Tackling covid-19: are the costs worth the benefits?
BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1496 (Published 21 April 2020) Cite this as: BMJ 2020;369:m1496Read our latest coverage of the coronavirus pandemic
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Dear Editor,
The Unintended Costs of Successful Lockdown
As this article describes COVID-19 has come at a significant economic cost and it rightly identifies the collateral cost to the lives of those without COVID-19.
Anxiety is rife, with 52% of those with underlying health problems and 42% of those over 70 scoring high on national anxiety scores [1]. Lockdown has seen several thousands of excess deaths outside COVID-19 itself. During the first week of lockdown, there were 6,082 excess deaths compared to a five-year average, of which 42% were not due to COVID-19 5. The second week saw 7,996 excess deaths, of which 28% were not caused by COVID-195. Furthermore [2], despite online triage services such NHS 111 seeing a 500% increase [3], Accident and Emergency attendances have dropped by 25% [4].
At our major London teaching Hospital we have observed significant and alarming differences in the total observed versus expected presentations to the Medical Take during the seven week period from 1st March to 25th April. Although the number of COVID cases presenting has fallen to 30% of the early April peak, suggesting that the lockdown is indeed working to limit transmission, the Medical Take, which encompasses the most unwell patients seen by Accident and Emergency and General Practice, saw worrying falls in other presentations including chest pain, renal failure, strokes and gastrointestinal bleeding. The most significant reduction in presentations compared to the same period in 2019 were observed during lockdown itself with cardiac presentations dropping by up to 72%, renal up to 81%, gastroenterological up to 71%, neurological presentations (outside stroke) by up to 74% and stroke admissions also fell by up to 59%. Please see our figures at http://www.imperialendo.co.uk/Newskills/FiguresBMJ.htm.
Whilst it appears that the social distancing measures have been successful at reducing admissions with COVID in April 2020, the reduction in patients presenting with treatable conditions may be an unintended consequence of the instruction for people to stay at home unless absolutely essential. Anecdotally, we have seen patients with focal neurological signs delaying presentation and missing treatment windows through fear of COVID-19 and here we demonstrate substantial falls in the frequency of most major treatable presentations. Whilst some conditions might be self-limiting, there are many patients with time-critical treatable conditions who may be coming to harm due to a reluctance to seek timely medical attention.
The balance of risks requires careful consideration such that patients feel empowered to seek medical attention when indicated, especially where the benefits of established evidence-based treatments for many conditions may outweigh the smaller probability of contracting and dying from COVID-19.
References
1. Office for National Statistics UK: COVID dataset
2. Office for National Statistics UK: Births, deaths and marriages. COVID dataset
3. NHS England 111 Statistics 2020
4. BMJ 2020;369:m1401
Competing interests: No competing interests
Dear Editor
As an 83 year old my sympathies are with “No” ( ie, It is not wrong to prioritise younger patients) in the previous item Head to Head (BMJ 2020,369:m1509). Collateral damage from a second peak is more likely to be harder and more prolonged on the young than on the old. Provided that at least some level of immunity is achieved, it is self evident that the greater the prevalence of those who have recovered with little or no symptoms the better.
Once the situation has stabilised with the present measures, the Government should not, like King Canute, attempt to do the impossible and totally suppress the infection, but manage it. Taking advantage of the season, it should aim at achieving the optimal level of infection in children and the working population, aiming to cause least health and economic cost whilst protecting the vulnerable. This will be more difficult to manage and to present to the public than attempting total suppression. It will require equal if not a greater flexibility in adapting as ongoing data becomes available. The precise value of each of the present draconian measures in giving proportionate protection to individuals or preventing the establishment of new clusters must be determined and those aspects that have neglible impact should be recognised. This is essential to inform policy and ensure compliance.
Should the Goverment take this approach it should be open about it, because it would almost certainly have net gain in preventing or ameliorating a winter peak, which would be far more dangerous and damaging in every respect. The practicalities of the two different approaches might be very similar but the philosphy of accepting that achieving the lowest prevalence at all times is likely be counterproductive is vital. A subtle changing of the wording in the current slogan from “save lives” to “safeguard life and the future” would help in the understanding of what should be attempted.
Competing interests: Age. Fundamental objection to the universal application of the precautionary principle
Dear Editor,
Despite much of the uncertainty around the covid-19 pandemic and the mounting economic costs of current government guidelines, the risk posed to life should remain the government’s top priority.
The question of whether the value of deaths averted compared to the cost of interventions is bleak but fair. However, the economy requires human life to function, either as consumers or service providers. To echo the sentiments of the president of Ghana, ‘we know how to bring the economy back to life. What we do not know is how to bring people back to life’. (https://bit.ly/3bGCUIy)
With the current government interventions, covid-19 related deaths are estimated to reach 250,000 but without intervention and prioritising the economy, deaths will double to 510,000 over a seven to eight-month period. (https://bit.ly/3azW94Z) This number appears even starker considering that the virus will remain in our presence until a vaccine is developed. Which could be up to 18 months according to the most optimistic estimates. ( doi:10.1021/acsnano.0c02540 ) The untold damage this will do to the United Kingdom economy and health service is unmeasurable, be it through increased cost of mental health provision ( doi:10.1177/0141076814522144 ) for grieving families or loss of the workforce.
Additionally, although current covid-19 data is imperfect and premature, it is the best available to medical and government teams. The alternative would be to do nothing and carry on as normal based on unknown impacts to the economy and perceived lack of benefit of scientific guidance. Such decisions are improper.
We will only know the benefits or drawbacks of interventions after they have been implemented. We cannot renege on enforced measures or wait to see if the number of deaths will be as high as predicted; by then it will be too late.
Competing interests: No competing interests
Dear Editor,
COVID in (country) context
John Appleby asks whether the costs of tackling covid-19 are worth the benefits but implies that many readers might find the question itself “outrageous”? Indeed they might, but surely only in countries where people can afford to be outraged, like those in Western Europe or in the OECD.
Despite its global reach, COVID-19 does not pose the same threat for all countries. Context matters. In many of the world’s least developed countries, the everyday threats of diarrhoeal disease, maternal mortality, malnutrition and malaria remain dominant, even as COVID-19 now dominates the thinking of more developed, and more headline-worthy, countries.
Consider for example, the very different circumstances that obtain in Italy and Niger. Assuming a worldwide uniform rate of infection of individuals with SARS-Cov-2, preliminary data on the age-specific infection fatality ratio [1] combined with information about country-level population structure [see figure, 2], suggest a near eight-fold difference between the two countries in predicted per-capita COVID-19 deaths.
Even without further analysis, the difference implies that the two countries should respond very differently to the pandemic threat, as indeed they have. So far, Niger has implemented few restrictions on movement, perhaps because of the importance that seasonal migration, particularly between January and April, plays in the economy of the country. In contrast, Italy has.
Now combine the differences in population structure with information about basic health [3]. In Italy, 96·2% of the population use safely managed sanitation services; in Niger, 9·6%. In Italy, in 2017, primary health care expenditure per capita in Italy was US$2840; in Niger, it was US$29.
If Italy temporarily diverted some of its immense resources from reducing, say, the under-five mortality rate (U5MR; 3·0 per 1000 live births in 2018, down from 10·0 in 1990), the already low U5MR and small proportion of the population under five-years of age (3·9%) suggests little likely impact. In stark contrast, in 2018 Niger’s U5MR was 83·7 per 1000 live births—a hard-won reduction from 328·6 in 1990. Diverting even a small proportion of the limited health budget towards managing COVID-19 could see a substantial increase in the U5MR on the relatively large cohort (19·9%) of children under the age of five.[4]
A single, global, COVID-19 focused response ignores important inter- and intra-country variations in socioeconomic, health and demographic factors that could result in some countries bearing an excessive non-COVID-19 burden.
Daniel D. Reidpath, Ph.D.
icddr,b (International Centre for Diarrhoeal Disease Research)
daniel.reidpath@icddrb.org
Pascale Allotey, Ph.D.
International Institute for Global Health, United Nations University
pascale.allotey@unu.edu
Angela O’Brien-Malone, Ph.D.
School of Psychology, University of Tasmania, Hobart, Australia
aobrienmalone@yahoo.com.au
Mark R. Diamond, Ph.D.
School of Psychology, University of Tasmania, Hobart, Australia
Corresponding author: Mark Diamond, School of Psychology, University of Tasmania, Private Bag 30, Hobart TAS 7001, Australia
Email: mark.diamond@yahoo.co.uk
1 Verity R, Okell LC, Dorigatti I, et al. Estimates of the severity of coronavirus disease 2019: a model-based analysis. Lancet Infect Dis Published Online First: 30 March 2020. doi:10.1016/S1473-3099(20)30243-7
2 Diamond MR. Italy-Niger-Percentage-Pyramid.pdf. 2020. doi:10.6084/m9.figshare.12173922.v1
3 World Bank. World Development Indicators | DataBank. 2020.https://databank.worldbank.org/source/world-development-indicators#selec... (accessed 23 Apr 2020).
4 UNICEF. Data Warehouse. UNICEF Data. 2020.https://data.unicef.org/ (accessed 23 Apr 2020).
Competing interests: No competing interests
Tackling COVID-19 Pandemic: all relevant impactful observables should be captured in the cost-benefit balance
Dear Editor
Attention has recently been focused on the ‘Costs’ of addressing the ‘COVID-19 Pandemic’ and balancing these with the ‘Benefits’ of the ‘Pandemic Interventions’ [1]. The ‘Costs’ enunciated include essentially: Reductions in ‘Actual COVID-19 Pandemic Mortality’ compared with the ‘Model Predicted COVID-19 Pandemic Mortality’ as in the UK as a Case-in-Point [2]. With a ‘Model Predicted Mortality’ of 500, 000 in the UK over a 2-year Period, the ‘Actual Mortality’ could be reduced to 250, 000 with the ‘COVID-19 Pandemic Interventions’ and certainly at some ‘Computable Costs’! Specifically deploying the ‘Non-Pharmaceutical Interventions’ (NPIs), the ‘Mitigation Measures’, the ‘Model Predicted Mortality’ of 1800 may be significantly reduced to 370 [3]! These ‘Mitigation Measures’ include, among others: Lockdowns-Shutdowns, Social Distancing, Self-Isolation, Mass Gathering Prohibitions and all these have their ‘Cost Implications’!! There are also ‘Other Costs’ that need to be disposed: ‘Economic’, ‘Health’, ‘Healthcare’ [1]! These ‘Cost Domains’ were not disposed in detail but they certainly have ‘Huge Implications’!! What about the ‘Cost Implications’ of the ‘Production, Transportation, Supplies and Distribution’ of the ‘Critical Care Essentials’: Personal Protective Equipment (PPEs), Screening/ Testing Kits, Ventilators, Surgical Masks/ Respirators, On-going Research into Drugs and Vaccines Production? What are the ‘Computable Cost Implications’ of the various ‘Repurposing of Industrial Production Lines’ and ‘Repurposing/ Reconfiguration of Complexes and Infrastructure such as Stadia, Sports Arenas, Conference Centers and Hotels’ to address the ‘COVID-19 Pandemic’? Other ‘Healthcare Costs’ can be gleaned from the ‘Prioritization’ and ‘Fairness’ in the ‘Rationed Deployment of Resources’ [4]! What about the ‘Computable Cost Implications’ of ‘Prioritizing Care’ in favour of ‘COVID-19 Pandemic’ and against ‘Other Non-COVID-19 Health Conditions/ Disorders’ [1]? It is hoped that, as disposed by the National Institute for Clinical and Health Excellence (NICE), the ‘Decision-making Processes’ will be more ‘Transparent’ and ‘Consistent’!! Healthcare Staff deployed to the ‘Formidable Frontline Force (F3)’ against the ‘Unseen Enemy’ in the ‘Global War’ against the ‘COVID-19 Pandemic’ have been infected and lost in bothersome numbers in different Countries! What is the ‘Cost Implication’ of ‘Skilled Healthcare Personnel Loss’ and how is this factored into the ‘Comprehensive Cost-Benefit Analysis’? The real ‘Costs’ must be ‘Comprehensively Computed’ to have a proper ‘Cost-Benefit Balance’ for the ‘COVID-19 Pandemic’!!
Concerning the ‘Composite Costs’ of the ‘COVID-19 Pandemic’, several other ‘Cost Domains’ are relevant and must be factored into the ‘Cost-Benefit Balance’: These can be gleaned from the ‘Various Aspects of Human Existence and Development’ [5-9]! All ‘Aspects of Sustainable Development’ are substantially affected: Social, Economic and Environmental Domains! The ‘COVID-19 Pandemic Costs’ go well beyond the ‘Economic, Health and Healthcare Costs’ [1]!! Engaging in a ‘Cost-Benefit Consideration’ may not be an easy and straight ‘Enterprise’!! The ‘Benefits’ focused largely on the ‘Reductions in Model Predicted COVID-19 Pandemic Mortality’ [1]. There are definitely ‘Other Benefits’ that should be computed in the discourse on the ‘Cost-Benefit Analysis’ for the ‘COVID-19 Pandemic’! Some ‘Communications’ have highlighted the ‘Potential Sustainable Benefits’ [7,10] of the ‘COVID-19 Pandemic’ and it may be desirable to dispose the ‘Cost Implications’ of these ‘Protean Benefits’!!
A proper ‘Cost-Benefit Consideration’ for the ‘COVID-19 Pandemic’ should go beyond ‘Cost Consideration’ in terms of ‘Financial Expenditure’ but should also consider the ‘Pandemic Burden’ beyond ‘Direct Financial Costs’! Additionally, the ‘Benefit Consideration’ must include the ‘Pandemic Benefits’ which are beyond ‘Death Reductions’ and include previously highlighted ‘Potentially Sustainable Impacts’ for a possible ‘Improved Humanity’ [7,10].
It was clearly indicated that ‘Too much uncertainty remains with evidence-based decisions’ [1]! Indeed, caution needs to be exercised in the ‘Comprehensive Cost-Benefit Analysis’ with the ‘COVID-19 Pandemic’ as ‘Current Analysis’ appears ‘Imperfect and Premature’ [1]!! Increasingly, so much doubt is being cast on the ‘Touted Numbers/ Data’ concerning ‘COVID-19 Pandemic’ and this is certainly not helped by the ‘Politics’ on ‘Research Evidence’ and ‘Evidence-based Medicine’ which also requires critical attention in the ‘Cost-Benefit Consideration’!
REFERENCES
1. Appleby J. Tackling covid-19: are the costs worth the benefits? BMJ 2020; 369:m1496
2. Imperial College Covid-19 Response Team. Impact of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand. Report 9. 2020. https://www.imperial.ac.uk/media/imperial-college/media/sph/ide/gida-fel... pdf
3. Imperial College Covid-19 Response Team. Estimating the number of infections and the impact of nonpharmaceutical interventions on COVID-19 in 11 European Countries. Report 13. 2020. https://www.imperial.ac.uk/media/imperial-college/media/sph/ide/gida-fel... and NPI-impact-30-03-2020 pdf
4. Orr S, Wolff J. Reconciling cost-effectiveness with the rule of rescue: the institutional division of moral labors. Theory Dec 2014; doi: 10.1007/s11238-014-94343
5. Godlee F. COVID-19: Weathering the storm. BMJ 2020; 368:m1199 of 26th March 2020
6. Eregie C.O. COVID-19 Pandemic: Still on the difficult unresolved increasing challenges in weathering the storm. https://www.bmj.com/content/368/bmj.m1199/rr-13 of 2nd April 2020
7. Kickbusch I, Leung GM, Bhutta ZA, Matsoso MP, Ihekweazu C, Abbasi K. Covid-19: how a virus is turning the world upside down. BMJ 2020; 369:m1336 of 3rd April 2020
8. Eregie C.O. COVID-19 Pandemic: Further perspectives on the difficult unresolved increasing challenges in weathering the storm. https://www.bmj.com/content/368/bmj.m1199/rr-16 of 5th April 2020
9. Eregie C.O. COVID-19 Pandemic: The daunting challenges of assuring sustainable benefits from weathering the storm. https://www.bmj.com/content/368/bmj.m1199/rr-14 of 8th April 2020
10. Eregie C.O. Breastfeeding and ‘COVID Phenomenon’: Demystifying the innovative conceptual coinage in human development and sustainable development. https://www.bmj.com/content/369/bmj.m1336/rr-14 of 12th April 2020
Professor Charles Osayande Eregie,
MBBS, FWACP, FMCPaed, FRCPCH (UK), Cert. ORT (Oxford), MSc (Religious Education),
Professor of Child Health and Neonatology, University of Benin, Benin City, Nigeria and
Consultant Paediatrician and Neonatologist, University of Benin Teaching Hospital, Benin City, Nigeria.
UNICEF-Trained BFHI Master Trainer and ICDC-Trained in Code Implementation.
*Technical Expert/ Consultant on the FMOH-UNICEF-NAFDAC Code Implementation Project in Nigeria.
*No Competing Interests.
Competing interests: No competing interests