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COVID-19 Emergency public health and economic measures causal
loop: Laying the groundwork for a computable framework

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Henri E.Z. Tonnang1, §, Jay Greenfield2, §, Gary Mazzaferro3, Claire C. Austin4, §; and the
RDA-COVID19-WG5

1International Center of Insect Physiology and Ecology (ICIPE), Kenya, 2Data Documentation
Initiative, USA, 3Consultant, USA, 4Environment and Climate Change Canada, 5This work was
developed as part of the Research Data Alliance RDA-COVID19-WG Recommendations and

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guidelines on data sharing, and the RDA COVID-19 Epidemiology WG Data sharing in
epidemiology, and we acknowledge the support provided by the RDA community and structures.

All views and opinions expressed are those of the co-authors, and do not necessarily reflect the
official policy or position of their respective employers, or of any government, agency or organization.

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§
Corresponding authors: htonnang@gmail.com and claire.austin@mail.mcgill.ca

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CITE AS: Tonnang, E. Z., Greenfield, J., Mazzaferro, G., Austin, C. C.; and the RDA-COVID19-WG.
(2020). COVID-19 Emergency public health and economic measures causal loops: A
computable framework. In COVID-19 Data sharing in epidemiology, version 0.06b.
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Research Data Alliance RDA-COVID19-Epidemiology WG.
https://doi.org/10.15497/rda00049

ABSTRACT
COVID-19 infections follow dynamic patterns across society. We propose using a “systems
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thinking” approach to better understand multiple interrelated factors and impacts. Building upon
the work of others, we have extended the use of Causal Loop Diagrams (CLD) for whole system
qualitative analysis of the linkages and interrelationships between COVID-19 contagion,
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healthcare, and economic components. The approach used is generic and can easily be applied
to both developing and developed countries.

KEYWORDS: Contagion, healthcare, economy, holistic, system thinking, reinforcing and

balancing, causal loop diagram, CLD, systems research.
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BACKGROUND
In the context of infectious disease epidemiology, several theoretical methods have played an
important role in enhancing the understanding and describing the mechanisms of disease and
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assessing the efficacy of interventions. Most of these methods focus on single system
components such as health and contagion without integrating the linkages and underlining
complexity in the overall setting where the disease is transmitted. Common methods for
modeling epidemics with a series of differential equations are the SIR (Susceptible, Infected,
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and Recovered) model (Kermack et al. 1927), and various modifications of SIR such as the
SEIR model (Susceptible, Exposed, Infected, and Recovered), a multi-agent modelling

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3686027
 framework used to represent different stages of infection in different hosts (Carcione et al.

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2020). The SEIR model is the basis of a number of forecasting models currently used to inform
public health authorities and politicians for decision-making during the COVID-19 pandemic,
with varying degrees of success (Austin et al. 2020). These include COVID-19 models from
Columbia, Johns Hopkins, MIT, Notre Dame, UCLA, and Harvard universities, and the US Army

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ERDC amongst others. Various assumptions are associated with some of these models, such
as varying the reproductive number to a range of values below and above 1, or that current
interventions will remain in place during the forecast period. See Dehning et al. (2020) for an
example of a Bayesian SIR model incorporating prior knowledge of the time points of
governmental policy changes to quantify the effects of intervention policies on the spread of
COVID-19 (code and data are available on GitHub).

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One weakness of traditional deterministic, compartmental models is interaction and feedback
mechanisms between system components are neglected (Xia et al. 2017). Interrelationships
between contagions, population health and economic systems are complex; today’s modeling is

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challenged to represent all the interrelationships. Policymakers and the public are sometimes
presented with the logical fallacy of a binary choice between “save the economy” or “save
lives.”
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The present paper uses a “systems thinking” approach to capture elements and components of
the COVID-19 pandemic. Systems thinking is a way of thinking about, and a language for
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describing and understanding the forces and interrelationships that shape the behaviour of
systems (Senge 1991), that has been embraced by the WHO:

“Health policy and systems research (HPSR) is an emerging field that seeks to
understand and improve how societies organize themselves in achieving
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collective health goals, and how different actors interact in the policy and
implementation processes to contribute to policy outcomes. By nature, it is
interdisciplinary, a blend of economics, sociology, anthropology, political science,
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public health and epidemiology that together draw a comprehensive picture of

how health systems respond and adapt to health policies, and how health
policies can shape − and be shaped by − health systems and the broader
determinants of health” (WHO and the Alliance for HPSR 2007).
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One tool available for HPSR is Causal Loop Diagrams (CLD). CLDs provide the means to
capture interacting elements of systems. Used in public health for a number of years, CLDs
provide qualitative conceptual models that document reinforcing and mitigating drivers (de
Pinho 2015). COVID-19 CLDs have recently been proposed by a number of authors (Bahri
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2020; Bradley et al. 2020, Sahin et al. 2020), while Wicher (2020) has proposed a CLD that
includes a media interest loop that produces fake news.

Bradley’s COVID-19 CLD et al. (2020) illustrates why, “policymakers should aim to bring about
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protective structural system changes so that the readiness of society to prevent emerging
infectious disease outbreaks is independent of the current perceived number of cases.” A CLD

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3686027
 representing dynamics and relationships between COVID-19 contagion, healthcare, and

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economic factors with a total of nine balancing loops, and seven reinforcing loops Bahri et al.
(2020). Sahin et al. (2020) further explored the complexity of the COVID-19 pandemic using a
CLD including contagion, healthcare, economic, social, and environmental components with a
total of five balancing and 12 reinforcing loops.

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The objective of the present paper is to envision linkages between the elements of the
contagion, healthcare, and the economy, and visualize key components that characterize the
whole system.

METHODS

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The transmission of COVID-19 is represented as dynamic interrelationships between four
systems: contagion, vaccination, healthcare, and the economy. Interrelationships are
conditioned by multiple variables that can increase or decrease. Interrelationships occur through
a series of “reinforcing” and “balancing” loops. Causal relationships between variables are

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captured with arrows specifying the path of causality and the type of relationship. These may be
positive or negative, and there may be delayed effects before a real occurrence (Binder et al
2004).
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The CLD was developed in two phases: (A) Problem articulation was the elaboration of the
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dynamic postulate where each component comprising the system was described; and, (B) All
system elements were synthesized into endogenous (feedback-based) theory. Problem
articulation occurred in four steps:
1. Select system components and establish the aim. This will enhance understanding between the
links and transitions among and between components. For each system component, a number
of variables were identified with a defined time horizon for causality.
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2. Identify and sketch variable behavior over time. The current state and structure of the system
component needs to be well described for improved accuracy in system behavior predictions.
3. Establish a boundary and avoid redundancy by the limiting number of variables that are
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included.
4. Determine the links that have delayed responses, since these are an important source of
imbalances that often make predictions unreliable.
The process of synthesizing the CLD into loops was guided by expected outcomes from “action”
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and “reaction” mechanisms, and attention to unintended consequences. A loop was considered
“balancing” or “reinforcing” by counting the number of (+)’s and (-)’s. An odd number represents
a balancing loop, while an even number represents a reinforcing loop.
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RESULTS
The basic CLD characterizing the interrelationships and dynamics between the COVID-19
contagion, vaccinations, healthcare, and economic subsystems are shown in Figure 1.
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This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3686027
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Figure 1. A conceptual COVID-19 emergency public health and economic

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measures causal loop. The colours green, violet and blue indicate pandemic effects
on the population, healthcare system, and economic sector, respectively. Diagram
prepared using VENSIM software.
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The interacting system consists of a total of 12 balancing loops (B1-B12), and 16 reinforcing
loops (R1-R16):
• The contagion system component (green) has eight balancing loops (B1-B8), and five reinforcing
loops (R1-R5);
• The healthcare component (purple) has three reinforcing loops (R6-R8); and,
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• The economy component (blue) has four balancing loops (B9-B12) and eight reinforcing loops
(R9-R16).

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3686027
 Table 1 describes the interacting loops from Figure 1 for each of the system components

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(contagion, vaccination, healthcare, economy).

Table 1. COVID-19 causal loops by system component

LOOP* DESCRIPTION IMPLICATION

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CONTAGION ON THE HUMAN POPULATION SYSTEM COMPONENT
R1 Asymptomatic-infected-asymptotic Exponential growth of infected individuals among human
population
R2 Infected – symptomatic - infected Upsurge in number of dead and isolated individuals
R3 Immune system – asymptomatic – recovered - Strong immune system upsurges the number of
immune system asymptomatic individuals
R4 Susceptible - social distance - public perception - Wearing mask and social distancing growth the number of

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wearing mask - susceptible susceptible individuals
R5 Contact tracing – diagnosed - contact tracing Contact tracing growth number of diagnosed individuals
B1 Symptomatic – dead - symptomatic Symptomatic individual after a time delay could die
B2 Recovered – symptomatic – isolated - recovered Recovered individual reduce the number of symptomatic

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B3 Isolated - dead - isolated After delay, section of isolated individuals dies contributing
to increase the number of dead individuals
B4 Recovered – isolated - recovered After delay section of isolated individuals recovered
B5 Asymptomatic – recovered - asymptomatic
POTENTIAL CONTRIBUTION OF VACCINE
B6 Vaccination-vaccinated-susceptible-vaccination
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Vaccine contribute to decline in the number of the

susceptible individuals
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B7 Vaccination – susceptible - vaccination Number of susceptible individuals reduced due to vaccine

B8 Vaccination - public perception of risk - Public perception influences vaccine intake

vaccination
HEALTHCARE COMPONENT
R6 Health system - immune system - health system Upright health system enhances immune system
R7 Healthy habit - health system - healthy habits Healthy habits upsurge number of individuals with strong
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immune system
R8 Health intervention – isolated - occupied health Increase health interventions upsurge the number of
facilities -shortage - health interventions isolated and occupied health facilities contributing to
shortage
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ECONOMY COMPONENT
R9 Aid and monetary stimulus – cash reserve – Increased aid boots spending which may reduce GDP
spending
R10 Capital - GDP – income – investment - Capital Injection of capital boosts the GDP which increases
income and investment
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R11 Unemployment – aid and monetary stimulus – Unemployment triggers aid and monetary stimulus for
spending – GDP -employment - unemployment spending that contribute to GDP loss and reduced
employment
R12 Employment – GDP – demand - employment Job creation growth the GDP which contribute to total
demand
R13 Employment – unemployment - disposable Reduces in employment surges the number of
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income -demand - employment unemployed individuals reducing disposable income

R14 Total demand - digital channels - total demand Exponential growth in the use of digital channels
R15 Return - stock price - recent stock price - price Volatility increases in recent stock prices provoking price
appreciation - return appreciation and return
R16 Stock price – fear – returns – stock price Stock volatility create fear, leading to low returns
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B9 Lockdown – travel – tourism - lockdown Lockdown reduces travel with negative impact on tourism

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 LOOP* DESCRIPTION IMPLICATION

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B10 Lockdown - supply chain disruption - lockdown Lockdown reduces supply chain causing distortion
B11 Income – consumption - investment – capital – Income contributes to consumption limiting investment
GDP - income
B12 Unemployment – employment – unemployment Aid and monetary stimulus boost unemployment, reducing
employment

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* R - Reinforcing; B - Balancing

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Figure 2. Interaction channels between the contagion, healthcare
and economic system components
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Table 2 describes the interacting loops from Figure 2 across the contagion, healthcare, and economic
components.
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Table 2. COVID-19 causal loop diagram by system

LOOP* DESCRIPTION IMPLICATION
RCHE1 GDP – health interventions – shortages – occupied Overcoming fears and upsurge interest in investing
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health facilities – treated – recovered – isolated –
lockdown – fears – return– stock price – digital
channels – income – investment - GDP
RCHE2 GDP – health interventions – isolated – lockdown –
fears – return– stock price – digital channels –
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in stock market may help increase the GDP and
revive national economy to exponential growth
Overcoming fears and upsurge interest in investing
in stock market may help increase the GDP and

income – investment - GDP revive national economy to exponential growth

BCHE1 GDP – health interventions – shortages – occupied
health facilities – treated – recovered – isolated –
lockdown – mobility – unemployment – aid and
monetary stimulus – spending - GDP
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Continuing depletion of the GDP through aid,
monetary stimulus and interventions in health
system component will lead national economy to
recession and loss of employment

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3686027
 BCHE2 GDP – health interventions – shortages – occupied Continuing depletion of the GDP through aid,
health facilities – treated – recovered – isolated – monetary stimulus and interventions in health

lockdown – mobility – unemployment – employment
- GDP
BCHE3 GDP – health interventions – isolated – lockdown –
mobility – unemployment – aid and monetary
stimulus – spending - GDP
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system component will lead national economy to
recession and loss of employment
Continuing depletion of the GDP through aid,
monetary stimulus and interventions in health
system component will lead national economy to

BCHE4 GDP – health interventions – isolated – lockdown –
mobility – unemployment – employment - GDP
* R - Reinforcing; B - Balancing
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recession and loss of employment
Continuing depletion of the GDP through aid,
monetary stimulus and interventions in health
system component will lead national economy to
recession and loss of employment

DISCUSSION

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CLD’s complement deterministic methods, emphasizing a systems approach that integrates
relationships between the contagion, health and economic components. The CLD developed in
the present paper visualizes interrelationships among numerous variables and allows us to

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explore causal links potentially impacting the economy. This allows us to explore potential
measures to mitigate the economic impact of the pandemic.
The qualitative CLD could be improved by combining it with quantitative methods. For
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example, Dhirasasna and Sahin (2019) combined qualitative and quantitative methods for
selecting stakeholders and identifying endogenous and exogenous variables in the development
of CLDs. Binder et al. (2004) and Aronson et al. (2018) have converted CLD conceptual models
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into Stock and Flow Diagrams quantitative simulation.
Conversion of the CLD developed in the present paper to Stock and Flow Diagrams would
enable quantitative analysis and simulations based on data and a set of differential equations.
This would complement other data-driven approaches to help guide pandemic decision-making
such as COVID-19.
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AUTHOR ROLES
All authors accept responsibility for the content of the article.
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Conceptualization: HT, JG, GM. Methodology: HT. Investigation: CCA. Formal analysis: HT.
Writing: HT, CCA, JG. Bibliographic review and analysis: CCA, JG. Visualization: HT

ACKNOWLEDGMENTS
The authors would like to thank Dr. Meg Sears for her valuable comments and suggestions, and
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Maeve Campman for her bibliographic assistance.

Funding: None.
Conflict of interest: None declared.
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This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3686027
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This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3686027