Opinion: Why aren't all risk-reducing interventions merely based on recommendations?

Published 6 May 2020, by Finn Nilson, Associate Professor in Risk- and Environmental Studies and Director of the Centre for Societal Risk Research, CSR

Sweden’s handling of the Covid-19 pandemic stands out in many ways compared to other countries. One of the most obvious is the method of implementing interventions. Specifically, the Swedish strategy is based on recommending its citizens to act in a certain way and trusting them to follow these recommendations. In other words, instead of forcing individuals through legislation, the state pleads with the individual’s sense of solidarity and sense of community in order for societal changes to occur¹.

This trust-based method is in many ways typical of the Nordic societies in which citizens have high levels of trust to both each other and the state (Trägårdh et al., 2013). Importantly, the method has also been used successfully in many public health-related areas. For example, inoculation levels amongst Swedish children are amongst the highest in the world despite the practice being voluntary.

However, whilst recommendations and trust-based strategies can be effective and ideologically pleasing, the following question could be raised; if recommendations and trust-based strategies were the optimal risk-reducing method, why are not all risk-related interventions solely based on recommendations?

In order to answer this question, the issue of risk and risk analyses needs to be discussed and specifically how risk analyses are performed. In a crude risk analysis, the risk analyst, regardless if this is an individual, a company or country, needs to ascertain and balance the potential negative consequences and the potential positive gains of any action. The resulting equation will give the risk analyst the answer to whether the action should be performed or not. As such, not all actions will be judged the same by different risk analysts.

There are a number of examples where different societal actors place different values on the potential losses and potential gains. For example, in regards to industrial pollution, industries will weigh the potential gains of unrestricted production and pollution against the environmental impact and often conclude that polluting is worthwhile. Society, on the other hand, will have much less to gain from industries who pollute and will therefore place a higher value on environmental protection. As such, the risk analyses are incompatible and environmental legislation is put in place.

Whilst this is clear and generally accepted in the business-society relationship, the same theory is applicable to personal safety and most clearly illustrated in regards to seatbelt legislation. Research from the 1970s showed that although large number of individuals were injured and died in road traffic accidents, the actual risk per kilometre travelled for each individual was very low, a fact that most individuals were inherently aware of. As such, the basic motivation of wearing a seatbelt was low. Given that there was also a positive element of a sense of freedom connected to driving without a seatbelt, Slovic (1978) could show that in the individual’s risk analysis, the positive aspects of driving without a seatbelt overshadowed the risk of being injured or dying in an accident.

Importantly, however, for society the equation is not the same. For society there are no advantages of individuals driving without a seatbelt² though large negative aspects of serious traffic accidents leading to injuries, deaths, congestion, lower production, etc. Consequentially, the rational risk analyses differ between the individual and society.

Slovic et al (1978) argues that in such situations, where society wants the individual to make choices in line with society, two options are available. Firstly, the individual’s perceived risk can be increased. I.e., if the individual believes the risk of being injured or dying in a traffic accident is higher, then this will compensate for the perceived advantages of not having a seatbelt. The second option is to force the individual into cooperating through legislation, i.e., the method often applied in the society-business relationship.

Returning to Covid-19, although the risk of requiring intensive care or dying is still somewhat uncertain, the risks for most healthy individuals is very low. However, in order to prevent high-risk individuals from being infected, strict interventions and sacrifices are required from low-risk individuals. As such, there is a clear difference between the (healthy) individual’s risk perception and society’s risk perception. Put simply, societies want individuals to radically reduce their social interactions, their freedom and their livelihood despite their own risk of becoming seriously ill or dying being very low.

Given the large differentiation between society’s risk analysis and the individual’s risk analysis, most countries (even those with high levels of trust such as Norway) have applied the theories above and attempted to equalise the difference in risk analyses. Political leaders (such as UK’s Boris Johnson of France’s Emmanuel Macron) have used war-rhetorics in order to increase the sense of national solidarity and thereby increase compliance. Health administrations in many countries have continuously reported that many younger patients without underlying diseases are treated in intensive care in order to increase the perceived risk and thereby compliance. Finally, countries have enforced legislation (including fines) to individuals who do not follow the rules, thereby forcing compliance.

In Sweden, although the health administration (particularly in Stockholm) have reiterated that many younger patients are being treated in intensive care, the Public Health Agency and politicians have delivered very different messages. Specifically, the focus from the Swedish government and Public Health Agency has been that the very large majority of deaths are amongst the very old or those with considerable underlying health issues. As such, younger, healthier people should not be worried. However, whilst objectively correct, this is problematic in regards to increasing compliance and closing the risk analysis gap.

Most likely, the chosen rhetoric from the Swedish government and Public Health Agency originates from the government’s official document on handling the Corona pandemic³ . Specifically, one of the six strategic points is to reduce fear and anxiety in the population as a consequence of the pandemic. Whilst this is obviously a noble approach, given that mental health is an important issue, from a risk management perspective of reducing the spread of Covid-19 and increasing the compliance to government recommendations, the strategy is perhaps less than ideal. In fact, new data from Norway⁴ shows that having some level of fear and anxiety is critical in terms of whether individuals follow the government’s Covid-19 recommendations or not. Whilst this relationship does not seem to be linear (i.e. increasing the level of fear from a moderate to a high level will not further increase the compliance rate), it does suggest that reducing anxiety and fear in the population is not without problems.

In summary, therefore, relying on trust and solidarity in handling the Covid-19 pandemic is problematic. Whilst it is too early to assess whether the Swedish strategy has been successful or not, there are theoretical aspects that at least question the underlying strategies. Importantly, this does not necessarily mean that the strategies will fail, nor that the strategies are sound, merely that there are questions that need to be asked.

This is perhaps most eloquently declared by the world-renowned risk researcher Nassim Taleb when asked whether Sweden’s strategy is good or not, he answered “Imagine that I decide to play Russian roulette. I raise the gun to my head and pull the trigger, nothing happens. Then I laugh and mock you for warning me: look I'm still alive! This is not very wise and it doesn't prove that Russian roulette is a good idea.”

Footnotes

1. N.b. it is possible to for example fine restaurants or shops who do not follow official recommendations. However, this is rarely done. Rather, the issue is pointed out to the restauranteur or shop-owner who is then expected to make changes.
2. N.b. it could be argued that individuals would be happier and this should therefore be weighed against the risk of injury or death.
3. https://www.regeringen.se/regeringens-politik/regeringens-arbete-med-anledning-av-nya-coronaviruset/strategi-med-anledning-av-det-nya-coronaviruset/
4. https://www.aftenposten.no/viten/i/Jo5aA6/ny-undersoekelse-farlig-aa-senke-skuldrene-for-mye?

References

• Slovic, P., Fischhoff, B. & Lichtenstein, S. (1978) Accident probabilities and seat belt usage: A psychological perspective. Accident Analysis & Prevention, 10, 281-285.
• Trädgård, L., Wallman Lundåsen, S., Wollebæk, D. & Svedberg, L. (2013) Den svala svenska tilliten: Förutsättningar och utmaningar, SNS förlag.