In the UK in its first lockdown the death rate rose 37% above the recent average. Many were covid deaths but a substantial number were an indirect result of the lockdown. Lockdowns not only save lives, they take them. Any attempt to deal with covid involves a balance. I do not want to tell you what that balance is. I want to tell you how to think about it.
Lockdowns and the Economy Myths
A lot of people have fixated on a bad graph. It claims to show that the harder you lockdown the better the health and the economic outcome. Here is an example
Why is it a bad graph?
- It only looks at the first part of the pandemic – the second wave is looking different.
- The huge technical problems in measuring Covid deaths and GDP fall are ignored.
- Lots of other factors affect both covid deaths and GDP and make comparisons hard.
- Covid is one cause of death. The key health measure is not Covid deaths but what is called all cause mortality (and excess mortality)
- The world is inter-related but the graph ignores how what happens in one place affects conditions in another.
- Most importantly perhaps the graph ignores negative feedback loops
Any action to deal with Covid will have positive and negative effects. We want the positive to be more than the negative. Negative effects can be considerable but they are harder to see. They may also not be immediate. There are what we call first order – immediate effects – and second, third orders etc of less direct effects. Suppose we fine people heavily for breaking isolation. The result might be to reduce the numbers doing this. But could also then lead to less people getting tested.
Negative feedback loops are complex
Ironically doctors and disease specialists spend a lot of time thinking about these negative effects. They form part of the idea of doing no harm. The table below sets out some of the things that the UK advisory body Sage considers in its analysis. It is worth looking at carefully.
Often outcomes are hard to judge. We know that lockdowns reduce screening for things like cancer. However breast and prostate cancer screening are notorious for not saving many lives. Worse they cause lots of unnecessary treatment. The balancing act is therefore hard with lots of arguments from vested interests to confuse it.
Are all lives the same?
At first glance it seems obvious that the answer is yes. But the average age of a Covid patient in the UK dying is 82.4 years. This is above average life expectancy. There have also been 800 excess deaths from heart diseases – many under 65. It would be great to save both. The reality may be that doing stuff to save an older person makes it harder to save someone younger. So what do we do? Health planning has a solution – it does try to factor in the length of lives saved but too few people want to discuss this.
Even this may not be enough. What also matters is quality of life. The potential negative effects of what we do may be much longer lasting. We know, for example, that lockdowns increase mental ill-health and that the stresses seem to be falling more on the young. They might be gaining a long-term problem. So, what is the balance?
Actions have very different social effects
It is always easier to propose things if we are going to be less affected by them. The very rich are doing well. But a lot of us (me included) are safe at home with relatively secure incomes and less pressures than before. Others are locked down in tiny flats with little money or going out to work to supply the rest of us. We are not all in it together. We need to factor these effects in too.
Disease (morbidity) and death (mortality) follows clear social gradients. The average person on an above average income lives not only better but longer and more healthily than the average person on a below average income. Doctors think a lot about this too that is why it is incuded in the UK Sage analysis above.
We have to think about politics.
Governments are assuming more and more draconian powers. It is not just ‘libertarians’ who are concerned with this. There is a case to be made for curfews, harsh administrative punishment and the like. But there is also a case to be made against them. This is an argument that needs to be had.
And who is that really feels the harshness of these? Every country has its top rule breakers who seem to be able to do what they want. When the heavy hand of the state falls it does not do so evenly – it falls more on the poor, the weak, and minorities. Can we turn a blind eye to this?
So, whatever we do we are faced with uncomfortable choices. It is time we were more open about them.