Tuesday, March 24, 2020

Maintaining a Sense of Perspective and Proportionality During the COVID-19 Pandemic

I thought long and hard about posting something about the current pandemic. The flurry of social media posts about the subject often add to the confusion and panic rather helping and adding clarity. So it is with some hesitation that I post this blog entry. But I decided to write and post my thoughts here on my blog so I can reflect back on them later, when the dust has settled a bit, and see if my thoughts and insights were on or off target, etc.

Before we narrow in on the effort to mitigate the risks of COVID-19 specifically, let us start with a “big picture” perspective on some of the mortality risks human populations face in general in this precarious world of ours.

I suggest we start by acknowledging the realities of 3 very common causes of mortality- cancer, cardiovascular disease and traffic accidents.

Last year in the world approximately 10 million people died of cancer. The vast majority of people who died of cancer were older persons (age ≥ 60). Some of these deaths could have been prevented (but arguably not avoided completely) by smoking cessation, cleaner air, better diet and more exercise, early detection, and more effective cancer treatments.

Heart disease and stroke killed approximately 17 million people last year. Again, the vast majority of people who died from CVDs were older persons (age ≥ 60). Some of these deaths could have been prevented (but arguably not avoided completely) by smoking cessation, cleaner air, better diet and more exercise, early detection and more effective treatments.

Road traffic accidents cause over a million deaths worldwide every year. Some of these deaths could be prevented by improvements in vehicle design/safety, road infrastructure and driving regulations (preventing impaired driving) etc.

Cancers, CVDs and traffic accidents can overwhelm any country’s healthcare resources if they are not sufficiently funded and developed. Suffering a stroke, developing cancer, or getting into a serious car accident, can be a sentence to a premature death for people that live in countries that lack the medical expertise and resources to help these patients. But even in the most affluent countries, lengthy waits for seeing an oncologist or receiving cancer treatment means that many patients die before receiving the kind of diagnostics and treatments that could have possibly prolonged their lives. This happens every single day, everywhere in the world (though it is obviously a more pronounced problem in less affluent countries, and for less affluent citizens within richer countries).

What I note above are simply facts about the world today. I do not think they are particularly contentious statements. But pointing them out, and reflecting upon them, is, I believe, helpful because they remind us of the reality that, in a world with suffering and disadvantage and limited resources, rationing, priority setting and trade-offs are inevitable.

A sage society will (1) take empirically-informed, cost-effective measures to try to mitigate the risks of preventable suffering, disease, disability and death. And a sage society will also (2) pursue the fair distribution of the treatments needed to alleviate these disadvantages once they are manifest.

Now let us add a new unknown risk into this complex mix- COVID 19 , a newly discovered coronavirus.

There are over 1415 species of infectious organisms have been identified as causing disease in humans. And the discovery of COVID-19 adds yet one more to this list. As a newly discovered virus it raises many uncertainties (e.g. about its transmission and mortality risks, and the possibility of developing a new vaccine or treatment) and this uncertainty is what makes it such a significant public health threat.

The evidence to date suggests that most people infected with COVID-19 will experience mild to moderate respiratory illness and recover without requiring special treatment. This is good news. However older persons and those with comorbidities (such as cancer and diabetes) will be at risk of developing more serious illness, including death.

COVID-19 spreads primarily through droplets of saliva or discharge from the nose when an infected person coughs or sneezes. At the moment, there are no vaccines or treatments for this new infectious disease.

How does the health threat posed by COVID-19 compare to the flu? In the US, for example, the flu season from October 2019 to March 14th brought the following:

38,000,000 – 54,000,000 flu illnesses
17,000,000 – 25,000,000 flu medical visits
390,000 – 710,000 flu hospitalizations
23,000 – 59,000 flu deaths

The seasonal incidence of influenza is often approximated as 5%–20%

How many people will get COVID-19? And what is it’s death rate? These are very important questions, with lots of conflicting information and (for now at least) some unknowns. How many people will be infected in a given population will depend, in large part, and how soon and effective protective measures (e.g. social distancing, closing schools, quarantines for those infected or at higher risk (travel)) were in place. And the reported death rates for COVID-19 vary. This study suggests it has a death rate of about 1.4% (at least in China).

In the US, the flu has a reported death rate of approximately 0.1%. Many experts suggest that COVID-19 is 10 times as lethal as the flu. And that statistic alone demonstrates why it is a significant threat to population health.

As noted on my blog all the back in 2006, rational decision-making is much harder to achieve when ignorance and emotions reign supreme. We have seen two extremes of the emotional response to COVID-19 domestically in Canada. People hoarding supplies (like face masks and toilet paper) at the panicked end of the spectrum, and people socializing (in violation of the prescriptions of social distancing and self-isolation) as if there was no reason to alter their behaviours at all at the apathetic/aloof end of the spectrum. These behaviours show us that we, as a culture, were unprepared for this pandemic (despite the repeated warnings from epidemiologists that a major pandemic in the future was a certainty).

My observations of this episode to date has lead me to two general conclusions. The conclusions concern the complexities of the trade-offs involved in navigating policy decision making about COVID-19. My second conclusion is that I believe this pandemic will teach us some harsh learning lessons, lessons that, if we take seriously, will lead to important benefits in the future in terms of helping us be better prepared for the next pandemic.

Conclusion #1:

COVID-19 makes vivid the reality of the complexity of trade-offs that must be managed when implementing public health measures. Social distancing, self-isolation, travel bans, closing non-essential businesses, etc. all impose significant economic burdens on a society. Some pundits argue that we shouldn’t spare any costs to prevent potential COVID-19 deaths, but that is certainly not the attitude we take to any other cause of mortality- cancer, CVDs, traffic accidents, violence, suicide, the flu, etc. Some degree of cost-effectiveness has to be figured into the equation, if for no other reason than the reality that imposing financial hardship (e.g. unemployment) or fixating so much on COVID-19 can have significant health and economic risks for the population. We may inadvertently increase different risks of harm by trying to mitigate the risks of COVID-19. Bottom line, there must be a sense of proportionality and an awareness of the need for reasonable trade-offs of different sorts.

Furthermore, this pandemic also raises the complex issue of how we balance the trade-off between liberty and public health. Quarantining infected patients until they are no longer infected is one thing, but how far can/should the state go in terms of recommending/compelling isolation for those with no symptoms of the infection? Authoritarian regimes do not make individual autonomy and liberty a priority, and thus they might be able to implement more effective preventative measures than free and democratic societies. Does this mean liberal democracies should consider sacrificing liberties like freedom of mobility to help guard against higher infection rates? And how long can a government realistically expect the citizenry to comply with self-isolation directives before they will defy them. Humans are social beings, and cannot be locked up indefinitely before mental health, and even potential civil unrest, because real and significant problems. Just the fear of a potential lockdown itself leads to panic buying, which then exacerbates the predicament.

I believe history will judge a liberal democracy’s response to COVOID-19 along three distinct measures- the potential deaths we averted/could have averted by the measures we did /did not pursue, the economic costs of those measures, and the potential costs to liberty.

The sage response to COVID is to avoid treating any one of these 3 measures as “sacred values”- values that are inviolable and cannot be balanced against other pressing societal goals and aspirations. Yes we all want to survive this pandemic, but we also want to remain an economically sustainable society and a free society. The key is to find the reasonable balance, and that is not easy when there is so much uncertainty as there is at present. When we look back in history we will be judged by all 3 of these measures- did we save lives? Did we do so in a fiscally responsible way? And did we respect people as free and autonomous social agents?

Conclusion #2:

I conclude by noting what I think are some of the potential positives that might emerge from this pandemic:

(1) At the level of individual citizens, an improved preparedness for future pandemics. So less non-compliance with measures like social distancing, less hoarding of supplies, less irrational fear, etc.
(2) A boost in R&D for vaccines and treatments for infectious disease
(3) Greater collaboration between countries (e.g. travel bans, etc.) and within countries (e.g. states/provinces) in responding to infectious disease threats.