant error. an additional layer of complexity arises because the virus which is itself a complex phenomenon is interacting with a further complex phenomenon represented by the various political, economic, cultural and institutional arrangements across the world that might affect the manner of spread. as ormerod ( ) notes, one of the key limitations of epidemiological models is that their projections often fail to account for human behaviour and changes in that behaviourincluding those induced by public policy. there is, for example, considerable uncertainty about how the new coronavirus will respond to various public policy interventions. it is unclear how 'lockdown' policies might affect the size of a possible second wave of transmission. on one scenario lockdowns might be essential to reducing the spread of the disease to the point where infections in any 'second wave' could be more easily managed and controlled. on the other hand, however, it could be that the success of lockdowns in limiting the spread of a first wave of the virus will only contribute to a much larger and potentially uncontrollable second wave of infections owing to the limited extent of herd immunity arising from the lockdown measures. still further complexity is injected into the policy conundrum by uncertainties about how different populations with different social attitudes, time horizons and belief systems may respond to the various policy measures that are adopted, or to news about developments that are affecting the spread of the virus. within this context, there is a distinct possibility for 'lucas effects' to arise. in macro-economic analysis these refer to situations where public policy measures might be counteracted by shifts in behaviour which are a response to the measures concerned (for example, lucas ). if for example policymakers seek to raise inflation in the hope of lowering unemployment, then this may lead to a shift in employers inflation expectations which may lead them to decrease employment. macro-economic models if they are to be useful to policymakers need, therefore, to factor in how changes in policy might change the expectations and behaviour of the agents on which the policy is supposed to act. in the specific context of pandemic response it is possible that if people come to believe that a vaccine is imminent or that herd immunity is close to being achieved they may start to behave in wayssuch as abandoning social distancing measuresthat make the immediate problem worse. on a hayekian view, however, there is a significant 'knowledge problem' for policymakers in understanding how expectations will be changed by the pattern of events or by policy interventionsand this problem is especially severe in a context of heterogenous individuals with divergent ideas whose actions cannot be reduced to those of a 'representative agent'. the complexities discussed thus far raise significant challenges for policymakers even if they concern themselves solely with managing the health effects of the virus. to approach pandemic response in such a way would be to see it as primarily a 'technological problem'where the task at hand is to allocate resources to achieve a singular 'technical' end. pandemic response, however, is not best understood as a narrowly technical exercise but as an 'economic problem' which involves allocating resources between multiple competing ends. in the context of health objectives there are complex and uncertain trade-offs to be made between the possible reduction of deaths from the coronavirus that might follow lock-down measures and the possible increased deaths arising from illnesses that might go undiagnosed or untreated because of such measures. away from the problem of trying to trade off deaths from these different sources, there are also costs to be considered pertaining to the possible deterioration in people's mental health as well as to possibilities such as increases in domestic violence that may also accompany prolonged periods of confinement and social isolation. turning away from these health-related trade-offs to broader socio-economic questions there is great uncertainty over the extent to which the socio-economic damage that may have been inflicted by a less controlled spread of the virus is matched or outweighed by the scale of the socio-economic costs associated with the measures being taken to contain it. part of this challenge can be understood as arising from tradeoffs between different sources of what higgs ( ) refers to as 'regime uncertainty'. on a hayekian view, one of the primary functions of social institutions such as private property rights and contract law is to provide a measure of certainty to decision-makers in an otherwise highly complex and uncertain world. agents operating in a market economy cannot be sure that their ex ante assessment of a decision situation will be confirmed ex postbut secure property rights do provide some degree of certainty that agents can retain the profits from decisions that turn out well and face the costs of those that turn out badly. regime uncertainty however arises precisely in contexts where the basis of social rules such as security of property itself becomes subject to uncertainty. in the context of pandemics regime uncertainty could arise from the failure of political authorities to act. an uncontrolled pandemic might lead to social dislocation and a break down in respect for the social norms and institutionssuch as respect for propertythat provide much of the glue sustaining social life. on the other hand, however, regime uncertainty might also arise from badly judged public policy interventions. there is a danger that political authorities may intervene in market relationships in unpredictable ways to a point that this destroys the confidence of people in the impartiality of the law. consider in this context the worker 'furlough schemes' that have been introduced in parts of europe and the united states. these schemes pay out a large proportion of the wage bill for employers in businesses that have been closed by lockdown policies. in a context where public health measures have effectively 'paused' the economic system there is a strong case for schemes of this kind. there is however also a danger that political pressures could be brought to bear on policymakers in ways that introduce significant arbitrariness in the operation of the schemes. the problem here is that any evidence of political favouritism may reduce the long term confidence of investors who in addition to navigating the inevitable uncertainties of business life may also fear having to anticipate potentially arbitrary interventions that favour some sectors over others. a different though related set of issues arise with the introduction of measures such as contact tracing schemes where there are concerns that personal data initially used to track those infected with the coronavirus might be used by political authorities as sources of information to be used against their opponents. away from these issues of regime uncertainty there are wider and equally complex challenges arising from attempts to manage the macro-economic consequences of the pandemic and the policies to control it. returning to the case of employment 'furloughs', while government spending may be necessary to support workers and employers in the immediate term there is also a danger that schemes of this kind may cause lasting economic damage if they are maintained for too long. if the effect of lock-down policies is to induce longer term changes in behaviour which may persist after the pandemic has passedsuch as a greater reliance on home working, reduced demand for office space or increasing popularity for online delivery in fields such as educationthen these changes may imply the need for significant economic restructuring and reallocations of labour and capital which an overly long furlough period would delay. such changes cannot occur instantaneously but must occur over time as entrepreneurs try to discover which combinations of labour and capital are best suited to the new circumstancesand while this process unfolds there will inevitably be 'unused capacity' as a proportion of labour and capital will be left unemployed or 'idle'. in these circumstances, keynesian inspired 'stimulus packages' and macro-economic interventions that seek to 'close the output gap' and to preserve the pre-pandemic pattern of employment by maintaining 'aggregate demand', are subject to the concerns raised by the hayekian critique of such measures in the context of financial or other economic crises (for a recent statement of these see white ) . more specifically, a focus on aggregate demand may obscure underlying shifts in the structure and distribution of demand across different sectors and hence the need for relative price adjustments to signal the need for changes in the structure of production. large scale public spending programmes that are not themselves subject to profit and loss signals risk delaying the necessary adjustments and indeed may lead to malinvestments. judging the timing for withdrawing furlough measures or macro-economic stimulus policies that seek to preserve pre-pandemic employment patterns will therefore be subject to a high level of both economic and political uncertainty and modelling efforts to time these decisions and their likely effects will involve a high degree of subjectivity and potential for significant error. complexity and pandemic response: avoiding systemic error and the scope for policy learning on a hayekian view, understanding society as a set of ordered though dynamic relationships rather than a static equilibrium means that justifying public policy responses to the complex dilemmas set out in the previous section does not require that these responses will be 'optimal' -precisely because the uncertainties and complexities at hand may preclude the identification of 'optimal solutions.' given the character of pandemics as public health problems involving potentially significant externalities, market solutions and those based on voluntary associations may not be viable so there are strong grounds for endorsing some form of public policy response (for example, ramanan and malani ) . nonetheless, the question that hayek's perspective might ask is whether there are any systemic mechanisms that may enable policy-makers to avoid large scale decision-making errors and to identify and act upon knowledge of relatively 'better' or 'worse' responses. turning first to the question of avoiding large scale error, it is important to recognise that as lindblom and other analysts of public administration have shown, states are not unitary hierarchies operating with a singular 'directive intelligence', but are better understood as networked structures where many different organisational 'brains' are linked together through bargaining and mutual adjustment (lindblom (lindblom , . unlike most market settings however, these are networked arrangements where competition is limited and where particular organisational nodes, or coalitions of actors may exercise a disproportionate or monopolistic influence over the network, as a whole (wagner (wagner , . in the specific case of pandemic response public health bodies and economic agencies such as treasuries and central banks are 'big players' within the social ecology that owing to their size and/or unique powers, have the potential to inflict large scale errors on the wider polity (koppl ) . it should be acknowledged here that expert epidemiological opinion and economic opinion over how to respond to the pandemic is not characterised by a consensus so in practice the decisions made by public health authorities, treasuries and politicians will reflect those of a dominant coalition in the jurisdictions concerned. within this context, an important institutional limitation on the scope for systemic error by 'big players' is that the world lacks an international administrative structure with the powers to enforce a 'global governance solution' to the pandemic. relative to what might be the case under the existing more fractured and decentralised governance regime a global governance approach might increase the likelihood of a large scale health or economic disaster should those who control public health bodies, treasuries and central banks err in their choice of policy measures. writing in the context of common pool resource management elinor ostrom makes a point that may be equally applicable to pandemic response. "where there is only a single governing authority, policy-makers have to experiment simultaneously with all the common pool resources within their jurisdiction with each policy change.... thus an experiment that is based on erroneous data about one key structural variable or one false assumption about how actors will react can lead to a very large disaster.... the important point is that if systems are relatively separable, allocating responsibility for experimenting with rules will not avoid failure but will drastically reduce the probability of immense failures for an entire region (ostrom : ) ." the current pattern of pandemic response does not rely heavily on global 'bigplayers' or a 'single governing authority'. rather, there is some level of decentralisation exercised largely through the powers of nation states and to a lesser extent within nation states where federal political systems are operative. it is perhaps significant in this regard that many countries started to introduce response measures, such as social distancing and travel restrictions, before international bodies such as the world health organisation made such recommendations, while others resisted implementing measures after the who declared a 'global pandemic'. similarly, it may be significant that in federal political systems such as the united states, some jurisdictions introduced lockdown measures before such recommendations were made by the federal centre for disease controlas did many private employers, while other states resisted these calls. nonetheless, it needs to be emphasised that while the relatively decentralised structures of international and in some cases national governance may reduce the risk of large-scale policy failure, the powers exercised by public health and economic agencies within nation states are such that the scope for error by 'big players' remains considerable. the problem here is that there a few mechanisms that enable an effective balance to be struck between the need to reduce the high transactions costs that may be associated with an excessively decentralised response to the virus with the systemic risks associated with over-centralisation. as coase ( ) points out, in market economies under normal circumstances the balance between centralisation and decentralisation is continually determined and re-determined through an ongoing process of competition embedded in profit and loss signals as firms of different sizes compete within one another and the process of mergers, demergers and new entrants unfolds. similarly, ostrom points to the importance of institutional diversity in addressing problems of scale where the existence of competing and overlapping decision centres whether private, communal or public allow multiple comparisons between governance regimes and knowledge of relative successes and failures in the supply and management of public goods to be spread through an experimental process (for example, ostrom ). this may be particularly important in the context of pandemic response because the management challenge at hand may not equate to a singular collective action problem. rather it may be that the spread of the virus requires responses to a range of multiple and more localised collective action problems the structure of which will vary according to geography, population density and the cultural characteristics and beliefs of the populations concerned. unfortunately, however, there may not be mechanisms to decipher what level of political and legislative decentralisation best matches these varying socio-environmental characteristics. this is not to say that there is no scope for determining such a balance. centralised trial and error and 'muddling through' by 'big-players' can lead to some changes in decision-making that reduce the scale of individual public decision failures. in both the united kingdom and the united states for example, the initial failure of national public health agencies to involve private and voluntary sector agents in the roll out of coronavirus testing appears to have been a key factor behind what was initially a miniscule number of completed tests. subsequent lobbying by private bodies and media commentary led to a reversal of this stance which was then followed by significant expansions in testing delivery (bbc news may , ). pointing to the success of centralised trial and error in such examples, however, may only serve to illustrate the broader weaknesses of such an approach when faced with more complex, multi-dimensional challenges. in the example just given, the focus of trial and error learning was confined to a very narrow 'technical' endi.e. how to increase the number of completed tests. problems of this kind may be more amenable to a centralised learning process because there is scope for 'before and after' type observations to discern the effect of particular interventions. learning of this kind may be much more problematic however, when the problems at hand are 'economic' in nature and involve many competing margins for adjustment that may only be revealed in a context where multiple governance models can coexist and where trial and error learning occurs in a more decentralised manner. with respect to broader matters of pandemic response therefore, such as the costs of decisions to lock down populations and businesses or to engage in economic policy measures to counteract the effects of such decisions, then the scope for institutional evolution may be very limited. owing to the 'emergency' nature of the pandemic, to all intents and purposes the inhabitants of nations may be 'stuck' with whatever institutional configurations they have. this may be a significant problem, because institutional configurations that work well under 'normal' circumstances may not be well adapted for pandemic response and the scope to avoid potentially large-scale decision failures associated with these may thus be limited. while the avoidance of large-scale policy failure is an important institutional consideration, from a hayekian view so too is the importance of generating counterfactuals to allow for policy-learning. as with the previous discussion this speaks to the value of a fractured governance regime based on nation states or varying degrees of federalism rather than a global governance approach. just as central economic planning deprives consumers and producers of the information generated by competitive experimentation in a market, so a global governance approach would deprive decision-makers of any sense of the possible opportunity costs associated with different responses to the virus. on this understanding, it may be a virtue of the predominantly nation-centric approach that while many countries have chosen to pursue 'lockdown' measures, others such as sweden have opted for a very different approach based on allowing a gradual spread of the virus through the population. the swedish approach may not be the 'right one' but without its existence or others like it there would be no comparative base against which to evaluate the policy measures adopted elsewhere, and potentially to learn from these. indeed, outside a context that allows for at least some level of decentralisation terms such as policy 'success' or 'failure' are meaningless. on a hayekian view, one cannot judge policy responses against a vision of an 'idealised' policy that might be implemented by omniscient agents because in conditions of complexity and uncertainty knowledge of such an ideal is elusive. the success or failure of a policy can only be determined through a process of endogenous comparisonand this requires a framework that allows for the generation of such comparisons. while the scope for counterfactuals generated by the fractured nature of international governance is important for policy learning, in the context of pandemic response it needs to be recognised that politicians and regulators in nation states and other levels of decisionmaking face a significant 'signal extraction problem' in deciphering what the results of various policy experiments may mean and whether any lessons can be applied elsewhere. as noted earlier, the prices, profits and losses generated in markets do not necessarily provide a transparent signal 'telling' decision-makers how to act. in market settings, however, the feedback received from consumer spending decisions on specific products is such that the profits/losses made relative to those of competitors, combined perhaps with knowledge from market research, provides a relatively clear signal that competitors should move in the direction of their rivals practices. relative to this situation the 'noise' around the different outcomes arising from various approaches to managing the coronavirus may be much more pronounced. thus, even if the swedish model produces satisfactory results from a swedish perspective it does not follow that the same results would or could be achieved with this model in countries such as the uk or france that have very different cultural traditions with which the policy would be interacting. similarly, it is hard to judge whether the apparent success of countries such as germany and switzerland in having a death rate far lower than that found in the uk follows from the characteristics of the populations infected by the disease, other factors such as housing conditions or the nature of urban form in these countries or, whether the lower death rates reflect instead the superiority of health care systems that make much greater use of private providers and market forces. if any of these factors are significant, then it is far from clear that any policy lesson from the pandemic could be implemented with sufficient speed, or indeed whether it could be implemented at all. the difficulty of interpreting policy results highlighted above is compounded by the question of what an appropriate time frame might be in which to make a comparative evaluation of the health and socio-economic effects of alternative policy measures. will countries that look to be performing relatively well with respect to death rates look to have chosen effective responses if a second and possibly larger wave of the virus arrives in the autumn/winter when the prevalence of some level of herd immunity might be desirable? with respect to economic evaluation, will countries that have adopted measures that have in the short term succeeded in reducing the spread of the virus by massively curtailing economic activity be able to sustain such measures if the virus remains a public health hazard over a number of years? given the complications that time frames introduce into the analysis it is hard to see how any policy lessons if they can be detected might be adopted with sufficient speed. moreover, it should be noted here that any short to medium term evaluations may change radically depending on whether an effective vaccine is found. lockdown measures that may have saved lives at great economic cost might still look to have been the best available response should a vaccine be developed relatively speedily. if a vaccine is not forthcoming, however, then those responses or non-responses that have not involved large scale economic contraction may turn out to be the most effective with respect to health and socio-economic objectives. finally, it should be emphasised that while the possible arrival of a vaccine may be affected by investments made by public and private agents, no matter how much private or public money is spent in this regard the discovery of a vaccine will to a significant degree lie beyond any authorities control. the conclusion that would seem to follow from this analysis is that the scope for both error avoidance and policy learning in the context of pandemic response is heavily constrained. the rationalistic models depicted in many public health and welfare economics accounts that conceptualise policy as a process wherein policymakers list the possible options they face, evaluate the options, and then select the option that generates the highest value are entirely inappropriate to this and indeed most other forms of government decision-making. in the specific case of pandemic response, the level of complexity and uncertainty may be so great that it is not possible for such calculations to be made. the data that would be needed to calculate in this manner either do not existat least not in 'concentrated or integrated form' (hayek : ) and, to the extent that there are institutional procedures that help to generate and communicate relevant data the relations between cause and effect and the micro-level connections that underlie such data are opaque. much of the response will therefore be based on centralised guesswork by 'big players' and while there may be no alternative other than for policymakers to rely on subjective interpretations of epidemiological and economic models to guide their decisions, these are fraught with the possibility of large scale error. now of course, scientific understanding in both the natural and social world is always highly imperfect and as new data emerge this may enable an evaluation of which models were more accurate in an ex post sense. the hayekian perspective presented here is not incompatible with this stance but it emphasises that should it be possible to explain retrospectively which policy responses have been more or less efficacious this will not necessarily inform policy-makers whether the same responses would work for a future such event. beyond perhaps some very basic and general lessons such as the importance of maintaining adaptable/flexible health care systems (which are desirable at all times), some (though not all) social distancing measures, and perhaps the wearing of face coverings it may be hard to discern what lessons should be learned from the current episode. this does not necessarily undermine the case for a public policy responsethough neither does it imply that voluntary measures are obviously inferior -but at the very least it suggests that expectations for publicly organised pandemic response should be modest. though it is not a conclusion that many citizens, politicians or social scientists may feel comfortable in accepting, the hayekian perspective suggests that policymakers may be operating in a fog of ignorance where insofar as tolerable responses are reached, these may to a large degree result from fortuitous accidents arising from a process of 'muddling through'. the analysis thus far has focussed on the challenge of discerning appropriate responses to the pandemic, but the hayekian perspective also points to important considerations for the post-pandemic world. if historical experience of crises whether wars or natural disasters are any guide to the post-pandemic political economy, then this period seems likely to be characterised by increasing calls for more government activism and control (on this see higgs ). on the one hand, these calls may be driven by demands for preventive measures to avoid anything like the present crisis happening again. on the other hand, states that have assumed significant control over resource allocation during the pandemic may be reluctant to relinquish their powers and may be encouraged to retain them by those who envisage significantly expanding the role of government in the economy. the concluding part of this paper briefly sets out why these forces should be questioned. while it is understandable that citizens and politicians should seek to avoid a repeat of current events, the hayekian perspective suggests that 'scientific management' of future risks is unlikely to be successful. that politicians and regulators were, prior to the current pandemic, overwhelmingly concerned with the threat of a 'climate emergency' and seem to have been taken aback by the new coronavirus, only serves to demonstrate that there is great uncertainty over which risks should be the focus of attention. neither are such oversights confined to governmental actorsas recently as january this year a variety of corporate bodies representing major business interests at the world economic forum were also citing climate change as the most important global risk, with the threat of infectious diseases rating much lower in the scale of priorities (world economic forum ). to point out these oversights is not of course, to say that climate change or other such risks should not be taken seriously. rather, it is to highlight the problem of assigning weightings to these risks in conditions of radical uncertainty. looking to the future, it is not the case that precautionary measures should be taken against all possible catastrophes because the accumulated costs of responding to every such possibility may be as great, or greater than that of the catastrophes to be avoided (on this see for example, martin and pindyck ) . it is, therefore, essential to choose from multiple conceivable disaster avoidance measures, which should be prioritised. should the focus of risk avoidance be on the possibility of further pandemics, climate change, the threat of nuclear terrorism, or bioterrorism? the problem here is that many of the parameters relevant to discerning these probabilities and the possible interactions between them are simply unknown. this challenge is surely significant in the context of known threats, but it is compounded by the possibility of unknown, unknowns. in conditions of radical uncertainty, it is not merely that actors may not know which possibility from a given set will occur but that the set itself may be unbounded and hence unknowable (knight ) . none of the above should be taken to imply that all scenario planning and spending based on such planning to account for future risks should be discarded. there is a limited, prudential case for private and public funding of measures to guard against future pandemics or other threats such as climate change. what the hayekian perspective suggests however, is that relatively little faith should be placed in these measures because given the nature of uncertainty, the next disaster to strike may well be one that has yet to be conceived. in the final analysis, 'what cannot be known, cannot be planned for' (hayek ) so there are grounds to be wary of granting authority to political agencies that justify their assumption of new powers on the basis of highly uncertain and perhaps unknowable likelihoods of future risks. moreover, insofar as authority is granted to public bodies rather than for example leaving these decisions to private insurance markets, then an important implication from the hayekian analysis is that this authority should be fractured and should where possible avoid reliance on global governance schemes. should the wrong risks be chosen by big players in a global governance structure then the negative consequences will be felt globally. in a more fractured regime on the other hand, unless all decision-making units perceive risks in the same way then the greater heterogeneity of decisions, may reduce though it may not eliminate, the possibility of system-wide failures of risk management. if there is reason to doubt the efficacy of centralised governance in strategic risk planning then the most effective and multipurpose 'insurance policy' that might account for the broadest range of future risks may be to sustain robust levels of economic growth. the resources generated by such growth may provide resilience against risks from multiple directions. in a context where states have recently assumed massive responsibilities for directing economic activity, however, many may argue that securing growth and the form it will take should be the responsibility of the state. there is a long line of thinking in the social democratic and progressive traditions, inspired by thinkers such as john dewey ( ) and john maynard keynes ( ) and reflected more recently by mariana mazzucato ( ) , which suggests that crisis situations require bold and radical experimentation by state agencies. on this view, only the state has the capacity to engage in the 'transformational' measures that might be required to 'jolt' society out of crises events. support for this worldview was evident prior to the current pandemic with the renewed enthusiasm across the political spectrum for various industrial policies, green 'new deals' and targeted protectionism, but post-pandemic these pressures may well grow in intensity (for example iipp ). on a hayekian view, however, these trends should be resisted. one reason for this is the danger of injecting a further source of 'regime uncertainty' into what may already be unstable political economic environments. in responding to the pandemic governments across many parts of the world have already engaged in socio-economic interventions of unprecedented scale, and as noted earlier both the socio-economic effects of these interventions and of measures to unwind them are subject to significant uncertainty and scope for systemic error. these policies have also followed in the wake of the massive interventions in financial markets by monetary authorities in the years since the crisis of . to embark on 'transformational' measures in such a context would be to generate an additional source of systemic risk and may further undermine the background foundations of competition and private contracting, in favour of a regime where discretionary political and bureaucratic power by 'big players' exercises a growing and unpredictable element in the calculations that private agents must make. the second and related reason to resist any post-pandemic expansion in governmental power is that this may recreate the severe knowledge problems that politicians have faced in choosing how to respond to the pandemic -on a near permanent basis. now, this is a bold conjecture, so it is important to be precise in specifying the content of the claim. part of the knowledge problem of pandemic response discussed in this paper is that the emergency nature of the situation severely limits the scope for policymakers to avoid large scale errors and to learn in a sufficiently timely manner. this is clearly not a characteristic that would be shared by measures such as industrial policies that can be implemented over a longer time scale and with greater scope for trial and error learning. nonetheless, from a hayekian perspective, the nature of this learning will be dominated by the 'muddling through' of 'big players' in a context that limits the generation of counterfactuals and which operates largely without guidance from competitive profit and loss signals. it is in this respect that 'transformational' public policies may replicate the knowledge poor environment that characterises the setting of pandemic response. compared to the decentralised experimentation that takes place in competitive markets the type of experimentation involved in state-centred schemes of economic 'transformation' lacks a systemic mechanism to decipher relatively better from relatively worse decisions. it is the systemic discipline provided by competition and profit and loss accounting that, while never guaranteeing successful investment or effective coordination, increases the chance of discovering beneficial investments and the shutting down of those that fail to add value. the greater pluralism of decisionmaking in markets compared to democratic or bureaucratic settings -the fact that in most markets multiple firms offer consumers different products and services -facilitates comparisons between alternatives. moreover, in these settings there is no need for agents to fully comprehend the reasons underlying their success or failure. the generation of profits and losses, combined with the existence of hard budget constraints, continually prods agents towards better decisions and away from relatively worse ones without needing to wait for complex factual and theoretical knowledge or the interpretation of data regarding cause-effect relationships. by contrast, state-dominated 'transformations' thwart the emergence of counterfactuals and knowledge of opportunity costs by limiting competition. as with pandemic response, the scale of the expenditures or the scope of the regulations concerned, and the lack of profit and loss signals attached to them, may block the communication of which 'bits' of expenditure or regulation are adding value. without profit and loss accounting policymakers must rely on centralised guesswork, or at best reliance on modelling procedures that if they ever do generate knowledge of cause-effect relationships may not do so with sufficient speed to shut down failing projects. this problem is compounded by the much softer budget constraints in the public sector that may enable policymakers to continue supporting ventures that fail to add value. even when particular firms or industries do make positive returns, if these have been supported by public funds then knowledge of the returns that might have been generated had tax payers been allowed to invest the capital elsewhere will be foregone. to the extent that 'transformational expenditures' work to promote growth, therefore, then as is the case with pandemic response, this may to large degree be the result of fortuitous accident. to illustrate the empirical relevance of this perspective, consider the arguments for industrial policy espoused recently by mazzucato ( ) . she maintains that because some of today's technological innovations had their origins in acts of government spending rather than private investments this demonstrates that 'directional planning' by the state can improve on market outcomes and that states should be bold in their willingness to spend on transformational projects. yet the evidence mazzucato cites simply fails to support these conclusions (see for example, mingardi ) . first, she ignores the opportunity costs of the massive cold war related military spending she claims was partly responsible for innovation and growth. while some of this expenditure may well have added value mazzucato offers no analysis of the multiple acts of military spending that failed to stimulate beneficial innovation, and which were not shut down. second, mazzucato fails to recognise that those elements of public spending that may have generated benefits were not 'planned'. at no point does she specify processes that demonstrate how 'directional intelligence' and 'strategic planning' led to specific instances of success. on the contrary, the success stories she refers tosuch as the development of various digital technologies, appear to have been unintended or accidental consequences emerging from essentially random spending in the defence sectorunintended consequences that were adapted to and seized upon by private agents operating in competitive markets guided by profit and loss signals (ibid). mazzucato is not alone in downplaying or ignoring opportunity costs and in failing to specify the processes that allow the 'directive intelligence' of the state to 'beat the market'. a similar problem besets the strands of political economy literature that favour targeted protectionism (for example chang ) . in this instance, the relative success of some countries that have pursued protectionist policies is touted as evidence in their favour without adequate discussion of the multiple examples where similar measures have failed to deliver success. moreover, where successes have occurred little if any account is given of the processes or mechanisms that could credibly connect the outcomes to specific acts of directive intelligence. it is simply assumed that the intervention in question was responsible for the outcome rather than arising despite the intervention, or as an accidental or unintended consequence from it (panagariya ). the hayekian perspective that has informed this paper does not claim that it is impossible for industrial policies, large public spending projects or targeted protectionism to generate positive results, any more than it claims that is impossible for governments to respond effectively to pandemics. as with pandemic response, what it suggests is that relative to markets there are few systemic mechanisms that enable decision-makers to learn whether their decisions add more, or less to public welfare than possible alternatives. from a hayekian perspective, what the dewey/keynes/ mazzucato case for state-based experimentation amounts to is the suggestion that if governments commit to spending enough public money on their favoured projects it would be remarkable if none of this expenditure did any good. yet, this position hardly amounts to an endorsement of the transformational potential of the state. that it may be necessary to rely on the 'muddling through' of public agencies when responding to a pandemic, does not imply continued deference to such agencies when the emergency has passed. open access this article is licensed under a creative commons attribution . international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creativecommons.org/licenses/by/ . /. discordant harmonies hayek's challenge bad samaritans the institutional structure of production calculation, complexity and planning, the socialist calculation debate once again the public and its problems uk suffers second highest death rate from coronavirus engineering the financial crisis on the impossibility of informationally efficient markets the road to serfdom the use of knowledge in society individualism and economic order the theory of complex phenomena the pretence of knowledge in hayek competition as a discovery procedure crisis and leviathan regime uncertainty: why the great depression lasted for so long and why prosperity returned after the war socialism against markets: a critique of two recent proposals radical uncertainty. london: the bridge street press risk, uncertainty and profit big players and the economic theory of expectations the intelligence of democracy: decision through mutual adjustment still muddling, not yet through econometric policy evaluation: a critique averting catastrophe: the strange economics of scylla and charybdis the entrepreneurial state a critique of mazzucato's entrepreneurial state understanding institutional diversity chaos, management and economics. london: institute of economic affairs the oxford handbook of health economics freedom ucl institute for innovation and public purpose (iipp) politics as a peculiar business macro-economics as systems theory austerian economics: does the vienna school favour fiscal deficit reduction even in a subpar economy the global risks report publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord- -ztgrxucb authors: ben-michael, eli; feller, avi; stuart, elizabeth a. title: a trial emulation approach for policy evaluations with group-level longitudinal data date: - - journal: nan doi: nan sha: doc_id: cord_uid: ztgrxucb to limit the spread of the novel coronavirus, governments across the world implemented extraordinary physical distancing policies, such as stay-at-home orders, and numerous studies aim to estimate their effects. many statistical and econometric methods, such as difference-in-differences, leverage repeated measurements and variation in timing to estimate policy effects, including in the covid- context. while these methods are less common in epidemiology, epidemiologic researchers are well accustomed to handling similar complexities in studies of individual-level interventions."target trial emulation"emphasizes the need to carefully design a non-experimental study in terms of inclusion and exclusion criteria, covariates, exposure definition, and outcome measurement -- and the timing of those variables. we argue that policy evaluations using group-level longitudinal ("panel") data need to take a similar careful approach to study design, which we refer to as"policy trial emulation."this is especially important when intervention timing varies across jurisdictions; the main idea is to construct target trials separately for each"treatment cohort"(states that implement the policy at the same time) and then aggregate. we present a stylized analysis of the impact of state-level stay-at-home orders on total coronavirus cases. we argue that estimates from panel methods -- with the right data and careful modeling and diagnostics -- can help add to our understanding of many policies, though doing so is often challenging. to limit the spread of the novel coronavirus, governments across the world implemented extraordinary "non-pharmaceutical interventions," such as closing non-essential businesses and imposing quarantines. the specific policies -and the decisions to lift them -varied widely, with particularly dramatic variation within the united states. learning about the impact of these policies is important both to inform future policy decisions and to construct accurate forecasts of the pandemic. there are well-established epidemiologic methods for estimating the impact of an intervention that occurs in a single location and at a single time point, dating back to john snow and the cholera epidemic in london. often known as difference-in-differences, the basic approach constructs counterfactual outcomes using group-level longitudinal data from the pre-and post-policy change time periods and from localities (e.g., states) that did and didn't implement the policy. variants of this approach are known as panel data methods and include event studies and comparative interrupted time series models. there is no clear consensus in epidemiology, however, on how to proceed when many localities implement a policy over time, sometimes known as staggered adoption. fortunately, epidemiologic researchers are well accustomed to handling similar complexities in studies of individual-level interventions, with decades of research on strong non-experimental study designs, including methods that handle confounding and variation in timing of treatment across individuals. "target trial emulation" emphasizes the need to carefully design a non-experimental study in terms of inclusion and exclusion criteria, covariates, exposure definition, and outcome measurementand the timing of all of those variables. in this paper, we argue that policy evaluations using panel data need to take a similarly careful approach to study design, which we refer to as "policy trial emulation." the main idea is to construct target trials separately for each "treatment cohort" (states that implement the policy at the same time) and then aggregate. we illustrate this approach by presenting a stylized analysis of the impact of state-level stay-at-home orders on total coronavirus cases. we believe this new connection to trial emulation is an important conceptual advance, though the underlying statistical methods we discuss are well-established, and many of these points have been made in other contexts. we argue that estimates from panel methods -with the right data and careful modeling and diagnostics -can help add to our understanding of policy impacts. the underlying assumptions, however, are often strong and the application to covid- anti-contagion policies is particularly challenging. we now describe key steps in conducting "policy trial emulation," which are necessary and obvious when designing a randomized trial and are becoming more common in the design of nonexperimental studies. we argue that these steps are just as important when evaluating policies with aggregate longitudinal panel data. we illustrate the key idea with a stylized policy evaluation: measuring the impact of us states adopting a "shelter in place" or "stay-at-home" policy on covid- case counts. these orders urge or require citizens to remain at home except to conduct essential business, e.g., grocery shopping or exercise; we use nyt tracker to define policy enactment dates and obtain daily case counts. no irb approval was needed for this use of publicly available aggregate data. first, we must have a consistent definition of the exposure. specifically, there is only one form of treatment, and the outcome we see under a particular policy environment is equal to the potential outcome under that policy environment. for stay-at-home policies, different states enacted different requirements that broadly fall under this header, and the nyt definition is just one. this introduces a trade-off. we could consider multiple types of treatment separately, such as closing schools versus closing non-essential businesses. however, this greatly expands the dimensionality of the specific exposure under consideration. instead we consider "packaging treatments" together, allowing for some variation in the specific implementation of the policy across units. as a result, the estimated effect averages over different policy-specific effects within the data, which may be less interpretable and may violate the consistency assumption. second, there is growing evidence that stay-at-home orders had only modest impacts on individual behavior -in many states, individuals reduced their mobility even in the absence of official policy changes. thus, we focus here on emulating an intent-to-treat (itt) analysis, where individuals are randomized to treatment conditions, but the amount of treatment actually received (e.g., the dose) may differ across people. the itt is often relevant for examining whether the policy is effective overall, regardless of specific implementation. if we had data on, e.g., state-wide implementation of the policy or the level of adherence as determined by mobility measures, we could conduct an analysis analogous to a per protocol effect, e.g., estimating the effect of "full" policy implementation (i.e., all individuals following the stay at home guidelines). the trial emulation framework helps clarify the additional assumptions necessary for conducting a per protocol analysis in this context. finally, an important complication is reasoning about interactions between units, e.g. people with covid- traveling across state lines and spreading infection. the trial emulation framework makes clear that we must pay close attention to this when defining our target trials: nearly all standard tools for policy evaluation assume no interference between units, that is, a state's outcome only depends on that state's intervention. violations of this assumption, sometimes known as spillovers or contagion, complicate the definitions of units and exposures and can lead to bias. understanding and explicitly modeling these violations is paramount when studying policies to control infectious diseases. for example, holtz et al. use travel and social network information to account for spillovers across states. we refer interested readers to the large literature on observational causal inference with interference in general and on panel data methods in particular. after defining units and exposures, the next step in the trial emulation framework is to define the estimand of interest. as discussed above, we focus on the itt for treated states. formally, let !" be an indicator that state i has a stay-at-home order at time t; and let !" be the corresponding observed outcome. we can express the causal quantity of interest via potential outcomes: !" ( !" = ) is the outcome if the stay-at-home order is enacted, and !" ( !" = ) is the outcome if the order is not enacted. the causal contrast of interest is then a difference between these potential outcomes, !" ( ) − !" ( ), averaged over the states that implemented the policy and over post-treatment time periods. we also focus on the impact of "turning on" these policies, but of course states also turn them "off." just as in the individual exposure case, modeling individuals or locations turning exposures on and off is complex. if that seems ambitious in a trial setting it is often even more ambitious in a non-experimental context! the next step in trial emulation is to define "time zero", i.e., the point in time when individuals or states would have been randomized to treatment conditions. this is crucial for clearly distinguishing baseline (pre-treatment) measures from outcomes (post-treatment): inappropriately conditioning on or selecting on post-treatment variables can cause as much bias (including immortal time bias) as can confounding. . in standard target trial emulation, time zero is often defined based on when individuals meet the specified eligibility criteria and is applied equally to both treated (exposed) and control (unexposed) units. in policy trial emulation, states are often "eligible" to implement a policy at any point, though this can also occur in standard target trial emulation. for treated states, we typically use the date the policy is enacted as time zero; for comparison states, however, analysts essentially need to identify the moment in time that a state "could have" implemented the policy but did not. for states that enact stay-at-home orders on march ; we similarly set march as "time zero" for the comparison states. in the covid setting, however, we might instead want to measure time since the start of the pandemic in a specific location ---given the sudden emergence of the pandemic, case counts are essentially undefined before this time. this presentation is in line with many of the epidemiologic models. we refer to this as case time and, as an illustration, index time by the number of days since the th confirmed case. calendar dates with fewer than cases and case times after april th, are unshaded. the choice of time zero will depend on the context. in the covid setting, case time is more consistent with models of infectious disease growth but is also more sensitive to measurement error. calendar time is more natural for accounting for "common shocks" to states, such as changes in federal policy, which occur on a specific date. moreover, for some specific questions, such as impacts on employment outcomes, this distinction might not be relevant. for ease of exposition, we focus on calendar time in the main text and give analogous results in case time in the appendix. the next step in policy trial emulation is to clearly define the outcomes, both the measures themselves and their timing ( in the notation above). in a typical trial, the outcomes might be something like "mortality within months." in our covid case study we focus on two different outcome measures: (a) the (log) number of cases, and (b) the log-ratio of case counts from the previous day. the first is a measure of the cumulative effect, while the latter is a measure of the day-by-day changes in growth. we focus on log transformed data because exponential disease growth can result in different pre-intervention trends on the raw outcome scale; we further discuss the risk of pre-trends below, and present results for raw case counts and case growth in the appendix. data quality is also a key concern. care needs to be taken to select outcomes that can be measured accurately; in particular, differential changes in the testing regime across states over time can lead to the illusion of an effect. finally, we focus on outcomes that are measured at the aggregate (e.g., state) level, which is natural given the outcomes we examine. however, it is sometimes more reasonable to consider targeting a cluster-(rather than individual-) randomized trial in which treatment occurs at some aggregate level but outcome data are measured at the individual level data. the same trial emulation principles apply, and hierarchical modeling can be used to account for the multilevel structure. we now describe a single target trial, and then turn to describing a sequence of nested target trials, which more fully captures the staggered adoption setting. here the goal is to estimate the impact for a single cohort of states that enact a stay-at-home order at the same time. for now, we focus on the five states that enacted the policy on march , : connecticut, louisiana, ohio, oregon, and washington. in a randomized trial, researchers have the "luxury" of knowing that the exposed and unexposed units are similar on all baseline characteristics in expectation. this is not the case in nonexperimental studies such as policy evaluations. thus, a key step in policy trial emulation is carefully selecting comparison units. we discuss statistical approaches for adjusting for differences in the next section. an important consideration in selecting comparison units is the length of follow up -once a comparison state enacts the treatment, it is no longer a useful comparison without strong modeling assumptions. only days passed between when the first and last states enacted stay-at-home orders, and if we compare the march cohort to late-adopting states, we can observe effects for at most days. in general, across cohorts, the longer the follow up, the fewer available comparison states. * due to the lag between virus exposure, symptoms, and testing, we expect stay-at-home-orders to have delayed or gradual effects on the number of confirmed cases and case growth. how we define the start of the "outcome" time period (to then allow for different patterns of effects) is intimately related to the question of defining time zero, discussed above. therefore, we compare the treated cohort to the eight "never treated" states, allowing for estimates of longer-term effects. † in principle, we could use "not yet treated" states in the comparison group, dropping states from the comparison group at the time they enact the policy. however, the set of "not yet treated" states will change throughout the follow up period. it may then be difficult to assess whether changes in * the choice of time scale is especially important if comparing with late adopters, since a state might be a valid comparison in calendar time but not case time: ohio's stay-at-home order was enacted after california in calendar time but before california in case time. † these are arkansas, north dakota, south dakota, iowa, nebraska, oklahoma, wyoming, and utah. effects are merely due to the changing composition of the comparison states. additionally, for each set of comparison states at each follow up period we will need to perform the diagnostic checks we describe below, potentially leading to an unwieldy number of diagnostics. once we have specified the target trial, the final stage is estimating the treatment effects and evaluating diagnostics for underlying assumptions. while similar to standard trial emulation contexts in many ways, there are particular nuances and complications in the policy trial emulation setting given the longitudinal time-series nature of the data and the relatively small number of units (e.g., states). we illustrate this setup with simple estimators, especially the canonical "difference-in-differences" estimator; we discuss alternative estimators below. against shared "shocks" between the two cohorts -e.g., changes in national policy or testingit does not adjust for any differences in pre-intervention cases. difference-in-differences combines these two approaches. first take the pre/post estimate of a decrease in the log growth rate by . in the march cohort and compare it to a pre/post change in the never treated states, a decrease of . . taking the difference of these differences (hence "difference-in-differences") yields an estimated reduction of the log growth rate by . , or an percentage point decrease in the growth rate (table ) . formally, this estimator is: where &$ ---and %$ ---denote the pre-and post-treatment average outcomes for cohort , and = ∞ denotes the never treated cohort. the key to the differences-in-differences framework is a parallel counterfactual trends assumption: loosely, in the absence of any treatment, the trends for the treated cohort would be the same as the trends for the never-treated states, on average. this assumption is inherently dependent on the outcome scale: if trends in log cases are equal, then trends in "raw" case numbers cannot also be equal. this assumption would be violated if: • anticipation: behavior changes before the state-wide shutdown, since pre-time zero measures would no longer truly be "pre-treatment." in the case of stay-at-home orders, there is strong evidence of such anticipatory behavior. finally, this approach relies entirely on outcome modeling and therefore differs from many common methods in epidemiology that instead model treatment, especially inverse probability of treatment weighting (iptw). recent "doubly robust" implementations of difference-indifferences also incorporate iptw and therefore rest on different assumptions than outcome modeling alone, including the positivity assumption that all units have a non-zero probability in being in each of the treatment conditions. standard difference-in-difference models avoid positivity by instead relying on a parametric outcome model that potentially extrapolates across groups. tool: it estimates the effect averaged over the entire post-treatment period. by combining various x did estimators we can estimate how effects phase in after march . first, we pick a common reference date, often the time period immediately preceding treatment (here, march ) . then for every other time period we estimate the x did relative to that date. concretely, to estimate the effect k periods before/after treatment we compute the x estimator: where ($ ---is the average for cohort , periods before/after treatment. figure shows these estimates for the march cohort, sometimes known as event study plots, with uncertainty quantified via a leave-one-unit-out jackknife. finally, for ≥ we estimate a different treatment effect for each period succeeding treatment, without imposing any assumptions on how we expect the treatment effects to phase in or out. from figure we see that in this single target trial there is insufficient precision to differentiate the effects from zero, let alone to distinguish a trend. we now estimate the overall average impact by repeating the trial emulation approach for all states that eventually adopt a stay-at-home order. as above, the first step is to divide treated states into cohorts based on adoption date. for each cohort, we then emulate a single target trial, selecting the same eight never-treated states as comparisons for every target trial. finally, we aggregate results across these target trials. these are nested target trials in the sense that each target trial can have a different starting point and length of follow up. this approach is sometimes known as stacking or event-by-event analysis in the econometrics literature. the specific approach we implement here is equivalent to that in abraham and sun ( ) and callaway and sant'anna ( ) without any covariates. in each single target trial, we estimate a series of two-period difference-in-differences estimates for that cohort as in the previous section. there are many ways to aggregate these estimates across cohorts. here we aggregate based on days since treatment (sometimes called "event time"): where is the total number of cohorts, $ is the number of treated units in cohort , and is the total number of treated states. we refer to these as nested estimates. figure shows the estimates from this approach, both for the effect on log case growth and on log cases. as with the single target trial, estimates to the right of zero are the treatment effects of interest, and estimates to the left of zero are "placebo estimates" of the impact of the treatment prior to the treatment itself. for the left panel (log case growth), the placebo estimates for the ten days before a state enacts a stay at home order are precisely estimated near zero; however, placebo effects prior to this are highly variable and show a downward trend over time. this suggests caution in interpreting the negative estimates to the right of zero. for the right panel (log cases), the placebo estimates are even more starkly different from zero, suggesting that this would not be an appropriate analysis and that the estimated effects are likely merely a reflection of these differential trends. epidemiologists regularly confront settings where multiple jurisdictions adopt a policy over time and the data available are aggregate longitudinal data on those and other jurisdictions. policy trial emulation provides a principled framework for estimating causal effects in this setting. the specific approach we advocate is not new; there is a growing literature in statistics and econometrics proposing robust methods for panel data. here we show that these ideas fit naturally into the trial emulation framework, especially the notion of aggregating across multiple target trials. as a result, we can leverage recent methodological advances to enable more sophisticated estimation that allows for looser assumptions (e.g., parallel trends conditioned on covariates), including inverse propensity score weighting, doubly robust estimation, synthetic controls, and matching. we could also impose stronger modeling assumptions on the time series, e.g., a linear trend, such as in comparative interrupted time series. one approach we caution against is the common practice of using regression to fit a longitudinal model to all the data, with fixed effects for state and time. as with individual data with timevarying treatments and confounders, naive regression models can mask important issues. in particular, it has been shown that the coefficient in this pooled model estimates a weighted average over all possible x difference-in-differences estimates, where the weights can be negative. moreover, some of these estimates are not in the spirit of trial emulation, e.g., by comparing two states that are entirely post treatment. in practice, these complications mean that the sign of the estimated effect can be flipped relative to the nested estimate. while some approaches, such as "event study models," are less susceptible to this critique, we believe that the trial emulation framework we outline here is more transparent and less prone to error, partly by being explicit about all the causal contrasts. the issues that we highlight are just some of many major challenges in estimating policy effects more generally, including: differences in the characteristics of states that do and don't implement the covid- pandemic adds additional complexities to these policy evaluations. for example, the disease transmission process, and the up to two-week lag in the time from exposure to symptoms, makes it difficult to identify the precise timing of expected effects. data on outcomes of interest are also limited or problematic; for example, case rates need to be considered within the context of the extent of testing. finally, methods that do not account for spillovers and contagion are likely to be biased in this setting, and so properly addressing interference is a key methodological and practical concern. these issues -and the strong underlying assumptions -suggest caution in using difference-indifference methods for estimating impacts of covid- physical distancing policies. at the same time, the policy trial emulation framework suggests a rubric by which we can assess the quality of evidence presented in these studies. we anticipate that high-quality panel data methods will add to our understanding of these policies, especially when considered alongside other sources of evidence. see how 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difference-in-differences analysis health policy data science lab. difference-in-differences evaluating methods to estimate the effect of state laws on firearm deaths: a simulation study correcting under-reported covid- case numbers: estimating the true scale of the pandemic appendix figure : nested estimates of the impact of statewide stay-at-home orders on log cases and log case growth, in case time. standard errors estimated with the jackknife. key: cord- -rzrfkkci authors: dua, pami title: monetary policy framework in india date: - - journal: indian econ rev doi: . /s - - - sha: doc_id: cord_uid: rzrfkkci in , the monetary policy framework moved towards flexible inflation targeting and a six member monetary policy committee (mpc) was constituted for setting the policy rate. with this step towards modernization of the monetary policy process, india joined the set of countries that have adopted inflation targeting as their monetary policy framework. the consumer price index (cpi combined) inflation target was set by the government of india at % with ± % tolerance band for the period from august , to march , . in this backdrop, the paper reviews the evolution of monetary policy frameworks in india since the mid- s. it also describes the monetary policy transmission process and its limitations in terms of lags and rigidities. it highlights the importance of unconventional monetary policy measures in supplementing conventional tools especially during the easing cycle. further, it examines the voting pattern of the mpc in india and compares this with that of various developed and emerging economies. the synchronization of cuts in the policy rate by mpcs of various countries during the global slowdown in and the covid- pandemic in the early s is also analysed. the monetary policy framework in india has evolved over the past few decades in response to financial developments and changing macroeconomic conditions. the operational framework of monetary policy has also gone through significant changes with respect to instruments and targeting mechanisms. the preamble of the reserve bank of india (rbi) act, was also amended in , which now clearly provides the mandate of the rbi. it reads as follows: "to regulate the issue of bank notes and keeping of reserves with a view to securing monetary stability in india and generally to operate the currency and credit system of the country to its advantage; to have a modern monetary policy framework to meet the challenge of an increasingly complex economy; to maintain price stability while keeping in mind the objective of growth." the aim of monetary policy in the initial years of inception of rbi was mainly to maintain the sterling parity, with exchange rate being the nominal anchor of monetary policy. liquidity was regulated through open market operations (omos), bank rate and cash reserve ratio (crr). soon after independence and through the late s, the role of the central bank was aligned with the planned development process of the nation in accordance with the -year plans. thus, it played a major role in regulating credit availability, employing omos, bank rate, and reserve requirement towards this end. with the nationalization of major banks in , the main objective of monetary policy through the s till the mid- s was the regulation of credit in accordance with the developmental needs of the country. this period was marked by monetization of fiscal deficit while inflationary consequences of high public expenditure necessitated frequent recourse to crr. in , on the recommendation of the committee set up to review the working of the monetary system (chairman: dr. sukhamoy chakravarty), a new monetary policy framework, monetary targeting with feedback was implemented based on empirical evidence of a stable demand for money function. however, financial innovations in the s implied that demand for money may be affected by factors other than income. further, interest rates were deregulated in the mid- s and the indian economy was getting increasingly integrated with the global economy. therefore, the rbi began to deemphasize the role of monetary aggregates and implemented a multiple indicator approach (mia) to monetary policy in encompassing all economic and financial variables that influence the major objectives outlined in the preamble of the rbi act. this was done in two phases-initially mia and later augmented mia (amia) which included forward looking variables and time series models. based on rbi's report of the expert committee to revise and strengthen the monetary policy framework ( , chairman: dr urjit r patel), a formal transition was made in towards flexible inflation targeting and a six member monetary policy committee (mpc) was constituted for setting the policy repo rate. the monetary policy framework agreement (mpfa) was signed between the government of india and the rbi in february to formally adopt the flexible inflation targeting (fit) framework. this was followed up with the amendment to the rbi act, in may to provide a statutory basis for the implementation of the fit framework. with this step towards modernization of the monetary policy process, india joined the set of countries that adopted inflation targeting, starting from by new zealand, as their monetary policy framework. the central government notified in the official gazette dated august , , that the consumer price index (cpi) inflation target would be % with ± % tolerance band for the period from august , to march , . at the time of writing (april ), this period is drawing to a close in less than a year. in this backdrop, this paper discusses the evolution of the monetary policy framework in india and describes the workings of the current framework. the paper is divided into the following sections. section presents a schematic representation of the main components of a general monetary policy framework and describes its key features. section describes the genesis of the monetary policy framework in india since covering the monetary targeting framework, multiple indicator approach and flexible inflation targeting. the main recommendations of rbi's report of the expert committee to revise and strengthen the monetary policy framework ( , chairman: dr urjit r patel) are also discussed. composition, workings and voting pattern of the monetary policy committee from october to march are also provided. further, a comparison of voting patterns with various countries across the globe is undertaken. section discusses a general framework for monetary policy transmission and applies the framework to india. it also describes interest rate linkages at the global level. section examines unconventional monetary policy measures adopted in late and early . section concludes the paper. the specification of the monetary policy framework facilitates the conduct of monetary policy. the general framework comprises well-defined objectives/goals of monetary policy along with instruments, operating targets and intermediate targets that aid in the implementation of monetary policy and achievement of the ultimate objectives. a schematic representation of a monetary policy framework is shown in fig. (laurens et al. ; mishkin ) . instruments are tools that the central bank has control over and are used to achieve the operational target. examples of instruments include open market operations, reserve requirements, discount policy, lending to banks, policy rate. operational targets are the financial variables that can be controlled by the central bank to a large extent through the monetary policy instruments and guide the day-to-day operations of the central bank. these can impact the intermediate target and thus help in the delivery of the final goal of monetary policy. examples of operational targets include reserve money and short-term money market interest rates. intermediate targets are variables that are closely related with the final goals of monetary policy and can be affected by monetary policy. intermediate targets may include monetary aggregates and short-term and long-term interest rates. goals refer to the final policy objectives. these may include price stability, economic growth, financial stability and exchange rate stability. this general framework is applied to the monetary targeting framework with feedback that prevailed from to and to the inflation targeting framework that exists from onwards. the multiple indicator approach that was operational from to was based on a number of financial and economic variables and was not exactly specified on the basis of this framework although broad money was treated as an intermediate target and the goals of monetary policy are the same across the various frameworks. in the s through the mid- s, monetization of the fiscal deficit exerted a dominant influence on monetary policy with inflationary consequences of high public expenditure necessitating frequent recourse to crr. against this backdrop, in , on the recommendation of the committee set up to review the working of the monetary system (rbi ; chairman: dr. sukhamoy chakravarty), a new monetary policy framework, monetary targeting with feedback was implemented based on empirical evidence of a stable demand for money function. the recommendation of the committee was to control inflation within acceptable levels with desired output growth. further, instead of following a fixed target for money supply growth, a range was followed which was subject to mid-year adjustments. this framework was termed "monetary targeting with feedback" as it was flexible enough to accommodate changes in output growth. this operational framework is depicted in fig. . (definitions of variables shown in fig. are given in appendix ). the main instruments in this framework were cash reserve ratio (crr), open market operations (omos), refinance facilities and foreign exchange operations. broad money (m ) was chosen as the intermediate target while reserve money (m ) was the main operating target. however, an analysis of money growth outcomes during the monetary targeting framework reveals that targets were rarely met (rbi (rbi - . even with increases in crr, money supply growth remained high and fuelled inflation. further, financial innovations in the s implied that demand for money may be affected by factors other than income. since the mid- s, with global integration, factors such as swings in capital flows, volatility in the exchange rate and global growth also impacted the economy. moreover, interest rates were deregulated allowing for changing interest rates and a market determined management system of exchange rates was also adopted. ( ) primary objective of monetary policy in india is to maintain price stability, while keeping in mind the objective of growth. ( ) definitions of variables are given in appendix against the backdrop of changing domestic and global dynamics, rbi implemented a multiple indicator approach (mia) to monetary policy in encompassing various economic and financial variables based on the recommendations of rbi's working group on money supply (rbi ; chairman: dr yv reddy). these variables included several quantity variables such as money, credit, output, trade, capital flows, fiscal indicators as well as rate variables such as interest rates, inflation rate and the exchange rate. the information on these variables provided a broad-based monetary policy formulation, which not only encompassed a diverse set of information, but also accorded flexibility to the conduct of monetary management. the mia was conceptualized when dr bimal jalan was governor and was implemented in two stages-mia and later augmented mia, by including forward looking variables and a panel of time series models, in addition to the economic and financial variables (mohanty ; reddy ) . forward looking indicators were drawn from rbi's industrial outlook survey, capacity utilization survey, inflation expectations survey and professional forecasters' survey. all the variables together with time series models provided the projection of growth and inflation while rbi provided the projection for broad money (m ) and treated this as the intermediate target. the operational framework of amia is illustrated in fig. . compared to the monetary targeting framework, the goals of monetary policy remained the same and broad money continued to serve as the intermediate target while the underlying operating mechanism of mia evolved over time. in may , the weighted average call money rate (wacr) was explicitly recognized as the operating target of monetary policy while the repo rate was made the only one independently varying policy rate. these measures improved the implementation and transmission of monetary policy along with enhancing the accuracy of signaling of monetary policy stance (mohanty ) . the importance of focusing on inflation was first highlighted in the report of the committee on financial sector reforms (government of india ; chairman: dr. raghuram rajan) constituted by the government of india. the report recommended that rbi can best serve the cause of growth by focusing on controlling inflation and intervening in currency markets only to limit excessive volatility. the report pointed out that the cause of inclusion can also be best served by maintaining this focus because the poorer sections are least hedged against inflation. further, the report recommended that there should be a single objective of staying close to a low inflation number, or within a range, in the medium term, moving steadily to a single instrument, the short-term interest rate to achieve it. former environment. the committee was also required to review the organizational structure, operating framework and instruments of monetary policy, liquidity management framework, to ensure compatibility with macroeconomic and financial stability, as well as market development. the impediments to monetary policy transmission were to be identified and measures along with institutional pre-conditions to improve transmission across financial markets and real economy were to be suggested. some issues central to the report were selecting the nominal anchor for monetary policy, defining the inflation metric and specifying the inflation target. a nominal anchor is central to a credible monetary policy framework as it ties down the price level or the change in the price level to attain the final goal of monetary policy. it is a numerical objective that is defined for a nominal variable to signal the commitment of monetary policy towards price stability. generally five types of nominal anchors have been used, namely, monetary aggregates, exchange rate, inflation rate, national income and price level. the expert committee recommended inflation to be the nominal anchor of the monetary policy framework in india as flexible inflation targeting recognizes the existence of growthinflation trade-off in the short-run and stabilizing and anchoring inflation expectations is critical for ensuring price stability on an enduring basis. further, low and stable inflation is a necessary precondition for sustainable high growth and inflation is also easily understood by the public. regarding the inflation metric, the committee recommended that rbi should adopt the all india cpi (combined) inflation as the measure of the nominal anchor. this is to be defined in terms of headline cpi inflation, which closely reflects the cost of living and influences inflation expectations relative to other available metrics. cpi is also easily understood as it is used as a reference in wage contracts and negotiations. headline inflation was preferred against core inflation (headline inflation excluding food and fuel inflation) since food and fuel comprise more than % of the consumption basket and cannot be discarded. the committee recommended the target level of inflation at % with a band of ± % around it. the tolerance band was formulated in the light of the vulnerability of the indian economy to supply and external shocks and the relatively large weight of food in the cpi basket. the expert committee also recommended that decision-making should be vested in a monetary policy committee (mpc). with the signing of the monetary policy framework agreement (mpfa) between the government of india and the rbi on feb , , flexible inflation targeting (fit) was formally adopted in india. in may , the reserve bank of india (rbi) act, was amended to provide a statutory basis for the implementation of the fit framework. the amended rbi act, also provided that the central government shall, in consultation with the bank, determine the inflation target in terms of the consumer price index, once in every years. accordingly, the central government has notified in the official gazette % consumer price index (cpi) inflation as the target for the period from august , to march , with the upper tolerance limit of % and the lower tolerance limit of %. the amended rbi act, also provides that rbi shall be seen to have failed to meet the target if inflation remains above % or below % for three consecutive quarters. in such circumstances, rbi is required to provide the reasons for the failure, and propose remedial measures and the expected time to return inflation to the target. in , india thus joined several developed and emerging market economies that have implemented inflation targeting. figure shows the timeline for implementation of inflation targeting for countries in this category, starting in . the amended rbi act, provides for a statutory and institutionalized framework for a six-member monetary policy committee (mpc) to be constituted by the central government by notification in the official gazette. the central government in september thus constituted the mpc with three members from rbi including the governor as chairperson and three external members as per gazette notification dated september , . (details of the composition of mpc are given in appendix ). the committee is required to meet at least four times a year although it has been meeting on a bi-monthly basis since october . each member of the mpc has one vote, and in the event of equality of votes, the governor has a second or casting vote. the resolution adopted by the mpc is published after conclusion of every meeting of the mpc. on the th day, the minutes of the proceedings of the mpc are published which includes the resolution adopted by the mpc, the vote of each member on the resolution, and the statement of each member on the resolution. it may be noted that before the constitution of the mpc, a technical advisory committee (tac) on monetary policy was set up in which consisted of external experts from monetary economics, central banking, financial markets and public finance. the role of this committee was to enhance the consultative process of monetary policy by reviewing the macroeconomic and monetary developments in the economy and advising rbi on the stance of monetary policy. with the formation of mpc, the tac on monetary policy ceased to exist. the mpc is entrusted with the task of fixing the benchmark policy rate (repo rate) required to contain inflation within the specified tolerance band. the framework entails setting the policy rate on the basis of current and evolving macroeconomic conditions. once the repo rate is announced, the operating framework looks at liquidity management on a day-to-day basis with the aim to anchor the operating target-the weighted average call rate (wacr)-around the repo rate. this is illustrated in fig. , where the intermediate targets are the short-term and long-term interest rates and the goals of price stability and economic growth are aligned with the primary objective of monetary policy to maintain price stability, keeping in mind the objective of growth. in addition to the repo rate, the instruments include liquidity facility, crr, omos, lending to banks and foreign exchange operations (rbi ). ( ) ( ) primary objective of monetary policy in india is to maintain price stability, while keeping in mind the objective of growth. ( ) definitions of variables are given in appendix it is imperative here to note some of the key elements of the revised framework for liquidity management (rbi ) that are particularly relevant for the operating framework shown in fig. . as noted in the rbi monetary policy report, . • liquidity management remains the operating procedure of monetary policy; the weighted average call rate (wacr) continues to be its operating target. • the liquidity management corridor is retained, with the marginal standing facility (msf) rate as its upper bound (ceiling) and the fixed reverse repo rate as the lower bound (floor), with the policy repo rate in the middle of the corridor. • the width of the corridor is retained at basis points-the reverse repo rate being basis points below the repo rate and the msf rate basis points above the repo rate. (the corridor width was asymmetrically widened on march and april , .) • instruments of liquidity management continue to include fixed and variable rate repo/reverse repo auctions, outright open market operations, forex swaps and other instruments as may be deployed from time to time to ensure that the system has adequate liquidity at all times. • the current requirement of maintaining a minimum of % of the prescribed crr on a daily basis will continue. (this was reduced to % on march , .) the first meeting of the mpc was held in october . between october and march , the mpc has met times. table shows the voting patterns for each meeting with respect to the direction of change in the policy rate, magnitude of change and the stance of monetary policy. table , on the other hand, provides an overall summary of the voting of all the meetings. it is interesting to note in table , that with respect to direction of change/status quo of the policy rate, consensus was achieved in meetings out of . of these meetings, there were three meetings where there were differences in the magnitude of the change voted for although there was consensus regarding the direction of change. the diversity in voting of the mpc members reflects the differences in the assessment and expectations of individual members as well as their policy preferences. to examine if this diversity exists in mpcs of other countries as well, we analyse the voting patterns of countries across the globe during october to march in table . for many countries, we find dissents in some of the meetings, similar to the lack of consensus in some of the meetings of the indian mpc. it merits mention that the committee approach towards the conduct of monetary policy has gained prominence across globe. the advantages of this approach include confluence of specialized knowledge and expertise on the subject domain, bringing together different stakeholders and diverse opinions, improving representativeness and collective wisdom, thus making the whole greater than the sum of parts (blinder and morgan ; maier ). further, rajan ( ) notes that mpc would bring more minds to bear on policy setting, preserve continuity in case a member has to quit or retire, and be less subject to political pressures. maintain neutral - august reduce bps . to . bps reduce bps [ ] maintain . bps [ ] maintain neutral - october maintain . bps reduce bps [ ] maintain neutral - december maintain . bps reduce bps [ ] maintain neutral - february maintain . bps increase bps [ ] maintain neutral - april maintain . bps increase bps [ ] maintain neutral - june increase bps . to . bps maintain neutral - august increase bps . to . maintain . bps [ ] maintain neutral - october maintain . bps increase bps [ ] change to calibrated tightening - december maintain . bps maintain calibrated tightening - reduce bps . to . bps maintain . bps [ ] change to neutral - april reduce bps . to . bps maintain . bps [ ] maintain this section presents a stylized representation of a framework for monetary policy transmission and also applies this framework to india. monetary policy transmission is the process through which changes in monetary policy affect economic activity in general as well as the price level. with note: the decided rates are in bold, the minority votes are italicized, the meetings with changes in stance are underlined developments in financial systems, the world over, and growing sophistication of financial markets, most central banks use the short-term interest rate as the policy instrument for the conduct of monetary policy. monetary policy transmission is thus the process through which a change in the policy rate is transmitted first to the shortterm money market rate and then to the entire maturity spectrum of interest rates covering the money and bond markets as well as banks' deposit and lending rates. these impulses, in turn, impact consumption (private and government), investment and net exports, which affect aggregate demand and hence output and inflation. there are five channels of monetary transmission-interest rate channel; exchange rate channel; asset price channel; credit channel and expectations channel. the interest rate channel is described above. monetary transmission takes place through the exchange rate channel when changes in monetary policy impact the interest rate differential between domestic and foreign rates leading to capital flows (inflow or outflow) which in turn affects the exchange rate and hence the relative demand for exports and imports. transmission through the asset price channel occurs when changes in monetary policy influence the price of assets such as equity and real estate that lead to changes in consumption and investment. a change in prices of assets can lead to a change in consumption spending due to the associated wealth effect. for example, if interest rates fall, people may consider purchasing assets that are non-interest bearing such as real estate and equity. a rise in demand for these assets may result in higher prices, a positive wealth effect and thus higher consumption. further if equity prices rise, firms may increase investment spending. transmission through the credit channel happens if monetary policy influences the quantity of available credit. this may happen if the willingness of financial institutions to lend changes due to a change in monetary policy. further, debt obligations of businesses may also change due to a change in the interest rate. for instance, if the policy rate falls, debt obligations of firms may decrease, strengthening their balance sheets. as a result, financial institutions may be more willing to lend to businesses, thus increasing investment spending. monetary policy changes can impact public's expectations of output and inflation and accordingly, aggregate demand can be impacted via the expectations channel. for instance, expected future changes in the policy rate can impact medium-term and long-term expected interest rates through market expectations and thus affect aggregate demand. further, if inflation expectations are firmly anchored by the central bank, this would imply price stability. a stylized representation of the monetary policy transmission framework of a change in the policy rate is shown in fig. . figure depicts the monetary transmission through the interest rate channel with specific reference to india. (definitions of all variables shown in fig. are given in appendix .) this shows that a change in the policy rate (repo rate) first impacts the call money rate (weighted average call money rate-wacr) and in turn all other money market rates as well as bond market rates including the repo market, certificates of deposit (cd) and commercial paper (cp) markets, treasury bill (t-bill) market, government securities (g-sec) market and the bond market. the lending rate of banks also changes as depicted by the marginal cost of funds based lending rate (mclr). this further impacts consumption and investment decisions as well as net exports and through these, aggregate demand and ultimately the goals of monetary policy. details of the monetary transmission process are given in rbi ( c). the transmission mechanism is beset with lags. as explained in simple terms in rangarajan ( ) , there are two components of the transmission mechanism. the first is how far the signals sent out by the central bank are picked by the banks and the second is how far the signals sent out by the banking system impact the real economy. rangarajan ( ) labels the first component as "inner leg" and the second as "outer leg". to illustrate monetary transmission of the first kind, we examine the impact of a cumulative reduction in the policy repo rate by basis points between february and january . during this period, transmission to various money and bond markets ranged from basis points in the overnight call money market to basis points in the market for -year government securities to basis points in the market for -year government securities. transmission to the credit market was also modest with the -year median marginal cost of funds-based lending rate (mclr) declining by basis points during february and january . the weighted average lending rate (walr) on fresh rupee loans sanctioned by banks fell by basis points while the walr on outstanding rupee loans declined by basis points during february to december . monetary transmission increased somewhat after the introduction of the external benchmark system in october whereby most banks have linked their lending rates to the policy repo rate of the reserve bank. during october to december , the walrs of domestic banks on fresh rupee loans fell by basis points for housing loans, basis points for vehicle loans and basis points for loans to micro, small and medium enterprises (msmes). monetary transmission in various markets is depicted in figs. , and . figure shows the policy corridor with the msf rate as the ceiling and the reverse repo rate as the floor for the daily movement in the weighted average call money rate. the figure shows that the wacr moved closely in tandem with the policy rate (repo rate). figure shows that the g-sec market rates followed the movements in the policy rate. figure shows that the direction of change of mclr was more or less in synchronization with that of the repo rate. the walr for fresh rupee loans tracked the repo rate much more than the walr on outstanding loans. figure shows the % target inflation rate with the ± % tolerance band along with the headline inflation rate. this shows that the headline inflation generally stayed within the band. the average inflation rate from august to march was . % and up to december , it was . %, i.e. close to %. the average gdp growth between q : - and q : - was . % (fig. ). an interesting phenomena, world-wide is the synchronization in the movements in interest rates across the globe. table shows that mpcs in various countries have voted for a cut in their policy rate in at a time when many countries were simultaneously experiencing a slowdown. due to covid- pandemic, in early , some countries have cut the policy rate sharply. this pattern of rate cuts in up to march is almost perfectly aligned with the movements in the repo rate (policy rate) in india. these global patterns are illustrated in figs. and . figure shows that the policy rates for the brics nations moved in tandem from to . figure indicates a similar pattern amongst policy rates of us, ecb, uk and japan. we have so far discussed conventional monetary policy. as already described, monetary transmission of conventional monetary policy entails a change in the policy rate impacting financial markets from short-term interest rates to longer-term bonds and bank funding and lending rates. a change in the policy rate is thus expected to permeate through the entire spectrum of rates that further translates into affecting interest sensitive spending and thus economic activity. however, if there are problems in the monetary policy transmission mechanism or if additional monetary stimulus is required in the circumstances that the policy rate cannot be reduced further (or in addition to a change in the policy rate), then the central banks may employ unconventional monetary policy tools. unconventional monetary measures target financial variables other than the short-term interest rate such as term spreads (e.g., interest rates on risk free bonds), liquidity, credit spreads (e.g. interest rates on risky assets) and asset prices. the objective of unconventional tools is to supplement the conventional monetary policy tools especially in the easing cycle to boost economic growth. in the recent past, rbi has utilized various unconventional tools in addition to conventional monetary policy measures. to better understand the use of accommodative: interest rates stay the same or decrease; tightening: interest rates stay the same or increase: neutral: interest rates can decrease, increase or stay the same table . . large scale asset purchases (also referred to as quantitative easing) by a central bank involve purchase of long-term government securities financed by crediting reserve accounts that commercial banks hold at the central bank. this purchase would lower government bond yields and serve as a signal that the policy rate will stay at a lower level for a longer period. sellers of government bonds may, in turn, change their investment portfolios and invest in more risky assets (e.g., corporate bonds) leading to a decrease in the relevant interest rate and higher asset price and thus boost economic growth. central banks can also purchase assets from the private sector. . lending operations entail provision of liquidity to financial institutions by the central bank through the creation of new or extension of existing lending facilities. this mechanism is different from conventional lending since this is undertaken at looser or specific conditions, e.g., expanding the set of eligible collateral, extending maturity of the loan, providing funding at lower cost and channel/target lending to desired areas or activities with explicit conditions on loans. this lending increases the credit flows to the private sector and helps to restart flow of credit to credit-starved sectors. it can also lead to lower borrowing costs for the financial and real economy sectors. . forward guidance involves central banks communicating future policy intentions and commitments regarding the policy rate to influence policy expectations. forward guidance is given routinely by most central banks. its use as an unconventional tool implies that a central bank uses this to signal that it is open to undertaking extraordinary policy actions for a longer duration. forward guidance can be 'time specific' or 'state specific'. under the former, the central bank makes a commitment to keep interest rates low for a specified period. under the latter, the central bank maintains low rates until specific economic conditions are met. . the rationale of a negative interest rate is that if an interest rate is charged on the reserves that commercial banks hold at the central bank, the banks may be induced to reduce their excess reserves by increasing lending. the first three of these have been applied to india and are reported in table . these include operations twist in december and january as well as april , long-term repo operation (ltro) in february , targeted long-term repo operations (tltro) in march and april , and special refinance facilities to national bank for agriculture and rural development (nabard), small industries development bank of india (sidbi) and national housing bank (nhb) in april . the application of these unconventional monetary tools was necessitated, first by the slowdown in the indian economy in , and second, by the impact of covid- pandemic due to which economic activity and financial markets, the world over, came under severe stress. it was thus necessary for the reserve bank to employ measures to mitigate the impact of covid- , revive growth and preserve financial stability. thus the unconventional monetary policy tools supplemented the conventional monetary policy measures to stimulate growth in the economy. this paper reviews the evolution of monetary policy frameworks in india since the mid- s. it also describes the monetary policy transmission process and its limitations in terms of lags in transmission as well as the rigidities in the process. it also highlights the importance of unconventional monetary policy measures in supplementing conventional tools especially during the easing cycle. at the time of writing (april ), three and a half years have passed since the implementation of the flexible inflation targeting framework and the constitution of the monetary policy committee. with the implementation of fit, india joined the group of various developed, emerging and developing countries that have implemented inflation targeting since . the inflation target specified by the central government was % for the consumer price index (cpi) inflation for the period from august , to march , with the upper tolerance limit of % and the lower tolerance bound of %. as shown in fig. , from august through march , the headline inflation generally stayed within the tolerance band with the average inflation rate slightly less than % during this period. there were episodes of high/unusual inflation due to supply shocks (food inflation, oil prices) but these were suitably integrated in the policy decisions. the monetary policy committee has also been in existence since october . the mandate of the mpc is to set the policy repo rate while taking cognizance of the primary objective of monetary policy-to maintain price stability while keeping in mind the objective of growth-as well as the target inflation rate within the tolerance band. once the policy repo rate is set, the monetary transmission process facilitates the percolation of the change in the policy rate to all financial markets (money and bond markets) as well as the banking sector which further impacts interest sensitive spending in the economy and eventually increases aggregate demand and output growth. in practice, however, there are rigidities as well as lags in the transmission process that impede the speed and magnitude of the transmission and thus question the efficacy of monetary policy with respect to the policy repo rate. nevertheless, the external benchmarking system introduced by rbi from october , whereby all new floating rate personal or retail loans (housing, auto etc.) and floating rate loans to micro and small enterprises extended by banks were benchmarked to an external rate, strengthened the monetary transmission process with several banks benchmarking their lending rate to the policy repo rate. this requirement of an external benchmark system was further expanded to cover new floating loans to medium enterprises extended by banks with effect from april , . this is expected to further improve the transmission process. of course, the policy repo rate is not a panacea for all ills but serves well as a signaling rate. the rbi routinely brings out the statement on developmental and regulatory policies that is released simultaneously with the resolution of the mpc. rbi has also taken recourse to unconventional measures to supplement the conventional tools to boost economic growth. more recently, with the slowdown in followed by the extraordinary slump in economic activity due to covid- pandemic, rbi has been compelled to use rather innovative and unconventional tools starting in december as discussed in table . needless to say, in the unprecedented times of the global pandemic (and, in general, in periods of severe crises), a multi-pronged approach comprising monetary, fiscal and other policy measures is required to protect economic activity and minimize the negative impact of the pandemic (crisis) on economic growth. the importance of monetary-fiscal coordination is highlighted in the resolution of the monetary policy committee dated march , (available on the rbi website) that states the following: "strong fiscal measures are critical to deal with the situation." thus, in addition to monetary policy, fiscal policy has a major role in combating the economic effects of the covid- pandemic. in response to the need of the hour, the government of india has implemented various fiscal measures to provide a boost to the economy. while central banks across the globe have responded to the global pandemic with monetary and regulatory measures, various governments have reinforced the monetary measures by deploying massive fiscal measures to shield economic activity from the effect of the covid- pandemic. a few words about the workings of the mpc are also warranted. as discussed in the paper, the voting pattern of the indian mpc is comparable to international standards, reflecting the healthy diversity in the assessment of the members. the workings of the mpc are transparent with the resolution being made available soon after the end of the meetings. furthermore, each member of the committee has to submit a statement that is made available in the public domain on the th day after the meeting. thus, each member is individually accountable, making the process perhaps more stringent than that of mpcs in other countries. the governor of the bank-chairperson deputy governor of the bank, in charge of monetary policy-member one officer of the bank to be nominated by the central board-member professor, indian statistical institute (isi)-member professor pami dua, director, delhi school of economics (dse)-member; and the three external members have served on the committee since its inception and continue to serve. there have been some changes in the rbi members as follows urjit patel chaired the committee from former deputy governor attended the viral acharya, former deputy governor in charge of monetary policy attended the meetings from deputy governor attended the meetings from michael patra attended all the meetings, first as executive director till december and continues to attend meetings as deputy governor in charge of monetary policy janak raj has attended meetings since february as executive director. references bank for international settlements 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chakravarty) report on currency and finance - : fiscal-monetary co-ordination report of the expert committee to revise and strengthen the monetary policy framework (chairman: dr. urjit patel) report of the internal study group to review the working of the marginal cost of funds based lending rate system (chairman: dr. janak raj) forex market operations and liquidity management (by-janak raj, sitikantha pattanaik, indranil bhattacharya and abhilasha) report of the internal working group to review the liquidity management framework governor's statement, sixth bi-monthly monetary policy statement governor's statement, seventh bi-monthly monetary policy statement monetary policy transmission in india-recent trends and impediments (by-arghya kusum mitra and sadhan kumar chattopadhyay). reserve bank of india bulletin monetary policy report, april. mumbai. reserve bank of india. ( e) reflections on analytical issues in monetary policy: the indian economic realities publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations acknowledgements i am grateful to michael patra and janak raj, deputy governor and executive director respectively, reserve bank of india for useful and constructive suggestions. i also gratefully acknowledge help and support from hema kapur, deepika goel and neha verma, teachers in colleges of the university of delhi, who also motivated me to write in a student-friendly manner. special thanks are due to naina prasad for competent and diligent research assistance. i am grateful to the editors of the indian economic review for inviting me to contribute to the newly instituted section on policy review. earlier versions of this paper were presented as a public lecture at the delhi school of economics in march and as a keynote address at the annual conference of the indian econometric society at madurai kamaraj university in january . i am grateful to the participants of these events for their feedback. repo rate is the (fixed) interest rate at which the rbi provides overnight liquidity to banks against the collateral of government and other approved securities under the liquidity adjustment facility (laf) reverse repo rate is the (fixed) interest rate at which the rbi absorbs liquidity, on an overnight basis, from banks against the collateral of eligible government securities under the laf liquidity adjustment facility (laf) enables the rbi to modulate short-term liquidity under varied financial market conditions to ensure stable conditions in the overnight (call) money market. the laf operates through daily repo and reverse repo auctions thereby setting a corridor for the short-term interest rate consistent with policy objectives corridor is determined by the msf rate as ceiling and reverse repo rate as the floor of the corridor for the daily movement in the weighted average call money rate marginal standing facility (msf) is the facility under which scheduled commercial banks can borrow additional amount of overnight money from the rbi at a penal rate against eligible securities. banks are allowed to dip into their statutory liquidity ratio (slr) portfolio to borrow funds under this facility up to a limit decided by the rbi. this provides a safety valve against unanticipated liquidity shocks to the banking system bank rate is the standard rate at which the rbi is prepared to buy or rediscount bills of exchange or other commercial papers eligible for purchase under the reserve bank of india act, cash reserve ratio (crr) is the minimum cash balance that a scheduled commercial bank is required to maintain with the rbi as a certain percentage of its net demand and time liabilities (ndtl) relating to the second preceding fortnight. it is prescribed by rbi from time to time statutory liquidity ratio (slr) is the share of ndtl that the scheduled commercial banks are required to maintain on a daily basis in safe and liquid assets, such as unencumbered government securities and other approved securities, cash and gold open market operations (omos) are conducted by the rbi by way of sale/ purchase of government securities to/ from the market with an objective to adjust the rupee liquidity conditions in the market on a durable basis market stabilization scheme (mss) was introduced as an instrument for monetary management in april . surplus liquidity of a more enduring nature arising from large capital inflows is absorbed through sale of short-dated government securities and treasury bills. the cash so mobilized is held in a separate government account with the rbi monetary base (reserve money/m ) = currency in circulation + bankers' deposits with the rbi + 'other' deposits with the rbi m = currency with the public + demand deposits with the banking system + 'other' deposits with the rbi m = m + saving deposits of post office saving banks call money rate is the rate at which overnight money are lent and borrowed in the money market weighted average call money rate (wacr) is volume weighted average of rates at which overnight money or money at short notice (up to a period of days) are lent and borrowed in the money market. this weighted average rate can be computed for any period such as, daily, weekly, yearlyrefinance facility under monetary targeting framework was provided by rbi as an additional source of reserves. the two types of refinance facility provided to banks include export credit refinance (extended against bank's outstanding export credit eligible for refinance) and general refinance (provided to banks to tide over their temporary liquidity shortages) (excluding rrbs, payment banks and small finance banks) on the outstanding rupee loans and fresh rupee loans sanctioned by the banks. it is based on lending rates to different sectors with weights based on credit extended to different sectors money market: market for lending and borrowing of short-term funds which are highly liquid. it covers money and financial assets that are close substitutes for money including call money, repo, tri-party repo, t-bills, cash management bills, commercial paper and certificate of deposit call money market: instrument: overnight money and money at short notice (up to a period of days) is lent and borrowed without collateral. call money is liquid and can be turned into money quickly at low cost and provides an avenue for equilibrating the short-term surplus funds of lenders and the requirements of borrowers borrowers: scheduled commercial banks (excluding rrbs), co-operative banks (other than land development banks), and primary dealers (pds) lenders: same as borrowers market repo: instruments: repurchase agreement (repo) which is used for borrowing funds by selling securities with an agreement to repurchase the said securities on a mutually agreed future date at an agreed price which includes interest for the funds borrowed. government securities, cps, cds, units of debt etfs, listed corporate bonds and debentures are eligible securities for repo. repo against corporate bonds are called repo in corporate bond participants: banks, pds, mutual funds, listed corporates, all india financial institutions, any other entity approved by the rbi tri-party repo market: instrument: tri-party repo, a repo contract where a third entity (apart from the borrower and lender), called a tri-party agent, acts as an intermediary between the two parties to the repo to facilitate services like collateral selection, payment and settlement, custody and management during the life of the transaction participants scheduled commercial banks, recognized stock exchanges and clearing corporations of stock exchanges or clearing corporations authorized under pss act and any other entity regulated by rbi or sebi are eligible subject to certain criterion. all the repo market eligible entities are permitted to participate in tri-party repo market instrument: short-term debt instruments issued by the goi and sold by rbi on an auction basis. treasury bills are zero coupon securities that pay no interest, issued at a discount and redeemed at the face value at maturity. they are currently issued in three tenors, namely, days, days and days. they are also traded in the secondary market investors: any person resident of india, including firms, companies, corporate bodies, institutions and trusts along with non-resident indians and foreign investors (subject to approval by government) can invest through a competitive route certificate of deposits market: instrument: a negotiable money market instrument issued in dematerialized form or as a usance promissory note against funds deposited at a bank or other eligible financial institution for a specified time period. maturity ranges from days to years. cds can be traded in the secondary market issuers: banks and financial institutions investors: individuals, corporations, companies (including banks and pds), trusts, funds, associations and non-resident indians (but only on non-repatriable basis) commercial paper market: instrument: an unsecured money market instrument issued in the form of a promissory note. they are issued for the maturities between a minimum of days and a maximum of up to year from the date of issue (given that the credit rating of the issuer is valid in the period). cps can be traded in the secondary market issuers: corporates, pds and all india financial institutions (fis) investors: individuals, banks, other corporate bodies (registered and incorporated in india), non-resident indians, bond market: instrument: a debt instrument whereby an investor loans money to an entity (typically corporate or government) which borrows the funds for a defined period of time at a variable or fixed interest rate. bonds are used by companies, municipalities, states and sovereign governments to raise money to finance a variety of projects and activities issuers: government or corporates investors: banks, mutual funds, foreign institutional investors, provident funds, pension funds government securities market: instrument: a tradable instrument issued by the central or the state governments. it acknowledges the government's debt obligation. securities issued by state governments in india are known as state development loan (sdl). the short-term g-secs (treasury bills) have original maturities of less than year while long-term g-secs (government bonds or dated securities) have original maturity of year or more. there is an active secondary market in g-secs participants: commercial banks, pds, institutional investors like insurance companies, other banks including cooperative banks, regional rural banks, mutual funds, provident and pension funds, foreign portfolio investors (allowed with quantitative limits prescribed from time to time), and corporates instrument: debt securities issued by private and public corporations. companies issue corporate bonds to raise money for a variety of purposes, such as building a new plant, purchasing equipment, or growing the business. the stock exchanges have a dedicated debt segment in their trading platforms to facilitate the needs of retail investors. a corporate bond is generally priced on the basis of price of g-sec of comparable tenure with a spread added to it. they are also traded in secondary market participants: corporates, banks, retail investors and institutional investors including insurance companies and mutual funds, foreign investors the gazette notification of the ministry of finance dated september , notes the following. "in exercise of the powers conferred by section zb of the reserve bank of india act, act, ( of , the central government hereby constitutes the monetary policy committee of the reserve bank of india, consisting of the following, namely: key: cord- -mzv t ex authors: jackson-lee, angela; barr, neil g.; randall, glen e. title: mandating influenza vaccinations for health care workers: analysing opportunities for policy change using kingdon’s agenda setting framework date: - - journal: bmc health serv res doi: . /s - - - sha: doc_id: cord_uid: mzv t ex background: the consequences of annual influenza outbreaks are often underestimated by the general public. influenza poses a serious public health threat around the world, particularly for the most vulnerable populations. fortunately, vaccination can mitigate the negative effects of this common infectious disease. although inoculating frontline health care workers (hcws) helps minimize disease transmission, some hcws continue to resist participating in voluntary immunization programs. a potential solution to this problem is government-mandated vaccination for hcws; however, in practice, there are substantial barriers to the adoption of such policies. the purpose of this paper is to identify the likelihood of adopting a policy for mandatory immunization of hcws in ontario based on a historical review of barriers to the agenda setting process. methods: documents from secondary data sources were analysed using kingdon’s agenda setting framework of three converging streams leading to windows of opportunity for possible policy adoption. results: the problems, politics, and policies streams of kingdon’s framework have converged and diverged repeatedly over an extended period (policy windows have opened and closed several times). in each instance, a technically feasible solution was available. however, despite the evidence supporting the value of hcw immunization, alignment of the three agenda setting streams occurred for very short periods of time, during which, opposition lobby groups reacted, making the proposed solution less politically acceptable. conclusions: prior to the adoption of any new policies, issues must reach a government’s decision agenda. based on kingdon’s agenda setting framework, this only occurs when there is alignment of the problems, politics, and policies streams. understanding this process makes it easier to predict the likelihood of a policy being adopted, and ultimately implemented. such learning may be applied to policy issues in other jurisdictions. in the case of mandatory influenza vaccinations for hcws in ontario, it seems highly unlikely that a new policy will be adopted until perception of the problem’s importance is sufficient to overcome the political opposition to implementing a solution and thus, create a window of opportunity that is open long enough to support change. the consequences of annual influenza outbreaks are often underestimated by the general public. this circumstance may be due in part to a large proportion of healthy young adults experiencing only minor symptoms [ ] , which has contributed to a lack of public awareness and complacency regarding the severity of its effects on vulnerable populations such as the elderly and individuals that are immunocompromised. despite this misconception, influenza poses a serious public health threat around the world. the world health organization (who) estimates that annual influenza epidemics cause to million cases of severe illness worldwide, along with , to , annual deaths [ ] . these epidemics are also associated with overwhelmed clinics and hospitals, many of which need to account for increased staff absenteeism and productivity losses due to illness of health care workers (hcws) [ ] . the impact of annual influenza epidemics on some of the most susceptible populations, such those living with chronic conditions, is even more striking. global metaanalyses of risk factors for severe disease from pandemic influenza found that % of patients hospitalized had at least one other chronic medical condition, as did % of those admitted to intensive care units and % of fatal cases [ ] . in the united states, individuals who were or older consistently accounted for approximately % of all influenza related deaths between and [ ] . fortunately, vaccination can mitigate the negative effects of this common infectious disease. during the influenza seasons of - , the centers for disease control and prevention found that influenza vaccination helped reduce children's risk of influenza-related intensive care unit admissions by % [ ] . the use of vaccinations has also been associated with a % reduction in influenzarelated hospitalization among adults aged or over [ ] . in addition, rates of influenza infections were found to be lower in vaccinated hcws versus unvaccinated hcws [ ] and other healthy adults [ ] . however, while vaccination may reduce the risk of influenza in hcws, a recent systematic review reported the reduced risk to be less than % as compared to hcws who are not vaccinated; which suggests the need for additional solutions beyond hcw vaccinations [ ] . furthermore, recent reviews highlight the lack of clear evidence to support the benefit of vaccinating hcws [ ] to prevent the spread of influenza to elderly [ ] . within high-income countries, influenza vaccination is readily accessible and many jurisdictions have implemented publicly funded programs to cover the cost [ ] . however, public vaccination uptake has been variable [ , ] , and perhaps more importantly, some hcws continue to resist participation in vaccination programs. for example, in canada, voluntary uptake of the seasonal influenza vaccine by hcws remains below the % recommended level [ ] and varies substantially across health care organizations [ ] . other studies have reported that in some locations more than % of physicians also fail to take advantage of the annual influenza vaccination [ ] . inadequate levels of hcw immunization can place the vulnerable populations they care for at greater risk of health complications [ ] . a potential solution to this problem is governmentmandated inoculation for hcws. however, in practice, there are substantial barriers to the adoption of such policies. for instance, the attitudes of hcws in the united states toward whether to be vaccinated against influenza or not remains divided, prompting a backlash against suggestions of any mandatory policies [ ] . surveys have revealed multiple reasons why hcws disapprove of mandated vaccination. these include beliefs that the decision to be vaccinated is personal, fears of side effects, and concern that influenza vaccines are ineffective [ ] . there have also been legal obstacles to mandating vaccination as worker unions and professional associations have argued that such policies violate individual rights and freedoms [ ] . specifically, in canada, it has been argued that mandated immunization violates one's right to refuse unwanted medical treatment under section of the canadian charter of rights and freedoms [ ] . new public policies are rarely adopted based solely on supportive evidence, public opinion, or interest group lobbying; rather, they typically require a confluence of events that is difficult to predict or orchestrate. through the use of relevant frameworks, theories, or models, policy analysis can provide a greater understanding of the various processes involved and, in turn, enhance the likelihood of recognizing and seizing opportunities for new policies to be adopted [ ] . in this vein, kingdon's [ ] three process streams framework helps to explain how three elements or "streams"-problems, politics, and policiesaffect policy agenda setting dynamics. kingdon argues that, while there is some interplay among the streams, they are largely independent of one another [ ] . this framework can be used to explain how issues may make their way onto the government's decision agenda, which is a key step in the policy adoption process. the purpose of this paper is to identify the likelihood of adopting a policy for mandatory immunization of hcws in ontario based on a historical review of barriers to the agenda setting process. background information regarding the effectiveness and uptake of influenza vaccinations was gathered via narrative review, which included academic and newspaper articles, as well as government reports. subsequently, these materials were analysed using kingdon's agenda setting framework of three converging streams leading to windows of opportunity for possible policy adoption. no permissions to analyse the data used in this study were necessary or granted. the authors independently categorized historical events as falling primarily into the problems, politics, or policies stream (see table ). categories are based on kingdon's description as noted below. any discrepancies in classification were resolved through discussion. in kingdon's framework, the problems stream involves the identification of a particular social problem that has gained public or decision-maker attention and cannot be easily ignored. these problems may come to light through awareness of a change in an indicator, such as an increased infection rate, or a focusing event/crisis, such as the severe acute respiratory syndrome (sars) outbreak in . in the politics stream, the governmental agenda is formulated and the list of issues or problems to be given attention is prioritized. this stream is impacted by political events (such as changes in public opinion/national mood), and organized forces (such as a change in government due to elections). in the policies stream, experts analyse the various problems, and suggest technically feasible and politically acceptable solutions to them. generally, the three streams flow independently of one another; however, a time-limited window of opportunity may open when these streams converge (as politically acceptable solutions to prioritized problems are identified). at this point of convergence, issues are most likely to reach the government's decision agenda-where policy problems and their proposed solutions are under active discussion by government decision-makers-and thus, most likely to result in the adoption of a new policy. policy windows can also close rapidly. this tends to occur when: problems, politics, and policies are not adequately linked together; initiatives that are implemented lead to either failure or success; indicators of severity lessen; other critical items push the issue off the agenda; there has been movement through an "issue attention cycle" (i.e., a gradual decline of interest in the condition). using kingdon's agenda setting framework (three process streams that lead to windows of opportunity when they converge) the objective of this paper is to analyse the likelihood of government adopting a mandatory vaccination policy for hcws in ontario. ontario endured through a difficult - influenza season. hospital emergency departments experienced serious overcrowding [ ] , which resulted in less access to health services for patients seeking critical care. this unfavourable set of circumstances was a focusing event/crisis (problems stream) that resulted in heightened media attention and highlighted the need for government action (politics stream) [ ] . during this period, an effective influenza vaccine that had been used as part of a public program in other jurisdictions was available, suggesting that mandatory vaccination was a technically viable and politically acceptable solution (policies stream). in july it was announced that ontario would be the first province in the country to offer free influenza vaccinations to all citizens for the upcoming season to relieve the aforementioned pressure on emergency departments [ ] . ontario's universal influenza immunization program (uiip) is offered annually through the ministry of health and long-term care (mohltc), with the goal of reducing the number of influenza cases and the associated negative impact on the health care system. all individuals who live, work, or attend school in the province, and are months of age or older, are covered by the program [ ] . in recent years, uiip has increased the accessibility of vaccinations by making them available at a variety of locations such as employer-sponsored clinics and pharmacies [ ] . by immunizing a critical mass of the general population, as well as hcws, it was expected that there would be a dramatic reduction to the death toll as well as the social and economic costs associated with annual influenza outbreaks. studies have shown that since introducing uiip in ontario, the number of reported cases of influenza has [ ] . despite broad public acceptance and substantial participation in the voluntary immunization program, pockets of hcw resistance persisted (politics stream), and outbreaks in long-term care facilities and hospitals continued to occur, resulting in preventable illness and death [ ] . as a consequence, ontario's mohltc attempted to promote voluntary vaccination of hcws by requiring health care facilities to report vaccination rates [ ] . by winter , uiip was in its second year and the issue of mandatory vaccination of hcws was beginning to become controversial and disputed in the courts [ ] . when a health care system in hamilton instituted a mandatory vaccination policy during outbreaks, or work suspension for non-compliance, staff members refused inoculation and were removed from duty without pay. this led to arbitration where the union presented its case as forced medical treatment. the arbitrator agreed with the union position citing that the policy was not supported by regulatory or statutory authority. in the decision, the arbitration board declared a violation of section of the charter of rights and freedoms, which assures security of the person. mandatory influenza vaccination, the arbitrator decided, was a forced medical act and therefore, contravened the charter (st. peter's health system v. cupe local , ) [ ] . around the same time, a paramedic working in ontario was making a constitutional challenge against the addition of annual influenza immunization to the ontario ambulance act (north bay hospital v. cupe local , ) [ ] . his challenge also argued that mandatory immunization violated section of the charter. pressure from the unions resulted in an amendment to the ambulance act in , replacing mandatory vaccination with a requirement for influenza education. these cases/ political events represented a coordinated force in opposition to the mandatory vaccination initiative (politics stream). as a result, the problems, politics and policies streams were no longer aligned, closing the window of opportunity for policy change. after the sars outbreak, significant changes came to the public health system in canada, bolstering pandemic preparedness and the ability to monitor emerging disease [ ] . when an arbitration board faced a union challenging mandatory influenza vaccination, this time in british columbia, the arbitrator sided with the employer noting a requirement for general immunization in the union collective agreement. in this case the employee had choices: vaccination, anti-viral medication, or to be off work without pay. the arbitrator ruled that the choices, which were not dealt with in the st. peter`s decision, meant there was no violation of the charter under section . an important note in the decision summary was the rationale that preventing the spread of influenza to vulnerable populations is clear and was agreed upon by both the employer and the union, which allowed for a realignment of the policies stream with problems and politics streams. may saw the first wave of the h n pandemic influenza strain. by july , the public health agency of canada reported it still did not have a plan in place to manage hcws who refused the seasonal influenza vaccine [ ] . the seasonal vaccine did not include protection from the novel h n strain and thus, worldwide production of a vaccine was implemented. stories of production delays, low vaccine supplies, and rationing caused long lines at vaccination clinics and resulted in public anxiety [ ] . even after this pandemic experience, uptake of the vaccine by hcws the following season remained low [ ] . the h n pandemic could have resulted in the opening of a new policy window, but with the relatively mild nature of the h n strain, the mandatory vaccination issue did not gain adequate or sustained public attention (politics stream), closing another window of opportunity. a long-awaited economic appraisal of ontario's uiip was published in [ ] . based on a measure of qualityadjusted life years, the study concluded that uiip was cost-effective and might be considered for adoption in other provinces and countries with similar populations, health care models, and influenza rates. this evidence bolstered ontario's influenza vaccination program and may have served as a catalyst to support further expansion of the program to include mandatory hcw vaccination, however, it was not sufficient to make mandatory vaccination a politically acceptable option. in other jurisdictions, most notably the us, consideration of mandatory vaccination for hcws was gaining momentum. a large us health care employer had published their successful program requiring influenza immunization for employment [ ] . in canada, the province of british columbia initiated a task force in to investigate and recommend plans for mandatory immunization programs [ ] . the task force visited nine us sites with programs in place before making recommendations in to the provincial government. pressure on the ontario government to act intensified as both the evidence and prominent organizations supported mandatory hcw vaccination. for instance, the influenza surveillance protocol for ontario hospitals was revised and included the national advisory committee on immunization statement that "… refusal of health care workers who have direct patient contact to be immunized against influenza implies failure in their duty of care to their patients [ ] ." the association of medical microbiology and infectious disease also presented a position paper supporting mandatory immunization acknowledging that all efforts at voluntary programs had failed [ ] . public health ontario, the canadian medical association journal, and the american academy of pediatrics joined in the call for mandatory immunization [ ] . in july , the british columbia government announced a new policy that would require either influenza immunization or the wearing of a surgical mask for all hcws during influenza season when in direct patient contact. by october the health sciences association of british columbia union had filed a grievance citing privacy issues relating to the freedom of information and privacy act (fipa) and violations of the human rights code, the charter of rights and freedoms, and their collective union agreement [ ] . facing an election the following spring, the incumbent government did not repeal the policy but announced that it would wait for the outcome of the arbitration hearing and that workers who did not comply in the - season would not face disciplinary action [ ] . the government revised and softened the policy in july before going to arbitration [ ] . the decision was released in october and the arbitrator had sided with the employer. it was determined the policy aligned with fipa and there were no violations to the union agreement, the charter of rights and freedoms or the human rights code. this court ruling provided the ontario government, and health care organizations, with greater assurances that movement in the direction of mandatory vaccination for hcws could be a viable policy option subject to hcws being given some limited alternative to vaccination. despite this, the ontario government did not step forward with a consistent policy for the province. in an effort to fill this vacuum, numerous high profile ontario hospitals announced plans to implement a mandatory "vaccinate or mask" policy that would require hcws who chose not to get vaccinated to wear a mask during the influenza season [ ] . even though the canadian nurses' association supported mandatory influenza vaccinations for hcws, the ontario nurses' association filed a grievance in opposition to the "vaccinate or mask" policy adopted by several ontario hospitals. following several weeks of testimony, the arbitrator found that the policy was unreasonable (policies stream) [ ] . concerns identified included that wearing a mask revealed personal health information about the hcws decision not to vaccinate, masks were not effective, and the policy was designed to coerce hcws [ ] . this ruling leaves ontario hospitals with no clear policy direction for the foreseeable future. by analysing the progress of mandatory hcw immunization through the lens of kingdon's framework, the separate streams of problems, politics, and policies can be seen to converge and diverge repeatedly over an extended period (policy windows have opened and closed several times). since the implementation of uiip in ontario, there have been several potential opportunities to pursue a mandatory hcw vaccination policy. in each instance a technically feasible solution was available (policies stream). however, despite the policy's importanceprotecting the public-the problem's prominence (problems stream) and the political environment (politics stream) only aligned with the policies stream for a very short period of time. during these periods there was inadequate support for the issue to remain on the government's decision agenda long enough to result in the adoption of a new policy. in part, this seems to have been due to other problems gaining prominence and displacing the issue of mandatory vaccination of hcws from a priority position. in addition, each time this issue gained prominence, opposition lobby groups reacted, making the proposed solution less politically acceptable. although the call for mandatory hcw vaccination has withstood some legal challenges-including to the charter of rights and freedoms, the freedom of information and privacy act, and the human rights code-there remains small but committed groups who continue to oppose such a policy. as a result, it seems highly unlikely that a mandatory hcw vaccination policy will be adopted by the ontario government until perception of the problem's importance is sufficient to overcome the political opposition to implementing a solution. abbreviations fipa: freedom of information and privacy act; hcws: health care workers; sars: severe acute respiratory syndrome; uiip: universal influenza immunization program; who: world health organization acknowledgments not applicable. not applicable. the datasets during and/or analysed during the current study available from the corresponding author on reasonable request. authors' contributions aj was responsible for the conception and design, data collection, analysis of data, interpretation of data and drafting of manuscript. nb was responsible for revisions to design, analysis of data, interpretation of data and revisions to influenza vaccination for healthcare workers who care for people aged or older living in long-term care institutions influenza (seasonal) background paper on influenza vaccines and immunization key facts about seasonal flu vaccine effectiveness of influenza vaccine for preventing laboratory-confirmed influenza hospitalizations in adults, - influenza season incidence of influenza in healthy adults and healthcare workers: a systematic review and meta-analysis vaccines for preventing influenza in healthy adults effectiveness of seasonal influenza vaccination in healthcare workers: a systematic review macroepidemiology of influenza vaccination study group. the macroepidemiology of influenza vaccination in countries association of state laws and healthcare workers' influenza vaccination rates influenza vaccination uptake among victorian healthcare workers: evaluating the success of a statewide program statement on influenza vaccination for the - season. ottawa, on: public health agency of canada seasonal influenza vaccination campaigns for health care personnel: systematic review mandatory influenza vaccination of health care workers: translating policy to practice policies and practices for improving influenza immunization rates among healthcare workers influenza vaccination for health care workers: towards a workable and effective standard social determinants of health and health equity policy research: exploring the use, misuse, and nonuse of policy analysis theory agendas, alternatives, and public policies free flu shots for ontario residents universal influenza immunization program (uiip) economic appraisal of ontario's universal influenza immunization program: a cost-utility analysis benefits of a universal influenza immunization program: more than the reduction in the use of antibiotics ammi canada position paper: mandatory immunization of health care workers ontario ministry of health and long-term care. seasonal influenza / : ontario's blueprint for action the canadian bar association. pandemics and the workplace: a resource for lawyers health agency won't force flu shots on health-care workers the calm face at the centre of canada's immunization campaign in re the matter of an arbitration under the b.c. labour relations code on: public health agency of canada flu shot should be mandatory, journal says health-care workers cheer softened stand on flu shots re: healthcare worker influenza vaccination policy -vaccine required date and vaccine required period union says ontario nurses can't be forced to wear masks in flu season manuscript. gr was responsible for revisions to design, analysis of data, interpretation of data and revisions to manuscript. all authors read and approved the final manuscript. the authors declare that they have no competing interests. not applicable.ethics approval and consent to participate not applicable. submit your next manuscript to biomed central and we will help you at every step: key: cord- -hc jwzn authors: escontrela, alejandro; yu, george; xu, peng; iscen, atil; tan, jie title: zero-shot terrain generalization for visual locomotion policies date: - - journal: nan doi: nan sha: doc_id: cord_uid: hc jwzn legged robots have unparalleled mobility on unstructured terrains. however, it remains an open challenge to design locomotion controllers that can operate in a large variety of environments. in this paper, we address this challenge of automatically learning locomotion controllers that can generalize to a diverse collection of terrains often encountered in the real world. we frame this challenge as a multi-task reinforcement learning problem and define each task as a type of terrain that the robot needs to traverse. we propose an end-to-end learning approach that makes direct use of the raw exteroceptive inputs gathered from a simulated d lidar sensor, thus circumventing the need for ground-truth heightmaps or preprocessing of perception information. as a result, the learned controller demonstrates excellent zero-shot generalization capabilities and can navigate different environments, including stairs, rugged land, cluttered offices, and indoor spaces with humans. the ability to traverse unstructured terrains make legged robots an appealing solution to a wide variety of tasks, including disaster relief, last-mile delivery, industrial inspection, and planetary exploration [ ] , [ ] . to deploy robots in these settings successfully, we must design controllers that work well across many different terrains. due to the diversity of environments that a legged robot can operate in, hand-engineering such a controller presents unique challenges. deep reinforcement learning (drl) has proven itself capable of automatically acquiring control policies to accomplish a large variety of challenging locomotion tasks. however, many of these approaches learn control policies that succeed in a single type of terrain with limited variations. this approach limits the robot's ability to generalize to new or unseen environments, which is a crucial feature of a useful locomotion controller. in this paper, we develop an end-to-end reinforcement learning system that enables legged robots to traverse a large variety of terrains. to facilitate learning generalizable policies, we make two purposeful design decisions for our learning system. first, we formulate the problem as a multi-task partially observable markov decision problem and show that the robot learns a robust policy that works well across a wide variety of tasks (terrains). to this end, we develop a novel procedural terrain generation method, which can efficiently generate a large variety of terrains for training. second, we design an end-to-end neural network architecture that can handle both perception and locomotion. we call this parameterization a visual-locomotion policy. while many google brain robotics, {georgeyu,pengxu,atil,jietan}@google.com georgia institute of technology, aescontrela@gatech.edu work performed while alejandro was an intern at google brain. prior works in the legged robot literature focused on blind walking, which does not involve exteroceptive sensors (e.g., camera, lidar), we find that exteroceptive perception is essential for robots to navigate in diverse environments. our end-to-end visual-locomotion policy takes both exteroceptive (a lidar scan) and proprioceptive information of the robot and outputs low-level motor commands. we embed the policies modulating trajectory generator (pmtg) [ ] framework into our policy architecture to generate cyclic and smooth actuation patterns, and to facilitate the learning of robust locomotion policies. we evaluate our learning system using a high-fidelity physics simulator [ ] and visually-realistic indoor scans [ ] ( figure ). we test the learned policy in thirteen different and realistic simulation environments (five training and eight testing). our system learns highly generalizable locomotion policies, which demonstrate zero-shot generalization to unseen testing environments. we also show that our visuallocomotion policy's parameterization is key to generalization and yields far better performance than commonly-used reactive policies. this paper's main contributions include an end-to-end visual-locomotion policy parameterization and a complete multi-task learning system, with which a quadruped robot learns a single locomotion policy that can traverse a diverse set of terrains. locomotion controllers can be developed using trajectory optimization [ ] , whole-body control [ ] , model predictive control [ ] , and state-machines [ ] . while the controllers developed by these techniques can generalize to a certain degree, expertise and manual tuning are often needed to adapt them to different terrains. in contrast, deep reinforcement learning [ ] can automatically learn agile and robust locomotion skills [ ] , [ ] , [ ] , [ ] . prior work in rl has learned policies that are specific for a single environment [ ] , or generalize to variations of a single type of terrain [ ] , [ ] , [ ] . recently, lee et. al. [ ] combined various techniques, such as actu-atornet [ ] , pmtg [ ] , curriculum learning and "learning by cheating" [ ] , which successfully performed zero-shot transfer from simulation to many challenging terrains in the real world. while our paper's high-level goal is similar to this prior work, our approach incorporates exteroceptive sensors that enable the robot to navigate in cluttered indoor environments where blind walking may have difficulties. multi-task reinforcement learning (mtrl) [ ] is a promising approach to train generalizable policies that can accomplish a wide variety of tasks. hessel et. al. [ ] learned a single policy that achieves state-of-the-art performance on atari games. yu et al. [ ] evaluated the performance of various rl algorithms on a grasping and manipulation benchmark and demonstrated that a single control policy is capable of completing a variety of complex robotic manipulation tasks. in this paper, we apply mtrl to develop a learning system for locomotion that enables legged robots to navigate in a large variety of environments. in this work, we frame legged locomotion as a multitask reinforcement learning problem (mtrl) and define each task as a type of terrain that the legged robot (agent) must traverse. to learn generalizable locomotion policies, our learning system consists of a procedural terrain generator that can efficiently generate diverse training environments, and an end-to-end visual-locomotion policy architecture that directly maps the robot's exteroceptive and proprioceptive observations to motor commands. given a distribution of tasks m, each task m i ∈ m is a partially observable markov decision process (pomdp). a pomdp is tuple, is the transition probability function, and r : s × a → r is the reward function. during training, the agent is presented with randomly sampled tasks m i ∈ m (section iii-b). the solution of the multi-task pomdp is a stochastic policy π : o × a → r + that maximizes the expected accumulated reward over the episode length t . our problem is partially observable because of the limited sensors onboard the robot . the robot is equipped with a lidar sensor to perceive the distances d to the surrounding environment. proprioceptive information comes from a simulated imu sensor, which includes measurement of the roll φ, pitch θ, and the angular velocity of the torso β ω = (φ,θ,ψ), and from motor encoders that measure the robot's joint angles q. the complete observation at timestep t is ] are the sensor observations, g d and g h are the distance and relative heading to the target, a t− is the action at the last timestep, and s t tg are the parameters of the trajectory generator (section iii-c). unlike some prior work in mtrl, where the task id is part of the observation [ ] , [ ] , we purposefully choose not to leverage such information, because identifying tasks automatically in the real world is challenging. instead, we would like to train a policy that can rely on its own perception input and demonstrates zero-shot generalization to new tasks, without knowing the task id explicitly. in section iv, we demonstrate our perception is crucial in learning policies which generalize well to new tasks. the output action a t of the policy specifies the desired joint angles, which are tracked by pd controllers by the simulated robot. we employ a simple reward function, which encourages the agent to navigate to a target location g = (x g , y g , z g ) (the red ball in figure ): where g d,t is the euclidean distance from the robot to the target location at timestep t, and ∆t is the timestep duration. this reward can be interpreted as the speed that the robot is moving towards the target location. once the robot's center of mass is within a threshold distance to the target location, the task is complete. we develop a procedural terrain generator to generate diverse and challenging terrains that provide the robot with a large quantity of rich training data. the environment is composed of m×n pillars, each pillar having cross-sectional dimensions of l, w, and height h. we denote h = {h i,j } ∈ obstacles number of obstacles: n obstacle height: h r m×n as the height field for all the pillars. during training, we select a task m i and adjust each pillar's heights to reflect the chosen task. each task is a set of randomly generated terrains that belongs to the same type (e.g., flat, stairs). each type of terrain is described by a parameter vector φ i , which provides the lower and upper bounds for the random sampling. the terrain generator constructs the heightfield h from the given parameter vector φ. for example, the parameter vector φ for the rugged terrain task (fig. b) includes the minimum and maximum values of the heightfield; for the stairs task, the parameter vector defines the height and length of each step. table i summarizes the parameters and terrain generator for selected terrain types. with this simple parameterization, we can generate over ten different types of terrains that a robot may encounter in the real world. our procedural terrain generation algorithm provides a rich set of training data essential for generalizable policies to emerge. exteroceptive perception plays a crucial role when legged robots need to navigate different terrains and environments with obstacles and humans [ ] , [ ] . as such, we aim to incorporate perception into our policy architecture such that information from the robot's surroundings can modulate locomotion. additionally, the policy's low-level actuation commands need to be smooth and realizable on the physical robot. to this end, we seek to restrict the search space of possible gaits to be cyclic and smooth while still expressive enough so that the perception can modulate locomotion sufficiently to work on different terrains. in our visual-locomotion policy architecture (fig. ) , we use two separate neural network encoders to process the proprioceptive and exteroceptive inputs. the upper branch of fig. a processes the lidar input, while the lower branch takes care of proprioceptive information. the learned lower-dimensional features are concatenated with the target information before being passed to the policy's locomotion component. we chose to use policies modulating trajectory generators (pmtg) [ ] as our locomotion component architecture (fig. b) . pmtg encourages the policy to learn smooth and cyclic locomotion behaviors. pmtg outputs a desired trajectory for the legs that is modulated by a learned policy π θ (·): the policy observes the state of the trajectory generator (tg), s tg , and the robot's observation s t , then outputs parameters of the tg, p tg , including gait frequency, swing height, and stride length, and a residual action term µ f b . the final output action of our visual-locomotion policy is the combination of the trajectory generator and the residual action: a t = µ tg + µ f b . please refer to the original paper [ ] for more details. as detailed in [ ] , our visual-locomotion policy architecture achieves a separation of concerns between the basic locomotion skills and terrain perception, which enables the robot to adapt its smooth locomotion behaviors according to its surrounding environments. we design experiments to validate the proposed system's ability to learn a visual locomotion policy that generalizes well to terrains not encountered during training. in particular, we would like to answer the following two questions: • can our system learn visual locomotion policies that demonstrate zero-shot generalization to new terrains? • can our policy architecture effectively use lidar input and pmtg parameterization to improve the generalization performance over unseen terrains? to answer the above questions, we evaluate our system using a simulated unitree laikago quadruped robot [ ] , (a) visual-locomotion policy architecture. (b) the locomotion component using pmtg [ ] for smooth and cyclic actuation patterns. which weighs approximately kg and is actuated by motors. we simulate the onboard velodyne vlp- (puck) lidar sensor, which provides the perception of the surrounding environment (see figure b) . the lidar measures the distance from the surrounding obstacles and terrain to the robot. this sensor supports channels, a • horizontal field of view, and a • vertical field of view. we add gaussian noise to the ground-truth distance readings in simulation to mimic the real-world noise model. the d lidar scan matrix d is normalized to range [ , ] and flattened to a vector d. our policy computes joint target positions (a t ), which are converted to target joint torques by a pd controller running at khz. rigid body dynamics and contacts are also simulated at khz. in other words, the position and velocity (provided by pybullet [ ] ) and the desired torque (provided by the pd controller) are sent to the actuator model every ms. the actuator model then computes internal µs steps and provides the effective output torque of the actuator, which is then used by pybullet to compute joint accelerations. the simulation environment is configured to use an action repeat of steps, which means that our policy computes a new action a t and receive a state s t every ms ( hz). we train the visual-locomotion policy using the mtrl formulation with simulated environments randomly generated using our procedural task generation method (section iii-b). we choose a distributed version of the proximal policy optimization (ppo) [ ] in tf-agents [ ] for training. we use a -layer fully-connected neural network of dimensions ( , ) to parameterize the value function and another network of dimensions ( , ) to parameterize the policy. the policy outputs the parameters of a multivariate gaussian distribution, which we sample actions from during training. we use a greedy policy during evaluation by executing the mean of the multivariate gaussian distribution provided by the policy network. the dimensions of the exteroceptive and proprioceptive input encoders are both ( , , ), respectively. we use the relu activation function for all layers in both networks [ ] . the advantages are estimated using generalized advantage estimation [ ] . we then evaluate the trained policies on a suite of testing environments not encountered during training. figure illustrates a subset of these testing environments. these high-fidelity simulated environments are created in pybullet physics engine [ ] with gibson scenes [ ] . a policy's ability to successfully navigate across a given terrain is measured using the task completion rate, tcr, which measures how close the agent gets to the target relative to its starting position: where g d,t is the final euclidean distance between the robot and the target when the robot falls or completes the task, and g d, is the distance at the beginning of the episode. a task completion rate of indicates successful navigation to the target, whereas tcr close to zero means that the robot cannot navigate across the terrain. table ii shows the generalization performance of our visual-locomotion policy trained on different types of terrains (rows) and tested in unseen environments (columns), including a maze (maze), a steep and rugged mountain (mountain), two indoor scenarios (office and office ), an office space with moving humans (dynamic env), a forest scene with rugged terrain and obstacles (forest), a winding path with a cliff on both sides (cliff), and a randomlygenerated continuous mesh (continuous). policies trained on a single type of terrain achieve a low task completion rate in the testing environments due to a lack of diverse training data. in contrast, our approach achieves much higher generalization performance. for instance, our method on average achieves a task completion rate of % on the mountain task, while policies trained in a single type of terrain only achieve % at best (see figure for a snapshot of our policy navigating up the rugged mountain trail). these results indicate that our mtrl formulation using procedural task generation, and visual-locomotion policy architecture, results in superior generalization performance. the policy we perform three ablation studies to understand the importance of each design decision in our system. table iii summarizes their impacts on the resulting generalization performance of the policy. a) pmtg: we replace the locomotion component of the visual-locomotion policy with a reactive policy that does not have a trajectory generator. our pmtg-parameterized visual-locomotion policy performs %- % better than a pure reactive locomotion component. we find that pmtg produces smoother actions and leads to improved zero-shot generalization to new terrains. b) exteroceptive input: we remove the lidar input from the visual-locomotion policy. observing table iii , it is clear that the exteroceptive information plays a critical role in learning generalizable locomotion policies that can adapt to a wide variety of terrains. this finding agrees with results from the field of experimental psychology, which establish the importance of exteroceptive observations in guiding foot placement when navigating over complex terrains [ ] , [ ] . figure visualizes the trajectory produced by our visual locomotion policy in a terrain with obstacles. when walking over flat terrain, the robot's foot height is constant and cyclic, only varying when turning to avoid obstacles. in contrast, on rugged terrain (figure ), the robot carefully places its feet to adapt to the geometry of the terrain to maintain balance. this careful foot placement is essential for challenging terrains and requires a visual feedback loop, which our learning system can provide. c) mtrl training scheme: our system generates a new random locomotion task at each episode for all the distributed workers. this ensures a steady stream of rich training data to the agent. in this study, we lower the variety of tasks supplied in a single training step by proving tasks sequentially. that is, the agent learns one task for a fixed number of training steps before switching the task. the policy trained in a sequential fashion performs poorly due to catastrophic forgetting [ ] . these ablation studies confirm the importance of each component of our system, including the exteroceptive input and pmtg used in the visual-locomotion policy architecture, as well as our multi-task pomdp training formulation. by fig. . visualization of trajectory generated by our method in a rugged terrain. foot z positions for the left hind, right hind, left forward, and right forward feet are shown. the rugged terrain requires that the robot carefully place its feet to maintain balance. combining these components, our system can learn locomotion policies that work on various terrains and demonstrate zero-shot generalization to new environments. we introduce a learning system that enables legged robots to traverse various environments and demonstrates zero-shot generalization to new terrains. our system consists of a novel multi-task reinforcement learning formulation of the locomotion problem, a visual locomotion policy architecture that encourages smooth actions and incorporates perception to modulate locomotion, and a novel procedural terrain generation algorithm that provides the agent with rich training data from a variety of simulated terrains. our results on a suite of simulated environments show that treating legged locomotion as a multi-task pomdp leads to increased generalization performance. additionally, we show that providing the policy with a strong prior over the space of gaits further enhances its ability to generalize to unseen terrains. in future work, we plan to evaluate our work on a real-world robot. real-time motion planning in unknown environments for legged robotic planetary exploration advances in real-world applications for legged robots policies modulating trajectory generators pybullet, a python module for physics simulation for games, robotics and machine learning gibson env: real-world perception for embodied agents gait and trajectory optimization for legged systems through phase-based endeffector parameterization stabilizing series-elastic point-foot bipeds using whole-body operational space control feedback mpc for torque-controlled legged robots mit cheetah : design and control of a robust, dynamic quadruped robot reinforcement learning: an introduction sim-to-real: learning agile locomotion for quadruped robots learning to walk via deep reinforcement learning learning agile and dynamic motor skills for legged robots learning quadrupedal locomotion over challenging terrain learning to walk in the real world with minimal human effort emergence of locomotion behaviours in rich environments deeploco: dynamic locomotion skills using hierarchical deep reinforcement learning deepgait: planning and control of quadrupedal gaits using deep reinforcement learning learning by cheating multitask learning: a knowledge-based source of inductive bias multi-task deep reinforcement learning with popart meta-world: a benchmark and evaluation for multi-task and meta reinforcement learning multi-task reinforcement learning without interference gaze and the control of foot placement when walking in natural terrain visual control of foot placement when walking over complex terrain laikago: let's challenge new possibilities proximal policy optimization algorithms tf-agents: a library for reinforcement learning in tensorflow what matters in on-policy reinforcement learning? a large-scale empirical study highdimensional continuous control using generalized advantage estimation catastrophic interference in connectionist networks: the sequential learning problem key: cord- -k ng nl authors: hoekman, lieke michaela; smits, marlou marriet vera; koolman, xander title: the dutch covid- approach: regional differences in a small country.: the dutch covid- approach. date: - - journal: health policy technol doi: . /j.hlpt. . . sha: doc_id: cord_uid: k ng nl objectives: this paper describes the first months of the covid- pandemic in the netherlands, including policies to reduce the health-related and economic consequences. the netherlands started with containment yet shifted to mitigation when a ‘mild’ lockdown was implemented. the initial focus was to obtain herd immunity while preventing intensive care units from getting overwhelmed. methods: an in-depth analysis of available national and international covid- data sources was conducted. due to regional variation in covid- hospitalization rates, this paper focuses on three distinct regions; the initial epicenter; the most northern provinces which – contrary to national policy – decided not to switch to mitigation; and the bible belt, as congregations of religious groups were initially excluded from the ban on group formation. results: on august (th), , covid- deaths were reported with excess mortality rates about % higher. as a result of the pandemic, the economy took a severe hit and is predicted to reduce by . % compared to prognosis. the hospitalization rates in the northern regions are over % lower as compared to the rest of the country ( vs per , inhabitants, respectively). differences between the bible belt and the rest of the country were hardly detectable. conclusion: the dutch have shown a way to effectively slow down transmission while allowing more personal and economic freedom than most other countries. furthermore, the regional differences suggest that containment with testing and tracing reduced the virus dissemination. the results should be interpreted with caution, due to the descriptive nature of this evaluation. the covid- pandemic reached the netherlands on february th , , when the first patient tested positive for the virus. the country has taken a liberal policy course, with an early shift from containment to mitigation on march th . a comparatively mild lockdown was implemented with much individual freedom and responsibility, in contrast with other neighbouring countries where complete restriction on movement was quickly implemented by the government ( , ). irrespective of the mild measures, the economy took a severe hit. the government therefore quickly adopted several economic measures. regional variation was initially due to the first cases popping up in the south of the country and community transmission was quickly observed in the two most southern provinces ( ) . soon, more cases started to arise throughout the rest of the country. to prevent further spread of the virus, initial containment policies were strengthened by lockdown measures. as the capacity for testing and tracing was quickly pressured in the southern provinces, the policy switched from containment to mitigation aiming to prevent overwhelming intensive care units (icus). the mitigation policy was motivated by the aim to achieve herd immunity in the population ( ) . however, due to the organisation of the health system, many decision-making powers are decentralised which led to regional policy differences. this allowed tree provinces to object to this change in strategy and continued with their containment policy of testing and tracing, in effect following the world health organization"s guidance ( ). even within the small and interconnected country, the number of infected people -indicated by hospitalization ratescontinued to vary markedly between regions ( ) . the initial high infection rate in the two southern provinces is likely related to the locally celebrated carnival in the week before the first confirmed case. besides, many early detected cases were traced back to epicentres in other european countries ( ) . due to school holiday regulations, many families in the north enjoyed their spring break a week before those in the south, minimizing exposure to spreading events during their holidays. while these explanations may have contributed to the initial regional variation in cases of the virus, policy differences likely played a role in the subsequent spread throughout the country. a better understanding of the impact of the country"s approach on the spread of the virus requires a nation-wide description of covid- trends, the government"s approach of policies regarding citizens" health, the health system, and the economy. data on covid- patients is collected similarly in the same health system, which offers a unique opportunity to compare variation in covid- health data, keeping many external factors constant. besides, from an international perspective, the netherlands is a homogenous country in terms of culture, income, and education. however, regional authorities remained a certain degree of decision-making power which led to different regional policies, that opposed national policy. this makes the netherlands a nearideal country to study the effects of different covid- approaches. this paper aims to describe the health and economic impact of the pandemic and the policies introduced to alleviate them during of the first half year of the pandemic in the netherlands. this is done first by providing a short description of the dutch health system after which the nation-wide covid- data is presented. second, elaboration on the government"s responses and the nation-wide policy roadmapboth on controlling the virus and protecting the economyis presented. third, the differences in regional policy implications are clarified followed by the differences in hospitalization rates in these discussed regions. to understand these differences, aggregate data on hospitalization rates for four specific regions is compared. last, concluding remarks are given on the state of covid- in the netherlands. here, policy implications and suggestions for further in-depth research are made. the netherlands is organized in twelve provinces, municipal health service (ggd) regions, and municipalities ( ). with . million people, it is a small and dense country ( individuals/km ) compared to the average of organisation for economic co-operation and development (oecd) countries ( individuals/km ) ( ). within-country density differences can be observed between the western megalopolis, the randstad, which has the highest density especially in some major cities, and the rural countryside ( ). concerning health outcomes, avoidable mortality is lower ( versus per , individuals) and life expectancy at birth is a bit higher than the oecd average ( . versus . ) ( ). the dutch spend about . % of their gross domestic product (gdp) on healthcare and have . practising doctors and . practising nurses per , individuals (an average of . and . for oecd countries, respectively). compared to international standards, the dutch have a stringer focus on primary and long-term care, where expenditure on the latter is the highest in the european union ( ) . even though the netherlands hascompared to european averagesa low number of acute beds per person ( versus per , ), access to health care seems to be sufficient, since a low number of unmet needs is reported. moreover, no significant shortages or oversupply of healthcare professionals and infrastructure are indicated ( ). the roots of the dutch health system lay in the bismarckian tradition of social health insurance, with both private and public stakeholders. the system is partly characterized by regulated competition in which it is up to citizens, private insurance companies, and private care providers -where the last two can negotiate on the price and volume of the delivered care -to define the healthcare market. although private players play a significant role in the dutch system, it is ultimately the dutch government"s responsibility -i.e. of the ministry of health, welfare and sport -to make sure that healthcare is accessible, affordable and of good quality ( ). besides, other public health services such as prevention, vaccination, and screening are the responsibility of governmentowned institutions. a major player in the organisation of public health is the national institute for public health and environment (rivm) which has an advising role to the government on environmental issues and policy support in several public health areas. as a part of public health, the institute is also the central referral point when it comes to infectious diseases, which increased the institute"s importance during the covid- pandemic. the executive responsibility of public health services is covered by the regional ggds. as such, the ggds were responsible for the organization of testing and tracing of possibly infected individuals during the pandemic. data regarding covid- is collected by the ggds, who distribute the regionally gathered information to the rivm. data is updated and presented daily by rivm including retrospective changes when needed e.g. due to delay in reported information. in these official reports, among other things, the number of reported infected, hospitalized, and deceased patients were presented. on august th , , the total number of people tested positive for the virus rose to , , leading to , confirmed covid- deaths ( ) . the netherlands handles a strict definition of covid- reported deaths, as only those who tested positive for the virus were included in the total number of deceased people ( ) . data on covid- reported deaths and hospitalization rates are presented in figure , showing the peak of the epidemic around april th . to better understand the mechanisms of the virus, data on the proportion of reported covid- deaths among risk groups is an important indicator. when comparing the gender aspect, women made up to . % of the total number of positively tested people, yet surprisingly men made up to . % of those hospitalized and . % of deaths. these numbers suggest men are more severely impacted by the disease once infected, yet epidemiological research is required to confirm this hypothesis. furthermore, most deceased patients were old, with . % being years or older ( ) . therefore, the central bureau of statistics (cbs) investigated the effect of covid- in long-term care facilities such as nursing homes. they reported , additional deathsa % increase -in the period between march th and may th compared to previous weeks, controlled for seasonal trends ( ) . for those younger than years old, the two important risk groups are cardiovascular disease and diabetes, with . % and . % of covid- deaths, respectively ( ) . post-mortem covid- tests were not performed, yet general practitioners (gps) were asked to keep track of suspected virus-related deaths. on april th , already possibly related cases were reported ( ). the rivm and the cbs report this uncertainty in the true number of covid- related deaths by providing information on excess mortality ( ). excess mortality rates provide information on the "surplus" of deaths compared to the expected number of deaths based on the same period in the previous years. in case of an epidemic, this number is expected to provide a better overview of the impact of the virus on mortality by also including undiagnosed patients with a high likelihood of infection. the total number of diseased people is combined with the standardized z-scores on excess mortality as calculated by euromomo ( ) and presented in figure . [insert figure ] according to euromomo"s classification of z-scores, any rate lower than does not show any excess, which is observed up to week in the netherlands. at this point, the z-score rapidly increases and in week a zscore of , can be observed. for five weeks in a row, both very high ( <z≤ ) and extremely high (> ) excess scores are found. even during the flu epidemic of , which had a significant elevation in excess mortality, only one week showed a very high excess mortality with a z-score of ( ). after the initial peak in excess mortality, the number of diseased people decreased, and no excess mortality is observed since week ( ). as of january th , covid- was classified as an "a-disease". this indicated a major public health threat and gave the government more power to intervene ( ) . the government installed an outbreak management team (omt). the omt consists of medical experts and officially advises the minister of health on the strategy against infectious diseases ( ) . however, at the beginning of the outbreak, the prime minister announced during a public debate that the government is executing the recommendations given by the omt, rather than solely consulting them ( ) . the first outbreak of the virus occurred in the south of the country which quickly overwhelmed local hospitals and especially their icus. to deal with the rapidly expanding need for icus, other regional hospitals were asked to accept patients from the epicentre. due to the structure of the dutch health system, hospitals and their medical staff retain a large degree of autonomy and were not sure whether they could be hit by such cooperation. therefore, hesitation and resistance were observed during the initial response. similarly, health insurance companies faced financial incentives that were not aligned with a national distribution of the icupatients. as the stress was building, parties quickly agreed to stop the competition among insurance companies and provided financial guarantees to all hospitals ( ) . while this helped during the first weeks of the outbreak, numbers of icu-admitted patients continued to rise. to coordinate the use of icus, the government supported the largest academic hospital to function as a national coordination centre ( ) . during the peak, a total of , covid- patients were treated at the national icus which far exceeded the maximum capacity of , icus before the covid- pandemic ( ). this surge capacity of expanding icu capacity to a total of , beds within weeks led to high stress-levels and required the nationwide cancellation of virtually all elective care ( ) . the dutch healthcare authority reported a reduction in other health services. between march th and april th , , fewer referrals by gps to hospital care were reported as compared to previous years ( ). furthermore, referrals to mental healthcare institutes decreased by , between mid-march and mid-may ( ) . as of mid-may, regular care was slowly scaled-up again ( ). other healthcare providers, such as physiotherapists and home care providers, implemented e-health technologies to ensure continuous care. these innovations were financially supported by the government with a temporary covid- e-health subsidy ( ). besides, due to the rising number of covid- patients, the demand for personal protective equipment (ppe) rose tremendously. as a consequence of closing borders by ppe producing countries, limited production of ppe within the netherlands, and lack of emergency storage, ppe quickly became scarce ( ) . according to daxin ni, deputy director of the chinese center for disease control, two strategies in response to the covid- virus exist: a sars-like strategy and a pandemic flu-like strategy ( ) . the sars-like strategy focusses on complete containment of the spread of the virus and emphasizes early detection and isolation. the pandemic flu-like strategy focusses on controlling the spread, reducing overall harm, and building herd immunity. for a flu-like strategy, the focus is not on early detection and isolation, but on protecting risk groups and the ability to treat severe cases ( ) . following this rationale, the dutch policy response can be classified as a pandemic flu-like strategy. this classification follows from limited testing, limited travel restrictions, and limited quarantining requirements for people returning from international epicentres. to control the spread of the virus the dutch did make an initial -albeit slow and narrowly defined -effort to test, trace and quarantine infected people and their recent contacts. as the virus spread, the main goal became to avoid overwhelming icus and to protect risk groups through the flattening of the epidemic curve ( , ) . the government aimed to allow a controlled spread of the virus over several months to establish herd immunity, which was presented to the public by the prime minister ( ). this approach received little support from the public. subsequently, herd immunity was reframed into a consequence rather than the aim of the policy. however, the actual measures remained the same ( ) . afterwards, the government based its approach on indicators such as the basic reproduction number (r ) to remain below the critical value of ( ) . the r value is a well-known epidemiological measure, which can be interpreted as the expected number of new infections in the population coming from one infected individual. different government responses to the pandemic are observed around the world. to compare these measures taken across borders, the oxford covid- government response tracker (oxcgrt) provides a stringency level scale ( ) . based on the characteristics and intensity of the measures taken by each country, a score from to is attributed. figure presents the score of the netherlands on this scale, which shows that the highest stringency level score reached is , . additionally, the figure provides information on the r level since the government announced to utilize that number as the main value of interest for policymaking ( ) . the adopted policies of the dutch government can be classified in four levels following the scaling method by moy et al ( ) . these include the minimal (recommended), the medium (mandated), the significant (mandated and enforced), or the very significant (complete restriction on movement) policies. with the relative mild lockdown implemented in the netherlands, no very significant policy has been implemented. an overview of the most important policies over time is shown in figure . [insert figure ] the first minimal level policy was introduced on march th , where people in the southern province noord-brabant were advised to practice social distancing. three days later, the first nation-wide recommendation involved hygienic measures ( ). as of march th , the government moved from containment to mitigation when policies were extended to the nation as a whole and people with non-vital jobs were requested to work from home ( ) . besides, large events were cancelled, and universities closed. on march th, additional measures were mandated, including closing all sports facilities and hospitality services. against the omt"s advice, the government decided to close all schools due to the critique building from teachers and parents on the previous decision to keep schools open ( ). the overall focus was on social distancing where people were to keep a distance of at least . meters from each other ( ). however, these policies did not bear the desired effects, as public places were often still crowded. therefore, on march rd , new policies were implemented through an emergency ordinance. municipalities were authorized to fine group formation with more than people and businesses who did not adhere to the social distancing measures. the implemented measures by the government still allowed people to go for a walk or visit family while adhering to the . meter distance measure ( ). these measures were extended multiple times ( , ) . the effectiveness of the policy measures can be seen in the movement data provided by google, where a % increase in residential mobility is detected during these months ( ). on may th , the covid- approach changed from a mitigation approach back to aiming for containment ( ). to relax previously implemented measures, policies aimed at more stringent testing and tracing were announced. as of may th , primary schools re-opened and contact professions could be performed. on june st , hospitality services re-opened, although in reduced capacity which number was enlarged one month later. besides, all secondary education institutes opened ( ) . these measures remained in place until the time of writing this paper. furthermore, digital initiatives arose in response to the virus. to provide insight into the spread of the virus to the public, the government established an interactive covid- dashboard, which contained data on multiple indicators. these included icu hospitalization rates, r -trends, and the number of people tested positive for the virus -both at the national and regional level ( ) . the containment measures implemented ensured the icus were not overwhelmed. however, as a result, the economy was impacted in several ways. before the arrival of the virus, the dutch economyas measured by gdp -was growing over the last quartiles, yet it was estimated that the dutch" gdp dropped with . % in the first quarter of compared to the last quarter in ( ) . this is, among other things, due to a decrease in household spending of . % in march compared to the same period in . the reduction is mainly attributed to less spending on services and durable goods ( ) . comparing the exportation of goods in the same period, a reduction of . % was observed, which was the first reduction in export observed since may . a similar trend can be found for the number of imported goods which decreased by . % ( ). compared to the first quarter of , the second quarter experienced an even more severe drop of . %. household spending continued to decrease by . % compared to the first quarter, as well as investments made (- . %) and the number of exported goods (- . %). the restrictive measures and corresponding limited production in the transportation and hospitality sector further contributed to the drop in the economy ( ). in contrast to previous years where the national debt kept decreasing, the debt increased by billion euros to a total of billion euros during the first six months of ( ) . currently, the economic losses are estimated to reach at least € . billion in , corresponding to a reduction of . % compared to the prognosis ( ) . although severe, the dutch economy seems less severely impacted by the pandemic as compared to neighbouring countries ( ). the reduction of trust in the economy by entrepreneurs encountered the largest drop ever measured by cbs in the first quarter in . based on the indicators on which this trust is based, the reduction seems mainly attributable to turnover losses. the arrival of the virus also impacted the labour market. a reduction of , job vacancies was observed in the first quarter in , a drop of % compared to the quarter before. although this reduction was the largest drop in vacancies ever measured by the cbs, yet the outlook seemed to be less severe compared to other western countries ( , ) . the dutch stock market was also impacted. the amsterdam exchange index experienced a large drop of over % between the day of the first positively tested patient (february th , . ) and its lowest points (march th , . ). afterwards, growth was again observed in the stock market (june th , . ) ( ) . to protect the economy and employment, several nation-wide economic emergency policies were adopted. years lost and corresponding qalys lost per death would provide us with a range of , to , , life years lost and , to , qalys lost ( ). using an estimate of € , per qaly lost ( ) , this would have resulted in an expected health loss between € . billion and € . billion. the magnitude of the total economic losses would have been much lower for the hypothetical situation described above as compared to the current situation in which restrictive measures were implemented and an economic loss of € . billion is found. the pandemic flu-like strategy was coherent with the testing and tracing policy. partly due to the lack of focus on early detection, a limited testing policy -as recommended by the omt -was applied. this decision was also based on the fear of test materials becoming scarce. however, retrospective research found that most laboratories did not use their full testing capacity. in march, just half of all available tests at laboratories were used and in april this number even dropped to one-third of the total capacity ( ) . due to the limited testing policy, on april th the country tested only . people per , inhabitants, which is far below the oecd average of . people per , residents ( ) . from the beginning, testing was only done for hospital employees and patients with severe covid- symptoms who had travelled to risk areas and/or had been in contact with contaminated people ( ) . later, testing was slowly extended to extramural health workers and later to educational staff ( , ) . with the primary schools reopening in may, the testing policy started to expand to more professions and as such shifted back to containment strategies. as of june st , the ggds were able to test every willing person with covid- symptoms with a maximum test capacity of , tests per day ( ) . the changes in testing policies are reflected in figure , where both the weekly number of people being tested and the percentage of those who tested positive is presented. with the testing policy shifting back to containment where every citizen could be tested, other testing issues occurred. particularly, the testing times between making an appointment to receiving the results took on average days. to effectively implement a containment strategy, the average testing times should decrease ( ) . besides, to support the contact tracing currently done by the ggds, the government aimed to develop a covid- tracing app. at the time of writing such an app has not yet been implemented, although the testing phase has begun. due to privacy concerns of the public, the implementation date has been postponed multiple times and further development of the app is required ( ). apart from covid- testing policies, as of early april, additional serology tests were done by the blood bank which provided insight into the spread of the virus among the population. these tests estimated that mid-april about % of the population had antibodies for the virus in their blood and continued to slowly increase to . % ( ) . however, the testing results of mid-july showed a decrease when only for . % of the test population antibodies were found ( ). testing the herd immunity level is in line with the covid- approach of the netherlands of maximum control of the spread of the virus, rather than complete containment. due to the organization of the health system, hospitals and testing centres have the autonomy to deviate from the national policies ( ). the university medical centre groningen (umcg), the only medical centre in the northern provinces, did not follow the national testing policy. together with the ggds in the region, umcg continued to test both intra-and extramural health personnel with mild symptoms to avoid possible contamination between colleagues and patients and as such adopted a more extended testing policy ( ). . regional differences regional differences in above-average mortality during the covid- pandemic can be observed per , inhabitants, as shown in figure ( ) . density levels possibly contribute to the spread of the virus, as it is believed that more interaction takes place in more dense areas, which in turn would lead to a faster spread of the virus. however, regional density variation does not overlap with the hospitalization rate per municipality, as some highly dense areas show low hospitalization rates and vice versa. thus, other factors could be better explanations for the variation. these could include regional variation in policy adherence and are therefore investigated below. [insert figure ] a. regions of interests to study these differences, this study identifies three major regions, namely the initial epicentre with high hospitalization rates, the northern regions with low hospitalization rates, and the bible belt region with somewhat higher hospitalization rates. the bible belt stretches from the south-west to the north-east and has the highest concentration of religious communities, mainly orthodox protestants ( ) . the northern regions and bible belt are further explored, as these regions deviate from the national policy, namely in adherence to the national testing policy and the utilization of legal exceptions on group formation. due to the variation in testing and tracing policies between the three northern provinces and the rest of the country, the observed differences can be investigated within the otherwise comparatively homogeneous country of the netherlands. another possible explanation for regional variation is the legal exception for religious groups to congregate, while other similar sized groups were barred from gathering. for religious gatherings, groups up to people were allowed, if they adhered to the . meter policy ( ) . while the catholic church the results of the northern regions suggest some underlying factors explaining this deviation from the country averages, such as the difference in testing policy between the north and the rest of the country. another factor that is often suggested for this difference is the average lower density in the north as compared to the rest of the country. however, parts of the epicentre report similar density rates. also, due to the virus being introduced first in southern regions, the spread to the northern regions started later. this allowed the rest of the country to prepare and adopt containment strategies before their first confirmed case, which in turn could have contributed to controlled dissemination. further research is needed to investigate this effect. furthermore, the aggregated regional data show no substantial difference between bible belt municipalities and country averages in terms of hospitalization rates. this could imply that small group formations are not or only to a small extend related to the dissemination of the virus. however, additional in-depth analyses of the data are required before this effect can be rejected. compared to other countries the dutch responded late and with relatively mild measures against the covid- pandemic. this was in line with the initial policy choice to consider covid- to be a severe flu and to strive for herd immunity. the government argued that it relied heavily upon the omt"s scientific medical advice, even though many of the considerations were societal and economical in nature. therefore, the position and the composition of the omt was criticized since the involved members were mostly medical while its advice had severe social and economic impact. ultimately the government opted to shift from containment to a mitigation strategy and focussed on staying within icu capacity while protecting risk groups and obtaining herd immunity. although the latter was later referred to as a consequence rather than a goal, the serology tests done by the blood bank show limited immunity among the population. the government"s focus on immunity therefore received ample critique. with the limited knowledge of the effects of the covid- virus at the time, aiming for herd immunity was considered a high-risk strategy. as the virus spread quickly, icu capacity was ramped up from , to , in a matter of weeks and shows the great surge capacity of the netherlands. to achieve this, the regulated competition health care system was swiftly replaced by a centrally organised one, and virtually all elective hospital care was postponed by several weeks. this prevented the icus from becoming overrun. the relative late lockdown measures, combined with limited testing and tracing, did probably contribute to the high levels of excess mortality -especially in longterm care facilities such as nursing homes. a variety of initiatives exist that use advanced technological approaches, mainly when it comes to telehealth and care on distance. many private health institutes adopted at least some digital initiatives to ensure continued care for their patients. the dutch government, however, took a lot of time to implement technological support to improve and protect public health. the track and tracing app is at the time of writing in its testing phase and is expected date to be implanted nation-wide on the st of september. the dutch government could therefore invest more in disruptive technologies and benefit from cross-border collaboration both in development and implementation of such technologies. to shield the economy, the government implemented various measures to prevent unemployment rates to rise drastically and to protect the economy. initially, these policies were to some extent effective. an economic shock did occur, although less severe than the ones in neighbouring countries. looking at the number of bankruptcies in the first half of , the initial effect of the financial support by the government has protected a large set of businesses. however, these financial measures are not sustainable during the more prolonged and structural duration of the crisis and will therefore have to be replaced. the decision-making power by regional authorities can be observed in the three most northern provinces, which stuck to containment measures and seem to have escaped high covid- hospitalization rates. these preliminary findings seem to confirm that more extensive testing and tracing policies in regions other than the epicentre could contribute to less dissemination of the virus. the effect of group formation on hospitalization rates may have led to the dissemination of the virus in very religious regions. however, our findings do not, or only to a limited extent, show higher hospitalization rates for the dutch bible belt. note that all findings should be interpreted with caution, due to the descriptive nature of this evaluation and the early stage of this analysis. however, the initial investigation done to the regional variation in terms of both excess mortality and hospitalization rates indicate the need for regional variations to the national mitigation measures. in line with this finding, the dutch government gave more decision-making power to the regional authorities during the controlled stages of the virus. in sum, the dutch quickly abandoned containment in favour of mitigation with a focus on herd immunity. contrary to the national policy, the three most northern provinces continued their containment strategy and were able to prevent local transmission of the virus. the mitigation measures in the rest of the country first resulted in further local transmission, but the mild lockdown eventually slowed transmission down quite effectively, and by the end of may containment became the official strategy again. taken together, the dutch have shown a way to effectively slow down transmission while allowing more personal and economic freedom than most other countries, and a way to keep the virus from spreading using containment policy based on tracking, tracing and voluntary isolation and quarantining. this provided the country with a successful medium-term perspective on flattening the epidemiological curve whit reasonable levels of personal and economic freedom. however, economic costs remain significant compared to the prevented health losses and long-term equilibria should either greatly reduce the societal cost of containment or involve safe ways to build up herd immunity. . regional variation in above-average mortality per , inhabitants for weeks [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , as compared to weeks - , . stand van zaken bestrijding covid- oxford covid- government response tracker. blavatnik school of government kamerbrief maart : kamerbrief over covid- nieuw maatregelen advies afstemmingsoverleg en internationale ontwikkelingen kamerbrief maart : covid- update stand van zaken epidemiologische situatie covid- in nederland op juni. . . bevolkingsontwikkeling; regio per maand netherlands: country health profile. . . rijksoverheid. het nederlandse zorgstelsel epidemiologische situatie covid- in nederland augustus huisartsen melden ongeteste doden met covid- -verschijnselen. . . overledenen centraal bureau voor de statistiek. . . graphs and maps the netherlands infectieziekten met meldingsplicht rijksinstituut voor volksgezondheid en milieu. preventing, treating and controlling infectious diseases: rivm op dit "schaduwkabinet" van deskundigen vaart premier rutte. algemeen dagblad gaat gereguleerde marktwerking tot de ijskast in? zorgvisie kamerbrief maart : kamerbrief covid- update stand van zaken. . . covid- infecties op de ic"s kamerbrief over stand van zaken covid- . . . nederlandse zorgautoriteit. reguliere zorg komt gefaseerd weer op gang verwijzingen naar ggz komen na terugval weer op gang guest post: a comparison of coronavirus approaches kamerbrief over covid- nieuwe maatregelen. . kamerbrief mei : kamerbrief covid- update stand van zaken working paper: categorising policy & technology interventions for a pandemic: a comparative and conceptual framework. . . rijksoverheid. kamerbrief april : kamerbrief covid- update stand van zaken economie krimpt met . procent in eerste kwartaal consumptieve bestedingen van huishoudens; nationale rekeningen centraal bureau voor de statistiek. economie krimpt . procent in tweede kwartaal schuld rijksoverheid steeg in de eerste helft van met miljard euro aantal vacatures daalt met duizend in eerste kwartaal arbeidsmarkt: historische daling werkzame personen, maar internationaal gezien beperkt overleg bankensector en financieringsbehoefte ivm noodpakket zijn er meer faillissementen dan vorig jaar? the reproductive number of covid- is higher compared to sars coronavirus what the proponents of "natural" herd immunity don"t say. the new york times how deadly is the coronavirus? scientists are close to an answer. nature. . . briggs a. moving beyond "lives-saved" from covid- rijksinstituut voor volksgezondheid en milieu. state of infectious diseases in the netherlands er kon veel meer getest worden in de zorg en dat had doden kunnen schelen these are the oecd countries testing most for covid- . world economic forum de tweede golf dat zijn wij corona antistoffen bij donors landelijk gedaald bovengemiddelde sterfte naar corop (per , ), wk - (t.o.v. wk - ), religious subgroups influencing vaccination coverage in the dutch bible belt: an ecological study corona cijfers per dag op gemeente, provincie en landelijk niveau key: cord- -zkwxc xy authors: renne, jean-paul; roussellet, guillaume; schwenkler, gustavo title: preventing covid- fatalities: state versus federal policies date: - - journal: nan doi: nan sha: doc_id: cord_uid: zkwxc xy are covid- fatalities large when a federal government does not impose containment policies and instead allow states to implement their own policies? we answer this question by developing a stochastic extension of a sird epidemiological model for a country composed of multiple states. our model allows for interstate mobility. we consider three policies: mask mandates, stay-at-home orders, and interstate travel bans. we fit our model to daily u.s. state-level covid- death counts and exploit our estimates to produce various policy counterfactuals. while the restrictions imposed by some states inhibited a significant number of virus deaths, we find that more than two-thirds of u.s. covid- deaths could have been prevented by late september had the federal government imposed federal mandates as early as some of the earliest states did. our results highlight the need for early actions by a federal government for the successful containment of a pandemic. covid- is a rampant disease that has affected the world population to an unprecedented scale. this experience has pushed state and federal governments to implement drastic regulatory policies to contain the spread of the disease. in many countries, such as the united states, state governments can independently implement policies while other states or the federal government do not impose any restrictions. this begets the questions: how effective are policies implemented at a local level? and what could be gained from unified containment policies at the federal level? we answer these questions by developing an extension of the standard sird model of kermack et al. ( ) that allows for travel and commuting across states within a country. in our model, the government of a state can impose three types of regulations. it can impose a mask mandate that shrinks the transmission rate in the state. it can impose a stay-at-home order that shrinks the transmission rate in the state as well as the inflow of out-of-state commuters and travelers. or it can also issue a travel ban that shrinks the inflow of out-of-state travelers. the federal government can force all states to implement the same policies or allow states to decide individually what policies to implement, if any at all. we assume that a coronavirus infection takes on average days to resolve and that the fatality rate of the disease is . %. to incorporate uncertainty about the contagiousness of covid- , we assume that the transmission rates in individual states vary randomly over time and are not directly observable. they fluctuate around a natural mean rate but can be substantially higher or lower at times. we fit our model to data on state-level covid- fatalities from the united states between february and september , . we then run counterfactual experiments using the estimated model under the assumption that states implemented policies different than the ones they adopted in reality. we measure the effectiveness of the different policies by looking at the difference between the observed and counterfactual numbers of virus deaths on september . all of our results are replicable by using our codes that are available on github. our results show that a lack of unified policies at the federal level results in significantly elevated virus deaths nationally. we estimate that more than , deaths could have been we are inspired by mean-field models that are commonly used in the financial economics literature to model credit risk contagion across financial institutions; see cvitanic et al. ( ) , giesecke et al. ( ) , giesecke et al. ( ) , and others. these assumptions are consistent with fernández-villaverde and jones ( ), perez-saez et al. ( ) , and stringhini et al. ( ) , and are benchmarked against alternatives in a sensitivity study. prevented by september , -over two-thirds of all death cases recorded in the u.s. by that date -if the federal government had imposed federal policies that mirrored those of the earliest and strictest states. our results also show that containment policies implemented by individual states are effective. we find that the u.s. would have recorded more than , , additional virus deaths if states had not implemented any containment policies at all. our study suggests that a large number of covid- deaths could have been prevented if the federal government had imposed stay-at-home orders or mask mandates that followed the leads taken by the different states. we estimate that more than , deaths could have been prevented if the federal government had imposed a federal stay-at-home order that had gone into effect on march , , corresponding to the start of the stay-at-home order in california. imposing a federal mask mandate as early as connecticut did on april , , would have prevented more than , deaths. considering that shutting down the national economy with a federal stay-at-home order carries significant economic costs, which we do not consider in this paper, a federal mask mandate would likely be preferred over a federal stay-at-home order. our counterfactuals suggest that between , and , virus deaths could have been prevented if the federal government had enacted a federal mask mandate sometime between march and april , , on top of the stay-at-home and travel ban policies adopted by the different states. an early federal mask mandate would have contributed to slowing down the transmission of the virus early in the spring of , when we estimate the reproduction numbers to have been the highest. while it is questionable whether an early mask mandate would have been realistic or whether there existed political or even scientific consensus for enacting such a policy, what our results indicate is that early action by the federal government that complemented the steps taken by state governments could have resulted in significantly less virus deaths. these results provide an important policy lesson for future waves of the pandemic by highlighting that early by matching death counts only, we estimate that the effective reproduction numbers of the virus in the different states during the spring of must have been up to two-times higher than prevailing estimates that are based on infection cases, which are likely under-measured due to the large number of undetected infections and asymptomatic individuals. since our estimates depend on our modeling and parametric assumptions, we carry out several experiments that assess how sensitive our findings are to our assumed parameter values. these experiments corroborate our findings. during the month of march, the who recommended masks be reserved to medical staff and discouraged a widespread use to the general public (see who interim guidance of april , ). as noted by feng et al. ( ) , the rationale underlying the discouragement of mask use was to preserve the limited supplies of masks in countries were the health-care system and icu use was under pressure. action by a federal regulator when the reproduction rates are high is key to prevent virus deaths. we find that interstate travel bans do not accomplish significant virus death prevention, mostly for two reasons. first, travel bans are often imposed once a regulator becomes aware of the virus, at which point the virus has already penetrated and spread in the states. the first travel ban in the u.s. went into effect in hawaii on march , . our counterfactuals indicate that only around , u.s. virus deaths could have been avoided if the federal regulator had imposed a nationwide ban of interstate travel on the same day as hawaii and maintained it through september . in contrast, we find that close to , deaths could have been prevented if the nationwide interstate travel ban had begun by the start of our sample on february . such an early ban of interstate travel is unrealistic given that the severity of the virus was not perceived to be as serious at that point of time as to justify such a drastic policy. second, interstate mobility scatters virus cases across state lines and this may slow down the spread of the virus within a country. in our model, states that are net importers of individuals record higher numbers of infections than they would in the absence of interstate movement while states that are net exporters of individuals record lower number of infections. when interstate mobility is restricted, infected population that would otherwise disperse out-of-state is forced to stay in-state. the higher concentration of infected population in some states can result in accelerated virus transmission in those states and worse death outcomes at the federal level. our counterfactuals suggest that this is only a minor effect, nonetheless. for example, we find that only around of the more than , virus deaths that could have been prevented with a federal stay-at-home order on march are explained by the fact that interstate commuting and traveling are discouraged when individuals are required to stay at home. our results suggest that policies that restrict cross-border mobility accomplish little in preventing covid- deaths unless they are imposed so early and for so long that they prevent the virus from initially taking hold in a population. to the extent that our results can be extrapolated to a global setting with multiple countries, they suggest that the late banning of international travel may be an ineffective tool in combating covid- . finally, we focus on individual states and find that the states that imposed some of the strictest containment policies were able to reduce the spread of the disease. our counterfactuals suggest that new york would have only recorded % fewer death cases if all states had imposed strict containment policies, while california would have recorded close to , additional deaths if the state government had not imposed any containment policies at all. these results suggest that strict-policy states, such as new york and california, were protected by their policies even when other states implemented weaker policies. on other end of the spectrum, we find that states that adopted weak or no containment policies could have prevented a significant number of covid- deaths by adopting stricter policies. our results suggest that over , deaths could have been prevented if florida and texas had adopted strict containment policies. we also find that the four states that adopted no containment policies in our sample-iowa, nebraska, south dakota, and utah-could have prevented more than % of their death cases by adopting early mask mandates. our results hinge on modeling choices and assumed parameter values. to understand how sensitive our findings are to our choices, we carry out several sensitivity analyses that assume alternative parametric values and provide a reasonable set of bounds for our results. we find, for example, that the number of preventable deaths is higher if we assume that it takes less times for a virus infection to resolve; i.e., if the virus is less severe. this is because, if a virus infection is less severe, there must have been many more infections early on in the sample to match the observed death data. therefore, early action by the federal regulator would have been even more impactful. the sensitivity analyses highlight a key benefit of our approach. by relying on death counts only, we allow our methodology to infer how many infections there must have been to justify the death data. this enables us to make data-driven inferences on how many infections and ultimate deaths could have been prevented through regulatory actions. our contributions are methodological and normative. on the methodological front, we develop a novel model for infectious disease transmission within a country composed of multiple states. our model incorporates the effects of interstate traveling and commuting, as well as uncertain transmission rates. it also allows for independent regulatory policies across states. our methodology delivers daily estimates of the transmission rates and effective reproduction numbers (r ); these objects are jointly estimated for u.s. states based solely on death cases. stochastic sir models of covid- have recently been used by fernández-villaverde and jones ( ) and hong et al. ( ) . deterministic mean-field models of infection rates have been considered by read and keeling ( ) , youssef and scoglio ( ), zhang et al. ( ) , and others. brady et al. ( ) study an sir model with spatial interaction of susceptible and infected people across neighboring states and allow for independent social distancing policies across states. this model, however, does not account for interstate travel. it also does not account for the effects of mask mandates. for single-state models, a related methodology is discussed in gouriéroux and jasiak ( ) and implemented in arroyo marioli et al. ( ) , , and hasan and nasution ( ) using infections data. fernández-villaverde and jones ( ) we briefly describe our model here and provide a detailed model formulation in appendix a. we assume that a unit of time is one day and that a country is composed of several states. we model the number of people in each state that are (i) susceptible to the virus (i.e., have never been infected), (ii) infected by the virus, (iii) recovered from the virus (and immune to subsequent estimates of the r using death counts only but it requires extensive smoothing of the data. studying the economic impact of state-level stay-at-home orders, rothert ( ) infections), and (iv) deceased due to the virus. our model explicitly takes into account the impact of different containment policies on the transmission of the disease. we consider three different types of containment policies: mask mandates, travel bans, and stay-at-home orders. our model also accounts for the effects of traveling and commuting across state lines. each state is endowed with a certain number of inhabitants. on any given day in a given state, the number of people that are contaminated by an infected person is assumed to be a random draw from a poisson distribution whose rate is the product of the policy-adjusted transmission rate in the state and the fraction of the state's population that is susceptible to the virus. if a person is infected on any given day, that person either dies, recovers, or continues to be infected in the next day with certain probabilities. we assume that it takes on average days for an infection to resolve and that the fatality rate by the end of this time period is . %. all in one, on aggregate in a state, the net number of new infections in a day is poisson distributed with rate equal to the product of the policy-adjusted transmission rate, the ratio of susceptible population, and the number of infected inhabitants of the state, after subtracting the number of infected individuals that recover or die from the disease. we assume that the transmission rates in the different states are unobservable and evolve stochastically from day to day. they are positively correlated across states and time. we account for interstate commuting and traveling as follows. each day, an inhabitant of a state can commute to another state, travel to another state, or remain in the home state with given probabilities. inhabitants that stay in their home states contribute to the disease transmission in their home states. commuters travel during parts of the day and return to their home states at the end of a day. they contribute to the transmission of the disease in their home states and the visited states. travelers spend several days in the visited state. they only contribute to the transmission of the disease in the state they visit. the transmission rates in each state, as well as the travel and commuting probabilities across states, are adjusted to reflect the containment policies adopted by the different states. the effects of the different policies are modeled by shrinking the transmission rates or the inflows of travelers and commuters when the policies are active. we assume that a mask mandate in a given state shrinks the transmission rate in that state by % but does not affect the inflow or outflow of travelers and commuters. a travel ban in a given state shrinks the inflow of travelers our assumption on immunity post-infection is merely a simplification given that current evidence on reinfections from covid- is thin and mixed, see, e.g., iwasaki ( ) . we justify this value as follows. based on the estimates of fischer et al. ( ) , we assume that a typical mask by %, but does not affect the transmission rate or the inflow of commuters in that state. finally, a stay-at-home order shrinks both the transmission rate and the inflow of commuters and travelers in that state by %. appendix e considers variations of these parameters and measures the sensitivity of our results to our assumptions. we use mobility, travel, and state-level policy data from the united states to calibrate most of the parameters of our model. we develop a filtering-based maximum likelihood methodology to estimate some of the parameters governing the transmission rates of the different states. we rely on daily state-level death counts from the covid tracking project since they are the least likely to be contaminated with substantial measurement issues (compared to the number of infections, for instance). the sample period is february through september , . appendix b provides details of the approach we take to fit our model to the data. state-level and aggregate death counts. we show in appendix b that our model implies that, in order to match the levels of fatalities we observed over the sample period in u.s. states, the effective r of the disease in the different states must have been substantially higher than through april for the majority of the states. we also show that the r grew larger than in several states over the summer. our estimates suggest that the number of infections in the different states required to match the history of covid- fatalities in the u.s. must have been substantially higher than recorded in the data. unreported model outcomes show that the worn in the u.s. filters out particles by a median value of %. we assume that only half of the population wears masks as suggested by data from the institute of health metrics and evaluation, justifying a reduction factor of approximately %. we estimate the % impact of travel bans as the reduction factor in the average number of daily trips of more than miles that were taken in the u.s. between march and april , , compared to . we assume that travel bans do not reduce the inflow of commuters into a state because travel bans were often accompanied by exemptions for commuters. we estimate the impact of stay-at-home orders on transmission rates as the reduction factor in the average number of daily trips of less than miles taken in versus those taken between march and april , , which is the period in which most stay-at-home orders were active in the united states. because stay-at-home orders were often accompanied by lockdowns which closed out office buildings, we assume that stay-at-home orders also reduce the inflow of commuters into a state. finally, because stay-at-home orders were also associated with closed out tourist attractions, we also assume that stay-at-home orders reduce the inflow of travelers into a state. the fact that our estimation approach relies on death counts data only, as in flaxman et al. ( ) , is an advantage over standard approaches to estimate time-varying reproduction numbers (e.g. bettencourt and ribeiro ( ) , cori et al. ( ) , thompson et al. ( ) ), as these approaches necessitate data on infection cases. estimated number of infected individuals in mid march was about -times larger than data records show, while it was about -time as large as in the data by late september. our results imply that many infected people remained undiagnosed and contributed to the spread of the disease early in the sample. we run counterfactual experiments in our model to study the effectiveness of the different containment policies. the underlying assumption of our counterfactuals is that states deviate from the policies they enacted in reality by imposing stricter or looser restrictions in a hypothetical world. we ask: what would have happened to the death count of a state if it had enacted a stricter containment policy than it actually did? what would have happened if it had adopted a policy that it did not enact in reality? and how would these deviations have impacted the aggregate death count in the u.s. by the end of our sample? we answer these questions for mask mandates, stay-at-home orders, and travel ban policies. we assume that a state adopts a loose policy if it does not impose that policy at all over our sample period. in contrast, we assume that a state adopts a strict policy if it adopts that policy as early as the earliest state adopted the policy in the data, and keeps the policy active until the last state in our sample shuts off that policy. our strict policy scenario therefore avoids forward-looking biases. any regulator could have adopted a strict policy scenario in real life by moving along with the first state that adopted a policy and ending the policy as soon as no other state had the policy in place. the strict scenarios for the different policies are: • stay-at-home: start on march , (the day when california activated its stay-athome mandate) and keep it active through september , (the last day in our sample in which the stay-at-home order was still active in california). • travel ban: start on march , (the day the first interstate travel ban in the u.s. went into effect in hawaii) and keep it active through september , (the last day in our sample in which an interstate travel ban was still active in alaska). • mask mandate: start on april , (the day the first mask mandate in the u.s. went into effect in connecticut) and keep it active through september , (the last day in our sample in which several states had mask mandates in place). the legality of such federal mandates are outside of the scope of this paper. we consider two variations of our counterfactual experiments. one in which only one state at a time deviates from its actual policies at a time, and another one in which all states take on the same policy jointly at the same time. with the first set of experiments we seek to answer how impactful deviations at the state level would have been. the second set of counterfactuals studies how impactful federally mandated polices would have been. to evaluate the effectiveness of the different policies, we compare the number of deaths at the state and federal levels in the different counterfactual experiments to the baseline levels in the data. appendix c provides details of our approach to computing counterfactual results. table shows the results of the counterfactual experiments in which we assume that all states deviate jointly. figure breaks down the number of deaths that could have been prevented through federal mandates by states and displays these in proportion to the number of death in the data of the individual states. figure table and further elaborated in appendix e. the additional sensitivity analyses are consistent with our main conclusions and provide validity for our results. have been prevented if the federal government had imposed strict stay-at-home orders, mask mandates, and interstate travel bans. these states adopted some of the weakest containment policies during our sample period. although table suggests the biggest reduction of fatalities could be achieved through a federal stay-at-home mandate, this comes at the cost of shutting down the national economy. the potential substantial economic costs inherent to that policy cast doubt on whether the federal government would have been persuaded to carry out such a drastic step. instead, imposing a federal mask mandate could have been a cost-effective option. we ask: how many deaths could have been prevented if the federal government had imposed an early federal mask mandate sometime between march and april that complemented the stay-at-home and interstate travel policies that were in effect in the different states? we run an additional counterfactual experiment to answer this question; figure summarizes our findings. our results indicate that between , and , deaths could have been prevented if a federal mask mandate that complemented the state-level stay-at-home and travel ban policies went into effect sometime between mid march and mid april. what drives our findings is that an early federal mask mandate could have provided a significant boost in reducing the potential for infections. as figure in appendix b shows, the effective reproduction number (r ) of the virus was substantially high -much higher than -in all states through april even while stay-at-home orders were in place in the different states. by imposing an early mask mandate, the federal regulator could have contributed to drastically reducing the infection potential in all states early in the sample. this would have contributed to slowing down new infections over time even while some state-level policies were relaxed. indeed, table shows that, in a counterfactual world in which a federal mask mandate had gone into effect on march while no state-level policies had been enacted, only , virus deaths would have been prevented. this result suggests that the key step for the federal regulator would have been to issue an early federal mask mandate that complemented, but did not replace, the state-level stay-at-home and travel ban policies that were enacted over time. the number of deaths that could have been prevented with early federal policies depends on our assumptions on how fatal covid- is and how long it takes for an infection to resolve. we run sensitivity analyses in appendix e to verify that our results are robust to different calibrations. the results of appendix e are generally consistent with table and figures through . they also highlight an important benefit of our methodology. appendix e establishes that the number of preventable deaths is higher if we assume that it takes only days for an infection to resolve. we find that this is the case because, in order to match the number of deaths observed in the data if the virus were less severe, the methodology infers that there must have been many more infected individuals early in the sample so that early federal action would have been even more impactful. we obtain these results because we rely only on death counts to make our inferences and allow the methodology to estimate how many infections there must have been to match the data. this highlights a fundamental benefit of of our approach relative to alternative approaches that rely on infection cases, which may be under-counted in the data due to the large number of asymptomatic cases or undetected infections, looking forward to future waves of the covid- pandemic, our results suggest that early actions by the federal government when the reproduction numbers are high could have a great impact on preventing virus deaths. our counterfactual experiments indicate that the actions taken by individual states benefited both the states that implemented the policies and the u.s. as a nation. we find that the u.s. would have been much worse off if no state had adopted any containment policies. in a hypothetical scenario in which no state had imposed any policies, table indicates that the u.s. would have observed , , additional deaths due to covid- . our results show that states that implemented strict containment policies were able to contain the spread of the disease. figure shows that a state like new york, which had one of the longest running stay-at-home and mask mandates, would have experienced only % fewer death cases if all states had imposed all three strict policies simultaneously. figure also shows that a state like california, which imposed the strictest stay-at-home policy in the country, would have recorded around , additional covid- deaths, or -times its end-of-september toll, if it had not imposed any containment policies at all. these results suggest that the measures adopted by individual states to contain the disease were highly effective and shielded states from inaction from other states. we find that the four states that implemented no containment policies at all during our sample period-iowa, nebraska, south dakota, and utah -could have benefited if they had implemented mask mandates by april without forcing stay-at-home orders or interstate travel bans. figure suggests that strict mask mandates could have prevented as many covid- deaths as - , in iowa ( % of all covid- deaths in the state), in nebraska ( %), in south dakota ( %), and in utah ( %). these results corroborate our findings on the effectiveness of mask mandates for preventing covid- transmission and deaths, both at the federal and the state levels. the results of table is not allowed to cross state borders, infected individuals are forced to stay within the home state. the higher concentration of infected population in those state leads to an accelerated spread of the disease and therefore also to higher infections and death cases. this is showcased in figure of appendix d, in which we plot the estimated cumulative number of infections in south carolina both under the baseline and in the counterfactual in which a strict federal interstate travel ban is imposed. consider wyoming, on the other hand. wyoming is a net importer of travelers and commuters, receiving on an average day a net inflow of around , out-of-state individuals. figure indicates that wyoming would have recorded % fewer death cases if a federal ban of interstate travel had gone into effect on march . figure we show that more than two-thirds of all covid- death cases is the u.s. were preventable had the federal government followed the leads of several states that took early actions to contain the virus. our results indicate that, in the absence of a unified federal approach, the policies enacted in individual states were effective and resulted in reduced virus fatalities. this benefited both the individual states and the u.s. as a whole. as a lesson for future waves of the covid- pandemic, as well as future pandemics, our results highlight the need for decisive and impactful early actions by a federal regulator to complement actions taken by state regulators, especially at times when the reproduction numbers are substantially large. -appendix - a. single-state model we first introduce a single-state model to provide an overview of the assumptions underlying the stochastic evolution of the covid- disease. this provides a basis that we extend in the following section to account for a network of n states. consider individual j that was infected on date t − (i.e., j ∈ { , . . . , i t− }). we assume that the number of people infected by this individual between dates t − and t follows a using the fact that a sum of poisson-distributed variables is poisson, the total number of people infected between dates t − and t is if j is infected on date t, then the probability that she dies between dates t and t + is δ (i.i.d. bernoulli) and, if she does not die, the probability she recovers between dates t and t + is γ/( − δ). (in such a way that the probability she recovers if γ.) the cumulated number of dead people on date t (d t ) is given by d t = d t− + d t , where d t is the number of deaths taking place on date t. under the assumptions stated above, d t follows a binomial distribution: d t ∼ b(i t− , δ). moreover, the number of people who recover between where s t and r t respectively denote the number of susceptible and recovered persons as of date t. (it is easily the transmission rate β t is assumed to follow a non-negative square root process whose euler discretization reads: where ε β,t ∼ n ( , ) and e t− (β t ) = β t− + κ(β − β t− ). let us now write the state-space representation of the model in a context where only d t is the measurement equation is ∆d t = δi t− + ε d,t . the transition equations are: we now consider a n -state model. inhabitants may travel across states for commuting or other reasons -we refer to the latter as "traveling." in terms of notations, superscript j refers to a given state. variables without superscripts denote n -dimensional vectors. we denote by p = [p , . . . , p n ] the vector of the state population sizes. s t , i t , r t and d t are n -dimensional vectors gathering the number of susceptible, infected, recovered, and deceased people in each state. the transmission rates β j,t and the flow probabilities are impacted by the containment policies implemented in the different states. we consider three containment policies: mask mandates, stay-at-home orders, and travel bans. the effect of each policy is captured through the binary variables θ j t,m , θ j t,s and θ j t,t , respectively valued in {θ low m , }, {θ low s , }, and {θ low t , }. the parameters θ low m , θ low s , and θ low t are strictly lower than one; they reflect the effects of the containment policies. more precisely: • the transmission rate β j,t is reduced when mask mandates or stay-at-home policies are implemented. formally, it is of the form β j,t θ j t,m θ j t,s , where β j,t is an exogenous transmission rate following the dynamics depicted by ( ). given that the θ variables are equal to one when the policies are not in place, it follows that β j,t coincides with the effective transmission rate (β j,t ) when mask mandates and stay-at-home policies are not implemented. • the probability that a given inhabitant of state j commutes to state k, that is w com j,k,t , is of the form w com j,k θ k s,t . similarly, the travel probability is given by w trav j,k,t = w trav j,k θ k s,t θ k t,t . these probabilities are therefore lower when (i) stay-at-home orders are in place or (ii) when travel bans are enforced in the visited state. the variables flow j trav,s,t , flow j trav,i,t , and flow j trav,r,t are net travel inflows of susceptible, infected, and recovered populations, respectively. we denote by w k,j trav,t the average fractions of the date-t population of state k that travels to state j; e j is the j th column of the n × n identity matrix; is a n × vector of ones; w j,• trav,t and w •,j trav,t respectively denote the j th row vector and column vector of w trav,t . consistent with the assumptions made in a. . , we have: here, τ trav measures the average number of days that a traveler spends in the visited states. using the poisson approximation of the binomial distribution, we consider that the number of outward travelers is drawn from poisson distributions. for example, the number of susceptible individuals traveling from state k to state j between dates t and t + is: this implies in particular that the net number of inhabitants traveling into state j between dates t and t + (denoted by flow j trav,s,t ) is such that: using the convention w j,j trav,t = , it follows that the n -dimensional vector φ trav,s,t is given by where by the same token, and with obvious notations for φ trav,i,t and φ trav,r,t : φ trav,i,t = Ω trav,t i t and φ trav,r,t = Ω trav,t r t . interstate commuters are people who spend a fraction τ of each day in another state. consider the infected inhabitants of state k working in state j. they contaminate less people in state k because they spend less time in that state. but they may also contaminate people in state j because they spend some time in that state while commuting. we respectively denote by flow j← com,s,t , flow j← com,i,t , and flow j← com,r,t the commuting inflows of susceptible, infected and recovered people in state j. outflows are given by flow j→ com,s,t , flow j→ com,i,t and flow j→ com,r,t . let us denote by w com,t the "commute" matrix; that is, the matrix whose component (i, j), denoted by w i,j com,t , is the fraction of the date-t population of state k that commutes to state j. on date t, the number of susceptible people commuting from state k to state j is: this implies in particular, with obvious vectorial notations, that: with (consistently with the assumptions made in a. . ): where w com is the commute matrix that would prevail under no containment policies. by the same token: all in all, if we denote by flow com,s,t the vector of time-weighted commuters net inflows, we have: with Ω com,t = τ com w com,t − τ com d(w com,t ). each state j features an autonomous β j,t process (see a. . ). these variables, gathered in vector β t , follow non-negative square-root processes whose dynamics is approximated by: where the diagonal elements of Σ are ones and the extra-diagonal entries are set to ρ. the state-space model is characterized by we have: where Ω t− = Ω com,t− + Ω trav,t− , where the latter two matrices are respectively defined in equations ( ) and ( ). notice that the state-space ends up being of size × n , where n is the number of states, so in our application. appendix g details the computation of the conditional variance of [d t , s t , i t , r t , β t ] (see equation in g. ). the previous equations constitute the set of transition equations of the state-space. we complete the formulation with the measurement equations being only the (seasonally adjusted) time series of fatalities per day, for each state, which we denote by d obs t . we assume that the number of deaths per day is measured nearly perfectly, such that: since the state-space is non-linear, we resort to the extended kalman filter for estimation. this requires the computation of the jacobian matrix of e t− [d t , s t , i t , r t , β t ] with respect to [d t− , s t− , i t− , r t− , β t− ], which is closed-form and detailed in appendix h. we then apply a fixed-interval rauch-tung-striebel smoother (backward filter) with the estimated trajectories produced by the filter. our model features several parameters that we need to fix: the death rate δ, the recovery rate γ, the parameters β, κ, σ, and ρ governing the dynamics of transmission rates in the states, the effects θ low m , θ low s , and θ low t of the different containment policies, and the average traveling and commuting flows across states. we proceed as follows to select parameter values. we summarize our parameter estimates in table . we follow fernández-villaverde and jones ( ), perez-saez et al. ( ), and stringhini et al. ( ) and assume that it takes on average days for an infection to resolve. we assume that after this period, an infected person either recovers and becomes immune, or dies with a probability of . %. these assumptions imply that γ = and δ = . % = . . we estimate average interstate travel flows from travel and mobility data in the united states. we collect data on interstate travels from the traveler analysis framework published by the federal highway administration (https://www.fhwa.dot.gov/policyinformation/ analysisframework/ .cfm). we also collect data on state-level mobility and staying-at-home from the trips by distance database of the bureau of transportation statistics (https://www. bts.gov/distribution-trips-distance-national-state-and-county-level). we combine these two databases to compute the percentage of a state's population that stays home before and during the pandemic, as well as the percentage of a state's population that traveled across state boundaries before and during the pandemic. we use these data to determine the travel matrix w trav of appendix a. . . we illustrate the estimated interstate travel network in figure (a figure (b) shows the implied commuting travel network. in this figure, however, the size of a node is proportional to the logarithm of the percentage of a state's population that commutes outwards. we assume that out-of-state commuters spend hours each business day and no time during a weekend in the visited state. we also assume that commuters sleep hours a day and during that time infections are not possible. as a result, we set τ trav = . ≈ × × . we calibrate the parameters θ low m , θ low s , and θ low t to match mobility and mask usage data from the united states. we collect data on when the different policies were active in the different states from the national academy for state health policy (https://www.nashp. org/governors-prioritize-health-for-all/) and the steptoe covid- state regulatory tracker (https://www.steptoe.com/en/news-publications/covid- -state-regulatorytracker.html). figure showcases the time periods in which policies were active in the different states. we also collect data on average mask adoption across u.s. states from the institute of health metrics and evaluation (https://covid .healthdata.org/united-statesof-america). we assume that a stay-at-home policy is in place for the time period that covers any order for staying at home, sheltering at home, or being safer at home issued by a state governor. we neglect any stay-at-home advisories that are not strictly enforced by law officials. we estimate θ low s = . as the reduction factor in the number of short trips taken during the pandemic versus before the pandemic. we consider a travel ban to be active when a state requires inbound travelers to self-quarantine for an extended period of time. travel bans are active in our model only if they apply for all states. that is, we neglect any travel ban that only applies for travelers from selected states. we estimate θ low t = . as the reduction factor in the number of long trips taken during the pandemic versus before the pandemic. finally, we assume that a mask mandate is active if a state requires the use of masks indoors in public places. we do not consider mask mandates to be active if mask wearing is only recommended or only required outdoors. we estimate θ low m = . by assuming that only half of the population adopts mask usage (as suggested by the institute of health metrics and evaluation) and that an average mask used in the u.s. reduces covid- transmission by % (as suggested by fischer et al. ( )). we develop a quasi maximum likelihood methodology to estimate the parameters governing the dynamics of the transmission rates β j,t from daily data on state-level deaths in the united states for the time period between february through september , . we remove weekly seasonality patterns observed in covid- fatality records using an stl approach. our methodology assumes that daily death counts at the state-level are measures with small measurement errors. we take into account all state-level containment policies that were observed over the sample period. we write a non-linear state-space representation of the model, gathering s j t , i j t , r j t , d j t , and β j,t for all states simultaneously ( variables). filtering is easily performed through the first order extended kalman filter algorithm. while we could estimate the speed of reversion κ with our methodology, we find that the data prefers to set κ arbitrarily close to zero, implying an extremely high persistence for the β j,t . this results in numerical instabilities. to avoid these issues, we fix κ = . so that the first-order autocorrelation of the β j,t is . . we then estimate the remaining parameters β, σ, and ρ using our quasi maximum likelihood methodology. the estimates are provided in table . we find that our parameter estimates are more precisely, for each state we evaluate the average number of daily trips of less than miles taken in and compare that number to the average number of daily trips of less than miles taken during the time frame march through april , . we compute θ low s as the average reduction factor across states. we evaluate the average number of daily trips of more than miles taken in and compare that number to the average number of daily trips of more than miles taken during the time frame march through april , . we compute θ low t as the average reduction factor across states. not very sensitive to alternative choices for the value of κ. figure shows the data-implied death counts in each state as well as the smoothed modelimplied death counts. we see that our model performs well at fitting the state-level data. the estimated measurement errors are fairly small. figures and show the smoothed modelimplied effective r and cumulated infections for each state. the data pushes our model to showcase high r in the different states. the highest r were observed in new jersey, new york, and washington in february and march, reaching levels of more than . indeed, we find that the state-level r must have been substantially higher than for most states through overall, our findings suggest that the virus spread drastically in the u.s. through the fall of . in fitting the data, our model estimates that the number of infections in the different states must have been significantly higher than recorded in the data. these observations suggest that there must have been many undiagnosed infections that facilitated the spread of the disease throughout our sample period. note that we never use infections data for the estimation or calibration of our model parameters. this section details how our counterfactual experiments are conducted. the r of state j in our model is given by θ j t,m θ j t,s β j,t /(δ + γ). our estimates of the effective reproduction numbers are one-and-a-half to two-times larger than prevailing estimates in fernández-villaverde and jones ( ). we find that this is driven by a key difference in our models. fernández-villaverde and jones ( ) assume that, while it take two weeks for an infection to resolve, an infected individual is only contagious for the first days of an infection. we, instead, assume that an infected individual is contagious during the whole infection period. we run several experiments in appendix e in which we study whether are results are sensitive to this assumption, and we find that this is not the case. the estimated dynamics constitutes our baseline scenario. all of our results are presented as a difference with respect to this baseline scenario. we compare the outcomes in terms of fatalities. we consider two types of experiments, which we call strict and loose, respectively: • in the strict scenario, we assume that the states start adopting the same policy as that implemented by the earliest state during the sample period and relax it when the latest state does so. the scenarios are as follows: -stay-at-home: start on march , (the day when california activated its stayat-home mandate) and keep it active through september , (the last day in our sample in which the stay-at-home order was still active in california). -travel ban: start on march , (the day the first interstate travel ban in the u.s. went into effect in hawaii) and keep it active through september , (the last day in our sample in which an interstate travel ban was still active in alaska). -mask mandate: start on april , (the day the first mask mandate in the u.s. went into effect in connecticut) and keep it active through september , (the last day in our sample in which several states had mask mandates in place). • for the loose scenario, we assume that states do not implement a specific policy at all. we then re-propagate the model with these counterfactual policies according to the methodology described below. we conduct these two types of experiments one policy at a time, and one last time all together. our analysis is split into joint and state-by-state experiments. for the former, we assume that the federal government imposes on all states the counterfactual policy (strict federal mandate), i.e. to be as strict as the strictest or to do nothing (loose federal mandate). for the latter, we take each state one at a time and assume that only this state follows the strict or loose scenario and compute the counterfactual outcomes one state at a time. recall that the model parameters and the latent variables (s t , i t , r t and β t ) are estimated by employing the extended kalman filter. the observed variables are the numbers of deaths d obs. t , as well as the observed implemented policies θ obs. . in order to derive our counterfactual outcomes, we also extend our filtering approach. the broad idea is the following: we augment the state vector used at the estimation step -i.e. x t = [d t , s t , i t , r t , β t ] -with a similar state vector for a fictitious country (f ict.), with the same number of states, where the counterfactual policies would be implemented. critically, we assume that the basic, standardized, shocks affecting the two countries are almost perfectly correlated, implying in particular that the β t 's are the same for the baseline and fictitious countries. specifically, let us denote by x * t the state vector corresponding to the fictitious country. the transition equation of the augmented state-space model are: where θ obs. and θ f ict. contain the full trajectories of observed and fictitious policies, respectively; where ε t rue,t and ε f ict.,t denote differences of martingale sequence; and where v / (s, i, θ) is such that v / (s, i, θ) v / (s, i, θ) = v(s, i, θ), with the function v defined in ( ). to capture the idea that the two countries are affected by very similar standardized shocks, which are the ε t rue,t 's and the ε f ict.,t 's, we further assume that: on top of the transition equation ( ), the state-space model comprehends the following measurement equation: where d obs. t is the observed vector of numbers of deaths (in the "observed" country). by construction, the filtered variables x t resulting from this augmented state-space framework are exactly equal the the ones of the regular state-space. indeed, it produces the moment e(x t |d obs t , d obs t− , . . . ), which is the same in both state-space models. however, x * t will be different from x t since the implemented policies are different, and their impacts are non-trivial since they are non-linearly propagated in the state-space. as a last step, we provide backward path estimates using the bryson-frazier smoother and compare the paths of d t and d * t produced by the smoother. we used bryson-frazier rather than rauch-tung-striebel because the latter requires to invert the conditional variance-covariance matrices of the transition equations, which are of size ( n × n ) . in our empirical application ( states), this results in matrices of size ( × ) that have to be inverted for each day of data. this results in a large numerical instability. instead, the bryson-frasier smoother only requires the inversion of the variance-covariance matrix of the observables, that is of matrices of size (n × n ). the time series dynamics of the federal counterfactuals are presented on figure . we run several analyses to understand how sensitive our results are with respect to changes in our parameter values. table shows confidence bands that are derived from re-estimating the number of preventable deaths if the policy that deviated from the data was either twice or half as impactful. what we mean in precise terms by this is that if, for example, we assume that a counterfactual is carried out with respect to changes in a mask mandate, we would evaluate the number of preventable deaths by assuming that θ low m is either half or twice as large as indicated in table . this sensitivity analysis provides confidence bands for our estimates of the number of deaths that could have been prevented by adopting policies different than the ones that were adopted in reality by considering that the policies may have a different impact on reducing transmission rates and traveler and commuter inflows than what we assume in our study. we also carry out additional sensitivity analyses with respect to two key parameters in our model: the number of days that it takes for an infection to resolve, and the fatality rate of the disease. tables through repeat the experiments of table by assuming that it either takes or days for an infection to resolve, or that the fatality rate of the disease is . % or %. to obtain the results, we re-estimate the parameters β, σ, and ρ that would be necessary under the new assumptions for the fatality rate or the number of days for infection resolution. the sensitivity analyses are carried out one-by-one. we find that adopting early federal containment policies would have been less impactful and prevented less deaths if an infection took longer time to resolve. vice versa, we find that early federal action would have been more impactful if an infection took less time to resolve. this is primarily because, if the disease were less severe than we assumed and it took less time to resolve an infection, then the methodology estimates that there must have been many more infections early on in the sample to match the number of deaths observed throughout the sample. that means that early action would have been more impactful if the disease is less severe than we assumed. note that this is always a conclusion based on matching the amount of death cases that we observe in the data. if the disease were less severe and we still observed as many deaths as in the data, then the only possible explanation is that there must have been more infections early on in the sample. as a result, early action would have been the more impactful. we find that the number of preventable deaths would not be much different if the virus were less lethal. however, we find that the costs of inaction at the state level would be much higher if the virus were more lethal. we find that close to , , additional deaths would have been observed if no state enacted any policy and if the lethality rate of the virus were %. these observations further corroborate our findings of the success of the policies enacted by the individual states to prevent covid- deaths both at the state and federal levels. we have: because d t + r t , on the one hand, and i t , on the other hand, are independent conditional on the information available on date t − , it follows that: remark: let us introduce z t ≡ ∆i t − e t− (∆i t ). by construction, e t− (z t ) = . it can be seen that z t is the sum of i t− i.i.d. random variables. hence, if i t− is large, we approximately have: conditional on the information available on t − . this is also true for i t , r t and d t + r t . because the conditional variances of these variables are in i t− (and not in i t− ), it follows that, when i t− is large, the deterministic version of the sir model provides a good approximation of the dynamics of (s, i, r, d) -at least up to potential stochastic variation of β t . in the remaining of this appendix, we detail the computation of some of the covariances appearing in equation ( ) cov var t− (r t ) = var t− (e t− (r t |d t )) + e t− (var t− (r t |d t )) using equations ( ) to ( ), we have, in particular: we also have cov(flow com,i,k,t , flow com,i,j,t |i t ) = that is, in vectorial form: which we denote by where function c is defined by the same type of computation leads to var(flow com,s,t |s t ) = c(w com,t , s t , τ ) ( ) var(flow trav,i,t |i t ) = c(w trav,t , i t , ) ( ) var(flow trav,s,t |s t ) = c(w trav,t , s t , ). for any pair of independent random vectors x and y , we have therefore: where Ω t− = Ω trav,t− + Ω com,t− and where d(w , w , s, i, τ, Ω) = c(w , i, τ ) + c(w , i, ) c(w , s, τ ) + c(w , s, ) + c(w , i, τ ) + c(w , i, ) (id + Ω)ss (id + Ω) + c(w , s, τ ) + c(w , s, ) (id + Ω)ii (id + Ω) , function c being defined in ( ). let us use the notation: i * t = i t + flow com,i,t + flow trav,i,t and s * t = s t + flow com,s,t + flow trav,s,t . using the law of total variance: let's denote the previous conditional variance by Θ t− . we have: where Ω t− = Ω com,t− + Ω trav,t− and function d is defined by ( ). what precedes implies that: and where Θ t is defined by equations ( ), and ν is defined in equation ( ). we hereby provide the formulas for the jacobian computation in the extended kalman filter the matrix of partial derivatives is given by: counterfactual assumption travel bans for all states. [- , ; - , ] strict stay-at-home orders in all states, and all other / - , state-level policies remain as in the data. [- , ; - , ] strict mask mandates in all states, and all other state-level / - , policies remain as in the data. [- , ; - , ] strict travel bans in all states, and all other state-level / - , policies remain as in the data. [- , ; - , ] no stay-at-home order, mask mandate, or travel ban + , , in any state. [+ , ; + , , ] no stay-at-home order in any state, but all other + , policies remain as in the data. [+ , ; + , , ] no mask mandate in any states, but all other + , policies remain as in the data. [+ , ; + , , ] no travel ban in any states, but all other + , policies remain as in the data. [+ , ; + , ] mask mandate in all states on march , , while no / - , state adopts any state-level policies. [- , ; , ] strict travel bans in all states by february , , while / - , all other state-level policies remain as in the data. [- , ; - , ] table : results of the counterfactual experiments in which we assume that all states jointly deviate from their enacted policies and adopt either strict or loose versions of the policies instead. the reported values are excess deaths relative to the number of u.s. deaths recorded in our data on september , . in the counterfactuals, we compute the trajectories of death counts per state under the alternative policy scenarios that are consistent with the susceptible, infected, recovered, and dead populations as well as the transmission rates filtered from the observed data. the values in brackets give confidence bounds based on a sensitivity analysis of the estimates of the impact of the different policies on transmission rates and traveler and commuter inflow. the lower bounds assume that any policy that deviates from what it was in the data is half as impactful, while the upper bound assumes that any policy that deviates is twice as impactful. table in appendix e provides the parameter values used for the sensitivity analyses. in the sensitivity analysis, we proceed in a similar way as for the counterfactuals and first compute posterior means of the state-level transmission rates that would explain the observed death counts under the assumption of alternative effectiveness for the different policies. we then compute the number of death that would have been observed if the policies had changed while keeping the recomputed trajectories of the transmission rates fixed. all other state-level policies remain as in the data. table : results of the counterfactual experiments in which we assume that all states jointly deviate from their enacted policies and adopt either strict or loose versions of the policies instead. here, we assume that it takes on average days for an infection to resolve, while keeping the fatality rate of the disease fixed at . %. the reported values are excess deaths relative to the number of u.s. deaths recorded in our data on september , . in the counterfactuals, we compute the trajectories of death counts per state under the alternative policy scenarios that are consistent with the susceptible, infected, recovered, and dead populations as well as the transmission rates filtered from the observed data. the values in brackets give confidence bounds based on a sensitivity analysis of the estimates of the impact of the different policies on transmission rates and traveler and commuter inflow. the lower bounds assume that any policy that deviates from what it was in the data is half as impactful, while the upper bound assumes that any policy that deviates is twice as impactful. table in appendix e provides the parameter values used for the sensitivity analyses. in the sensitivity analysis, we proceed in a similar way as for the counterfactuals and first compute posterior means of the state-level transmission rates that would explain the observed death counts under the assumption of alternative effectiveness for the different policies. we then compute the number of death that would have been observed if the policies had changed while keeping the recomputed trajectories of the transmission rates fixed. counterfactual assumption (γ = . ) all other state-level policies remain as in the data. table : results of the counterfactual experiments in which we assume that all states jointly deviate from their enacted policies and adopt either strict or loose versions of the policies instead. here, we assume that it takes on average days for an infection to resolve, while keeping the fatality rate of the disease fixed at . %. the reported values are excess deaths relative to the number of u.s. deaths recorded in our data on september , . in the counterfactuals, we compute the trajectories of death counts per state under the alternative policy scenarios that are consistent with the susceptible, infected, recovered, and dead populations as well as the transmission rates filtered from the observed data. the values in brackets give confidence bounds based on a sensitivity analysis of the estimates of the impact of the different policies on transmission rates and traveler and commuter inflow. the lower bounds assume that any policy that deviates from what it was in the data is half as impactful, while the upper bound assumes that any policy that deviates is twice as impactful. table in appendix e provides the parameter values used for the sensitivity analyses. in the sensitivity analysis, we proceed in a similar way as for the counterfactuals and first compute posterior means of the state-level transmission rates that would explain the observed death counts under the assumption of alternative effectiveness for the different policies. we then compute the number of death that would have been observed if the policies had changed while keeping the recomputed trajectories of the transmission rates fixed. counterfactual assumption ( all other state-level policies remain as in the data. table : results of the counterfactual experiments in which we assume that all states jointly deviate from their enacted policies and adopt either strict or loose versions of the policies instead. here, we assume that the fatality rate of the disease is . % instead of . %, and keep the number of days that it take for an infection to resolve at days. the reported values are excess deaths relative to the number of u.s. deaths recorded in our data on september , . in the counterfactuals, we compute the trajectories of death counts per state under the alternative policy scenarios that are consistent with the susceptible, infected, recovered, and dead populations as well as the transmission rates filtered from the observed data. the values in brackets give confidence bounds based on a sensitivity analysis of the estimates of the impact of the different policies on transmission rates and traveler and commuter inflow. the lower bounds assume that any policy that deviates from what it was in the data is half as impactful, while the upper bound assumes that any policy that deviates is twice as impactful. table in appendix e provides the parameter values used for the sensitivity analyses. in the sensitivity analysis, we proceed in a similar way as for the counterfactuals and first compute posterior means of the state-level transmission rates that would explain the observed death counts under the assumption of alternative effectiveness for the different policies. we then compute the number of death that would have been observed if the policies had changed while keeping the recomputed trajectories of the transmission rates fixed. counterfactual assumption (δ = . ) all other state-level policies remain as in the data. table : results of the counterfactual experiments in which we assume that all states jointly deviate from their enacted policies and adopt either strict or loose versions of the policies instead. here, we assume that the fatality rate of the disease is % instead of . %, and keep the number of days that it take for an infection to resolve at days. the reported values are excess deaths relative to the number of u.s. deaths recorded in our data on september , . in the counterfactuals, we compute the trajectories of death counts per state under the alternative policy scenarios that are consistent with the susceptible, infected, recovered, and dead populations as well as the transmission rates filtered from the observed data. the values in brackets give confidence bounds based on a sensitivity analysis of the estimates of the impact of the different policies on transmission rates and traveler and commuter inflow. the lower bounds assume that any policy that deviates from what it was in the data is half as impactful, while the upper bound assumes that any policy that deviates is twice as impactful. table in appendix e provides the parameter values used for the sensitivity analyses. in the sensitivity analysis, we proceed in a similar way as for the counterfactuals and first compute posterior means of the state-level transmission rates that would explain the observed death counts under the assumption of alternative effectiveness for the different policies. we then compute the number of death that would have been observed if the policies had changed while keeping the recomputed trajectories of the transmission rates fixed. all states adopt the three policies simultaneously into a strict scenario in which a particular state implements a policy as long as at least one state decides to do so, and a loose scenario in which a state does not implement a particular policy. counterfactual death counts are computed through the methodology detailed in appendix c. figure : number of deaths that could have been prevented through an early federal mask mandate. the x-axis indicates the date in which we assume a federal mask mandate had gone into effect, while the y-axis gives the number of deaths that could have been prevented had a federal mask mandate gone into effect on that date. we assume that state-level stay-at-home and travel ban policies remain as in the data, and that a federal mask mandate supersedes the state-level mask policies. is performed through forward/backward extended kalman filtering, using the time series of death counts per state from february to september , . our estimation methodology is detailed in appendix b. the r estimates correspond to the ratios of estimated β t multiplied by the policy dummies and divided by the sum of the daily fatality and recovery rates (γ + δ). the figure also shows the periods of time in which the different containment policies were active. green shaded areas correspond to active stay-at-home policies, purple areas to active mask mandates, and yellow areas to active travel bans. horizontal blue lines correspond the standard value of r e+ e+ e+ figure : time series of counterfactual death counts in which the federal government imposes strict joint mandates (left axis), along with the number of states that adopted stay-at-home or mask mandates in the data (right axis). the black solid line provides the death count obtained from the original data. the grey, red, and beige solid lines provide the time series of deaths that would have been observed if the federal government had imposed strict stay-at-home, masks, and all policies together on all states, respectively. the strict mandates start as early as the earliest state in the sample, that is march , for stay-at-home, and april , for mask mandates. the red dashed line presents a counterfactual scenario where masks are imposed as early as march , . green and purple-shaded areas provide the number of states that implemented stay-at-home policies and mask mandates in the data, with respect to time. their units are presented on the right axis. social interactions in pandemics: fear, altruism, and reciprocity. nber working paper no. a simple planning problem for covid- lockdown tracking r of covid- : a new 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fatalities in the united states large portfolio asymptotics for loss from default inference for large financial systems analysis of virus propagation: a transition model representation of stochastic epidemiological models a new estimation method for covid time-varying reproduction number using active cases a compartmental epidemic model incorporating probable cases to model covid outbreak in regions with limited testing capacity', medrxiv implications of stochastic transmission rates for managing pandemic risks what reinfections mean for covid- containing papers of a could masks curtail the post-lockdown resurgence of covid- in the us? serology-informed estimates of sars-cov- infection fatality risk disease evolution on networks: the role of contact structure avoidable covid- deaths -and counting -in the u.s. working paper optimal federal redistribution during the uncoordinated response to a pandemic. united states naval academy working papers the psychology underlying biased forecasts of covid- cases and deaths in the united states serocov-pop): a population-based study a modelling framework to assess the likely effectiveness of facemasks in combination with 'lock-down' in managing the covid- pandemic improved inference of time-varying reproduction numbers during infectious disease outbreaks an individual-based approach to sir epidemics in contact nnetworks modeling epidemics spreading on social contact networks key: cord- -mey e gd authors: albers, heidi j.; lee, katherine d.; rushlow, jennifer r.; zambrana-torrselio, carlos title: disease risk from human–environment interactions: environment and development economics for joint conservation-health policy date: - - journal: environ resour econ (dordr) doi: . /s - - - sha: doc_id: cord_uid: mey e gd emergence of covid- joins a collection of evidence that local and global health are influenced by human interactions with the natural environment. frameworks that simultaneously model decisions to interact with natural systems and environmental mechanisms of zoonotic disease spread allow for identification of policy levers to mitigate disease risk and promote conservation. here, we highlight opportunities to broaden existing conservation economics frameworks that represent human behavior to include disease transmission in order to inform conservation-disease risk policy. using examples from wildlife markets and forest extraction, we call for environment, resource, and development economists to develop and analyze empirically-grounded models of people’s decisions about interacting with the environment, with particular attention to lmic settings and ecological-epidemiological risk factors. integrating the decisions that drive human–environment interactions with ecological and epidemiological research in an interdisciplinary approach to understanding pathogen transmission will inform policy needed to improve both conservation and disease spread outcomes. soon after the discovery of sars- -cov, covid- became a pandemic event that spread worldwide, infected millions of people, and created unprecedented economic impact (who a; guan et al. ) . current evidence suggests that covid- resulted from a zoonotic pathogen "spillover" event-transmission of a pathogen from wildlife to humans (andersen et al. ) . the majority (~ %) of the emerging infectious diseases (eids) since had an animal origin with most of these (> %) caused by pathogens associated with wildlife (jones et al. ) . although pandemics are rare, zoonotic disease incidence and novel spillover events cause frequent and serious health, social, and economic losses in tropical low and middle income countries (lmics) (morse et al. ) . as covid- spread around the globe, several countries in latin america experienced an extreme outbreak of dengue and other vectorborne diseases (lorenz et al. ) and the democratic republic of the congo endured their eleventh ebola outbreak since (who b). because zoonotic spillover events occur in human-animal interfaces, policy to address such disease risks requires interdisciplinary analysis of the epidemiological, environmental, and human processes occurring on the landscape. data analyses find that disease emergence and biodiversity loss share common anthropogenic drivers: land use change, habitat fragmentation, expansion of the agriculture frontier, and wildlife harvest and trade (patz et al. ; wolfe et al. ; loh et al. ; huong et al. ) . given that people's decisions are the root of these drivers, the choices people make about interactions with the environment influence both conservation outcomes and infectious disease risk (murray and daszak ) . in many lmics, human-environment interactions occur during activities that are integral to daily life and are a function of specific socio-economic and institutional settings (albers and robinson ; nielsen et al. ) . establishing policy to increase conservation and reduce disease risk requires understanding both people's decisionsincluding land use, resource extraction, and market activities-within their context, and how environment-human interactions lead to disease risk. environment, resource, and development economists explore models and data to determine why and how humans interact with the environment in lmics, which informs conservation policy. here, we review how these economic frameworks capture-or do not capture-drivers and characteristics of the human-environment interaction, while reflecting the natural and socio-institutional settings of lmics. we then propose how modeling frameworks can be expanded to incorporate the disease risk posed by that interaction to inform needed socio-enviro-epidemiological research and policy analysis, using an iterative process of data collection and modelling in an interdisciplinary setting. finally, we discuss how expanded models can provide insight into behavioral drivers of risk and inform design of policy for two general types of pathogen transmission pathway from wildlife to humans: direct-contacting a pathogen through hunting, marketing, or consumption of wildlife, with an example from indonesian wildlife markets; and indirect-exposure to pathogens while undertaking livelihood activities, with an example of malaria transmission. filling this research gap will address calls from many conservation and health actors to incorporate human dimensions of disease risk into joint conservation-health policy (romanelli et al. ; díaz et al. ; whitmee et al. ; who ) . the effectiveness of conservation policy is dependent on its ability to influence human-environment interactions. conservation economics in lmics provides both empirical and theoretical models of human behavior that inform conservation policy to address anthropogenic causes of biodiversity loss, as called for by conservation scientists (reddy et al. ; dobson et al. ) . these frameworks recognize that patterns of land use are informed by, and inform, decisions of people in lmics that cause biodiversity loss (e.g. pfaff ; andam et al. ; pfaff et al. ; albers et al. ) . both environmental and socio-economic characteristics of lmics inform people's decisions and interactions with their environment and are often critical considerations in conservation policy. governments, large scale land actors, and individual people make decisions that combine to determine the pattern of landscapes and land uses. in turn, tropical lmic people's land use and environmental interaction decisions consider patterns of government investments in roads and protected areas, larger scale land users, and agricultural policies (albers et al. ) . here, we discuss the empirical analyses that identifies drivers of conservation outcomes, critique their ability to identify policy tools to influence individual decisions, and describe existing lmic models of human-environmental interaction with conservation policy levers to form the basis for the next section's discussion of incorporating disease risk in these frameworks. investigating deforestation, land use change, fragmentation, and park effectiveness, econometric analysis of spatial imagery and gis datasets identifies correlations between physical and socioeconomic characteristics and conservation outcomes (e.g. pfaff ; andam et al. ; pfaff et al. ; busch et al. ; leblois et al. ) . roads both create fragmentation and encourage follow-on land conversion and fragmentation (saunders et al. ; freitas et al. ) , and protected areas and community management alter fragmentation (sánchez-azofeifa et al. ; southworth et al. ; nagendra et al. ; sims ) . although such empirical analysis is important for identifying big-picture issues and correlations, this style of empirical analysis presents three challenges for policy to influence people's behavior. first, such analysis obscures the incentives driving behavior and considers the actions of people only implicitly, which complicates identification of behavioral policy levers. second, remotely sensed datasets often do not contain information about socio-economic and institutional settings that influence behavior, such as which forests are effectively managed by community organizations or which villages face costly market access ghate et al. ). third, heterogeneity of cultures, landscapes, and other characteristics of individual lmics make extrapolating empirical results from one location to another difficult (leblois et al. ) , such as across settings with different acceptability of eating primate meat between muslims and christians (nyanganji et al. ) . conservation economics modeling work in lmics emphasizes the role of the socioinstitutional and ecological settings in which people make decisions on human-environment interactions (e.g. gunatileke and chakravorty ; albers and robinson ) . in lmics, many production and labor allocation decisions are influenced by natural environments, such as agricultural activities and non-timber forest product (ntfp) extraction, including hunting (robinson ; nielsen et al. ) . costly or limited market access influences decisions about how much to interact directly with natural environments for extraction and farming when facing a subsistence need or cash requirement (robinson et al. ; sills and abt ; muller and albers ; ghate et al. ). decisions to consume or trade wildlife depend on market access, prices, and opportunity costs (damania et al. ; wilkie et al. ) , in addition to other aspects of the household's production function including protecting crops from wildlife (johannesen and skonhoft ; bulte and rondeau ) . lack of clearly defined or enforced property rights create incentives that result in de facto open access use and habitat degradation (bulte and engel ; lópez-feldman and wilen ) . models that incorporate spatial decisions-about extraction and land use-provide a more explicit representation of the human-environment interactions that drive conservation outcomes and reflect the impact of property rights, community management, resource density, and market access on those interactions (robinson et al. albers et al. ). these economic decision models provide a lens through which to interpret data correlations and highlight policy levers for steering human interactions with the environment. developing general models of people's decisions within their social and ecological context, augmented with appropriate observation and data, can help form context-specific policy that focuses on changing people's behavior in pro-conservation ways that data analysis identifies as policy priorities. economists, health scientists, and conservation actors alike call for more research and policy that simultaneously addresses conservation and disease risk (salkeld et al. ; civitello et al. ; pattanayak et al. ) . often, conservation policy mitigates disease risk simply because conservation policy reduces contact between people and natural environments and wildlife. deforestation, land use change, and fragmentation all correlate with both biodiversity loss and zoonotic disease risk (patz et al. ; suzán et al. ; morand et al. ) . ecological models predict the geographic locations where new diseases may emerge or from which wildlife species they may emerge, but, despite including demographic variables, these models do not explicitly consider the interactions of people with their environment, which is a factor in the risk of zoonotic disease transmission (allen et al. ; olival et al. ). that transmission occurs through a combination of environmental, epidemiological, and human behavioral factors: first, human decisions determine the characteristics of the ecological landscape; second, the resulting environmental conditions determine the distribution of, and intensity of infection in, reservoir hosts; and third, the choice of activity and amount of time allocated to specific activities (hunting, farming, harvesting ntfps) drive the risk of exposure to pathogens (plowright et al. ) . as an example, the likelihood of mosquito-borne pathogen transmission depends on the abundance of mosquito vectors on a landscape, the pathogen load within the mosquito population, the chance that a pathogen-carrying mosquito bites a person, and the probability that the pathogen successfully infects the human (baeza et al. ). to depict risks on the landscape, disease ecologists create global emerging infectious disease "hotspot" maps that correlate past emerging infectious disease events, demographic data, and environmental variables to estimate the spatial relative risk of zoonotic spillovers worldwide. these models were developed at a coarse spatial resolution due to the sparsity of the data and multi-scale variables (allen et al. ) . human decisions around resource use and environmental interactions occur at a finer scale, making those interactions difficult to represent in this framework despite their critical role in determining the risk of disease. to address how humans influence zoonotic disease risk borne from environmental interactions, these hotspot maps can be combined with economic decision models at fine resolution that specify markets and institutions, landscape patterns, and resource use in lmics, and thereby illustrate the decisions behind where and how people overlap with pathogen hosts, which influences their pathogen exposure. using conservation economics models as a basis for developing policy that addresses both conservation and disease risk requires modeling extensions and new information. first, because both the amount of time and the locations of human-environment interactions contribute to disease risk within the ecological setting, expanding models of decisions about agricultural expansion, wildlife hunting and marketing, and resource extraction to incorporate space and time as decision variables provides a mechanism for characterizing the disease risk of such actions and for policies to internalize the disease risk into decisions. second, because both the ecological landscape of pathogens and human activities vary seasonally, economic models at the sub-annual level could identify seasonally targeted policies to mitigate disease risk. third, although empirical analysis signals the role of fragmentation in both biodiversity loss and zoonotic disease incidence, little ecological, economic, or interdisciplinary research depicts the process of fragmentation in a manner that helps define policy tools that influence people's actions in ways that could limit conservation losses and disease risk from fragmentation. in addition to such extension of modeling frameworks to address disease risk in the lmic context, we propose an interdisciplinary and iterative process of on-the-ground observation; economic, behavioral, and epi-ecological modeling to guide further field work; and data collection in a standardized manner to inform further research and policy efforts. that iterative process might begin with observation, both finding correlations in data and through stakeholder input; followed by economic analysis of models of human decisions parameterized with empirically-relevant values to identify the critical mechanisms and drivers of the human-environment interaction and potential for policy; followed by prioritization of ecological or economic data collection to form policy in specific settings; and an iteration back to broader data analysis to discern policy impact. such interdisciplinary analysis incorporating economic modeling will improve our ability to define factors that influence people's decisions involving interaction with the environment and the related disease risk. in the next two sub-sections, we discuss how to extend economic models of environmental interactions in lmics to incorporate disease risk in settings in which the risk is directly related to the actions taken by people, such as wildlife marketing, and in settings in which the disease risk derives indirectly or incidentally from the environment, such as siting livestock operations at the forest margins. the trade in legal and illegal wildlife is worth billions of dollars, with hundreds of millions of animals and plants traded globally (fukushima et al. ) . wildlife trade creates a direct human-wildlife interaction through intentional contact with the live or dead wildlife species at any point along the supply chain-from hunting to trading and selling to consumption (daszak et al. ; kruse et al. ; breed et al. ) . for example, sars-cov and sars- -cov are linked to wildlife trade in china, hiv to primate bushmeat hunting, monkeypox virus to the exotic pet trade, and h n and h n to domestic poultry (karesh et al. ; gilbert et al. ; andersen et al. ) . capturing, raising, and transporting live animals brings many individuals into close proximity, creating opportunities for inter-and intra-species pathogen transmission and potentially spillover to humans. for example, sars originated in wet markets where the pathogen spilled over from bats to civets (li et al. ) , and sars- -cov may have originated with pangolins as an intermediary host (andersen et al. ) . in these cases, the lack of regulations and poor biosafety at nodes on the supply chain increased the risk for vendors and purchasers further downstream. as the starting point of the wildlife supply chain, hunting activity that supplies markets poses a risk of disease spread as hunters interact with live animals (wolfe et al. ) . given that interaction, the drivers of hunting decisions can be targeted by policy to reduce disease risk and promote conservation. households face tradeoffs in their decisions to allocate time or land between agriculture and wildlife harvesting (bulte and horan ) . when these households also consume harvested wildlife, the income elasticity of demand for bushmeat drives the response to an alternative livelihood policy, identifying this elasticity as priority data (damania et al. ). response to policy may also differ when the hunted species are considered a nuisance to agriculture and are taken to defend crops as well as for consumption or sale. this dual purpose of hunting affects the tradeoffs hunters face when reacting to policy (johannesen and skonhoft ; bulte and rondeau ) . empirical analyses find variation in the response of hunters to the relative costs of hunting in an environment, such as park proximity; labor tradeoffs with other activities, particularly livestock; and household characteristics (e.g. brashares et al. ; foerster et al. ; van velden et al. ) . hunters may respond to the increased opportunity cost of hunting by switching to more efficient hunting techniques and more valuable species, which does not address disease risk and presents a conservation risk when those valuable species are protected species (damania et al. ) . when hunters cannot discriminate in the species they hunt, enforcement policies may have unintended consequences around consumption of protected species (robinson ) . hunters' decisions rarely include disease risk mitigating activities, perhaps due to a lack of knowledge of the risk the animal presents (harrison et al. ) . policies to alter incentives for bushmeat hunting and consumption include enforcement of illegal hunting, community-based conservation, and alternative or additional livelihoods and protein sources (foerster et al. ; van velden et al. ) . models predict the outcomes of these policies, showing in what circumstances alternative livelihoods, enforcement, and expanding protected areas lead to negative conservation outcomes (damania et al. ; johannesen ; robinson ) . policies that reduce hunting itself create conservation and disease risk mitigation but can impose economic burdens on hunters and demand for wildlife/bushmeat continues to create incentives for hunting. policies that promote safer hunting practices, information about disease risk, and incentives to hunt lower risk species directly alter the disease risk within the context of ongoing hunting. between the hunters and the final markets, traders, middlemen, and sellers in the wildlife/bushmeat supply chain serve a crucial role in lmics by providing access to markets, and also face disease risk. yet, few economic models and empirical analyses include the role of these other actors, which misses additional points of human-disease interaction that could respond to policy (bowen- jones et al. ; cowlishaw et al. ; kamins et al. ; nielsen et al. ; bachmann et al. ; van vliet et al. ; latinne et al. ) . middlemen with sufficient market power can pay lower prices to hunters than middlemen operating competitively and prevent the system from reaching the open access outcome (tháy et al. ). this role of middlemen is relevant in modeling wildlife supply chains and the resulting disease externality because they drive two elements of the disease risk: the amount of wildlife being harvested and the number of people directly contacting the wildlife. all points of human-wildlife contact along the supply chain represent areas of zoonoses spillover risk and possible opportunities for changing human behavior with policy levers. both local and global consumers contribute to the demand for wildlife and bushmeat (mcnamara et al. ; fukushima et al. ) . local demand in lmics is largely driven by wealth, nutritional needs, and prices (wilkie et al. ; fa et al. ; godoy et al. ) . analysis of demand across countries finds a range of income elasticities and price elasticities for bushmeat (wilkie and godoy ; east et al. ; wilkie et al. ; mcnamara et al. ) . policy can be aimed at manipulating the prices of bushmeat to reduce demand, and thereby reduce disease risk to consumers and the supply chain by reducing supply, but variation across settings in demand response imply a need for contextspecific information. here we demonstrate the role of balancing observation and data collection with modeling of people's decisions around their interaction with wildlife to inform conservation and disease policy. the wildlife markets in north sulawesi, indonesia sell a variety of wildlife and domestic animals, including bats like large flying foxes, which could potentially lead to disease spillover events. bat sales in these markets have been increasing for decades (clayton and milner-gulland ; lee et al. ; latinne et al. ) and concerns about declining bat populations and potential pathogen spillovers led to calls for policy to reduce bat harvesting (sheherazade and tsang ; latinne et al. ) . latinne et al. ( ) conducted stakeholder interviews with hunters, local collectors, middlemen, and vendors, and collected market data during - to describe the supply chain and estimate quantities of marketed bats. an important feature of these markets is that regional resource use and cultural differences between geographic regions create the current structure of the supply chain. demand for bat protein stems from christians in northern sulawesi, where hunting has historically occurred and reduced bat populations. current supply is transported from provinces in southern sulawesi, which are predominantly muslim and do not consume bats, and therefore have larger populations to hunt (clayton and milner-gulland ; lee et al. ; sheherazade and tsang ) . hunters sell the bats to either to local collectors or directly to middlemen, who transport the bats to the markets in the north (latinne et al. ) . by identifying the actors and collecting data on revenues and costs, latinne et al. ( ) identifies two salient characteristics of this market for policy development-hunters operate under open access conditions and middlemen transport animals to markets, factoring transportation costs into prices. combining observations, stakeholder interviews, and data collection, followed by modeling the entire supply chain, highlights specific incentives to target in order to conserve bats and mitigate pathogen spillovers from wildlife. the construction of the trans sulawesi highway in allowed vendors to travel further to collect wildlife and expanded the region over which bat harvest creates conservation losses and disease risk (clayton and milner-gulland ) . policies such as highway tolls that increase transportation costs to middlemen could reduce the volume of bats traded because hunters cannot readily access markets. in this case, data collection on the elasticities of demand for bat meat would be a critical piece of information to collect to determine whether the middlemen may pass on the price increase to consumers. second, policies aimed at providing alternative income sources to hunters could increase middlemen costs and reduce both harvest and disease risk. the policy could also increase the practice of middlemen transporting hired hunters to harvest the area, and disease risk and conservation concerns would continue (latinne et al. ) . to counter coordination between middlemen and hunters, policies that provide incentives for people in southern sulawesi to both forego hunting and protect bats from hunting could prevent these migrant hunters from accessing bat habitat. despite the valuable ecosystem services provided by bats, including fruit pollination, bats are generally considered a nuisance species by fruit farmers on sulawesi, which limits the farmers' interest in providing such incentives to bat hunters (banack ; latinne et al. ) . closer collaboration between conservation and health organizations could support payments for ecosystem services to potential bat hunters to discourage bat harvest and disease risk while promoting bat conservation for bat pollination and seed dispersal services. the iterative process of field work and modeling the supply chain, informed by stakeholder interviews, establishes a fuller picture of the disease externality risk at each contact point and the decisions of all actors and forms the basis for policy analysis aimed at reducing human-wildlife contact's disease risk and promotes conservation. some risk of disease arises through frequent human interactions with the environment in which contact with wildlife hosting a pathogen is incidental or an unintended consequence. these types of environmental interactions tend to drive persistence of endemic infectious diseases. for example, while harvesting fuelwood or other ntfps, individuals increase their exposure to arthropods or non-target wildlife species that are carriers of infectious pathogens like malaria and yellow fever (barros and honório ) . in southeast asia, pathogen transmitting mosquito species are found in greater abundance near deforested land and oil palm plantations (young et al. ) . the expansion of agricultural land, in particular oil palm and rubber in liberia and sugar-cane in bolivia, has increased the frequency of contact between plantation workers and rodents that are attracted to these environments, increasing thus the risk of hemorrhagic fevers (e.g. lassa fever in africa or ordog fever in south america) (olugasa et al. ; patterson et al. ; gibb et al. ) . the decision to site livestock operations near forest habitat increases the likelihood of interactions and conflicts between livestock and potential wildlife reservoirs for pathogens. for example, the emergence of nipah virus in malaysia was directly linked to agricultural intensification. pig farms were established in close proximity to forest; farmers planted fruit trees for additional income with the unintended result of attracting bats, which are natural reservoirs of nipah virus . in each of these examples, the risk of disease is endogenous in the decision to interact with the environment, but the risk is incidentally related to that decision. in these settings, the context of when, where, and how individuals interact with the environment plays an important role in the risk of disease. indirect interactions with disease risk are driven by choices individuals make about how and where they spend their time with respect to activities such as subsistence farming, collecting ntfps, mining, or working in the agricultural sector. these choices affect the land covers, habitat degradation, and wildlife with which individuals interact. as an example of a modeling opportunity, the ecological literature indicates that disease risk is greatest in altered or degraded natural habitats (murray and daszak ) , which could link to people's decisions as a function of resource quality. modeling the choice of labor allocation within a particular socio-institutional setting explicitly allows for representing trade-offs of allocating time to specific activities across land covers. labor allocation results can be combined with ecological models or data on vector or pathogen abundance across landscapes to determine individual pathogen exposure risk. the setting's institutions can also influence disease risk. for example, introducing markets for fuelwood substitutes alters the labor allocation to that environmental interaction and exposure to pathogens. similarly, establishing community property rights in forests that have been degraded by overextraction in de facto open access mitigates disease risk by reducing pathogen prevalence and reducing extraction within the forest. with more contextual information about activity choices from socio-economic field work, the daily and seasonal timing of activities can further inform infection risk. for example, if a wildlife species has crepuscular activity and agricultural work is conducted in the cool early morning, high vector activity and human presence on the same landscape may create a high-risk setting for pathogen transmission (vittor et al. ) . policy to reduce the risk of disease transmission through indirect interactions can take one of two approaches, either limiting resource extraction or limiting exposure to pathogens in risky environments. limiting the extent of extractive industries can simultaneously address conservation and health policy goals, but limiting opportunities for economic activities can result in illegal resource extraction, and disease incidence is often greater around illegal resource extraction operations (castellanos et al. ) . to limit extractive industries would therefore require creating alternative (legal) economic opportunities or payment for ecosystem service programs (cárdenas ) and monitoring and enforcing regulations. alternatively, policies can be developed using information about which specific actions increase human contact with the pathogen, and therefore create the greatest risk of pathogen transmission. for example, if oil palm plantation workers live near fields, increasing their risk of exposure to rats and lassa fever, housing can be sited in locations farther away from the source of risk. finally, disseminating information about how specific activities increase disease risks may be a viable policy to mitigate pathogen transmission. here, we explore an example of how leveraging empirical findings and expanding existing models, in combination with socio-economic and environmental observations, can inform policy to reduce malaria risk. a majority of the empirical disease research examines disease incidence from incidental interaction between humans and disease vectors stemming from economic activities such as land use change. ecological research suggests that deforestation opens the forest canopy, which modifies moisture and sunlight that reaches the ground and creates ideal breeding conditions for mosquitoes, which can transmit malaria (de castro et al. ; vittor et al. vittor et al. , . simultaneously, deforestation reduces the abundance of species that feed on mosquitoes, amplifying both the density of the vector and pathogen (baeza et al. ). in the amazon region of south america, the malaria vector species anopheles sp. occurs in greater abundance at forest edges and agricultural landscapes and in lower densities in forests and protected areas; anopheles abundance and diversity varies across land cover types (space); and anopheles feeding activity varies by time of day and season (stefani et al. ; bauch et al. ) . these findings imply that where and when people choose to perform activities is important in exposure to pathogens and disease risk. combining evidence from the natural sciences with economic models that explicitly represent when and where individuals spend time between, for example, collecting ntfps in a protected area and working in agricultural fields can provide insight into how incentives shape risk of infectious disease. existing econometric studies relating deforestation to malaria incidence have been conducted for south america, africa, and asia, and rely on geospatial datasets in combination with either regional epidemiological data (valle and clark ; hahn et al. ; terrazas et al. ; garg ) or individual health survey data (berazneva and byker ; bauhoff and busch ) . while the majority of studies find either positive correlation or causation between deforestation and disease incidence, these results are not consistent across all published works (e.g. valle and clark ; bauhoff and busch ) . although the increasing availability of geospatial and large datasets provides insight into global trends and hotspots for diseases, how people's decisions contribute to the risk of disease spread cannot be discerned from data at the parcel or pixel unit of analysis. as a result, the policy implications and ability to generalize results from these empirical studies are limited to identifying specific demographics that can be targeted for malaria prevention and control programs and broad statements about curbing rates of deforestation. as one possible starting point, albers et al. ( ) 's model of labor time allocation between wage labor and ntfp extraction incorporates both an individual spatial extraction path decision and an aggregate spatial equilibrium of ntfp extraction in a forest. that framework could be expanded to replace wage labor with agriculture, to further refine the timing and seasonality of decisions, and to reflect a range of socio-institutional and ecological settings. this modeling framework can be validated and parameterized using stakeholder interviews and observational data. then, overlaying this economic spatial land use model with ecological models that determine mosquito bite rate probabilities in agricultural land, fringe forest, deeper forests, and protected areas allows the model's solution to define the malaria transmission risk facing each individual based on their where and when they decide to perform specific activities. analyzing the spatial pattern of resource extraction decisions as a function of ecological, socio-institutional, and market settings can reveal the characteristics of settings and individuals that drive malaria risk and provide insight for policy development. simultaneously considering the daily and seasonal timing of human and vector activity (mosquitoes are most active at dawn and early evening, and most abundant around rainy seasons (de castro et al. ) ) can avoid creating policies that unintentionally increase pathogen transmission risk. for example, creating alternative fuel sources may decrease the total time spent in forests extracting fuelwood but focus that reduced time in ntfp extraction in fringe forests that have higher mosquito abundance, thereby increasing disease risk. joint consideration of the impact of policies on conservation and health outcomes can avoid perverse incentives and unintended outcomes. supplementing sensitivity analysis with stakeholder observations and data to describe particular settings produces stronger understanding of the drivers of decisions that create the disease risk and identifies the information and data necessary to provide the right policies for the ecological and institutional setting, across seasons. environment, resource, and development economists are particularly well-suited to developing frameworks of people's decisions to interact with their environments; and such models can identify policy levers that alter people's actions in ways that promote both conservation and disease risk mitigation. we suggest three guides for policy-relevant research: data analysis to identify correlations between land/resource characteristics and disease risk is necessary and important but not sufficient to guide joint conservation and disease-risk mitigating policy. empirical analysis that defines correlations but is not specific to people's decisions does not provide information about how human-environment interactions affect conservation or disease spread, which implies that policy levers are difficult to identify below generalities, such as "slow deforestation," "limit fragmentation," and "close wildlife markets." modeling people's decisions to interact with natural resources in a lmic setting, while using an iterative process that incorporates context and data, enables policy design based on people's decisions and disease spread mechanisms that can be modified for specific settings. because empirically-informed models characterize decisions about interactions with the environment, they can be used to identify how people react to policies that drive both conservation and disease risk outcomes. in the absence of detailed data at every site of conservation and disease policy interest, general models can prioritize particularly important data collection to enable the model's application in other eco-institutional settings. although economic models of people's decisions to interact with the environment are important for defining conservation-disease policy, interdisciplinary research with ecologists and epidemiologists is necessary to accurately reflect the mechanisms of disease spread that matter for policy. the risk of disease spread is a function of people's choices and of how those choices lead to pathogen exposure, which implies that economic models must be paired with data and models of those disease risks. economic models of humanresource interaction that differentiate across choices of locations and time spent, and across seasons, may be necessary to characterize human infection risk. in turn, economic policy analysis can prioritize further research into ecological mechanisms that drive risk in specific environments. open access this article is licensed under a creative commons attribution . international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were 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prediction of zoonotic disease emergence world health organization ( a) coronavirus disease (covid- ) situation world health organization ( b) new ebola outbreak detected in northwest democratic republic of the congo: who surge team supporting the response world health organization ( ) connecting global priorities: biodiversity and human health identification of mosquito bloodmeals collected in diverse habitats in malaysian borneo using coi barcoding publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord- -vm btiue authors: walwyn, david r. title: turning points for sustainability transitions: institutional destabilization, public finance and the techno-economic dynamics of decarbonization in south africa date: - - journal: energy res soc sci doi: . /j.erss. . sha: doc_id: cord_uid: vm btiue existing socio-technical systems tend to be intransigent to change. decarbonisation, on the other hand, is an imperative, leading to an obvious conflict between the need for, and highly effective resistance to, change. moreover, the abandonment of fossil fuel-based technologies in favour of more sustainable alternatives will require substantial reallocation of government’s operational expenditure, particularly in countries like south africa with high per capita greenhouse gas emissions and low per capita income. in this article, it is argued that reallocation will require more than niche experimentation and destabilisation of the present socio-technical regime. based on a study of south africa’s budget processes, it is concluded that change will only occur when four separate pre-conditions converge, namely a rapidly growing environmental problem capable of leading to civil unrest, a supportive and recently developed policy framework, decreasing techno-economic costs for its solution, and strong political support from an effective ministry or minister. turning points for transition, although infrequent, can be reached through strategic attention to these pre-conditions. a modified kingdon multiple streams approach, which introduces the additional dimension of techno-economic feasibility, is proposed as a useful framework for anticipating when and how to act in order to mobilise sufficient public resources for decarbonisation. the decarbonisation of energy and other systems is essential for the transition to a low-carbon future [ ] . many countries have committed to binding targets for greenhouse gas (ghg) emissions, including the attainment of net zero emissions by [ ] . the paris agreement is clear on what countries need to achieve in terms of such emissions, and over what time period these nationally determined contributions (ndcs) must be realised [ ] . however, the costs of decarbonisation have not been similarly specified in the agreement. individual countries are only now beginning to fully understand and quantify what investment will be required to reach the ndcs, and how these funds might be secured. some initial assessments have been reported in the literature [ ] [ ] [ ] [ ] . for the united kingdom, it has been estimated that the plan to reach net zero ghg emissions by will cost $ . trillion or $ , per metric tonne (mt) carbon dioxide equivalent [ ] . a similar value has been estimated for the united states of america, where the cost of replacing fossil fuels in the energy sector is estimated at $ . trillion or $ , per mt carbon dioxide equivalent [ ] . these values can be more easily comprehended by firstly calculating a total cost based on the present carbon emissions, then annualising this cost by assuming that the transition to low-carbon will take place over a -year period ( to ), and finally expressing the annual cost as a proportion of gross domestic product (gdp). the normalised costs of decarbonisation for the united kingdom and the united states of america are estimated at . % and . % of gdp respectively, whereas for south africa the value is about %. the issue of cost will be particularly acute for south africa [ ] . it is an upper middle-income country, heavily dependent on coal as a source of both electricity and liquid fuel [ , ] . decarbonisation of the energy sector will be a formidable undertaking, whose solution is made more difficult not only by the extent of the economic disruption and social dislocation that may result, but also by the constrained resources with which to address the issue [ , ] . a similar conclusion about the limited readiness of south africa for a low-carbon future has been reached by the world economic forum, which has placed the country in the th position out of countries based on the energy transition index [ , ] . already south africa has been criticised for its insufficient progress towards the attainment of the country's ndc targets [ ] . there is concern about its renewable energy programme, including ongoing delays [ ] , a poor outcome relative to the intended targets for economic development [ ] , and general deficiencies in the implementation of off-grid solar home systems [ ] [ ] [ ] . the government has also significantly alleviated the impact of a recently introduced carbon tax, and is failing to adequately resource the realisation of its ndcs [ ] . moreover, the covid- pandemic has caused a massive shock to the economy, reducing tax revenue collection by % and cutting at least % from the gdp [ ] . in short, the south african government appears unwilling and increasingly unable to resource its low-carbon transition. the issue of public sector resource allocation is critical for sustainability transitions. budget decisions within governments have direct and often irredeemable consequences. once such decisions are made, the resultant allocation of funds allows some programmes to be pursued and compels others to be halted. although there are several publications on green financing within south africa, such as its broader challenges and necessary design features [ ] and the role that public financial intermediaries have already played in the country's energy transition [ ] , there have been no specific studies on how to mobilise and reorient government expenditure for sustainability transitions, and particularly the decarbonisation of its energy sector. the unique contribution of this paper is its analysis of budget processes, leading to the proposition that four preconditions should be met before a significant reallocation of government's operational budgets, in support of decarbonisation, can be achieved. notably, in addition to the three factors of problem, policy and politics, which are central to kingdon' s multiple streams approach (msa) and are already welldescribed [ ] , the techno-economic value of the proposed solution must be addressed. the analysis in this paper seeks not only to support its claim for the four streams approach, but also to recommend ways of dislodging lock-in and re-directing government expenditure. the study was exploratory in its approach. it drew on interviews with ex-government officials, examples of previous re-allocations and government documents relating to the budget process. its objective was to identify the causal factors that could lead to profound changes in these budgets, and then to present these factors as preconditions that should be concurrently fulfilled. in its analysis, the study uses a theoretical framework which combines msa [ ] with historical instutionalism [ ] , as explained in the second section. the third section presents the relevant background on south africa's budget processes. the methodology, results, discussion and conclusions follow in sections , , and respectively. kingdon's msa postulates that change happens at single points in time or 'policy windows', when a number of causal chains or streams converge [ , ] . typically, the three streams comprise of the problem itself, a relevant policy framework and the political process through which change can be realised. msa further stresses the importance of policy entrepreneurs, who must attempt to couple the three streams through process of power brokerage and manipulation of problem contexts [ ] . msa specifically acknowledges the complex and chaotic nature of policymaking, and the difficulty of operating within an environment of ambiguity, irrationality and unpredictability [ ] . changes in policy are seen in msa to emerge spontaneously and stochastically, and can be missed by policy entrepreneurs due to the absence of well-developed policy solutions [ ] . msa's emphasis on windows of opportunity and convergence is also a central aspect of historical institutionalism, which refers to windows of opportunity as critical junctures and convergence as a process of conjuncture [ ] . historical institutionalism emerged in the s as a means of conceptualising and theorising how reform takes place at the meso-level, introducing such terms as path dependence and selfreinforcing processes, whose identification are critical to understanding and hence overcoming intransigence to transition and change. it adopts a longitudinal approach, perhaps over several decades, the analysis of which is used to identify the relationships of lock-in and dependence that comprise the socio-technical landscape [ ] . the hierarchies of micro, meso and macro, as developed within historical institutionalism, have become widely accepted and applied in the sustainability transitions literature [ , ] , as exemplified by its adoption of the multi-level perspective (mlp). the latter defines the three levels as the socio-technical landscape, consisting of government policy and inter/national systems, the socio-technical regime and the niche level, the latter including firms and networks of individual actors. although arguably a simplification of the broad diversity of individuals, collectives, organisations and systems, this layered hierarchy is fundamental to an understanding of transition, and how different processes take place within each level. in much of the mlp literature, change is considered to begin through niche innovations and policy experimentation, undertaken by an array of minor actors. the efforts of these actors may eventually become aligned and sufficiently powerful to destabilise an extant socio-technical regime, which has been wellestablished at the meso-level over a long period [ ] . a possible weakness of this model in the context of a developing country is the extent to which agency is possible within a highly resource-constrained political system. indeed, in the wider debate about structure vs agency, it can be argued that individuals and small networks of actors are disempowered by the broader structural context. it is precisely this consideration which makes the use of historical institutionalism, with its focus on the meso-level, as a highly relevant analytical framework for a country such as south africa. although operating as a democracy, it is clear that the societal environment in south africa still acts as a major constraint on the micro-level actors, given the low level of education and human capability [ ] . furthermore, the highly rigid approach of the pre- system of apartheid resulted in an extensive entanglement of the technological systems and the state, creating an almost irreversible degree of lock-in [ ] . in some senses, historical institutionalism is about theories of continuity, providing an explanation for why regimes remain stable, even though they are contested, rather than why they change. in order to address this gap, roberts and geels [ ] supplemented the insights of historical institutionalism with those of mlp as a means to further develop a theory of change. in their analysis of conditions for politically accelerated transition, informed by two case studies in the united kingdom, they argue that conditions for change must include both a weakening of the socio-technical regime, which they refer to as a push factor, and a strengthening of niche actors, which they label as a pull factor. following the insights from historical institutionalism, in which major policy change arises from struggles for power at the meso-level, they conclude that at least one mechanism of change is a macro-or landscape level shock. this severely disrupts the incumbent regimes and allows the emergence of niche actors as a new socio-technical system [ ] . in summary, historical institutionalism has two specific advantages when used to understand sustainability transitions, firstly its focus on meso-level institutions and policy regimes, and secondly the recognition that power struggles between political collectives or groups over scarce resources lie at the centre of politics and are critical to policy change [ , ] . institutional structures and arrangements, typically referred to as a political community or polity, engage in power struggles through the process of politics. in this sense, historical institutionalism is more appropriate in understanding south africa's budget processes and has been used in this study. it is argued that important decisions relating to resource allocation, which have the capacity to alter the course of sociotechnical systems, are the consequence of conjunctures taking place at critical moments. such turning points have a low probability of occurrence, given the dominant approach to policy stability and lock-in. the state can play an important role in transitions, either through exogenous changes at the level of the socio-technical landscape, or by strategic and planned initiatives to change the institutional environment [ ] . it is precisely the issue of the role of the state, and how it can be internally directed, that is the subject of this article. the study considers the separate roles of the executive, the administration and the legislature. the nature of the power balances between these three arms is explored by analysing their relative roles with respect to a core public sector process, namely the allocation of funds from the national fiscus to individual departments. an overview of this process, as it normally takes place, is presented in the next section. the adoption of south africa's new constitution in necessitated a comprehensive reform of the management of public finances, including its budget procedures. the latter were amended in several respects, such as strengthening the link between policy and budget allocations, the introduction of systems to address fragmentation and lack of clarity, and measures to improve transparency and re-establish fiscal stability [ ] . although the new processes were more top-down, the changes improved the alignment between post- priorities and actual public expenditure [ ] . a core feature of the revised budget process was the introduction of the medium-term expenditure framework (mtef), which was intended as the means by which government could ensure budget stability and predictability while allowing changes "at the margin" [ , p ] , thereby managing the "tension between competing policy priorities and budget realities" [ , p ] . the mtef was positioned as a first step in the "wider overhaul of the budgetary process, emphasising transparency, output-driven programme budgeting and political prioritization", that provided the link between the "technical preparation of budgets and the need to reflect political priorities in expenditure plans" [ p ]. its key features include rolling baselines, which are the core budgets for each department and are substantially unchanged within a single mtef, and a contingency reserve, which is intended to cover unforeseen expenditure. a detailed review of the timeline for the budget process is not possible in this article. in summary, the process is initiated by a cabinet lekgotla, which takes place in february to march of each year (see fig. ). at this meeting, the cabinet reviews the macroeconomic and fiscal policies, and the extent of the required budget cuts, or the additional funding that may be available for new priorities. these changes are then incorporated in a set of mtef budget guidelines [ ] , which are issued to the various national departments and provinces. in response to the guidelines, the departments prepare budget proposals, which are then submitted to national treasury, where they are consolidated into an overall budget estimate. based on the alignment between the estimates and the guidelines, national treasury provides feedback and, if necessary, requests revisions from the departments. the adjusted budgets are then assessed in the ministers' committee on the budget (mincombud) technical committee (mtec), which is composed of senior officials from national treasury (nt), the department of planning, monitoring and evaluation (dpme), the department of cooperative governance (dcog) and the department of public service and administration (dpsa). mtec then prepares recommendations for mincombud and cabinet regarding budget allocations in the mtef, taking into account government priorities, funding available, exchange rates, alternative funding sources and the division of revenue amongst the three spheres of government [ ] . once mincombud has approved the budgets, the minister of finance tables the medium-term budget policy statement in the whole process intentionally reinforces a central design principle of the post- reforms, namely the establishment and maintenance of a stable public finance environment, otherwise stated as a predictable expenditures and policies [ ] . one effect of this approach is that it severely limits the available funding for new policies or initiatives and reinforces a pattern of lock-in or pathway dependence within the budget allocations. however, there are two mechanisms through which small amounts of money can be sourced for new policies, if there is sufficient political support. before the estimated income is divided between the different departments and spheres of government, a contingency reserve is 'top-sliced' and retained by national treasury for emergency needs or novel policy instruments. this reserve provides a level of flexibility to the budget allocations, although, as shall be discussed later, it is a small amount relative to the demand for new funding from the various departments. the other mechanism, known as virement, involves the shifting of funds from one subdivision of a budget vote to another. there are a number of restrictions to this practice, including the requirement that it may not exceed % of the total allocation in the source subdivision (from which the funds are taken), that it may not involve the shifting of funds from capital to recurrent expenditure and that it cannot be used to increase remuneration without special approval from national treasury. clearly, expenditure predictability and budget stability are important objectives, especially in respect of financial markets and the cost of borrowing. however, both elements act against the needs of transition or change, particularly where the change has a significant cost or budget implication. the prospects of sufficient allocations for major new policy directions are limited by the mtef and the system weakens the role that government can play in enabling such changes. this imbalance has led to the growing realisation by south africans that reform can only take place in response to external pressure, widespread protest, and even violence. the / student protests regarding "free" higher education are an illustration of this perspective. provoked by a statement from the department of higher education and training (dhet) on transformation in higher education [ ] , the students embarked on nationwide protests, demanding that promises of free education be fulfilled. after a number of incremental changes, president zuma finally announced on december that higher education for the poor and working class students would be free [ ] . the president's decision was taken against the advice of national treasury, especially since it ran counter to the agreed budget processes and mechanisms [ ] . moreover the impact was profound; funding for the national student financial aid scheme (nsfas), the primary vehicle for the implementation of the new policy, a 'mere' r . billion in / , increased to r billion in - [ ] , as shown in fig. . certainly, in respect of this decision, it can be concluded that the executive directed, the administration was out-manoeuvred and the legislature side-lined. the intent that such decisions should be the outcome of evidence-based information and a collective consensus between the three arms, as stipulated by a range of policy documents, was over-ruled. thus, issues of policy conflict and priorities are often resolved through a political process which may relate to the power or influence of key positions within the executive arm of government (cabinet), or to the ability of the operational and legislative arms to determine the expenditure allocations. despite such processes being of critical importance to an understanding of how decisions on resource allocation are made, there is little published research in south africa on this topic. as illustrated by the earlier example of the nsfas, budget re-allocations are possible and do take place. accelerated sustainability transitions, as will be necessary for the timely implementation of the paris agreement, will require significant government investment, especially in new systems of transport and energy. to disregard or overlook these outlays under the pretext of lacking the necessary funds, appears disingenuous. it is a matter of priority and policy, and of avoiding the disrpution of existing, exclusive institutions [ ] . in summary, the analysis of budget processes leads to the following propositions about how change, and in particular realignment to operational budgets in favour of sustainability transitions, could take place. • for change to take place, the problem must be highly visible, a coherent and aligned policy framework must be in place, the solution should be affordable, it must require a political intervention, and failing to act must have severe consequences (such as social unrest). • the dynamics of each aspect are the problem must be accelerating in its severity; the solution must have falling cost implications; the window of change is generally very brief, opened by the sway of politics and rising popular dissent; and the political response must be rapid and effective. • the simultaneous convergence of these four aspects, described as a process of conjuncture resulting in a turning point or critical juncture, is essential for change to take place. in order to explore the validity of these propositions, a research project, involving a series of interviews over an -month period, was designed and initiated. the overall objective of the study, as already noted in the introduction, was to identify the factors that can lead to profound changes in government expenditure, and hence how greater priority can be mobilised for the support of sustainability transitions. further details of the research method are provided in the next section. the research followed a qualitative, inductive and exploratory approach with a purposive sampling strategy [ ] . the population consisted of ex-members of national treasury, and other departments, who had occupied senior positions within government in the recent past, including director-general, deputy director-general and chief director, and had more than years' experience of budget processes in the public sector. approval of the project by the faculty ethics committee was subject to two explicit conditions, namely that only exmembers could be interviewed and the responses had to be anonymised. the latter is a standard requirement and was fulfilled by following the normal procedures. however, the former condition added lengthy delays to the project due to the difficulty in identifying suitable respondents meeting the two criteria of having recently left a senior post in government. altogether, six interviews were completed. the respondents were interviewed using a semi-structured questionnaire in order to understand, primarily, how policy priorities are assessed and balanced within the public sector. the questionnaire was divided into four separate sections, with the first section covering the participant's view on the role of the state with respect to the environment and how this is presently being fulfilled, followed by three sections on the process of budget allocations and determination of funding priorities, the resolution of cases involving competing priorities, and general recommendations on accelerating support for sustainability transitions, respectively. in each case the interviews were recorded, transcribed and then analysed using atlas.ti. the coding structure was developed based on the research questions, with the coding groups covering the core questions of role, examples of policy conflict, the determination of priorities, details of the budget process, moments of change and lessons for sustainability transitions. it is acknowledged that the small sample size limits the external validity or generalisability of the results [ ] . the credibility and exclusivity of the data is, however, robust in that the respondents had all occupied senior positions and accumulated more than fifteen years of experience in budget processes within the public sector. although there were differences in perspectives, mostly there was agreement on the main determinants of the central question that this article seeks to address, namely how to influence such budget processes. as a result, it has been possible to extract a set of useful insights from the data. as mentioned earlier, south africa faces a huge decarbonisation challenge. its electricity sector is the most carbon intensive of all the g countries, it has a bankrupt power utility without resources to finance its normal operations, let alone decarbonisation, and it has a high level of unemployment, which places even more pressure on the imperative for a just transition [ ] . the global decarbonisation imperative will place huge financial pressure on state income. it has been estimated that the cumulative impact on south africa of a low-carbon transition, referred to as the 'transition risk' will be $ billion, which includes the loss of export revenue, and the loss of local markets for coal and liquid fuels [ ] . in addition, south africa will need to invest in new energy infrastructure, the extent of which can be illustrated by considering investment cost normalised for gdp. using data for carbon emissions and gdp data from the world development indicators database [ ] , and assuming that the average investment cost will be $ , per mt of carbon, it is calculated that south africa must source $ billion, or % of the gdp to finance the transition, as shown in fig. . it is clear from this comparison that the cost of decarbonisation will be more acutely experienced by countries with lower gdp and higher carbon emissions. for instance, iran, russia, india and saudi arabia have high relative ghg emissions and can expect a larger cost, normalised to gdp, than other countries. the combined impact of this investment cost and the transition risk, which represent a major challenge to the south african government, has a number of budgetary implications. as will be the case in many countries, the public sector will be required to implement mitigation strategies, such as the retraining of mining sector employees, introduction of new policy instruments to support the renewable energy sector, changes to legislation, interim approaches to reduce the impact of revenue changes on municipalities, measures to build resilience to climate change, programmes in research and development focussed on the necessary diversification of the economy and the remediation of environmental damage from fossil fuel usage. although several departments will be affected by transition risk, this study has looked specifically at the department of environment, forestry and fisheries (deff), which has overall responsibility for environmental management and is represented at executive level by the minister and deputy minister. the department has an annual budget of about $ billion, an amount which has not changed much over the last seven years, and under the medium-term expenditure framework allocations is projected to stay at a similar level in the immediate future (see fig. ). allocations to the department were considered by the interviewees to have grown from a low base, with the department being one of those to have benefitted from the growth in overall government revenue over the period to . opinions as to the adequacy of the present budget in meeting the department's responsibilities were mixed, although it was generally considered that the major constraint was not funding, but capacity to deliver. this sentiment is not echoed by the present minister, who indicated a need to leverage the resources of other sectors in order to ensure that the department could deliver on its present mandate [ ] . the respondents agreed that deff's role is to ensure the protection and preservation of the environment, or in broad terms 'environmental sustainability', and that this role was being fulfilled through the combined actions of regulation and enforcement. however, it was noted by the respondents that the department's efforts can be compromised by the very nature of public policy, which is to represent a broad range of interest groups, and the diversity of government's activities, some of which can impinge on the environment and have direct environmental costs. for instance, the granting of coal mining or fishing licenses was cited as an example of the tension between protection of the environment and economic development. in the case of fishing licenses, the desire to ensure the economic livelihoods of small fishing enterprises was considered to have led to over-harvesting of fish stock, with subsequent depletion, and in some cases collapse, of fish populations. similarly, the granting of additional coal mining licenses as a means of transforming the sector, or the use of pesticides to control malaria, had led to significant degradation of the environment in the affected areas. it can also be argued that environmental protection through restrictions on mining and other resource extraction activities can be justified economically, and that defining sustainability vs. development as a dichotomy is unproductive and misleading. longer term economic development is about environmental sustainability, a perspective which is expressed by the present minister, barbara creecy, who stated [ ] : "what i want to bring to this portfolio is the understanding that caring for the environment, caring about climate change and threats to biodiversity may well be an emotional concern for some people, but -million south africans are directly dependent on our natural resources." it is clear that conflict between the mandate of deff and other departments arise on a regular basis, and that in some cases, the deff is successful in preventing decisions leading to adverse environmental impacts. although no clear pattern emerged from the discussions, the interviewees were questioned about how such tension was managed, and, typically, which areas were prioritised. the results of these questions are presented in the next section. disagreements on government choices are generally resolved through the existing policy framework, which forms the blueprint for government action. however, in ambiguous situations, where proponents of each position can find relevant policies in support of their perspectives, decisions are taken based on the power of coalitions, politics, the charisma of individuals and the strength of lobby groups. such decisions often take place in the executive, which, in the view of one respondent, is a forum with weak environmental representation, given that there is one minister of environmental affairs, but five or six economic ministries, and eight or nine social ministries. in order to ensure a positive result for the environmental portfolio, it is therefore essential that the minister attempts to build an alliance with other ministries and civil society, and is then able to depend on this alliance in supporting a particular issue. as noted by one respondent: [ : ] "a flat-footed environment ministry that refuses to play the politics that is required ain't going to get anywhere." (respondent ) the choice of alliance partners is one of several important components in the construction of such a coalition. it was indicated that likely partners for environmental issues included the security cluster (defence, police, justice) and one or several of the cross-cutting departments (finance; foreign affairs; public service and administration; and planning, monitoring and evaluation). it was noted that the former was often supportive of longer-term perspectives as a means of averting social unrest and inter-nation conflict. apart from being a forum in which the environmental mandate is outnumbered, the executive is also a constitutional body which lacks a referee, particularly if the president does not assume at least some responsibility for non-partisanship. this one-sidedness is especially relevant in decisions relating to the construction of infrastructure or the expansion of one of its public enterprises, where the government acts as both the regulator and the player, and may too easily be able to bend the rules in its favour, or make a trade-off, as described by one respondent: [ : ] government always has to make trade-offs between various sectors and importantly with respect to the environment it is constantly making trade-offs between environmental and economic/social objectives, and really that is its function. so, it is not just a regulator of the environment. in regulating the environment, it balances multiple competing objectives …. i think that is just the hierarchy of decisionmaking that it needs to do (follow). (respondent ) it is not clear how such a hierarchy of decision-making is established, other than that it is political and highly contextual. a propensity for persistent and patient negotiation is an important prerequisite for the minister of environment, forestry and fisheries, especially in pursuing a pro-environment agenda which may be perceived as anti-employment or economic growth. in the next section, the respondents' comments on how such agendas have evolved, and particularly the reasons for any successes, are discussed. during the interviews, several incidents of decisions relating to significant policy changes were discussed, including the implementation of the sugar tax, the introduction of plastic bag regulations, the proposed carbon tax and the reforms on student fees. in the earlier discussion on historical institutionalism, it is argued that such moments of change require, inter alia, strong political support. one important strategy for obtaining this support, which emerged from the discussions, is the inclusion of revenue collection, which predictably secures agreement of arguably the most powerful government department, the department of national treasury. according to the respondents, the ability to extract additional fiscal revenue accounts for the relative ease with which changes such as the sugar tax were introduced, compared to other policy initiatives. the respondents noted, however, that even in the case of additional tax revenue, obtaining consensus from the executive always required a great deal of finesse. the nature of this 'footwork' is central to this study, but inevitably the most elusive aspect to define. it depends on the issue, the context, the personalities, the relevant institutions, the affected sectors, and a number of other factors. it is what distinguishes an effective from an ineffective minister, a progressive from an intransigent or reactionary administration. the respondents noted that in government change generally takes place with difficulty, if at all. the processes and systems are designed to maintain the status quo, perhaps for important reasons. policy stability, particularly macro-economic, is both a desire and a goal in governments, and change, especially when it is driven by narrow political interests outside of established governance processes, can be damaging to countries and economies. such momentum in government action is reflected acutely in budget allocations. the respondents commented that these allocations are mostly unchanged from one year to the next, giving little flexibility to the executive in being able to implement new initiatives. for instance, [ : ] "… every now and then there are some shifts, but those shifts might be fairly significant in the context of one particular department, but i'm not sure that they are significant in the context of an entire sector and usually those shifts are either … i don't think that they are ever more than maybe % of any government's allocation from one year to the next." (respondent ) in other words, there is no new money within treasury and budgets remain substantially unchanged from one year to the next. moreover, the re-allocation of funds from one budget line to another, within the rules of virement, is tightly controlled and requires national treasury approval. individual line managers are able to re-allocate unspent funds within a programme or line item, such as from one project to another, but these changes are relatively minor and cannot be applied to the funding of new initiatives. the challenge for the funding of sustainability transitions is, therefore, to persuade government departments to redirect their existing budgets over time, and mainstream the sustainability development goals in their daily practices. this challenge is recognised by deff as being central to its mandate and it engages regularly with other departments on the need to include such goals with some success. for example, the establishment of the biodiversity centre of excellence by the department of science and technology (now the department of science and innovation), the creation of the green fund and the implementation of the renewable energy independent power producers procurement programme were mentioned by the respondents as resulting from such inter-departmental discussions. there is one important exception to the overall situation of budget stasis, which is the power afforded to the president of south africa. although not explicitly stated in the constitution or the legal system, it appears that the president is able to circumvent the standard budget processes, as happened in the example of the student fees crisis of [ ] . the appropriateness of this use (or abuse) of power was questioned by a respondent: [ : ] "you know if the politicians don't accept the institutional rules of the game, then it is very easy for them to wreck the institutions. … there has to be a basic acceptance, a collective acceptance that this is the rules and this is how you do things. if people don't accept that, they can just wreck institutions very, very easily." (respondent ) in summary, the interviewees concurred on the budget situation as being highly constrained with the opportunity of finding new funding to support sustainability transitions (in pursuance of the sustainability development goals) as being not just remote, but impossible. the redirection of existing funds is the only option, although the budget process is ill-suited to such changes and in general only incremental adjustments over a long period are possible. the implication of these results for sustainability transitions are discussed in the next section. decarbonisation of south africa's energy sector is largely a problem for the state. more than % of the country's carbon emissions derive from the fleet of coal-based power stations owned and operated by the state-owned power utility, eskom [ ] . replacement of these facilities with renewable energy alternatives will require significant new finance. given its present financial circumstances, eskom itself is highly unlikely to be at the forefront of this reinvestment and the reform of the electricity sector. as already noted, the utility is deep in debt, and embroiled in a series of technical and political crises which severely constrain its ability to raise finance from capital markets or the state [ ] . this outlook suggests that much of the investment finance for the energy transition will be provided by the non-government sources. however, government will be required to provide financial support for a range of operational activities, including energy research and development, retraining workers affected by the energy transition, building of capacity to manage energy markets, and incentives to support local manufacture of renewable energy equipment. such funding will be mostly additional to the existing budgets of government departments, and will require either new funding or the re-allocation of budgets from other activities. the likelihood of new funding is minimal. government finances, already stretched to the limit before covid- , are now in a highlyborrowed predicament, with the level of government debt rising to % of gdp in the / financial year [ ] . the re-allocation of monies from other expenditure items within the operational budgets will be an imperative if government funding for decarbonisation and the energy transition is to be made available. the premise of this article has rested on the assumption that high-level decisions for such changes reflect not only the extent of the need to fulfil each department's public mandate, but also the strength or weakness of the interdepartmental power relationships. an understanding of these dynamics is therefore critical to the implementation of emergent and experimental policies within government, such as policies to support decarbonisation, sustainability transitions and the transformation of socio-technical systems. this study has intimated that the budget process affords limited opportunity for negotiations on departmental budgets. however, there are points in the process, referred to as windows of opportunity, when such changes are possible if a number of preconditions have been met. the concept of a window of opportunity is by no means unique. as already outlined, it is shared by both msa and the multi-level perspective; the latter focuses on the two streams of regime destabilisation and niche consolidation, whereas msa requires the conjuncture of problem, policy and politics. the south african context supports both approaches, but identifies the fourth precondition of an affordable solution. conditions in developing countries are frequently resourceconstrained, implying that regime changes lead to extreme changes for the affected parties. as a result, the conflict can be more apparent, the outcomes more divisive and the moments of change take place more unpredictable. in other words, the higher financial stakes determine the nature of the struggle and the resultant change, should it occur. the critical junctures or windows of opportunity are less frequent, more contested, require more significant alignment of interest groups and are characterised as strong conjunctural processes. the pre-conditions for these windows of opportunity are also different. it is argued here that one further stream is required, namely favourable techno-economic value or improvements in the benefit to cost ratio of the potential solution, as exemplified by the introduction of the sugar tax. this amendment to the msa is essential to understand how change can emerge, and hence to engineer or accelerate sustainability transitions. furthermore, each of the four streams needs to be characterised based on its dynamics or rates of change. the four streams are now discussed in more detail. policy changes rarely seem to take place in response to opportunities. politics is a domain that appears to be mainly reactive, and often takes the form of crisis management. given the multiple demands on the public sector, and the huge scale of the issues, this reactiveness is perhaps not surprising. one general precondition for policy change seems to be clear: there must be a shared understanding of a clearly defined problem for such changes to be considered. the mere existence of a problem is also not on its own sufficient; policy windows are more likely to open when the problem is both growing in scope and the rate of growth is accelerating, to the extent that it is mobilising extensive political support outside of government, most notably in civil society with its ability to mobilise civil unrest. the power of civil society to destabilise the landscape depends on the extent of mass mobilisation and public support for a particular issue, and the degree to which this support is able to gain momentum within nation states. government may then act to repress or outlaw civil society protest, as happened repeatedly under apartheid south africa [ ] . the inclusion of regime destabilisation as a necessary step in the processual framework of this model is also part of the msa and also the multi-level perspective. examples of such changes include the occurrence of pandemics, the environmental crisis, the advent of widespread road transport and the rise of wheat mono-culture [ ] . opinions on how to change a dominant regime have been offered by many authors. milton friedman, well known for the development of stabilisation policy, surprisingly had a perspective on how to change a socio-technical regime. he considered that only a crisis produces change, and that the most important pre-condition was to be wellprepared [ , p ix] . this requirement of being well-prepared is partly captured in the theories of policy experimentation and strategic niche management [ , ] . these argue that transition requires initial experimentation with new approaches, some of which may fail, but the successful interventions may eventually gather sufficient momentum to result in changes at the meso level. importantly, there are no clear predictors of success with early experiments, and policy frameworks may themselves not achieve the desired outcomes. it is therefore critical that such interventions be accompanied by a transparent and insightful monitoring and evaluation framework, which can inform whether the policy should be continued, strengthened or withdrawn. the stream of techno-economic value refers to the perceived cost benefit ratio of a public policy or intervention [ ] . such analyses are a legislative requirement within the south africa public service, and are typically framed with questions such as "what is the value for money?" or "what is the cost/benefit ratio?" [ ] . cost/benefit analysis is used as a means of informing budget decisions based on the economic viability or socio-economic benefit of a particular intervention. there are multiple approaches to the analysis, including the use of standard financial techniques such as discounted cash flows, net present values, internal rates of return and payback periods [ ] . mostly, the analysis requires the monetisation of the resultant social welfare and economic benefits of the intervention, the sum of which are then compared to the overall costs. measurement of the net social welfare is complicated by the large variety of possible benefits, the relative value of each intervention and the prediction of its impact. although costs are mostly explicit and relatively straightforward to calculate, the quantification of benefits is subject to assumptions on critical issues such as the contribution of energy to the quality of life, or the magnitude of the social discount factor, or the value of possible externalities (such as an improvement in the quality of the natural environment) which are associated with a particular intervention. some of these limitations can be avoided by applying cost/benefit analysis only as a comparative technique. in this way, the same assumptions apply to all the options being reviewed, and allow for the selection of the most cost-effective alternative amongst a portfolio of analogous projects. a useful example of how the techno-economic value can influence resource allocation decisions is the case of the declining cost of renewable energy technologies. although the cost of electricity from photovoltaic panels and onshore wind turbines was, prior to , generally more expensive than energy obtained from fossil fuels, this situation has now reversed and renewable energy technologies are now consistently cheaper [ ] , due mostly to improved manufacturing efficiencies and greater production capacity within the sector [ ] . the lower levelised cost of energy has been an important influence on the planning of national energy systems and the decisions to incorporate higher levels of renewable technologies within such systems [ ] . as for the problem stream, a positive impact on social welfare is not a sufficient condition; the benefit should have, at least, the prospect of growth. in other words, the potential savings should be increasing, or the cost of implementation should be decreasing, as indicated in the example of renewable energy technologies. accepting the validity of the normative process that policy determines strategy, strategy determines operational plans and operational plans drive budget allocations, it is reasonable to assume that budget allocations match the overall policy framework. however, government as a punctualised actor is in fact not a single entity; it is a loose agglomeration of multiple actors with overlapping but also conflicting policy objectives. for instance, industrial policy may contradict environmental policy, fiscal policy may oppose energy policy, health policy may conflict with trade policy, and defence policy may act against science and technology policy. in terms of decarbonisation, and the likelihood that departments of the environment will be able to secure funds from the national fiscus in support of decarbonisation, it is clear that attention to the politics is critical. for south africa, which faces a million metric tonne per annum decarbonisation challenge with limited ability to raise the necessary resources, this aspect of the environmental campaign will be vital. using the estimated value of $ , per mt carbon dioxide equivalent, the decarbonisation cost for south africa will amount to $ , billion, or % of gdp over a -year period ( to ). in comparison, the decarbonisation costs for the united kingdom will be . % of gdp, as previously indicated in the introduction. south africa, therefore, has limited options in addressing the decarbonisation challenge, other than to consider budget reallocation. the issue of securing resources to support sustainability transitions, and particularly public funding, is also highlighted in the literature on technological innovation systems, where resource mobilisation is identified as one of several critical functions for the establishment of systems to support such transitions [ ] . technological innovation systems as a conceptual model for transition is also a processual framework and in its discussion of resource mobilisation, it is argued that this function needs to be sufficiently covered from the early stages in the development of a new system. identifying resource allocation as an important part of the overall transition process is in itself insufficient in supporting the transition. it is equally important to understand the source of the funds and how they can be secured. public funding is critical in such transitions since the initial stages will be characterised by high levels of risk and limited participation from private funders. however, public budgets are subject to intense competition from other priorities including health, security, education and infrastructure, and the prospects of successfully lobbying for the re-direction of public funds from existing portfolios are severely restricted. this article has argued that such moments do exist, but in resource constrained setting such as south africa, they occur only within narrow windows of opportunity characterised by an escalating problem, the adoption of a recent policy framework, the prospects of an improving benefit to cost ratio, and a willingness to engage in realpolitik. previous studies have concluded with a number of policy recommendations for low-carbon transitions including the need for dynamic policy mixes dealing with demand-and supply-side instruments, a focus on politics in addition to policy, and active steps to phase-out existing technologies in addition to supporting niche-innovation [ ] . the results of this study suggest a number of more specific recommendations for resourceconstrained countries as follows. low-carbon futures are unlikely to be realised without public funding. as is argued in the case of public-funded research and development, such transitions will be subject to market failure and under-investment in the absence of public support. it is therefore important that government establish dedicated funding for sustainability transitions, in the same way that they have created budgets for industrial development or energy infrastructure. developing the structure and rationale for these budgets is an important step towards securing the actual funding. in resource-constrained settings, it will be hugely challenging to secure funds without re-allocation from existing portfolios, the prospects of which are unlikely on a daily basis. however, there will be windows of opportunity or critical junctures, which will arise when there is alignment between an escalating problem, a supporting policy framework and a rising benefit to cost ratio. an appreciation of such moments, and a mechanism for recognising their opening, is an important insight of this study. although leadership and agency are critical, engaging in politics is more that individual action. all actors, but especially politicians and senior public servants, need to enter into relationships with each other, and with civil society, labour and advocacy organisations. in the final decision on budgets, the most important factor may not be the strength of the evidence for the intervention, but the strength of the alliances which are willing to support the re-allocation proposal. conclusion and recommendations in addition to an overall cultural change, transitions to sustainability in south africa, and perhaps other countries, will require new programmes and projects within government. importantly, these programmes will require new funding. however, the prospects for this are severely limited by the present situation of decreasing government revenues and the overall path dependence of budget allocations. the lack of new funding will hinder such transformation and requires the development of new strategies. this research has sought to define the main components of the budget process in south africa and hence develop a strategy to overcome funding limitations for necessary and important operational programmes. it concludes that the conjunction of four streams is key to successful changes in budget allocations, namely a growing problem, preferably accelerating, a recently developed policy framework, a strong techno-economic justification whose prospects likely to become more attractive, and a strengthening political stream consisting of powerful alliances able to drive budget changes through the executive. these conclusions align with the insights of historical institutionalism, which include the supposition that change takes place as a result of contestation, and at the meso level, the destabilisation of the existing socio-technical regime combined with significant challenge from an alliance of niche players. this result implies that sustainability transitions in south africa will require highly strategic leadership of the environmental portfolio, which can direct the processes of conjuncture and act at critical moments in order to effect transformation. in particular, this leadership needs to sharpen the arguments for public funding to support sustainability transitions, develop the necessary budget structure, learn to recognise critical junctures or windows of opportunity, and network with power actors willing to support budget reallocations. waves of disruption in clean energy transitions: sociotechnical dimensions of system disruption in germany and the united kingdom these countries have committed to a net-zero emissions goal -could it solve the climate crisis? /l. /rev. : adoption of the paris agreement the analyses on the economic costs for 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journeys: theory, findings, research agenda, and policy applied welfare economics: cost-benefit analysis of projects and policies socio-economic impact assessment system guidelines, department of planning monitoring and evaluation renewable energy gathers steam in south africa functions of innovation systems: a new approach for analysing technological change the socio-technical dynamics of low-carbon transitions the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. key: cord- -d qevnl authors: brown, stephen p.a.; brown, marilyn a.; madlener, reinhard; thomas, stephen; zhou, peng; antunes, carlos henggeler; yeh, sonia; du, huibin; goutte, stéphane title: the continuing evolution of energy policy date: - - journal: energy policy doi: . /j.enpol. . sha: doc_id: cord_uid: d qevnl nan available online april - /© published by elsevier ltd. the continuing evolution of energy policy as the world confronts the covid- pandemic, we hope that all of you are doing well. we know that many lives have been greatly disrupted, and that world economic activity is slowing and maybe declining in some places. we have read reports that energy consumption has been greatly affected by the slowdown in world economic activity-likely contributing to the sharp plunge in oil prices earlier this year. we do not know how long this pandemic may last. as we look forward to the end of the pandemic and a recovering world economy, however, we wonder if and how energy systems may have to be transformed, and whether new energy policy needs and approaches will emerge. will we see any change in the trajectory of adopting sustainable energy systems and reducing carbon emissions? in the academic world, many of us are now teleworking and teaching our courses online. this transition has proved time consuming-so we want to thank our many reviewers who are staying on or close to schedule. so far, energy policy has been mostly unaffected by the pandemic, but we must recognize that the elsevier employees who are responsible for the operations side of the journal may at some time be affected by in the meantime, we want to keep you informed about some recent developments regarding energy policy, including a little about its history and our editorial priorities. the first issue of energy policy was published years ago in june . in its first year of publication, energy policy had three issues that contained research articles and several reports. the focus was on oil, natural gas, electricity markets and nuclear energy. none of the articles in the first year focused on environmental issues, climate change issues, energy efficiency/conservation or renewable energy. john a.g. thomas was the editor with ivan f. klimes as the assistant editor. the international editorial board, as it was then called, included such well-known energy researchers as morris adelman, peter odell and sam schurr. over the years, the important policy issues in energy use and supply have changed, and the interest in energy policy issues has grown. as a result, energy policy's content has evolved and expanded, reflecting the pivotal role that policies play in shaping energy systems across the globe (fig. ). the volume had one article out of that addressed environmental issues related to energy use. the the , volumes had one article each on climate change issues related to energy use. the volume also had one article addressing environmental issues related to energy use. dominated by the oil crises, security of supply, and energy efficiency, the , , and volumes did not have any articles addressing environmental or climate change issues. the volume had one article that addressed energy efficiency/ conservation. the volume had several such articles. the volume had one article that addressed renewable energy. the , , volumes had no articles about renewable energy. by the mid- s, however, the journal regularly published articles addressing energy efficiency, energy conservation and renewable energy. today, these topics occupy regular space in every volume of energy policy. chernobyl (and later fukushima), acid rain, climate change and other environmental issues related to energy supply and use gradually changed the direction of research about policies affecting energy use and production. by the mid-to late s, the journal regularly published articles on environmental issues. articles about climate issues related to energy use took a bit longer to develop, and the journal published a special issue on climate policy in . today, both environmental and climate change topics are featured in every volume of energy policy fig. ). during its first ten years of publication, energy policy grew fairly robustly in size. volume (published in ) comprised four issues with a total of articles, representing a doubling of articles compared to and an annual average growth rate of . % ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . volume (published in ) comprised issues with a total of articles, representing more than a tripling of articles published in comparison to volume and an annual average growth rate of . % ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . perhaps reflecting the weakness in world oil prices, volume (published in ) comprised issues with a total of "only" articles, representing a . % increase of articles over volume and an annual average growth rate of merely . %. increased recognition about environmental issues and climate change associated with energy use and then rising oil prices have stimulated a strong surge in research about energy policy. in , energy policy had about a percent acceptance rate and published articles. the figure represents nearly a -fold increase over the number of articles published in , or an annual average growth rate of . % (from to ). the articles published in covered a wide variety of topics in energy policy including primary energy resources; energy conversion, transportation, transmission and storage; energy use and end-use technologies; energy markets and pricing; contents lists available at sciencedirect energy policy journal homepage: http://www.elsevier.com/locate/enpol https://doi.org/ . /j.enpol. . energy and society; energy and the environment; investment, financing and other economic issues; and technological change. clarivate reports a fairly steady climb in energy policy's two-year impact factor since . the respective figures are . in , . in , . in , . in and . in . the impact factor will become available in june . the impact factor places energy policy in the top quartile of journals in economics (ssci), environmental studies (ssci), environmental sciences (scie) and energy & fuels (scie). similarly, research papers in economics' (repec's) aggregate ranking for energy policy places it in the top of economics journals over the past ten years. energy policy is available in thousands of academic libraries and government institutes and had more than million full-text downloads in . after john a. g. thomas, patrick coyne served as editor for a number of years. with several changes in publication houses, the records of editorial leadership are less clear in the s and s. by , however, the editorial team was lyndon driscoll, managing editor and nicky france, editor. by , lyndon driscoll was the publisher and nicky france was the sole editor-a role she served in for many years before lorna greening and michael jefferson took over as editors in . with greening's departure in , the editorial team expanded to five people: stephen p. a. brown, michael jefferson, reinhard madlener, stephen thomas, and peng zhou. marilyn brown joined the team in . when michael jefferson retired as senior editor in early , carlos henggeler antunes and sonia yeh joined the editorial team. more recently huibin du and st� ephane goutte joined the editorial team, bringing the number to nine. as described above, energy policy recently added two members to the editorial team, huibin du and st� ephane goutte. huibin du joined energy policy as an associate editor on december , . prof. dr. du is a professor and the vice dean of the college of management & economics, tianjin university. her expertise is in resource and environmental management. as a principal investigator, she has conducted a national key r&d program of china, a national natural science foundation of china (nsfc) key project, and many other projects. based on these programs, she co-led a large collaborative team from georgia institute of technology, stony brook university, the university of adelaide, chinese academy of sciences, peking university and several other universities/institutes to implement research on air pollution regional joint governance, renewable energy development, and energy-water nexus, energy-economy-environment ( e) his interests lie in the area of mathematical finance and econometric applied to energy or commodities. he has published more than research papers in international peer-reviewed journals. he has also been a guest editor of various special issues of international peerreviewed journals and editor of many handbooks. he was a visiting professor at university of luxembourg and vietnam national university of hanoi, vietnam. although energy policy has evolved and taken on a greater academic relevance since its beginnings in , in many ways it remains the same. although the journal has become more technical as the field of energy-related research has matured, we expect the articles that we publish to inform energy-related policy. mathematical modeling, econometrics and other approaches should serve only to support the policy issues being examined. modeling should be a means rather than an end. papers that are focused on technology assessment, mathematical modeling, econometrics and other approaches with a few policy implications tacked on at the end, or no deeper and explicit new policy insights and implications derived from the analysis, do not belong in energy policy. they should be sent to more technically oriented journals. at energy policy, we consider a wide variety of topics that include fossil energy, renewable energy, nuclear power, behavioral, environmental and climate issues-provided that the manuscript focuses on the policy issues related to energy supply or use. we consider manuscripts with research methods from a wide variety of disciplines-including economics, engineering, law, political science, public policy, psychology and sociology. we expect these manuscripts to either advance research methods or represent the current state of the art in these disciplines, and for the manuscripts to address policy issues about energy supply or use. energy policy's editors do have the ability to make the direct transfer of a manuscript to some other elsevier journals and occasionally will suggest such a transfer (either pre-or post-review). a direct transfer does require author approval, and avoids the authors' burden of resubmission to another journal. in most cases, however, the editors prefer to make suggestions about other journals and let the authors decide which journal is most appropriate. first page of the first article ever published in energy policy (leslie dienes was associate professor in the department of geography-meteorology at the university of kansas), compared to the appearance of a specimen article (on regional energy inequality in the uk by a group of authors from leeds and sheffield university) in may . we have made a few additional changes at energy policy, as explained below in some detail. we have reduced considerably the delay in handling manuscripts. we have increased the word limit for policy perspectives. we are working to increase the number of invited review articles, and we continue to seek the submission of manuscripts addressing behavioral aspects of energy choices that need to be better understood in order to design effective programs and policies. surprisingly, a number of manuscripts fail initial technical checks and are returned to the authors for correction. such problems can greatly delay assignment to an editor, and we encourage the authors to take responsibility for the submission of appropriately formatted articles (i.e. such that they match the requirements described in the guide for authors). throughout most of , the editorial capacity of the energy policy was somewhat less than the more than submissions that the journal sees during a typical year. by fall ( ), energy policy had a backlog of unprocessed manuscripts that led to a delay of - weeks between the time a manuscript was submitted to the journal and it was assigned to an editor. the delay resulted in considerable author concern and frustration. in late december and early january , the editors undertook a special project to substantially reduce the backlog of manuscripts by culling out the considerable number of manuscripts that did not meet the aims and scope of the journal. by the end of january, the time between submission and assignment to an editor was reduced to several weeks. we are continuing the practice of quickly culling out manuscripts that do not meet the aims and scope of the journal, with hopes of being able to maintain relatively quick assignment of the surviving manuscripts to editors throughout and beyond. full length articles are the principal work that we publish. these articles should present rigorous research about energy policy issues. they are normally - words. the editors will consider papers of exceptional merit up to , words. authors submitting a full length article of more than words must submit a brief statement in their cover letter, explaining the exceptional merit of the submission to energy policy. research notes are shorter papers of less than words. research notes should present fully realized research but are shorter in length than full length articles. we have increased the word limit for policy perspectives from to words. a policy perspective is a relatively short contribution that offers judgment on an energy policy issue-normally without original research. a policy perspective should present well-reasoned and fully considered thinking to reach conclusions that are germane to important policy issues in energy supply or use. the number of policy perspectives per journal volume may be limited at the discretion of the editors. energy policy occasionally publishes invited review articles that are reviews of the literature. it does not publish reviews of the energy situation in a region, country or group of countries as invited review articles. invited review articles are typically initiated by one of the editors inviting a senior person to provide such an article. the editorial team will consider proposals for outstanding articles that review the literature and well capture the policy issues, but such proposals are typically expected to be received from individuals with senior standing in the profession. the editors of energy policy recognize that additional theoretical and empirical analysis of the behavioral aspects of energy choices is needed to better inform the design of energy programs and policies. we continue to seek more submissions examining the behavioral aspects of energy choices. what is the role of consumer trust and social norms, cognitive effort and rational inattention, environmental attitudes, time preferences, loss aversion, habits and habit formation, status quo bias, and more? these concepts need to be examined more fully to better understand how behavioral responses and shifts (including the rebound effect) could run counter to policy goals and alter policy effectiveness, and to assess how energy policy could be reformulated to address these behavioral responses. before it is assigned to an editor, each new manuscript is screened by elsevier's technical staff to assure that it complies with submission requirements. a surprising number of manuscripts are returned to the authors for failure to comply with the submission requirements. the technical expectations are: ) the submission includes all the expected files, including cover letter, highlights, manuscript file, tables (if needed) ) the authors listed on the manuscript match the list of authors specified in the submission; ) - keywords are present in the manuscript file; ) all headings and subheadings are numbered throughout and in the journal's style; ) the first main heading is labelled 'introduction' and the last main heading is labelled 'conclusion and policy implications'; ) references are provided in the journal's style (author þ year); ) the paper is formatted with double-line spacing; ) all of the submission questions have been answered correctly; ) the word count is below the maximum, and that the number matches the actual word count of the paper (according to the counting rules specified in the guide for authors); ) - reviewers are suggested, ideally with a doctoral degree, and none of them are at the same institution as any of the authors; and ) the abstract is - words as peter odell ( ) wrote on the tenth anniversary of this journal: "energy policy, which commands the interest and respect of both scholars and policymakers in so many aspects of the important energy issues, will remain an important forum for presentation and discussion …" energy policy has a continuing mission of advancing and informing policy issues about energy use and supply. fulfilling this mission requires well-researched articles using rigorous research methods and thinking about energy policy issues. we consider a continuum of papers, from those that make more substantial contributions to policy to those that make more substantial contributions to methodology, but we expect all papers to have a focus on policies about energy supply or use. by characterizing our priorities, the editors hope to continue to attract strong manuscripts with meaningful energy policy implications that can be published in future issues of energy policy. energy policy, - : retrospect and prospect key: cord- -zu mns authors: gao, jian; yin, yian; jones, benjamin f.; wang, dashun title: quantifying policy responses to a global emergency: insights from the covid- pandemic date: - - journal: nan doi: nan sha: doc_id: cord_uid: zu mns public policy must confront emergencies that evolve in real time and in uncertain directions, yet little is known about the nature of policy response. here we take the coronavirus pandemic as a global and extraordinarily consequential case, and study the global policy response by analyzing a novel dataset recording policy documents published by government agencies, think tanks, and intergovernmental organizations (igos) across countries ( , policy documents from jan nd through may th ). our analyses reveal four primary findings. ( ) global policy attention to covid- follows a remarkably similar trajectory as the total confirmed cases of covid- , yet with evolving policy focus from public health to broader social issues. ( ) the covid- policy frontier disproportionately draws on the latest, peer-reviewed, and high-impact scientific insights. moreover, policy documents that cite science appear especially impactful within the policy domain. ( ) the global policy frontier is primarily interconnected through igos, such as the who, which produce policy documents that are central to the covid policy network and draw especially strongly on scientific literature. removing igos' contributions fundamentally alters the global policy landscape, with the policy citation network among government agencies increasingly fragmented into many isolated clusters. ( ) countries exhibit highly heterogeneous policy attention to covid- . most strikingly, a country's early policy attention to covid- shows a surprising degree of predictability for the country's subsequent deaths. overall, these results uncover fundamental patterns of policy interactions and, given the consequential nature of emergent threats and the paucity of quantitative approaches to understand them, open up novel dimensions for assessing and effectively coordinating global and local responses to covid- and beyond. human society is often challenged by emergencies, from natural disasters [ ] [ ] [ ] and pandemics [ , , , ] to human conflicts [ , ] and other emergent crises [ , , ] . despite the consequential nature of public response [ ] [ ] [ ] [ ] [ ] [ ] [ ] , governments often struggle to manage these emergent problems, potentially due to various reasons ranging from the inherent difficulties in altering rules and allocating attention and resources [ , ] to uncertainties about the evolving nature of the problems [ ] [ ] [ ] .the covid- pandemic provides a high-stakes case for examining the nature of policy response [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] ]. indeed, the coronavirus pandemic is not only a public health crisis but also creates enormous challenges to social, economic, and political systems around the world [ , , ] . at the same time, evolving knowledge about the nature of the disease [ , ] , as well as evolving knowledge about containment policies and social implications [ , - , , , ] , presents a dynamic and uncertain policy environment. to quantify the global policy response to the covid- pandemic, we analyze a novel dataset of policy documents ( , documents published from january nd to may th , ). the dataset categorizes the source, topics, publication date of each policy document, and further includes each document's cited references. the institutions include government agencies, think tanks, and intergovernmental organizations (igos). the coverage is worldwide, with policy documents from countries, and includes all major economies and large population centers, with a notable exception of mainland china, overall covering ~ . % of the world population, ~ . % of total gross domestic product (gdp), and ~ . % of confirmed deaths worldwide due to (as of may th , see fig. s and si s . for further description). within this corpus, we identify covid- related policy documents through keyword filtering ( , documents in total, see si s . ), allowing us to compare covid- policy documents with all other policy documents published in . for each policy document, we further analyze all the references cited therein, allowing us to link policy documents to scientific papers and other policy documents they reference. these linkages can inform how different institutions interact in policy making and also illuminate the nature of the scientific knowledge upon which these policies draw. overall, the total number of policy documents recorded in our database grows roughly linearly with time, averaging approximately new policy documents per day (fig. a) . by contrast, the number of covid- related policy documents features highly non-linear growth, approximated by an exponential pattern ( fig. b and inset) , showing rapid shifts in global policy attention over the past few months. to understand how policy attention tracks the coronavirus outbreak, we measure the share of policy attention to covid- by calculating the proportion of covid- related policy documents among all policy documents published on a given day. we then compare this share with how the pandemic unfolded globally, as traced by the johns hopkins covid- tracking map [ ] . we find that the share of covid- policy attention shows a remarkably similar trajectory as the total confirmed cases of covid- over time (fig. c , red vs blue). we observe the same pattern when using total confirmed deaths (fig. s ) . together, these results show that the share of policy attention to covid- closely corresponds to the global unfolding of the pandemic (see si s . for more detail). to inform how the covid- policy attention may reflect policy-making institutions' priorities, we further examine the content of the covid- related policy documents, breaking them down by field (fig. d ) and topic (fig. e ). for both analyses, we observed clear shifts in policy attention related to the pandemic, with policy priorities shifting from issues in public health to economy and society. indeed, we first classify covid- related policy documents by field, grouping them into three major field categories ("science & health", "economy & labour", and "society & others", see si s . for more detail). plotting the share of covid- policy documents across these field categories (fig. d ), we find that in the early stage of the outbreak (january and february ), about % of covid- policies belong to the health and science category, showing a clear, initial focus on public health issues. the policy priorities show a visible shift, however, since early march , with a notable rise in policy attention to issues around the economy and society, suggesting a growing policy balance between health and socio-economic implications of the pandemic (see fig. s b for results at the individual field level). we further break down these policy documents at the narrower topic level, plotting dynamics related to covid- for the top topics (fig. e) . we find again an initial focus on healthrelated topics (in blue), followed by a clear increase over time in the share of topics related to economy and society (in red). indeed, fig. f -g respectively show the word cloud of all topics pre-and post-who's pandemic declaration, which illustrates a stark difference in policy priorities across the two periods, shifting sharply from public health to socioeconomic issues (see fig. s a for topic changes by month). furthermore, the shifts documented in figs. d-g are observed in covid- policy documents only, as we repeated all our analyses for other policy documents published in the same period, finding that their shares by field or topic are relatively stable over time (fig. s ). overall, fig. demonstrates a rapidly evolving global policy frontier that closely corresponds to the evolution of the pandemic. yet at the same time the scientific research related to covid- also evolves rapidly, as exemplified by the strong response from the global research enterprise [ , ] . indeed, as of may th , over , papers on coronavirus research have been published in , with preprint servers playing an outsize role in disseminating the latest science [ , ] . the parallel advancement of the policy and scientific frontier in response to the pandemic raises a crucial question: is our policy understanding of covid- closely linked with scientific understanding, or largely separated from the ivory tower? to answer this question, here we trace all scientific papers cited by policy documents in our corpus and match them to large-scale publication and citation databases (si s . ), offering a unique opportunity to quantify the role of science in the global policy response to covid- . we find that covid- policy documents rapidly evolve with the scientific frontier. first, fig. a shows that the probability for these policy documents to cite at least one scientific paper fluctuates until who's pandemic declaration, and features a steady increase afterward. fig. b plots the age distribution of scientific evidence referenced by covid- policy documents, showing that covid- policies are disproportionately centered on the latest scientific frontier. indeed, out of all scientific references drawn upon by covid- policy documents, . % of the scientific papers were published in . this rate of utilizing the most recent scientific knowledge is over ten times larger than seen for other policy documents. not surprisingly, we find that the latest scientific evidence cited by covid- policies is primarily related to research on coronavirus ( . %). however, as policy attention shifts gradually from health to economy over the course of the pandemic (fig. d-e) , we also observe a similar shift in the fields of science that covid- policies cite (fig. c) , showing a clear shift from drawing primarily upon the biomedical literature to citing economics, society, and other fields of study (figs. s c). together, these results suggest that despite the extremely recent development in covid- related scientific research, new scientific work substantially finds its way into policy documents, prompting us to next examine the quality of scientific evidence that informs policy. to proceed, we separate covid- related papers into two groups based on whether or not they are referenced by policy documents. we then measure each paper's scientific impact, approximated by the number of citations the paper receives from other scientific papers. we find a dramatic impact difference between the two groups ( publication venues. we find that different venues differ widely in publication volume, with preprint servers such as medrxiv, biorxiv, and ssrn publishing an order of magnitude more covid- related papers than peer-reviewed journals. yet, despite the large amount of papers posted on preprint servers, their impact in policy is rather limited, as these preprint servers show consistently fewer policy citations than average. by contrast, covid- policies disproportionately reference peer-reviewed insights, drawing especially heavily on respected medical journals, both general (e.g., lancet) and specialized (e.g., clinical infectious diseases). amid growing concerns over the quality and abundancy of coronavirus research posted on preprint servers [ ], these results show that peer-reviewed journals appear to remain an important institution in supplying scientific evidence for policy making. overall, the covid- policy frontier appears grounded in extremely recent, peer-reviewed scientific insights, and science directly drawn by this policy frontier is viewed as especially impactful within the scientific community itself. our next set of analyses present the same pattern but on the other side of the policy-science interface, showing that policy documents that are grounded in the scientific frontier tend to gather substantially more use within the global policy network. figure f separates covid- policy documents by whether they cite any scientific reference or not, and compares the average number of citations from other policy documents. we find that covid- policy documents that cite at least one scientific paper are associated with a significantly higher number of citations from other policies, more than doubling its policy use than those without scientific references. to test if the difference observed in fig. f can be explained by other covariates, we further use a regression model (see table s and si s . for more detail) to control for policy sources, the total number of scientific references, the date of policy documents, and self-citations, finding our conclusions remain the same (p < . ). together, the results in fig. show that, despite the rapidly evolving nature of the pandemic, the policy and scientific frontier of covid- are closely interlinked, with advances directly along the policy-science interface being notably more impactful within their own domains. (government agencies, think tanks, and igos), we find that overall igos produce the fewest number of documents ( fig. a ), yet the policy documents they produce tend to be most closely connected to the scientific frontier ( fig. b ) and occupy a central position within the global policy network (fig. c-e) . we visualize the policy citation network among covid- policy documents in fig. e . each node is a covid- policy document with at least one citation linkage to other covid- policy documents, and two nodes are connected if one policy cites the other. we color the nodes based on the institution that published the policy (igos in blue, think tanks in orange, and governments in green). a node's size is proportional to the number of citations received within this policy network. we also add a node border (in black) for those that draw on scientific papers. the networks convey three primary insights ( fig. c-e) . first, although igos produced the fewest number of policy documents among the three types of institutions (fig. a) , blue nodes are the most visible within the network, indicating igos are disproportionately more likely to produce hubs within the policy network (fig. f) . second, hubs in this policy network mostly have black borders, indicating that those that attracted more policy use are also directly grounded in science, consistent with fig. f . third, while the connectivity among policy documents is relatively sparse ( , linkages between , nodes, <kin> = <kout> = . ), a high fraction of policy documents coalesce into the same giant weakly connected component (gwcc, . %), illustrating the connectedness within the global policy frontier. to quantify the relative locations of policy documents within the network, we use the k-core algorithm to calculate the coreness of each node (fig. f inset, si s . ). a popular concept to measure the core-periphery structure of complex networks, k-core is a maximal subgraph of the original network, all of which are connected to at least k other nodes in the group [ ] . figure f inset compares the distribution of coreness for policy documents produced by the three institutions, showing policy documents produced by igos systematically occupy central positions within the network, characterized by a high k-core score. more importantly, these igo documents appear critical for the global connectivity of this policy network. in fig. g we randomly remove a fixed number of nodes from certain types and measure the remaining gwcc size [ , ] , finding igo documents carry disproportionate importance in connecting the network. indeed, as fig. e shows, removing igos' policy documents drastically alters the structure of the policy network. while igos only account for . % of the nodes (fig. c ), removing them shrinks the gwcc from . % to . % (fig. dg ). contrasting igos with other institutions, we find that the effects of removing policy documents by think tanks or government agencies are not nearly as significant (fig. d -eg). lastly, the fraction of the gwcc decreases to merely . % if we further remove all think tank policy documents, keeping only those by government agencies (fig. e ), highlighting that policies by individual countries rarely connect directly across geopolitical boundaries. taken together, fig. shows that the overall connectedness in the covid- policy frontier is mainly mediated by igos, the absence of which alters the global policy landscape. and among igos, the who plays a dominant role across all organizations recorded in our data (fig. h ). while these results highlight the critical role of igos and especially the who in policy responses to ] , they also suggest that the apparent connectivity in the global covid- policy network hides a high degree of isolation at the individual governmental level. indeed, if we only consider policy responses by government agencies, individual countries are fragmented into small isolated clusters, as their covid- policies primarily interact within their geopolitical boundaries. this suggests that individual countries may differ in their policy response to covid- [ , ] , prompting us to examine whether country-level variations in covid- policy attention may predict country-specific realities of the pandemic. therefore, in our final analyses, we consider the covid- policy response at the individual country level, and explore its correlation with the country's effectiveness in containing the pandemic (fig. ) . for each country in our database, we mark the calendar date when three covid- deaths were first recorded within the same day [ ] . we then measure the country's total deaths from covid- over the following days, which approximates the country's effectiveness in containing the disease. we further calculate the share of policy attention to covid- in that country during the prior days, i.e., in the days before three daily deaths were first recorded in that country. plotting the results in fig. a , we find a strong negative correlation (n = , p < . ), showing that countries with a greater share of policy documents addressing covid- experienced substantially fewer subsequent deaths. several additional analyses help further assess this result. specifically, countries with larger populations may naturally experience greater deaths. countries with greater per-capita income may also be more susceptible (e.g., through higher influxes of international travel). finally, countries that experienced later onset of the outbreak may have more time to prepare and learn from others. table s considers various regression models to control for these additional features. we find robust evidence that greater population predicts greater death and that later onset of the disease is associated with less ensuing death, which is consistent with global learning about how to handle the pandemic. at the same time, the explanatory power of a country's early policy attention remains robust. figure b shows the ongoing predictive role of a country's prior policy attention, net of other controls (p = . ). figure c shows the collective power of prior policy attention and the other controls in predicting subsequent deaths, demonstrating the substantial predictive capacity of this simple model. we further test the robustness of these findings across several additional dimensions. we restrict the analysis to countries with higher volumes of policy documents recorded in our database (tables s -s ) , examine different daily death thresholds to mark the onset of the disease for each country ( fig. s ) and consider alternative functional forms (tables s -s ). we also adopt alternative data sources for the covid- tracking data, as provided by the european centre for disease prevention and control (fig. s d) , alter the measures of a country's effectiveness in containing the pandemic by calculating total confirmed cases instead of deaths (fig. s a) , examine per-capita death rates for each country (fig. s b) , and restrict the analysis to countries with a minimum number of covid- policy documents (fig. s ). the findings are broadly robust to these many alternatives. finally, we use an alternative policy attention measure -the stringency index provided by the oxford covid- government response tracker (oxcgrt) [ ] -which is developed independently of the overton policy document database we studied. this alternative source shows a similar relationship (table s ) , where greater policy stringency predicts fewer subsequent deaths, and further suggests the robustness of our result. overall the results suggest a country's early policy attention to covid- predicts its containment of the outbreak. the patterns presented in fig. are correlations and do not identify causal mechanisms. indeed, there are a large number of social, cultural, economic, and political factors that may influence a country's response to covid- . yet, despite these many potential influences and complex factors, a country's early policy attention provides a simple yet powerful proxy that closely predicts a country's effectiveness in containing the pandemic, offering a new dimension in measuring heterogeneous policy responses and predicting differences in outcomes. while the data used in this paper represents among the largest collection of policy documents worldwide, there are limitations of the data that should be considered when interpreting the results (si s . , s . -s . ). first, policy documents from mainland china, where the covid- originated, are notably missing from the data. second, many policy documents are written in the native language of a country, requiring an additional machine translation step to integrate the corpus, which was performed at the data source. it is important to keep this language effect in mind, which may generate differential data quality for non-english speaking countries. it is worth noting that potential sampling biases in our data are likely to be conservative. indeed, we repeated our analyses in fig. for english-speaking countries only (si s . ), finding that the relationship further strengthens (fig. s c) . lastly, the data focus on policy responses at the country level, while across regions within each country there can be important local differences in response [ , , ], which are not captured by our data. the data and methodologies presented in our paper are not limited to analyzing covid- policy, the authors declare no competing interests. data availability deidentified data necessary to reproduce all plots and statistical analyses will be made freely available. covid- cases and deaths data are publicly available. those who wish to access raw data should contact the data sources directly. code availability code will be made freely available. quantifying policy responses to a global emergency: jian gao ¶ , yian yin ¶ , benjamin f. jones * , dashun wang * ¶ these authors contributed equally to this work. *correspondence to: bjones@kellogg.northwestern.edu, dashun.wang@northwestern.edu. [ ] . note that the list of keywords also relies on pre-translation to english by overton (see s . below). while the data cover a large number of countries, there are two notable exceptions in our analyses. first is the netherlands. one empirical limitation is that our access to the api only allows for at most , results per query, and there is one country that has exceeded this limit. indeed, the government of the netherlands (rijksoverheid) has published over , documents in , making it impossible to collect the full set of its policy documents. we therefore exclude netherlands from our analysis to avoid potential bias. second is mainland china. although covid- originated from wuhan, china, policy documents from mainland china are missing in the overton database for . personal correspondence with the overton team has not pinpointed the reason for this missing data, but it may have to do with web crawling issues on chinese government websites [ ] . we focus on policy documents published by ( ) government agencies and think tanks in country members of the united nations, and ( ) intergovernmental organizations (defined by "igo" and "eu" source labels in the overton data). for the temporal coverage, we froze our data on may th, . we noticed that there is an unusual number of documents published on january st ( , documents, about times of a normal day), possibly due to default classification to this date. we further excluded these documents from our analyses to avoid including policy documents that have inaccurate publication dates. lastly, since our main focus is on policy documents, we follow overton's suggestion [ ] and further filter on the document type by using only "publications" ( % of the total documents), removing other types such as "working papers", "transcripts", "blog posts", and "clinical guides". in total, we analyzed , covid- documents out of , documents published across countries (including think tanks), igos (including in eu). we further link the scientific references cited within the policy documents to a database of we also constructed another set of covid- related scientific publications by searching for papers published in with the following query suggested by dimensions [ ] : " -ncov" or "covid- " or "sars-cov- " or "hcov- " or "hcov" or "ncovid- novel)), yielding in total , papers published in out of all articles indexed by dimensions. we use country-level daily statistics for covid- confirmed cases and deaths from two independent sources. our primary data source is the covid- data repository provided by the center for systems science and engineering (csse) at johns hopkins university [ ] , which has been extensively used in covid- related studies. to ensure the robustness of our results, we also repeated our analyses using an alternative dataset provided by the european centre for disease prevention and control (ecdc) [ ] , which includes not only information on covid- confirmed cases and deaths, but also country-level covariates such as gdp per capita and population (see also s . ). in our robustness checks (s . ), we repeated our analyses using the covid- confirmed deaths reported by ecdc, confirming that our results are not sensitive to the specific covid- tracking data source. producing their own covid- analysis [ ] reveals that the keyword list contains several covid- wikidata [ ] ). although this list is still not exhaustive, such efforts may help to reduce potential language biases. taken together, there are several potential sampling biases by countries and languages that readers should keep in mind. however, in the context of regression relationships (e.g., as in fig. of the main text), it is worth noting that noise in explanatory variable (e.g., the covid- policy share) will attenuate the results toward zero, making it harder to find a significant statistical relationship. indeed, as measurement errors are likely to introduce noise to our data, they suggest conservative biases to the regression relationships we observed. related, in several different robustness checks, we find that if we focus on the portion of the data that has a higher reliability, the relationships we observe tend to strengthen further. for example, s . presents robustness checks by separating english and non-english speaking countries, showing that if we only focus on english speaking countries (less bias by language), the correlations we observe become stronger. similar trends are found in s . , where we limit the minimum number of covid- policy documents published by each country, which again increases the overall correlation. we leverage field and topic classifications from overton and dimensions to determine the primary focus of each policy document and scientific paper. overton uses machine learning approaches to assign fields and topics to policy documents. the telecommunications council (iptc) subject codes taxonomy, the global standards body of the news media. in our analysis, we use top-level fields in overton and further group them into three major field categories: science & health: "health", "science and technology". economy & labour: "economy, business and finance", "labour", "prices". society & others: "arts, culture and entertainment", "conflicts, war and peace", "crime, law and justice", "disaster, accident and emergency incident", "education", "environment", "human interest", "lifestyle and leisure", "politics", "religion and belief", "society", "sport", "weather". the overton policy topic also implements a more fine-grained classification system. for example, in fig. e , we used this classification scheme and show the top topics by volume, after excluding one generic topic ("coronavirus disease "). system, which follows a three-level hierarchy (divisions, groups and fields) and covers a broad set of research fields from the sciences and engineering, social sciences, and arts and humanities. in our analysis, we use top-level divisions as the research fields of scientific papers. analogously, as we do for policy documents, we further group top-level divisions into the same three major field categories: science & health: "agricultural and veterinary sciences", "biological sciences", "chemical sciences", "earth sciences", "engineering", "environmental sciences", "information and computing sciences", "mathematical sciences", "medical and health sciences", "physical sciences", "psychology and cognitive sciences", "technology". economy & labour: "commerce, management, tourism and services", "economics". society & others: "built environment and design", "education", "history and archaeology", "language, communication and culture", "law and legal studies", "philosophy and religious studies", "studies in creative arts and writing", "studies in human society". we construct a citation network using all covid- related policy documents, where each directed link a→b corresponds to a citation from document a to document b. self-citations (selfloops) are removed and only nodes with non-zero degree (i.e. documents that either cite or are cited by at least one other covid- policy document) are visualized in the network (fig. of the main text). to compare the importance of documents from various institutions, we simulate a random node removal procedure and study the relative size of the giant weakly connected component when a small fraction f of the nodes is removed [ , ] . for each institution type (igo/think tank/government), we perform independent simulations. the relative importance of individual nodes is measured by k-core decomposition [ , ] , where k-core is defined as the maximal subgraph with all nodes having degree no smaller than k. a node has coreness of k if it belongs to k-core but not (k+ )-core. nodes with higher/lower coreness are located in the core/periphery of the network. we treat the network as undirected (defining degree as the sum of in-degree and out-degree) when calculating the coreness index. we quantify the covid- policy attention at the individual country level and explore its correlation with the country's effectiveness in containing the pandemic. for each country in our analysis, we mark the calendar date on which three deaths from covid- in one day were first recorded [ ] . we then calculate the share of covid- policy documents among all policy documents in a country during the prior days (i.e., in the days before three daily deaths were first recorded in that country), which approximates the country's covid- policy attention. we further measure the country's total deaths from covid- over the following days (i.e., in the days after three daily deaths were first recorded in that country), which approximates the we employ an ordinary least squares (ols) regression model to estimate the relations between the country-level covid- policy attention and the country's effectiveness in containing the pandemic. the ols regression takes the following form: where ' indexes a country and & ! is the error term. other variables are defined as follows: dependent variable: the dependent variable ! ! = log #" +,-.ℎ ! is the total covid- confirmed deaths in the logarithmic scale in country ' in the days after three daily deaths were first recorded in that country (i.e., the following days), which approximates the country's effectiveness in containing the pandemic. ) % !,# = log #" (# + ! /# ! ) is the share of covid- policy documents, now measured on the logarithmic scale. note that the logarithmic value is undefined when ) % !,# = log #" [(# + ! + )/(# ! + )] is the covid share in the logarithmic scale. as in ), we add one to both the number of covid- policy documents and the number of all policy documents before taking the log. this provides a simple alternative to avoid dropping cases where # + ! = and is visualized in fig. of the main text. we compare the share of covid- policy attention and total confirmed deaths from covid- over time, finding a high degree of similarity between the two trajectories (fig. s a) . to test if there are systematic delays between the share of covid- policy attention and the pandemic progress (both cases and deaths), we further calculate the correlation between the two time-series. to account for the approximate exponential growth of both curves, we take the first-order difference of logarithm transformation, defined as correlations between the transformed series suggest that the relationship between the time series is closest when the time offset, Δt, between the share of covid- policy documents and covid- deaths is close to (see fig. s b for deaths and fig. s c for cases) , suggesting a high degree of synchronicity between the share of covid- policy attention and how the pandemic evolves. in fig. d of the main text, we group covid- related policy documents into three major field categories (see also s . ) and observe clear shifts in policy attention related to the pandemic, with policy priorities shifting from issues in public health to economy and society. at the narrower topic level, in fig. e and f we find a clear decrease in the share of health-related topics and an increase of topics related to economy and society since early march . here, we test the robustness of these observations by looking into data by month and for individual fields. we find similar shifts in topics of covid- policy documents around march ( policy documents published in the same period. we find that the shares of policy documents by three major field categories (fig. s a ) and individual fields (fig. s b) stay relatively stable over time, suggesting that the shifts are observed in covid- policy documents only. table s . regressions considering the effects of policy publication date, the country, and the type of the institution. notes: column ( ) and ( ) shows the results on using citations from same/different sources only. standard errors in parentheses. significant level: *p< . ; **p< . ; ***p< . . we explore the relationship between a country's covid- policy response and its effectiveness given by three alternative functional forms, namely, the linear share of covid- policy documents, # +/# ; the logarithmic share of covid policy documents, log #" ( #)*+,-# ); and the logarithmic covid share after adding for both numbers of covid and all policy documents: log #" ( #)*+,- # # # ) (see s . for more detail). here, together with each of these functional forms for the independent variable of interest, we gradually include other control variables in the regression. table s . regressions considering the effects of covid- policy attention on total deaths. notes: the dummy variable ! "#$%& = if ##$%&! = , and ! "#$%& = if otherwise. countries where##$%&! = are dropped in column ( ), and these countries are included in column ( ) after resetting the value of log '( (##$%&!/#/ ) to . standard errors in parentheses. significant level: *p< . ; **p< . ; ***p< . . in columns ( - ) of table s , we use the covid share # +/# as a proxy for the share of covid- policy attention. we find that this covid- policy attention share by itself exhibits a significant, negative correlation with total deaths (see column ( )). further, in column ( ) we include the dummy variable + )*+,that indicates whether a country has yet published covid- policy documents and find the negative correlation further improves. in column ( ) we include three other control variables, namely, gdp per capita, population, and the calendar day of daily deaths were first recorded for each country. we find that the covid share still has a significant predictive power for the total deaths after controlling for all other variables. in columns ( ) ( ) , we use the covid share in the logarithmic scale log #" ( #)*+,-# ) as a proxy for the share of covid policy attention. when including log #" ( #)*+,-# ) solely in column ( ), the regression drops countries with # + = (i.e., where log #" ( #)*+,-# ) is undefined). in columns ( - ), we include all countries after resetting log #" h #)*+,-# i = for countries where # + = and use the dummy variable + )*+,to account for publishing no covid- policy documents. we find that the negative correlation between the covid share and total deaths remain strong and significant. in columns ( - ), we repeat the regression by using log #" ( #)*+,- # # # ) as a proxy for the share of covid policy attention. we find that the negative correlations remain robust, with a percent increase in the adjusted covid- policy share variable predicting . percent fewer deaths. gdp per capita has no significant effect on total deaths, whereas population size has a positive effect. moreover, the calendar day of the first daily deaths has significantly negative effects, suggesting that a later onset of covid- outbreak is associated with fewer deaths in the following days. these variables together can explain up to . % of the variation in total deaths. we further check the robustness of the negative correlation between the covid- policy attention in the prior days and the total deaths in the following days (i.e., the days after daily deaths were first recorded), by restricting the analysis to a minimum threshold number of policy documents that a country published in the prior days (i.e., the days before daily deaths were first recorded), table s summarizes the results of regressions where we only include countries that published at least policy documents in the prior days. we find that the negative correlations remain largely significant. in particular, we notice from column ( ) that the regression coefficient of the covid share increases to - . (from - . in table s ), suggesting that that covid share exhibits a slightly stronger predictive power for total deaths in countries that published more policy documents. table s . regressions considering the effects of covid- policy attention on total deaths for countries that published at least policy documents in the prior days. notes: the dummy variable ! "#$%& = if ##$%&! = , and ! "#$%& = if otherwise. countries where##$%&! = are dropped in column ( ) , and these countries are included in column ( ) after resetting the value of log '( (##$%&!/#/ ) to . standard errors in parentheses. significant level: *p< . ; **p< . ; ***p< . . in table s , we further limit our regression analysis to countries that published at least policy documents in the prior days. we notice that the regression coefficient of covid share in column ( ) further increases to - . , showing that the share of covid- policy attention in the prior days in countries that published more policy documents has again a steeper relationship with the total deaths in the following days. with the smaller number of country observations that result from these policy document count restrictions, the standard errors tend naturally to increase in these regressions, yet most specifications remain statistically significant. overall, these analyses tend to further support the robustness of our findings. table s . regressions considering the effects of covid policy attention on total deaths for countries that published at least policy documents in the prior days. notes: the dummy variable ! "#$%& = if ##$%&! = , and ! "#$%& = if otherwise. countries where##$%&! = are dropped in column ( ) , and these countries are included in column ( ) after resetting the value of log '( (##$%&!/#/ ) to . standard errors in parentheses. significant level: *p< . ; **p< . ; ***p< . . in fig. a of the main text, we presented the negative correlation between the share of covid- policy attention in the prior days and the total confirmed deaths in the following days, where we use the covid- death tracking data provided by johns hopkins university (jhu). here, we consider alternative measures and show that our results are robust when using total confirmed cases ( fig. s a ; columns ( - ) of table s ) and confirmed deaths per million population of a country ( fig. s b ; columns ( ) ( ) of table s ) in the following days. we further leverage a new dataset for daily covid- case and death statistics, provided by the european centre for disease prevention and control (ecdc). country-level death statistics collected by jhu and ecdc are highly correlated with each other. for example, the pearson correlation coefficient between the total deaths (in the logarithmic scale) in the following days recorded by the two data sources is . . here, we show that our results remain robust when using ecdc death statistics ( fig. s d ; columns ( - ) of table s ). table s . regressions considering the effects of covid policy attention on the effectiveness in containing the pandemic. notes: the dummy variable ! "#$%& = if ##$%&! = , and ! "#$%& = if otherwise. standard errors in parentheses. significant level: *p< . ; **p< . ; ***p< . . to address possible concerns on the potential bias by language in overton policy documents, we further performed robustness checks by separating english and non-english speaking countries in our analysis. based on whether english is an official language [ ] , we consider a combination of three sets of countries as english-speaking countries in our analysis: ( ) countries where english is a de facto (i.e., practices that exist in reality) official language; ( ) countries where english is a de jure (i.e., practices that are legally recognized) and de facto official language; ( ) countries where english is a de facto official, but not primary language. out of all countries in our analysis for we further focus on the portion of the data that has a higher reliability in our analysis by limiting countries that have published a minimum threshold number of covid- policy documents in the prior days. we find that the negative correlation between the share of covid- policy attention and total deaths that we observe tends to strengthen. specifically, when increasing the minimum number of covid- policy documents from to , the pearson correlation coefficient increases from - . to - . (fig. s ) , and the correlation remains largely significant when controlling for other variables (table s ) . table s . regressions considering the effects of covid policy attention on total deaths for countries that published a minimum number of covid policy documents in the prior days. notes: standard errors in parentheses. significant level: *p< . ; **p< . ; ***p< . . as a reference point approximating the onset of the outbreak, the paper takes the day where daily deaths were first recorded. here we present robustness checks on this reference point ( fig. s ; table s ). specifically, when taking the day where the first death was recorded in each country as the reference point [ , ] , a total of countries are included in the analysis, and we find a significantly negative correlation (- . ) between covid share and total deaths ( fig. s a; columns ( - ) of table s ). taking the reference point as the day when daily deaths were first recorded ( fig. s b; columns ( - ) of table s ) and the day where daily deaths were first recorded ( fig. s c ; columns ( - ) of table s ), the negative correlation between covid share and total deaths remains strong and significant, again confirming the robustness of our results. besides the number of daily deaths, we use an alternative method by taking the day where a cumulative number of deaths was first recorded as the reference point. after checking the relations between the share of covid- policy documents in the days before total deaths was first recorded in a country and the total deaths after total deaths was first recorded in that country, we find that the negative correlation further improves and remains significant ( fig. s d ; columns ( - ) of table s ). overall, these results support the robustness of our results. finally, we leverage an independent measure on covid- policy, the stringency index provided by the oxford covid- government response tracker (oxcgrt) [ , ] , to further test the robustness of our finding on the relationship between covid- policy attention and the effectiveness in containing the pandemic. for each country we calculate an average stringency index during the prior days and employ it to predict the total deaths in the following days. table s summaries the results of regressions that include both the share of covid- policy documents and the average stringency index together with other control variables. in order to compare the values of regression coefficients, here we take the z-score for all variables. ( ) and ( ), and these countries are included in other columns after resetting the value of log '( (##$%&!/#/ ) to . standard errors in parentheses. significant level: *p< . ; **p< . ; ***p< . . in columns ( - ) of table s , we include alternative functional forms for the share of covid- policy documents and the average stringency index, finding that the covid share and the stringency index have independent and comparable predictive power for total deaths. in columns ( ) ( ) , we include both the policy document share and the stringency index and find that they augment each other's predictive power and have similar coefficient magnitudes. in columns ( - ), we include the dummy variable whose value + )*+,-= if a country did not publish any covid- policy documents in the prior days and + )*+,-= if otherwise. we find that the predictive powers of covid share and stringency index are again similar to each other and augmentative. in columns ( ) ( ) ( ) ( ) ( ) , we further include controls for gdp per capita, population, and the calendar day where daily deaths were first recorded in each country. after controlling for all variables, we find that the effects of the share of covid- policy documents remain negative and significant in columns ( ) ( ) . moreover, the covid share exhibits a slightly stronger power than the stringency index in predicting total deaths in columns ( ) ( ) . these observations are encouraging, as the stringency index measures policies that are specifically designed toward containing the pandemic, which exhibits a comparable level of predictive power as our measure. overall these results further confirm the robustness of our results, showing that at the country level, greater covid- policy attention predicts fewer subsequent deaths. predictability of population displacement after the haiti earthquake rapid assessment of disaster damage using social media activity collective response of human populations to large-scale emergencies the parable of google flu: traps in big data analysis policy opportunities to enhance sharing for pandemic research variation in government responses to covid- , in blavatnik school of government working paper the effect of human mobility and control measures on the covid- epidemic in china the effect of travel restrictions on the spread of the novel coronavirus (covid- ) outbreak. science how will country-based mitigation measures influence the course of the covid- epidemic? estimating the effects of non-pharmaceutical interventions on covid- in europe the effect of large-scale anti-contagion policies on the covid- pandemic interdependence and the cost of uncoordinated responses to covid- population flow drives spatio-temporal distribution of covid- in china modeling the worldwide spread of pandemic influenza: baseline case and containment interventions pattern in escalations in insurgent and terrorist activity quantifying the dynamics of failure across science, startups and security bursts: the hidden patterns behind everything we do, from your e-mail to bloody crusades the black swan: the impact of the highly improbable advice and answers from the overton team who are covid- guidelines & policy documents citing? dimensions: bringing down barriers between scientometricians and data. quantitative science studies dimensions covid- publications, datasets and clinical trials an interactive web-based dashboard to track covid- in real time european centre for disease prevention and control. covid- situation update worldwide who are covid- guidelines & policy documents citing? . . wikidata contributors. covid- error and attack tolerance of complex networks percolation in directed scale-free networks a model of internet topology using k-shell decomposition identification of influential spreaders in complex networks coronavirus tracked: has your country's epidemic peaked variation in government responses to covid- , in blavatnik school of government working paper whose coronavirus strategy worked best? scientists hunt most effective policies list of territorial entities where english is an official language key: cord- -deoyowto authors: mcbryde, emma s.; meehan, michael t.; adegboye, oyelola a.; adekunle, adeshina i.; caldwell, jamie m.; pak, anton; rojas, diana p.; williams, bridget; trauer, james m. title: role of modelling in covid- policy development date: - - journal: paediatr respir rev doi: . /j.prrv. . . sha: doc_id: cord_uid: deoyowto models have played an important role in policy development to address the covid- outbreak from its emergence in china to the current global pandemic. early projections of international spread influenced travel restrictions and border closures. model projections based on the virus’s infectiousness demonstrated its pandemic potential, which guided the global response to and prepared countries for increases in hospitalisations and deaths. tracking the impact of distancing and movement policies and behaviour changes has been critical in evaluating these decisions. models have provided insights into the epidemiological differences between higher and lower income countries, as well as vulnerable population groups within countries to help design fit-for-purpose policies. economic evaluation and policies have combined epidemic models and traditional economic models to address the economic consequences of covid- , which have informed policy calls for easing restrictions. social contact and mobility models have allowed evaluation of the pathways to safely relax mobility restrictions and distancing measures. finally, models can consider future end-game scenarios, including how suppression can be achieved and the impact of different vaccination strategies. models have played an important role in policy development to address the covid- outbreak from its emergence in china to the current global pandemic. early projections of international spread influenced travel restrictions and border closures. model projections based on the virus's infectiousness demonstrated its pandemic potential, which guided the global response to and prepared countries for increases in hospitalisations and deaths. tracking the impact of distancing and movement policies and behaviour changes has been critical in evaluating these decisions. models have provided insights into the epidemiological differences between higher and lower income countries, as well as vulnerable population groups within countries to help design fit-for-purpose policies. economic evaluation and policies have combined epidemic models and traditional economic models to address the economic consequences of covid- , which have informed policy calls for easing restrictions. social contact and mobility models have allowed evaluation of the pathways to safely relax mobility restrictions and distancing measures. finally, models can consider future endgame scenarios, including how suppression can be achieved and the impact of different vaccination strategies. infectious diseases modelling in the current covid- pandemic has had more attention from government and media (both social and traditional) than for any previous pandemic. this can be attributed to the huge impact of the pandemic, changes in global communication and technical advances in modelling. these advances encompass new methods, improved computational tools, public data sharing, improved code availability and better visualisation methods, which have all advanced markedly in the decade since the h n influenza pandemic in . policy makers have placed greater trust in models than ever before, although models have also received considerable criticism, and their limitations need to be acknowledged. in this paper, we describe ways in which models have influenced policy, from the early stages of the outbreak to the current date -and anticipate the future value of models in informing suppression efforts, vaccination programs and economic interventions. policy on border closures followed early estimates of trans-national spread of covid- and was strongly influenced by modelling. in january , modelling based on travellers from wuhan found that early covid- case rates were significantly under-reported both in china and overseas , and border closure policies promptly followed. china imposed an internal travel lock-down on wuhan on rd january and most countries enacted limited restrictions through february and comprehensive restrictions through march; many governments using travel risk models to anticipate case numbers with and without border closures (see for example, shearer et al. ). fully connected meta-population travel models have provided additional insights. retrospective analyses have shown that the wuhan lockdown imposed by china did little to delay the outbreak within china, but had a greater impact on other countries . models have also predicted the shifting of epicentres from asia to europe and from the usa to south america and africa, based on the connectedness of these regions , enabling enhanced surveillance in vulnerable destination countries. currently, almost every country in the world has experienced local transmission, such that border restrictions are of lesser importance. however, as countries begin to move out of lockdown and seek to reignite their economies, travel modelling will again become helpful for anticipating the risk of reintroduction of cases to jurisdictions that have successfully reduced transmission. many early models estimated a high reproduction number -the average number of secondary cases per infected case. although precise values differed, in china prior to interventions, these mostly fell between a value of two and three , heralding the seriousness of the pandemic. based on these estimates, model projections were consistent in predicting that an unmitigated epidemic would overwhelm health systems and lead to unacceptable loss of life , , . a prominent example was the report by imperial college london on the potential of covid- to cause widespread infection across the uk and the us if a mitigation (reproduction number greater than one) rather than suppression (reproduction number less than one) strategy was pursued . consistent model findings of high infection rates and mortality collectively resulted in many countries grasping the seriousness of the epidemic. consequently, public health interventions and governmentimposed restrictions on human movement were initiated to reduce transmission. models showing changes in transmission rates over time have been powerful tools for enabling policy-makers to demonstrate gains in epidemic control through public health policy and action. many media outlets and public health officials around the world have provided explanations about the effective reproduction number and its critical threshold of one, which is the key to escaping from lockdown. political leaders of new zealand , australia , the uk , indonesia and germany have all used this terminology in communicating decision making for easing lockdowns, demonstrating the marked increase in the public's understanding of infectious disease modelling. as countries see their epidemic incidence curves decline in response to changes in behaviour and policy, developing a strategy to exit lockdown is vital. the aim is to do so gradually, without pushing the effective reproduction number above one and risking a second pandemic wave. models can predict the impact of resuming different activities if the impact of each behavioural intervention is well quantified. since most interventions were applied simultaneously, their individual contributions are unknown, and an alternative approach is required. one approach is to examine contact patterns and thereby infer infection risk using age-specific mixing models. in , age-specific contact patterns were estimated in several european countries , and synthetic matrices were later developed for countries . changes in contact rates resulting from covid- policy can be estimated using a number of sources: google mobility data provides the amount of time spent in locations (https://www.google.com/covid /mobility/), city-mapper (http://citymapper.com/cmi) provides regularly updated data on direction requests, nation-wide behaviour surveys provide information on the impact of policies for both the number and duration of contacts in some countries. mixing models synthesise these results to identify age-specific contact rates and use relative infectiousness and susceptibility to infer age-specific infection rates. the findings that children are probably less likely to acquire infection and are much less likely to show symptoms when infected have been incorporated into these models to assist with policy development. in particular, mixing models have shown that school closure has a modest impact on disease transmission at best, which has encouraged several jurisdictions to accelerate school reopenings, or avoid school closure. , , models designed to inform policy in low-middle income countries [lmics] need to capture variation in transmissibility of covid- with socio-demographic features. models forecasting the covid- epidemic in lmics indicate that transmission is likely to be delayed by the relatively low travel numbers and the higher proportion of children in these countries . this delay has given countries critical time to prepare and strengthen their often limited health infrastructure and diagnostic and surveillance capacity . for example, there are only . ventilators per , of population in uganda, compared with nine in australia and eleven in europe , . despite the delay, models predict that any natural protection offered by a younger population is likely to be offset by weaker health systems, overcrowding and comorbidities ; hence lmics have been advised to prepare for a "slow burn" covid- epidemic. brazil has been one of the lmics most severely affected by covid- (thus far), and its epidemic trajectory provides some insight into the different pandemic trajectories of lmics compared to higher income settings. the first case of covid- occurred in brazil on th february, and by early may there were over , reported cases and , deaths, an estimated epidemic doubling rate for deaths of five days (the highest of countries analysed) . the rapid transmission in brazil is attributed to a combination of inadequate policy response, high population density, close living quarters, limited access to clean water, informal employment, and transmission to indigenous populations through encounters with illegal miners and loggers in the amazon rainforest . on top of the direct covid- -related morbidity and mortality, indirect effects associated with disruptions to other critical medical services are anticipated. in some lmics, health care systems will be faced with concurrent outbreaks, such as dengue in ecuador, brazil and other latin american countries . models can also help estimate the indirect effects of covid- , such as through interruptions to the supply of antiretroviral therapy (hiv treatment) in south africa due to covid- . it has been estimated that this disruption could cause a death toll on the same order of magnitude as the deaths that would be averted by physical distancing interventions for covid- itself . similarly, disruptions to vaccine delivery in lmics could lead to major outbreaks of vaccine preventable diseases, such as measles, for many years to come . policies that have been effective in developed countries may not translate to impact in lmics. this has been attributed to physical distancing often being impractical due to large household sizes, overcrowded settlements, and informal economies . lockdowns that severely restrict movement outside the home are less feasible and more harmful in countries where work is essential for survival. it seems almost certain that a vaccine will be needed if covid- is to be eliminated globally. as of nd june, , there are ten clinical trials for covid- vaccines in different stages of development and molecules in preclinical evaluations . modelling can be useful in evaluating the efficacy of vaccines during clinical trials and diminishing biases , . models have already shown that an immunity of % is desirable to protect those who cannot or choose not to become vaccinated. however, once a vaccine becomes available, an implementation strategy will be required as supply scales up. should we vaccinate the most vulnerable groups, those at the front-line of control or those contributing the most to transmission first? while ethical and equity considerations will appropriately drive much of this debate, modelling has a role to play. modelling can help to assess the potential effectiveness of different vaccination strategies, such as location-specific ring-vaccination for ebola , age-specific vaccination for influenza and assessing long-term risks and benefits of dengue vaccination . for covid- , strategies may differ between countries depending on the acuity of the epidemic, the age groups driving the infection or at higher risk for severe disease, and the age structure of the population. the containment and mitigation measures implemented by countries around the world to slow the spread and reduce mortality due to covid- have resulted in a worldwide economic crisis, with the cost likely to exceed the damage from the global financial crisis of - . unlike previous such crises, the covid- pandemic has simultaneously created major downturns in both supply and demand across the world . this creates significant policy challenges for governments to design strategies that take into account both the effectiveness of public health intervention measures and their negative socioeconomic consequences . containment and mitigation efforts, which are aimed at saving lives, avoiding human capital losses and flattening the epidemic curve, also reduce economic activity , . this intentional reduction of economic transactions has been undertaken by many governments as a necessary public health measure, at least in the early stages of the epidemic. apart from the humanitarian perspective, there are economic benefits to counter some of the losses of these policies, such as avoiding loss in income due to premature deaths, workplace absenteeism, and reduction in productivity. contractions in supply and demand also come from physical distancing, travel restrictions, non-essential business closures and other measures, as people work and consume less . some studies have used early estimates of infection rates and case fatality ratios to assess healthcare costs due to the pandemic and provide cost-benefit analysis of non-pharmaceutical interventions . others have used simulations to model epidemiological scenarios in inter-temporal general equilibrium models . for example, a dynamic stochastic general equilibrium model is used to model global economic outcomes under different scenarios of the pandemic's evolution over the remainder of this year . a limitation of this modelling approach is that it requires a large number of inputs and assumptions on economic relationships and epidemiological characteristics. as economic consequences from the covid- pandemic originated from epidemiological factors and these factors will continue to play a role in the dynamics of control, the economic trade-offs between public health and economics should be considered and analyses that combine epidemiological and economic modelling will be valuable. much of the value of models in the covid- pandemic is in informing immediate policy decisions. a collaborative relationship between modellers and policy-makers ensures that models focus on priority questions. providing modellers with a clear view of the policy environment allows them to propose and develop models that support decision making. this may go beyond policy-makers outlining the policy questions of interest and the interventions under consideration, and should ideally create an environment where modellers and policy makers work in partnership. modelling analyses may also play a role in broadening the scope of options under consideration. for example, modellers advising the uk health authorities did not initially explore a strategy that involved increased testing because they had been advised that there were limits on the extent to which testing capacity could be scaled up . however, modelling more ambitious scenarios can provide high benefits at low cost, even if the strategies simulated are not immediately able to be enacted -if models had shown that increasing testing, tracing, and isolation would result in dramatically better outcomes, these activities may have been prioritised sooner in the uk . similarly in australia, models presented to the australian government in march examined only mitigation strategies . had these early models shown the enormous impact potential for suppression, earlier and shorter lockdowns may have been planned. the current pandemic crisis has led to a resurgence of interest in modelling, and an increase in its use for guiding policy. modelling advice should always be developed and considered in context, allowing for setting-specific limitations in capacity. early analyses have been biased towards high-income settings where both modelling expertise and reported cases have been concentrated. however, as the pandemic now shifts towards highly-vulnerable lmics, a concerted effort is required to provide international modelling support to local containment efforts. technology to advance infectious disease forecasting for outbreak management report . imperial college london, uk. who collaborating centre for infectious disease modelling mrc centre for global infectious disease analysis identifying locations with possible undetected imported severe acute respiratory syndrome coronavirus cases by using importation predictions assessing the risk of 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impacts of covid- : seven scenarios special report: the simulations driving the world's response to covid- modelling the pandemic modelling the impact of covid- in australia to inform transmission reducing measures and health system preparedness key: cord- -y wwy authors: white, anthony r. title: the pharmaceutical company approach to antibiotic policies date: journal: antibiotic policies doi: . / - - - _ sha: doc_id: cord_uid: y wwy nan the word "policy" is defined as "prudent conduct, sagacity; course or general plan of action (to be) adopted by government, party or person." in this sense, antibiotic policies range from local hospital or community policies to national treatment guidelines for specific infections, regulatory policy, and regional and global strategies. all have the potential to impact on the pharmaceutical industries' (pharma) integrated activities of discovering, developing, and marketing antibacterials. this article reviews the relationship between antibacterial policies and the role of pharma. for almost years, pharma has played a major role in discovering, developing, and making available antibacterials for human and veterinary use (garrod et al., ) . today, more than in recent decades, there are high demands on pharma to deliver to patients new, effective antibacterials to replace those agents for which clinical utility is compromised by emerging bacterial resistance. this "crisis," with the daunting prospect that one of the most beneficial discoveries and developments in the history of mankind could become extinct within a mere few human generations, has understandably also prompted a wide range of recommendations, guidelines, and policies with the intent of preserving and protracting the utility of our current antibacterial armamentarium. however, in some cases, these policies themselves are reducing the chance of success of pharma delivering the antibacterial agents for the future. in order to succeed, pharma will need to adapt to the new environment, but there is a very real and immediate danger that the extent of change in the environment is presenting significant hurdles that will prevent or delay the discovery and delivery of new agents. a greater understanding of the collective impact of policies on pharma's ability and willingness to conduct sustainable research and development (r&d) of antibacterials is needed along with a cooperative partnership approach. there is a need for governments, nongovernmental organizations (ngos), policy-makers, regulators, and infectious disease experts to collaborate with pharma to establish ways to maximize the chance of bringing new antibacterials into clinical use and sustain their utility. unfortunately, individual pharma companies continue to exit from antibacterial discovery and development and the pool of major companies is likely to soon be occupied by a handful or less, severely restricting the ability of pharma to meet the medical needs of infectious diseases, particularly those which require flexibility and responsiveness, such as epidemics and those arising from bioterrorism. once r&d efforts are terminated it will require substantial new investment, both in monetary and intellectual terms, as well as time to re-initiate effective programmes. without continued, sustainable, and successful antibacterial r&d, we will certainly be facing the prospect of "antibacterial extinction." there is no doubt that research-based pharma has for many years been instrumental in providing the wide range of clinically important agents which are available today. garrod et al. ( ) described three eras of antimicrobial chemotherapy: • alkaloids: from and use of cinchona bark to treat malaria • synthetic compounds: from and the discovery of the arsenical salvarsan by ehrlich, and including prontosil/sulfonamides in • antibiotics: from with the discovery of penicillin. pharma has been predominant in discovering or developing antibacterials in the two most recent of these three eras. while not all antibacterials were discovered by pharma, many of the early members of today's antibacterial classes were brought to clinical use through the development and scale-up activities of pharma, in some cases through collaboration by a number of companies, notably in the development of penicillin g in the s. the majority of discoveries and developments that have produced the major classes of antibacterials, as well as the many significant developments within these classes, have been the result of the pharma industries' innovation and expertise. it is probable that without the efforts of research-based pharma and the associated integrated competitive and commercial aspects, many of today's agents would not yet have been discovered, developed, or available to physicians. the now somewhat famous declaration in by the us surgeon general, william stewart, testifying before us congress that it was time to, "close the book on infectious diseases," illustrates the degree of success that was perceived to have been achieved at that time. although there is a sector of the pharma industry that focuses on the sale of generic versions of agents discovered and developed by the research-based companies, these activities mainly require only manufacturing and distribution expertise. now, as in the past, it is the research-based companies to which we need to continue to look to for the provision of agents for the future. the discovery, development, and appropriate use of new agents is a key theme in the major antibacterial strategies and policies to combat resistance which have been reviewed by carbon et al. ( ) . against this background it may be considered surprising or even alarming that the interscience conference on antimicrobial agents and chemotherapy for (icaac, ) includes a symposium entitled why is big pharma getting out of anti-infective drug discovery? a review of abstracts on new antibacterial agents or targets/methods presented at icaac indicates some companies involved in this field including of the "top " companies as determined by sales (table ) . of the total, companies presented data from established classes (␤-lactams/ inhibitors, lipopeptides/glycopeptides, fluoroquinolones, oxazolidines, protein synthesis inhibitors) and of these companies were from the top companies by sales. twenty-one companies presented data on targets or methods, thirteen exclusively, and seven on novel agents or immunomodulators (table ) . this analysis represents only a snapshot of those companies presenting at icaac and not the total discovery programmes currently being undertaken, some on areas not yet disclosed, others since terminated. despite the wide range of presentations by pharma at icaac , there has undoubtedly been a consolidation in antibacterial r&d in the large pharma companies, and a dearth of novel agents emerging from the pipelines. increasing discovery activity in smaller companies may offset this, although the capabilities of smaller companies to develop antibacterials to market may be limited in the face of increasing development hurdles. the future model of discovery and development may well have to rely on collaborations and cooperations between small/discovery and large development/supply pharma. mergers and acquisitions have resulted in the key players becoming significantly fewer and each withdrawal from antibacterial development has an anthony r. white have evolved from some to companies with antibacterial r&d heritages. some are the result of none or few amalgamations while others are many-fold. of the top companies, less than half are believed to be currently active in antibacterial r&d. within the remaining companies the discovery effort has been directed towards either defined niche disease areas, or large "blockbuster" commercial areas, with a consequent reduction in diversity across the industry. individual specializations within pharma, such as was the case when companies almost exclusively worked on penicillins (beecham research laboratories), cephalosporins (glaxo), or quinolones (bayer ag), for example, are becoming less as the companies look to satisfy commercially attractive target product profiles from whichever molecular classes that are available through their r&d efforts or in-licensing. the emphasis on development of line extensions of existing molecules has also increased as a means to improve patient benefits such as convenience and efficacy and importantly for pharma, to maintain development and commercial activity to offset patent loss and bridge the gap to the introduction of new agents. critically, of the companies which have exited or severely reduced their antibacterial r&d (e.g., aventis, bristol-myers squibb, eli lilly & co, roche-chugai, and wyeth research) (idsa, ) , these decisions have been taken relatively recently at a time when the need for new effective antibacterials is arguably greater, but also at a time when policies and regulations for the development and use of antibacterials have proliferated. the crucial issue will be the ability of companies, big or small, alone or in collaboration, to bring novel agents to the market and whether the agents being discovered and developed today will satisfy both the medical and the commercial needs to provide a sustainable future for antibacterial chemotherapy. continued investment and commitment of big or small pharma into research for new antibacterials to meet current and future clinical needs is crucial and yet is at a crisis and being impacted by antibacterial policies which are increasingly being developed and implemented. the infectious disease society of america (idsa) newsletter, march , entitled the future of antimicrobial drug availability: an impending crisis (idsa, ) , highlights the current issues facing the development of antimicrobial drugs. infectious diseases are the second leading cause of death and the leading cause of disability-adjusted life years worldwide. antibacterials are key tools in treating many globally important infectious diseases, including meningitis, pneumonia, diarrhoeal illness, skin and bone infections, tuberculosis, sexually transmitted infections (gonorrhoea, syphilis, and chlamydia), hiv/aids-related bacterial infection, and diseases that may be spread as a result of bioterrorist acts. withdrawal from antibacterial research will have a major impact on global health. a letter to the journal of the american society for microbiology (appelbaum, ) states that, "a crisis has developed and we are doing nothing about it," highlighting that pharma companies are reducing or closing their antibacterial research and that pipelines are, "practically empty." appelbaum suggests that, unlike drugs for long-term treatments, there is a lack of funding for research into antibacterials, one of the reasons for this being the overly stringent approval criteria imposed by the federal drug agency (fda), making it practically impossible or prohibitively expensive to bring new antibacterials to market (appelbaum, ) . for those who have worked in the antibacterial field from the hey-day of discoveries in the s and s it is very apparent that the number of new chemical agents being progressed to man and subsequently marketed is much reduced. idsa reported that of new medicines reaching the us market in none was an antibacterial, with only new antibacterials being approved since (idsa, ) . a review of company reports for the major pharma companies listed only new antibacterials in the drug pipeline out of agents listed ( . %) (idsa, ) and that on average the time to develop new antibacterials was - years from discovery to first approval. although pharma has continued to explore ways to increase efficiencies and decrease development times, these have largely remained stable due to the increased numbers of patients required for new drug applications (ndas), as well as increased complexity and costs in meeting regulatory approval requirements (kaitin and dimasi, ) . an important consideration for pharma companies involved in r&d and commercialization of therapies for a range of disease areas, is that other therapeutic areas are increasingly more profitable than antibacterials. today, there are fewer large companies specializing in antibacterials as a main r&d area. investment decisions are made across and between therapeutic areas and pharma has an obligation to maintain shareholder value and commercial viability or else no new drugs would become available in any therapy area. the reasons for the "crisis" in antibacterial r&d, manifested by fewer new agents or classes reaching clinical use, are complex and multifactorial but undoubtedly the impact of the changing environment of regulations, guidelines, and policies on the development and use of antibacterials is an important contributory factor. stated simply, antibacterials are developed and used to overcome bacterial infection. the progressive discovery and introduction of new classes and agents extended the range of bacteria and associated infections that could be successfully treated. antibacterial resistance, which has emerged from the beginning of antibacterial chemotherapy, has provided a key medical reason for the development of new agents, along with the wish to improve efficacy, safety and tolerability, and dosing convenience. anti-infectives are unique (with the exception of some increasing evidence in oncology) in that the target of their action can change and provide the rationale, medical need, and commercial incentive for the development of new agents. the need for new agents or classes to combat antibacterial resistance is arguably greater today than it has been for some decades. concerns about emerging resistance, increasing loss of utility of existing antibacterials and associated negative impacts on health have given rise to a wide range of strategies (strategic plans, action plans), policies (rules and directives), and guidelines or guidance. some are advisory and others mandatory but all constitute broad policy with respect to the development and use of antibacterials. the sources of policy activities range from global ngos, such as the world health organization (who), regionally based bodies such as the european union (eu) and european medicines evaluation agency (emea), countrybased public health and regulatory bodies such as the centres for disease control (cdc), and fda, and physician associations (idsa), to the local, and institutional level within countries. a comprehensive summary of the more influential recommendations for the control of antimicrobial resistance has been prepared by carbon et al. ( ) (toronto declaration, ) , and one from the who global strategy for containment of antimicrobial resistance ( ). all these recommendations date from to with the majority being published between and . undoubtedly, there are more or updated recommendations in the pipeline and continuing activities of bodies addressing the topic, such as the usa cdc task force (idsa, ; shlaes and ryan, ) . common themes, which emerge from the range of recommendations related to antibacterials and antibacterial resistance, are the need for: • surveillance of resistance and antibacterial usage • optimizing antibiotic use (reduce inappropriate use), guidelines, and policies • education of professionals and patients into judicious/prudent use • prevention through infection control, interventions, immunization • focused development of new agents, diagnostics, and strategies • regulatory/label guidance, prescribing, and advert restriction • audit of evaluation of intervention and compliance. the objectives of most strategies and policies are to better control antibacterial use with the intent of reducing or preventing antibacterial resistance. this, accompanied by parallel activities to monitor and understand resistance (such as its consequences and relationship to antibiotic use), improve infection control, and development of new agents (antibacterials and vaccines) and therapeutic approaches, is hoped to provide a sustainable solution in combating bacterial infection. carbon et al. ( ) state that these recommendations rightly focus on controlling resistance in the community through surveillance of resistance and usage, and education of prescribers and the public in judicious antibiotic use. nevertheless, the authors point to the need for more research to fill substantial knowledge gaps, notably the reversibility or containment of resistance with the optimization of antibiotic usage has yet to be definitely established davey et al., ) . it is suggested by carbon et al. ( ) that for now, antimicrobial management programmes should focus on ensuring the most appropriate use of antimicrobials rather than simply on limiting choices. interventions must also be audited for effectiveness/cost . it is also suggested that the programmes in the recommendations can not succeed if they do not imply the active contribution of health professionals, politicians, consumers, and pharma, and that the creation of optimal conditions for this type of cooperation is of critical importance chahwakilian, ) . the key role of pharma in these strategies is to deliver new antibacterials, although the cumulative impact of the parallel recommendations may present significant barriers to achieving this aim ( figure ). surveillance programmes of bacterial susceptibility have become commonplace in the field of antibacterials over the last decade and feature in most recommendations and policies relating to combating resistance. the principles of surveillance, key studies, data, and issues have been extensively reviewed (bax et al., ; felmingham et al., ; hunter and reeves, ) . good quality surveillance methodology and interpretation are essential to the understanding of resistance emergence and its control. the main functions for surveillance were described by felmingham et al. ( ) as: • quantification of resistance: resistance prevalence/distribution/changes over time • guidance for antibiotic use: individual patient level/guidelines/policies • research/education: epidemiology of resistance/link with usage • industry: r&d/licensing/marketing/post-marketing • resistance control: design of strategies/impact of strategies/interventions. pharma is both a generator and user of surveillance. additionally, all the functions for surveillance described by felmingham et al. ( ) have the potential to impact pharma's development strategies and potential success in delivering new antibacterials. the relationship between resistance, antibiotic usage patterns, and clinical outcomes is an important factor in determining policies for antibacterial use. scientifically robust methodologies and interpretations are critical but have not yet been fully defined or attained for many surveillance studies (bax et al., ) . pharma itself has been actively involved in the initiation and support of a number of key surveillance studies over many years (felmingham et al., ) . these studies are mostly aligned with the companies' discovery and marketing interests but nevertheless have provided good quality data in many cases where data were lacking and even pre-date the recent calls in strategy and policy documents for antibacterial surveillance. indeed, global studies, such as the alexander project (felmingham et al., ) , initiated in and funded by smithklinebeecham (now glaxosmithkline) pioneered the standardization and quality control of methodology across countries and laboratories in the surveillance of bacterial resistance in community-acquired lower respiratory tract infection and provided a model for a number of subsequent global and national studies. pharma involvement and funding in surveillance may be a continuing necessary and desirable role. pharma need data from which to establish and drive the need for r&d activities into new antibacterials. surveillance data are also needed for product labelling, such as the resistance prevalences required, for example, by emea. susceptibility data from surveillance are important to support product differentiation and benefits in the market place, and may also be required as part of a phase iv regulatory commitment for a new agent. academia and policy-makers also need such data to assess the antibacterial environment and the appropriate policy and practice interventions and outcomes. all parties need good quality, scientifically valid data. however, there may be differences in needs regarding the scope of studies, such as the organisms that are included, the agents tested, or the reporting of data (minimum inhibitory concentrations vs susceptible/intermediate/resistance), but the demand for quality and accuracy of interpretation should be equal. a key issue is the source and sustainability of funding of surveillance, along with ownership, interpretation, and dissemination of data. global or regional, longitudinal surveillance studies are extremely expensive and resource intensive. individual pharma companies have initiated and solely sponsored studies to support the development and marketing of new agents (bax et al., ; felmingham et al., ; hunter and reeves, ) . this creates a situation where at a particular time a number of pharma companies may compete for collecting centres for key isolates and be funding a number of laboratories to screen similar isolates and agents while at other times or for other pathogens or agents, there may be little pharma support, or data available from any source. surveillance funded by government, societies, or other non-pharma sources may not meet pharma's specific needs. conversely, pharma's studies may not meet broader needs (bax et al., ; lewis, ) , or be perceived as "distorted" source of data because they are funded by pharma (lewis, ) . pharma support for large single-sponsored surveillance studies is dependent on successful product registrations and marketing. similarly, pharma support for broad regional and national studies, of value to strategists and policy-makers in these areas will become limited in an environment of reduced investment and commercial success. collaborative surveillance between and within pharma and academia or regulators may become increasingly necessary but is difficult to implement in terms of mutually acceptable objectives, scope, methods, timelines, funding agreement, management, and publication/presentation rights. bax et al. ( ) stated that consortium funding will be necessary for large schemes to be successful, and that there is no "ideal" surveillance system. new approaches to the funding, conduct, and availability of surveillance data while recognizing individual pharma confidentiality and commercial interests, include the purchasing of surveillance data from commercial surveillance companies or entering into collaborative surveillance studies with specific protocols. sources of purchased data, such as from focus technologies (formerly mrl/tsn) (bax et al., ; hunter and reeves, ) , may provide solutions to many requirements although the extent, quality, and utility of the data is dependent on the database and may not be as well defined or specific for a purpose as a pre-defined protocol. examples of collaborative predefined protocols are the british society for antimicrobial chemotherapy (bsac) surveillance projects for respiratory tract pathogens (reynolds and bsac extended working party on respiratory resistance surveillance, ) and bacteraemia pathogens in which a number of pharma sponsors support a core protocol and panel of antibacterials, along with the ability to have research agents tested under confidentiality. the results from the core protocol, which has been developed by experts in academia, specialist testing laboratories, and pharma are made available via the website to the bsac membership (www.bsacsurv.org). this approach, combining support from a number of companies, with the wide and timely dissemination of core data resolves some of the issues and conflicts relating to quality, interpretation, and dissemination associated with single-company studies and also is hoped to increase sustainability. the current utility of this programme is, however, restricted due to the data and methods being specific to the united kingdom. in conjunction with the generation and use of susceptibility surveillance data, there is need for a clear understanding of the limitations, validity, and consequences of studies to correlate antibacterial usage with resistance. the relationship between antibacterial usage and resistance is complex, and while there is a clear association between use and resistance, cause and effect has not been substantially defined davey et al., ) . there are a number of confounding variables that are important to consider in the interpretation of simple cause and effect (davey et al., ) . reversibility or containment of resistance with optimization (or reduction) of antibacterial usage has yet to be definitely established . consequently, policies designed to curtail or prevent antibacterial resistance based on reduction or change in antibacterial use need to be based on sound science and importantly, the objective of maintaining or improving patient outcomes. bax et al. ( ) concluded that for surveillance: . decisions need to be made regarding the critical populations to be monitored for both local and national comparisons of resistance rates, that is, what level of resistance warrants intervention, and what should be the nature of the intervention; . quantitative data are more valuable than qualitative data and all testing must be shown to yield results that are capable of valid comparison; . molecular techniques should be used to define strains and detect mechanisms of resistance (see poupard, chapter ); . there is a place for both narrow focus and broader surveillance studies: both require funding, but broader studies, including a wide range of organisms and compounds, require consortium funding. there is a need for the interested parties such as academia, policy-makers, regulators, and pharma to consider mutually beneficial surveillance programmes, with agreed methodologies and interpretations persuant to their purpose. this approach may not only provide efficiencies in utility, support, and sustainability but also a better understanding of relationship between antibacterial use and resistance and the role and impact of policies and interventions. in addition to the key influential recommendations described by carbon et al. ( ) there are many other national and local guidelines, guidances, policies, and educational campaigns which impact antibacterial use. most such policies either describe the need for implementation of "judicious" or "prudent" use of antibacterials, or use terms such as "misuse" and "overuse" as causes of resistance and imply that a reduction in antibacterial prescribing per se will have a beneficial and sustainable effect on resistance. there is a recognition that while prescribing guidelines and other prescribing support systems should help control bacterial resistance in the community, their actual effect on resistance patterns is largely unknown (finch and low, ) and the reversibility or containment of resistance with the optimization of antibiotic usage has yet to be definitely established davey et al., ) . davey et al. ( ) described the control of antibiotic prescribing as a crucial part of any strategy to limit the development of resistance as advocated by the uk house of lords recommendations and the copenhagen recommendations . these authors recognized the difficulty in proving that antibiotic policies help to resolve a problem of resistance that has already developed and also recognized the greater difficulty in proving that policies prevent the development of resistance. most policies (and guidelines) are concerned with which antibiotic is prescribed and davey et al. ( ) state that it is more likely that development of resistance will be contained by policies which also try to limit unnecessary prescribing of antibiotics (i.e., prescribing for non-bacterial or self-limiting illness). the general advantages of an antibiotic policy are described by davey et al. ( ) as: • promotion of awareness of benefits, risks, and cost of prescribing • facilitation of educational and training programmes • reduction of aggressive marketing by pharma • encouragement of rational choice between drugs based on analysis of pharmacology, clinical effectiveness, safety, and cost; and specifically to antimicrobials as: • the promotion of education on local pathogen epidemiology and susceptibility along with awareness of infection control. the general benefits are described as: • improved efficacy of prescribing (sensitivity and specificity) • improved clinical outcome • reduced medical liability; and specifically to antimicrobials as: • limited emergence and spread of resistance. davey et al. ( ) suggest that antibacterial policies can definitely improve the quality of prescribing and may be used to limit cost and that limiting superinfections and antibiotic resistance should be viewed as additional benefit (and probably not a realistic primary aim). similarly, ball et al. ( ) stated that when prescribing is necessary, quality prescribing may not only combat resistance and optimize patient outcomes but also provide cost benefits. in a review of the impact of guidelines in the management of communityacquired pneumonia, several studies were identified which showed that an increase in the proportion of patients who receive prompt, appropriate therapy was associated with improvements in outcome measurements such as mortality and length of hospital stay (nathwani et al., ) . gould undertook a review of the role of antibiotic policies in the control of antibiotic resistance, noting that the pragmatic and essential approach to the control of antibiotic resistance is to control antibiotic use (gould, ) . he also noted that policies can be efficacious in reducing costs and levels of antibiotic use, but the subject of debate is whether antibiotic control measures can reduce current levels of resistance rather than just halting it. there are examples where control of antibiotic use has reduced the incidence of outbreak and resistant organisms in hospitals and similar examples where reduction of prescribing in the community has led to a degree of control of resistance. there are a number of confounding factors which make it difficult to attribute cause and effect entirely to reduction in antibiotic prescribing (davey et al., ; gould, ) . mathematical modelling seeks to take these factors into account and, while also casting doubts on whether reduction alone will prevent or reduce resistance (austin et al., ; gould, ) , may help with future understanding of measures which contribute to or reduce antibacterial resistance, and as such should be encouraged. use of this approach to define policies has been limited (if used at all) (davey et al., ) . nevertheless, policy decisions should be supported by evidence, and not just by concerns about future development of resistance or the desire to reduce costs (davey et al., ) . importantly, appropriate use of antibacterials needs a clear definition. it is recognized that recommendations and guidelines should emphasize that the role of antibacterials is for treating bacterial infection, when known or suspected (ball et al., ; davey et al., ) . use of antibacterials outside of this scenario is unnecessary, contributes to overuse and is an avoidable risk factor in the development of resistance (ball et al., ; davey et al., ) . however, when use of antibacterials is warranted (necessary) to treat bacterial infection, such use may also be inappropriate or suboptimal in terms of choice of antibacterial, dose, or duration. for example, schlemmer ( ) concluded that antibiotic misuse does have an impact on promoting antibiotic resistance, and that antibacterial choice, dosage, dosing regimen, or duration of therapy must also, therefore, be considered. carbon et al. ( ) suggested that, for now, antimicrobial management programmes should focus on ensuring the most appropriate use of antimicrobials rather than simply on limiting use or choices. a consensus group (ball et al., ) has recently identified principles for appropriate prescribing of antibacterials in lower respiratory tract infection with which to underlay prescribing and guideline formulation. these principles include: • identification of bacterial infection by optimized diagnosis • severity assessment where relevant • recognition and incorporation of ambient resistance data • targeting bacterial eradication (or maximal reduction in bacterial load) • use of pharmacodynamic (pd) indices to optimize choice and dosage • objective assessment of true (overall) costs of resistance and related treatment failure. guidelines, policies, and educational campaigns should seek to better define, support, and implement appropriate use based on principles such as those from the consensus group (ball et al., ) . "prudent" use or reduction in use alone will not adequately define or ensure optimum or appropriate use of antibacterials. the definition and implementation of appropriate prescribing based on evidence-based optimization of quality antibacterial use (right drug/dose/duration based on pd indices and local resistance patterns), rather than reduction in quantity alone may contribute towards the aim of slowing or preventing the emergence of antibacterial resistance, and also offer associated cost and efficiency benefits. importantly, this approach may also maintain an environment that supports the use of new effective antibacterials and a commercial rationale for investment and development by pharma. an ill-defined environment, focusing on the need to reduce quantity with little differentiation between optimal and suboptimal agents is not conducive to the development and marketing of agents with improved activity and efficacy benefits. increasing development costs and hurdles and shrinking market sizes, means that pharma has to get more value out of the r&d investment by improving productivity, reducing development timelines, reducing risk, and increasing the value of agents progressed to market. in the case of antibacterials, the situation is compounded by increasingly demanding regulatory policies affecting the activities required to secure product registration, the product label and clinical use (shlaes and ryan, ). the extent and success of antibacterial research has declined (idsa, ) and is partly a reflection of its relatively low commercial attractiveness compared to other therapeutic areas. the relative return on investment (roi) or net present value (npv) of antibacterials is a reflection of the market size and chance of success in capturing a commercially acceptable part of that market. this important "market share" will be a reflection of the properties and utility of the agents along with the success of marketing activities. differentiation of comparative benefits, such as efficacy against resistant organisms, broader spectrum of pathogens for a given indication, superior efficacy over commonly used treatments, improved dosage regimens and compliance, or better safety characteristics are important features in marketing an antibacterial and in the acceptance and uptake by policy-makers and in the demonstration of cost-benefits to formularies. policies or guidelines which decrease the ability of pharma to demonstrate these benefits, reduce the chance of gaining differentiated label indications (such as the inclusion of resistant organisms), or restrict usage to limited indications (such as only to resistant organisms) will negatively impact npvs and rois for new agents. development of an antibacterial agent for restricted use only may not be a commercially attractive proposition for pharma companies with interests in other therapeutic areas. in order for pharma to succeed and maintain investment, hurdles in productivity in discovery and development need to be overcome and the key issue of roi based on product benefits and use needs to be addressed. although policies themselves do not directly impact upon the process of discovery of new antibacterials, they do have a cumulative negative impact on the chance of success of developing and marketing new differentiated antibacterials and consequently, the willingness of companies to initiate or continue investing in antibacterial discovery research. the urgent need for new classes of antibacterials has, however, increased the pressure in pharma to maximize efficiencies in identifying new molecular targets for antibacterials and compounds active against those targets. genomics and high-throughput screening (hts) offer important potential advances in this area. on april francis crick and james d. watson published their paper "molecular structure of nucleic acids" in nature (watson and crick, ) the role of genomics in antimicrobial discovery should be considered against the background of pharma's efforts over many years in fine-tuning the existing classes of antibacterials to improve their spectra, efficacy, and safety through semisynthetic and wholly synthetic chemistry approaches. linezolid, an oxazolidinone, represented the first novel compound class introduced to the market in more than years (diekema and jones, ) . traditional chemical modification to produce new members of existing classes has resulted in significant improvements in ␤-lactams, macrolides, and fluoroquinolones (e.g., rasmussen and projan, ) , but has been a relatively slow and labourintensive process with limited additional success in recent years. a team of bench chemists in the s might produce up to novel compounds each per annum for biological screening against a panel of target organisms, resulting in a total, perhaps of hundreds of compounds being screened. for example, methicillin, discovered in had a beecham research number of brl , and was followed by many valuable semisynthetic penicillins over the next decade, notably ampicillin (in (in ), carbenicillin ( (in ), and amoxicillin, designated brl (in ( , indicating the extent of synthesis and screening of this highly successful semisynthetic range of compounds, at approximately per year. unfortunately, this approach of chemical modification based on knowledge of structure-activity relationships combined with improvements in throughputs of screening has failed to increase the number and diversity of antibacterials in recent times. mills ( ) describes genomics-related technologies as they are currently applied to the discovery of small molecule antibacterial therapies. with respect to microbial genomics, the dna sequence of haemophilus influenzae was published in (the first free-living whole-organism sequence), followed by mycoplasma genitalium and many other sequenced complete bacterial genomes, of which are publicly available, including those of more than human pathogens. the process of antibacterial discovery through genomics revolves around the "minimum gene set for cellular life hypothesis" (koonin, ; mills, ) and a number of defined stages in the process. (a) genome-scale transposon mutagenesis to identify all non-essential genes (inferring essential genes); (b) expression of anti-sense rna to probe suspected essential genes, and knocking out conserved genes of unknown function to identify novel "broad-spectrum" essential genes. . identification of target genes: (a) select target gene either as narrow-or broad-spectrum by specific conservation profile based on comparative genomic analysis; (b) prove essential for in vitro growth, for example, by gene knockout in relevant bacteria; (c) clone and sequence gene and optimally express protein product; (d) purify and develop assay, and screen and identify target inhibitors "hits"; (e) characterize hits in terms of potency, mechanism of action, spectrum, and selectivity. for broad-spectrum targets a key issue is to study isozymes from several genetically diverse bacterial species along with further screening against a panel of microbes for cellular activity, particularly to address the potential role of intake cell membrane barriers or efflux mechanisms (mdrs) on antibacterial activity. lead compounds can be further optimized in terms of potency, spectrum, and selectivity through studies on the mode of action (moa). optimization of pharmacokinetic (pk) and pd properties through distribution, metabolism, and pk (dmpk) studies and drug delivery/formulation are increasingly important areas in the development process. in particular, knowledge of the role of pk/pd in relation to appropriate dosing and the potential for resistance development is evolving and is being used increasingly by pharma. the proof of principle of this genomics-driven, target-based approach, starting with a conserved gene and leading to antimicrobial compound is the discovery of bb- , a peptide deformylase inhibitor with gram-positive and gram-negative activity. optimization by hts is exemplified by methionyl trna synthetase. a target identified through genomics and genetics and to which whole-cell screening of target-specific inhibitors has been undertaken is lpxc, a metallo-enzyme essential for growth of gram-negative bacteria. high-density dna microarrays is a technology undergoing validation which has the potential to generate a vast amount of functional information on coordinated gene expression under various growth conditions. there are a number of new antibacterials currently in late-stage development, although all of these are from existing established classes (e.g., penem, fluoroquinolone, glycopeptide, lipopeptide, glycylcycline) (rasmussen and projan, ) . it is hoped that use of genomics to identify novel targets with biological and clinical relevance and hts to increase the chance of "hits" may result, in time, in a range of novel antibacterials for development (mills, ; rasmussen and projan, ) . many, if not all, of the bacterial targets have now been identified, but hts has yet to deliver the range of novel antibacterial compounds that hit these targets. encouragingly, the most advanced hts plants now have the capacity to screen , compounds per day. worryingly, there are increasing hurdles in the development and commercialization of antibacterial agents that might adversely impact the willingness of companies to initiate or continue investing in antibacterial discovery research. new antibacterials are unlikely to be recommended as first-line clinical agents in policies designed to control antibacterial use unless they offer benefits, often assessed in relation to cost over existing branded or generic agents. efficacy against organisms resistant to other antibacterial choices is a potential benefit but if it is the sole indication it may be of limited commercial attractiveness. there are a number of significant hurdles in being able to demonstrate and use differential benefits. these relate to governmental/ regulatory policy with respect to clinical development, product labelling, and promotion. shlaes and ryan ( ) reviewed the strategic and regulatory considerations in the clinical development of anti-infectives. a new and evolving set of challenges exists for pharma in the clinical development of antibacterials with a number of requirements from existing or proposed regulatory guidelines posing significant hurdles and complexity. the key points of concern to pharma are listed below. . removal of in vitro activity from product label (fda)-limits potential for description of agents' full spectrum of activity (such as against rare or bioterrorism pathogens), differentiation and promotion. . post-marketing surveillance of resistance and label updates (as required (fda and national eu agencies) )-presents "unlevel playing field" with established/older products. . requirement for in vitro percentage susceptibility of organisms from eu countries (committee for proprietary medicinal products [cpmp])requires product-specific broad surveillance (organisms and geography). . powering of clinical trials to % non-inferiority powered at % level (fda, cpmp)-substantially increased patient numbers and cost. . placebo-controlled superiority trials requested for acute otitis media and acute exacerbations of chronic bronchitis (fda, cpmp)-increased patient numbers and increased risk of not achieving relevant outcomes. . paediatric rule (fda); the requirement to progress paediatric indications/ registration-increased or earlier resource/cost for paediatric studies. . specific indications, for example, pharyngitis, otitis media, rather than upper respiratory tract infection (fda, cpmp)-larger number of phase iii randomized controlled comparator studies required to achieve a broad label. . bacteriological study populations and endpoints requirements (fda, cpmp)-bacteriological endpoints required for breakpoints, labelling, and differentiation. . national comparators and resistance in eu (cpmp)-additional studies needed to address national comparators. the regulatory guidelines are increasingly focusing on the need for demonstrations of non-inferior clinical efficacy in randomized controlled trials in the specific indication. in the united states, inclusion in the product label of only those organisms isolated from the indication under study and for which clinical cure was achieved is proposed, irrespective of the in vitro activity spectrum. label indications are a key point to control antibiotic use (schlemmer, ) and any information given to the prescriber that is able to help select for proper indications is potentially an important tool for good antimicrobial practice (schlemmer, ) . however, schlemmer ( ) also states that there is a critical need for trials to select for those patient populations who really need antibiotics, or to look for new endpoints able to differentiate between drugs, rather than only demonstrating equivalence. this approach may ensure that clinical evidence supports the claim for beneficial activity against a particular organism in a particular indication, or population, but inevitably will restrict the breadth of label. the commercial implications of limited labels based on proof of superior benefits (and not just equivalence), compared with broader labelling based on equivalence will be critical to pharma. the value of studying new endpoints for differentiation will also be dependent on acceptance of the endpoints by regulators, and their incorporation into product labelling, enabling promotion and communication. the differential benefits would also need to translate into guidelines and formulary inclusion. it has been argued by monnet and sorensen ( ) , that antimicrobials that represent real innovations are readily accepted by hospital prescribers and naturally gain market shares. the hurdle is in being able to demonstrate the innovative benefits to the satisfaction of the regulators and decision-makers, and in there being sufficient commercial return from use in a narrow-defined patient group. a particular issue is that there will be significant hurdles in the ability of pharma to demonstrate clinical efficacy against emerging resistant organisms, which may only rarely be isolated in clinical trials. pk/pd data which allow predictions of bacteriological efficacy to be made and tested, for example, in in vivo infection models of simulated human pk, or in small pd studies in patients, have been proposed by a number of bodies, including the eu cpmp (emea). however, the use of such data has yet to be fully accepted and adopted by the fda as a surrogate for clinical efficacy and breakpoint determination. pk/pd data are of particular interest when trying to define the best dosage and dosing regimens for new compounds. as the bacteriological endpoint correctly defines the outcome in an infectious process it would serve to assess the pk/pd relationship of a drug (schlemmer, ) . using pk/pd data to predict bacterial eradication or clinical outcome should be considered as the only way to select for optimal therapeutic regimens regarding antibiotic choice and dosing regimen as well as determining the optimal therapy duration (ball et al., ; schlemmer, ) . a greater role of predictive pk/pd data and modelling under certain circumstances and for specific target populations, has been proposed by cpmp (emea) and is supported in general by pharma. global pharma need to conduct clinical development programmes that satisfy the highest requirements of both fda and emea. in europe, there is a need to include comparative agents approved and relevant to individual eu countries, or for which a consensus justification can be argued, for technical approval (emea). phase iii clinical trials are designed primarily to meet the requirements of the regulators. however, these traditional comparative noninferiority trials fail to provide important evidence of potential benefits over existing therapies. with clinical success for antibacterials in the % or more level, demonstrations of superiority require vast patient populations. pharma rely on other data to indicate superiority and benefit, ranging from potency (minimum inhibitory concentrations, etc.), per cent susceptibility based on breakpoint, in vitro and in vivo models, pk/pd, and defined clinical studies to demonstrate bacteriological and health-outcome benefits. much of the clinical work undertaken to secure regulatory approval fails to best demonstrate the role and clinical benefits of new agents (bax et al., ) and yet is often used as the evidence base for reimbursement, guidelines, and policies. there has also been a proposal to update and harmonize antibacterial product labels between european countries, particularly for "old" antibiotics and their datasheets (summary of product characteristics) at the time of generic introductions because lack of relevant product information promotes inappropriate use (european conference on antibiotic use in europe, - november, ; schlemmer, ) . the burden of cost to provide new data to demonstrate the benefits of marketed and new agents would lie with the pharma r&d companies. failure to produce data to support current claims could result in removal of differentiation from established branded products, while provision of data may strengthen the labels of generic products. bax et al. at the whitley park symposium in reviewed the limitations of the current clinical evaluation process and stated that the lack of development in how to define precisely both drug value and appropriate use will seriously hamper the drug industry's ability to develop important new medicines discovered by new technologies (bax et al., ) . the authors suggested that what is needed is further and much more rapid development of conventional means of drug evaluation, such as the clinical trial, as well as visionary use of new methods in epidemiology, and new use of electronic data merged in a way that identifies drug effects on both a population and individual basis. the role of r&d-based pharma is to discover, develop, and commercialize antibacterials. there is a danger that the wide range of policies which have been introduced under the auspices of "combating resistance" will themselves hamper pharma's ability to deliver a key strategy, if not the most important weapon in the battle against bacterial infection and resistance, the introduction of novel antibacterials. policies and improvements in the quality of antibacterial prescribing have an important role to play, as do diagnostics, vaccines, infection control, and other interventions. pharma is clearly an important partner along with government, ngos, regulators, infectious diseases experts, practioners, and patients in the battle against bacterial infection. the "conflicts of interest between the prescriber, the regulator, and the profit maker" was the subject of a supplement to clinical microbiology and infection. the editor (gould, a) , recognized that the calls for restrained use of antibacterials to combat and control resistance counters the natural instincts of doctors to do the best for their patients and of pharma, which of necessity, needs to profit to exist and continue. it is, however, unfortunate that pharma can be regarded first as "profit makers" and can even be excluded from contributing to debates on the subject of antibacterial use (european conference on antibiotic use in europe, - november ) . there needs to be a distinction between companies which are solely suppliers of generic products and those who have the objective, dedication, and expertise to discover and introduce new antibacterials. these are undoubtedly profit makers, being subject to commercial and shareholder expectations, but perhaps should be considered foremost as "providers" with respect to new antibacterial solutions. gould describes an international partnership of medical societies and industry, in association with regulators as a model for the future in the battle against antibacterial resistance (gould, b) . schlemmer ( ) highlighted that while antibacterial policies were the keystone in promotion of good antimicrobial practice, more accurate and relevant information on antibiotics is urgently needed and that it is the responsibility of pharma and regulators to move together towards an improvement in antibiotic evaluation. the objective would be to give prescribers more critical product information and to help the experts create better guidelines. who included pharma via the international federation of pharmaceutical manufacturers association (ifpma) in consultation on their containment strategy and model prescribing guidelines (www.who.int/emc/amr.html) and the european federation of pharmaceutical industries and associations (efpia) have represented pharma in eu and emea discussions and consultations on clinical trial guidelines and labelling. in the united states a multiagency task force of fda, cdc and the national institute of health (nih) issued a document entitled public health action plan to combat antimicrobial resistance in with a priority to create an interagency antimicrobial resistance product development working group coordinated by the fda, us department of agriculture (usda), and cdc (shlaes and ryan, ) . a second priority was to, "investigate and act upon potential approaches for stimulating and speeding the entire antimicrobial resistance product development process, from drug discovery through licensing," including exploring the economics of the situation and incentives. while monnet and sorensen ( ) argue that much investment from pharma is into marketing and not r&d and that the so-called "r&d scare card" is not justified, it is clear that pharma companies are increasingly taking the commercial decision not to invest in r&d for antibacterials, but in other areas. according to shlaes and ryan, incentives for increasing pharma r&d into priority infectious diseases include the need for more information on the market and disease areas (based on market identification, disease-specific bioinformatic systems, development of surrogate endpoints), more predictability (based on market assessment, international regulatory harmonization, and reinforcement of intellectual property rights), and more cost-risk sharing (market creation, patent extension, orphan drug legislation) (shlaes and ryan, ) . a number of bodies, such as who, idsa, and eu task forces have begun processes to assess the situation and identify some areas of action. these include: • summarizing the value of antibacterials • identifying the status of clinically relevant resistance and priority pathogens • evaluating the state of antibacterial research/regulatory submissions/industry involvement and outlook • maintaining databases of funding agencies, their research interests, new opportunities for funding • documenting the vulnerabilities related to the manufacture of antibacterials/ shortages/negative impacts on public health: gap analysis • undertaking the identification, prioritization, and tracking of global public health needs (a global agenda) • reviewing/documenting government activities to foster development of new antibacterials • reviewing recommendations for "incentivizing" • modifying regulatory approval processes such as priority review, fast track, waiver of user fees, orphan drug status, modified/smaller clinical trials, and/or reduced number of efficacy studies per indication (and use of surrogates such as pk/pd) • harmonizing clinical trial methodologies and implementing coordinated action by regulatory agencies in registration of new products • increasing education and training opportunities. research-based pharma needs to be included as a partner in these collaborative initiatives in order to help shape the future in a way which will be conducive to continued investment into r&d for new antibacterials while improving their use and sustainability. this will require a full consideration of the contributing factors, actions, and impacts in order to find a way to maintain a critical balance ( figure ). a new model may need to be defined which explores alternative roles of small companies, government, and ngo bodies along with big pharma in the conduct and funding of antibacterial discovery, development, and distribution. policies are important and necessary in controlling antibacterial use in an attempt to preserve the utility of existing and future antibacterials. they should aim to minimize unnecessary and inappropriate use, as avoidable risk factors in the development of resistance, while maintaining or improving patient outcomes. the effect of antibacterial policies on the containment or reduction of resistance is largely unknown and should focus not on quantity of prescribing alone but on quality to ensure appropriate prescribing in terms of antibacterial choice, dosage, dosing regimen, or duration. policies that relate to figure . from the past to the future: hypothetical potential scenarios evolving from the relationship between antibacterial need/resistance, antibacterial productivity and policy. (a) sustainable balance of antibacterial productivity, resistance, and regulation/policy; oscillations may decrease over time with better understanding of the relationships and balanced management. (b) crisis of imbalance of increased policy/regulation, decreased incentives and antibacterial productivity and increasing/uncontrolled resistance. antibacterial use have the potential to reduce the antibacterial market size and commercial attractiveness relative to other therapeutic areas. policies that relate to development activities and labelling have the potential to increase development costs, restrict use, and limit the ability to differentiate benefits. collectively policies are negatively impacting big pharma's willingness to continue investment in this field. the combined and cumulative effects of the various policy items related to surveillance, use, clinical trial guidelines, product labelling, and promotion require a broad, collaborative, and global view of the impact on pharma r&d. collaboration is required to identify agreed and mutually acceptable ways to streamline development, implement appropriate prescribing, demonstrate and promote product benefits, and maintain financial incentives. antibacterial discovery, development, and use are related within a dynamic environment that includes bacteria, their resistances, and policies. as with any dynamic environment, change will alter the balance (figure ). policies are contributing to a change and a negative impact on the potential and willingness of pharma to develop new antibacterials. while change may require adaptation for survival and success, careful consideration and collaboration is needed by all parties to help to ensure that insurmountable hurdles are not created leading to the inability of pharma to survive and succeed in antibacterial r&d. failure of pharma to deliver new antibacterials would lead to "antibacterial extinction." pharmaceutical company approach bacterial resistance concerns the relationship between the volume of antimicrobial consumption in human communities and the frequency of resistance antibiotic therapy of community respiratory tract infections: strategies for optimal outcomes and minimized resistance emergence surveillance of antimicrobial resistance-what, how and whither? antibiotic clinical trials-the witley park symposium moving from recommendation to implementation and audit: part . current recommendations and programs: a critical commentary politiques d'antibiothérapie a l'échelon national dans divers pays moving from recommendation to implementation and audit: part . review of interventions and audit antibiotic policies oxazolidinones: a review european conference on antibiotic use in europe. - surveillance of resistance in bacteria causing community-acquired respiratory tract infections a critical assessment of published guidelines and other decision-support systems for the antibiotic treatment of community-acquired respiratory tract infections the evolution of anti-microbic drugs a review of the role of antibiotic policies in the control of antibiotic resistance minimum antibiotic stewardship measures the current status of surveillance of resistance to antimicrobial agents: report on a meeting abstracts of the nd interscience conference on antimicrobial agents and chemotherapy abstracts of the rd interscience conference on antimicrobial agents and chemotherapy the future of antimicrobial drug availability: an impending crisis measuring the pace of new drug development in the user fee era how many genes can make a cell: the minimal-gene-set concept antimicrobial resistance surveillance: methods will depend on objectives the role of genomics in antimicrobial discovery the patient, the doctor, the regulator and the profit maker: conflicts and possible solutions do guidelines for communityacquired pneumonia improve the cost-effectiveness of hospital care? antibacterial drug discovery: what's in the pipeline? bsac respiratory resistance surveillance programme: first results of the winter - collection impact of registration procedures on antibiotic policies strategic and regulatory considerations in the clinical development of anti-infectives molecular structure of nucleic acids: a structure for deoxyribose nucleic acid figure . a question of balance: increasing and decreasing factors in the environment of antibacterial resistance, usage, discovery, and development. key: cord- - calrk l authors: bhar, ramaprasad; malliaris, a.g. title: modeling u.s. monetary policy during the global financial crisis and lessons for covid- () date: - - journal: j policy model doi: . /j.jpolmod. . . sha: doc_id: cord_uid: calrk l the paper formulates the modeling of unconventional monetary policy and critically evaluates its effectiveness to address the global financial crisis. we begin with certain principles guiding general scientific modeling and focus on milton friedman's presidential address that delineates the strengths and limitations of monetary policy to pursue certain goals. the modeling of monetary policy with its novelty of quantitative easing to target unusually high unemployment is evaluated by a markov switching econometric model using monthly data for the period - . we conclude by relating the lessons learned from unconventional monetary policy during the global financial crisis to the recent bold initiatives of the fed to mitigate the economic and financial impact of the covid- pandemic on u.s. households and businesses. the federal reserve act of established the u. s. central bank called the federal reserve system and charged it to design a national currency and conduct a monetary policy to promote financial stability. in , congress amended the federal reserve act, stating explicitly the monetary policy objectives of the federal reserve as: committee shall maintain long run growth of the monetary and credit aggregates commensurate with the economy's long run potential to increase production, so as to promote effectively the goals of maximum employment, stable prices and moderate long-term interest rates." among the three goals of maximum employment, stable prices and moderate long-term interest rates, the first two have received precedence and thus most consideration over the years. for example, during the late s and early s when the fed was fighting inflation and long-term interest rates had approached very high levels, around %, such elevated interest rates did not cause the fed to deviate from its inflation targeting. the pursuit of maximum employment and price stability as the fed's primary goals has evolved into the fed's "dual mandate". this dual goal involves some possible trade-offs between inflation and unemployment, often called the phillips curve and the appraisal of their associated risks. for example, the fight against inflation during the s and early s had as a consequence the increase in unemployment. more recently, after the global financial crisis of - , the fed pursued maximum employment, understanding the risks of possible inflation. in this paper we accomplish four goals: first, present the methodological elements of m. the epistimological prominence of models in science has increased significantly during the past several decades and both philosophers and historians of science have studied these valuable tools. frigg and hartmann ( ) present a critical literature overview on models and modelling in science and list a large group such as: computational models, developmental models, explanatory models, testing models, theoretical models, heuristic models, mathematical models, and formal models, among several others. this large variety makes it difficult to propose a uniform definition. milton friedman ( ) participated in debates about the role of models in economic methodology and is known to have argued that models should not be judged by the realism of their assumptions but only by the success of their predictions. for our discussion, a model is a conceptual representation of some aspect of reality we wish to understand; or a model may highlight important connections among sets of data representing certain variables. according to friedman we may not have an exact set of j o u r n a l p r e -p r o o f assumptions about the behavior of economic agents but if the model generates a testable prediction and offers a policy recommendation then such a model is useful. so a model is like a tool. if it works it is useful. this pragmatic methodology of modeling suggested by friedman ( ) is carefully explored methodologically in isaac ( ) . how have economists modeled monetary policy? keynes observed that during the depression of the the s interest rates were very low and investments were unresponsive. he offered a model for monetary policy known as the liquidity trap and argued that monetary policy under such circumstances is ineffective and cannot help an economy overcome the depression. monetarists who followed keynesians in early s argued that monetary policy had a major impact on an economy and played an important role on business cycles, exactly in opposition to the keynesian model. however, monetary policy can prevent money itself from being a major source of economic disturbance; offer a stable background of expectations and offseting major disturbances in the economic system arising from other sources. how should monetary policy be conducted? friedman advises that the most appealing guides for monetary policy are exchange rates, the price level as defined by some index, and the quantity of some monetary aggregate. friedman ( , p. ) asserts "i believe that a monetary total is the best currently available immediate guide or criterion for monetary policy-and i believe that it matters much less which particular total is chosen than that one be chosen." fifty years later, mankiw and reis ( ) skillfully evaluate the brilliant contribution of friedman on modeling the role of monetary policy by affirming the intellectual prescience of some of his proposals but also by replacing others that were less enduring. friedman's view that in the long run the central bank cannot peg unemployment nor real interest rates has persisted. instead of targeting friedman's suggested variable of the growth rate on some monetary aggregate, central banks for the last two decades embraced price stability and in particular, often advocate a precise % inflation target. also, the emphasis has shifted from using monetary variables as tools to using the very short term interest rate. mankiw and reis ( ) give a j o u r n a l p r e -p r o o f detailed exposition of the role of the natural rate of interest, introduced by knut wicksel, and explain how central banks currently interpret inflation targets in a flexible framework that adjusts to the business cycle. put differently, the short run flexible decision-making by central banks to achieve their mandates by setting short term interest rates subject to new data may not have appealed to friedman who prefered a much longer run strategy. it was in the longrun that "major sources of economic disturbances" occurred as in wars, periods of financial exhuberance or panics and friedman's insightful advice suggested "offseting" such developments. such "offseting" is central to the modeling of "unconventional monetary policy" presented next. we now know that the financial crisis began as a subprime mortgage lending problem in the economy. it had also validated that using the fed funds as a tool to achieve its dual mandate was most appropriate. these significant accomplishments of monetary policy were called the "great moderation". so when unemployement reached a high of % during the great recession, the fed's objective function had to prioretize tagetting unemployment over inflation. initially, while the economy was in recession, the risks of inflation were very low but from mid- to the end of , when the fed increased the fed funds rate from the range of % to . % to the range of . % to . %, the assessment of pursuing easy policies to achieve maximum employment j o u r n a l p r e -p r o o f against the potential risks of reigniting inflation were continuously monitored and assessed. the importance of job creation as the primary goal of unconventional monetary policy is expounded in baghestani ( ) , evans ( ) , kuttner ( ) . during september , fed funds were between . % to %. three months later, during december , fed funds were between % to . %. this great tool of normal monetary policy over several decades had become of no further use. in late , the fed decided to use an unconventional method to stimulate the u.s. economy constrained by the zero lower bound of fed funds. these tools included the so called large-scale of asset purchases (lsap) or quantitative easing (qe). the tool of qe consists of the federal reserve purchasing longer-term u.s. treasury securities and agency mortgage-backed securities (mbs) with the aim of driving down longer-term interest rates, thereby stimulating economic activity. in other words, if the short-term fed funds rate has reached the zero level and cannot go any lower, the next option for the fed to accomplish its dual mandate was to target the longer-term interest rate. independent of the debate whether the fed can influence longer-term interest rates, bernanke ( bernanke ( , argues that qe works via the portfolio balance channel. the simple logic of this channel indicates that different classes of financial assets are not perfect substitutes in portfolios formed by investors and if the fed can purchase large quantities of a certain asset and influence its price and therefore its yield, such changes may, through arbitrage transactions, spread to other asset classes. if the final result of qe is the increase of long-term bond prices and the decline of yields across many asset classes, the overall economic result is an increase in wealth that leads to more consumption and investment. with increases in consumption and investment, the economy grows and generates jobs to achieve the fed's goal of maximum employment. not all economists accept this line of reasoning. thornton ( ) does not find any empirical evidence in support of the portfolio balance channel and taylor ( ) pieces of the unconventional monetary policy modeling evolved gradually. bernanke ( ) and kuttner ( ) discuss the progression of qe in detail. it was not known at the beginning how many rounds of qe were necessary for the restoration of financial stability in the financial sector and economic recovery in the real economy. today, with the benefit of historical experience we know that the fed executed main rounds of qe. during the long period of about seven years, - , with fed funds rate remaining essentially at zero, monetary policy followed qe and increased its balance sheet from about trillion to . trillion to stimulate the economy that found itself to be in a liquidity trap. the use of qe was motivated by the pursuit of its goal of maximum employment. it was modeled in j o u r n a l p r e -p r o o f friedman's belief that it is the role of monetary policy to offset major economic disturbances and the prediction of lowering unemployment was viewed as verification of its appropriateness. forward guidance about keeping the fed funds rate at the zero lower bound and pursuing lower longer term interest rates was carefully articulated in numerous fed communications to reduce financial uncertainty while at the same time it was made clear that inflationary expectations were clearly and carefully monitored to enhance the fed's hard won credibility as an inflation fighter. numerous speeches by fed officials document in detail these strategic efforts to employ unconventional monetary policy tools. bernanke ( ) jointly using monthly qe data and also longer term interest rates (say for -year treasury notes), how have these series impacted the u.s. labor market? we formulate basic hypotheses to connect empirically monthly qe and longer term interest rates to various data describing labor markets to investigate empirically the effectiveness of unconventional monetary policy that targeted maximum employment in the aftermath of the financial crisis? we claim that the unconventional tools of monetary policy targeted primarily the unemployment rate. we also view the bernanke fed's targeting of employment as confirmation of the validity of its policies. it was the fed's affirmation of its new policies that qe and lower longer term t-notes rates would yield the forecasted lowering of unemployment. we use all six measures of unemployment, u , u , u , u , u , and u to perform an exhaustive analysis of this dimension of labor markets. u is the most representative measure that is used most commonly. these hypotheses display the very practical and realistic goal of unconventional monetary policy that targeted the reduction in unemployment. what do we mean by such a statement? by unconventional monetary policy we mean the use of qe as a tool whose goal was to reduce the steepness of the yield curve, increase financial wealth, eventually increase aggregate demand and thus bring down unemployment. in the spirit of friedman's scientific methodology numerous assumptions are made about these developments and what matters most is not the exact nature of these assumptions but the prediction that unemployment will decline. an early analysis of qe is found in gagnon et al. ( ) and more recently in engen et al. ( ) . the comprehensive paper of gagnon et al. ( ) argues that in contrast to the pre-crisis additional theoretical support for the hypotheses we are formulating can be provided by chiarella and guilmi ( ) . actually these authors develop a dynamic macroeconomic model in the spirit of hyman minsky's ( ) the independent variable is monetary policy. we employ two proxies for monetary policy during the period studied: first we use total fed assets and second we use the -year treasury note which under normal conditions is determined solely by market conditions but during the financial crisis was targeted by the fed via its qe strategies. we hypothesize: following hamilton ( ) , the matrix of transition probabilities is defined as: the expected duration of the high volatility regime is given by e(s= ) = /( -p ) and that for the low volatility regime is given by e(s= ) = /( -p ). since we are interested in establishing the efficacy of the modelling approach over this rather long sample period, we initially focus on the diagnostic tests of the model. although, the residual analysis from the regression equation ( ) without switching shows no significant serial correlations, the cusum-square test shows instability in variance and/or parameters. this is further corroborated by the chow break point test. these results are not included in the paper. although the garch variance captures the time varying nature of conditional variance, it cannot address it, if there is structural discontinuity in the level of variance. in order to explore more effectively the influence of the independent variables on the various measures of unemployment as well as parameter and variance discontinuity over the long sample, we investigate the non-linear modelling approach via a two state markov chain shown in equation ( ). the subscript is used to denote dependence of these parameters on the prevailing markov state. the law guiding the evolution of this unobserved state variable is a time homogenous transition probability matrix. the residual term is also dependent on the markov state occurring and the variance of this residual variable is also state dependent. in fact, the realization of the j o u r n a l p r e -p r o o f residual variance is one way of classifying the states to which we may be able to attach economic significance in contrast to linear models that assume stationary distributions, regime-switching models are based on a mixture of parametric distributions whose probabilities depend on unobserved state variable. in our model, the economy alternates between two unobserved states of high volatility and low volatility according to a markov chain process. since we have identified that the parameters are not constant through time, and some sort of structural break occurs in the series, we have certain modelling choices. one alternative is to estimate the model over different sub-samples if the timing of the break is known. another alternative is to make the structural break endogenous to the model since in many cases the timing of the shift may not be known. by making the shift(s) endogenous to the model, we can also make inferences about the process that drives these shifts. models that shift between various densities allow us to incorporate structural breaks in the estimation procedure. a source of uncertainty, idiosyncratic to regime switching models is the ex-post determination of regimes. in switching models, it is assumed that the occurrence of a regime is observed by the market but not by the econometrician who must infer it from the model. until recently, the quality of regime classification was determined by focusing on the smoothed expost regime transition probabilities. an innovation in this area is the regime classification measure (rcm) proposed by ang and bekaert ( ) . this is essentially a sample estimate of the variance of the probability series. it is based on the idea that perfect classification of regimes would infer a value of or for the probability series and would be a bernoulli random variable.  u = percentage of labor force who lost jobs or completed temporary work.  u = percentage of labor force who are without jobs and have looked for work in the last four weeks (note that this is the officially-reported unemployment rate).  u = u plus the percent of the labor force that count as "discouraged workers," i.e. people who would like to work but have stopped looking because they are convinced that they can't find jobs.  u = u plus the percent of the labor force that count as "marginally attached" or "loosely attached" workers, i.e. people who would theoretically like to work but haven't looked for work within the past four weeks.  u = u plus the percent of the labor force that count as "underemployed," i.e. parttime workers who would like to work more but can't find full-time jobs. graph illustrates these six proxies for the unemployment rate first, all tables show that all measures of unemployment changes are driven by changes in independent variables that are significant in both the low and the high volatility markov regimes. we work with first differences because of the non-stationarity of our variables. second, the monetary policy instruments used by the fed after the lehman brothers bankruptcy were qe and its impact on reducing longer-term interest rates on government bonds. j o u r n a l p r e -p r o o f studied and summarized in williams ( williams ( , and more recently in bhar, malliaris and malliaris ( ) . u is driven by the long-run -year t-note rate in the low volatility regime and by its own -period lag in the high volatility regime. u is driven by the lagged t-note rate in the low volatility regime and by fed assets in the high volatility regime. autoregressive terms play also significantly for u . third, our results are very interesting for u in table . since this is the official measure of unemployment, it is encouraging to observe that u is driven by fed assets in both the low (level of significance %) and high volatility (level of significance %) regimes. also, it is important to indicate that the average duration of the high volatility regime for u is about . months that is higher than the low volatility regime that lasts only . months. u is driven by fed assets (significance level %), the t-note rate and autoregressive factors in the low volatility regime. u on the other hand is influenced by fed assets in the low volatility regime and by the t-note rate in the high volatility regime. finally, u is significantly influenced by both fed assets and the t-note rate in the low volatility regime and by autoregressive factors in the high volatility regime. the over-all conclusion of these tables is that monetary policy in its unconventional approach with qe and the year t-note rate appears statistically significant in out of regimes-recall we analyze six unemployment measures each in a low and high volatility regime. if we focus on u as the official statistic that does not include chronically discouraged workers for whom monetary policy has very limited effectiveness, then our results are much stronger. recall, as was said earlier that fed assets enter as statistically significant for both the low and high volatility regimes of u (at the % and the % level respectively). this paper articulates that friedman's modeling of monetary policy emphasizes its role as offsetting major disturbances in the economic system arising from sources such as a financial crisis. this conviction is in opposition to the keynesian model that pronounces the ineffectiveness of monetary policy during a liquidity trap. friedman also argues that models j o u r n a l p r e -p r o o f should not be judged by the realism of their assumptions but only by the success of their predictions. the bernanke fed, soon after fed funds were decreased close to zero in late , chose new tools to target unemployment that had reached about %. no one knew during the months that followed the lehman brothers bankruptcy, the magnitude, duration and impact of these policies. what was known at the beginning was the hard economic facts of high unemployment, very low inflation, frozen financial markets and both national and international financial instability. when fiscal policy faced both budgetary and political constraints, a consensus was rapidly built by fomc members to target unemployment as directed by the fed's dual mandate. this consensus was not formed on solid analytical grounds of a macroeconomic model describing the channels connecting monetary policy to increased employment but rather on a careful calculus of risk management, that is, by assessing the benefits from lowering unemployment versus the risks of creating inflation, with a conviction in the effectiveness of monetary policy. what central bankers learned during the - period is that the effectiveness of qe was due to four factors: first, the rapid and careful formulation of unconventional monetary policy to replace traditional fed funds management when these had reached zero; there was no lamenting that monetary policy had arrived to its dead end. second, the commitment of central bankers to unconventional qe that was extended over years with major rounds rather than being abandoned after its first or second round. third, the boldness of policy makers to pursue large qe rather than moving very cautiously, say by only doubling the size of the fed's balance sheet instead of actually growing it by %, and, fourth, the achievement of its goal to reduce unemployment substantially. of course there was some good fortune, meaning that the monthly, data-driven, communications and evaluations of qe never were confronted with unpleasant issues of financial instability, rapid inflation or re-occurring recessions. economy. these initiatives are described in detail in fleming, sarkar, and van tassel, ( ) who also compare whether the covid- initiatives are similar to the ones taken during the global financial crisis or new, specially designed for covid- . to make some preliminary comparisons between the two crises-the global financial this paper discusses certain principles guiding general scientific modeling and focuses on milton regime switches in interest rates federal reserve versus private information: who is the best unemployment rate predictor? aggregate demand and long-run unemployment the impact of large-scale asset purchases on the s&p index, long-term interest rates and unemployment the crisis and the policy response monetary policy since the onset of the crisis the courage to act: a memoir of a crisis and its aftermath american economic association presidential address at the allied social sciences association annual meetings in the financial instability hypothesis: a stochastic microfoundations framework the macroeconomic effects of the federal reserve's unconventional monetary policies innovative federal reserve policies during the great financial crisis labor markets and monetary policy the covid- pandemic and the fed's response models in science the methodology of positive economics the role of monetary policy modeling without representation large-scale asset purchases by the federal reserve: did they work? monetary policy surprises, credit costs, and economic activity what happened: financial factors in the great recession money, banking and monetary policy from the formation of the federal reserve until today monetary policy and balance sheets outside the box: unconventional monetary policy in the great recession and beyond an exploration of optimal stabilization policy friedman's presidential address in the evolution of macroeconomic thought a theory of systemic fragility monetary policy and job creation". a speech at the university of maryland smith school of business distinguished speaker series unwinding quantitative easing: how the fed should promote stable prices, economic growth and job creation qe: is there a portfolio balance effect? unconventional monetary policy and aggregate bank lending: does financial structure matter? unconventional monetary policy: lessons from the past three years lessons from the financial crisis for unconventional monetary policy key: cord- -gtfx cp authors: hsiang, solomon; allen, daniel; annan-phan, sebastien; bell, kendon; bolliger, ian; chong, trinetta; druckenmiller, hannah; hultgren, andrew; huang, luna yue; krasovich, emma; lau, peiley; lee, jaecheol; rolf, esther; tseng, jeanette; wu, tiffany title: the effect of large-scale anti-contagion policies on the coronavirus (covid- ) pandemic date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: gtfx cp governments around the world are responding to the novel coronavirus (covid- ) pandemic with unprecedented policies designed to slow the growth rate of infections. many actions, such as closing schools and restricting populations to their homes, impose large and visible costs on society. in contrast, the benefits of these policies, in the form of infections that did not occur, cannot be directly observed and are currently understood through process-based simulations. here, we compile new data on , local, regional, and national anti-contagion policies recently deployed in the ongoing pandemic across localities in china, south korea, iran, italy, france, and the united states (us). we then apply reduced-form econometric methods, commonly used to measure the effect of policies on economic growth, to empirically evaluate the effect that these anti-contagion policies have had on the growth rate of infections. in the absence of any policy actions, we estimate that early infections of covid- exhibit exponential growth rates of roughly % per day. we find that anti-contagion policies collectively have had significant effects slowing this growth. our results suggest that similar policies may have different impacts on different populations, but we obtain consistent evidence that the policy packages now deployed are achieving large, beneficial, and measurable health outcomes. we estimate that, to date, current policies have already prevented or delayed on the order of million infections across these six countries. these findings may help inform whether or when these ongoing policies should be lifted or intensified, and they can support decision-making in the other + countries where covid- has been reported. the novel coronavirus pandemic is forcing societies around the world to make consequential policy decisions with limited information. after containment of the initial outbreak failed, attention turned to implementing large-scale social policies designed to slow contagion of the virus, with the ultimate goal of slowing the rate at which life-threatening cases emerge so as to not exceed the capacity of existing medical systems. in general, these policies aim to decrease opportunities for virus transmission by reducing contact among individuals within or between populations, such as by closing schools, limiting gatherings, and restricting mobility. such actions are not expected to halt contagion completely, but instead are meant to slow the spread of covid- to a manageable rate. these large-scale policies are developed using epidemiological simulations , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] and a small number of natural experiments in past epidemics. however, the actual impacts of these policies on infection rates in the ongoing pandemic are unknown. because the modern world has never experienced a pandemic from this pathogen, nor deployed anti-contagion policies of such scale and scope, it is crucial that direct measurements of policy impacts be used alongside numerical simulations in current decision-making. populations in almost every country are now currently weighing whether, or when, the health benefits of anti-contagion policies are worth the costs they impose on society. for example, restrictions imposed on businesses are increasing unemployment, travel bans are bankrupting airlines, and school closures may have enduring impacts on a↵ected students. it is therefore not surprising that some populations hesitate before implementing such dramatic policies, particularly when these costs are visible while their health benefits -infections and deaths that would have occurred but instead were avoided or delayed -are unseen. our objective is to measure this direct benefit; specifically, how much these policies slowed the growth rate of infections. we treat recently implemented policies as hundreds of di↵erent natural experiments proceeding in parallel. our hope is to learn from the recent experience of six countries where the virus has advanced enough to trigger largescale policy actions, in part so that societies and decision-makers in the remaining + countries can access this information immediately. to exhibit almost perfect exponential growth. , , the rate of this exponential growth may change daily and is determined by epidemiological factors, such as disease infectivity and contact networks, as well as policies that induce behavior changes. , , we cannot experimentally manipulate policies ourselves, but because they are being deployed while the epidemic unfolds, we can measure their impact empirically. we examine how the growth rate of infections each day in a given locality changes in response to the collection of ongoing policies applied to that locality on that day. we employ well-established "reduced-form" econometric techniques , commonly used to measure the e↵ect of policies , or other events (e.g., wars or environmental changes ) on economic growth rates. similarly to early covid- infections, economic output generally increases exponentially with a variable rate that can be a↵ected by policy or other conditions. unlike process-based epidemiological models, - , , , , the reduced-form statistical approach to inference that we apply does not require explicit prior information about fundamental epidemiological parameters or mechanisms, many of which remain unknown in the current pandemic. rather, the collective influence of these factors is empirically recovered from the data without modeling their individual e↵ects explicitly (see methods). prior work on influenza, for example, has shown that such statistical approaches can provide important complementary information to process-based models. to construct the dependent variable, we transform location-specific, sub-national time-series of infections into first-di↵erences of their natural logarithm, which is the per day growth rate of infections (see methods). we use data from first-or second-level administrative units and data on active or cumulative cases, depending on availability (see appendix section ). we then employ widely-used panel regression models , to estimate how the daily growth rate of infections changes over time within a location when di↵erent combinations of large-scale social policies are enacted (see methods). our econometric approach accounts for di↵erences in the baseline growth rate of infections across locations due to di↵erences in demographics, socio-economic status, culture, or health systems across localities within a country; it accounts for systemic patterns in growth rates within countries unrelated to policy, such as the e↵ect of the work-week; it is robust to systematic under-surveillance; and it accounts for changes in procedures to diagnose positive cases (see methods and appendix section ). the reduced-form statistical techniques we use are designed to measure the total magnitude of the e↵ect of changes in policy, without attempting to explain the origin of baseline growth rates or the specific epidemiological mechanisms linking policy changes to infection growth rates (see methods). thus, this approach does not provide the important mechanistic insights generated by process-based models; however, it does e↵ectively quantify the key policyrelevant relationships of interest using recent real-world data when fundamental epidemiological parameters are still uncertain. we estimate that in the absence of policy, early infection rates of covid- grow % per day on average, implying a doubling time of approximately two days. country-specific estimates range from . % per day (p< . ) in china to . % per day (p< . ) in iran, although an estimate only using data from wuhan, the only chinese city where a meaningful quantity of pre-policy data is available, is % per day (p< . ). growth rates in south korea, italy, france, and the us are very near the % average value (figure a ). these estimated values di↵er from the observed growth rates because the latter are confounded by the e↵ects of policy. in the early stages of most epidemics, a large proportion of the population remains susceptible to the virus, and if the spread of the virus is left uninhibited by policy or behavioral change, exponential growth will continue until the fraction of the susceptible population declines meaningfully. , this decline results from members of the population leaving the transmission cycle, due to either recovery or death. at the time of writing, the minimum susceptible population fraction in any of the administrative units analyzed is . % of the total population (lodi, italy: , infections in a population of , ). this suggests that all administrative units in all six countries would likely be in a regime of uninhibited exponential growth if policies were removed today. consistent with predictions from epidemiological models, , , we find that the combined e↵ect of all policies within each country reduces the growth rate of infections by a substantial and, except in the us, statistically significant amount ( figure b ). for example, a locality in italy with a baseline growth rate of . (national avg.) that deployed all policy actions used in italy would be expected to lower its daily growth rate by . to . . in general, the estimated total e↵ects of policy packages are large enough that they can in principle o↵set a large fraction of, or even eliminate, the baseline growth rate of infections-although in several countries many localities are not currently deploying the full set of policies. our estimate for the total growth e↵ect of all us policies is quantitatively substantial (- . ) but not statistically significant. us estimates are highly uncertain due to the short period of time for which data are available and because the time elapsed since these actions may be too short to observe a significant impact. in china, where policies have been enacted for over seven weeks, we observe that policy impacts have grown over time during the first three weeks of deployment (- . to - . ) . in all other countries except china, we only estimate an average e↵ect for the entire interval of observation, due to the short temporal length of the sample. the estimates above describe the superposition of all policies deployed in each country, i.e. they represent, for each country, the average e↵ect of policies on infection growth rates that we would expect to observe, if all policies enacted anywhere in the country were implemented simultaneously in a region of the country. we also estimate the e↵ects of individual types of policies or clusters of policies that are grouped based on their similarity in goal (e.g., closing libraries and closing . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted march , . . https://doi.org / . / . / museums are grouped) or timing (e.g., policies that are generally deployed simultaneously in a certain country). in many cases, our estimates for these e↵ects are statistically noisier than the estimates for all policies combined (presented above) because we are estimating multiple e↵ects simultaneously. thus, we are less confident in individual estimates and in their relative rankings. estimated e↵ects di↵er between countries, and policies are neither identical nor perfectly comparable in their implementation across countries or, in many cases, across di↵erent localities within the same country. nonetheless, overall we estimate that almost all policies likely contribute to slowing the growth rate of infections (figure c ), except two policies (social distancing in france and italy) where point estimates are slightly positive, small in magnitude, and not statistically di↵erent from zero. we combine the estimates above with our data on the timing of hundreds of policy deployments to estimate the total e↵ect to date of all policies in our sample. to do this, we use our estimates above to predict the growth rate of infections in each locality on each day given the policies in e↵ect at that location on that date ( figure , blue markers). we then use the same model to predict what counterfactual growth rates would be on that date if all policies were removed ( figure , red), which we refer to as a "no policy" scenario. the di↵erence between these two predictions is our estimated e↵ect that all anti-contagion policies actually deployed had on the growth rate of infections on that date. we estimate that since the beginning of our sample, on average, all anti-contagion policies combined have slowed the average daily growth rate of infections . per day (± . , p < . ) in china, . (± . , p < . ) in south korea, . (± . , p < . ) in italy, . (± . , p < . ) in iran, . (± . , p < . ) in france and . (± . , p = . ) in the us. taken together, these results suggest that anti-contagion policies currently deployed in the first five countries are achieving their intended objective of slowing the pandemic, broadly confirming epidemiological simulations. we estimate that anti-contagion policies have not yet had a substantial nor significant impact suppressing overall infection growth rates in the us. at a particular moment in time, the total number of covid- infections depends on the growth rate of infections on all prior days. thus, persistent decreases in growth rates have a compounding e↵ect on total infections, at least until a shrinking susceptible population slows growth through a di↵erent mechanism. to provide a sense of scale and context for our main results in figures and , we integrate the growth rate of infections in each locality from figure to estimate total infections to date, both with actual anti-contagion policies and in the "no policy" counterfactual scenario. to account for the declining size of the susceptible population in each administrative unit, we couple our econometric estimates for the e↵ects of policies to a simple susceptible-infected-removed (sir) model of infectious disease dynamics , (see methods). this allows us to extend our projections beyond the initial exponential growth phase of infections, a threshold which our results suggest would currently be exceeded in several countries in the "no policy" scenario. our results suggest that ongoing anti-contagion policies have already substantially reduced the number of covid- infections observed in the world today ( figure ). our central estimates suggest there would be roughly -million more cumulative cases in china, -million more in south korea, . -million more in italy, . -million more in iran, , more in france, and , more in the us had these countries never enacted any anti-contagion policies since the start of the pandemic. the relative magnitudes of these impacts partially reflects the intensity and extent of policy deployment (e.g. how many localities deployed policies) and the duration for which they have been applied. several of these estimates are subject to large uncertainties (see intervals in figure ). overall, our results indicate that large-scale anti-contagion policies are achieving their intended objective of slowing the growth rate of covid- infections. because infection rates in the countries we study would have initially followed rapid exponential growth had no policies been applied, our results suggest that these ongoing policies are currently providing large health benefits. for example, we estimate that there would be roughly ⇥ the current number of infections in south korea, ⇥ in italy, and ⇥ in iran if large-scale policies had not been deployed during the early weeks of the pandemic. consistent with process-based simulations of , , [ ] [ ] [ ] , , our empirical analysis of existing policies indicates that seemingly small delays in policy deployment likely produce dramatically di↵erent health outcomes. while the quantity of currently available data poses challenges to our analysis, our aim is to use what limited data exist to estimate the first-order impacts of unprecedented policy actions in an ongoing global crisis. as more data become available, empirical research findings will become more precise and may capture more complex interactions. for example, this analysis does not account for potentially important interactions between populations in nearby localities, , nor the structure of mobility networks. , , , , , nonetheless, we hope the results we are able to obtain at this early stage of the pandemic can support critical decision-making, both in the countries we study and in the other + countries where covid- infections have been reported. based on our results from china, where the most post-policy time has elapsed and where a relatively uniform set of policies were imposed during a narrow window of time, it appears that roughly three weeks are required for policies to achieve their full e↵ect. in other countries, these temporal dynamics are more di cult to disentangle with currently available data, in part because less post-policy data is available and also because countries continue to deploy new policies, making it more challenging to precisely measure the lagged e↵ects of earlier policies. future work should investigate these timing changes after more time has passed and new data become available. a key advantage of our reduced-form "top down" statistical approach is that it captures the real-world behavior of a↵ected populations without requiring that we explicitly model all underlying . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted march , . . mechanisms and processes. this property is useful in early stages of the current pandemic when many process-related parameters remain unknown. however, our results cannot and should not be interpreted as a substitute for process-based epidemiological models specifically designed to provide guidance in public health crises. rather, our results complement existing models, for example, by helping to calibrate key model parameters. we believe both forward-looking simulations and backward-looking empirical evaluations should be used to inform decision-making. here we have focused our analysis on large-scale social policies, specifically, to understand their impact on infection rate growth within a locality. however, contact tracing, international travel restrictions, and medical resource management, along with many other policy decisions, will play key roles in the global response to covid- . our results do not speak to the e cacy of these other policies. our analysis accounts for some known changes in the availability of testing for and changes in testing procedures; however, it is likely that other unobserved changes in patterns of testing could a↵ect our results. for example, if growing awareness of covid- caused an increasing fraction of infected individuals to be tested over time, then unadjusted infection growth rates later in our sample would be biased upwards. because an increasing number of policies are active later in these samples as well, this bias would cause our current findings to understate the overall e↵ectiveness of anti-contagion policies. it is also possible that changing public information during the period of our study has some unknown e↵ect on our results. if individuals alter their behavior in response to new information unrelated to anti-contagion policies, such as news reports about covid- , this could alter the growth rate of infections and thus a↵ect our estimates. because the quantity of new information is increasing over time, if this information reduces infection growth rates, it would cause us to overstate the e↵ectiveness of anti-contagion policies. we note, however, that if public information is increasing in response to policy actions, then it should be considered a pathway through which policies alter infection growth, not a form of bias. investigating these potential e↵ects is beyond the scope of this analysis, but it is an important topic for future investigations. lastly, we note that the results presented here are not su cient, on their own, to determine which anti-contagion policies are ideal for individual populations, nor whether the social costs of individual policies are larger or smaller than the social value of their health benefits. computing a full value of health benefits also requires understanding how di↵erent growth rates of infections and total active infections a↵ect mortality rates, as well as determining a social value for all of these impacts. furthermore, this analysis does not quantify the sizable social costs of anti-contagion policies, a critical topic for future investigations. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted march , . . https://doi.org / . / . / we have provided a brief summary of our data collection processes here (see appendix section for more details, including access dates). epidemiological and policy data for each of the six countries in our sample were collected from a variety of in-country data sources, including government public health websites, regional newspaper articles, and wikipedia crowd-sourced information. the available epidemiological and policy data varied across the six countries, and preference was given to collecting data at the most granular administrative unit level. the country-specific panel datasets are at the region level in france, the state level in the us, the province level in south korea, italy and iran, and the city level in china. below, we describe our data sources. china we acquired epidemiological data from an open source github project that scrapes time series data from ding xiang yuan. we extended this dataset back in time to january by manually collecting o cial daily statistics from the central and provincial (hubei, guangdong, and zhejiang) chinese government websites. we compiled policies by collecting data on the start dates of travel bans and lockdowns at the city-level from the " hubei lockdowns" wikipedia page , the wuhan coronavirus timeline project on github , and various other news reports. as we suspect that most chinese cities have been treated by at least one anti-contagion policy, due to their reported trends in infections, we have dropped cities where we cannot find a policy deployment date to avoid miscategorizing the policy status of cities. we manually collected and compiled the epidemiological dataset in south korea, based on provincial government reports, policy briefings, and news articles. we compiled policy actions from press releases from the korean centers for disease control and prevention (kcdc), the ministry of foreign a↵airs, local governments' websites, and news articles. iran we used epidemiological data from the table "new covid- cases in iran by province" in the " coronavirus pandemic in iran" wikipedia article, which have been compiled from the data provided on the iranian ministry of health website (in persian). we relied on news media reporting and two timelines of pandemic events in iran to collate policy data. italy we utilized epidemiological data from the github repository maintained by the italian department of civil protection (dipartimento della protezione civile). for policies, we primarily relied on the english version of the covid- dossier "chronology of main steps and legal acts taken by the italian government for the containment of the covid- epidemiological emergency" written by the department of civil protection (dipartimento della protezione civile) . france we used the region-level epidemiological dataset provided by france's government website and supplemented it with scraped number of confirmed cases by region on france's public health website, which is updated daily. we obtained data on france's policy response to the covid- pandemic from the french government website, press releases from each regional public health site, and wikipedia . we used state-level epidemiological data from the github repository associated with the interactive dashboard from johns hopkins university (jhu). for policy responses, we relied on a number of sources, including the u.s. center for disease control (cdc), individual state health departments, as well as various press releases from county and city-level government or media outlets. policy data policies in administrative units were coded as binary variables, where the policy is coded as either (after the date that the policy was implemented, and before it is removed) or otherwise, for the a↵ected administrative units. there were instances when a policy implementation only a↵ected a portion of the administrative units (e.g. half of the counties within the state). in an attempt to accurately represent the locality and impact of policy implementation, policy variables were weighted by the percentage of population within the administrative unit that was treated by the policy. the most recent estimates available of population data for countries' administrative units were used (see the population data section in the appendix). additionally, in order to standardize policy types across countries, we mapped country-specific policies to one of our broader policy categories used as variables in our analysis. in this exercise, we collected policies for . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted march , . . we collected information on cumulative confirmed cases, cumulative recoveries, cumulative deaths, active cases, and any changes to domestic covid- testing regimes. for our regression analysis (figure ), we use active cases when they are available (for china and south korea) and cumulative confirmed cases otherwise. we document quality control steps in detail in appendix section . notably, for china and south korea we acquire more granular data than the the data hosted on the john hopkins university (jhu) interactive dashboard ; we confirm that the number of confirmed cases closely match between the two data sources (see appendix figure a ). to conduct the econometric analysis, we merge the epidemiological and policy data to form a single data set for each country. reduced-form approach the reduced-form econometric approach that we apply here is a "top down" approach that describes the behavior of aggregate outcomes y in data (here, infection rates). this approach can identify plausibly causal e↵ects , induced by exogenous changes in independent policy variables z (e.g. school closure) without explicitly describing all underlying mechanisms that link z to y and without observing intermediary variables x (e.g. behavior) that might link z to y nor other determinants of y unrelated to z (e.g. demographics), denoted w. let f (·) describe a complex and unobserved process that generates infection rates y: process-based epidemiological models aim to capture elements of f (·) explicitly, and then simulate how changes in z, x, or w a↵ect y. this approach is particularly important and useful in forwardlooking simulations where future conditions are likely to be di↵erent than historical conditions. however, a challenge faced by this approach is that we may not know the full structure of f (·), for example if a pathogen is new and many key biological and societal parameters remain uncertain. crucially, we may not know the e↵ect that large-scale policy (z) will have on behavior (x(z)) or how this behavior change will a↵ect infection rates (f (·)). alternatively, one can di↵erentiate equation with respect to the k th policy z k : which describes how changes in the policy a↵ects infections through all n potential pathways mediated by x , ..., x n . usefully, equation does not depend on w. if we can observe y and z directly and estimate @y @z k with data, then intermediate variables x also need not be observed https://github.com/cssegisanddata/covid- . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted march , . . nor modeled. the reduced-form econometric approach , thus attempts to measure @y @z k directly, exploiting exogenous variation in policies z. model active infections grow exponentially during the initial phase of an epidemic, when the proportion of immune individuals in a population is near zero. assuming a simple susceptible-infected-recovered (sir) disease model (e.g. ref. [ ]), the growth in infections during the early where i t is the number of infected individuals at time t, is the transmission rate (new infections per day per infected individual), is the removal rate (proportion of infected individuals recovering or dying each day) and s is the fraction of the population susceptible to the disease. the second equality holds in the limit s ! , which describes the current conditions during the beginning of the covid- pandemic. the solution to this ordinary di↵erential equation is the exponential where the growth rate g = and t are the initial conditions. taking the natural logarithm and rearranging, we have anti-contagion policies are designed to alter g, through changes to , by reducing contact between susceptible and infected individuals. holding the time-step between observations fixed at one day (t t = ), we thus model g as a time-varying outcome that is a linear function of a time-varying where ✓ is the average growth rate absent policy, policy t is a binary variable describing whether a policy is deployed at time t, and ✓ is the average e↵ect of the policy on growth rate g. ✏ t is a mean-zero disturbance term that captures inter-period changes not described by policy t . using this approach, infections each day are treated as the initial conditions for integrating equation through to the following day. we compute the first di↵erences log(i t ) log(i t ) using active infections where they are available, otherwise we use cumulative infections, noting that they are almost identical during this early period (except in china, where we use active infections). we then match these data to policy variables that we construct using the novel data sets we assemble and apply a reduced-form approach to estimate a version of equation , although the actual expression has additional terms detailed below. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted march , . . https://doi.org / . / . / estimation to estimate a multi-variable version of equation , we estimate a separate regression for each country c. observations are for sub-national units indexed by i observed for each day t. because not all localities began testing for coivd- on the same date, these samples are unbalanced panels. to ensure data quality, we restrict our analysis to localities after they have reported at least ten cumulative infections. we estimate a multiple regression version of equation using ordinary least squares. we include a vector of sub-national unit-fixed e↵ects ✓ (i.e. varying intercepts captured as coe cients to dummy variables) to account for all time-invariant factors that a↵ect the local growth rate of infections, such as di↵erences in demographics, socio-economic status, culture, or health systems. we include a vector of day-of-week-fixed e↵ects to account for weekly patterns in the growth rate of infections that are common across locations within a country. we include a separate singleday dummy variable each time there is an abrupt change in the availability of covid- testing or a change in the procedure to diagnose positive cases. such changes generally manifest as a discontinuous jump in infections and a re-scaling of subsequent infection rates (e.g. see china in figure ), e↵ects that are flexibly absorbed by a single-day dummy variable because the dependent variable is the first-di↵erence of the logarithm of infections. denote the vector of these testing dummies µ. lastly, we include a vector of p c country-specific policy variables for each location and day. these policy variables take on values between zero and one (inclusive) where zero indicates no policy action and one indicates a policy is fully enacted. in cases where a policy variable captures the e↵ects of collections of policies (e.g. museum closures and library closures), a binary policy variable is computed for each, then they are averaged, so the coe cient on these variables are interpreted as the e↵ect if all policies in the collection are fully enacted. in some cases (for italy and the us), policy data is available at a more spatially granular level than infection data (e.g. city policies and state-level infections in the us). in these cases, we code binary policy variables at the more granular level and use population-weights to aggregate them to the level of the infection data. thus, policy variables may take on continuous values between zero and one, with a value of one indicating that the policy is fully enacted for the entire population. for each country, our general multiple regression model is thus where observations are indexed by country c, sub-national unit i, and day t. the parameters of interest are the country-by-policy specific coe cients ✓ pc . we verify that our residuals ✏ cit are approximately normally distributed (appendix figure a ) and we estimate uncertainty over all parameters by clustering our standard errors at the day level. this approach non-parametrically . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted march , . . https://doi.org / . / . / accounts for arbitrary forms of spatial auto-correlation or systematic misreporting in regions of a country on any given day (it generates larger estimates for uncertainty than clustering by i). when we report the e↵ect of all policies combined (e.g. figure b ) we are reporting the sum of coe cent estimates for all policies p pc p= ✓ cp , accounting for the covariance of errors in these estimates when computing the uncertainty of this sum. note that our estimates of ✓ and ✓ in equation are robust to systematic under-reporting of infections, a major concern in the ongoing pandemic, due to the construction of our dependant variable. if only a fraction of infections are being reported such that we observeĨ = i rather an actual infections i, then the left-hand-side of equation will be and is therefore una↵ected by the under-reporting. thus systematic under-reporting does not a↵ect our estimates for the e↵ects of policy ✓. there are some country-specific adjustments to equation due to idiosyncratic di↵erences between samples. in china, we code policy parameters using weekly lags based on the date that the policy is first implemented in locality i. as discussed in the main text, this is done to understand the temporal dynamics of the response to policy in the one country where policy has been enacted the longest and in the most consistent way. weekly lags are used because the incubation period covid- is thought to be - days. econometrically, this means the e↵ect of a policy implemented one week ago is allowed to di↵er arbitrarily from the e↵ect of a policy implemented two weeks ago, etc. these e↵ects are all estimated simultaneously. also in china, we omit day-of-week e↵ects because there is no evidence to suggest they are present in the data -this could be due to the fact that the outbreak of covid- began during a national holiday and workers never returned to work. in iran, we estimate a separate e↵ect of policies implemented in tehran that is allowed to di↵er from the e↵ect in other locations by creating tehran-specific dummy variable that is interacted with both policy variables. this is implemented because of the stark and significantly di↵erent e↵ect of policies in tehran relative to e↵ects in other parts of the country. daily growth rates of infections to estimate the instantaneous daily growth rate of infections if policies were removed, we obtain fitted values from equation and compute a predicted value for the dependent variable when all p c policy variables are set to zero. thus, these estimated growth ratesĝ no policy cit capture the e↵ect of all locality-specific factors on the growth rate of infections (e.g. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted march , . . demographics), day-of-week-e↵ects, and adjustments based on the way in which infection cases are reported. this counterfactual does not account for changes in information that are triggered by policy deployment, since those should be considered a pathway through which policies a↵ect outcomes, as discussed in the main text. when we report an average "no policy" growth rate of infections (figure a) , it is the average value of these predictions for all observations in the original sample. location-and-day specific counterfactual predictions (ĝ no policy cit ), accounting for the covariance of errors in estimated parameters, are shown as red markers in figure . to provide a sense of scale for the estimated cumulative benefits of e↵ects shown in figure , we link our reduced-form empirical estimates to the key structures in a simple sir system and simulate this dynamical system from the start of the pandemic to the present in each country. the system is defined as the following: where s is the susceptible population and r is the removed population. here is a time-evolving parameter, determined via our empirical estimates as described below. accounting for changes in s becomes increasingly important as the size of cumulative infections (i t + r t ) becomes a substantial fraction of the local subnational population, which occurs in some "no policy" scenarios. our reduced-form analysis provides estimates for the growth rate of active infections (ĝ) for each locality and day, in a regime where s ⇡ . thus we know able to obtain, individuals are coded as "recovered" when they no longer test positive for covid- . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted march , . . https://doi.org / . / . / , whereas in the classical sir model this occurs when they are no longer infectious. we adopt the average of these two medians, setting = . . we use medians rather than simple averages because low values for i induce a long right-tail in daily estimates of and medians are less vulnerable to this distortion. we then use our empirically based reduced-form estimates ofĝ (both with and without policy) combined with equations - to project total cumulative cases in all countries, shown in figure . we simulate infections and cases for each administrative unit in our sample beginning on the first day for which we observe or more cases (for that unit) using a time-step of hours. we estimate uncertainty by resampling from the estimated variance-covariance matrix of all parameters. [ ] who novel coronavirus (covid- ) situation. https://experience.arcgis.com/ experience/ d ace f a beeeee b cd. accessed: - - . [ ] with new state decrees, in americans to be ordered indoors. https://www.nytimes. com/ / / /world/coronavirus-news-usa-world.html?action=click&module= spotlight&pgtype=homepage. accessed: - - . [ ] chowell, g., sattenspiel, l., bansal, s. & viboud, c. mathematical models to characterize early epidemic growth: a review. physics of life reviews , - ( ). . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted march , . . https://doi.org / . / . / [ ] ma, j. estimating epidemic exponential growth rate and basic reproduction number. infectious disease modelling ( ). the lancet , - ( ). . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted march , . . . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted march , . . or timing (e.g. policies that are deployed simultaneously in a given country) to reduce the number of estimated parameters. e↵ects are all estimated simultaneously within a country. for china, we simultaneously estimate separate e↵ects for each week after the policy was implemented (e.g. "china, week " is the change in daily growth rates caused by policies implemented - days prior). . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted march , . infections based on the observed timing of all policy deployments within each country (blue) and in a scenario where no policies were deployed (red). the di↵erence between these two predictions is our estimated e↵ect of actual anti-contagion policies on the growth rate of infections. small markers are daily estimates for sub-national administrative units (vertical lines are % ci). large markers are national average values for all sub-national units in our sample on that day. black circles are observed changes in log(inf ections), averaged across the same administrative units. predictions are only for observations in our sample, and we omit observations before sub-national units report ten cumulative cases. to focus our analysis on the impact of new policies, we omit data from china after march , because policies began to be rolled back during this period. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted march , . . https://doi.org / . / . . . doi: medrxiv preprint figure : estimated cumulative covid- infections with and without anti-contagion policies. the predicted cumulative number of covid- infections based on each country's actual policy deployments (blue) and in the "no policy" counterfactual scenario (red). sub-national infection growth rates from figure are integrated adjusting for sir system dynamics in each sub-national unit (see methods). shaded areas show uncertainty based on , simulations where estimated parameters are resampled from their joint distribution (dark = inner % of predictions; light = inner %). black circles show the cumulative number of reported infections observed in the data. in both scenarios, the sample is restricted to units we analyze in figures and . note that infections are not projected for administrative units that never report infections in the data, but which plausibly would have experienced infections in a "no policy" scenario. the jump in infections in france on march , occurs due to administrative units entering the sample. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted march , . . . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted march , . . table a : number of policies tabulated by administrative divisions of each country. table a : policy data have been collected at various levels of administrative divisions in each country. "adm " represents the country level, and higher "adm*" numbers indicate smaller administrative subdivisions. each policy is counted at the highest level of specificity of the regions where the policy is applied. for example, if a country has ten regions at the "adm " level, and a policy is applied across five of those regions, the policy is counted as five separate "adm " policies rather than a single "adm " policy. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted march , . . figure a : error distributions for estimated growth rates of covid- cases by country. figure a : these plots show the error structure for each country-specific econometric model used to predict the daily growth of active or cumulative covid- cases under the country's actual policy regime, as compared to the counterfactual world where no policies were enacted. see the full model under the methods -econometric analysis section as well as the results in figure of the main paper. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted march , . . https://doi.org / . / . / . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted march , . . figure a : as an additional check, we compared the cumulative number of confirmed cases from a handful of regions in our collated epidemiological dataset to the same statistics from the novel coronavirus covid- ( -ncov) data repository by the johns hopkins center for systems science and engineering (jhu csse). we conducted this comparison for the two countries that we had the most data for and at two different administrative levels. in china, we aggregate city level data up to the province level, and in korea we aggregate provincial level data up to the country level. the numbers tracked each other for the entire time series we have collected thus far. this section describes the data acquisition and processing procedure for both epidemiological and policy data used in this paper. the sources for both types of data come from a variety of in-country data sources, which include government public health websites, regional newspaper articles, and wikipedia crowd-sourced information. we have supplemented this data with international data compilations. a list of the epidemiological and policy data compiled for this analysis can be found here . the epidemiological datasets and sources used in this paper are described below. the main health variables of interest: . " cum_confirmed_cases ": the total number of confirmed positive cases in the administrative area since the first confirmed case. . " cum_deaths ": the total number of individuals that have died from covid- . . " cum_recoveries : the total number of individuals that have recovered from . " cum_hospitalized ": the total number of hospitalized individuals. . " cum_hospitalized_symptom ": the total number of symptomatic hospitalized individuals. . " cum_intensive_care" : the total number of individuals that have received intensive care. . " cum_home_confinement ": the total number of individuals that have been self-quarantined in their homes as a result of a positive test. . " active_cases ": the number of individuals who currently still test positive on the date of the observation. . " active_cases_new ": the number of new cases since the previous date. . " cum_tests ": the total number of tests (includes both positive and negative results) conducted in an administrative unit. additional metadata accompanying the health outcome variables: . " date ": the date of observation. . " adm _name ": the iso code to which this observation belongs. . " adm _name ": the name of the "adm " region to which this observation belongs. https://github.com/cssegisanddata/covid- . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted march , . . . " adm _name ": if the dataset contains observations at the "adm " level, then this is the name of the "adm " region to which this observation belongs. . " adm [ , ] _id ": any alphanumeric id scheme to identify different administrative units (e.g. fips code). . " lat ": the latitude of the centroid of the administrative unit. . " lon ": the longitude of the centroid of the administrative unit. . " policies_enacted ": the number of active policies that are in place for the administrative unit as of that date. this variable is not population weighted. . " testing_regime ": a categorical variable used to identify when an administrative region (or country) changed their covid- testing regime. this is zero-indexed, with the ordering only indicating chronological progression (there is no external meaning to regime vs. regime vs. regime , and there is no consistency enforced for coding across countries). for example, if china changes their testing regime twice, all observations prior to the first regime change would be coded " testing_regime = ," all observations in between the two changes would be coded " testing_regime = ," and all observations after the second change would be coded " testing_regime = ." data imputation: in instances where health outcome observations are missing or suffer from data quality issues, we have imputed to fill in the missing values. imputed health outcome variables are denoted by " [health_outcome]_imputed. " for the majority of our analyses we do not use imputed data; france is the exception where we impute two days of missing data. we do this to ensure we have variation in policy variables for use in the analysis. we impute by: . taking the natural log of the non-missing observations pertaining to that health outcome variable. . linearly interpolating over the missing dates for that health outcome variable. . exponentiating the interpolated values back into levels and rounding to the nearest integer. we have collated a city level time series health outcome dataset in china for cities from january , to present-day. for data from january , onwards, we relied on the public dataset ding xiang yuan (dxy) that reports daily statistics across chinese cities. since dxy only publishes the most recent (cross-sectional) statistics (and not the historical data), we used the time series dataset scraped from dxy in an open source github project . the web scraper program checks for updates at least once a https://ncov.dxy.cn/ncovh /view/pneumonia https://github.com/blankerl/dxy-covid- -data . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted march , . . https://doi.org / . / . / day for the statistics published on dxy and records any changes in the number of cumulative confirmed cases, cumulative recoveries or cumulative deaths. we assumed that no updates to the statistics meant there had been no new cases. we dropped a small number of cases that had been recorded but not assigned to a specific city (many of these cases are imported ones from other cities). we also dropped confirmed cases in prison populations (we assumed the spread of covid- in prisons was not affected by the implementation of city-level lockdowns or travel ban policies). for city level health outcomes prior to january , , we manually collected official daily statistics from the central and provincial (hubei, guangdong, and zhejiang ) chinese government websites. we did not collect city level health outcomes recorded prior to january , in provinces that had fewer than ten confirmed cases at that date. we made this decision since our analysis dropped observations with fewer than ten cumulative confirmed cases to prevent noisy data during the early transmission phase from disproportionately biasing the estimated results. after merging the two datasets, we conducted a few quality checks: ( ) we checked that cumulative confirmed cases, cumulative recoveries, and cumulative deaths were increasing over time. in instances when cumulative outcomes decreased over time, we assumed that the recent numbers were more reliable, and treated the earlier number of cumulative cases as missing (this was often due to data entry errors or cases where patients that were reported to have been diagnosed with covid- , but were later found out to actually have tested negative). the magnitude of these errors was relatively small. we filled in any missing data with the imputation methodology described in the health data overview section. ( ) we validated our city level dataset by aggregating observations up to the provincial level and comparing the time trends from the aggregated dataset to that of the provincial dataset collated by johns hopkins university. we confirmed that the two datasets matched very closely (see figure a panel a). as of the time of writing, the criteria for being diagnosed with covid- had changed twice in china. on february , , china recategorized patients who exhibited symptoms, as determined through a chest scan, as part of the "confirmed" cases count even if they had not tested positive in the pcr test. this was due to concerns that the pcr test had relatively high false negative rates. on february , , china reversed this decision. we included this information in the dataset because it could have potentially changed the levels and short-term growth rates of the number of confirmed cases. we have collated a regional level time series health outcome dataset in france from february , to present-day. we used the number of confirmed covid- cases by région from france's government website. the sources listed for this dataset were the french public health website, the ministry of solidarity and health, french newspapers that reported government information, and regional public health websites. given that this dataset was not published on a daily basis, we supplemented it by scraping the number of confirmed cases by région on the french public health website, which has been updated every day. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted march , . . https://doi.org / . / . / have been reporting the number of confirmed cases on a daily basis. for these provinces, we recorded this published health data. given that the province of gangwon-do does not report provincial level health data, we refer to the daily number of new cases reported by each of its counties taebaek-si, sokcho-si, and samcheok-si ). as a result, we manually collected the number of new not explicitly publish the number of cumulative confirmed cases. however, they did publish patient-level data, including the date of when patients had tested positive. for these provinces, we constructed the measure of cumulative confirmed cases by counting the number of daily confirmed cases and adding it to the previous date's total. most provinces did not publish the number of deaths. instead, we checked the daily policy briefings posted on the government homepages mentioned in the footnotes and manually collected mortality data. in instances when mortality data were not found in the briefings, we obtained the mortality data from other official sources, such as through social media sources (e.g. facebook) and blogs maintained by local governments. lastly we supplement these sources with mortality data reported in news articles. we collected information on testing regime changes from the homepage of the korean center for disease control and prevention (kcdc). in the press release menu, the kcdc uploaded daily briefing announcements which contained information on testing criteria and changes to the testing regime. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted march , . . initially, the south korean government only tested people who: ) demonstrated respiratory symptoms within days after visiting wuhan south china seafood wholesale market and ) those who had pneumonia symptoms within days after returning from wuhan. as the outbreak spread, the kcdc broadened the criteria for testing. starting january , , the agency isolated ) those who had fever or respiratory symptoms upon returning from hubei province and ) those who had symptoms of pneumonia upon returning from mainland china. , we coded this as the first change in the testing regime. the second testing regime change occurred on february , , when the kcdc announced that people who had had any "routine contacts" with confirmed cases were required to self quarantine for a -day period. the agency defines two categories of contacts: close contacts and routine contacts. the former is defined as a person who has been within two meters of, in the same room as, or exposed to any respiratory secretions of an infected individual. the latter refers to whether the individual conducted any activity in the same place and time as the infected person. prior to this regime change, kcdc separated those two cases and applied different quarantine policies; starting february , , any routine contacts were also required to be self-quarantined. shortly thereafter, south korea aggressively expanded the scope of their testing. starting february , , the kcdc broadened the definition of suspected cases to ) anyone who developed a fever or respiratory symptoms within days after returning from china, ) anyone who developed a fever or respiratory symptoms within days after being in close contact with a confirmed case, and ) anyone suspected of contracting covid- based on their travel history to affected countries and their clinical symptoms. moreover,the kcdc announced that the test would be free for all suspected cases and https://www.cdc.go.kr/board/board.es?mid=a &bid= &list_no= &act=view https://www.cdc.go.kr/board/board.es?mid=a &bid= &list_no= &act=view nb: the kcdc english website explains the testing regime change in a more condensed format: "any citizens identified with a fever or respiratory symptoms and have visited wuhan will be isolated and tested at a nationally designated isolation hospital, and any foreigners staying in korea will be conducted in cooperation with police." https://www.cdc.go.kr/board/board.es?mid=a &bid= &act=view&list_no= &tag=&n page= http://www.mohw.go.kr/react/al/sal vw.jsp?par_menu_id= &menu_id= &page= &cont_s eq= https://www.cdc.go.kr/board/board.es?mid=a &bid= &act=view&list_no= &tag=&n page= nb: the date of this press release is february , , but the definition of "suspected cases" was effective starting from february , . . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted march , . . https://doi.org / . / . / confirmed cases. as a result of these efforts, kcdc announced that they would begin to test , people daily, a marked increase from only people a day. the kcdc revised their guidelines on february , in order to test more people. their press release stated: "suspected cases with a medical professional's recommendation, regardless of travel history, will get tested. additionally, those who are hospitalized with unknown pneumonia will also be tested. lastly, anybody in contact with a diagnosed individual will need to self-isolate, and will only be released when they test negative on the thirteenth day of isolation." as the number of patients grew rapidly, the kcdc decided to focus on more vulnerable groups. in their february , press release, the agency stated: "the kcdc has asked local government and health facilities to focus on tests and treatment, especially targeting those aged + and those with underlying conditions who need early detection and treatment." this change was coded as our last testing regime change in the dataset. we have collated a regional and provincial level time series health outcome dataset in italy from february , to present-day. this data came from the github repository maintained by the italian department of civil protection ( dipartimento della protezione civile ). health outcomes included the number of confirmed cases, the number of deaths, the number of recoveries, and the number of active cases. these figures have been updating daily at or pm (central european time). the regional level dataset was pulled directly from " dati-regioni/dpc-covid -ita-regioni.csv, " and the provincial level dataset was pulled from " dati-province/dpc-covid -ita-province.csv. " the testing regime change in italy occurred when the director of higher health council announced on february , that covid- testing would only be performed on symptomatic patients, as the majority of the previous tests performed were negative. cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted march , . . we have collated a provincial level time series health outcome dataset in iran from february , to present-day. the iranian government had been announcing its new daily number of covid- confirmed cases at the provincial level on the ministry of health's website. this data has been compiled daily in the table "new covid- cases in iran by province" located in the " coronavirus pandemic in iran" article on wikipedia. we spot-checked the data in the wikipedia table against the iranian ministry of health announcements using a combination of google translate and a comparison of the numbers in the announcements (which were written in persian script) to the persian numbers. on march , , the ministry of health announced a national coronavirus plan, which included contacting families by phone to identify potential cases, along with the disinfecting of public places. the plan was to begin in the provinces of qom, gilan, and isfahan, and then would be rolled out nationwide. on march , , the government announced a military-enforced home isolation policy throughout the nation. this announcement included nationwide disinfecting of public places. while a follow-up announcement of the march high testing regime stating its complete rollout was not found, the march announcement did reference the implementation of the public spaces component of the earlier plan across the country. we thus assumed that the high testing regime had also been fully rolled out on march , . we have collated a state level time series health outcome dataset in the united states from january , to present-day. the data comes from the github repository associated with the johns hopkins university (jhu) interactive dashboard (dong, du & gardner , lancet). as of the time of writing, the data are available here . the repository and dashboard are updated essentially in real-time; at least daily. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted march , . . to determine the testing regime, we used estimated daily counts of the cumulative number of tests conducted in every state, as aggregated by the largely crowdsourced effort named "the covid tracking project" ( covidtracking.com ). we estimated the total number of tests as the sum of confirmed positive and negative cases. for some states and some days, there have been no negative case counts, in which case we utilize just the confirmed positive cases. we also ensured that the confirmed number of positive cases agreed with the counts in the jhu dataset. we programmatically filtered for possible testing regime changes by filtering for any consecutive days during which the testing rate increased at least % from one day to the next, and where this jump was an increase of at least total tests over one day. after visually inspecting the candidates, we removed detected testing regime changes for north carolina and connecticut, as these states did not demonstrate spikes in their testing rate, but rather a more gradual and steady rate in the increase of testing. (nb: the last download from covidtracking.com was march , : pst. we have been updating the process and the removal of detected testing regime changes periodically, so this may change.) the policy events, datasets, and sources used in this paper are described below. for each country, the relevant country-specific policies identified were then mapped to a harmonized policy categorization used across all countries. the policy categories are coded as binary variables, where " [policy_variable] " = before the policy is implemented in that area, and " [policy_variable] " = on the date the policy is implemented (and for all subsequent dates until the policy is lifted). the main policy categories identified across the six different countries fall into four broad classes: . restricting travel: a. " travel_ban_local " : a policy that restricts people from entering or exiting the administrative area (e.g county or province) treated by the policy. b. " travel_ban_intl_in ": a policy that either bans foreigners from specific countries from entering the country, or requires travelers coming from abroad to self-isolate upon entering the country. c. " travel_ban_intl_out ": a policy that suspends international travel to specific foreign countries that have high levels of covid- outbreak. d. " travel_ban_country_list ": a list of countries for which the national government has issued a travel ban or advisory. this information supplements the policy variable " travel_ban_intl_out. " e. " transit_suspension ": a policy that suspends any non-essential land-, rail-, or water-based passenger or freight transit. . distancing through cancellation of events and suspension of educational/commercial/religious activities: a. " school_closure ": a policy that closes school and other educational services in that area. b. " business_closure ": a policy that closes all offices, non-essential businesses, and non-essential commercial activities in that area. "non-essential" services are defined by area. c. " religious_closure" : a policy that prohibits gatherings at a place of worship, specifically targeting locations that are epicenters of covid- outbreak. see the section on korean policy for more information on this policy variable. d. " work_from_home ": a policy that requires people to work remotely. this policy may also include encouraging workers to take holiday/paid time off. e. " event_cancel ": a policy that cancels a specific pre-scheduled large event (e.g. parade, sporting event, etc). this is different from prohibiting all events over a certain size. f. " no_gathering ": a policy that prohibits any type of public or private gathering. (whether cultural, sporting, recreational, or religious). depending on the country, the policy can prohibit a gathering above a certain size, in which case the number of people is specified by the " no_gathering_size " variable. g. " no_demonstration ": a policy that prohibits protest-specific gatherings. see the section on korean policy for more information on this policy variable. h. " social_distance ": a policy that encourages people to maintain a safety distance (often between one to two meters) from others. this policy differs by country, but includes other policies that close cultural institutions (e.g. museums or libraries), or encourage establishments to reduce density, such as limiting restaurant hours. . quarantine and lockdown: a. " pos_cases_quarantine ": a policy that mandates that people who have tested positive for covid- , or subject to quarantine measures, have to confine themselves at home. the policy can also include encouraging people who have fevers or respiratory symptoms to stay at home, regardless of whether they tested positive or not. b. " home_isolation ": a policy that prohibits people from leaving their home regardless of their testing status. for some countries, the policy can also include the case when people have to stay at home, but are allowed to leave for work-or health-related purposes. for the latter case, when the policy is moderate, this is coded as ' home_isolation = . .' . additional policies a. " emergency_declaration ": a decision made at the city/municipality, county, state/provincial, or federal level to declare a state of emergency. this allows the affected area to marshal emergency funds and resources as well as activate emergency legislation. b. " paid_sick_leave ": a policy where employees receive pay while they are not working due to the illness. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted march , . . https://doi.org / . / . / optional policies: in the cases when the aforementioned policies are optional, we denote this as " [policy_variable]_opt. " population weighting of policy variables: in the cases when only a portion of the administrative unit (e.g. half of the counties within the state) are affected by the implementation of the policy, we weight the policy variable by the percentage of population within the administrative unit that is treated by the policy. this is denoted as " [policy_variable]_popwt, " and the value that this variable can take on is a continuous number between and . sources for the population data are detailed in a later section. we obtain data on china's policy response to the covid- pandemic by culling data on the start dates of travel bans and lockdowns at the city-level from the " hubei lockdowns" wikipedia page, the wuhan coronavirus timeline project on github, and various news reports. to combat the spread of covid- , the chinese government imposed travel restrictions and quarantine measures, starting with the lockdown of the city of wuhan, the origin of the pandemic, on january , . immediately following the wuhan lockdown, neighboring cities followed suit, banning travel into and out of their borders, shutting down businesses, and placing residents under household quarantine. the same policy measures were implemented in cities across china for the next three weeks. some lockdowns occurred during the national chinese new year holiday (january - , ) when schools and most workers were on break. on january , , china extended the official holiday to february , , while many additional provinces delayed resuming work and opening schools for even longer. the chinese new year holiday is analogous to containment policies such as school closures and restrictions on non-essential work. we do not specifically estimate the effect of this holiday extension, as most cities were in lockdown during the extended holiday, and a lockdown is a more restrictive containment measure. a lockdown requires all residents to stay home, except for medical reasons or essential work, and only allows one person from each household to go outside once every one to five days (exact policy varied by city). we obtain data on france's policy response to the covid- pandemic from the french government website, press releases from each regional public health site, and wikipedia. https://en.wikipedia.org/wiki/ _hubei_lockdowns https://github.com/pratitya/wuhan -timeline https://www.china-briefing.com/news/china-extends-lunar-new-year-holiday-february- -shanghai-february - -contain-coronavirus-outbreak/ . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted march , . . https://doi.org / . / . / the french government website contains a timeline of all national policy measures. each regional public health agency ( l'agence régionale de santé ) in france posts press releases with information on the policies the région or départements within the région will implement to mitigate the spread and impact of the covid- outbreak. the wikipedia page on the coronavirus pandemic in france has collated information on the major policy measures taken in response to the starting february , , france banned mass gatherings of more than , people nationwide, while some major sporting events were cancelled and a handful of schools closed to mitigate the spread of the virus. as more covid- cases were confirmed during the following week, additional sporting events were canceled, more schools decided to close, and certain cities and départements limited mass gatherings to no more than people, excluding shops, business, restaurants, bars, weddings, and funerals. some régions closed early childhood establishments (e.g. nurseries, daycare centers) and prohibited visitors to elderly care facilities. on march , , france banned mass gatherings of more than , people nationwide. other schools, cities, and départements followed suit with additional school closures and limiting mass gatherings. on march , , france prohibited all visits to elder care establishments. starting march , , france closed all schools nationwide. we have coded various policies that cancel events and large gatherings as such: any cancellations of professional sporting and other specific pre-scheduled events as the policy variable " event_cancel ." the " no_gathering " policy variable represents policy measures that banned all events or mass gatherings of a certain size, e.g. no gatherings of over , people. the " social_distance " policy variable includes measures preventing visits to elder care establishments, closures of public pools and tourist attractions, and teleworking plans for workers. we obtained data on south korea's policy response to the covid- pandemic from various news sources, as well as press releases from the korean centers for disease control and prevention (kcdc), the ministry of foreign affairs, and local governments' websites. the policy variables coded in the dataset are: " business_closure, " " business_closure_opt, " " emergency_declaration, " " no_demonstration, " " religious_closure ," " school_closure, " " social_distance_opt, " " travel_ban_intl_in_opt, " " travel_ban_intl_out_opt, " and " work_from_home_opt. " the kcdc announced on february , that health-related public facilities were recommended to be closed; hence, the policy variable " business_closure " was coded as one from the announcement date. even though it was technically a recommendation, we did not code this policy as an optional . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted march , . . https://doi.org / . / . / the first travel ban in our dataset, since level alerts are issued relatively rarely, such as during a significant demonstration or military coup. as a result, we coded the level alert due to into the dataset for the policy analysis. the policy variable " work_from_home_optional " indicates when kcdc began recommending that people work from home. on march , , the kcdc press release stated: "since contact with confirmed cases in an enclosed space increases the possibility of transmission, it is recommended to work at home or adjust desk locations so as to keep a certain distance among people in the office. more detailed guidelines for local governments and high-risk working environments will be distributed soon." we have obtained data on italy's policy responses to the covid- pandemic primarily from the english version of the covid- dossier "chronology of main steps and legal acts taken by the italian government for the containment of the covid- epidemiological emergency" written by the department of civil protection ( dipartimento della protezione civile ), most recently updated on march , . this dossier details the majority of the municipal, regional, provincial, and national policies rolled out between the start of the pandemic to present-day. we have supplemented these policy events with news articles that detail which administrative areas were specifically impacted by the additional policies. the first major policy rollout was on february , , when municipalities across two provinces in northern italy were placed on lockdown. these policies included closing schools, cancelling public and private events and gatherings, closing museums and other cultural institutions, closing non-essential commercial activities, and prohibiting the movement of people into or out of the municipalities. the second major policy rollout was on march , , when two provinces and three regions in northern italy were placed on partial lockdown. these policies also included closing schools, cancelling public and private events and gatherings, closing museums, closing non-essential commercial activities, as well as limiting the number of people at places of worship, restricting operating hours of bars and restaurants, and encouraging people to work remotely. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted march , . . https://doi.org / . / . / the third major policy roll-out was on march , , when all schools across the country were closed. the fourth major policy roll-out was on march , when the region of lombardy and provinces in northern italy were placed on lockdown. these policies included the cancellation of public and private events and gatherings, closing of museums, encouraging people to work remotely, limiting the number of people at places of worship, restricting opening hours of bars and restaurants, mandating quarantine of people who tested positive for covid- , prohibiting the movement of people into or out of the affected area, and restricting movement within the affected area to only work-or health-related purposes. commercial activities were still allowed, as long as they maintained a safety distance of one meter apart per person within the establishment. all civil and religious ceremonies, including weddings and funeral ceremonies, were suspended. during this same policy roll-out, the rest of the country faced less stringent policies: cancelling of public and private events, closing of museums, and requiring restaurants and commercial establishments to maintain a safety distance of one meter apart per person within the establishment. the fifth major policy roll-out was announced on march , , and went into effect on march , , when lockdown policies applied to northern italy were rolled out to the entire country. lastly, on march , , the lockdown was changed to also cover the closing of any non-essential businesses and further restricted people from leaving their home. for iran's policy response to the covid- pandemic, we relied on news media reporting as the primary source of policy information (mostly due to translation restrictions). we also relied on two timelines of pandemic events in iran to help guide the policy search. the first major outbreak in iran was connected to a major shia pilgrimage in the city of qom that brought shiite pilgrims from iran and throughout the middle east, where they came to kiss the fatima masumeh shrine. it is possible that the disease was brought to qom by a merchant traveling from wuhan, china. in addition, it is believed that the iranian government knew of the covid- outbreak prior to its february , parliamentary elections, but downplayed the risks associated with the disease as not to suppress voter turnout (given concerns that a low turnout would reflect poorly on its legitimacy). the disease, initially centered in qom and neighboring tehran, spread rapidly throughout the country. https://www.thinkglobalhealth.org/article/updated-timeline-coronavirus https://en.wikipedia.org/wiki/ _coronavirus_pandemic_in_iran https://www.newyorker.com/news/our-columnists/how-iran-became-a-new-epicenter-of-the-coronavirus-o utbreak https://www.newyorker.com/news/our-columnists/how-iran-became-a-new-epicenter-of-the-coronavirus-o utbreak . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted march , . . https://doi.org / . / . . . doi: medrxiv preprint the k- and higher education level. business closures have also been recommended or enforced, such that employees should work from home, unless their work is considered essential to the greater public (e.g. health care, grocery stores). to support employees working remotely or staying home when sick, a number of states have also mandated paid sick leave for those who are affected by . free testing has also been implemented in certain states, so that anyone experiencing symptoms or has been exposed to the virus can now get tested for free. we coded various policies that cancel events and large gatherings as follows: the cancellation of large events, specifically the election postponement in louisiana, is categorized as " event_cancel ." the separate " no_gathering " policy variable represents policy measures that banned all events or mass gatherings of a certain size, i.e. no gatherings over a certain number of people (where this number has varied by region). the " social_distance " category includes measures that prevent visits to elderly care facilities, close public facilities such as libraries, and require workers to work remotely. the " emergency_declaration " encompasses the declarations of a state of emergency at the city, county, state, and federal level. this declaration allows the affected area to immediately marshal emergency funds and resources and activate emergency legislation, while also giving the public an indication of the gravity of the situation. in order to construct population weighted policy variables and to determine the susceptible fraction of the population for disease projections under the realized and the "no policy" counterfactual scenarios, we obtained the most recent estimates of population for each administrative unit included in our analysis. the sources of that population data are documented below. city-level population data have been extracted from a compiled dataset of the chinese city statistical yearbooks. we matched the city level population dataset to the city level covid- epidemiology dataset. as the two datasets use slightly different administrative divisions, we only matched cities that exist in both datasets, and grouped the remaining cities in our compiled epidemiology dataset into "other" for prediction purposes. cities grouped into "other" because of mismatches have a total population of , , , or . % of the total population in china. département -level populations are obtained from the national institute of statistics and economic database https://www.insee.fr/fr/statistiques/ #tableau-tcrd_ _tab _departements . we used the most up to date estimation of the population in france as of january . https://www.cdc.gov/coronavirus/ -ncov/community/large-events/mass-gatherings-ready-for-covid- .html https://appropriations.house.gov/sites/democrats.appropriations.house.gov/files/families% first% summary.pdf . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted march , . . https://doi.org / . / . / substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (covid- ). preprint, infectious diseases (except hiv/aids reporting, epidemic growth, and reproduction numbers for the novel coronavirus ( -ncov) epidemic estimation of the transmission risk of the -ncov and its implication for public health interventions physical interventions to interrupt or reduce the spread of respiratory viruses early dynamics of transmission and control of covid- : a mathematical modelling study could influenza transmission be reduced by restricting mass gatherings? towards an evidence-based policy framework novel coronavirus -ncov: early estimation of epidemiological parameters and epidemic predictions a conceptual model for the outbreak of coronavirus disease china with individual reaction and governmental action public health interventions and epidemic intensity during the influenza pandemic the staggering rise in jobless claims this week global fear of flying spawns crisis for airlines ?mid=a &bid= one because a majority of facility types listed in the press release (senior centers, job centers, children's centers, etc.) are under public administration, so these facilities likely would have followed recommendations. indeed, some news articles have reported that all children on march , , the mayor of seoul advised that popular commercial establishments such as karaoke places, clubs, and cyber cafes be closed gyeonggi-do issued an executive order limiting the usage of commonly frequented commercial establishments and requiring a higher standard of cleanliness. we coded this as an optional business closure given that the policy discourages usage of these facilities but did not explicitly order them to shut down the government of south korea declared an emergency for those two areas on march , . we incorporated this information into the variable " emergency_declaration many province level covid- policies have targeted religious gatherings at shincheonji church of jesus, since its religious gatherings have been linked to the explosion in the number of cumulative confirmed cases. provincial governments tried to shut down shincheonji-related places of worship, and the related policy implementation is encoded in the variable " religious_closure c%a % - %eb%aa% -%ec%a % - %eb%aa% -%ed% % %ec%a % %c %b this is because all schools were already on vacation during the beginning of the outbreak, and the government then postponed their start dates when kcdc recommended social distancing as one of the main tools to deal with the outbreak. in their press release, they recommended that "people maintain personal hygiene and practice 'social distancing' until the beginning of march, an important point of this outbreak it is recommended for residents in daegu to minimize gathering events and outdoor activities it is worth noting that it was not a total prohibition of incoming visitors; rather, it means inbound travellers were subject to covid- specific emergency measures. kcdc mentioned that starting on the datasets for all italian regions and provinces are scraped from istat's website in get_adm_info.ipynb . iran province level population data for iran comes from the census, as listed on the city population website united states state and county level population data come from the american community surveys dataset, and is downloaded via the census python package in get_adm_info as the number of cases grew, the iranian government started to increase the stringency of its response. the first case was reported on february , (two individuals who both were reported to have died that day). the next day, school closures were announced in the province of qom and travel in the region was discouraged. by february , the government closed schools in provinces and closed down major gathering sites such as football matches and theaters. by march , schools were closed nationwide and government employees were required to work from home. home isolation was implemented by the military on march , , which the media described as "the near-curfew follows growing exasperation among mps that calls for iranian citizens to stay at home had been widely ignored, as people continued to travel before the nowruz new year holidays." for the united states' policy response to the covid- pandemic, we relied on a number of sources, including the u.s. center for disease control (cdc), individual state health departments, as well as various press releases from county and city-level government or media outlets. the cdc has posted and continually updated a community mitigation framework that encompasses both mandatory and recommended policies at a national level.this framework was interpreted by individual states as they each declared their own states of emergency at various dates, and subsequently released their own community mitigation plans. some of the first states to release such plans include massachusetts, california, florida, washington, and new york. each respective community mitigation framework included both mandatory and optional policies to prevent the covid- spread. in addition to both national and federal level policies and recommendations, cities and counties have also taken on the role of providing guidance and implementing policies to mitigate the spread of covid- .there have been a wide range in responses across states since the first case of covid- was announced in washington state on january , . upon this, the cdc began releasing recommendations to those at risk of being exposed to the virus. the initial recommendations included travel warnings and restricted travel to countries with confirmed cases and sustained covid- spread. these travel restrictions grew to include inbound and outbound travel bans to a list of countries, in both europe and asia. key: cord- -iuo ukaz authors: engström, gustav; gars, johan; jaakkola, niko; lindahl, therese; spiro, daniel; van benthem, arthur a. title: what policies address both the coronavirus crisis and the climate crisis? date: - - journal: environ resour econ (dordr) doi: . /s - - -y sha: doc_id: cord_uid: iuo ukaz the coronavirus pandemic has led many countries to initiate unprecedented economic recovery packages. policymakers tackling the coronavirus crisis have also been encouraged to prioritize policies which help mitigate a second, looming crisis: climate change. we identify and analyze policies that combat both the coronavirus crisis and the climate crisis. we analyze both the long-run climate impacts from coronavirus-related economic recovery policies, and the impacts of long-run climate policies on economic recovery and public health post-recession. we base our analysis on data on emissions, employment and corona-related layoffs across sectors, and on previous research. we show that, among climate policies, labor-intensive green infrastructure projects, planting trees, and in particular pricing carbon coupled with reduced labor taxation boost economic recovery. among coronavirus policies, aiding services sectors (leisure services such as restaurants and culture, or professional services such as technology), education and the healthcare sector appear most promising, being labor intensive yet low-emission—if such sectoral aid is conditioned on being directed towards employment and on low-carbon supply chains. large-scale green infrastructure projects and green r&d investment, while good for the climate, are unlikely to generate enough employment to effectively alleviate the coronavirus crisis. electronic supplementary material: the online version of this article ( . /s - - -y) contains supplementary material, which is available to authorized users. as decision makers around the world scramble to respond to the coronavirus crisis and the deep and possibly prolonged recession that follows it, commentators have called for them to use the opportunity to also further our progress in mitigating climate change, which a majority of people believe to be as serious a crisis as the coronavirus (ipsos ) . by pursuing policies that can both alleviate the economic recession caused by the coronavirus and help reduce greenhouse gas emissions, the current crisis presents an opportunity to put the world on a new trajectory with a lower risk of future climate calamities. crisis management often requires exceptional policies, and may temporarily alter constraints on decision making. strategic vision at such a time can help decision makers take into account longer-term objectives, which might be difficult to meet under normal circumstances. as rahm emanuel famously said, "you never want a serious crisis to go to waste". yet, for climate policies to have a chance of implementation at this moment, they cannot be at odds with addressing the current crisis. in this paper, we seek to systematically identify where the intersection between 'coronavirus policies' and 'climate policies' lies. we are interested in which types of policies can help mitigate the impacts of the coronavirus crisis, and also make headway in setting societies on low-carbon pathways. we intentionally focus on long-term climate impacts. many coronavirus policies have temporary effects on carbon emissions (e.g., reduced traffic due to a lockdown), but we see such temporary effects as unimportant, given the long timescales involved in anthropogenic climate change (le quéré et al. ) . specifically, our contribution is the following. we first identify policies which alleviate the coronavirus crisis, as well as a set of channels through which relatively short-term policies can have impacts on climate change in the longer run. second, we present data on sector-specific economic activity and emissions. we then use these tools, together with previous research, to evaluate and score policies in terms of their usefulness in tackling the climate and coronavirus crises. policies ranked as 'good for climate' should be expected to yield substantial long-run emission reductions. policies ranked as 'good for coronavirus recession' should help alleviate the job losses due to the current recession and (in some cases) have public health benefits regarding current or future pandemics. we present a set of policies that can help reduce the economic fallout of the coronavirus crisis, and simultaneously aid societies in meeting climate change mitigation targets in the longer run. we hope this exercise can help policymakers think through their policy options if they want to chart a 'green recovery' while dealing with the coronavirus crisis. 'green stimulus' is of course not a new term. in the wake of the financial crisis of - , strand and toman ( ) evaluated potential stimulus policies in terms of their potential to improve long-term environmental outcomes. some of their recommendations are still valid. however, for the current crisis one has to evaluate policies that are specific to it, i.e., that are adapted to the health aspects of the coronavirus, and the unprecedented economic shock of a simultaneous sharp fall in both demand and supply. hence, our set of policies differ from strand and toman ( ) . we also consider some channels for long-run impacts that they did not touch upon. other, more recent, analyses (e.g., cat ) outline the climate effects of various policies, but ignore whether any of the policies (such as green r&d) are actually good at alleviating the coronavirus crisis. the paper by hepburn et al. ( ) has a similar objective to ours, but their analysis starts from previously used stimulus policies (since the financial crisis of [ ] [ ] and is based on surveys of expert opinions. we start from policies that seem especially appropriate in the current crisis, and evaluate them based on an analysis of the individual policies, combined with basic empirical observations about the carbon, labor and layoff intensity of different sectors and jobs. finally, helm ( ) discusses the broad effects macroeconomic policies intended to tackle the coronavirus may have on carbon emissions. we take a complementary perspective, looking at a large set of individual policies in more detail. we want to defuse two potential criticisms against the notion that crisis policies should be evaluated based also on their effect on environmental outcomes. the first relates to the tinbergen rule: that, to obtain an efficient outcome, one needs as many instruments as there are externalities. in particular, policymakers should use one set of instruments to deal with the health crisis, another to achieve macroeconomic stabilization, and a third to achieve long-term environmental objectives. in a first-best world this would of course be true. in practice there are constraintspractical and political-that make perfect fine-tuning difficult. given such constraints, we have to ensure that measures to address one goal do not undermine another. we illustrate with two examples from our analysis. first, implementing a carbon tax would, if done in isolation, likely worsen the current recession. but if the proceeds were used to lower labor taxes, the policy could instead alleviate the coronavirus crisis. second, economic stabilization will involve government investment, or subsidies to private investment, into capital assets. the question is then: which types of capital assets? the answer necessarily has to account for the effect the assets will have on the climate. the second criticism is that beneficial long-term effects on climate are unlikely to be achieved in the absence of long-term policies to price externalities (strand and toman ) . without pricing the externality directly, rebound effects can undo the beneficial effects of e.g. green stimulus policies. further, the general equilibrium effects of stimulus policies on emissions may be hard to assess. sectoral policies should consider the complementarity of targeted sectors with emissions-intensive sectors. a prominent example relates to sectors linked to air travel: e.g., hotels and restaurants have limited direct emissions, but high indirect emissions through tourism and business travel. stimulus payments aimed at such carbon-complementary sectors may backfire unless also accompanied by other measures, such as carbon pricing (dwyer et al. ) . uniform carbon pricing on all fuels would eliminate such concerns. our immediate answer is that we agree that long-term externality pricing is critical, and we include tax and subsidy reforms such as revenue-neutral carbon pricing in our set of policies. a further riposte, indeed to both of the above criticisms, is that long-term pricing policies are endogenous: policies today affect what is politically feasible tomorrow (acemoglu and robinson ). subsidies are not a substitute for carbon pricing (helm ) but may help pave the political route to their implementation. our goal is to evaluate policies in terms of their potential to mitigate the economic fallout of the coronavirus pandemic, and their long-term effect on climate change. to this end, we start by discussing what types of policies can help deal with the consequences of the pandemic. we then present channels via which relatively short-term policy interventions can have longer-run impacts on climate change and climate policy. these two classification exercises allow us to identify policies that have effects on both crises. we then present some data that will be useful in evaluating policies. when people are forced to stay at home they do not go to work and they consume less. the inability to work is a supply shock, while the reduction in consumption is a demand shock. the combination of the two implies bankruptcies and layoffs, aggravating income losses and lowering demand even further. the supply shock will disappear as an improving understanding of the coronavirus allows for more targeted public health measures, and eventual control of the pandemic. however, the economic effects on aggregate demand are likely to persist, so that the demand shock will outlive the supply shock. we mainly focus on policies implemented in the medium term, and thus centered around the economic recovery, rather than around pandemic control per se. economic stimulus policies-in particular, ensuring high demand by supporting incomes and employment-will be central for mitigating the economic fallout. it is well established empirically that wealthy capital owners tend to save a larger share of their income than people who are poorer and who rely on labor income (see e.g. bernheim and scholtz ; beverly ; browning and lusardi ; dynan et al. ; diamond and hausman ; gentry and hubbard ; quadrini ; alan et al. ; dupas and robinson ; gandelmann ) . hence to assess the potential of a policy to restart the economy, we will evaluate policies based on their potential to secure employment (which also benefits mental health) and labor income. some of the firms that now go bankrupt may not be able to quickly resume their old activities once the health crisis is over. it may take time for firms and labor to match, for investors and firms to match, and so on. helping businesses survive will reduce such frictions. for this reason, policies that reduce bankruptcies can also help the recovery. unfortunately, data on bankruptcies are not yet readily available. we conjecture (based, e.g., on andersen et al. , carvalho et al. , and our own analysis using preliminary data, see appendix a. ) that bankruptcies are highly correlated with layoffs. policies may have long-run implications on climate change through a variety of channels. we have identified four channels we see as particularly relevant for our purpose. . investment -direct effect of long-lived investments. to mitigate the unprecedented economic crisis, governments are planning to stimulate economies through massive investment programs, either implemented directly by governments, or by subsidizing private-sector investments. such investments have direct long-run impacts once sunk: some will be long-lived, and either substitute or complement fossil fuels (e.g., power generation or transportation infrastructure). once made, they will be used, and thus have long-run impacts on baseline emission pathways and on the cost of implementing future climate policies (shalizi and lecocq ; seto et al. ). . political -dynamic political economy effects. policy can be persistent: economic decisions taken by firms, in response to policies intended to be temporary, can affect political incentives, preventing a future reversal of a policy (coate and morris ) . this can happen as an indirect effect of sunk investments which changes the structure of vested interests (with respect to climate policies): a devaluation of fossil-related assets, or the introduction of new assets complementary to climate policies, will affect the power and incentives of interest groups to influence future policies (acemoglu and robinson ) . similar effects could result from the destruction of interest groups, e.g. due to bankruptcies in a sector that receives little stimulus money. the formation of special interest groups may also prove to be a self-fulfilling prophecy (grey ) , and short-term disruptions to interest group formation can have long-run effects. . technological -path dependence due to technological development. a further indirect effect may arise through changes in the direction of r&d (e.g. low carbon versus carbon intensive). when technological change is directional, temporary policies may determine in which direction an economy develops. such differences can persist: tem-porary growth in one type of technology may sustain itself, due to innovation incentives being geared towards a dominant technology, and due to complementarities in r&d (acemoglu et al. ; hart ; van der meijden and smulders ). . learning -forced experimentation and learning effects. consumers and producers may not perfectly optimize their choices, e.g. due to costs of finding out about the characteristics of various options, because of biases in decision making, institutional constraints, or because of habit formation favoring status quo behavior. temporary disruptions to choice sets may force them to look for new options, which may be preferred after the disruption has ended (seto et al. ; larcom et al. ; helm ) . policies that promote or subsidize experimentation can help a wider set of agents explore novel options, and thus promote permanent changes in behavior. we focus on two metrics for alleviating the coronavirus crisis: the number of layoffs in an industry and the labor intensity of the industry, expressed in employees per unit of value added. for judging the climate effects, we focus on the emissions intensity of an industry: climate goals suggest the long-run prospects of relatively clean industries should be prioritized. we use two empirical metrics: emissions per unit of value added, and per employee. we collect data on emissions, number of employees and value added by sector from eurostat. layoffs data are from national sources: swedish public employment service for sweden; the helsinki gse situation room for finland. we show results for labor and emissions intensity for the european union, germany, france, the united kingdom, sweden and finland. our results for layoffs are limited to the countries for which we could find reliable data on recent layoffs during the coronavirus recessions (sweden and finland). these roughly correlate with productivity and demand declines (see appendix figure a ). figure plots both layoffs and layoffs per thousand employees against co emissions per employee (note the logarithmic scale on the horizontal axis) for the sectors given in table . the most affected sectors in sweden, in terms of total layoffs, are i (hotels and restaurants), g (wholesale and retail trade), h (transport and storage), n (rental and real estate), and r (culture). some of these show large layoffs simply because of their size. when layoffs are normalized per , employees, the same sectors stand out except that sector e (water and sanitation) is badly affected while sector g (wholesale and retail trade) appears less affected. the picture for finland is broadly similar, except that there are more layoffs in sector c (manufacturing). we emphasize that this is a high-level categorization which masks detail-yet it serves as a useful benchmark for stimulus and other policy decisions. we specifically highlight three caveats. first, co intensity is measured in a narrow sense: direct emissions from the sector under consideration. since sectors are connected, a subsidy to one sector will affect other sectors as well, e.g. indirectly subsidizing sectors that produce complementary outputs. the full effect of a sector-specific subsidy should include any indirect emissions coming from the effects of the subsidy on related sectors, i.e., the total general-equilibrium effect. second, layoffs are a recent snapshot and may be temporary. figure is likely to change over the course of the coronavirus recession, and in the absence of uniform carbon pricing across all sectors, accounting for indirect emissions may be important. for example, hotels have a low emissions intensity as the emissions from associated travel are allocated to the transport sector, but clearly hotels facilitate (carbon-intensive) travel via tourism and business trips (dwyer et al. ) . greenhouse gas emissions from tourism are substantial, with estimates suggesting the sector accounts for more than % of global greenhouse gas emissions (lenzen et al. ; see appendix a. for a further discussion of this). a second example relates to the relationship between the emissions-intensive transport sector, and the seemingly low-emissions services sectors. an important fraction of transport demand results from activity in services sectors (alcántara and padilla ). in the construction sector, also, indirect emissions can make up a large share of total emissions (acquaye and duffy ). the indirect effects of policies on emissions, output and employment may be important to consider and could be tackled using input-output analysis (mäenpää and siikavirta ; markaki et al. ). this is a promising avenue for further research, both academically and for applied policymaking, but beyond the scope of the present paper. to overcome some of these concerns, fig. plots a measure of labor intensity (employees per million euros of value added) against a measure of emissions intensity (co emissions per million units of value added) for each of the sectors in the european union, germany, france, the united kingdom, sweden and finland. per amount of stimulus spent, industries with high labor intensity may also be relevant to target from a recession perspective, since each unit of spending can be expected to have a larger employment effect in those sectors. from the climate perspective, one would like to focus on sectors with low emission intensities. the results vary somewhat across countries, but paint a remarkably consistent picture. first, there is a slight negative relationship between labor intensity and emissions intensity, perhaps reflecting that sectors with low labor shares rely on more energy-intensive capital. industries that stand out as potential targets that score well on the coronavirus-climate interface are not necessarily the ones that have seen the most layoffs, although they overlap partially. for the european union as a whole, the set of high-labor, low-emissions sectors include i (hotels and restaurants), g (wholesale and retail trade), n (rental and real estate), q (health care and elder care), p (education), r (culture) and s (services). sectors i, g, n and r have also experienced a peak in recent layoffs. for each of the individual countries, almost the same set appear on the high-labor, low-emissions list. in appendix a. , we comment on these sectors individually, and end by commenting on some other industries. to structure our analysis we categorize policies along the following dimensions (table ) . first, we split them into policies that are primarily motivated by their effects stimulus spending refers to policies that require substantial amounts of government funds, with the aim to preserve employment, avoid bankruptcies, create new jobs, and help the hardest-hit consumers. the second category includes tax reform policies that are complementary or even somewhat orthogonal to stimulus, but that raise extra revenues that can be used as additional stimulus, and that have overall economic efficiency benefits. third, some policies do not require large financial injections from the government; e.g., mandates, standards, or bans. they may also span several categories. we group them under 'cross-cutting' policies. any categorization of policies is necessarily imperfect: there is no optimal choice of dimensions and policies will spill across categories or overlap with each other. policies vary in their breadth and budgetary requirements. the most important matter is that our list of policies is reasonably complete. we believe it is, with some caveats. we purposely omit some policies. we do not tackle coronavirus policies that have no long-run climate impacts, or that are not relevant beyond the immediate crisis. these include test-trace-isolate, travel restrictions, and vaccine development. similarly, some central policies to manage the pandemic have significant but short-lived effects on emissions-yet long-run climate impacts appear highly limited. these include distancing policies such as lockdowns, restricting access to public spaces, and the closing of restaurants and schools. we have evaluated the set of policies in tables and (the latter breaks down financial assistance to firms by industry). figure summarizes the conclusions from this analysis. we plot policies according to how good they are for the coronavirus crisis (vertical axis) and for the climate crisis (horizontal axis). policies marked green denote stimulus policies, policies marked red denote tax reform policies, and policies marked blue denote other cross cutting policies. below we proceed to comment on policies we have identified as particularly promising (located in the upper right corner). a detailed analysis of these-and other policies-can be found in the appendix (a. -a. ). there, after describing each policy and briefly analyzing it, we draw a conclusion as to how it scores in terms of alleviating the recession and its long-run climate impact. these scores take seven levels: very bad; bad; bad-to-neutral; neutral; neutral-to-good; good; very good (these results are also presented in tables and ). the precise scoring can be refined, but we present a conceptual framework for analyzing the joint set of policies meant to address the coronavirus recession and climate crises. small scale green infrastructure investment (good, good, a. ) aiding industries (see table and fig. we plot these policies in green, labelled by industry. there have been various policy proposals on how to support businesses and workers, in general, during the crisis. these include giving out loans or grants to small businesses, or providing firms with tax relief (becker et al. ; scarpetta et al. ) . these policies aim to support business owners, to support workers and allow them to maintain their relationship with the firm, or to prevent the overall collapse of businesses. the choice between different industries appears the most consequential decision that governments can make. how the stimulus funds are allocated across industries determines both the short-run employment effects and could have long-run climate implications. the question we therefore ask is: which sectors should be targeted for aid (bailouts, investments, loans, etc.) if the objective is for this to both alleviate the current crisis and be good for the climate? whether stimulus for particular industries has meaningful impacts on long-term climate goals depends on several factors. for example, preferentially saving firms in a given sector may not have a large direct impact on the sector in the long run. the reason is that the capital assets, many of them specific to the sector, will still exist; so will a large fraction of the sector-specific human capital. thus, even if a wave of bankruptcies were to destroy many businesses in some low-emissions sector, that sector may spontaneously recover once the crisis has passed. one potential long-run effect from extensive bankruptcies in a sector is that consumers and buyers may shift their habits away from that sector, implying a longrun decline in sector-specific demand. furthermore, persistent changes may result through the forced experimentation mechanism or long-lived government investments. bankruptcies among firms conducting r&d into renewables may lead to a slowing of technological change (which we address separately below). the political channel can also be at work. firms will likely vary in their ability to weather the current crisis along many dimensions. if there is systematic variation in survival probability between firms in competing subsectors, long-term effects may result from subsectors that see many firms go bankrupt being unable to represent their interests in the political process. for example, in the european electricity sector, the largest firms tend to focus on fossil-fuel technologies in their innovation. large firms also likely have better access to credit. thus, a wave of bankruptcies may mean policies in the recovery stage may favor large, fossil-oriented firms. such temporary disruption can have persistent effects, by strengthening the structure of vested interests in the sector, and thus the persistence of policy (brainard and verdier ; coate and morris ) . this presents another reason for supporting vulnerable 'green' industries. a word of caution is in place. aiding industries has at least two problems. first, it may not be politically feasible. second, it may not be very efficient in general compared to more direct measures at tackling unemployment. funds to aid firm survival will help firms' owners without necessarily boosting employment. the same holds for tackling climate change. this is since such assistance would work only indirectly to affect the goals (such as employment and lower emissions) and firms may not use the aid as intended. a valuable complement could be conditioning of aid at the firm or industry level, for those who receive it. this policy is orthogonal to other policies but could ensure that industry aid becomes more effective, by aligning the recipient's goals with those of the policy-maker. for instance, assistance could be made conditional on lowering emissions or on the funds being used for hiring or retaining labor. conditioning loans is common practice at the world bank and imf, and for many governments. there are several examples of such conditioning having already been used in the current crisis. for more details on contingent policies, see sect. . . . based on this analysis, previous research and data of employment and emissions, the sectors hotels and restaurants, health care and education would be good candidates but for different reasons (for a results of the other sectors see table ; for a fuller analysis of all sectors see also appendix a. ). restaurants are very labor intensive, have been hit hard by the lockdown and have low direct emissions. targeting this sector in the recovery phase could therefore be a good idea. hotels have also been severely affected, but subsidizing hotels likely aids the transport sector which is very emissions intensive. hence, a finer targeting may be needed here, for instance, only towards restaurants or more broadly to other service industries. we rank aiding this sector as good at alleviating the coronavirus crisis and neutral-to-good for the climate. the education sector has not been hit by the crisis. but having a high labor share and being essential in the structural transformation of the economy forced by the coronavirus crisis, this sector is key in dealing with that crisis. at the same time, it is low on emissions. stimulus may thus shift production and 'consumption' in a climate-friendly direction. we rank aiding this sector as good at alleviating the coronavirus crisis and good for the climate. health care also has high employment intensity. it of course has not seen any layoffs, being essential for dealing with the medical fallout of the current or future pandemics. it is also low on emissions, so the same motivation as for education applies here. we rank aiding this sector as good for alleviating the coronavirus crisis and good for the climate. economic stabilization can of course take the form of monetary stimulus. relatedly, it has been suggested the fiscal commitments could be funded as 'helicopter money'by printing money. we are not aware of research on the climate effects of such policies, so we do not include them in our ranking, summary and conclusions. see appendix a. for further details. these policies are also plotted in green. fiscal stimulus can be aimed at 'climate-oriented' infrastructure investment such as renewable-energy generation facilities, associated infrastructure, and energy-saving investments. governments have already announced very large investments in infrastructure as part of stimulus programs. on may th , the european commission presented a revamped long-term eu budget and a € . trillion recovery plan, with the explicit goal to provide the instruments to build a modern, clean and healthy economy, better known as the 'eu green deal' (new europe ). stimulus spending should be directed according to these plans if governments are serious about climate change mitigation. not doing so will undermine the climate targets: recovery from the coronavirus crisis will exhaust the appetite for public spending for many years. but from a coronavirus perspective, the immediate benefit of such investment stimulus is unclear. the stimulus would primarily operate through the construction sector. however, this sector has not seen severe layoffs due to the health crisis. there is thus a trade-off between optimizing strategic investments that move societies onto more sustainable pathways, and getting societies out of the immediate coronavirus recession as rapidly as possible. if there is potential for sufficiently skilled workers to move in from other sectors, there could be beneficial short-run effects on overall employment. the most direct long-term climate policy effect of green infrastructure investments is their emissions reduction throughout their long lifetimes. complementarities (for example due to network infrastructure investments) mean they can also spur further, private investment, and shift societies away from 'carbon lock-in' and towards a 'green lock-in' path. this lock-in can be reinforced by indirect channels. a shift towards green investment generates larger vested interests in favor of e.g. carbon pricing policies, given that renewable investments stand to gain from such policies. for example, in germany, the feed-in tariffs for renewables generated constituencies and advocacy groups which stabilized the policy regime and led to an expansion of the sector (jacobsson and lauber ; strunz et al. ) . further, any shift towards greener infrastructure and future pricing policies incentivizes green r&d investments, due to larger potential market size (acemoglu et al. ). the channels involved here are thus long-lived investment, changing political status quo and technological changes. an important point here is that the labor intensity of infrastructure projects depends on their scale: small-scale projects are more labor-intensive than large-scale projects (strand and toman ) . this could favor small-scale renewables such as residential solar and retrofit projects. our judgment of the effect on coronavirus crisis is therefore based on the scale of the projects. based on the above, we particularly want to highlight smallscale infrastructure projects such as retrofitting insulation and installing solar panels on houses. we rank this policy as good at alleviating the coronavirus crisis and good for the climate. for reasons similar to those in the case of large-scale infrastructure investment, we do not think that extensive green r&d investment, while good for climate, will be particularly well-suited to deal with the coronavirus crisis as the effects on employment in the short-to-medium run are essentially limited to those holding the right competence. investing in green r&d will just shift research labor from one area to another. fiscal stimulus to private r&d spending in the renewable energy sector, by way of grants or loans, can prevent bankruptcies and the breaking up of successful r&d teams. more details can be found in appendix a. . we rank both policies as neutral-to-good at alleviating the coronavirus crisis and good for the climate. another promising green stimulus option is planting trees. afforestation and reforestation activities are likely cost-effective both in terms of climate and in terms of the coronavirus crisis, as the trees will absorb co and as planting requires large numbers of manual and unskilled labor (strand and toman ) . we rank this policy as good at alleviating the coronavirus crisis and good for the climate (see more in appendix a. ). we plot these policies in red. while tax reforms obviously do not need to be climatemotivated, we have identified revenue-neutral 'green tax reform' (involving for example carbon taxes, an abolition of fossil fuel subsidies, tighter emission caps, and meat consumption taxes) as especially promising, because it would enable an even more aggressive stimulus package (see appendices a. -a. ). revenue-neutral policies not only have important long-run climate effects, but also have the potential to improve economic recovery. green taxes improve economic efficiency by internalizing the carbon externality. they would thus also help to internalize potential negative externalities from indirect emissions that could result from certain sectoral aid (e.g., aiding hotels and restaurants that are closely linked to travel). how the revenues are spent determines which industries and consumers are winners vs. losers (and thus whether the policy is on net favorable or unfavorable to preserve employment). there is a possibility of a double dividend if the revenues are used to offset preexisting distortionary taxes (goulder ; de mooij ) . the coronavirus recession may thus be a politically opportune moment for well-designed green tax reform that enables environmental and employment benefits at the same time. we rank carbon taxes, an abolition of fossil fuel subsidies and tighter emission caps as good at alleviating the coronavirus crisis and very good for the climate. we rank a meat consumption tax as good at alleviating the coronavirus crisis and good for the climate. as a benchmark for the neutrality of the green taxes, we assume that the proceeds are spent on reducing labor taxes. one reason for using this benchmark is that fiscal stimulus in the form of reduced labor taxes takes effect more quickly than monetary stimulus (kaplan and violante ) . this could be good for a rapid exit from the coronavirus crisis by stimulating labor demand. such tax cuts can also be tailored with distributional impacts in mind, and could thus be designed to help households most likely at risk of an immediate liquidity crisis. to use the proceeds for labor tax reductions is of course just one option out of many. a green tax reform would have an even more favorable impact on the climate if the revenues were spent on direct investments in renewable energy, clean tech r&d, and other low-carbon technologies. in this case, both the tax itself and the revenues provide immediate incentives to reduce emissions, while also benefiting from path-dependency effects of redirecting capital to build up a greener capital stock. this type of revenue recycling is less attractive from the perspective of mitigating the recession, as many green investments do not require much labor. we would therefore focus on policies that reduce labor taxes economy-wide. labor tax cuts are a form of fiscal stimulus which could be considered in isolation for tackling the coronavirus fallout. we are not aware of research that would shed light on the impact of labor tax reductions, in isolation, on climate outcomes. we rank this policy as good for the coronavirus crisis and neutral for climate. see appendix a. for further details. we plot the cross-cutting policies in blue. the pandemic has led many governments to impose different forms of regulations and restrictions on citizens and businesses, related for example to travel, sick leave, and way of doing business. there are also mandates that have been, or could be, imposed with the primary purpose to mitigate emissions and air pollution. these are relevant to analyze as they in turn may impact economic recovery, or adaptation potential for the current or future pandemics. we comment on the most promising of such policies here. neves and brand ( ) find that about % of short car trips could in theory be replaced by cycling or walking, reducing emissions from car travel by about %. city planning policies and infrastructure investments promote active modes of transportation by making car travel more expensive (e.g., congestion charging) and less convenient (winters et al. ) . we already see initiatives along these lines. milan plans to reallocate km of street space from cars to cycling and walking in the summer of , in response to the coronavirus crisis. given path dependencies of infrastructure investment and forced experimentation, initiatives like this can also foster persistent change. a shift towards active modes of transportation could also have long-run health effects in the form of lower rates of obesity, diabetes, and hypertension (pucher et al. ; rasmussen et al. ; grøntved et al. ). this reduces the share of people vulnerable to the coronavirus. we rank this policy as good at alleviating the coronavirus crisis and good for the climate. tighter air pollution regulation would reduce carbon emissions: this could involve switching from coal generation to gas generation, especially near population centers, and boosting less emission-intensive transport. such policies may involve long-lived investments (into renewables and gas-fired plants to replace coal) which will be long-lasting. they will also generate new interest groups (cyclists, drivers of electric vehicles) and perhaps reduce the power of coal generators. there is also some preliminary evidence that local air pollutants, such as nitrogen oxides (no x ) and atmospheric particulate matter with a diameter of less than . microm (pm . ) may increase mortality from the coronavirus (ogen ; wu et al. ). if these preliminary findings hold up, they point to long-term benefits if the virus becomes endemic, circulating in the population indefinitely. we rank this policy as good at alleviating the coronavirus crisis and good for the climate. there has been a broad debate about conditioning bailouts to firms in polluting sectors. if a bailout can be credibly conditioned on future changes in activity, and if, in the absence of bailouts, the industry is likely to resurrect after any bankruptcies, then conditional bailouts of emission-intensive sectors may be beneficial to the climate. consider airlines: a wave of bankruptcies will wipe out current shareholders, but the aircraft assets will be sold to new companies once the health crisis subsides, and these new firms will operate according to market incentives. a bailout will save the current firms, but it can set conditions on their future behavior, such as reducing the number of short-haul flights for which feasible low-emission alternatives exist. several airlines have already been given bailout loans with no conditions attached (laville ) . on the other hand, the bailout given to air france comes with the requirement that the company halve its carbon emissions from domestic routes, essentially forcing it to cut back services on routes (financial times ). we rank this policy as neutral-to-good at alleviating the coronavirus crisis and neutral-to-good for the climate. recapitalization is an alternative to conditional bailouts. rescuing firms by injections of equity using public funds are, effectively, partial nationalizations. as such, they give the state an ownership stake in the firm, and thus a voice in the management of the firm. many commentators warn against the state taking a role in commercial decisions, even in situations in which it does hold a stake. however, where a firm's commercial decisions involve important externalities, it may be justifiable to have the state exercise its owner's right to influence commercial decisions, so as to take account of the full social costs of these decisions. the recapitalization should be large enough to give a state a voice as a major shareholder. the channels involved here are thus through long-lived investment and political status quo. government may pay wages for private employees as a way to avoid the labor search costs associated with rehiring once the economy starts to recover (as proposed by sinn ). with regards to the long-term climate effects from this policy the results are less clear. if labor gets increasingly replaced by capital as a result of forced experimentation, where companies adopt new technologies or management practices that replace some of the previous jobs, this shift in the capital-labor share could potentially have a negative climate impact since capital is typically more fossil fuel intensive. the specific impacts may depend on industry; the analysis of sect. . . applies. we conclude that his policy is very good for addressing the coronavirus crisis and neutral-to-good in terms of climate. in this category we have also looked into tightening renewable portfolio standards, and encouraging working from home. we have ranked these policies as neutral for alleviating the coronavirus crisis and good for climate (the analysis is found in a. and a respectively). a cross-cutting policy that is not promising though is extending sick leave provisions (see appendix a. ). unless also financed by the government, such provisions may lead to bankruptcies and substitution away from labor. we rank this policy as neutral-to-bad for alleviating the coronavirus crisis and neutral-to-bad for climate. the severity and abruptness of the coronavirus crisis do not make the climate crisis any less pressing. our societies need to solve the former, immediate crisis without taking our eye off the latter, inexorable one. we have above identified a set of policies that would help in tackling both the coronavirus crisis and climate change. the most effective policies involve revenue-neutral tax reforms towards carbon pricing, which would be excellent climate policies and also help deal with the coronavirus crisis by allowing reductions to labor taxes. subsidizing temporary employment in less emissionsintensive industries (services sectors including leisure services like restaurants and culture; or professional services like technology, education, and healthcare) can help laid-off workers try out occupations that have potential even under tougher climate policies. here one needs to be aware of potential indirect emissions effects in sectors with complementary goods, but with proper carbon pricing, such effects could be internalized. labor-intensive investments into natural capital (tree planting) and into low-carbon physical capital can both support employment and incomes, while storing carbon or helping societies transition towards a low-carbon future. health and climate goals can also be achieved by promoting transport methods which not only reduce carbon emissions, but local pollutants too, improving cardiovascular health. all sectoral aid should be conditioned on being directed towards employment and on low-carbon supply chains. the crisis is ongoing, and the full outcomes in terms of health and unemployment are yet to be known. policies will be tried out, and 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lindahl , · daniel spiro · arthur a. van key: cord- -ts sfxx authors: yang, yang; su, yingying title: public voice via social media: role in cooperative governance during public health emergency date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: ts sfxx with the development of the internet, social networking sites have empowered the public to directly express their views about social issues and hence contribute to social change. as a new type of voice behavior, public voice on social media has aroused wide concern among scholars. however, why public voice is expressed and how it influences social development and betterment in times of public health emergencies remains unstudied. a key point is whether governments can take effective countermeasures when faced with public health emergencies. in such situation, public voice is of great significance in the formulation and implementation of coping policies. this qualitive study uses china’s health code policy under covid- to explore why the public performs voice behavior on social media and how this influences policy evolution and product innovation through cooperative governance. a stimulus-cognition-emotion-behavior model is established to explain public voice, indicating that it is influenced by cognitive processes and public emotions under policy stimulus. what is more, as a form of public participation in cooperative governance, public voice plays a significant role in promoting policy evolution and product innovation, and represents a useful form of cooperation with governments and enterprises to jointly maintain social stability under public health emergencies as a positive extra-role behavior, voice has attracted extensive interests from scholars and gained substantial attention in the organizational behavior literature [ ] [ ] [ ] . public voice is a new type of voice behavior that refers to the behavior of citizens who share opinions on social media to improve the social status quo or prevent harmful practices [ ] . as a pro-social behavior, public voice is vital for advancement and betterment of society [ ] , and it is believed that public voice plays an important role in the cooperative governance of government and other organizations (e.g., enterprises, non-profit organizations) under a public health emergency. considering that public participation in public administration and policy formulation is beneficial to government performance, governments attach much importance to the public's role in policy-making, especially in the areas of environmental governance, public health, and sustainable development [ ] [ ] [ ] [ ] . in the face of extraordinary development problems, such as economic recession, public opinion in policy-making is extremely important [ ] . thus, to ensure the timeliness and efficiency of policy in the case of public health emergencies, the value of public voice, along with technical support from enterprise, should not be underestimated. in the covid- epidemic, many governments have begun to cooperate with high-tech enterprises to formulate epidemic prevention and control policies such as the health code in china, covidwise in virginia, and corona-warn in germany [ ] [ ] [ ] [ ] . public voice on social media has effectively promoted the evolution of epidemic control policy and tracking applications developed by enterprises, making an outstanding contribution to social stability. thus, it is necessary to study public voice in public health emergencies in relation to the implementation of government policies and the promotion of enterprises' product innovation. public voice is also of great significance in further realizing cooperative governance. voice behavior refers to the extra-role interpersonal communication behavior in which organizational members actively make constructive suggestions to the organization for the purpose of improving work or organization status quo [ ] . previous studies on voice behavior have mainly focused on employee voice and customer voice within organizations; public voice in a broader context has received little attention. the importance of employee voice and customer voice for the sustainable development of enterprises suggests that the role of public voice in social improvement should not be underestimated, and is worthy of in-depth discussion [ ] . given that public voice can have wide ranging influence in terms of social change, this research focuses on its effect on the evolution of policy implemented under public health emergencies. public voice in public health emergencies has several important characteristics: first, the target of public voice is more extensive. the targets of employee voice and customer voice are employees inside the enterprise and customers who have cooperative relationships with the enterprise, respectively. they often offer advice to the enterprise as a single identity. however, for public voice, the target is the general public, who have dual identities as policy participants and enterprise customers. second, under cooperative governance, multiple subjects participate in policy-making, so the targets and content of public voice are also diverse. for example, voice to a government may relate to the implementation of policy, while that to an enterprise may focus on product improvement. third, the channels for public voice are more diverse. employees mainly voice to supervisors face-to-face or make suggestions through the internal social networks of an enterprise, and most customer voice occurs through the virtual community created by the enterprise. as social networking sites provide a more convenient platform for people to voice their concerns and make their voices heard, the public can voice through a variety of social networking sites [ ] . finally, the effect of public voice is more significant. public health emergencies prompt the public to respond to the policy more actively and provide timely feedback [ ] , which forces the governments and enterprises to absorb public opinion as soon as possible to improve policies and products. overall, research on public voice behavior is still in its infancy. the factors driving public voice and the mechanism of its action on government policies and enterprise product innovation are unclear. the purpose of this study is to address this gap and further explore the role of public voice in promoting cooperative governance under public health emergencies. the main contributions of this paper are threefold. first, it extends the literature on voice behavior. most studies on voice behavior have focused on employee voice and customer voice. under cooperative governance, the public is a participant in government policy as well as a customer of enterprises, yet the mechanisms for the influence of public voice on policy and product are not clear. this paper focuses on the dynamic role of public voice in policy-making and evolution and product innovation. second, it constructs a dynamic model of public voice to promote policy implementation under public health emergency. studies of public participation have mainly focused on its effect on environmental projects and decision, as public participation is seen as highly valuable and necessary to achieve the goal of environmental pollution control [ , , ] . however, the voice behavior of the public in the formulation and evolution of policies in public health emergencies is unknown. finally, this paper extends the literature on cooperative governance in a public health emergency and attaches more importance to the role of public voice in the process of collaborative. this research uses china's health code policy under covid- as an example. this is an epidemic prevention policy whose implementation relies on a health rating system developed by alibaba, tencent, and other firms. the system uses opaque algorithms and individuals' data, such as physical condition and contact with an infected person, to make judgments about the infection risk of system users [ ] . the system then generates a qr code corresponding to this risk level that is used as a passport. based on the evolution process of health code policy, this paper downloads comments about the health code policy to do research. this study uses the qualitative research method of grounded theory to explore the factors driving public voice and reveals the dynamic mechanism of its influence on policy formulation and product innovation. further, this research provides support for cooperative governance involving government, enterprises, and the public under public health emergencies. the concept of voice was first proposed by hirchman in the field of economics. it has been further developed in the field of organizational behavior [ ] . currently, voice behavior is divided into employee voice, customer voice, and public voice. most research on voice behavior has been in the field of organizational behavior and mainly aimed to explain employee voice within organizations. van dyne and lepine define employee voice behavior as a positive extra-role behavior focused on improving existing working methods and procedures through constructive suggestions; they emphasize the 'promoting' role of employee voice for the organization [ ] . van dyne et al. further expand the concept, pointing out that voice includes not only suggestions for improvement, but also concerns about the organization [ ] . on this basis, liang et al. clearly divide voice behavior into promotive voice and prohibitive voice [ ] . promotive voice refers to innovative ideas or suggestions put forward by employees to improve the overall operation of the organization, while prohibitive voice refers to employees' attention to work practices, and events and employee behaviors that are not conducive to the development of the organization [ ] . employee voice is widely considered a valuable and positive extra-role interpersonal communication behavior, a kind of organizational citizenship behavior that plays an important role in the team and organization. scholars have conducted in-depth research on the influential factors and outcome variables of employee voice. previous studies indicate that personal characteristics, leadership, and organizational climate can influence employee voice, which will be beneficial to organizational betterment [ , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . additionally, the approaches of employee voice are also optimized due to the development of the internet [ ] . with the aggravation of market competition, customer participation becomes crucial for the product and service innovation of enterprises, and enterprises have created brand virtual communities to gather customers' ideas and opinions. research on voice behavior has also expanded from the internal voice of the organization to the field of consumer behavior. on the connotation level, griffin and hauser regard customer requirements as customer voice, holding the view that customers would sort their needs according to importance and convey them to enterprises [ ] . enterprises can then develop new products based on customer requirements. lee et al. expand the connotation of customer voice and define it as a description of customers' needs and expectations or preferences and dislikes, including the pursuit of rights and interests, suggestions for new products and services, and complaints about previous use experience. earlier definitions of customer voice are based on customer needs, but with advances in research on employee voice within organizations, scholars have begun to redefine customer voice from the perspective of role orientation. ran and zhou clearly define customer voice as the extra-role communication behavior in which customers actively make suggestions or express opinions to improve the status of enterprises; this kind of behavior belongs to the category of customer citizenship behavior [ ] . at the dimension level, most previous studies on customer voice divide it into two categories: customer satisfaction and customer complaint [ ] . with the deepening of research, scholars find that customers not only express dissatisfaction regarding product and service providers, but also express satisfaction and praise, and make their own suggestions. therefore, with reference to the classification of employee voice by liang et al., customer voice can be divided into promotive voice and prohibitive voice [ ] . promotive voice refers to the innovative ideas and suggestions of customers regarding improvements to the efficiency of enterprises, while prohibitive voice refers to the expression of opinions on actual and potential problems within the products, services, or management of an enterprise that are harmful to the enterprise or its customers. as the input behavior of customers to enterprises, customer voice can urge enterprises to innovate products and services to meet the needs of customers, thus improving customer satisfaction and maintaining customer loyalty. it can also help enterprises correct errors, provide solutions to problems, and improve enterprise performance [ , ] . with the rapid development of social media, people can express their views on social issues more directly and conveniently, and research on voice behavior has been further extended to a broader social life context. public voice behavior refers to citizens sharing opinions on social media to improve their social status quo or prevent harmful practices. it is essentially a pro-social behavior [ ] . public voice channels have begun to focus on social media, because in the modern world, social media presents extensive information; people express their concern about education, security, the environment, work-life balance, and many other issues online. moreover, the diversity and openness of social media provides a broad platform for public expression. the public can conduct online voice behavior through third-party social media and public participation is increasing. however, research on public voice based on social media is still in its infancy and is uncommon. bhatti et al. explore the mechanism of the effect of individual moral identity and proactive personality on public promotive voice and prohibitive voice based on self-consistency theory [ ] . research on voice behavior as discussed above has several characteristics. first, the research field has shifted from intra-organization to a broader social background. second, the voice subjects present a change trend of 'employee-customer-public'. third, the targets of voice behavior change from organizational practice to general social phenomena. fourth, the form of voice presents the evolution trend of "face-to-face-virtual community-social media". citizen participation in the formulation and consultation of public policies is an important way to strengthen and support modern democracy [ ] . regarding the influence of public participation on policy, most research reveals extensive interest in environmental protection and pollution control, as public participation can help decision makers recognize public concern and demands, and handle environmental conflict in a more flexible manner [ , ] . fu and geng explore the influence of public participation and regulation compliance on 'green development' with panel data from provinces in china from to , finding that public participation can lead enterprises to improve compliance and thus promote green development [ ] . regional environmental quality (req) is a comprehensive indicator of emissions of waste gas, waste water, and waste solids, and its improvement requires coordination between governance and public participation. public participation can be coordinated with governance to effectively improve req effectively, and further promote the optimization of environmental governance system [ ] . the arrival of the internet era has changed the method of public participation. as a branch of e-government, e-participation has been widely examined by scholars. considering that public participation is a voluntary activity, whether the public is willing to participate is the decisive factor affecting the success of e-government platforms. scholars consider that in addition to demographic differences, willingness to use an e-participation system is affected by system technical factors, personal incentive factors, and social capital factors. based on the unified theory of acceptance and use of technology, planned behavior theory, social capital theory, and other information system theories, previous studies have explored the willingness of the public to use the e-community to participate in policy-making and provide strategic suggestions for governments to improve e-government platform [ , ] . product innovation is an important focus in the innovation research field and is key for enterprises to obtain sustainable competitive advantage. at present, there is no unified definition of product innovation in academia. katila and ahuja define it as change in design attributes-such as technology, appearance, quality, and structure-relative to the existing products of an enterprise. this is also known as technological innovation or design innovation [ ] . the organization for economic co-operation and development defines product innovation as the process leading to a new or significantly improved product or service [ ] . various scholars' definitions of product innovation, identify two aspects: entity product innovation and service-related innovation. according to the different degree of innovation, product innovation can be divided into radical innovation and incremental innovation [ ] . rapid change in the external environment drives enterprise innovation; enterprises can only achieve long-term development by constantly producing more competitive products according to the needs of users. as an external innovation resource, customer voice can be regarded as a gift given by users to enterprises to help them carry out product innovation based on the collective wisdom [ ] [ ] [ ] . customer voice provides valuable information for enterprises, which can help product designers and engineers to understand customers' needs and preferences, and turn them into key objectives of product improvement by making targeted adjustments to products and services to meet the needs of users [ ] . further, customer voice can help enterprises identify the product attributes to which customers pay most attention and focus on product improvement and new product development [ ] . governance refers to processes and structures in public decision making and may involve the participation of multiple agents, such as governments, corporations, and the public, with the aim of carrying out a public purpose that cannot be accomplished by single force [ ] . cooperative governance is not limited to formal government-initiated arrangements, but involves diverse kinds of multi-partner governance related to a wide range of fields [ ] . for example, because of the production of pollution, enterprises take the greatest responsibility for environment contamination control. however, as it is difficult for governance goals to be achieved through the actions of a single enterprise, so governance among enterprises is indispensable [ ] . with regard to cooperative governance among governments, zhang et al. find that superior government should supervise heterogeneous local governments and increase penalties for non-cooperative parties to improve the efficiency of haze pollution control [ ] . further, cooperative governance can provide guidance for participatory governance by the public [ ] . studies of cooperative governance involving public participation have focused on environmental governance and sustainable development. when making local energy decisions, local governments should be given more autonomy and sufficient capacity to strengthen public participation. what is more, public opinion ought to be taken into consideration when developing policy [ ] . studies show that policy-making style presents convergence to the cooperation among government, public and non-profit organizations. as the government may lack the necessary resources to deal with issues, they rely on other subjects to provide support to ensure policy utility [ ] . to summarize, there are several problems needing to be solved: first, research on public voice is not mature and more studies are needed to clarify its antecedents as well as its effects on policy implementation and social development. second, it is undeniable that the public plays a crucial role in environmental governance, but the role of public voice behavior in policy-making and implementation under public health emergencies is still unclear. third, the role played by public voice in cooperative governance and how this happens deserve exploration. at the beginning of , the outbreak of covid- brought great impact on people's life and work. in order to contain the spread of novel coronavirus and speed up the normalization of production and life, on february , yuhang first launched the yuhang health code. and on february , hangzhou launched the hangzhou health code to implement "green code, red code, yellow code" three-color code dynamic management [ ] . the implementation of this policy has aroused widespread concern of the people all over the country, and local governments have followed up and implemented a local version of code in few weeks [ ] . the implementation of health code policy is assisted by the qr rating health code system developed by alibaba, tencent, or other firms. when registering, individuals should provide their names, id numbers, phone numbers, and answer a series questions about physical health conditions and travel trajectory to get the initial rating [ ] . in addition, the rating changes according to individual real-time data, which consists of individuals' travel history, directly related health information, overall medical test results, and overall risk assessment from individuals' reports, information from gps (global positioning system), telecommunications supplier, consumption record, qr code usage record, etc. the system assesses individual's infection risk and generates green, yellow, or red codes according to individual's data [ ] . people with green codes have a very low probability to be infected and can move around freely, while people with yellow codes have a risk to be infected to some extent and should be quarantined for a week. people with red codes are at great risk of infection and need to be quarantined for weeks. during the quarantine, if people with yellow or red codes check in on the app every day, the codes will turn green at the end of quarantine periods. and if the real-time information shows that people with green codes have gone to a high-risk area or been in contact with an infected person, the code will turn yellow or red as well [ ] . up to august , the tencent health code covers a population of hundred million people, more than cities and counties, and more than villages in china, with a cumulative total of billion visits [ ] . with the evolution of the health code policy, the effective circulation of personnel from all over the country has met the needs of residents' normal life and enterprises' resumption of work and production. at present, residents only need to provide a real-time qr code generated in a mini-app embedded in alipay (alibaba, hangzhou, china) or wechat (tencent, shenzhen, china) to the guard, they can move around [ ] . in the health code policy implementation process, the high-tech enterprises not only provide technical support to develop the health code system, but also participate in the formulation of policy standards and establishment of policy platforms. for example, alibaba and tencent have been fully involved in the formulation of national standards for the personal health information code series [ , ] . besides, during this process, the public is actively voicing on the implementation and evolution of the health code policy as well as improvements of health code application on social media. in the official weibo of people's daily, tweets about the health code policy get plenty of comments and followers, most of which are advice for policy implementation and system improvement. for example, the tweet about the hangzhou health code has comments and , followers. the government press conference and reports about enterprises confirm the public voice does play an important role in the evolution and promotion of health code policy and the voice is fully considered and adopted by government and enterprises when making decisions. on the joint prevention and control conferences of covid- , the government spokespersons provided response to public concern and the governments also instructed local government and related enterprises to take measures to meet public voice. in addition, the enterprises responded to public voice as well. in the government affairs strategy conference, yuepeng qiu, vice president of tencent, said that they had updated the system more than times. this study adopts a dynamic research perspective, and takes the dynamic evolution of health codes policy as an example, focusing on exploring how public voice promoted the improvement of products by enterprises and the implementation of policies by the government under a public health emergency. the core of grounded theory emphasizes the process of collecting and analyzing original data. in the data collection stage, the researcher takes the evolution process of the health code policy as the time axis, and collects public comments under the official microblog of the people's daily as the research object. data analysis included the following stages: firstly, open coding is used to identify phenomena, define concepts, and discover categories from the original data. secondly, axial coding is carried out to further analyze to get the main category. thirdly, selective coding is used to find the core category, and systematically connect it with other categories to construct a logical relationship. in the whole coding process, researchers keep supplementing the material. finally, the selective coding is analyzed and theoretical construction is carried out, and the density, variation, and high integration of theoretical concepts are adjusted to form a theoretical framework. the qualitative analysis software nvivo . (qsr international, melbourne, australia) was used for the analysis of this study. open coding is to analyze the original data word by word, so as to summarize the initial concepts and categories in the original data. following the process of "tagging-conceptualizationcategorization", the researchers analyzed the collected data word by word and refined the semantics of the data to obtain the corresponding concepts and categories. examples are shown in table . it's much more convenient than running around to apply material this is not only efficient to reduce the burden of screening personnel, but also can record personal travel the purpose of axial coding is to explore the potential logical relationship between categories and develop main categories. this study classifies different categories according to their relationship at the conceptual level, and concludes eight main categories, which are divided into three classifications. the main categories and their corresponding classifications and relations are shown in table . there is a risk of information leakage when the product collects too much user information there is a risk of abuse of rights when enterprises assume part of government responsibilities on the basis of axial coding, selective coding excavates the core category from main categories and analyzes the connection relationship among them. as shown in figure , the dynamic mechanism of public voice behavior to promote policy implementation and evolution in public health emergencies is as follows: first, under the guidance of the government, enterprises participate in the development of policy and design products to assist policy implementation with advanced technologies. second, in response to the government policy, the public will use enterprise products in their daily life and work. and through judging whether the policy can effectively solve the current problems and guide the future development of the society to form the policy effectiveness perception. third, public's perception of the effectiveness of policies will trigger public emotions. different perceptions of policy effectiveness can lead to positive or negative emotions. then, emotions can induce public voice behavior, including voice for government policies and for enterprise products. finally, the government and enterprises will give feedback to the public voice and improve the policies and products accordingly. as a new external stimulus, the improved policies and products also have an impact on the public's perception of policy effectiveness, forming a dynamic mechanism of public suggestions to promote policy evolution and product innovation, as shown in figure . induce public voice behavior, including voice for government policies and for enterprise products. finally, the government and enterprises will give feedback to the public voice and improve the policies and products accordingly. as a new external stimulus, the improved policies and products also have an impact on the public's perception of policy effectiveness, forming a dynamic mechanism of public suggestions to promote policy evolution and product innovation, as shown in figure . based on the results of grounded theory and cognitive appraisal theory of emotion, this paper constructs a driving mechanism of public voice behavior: "stimulus-cognition-emotion-behavior" model. the model shows that there are causal relationships among cognition, emotion, and behavior. according to the cognitive appraisal theory of emotion, under the stimulation of external events, the external information obtained by individuals first enters the perceptual system for compilation and processing, forming specific cognitions. cognitions trigger the individual's emotional response, and finally produces specific behavioral tendency [ ] . based on the results of grounded theory and cognitive appraisal theory of emotion, this paper constructs a driving mechanism of public voice behavior: "stimulus-cognition-emotion-behavior" model. the model shows that there are causal relationships among cognition, emotion, and behavior. according to the cognitive appraisal theory of emotion, under the stimulation of external events, the external information obtained by individuals first enters the perceptual system for compilation and processing, forming specific cognitions. cognitions trigger the individual's emotional response, and finally produces specific behavioral tendency [ ] . public policy is the political and technical approach to solve problems, fundamentally, it is pragmatic [ ] . under the cooperative governance, the government is no longer the only decision-maker, but the main participant plays a guiding role [ ] . with the advent of the new internet era, the impact of big data, cloud computing, and other technologies on policy formulation and implementation cannot be ignored. first of all, the internet can optimize the link of policy-making, and the process of it can be completed with the help of the internet, thus making policy-making more efficient. secondly, big data can provide a wider range of data sources for policy evolution. through data mining and analysis, it can provide big data support for policy evolution, making policy formulation and implementation more reasonable. finally, the open data system can further broaden the channels for the public to participate in policy discussions and make policy-making more democratic. due to the immature application of big data by the government and lack of professional talents, enterprises are required to provide technical support. the technical support of enterprises is more important for the formulation of policies under public health emergencies. as public health emergencies tend to be urgent, destructive, and uncertain, putting forward higher requirements for the timeliness, scientificity, and effectiveness of policies. in this case, it is very necessary for the government to cooperate with enterprises to formulate policies. the government is responsible for policy formulation and implementation, while enterprises take technological advantages to provide products or services to assist policy implementation. according to the cognitive appraisal theory of emotion, when individuals encounter the external stimuli, they will experience two-stage cognitive appraisal processes: primary appraisal and secondary appraisal. in addition, through the appraisal, people can assess the relevance of external stimuli to themselves and whether the resources they have can cope with the situation [ ] . in public health emergencies, the policy launched by government-enterprise cooperation is an external stimulus for the public. additionally, public appraisal mainly focuses on whether the policy can achieve policy purpose and effectively solve specific public problems, that is, perceived policy effectiveness. under the policy stimulation, the public will use the cognitive system to make evolution of it [ ] . the perception of policy effectiveness reflects the individual's judgment of the correlation between the policy and himself and is an important way for policy to act on public behavior. a high level of perceived policy effectiveness indicates that the public believes the policy is beneficial to their daily life, while on the contrary, they consider that the policy has no significant positive impact or may pose a threat. policy is the action route or method to guide the current and future decision-making, and its role should not be limited to solving the current problems, but also should be instructive for future development of society [ ] . according to the results of analysis, the policy effectiveness in public health emergency includes crisis resolution and social normalization. in the case of public health emergencies, the first problem to be solved by policies is to reduce the adverse impact of emergencies, that is crisis resolution. on the premise that the crisis is under control, policies should also have effects of accelerating the social normalization and promoting economic recovery, that is, the social normalization function. taking the health code policy as an example, if the public thinks that the health code policy cannot effectively control the spread of covid- , or cannot speed up work resumption, the public's perceived effectiveness of health code policy will be low. otherwise, the perception will be high. emotions are the products of an individual's appraisal of the person-environment relationship and of great diagnostic value to help an individual identify what is important under a specific situation. additionally, emotions vary with the change of appraisals [ ] . the public's emotional response to policy is formed on the basis of perceived policy effectiveness. according to the cognitive appraisal theory of emotion, emotion intuitively shows the public's evolution of external stimulus perception, and its core is evaluative cognition. almost everything will stimulate people to produce emotion, no matter if it happens or not [ ] . however, emotion cannot be aroused by external stimulus directly; the appraisal process of relationship between person-environment is necessary to evoke emotion. when individuals are in a certain situation, they will evaluate it, be satisfied or dissatisfied, beneficial or harmful, and make corresponding emotional reactions [ ] . if perceived policy effectiveness is high, the public will have a positive emotion, or vice versa. taking the health code policy as an example, different perceptions of public policy effectiveness will stimulate different emotions. when the public perceive that the health code policy can effectively control the spread of covid- or accelerate economic recovery, they will generate positive emotions. otherwise, they will hold negative emotions. examples of comments about health code policy are as follows. comment : as i am from hubei province, i didn't go back to my hometown, so i couldn't enter the market for days. after having the health code, i entered the market for the first time without being stopped. it is easy to use and it's really convenient, give it a thumb up! comment : i'm in fuyang, and i'm not even allowed to go to my husband's hometown in the countryside. i haven't left fuyang for nearly a month. i haven't even gone to downtown or move around fuyang. what the hell is this code? i don't understand. i'm so angry! according to the cognitive appraisal theory of emotion, the cognition and appraisal of external environment will stimulate special emotions. then, the emotion will motivate coping behaviors to prevent harm or to improve the prospects for benefit [ ] . public voice behavior is generated under the influence of public emotions. according to cognitive appraisal theory of emotion, emotional response will lead to an individual's specific behavior tendency to regulate the emotion (emotion-focused coping) or change for the better the problem (problem-focused coping) [ ] . on the basis of the public perceived policy effectiveness, the emotional reaction is finally transformed into the driving force to improve the effectiveness of the policy, which urges the public to put forward a constructive voice or point out the problems existing in the policies and products. when the public believe the policy can effectively defuse the current crisis and benefit future development, they will hold positive emotions and employ behaviors that can maximize the policy benefits. however, when the public think that there are some defects in the process of policy implementation undermining the policy effectiveness, they will generate negative emotions and take actions to reduce potential harm. after analysis, it is found that public voice can be divided into two dimensions: policy voice and product voice. according to the content of voice, policy voice can be divided into policy evolution and policy implementation. policy evolution voice is promotive voice and usually occurs when the public is in positive emotion, referring to the public's suggestions on the promotion and unification of policies across the nation. policy implementation voice refers to the voice made by the public for the actual implementation process of policies. in a public health emergency, policy implementation voice is mainly in the form of pointing out defects in the process of policy implementation, and it usually happens when the public is in negative emotion. public voice on products can be divided into product utility and potential risk. product utility voice refers to the public's suggestions on improving product efficiency and it includes both promotive voice as well as prohibitive voice. while potential risk voice is prohibitive voice, referring to the public's concern about the negative effects caused by enterprise's products. the examples of the health code policy are shown below. comment : now in many provinces, the biggest problem is that people are not allowed to enter the community! not even people with health codes! this is too unreasonable! if a policy is made, it is to be implemented. what good is policy if the implementation problem at the grassroots level is not solved? comment : the health code really gives me a great convenience in my life. it's easy to go out with it. i hope it can be promoted nationwide. in conclusion, the formation process of public voice behavior conforms to the "stimulus-cognition-emotion-behavior" model of cognitive appraisal theory of emotion. policy stimulus leads to the public's cognition of the effectiveness of policy, which arouses public emotion response and further leads to public voice behavior. the formation and evolution of policy is a dynamic and continuous process. previous studies have paid more attention to the impact of public participation in the policy-making stage [ , ] . however, this study finds that after policies are made, public voice also has a great impact on the evolution and implementation of policies. based on the results of grounded analysis, this paper divides the process of policy evolution into three stages: policy formation, policy promotion, and policy optimization, and constructs a dynamic mechanism of public voice to promote policy evolution and product innovation, as shown in figure . the policy is formed in accordance with the rigorous policy-making process in order to solve specific public problems. as the output of the political system, the main function of policy is to solve social public problems effectively. as public health emergencies often pose a major threat to social security and public order, as well as the safety of citizens' lives and property, the policy under public health emergencies aims to resolve the crisis state timely and effectively and restore the normal life order as soon as possible [ ] . as an external stimulus, the formation of policies will lead to the public's perceived policy effectiveness. at this stage, citizens' cognition of policy effectiveness mainly focuses on crisis resolution. whether the policy can effectively alleviate the adverse impact of public health emergencies is an important factor affecting public emotion. when policy is implemented, the public will form the perception of whether the policy can resolve the crisis effectively. when perceived policy effectiveness is high, the public will have positive emotion and tend to conduct promotive voice. as the construction of national emergency management system follows the basic principles of "ability-standard" and "center of gravity down", the local government is in the front line when dealing with public health emergencies and bears the main responsibility. therefore, the policies under public health emergencies are often formulated by the local government, and the superior government selectively promotes the policies according to the evolution of the applicability. so the public will suggest to promote policy across the country if they think the policy is effective enough. besides, the public will provide promotive voice to improve product utility in a state of positive emotion. when the public perceive the policy is not effective enough, they will have negative emotion and tend to conduct a prohibitive voice. public health emergencies prevent policy-making from following a strictly procedural process. the government needs to complete the implementation of the policy in a limited time, and it is difficult to guarantee the implementation of the grassroots administrative staff in a short time [ ] . therefore, the prohibitive voice mainly focuses on pointing out the problems existing in the implementation of the policy at the grassroots level. in the policy formation stage, as the implementation of enterprise's product auxiliary policy, the public's requirements for its effectiveness are more stringent. therefore, the public will be more active in pointing out problems in the use of products. through the evolution and adoption of public voice, the government improves the policy and the policy is formed in accordance with the rigorous policy-making process in order to solve specific public problems. as the output of the political system, the main function of policy is to solve social public problems effectively. as public health emergencies often pose a major threat to social security and public order, as well as the safety of citizens' lives and property, the policy under public health emergencies aims to resolve the crisis state timely and effectively and restore the normal life order as soon as possible [ ] . as an external stimulus, the formation of policies will lead to the public's perceived policy effectiveness. at this stage, citizens' cognition of policy effectiveness mainly focuses on crisis resolution. whether the policy can effectively alleviate the adverse impact of public health emergencies is an important factor affecting public emotion. when policy is implemented, the public will form the perception of whether the policy can resolve the crisis effectively. when perceived policy effectiveness is high, the public will have positive emotion and tend to conduct promotive voice. as the construction of national emergency management system follows the basic principles of "ability-standard" and "center of gravity down", the local government is in the front line when dealing with public health emergencies and bears the main responsibility. therefore, the policies under public health emergencies are often formulated by the local government, and the superior government selectively promotes the policies according to the evolution of the applicability. so the public will suggest to promote policy across the country if they think the policy is effective enough. besides, the public will provide promotive voice to improve product utility in a state of positive emotion. when the public perceive the policy is not effective enough, they will have negative emotion and tend to conduct a prohibitive voice. public health emergencies prevent policy-making from following a strictly procedural process. the government needs to complete the implementation of the policy in a limited time, and it is difficult to guarantee the implementation of the grassroots administrative staff in a short time [ ] . therefore, the prohibitive voice mainly focuses on pointing out the problems existing in the implementation of the policy at the grassroots level. in the policy formation stage, as the implementation of enterprise's product auxiliary policy, the public's requirements for its effectiveness are more stringent. therefore, the public will be more active in pointing out problems in the use of products. through the evolution and adoption of public voice, the government improves the policy and policy evolution enters the policy promotion stage. as a new external stimulus, the improved policy continues to act on public cognition. more than that, the focus of perceived policy effectiveness begins to shift from crisis resolution to social normalization. under the control of the government, the grassroots implementation has been further improved, and the effectiveness of policies to solve current problems (i.e., crisis resolution effectiveness) has been effectively played. however, the effects of policies cannot limit to provide methods to solve the current problems, but also play a guiding role in the future development of society [ ] . public health emergencies make society change from normal state to emergency state, which has a great impact on public life and work [ ] . therefore, on the basis of effective resolution of the crisis, whether the policy can further promote the recovery of social normality has been widely concerned by the public. under the influence of public emotion caused by the cognition of policy utility, voice behavior emerges. in the stage of policy promotion, public promotive voice is policy unification. government policy-making under public health emergencies emphasizes the local government's ability of 'territorial management'. however, with the promotion of local policies across the country, the problem of compatibility between policies begins to emerge. the inconsistency of policies in different regions will bring many inconveniences to the public. therefore, in order to improve the effectiveness of policies, the public suggests that policies should be unified across the country. at this stage, with policy promotion, the audience range of the product is constantly expanding, the public's attention to the product utility is also increased. improvement suggestions to enhance the effectiveness are still the focus of voice. however, in addition to the utility of the product, the public also began to pay attention to the use experience of the product, pointing out the problems of the system in the use process. under the influence of public voice, the government and enterprises constantly improve the policies and products, and the policy evolution enters the optimization stage. at this time, with the public health emergency in the rehabilitation stage, the effectiveness of the policy has been played out to a greater extent; the public urgently need to return to normal life and work state, so the focus of perceived policy effectiveness is social normalization. public voice is still affected by the emotional response based on cognition, and the content of public voice has changed further. considering the adverse impact of public health emergencies, with the purpose of preventing the recurrence of the public health emergency, the public suggest that the policy should be normalized. policy normalization can predict the occurrence of public health emergencies in the early stage and minimize the loss. in addition, the public begin to pay attention to the coverage of the policy, pointing out that the omission of the population covered by the policy may have a negative impact on the fairness. with regards to the products of enterprises, the public voice focuses on the risks of long-term use of products. products are tools for enterprises to participate in cooperative governance and used to supply policy implementation. with the help of products, enterprises take part of the responsibilities originally belonging to the government, which will cause public concern. to sum up, public voice plays an important role in the evolution of policies. first, public opinion provides the widest source of information for policy feedback. public health emergencies require the government to formulate effective policies in the shortest time based on the least information and resources, and the effectiveness of the policies is uncertain [ ] . the public voice gives quick feedback to the policy, which provides the basis for the government to evaluate the effectiveness of the policy. second, the public voice expresses the public interest demands and promotes the policy to be more democratic and efficient [ ] . in order to gain more and more public support in the process of policy-making, public voice is an important consideration for the government in the process of formulating and implementing policies. finally, public voice behavior also plays an important role in product improvement and innovation. it can be seen from the analysis, that in the policy of government enterprise cooperation, due to the particularity of the product, the public's requirements are more stringent. voice for product improvement aims at making it more suitable to assist policy implementation, and it will provide an important reference for enterprise product innovation. this study reveals the driving mechanism of public voice behavior and enriches the literature on voice behavior. first, based on the results of qualitative research, this paper employs the cognitive appraisal theory of emotion to explain the process of formation of public voice behavior under public health emergencies, via the stimulus-cognition-emotion-behavior model. unlike voice within an organization, public voice on social media is a kind of self-motivated behavior free from the pressure of peers and organizational climate [ ] . what is more, as the purpose of public voice is to improve social status quo, the cognitive appraisal theory of emotion is eminently suitable for explaining the formation of public voice behavior. as an external stimulus, a policy will have an impact on the public's cognitive processes, and prompt them to evaluate whether the policy can resolve a current issue and play a guiding role in the future development of society. when the public perceives the policy to be highly effective, they will have positive emotions; otherwise, they will have negative emotions. take the health code policy as an example, if the public think that the policy can effectively contain the spread of the novel coronavirus and speed up the resumption of the normal activities, they will experience positive emotions, and vice versa. in accordance with the cognitive appraisal theory of emotion, emotional response will stimulate behavioral tendencies. the public's positive emotions will lead them to employ a promotive voice to expand the effectiveness and coverage of the policy, whereas the public has the tendency to use prohibitive voice to reduce the possible negative effects of a policy when they are not satisfied with its effectiveness. this result is consistent with previous studies that make a clear distinction between promotive voice and prohibitive voice, where the former is positive in tone and the later negative [ ] . in this study, members of the public feeling positive emotions will voice to promote a policy and establish uniform standards throughout the nation, whereas those experiencing negative emotions will identify deficiencies such as implementation at the grassroots level. second, this study clarifies the objects and types of public voice. compared with employee voice and customer voice, the coverage of public voice is more extensive. thus, for different problems, the objects of public voice are also different, which require separate analysis in each situation. under this circumstance, the objects of public voice include two main bodies involved in policy-making: governments and enterprises. for the health code policy, the objects of public voice are the government, alibaba, and tencent. with regard to voice type, there is some similarity with the other two kinds of voice-public voice can also be divided into promotive voice and prohibitive voice. finally, through qualitative research, this paper has attempted to reveal the role of public voice in policy evolution and product innovation, clarifying the promoting effect of public voice on societal improvement. the study emphasizes the importance of public voice via social media, suggesting that both government and enterprises ought to attach more significance to public voice when making decisions. taking china's health code policy under covid- as an example, this paper has constructed a dynamic mechanism for the effects of public voice on policy evolution. the study focused on the promotion of public voice for policy improvement and evolution in the late stages of policy-making. public opinion contains information about demands and aspirations which is very valuable for decision makers. to absorb more public opinions and take into account public aspirations or priorities before policy formulation, previous research has paid much attention to the impact of public opinions at the pre-policy-making stage [ , ] . no studies have examined the impact of public voice on policy after its implementation. the development of social media not only provides a wider source of information for the public, but also builds a more convenient platform for the public to voice their opinions at any stage of policy formulation or implementation, thus having effect on policy. this study shows that after a policy is implemented, public voice is still of great value for policy evolution. however, this study divides policy evolution into three stages: policy formation, policy promotion, and policy optimization. it introduces changes in public policy utility perception and public voice content at different stages, and constructs the dynamic mechanism of the effect of public advice on policy improvement based on the government's adoption of public advice to promote policy evolution and implementation. to some extent, this study provides support for cooperative governance research. cooperative governance has different connotations in different situations, and there are also some differences among participants. the formulation and evolution of policies under public health emergencies is an important practice of cooperative governance. faced with a public health emergency, the government, enterprises, and citizens should form an open overall system to jointly govern social public affairs. the government, enterprises, and individuals play their own roles, participate and cooperate with each other to effectively reduce the negative impacts of a crisis and maintain the stable development of society. in this process, governments, enterprises, and the public are in a more equal position, and multi-agent participation is truly realized. faced with covid- , yaowen wang, deputy director of shenzhen municipal government service data management bureau, said the epidemic situation was a great challenge to the government's governance ability and level. in addition, the fundamental problem was laid in whether the whole society could be quickly mobilized and organized to participate in the prevention and control in a short period of time. as an organ of power, the government is responsible for the formulation and implementation of policies. enterprises participate in the formulation of policies, and provide products and services with technical advantages to assist with policy implementation. as for the public, in addition to regulating their own behaviors under the guidance of policies, they also provide feedback and voice on policies and enterprises' products and services. take china's health code policy as an example, the government is responsible for the formulation and implementation of the policy. alibaba and tencent are committed to the development and updating of the health code system and participate in the formulation of the policy standards. the public need to move around in strict accordance with the policy guidelines and actively provide voice. under a public health emergency, public voice is an important way for public to participate in cooperative governance. it provides real-time feedback for policy, helping government and enterprises to make decisions as quickly as possible and set aside more time to fight against emergencies. further, public voice can facilitate the promotion of effective policy, improving prevention efficiency. as a universal way of participating in cooperative governance, public voice via social media deserves more attention in the future. although this research makes several contributions, there are still some limitations. first, we studied the influence of public voice only on policy evolution and specific product innovation. as public voice is social-oriented, it will affect almost all social affairs and phenomena. future research can explore the influence of public voice behavior in other respects. second, this study revealed the generative mechanism of public voice behavior from the perspective of emotional cognition. as a self-oriented behavior, public voice may be triggered by other internal processes. future research could explore the antecedents of public voice from different perspectives. third, this study was conducted under a public health emergency, covid- . as public emergencies take several forms, the results differ in different situations. future research might examine public voice in other contexts. fourth, although many countries and regions have formulated corresponding policies in the context of public health emergencies, results from the study of china's health code policy under covid- may not be fully applicable to other nations, and future research should be conducted in different cultural contexts. author contributions: y.y. conceived the idea of this study, y.s. collected and analyzed data and wrote this paper. all authors have read and agreed to the published version of the manuscript. speaking up when water is murky: an uncertainty-based model linking perceived organizational politics to employee voice leadership behavior and employee voice: is the door really open? acad leader personality traits and employee voice behavior: mediating roles of ethical leadership and work group psychological safety constructive voice behavior for social change on social networking sites: a reflection of moral 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arrangements in switzerland and germany cooperative forms of governance: problems of democratic accountability in complex environments hangzhou proposes more expansive health code system we read the technical standards for china's 'health code has launched for days, covering billion users the national health code standard, which tencent participated in developing, was officially released the national standard of personal health code was released, and alibaba participated in the formulation introduction: understanding public policy through its instruments-from the nature of instruments to the sociology of public policy instrumentation if it changes it must be a process: study of emotion and coping during three stages of a college examination emotion and adaptation how governmental policy is made dynamics of a stressful encounter: cognitive appraisal, coping, and encounter outcomes sacred land, mineral wealth, and biodiversity at coronation hill, northern australia: indigenous knowledge and sia. impact assess. proj democratisation versus engagement? social and economic impact assessment and community participation in the coal mining industry of the bowen basin public deliberation in an age of direct citizen participation servant leadership and follower voice: the roles of follower felt responsibility for constructive change and avoidance-approach motivation this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors declare no conflict of interest. key: cord- -wwtpkinj authors: atkinson, p.; gobat, n.; lant, s.; mableson, h.; pilbeam, c.; solomon, t.; tonkin-crine, s.; sheard, s. title: understanding the policy dynamics of covid- in the uk: early findings from interviews with policy makers and health care professionals date: - - journal: soc sci med doi: . /j.socscimed. . sha: doc_id: cord_uid: wwtpkinj the uk government response to covid- has been heavily criticised. we report witnesses’ perceptions of what has shaped uk policies and how these policies have been received by healthcare workers. such studies are usually affected by hindsight. here we deploy a novel prospective approach to capture real-time information. we are historians, social scientists and biomedical researchers who study how societies cope with infectious disease. in february we began regular semi-structured calls with prominent members of policy communities, and health care professionals, to elicit their roles in, and reactions to, the pandemic response. we report witnesses’ perceptions that personal protective equipment (ppe) stocks were too small, early warnings have not led to sufficiently rapid policy decisions, and a lack of transparency is sapping public trust. significant successes include research mobilisation. the early experiences and reactions of our witnesses suggest important issues for investigation, notably a perception of delay in decision making. during public health emergencies policymakers are under unparalleled pressures, including from the media, public, healthcare workers, and politicians. we consider the dynamics of the uk policy response to the current covid- pandemic, through the lens of 'policy sciences' literature, including its analysis of disaster response. this lens offers a valuable corrective to a positivist, linear view of the links between scientific knowledge and policy. berridge reviews this linear view and its more realistic alternatives, drawing on the sociology of scientific knowledge and science policy studies. , berridge's paper on the uk response to the influenza pandemic highlights the utility of using contemporary oral history in shaping effective health policy. the work of jasanoff and others in establishing the discipline of science and technology studies (sts) calls attention to 'the untidy, uneven processes through which the production of science and technology becomes entangled with social norms and hierarchies.' black and donald's account of the pitfalls of 'evidence-based policy' is an accessible summary of much other work. policy science work on how policymakers use evidence also helps interpret policy responses to coronavirus. a recent body of work by paul cairney and others discusses how they select which evidence they have time to use, sometimes starting from emotions, belief and habits rather than rational processes. cairney and oliver note the attractiveness, for ministers, of framing strategies based on appeal to the emotions and the familiar, in contrast to the exercise of rationality. as we discuss, this is a good lens for understanding ambitious coronavirus testing targets set without reference to how the results would be used. cairney and others also note j o u r n a l p r e -p r o o f how policymakers can only pay attention to a tiny proportion of their potential responsibilities. , , chris whitty, the chief medical officer for the uk government, has made a strong case for including more social science expertise in policymaking, since '[m]any policy decisions do not turn out the way they were intended because people do not behave in the way policymakers … thought they would.' weible et al, in an important contribution which was the first policy sciences paper on covid- , review how policy sciences can illuminate the interplay between scientific and technical expertise and policy choices in the covid- crisis. their discussion of the interaction of policy with science, and of ways to assess policy success and failure, shaped our analysis of our transcribed calls with witnesses. another valuable lens was black and donald's account of research as one of several contestable knowledge sources (which include public opinion, political insight, and managerial understanding). none of these, unaided, can dictate what policy should be. on february we began interviewing two panels of witnesses, from uk policy communities and front-line health care professionals, for the purpose of capturing events and their immediate reactions to them. interviews were semi-structured, beginning from a general question about what coronavirus-related work the witness had recently done: interviewers did not suggest particular themes. ethics approval was secured from research ethics committees of our two universities. recruitment was pragmatic, via personal contact, and, for the health care professionals, benefited from a 'snowball' approach. our witnesses from policy communities were selected j o u r n a l p r e -p r o o f for their closeness to uk central government decision making. we did not attempt to interview politicians or their political advisers ('special advisers') at this stage, but the witnesses we did choose were sufficient to understand the pattern of developing events. witnesses spoke on condition of anonymity, enabling them to speak more frankly. we do not disclose the organisations where they work, which include key sources of uk scientific advice on the outbreak. the anonymity of the witnesses is problematic, as it does not allow the reader to see the overall pattern of each witness' contributions. we had no alternative: our complete anonymity approach was the only one under which the policy witnesses would permit their evidence to be used. they felt they were a very small group, from which individuals could too easily be identified. the same constraint did not apply to the health care workers, drawn from a more numerous group. here we can describe someone, for example, as 'a clinical director'. in the initial phase of our data collection it would be unethical and impractical to distract witnesses from their outbreak response duties for full-length interviews. semi-structured telephone and online calls, typically of minutes, are recorded and transcribed, contacting each witness weekly or fortnightly. analysis at this stage focusses on any rapid learning which emerges. this prospective approach is novel, though some of the early oral history work on aids policy had a similar style and has been called 'history in the making'. the project continues until august : during its second phase we will conduct longer interviews and more formal data analyses, seeking broader findings valuable for longer term policy making, for example improving government readiness for future epidemics. the funders have played no role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication. the themes we discuss below are selected for their salience in the interviews. as mentioned, we did not guide witnesses to particular topics. the transcripts were not coded: instead we searched them for emergent themes. we now consider in turn the themes of early warning systems, clarity of communication, contingency planning, research readiness, delays, scientific advice, central-local tensions and visibility. [text box about here: 'early warning of emerging diseases the international health regulations require who member states to detect and report specific diseases. resulting intelligence is shared. a range of different international networks have been set up to meet specific needs, for example the us cdc's morbidity and mortality weekly report. , the emerging infections and zoonoses section of public health england (phe) is responsible for early warning. it conducts horizon scanning of nearly a hundred sources for rumours of diseases and incidents around the world. sources include the who and ministries of health, media, and social media, which are used because first news about infectious disease events now often comes from unofficial sources. ] j o u r n a l p r e -p r o o f . global -particularly who-based -early warning systems served their purpose well according to our witnesses. these systems triggered uk responses at the beginning of january . as the concern of specialists at public health england (phe) mounted, the issue was escalated on january to the government's new and we asked our witnesses how well this machinery worked in early . one said the processes had been: 'extremely confused to begin with … people were being on-boarded into [whitehall (central government) teams] at a rate of knots, so there was a certain amount of confusion: messages were being misunderstood, passed to the wrong people and so on. … now [ march], … the civil service is actually performing, but it took a few weeks.' concern mounted. we heard that: we're going to do now, but as soon as we have got this, we will do the next thing." the uncertainty of ppe is a nightmare.' communication, to health and social care staff and the public, has to be timely, accurate, and reconcile the pressure for simple messages with the need to justify changes of direction. however, a gp partner in the liverpool area described the stream of information they receive daily and the lack of nuance of these messages, which they felt were not sufficiently or appropriately targeted to healthcare professionals. association] as well. and a lot of it is just the same stuff re-cooked. … and … it hasn't really changed what we have done … four emails a day to read is just bonkers really. especially when you're still trying to do your full-time job. … that kind of sensationalisation, we don't need that sent to us by government. ' some communication to the public has been exemplary in its clarity. health care professionals in our study, however, have often been left confused and frustrated by the particularly poor communication of changes in ppe policies, which appears to be related to the unclear allocation of responsibilities between nhse and phe discussed below. one health care worker, commenting on the way ppe guidance changed, told us that it would have been better to tell the nhs that guidelines are j o u r n a l p r e -p r o o f "for now", based on availability of supplies, and would change. however a person close to the process spoke to us of their concern that such experience could have been used better, and about the impact of resource constraints: [lessons] '"learnt" implies you have done something with the knowledge, which isn't necessarily the case … bear in mind that … nhs england and phe … are much worse off in terms of staffing and funding compared to … … and … [the] department of health [and social care (dhsc)] as well. we are doing more with less, and it shows.' one element of dhsc 'doing more with less' has been the progressive stripping away of in-house medical advice to the chief medical officer (cmo), and a one-fifth reduction in its overall staffing since . , , contingency plans dealt, among other things, with the governance of an epidemic response, including the co-ordination of different agencies. faced with an unparalleled challenge in , there was considerable improvisation over governance, as we discuss in the section on central-local tensions. research is often neglected as an element of epidemic response, but is especially important when responding to a novel pathogen. through our interviews we heard about the valuable uk science contribution to global readiness initiatives in novel viral pathogen research, which allowed the global scientific community to sequence the virus and gather patient data to pre-established protocols with unprecedented speed, accelerating the introduction of accurate diagnostics and the development of vaccines and treatments. we conclude that the uk was particularly well prepared, in global terms, to respond rapidly with, for example, clinical trials. research indicates the sheer difficulty of crisis decision-making, stressing problems collecting and comprehending the necessary information, ambiguity, complexity, pace and organizational barriers to agile decision-making, including shared responsibilities between multiple organisations. in england, decisions -and, critically, implementation -were slow to follow the initial alert. we were told that 'six weeks of opportunity was wasted,' and that: 'from th january, it was clear there was human transmission … that this was going to spread around the world. and that was a six week window [for] ramping up ppe, making sure there was supplies, beds, making sure we were prepared for what was likely.' j o u r n a l p r e -p r o o f it is normal for health professionals and advisers to complain of delay when there is an urgent policy issue to be resolved. what is different about an epidemic is the need to react fast enough to start slowing its exponential growth, or as one witness put it: 'there is no point saying we are doing things quickly ... i have heard many times that ... [something] is going on at unprecedented speed. but ... until that speed is faster than the pace of the epidemic, you won't be able to mitigate ... or indeed bring the epidemic to an end. 'inevitably as things get passed down from committees, and this is in the ministers, sage, the lag phase between … advice [from] sage … or a decision made by whoever, minister or anybody else, there is a lag … until it gets through the system. and when you are in an epidemic which is very fast moving … it is no good to say we are going quicker than we usually go'. persuading government ministers to make the challenging decisions needed has often been difficult, though some decisions were said to be rapid. the majority of our policy witnesses frequently expressed frustration about delayed decisions. our health care professional witnesses noticed such lags in many places, notably in the redeployment and retraining of staff. we heard from the policy community of 'a couple of heated moments [in mid-march] where people were saying "you are not moving fast enough"'. the government's most senior advisers, we were told, responded that policy decisions were a process, that the politicians needed to be led through it. our evidence allows us to refine weible et al's observation that the covid- outbreak challenges scientific and technical advisers to simplify and communicate, and challenges policy makers to balance political judgement with the responsible use of expert advice. kogan et al studied the interaction between researchers and policy makers in dhsc's predecessor, the dhss, concluding that it was productive when participants could translate policy problems into research questions and research findings into actionable briefings. politicians use scientific and technical experts as part of the rationale for policy decisions, but the attractions of this tactic have never been greater than during this epidemic. scientific expertise is a comfort as well an intellectually valuable input to decisions: it can also comfort the public, as when scientific advisors such as whitty and vallance flank a senior minister in press briefings. but the 'what should we do' question made witnesses concerned that ministers were shifting the accountability for hard decisions onto them. this was emphasised by a public rhetoric of 'following the science', for example to justify the lockdown decision at the end of march: this rhetoric lasted until late april. ministers have met challenges such as testing, and the supply of ventilators, with promises that appear unsupported by evidence to demonstrate that delivery was feasible or explanation of how the test results would be used. this is an example of policymakers taking the 'shortcuts' that cairney described, where decisions are based on emotions, beliefs and habits: not, in these cases, following the science. disasters pose co-ordination problems, and these affected how scientific advice was once the top-level decision is made, the speed and quality of implementation is critical in disaster response. there is no obvious demarcation between decisions about policy and implementation. in the last ten years, government ministers have aimed to devolve decision-making from dhsc (and its predecessor, dh), setting the direction but leaving some important decisions to nhse. this approach was never going to apply in a major crisis such as covid- , where political pressure on the government for solutions was, inevitably, intense. the existing 'peacetime' model, which devolved responsibility, and effective public accountability, for many nhs matters to nhse and the nhs itself, was transformed by the pandemic. if such an ethically fraught policy needed to be considered, that needed to be done in public and not in private -a good reason for the uk authorities' decision against relying on the population acquiring immunity. these early findings are presented now because of the value of rapid feedback. there are inevitable methodological limitations to meeting this objective. there are availability biases in the witnesses: whilst all witnesses' time is at a premium during this phase of the outbreak, this may have been felt most acutely in key organisations such as dhsc, nhse and phe. policy dynamics vary between the four countries of the uk: while we do include health care professionals in scotland and wales, to date we have only included key informants from policy communities in england. we now draw out some conclusions about the interaction of policy with scientific and technical experts and information, and then conclude with the issue of policy success or failure. in relation to science and policy, we note the essential role of boundaryspanning individuals who can translate policy problems into research questions, and research results into advice. this is particularly necessary where governance is complex and fragmented, as in central government and the nhs, if knowledge which can be used is to reach decision-makers who could use it. without the efforts of these boundary-spanning individuals, we heard how dialogue can 'go round in circles.' uk government has been eager to use science to legitimise its choices -to the concern of several scientific advisers who told us policy makers were trying to pass responsibility for decisions to them. whatever the reluctance of politicians to j o u r n a l p r e -p r o o f make unpopular choices, there are now signs in the uk that scientists are emphasising the doctrine that 'advisers advise and ministers decide'. turning finally to the assessment of success and failure, as brändström and kuipers observe, policy decisions (and non-decisions) are heavily scrutinized and politicized through framing strategies and blame-games. our witnesses mostly felt that blame games had started by march, while framing contests, such as 'invisible foreign enemy' versus 'inevitable result of austerity/cuts in preparedness investment' are definitely evident. blame games about coronavirus response take place in a setting of media speculation about the newly-elected government's dissatisfaction with the general performance of the civil service, and about how to interpret the departure of its head, mark sedwill. the uncertain outcomes of blame games and framing contests serve as a reminder of the emergent and contingent element in the policy dynamics of coronavirus. richard horton wrote in a lancet editorial on march: 'the nhs has been wholly unprepared for this pandemic. it's impossible to understand why. … it is, indeed, as one health worker wrote … "a national scandal".' how far does our evidence support this? weible et al identify three fields of success (or failure). first, successful decisions 'contain threats, minimize damage, and restore order and stability'. uk planning anticipated that the initial 'containment' strategy would be overwhelmed by a sufficiently infectious pathogen: up to that point it appears to have done its job relatively well, though questions remain. the succeeding 'delay' and 'mitigation' phases have had much more mixed results: much better than nothing, but so far not nearly as effective as policies adopted, for example, in germany and south korea, as evidenced by the uk's 'r' trend. making health policy: networks in research and policy after the problems of commissioned oral history: the swine flu 'crisis' of states of knowledge: the co-production of science and the social order evidence based policy: proceed with care. commentary: research must be taken seriously the politics of evidence-based policy making evidence-based policymaking is not like evidence-based medicine, so how far should you go to bridge the divide between evidence and policy? why isn't government policy more preventive? what makes an academic paper useful for health policy? covid- and the policy sciences: initial reactions and perspectives researching contemporary history: aids early warning for infectious disease outbreak special report: johnson listened to his scientists about coronavirus -but they were slow to sound the alarm unattributable interview unattributable interview unattributable interview unattributable interview unattributable interview unattributable interview unattributable interview quacks and clerks: historical and contemporary perspectives on the structure and function of the the problems of commissioned oral history: the swine flu 'crisis' of revealed: the secret report that gave ministers warning of care home coronavirus crisis unattributable interview, april. bbc radio 'today' programme national audit office, ) national audit office. readying the nhs and adult social care in england for covid- public accounts committee. readying the nhs and social care for the covid- peak unattributable interview the new world of crises and crisis management: implications for policymaking and research unattributable interview unattributable interview unattributable interview unattributable interview covid- and the policy sciences: initial reactions and perspectives all the stars were aligned'? the origins of england's national institute for health research unattributable interview the ubiquitous rise of economists unattributable interview evidence-based policymaking is not like evidence-based medicine, so how far should you go to bridge the divide between evidence and policy? the problems of commissioned oral history: the swine flu 'crisis' of unattributable interview unattributable interview the new politics of the nhs: from creation to reinvention director of the francis crick institute and formerly of cancer research uk. a reference to the volunteer-manned 'small ships' said to have been instrumental in in evacuating troops from france. bbc radio 'today' programme the government should give local leaders control over nhs test and trace the uk's public health response to covid- unattributable interview unattributable interview wellcome trust chief denies claims sage group pressured ministers unattributable interview from 'normal incidents' to political crises: understanding the selective politicization of policy failures (pt. ). government and opposition unattributable interviews revealed: top civil servant in charge of britain's coronavirus response quits amid growing acrimony between downing street and the whitehall machine offline: covid- and the nhs -"a national scandal covid- and the policy sciences: initial reactions and perspectives unattributable interview highlights • uk coronavirus response delayed after the alarm was raised • politicians abdicated responsibility by their early 'follow the science' rhetoric • science advice to policy making needs people who bridge the two worlds • centralised responses wasted valuable local public health skills • pandemic response needs to move faster than the infectious disease key: cord- -o vm vdh authors: giordono, leanne; boudet, hilary; gard-murray, alexander title: local adaptation policy responses to extreme weather events date: - - journal: policy sci doi: . /s - - - sha: doc_id: cord_uid: o vm vdh at a global level, climate change is expected to result in more frequent and higher-intensity weather events, with impacts ranging from inconvenient to catastrophic. the potential for disasters to act as “focusing events” for policy change, including adaptation to climate change risk, is well known. moreover, local action is an important element of climate change adaptation and related risk management efforts. as such, there is a good reason to expect local communities to mobilize in response to disaster events, both with immediate response and recovery-focused activities, as well as longer-term preparedness and adaptation-focused public policy changes. however, scholars also note that the experience of disaster does not always yield policy change; indeed, disasters can also result in policy inertia and failure, perhaps as often or more often than major policy change. this study poses two key research questions. first, we ask to what degree policy change occurs in communities impacted by an extreme weather event. second, we seek to understand the conditions that lead to adaptation-oriented policy adoption in response to an extreme weather event. our results suggest two main recipes for future-oriented policy adoption in the wake of an extreme weather event. for both recipes, a high-impact event is a necessary condition for future-oriented policy adoption. in the first recipe for change, policy adoption occurs in democratic communities with highly focused media attention. the second, less expected recipe for change involves republican communities that have experienced other uncommon weather events in the recent past. we use a comparative case approach with cases and fuzzy set qualitative comparative analysis methods. our approach adds to the existing literature on policy change and local adaptation by selecting a mid-n range of cases where extreme weather events have the potential to act as focusing events, thereby sidestepping selection on the dependent variable. our approach also takes advantage of a novel method for measuring attention, the latent dirichlet allocation approach. electronic supplementary material: the online version of this article ( . /s - - - ) contains supplementary material, which is available to authorized users. at a global level, climate change is expected to result in more frequent and higher-intensity weather events, with impacts ranging from inconvenient to catastrophic (allen et al. ). the potential for disasters to act as "focusing events" that introduce windows of opportunity during which political actors compete to define the problem, identify solutions, and promote (or suppress) major policy change (birkland (birkland , kingdon ; rudel ) , is well known. in the face of a changing climate, local communities, which are heavily engaged in emergency and disaster preparation and often bear the brunt of losses associated with disaster events (crow et al. ; reinhardt and ross ; vogel and henstra ) might be expected to respond to extreme weather events with immediate response and recovery-focused activities, as well as longer-term climate change adaptationand mitigation-focused activities manifested as distinct policy changes. however, policy change is context-and event-dependent, and scholars note that the experience of disaster does not always yield policy change. indeed, disasters can also yield policy inertia and failure, perhaps as often or more so than major policy change (birkland (birkland , boin et al. ; nohrstedt nohrstedt , plein ) . while few studies have examined local policy responses to extreme weather events, those that do find both that extreme events can lead to policy change, and that community-and event-specific conditions matter. for example, mullin and rubado ( ) find that local problem conditions and institutional capacity influenced the adoption of water usage restrictions in the context of local drought. crow et al. ( ) find that disasters associated with colorado floods acted as "windows of opportunity for learning," especially in the context of lower fiscal capacity and high disaster-related damage. and yet, not all catastrophic events lead to policy change, as shown by the policy inertia that characterized response to the catastrophic flooding in southern west virginia (plein ) . a larger body of literature is focused on individuals' climate change beliefs, discussion, and policy preferences in the wake of extreme weather events, though results are mixed. despite broad evidence of political polarization on the issue of climate change (dunlap and mccright ; marquart-pyatt et al. ) , researchers have shown that personal harm from an event can change behavioral intentions and increase support for climate change policies (demski et al. ; zanocco et al. zanocco et al. , . however, recent research also suggests that community action may not be as sensitive to climate change beliefs and discussion as previously imagined javeline et al. ; orlove et al. ) . extreme weather events therefore provide fruitful ground for learning more about the role of focusing events in local climate change adaptation and mitigation efforts. this study explores the conditions under which an extreme weather event, with a strong potential to function as a focusing event, yields local policy change. weather events are exogenous at the local level, even when they are broadly attributed to human activity, strengthening our ability to infer a connection between the event and policy outcomes. this study poses two key research questions. first, we ask to what degree communities impacted by an extreme weather event enacted post-event policy change. second, we seek evidence of the conditions that lead to adaptation-oriented policy change in response to an extreme weather event. we selected cases where extreme weather events have the potential to act as "focusing events," on the basis of birkland's ( birkland's ( , birkland's ( , definition: events that are sudden, relatively rare, harmful and made known simultaneously to the public and policymakers virtually simultaneously. we expect that these cases will enable us to draw connections between extreme weather events and community-level adaptation-focused policy change. our approach fills several gaps in the literature. while the focusing events literature has contributed to our understanding of change at the national level, we know less about the conditions under which such events yield local policy change (crow et al. ; vogel and henstra ) , especially after extreme weather events, which may or may not yield catastrophic consequences. in contrast, the growing interdisciplinary literature linking extreme weather with climate change has focused primarily on individual attitudes and actions, yielding fewer insights about local policy actions resulting from such events. we take advantage of overlapping policy process and local climate change adaptation frameworks to develop a conceptual model of policy change in the wake of extreme weather events, contributing to the burgeoning adaptation (palutikof et al. ). moreover, while most studies select a small number of cases based on their responses to weather events, we select a mid-n number of cases ( ) based on their exposure to extreme weather events, rather than their policy response, offering more variation in our cases and avoiding the problem of selection on the dependent variable (king et al. ). finally, this study uses two novel methodological approaches: ( ) fuzzy set qualitative comparative analysis, a set-theoretic approach for identifying combinations of conditions that lead to an outcome; and ( ) latent dirichlet allocation, a computational topic modeling approach that uses text-based analysis to measure attention and problem definition. we find a moderate level of policy change in response to extreme weather events. the largest share of policy measures was focused on anticipating and responding to future risk, followed by responses to current risks, and building risk management capacity. we find scant evidence of policies focused on mitigation that were proposed after an event. enacted policies were relatively modest in scope, with few examples, if any, of pioneering policy innovations. we note two recipes for policy change. for both recipes, a high-impact event is a necessary condition for adaptation-oriented policy adoption. in the first recipe for change, policy adoption occurs in democratic communities with relatively focused median attention. the second, less expected recipe for change occurs in majority republican communities that have experienced other uncommon weather events in the recent past. moreover, we also find two recipes accounting for policy stasis (i.e., not policy change), both of which reflect the experience of predominantly democratic communities in the wake of low-impact and low-attention events. these results underscore previous observations about the power of focusing events, but importantly, suggest that political polarization and avoidance of climate change talk may not prevent communities from taking adaptation-oriented policy action after an extreme weather event. thus, while there is substantial evidence of political polarization about climate change, our work aligns with recent media coverage (flavelle ; smith and schwartz ) and scholarship javeline et al. ; orlove et al. ) highlighting the potential for communities to take action even while refraining from, or even avoiding, discussions about climate change, especially in the context of high-impact events. policy process scholars have long been interested in the determinants of policy change and conditions under which policy change occurs, in a variety of substantive arenas, including environmentally focused and disaster-inspired policy change. birkland's ( birkland's ( , development of the focusing events concept, inspired by kingdon's ( ) seminal work on agenda-setting in the policy process has demonstrated the power of catastrophic events to act as focusing events (birkland ; birkland and warnement ) . while it is widely accepted that some events have the potential to act as focusing events, generating significant attention, mobilization, and policy change, less is understood about the conditions under which some events gain attention and yield community-level change, while others do not (birkland and warnement ; nohrstedt and weible ; vogel and henstra ) . concurrently, a growing body of interdisciplinary literature seeks to better understand the link between the experience of an extreme weather event and individual beliefs, policy preferences, and local action in response to future disaster risk in the face of a changing climate. we synthesize the insights from these complementary literatures to develop a broad conceptual framework, which we use to inform our analysis and interpretation of results. specifically, we expect that combinations of event characteristics, features of the post-event debate, and community characteristics are likely to yield unique recipes for policy change, as shown in fig. . we expect that varying configurations of the three main conceptual elements from fig. -event characteristics, community characteristics, and agenda-setting-will influence the degree of policy change focused on adaptation. for the purpose of this study, we are primarily focused on formal policy changes that are adopted at the local or regional fig. conceptual framework (i.e., sub-state) level. we define policy change as local resilience and adaptation policies that are expected to: ( ) reduce community vulnerability to negative impacts of climaterelated change and/or ( ) improve community capacity to adjust to climate-related change (tiernan et al. ; vogel and henstra ) . motivation for the three main conceptual elements (event characteristics, community characteristics, and post-event attention) follows. both scholarship and anecdotal observation suggest that the characteristics of focusing events are critical to the policymaking process. birkland's ( ) own definition of potential focusing events-events that occur suddenly, rarely and with actual or projected harm-suggests that we should expect these characteristics to matter in the policy making process, compared with everyday events that do not exhibit such features. birkland and warnement ( ) further distinguish between events that are ( ) normal; ( ) novel; or ( ) normal with uncommon circumstances. normal events include those events that are likely to occur over the course of time, but are nonetheless unpredictable (e.g., tornadoes, hurricanes, industrial accidents). these events are distinguished from novel events, which are both unpredictable and new in nature or influence (e.g., / attacks; covid- pandemic). normal events with uncommon circumstances gain attention primarily due to unique or unusual features of the event (e.g., sandy hook elementary school shooting). accordingly, we anticipate that the impact of an event, with respect to losses and/ or government response, is likely to influence policy change. moreover, impact may be mediated by the timeframe of event onset, with discrete and rapid-onset events and resultant impacts being more influential than ongoing or slow-onset events and impacts (howe et al. ) . while particular types of extreme weather events are not likely to be wholly novel in nature, we may expect that, as the climate changes, some types events may be either new to a specific geographic area, result in a remarkable amount of damage or affect a previously unaffected population. furthermore, in the context of extreme weather, sisco et al. ( ) find that the "abnormality" of events, in comparison with the historical record, is a significant predictor of climate change attention, while boudet et al. ( ) find that events of unusual type or timing can lead to community climate change dialogue. moreover, our interview findings suggested that in the cases we examined, a series of multiple extreme events in a short timeframe, especially "opposite" types of events (e.g., flood and fire; drought and flood) were connected to discussion of climate change and future risks. some evidence suggests that repeated threats of disaster can yield public complacency (wang and kapucu ) and that repeated personal (negative) experience with disaster relief can undermine government authority (darr et al. ). however, cutter et al. ( ) note that "subjectively, people see an while we are aware that current scholarship is in the midst of theoretical distinctions about differences between resilience and adaptation, engaging in that discussion is outside the scope of this paper. furthermore, some scholarship suggests that local climate change initiatives themselves make little distinction between the terms (meerow and neuner ) , while other research suggests that the terms themselves reflect framing efforts by interested stakeholders (mcevoy et al. ) . as such, we use the terms interchangeably. our approach to operationalizing these concepts is described in a separate section (operationalization of outcome and causal conditions). initial event as discrete, but by the second or third event the initial disaster no longer is understood as singularity but becomes intertwined in its effects and historical meaning with other events" ( , ) . accordingly, we expect that extreme weather events that have a strong impact on human lives and/or property, exhibit unusual patterns and/or co-occur with other unusual or extreme events, are necessary for policy change, but not sufficient in isolation. by nature, disaster-focused research rarely examines non-disaster events, making it difficult to assess the influence of these characteristics on policy change. however, we can take observations of substantial variation in policy change in the wake of crises (nohrstedt and weible ) as suggestive of the insufficiency of extreme events alone in yielding policy change. while recent research substantiates the expectation that extreme weather events often lead to policy change, such changes are varied and far from inevitable. crow et al. ( ) , for example, describe changes in fiscal policy and related lessons learned among local governments in the wake of regional flooding in colorado. plein ( ) documents changes made in response to west virginia flooding, although most policy changes were focused on recovery, rather than adaptation and resilience. the ipcc report on local climate change adaptation efforts highlights the importance of contextualized adaptation strategies that take advantage of local culture, acknowledge cultural strengths and challenges, and build on existing local capacity as needed (cutter et al. ). accordingly, we expect two community characteristics to be relevant to the policy change process: political orientation and capacity. research consistently finds that political orientation plays a role in attitudes toward and beliefs about climate change, with self-identified liberals and democrats more likely to believe in anthropogenic climate change (albright and crow ; hamilton ) , perceive increasing risks related to climate change (hamilton et al. ; marquart-pyatt et al. ) and mobilize in information-seeking or activism lang ) , suggesting that party identification and/or political ideology are likely to influence support for policy change. however, the influence of political orientation on disaster response and policy is less clear. recent media coverage suggests that some communities that avoid discussing climate change may simultaneously engage in actions intended to build capacity for risk management and/or adapt to future risk (flavelle ; smith and schwartz ), an observation that has been borne out in recent research. indeed, javeline et al. ( ) find that actions by coastal homeowners are not associated with climate change beliefs, suggesting that post-event policy action may be equally likely among both democratic and republican communities. recent reviews of the adaptation and resilience literatures pay less attention to the influence of political orientation, instead emphasizing the importance of community capacity, including the presence of community leadership and community organizations (tiernan et al. ; vogel and henstra ) . moreover, while the impacts of extreme weather events are often felt most dramatically at the local level, adaptation is shared both horizontally and vertically among multiple jurisdictions, such that local policy decisions are nested in a broader policy system (nohrstedt and weible ; vogel and henstra ) . as such, we expect that a high community capacity for advocacy and mobilization to be an important condition for adaptation-oriented policy adoption, regardless of political orientation. agenda-setting concerns the process by which policy communities mobilize to frame policy failures, problems, and solutions. in the post-crisis context, the nature of the agendasetting process is expected to be highly contextualized, with variation reflecting differences in policy domains and relevant policy communities (birkland and warnement ) , as well as the degree to which the policies have "publics" (may ) . moreover, local contexts may differ substantially in the degree to which various groups have non-decisionmaking power, or the power to set the policy agenda and limit discussion of contentious issues (lukes ) , such as climate change. vogel and henstra ( ) suggest that climate adaptation policy is likely to be relatively low-salience without a "public" to seek and sustain attention. salience may be further inhibited by difficulties in communicating the relevant scientific knowledge; see tangney and howes ( ) . however, disasters may yield a sudden increase in salience and attention that open "windows of opportunity" (kingdon ) during which policymakers and entrepreneurs have a chance to influence policy discourse. indeed, recent studies demonstrate that disasters have "focusing power" (vogel and henstra , ) at the local level, prompting both dialogue and action. for example, henstra ( ) finds that policymakers used a severe storm in toronto, canada, to motivate adaptation-focused dialogue and action. we expect that highly focused media attention on a particular topic in the wake of an extreme weather event to be a condition that leads to policy change, while more diffuse media attention across a wide range of topics to limit policy change post-event. similarly, framing has been shown to play an important role in policy changes by drawing on collective beliefs and influencing both discourse and outcomes (boin ; boin et al. ; mcadam ; mcevoy et al. ) . for example, the argument for policy changes following a devastating storm in sweden was framed in terms of a challenge to the crisis response system (nohrstedt and parker ) . similarly, orlove et al. ( ) find that some glacial mountain communities draw more heavily on a community frame than a climate change frame when discussing adaptation projects, perhaps allowing them to bypass politically driven objections to adaptation policy. and in some cases, using a climate change frame to promote mitigation policy may be seen as exploiting event-related suffering shepard et al. ) as such, we expect that dialogue about climate change may offer an important path to policy change, but that it is unlikely to be the only path. vogel and henstra ( ) highlight comparative case study approaches as a promising method for gaining insight into local climate change adaptation and related policy change. we conducted a fuzzy set qualitative comparative analysis (fsqca) of cases of extreme weather events that occurred from to . fsqca is a set-theoretic approach that identifies configurations of causal conditions that are associated with observed outcomes of interest. the approach uses in-depth qualitative data to produce quantitative "scores" for outcomes and causal conditions associated with a mid-n set of cases and to identify necessary and sufficient configurations via boolean algebra algorithms (ragin (ragin , b . we used the "case-oriented" approach to fsqca, which emphasizes "the substantive interpretability of results" ( , ). one advantage of fsqca stems from its use of both qualitative and quantitative data to score and calibrate outcome and causal conditions, which offers distinct advantages compared to both traditional statistical approaches. first, fsqca permits equifinality, or the possibility that multiple paths can lead to the same outcome. second, fsqca accommodates causal asymmetry, allowing the positive expression of the outcome to result from a distinct set of causal conditions, compared with negation of the outcome. finally, conjectural causation, a hallmark trait of fsqca, allows multiple causes to act in combination to influence an outcome. the approach also offers advantages relative to traditional comparative qualitative analysis (qca), by introducing calibration of outcome and causal conditions that permits the analysis to move beyond the traditional qca binary scoring approach. unlike traditional qualitative comparative analysis, which uses similar techniques with binary ( , ) conditions, fsqca accommodates scores along the continuum from to , providing more opportunities to capture the rich variation available from qualitative data (ragin (ragin , b . we used the spatial hazard events and losses database for the usa (center for emergency management and homeland security ), also known as sheldus, as the main sampling frame for the study. the sheldus database provides county-level hazard data for us natural disasters; measures include event timing, location, property losses, crop losses, fatalities, and injuries. we limited our sheldus search to counties with weather events that caused fatalities and/or injuries between and (n = ) and then supplemented these data with weather events reported by noaa's billion-dollar climate and weather disasters (noaa national centers for environmental information (ncei) n.d.). to avoid over-sampling wealthy communities and under-sampling heatwaves, which yield little property damage (tierney ), we did not use property or crop damage as a selection criterion. after reviewing the initial sample, we selected events using a multi-step process. first, we selected events that resulted in at least countywide fatalities (n = ), with the intent of striking a balance between community impacts and the likelihood of media coverage. from among those cases, we further selected cases based on accessibility of a local (municipal or county) newspaper of record from the date of the event to months after the event, with coverage of the identified event in sufficient detail ( or more articles) (n = ). from the resulting list of potential cases, we then selected cases to cover different types of weather hazards: flooding, tornado, wildfire, landslide, winter weather, heat, and hurricane/tropical storm and all regions: northeast, southwest, west, southeast, and midwest. for multiple, co-located counties experiencing the same event as part of the same weather system, we typically included the most impacted county in terms of fatalities in our analysis. additionally, if the same weather event occurred in the same county years in a row, only one of these years was selected as a case-again typically the event with the highest number of fatalities. when weighing inclusion of competing cases, a diversity of hazard types and geographic areas sometimes superseded the number of fatalities from the event. figure displays the selected cases with relevant characteristics. online appendix a includes selected information about each case, including location, event, and number of injuries and fatalities. we began with a systematic search for articles and editorials about the event published in the year after its occurrence, following mcadam and boudet's ( ) advance preparatory fieldwork strategy. we supplemented the initial search with a second systematic search for the terms "climate change" and "global warming" in the year prior to the event and within the articles and letters focused on the event in the year after. we coded all relevant newspaper articles (n = ) and editorials (n = ) to identify leaders and key policy actors, groups and organization, events and meetings, and proposed policies. secondary data for county-level socioeconomic, demographic, organizational capacity, and event-related indicator were collected from multiple sources, including the us census bureau's american community survey (n.d.), the national center for charitable statistics (national center for charitable statistics n.d.), yale climate opinion maps (howe et al. ) , national academies report on event attribution (national academies of sciences, engineering, and medicine ). the newspaper and secondary data served as the primary sources for development of a preliminary case narrative, systematically structured to highlight our understanding of the weather event, related mobilization, and policy responses and to identify potential site visit and telephone interview contacts. we conducted a site visit to each case location, where we conducted interviews with key policy actors, including local and state elected officials, county/city staff, newspaper reports, leaders of local community organizations, and religious leaders. we logged a total of h over the course of interviews, averaging min per interview. while on site, we also attended relevant public meetings and conducted additional interviews, as suggested by our initial contacts. online appendices a through a include detailed information about newspaper and interview data by case, including sources, counts, and interview duration and protocols. for each case, we developed a detailed research memo write-up that systematically synthesized information from interviews, newspaper articles, and secondary sources (online appendix a ). we used the case data in these write-ups, as well as the original articles, interviews, and secondary data, to develop the outcome and selected causal condition. our primary research objectives were to identify ( ) the degree of local adaptation-focused policy change occurring in response to extreme weather events and ( ) the combination(s) of conditions leading to the presence or absence of adaptation-focused policy change. we operationalized our outcome and causal conditions based on both theoretical considerations and our empirical evidence derived from the cases. see online appendices a -a for detailed information about the development of conditions, including a codebook associated with the outcome conditions, as well as underlying data and calibration methods associated with all conditions. our primary outcome of interest, adaptation-and/or mitigation-focused policy change, which we refer to simply as "policy change," represents the degree to which the community enacted post-event public policies intended to address disaster-related risks. we searched newspaper articles and interview transcripts to compile evidence of local (and non-local) policy change and categorized each identified policy according to its proposal date (pre-or post-event), venue (private, administrative, legislative, ballot initiative, judicial), and jurisdiction (local/regional, state, national). for the purpose of this study, only policies that were local, public, and proposed after the event were retained in the data set for scoring and analysis. the ipcc report (cutter et al. ) identifies three main categories of potential policy change: ( ) coping with current data risk; ( ) building capacity to manage risk; and ( ) anticipating and responding to future data risk. we used insights from the ipcc report (cutter et al. ) to categorize each policy according to one of sub-categories, representing three major risk management categories, as shown in fig. . the first group of policies, "coping" measures, reflect how local places modify the impacts of disruptive events, features of the events themselves, and/or share or reduce the burdens of disaster risk. they include measures intended to improve the immediate capacity to respond to the event or similar events (e.g., equipment purchase, coverage of reliefrelated expenses, measures to prevent interference with emergency response), move people in response to an event (e.g., relocation) and/or rehabilitate and rebuild in response to the event (e.g., investments in new housing, changing building codes to encourage rebuilding). the second group, "capacity-building" policies, includes those that build the capacity of a community to manage future risk, such as long-range planning and knowledge production that is intended to improve the community or region's ability to respond to future events. the third group, "adaptation" policies, include land use and ecosystem protection measures (e.g., zoning changes, land acquisition, and resource management), structural measures (e.g., seawalls, measurement systems, and building codes, etc.), risk communication measures (e.g., warning systems, information channels, etc.), and resource storage, rationing protection (e.g., water rationing, medical triage systems, security measures). the last group, "mitigation" policies, include those target energy production and/or use at the local level (e.g., municipalization of energy production facilities, adoption of energy use reduction strategies) with an eye to limiting the rate or magnitude of climate change. see online appendix a for a description of each of these categories and codebook. each policy measure was independently assigned to one (mutually exclusive) ipccbased sub-category by two coders. after one reconciliation and independent recoding process, our coding efforts yielded a cohen's kappa of . across individual policy categories and a cohen's kappa of . across the four broad groups, indicating strong reliability (cohen ; mchugh ) . following ragin ( ) , we aggregated across these categorizations to create a macrocondition that ranged from (fully out of the set) to (fully in the set), prioritizing ( ) land use/ecosystem protection and structural measures; and ( ) policy change portfolios with a selection of new policies across all three categories. for example, for a case to be considered fully in the set of post-event policy change, we required evidence of either a new land use or structural policy, plus evidence of at least one recovery-focused policy and one capacity-building policy. we chose to privilege land use/ecosystem protection and structural measures based on the recognition that such policies, which tend to require broad support, political will, and considerable resources, can be an indicator of community investment in future-oriented adaptation. cases fully out of the set of post-event policy change included those without any evidence of land use or structural measures, and no evidence of any new recovery or capacity-building policies. see table for detailed information about the fuzzy set scoring process. we operationalized three types of causal conditions, based on the literature, including ( ) event-specific characteristics; ( ) context characteristics; and ( ) post-event attention. we briefly discuss the operationalization of each of these categories in turn below. operationalization of each causal condition is presented in table , with each causal condition scored along a continuum from to , in standard fsqca fashion. the underlying data and calibrated score for each causal condition are provided in online appendices a -a . while all of our cases can be described as non-typical weather events, on the basis of our fieldwork, we identified three characteristics for which we expected variation to influence the degree and type of event-related attention: ( ) event impact; ( ) event unusualness; and ( ) exposure to multiple extreme events. event impact was scored using a combination of the total number of fatalities, the number of fatalities experienced in a -h period, and the issuance of a presidential disaster declaration, with the highest impact events being those with or more fatalities in day and issuance of a presidential declaration. we used a combined measure of unusualness and exposure to multiple extreme events to measure events likely to represent an uncommon event, above and beyond its extreme nature. the unusualness of the event was scored on the basis of the event type and timing; events with the highest score are those that were described as not normal for the area in terms of both type and timing. we scored recent exposure to multiple extreme events with a combination of the number and type(s) of extreme events that occurred within a year prior to the event of interest. cases with the highest score on this causal condition included those that had experienced at least two events of opposing type (e.g., flood and fire, drought and flood); communities that had experienced at least multiple extreme events of the same type during a - years period were still in the set of multiple-occurring, but at lower scores. as suggested by our conceptual framework, we posited that two community characteristics, political orientation and environmental civic capacity, would be relevant to our analysis. for each county where our events took place, we measured political orientation as the percent of voters who voted democratic in the most recent pre-event presidential election ( or ), following levandusky et al.'s ( ) finding that presidential voting patterns are a good proxy for local partisanship. we measured local civic capacity as the pre-event number of nonprofit organizations per capita in the county, using data on the presence of nonprofits from the national center for charitable statistics (national center for charitable statistics n.d.) and aggregate population data from the american community survey (us census bureau n.d.). both measures were then calibrated using ragin's ( a) direct method of calibration for conventional interval-scale indicators. our theoretical expectations for community civic capacity was positive; we expected to see cases with either of those characteristics also present in the set of cases exhibiting post-event policy change. we did not have a theoretical expectation for percent democratic; while substantial literature points to political orientation as an important determinant of attitudes toward climate change, our knowledge of the cases and selected literature suggested that we might find majority republican cases exhibiting policy change, but without framing their action using climate change language. we measured post-event attention with two main indicators: ( ) attention focus and ( ) climate change discussion. both indicators were developed by applying latent dirichlet allocation (lda), a form of computational topic modeling, to local newspaper articles covering the event in the year after its occurrence. lda identifies the topics being discussed across a group of documents (blei et al. ) . lda operates by clustering words that appear in a group of documents based on their co-occurrence within individual documents. words that often appear together are (by assumption) more likely to be part of the same topic. though relatively new, lda has recently begun to be applied to studying climate change discourse (cody et al. ) . to measure attention focus, we used the kurtosis of the distribution of topics within each newspaper's coverage. this is a standard statistical measure which represents whether a distribution is more or less concentrated. lower kurtosis indicates a narrow-tailed distribution, meaning that coverage is focused on a relatively small number of topics. higher kurtosis indicates a heavy-tailed distribution, with more diffuse discussion of topics. in our data, attention focus ranged from a low of (relatively focused) to a high of (relatively diffuse). see online appendix a for a more detailed account of the lda method used in this study. we inverted the scale and normalized it to vary from to via calibration (ragin a) , so that a high fuzzy score would represent cases with focused attention. our measure of climate change discussion was the share of newspaper coverage clustered into the lda-generated topic that we identified as being devoted to climate change. while a fairly small proportion of coverage was devoted to climate change, the percentage ranged from less than to %, allowing us to calibrate the measure following ragin ( a) . we used ragin's ( ragin's ( , b method of fuzzy set qualitative comparative analysis (fsqca), a set-theoretic approach used to identify necessary and sufficient combinations of causal conditions, to explain variation in post-event policy response in the selected communities. according to standard fsqca methods, a necessary causal condition (or combination of conditions) is identified when the outcome is shown to be a subset of the condition. in other words, there are no cases of the outcome being present with the necessary condition absent, and for all cases where the outcome is present, the necessary condition is also present. consistency and coverage are the two standard measures for assessing the strength of the causal relationship between causal conditions and the outcome of interest. set-theoretic consistency reflects the degree to which cases with the same condition or combination of conditions also share the outcome of interest (ragin ) . strong evidence of necessity is indicated by the standard statistic, consistency of necessity (incln) greater than . , especially in the context of a high relevance of necessity (ron). the standard measure for assessing sufficiency is proportional reduction in consistency (pri); a pri score above . provides strong evidence of sufficiency. (ragin (ragin , a schneider and wagemann ) coverage represents the degree to which a specific condition or configuration of conditions explains occurrences of the outcome of interest among the selected cases. coverage is typically measured by raw coverage score (covs); a higher covs typically indicates that the given causal condition is more empirically relevant (ragin ) . following (ragin a) , we began by conducting tests of necessity for all hypothesized causal conditions, followed by tests of sufficiency. per schneider and wagemann ( ) , we conducted analysis of necessary and sufficient conditions as separate analyses and used standard metrics to assess the consistency and coverage of various models. the intermediate solution from all tests of sufficiency is presented in the text. finally, we conducted extensive sensitivity testing to assess the robustness of our findings, following schneider and wagemann's ( ) exhaustive enumeration approach. all fsqca analyses were conducted in r . . using the 'qca' package . described by duşa ( ) and thiem and duşa ( ) . we documented our analytic choices in extensive detail, as recommended by schneider and wagemann ( ) , and in alignment with recent studies conducted by boudet et al. ( ) and van der heijden ( ) . see online appendix a for a detailed description of our analytic approach and technical information about fsqca statistics used to assess necessity and sufficiency. see also online replication files. among the cases, we identified distinct policies that were formally proposed and adopted at the local level following these extreme weather events, ranging from to policies per case. as shown in fig. , the highest prevalence policy measures included emergency preparedness and response ( policies) and planning and partnership initiatives ( ), followed by structural measures ( ) and land use/ecosystem protections ( ). by major policy category, the largest share of policy measures included efforts to anticipate and respond to future disaster risk ( ; shaded gray), followed by policies to cope with current disaster risks ( ; horizontal lines). finally, a little over one-quarter of all policy measures were devoted to capacity-building activities ( ; dots). for our fuzzy set scoring, ten of the cases scored in the set of cases that enacted policy changes post-event (i.e., score > . ). those cases showed evidence of structural and/ or land use/ecosystem protection policy change(s), and most of them also adopted current-, future-or capacity-oriented policy. three cases, including lake county (ca), richmond county (ny), and travis county (tx), were fully in the set of events facilitating adaptation-focused policy change (i.e., score = ), having enacted both structural and land use/ ecosystem policies, as well as policies in all of the three main categories. these top scoring cases, which included a wildfire, flood, and hurricane, were diverse with respect to event type. despite evidence of policy change, it is important to note that qualitatively, few of these policy changes represented a full-blown shift in goals and values, or even in the means by which communities hedge against disaster risk. nor were most policies particularly innovative in nature. instead, as anticipated by policy change theory, they represented incremental changes to existing systems, sustaining status quo power structures and validating prevailing policy beliefs. indeed, evidence from our interviews suggests that some communities had already made relevant changes in response to events that occurred two to three decades earlier. that said, some communities took steps to reassess and adopt new goals, especially in relation to climate change and disaster risk management. for example, in richland county (sc), disaster recovery chief mike king noted that in the wake of floods "we are now looking at replacing at the level that fema recommends, not just… replac[ing] the same old culvert with the same old culvert. what we want to do is…to mitigate in every step forward now, try to mitigate future events because, it's going to happen again, with climate change, it's going to happen again." (interview ) other communities found that the experience of a major disaster opened the way to discussions about policy change. in richmond county (ny), the widespread devastation associated with hurricane sandy yielded extensive attention to the topic of climate in both local and national media, resulting in a wide variety of policy changes focused on adapting to future risks. one of the newspaper articles, for example, states, "as much as new yorkers would like to believe hurricane sandy is a once-in-a-lifetime event, the city is not taking any chances, especially as the science of climate change points to more such superstorms in our future" (article ). this sentiment was echoed by several interviewees, such as reverend karen jackson, director of recovery and community initiatives at project hospitality, who stated "…new york city is vulnerable, and therefore we need to be prepared for the next sandy, which will happen" (interview ). not surprisingly, we found that the impact of the event was an important motivating factor for policy change. indeed, our results indicate that a high-impact event was a necessary condition for policy change. in other words, most cases of policy change were in the subset of cases that experienced a high-impact event, while there were no cases of policy change that were in the set of low-impact events. in our test of necessity, the high-impact condition yielded a incln (consistency of necessity) score of . . see online appendix a for more detailed presentation of the results from these tests and our interpretation. in the set of communities that enacted policy change, articles and interviews indicated that the community had been devastated by the high number of fatalities and/or populations affected. for example, in cleveland county (ok), several children died during school hours when a tornado struck moore, ok (hampton ; kinney ). these deaths were described by interviewees as emotionally devastating and directly connected to subsequent policy change. robert romines, the superintendent of moore public schools stated, "buildings are easy to rebuild, but the loss of life and the seven kiddos that we lost, that is very hard to stomach," and went on to describe significant public interest and engagement related to a ballot measure funding storm shelters in every school (interview ). in contrast, in most of the communities that did not enact adaptation-focused policy measures, the human impact was low and the event did not yield a strong sense of urgency with respect to government intervention. all of these cases represented extreme temperature events that occurred in the context of an effective emergency response system, in part due to extreme weather events experienced decades earlier. in st. louis (mo), for example, all interviewees referred to the impacts of the "big daddy" heatwave that hit st. louis in the summer of , when more than st. louis metropolitan area residents died of heat-related causes and which motivated a series of key policy changes. such changes likely lessened the impact of the heatwave yielding policy changes that were more limited in scope and focused more on "tweaking" past changes. in the one community, suffolk county (ny), that experienced a high-impact event (blizzard), with a presidential declaration but a low number of fatalities; the majority of the resulting policy changes were focused on managing current disaster risk (e.g., snowplow purchases). our analysis of sufficient conditions yielded two distinct configurations, or "recipes," of other event-related conditions, community characteristics, and features of the agendasetting process, associated with post-event policy change. the overall sufficiency test associated with these causal combinations yielded both high consistency (pri = . ) and coverage (covs = . ), as shown in fig. and described in more detail below. see online appendices a -a for the truth table and results from our sufficiency analysis, as well as the results from our sensitivity testing process. the first causal combination yielded post-event policy change with moderate consistency ( . ) and coverage ( . ). this recipe to policy change was marked by a high-impact event occurring in a democratic county with relatively high post-event media attention. cases in this recipe included flooding events in boulder county (co), richland county (sc), and travis county (tx), as well as the snohomish county (wa) landslide and the lake county (ca) wildfire, all of which were in the set of policy change cases (i.e., fuzzy set score > . ). three of the five cases were fully in the set of adaption-focused policy adoption, with policies focused on land use/ecosystem protections or structural measures, as well as policies focused on building capacity and coping with current risks. lake county (ca) the "valley fire" that occurred in lake county, california, in autumn was the third most destructive wildfire in california's history at the time (lake county record bee a). governor brown declared a state of emergency for lake county the day of the fire, and president obama declared it a major disaster a week later (krohn ; lake county record bee b). the fire, which occurred in the midst of a major -year drought, burned , acres, caused the evacuation of nearly , residents, and destroyed structures (faries a, b; lake county record bee a, c; quirino ) . ultimately, the fire displaced residents, nearly % of lake county's population. lake county voted majority democratic ( %) in the presidential election. in response to the fire, lake county enacted as many as distinct policy measures across all three categories of adaptation policy. most policies were oriented toward adapting to future disaster risk, ranging from installation of a -foot fire break, plans and grant requests for activities to reduce fuel buildup, and the distribution of disabilityspecific warning equipment. lake county also implemented several changes to human resources procedures, including a shift in the organizational location of the office of emergency services to ameliorate coordination and information challenges experienced during the fire, as well as a grief program for public safety professionals. the county also began a broad initiative to revise its emergency operations plan, which had not occurred in over years. our topic analysis indicated that post-event local media coverage in lake county was relatively focused (kurtosis = ), with climate change making up a relatively high percentage of topical coverage ( %) compared to other cases. interviewees tended to associate the fire and the preceding drought with climate change, while also indicating that climate change was not a direct cause of the fire. at the state level, california governor jerry brown's acted as a statewide opinion leader, connecting wildfires throughout california to climate change: after meeting with fire officials to receive an update on the rocky fire, which has burned almost , acres of wildland and destroyed dozens of homes, the governor used the opportunity to tie this year's fire season to climate change, calling it an existential threat that could potentially spark similar large-scale destruction in the future. he attributed the now four-year drought california faces to the extreme weather conditions brought by climate change. (article ) these views were noted by local interviewees, including project coordinator for north coast opportunities traci boyle, who commented on the connections being made between the drought and climate change, "…because that's the conversation. particularly, that's what the governor on down is [saying and] all the state agencies are telling you" (interview ). not everyone agreed on the connection between climate change and the wildfire. greg giusti, for example, director of university of california cooperative extension for lake-mendocino county and advisor on forests and wildland ecology, described the fire as "a result of years of fire suppression and a weather event" (interview ). moreover, lake county also enacted at least one measure focused on achieving a rapid and comprehensive recovery, a relaxation of size requirements for lots and homes, highlighting the tension between human (re)development and disaster risk management in high-risk areas. most pointedly, will evans, director of the clear lake environmental research center, noted the distinct opportunity for change stemming from the wildfire, "it creates a policy window…the policy window has been open for a lot of stuff since the valley fire and then the floods this past year, like the whole oroville dam thing, another policy window opening up for more funding and changes to make things better." (interview ) ultimately, interviewees described the resulting policy changes as having occurred in response to the risk of future disasters and related discussions, even though the community had not reached consensus on climate change's role in the fire. the second causal combination yielded post-event policy change with a high degree of consistency ( . ) and moderate coverage ( . ). cases representing this recipe included the three tornados in our sample-cleveland county (ok), laurel county (ky) and winston county (ms)-as well as the yavapai county (az) wildfire and the richmond county (ny) hurricane. the affected communities represented by this recipe were majority republican counties that experienced high-impact and uncommon events. the yavapai county (az) stands apart as an example of a case with a high number of emergency responder fatalities (a hotshot crew), while the tornados resulted in a loss of citizen lives. moreover, all the events stood out to those interviewed as being uncommon, either because the event was unusual for the area in terms of type/timing or because the event occurred in sequence with other extreme events in a recent timeframe. the ef tornado that touched down in winston county was part of a series of tornadoes that swept across mississippi on april , -the beginning of days of severe weather in the state. all told, tornadoes caused deaths and damaged or destroyed approximately homes and businesses. in the wake of the tornado, the communities in and around winston county enacted two adaptation-focused policies, including application for and receipt of a federal grant for safe room construction at a local school and a new county policy to require every county building be insured. these policy measures were accompanied by ongoing efforts to map community structures, update emergency plans, and practice emergency operations drills. winston county is predominantly republican ( %). there was little evidence that the tornado led to climate change attention or increased awareness about climate change. among all the cases, winston county had one of the lowest levels of local media attention focused on the climate change topic ( %), and less than a third of interviewees described community dialogue about climate change in the wake of the event. interviewees indicated that climate change was not discussed in relation to the storm and attributed this to the fact that mississippi is simply known for experiencing tornadoes. indeed, joseph mccain, editor of the winston county journal, indicated that, "i think most people here, they explained [the tornado] with religion not science" (interview ). moreover, media attention was not singularly focused in the months after the event; the kurtosis measure was relatively high ( ), indicating fairly diffuse attention. that said, interviewees described a shift in the likely path of tornadoes, from tornado alley in the midwest to dixie alley in the southeast, and the need for new levels of awareness about potential risks, without explicitly linking the shift to climate change. for example, buddy king, the winston county emergency management director, discussed how technology has improved our ability to predict severe weather and increased awareness of severe storms, without attributing the observed increase to climate change: people are aware that this is happening. mississippi has now become the leader in tornadoes. and even though mississippi [has] a very rural nature…we're still having deaths because [of] the size and significance of the tornadoes. i don't know that it's new, but as our information increases in society, people are much more aware. (interview ) similarly, lacy vowell, administrator of the winston medical center nursing home, indicated that "i think things are changing and i think the intensity of any storm hitting anywhere in the world… you're just seeing bigger and worse" (interview ). some interviewees indicated that after the series of tornados, there was a shift in community members' perceptions of future weather risks, noting that people are much more aware of the weather and its potential impacts. mayor hill shared the following thoughts: "you can see these things on the weather channel. you can see them on your regional or local news where it hits someone else. but when it hits you or hits your neighbor and hits your community, you realize the destruction." (interview ). the evidence suggests that in the face of a high-impact event and shifting and unusual weather patterns, winston county mobilized to address future risks via adaptation-oriented policy, despite a reluctance to frame those risks in terms of climate change and political orientations that eschew the science of anthropogenic climate change. the fsqca process explained the occurrence of all ten cases of adaptation-oriented policy change. however, our analysis yielded one contradictory case, suffolk county (ny), which was scored as being out of the set of cases that adopted adaptation-oriented policy, but which exhibits the conditions represented by the first recipe (democratic and climate change attention). suffolk county experienced "winter storm nemo" in , yielding several fatalities and a presidential disaster declaration. policy changes were adopted across multiple towns, most of which were focused on purchasing new snow removal equipment, although instances of updated planning and efforts to protect an incoming supply line were also recorded, yielding a fuzzy set score of . , just below the cutoff score of . . the storm, however, came just on the heels of hurricane sandy (october ), which devastated the region and was readily linked to climate change, and indeed we observed that much of the climate change discussion was closely tied to that event. while our primary research question was focused on the conditions that lead to policy change, we used the same fsqca process to examine the conditions that led to policy stasis. five cases in our sample exhibited little to no policy change post-event, with two showing no evidence of post-event adaptation-oriented policy change: the heat events in cook county (il) and clark county (nv). minor policy measures were enacted after the cook county (il) cold event in the form of public transportation scheduling and notification policy, as well as disability-focused policy changes, while officials in st. louis (mo) conducted post-event research on respiratory issues related to climate change. as noted above, changes enacted in suffolk county (ny) included authorization for snow equipment purchase in multiple townships, as well as a plan to ensure a post-event supply line. while these policy changes were not irrelevant to these communities' needs, they did not meet our criteria for adaptation-oriented policy change. we hypothesized that the same underlying conditions would be relevant for policy stasis. our tests of necessity indicated no necessary conditions, although political orientation (democratic) was a close contender. as such, we included all six conditions in our main analysis, yielding two recipes for policy stasis, as shown in fig. . the recipes share three conditions, suggesting that a democratic community experiencing a non-impactful event that yields little attention is unlikely to show adaptation-oriented policy change in the wake of the event. the recipes differ only according to the last condition: ( ) relatively low attention to the topic of climate change; or ( ) low civic capacity. these recipes are aligned with the qualitative evidence. the fifth case, suffolk county (ny), remains unexplained, again likely due to the occurrence of that event within months of hurricane sandy, yielding high levels of lingering attention in affected communities. see online appendices a - for results from our tests of necessity, directional expectations, tests of sufficiency, and sensitivity testing. we found substantial evidence of local adaptation-focused policy change in most caseson average, measures per event-as well as distribution of those changes among the three major categories of policy change inspired by cutter et al.'s ( ) report on local opportunities for advancing climate change adaptation. almost half of the enacted measures were focused on anticipating and responding to future disaster risks, suggesting that these communities were able to orient themselves toward adaptation, even in the wake of significant disasters. moreover, a considerable portion of policy efforts were directed at building local and regional capacity, especially among cases representing communities with conservative political orientations. however, none of our cases passed mitigation-focused policies, the overall number of policies remained fairly modest, and the policies themselves were heavily oriented toward the type of event that had been experienced (e.g., safe rooms for tornados). furthermore, we find little evidence of policy change in communities that experienced low-impact events with low attention levels. in those cases, most of which were extreme temperature events, prior preparation levels may have contributed to both the low level of impact, as well as a strong sense of resiliency, thus alleviating the apparent need to adopt new policies. there are admittedly limits to our analysis. our cases-which were purposively selected on the basis of impact, event type diversity, and media availability-are a non-representative sample of extreme weather events, which limits generalizability. that said, the use of fsqca is not predicated on a representative sample; indeed, the method is intended as a case-based approach that takes advantage of existing diversity in the sample, yielding analytically generalizable results. finally, our operationalization of the primary elements from our conceptual framework is undoubtedly imperfect; another fsqca feature enables us to address this challenge, using our knowledge of these cases to calibrate our measures. all told, our findings substantiate two enduring propositions for the policy change literature, including: ( ) extreme events and disasters motivate policy change; and ( ) agenda-setting matters. however, our findings also underscore the complexity and diversity of recipes for change highlighted by the disaster and risk management literature and suggest an unexpected path to adaptation among conservative communities that resist (or at least remain silent about) attributing extreme events to climate change. in those communities, the use of alternative framing may yield more adaptation-oriented change than climate change frames. furthermore, policy adoption alone does not necessarily mean effective implementation or use of best practices (cutter et al. ) . we note the fairly narrow scope of the observed policy changes, suggesting that extreme events may trigger discovery of new policy tools and designs, or "instrumental learning," (may ) without yielding deeper social and political change. finally, while all of the communities represented by these cases were committed to recovery in the face of potential future risk, some adopted policies that were explicitly intended to facilitate rapid rebuilding, with little attention to longer-term risks, highlighting a paradox of policy change in the wake of an extreme weather event. adoption of adaptation-focused policy measures inherently suggests a longterm commitment to community, even in the face of the future risk of disaster associated with climate change. our analysis highlights the potential for adaptation-focused policy change in the wake of extreme weather events, even in communities that otherwise exhibit a strong avoidance of climate change discussion. borrowing from the old adage, perhaps climate change adaptation by any other name smells equally sweet. beliefs about climate change in the aftermath of extreme flooding. climatic change an ipcc special report on the impacts of global warming of . °c above pre-industrial levels and related global greenhouse gas emission pathways, in the context of strengthening the global response to the threat of climate change, sustainable development, and efforts to eradicate poverty after disaster: agenda setting, public policy, and focusing events focusing events, mobilization, and agenda setting lessons of disaster: policy change after catastrophic events 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australia and the uk designing research with qualitative comparative analysis (qca): approaches, challenges, and tools a review of themes in disaster resilience literature and international practice since from the margins to the mainstream? disaster research at the crossroads social explorer: - american community survey -year estimates innovations in urban climate governance: voluntary programs for low-carbon buildings and cities studying local climate adaptation: a heuristic research framework for comparative policy analysis public complacency under repeated emergency threats: some empirical evidence personal harm and support for climate change mitigation policies: evidence from us communities impacted by extreme weather place, proximity, and perceived harm: extreme weather events and views about climate change publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations acknowledgements we greatly appreciate the contributions made by our interview participants. we also express our thanks for the data collection contributions made by n. downing, c. flathers, j. knobloch, r. nilson, h. satein, s. shepard, h. whitley, i. widiyasari, and c. zanocco, as well as guidance from j. flora and d. mcadam. this work was supported by a grant from the national science foundation, sociology program (no. ). leanne giordono · hilary boudet · alexander gard-murray oregon state university, corvallis, usa key: cord- - jjg qw authors: kiendrébéogo, joël arthur; de allegri, manuela; meessen, bruno title: policy learning and universal health coverage in low- and middle-income countries date: - - journal: health res policy syst doi: . /s - - -z sha: doc_id: cord_uid: jjg qw learning is increasingly seen as an essential component to spur progress towards universal health coverage (uhc) in low- and middle-income countries (lmics). however, learning remains an elusive concept, with different understandings and uses that vary from one person or organisation to another. specifically, it appears that ‘learning for uhc’ is dominated by the teacher mode — notably scientists and experts as ‘teachers’ conveying to local decision/policy-makers as ‘learners’ what to do. this article shows that, to meet countries’ needs, it is important to acknowledge that uhc learning situations are not restricted to the most visible epistemic learning approach practiced today. this article draws on an analytical framework proposed by dunlop and radaelli, whereby they identified four learning modes that can emerge according to the specific characteristics of the policy process: epistemic learning, learning in the shadow of hierarchy, learning through bargaining and reflexive learning. these learning modes look relevant to help widen the learning prospects that lmics need to advance their uhc agenda. actually, they open up new perspectives in a research field that, until now, has appeared scattered and relatively blurry. advancing universal health coverage (uhc) to improve population health is a long-term objective that many low-and middle-income countries (lmics) have committed to. since the release of the world health report , entitled 'health systems financing: the path to universal coverage' [ ] the flagship document that popularised the conceptextensive research and initiatives have focused on the subject matter at national and international level. such research and initiatives have helped to map the many challenges, identify best approaches to spur countries' progression [ , ] ; assess progress made by countries and build databases describing the situation prevailing in countries [ ] . yet, in many countries, challenges remain. research findings are not always properly integrated into policy and practice [ ] . above all, uhc is a complex endeavour at the crossroads of technique and politics, applied to health systems that are themselves complex and, thus, to some extent unpredictable [ , ] . for instance, a policy that has succeeded in one place may fail in another [ ] or the results of a policy designed and implemented in a country may be quite the opposite of what was expected [ ] . therein, it has been argued that the ability to continually learn and adapt is essentiallearning should then be at the heart of uhc-related policy processes [ ] [ ] [ ] . indeed, there is growing interest among global health actors towards 'learning for uhc'. some of them even have an explicit learning-oriented mandate in their support to countries such as the 'joint learning network for uhc', 'p h network', 'uhc partnership' and 'uhc ′. yet, there is not much scientific literature on learning processes related to uhc [ ] and questions abound, some highlighted in table . these questions, to a large extent, remain either not answered or only partially answered, probably because learning, itself, is an elusive conceptit is framed, defined, understood and used differently from one person or organisation to another [ ] . this article is not intended to provide a specific answer to each of these questions but to enrich our knowledge and understanding of what 'learning for uhc' could entail. it is worth mentioning that, if the attention to learning is relatively new in health policy, the concept has a long tradition in academia and has been extensively studied in other disciplines such as psychology, education, international relations, sociology, organisational studies and political science [ ] . learning can be approached through different theoretical and pragmatic perspectives, the most prominent ones including cognitivism, behaviourism and constructivism [ ] , or even social constructionism if we add a social dimension [ ] . from the cognitive stance, learning is related to the acquisition of new insights, assumptions, understandings and awareness resulting in new mental models or belief systems [ ] . the behavioural stance, meanwhile, insists on the need that such cognitive changes be followed, simultaneously or after, by 'shifts in actions or behaviours'the so-called 'cognitive-behavioural perspective' [ ] . changes in actions or behaviours in turn influence the cognitive aspects of learning in a kind of iterative loop [ ] , as observed in the 'action learning', 'after action review', 'action research' and 'learning-by-doing' approaches. as for the social constructionism stance, learning emerges from social interactions and realities through formal and informal networks such as communities of practice defined as "groups of people who share a concern, set of problems, or a passion about a topic, and who deepen their knowledge and expertise in this area by interacting on an ongoing basis" ( [ ] , p. ); for instance, when young practitioners learn by interacting with experienced medical staff in a hospital [ ] . this paper adopts and adapts the definition of learning put forward by two political scientists, dunlop and radaelli [ ] learning is the updating of knowledge, beliefs and actions based on lived or witnessed experiences, analysis or social interaction. beyond its synthetic nature, this definition meets our special interest for public policies, specifically uhc-related policy processes. the political science literature provides us with the concept of 'policy learning', which is learning applied to policy-making processes. it "occurs through the very practice of policy-making" ( [ ] , p. ). moyson and scholten define it as "the cognitive and social dynamic leading policy actors to revise or strengthen their policy beliefs and preferences over time" ([ ] , p. ). policy learning can manifest itself in a variety of ways, notably "as updates to our understanding of instrumental or technical aspects of a policy problem, as changes to our underlying policy beliefs or values about societal priorities in responding to problems, and as fundamental alterations to the institutions that target these problems" [ ] and also as adoption of new and innovative ideas. in the next sections of this paper, we first give a (nonexhaustive) overview of the literature on learning and how we came up to adopt the analytical framework by dunlop and radaelli [ ] . thereafter, we critically reflect on how this framework could help lmics widen the learning prospects they need to advance their uhc agenda. actually, without claiming to be exhaustive, we find this framework relevant to account for and capture a multitude of learning situations encountered empirically during uhc processes. these learning situations (or learning modes) could serve as reference points for national and international actors engaged in promoting learning for uhc to gain more insights on what they are doing and to help them make deep analyses and critical reflections on their actions in order to improve them. navigating the literature on policy learning is a daunting task since the latter is 'characterised by concept stretching' [ , , ] and resembles a maze where the risk of straying is ever present. this is exemplified by a recent bibliometric study conducted by goyal and howlett [ ] , which identified publications on the topic from to , and other literature reviews performed by leading scientists in the field [ , , ] . actually, the taxonomy of learning is rich, depending for instance on the content, direction and framing of learning [ ] or the methods and tools used. hence, learning types are diverse and not necessarily mutually exclusive, including, among table examples of relevant questions related to 'learning for uhc' • how does 'learning for uhc' occur at country level? • what type(s) of learning predominate or are favoured at country level and why? • what is the role of learning in policy-making processes? • what dynamics (actors and factors) facilitate or hinder learning processes at country level? specifically, how does context, including organisations' features and dynamics, shape learning and affect learning outcomes? • how and by whom are countries' learning needs identified? are they properly identified? • what actions are being taken to address these needs? are they successful? others, instrumental learning, social learning, political learning (may [ ] , hall [ ] ), policy-oriented learning (sabatier [ ] ), government learning (etheredge and short [ ] ) and organisational learning (argyris and schön [ ] ). besides, other concepts are closely linked to learning such as those of policy transfer (dolowitz and marsh [ ] ), policy diffusion (shipan and volden [ ] , marsh and sharman [ ] ), policy convergence (bennett [ ] , holzinger and knill [ ] ) and lesson drawing (rose [ ] ). in general, policy learning is studied in relation to policy change and fits best into the large group of cognitive approaches to public policy analysis, a school of thought that emphasises the role of ideas, beliefs, values and norms in public policy [ ] . actually, before heclo ( ) [ ] , the hitherto dominant paradigm was that only conflicts and power relations convincingly explain changes in public policy. heclo [ ] and followers of his school of thought challenge such prospect and emphasise the crucial role of ideas and learning. indeed, heclo argues that "politics finds its sources not only in power, but also in uncertaintymen collectively wondering what to do" ( [ ] , p. ); learning is thus seen as an answer to "the problem of managing and reducing radical uncertainty" ( [ ] , p. ) in policy-making. then, policy learning somehow opens perspectives in the analysis and understanding of complex interactions between knowledge, policy and power [ ] . moreover, it has been postulated that learning does not only generate positive effects and could have its setbacks. indeed, learning is not risk-free if one does not rely on the right actors, if its content is poorly understood and/or if its goals are diverted. for instance, it may happen that one is "persevering in listening to the wrong teachers", "implementing the wrong lesson" or "applying the right lesson to the wrong institutional context" ( [ ] , p. ), especially if there are no self-critical processes and/or iterative learning loops. furthermore, if learning purposes are ill-defined or poorly specified, it can be manipulated and used to legitimise choices already made and/or serve private or hidden interests [ ] . finally, as usual in any policy process [ ] , learning and its effects on subsequent policies can have political, economic or social implications, with vested interests of major players at stake. it is therefore important to analyse and consider the political economy surrounding learning endeavours [ , ] . by delving into the political science literature on learning, a book chapter has particularly attracted our interest since it was helpful in navigating the vast literature on 'policy learning'. this chapter concerns the allegorical description by dunlop et al. [ ] in the form of a family tree, of the evolution of the concept from the founding fathers (notably john dewey, harold lasswell, karl deutsch, charles lindblom, herbert simon and hugh heclo) to the most recent developments. dunlop et al. [ ] distinguish three main periods: the late s to the s (corresponding to the roots of 'policy learning'), the s to the s (assimilated to the trunk of the tree) and s to the present (representing the branches of the tree). they assert that recent work is "less concerned with the type of learning per se (instrumental, political, social …) and more focused on the characteristics of the policy process that determine varieties or modes of learning" ( [ ] , p. ). for example, the policy process can hold epistemic, hierarchical, bargaining-oriented or reflexive trait [ ] . this strong connection between learning features and policy process features resonated with recent work that dunlop and radaelli have pioneered, sparking our interest in the analytical framework they proposed [ ] . dunlop and radaelli [ ] use the 'concept formation' approach proposed by sartori [ ] and the 'exploratory typologies' technique described by elman [ ] to make the concept of policy learning more tangible. for that, they identify, from the literature, two main dimensions that matter in the social and learning mechanisms of policy processes. the first one is 'problem tractability', which relates to the level of uncertainty regarding the policy issue under discussion, the degree of solvency of the problems subject to learning [ ] -"a repertoire of solutions, algorithms, or ways of doing things" exists ( [ ] , p. ). low tractability is equivalent to high uncertainty and vice versa. when tractability is high, the transferability and diffusion of lessons learned and solutions from one setting to another is easier, and vice versa. the second one is 'actors' certification', that refers to "the authority and legitimacy of some key actors or venues" ( [ ] , p. )certified actors have a privileged position to influence decision/policy-making and the higher their level of certification, the higher this privilege. drawing on adult education science, dunlop and radaelli [ ] metaphorically assimilate 'learners' to decision/policy-makers or policy implementers and 'teachers' to knowledge holders or producers (e.g. experts, scientists, interest groups, think tanks) striving to influence decision/policy-making or institutional rules. in this perspective, low actors' certification equates to a low divide between the learner and the teacherthere is no knowledge hierarchy. by crossing these two dimensions, 'problem tractability' and 'actors' certification', dunlop and radaelli [ ] end up with a four-quadrants matrix and subsequently classify the vast literature on policy learning according to these four quadrants. in doing so, they identify four learning modesepistemic, reflexive, bargaining and hierarchical learningsdepending on the level of uncertainty or actors' certification vis-à-vis the policy issue ( fig. ) . we postulate that these four learning modes could help better understand the scope and variety of configurations that 'learning for uhc' can take. epistemic learning and learning in the shadow of hierarchy, typically, are vertical and prescriptive ways of learning. in epistemic learning, you have ( ) someone who 'knows' and someone who is likely to learn, ( ) intractable policy issues looking for technocratic answers. 'expert power' [ ] is actually used to look for solutions to well-identified problems. experts and scientists are at the heart of the policy process and enlighten policymaking through their authoritative knowledge. as for learning in the shadow of hierarchy, it piggybacks on the exercise of authority, such as a principal who creates some pressure on an agent to learn [ ] , for example, because of frequent supervisions. such learning may be used to achieve specific or predefined goals or results. if epistemic learning and learning in the shadow of hierarchy are two vertical learning modes, reflexive learning and learning through bargaining are rather horizontalthere is no pecking order in knowledge. reflexive learning entails open, deep, inclusive and critical discussions without (self) censorship between policy actors to gain mutual meaningful insights on issues at stake. learning through bargaining, meanwhile, implies repeated social interactions and "is often the unintended product of dense systems of interaction between politicians and bureaucrats" ( [ ] , p. ). dunlop and radaelli's approach to policy learning modes enriches the field of public policy analysis by highlighting the role of learning in policy-making and decision-making spaces, both conceptually and empirically. this is relevant from the uhc perspective regarding the critical role that learning could play in uhc processes, especially with the complexity of health systems [ , ] . our hypothesis is that dunlop and radaelli's work offers an opportunity to pursue a reflection in this direction, starting with the learning modes they propose. in the next sections, we offer some personal reflections on how these learning modes already contribute and could probably be even more applied to uhc in lmics. due to our professional history, we are probably privier or more acquainted to epistemic forms of learning through our own engagement in epistemic communities. however, where appropriate, we strived to ignore this posture and took the critical distance needed to explore/illustrate the other forms or modes of learning occurring in uhc processes. when relevant, we also highlight how learning intertwines with power relationships. epistemic learning is probably the most visible, analysed and rationalised mode of learning today in global health [ ] . this is probably also true for the uhc agenda, something which might be explained by its strong technical dimension and health financing lineage [ , ] . when we are facing a question, we look for an expert or an actor able to implement a rigorous approach to remove the uncertainty. it is so prevailing that it is actually our main understanding or expectation of how learning should take placethis seems particularly true within a scientific community so committed to research and the prospect of evidence-informed policy. epistemic learning takes several configurations in our 'collective action for uhc' in lmics. epistemic learning encompasses situations such as ( ) reading a policy-brief or even a scientific article, particularly a systematic review or a metaanalysis; ( ) attending national, regional or international meetings or training workshops; ( ) the release of conceptual or analytical frameworks to better understand the concept of uhc or its linkages with health system pillarsexamples include the health financing functions [ , ] or the 'uhc cube' [ ] ; or ( ) specialist agencies or researchers sharing lessons learned in other countries [ , ] or developing policy guidance notes on how to move quickly towards uhc [ ] [ ] [ ] . epistemic learning can also take a more active form, for instance, as technical assistance to countries in various possible arrangements -'fly-in/fly-out' or longterm technical assistance [ ] , with local and/or international experts who are embedded or not in government institutions, and acting as individuals or as part of national, bi-multilateral or international bodies. in any case, their mandate would be to assist countries implementing complex reforms or still struggling to find the 'right' policies tailored to their context and/or the proper way to design and implement them, including institutional arrangements and policy instruments [ ] . examples include how to improve healthcare services utilisation and quality, how to improve public financial management or how to make health care services purchasing more strategic. decision/policy-makers are thus expected to rely on the knowledge of scientists and experts, sometimes in the form of a coaching or mentoring approach [ ] to find solutions to these intractable issues. ideally, these scientists and experts should be people familiar with the technical and non-technical (e.g. political, social, cultural, economic) intricacies of the context a condition not always fulfilled [ , ] . they would then have both legitimate, expert and informational power [ ] to advise countries or technical departments of ministries in charge of uhc on how to successfully implement specific policies or processes, taking into account path-dependency and other local specificities [ ] . however, sometimes, even deep contextual knowledge, mobilised for instance through reliance on national experts, is not a guarantee of success. uhc policy processes are complex with many unknowns. for instance, we still do not know much on how to sequence steps towards uhc [ ] . it may happen that, because of haste or oversimplification, experts do not see the limits of their toolbox, including analytical frameworks or generic political guidance developed by international agencies. this is particularly problematic if critical thinking is poorly developed among decision/policy-makers. scientists and experts can also be seen just as useful contributors to policy processes. this situation is encountered in some middle-income countries [ ] ; an issue then is that experts may be used instrumentally to justify certain choices. scientists and experts may also be facing governments that know very well where they want to go but are in great need of advice on which path to take and are looking for experts willing to support them. in these situations, scientists and experts could be used as 'facilitators' since processes are country led. examples include rwanda or ethiopia, which show strong leadership in their uhc policy choices and bring external partners to follow the path set by the government [ , ] . the challenge for scientists and experts here is not to lose their independence vis-à-vis the government or the politicians and, sometimes, to push for more reflexivity. lastly, one can imagine a ministry or an actor that has some resources and capacities but appreciates external guidance on what to do and achieve. scientists and experts could thus play the role of 'producers of standards', with the big challenge to produce high quality standards tailored to country needsthis is not obvious if the scientists or experts lack in-depth contextual knowledge. however, this could also include the use of normative frameworks produced by individual scientists or experts, or international agencies [ ] [ ] [ ] . it seems to us that the international uhc community has so far paid little attention to this second mode of learning. in reality, it is taking place but it is not highlighted in the literature nor made explicit. in the context of uhc, a typical example of reflective learning could be the learning that emerges from what is coined "démocratie sanitaire" [health democracy] in the francophone systemthat is, a process promoting citizen participation in health policies development and implementation through consultation, public debates and dialogue [ ] . actually, community actors are directly involved in policy processes and learning is collective, arising through the co-production of ideas and discussions. another example of reflexive learning is deliberative processes bringing together various stakeholders to collectively reflect on complex issues to get better insights and suggest possible solutions [ , ] . there are flat power relations between policy actors and no knowledge hierarchyall types of knowledge are equally esteemed. here, we can draw a parallel with the facilitation techniques using the rules of brainstormingall the participants are equal, no idea is stupid and everyone participates. in the face of uncertainty, in a context of reforms, or in a situation where certain values and social norms must be questioned and new perspectives adopted, these open approaches based on dialogue, discussion, exchange of information and ideas are welcome rather than being an issue [ ] . indeed, they allow to gain mutual meaningful insights on issues at stake and there is room for serendipity as well as bold and innovative ideas. concretely, this learning mode seems little used in countries where decision-making is highly centralised. indeed, reflexive learning in some way would constitute a kind of 'endangerment' as it involves losing some control over the policy process. the national health assemblies in thailand, originating from the concept of the 'triangle that moves the mountain' [ ] (described below), which started in the early s, and the societal dialogue for health system reform, launched in tunisia in [ ] , are typical examples of situations where reflexive learning could occur. the societal dialogue in tunisia aims to develop a health system more responsive to citizens' expectations with a new mode of governance based on decentralisation and 'health democracy' [ ] . however, as in any process where decisions have to be taken by many at the same time, this dialogue turned out to be quite complex [ ] . learning through bargaining is probably the most overlooked mode of learning in the health policy literature. yet, we think that it happens daily, as policymakers constantly learn from their interaction with stakeholders. such learning arises when there are exogenous or endogenous attempts to shift policy objectives or instruments. learning will emerge from efforts done to reach an agreement. examples include ( ) the adoption (or not) of output-based financing mechanisms [ ] ; ( ) the degree of autonomy to be granted to health facilities in terms of organisation, service delivery and use of resources [ ] ; ( ) how health insurance funds should be collected [ ] , pooled, allocated and the benefit package designed [ ] ; ( ) changes in the market structure of healthcare provision, including the promotion (or not) of the private sectorthe so-called public-private partnerships [ ] ; and ( ) more generally, the adoption of some reforms, laws and regulations in the health sector [ ] . learning through bargaining is also a distinctive feature of certain permanent mechanisms such as priority-setting and budgetary negotiations [ ] , discussions between donors and their countries counterpart to set up health policies [ ] or, as part of the global fund, proposal developments for funding applications or principal recipients nominations by the country coordinating mechanisms [ ] . another example of learning through bargaining is the 'triangle that moves the mountain', a nice metaphor showing how sound interactions between key stakeholders in thailand, namely researchers producing policy-relevant knowledge, civil society organisations and communities leading a social movement, and politicians providing required resources, have been able to promote social learning and yield major changes in a difficult context [ ] . learning through bargaining focuses on the preferences of stakeholders [ ] and stems from a dialectical process. government officials negotiating with each other (e.g. ministry of health with other ministries such as social welfare or finance) and with external partners, civil society or unions to find out how to develop a coherent uhc policy are learning a lot. for instance, in morocco, such learning occurred when several ministries with divergent views gathered around the same table to discuss ramed (régime d'assistance médicale; a health coverage scheme for the poor) options, each bringing their own knowledge and experience [ ] . bargaining is essential as uhc policies may not be consensual and require trade-offs or choices that are eminently political, often involving resources redistribution and disruption of power relations. there seems to be little guidance today on how to institutionalise this learning mode; knowledge mainly remains tacit, as 'experience' and can 'evaporate' quite quickly [ , ] . in the context of uhc, learning in the shadow of hierarchy emerges from the very exercise of public authority. it is therefore practiced by all health authorities, although in varying ways and quality. hierarchical learning is particularly cherished by disease programmes and international agencies with an operational mandate such as unicef. indeed, like epistemic learning, hierarchical learning is directed and prescriptive. it corresponds to the situation where an actor uses his/her/its 'legitimate', 'coercive' or 'reward power' [ ] to purposively orient policy actions in a desired direction in order to enforce a policy or achieve specific goals or results. let us mention that some people in a high hierarchical position can also be scientists or experts (e.g. scientists or experts being decision-makers or politicians)we propose to consider these situations as learning in hierarchy instead of learning in epistemic contexts. in any case, the quality of learning will depend on the compliance of the governed, the clarity on the roles of stakeholders and the effectiveness of instructions. such learning, for example, is supported by field supervision visits, good monitoring and evaluation systems with adequate metrics to analyse policy actors' performance, or annual policy reviews. it thus values deliverables and measurable results. generally, knowledge is acquired both by the person holding authority who provides supervision or performs the monitoring and by the 'street-level bureaucrats' who make the effort to understand the instructions. learning can be enhanced if the supervisor is able to take advantage of the lay knowledge of the grassroots actors and not necessarily believe that his/her own hierarchical position or seniority means superior knowledge. in fact, hierarchical learning can be supported through the proper use of internal routine data. this is probably one of the great learning opportunities that remains minimally exploited for uhc [ ] . furthermore, like learning through bargaining, knowledge gained during the monitoring remains very tacit (embodied knowledge) and can get lost if, for example, a group of people is not stabilised at the head of uhc policy processes or if health workers are regularly deployed to other positions. several important points emerge from our research. it has shown that there are many ways to learn, materialised by the learning modes proposed by dunlop and radaelli. in-depth analyses of what mode(s) of learning is occurring, with whom, when, where, why, how, at what level and with what results, in relation to specific uhc processes in lmics, deserve being empirically investigated and, we trust, will be the subject of future research. further research exploring their triggers, constraints and pathologies [ ] would also be relevant. for instance, as hindrances, tacit knowledge gained during learning can get lost if people are not stabilised at their positions or if the turnover is too high. consequently, health authorities would lose learnings accumulated. learning for uhc naturally occurs. however, learning can also be organised or directed. among 'uhc promoters', there seems to have been so far an operational bias towards epistemic learning, often under a teacherlearner model. it is undeniable that this learning mode demonstrates some effectiveness to tackle technical knowledge and capacity gaps in many lmics, but this bias possibly stems also from power structures or unchallenged assumptions (e.g. donors knowing more than governments; academia knowing more than practitioners). in any case, there are probably missed opportunitiescountries do not leverage the large array of learning situations that have great potential to spur their progress toward uhc. today, too few ministries or technical departments are purposely investing in their own systemic learning capacities [ ] [ ] [ ] . beyond the illustrations we provided in this paper, applied work is needed to know more about what learning modes occur, when, where, how, at what level and under what circumstances. for instance, akhnif et al. [ ] already observed, in their case study on ramed, that "learning changes in nature across the different stages of the policy process"our study allows to deepen this subject matter by highlighting a grid to better categorise and analyse these different moments of learning. it would also be compelling to investigate what learning modes are mobilised or emerge at each stage of the strategic planning process, as proposed by who [ ] . furthermore, digitisation has created great potential for learning, both at the decision-making level and at the operational level, but this remains largely untapped [ ] and further research is needed to unravel ways to better exploit this potential. other studies could also explore the contribution of different hybrid models, that is, varying degrees of mixtures of different learning modes. indeed, learning modes are not mutually exclusive; they co-exist, occurring sometimes at the same time. a good example of a hybrid model is the 'coaching and mentoring' support provided by the strategic purchasing africa resource centre (sparc) to an expert panel of kenya's national hospital insurance fund to comfort it as a strategic purchaser of health services [ ] . this experience was rich in reflexive (through the engagement of various stakeholders), bargaining (to accommodate divergent opinions and reach consensus through formal and informal discussion channels) and epistemic (the mentor giving expert advice only when requested) learnings. learning generated through pilot schemes, as was the case for performance-based financing with rwanda [ ] , health equity funds in cambodia [ ] , the ramed in morocco [ ] , or user fees removal policies in burkina faso [ ] , is also an interesting case. policy actors and experts knew what they were looking for but they also acknowledged that there were many unknowns. by combining their assets (public authority, ideas and experimental methods), they together constituted an original body of knowledge that could be used to inform decision-making and scale-up processes [ ] . in the cases reported above, policy actors' learning seemed to have combined at least the epistemic and reflexive modes, both enhanced by experimental action, as promoted by garvin [ ] . similar hybrid learning is probably in application with the practice of study tours: there is an epistemic component (learning from another country with a more 'advanced' experience) and a reflexive component (since visitors, and possibly guests, informed by their own observations collectively reflect), before any experimentation or application back home. this paper aimed at illustrating the possibility and relevance of using the concept of 'policy learning' to analyse learning in uhc processes in lmics. dunlop and radaelli's framework allowed us to throw a new light on existing processes but also to widen the learning prospects that countries could tap into to advance their uhc agenda. the new perspectives highlighted in this article also echo implementation activities or research carried out by multiple actors involved in the field of learning for uhcthey could validate certain hypotheses, clarify grey areas and, above all, spark new reflections and ideas. all in all, there is room for action and building countries' systemic learning capacity for uhc. however, establishing an ambitious research and learning programme is crucial. our contribution fits in this voluntarist perspective. lmics: low-and middle-income countries; uhc: universal health coverage; ramed: régime d'assistance médicale the world health report: health systems financing: the path to universal coverage universal health coverage: friend or foe of health equity? going universal: how developing countries are implementing universal health coverage from the bottom up the update of the health equity and financial protection indicators database: an overview integrating evidence from research into decision-making for controlling endemic tropical diseases in 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the case of a ugandan hospital development cooperation as learning in progress: dealing with the urge for the fast and easy the global fund: managing great expectations triangle that moves the mountain and health systems reform movement in thailand the place of learning in a universal health coverage health policy process: the case of the ramed policy in morocco routine health facility and community information systems: creating an information use culture pathologies of policy learning: what are they and how do they contribute to policy failure? world health organization. strategizing national health in the st century: a handbook barriers and facilitators to health information exchange in low-and middle-income country settings: a systematic review advice from a mentor: legitimacy, flexibility & credibility from scheme to system (part ): findings from ten countries on the policy evolution of results-based financing in health systems translating knowledge into policy and action to promote health equity: the health equity fund policy process in cambodia how burkina faso used evidence in deciding to launch its policy of free healthcare for children under five and women in ownership of health financing policies in lowincome countries: a journey with more than one pathway learning in action: a guide to putting the learning organization to work publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the authors would like to thank wim van damme and maxime k. drabo for inputs they provided in this study. they also thank four anonymous peer reviewers who provided insightful comments that helped improve the paper. authors' contributions jak and bm performed study conceptualisation. jak made an extensive literature review and wrote the first draft of the study. bm and mda revised it thoroughly and mda provided further inputs into the study conceptualisation. jak drafted the final version that was revised by bm and mda. all authors read and approved the final manuscript. this article is part of jak phd thesis work. jak benefits from a grant for this thesis, funded by the belgian development cooperation.availability of data and materials not applicable.ethics approval and consent to participate not applicable. not applicable. the authors declare that they have no competing interests. key: cord- - if qquj authors: nan title: perspectives on the economics of the environment in the shadow of coronavirus date: - - journal: environ resour econ (dordr) doi: . /s - - - sha: doc_id: cord_uid: if qquj nan the environmental and resource economics special issue "economics of the environment in the shadow of coronavirus" comes at a hugely critical time for environmental economists and policy makers alike. we are in a situation of significant social change, a change that could potentially lay the foundation for mankind's future in the years to come. as part of this special issue, ere is trialling a novel, experimental form of article, drawing together short, focussed pieces from a wide group of authors addressing the plethora of issues which such a fundamental challenge as the coronavirus pandemic generates. these provide critical and reflective perspectives on the environmental, socio-economic and policy paths that may be taken in the near and further future-strategies that could lead mankind either on roads to a much more sustainable development, or along paths that could bring about more instability, inequality and further environmental pressures. this innovative article combines short, policy-relevant and less technical papers that deal with specific aspects and provide clear recommendations for policy makers and suggestions for future research alike. the target audiences are policy makers and companies, but also researchers who want quick yet sufficiently detailed knowledge about particular analyses relating to covid- and issues in environmental economics. we hope that the articles contained within this perspectives collection provide the necessary information for policy makers to take wise decisions for our future, and for researchers the knowledge to help guide policy makers in their decisions. humankind has been very fortunate to have lived through a period of sustained economic growth pretty much since the agricultural revolution, with especially high rates of growth starting from the second half of the twentieth century. this economic progress has allowed us to make unprecedented improvements in consumption, in health, in education and in addressing inequality. many of us have been fortunate enough to have lived without a war for the past years, which is widely believed to be due to the development of international institutions and a deepening of international trade that led to widespread cooperation and, with it, it brought a new era of global stability. at the same time, the rapid increases in humankind's population, from around billion in to . billion in , coupled with an increase in real-world gdp by a factor of roughly during the same period, have led mankind to progressively push closer to the boundaries of planet earth. to provide additional food for the surge in population, agricultural land use has increased by %; to provide goods and services for the surge in demand, the material footprint of our production increased by an estimated factor of ; and to provide energy for our lifestyles, our use of non-renewable and polluting resources (coal, oil, gas) increased by a factor of . this increase in consumption coupled with a similar increase in input use has transformed the face of the planet earth and has given rise to unwanted side effects and new challenges. some of these challenges are well known, such as local and global pollution, problems of waste and certainly climate change. another, often neglected challenge, has been a consistent pressure on biodiversity due to our increase in land use. a mixture of burgeoning population and increasing resource use that carved deeply in nature's pristine areas has led to species conflict manifested not only in the rapid loss of other species, but also in a much ignored yet increasingly visible negative feedback in the form of viral crossovers (smith et al. ). the linkages between economic development, viral crossovers in the form of communicable diseases and environmental issues in particular have, up to now, seen little attention from environmental economists. as we have now seen, it was worryingly neglectful on our part to not consider these feedbacks more seriously. the greater interconnectedness via global trade and international migration, air travel for both tourism and business purposes, as well as the ongoing growth of large city hubs, have made it easy for communicable diseases to transcend local spaces and quickly make their appearance in even remote corners of the world. while the black death and the spanish flu have been among the worst communicable disease outbreaks in recent history, in late a new virus was detected in wuhan, china. identified as a new member of the coronavirus family and subsequently called covid- , within the course of half a year this virus has spread out from the huanan wet market in wuhan across the whole world. even inhabitants from otherwise remote places such as villages in timbuktu, the korubo and yanomami tribes of the amazon, the navajo nation of north america and the arctic inuit have already tested positive for due to initial uncertainty surrounding both the impact of covid- and its spread through society, many policy makers quickly decided to shut down interactions among individuals by restricting local, national and international mobility. these "lockdowns" had pervasive impacts on economic activity across the globe, with significant reductions in production, increases in unemployment, falls in international migration, diminished levels of international trade, significant increases in bankruptcy filings and large ripple effects down supply chains. relative impacts between developed and developing countries are still very much developing. globally, herd immunity is expected to take some time to develop if indeed it ever does. a vaccine that has the potential to be potent and widely available may need at least another or years for development and broad deployment. some countries are already close to a second wave-this pandemic is here to stay for a while. the question is as to how we shall deal with it. while reducing physical contacts to "flatten the curve" of disease and death has been the preferred policy to slow down the spread of the were advocating for. it is at this point where the contributions selected for this special issue provide first thoughts, first answers and first suggestions for policy makers from the cuttingedge research of environmental economists. in particular, the arguments forwarded support a strengthened focus on economic recovery that, first and foremost, should not undermine the green transition, while also, if possible, provide measures to advance the green transition. the articles then discuss the approaches and potential difficulties that policy makers will be faced with when being confronted with the precise means to implement these green recoveries. as a first step, due to unprecedented levels of unemployment in places such as the usa and significant contractions to economic growth in most countries of the world, an important consideration is that the focus of the stimuli packages should be the economic recovery, i.e. to predominantly deal with the direct impact of the lockdowns on economic activity. once the virus is contained and the short-run recoveries are under way, then it is, however, important to quickly integrate longer-term factors into policy making (borghesi and co-authors). here, it is vital that, in contrast to the stimuli in the aftermath of the financial crisis, policy makers also address inequality (koundouri and co-authors). a more specific focus on furthering a green transition should only be placed once a certain level of economic recovery has been achieved. this is especially vital as the disruptions to supply chains can have fundamental and unpredictable consequences, as often even companies themselves are not fully aware of their complete supply chains. cazcarro and co-authors estimate some of the impacts of these trade-related supply chains and, for example, show that the european demand changes due to covid- have, in total, larger impacts on the rest of the world than on europe itself. requirements for successful green stimuli are that these policies are implemented in a clear and transparent manner (rickels and peterson). in this regard, ing and nicolai argue that companies are likely to prefer stimuli packages that are tight to some environmental efforts rather than to new environmental regulations. on the converse, linking stimuli with environmental efforts is more costly for policy makers and likely to be less efficient. several of the articles in this special issue draw particular attention to the fact that the green stimuli are not enough to successfully further a green transition. what is also necessary is to couple this with a price on carbon and a restructuring of the subsidies paying attention to both the green and fossil industry (gawel and lehmann). a stronger social contract with a higher degree of citizen involvement will furthermore help gain public support but also strengthen social norms and thus decentralized internalization of externalities. lopez-feldman and co-authors discuss the policy responses to covid- with a focus on latin america and argue that, to minimize the likely rebound effect, policies need to be much better coordinated. we have seen that international cooperation quickly breaks down when a crisis looms, so that it would make sense to design international institutions with binding laws and penalties in case of non-compliance. what we have seen so far is that covid- has the potential to become a game changer when it comes to combining stimulus packages with the green transition. that this is a sensible strategy derives from the observation that restricting global warming to . °c requires efforts that go beyond what countries were willing to do so far, and that the stimuli provide the needed opportunity. while the articles contained in this special issue already provide many reasons for policy makers to push for green stimuli, they also clearly point out the difficulties associated with implementing these well. some articles in this special issue also show limitations of current policies or research approaches. for example, borghesi and co-authors discuss that during the covid- crisis the market stability reserve helped to stabilize the eu ets price, but imperfectly. it is, therefore, important to consider ways in which these imperfections can be redesigned. on a different topic, laude explains how the covid- crisis has brought to light both advantages and problems with having local, short supply chains for food, and that there is a substantial lack of research directed towards the impact of crises on the agricultural sector. another example is a more cautionary tale and deals with the covid- cases data. here, cohen and co-authors show very clearly that researchers must be careful with simply using these data as there are many problems in the data collection processes, which differ across countries and also time. as a final remark, we would like to observe that this special issue not only comes at a very turbulent time for mankind in general, but it also comes at a special time for environmental economists in particular. the covid- crisis gives the opportunity to invest significant amounts of money towards aiding the green transition, and the widespread public support is there. we need to now be able to advise policy makers on efficient, reasonable and relevant policies that they may implement as part of the green stimuli packages. however, these policies also need to be well structured and grounded in good research. the peer-reviewed articles in this special issue provide suggestions and articles with these features and will thus, hopefully, serve as a first benchmark in this endeavour. in this paper, we use a multisectoral and multiregional model of the world economy to evaluate the short-term effects that the covid- crisis may have on environmental pressures and resource consumption (measured in terms of water, air emissions and materials extraction). specifically, we focus on the relationship between current and forecast changes in demand and mobility patterns in the eu + uk for and its effect on global resources through global supply chains. this integrated analysis could answer urgent research questions: what are the short-term impacts on emissions and resource consumption of the current and predicted declines in final demand? do the impacts differ among environmental pressures? how elastic are environmental responses to demand drops? on the basis of these short-term responses, what is the relationship between economic growth and environmental pressure? do these effects go beyond european countries through global supply chains? in order to evaluate the short-term effects of changes in aggregated sectoral consumption and demand on environmental pressures, and their diffusion through global supply chains, we develop an environmentally extended multiregional input-output model (see miller and blair , or recently hubacek et al. ; guan et al. ), using the exiobase . database (stadler et al. ) . we focus on water consumption (blue and green), mineral extraction and emissions (co eq , sox, nox, nh and co). we rely on the estimates from the eurostat spring forecast (ec a) which estimate for the eu + uk a change of − % in consumer expenditure, . % in government expenditure and − . % in investment for . sectoral changes in private consumption are estimated based on ec ( b) and oecd ( ), assuming different sectoral sensitivities to the covid- crisis. specific details and the complete matching process can be found in online appendix. our results are as follows: figure shows the eu + uk (light blue bars) and global (dark blue bars) change in different environmental pressures associated with the shock to final demand and household mobility in eu + uk, as a consequence of the covid- lockdown. the expected percentage impacts are much larger in the eu + uk, as the simulation of final demand and mobility directly affects these countries, given the high level of intra-eu dependence. however, the european lockdown also impacts foreign resources due to the interlinkages throughout the production chain. in general, the largest decline happens to gas emissions, both in eu + uk and worldwide. the average . % fall in the aggregate of the three cited components of european final demand (households, government expenditure and investment, representing a . % fall in total final demand) that globally represents a . % decline, would involve a . % decline in global water consumption and . % in mineral extraction. the global fall in emissions from the slowdown in economic activity and european mobility restrictions would be around . % (co eq ). comparing the effect in eu + uk with the global impact, the percentage change runs from four times larger in europe, in the case of water, to times greater for co eq emissions. we find a drop of more than % for mineral extraction and emissions in eu + uk. emissions are reduced, and by more than water and minerals. also, even when no direct electricity demand change is assumed, given the reduction in sector activity, indirect energy demand diminishes and so do emissions. specifically, our model indicates that the production and supply of electricity explain approximately % of the greenhouse emissions fall worldwide and % in the eu + uk. in line with the results of le quéré et al. ( ) , our estimates confirm that the reduction of emissions associated with private mobility restrictions would account for % of the total fall in emissions in europe, whereas the reduction linked to air travel reaches . %. worldwide, these drops would be % and %, respectively. the european lockdown affects the iron and steel industries globally, representing % of the global fall in greenhouse emissions. several other resources are less dependent on the most-affected sectors. the supply chain of food clearly depends on the supply of water. it is difficult to estimate the reductions in the horeca sector based on the available data. that sector, as well as many others that indirectly require these natural factors throughout their supply chains, exhibits significant reductions in resource use. our data show that the largest decline in water consumption (both blue and green) is associated with the primary sectors, which, as expected, experience slight negative growth rates around − . %, given the relatively stable and anticyclical nature of food demand. analysing the changes induced by the different components of final demand, the decrease in household consumption and investment drives environmental impacts to a lesser extent. worldwide, the fall in investment mainly affects environmental impacts (except for water consumption). reductions in investment have a larger role in reducing emissions in small countries like croatia and malta, and also in eastern europe, such as in hungary, latvia, and slovenia. in the eu + uk, household consumption is the most significant element of final demand driving the changes in environmental pressures (with the exception of mineral extraction), explaining % of the european greenhouse gas emissions fall. as for minerals, their strong dependency on gross capital formation destinations, such as construction, manufacture of machinery and equipment, computer and related activities, explains that the . % fall in investment worldwide (- . % in eu + uk) triggers a . % drop in their global extraction (− . % in europe). these changes are distinct by country, with implications for different areas of the world. the intra-eu trade is revealed to be highly important, showing that the main changes occur within the eu + uk countries (even if the individual shock of a given country is not so significant). figure displays the percentage falls in co eq , so x , no x and nh emissions by eu + uk country. according to the projected changes, the greatest cuts are expected in co eq emissions. almost a quarter of the estimated reduction in co eq emissions occur in germany (figure si ) . the reductions in co eq emissions in smaller economies, such as ireland, austria, greece, and cyprus exhibit the largest percentage falls. reductions in mediterranean and eastern countries are high, mainly in large countries like france, romania, portugal, and spain. we note the potential reduction in no x emissions as a consequence of the production shutdown in france and germany (as it occurs with nh emissions), but the largest percentage drops occur in smaller economies, like austria, ireland, and greece. france also shows the highest reductions in so x emissions, together with poland and germany, ireland and smaller countries. our model also allows us to evaluate how the reduction in the eu + uk demand modifies the pressures on environmental resources outside europe, by considering transmission effects through global supply chains. the largest percentage reduction in domestic impacts arising from the lockdown and subsequent situations in europe occurs in non-european developed countries, with smaller effects in developing economies (fig. ) . we find considerable indirect declines in mineral extraction (larger than %) and gas emissions (between − . and − . %) in the usa and japan. these are mostly associated with linkages with italy, germany, uk and france. in countries such as china, brazil and india, none of the falls in environmental pressure exceeds . % (with the exception of a % fall in mineral extraction in india). again, we find important declines related to the commercial linkages of developing countries with european powers, such as france, germany and the uk, and with other european countries severely affected by the pandemic (and thus their final demand), such as italy and spain. these results support the statements of baldwin and mauro ( ) on the existence of a "supply-chain contagion" related to the covid- lockdown (in europe in this study). however, the "environmental supply-chain contagion" is modest outside the eu + uk. one of the main implications of our work is that the changes occurring in in the eu + uk are not, in and of themselves, able to sufficiently reduce global environmental pressures. these changes have entailed reductions in domestic activities, which have also affected other eu partners, given the high level of intra-eu trade. although some of those changes do not have strong impacts on domestic environmental pressures, transport restrictions within the eu have notably reduced co eq emissions and, even more positively, reduced other pollution-induced health damage. changes outside europe occur due to spillover effects, being relatively more notable for minerals. however, the demand for goods, which ultimately depends on resource use and pressures external to the eu + uk, has not fallen so clearly, and the lion's share of the pressures has not been reduced as much as final demand. in short, we have shown the importance of intersectoral relationships and multipliers to understand demand changes, which are uncertain along , and which we anastasios xepapadeas on december , the european commission presented the european green deal (egd )-a roadmap for making the eu's economy sustainable by turning climate and environmental challenges into opportunities across all policy areas, and making the transition just and inclusive for all. the central objective of the egd is to attain a climate neutral eu by , which means that the eu will aim to reach net-zero greenhouse gas emissions by that year. the actions required to reach this target include decarbonizing the energy sector, which accounts for more than % of the eu's greenhouse gas emissions; renovating buildings to help reduce energy use which currently accounts for % of the eu's energy consumption; supporting industry so it can innovate and become a global leader in the green economy; and promoting cleaner transport, which constitutes an important source of the eu's emissions. in terms of resources needed, at least € trillion (european commission ) are projected to be necessary over the next decade according to the european commission, with sources including the eu budget, national budgets and the private sector. furthermore, the egd encompasses the so-called just transition mechanism whose objective is to help reduce the negative impacts on coal mines or steel factories associated with decarbonization. the roadmap for the egd includes actions related to climate ambition, clean energy, circular economy, smart mobility, greening the common agricultural policy, preserving and protecting biodiversity, and attaining a toxic-free environment and was planned to commence during the spring of . the covid- pandemic which appeared in europe in early , and the containment measures taken in order to control the pandemic and reduce the transmissibility of the virusthe r -below , have had a profound impact on the economy. in terms of macroeconomics, the covid- shock on the economy can be regarded as a keynesian supply shock in a multi-sector economy which triggers shortages in aggregate demand larger than the shocks themselves (guerrieri et al. ) . policies to deal with immediate impacts of covid- are aimed at a fast recovery from the recession, so that the policies are designed and implemented in a short-run context. the question which this note seeks to explore is whether the policies undertaken as a response to covid- could have long-run implications-positive or negative-in terms of sustainability and the objective of carbon neutrality. arrow et al. ( ) state that economic development is sustained at a given point in time if intergenerational well-being is non-declining at this point in time. intergenerational well-being is non-declining if the comprehensive wealth of the economy is non-declining. comprehensive wealth is the value of the assets of an economy, with the asset base or productive base consisting of reproducible capital, natural capital, human capital and health capital. social capital can also be included in the productive base. thus, the issue of sustainability can be analysed in terms of non-declining comprehensive wealth or productive base. the implications of the covid- shock on sustainability should therefore be examined in the context of its impacts on the productive base of an economy. the impact of covid- on the productive base is realized directly through morbidity and mortality and indirectly through the recession that is induced by policies implemented to contain the pandemic and the positive effects of public spending aimed at recovery. r is the basic reproduction number which is defined as the average number of secondary infections produced when one infected individual is introduced into a host population where everyone is susceptible. in a fully susceptible population, an infection can get started if and only if r > . if r < , a typical infective replaces itself with less than one infective, and the number of infectives tends to zero with the passage of time (e.g. hethcote ) . see, for example, the world economic outlook (imf, ) in which the projection for the percentage change in output in the euro area in is − . % with a rebound to + . % in . it should be noted, however, that in the current world of deep uncertainty, these predictions could be inaccurate. greenstone and nigam ( ) indicate that moderate distancing policies have substantial economic benefits in terms of mortality benefits and avoided hospital intensive care unit costs. the valuation is performed in shadow prices, with the shadow price for an asset being the present value of the contribution to well-being from one additional unit of the given asset. sustainability can also be defined in a similar way in terms of comprehensive investment. thus, the virus does not destroy reproducible capital per se, but it reduces its utilization through containment policies. however, the pandemic could affect capital accumulation if the recession slows down investment in reproducible capital. covid- seems to be beneficial for natural capital, at least in the short run. coal use fell by % at china's six largest power plants between the last quarter of and march , while in europe satellite images showed nitrogen dioxide (no ) emissions fading away over northern italy, with a similar picture in spain and the uk (henriques ) . according to a recent international energy agency ( ) report, global co emissions are expected to decline during to . gtco , which is . % lower than in ( . gtco ) (global carbon project ). this would be the lowest level since , and six times larger than the previous record reduction of . gt in due to the financial crisis. however, the international energy agency ( ) report also indicates that if efforts to contain the virus and restart economies are more successful, the decrease in energy demand could be limited to less than %. since the international energy agency's ( ) april report, data show signs of a recovery in carbon emissions. a very recent reportin june -states that new data show a v-shaped recovery in carbon emissions, with carbon emissions declining from february , reaching a minimum in april and then recovering slowly towards the february levels (domjan ) . regarding human capital, defined in terms of changes in the work force and education level, the pandemic is having a short-term negative effect on work force, but in the long term it might change educational patterns and the geographical structure of the supply of education if extensive on-line teaching is established. health capital is, of course, negatively affected through the value of statistical life. the above discussion suggests that the pandemic has a profound impact on the factors characterizing sustainability. thus, policies to start up the economy after appropriate containment of the pandemic and return to long-term desired growth paths will be beneficial for productive-based sustainability components such as health, human and social capital and reproducible capital through the increase in its utilization. the issue of primary interest is the impact of recovery-related policies on natural capital and climate change. this issue relates to the way in which the egd might be adjusted during the start-up period and whether the current beneficial impact of the virus-induced recession on emissions signals a long-term impact. recent results in climate science have established an approximately proportional relationship between the change in the global average surface temperature relative to the preindustrial period (the temperature anomaly) and cumulative co emissions relative to the same base period (e.g. matthews et al. ). with cumulative emissions since being approximately ± gtco (friedlingtein et al. ) , the expected reduction of approximately . gtco relative to due to the covid-related recession will have negligible effects on the temperature anomaly. furthermore, if the recovery projections in are realized, then it is reasonable to expect that the pre-pandemic situation will reemerge with regard to greenhouse gas emissions, unless the pandemic continues in strong recurring waves which make extended and persistent lockdowns necessary. this situation, however, cannot be regarded as the most likely scenario. if emissions recover in the short or even medium term, the projected time period for crossing the . °c threshold-according to the business-as-usual or alternative emissions paths-will not be affected in a significant way (ipcc ) . in this context, the covid- event is expected to have a negative impact on the global productive base (health, human, social and reproducible capital) and therefore on the global sustainability conditions, while the seemingly beneficial impact on natural capital, and especially climate, will be temporary and a return to pre-pandemic paths is most likely. this means that in the post-pandemic world, risks related to climate change damages, including risks from tipping elements and crossing of climate thresholds, are not expected to change. how does this picture fit with the european response to covid- in the context of the egd? the eu is currently developing and implementing a number of policies and stimulus packages to address the recession. the purpose of this note is not to analyse these measures, but rather to explore induced adjustments to the egd. it has been reported that there will be some reprioritization of edg initiatives as a result of the eu response to the pandemic (involved in europe ). some of the initiatives such as the renewed sustainable financial strategy, which aims to increase private investment in sustainable projects, or the "renovation wave", will remain since they are expected to stimulate economic activity; others such as "offshore renewable energy" or "the biodiversity strategy for " might be delayed, but initiatives such as the new eu strategy on adaptation to climate change and the new eu forest strategy will be delayed to . it is clear that the covid- shock and the need to start up the economy will make substantial policy changes necessary. looking at sustainability in terms of natural capital and the environment, it should be clear that any short-run improvement is transient, while looking at sustainability in terms of climate change, it is most likely that there will be no change in the long-term trends. what is important is that, after the shock, the start-up will be based on environmentally friendly policies. thus, maintaining initiatives such as the renovation wave, or promoting the pillar of cleaner transport, is important. on the other hand, delaying initiatives like the strategy on adaptation to climate change may need to be reconsidered. this is because the rationale behind delaying such strategies seems to be that recovery from the recession is expected to be rapid and therefore the delays will be of short duration and no significant time will be lost. however, recovery might be impeded or delayed by issues such as new, possibly weaker waves of the pandemic or more technical issues such as fiscal multipliers. fiscal multipliers during a recession when shocks are concentrated in certain sectors are not expected to be operational, with the multiplier for government spending being around one and the multiplier for transfers likely less than one. these factors might result in the delays-initially projected to be of short duration-extending for a much longer period. the important point here is that the covid- shock will have a negligible effect on the evolution of the temperature anomaly. thus, if adaptation activities and decarbonization do not proceed rapidly, the risks of a climate shock will not be sufficiently mitigated. the need for strong action now is exemplified by the fact that the emissions gap in between current policies and the emissions necessary to keep the temperature anomaly below . °c in is approximately - gtco (unep ). the covid impact on emissions in is expected to reduce the gap by approximately gtco , which falls very far short of the gap that needs to be closed. the important aspect of a climate shock is that in addition to the negative impacts on the productive base of the economy-human, health and social capital-it will have a much more serious negative impact on the reproducible capital relative to the pandemic. this is because the climate shock will not just reduce the utilization of this type of capital, it will destroy part of the capital stock, since it will affect infrastructure, equipment, buildings and so on. recovery in such a case will clearly be slower and more difficult. this creates a serious argument against delaying adaptation programmes which could provide substantial benefits in the presence of climate shocks. typical adaptation projects (e.g. early warning systems, water resource and flood-risk management, sustainable agriculture, strengthening the resilience of existing infrastructure making new infrastructure resilient) are characterized by high benefit-cost ratios (fankhauser ; gca ) . under the resource constraints imposed by pandemic containment policies and the deep structural uncertainty characterizing the situation, the prioritization of these adaptation policies could necessitate the use of max-min expected utility criteria in decision making. as second-round benefits, adaptation programmes which involve investment could stimulate the economy and provide new jobs. to summarize, three important points should be taken into account: (i) that the indications thus far suggest that the benefits associated with the reduction of greenhouse gas emissions because of the covid- are transient, which means that the long-term trends associated with climate change are not expected to change, and therefore, mitigation and adaptation strategies should be strongly pursued in the post-covid- era ; (ii) that there is a need for an ambitious and comprehensive european economic recovery plan from the covid- crisis (european economic and social committee b); (iii) that climate-change-related investments, in particular in adaptation, are expected to deliver significant economic benefits. based on these points, it becomes clear that a green recovery plan with resources directed towards achieving the combined objective of both providing the necessary economic stimuli for recovery and also promoting the transition to a low-carbon economy and adaptation to climate change along with investment in natural capital and increase in comprehensive savings could be a feasible and efficient plan. the egd is an important strategy for securing the sustained development of the eu and protecting climate as a global public good. at the same time, it is clear that addressing the pandemic requires action now in the form of new policies and changes in priorities. however, although covid- is of necessity in the spotlight at present as a major global threat, it should not displace action aimed at an equal or greater global threatthat of climate change-under the misconception that the temporary drop in emissions during the pandemic allows us to delay climate change action now. a green recovery plan could realistically provide the double dividend of helping the eu economies to recover from the covid- crisis and, at the same time, promote the attainment of a climate-neutral eu. according to the gca ( ) study, adaptation investment of $ . trillion in the areas mentioned will provide total net benefits of $ . trillion by , with benefit-cost ratios ranging between and . see, for example, the recent eu european economic and social committee ( a) opinion about the transition to a low-carbon eu and the financing of adaptation to climate change. involved in europe ( ), leaked: full list of delayed european green deal initiatives-euractiv.com. available at https ://europ e.vivia nedeb eaufo rt.fr/leake d-full-list-ofdelay ed-europ ean-green -deal-initi ative s-eurac tiv-com/. ipcc ( ), global warming of . °c. an ipcc special report on the impacts of global warming of . °c above pre-industrial levels and related global greenhouse gas emission pathways, in the context of strengthening the global response to the threat of climate change, sustainable development, and efforts to eradicate poverty. masson-delmotte, v., zhai, p. rebound effect studies have been generally focused on energy use (sorrell ) , although some studies for other natural resources have recently emerged (freire-gonzález and font vivanco ). rebound effect occurs when the use of resources is not reduced as expected after a resource efficiency policy or a specific behaviour. empirical rebound studies aim at capturing the secondary effects of policies and behaviours in order to obtain more adjusted assessments of policies and actions. it is well known in the rebound literature that, counterintuitively, resource efficiency may not reduce the use of these resources, but the contrary. this extreme case is known as backfire, khazzoom-brookes postulate, or jevons' paradox. rebound effects are not usually observed by policy-makers, as it requires different perspectives and approaches coming from social, behavioural and environmental sciences. environmental and social sciences show us that human-environment systems are deeply interconnected. this way of thinking has, however, still not fully permeated in mainstream policy decision circles, which are largely rooted in old intellectual paradigms and other short-term interests. the pandemic has caused many abrupt changes in production and consumption, transport patterns, working conditions, social interaction and many other aspects. most of these changes have been triggered by the policies implemented to contain the pandemic. overall, they have translated into improvements in most environmental indicators, such as carbon emissions, air quality and biodiversity loss (saadat et al. ) . while some authors claim that such changes will not have a lasting impact when the epidemic subsides (mccloskey and heymann ), others argue that aspects related to urban planning, micro-mobility, sharing economy, public transportation, teleworking, tourism, etc., may change for good (honey-rosés et al. ). an important question is, thus, whether covid- will reduce environmental impacts in the future, when economic activity returns to "normality" (in terms of pre-covid conditions). rebound literature shows the importance of considering behavioural and systemic responses to answer this question. beyond other considerations, the pandemic has accelerated some already observed trends, like the pace of implementation and use of digital technologies. one of the most remarkable changes are those related to the impulse of information and communications technologies (ict), due to imposed social distancing rules. there already was a tendency towards an increased use of ict, but its use has been dramatically accelerated due to the pandemic. this acceleration can be observed in many areas, such as teleworking, e-commerce, remote social relationships, virtual sightseeing, surveillance technologies, and other online areas and events (cultural, academic, leisure, educational, etc.) . for instance, in many countries, nonessential workers have been legally obliged to be confined during the pandemic to stop the contagion of the virus, thus promoting telework. despite the potential advantages of teleworking in increasing labour productivity in many industries (harker martin and mcdonnell ) , rigidities in corporate culture and other legal and cultural restraints were hindering and adjourning its consolidation. the use of ict is thought to be environmentally beneficial, largely due to decreased transport, but this premise has been challenged by rebound effect studies. gossart ( ) shows that existing evidence suggests that ict are subject to important rebound effects, mainly because it is a general-purpose technology, and so prone to backfire (sorrell ) . takahashi et al. ( ) calculated the rebound effect of ict services in a case study on videoconferences and found that rebound can reduce up to % of carbon savings. joyce et al. ( ) recently found for sweden strong environmental rebound effects associated with ict use, in most cases far above % (more resources use than before). this backfire effect is strongest for energy use and total material footprint, both close to %. another change may take place in land use and the housing sector, as initial evidence suggests that attributes such as floor space and outdoor space will have elevated importance (mikolai et al. ) . the potential re-distribution of time and expenditures towards resource-intensive sectors, such as construction, water and energy services, will likely cause material, water and energy rebounds. however, the expansion of teleworking can, at the same time, reallocate space and incomes in office rental market. city centres will not need to concentrate workspaces, changing mobility patterns and urban structures in the long term (elldér ). public transport may also be negatively impacted in the short and mid-term, leading to increased private transport (honey-rosés et al. ), another resource-intensive activity. other structural changes may also take place, such as changes in sufficiency measures and broader productivity, leading to macro-economic rebound effects (lemoine ). the pandemic may increase the social acceptance of sufficiency measures such as working less time, spending more time with family and friends, or connecting with nature. these measures have long been proposed to reduce consumption and associated environmental impacts (hayden and shandra ). these measures have, however, been associated with macro-economic price rebound effects as the decreased demand for some products can lower their price and induce additional demand (sorrell et al. ) . moreover, the postpandemic society may likely be a more productive one in labour and capital terms. for example, teleworking (harker martin and macdonnell ) and increased spending in research and development have been associated with productivity growth, which boosts economic growth and resource use. the covid- pandemic will likely cause a range of changes in society, but their permanence and effect on the environment are unclear, especially if we contemplate the secondary effects of behaviour, measures and policies. a key question is whether they will acquire a certain level of permanence, even modifying the mindsets of agents. given the high uncertainty around this aspect, its real dimension could only be assessed ex-post. however, due to confinements, the pandemic has greatly accelerated the expansion and use of general-purpose technologies, like ict. as this has been a long-observed trend, before the irruption of the virus, they have probably come to stay to a large degree. the pandemic offers a great potential to improving (and consolidating) environmental conditions. but beyond what conventional environmental indicators show, additional measures would be needed to counteract hidden rebound effects and, therefore, take full advantage of potential improvements. recent literature shows that different economic instruments like environmental taxation, resource pricing or setting limits to resource use, can be effective for this purpose. this is particularly necessary in this case, given the high risk of backfire due to the high expansion of general-purpose technologies observed. the global financial and commodity markets are facing economic distortions caused by the coronavirus (covid- ) pandemic (fernandes ; irwin ). covid- acts as a negative shock to overall demand of goods and services, resulting in aggravated shortrun volatility in prices (albulescu ). among these products, oil has been dramatically affected due to community lockdown regulations, shutdown of car factories, decline in energy use and increase in unemployment (reed a; the associated press ). however, a decrease in oil consumption may lead to reductions in carbon dioxide emissions (peña-lévano et al. ). data recorded by epa ( ) during march-april show an improvement in overall air quality, especially in high-density populated cities (regan ). air pollution is considered by many scientists as a negative contributor in the coronavirus situation by worsening the susceptibility of infection. a decline in emissions somehow may help prevent mortality temporarily, especially among more vulnerable individuals with underlying health conditions, such as heart and respiratory diseases (conticini et al. ; dutheil et al. ; mooney ; ogen ). thus, in this short article, we discuss the interaction between fossil fuels, air pollution and health risk under the coronavirus pandemic and the lockdown regulations during the period of march-may . the oil market has been dramatically affected by several exogenous factors during the pandemic period: ( ) "shelter in place" mandates aimed at curbing the spread of the coronavirus have decreased people's social mobility and transportation activities. households leave their houses just for short travels for some essential errands, such as shopping groceries and/ or medicine. only essential personnel are required to be physically present at their jobs, whereas the majority are working from home (reed a); ( ) commercial flight demand plummeted globally (reuters ). in the usa, the passenger volume dropped % from a year ago (compared to april ) as estimated by airlines for america, with an overall reduced accommodation of passengers per carrier (rappeport and chokshi ); ( ) tourism activity slumped as many governments banned international travel, heightened border and immigration controls and barred the entrance of foreign visitors to decrease risk of infection. these policies further decreased the demand for taxis and cruise services. for regions such as the caribbean islands (where tourism is a primary economic staple good), this also represents a significant decline in their gross domestic products (semple ); ( ) unemployment has pervaded among the national economies (mazzei and tavernise ). more than million people have filed for unemployment in the usa in a -week period (u.s. department of labor ). this condition is mirrored in other countries. worsening unemployment conditions have substantially reduced consumers' purchasing power. among its consequences is an overall decline in car sales (reuters ; the associated press ); ( ) many industries, restaurants and buildings have been shut down during the lockdown. these closures reduced energy consumption, especially petroleum use, which is a large energy input in the usa and other countries (eia ). meanwhile, global oil supply responded slowly to the decline in demand as refineries cannot abruptly halt production (caldara et al. ; peña-lévano ). the russia-saudi arabia oil price war in march worsened the situation by oversupplying the market and consequently dropping oil prices (irwin ; reed a). in april, the major petroleum exporting countries agreed to decrease the world oil output by % during may-july, which is equivalent to . million barrels a day (krauss ; reed b). two recent studies published in geophysical research letters validate the realized reduction in nitrogen dioxide (no ) pollution in several regions. bauwens et al. ( ) compared no levels in the atmosphere recorded in january to april and for the same period in . notably, no , which is produced by emissions from vehicles and industrial operations, can cause serious lung ailments. their estimates indicate a significant reduction of % in china and - % drop in the usa and western europe. shi and brasseur ( ) estimate a % reduction in no pollution in northern china in january and february . in the same period, they also found a % reduction in particulate matter pollution (particles smaller than . µm). while such cleaner air conditions may persist only temporarily, these trends indicate that the desired environmental gains are feasible and realizable if stringent emission regulations, perhaps mirroring to some extent the pandemic's enforced limits on social mobility and industrial activities, are enforced in the future. several studies relate ambient air quality to mortality and morbidity conditions caused by covid- . this contention echoes an earlier correlation applied to the sars virus outbreak in china in the early s. researchers from ucla's school of public health analysed air pollution levels and sars fatality rates among chinese residents. their results indicate that sars patients' probability of dying would be doubled among residents in areas with high air pollution indexes (cui et al. ) . as applied to the current pandemic, the center for disease control and prevention (cdc) explains that covid- causes a respiratory illness with a heightened risk among people who are years and older as well as those with certain underlying health conditions. latest cdc statistics on the pandemic's severity and fatality indicate that persons with heart ailment, diabetes and chronic respiratory diseases could be at a higher risk of being severely infected by the virus (vogel ). wu et al. ( ) further clarify that pre-existing health conditions identified as relatively more susceptible to contracting covid- are similar to those normally affected by air pollution in the usa. their study estimates that an increase of g m − in long-term exposure to particular matter (pm . ) increases the coronavirus mortality rate by %. isaifan ( ) presents corroborating evidence indicating that % of covid- -related deaths were cases with pre-existing illnesses, with majority of the victims over years of age. conticini et al. ( ) , however, warn that even young and healthy individuals could also be at risk as prolonged exposure to dangerous air pollutants causing chronic respiratory issues could be an additional co-factor that helps increase their vulnerability to being infected by the virus. ogen ( ) establishes that exposure to no may be an important instigator of covid- fatalities according to his research involving four european union countries. these findings are supported by the findings of a study published by the italian society of environmental medicine (setti et al. ) on virus infections in northern italy associated with air pollutants tagged as carriers and boosters. poor air quality has been cited as an aggravating factor in virus transmission. using data from italian province capitals, coccia ( ) notes an accelerated transmission dynamics of covid- leading to his conclusion that the spread of this virus can be considered more as following an "air pollution-to-human transmission" mechanism instead of an interpersonal transmission mode. moreover, fattorini and regoli ( ) analyse long-term air quality data in northern italy and suggest that chronic exposure to a contaminated atmosphere may have created conducive conditions for the spread of the virus. several studies relate the time frame of exposure to toxic air pollutants to mortality and morbidity conditions. lim et al. ( ) establish a significant association between longterm ozone (o ) exposure and elevated mortality risk of certain respiratory diseases. given limited data on the current pandemic, hoang and jones ( ) present emerging evidence on the severity of covid- infection attributed to persistent air pollution conditions, thus suggesting that longer exposure to a polluted atmosphere could aggravate virus infection. zhu et al. ( ) , however, provide concrete evidence suggesting that even short-term exposure to air pollution could increase probability of virus infection. their study analysed daily confirmed cases in cities in china recorded from january to february and found significant relationships between the levels of certain air pollutants and the number of newly identified covid- -infected cases. specifically, their results indicate that a -μg/m increase in the air pollutants' levels was associated with about . % to . % increases in daily new covid- cases. conversely, the health benefits of cleaner air resulting from reduced emissions from fossil fuel during the pandemic's lockdown period deserve attention. several studies recognize that improved air quality during the pandemic temporarily mitigated health risks associated with respiratory illnesses. cole et al. ( ) employed a two-step analytical approach using machine learning techniques and the augmented synthetic control method to estimate possible reductions in death rates in certain regions in china and for the whole country that may be attributed to actual reductions in no concentrations during the lockdown period. isaifan ( ) analyse air quality conditions prior to and during the lockdown period. his results indicate that lives may have been saved due to diminished ambient pollution levels, although eluding possible virus infection still is not necessarily guaranteed. this contention is corroborated by another china-based study conducted by dutheil et al. ( ) . these studies' assertions imply that air quality improvements realized even in such a shorter period of time (spanning less than half of a year) already could have some health benefit potentials, especially in relation to respiratory ailments. the health benefits of the current pandemic's notable environmental gain in air quality, however, will be optimized only if such favourable conditions are sustained over the longer term. the recent lockdown has been short-lived as some communities nowadays have started to revert to normal social routines and regular users of fossil fuels among industries have resumed operations. a brief respite from a usual contaminated atmosphere does not ensure an effective permanent eradication of chronic health conditions. the pandemic experience, however, demonstrates that better health is maintained and ensured not only through medical remedies and but also through more favourable environmental conditions, if sustained over a much longer period. current restrictions on social mobility and economic flexibility under covid- pandemic conditions have actually produced important economic and environmental repercussions that are interestingly contrasting. a general economic slowdown overtly reflected in, among others, reduced consumer demand, spiralling unemployment figures and significant drop in oil consumption causes heightened fears of an imminent economic recession. however, in spite of all the negativity surrounding the pandemic, its environmental consequence of improved air quality is a highly positive note. interestingly, the global community has been trying to accomplish such feat of attaining better air quality over many years of discussions, policy making and policing each other. unexpectedly, it took a serious pandemic to realize such feat. this article traces the interplay of reduced oil consumption with economic issues as well as environmental consequences under pandemic conditions. the more imperative issues now lie on the severity of a looming recession and the global economy's resiliency in transcending the difficult challenges it may bring. should that happen, will the economic cost burdens be outweighed by the realized environmental gains? experts may be quick to assert that improved environmental conditions actually may be short-lived as expected resurgence of resumed economic activities may only quickly bring back pre-covid air conditions. however, proponents of a cleaner world can always draw some inspiration from recent successes in air quality control, especially with the assurance that cleaner air is not necessarily a lofty goal. the challenge in the future lies in achieving such environmental benefit without the need to sacrifice the economic health of the global community. on february , , the brazilian ministry of health confirmed that a -year-old man was positive for sars-cov- : covid- had arrived to latin america. as of july , there have been . million confirmed cases in latin america, compared to . million in the european union and . million in the usa (jh-csse ). furthermore, so far there have been more than , deaths in the region and the trends show that the first wave of the pandemic is far from over (ibid.). there is of course no suitable time for a pandemic to arrive, but these are especially complicated times for latin america. the region is in the midst of a difficult economic situation accompanied by rising social discontent (eclac ; oecd ). moreover, it is characterized by high rates of informality, health systems with limited and unequal capacity, and most of the countries have high levels of debt (oecd ). under these circumstances, covid- is having major short-run socio-economic effects with possible serious long-run consequences, including several potential implications for the environment and the management of natural resources. restrictions of free movement and circulation within and across urban areas of latin america have reduced economic activity as well as the use of motorized vehicles. as a result, many latin american megacities have experienced a short-run decrease in air pollution. concentrations of no have decreased considerably in cities all over the region compared to the levels observed prior to the lockdown measures (iadb ). levels of pm , pm . and co have decreased in bogota, buenos aires and quito (bogota's district secretary of environment, personal communication, june ; roa ; rocha ). nevertheless, the pandemia has not had the same effect on air quality in all the major cities in the region. in mexico city, the reductions in so , pm . and pm concentrations have been modest, and there has been no reduction in ozone. in rio de janeiro, ozone concentrations have increased (dantas et al. ) . furthermore, as the virus and its negative consequences spread across rural areas and make its way through the southernmost part of the region, outdoor and indoor pollution might actually increase. in mexico, as well as in other countries in the region, the use of firewood is likely to rise as rural households try to deal with income reductions (masera et al. ). meanwhile, as winter hits central and southern chile, urban households might increase their use of firewood for heating given that, due to the lockdowns, they have to spend more time inside dwellings (encinas et al. ) . this rise in air pollution could arguably increase the risks associated with covid- . it is too soon to do a formal evaluation of the effects of the pandemic on deforestation and land use change in the region. nevertheless, the available information suggests that covid- is likely to have negative effects on forest cover across the region. early deforestation warnings from peru show that, although deforestation decreased between march and april , since then it has increased surpassing the levels observed during the same period in . according to data from the brazilian national institute for space research (inpe), the first quarter of already evidenced a rise of % in deforested hectares compared to last year's figures. the figures for april reinforce this pattern, with a % increase with respect to april (manzano ). from january to april , deforestation alerts in indigenous territory increased % when compared to the same period of the previous year (greenpeace brasil ). although at this point it cannot be claimed that the pandemic caused the observed increase in deforestation, it certainly does not seem to have provided incentives to halt it. in colombia, contrary to other countries in the amazon region, the trend in showed a reduction in deforestation compared to . however, started with an increasing tendency and the quarantine seems to have worsened the situation (fcds ). the absence of environmental monitoring during the pandemic seems to have encouraged illegal armed groups and regional mafias to take advantage of the situation, exacerbating deforestation with the possible intensification of illegal activities from which these actors derive income, such as illegal mining, land grabbing and illicit crops (bbc ). according to the pan american health organization, in may there were already , covid- -confirmed cases in the amazon basin (martín ). the impact of the pandemic in forest-based indigenous communities is an important source of concern. the spread of the virus in these communities could imply a tragedy that, in addition to the human losses, could affect the traditional knowledge, having negative impacts on the governance of natural resources in the region. this could lead to even more deforestation processes in the future. covid- has caused a disruption in the national and international trade of nature-based goods and services. tourism has come to a halt, affecting the economy of almost all of the countries in the region (mooney and zegarra ). in countries like costa rica, where the touristic industry is intertwined with nature, the shock to the sector could have negative effects for biodiversity and forests. without income from tourism, and given that as a slow recovery process is anticipated, the incentives to protect forests are expected to decrease in the short and medium run. fishing and aquaculture are other industries that have been negatively affected. information for the case of the chilean salmon aquaculture industry suggests that there has been a reduction in demand from international markets (chávez et al. ) . the effect of the shock is being transmitted through the value chain, affecting processing plants and farming facilities. the economic crisis can end up having long-run negative consequences for the environment if, as a result, regulations and environmental policies are relaxed or if institutions are weakened. although at this point there is no evidence of any country in the region purposefully relaxing environmental regulations to promote growth, it is certainly a possibility. what has been observed is that, in order to fund measures to reduce the economic and social impacts of the pandemic, some countries have decided to reallocate funds across the public administration. ecuador, for example, announced cuts affecting the ministry responsible for enforcing environmental regulations (bbc news ). something similar is happening in mexico, where the plan announced by the president is to reduce the operational budget of almost all government entities by % (d.o.f. ). even if countries have a relatively strong environmental legal framework, without a budget to monitor and enforce the regulations, this framework is worthless. countries in the region will very likely incur fiscal deficits and increase their debts in order to fight the crisis. it remains to be seen how the service of the increased debt will impact economic growth and the environment. in the meantime, it seems that the short-run legitimate demands to recover employment levels and improve the health systems might very well push aside the necessary investments to successfully tackle climate change and biodiversity loss. if this indeed happens, it could be the most serious effect of the covid- pandemic in both environmental and social terms. the economic projections suggest that the region will experience a crisis whose magnitude has no precedent in modern history (eclac ). in order to overcome this apparently insurmountable challenge, latin american countries will need well-designed policies that should reconcile economic objectives with social and environmental goals. the social unrest manifested recently in the social mobilizations in the region, should make clear that the apparent trade-off between economic, social and environmental objectives is the result of a false dichotomy between shortand long-run objectives. if environmental objectives are put aside, as has so often happened with social objectives, the economy might recover in the short run but at a very high price. the lockdown measures seem to be having a temporal positive effect on reducing urban pollution in some latin american cities. the challenge now is how to intervene to prevent a return to the same or even higher pre-quarantine emission levels. this is an opportunity to rethink the urban environmental policies while trying to recover from an unprecedented social crisis. at the same time, the observed increase in deforestation reopens political and academic debates about the role of national parks, indigenous reserves and other protection categories in a context of deteriorated livelihoods, illegal economies and a lack of state presence. latin american countries could see this moment as an opportunity to improve regional cooperation in order to design and implement coordinated policy responses not only to the economic crisis but also to the challenges of mitigation and adaptation to climate change. furthermore, countries should coordinate efforts to increase monitoring and presence in the region to effectively reduce deforestation. we have presented an account of some of the most evident environmental effects that the covid- pandemic is having in latin america at this point. considering that we are in the midst of the health crisis and in the beginning of an economic one, it is natural to expect that the trends that we see now will change in the near future and that other environmental impacts will become evident. research that contributes to a better understanding of the environmental impacts and the effectiveness of different policy responses to the pandemic in latin america will be invaluable. there are many potential paths for future research; here, we mention just a few. the consequences of the interactions between poor air quality and covid- on human health are clearly worth studying. this is particularly relevant for the latin american context, characterized by health systems with very limited capacity and high numbers of population without formal employment. results from studies in this area could help us provide better guides to set environmental quality goals, as well as to implement policy interventions that can reduce pollution in the region's context of income inequality and spatial segregation. the short-run environmental effects of covid- show early warnings of an increase in the pressure on forest and other ecosystems across latin america. understanding the impacts of the pandemic on terrestrial and marine ecosystems, as well as on livelihood opportunities for local communities, has the potential to contribute to the design of policies which can improve management and conservation. the pandemic is opening new research questions regarding the impacts of global shocks on natural resource-based industries that participate in international markets. furthermore, the paths that different countries take to get out of the economic crisis might have profound impacts on international trade. if, for example, the world transitions to more reliance upon local production, or if emissions-related tariffs are imposed, large exporters of commodities in the region will be highly affected. the impacts that these potential trade changes could have on the environment are unknown. furthermore, if developed countries implement recovery plans that include provisions to reduce emissions in significant ways, as has been discussed in the european union, will latin american countries be able to respond in the same way? in any case, latin american countries are highly vulnerable to the effects of climate change and some of these effects (e.g. migration) could result in future health crises. a better understanding of the ways in which individuals might adapt to a changing climate, as well as of the barriers that they face to adopt adaptation measures, will be a valuable tool for the design of adaptation policies that prevent future health crises in the region and elsewhere. the distributional and gender-differentiated impacts of the pandemic, and the related environmental policy responses, is another area that deserves attention, especially because early evidence shows that the more vulnerable segments of the population in the region are the ones that are being hit hardest. finally, as has been recently pointed out by , the experience of the pandemic might lead to changes in behaviour and personal choices. it remains to be seen if this is in fact the case, and if so, how are these changes in behaviour modulated by the local context. an even more important issue to consider is what would these changes imply for the design of behaviour-based policy instruments aiming to change consumption and production patterns, as well as transport and land use decisions in latin america. bbc ( ) the place where nature isn´t healing. https ://www.bbc.com/reel/video / p bd wfc/the-forgo tten-peopl e-of-the-globa l-pande mic accessed june bbc news ( ) coronavirus en ecuador: las multitudinarias protestas por las drásticas medidas económicas y recortes de lenín moreno. https ://www.bbc.com/mundo / notic ias-ameri ca-latin a- accessed june chávez c, salazar c, simon j ( ) efectos socioeconómicos y respuestas públicoprivadas de corto plazo ante la crisis del covid- en el sector salmonicultor, una fotografía de la experiencia internacional. interdisciplinary center for aquaculture research-incar, fondap-anid, center, chile. https ://www.incar .cl/wp-conte nt/ uploa ds/ / /pb .pdf accessed june dantas g, siciliano b, frança b. b, da silva c. m, arbilla g ( ) the impact of covid- partial lockdown on the air quality of the city of rio de janeiro, brazil. sci total environ . https ://doi.org/ . /j.scito tenv. . . d.o.f. ( ) decreto por el que se establecen las medidas de austeridad que deberán observar las dependencias y entidades de la administración pública federal bajo los criterios que en el mismo se indican. de abril de . presidencia de la república de méxico. eclac ( ) report on the economic impact of coronavirus disease (covid- ) on latin america and the caribbean: study prepared by the eclac, santiago, p encinas f, truffello r, urquiza a, valdés m ( ) covid- , pobreza energética y contaminación: redefiniendo la vulnerabilidad en el centro-sur de chile. centro de investigación e información periodística. https ://ciper chile .cl/ / / /covid - pobre za-energ etica -y-conta minac ion-redefi nien do-la-vulne rabil idad-en-el-centr o-surde-chile /. accessed june fcds. ( ). cifras deforestación en el bioma amazónico, enero-abril .https :// fcds.org.co/site/wp-conte nt/uploa ds/ / /defor estac ion_ .pdf accessed june greenpeace brasil ( ). desmatamento em terras indígenas aumenta % em . https ://www.green peace .org/brasi l/press /desma tamen to-em-terra s-indig enas-aumen ta- -duran te-a-pande mia-da-covid - / accessed june helm d ( ) . contributing to a global effort. oecd. roa s ( ) medidas para enfrentar al covid- mejoran calidad del aire en dos ciudades ecuatorianas. mongabay-latam.https ://es.monga bay.com/ / /menor -conta minac ion-del-aire-por-coron aviru s-en-quito -y-cuenc a-ecuad or/ accessed jun rocha l ( ) por la cuarentena, la contaminación del aire bajó a la mitad en la ciudad de buenos aires. infobae. https ://www.infob ae.com/socie dad/ / / /por-lacuare ntena -la-conta minac ion-del-aire-bajo-a-la-mitad -en-la-ciuda d-de-bueno s-aires / accessed june resource exporters are now facing new urgent economic policy challenges due to covid- . these challenges are aggravated due to their dependence on finite commodities with volatile prices and demand. in response to the pandemic, resource exporters (such as botswana and saudi arabia) announced cuts in expenditures along with large fiscal (tax relief) and consumption-focused macroeconomic stimulus packages. critically, the novel issues raised by the coronavirus pandemic bring new trade-offs of energy policy between shortterm gains and long-term sustainability, creating an urgent need for critical, quantitative, policy-focused research in the resource exporters-energy policy nexus. a few novel issues emerged in resource exporters during the pandemic that give rise to short-term economic challenges. first, price shocks of unprecedented magnitude for commodities (deutsche bank ; world bank ), from coffee (hernandez et al. ) to hydrocarbons (iea b), causing a large drop in energy investment (iea a). for oil, prices dropped initially due to travel bans and economic activities hiatus, and further with oil price wars following the collapse of opec + agreement. by april , with oversupply, the rise of stockpiles, and the saturation of available oil storage, oil prices reached the lowest level in more than years, and west texas intermediate (wti) reached negative levels for the first time. prices have subsequently partially recovered but are expected to remain low with continuous fears of new covid- waves and uncertain demand. second, unprecedented economic contraction, because the pandemic-triggered decline in economic activity was significantly exacerbated by declines in export revenue. third, unprecedented fiscal pressure, resulting from costs of fiscal and economic stimulus packages plus a simultaneous rise in domestic expenses (especially healthcare and unemployment benefits) and sharp declines in resource export revenue. the effects have been so colossal that states like kuwait are considering halting legally-mandated contributions to the future generations sovereign wealth fund (swf) to ease fiscal pressures (al-zo'bi ). fourth, record and continuous withdrawals from swfs to fund post-pandemic recovery along with reallocation of funds and increased government debt (examples in arabian business ; holter and bloomberg ). even states with the largest swfs such as norway and kuwait have been affected, with the latter expecting depletion of its fiscal stabilization swf (al-zo'bi ). fifth, in oil-exporting gulf states, the unusual stay of millions of citizens and guest workers in the upcoming scorching summer in lieu of usual tourism travel or home-country visits, pressuring existing energy capacity. critically, in oil exporters, these novel issues and policy responses to them further expose existing economic fragilities and challenges, threatening long-term economic and environmental sustainability. for distorted oil economies in urgent need for economic diversification, said diversification and reverse dutch disease are impeded by their existing high distortions in labour, fiscal, industrial and energy markets (shehabi ) . oil exporters suffer from economic inefficiencies resulting from pervasive oligopolies (shehabi ) and market failure in long-run contracts for exploration and development of natural resources (ruta and venables ). fossil fuels are the primary source of energy in most oil exporters. in developing oil exporters, the dominant political economy undergirding policy making is a welfare rentier state, in which maintaining a political equilibrium is central. balancing spending-saving decisions for sustainable resource rents management depends on the sustainability of windfall expectations (gelb and grassmann ). reforming energy policy-which drives fiscal, industrial and environmental policies-is critical for these states' long-term development. yet the novel issues create new trade-offs of post-pandemic energy policy: achieving short-term gains will be at the expense of longterm gains in resource economies. thus, it is critical for fast policy-focused research to address the resource exporters-energy policy nexus, especially in the following two areas. although investments in renewables have been more resilient than in fossil fuels, and while we have seen an increased share of global energy spending on clean energy technologies in (iea a), the reality in hydrocarbon-exporting developing states is different. global oil market supply and demand dynamics have raised their opportunity cost for transitioning away from fossil fuels and for investing in green technology. accordingly, post-pandemic economic stimuli might achieve short-term recovery but harm long-term energy transition. first, the rise in opportunity costs of energy transition will facilitate the reallocation of funds away from renewables projects towards post-pandemic economic stimuli (similar to "green tape" cuts in australia and canada). second, recovering lost investments in energy transition projects is unlikely because the resource rents that fund them are likely to continue to be low in the future, given low resource prices and demand pressures of climate change mitigation. third, continuous withdrawals of diminishing swfs will entail limited resources for future energy transition projects. this is especially so as recovering swfs' withdrawals is unlikely in the light of expected low resource export revenue and the collapse in financial and commodity markets accompanying the unprecedented global recession. finally, economic stimuli expand consumption and welfare redistributive measures, which increase greenhouse gas (ghg) emissions ) and exacerbate existing distortions that have been shown to prevent economic and energy diversification (shehabi ) . new research should investigate the design and implementation of new economic solutions that have at their forefront long-term energy transition goals along with short-term economic recovery. three policy solutions are suggested at the consumer, the energy industry and economy-wide levels. a policy solution to target consumers is technological advancements (both private and public funded) in energy efficiency coupled with economic incentives to rationalize energy consumption. this policy combination can achieve energy transition goals despite expected delays in renewables and without requiring large multiyear investments. it is especially important in gulf oil states where skyrocketing cooling and desalination needs in the summer will be met using fossil fuels (renewables contribute less than % of power generation). a policy suggestion at the sectoral level is investing in clean energy technologies to decarbonize the energy sector itself, namely through carbon capture and storage as well as hydrogen. beyond short-term economic and environmental benefits, these investments can keep oil exporters relevant in a future with a diminishing role of hydrocarbons and collapsing commodity prices. the final policy suggestion is microeconomic and energy policy reform that can moderate effects of export price declines on the economy without the need for additional cuts in renewables investments or further withdrawals from swfs. examples include microeconomic reforms of labour and human capital to increase long-term productive capacity and oligopoly regulation in non-tradables and energy sectors which can increase efficiency and welfare gains that translate economywide (shehabi ) . consequently, resource rents could be salvaged for swfs resources or investments necessary for future development. in the light of the aforementioned novel issues in resource exporters, the postpandemic energy policy and economic stimulus packages are likely to have negative long-term effects on the environment. the reasons are as follows. first, while lockdown measures that minimized transportation and human activity reduced short-term emissions, they also increased power demand which in resource exporters is met mostly through fossil fuels, especially as international demand and prices remain low. second, short-term improvements will be negated upon the resumption of human activity, absent changes in energy policy regimes. importantly, as domestic energy prices remain low and highly subsidized in developing resource exporters, the extent to which covid- restrictions would shift energy consumption habits and behaviours of agents (households and institutions) remains very doubtful. third, there will be limited resources in the future to dedicate towards environmental regulation and ghg emissions reduction. the reason is that funding the post-pandemic recovery will reallocate funds away from environmental projects and savings in swfs. fourth, ghg emissions will increase due to consumption-focused economic stimulus packages and expanded use of fossil fuels to meet rising energy demand. this is particularly problematic because even prior to the advent of the pandemic, resource exporters were among the highest energy consumers and carbon emitters globally. indeed, the ten highest per capita carbon emitters are all resource exporters, with emissions ranging from tonnes (t) per capita (qatar) to . t per capita (kazakhstan), more than . times the global average of . t per capita (ritchie and roser ) . finally, and most importantly, the implementation of policy instruments-namely energy subsidy reform and carbon taxes-to achieve resource exporters' intended nationally determined contributions (indcs), is rendered significantly more difficult post-pandemic. it is a consequence of the magnitude of novel economic contraction and fiscal pressures in welfare-based states. these additional political constraints exacerbate environmental laws' enforcement, for which there already was a widespread failure in resource exporters (unep ). therefore, new research must quantify effects of proposed economic stimuli and of rising use of fossil fuels on resource exporters' environment and economy and accordingly evaluate and design new alternative policies that can achieve short-term recovery and national climate target goals. to that end, four policy suggestions are offered. first, reducing emissions in ways other than the politically difficult tax instruments, mainly through enhancing energy efficiency that reduces emissions at a given consumption level coupled with economic incentives that reduce energy consumption. second, implementing carbon tax instruments in ways that do not harm the most vulnerable of populations and reduce resource exporters' fiscal distortions, thus achieving a "double dividend". third, in the light of the novel issues, a key policy solution is adopting "green welfare expansion": including green options in the typical post-pandemic welfare packages at lower governmental budgetary requirements. examples include expanding subsidies for green technologies (such as solar panels, public transportation or electric cars), as well as excluding from subsidies non-essential high-carbon-emitting products for households above a certain income level. fourth, increasing the political viability of green recovery packages (such as clean physical infrastructure and natural capital investments), including engaging the private sector in initiatives that are typically public-led-such as climate finance, renewables expansion and resource mobilization. this policy is critical because, although green recovery packages may boost economic growth while helping climate change , they are politically contentious in resource exporters where they compete with welfare distribution. critically, applicable to the aforesaid two research areas, the pandemic offers resource exporters an opportunity to engage in a comprehensive reform agenda that addresses short-term pandemic effects while advancing long-term energy transition, economic and resource sustainability. the challenge for policy makers is to avoid implementing policies in haste. properly coordinated policy reforms offer an avenue to address inefficiencies and underlying structural distortions in a way to realize mutual gains and multiple policy objectives at the lowest cost. in designing these reforms and addressing the two areas above, the most suitable research methods are economy-wide general equilibrium models that can quantify effects of shocks and policy solutions in a "second-best" environment. this feature is necessary given the large existing economic distortions in resource economies. these models represent economic linkages and agents and include a wide range of policies (energy, carbon, fiscal, labour or industrial). as such, they can inform evidence-based policy making that accounts for political economic considerations. this research will be critical for filling gaps in the literature on long-term economic and resource sustainability in resource exporters. the current global greenhouse gas (ghg) emissions trajectory indicates that the world is likely to experience catastrophic consequences due to climate change, unless swift action is taken towards funding green solutions and the defunding of fossil fuel activities ( given the ambition of the european union to become a net zero-carbon economy by and the numerous calls to avoid the bailout and stimulus packages towards fossil fuel companies , we examine whether the features of the european central bank's (ecb) € billion pandemic emergency purchase programme (pepp) encourages the resilience of the incumbent fossil fuel sector, or whether it promotes the growth of the emerging low-carbon energy sector during the covid- pandemic and beyond. we draw on a novel dataset of corporate bonds issued in the european energy sector between january and june in combination with the european central bank's (ecb) purchases under the pandemic emergency purchase programme in response to covid- . we show that the likelihood of an energy company bond to be bought as part of the ecb's programme increases with the ghg intensity of the bond issuing firm. we also find weaker evidence that the ecb's pepp portfolio during the pandemic is likely to become tilted towards companies with anti-climate lobbying activities and companies with less transparent ghg emissions disclosure in the event of increased euro-denominated bond issuances in the following months, or re-denominations of non-euro bonds already issued by european energy companies. kainen et al. ). that does not mean, however, that the aim of central banks to remain sector neutral is achievable in practice, as the implementation of ecb's post- quantitative easing shows that assets purchased by central banks to stimulate overall economic growth are benefitting more from the policy than assets which are not purchased by the bank (haldane et al. ; matikainen et al. ) . this means that the choice of asset class through which asset purchasing programs are implemented matters. this is particularly important in the low-carbon economy context, as the fossil fuel energy sector is largely financed through bonds and syndicated bank loans (cojoianu et al. ) , whereas much of the emerging clean technology companies are financed through private equity, equity issuances and asset financing (cojoianu et al. ; gaddy et al. ) . given that the ecb has chosen to enact its asset purchasing program post- crisis predominantly through bonds, this has been shown to favour the incumbent fossil fuel industry (battiston and monasterolo ; matikainen et al. ) , as % of ecb's corporate bond purchases (out of a total of € billion) are in ghg intensive sectorsthough they make up only % of the eurozone area economy and produce % of ghg emissions. the criteria for the corporate bonds bought under the pepp are that: (i) the company must be incorporated in the eurozone and its bond issuance denominated in euro, (ii) the firm cannot be a financial corporation (or a credit institution supervised by the ecb), (iii) it cannot be a public entity, (iv) the bond issuance has to be endorsed by one positive credit rating by an external credit assessment institution accepted within the eurosystem credit assessment framework and (v) they have a maximum maturity of up to years and a minimum maturity of months. in order to understand whether the ecb's bond buying activity during the covid- pandemic has been tilted towards less transparent, more fossil fuel intensive as well as anticlimate lobbying european energy companies, we undertake the following steps. first, we collect all the bonds issued by european energy companies during the period january to june from bloomberg. these span the following energy subsectors as classified by bloomberg industry classification system (bics): power generation, renewable energy, integrated oil and gas companies, oil and gas exploration and production, oil and gas services and utilities. this results in bonds. we then match each bond with ecb's bondholding portfolio, the borrower's record on pro/anti-climate lobbying from influencemap, the ghg intensity of the borrower (collected from bloomberg and measured as thousands tco -e/million eur revenue) and the ghg reporting completeness of the borrower (which is assessed by bloomberg and quantified as if the company is transparent about the organisational boundary it chooses to quantify its ghg emissions and otherwise, bloomberg terminal code es ). we further collect the borrower's revenue (million eur), bond amount issued (million eur) and coupon rate for each bond, also from bloomberg. our resulting dataset with complete data across all variables of interest is comprised of a cross-section of bonds issued across several currencies, and eurodenominated bonds. our dependent variable quantifies the likelihood that the bond of a european energy company is bought by the ecb during the first months of and coded as if it has been bought by the ecb, and if it has not. for our model, we employ a binary logistic regression model with robust standard errors. the full model specification is the following, where ε i is the stochastic error: we show that after controlling for the revenue of the issuer, the bond amount raised and the rate of the coupon, the ecb is statistically significantly more likely to buy the bonds of more ghg intensive european energy companies (models - , table ). on average, a one standard deviation increase in the ghg intensity of an energy company results in a % increase in the likelihood that its bonds are bought by the ecb (β = . , p < . , odds ratio: . , model ). when we consider only euro-denominated bonds (models and ), which are directly under the remit of the ecb, ghg disclosure completeness and pro-climate lobbying are statistically insignificant, yet negative, which suggests that the ecb may be likely to tilt its portfolio towards companies with poorer ghg emission disclosures and less responsible climate lobbying activities. subsequently, we include the bonds issued by european energy companies in denominations other than euro, to account for potential sample selection bias due to the choice of energy companies to abstain from issuing euro-denominated bonds as they may have received discouraging signals from the ecb. in other words, analysing the bond issuance of european energy companies in all currencies considers signals that the ecb may have given to the energy companies prior to issuance, while analysing only euro-denominated bonds only considers the observable decision of the ecb to purchase the bonds of specific energy companies post-issuance. when we do so (model ), it emerges that considering the entire universe of bonds issued by european energy companies, the ecb's portfolio is tilted not only to those energy companies that are more ghg intensive, but also to companies which are less transparent on their ghg performance as well as those companies who are more likely to oppose progressive climate action. having established statistical significance, we investigate the economic and statistical relevance (brooks et al. ) . inspecting the economic relevance of the ghg intensity variable in model , we find ghg intensity to have the largest marginal effects. in terms of statistical relevance, we find ghg intensity to have by far the largest shapley r-squared value, contributing more than % to the overall explanatory power of model . in conclusion, the importance of ghg intensity is underlined by its marginal economic effects and its statistical relevance, as it explains more variation in the dependent variable on its own than all other variables taken together. we also conduct further robustness tests controlling for ecb bond i = + * pro-climate lobbying activities score i + * ghg emissions intensity i + * ghg reporting completeness i + * borrower revenue i + * bond issuance amount i + * bond coupon rate i + i . bond maturity, bond rating and interactions of key variables and find our results to remain statistically significant. in conclusion, drawing on a novel dataset of corporate bonds issued in the european energy sector since january and the database of ecb's purchases under the pepp in response to covid- , we find evidence that the likelihood for a bond to be bought by the ecb increases with the ghg intensity of the bond issuing firm. we also find weaker evidence that the ecb's pepp portfolio during the pandemic is likely to become tilted towards companies with anti-climate lobbying activities and companies with less transparent ghg emissions disclosure. our findings imply that, at later stages of the covid- recovery, an in-depth analysis may be necessary to understand if, and if yes, why the ecb fuelled the climate crisis. even if one accepts that fossil fuel companies were eligible for pepp, then our preliminary evidence still raises the significant question, why the ecb was more likely to directly finance those fossil fuel firms that are likely more harmful to the planet (i.e. have a higher ghg intensity)? the coronavirus covid- pandemic is the defining global health crisis of our time, causing over half a million deaths to date ( july ). but covid- is much more than a health crisis, it has tremendous socioeconomic impact, the scale of which is still hard to assess. measures to address the health crisis generate economic impacts (and vice versa). social isolation measures to "flatten the curve of the pandemic" buy time to increase capacity in the healthcare sector but inevitably deepen the macroeconomic recession. the world bank expect the global economy contract by . % in , approximately three times the size of the - great financial crisis (gfc) and far more widespread. emerging markets and developing economies (emdes) have been severely hit by massive capital outflows, reducing debt servicing abilities (especially for dollardenominated debt) and generating long-term challenges; "with more than % of emdes expected to experience contractions in per capita incomes this year, many millions are likely to fall back into poverty" (world bank ). the economic consequences of the adverse coronavirus shock are: (i) an elevation of uncertainty, which increases precautionary savings, thus reducing consumption and also curtails the appetite for productive investments; (ii) a rise in unemployment, part of which is likely to be permanent; (iii) a decline in the volume of international trade and disruptions in global supply chains; (iv) falls in commodity prices (especially the price of oil), making current account financing of traditional commodity exports challenging; (v) a sharp increase in the required risk premia for holding risky assets. this initially resulted in a plunge in prices of risky assets (e.g. stocks or high-yield bonds) and a sharp increase in financial volatility. however, central bank interventions (especially by the federal reserve of the united states of america-us fed) have seen recoveries from march . extraordinary macroeconomic policy response, on both the fiscal and monetary fronts, has slowed the rates of economic decline. in many countries, fiscal measures have replaced a proportion of lost incomes and mitigated default risk, loan guarantees have helped keep businesses afloat, and liquidity provision by central banks have kept the financial system functional. fiscal authorities in european and the usa took measures that can be classified within three broad categories: immediate fiscal measures and direct transfers to households; tax deferrals and liquidity measures; and loan guarantees. the scale of intervention is truly unprecedented reaching almost % of gdp in germany and % of gdp in the usa. on the monetary front, the fed cut interest rates to zero, announced unlimited purchases of treasuries and mortgage backed securities and started buying corporate debt. moreover, the fed opened debt swap lines with foreign central banks to provide dollar liquidity to the international financial system. the value of fed measures to date exceeds . trillion dollars. the european central bank ecb "has offered low-interest loans to banks, significantly boosted asset purchases, and allayed fears of member-country defaults by lifting distributional restrictions on its bond-buying program" (world bank ). moreover, the eu's recovery plan (proposed may ) mobilizes investments through a recovery instrument of € bn for the period - and a reinforced a long-term budget of € . trillion for the period - . despite these unprecedented measures, the course of the pandemic and its developing economic impact remains uncertain. how can long-term economic dislocation be avoided? a first priority should be to ensure that the work force remains employed. second, governments should channel financial support to public and private institutions that support vulnerable citizen groups. third, small medium enterprises (smes) should be safeguarded against bankruptcy. (the need for taxpayer money to support large nonfinancial corporations is much less obvious.) fourth, policies will be needed to support the financial system as nonperforming loans mount. fifth, fiscal packages, comparable to the loss of gdp, will have to be financed by national debt. while this should be structured to avoid another debt crisis, finance should be directed to investments with positive social, economic and environmentally sustainable profiles, as discussed in the following. there is widespread scientific speculation that economic growth has pushed humanity into new ecological niches wherein humans and animals exchange novel, infectious viruses of which covid- is just the latest in a considerable list of examples. furthermore, the intergovernmental panel on climate change (ipcc) has warned that global warming will likely accelerate the emergence of new viruses. overall, climate change has the potential to end up killing more people than covid- , although this is obtusely referred to as an "increased frequency and severity of natural disasters". such language, the delayed, cumulative nature of the threat and the necessity of coordinated international response, all mitigate against the urgent action that is required. timing is also important. as ipcc ( ) reports, the level and speed of change needed to successfully tackle the climate crisis, is unprecedented; incremental changes will not be enough. that said, there are aspects of the climate change crisis which are less challenging than the covid- pandemic. as sterner ( ) notes, the climate crisis requires policy changes that are less disruptive, economically, socially and culturally, than the measures being taken right now to tackle covid- . for the climate, we do not need to close down the economy. on the contrary, we need a transition to a low-carbon economy that supports public and private investments in renewables, energy efficient and circular, technologies and infrastructure. these technologies exist (wind, solar, etc.) and are becoming consistently cheaper than fossil fuels, while energy storage installations are increasing exponentially. there is growing evidence that green stimulus policies have advantages over traditional fiscal stimulus and that climate-positive policies also offer superior economic characteristics. for example, hepburn et al. run a global survey to assess stimulatory fiscal recovery policies implemented in response to gfc. the economists from countries were asked to ascertain their perspectives on covid- fiscal recovery packages according to: "speed of implementation", "long-run economic multiplier", "climate impact potential" and "overall desirability" according to social, political and personal factors. the responses indicate that green stimulus policies deliver higher multiples due to reduced long-term energy costs and flow-on effects to the wider economy. "relaunching the economy does not mean going back to the status quo before the crisis but bouncing forward. we must repair the short-term damage from the covid- crisis in a intergovernmental panel on climate change, . way that also invests in our long-term future". this code explains the strategy of the eu recovery plan based on three axis: the european green deal, adaptation to the digital age, and a fair and inclusive recovery for all. we must start investing in what makes our socio-economic system resilient to crisis. now is the time to usher in systemic economic change and the good news is that we have our blueprint: it is the combination of un agenda ( sdg) and european commission's european green deal. the european green deal (egd) announced december is the new growth strategy of the european union and is based on four principles: (a) climate neutrality by , (b) protection of human life and biodiversity by cutting pollution, (c) world leadership in clean technology, (d) leave no one behind. the egd investment plan amounts to eur billion per year by . the egd just transition mechanism will help mobilize at least € billion over the period - in the most affected regions. the - multiannual financial framework (mff) allocates an overall target of % for climate mainstreaming across all eu programs. the proposed european climate law aims to turn the egd's political commitment of climate neutrality, into a legal obligation. based in un environment program (unep) emissions gap report , global emissions need to be reduced by % by . unfortunately, the proposed law does not include an ambitious goal with regards emissions, nor does it address the legislative interventions required to achieve climate neutrality by . together with the egd, the sustainable development goals (sdgs) and the paris agreement call for deep transformations. while significant progress is being made on some goals, no country is currently on track towards achieving all sdgs. sachs et al. ( ) identify the major interventions needed to achieve each sdg and group them in six sdg transformations, which operationalize the sdgs at government level and can prove instrumental for egd implementation. the success of the join implementation of the sdgs, the egd and the eu recovery plan will depend on the eu's capacity to engage with its citizens in codesigning the pathways that will allow them to reach the vision, hence the introduction of the european commission climate pact. https ://ec.europ a.eu/info/live-work-trave l-eu/healt h/coron aviru s-respo nse/recov ery-plan-europ e_en. european parliament, committee on environment, public health and food safety draft report on the proposal for a regulation of the european parliament and of the council establishing the framework for achieving climate neutrality and amending regulation (eu) / (european climate law), / (cod). the review of the climate law summarizes the review of the climate change committee of the greek ministry of energy and the environment, the first author of this paper is a member of this committee and co-author of this greek review. united nations environment programme ( ). emissions gap report . unep, nairobi. the proposed climate law does not allow the european commission to impose sanctions on member states (ms), while there is lack of reference to the financial mechanisms that will be required to achieve the goal of climate neutrality. moreover, the law does not consider (a) the well-documented heterogeneity in area-specific climate vulnerability among ms, (b) an eu wide carbon tax and (c) strengthening the european ets. sachs et al. ( ) : the sustainable development goals and covid- . sustainable development report . cambridge: cambridge university press. ( ) education, gender and inequality; ( ) health, well-being and demography; ( ) energy decarbonization and sustainable industry; ( ) sustainable food, land, water and oceans; ( ) sustainable cities and communities; and ( ) digital revolution for sustainable development. https ://ec.europ a.eu/clima /polic ies/eu-clima te-actio n/pact_en. recent generations, including the present, have experienced at least three global crises: the financial crisis - , the ongoing covid- pandemic and the developing climate crisis. if we continue attempting to address the latter two with the same socio-economic model that gave rise to the former crisis, we will fail to find a sustainable and resilient socio-economic-environmental pathway. we believe that we can even do better than just react to crises by adapting to the new crisis-born reality. we can use the integration of scientific, economic and socio-political knowledge to design policies which not only address the immediate impacts of the covid- pandemic, but mitigate the existential threats of future pandemics and the ongoing and unfolding disasters of climate change, biodiversity loss and planetary boundary exceedance. what is needed now is a fundamental transformation of economic, social and financial systems that will trigger exponential change in strengthening social, economic, health and environmental resilience. we need big thinking and big changes. system innovation and transitions thinking can help but calls for intense public participation. now is the time, in addition to directing funds to the control of the epidemic and relevant biomedical research, as well as investing in border security, safe travel and safe trade, now is the time for financial institutions and governments to embrace eu taxonomy for sustainable investments ( ) to phase out fossil fuels by deploying existing renewable energy technologies, eliminate fossil fuel subsidies and redirect them to green and smart climate mitigation and adaptation infrastructural projects, invest in circular and low-carbon economies, shift from industrial to regenerative agriculture and invest in food security, promote european supply chains, reduce transportation needs and exploit the limits of the digital revolution, while ensuring secure information and communication technology networks. a decisive march along this sustainable pathway will enhance economic and environmental resilience, create jobs, and improve health and well-being. the transition should be inclusive and "leave no one behind", hence the need of transforming citizens into codesigners and co-owners of the sustainability transition pathways. kiel institute for the world economy, kiellinie , kiel, germany. wilfried. committing to rigid shutdown measures to contain the spreading of the corona virus has been undertaken on the tacit assumption that these measures will be temporary and can be loosened when the covid- infection rates decrease and discontinued altogether once vaccines are available. mitigating climate change and achieving ambitious temperature targets as set out in the paris agreement require a long-term structural change taking us away from our current carbon-intensive economy to a zero-carbon and then net-negative carbon economy. as current research holds out little hope that a "perfect" vaccine in the form of solar climate engineering will be available in the future, the measures and efforts required must translate into a permanent, ongoing form of commitment. while progressive climate change and the spread of the coronavirus operate on very different timescales, impatience about the duration of corona lockdown has indicated once more a fundamental problem for (long-term) environmental concerns. clearly, the economic and social costs associated with the emergence of the virus and the shutdown are significant , oecd . but any serious cost-benefit analysis would need to take into account not only the fact that different degrees of lockdown are available but also that the overall cost is affected by the expectations of agents regarding possible future re-lockdowns due to insufficient containment of the virus. seen thus, it is anything but clear at which point in time the actual cost of lockdown would have exceeded the economic cost of the virus spreading in an unmitigated (or insufficiently mitigated) way. during the course of lockdown measures, voices calling for a "green" recovery stimulus package centring around low-carbon investments in the aftermath of the corona crisis have make themselves heard. by contrast, advocates of postponing climate mitigation-related taxes, levies, and regulations have also entered the fray, claiming that timely recovery should not be jeopardized by any additional economic burdens. the debate on the relation between (economic) recovery and climate policies has been conducted from three major perspectives. the first of these is largely notable for general statements of intent recommending that the recovery should be "green" and sustainable, that eu climate targets should be supported, and that other environmental targets (maintaining biodiversity, etc.) need to be taken into account when designing recovery measures. such well-meant counsels as the statement issued by the german national academy of sciences leopoldina ( ) are useful in reminding us that recovery from the corona crisis should not come at the expense of neglecting other objectives and that climate policy should not be backburnered, as was the case after the financial crisis in . otherwise, they are of little practical value. the second approach has involved rather detailed proposals calling either for a "greening" of recovery by foregrounding measures to support renewable energies, public transport, energy efficiency, etc. or for a "blackening" of recovery by postponing and/or abandoning climate measures and environmental regulations. predominantly, these proposals are representing the positions of the various interest groups involved. for example, representatives of the aviation industry try to prevent the harmonization of carbon prices on fuels with respect to kerosene and argue against the introduction of kerosene taxes. this idea resurfaces in the discussion on recovery measures by, say, the austrian aviation association ( ). on the other hand, in its comprehensive list of (recovery) demands, the ngo german environment action ( ) urges for example for the abandonment of blue hydrogen projects (though not explaining why this is likely to stimulate economic recovery). various other interest groups are in favour of postponing, suspending or even abandoning existing environmental and climate regulations. for example, janusz kowlaski, the polish deputy minister of state assets urges "…[that] the ets [european emissions trading scheme] should be removed from january , or at least poland should be excluded from the system". clearly, there is no point in discussing nonsensical ideas of this kind. but some of these proposals also make sensible suggestions like adjusting the german cap on renewable energy installations or abandoning the eu average fleet-consumption regulation because the former contradicts german renewable energy targets and the latter is an inefficient instrument for regulating vehicle emissions. however, these suggestions do nothing to provide stimulus for a quick recovery. while specific processes and regulation timelines for regulations may need to be adjusted in the context of the corona crisis, sensible measures of this kind should be discussed and decided upon in the regular political process. confining potential stimulus and recovery measures to their proper purpose does not mean imposing a ban on meaningful (climate or environmental) policies that are not associated with the corona crisis. the third and most sensible perspective replaces specific proposals with (sustainability) assessment guidelines like those suggested by the world bank ( ). while hardly any possible recovery measure would perform well against the comprehensive list of criteria provided by the world bank, such guidelines are helpful in arguing against interest group driven proposals. the world bank has suggested that potential measures up for consideration as part of a recovery strategy need to be assessed against both, short-and long-term criteria, an example for the former being the expected economic multiplier associated with certain measures. bayer et al. ( ) suggest that income transfers (as planned under the us cares package) perform well against this specific short-term criteria: they could help to stabilize private-sector spending and the multiplier could increase to in the case of transfers being conditional-but not related to emissions but to the propensity to consume, i.e. conditional on being unemployed. however, privatesector spending like this should not imply any unintended adverse effects on essential long-term structural change that might arise from such things as (temporarily) adjusted risk preferences. once postponed or stimulated demand and investment take place during the recovery process, carbon-price signals are vital in providing technology-neutral incentives for low-co purchasing and production decisions. overloading stimulus or recovery packages with too many (emission-related) conditions performs poorly against the short-term criteria with respect to a timely recovery. even worse, the inclusion in recovery packages of various detailed suggestions from the various interest groups usually results in a non-transparent, rent-seeking, and political bargaining process in which it remains unclear whether (sensible) individual emissionrelated decisions are being prioritized at the expense of a more challenging long-term climate policy. accordingly, accounting for the long-term criteria requires that existing or planned climate policies providing incentives for emission reductions and technological innovation should remain in place and not be postponed, let alone weakened. otherwise, uncertain (short-term) recovery impulses most likely come at the cost of less efficient emission-reduction paths in the long term. the coronavirus pandemic is having a serious impact on the economy. eurostat estimates that seasonally adjusted gdp decreased by . % in the eu during the first quarter of , compared with the previous quarter. in certain sectors, the covid- crisis has led to the temporary or even permanent closure of sites, a collapse in demand and an increase in production costs linked to the fight against the spread of the virus. this decline in activity can trigger bankruptcies, which result in unemployment and the destruction of physical and human capital, leading in turn to a loss of specific knowledge and skills and to market concentration and the partial relocation of production activities. from an environmental point of view, bankruptcies and relocation may generate higher emissions by increasing production in more polluting sites abroad and by increasing the transportation of goods. in addition, the decline in economic activity may have a negative effect on research and development spending, which is crucial for future growth and the development of more environmentally friendly technologies. many measures have been put in place to limit the economic effects of the covid- crisis. at the european union level, a number of measures such as direct subsidies, selective tax benefits, advance payments, state guarantees for loans and subsidized public loans to companies have been implemented. in addition, many large companies are being bailed out and there is a debate on whether conditions should be attached to this state aid. these conditions could relate to various commitments such as relocating activities, paying taxes, safeguarding employment, and protecting the environment. on may , the eu confirmed that large companies receiving emergency cash during the covid- crisis will not be obliged to devote funds to "greening" their operations. rescued firms will only have to report on their use of the aid and in some cases the aid could be attached to conditions such as a ban on dividends and management bonus payments. nevertheless, member states are free to design national measures in line with additional policy objectives, such as further enabling the green transformation of their economies. many stakeholders are still pushing for conditions to be attached to the bailouts. for instance, the eg think tank proposes making the rescue of airlines conditional on the use of less polluting fuels and tying aid to car manufacturers to the development of electric vehicles. a group of german companies has also requested that state aid be linked to climate actions. this article examines the merits of making aid conditional on environmental efforts. we focus on the rescue plans for companies rather than on recovery plans or the european green deal, which was launched before the covid- crisis. we show that tying aid to environmental efforts is difficult to implement and requires both controls and sanctions, as well as a large amount of information. we also discuss the merits of tying bailouts to environmental efforts compared with implementing more stringent environmental policies (presuming that companies will be bailed out in any case). since environmental efforts can lead to higher product prices and lower profits, two dimensions of acceptability must be taken into account: acceptability from the point of view of companies and social acceptability. acceptability of environmental policies by companies is a necessary condition for their implementation. in the midst of the current crisis, many polluting industries are lobbying to weaken and delay environmental regulations. for instance, the environmental protection agency issued a sweeping suspension of its enforcement of environmental laws, allowing companies to breach environmental standards during the coronavirus outbreak. in indonesia, the trade ministry revoked rules requiring basic certification that wood exports were legally produced, in response to lobbying from the furniture and logging industries. lobbyists may also encourage legislators to compensate companies for losses related to environmental regulation. the implementation of rescue plans, by providing aid and guarantees, could be a tool to make environmental efforts more acceptable for firms. acceptability by society is also central. it depends on the redistributive effects of environmental policies, especially since they are often regressive. in france, the "red caps" and "yellow vests" movements illustrate the difficulty of implementing such policies. both of these movements led to the cancellation and delay of environmental policies (eco-tax applied to heavy vehicles and carbon tax, respectively). the covid- crisis may affect societies' support for more ambitious environmental policies. several observations can be made. first, it appears that there is a confirmation bias, as countries and ngos that had already committed to fight against global warming want to intensify efforts, while countries that were already recalcitrant are calling for a decrease in efforts in the light of the economic crisis. second, the covid- crisis makes the risk of disaster more salient and vivid and may therefore increase the demand for stronger environmental protection. as explained by sunstein ( ) , if a particular risk is cognitively "available" then people will have an increased fear of the risk in question. finally, the crisis has revealed that populations will accept drastic measures (lockdown, wearing face masks) and a rapid change in social norms (social-distancing, for instance), which shows the ease with which individuals could adapt to more ambitious environmental policies. see oates and portney ( ) for a literature review of interest groups and environmental regulation. "polluter bailouts and lobbying during covid- pandemic", the guardian, april , . burkey and durden ( ) and joskow and schmalensee ( ) have detailed how firms can influence the regulator's decisions in the context of pollution rights markets, while bovenberg and goulder ( ) , hepburn et al. ( ) and nicolaï ( ) have shown that few permits are sufficient to neutralize the losses in profits and make the implementation of pollution permits acceptable. on march , the czech prime minister, andrej babis said that the european green deal should be put to one side. during the same period, the green coalition of environmental organizations organized an appeal urging lawmakers to design a green, healthy and just recovery. we study two possible ways of increasing environmental efforts: making aid to companies conditional on environmental efforts or making existing environmental policy more stringent. making aid conditional on efforts to protect the environment can take different forms. commitments may relate, for example, to reducing pollutant emissions, using less polluting production processes, increasing expenditure on research and development, and producing less polluting products. for instance, in france, renault's bailout requires it to increase the share of electric vehicles, while the billion euro air france bailout imposes the use of at least % of alternative jet fuel by , a target of % emissions cuts by , and a % decrease in domestic flights by , especially those that compete with high-speed trains. conditional aid as currently envisaged is equivalent to negotiating and implementing individualized standards on technology, final products, research and development efforts, emissions and performance for each company. the first question that arises is how to determine the conditions. conditional bailouts allow the regulator to individualize the standards applied to a particular firm, making it possible to set the most appropriate instrument and the optimal level of severity for each firm. when making its decisions, the regulator should consider the possibility of a rebound effect as explained by saunders ( ) . an emissions standard may avoid such an effect, but a standard on technology may increase emissions. furthermore, the regulator should take into account its access to information. if the firm commits to finance research and development in green technology in exchange for being bailed out, it will be hard for the government to determine whether the state aid was actually allocated to research. for example, since the results of research are uncertain, a lack of innovation may be explained either by the firm's characteristics (anti-selection problem) or by the misallocation of public funds (moral hazard problem). finally, the regulator should take into account competition, since firms receiving bailouts usually have market power. a government will mainly intervene to save a firm if its bankruptcy would have a significant effect on the economy. the government should hence ensure that the conditions do not further distort competition. a firm with a competitive advantage, for example with cleaner technology, may have an interest in advocating more ambitious environmental efforts for itself but also for its competitors in order to increase its market share by preventing the entry or inducing the exit of such competitors. the effectiveness of conditions will therefore depend on the type of commitment, competition in the market, and the demand elasticity of the final good. another question relates to the duration of the contract. some actions are reversible and after a certain period of time companies can cancel or amend them. for example, the use of cleaner but more expensive inputs is an easily reversible strategy, while a shift in production, for example from internal combustion vehicles to electric vehicles, is a more expensive choice to change. in addition, research and development efforts produce long-term effects with the creation of innovations and possible technological spillovers. the duration must therefore be individualized in function of the company's characteristics. it should also be noted that conditional aid can lead to windfall gains. some companies had already planned emission reductions and changes in strategy. these decisions were aligned with the companies' interests. if the company benefits from the environmental efforts put in place, these can no longer be considered as a counterpart to the company's bailout and the company should then make greater efforts. it seems clear that the success of such schemes lies in companies' compliance with the commitments. companies may nonetheless have an interest in not complying with them. it is therefore necessary to monitor companies' implementation of the commitments and to sanction those that fail to honour them. supervision costs will thus be incurred. one possibility for alleviating control costs is to publicly announce the commitments, which facilitates the monitoring of companies' commitments by society (e.g. by journalists, politicians and non-governmental organizations). this also gives the firm a further incentive to respect the agreement in order to maintain its reputation and to retain its customer base (heyes et al. ( ) and heyes and kapur ( ) ). we now focus on the sanctions to be applied in the event of non-compliance with the commitments. various penalties could be considered, such as financial penalties, a ban on applying for the attribution of public contracts and the state's participation in the company. the sanctions must be explicit, credible and sufficiently significant to discourage companies from breaking their contracts. however, given the current economic situation and the fragility of companies, governments should be cautious when using financial penalties or bans from participating in public contracts since, if effective, they could be fatal to companies. an alternative could be for the state to take a share in the company in the event of non-compliance with commitments. such shareholdings would make it possible to influence companies' strategic choices, but they raise efficiency problems. cavaliere and scabrosetti ( ) , schmidt ( ) and de fraja ( ) , for instance, highlight two effects: production is more efficient in privatized firms because better incentives can be given to managers and employees (productive efficiency), while public firms are more socially efficient because the government cares about social welfare and internalizes externalities associated with firm liquidations (allocative efficiency). existing environmental policies inevitably generate monitoring costs; however, these costs will be borne in any case. increasing the stringency of environmental policy involves determining new levels for existing instruments, which generates costs, but there will be no additional monitoring costs. moreover, opting for a more stringent environmental policy means that market-based instruments can be employed, which is not feasible in the first strategy. due to the principle of non-discrimination, it is unlikely that individualized taxes could be introduced under the negotiated bailout conditions. environmental economists agree that these instruments are more effective than command-and-control instruments since they have the potential to generate revenue and allow for a double dividend, provide incentives to invest in clean technology and require less information to be designed. nevertheless, making aid conditional on environmental efforts makes it possible to individualize the regulatory instruments for each firm, which is not possible in the context of marketbased instruments. the positive effect of the instrumental individualization induced by conditionality only materializes if the existing environmental policy is based on commandand-control instruments. with market-based instruments, individualization is not required to achieve an efficient outcome, whereas it is necessary in the case of command-and-control instruments. companies' negotiation power is an additional argument for increasing the severity of environmental policies rather than conditioning bailouts on environmental efforts. regardless of the policy, firms may use their bargaining power to mitigate the stringency of the regulation or the effort they commit to make. it is clearly easier for a firm to influence its specific negotiated conditions, which are one-on-one relationships, than to influence environmental policies, which would require coordination and a common interest among firms. furthermore, making environmental policy more stringent will affect all companies and not only those receiving bailouts, which increases the attractiveness of this strategy. since they apply to a larger number of companies, these more restrictive policies will have a greater effect on the environment. to conclude, this note analyses the advantages and disadvantages of making bailouts conditional on environmental efforts. we show that such a system could be beneficial for the environment and would be a counterpart to bailing out companies. however, it is costly, requires a large amount of information, and is less efficient than increasing the stringency of existing environmental policies. on the other hand, making aid conditional on environmental effort is more acceptable from the companies' point of view than increasing the severity of environmental policies. companies would rather commit themselves to environmental efforts than pay taxes or buy permits in order to minimize compliance costs. to succeed in making environmental policy more ambitious, the regulator needs the support of society to compensate for companies' reluctance. if there is strong public support, governments should not negotiate conditional aid but should increase the severity of environmental policies. they can integrate such actions into recovery plans or, in the case of the european union, into the revision of the green deal. it is therefore particularly important to study how the covid- crisis has changed society's perception of the need for more stringent environmental policies. for instance, a recent survey by ipsos shows that three out of four people in major countries expect their government to make protection of the environment a priority when planning a recovery from the coronavirus pandemic, although there is considerable heterogeneity across countries. the post-covid- reality is changing the context of most policies, including those in the fields of energy and the environment. the eu green deal objectives should be maintained but concrete policies may have to be adjusted to this new reality. a major energy transition is under way, shaped by political will to tackle climate change. policies have been defined under the paris agreement and geared to a number of targets. the eu has decided to reduce its greenhouse gas emissions by by at least % compared to and has agreed to continue the path towards climate neutrality by . the immediate recession following the covid- crisis drastically reduced energy consumption and greenhouse gas emissions (le quéré et al. ) . the sudden decline in greenhouse gas emissions is the opposite of what a meaningful response to climate change should be, in terms of both quality of life and economic efficiency. the challenge is to structurally decouple economic growth from emissions, not to have them both going down. the lockdown may have some lasting effect in changing some of our habits ), e.g. a generalized familiarity with telework. one can also expect a more general reflection on whether all business and leisure travel, not least by air, is necessary. nevertheless, many changes may not be as extensive and lasting as some would wish. for this reason, it is important to integrate a climate check into the stimulus packages that governments and european institutions are currently designing. the current health crisis and the likely economic downturn could be seen as an unsolicited-and much regrettableopportunity towards a carbon-neutral future koundouri ) . the agreements reached in the context of the eurogroup, the latest turn in the european budgetary discussions, as well as the statements by the commission president all point into this promising direction. the eu green deal has confirmed the eu emissions trading system (ets) as a key element and the price of eu allowances serves as a key indicator worldwide. as could and should be expected, carbon prices have fallen during the lockdown reflecting reduced demand for allowances in line with the drop in power and industrial production. this temporary drop from the € to a € - range, acts as an important automatic stabilizer for businesses in distress. a repetition of the experience of a sharp fall in the see on this issue the important draft report prepared by the european parliament committee on the environment, public health and food safety (european parliament, ). https ://lifed icetp rojec t.eui.eu/ / / /covid - -clima te-polic y-and-carbo n-marke ts/. https ://www.consi lium.europ a.eu/en/press /press -relea ses/ / / /repor t-on-the-compr ehens iveecono mic-polic y-respo nse-to-the-covid - -pande mic/-point : "work is ongoing on a broader roadmap and an action plan to support the recovery of the european economy through high quality job creation and reforms to strengthen resilience and competitiveness, in line with a sustainable growth strategy". https ://ember -clima te.org/carbo n-price -viewe r/. price of eu ets allowances after the recession and a long period of very lowcarbon price levels should be avoided. there are two reasons to believe that this could happen: (i) the eu ets now has a market stability reserve (msr) operating in the short-medium term and (ii) long-term market expectations could be shaped by the carbon neutrality objective. the msr started to operate last year and absorbs a potential oversupply in the market in the short and medium term. if the allowances market is "long" beyond a threshold set in legislation ( million tons, which is approximately % of ets emissions in ), the msr intervenes by withdrawing allowances equal to a percentage ( % up to , % thereafter) of the excess. at the end of , the allowance market was . billion tons "long" and, therefore, the supply of allowances for the period september to august has been reduced by million tons (these allowances are placed in the msr). some question whether the msr, with its delayed adjustment mechanism, will be sufficient to avoid a sharp fall in the allowance price (cf. flachsland et al. ) . in fact, any reduction in the supply of allowances through the msr for the period september -august will still be based on the excess supply of allowances in , i.e. before the current crisis started. in case the msr is unable to absorb the surplus, the eu commission should propose changes in the planned review of the ets in . long-term expectations might overtake this short-term risk. in its european green deal, the commission already indicated its intention to tighten the greenhouse gas emission reduction target from % to %, or even % (with respect to levels). today, the ets sectors face a mandatory emission reduction of % by compared to , and revised targets will likely increase that obligation by at least another or %. such a reduction in the supply of allowances would likely push their prices up, or at least reduce the extent of their decline, in the face of lower demand due to the economic downturn. therefore, carbon market participants as well as those developing innovative clean technologies and products of the future are likely to expect significantly higher carbon prices in the future. this raises the question about a possible loss of competitiveness in europe's traditional industries vis-à-vis competitors located in countries where no similar burden is imposed. some proposed a border adjustment, which would imply both a levy on imports and possibly a rebate on exports. however, such mechanisms are not easy to implement and are subject to criticism on both analytical and political grounds. therefore, it is of crucial importance to realize that a wto-compatible border adjustment mechanism will take some time before it can be implemented. meanwhile, at least equal attention needs to go to domestic policy reinforcement, such as support for innovation and a less rigid interpretation of the state aid rules. governments and european institutions are currently developing a major investment stimulus package. the commission's impact assessments on climate and energy policy serve as useful guidance on where a major surge in investments is needed. we know that energy efficiency requires a major push in the construction sector, both for new buildings and renovations in social housing, hospitals and schools. we know that the energy transition requires more investments in renewable energy, digitised grid infrastructure and energy storage. the significantly reduced electricity demand of today indicates that much more attention should go towards managing flexibility in real time instead of increasing baseload capacity. in transport, electrification is on its way, but investment in charging facilities, traffic management, clean public transport and long-distance rail needs to be ramped up. in industry, not least in power generation and carbon intensive industrial sectors, major efforts are being undertaken to develop new technologies based on hydrogen and carbon capture, use and storage, for example. such investments can create the jobs we need in the post-covid- era and allow to realise the eu green deal objectives at the same time. apart from carbon prices and investment support schemes, it remains of equal importance to maintain a consistent energy price signal throughout the economy. however, the recent fall in the prices of fossil fuels is upsetting the incentives that should support a transition towards sustainability. a reference criterion for economic decisions has been lost and the consequence may be a paralysis, or even a "comeback" of fossil fuels, mothballing or abandonment of investment in renewables. consequently, the business case of the green transition may appear to be weakened in the near term, but a clear policy response may be politically more acceptable because of the price drop in fossil fuels. this raises the question about the other half of europe's emissions, namely those not covered by the ets, in particular the sectors of transport and buildings. the pricing of these emissions can be much improved through the planned review of the eu's energy tax directive. this offers a major opportunity to remove the all too generous exemptions, such as on maritime and aviation fuels, or by adding a co element to the harmonized minimum tax rates. in such a manner, prices of fossil fuels could be stabilized at the pre-covid levels via temporary taxes, whose revenue could help finance the various income-support policies adopted and/ or an acceleration of investment projects for sustainability. in this way the eu should better prepare for a long period of low oil and gas prices and seize the opportunities these can offer. public measures to combat the covid- pandemic have led to a severe economic crisis. in order to cope with this crisis, comprehensive government aid is being requested. accordingly, governments across the world have pledged billions of euros for extensive recovery programs. one of the main questions debated in this context at the moment is how "green" these recovery programs should be ). the expectation of huge amounts of public money being distributed at short notice brings interest groups of every shade to the scene-preferably with old wish lists on hand. consequently, there is a big risk that recovery programs will be captured by interest groups (for an overview of the literature on regulatory capture, see dal bo ). on the one hand, climate change mitigation is put under pressure as being an "extra burden" for industries. for example, european car manufacturers have called for postponing the upcoming tightening of eu emission standards for car fleets (topham and harvey ) . some eu member states call for stalling the eu commission's plan of a european green deal (simon ). on the other hand, many recommend spending the public money mainly on measures that also help mitigating climate change-among them frans timmermans, executive vice-president of the european commission (schulz ), or fatih birol, head of the international energy agency (birol ) . there is one thing that must not be overlooked in this politico-economic competition: public funds are still short and must be used reasonably. otherwise ill-designed (green) subsidies can quickly turn into a part of the problem instead of being the solution. previous "cash for clunkers" programs warn as an example of a misguided recovery measure. these programs were introduced in many countries after the financial crisis and provided financial incentives to trade old, less fuel-efficient cars for new, more efficient ones. empirical analyses have shown very mixed results regarding both the economic and the environmental stimulus effects of these measures (grigolon et al. ; li et al. ; mian and sufi ) . at the beginning of every discussion about (green) recovery programmes, it is therefore important to develop transparent and sensible criteria based on which public aid should be allocated. after the initial bail-out programmes, public recovery programmes to stabilize the economy are now debated politically. certainly, this generates an unprecedented window of opportunity for structural transformation. moreover, the distribution of public aid may also justify committing beneficiaries to public interests to a certain extent. consequently, the currently available political degrees of freedom should be used to promote the transition of society towards sustainability. subsidies to branches like tourism, aviation and agriculture-which are particularly hit by the crisis and are lagging behind in terms of sustainability-should be paid conditional on meeting minimum environmental standards. new investments into long-lived, fossil-fuelled assets must be avoided. a recovery program cannot only be about re-establishing the status quo ante by assigning large public funds, possibly creating new barriers for sustainability transitions. in this respect, it makes sense to implement recovery programs that are in line with the objective of mitigating climate change-as called for by many at the moment. however, such green recovery programmes must not be arbitrary. green recovery programmes must go beyond green subsidies. first of all, it is also important to reduce unnecessary barriers for green investments, for example by revising legal constraints to the expansion of renewable energies like solar photovoltaics of wind power. moreover, any green recovery program can only effectively and efficiently spur decarbonization if it combines with a carbon price and the abolition of environmentally harmful subsidies. the direction of recovery must be crystal clear. otherwise green subsidies risk being ineffective and costly approaches to mitigating climate change (kalkuhl et al. ; palmer and burtraw ) , while imposing additional burdens on public budgets and reducing political degrees of freedom in the future. for subsidies to be economically justified, they need to meet clear criteria. for green recovery programs to succeed in the competition for public funds with other important policy fields (such as health or digitalization), they must help stabilize the economy. moreover, policy makers need to be aware that some of the currently observed economic problems might even resolve without any government aid. it can expected, for example, that global supply chains will resume and that people will catch up on purchasing durable goods like cars, at least partly. it is exactly (the maintenance of) environmental regulation that may help steer this consumption towards more sustainable modes. government interventions must take effect where permanent disruptions are looming. one example: innovative green business models may particularly be at risk if banks limit loans in the presence of the current uncertainties (lehmann and söderholm ) . in this case, government loans may provide direct assistance. in contrast, attempts to lower prices for goods and services-e.g. for cars (vat reduction, purchase premiums) or electricity (reduction of energy levies)-are rather inappropriate means to stabilize the economy. such measures fail to address the actual sources of insufficient investments or reduced purchasing power, and are therefore inefficient ways of spending public budgets. furthermore, it is unclear whether and to what extent such discounts will be passed through to final consumers by market prices (peltzman ) . green recovery programs should focus on government interventions that would also have been economically reasonable without the covid- crisis-for example, to correct market failures next to the co externality (bennear and stavins ; fischer and newell ; lehmann )-and that have the highest priority for climate policy. moreover, those measures should be implemented for which rational concepts have been drafted already and that can be realized promptly. positive examples of such "no-regret measures" can be found in the transport sector, for instance. this sector is severely lagging behind in terms of climate change mitigation, and economic rationales for public expenditures exist at least partly (briggs et al. ; low and astle ). in addition to that, numerous actors have already developed elaborated programmes of measures. those measures that can be implemented quickly, should now be launched-for instance to electrify the transport sector or to strengthen public transport. (green) recovery programmes must not only address the expenditure side. a currently still disregarded issue is the question how the required billions of euro could be raised. public expenditures for a green recovery program should at least partly be funded by polluters by implementing a carbon price and abandoning ecological harmful subsidies. such policies internalizing environmental costs would not be an extra sacrifice-but rather part of the solution both for revenue problems and for the redirection towards sustainability (for a review of the double-dividend hypothesis, see goulder ). the coronavirus crisis has opened up a window of opportunity for transformation. this should be used without getting off the regulatory track. green recovery programs must not be reduced to a mere competition for green subsidies. abandoning barriers to green investments and imposing a carbon price are equally important. where economically sensible, green subsidies should contribute to both stabilizing the economy and mitigating climate change. moreover, smart green recovery programs may contribute to raising revenues for the additionally necessary public expenditures. the world is currently facing the largest pandemic since spanish flu in . this has led to a lockdown policy on an unprecedented scale and measures of social distancing that are expected to continue. in france, as elsewhere, the "great lockdown" has disrupted food production chains through simultaneous shocks to demand and supply. populations have seen their food consumption habits be severely modified (e.g. closure of restaurants and markets). fearing food shortages, consumers have often stockpiled basic necessities, which has led them to actually provoke shortages, albeit temporarily. food production has also been disturbed, most notably by the reduction in the available workforce, whether domestic (due to the lockdown, illness or childcare) or foreign (temporary closure of borders). the issues at stakes are numerous, including deglobalization and environmental impacts, in both the long and short terms . the pandemic will lead to unprecedented uncertainties in food supply chains. in addition to the health crisis, a dramatic drop in worldwide gdp is anticipatedapproximately %-with a partial catch-up in , according to the international monetary fund (imf ). the reduction in income will soon impact food consumption. some authors are already pointing to an increase in social inequalities. the most fragile populations could slide into severe food insecurity, including in developed countries, as shown by deaton and deaton ( ) for canada and power et al. ( ) for the uk. however, the fao is rather reassuring about the total volume of food (cereal) at the global level. it also notes that the world price index has fallen in recent months. this does not necessarily mean that this decline is effective regardless of the type of agricultural production. in particular, fruits and vegetables could become more expensive. agriculture is by nature a risky activity, and the adoption of eco-environmental practices can only increase this risk. as a consequence, organic farmers, for instance, could be particularly affected by the combination of health and economic crises. the cost of organic production is therefore structurally higher, which could pose a problem in the event of an income shock. to add value to their production, many small farmers combine organic farming with short food supply chains. this makes it possible to regain a more comfortable margin than that allowed by mass distribution. however, here again, the health crisis has profoundly changed marketing channels. while supermarkets were stormed with shoppers at the beginning of the crisis, some short channels were closed, such as markets and restaurants, to preserve social distancing. this article therefore considers the consequences of covid- for sustainable agricultural practices, particularly for farmers who have chosen organic farming in short supply chains. to do so, we use the multi-level perspective (geels ) approach to conceptualize socio-economic transitions. the multi-level perspective (mlp) approach analyses transitions as mutation processes from one socio-technical regime to another under the pressure of macrolevel forces and the emergence of market niches that could provide the basis for a new regime (geels ) . we show here why local food supply chains are perceived by some farmers-especially the smallest-as a way to enhance the economic value of eco-friendly agricultural practices, such as organic farming. in france, the current dominant socio-technical regime based on conventional agriculture emerged gradually in the s. conventional agriculture diffuses slowly at first because of the high investment costs. however, the french state and farmers' unions support it as a means of increasing production and improving living and working conditions. farmers are then inclined to take on more debt and become dependent on their suppliers (phytosanitary products, seeds, tools, etc.), the food industry and supermarkets. as a result, this modernization of agriculture has been controversial from the outset, at least with regard to farmer autonomy and the country's food sovereignty (levidow et al. ). the early development of organic farming in france began in the s due to the effects of three negative effects of conventional agriculture, namely pollution, soil impoverishment and the lack of autonomy mentioned above. the organic label has become a marketing argument that is profitable for large farms, since they achieve significant scale effects on these standardized products. large scale organic farming is therefore less demanding and, by its nature, allows to benefit from the effects of scale. this is new competition for small farmers struggling to differentiate themselves. the organic label itself does not allow farmers to free themselves from the pressures upstream and downstream in the production chain. to differentiate themselves from large organic farms, some farmers are starting to sell in open-air markets again. at the same time, the idea that fair trade can concern north-north relations and not only north-south relations is beginning to emerge, which favours the development of community-supported agriculture. a new initiative is gradually emerging: collective farmers' shops. these initiatives began, for example, in the south of france in the mid- s and represent a more important restructuring of the farmers' market. in the medium term, the drop in income could increase the consumption of basic necessities (giffen goods) to the detriment of organic products. everything will depend on the elasticity of the demand for these products. until now, organic products have been extremely popular. it is possible that "industrial organic" will take market share from a "more artisanal organic" if consumers still want to consume organic products but cannot afford to spend a large part of their budget on them. farmers in short supply chains often have several distribution channels simultaneously, especially market gardening farmers. this allows them to be more responsive to demand. thus, the closure of farmers' markets and restaurants can be compensated for by farm shops, community-supported agriculture (csa), fixed point or home delivery, or collective farmers' shops. regarding hygiene measures, farmers are faced with two main types of strategies: receiving customers in the original locations or digitizing the process, including the more marginal case of automatic food dispensers (e.g. for eggs). selling in physical places must respect social distancing, which discourages consumption. however, conserving this method makes it possible to maintain the relational proximity between farmers and consumers. initially, this relational proximity is one of the main arguments in favour of short supply chains, as it is supposed to allow better traceability of products and to fight against social isolation (especially of the elderly). the other strategy, therefore, is to limit direct contact between human beings by means of computer tools. internet platforms already existed before the crisis and are expected to develop. some were public, such as those set up to supply school canteens. the pandemic has accelerated this process, and some regions have launched their own platforms. this solution is very time-consuming and seems difficult to sustain, unlike the others, which should have an impact in the long term. another practice has been reinforced: farm shops. during the lockdown, some consumers presumably had more time to cook and go to farms. others fled from supermarkets, considering that the products were handled by a large number of people and that there was too much traffic. it is difficult to predict whether these changes in behaviour will have a long-term impact. in addition, the pandemic has raised concerns about the reliability of international distribution channels. it is therefore possible that some policies may be sensitive to the has been growing at a very fast pace (see an indicative list of references in supplementary material ). however, little attention has been paid to the reliability of this type of epidemiological data to make statistical inferences. our initial aim was to produce a detailed statistical analysis of the relationship between weather conditions and the spread of covid- . this question has attracted significant attention from the media (e.g. ravilious ; clive cookson ) and the research community (e.g. araujo and naimi ; carleton et al. ; see a wider list in supplementary material ) due to the possibility that summer weather might slow the spread of the virus. after going through all the steps of such an analysis, we reached the unexpected conclusion that the limitations of the available covid- data are so severe that we would not be able to make any reliable statistical inference. this applies, for example, to the data provided by the john hopkins university (dong et al. ) and the data collated by xu et al. ( ) . this is a concerning and very important finding considering that such data are being widely used to make crucial policy decisions on a wide range of topics. since invalid causal inferences could be made with the publicly available covid- data, and then enter policy-making discourse, there is an urgent need to raise awareness among the scientific community and decision makers regarding the limitations of the information at their disposal. the elements discussed in this paper are also likely to be applicable to other epidemiological datasets obtained with insufficient testing and monitoring, either during exceptional epidemics or seasonal outbreaks. several challenges could undermine any causal statistical analysis of the influence of a potential determinant, such as the weather, on the spread of covid- . to start, confounding variables are likely to pose a significant problem: many factors (e.g. changes in policy or social interactions) are simultaneously influencing how the disease spreads. in addition, significant challenges come from the limitations of the covid- case count data itself. firstly, testing capacity has been a major issue in most countries. before march , very few countries had sufficient testing capacity. by april , highincome countries had significantly increased their testing capacity, but testing remained critically infrequent in most low-and middle-income countries. figure , panel a, illustrates the effect that insufficient testing capacity has on the number of confirmed cases. it distinguishes between three phases of limited (i), intermediate (ii) and widespread (iii) testing. in phases i and ii, there is a risk that the number of confirmed cases depends more on the number of tests available than on the actual number of people who have covid- , questioning the validity of any analysis relying too heavily on these data. moreover, there have been numerous concerns regarding the accuracy of the covid- tests performed so far (ai et al. ; apostolopoulos and tzani ; hu ; hall et al. ) . figure , panel b , illustrates the effects of both false-negative and false-positive test results on the number of confirmed cases. false-negative results would imply that the number of confirmed covid- cases is underestimated. false-positive results would imply that people who do not have covid- are included in the number of confirmed covid- cases. concerns regarding test accuracy create an additional problem of measurement that might affect statistical analyses. the two above-mentioned challenges are inherent in all current datasets of covid- confirmed case count and mortality. in addition, specific datasets may have imperfect geographical or time coverage. to look at the impact of the weather on the spread of covid- , we initially used a well-established approach, similar to the ones used previously to look at the impact of the weather on other diseases (e.g. deschenes and enrico ; gasparrini et al. ) (see details in supplementary material ). however, the fundamental measurement issues associated with the covid- case count data cannot be corrected by statistical techniques, as we outline in the following. the main problem is that the weather could be influencing the number of tests carried out and the segment of the population tested. for example, other respiratory diseases are often similar to covid- in their symptoms (e.g. who ) and are more common during cold weather (e.g. deschenes and enrico ; gasparrini et al. ) , which could influence the number of tests performed on people displaying symptoms of respiratory infection. therefore, even if the model correctly identified the impact of the weather on covid- case counts, it cannot distinguish between the impact of the weather on the spread of the disease and its impact on testing. table provides a non-exhaustive list of elements that could undermine any analysis of the impact of the weather on the spread of covid- using data on confirmed cases. the evidence suggests that the weather may correlate with the number of tests conducted and who gets tested. we have not been able to find any specific covid- -related evidence that the weather could impact test accuracy (e.g. the weather affecting the nasopharyngeal or oropharyngeal swabs used in the pcr analysis), even though this could be possible. other points of concern include: the fact that there may be indirect effects of weather conditions on other factors that could have an impact on the spread of covid- (such as social interactions or air pollution); the heterogeneity of impacts across populations and subgroups within a population; and the fact that some people may have travelled and therefore been infected in a different place from where the cases are reported. we ran our model (as detailed in supplementary material ) and provide results and robustness checks in supplementary material . the model would technically suggest a negative correlation (e.g. colder days would be associated with more confirmed covid- cases, and hotter days with fewer cases). yet, these results could be highly misleading since these estimates are likely to be substantially biased because of the aforementioned reasons. figure , panel a, provides an illustration of how we could have obtained a negative correlation even if temperature had no impact or a positive impact on the spread of covid- in our sample. the total number of estimated cases is given by the size of the circles as a function of temperature (x-axis). the circles in green correspond to the effects we are interested in-those that explain the influence of temperature on the spread of covid- . if temperature has no effect on the spread of covid- , then the green circles should be the same size at low and high temperatures. the pink circles represent the possible effect of temperature on testing (as reported in table ) under the illustrative assumption that high temperatures reduce testing frequency. in this case, the overall result is a negative correlation between temperature and confirmed covid- cases, even if temperature has no effect on the spread of the disease. in practice, we naturally do not know the direction of the bias caused by the effect of temperature on testing when using standard statistical methods. there is also no way for us to evaluate the contribution of each of these effects (green table non-exhaustive list of reasons why weather conditions could affect the number of covid- tests carried out and who gets tested potential reason potential implication unrelated respiratory diseases are weather sensitive (e.g. deschenes and enrico ; gasparrini et al. ) and can be confused with covid- (e.g. ai et al. ; chen et al. ) more patients with symptoms of unrelated respiratory diseases could be tested during cold weather the prevalence of other weather-sensitive respiratory diseases might make false-positive results more likely, especially if only radiographic imaging is used, since it is possible to confuse these diseases for covid- (e.g. ai et al. ; chen et al. ) the incidence of other pathologies (e.g. cardiovascular diseases) is influenced by the weather (e.g. deschenes and enrico ; gasparrini et al. ) hospital capacity and the workload of medical staff and testing structures are affected by weather conditions, with potential implications on the number of tests conducted at-risk individuals suffering from unrelated conditions are more likely to be tested for covid- , even if they only have mild symptoms for covid- people may be more inclined to seek medical attention depending on the weather (e.g. norris et al. ) due to weather conditions, people may or may not decide to seek medical attention, affecting the number of patients going to the hospital with covid- , and the workload of medical staff or pink) in our estimate. we arrive at the final size of the circles and cannot be sure if the association that we are interested in is either negative, null or positive. figure , panel b, focuses on the risk that effects could be different across different samples. the circles in blue capture other underlying factors that are influenced by temperature (such as acclimatization or the level of social interactions in the population), as well as other socioeconomic factors (such as the demographic characteristics of a population). these factors could be radically different in different regions but may also evolve over time (e.g. between winter and summer seasons). there are strong reasons to be concerned with the scenario illustrated in figure , panel b. in our sample, for example, we only have data from the start of the pandemic until end of april ; some countries (e.g. china) may be over-represented in the dataset; and the average daily temperature is relatively low at . °c. furthermore, many countries have implemented a stringent containment policy during the period covered by the sample. containment policies may have heightened (or lowered) the sensitivity of the spread of the disease to the weather because social interactions are limited. we are not able to observe how for example, sars-cov- is more infecƟous; the weather affects people's immune systems; people-to-people transmission is higher. for example, changes in the number of people with respiratory diseases other than covid- , affecƟng the number of tests performed. for example, social interacƟons evolve; or samples are for different countries. example temperature (a) esƟmates are likely to be biased because the weather influences data collecƟon (b) esƟmates could vary between samples fig. effects potentially captured by our estimate. the size of the circles represents the estimated number of cases at different temperatures. these are examples that do not correspond to actual data. in these examples, we assume no correlation between temperature and the effects in green (see legend), a negative correlation with the effects in pink (example ) and a positive correlation with those in blue. (color figure online) the impact of the weather on covid- might change at different gradients of social interaction. finally, our estimate is based on small, observed changes in temperatures, and not on radical increases or reductions in temperatures. the spread of covid- may respond differently to large variations in temperature, e.g. by °c or °c across seasons, making seasonal predictions even more unreliable. strong precautions need to be taken before using covid- case count datasets for inference. the results of our model using existing covid- data would seemingly imply a negative association between temperature and confirmed covid- cases. any projection of covid- cases with such estimates could conclude that, during the upcoming months of june to september , southern hemisphere countries would be exposed to higher risks of covid- spread and northern hemisphere countries to lower risks. these types of unsubstantiated results could be used as a misinformed justification for an early relaxation of effective social distancing measures in the northern hemisphere. these findings have equally strong implications for statistical analyses focusing on other questions that rely on covid- confirmed case count and/or mortality count data. even though the exact nature of the effects may change, such studies are also at risk of capturing the effect that their parameters of interest have on tests and test results. for example, studies interested in the effect of containment policies may have to consider that these policies substantially affect testing because they change the awareness of the disease in the population, political demands for more testing or the risk of contracting other respiratory diseases. other studies may also produce estimates that are very specific to the current circumstances in the development of the pandemic and are, therefore, not suitable to use for forecasts of what could happen in the coming months. in the medium term, more reliable data need to be gathered, for example through experimental studies that randomly test a sample of the population for covid- . in the short term, we are in a situation of fundamental uncertainty about how different factors affect or are affected by the widespread societal changes we see with the covid- pandemic. therefore, scientists, policy makers, journalists and the general public need to be very cautious when discussing how the spread of covid- correlates with the weather or any other factor. in the long term, this paper suggests that more attention should be given to how epidemiological data is recorded and used during exceptional epidemics and seasonal outbreaks, since insufficient testing and monitoring can undermine essential statistical analyses. this article calls for the complementary use of different methods for data collection, such as random testing in samples of the population. sars to novel coronavirus-old lessons and new lessons global rise in human infectious disease outbreaks carbon emissions come roaring back: will the economy, too? 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( ) consulted on th april use of radiographic features in covid- diagnosis: challenges and perspectives an empirical investigation into factors affecting patient cancellations and no-shows at outpatient clinics cohen is the first author. he had the original idea, wrote most of the paper and the code to produce the econometric analysis. he also coordinated the team. jani ensured the material was consistent with the epidemiological evidence. li produced the required climate data for the statistical analysis. lu helped on literature review, on coding the econometric analysis and on producing the tables. schwarz helped on data coding and matching and created the projections. all authors contributed to the text. data and materials availability all data and software are publicly available at https :// githu b.com/morit zpsch warz/covid - -weath er-oxfor d.