A pandemic is a moral and economic minefield. How should governments weigh up the difficult choices – and are they getting it right?
The dilemmas are achingly familiar by now. Should we lockdown or stay open? If we lockdown, when and in what order should the different sectors of the economy open up? What about schools? Places of worship? Cultural and sporting venues?
In each case, the question being asked is essentially the same: is saving x lives from Covid-19 worthy potential damage to society? The question is usually framed in terms of damage to the economy rather than damage to society because the former is easier to measure (how do you measure the damage done to religious people of not being able to pray together, to schoolchildren of not being able to mix, or to any of us of being deprived of art?) That calculation is complex enough, but feeding into it is another that’s even more morally fraught: are some human lives more valuable than others?
These questions have absorbed economists, epidemiologists, and lockdown skeptics alike this past year. But some people think this type of calculation doesn’t apply in an emergency such as a pandemic, while others consider it a distraction from the questions we should really be asking. Yaneer Bar-Yam, a physicist and president of the New England Complex Systems Institute in Massachusetts, is one of those who think we’ve been looking the wrong way, like a magician’s audience. “The key to a magic trick is to point at something that’s unimportant in order to distract you from what’s important,” he says.
Could it be time to stand back and look at the bigger picture?
In a way, it’s not surprising that pandemic-related choices have been framed in cost-benefit terms. When retired supreme court judge Lord Sumption suggested recently that some lives were more valuable than others, he provoked an outcry, but the reality is that governments make these kinds of value judgments all the time – for example, in deciding whether to offer a new treatment on the NHS. In fact, as independent British economist Julian Jessop points out, we all do. Asked whether it is worth £10bn to prevent one person from dying prematurely, most people would probably answer no. Asked whether they’d give the last seat in a lifeboat to a healthy child or a sickly old man, they’d probably choose the child. “It’s about using limited resources in the fairest way,” says Jessop.
There are two broad approaches to valuing human life. The first is known as the value of a prevented fatality (VPF), and it’s the one applied in the first scenario above. How much would you pay for, say, improving road safety to reduce the risk of premature deaths? It’s an average measure applied across the population as a whole.
The second approach applies when you have more information about the individuals concerned, as in the lifeboat example above, and it’s called the quality-adjusted life-year (QALY). A QALY is one year in full health, whatever that means for the individual in question. That’s an important detail, because the value of a QALY is the same for a person born deaf as one born hearing, but less for a “sickly old” man than for a “healthy young” child. Age and health are taken into account, but that’s all. “This is nothing to do with economic importance,” Jessop explains. “A rich person’s QALY is the same as a poor person’s.”
In the UK, a QALY is valued at £60,000, while the VPF is about £2m – the equivalent of 33 QALYs. These numbers inform decisions about the allocation of scarce resources, although, in practice, the numbers used may be lower, reflecting budgetary constraints and uncertainty around unproven benefits. The UK National Institute for Health and Care Excellence (Nice), for example, works with a QALY value of around £30,000. This means that a new drug that cost £10,000 per patient per course, and that added one more year of good health to that patient’s life, would be considered worth it; one that cost £50,000 wouldn’t.
That’s the typical scenario in which these tools are applied – when the “counterfactual”, or what would have happened in the absence of the drug or other intervention, can be fairly accurately assessed. In the context of the UK’s Covid-19 epidemic, for example, QALYs have been used to inform decisions about who should be prioritized for the vaccine, and whether it is better to give more people one dose or fewer people two doses.
From an economist’s point of view, at least, Jessop says these are reasonable applications of the tools. But problems arise when you try to apply them to extraordinary, society-wide interventions such as lockdown – when the counterfactual, or how many lives would have been lost or harmed if you hadn’t locked down, is much harder to assess. In the UK, the Treasury’s own guidance – known at the Green Book – on these kinds of appraisals explicitly warns against it. It states that these tools “are not designed for contexts such as situations of emergency or rescue”. And with good reason: it’s a minefield.
For a tiny glimpse of that minefield, think of the worst-case scenario predicted by Imperial College London’s modelers early in the UK epidemic, of more than 500,000 deaths if no action was taken. Say those 500,000 victims had on average 10 years of quality life left each, then saving them would become “worthwhile” at a cost of anything less than £300bn (500,000 x 10 x £60,000). But since we didn’t know exactly who would be dying, we could just as well use the VPF, in which case the break-even point would be higher, around £1tn (500,000 x £2m). The Imperial estimate was criticized, and other groups came up with different estimates, but since the UK didn’t take the “do nothing” route, who’s to say which, if any of them, was right. So which figures should we use?
The minefield gets even more hazardous. Imperial predicted that the NHS would be overwhelmed at 250,000 deaths, so how many deaths from both Covid-19 and non-Covid due to lack of treatment should we add to the counterfactual scenario? What about all the other known unknowns that emerged over time, such as the ongoing costs of long Covid – which we could be paying for long after the pandemic – not to mention the unknown unknowns? What about the fact that viruses and people adapt to one another in myriad ways, making the situation highly dynamic? Vaccines now exist, but when they will confer significant protection is another open question. “Frankly,” says Jessop, “you could come up with plausible numbers to support almost any conclusion.”
Some academics argue that such cost-benefit analyses could have been improved with input from a wider variety of disciplines. David Miles, an economist who also works at Imperial, points to a 2020 study by health economist Katharina Janke of Lancaster University and colleagues that found the increase in unemployment that followed the 2008 financial crisis led to 900,000 extra people with chronic illness in the UK over two years. Since the present economic slowdown is likely to result in a similar if not greater rise in unemployment, Miles thinks that kind of analysis could usefully inform decisions about, for example, when to lift lockdowns.
But for Bar-Yam, this is not the conversation we should be having. Researchers are focused on trade-offs, he says, because they assume we have to live with Covid-19 – that there is no exit from this situation. Pete Klenow, an economist at Stanford University in California, agrees. “Economists commonly assume a convex cost curve – that is, ever-increasing costs – on the basis that Covid-19 cannot be eliminated,” he says. But Bar-Yam doesn’t blame the economists. For him the culprit is the World Health Organization (WHO), which never communicated that elimination was possible even after China and other countries had demonstrated it. “The WHO, which has elimination plans for other diseases, did not put it on the table for Covid-19,” he says.
Epidemiologists such as Michael Baker in New Zealand nevertheless looked at China, saw that elimination was possible, convinced their governments of that, and have been vindicated. Baker belongs to a growing chorus of scientists, including the Lancet’s editor, Richard Horton, who are now urging countries such as the UK and US that it’s not too late for them to follow suit. Baker admits that his motives include national interest: the greatest threat to Covid-free countries now is other countries that remain stuck in the fatalistic mindset that Covid-19 is here to stay. “We can still stop it,” says Bar-Yam. “It starts with slight improvements to the lockdowns we have in place, to accelerate exponential decline [in infections], then judicious use of travel restrictions.” His own modelling efforts indicate that the cost of rolling lockdowns and lives lost to Covid-19 is much higher than one period of harsher action followed by full opening. “Even if this was not clear before, it is now from New Zealand and other successful countries,” he says.
The “No-Covid” strategy is fully aligned with the principle implied in HM Treasury’s Green Book: in an emergency, cost shouldn’t be what drives decision-making. It sounds more like the ethical approach to crisis management described by James Wilson, a philosopher and ethicist at University College London: start by determining your policy goals, then do what is necessary to achieve them. Most people instinctively endorse that, he says. As soon as the full implications of the UK government’s herd immunity strategy became apparent, for example, not only the government itself but most Britons easily rejected it. “An economist might say that decision showed people placed a very high value on saving a life,” Wilson says, “but I think a more enlightened interpretation might be that people came to realise that certain sorts of choices are unconscionable in a wealthy society.”
The irony is that the epidemiological case for “No-Covid” is gathering strength just as the UK’s chancellor Rishi Sunak has been pushing for the opposite – lifting the current lockdown sooner rather than later, and making it the last. In the US, meanwhile, President Biden who promised to “stop the virus” before he was elected has so far ruled out shutting down the economy. It’s time for a shift in mindset similar to the one that banished the herd immunity idea, No-Coviders argue. Since at this stage we know two things – that Covid-19 can be eliminated, and that the long-term costs of not doing so are incalculable but high, and growing with each week the pandemic lasts – the goal should be to eliminate it as fast as possible, with all means at our disposal.
Back in April, in a critique of efforts to cost Covid-19, Julian Jessop offered a historical parallel: “We wouldn’t have assessed the pros and cons of fighting the second world war in this way.” Imagine if Churchill had weighed his strategy toward Nazi Germany in terms of how many lives would have been saved in the short term? In case today’s prime minister is reading this, and is persuaded that it’s time to change tack, he could start by subjecting all future Covid-related decisions to the Churchill test: what would Britain’s most famous wartime leader have done?