LOCKDOWNS, LONGEVITY, LIBERTY & LONG-TERMISM
So the big question of the day is de what do we do about Covid-19?
The consensus winning out at the moment is to flatten the curve at any cost.
This is to be achieved by “social distancing”, the extent and severity of which varies considerably from country to country, but the effect of which in all cases is likely to be a global recession the like of which has never been seen before.
There is considerable opposition to this approach however, from those who argue that the consequences of mass unemployment and a crippling recession could be as bad if not worse than the disease itself.
Could a more targeted response, focused on protecting the elderly and those with pre-existing medical conditions, while allowing the young and healthy to get on with life and keep civilisation spinning, allow us to “surf the curve” while avoiding the total destruction of the world economy?
I very much want to believe the second option is possible. It sounds plausible, but is that just because it is a much more convenient solution for me, being (relatively) young, fit and healthy?
More Social Distancing = Less Deaths from Covid19
I think that this is a fairly uncontroversial statement.
More Social Distancing = Less Deaths in 2020
Probably also true? I’d imagine that in addition to the reduction in deaths from the coronavirus, social distancing will also reduce deaths from other infectious diseases, plus traffic accidents, work and sporting accidents, drink related accidents, and violent crimes. There’s also a study that claims that the lockdown in China may have saved up to 77,000 lives through reduced air pollution. (It’s estimated that 1.6 million die in China every year due to air pollution).
More Social Distancing = Less Deaths
This statement on the other hand is clearly false.
We still haven’t solved mortality, therefore it’s pretty much guaranteed that everyone alive now is going to die at some point. Hopefully neither you nor I in 2020 from the virus or anything else, but around 60 million people will kick the proverbial bucket before the clock strikes midnight on the 31st December, the vast majority from non Covid19 related causes.
This is where (at least for me) things get horribly complicated, and I really don’t know what to think.
Social distancing = Less QUALYs?
We see the daily figures for how many have died from the virus, and it’s horrifying.
At the time of writing this post, the current number of confirmed deaths from the virus was just over 16000 50,000 100,000+ and rising.
That is terrible. That’s lots of parents, relatives, friends, lovers, and children who are gone forever.
My heart goes out to anyone who’s lost someone they love to the virus.
This number, however, doesn’t give me enough information.
#OLDLIVESMATTER
Now, let me be very clear I am most certainly not saying “Let the pensioners die“.
Did Dominic Cummings say this? Who knows. Maybe he did, maybe he was actually saying something along the lines of what I’m about to thrash out here. Please bare with me to the end before leaping to any rash judgements or putting angry comments based on what you think I’m saying without carefully reading to the end.
We have established that, as yet, we can’t make people immortal. What we can try and do is maximise their lifespan, even better, their healthspan.
Rather than looking at “deaths” it’s more useful to look at QALYs – Quality adjusted life years.
The Italian National Health Institute pegged the median age of death from COVID-19 in Italy at 80.5. This is consistent with early data from the United States.
The average 80-year old in the United States has a life expectancy of about 9 years, suggesting that on average, a death averted will “buy” 9 extra years of life. In QALY-estimations, this number needs to be adjusted for the “quality of the years”. In Italy, 99% of deaths had an underlying pathology that needs to be incorporated in QALY adjustments. If we use diabetes as a reasonable proxy for the many chronic diseases, we would adjust the 9 years down to 7.8 years or QALYs. In other words: the average loss per person of quality-adjusted life years is 7.8.
Econlib
My neighbour José is 80. He is awesome. Everyday he walks around 3km from his residential home, up a huge hill across a rocky path to his allotment. His allotment is on a steep terrace. He’s fitter than most people 20 years younger than him. Maybe than some 20 year olds! I would be absolutely gutted if anything happened to José, and would happily self isolate and throw my businesses under the bus to buy him an extra 7.8 years or less.
But I’m not sure it’s that simple.
There is a very strong correlation between life expectancy and GDP.
As always, correlation does not imply causation, but there’s fairly strong evidence that over the long-term, increased wealth produces better health – better nutrition, better medical care, better education, etc.
(NB Over the short-term it’s more complicated).
Well, actually, over the long-term it’s more complicated too.
I’m sure any anti-capitalists out there are jumping up and down pointing at Cuba.
They’ve got a very respectable average life expectancy of just under 80 years old, with a GDP of under $10,000.
When it comes to health and longevity, a capitalist liberal democracy is a bit like digging a hole to use a ladder… Cheap alcohol, fast food, cars, there are many fruits of the system that reduce life expectancy. (Whether it’s possible or desirable to remove these whilst keeping the gains is for another discussion).
Look closely again at the graph, and you’ll note that the scale along the bottom is not linear.
GDP of €1000 very roughly correlates with life expectancy of around 60. 10x this to €10,000 to get close to 80. The other end of the graph is £100,000 another 10x.
Getting over the 80 year threshold is expensive – it accounts for a huge proportion of healthcare spending.
We can certainly avoid the deaths of many octogenarians in 2020 via social distancing measures, but can we really count on this equating to 7.8 QALYs each, if we totally destroy the economy in the process?
I’m also not sure I’m convinced by this figure of 7.8. On average an Italian that makes it to 80, will live to see 90, but as 99% of those that died had a pre existing medical condition, perhaps adjusting the QALYs down from 9 to 7.8 may not be enough?
What if the vast majority of virus deaths are all clustered at the lower extreme of the average, those who would have died within the year anyway had they not caught the disease?
Indeed, as more data comes in since I began writing this post, this hypothesis looks ever more accurate, and that it is very possible that many, if not most of the victims of Covid19 may have died anyway within the next 12 months.
It is crucially important that the NHS is not overwhelmed, but if COVID deaths can be kept in the order of say 20,000 by stringent suppression measures, as is now being suggested, there may end up being a minimal impact on overall mortality for 2020 (although background mortality could increase due to pressures on the health services and the side-effects of isolation).
David Spiegelhalter
The Oxford Centre for Evidence Based Medicine (CEBM) reduced their best-guess estimate of the Mortality rate from 0.51% down to 0.1–0.26%.
Among other things, they think some people who have been classified as dying of COVID-19 didn’t actually die of the disease but rather of serious existing conditions, and they just happened to have COVID-19 when they died.
Rob Wilbin 80,000 Hours
Is it possible that the worst recession of the century could in fact result in a greater reduction in life expectancy? That by saving lives in 2020, we actually have a net loss in QUALYs in the long-term?
Do we save grandma this year, only to lose her next year along with grandpa too, while losing the business and the house while we’re at it?
(It should also be noted that the cost of lockdown is not purely economic – It could result in severe psychological trauma, particularly for those living alone, or in difficult domestic situations).
What’s a QALY Worth?
How do you put a value on a human life?
One answer would be to say that you can’t – every human life is priceless, there should be no budget constraints.
But in the real world, we have budget constraints.
In the UK, the NHS typically uses an upper benchmark figure of £30,000 per QALY (€36,000) in order to decide whether a treatment should be approved or not.
How much will it cost per QALY to “flatten the curve”?
We calculated the cost per QALY gained from the current approach to be somewhere between approximately $75,000 and $650,000. We did this by dividing the planned stimulus package by the QALYs gain we estimated. This is somewhere between reasonably cost effective and clearly not a wise investment if we used the conventional standard cut-off point of $100,000 per life year gained. If the total investment was $4 trillion, the cost per QALY gained would rise to a range of $300,000 to $2.5 million per QALY gained — an expenditure far out of line from other healthcare investments.
Economic Cost of Flattening the Curve
Now these calculations are presuming that 7.8 QALYs will be saved per coronavirus death prevented, which as highlighted above, could very well be massively overestimated.
They also use the amount of government stimulation as the cost, but again, surely this is underestimating the cost? Shouldn’t the true cost be the total losses made to the economy, not the amount the government spends to try and keep it on life support?
Regardless of how you cut it, each QALY is going to cost a lot.
It should also be noted that the figures of £30,000 / $100,000 deemed as “cost effective” are for interventions that have been proven to work.
A major objective of “flattening the curve” is to make time to increase the capacity to hospitalise and ventilate critical patients. Sounds reasonable?
But again, as time progresses, the evidence is beginning to mount that neither are particularly effective treatments, with multiple studies showing that 80-90% of patients that are hospitalized go on to die anyway.
If we are extremely generous, and presume that 20% would certainly have died had they not been hospitalised and ventilated, and will all go onto live an additional 7.8 QALYs, we’re now looking at a minimum figure of €500,000 per QALY. More realistically, we’re looking at €Millions though.
In contrast, givewell.org calculate that by investing in the Against Malaria Foundation you can save lives for the average cost of around £1000 per QALY.
Testing Times
Without doubt, we need to start wide scale testing ASAP.
In an ideal world, only those with the virus need be kept in quarantine, the rest of us should be able to get on with our lives, and not suffer the economic and mental harm caused by long-term confinement.
The problem of course is that testing everyone on a regular basis would be extremely expensive and logistically very difficult.
One of the best solutions I have seen so far to get things moving again would be group testing:
There is now a 15-minute coronavirus test. What we need to do is group-household test each day. The method is simple. A testing mobile, manned by military personnel, would come to your street early each morning. The members of your household and maybe another 9 (the best number is yet to be determined) would be invited to provide a swab sample. All the swabs of all the households would be collectively used to test if any of the swabs was positive. Fifteen minutes later your group of households would either be cleared to go to work and frequent stores, restaurants, and other establishments for the day or not. If you’re cleared, you’d get a green bracelet that would automatically change to red after 24 hours. Those with green bracelets would be returned to normal society. If your group of households tested positive, subgroup testing would be done, on the spot, until it was discovered which of your group’s 10 households was infected and which weren’t. Those households that were infected (had one or more infected members) would need to go into quarantine.
Laurence Kotlikoff – Forbes
The main alternative is track and trace – identifying cases from symptoms early, testing to confirm, then tracing all the infected person’s contacts during the previous two weeks using mobile phone GPS data and testing them.
The latter was the method used with great success in countries such as South Korea and Singapore.
South Koreans’ cellphones vibrate with emergency alerts whenever new cases are discovered in their districts. Websites and smartphone apps detail hour-by-hour, sometimes minute-by-minute, timelines of infected people’s travel — which buses they took, when and where they got on and off, even whether they were wearing masks.
People who believe they may have crossed paths with a patient are urged to report to testing centers.
South Koreans have broadly accepted the loss of privacy as a necessary trade-off.
Max Fisher NYTimes
There are of course privacy fears with this method, which are certainly not unfounded.
If we consent to sharing this data now “temporarily” is it possible, or even likely, that this loss of privacy will become permanent?
I certainly think that privacy and surveillance are important issues that we should be concerned about. I highly recommend reading Data and Goliath for a deep exploration of this topic.
I think realistically though, that we relinquished our privacy some time ago, and continue to do so as long as we continue to choose to carry smartphones 24 hours a day.
The data is being generated. I don’t think granting temporary permission to use it to combat the virus greatly increases the risk of the same data being used nefariously in the future. This doesn’t mean to say we shouldn’t be worrying about this, nor that the data isn’t being used nefariously already. I just don’t believe there’s a downside to using the data for good, if it’s already being collected.
Of course, these two approaches are not mutually exclusive. Perhaps weekly group testing combined with track and trace would be a good solution.
Hammer Time?
This strategy of brute force lockdown followed by targeted quarantining via extensive testing and tracking has been nicknamed “The Hammer and The Dance”, and certainly seems to be be the most prudent solution.
The question still remains however, how brutal the “hammering” has to be until we can start “dancing”, particularly if it’s going to be a long time until we have wide scale testing capability.
The utilitarian response would appear, at least in part, to be stop attempting to hospitalise and ventilate the extremely ill that will die anyway.
Put this money and resources to more effective use, and don’t expose essential health workers to unnecessary risk. (Who have many more QALYs ahead of them, with which they could in turn save many more QALYs of others)
With the pressure on the health system eased in this way, could lockdown restrictions start to be gradually eased?
Open up all shops, not just food and pharmacies, allow bars and restaurants to reopen but at greatly reduced capacity and with extreme levels of hygiene?
Limit the percentage of people allowed out each day? Peru and Panama have done this by allowing only men out certain days, women the others. Perhaps it could be done by issuing all citizens a different coloured wrist band – Green = Mon + Thu, Blue = Tue + Fri, Red = Wed + Sat…
Keep the elderly and at risk as cocooned as possible, but let the majority of the population begin to be productive again?
The problem of course is that “cocooning” the at risk is extremely difficult, if not impossible, as they inevitably have to be cared for by young people. The more we relax the lockdown, the more risk there is of passing the virus to the carers, who in turn pass it to those in their care.
I should point out that I do not class myself as a utilitarian due issues such as the repugnant conclusion, cluelessness and the difficulty of measuring “utility”.
I do however believe that trying to prevent as many early deaths as possible AKA maximise QALYs is a goal worth pursuing (though not at any cost).
I’m just not convinced that total lockdown is definitely the way to achieve this goal.
Let me make it clear again that I am most certainly not saying that we should just throw all the old and infirm people under the bus, that their lives don’t matter, nor that we should save the economy in order to maintain our luxurious lives.
The ultimate goal is to “save lives”, I.e. maximise QALYs. If collapsing the economy will achieve this, I’m fully behind it. My fear how ever, is that a severe recession will not just result in a decrease in standard of living, but also ultimately in more lost QALYs.
While we certainly shouldn’t throw old people under the bus, we should also perhaps be wary of driving a full bus of a cliff to avoid old people in the road.
But Covid19 also kills young people!
While the virus mainly affects older people, with children and younger adults thankfully a tiny percentage of the fatalities, a tiny percentage of a huge number is still a big number.
If we relax social distancing by any degree, even while avoiding the collapse of the health system, we will inevitably have more young people and children die from Covid19.
If you’re young, fit and healthy, it’s not unrealistic to say that self isolation has near zero personal benefit – You’re at extremely low risk from serious harm from the disease. If (or when) you catch it, chances are it’ll be like a bad cold or mild flu.
You will, however, most likely suffer pretty severe consequences from the lockdown, economically and perhaps psychologically.
If we don’t all suffer these consequences, however, innocent young people and children will die avoidable deaths.
It sounds a bit like some kind of horrific moral dilemma from the Brothers Karamazov or the Ones Who Walk Away from Omelas, but this is basically the choice we are facing.
Now, most people’s initial reaction is simply, well stay at home, duh!
Afterall, home quarantine for a few months isn’t that bad, especially in today’s digitally connected age with free video conferencing, pretty much all the music ever created and all the books ever written available on demand and much of it for free, not to mention TV streaming, social media, etc.
And what’s the worst that can happen with the recession? If everyone loses their jobs, surely it can’t be that bad? They can’t evict everyone who can’t pay their rent, nor let everyone starve, can they? It’s not going to be pleasant, but it’s not so bad we’re willing to sacrifice innocent children to save the economy are we?
Sounds reasonable.
But if this is the case, when does the quarantine end?
Here’s a thought experiment…
X months down the line finally a cure has been found, and a vaccine manufactured and distributed. Coronavirus is no longer a threat. We can finally leave our houses without the risk of spreading the disease and causing unnecessary deaths from coronavirus.
But while we’ve been in self isolation there’s also been a dramatic drop in deaths from flu and other contagious diseases (usually around 10m per year), also a huge drop in deaths from road traffic accidents (usually around 1.25m per year), air pollution (usually around 4.6m per year), industrial accidents (?), etc.
It turns out, our normal day to day lives result in lots of “preventable” deaths.
So do we have a moral responsibility to never leave the house again?
This is where the whole situation starts to make my brain hurt!
On the one hand you can say, no, this crisis is different – there’s an unprecedented number of deaths, the health systems are at breaking point we all have to do something or millions will die unnecessarily. Which is hard to argue with.
But millions of people die unnecessarily every year and we do nothing about it.
Look at the chart of life expectancies again. Look at all these countries with average life expectancies below 70, below 60, below 55! But all of a sudden we are willing to give up our freedom and privacy, and potentially destroy the economy, predominantly to prolong the lives of wealthy 80 year olds?
Utilitarianism vs Nationalism
Why is it that all of a sudden we’re willing* to make huge sacrifices in order to “save lives”, when millions of people, including millions of young people and children, die every year from deaths for which there are already tried and tested interventions with much cheaper price tags?
Part of the answer of course is that we value QALYs in our own country more than QALYs in another country.
The QALYs at risk in our own country could very well belong to a friend or relative.
There is also perhaps a more selfish element at work; that one day it may be our own QALYs at risk – you’ll never be a 5 year old African child, but one day you will be an 80 year old that needs looking after.
Another argument might be that we prioritise our own citizens as they’ve paid taxes all their lives, and so are owed preferential treatment.
But if this is the case, does this mean we should be granting access to treatments in short supply based upon lifetime tax contributions?
If you had £100,000 and you had the choice to spend it saving the life of an 80 year old compatriot, or three 5 year old compatriots, which would you choose?
The three 5 year olds seems the obvious answer, despite the fact they’ve never paid any tax.
So should it make a difference where the children live?
It’s unlikely you could save the lives of three 5 year old compatriots for £100,000, but it’s quite possible you could save the lives of three children in a developing country.
Now perhaps you might say that there is a difference, as the children saved at home will go on to pay taxes in their future QALYs, thus paying back the “investment”.
But what if the children move to another country? Or what if they survive but with a disability which makes them unable to work and dependent upon benefits for the rest of their lives?
If you don’t want to send the money abroad, you could open the borders and save their lives by letting them come and live here, where they would most likely be much more productive and be an economic gain.
Well, opening borders is a discussion for another, post coronavirus, age, but I make the above points to (hopefully) illustrate that you can’t value a life by how much tax they’ve paid, or are likely to pay, nor IMHO where they had the luck to be born.
Does the answer change if the 80 year old is a parent or partner? If the 80 year old is you? Should it change?
Commute the Commute
While on the one hand I believe that the current lockdown is too extreme, I also think that we should take this opportunity to reevaluate our pre-corona lives, and that certain aspects should never return to normal.
I hope that one positive to come from this whole situation is the realisation that a huge number of jobs can be done just as effectively from home, if not more so. This could:
- Massively reduce deaths from pollution and traffic accidents
- Give people considerably more free time each day
- Give people more time with their families
- Remove the stress of commuting
- Reduce the spread of infectious diseases (During commute and in office)
- Free up land for housing and other uses
- Help in the fight against climate change
I’m sure there are advantages to meeting with your colleagues once in a while, but this could be done sporadically in co-working spaces.
I’d also hope that this will be the end of needless international business travel. I have a friend who was flying from Barcelona to Paris on a weekly basis to attend 1 hour long meetings. Complete insanity!
The End of the High Street?
The high street has been in decline for some time, will this be the final nail in the coffin?
Could this also be a good thing?
Ordering online for home delivery seems to be more efficient in terms of time, and energy.
As with offices, shops don’t appear to be particularly necessary use of land.
Could those buildings be repurposed as housing, bars, restaurants, museums, galleries, hospitals..?
Re-evaluation
I also hope that this whole experience makes us reflect, on an individual and a societal level, just how interconnected the whole world is, how our actions can have far reaching effects, and that our safe comfortable lives are not guaranteed nor should be taken for granted.
The things we buy, the waste we produce, the energy we use, the journeys we make – what effects are they having on other people, the planet, and the future?
I don’t believe that “capitalism is bad”. On the contrary, I think we owe it our amazing, long, healthy, rich lives.
It’s certainly not without issues, however, and we need to keep working in order to maximise the benefits, whilst minimising the negatives.
We should also realise that we just dodged a bullet. Covid-19 may well be worse than the flu, but it’s relatively light weight as far as infectious diseases go.
It almost certainly has a mortality rate of less than 1%, probably far less. What if it had have had a mortality rate of 50%+ which is not unheard of in other infectious diseases?
It doesn’t bare thinking about… but unfortunately we need to think about these things, as as we have seen, simply hoping something will never happen is not an effective strategy.
The total lack of preparedness for a “mild” pandemic also indicates that we’d be woefully under prepared for the numerous other unlikely, but altogether too possible potential apocalypses that might be waiting around the corner.
*Perhaps “Willing” is the wrong word?
Earlier I wrote:
Why is it that all of a sudden we’re willing* to make huge sacrifices in order to “save lives”?
That statement of course would imply that we were self-isolating voluntarily.
Here in Spain, this is not the case. We were asked nicely at first to stay at home and socialise as little as possible, but then two days later a state of emergency was announced and “lockdown” implemented.
The vast majority of businesses were shut down with immediate effect, and we were all ordered to stay home. We are not even allowed to go outside for a walk, unless it is to your nearest shop to buy essential supplies (unless you have a dog).
I am not sure how I feel about this.
I was, and still am, more than happy to self-isolate, and voluntarily stopped my in person fitness classes and capoeira classes before the official lock down.
Though I may have my doubts about the extent and duration of the lockdown, these are just hypothesis, and I am happy to defer to expert opinion.
Many, many people, however, I am sure would happily carry on living their lives more or less as normal, were the police not stopping people in the street and threatening them with fines or arrest.
Is this right? Is it legal? Is it democratic?
The state of emergency is written into law, and it was instigated by a democratically elected government, so I suppose it is legal and democratic. Something about the whole situation leaves me deeply uneasy however.
Now, I am not an anarchist, and believe that a capable state is necessary in order to maintain individual liberty, but this is a chilling reminder that this liberty could be taken away at any moment.
Hungary and Poland were both accepted as liberal democracies and accepted into the EU. It was clear that history had a direction, and it ended in liberal democracy and personal freedom. The tanks would never roll down the streets again in Europe, authoritarianism was a thing of the past, just like deadly pandemics.
Today the streets are patrolled by armed police and soldiers, and we are all effectively under house arrest “for our own protection”. Perhaps it’s warranted this time…