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Viewpoint
July 8, 2020

Challenges Estimating Total Lives Lost in COVID-19 Decisions: Consideration of Mortality Related to Unemployment, Social Isolation, and Depression

Author Affiliations
  • 1Harvard T.H. Chan School of Public Health, Boston, Massachusetts
JAMA. 2020;324(5):445-446. doi:10.1001/jama.2020.12187

The coronavirus disease 2019 (COVID-19) pandemic has claimed hundreds of thousands of lives, directly and indirectly, and threatens to claim many more. Nations have made different policy decisions that have affected the rate of infection, mortality, the economy, and the life of the country differently. The choices between various alternative policies have led to different trade-offs between what are arguably incommensurable goods, such as survival, mental health, social connection, and economic growth. It can seem difficult or impossible to weigh these numerous factors, yet policy decisions must be made, with countless implications for society. In the early stages of the pandemic, and when information was limited, a cautious approach was arguably most appropriate. As further information becomes available, it becomes possible to make better-informed decisions. However, the inherent challenges involved in the very real, and very difficult, trade-offs remain.

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    3 Comments for this article
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    Estimating Total Lives Saved and Lost from COVID-19
    Michael McAleer, PhD (Econometrics), Queen's | Asia University, Taiwan
    The cogent and informative Viewpoint by a respected academic on the challenges in estimating the total lives saved and lost based on economic, social connection, psychological, and medical considerations is essential reading for everyone involved in public health care policy decision making of the extent of the damaging effects of COVID-19 on modern society.

    Economic, social, psychological, and medical differences arise according to different cultures, countries, regions, and cities, and in how to deal with the first and second waves of the COVID-19 pandemic.

    Difficult and necessary trade-offs among economic, social, psychological, and medical considerations in protecting the physical and
    emotional health of individuals, versus opening up society and the economy, are essential challenges to enable society to function effectively rather than descending into chaos.

    There are serious problems associated with the development of a composite measure of "well-being–adjusted life-years", which depends on arbitrary and untestable assumptions regarding the quality of life and life satisfaction, especially for the poor, disabled, and those who are least capable of looking after themselves.  

    Similar difficulties are associated with a “total lives saved” approach, in that questionable assumptions must be made regarding economic, social, psychological, and medical measurements, which can be problematic in themselves regarding their accuracy.

    Community responses are essential in determining the acceptable trade-offs among economic, social, psychological, and medical options, which would lead to a range of assumptions in the associated models, before sensible, informed, and acceptable public policy considerations can be reached and implemented.

    This may be difficult during the COVID-19 pandemic, but as the new norm it is essential that any underlying assumptions in alternative modelling approaches be easy to understand, interpret, and communicate so that the associated predictions and prescriptions will not be dismissed by the general public, social media and (especially) politicians as yet another unrealistic set of ill-considered recommendations by academic researchers.
    CONFLICT OF INTEREST: None Reported
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    Lives vs Money (and Lives!!!)
    Gary Ginsberg, DrPH, MSc (Econ) | Braun School of Public Health, Hebrew University, Jerusalem
    As the authors correctly point out, its not only health vs economy, but it's actually health vs (economy and health). Israel (population 8.7 million), has had a relatively low death toll from COVID of 343 souls. Having successfully implemented a lockdown to almost eliminate the first wave (at one stage down to 5 new cases a day), we are now in the midst of a huge second wave (around 1,000 cases a day) and a further lockdown remains a possibility. Data from Scotland (Clemens et al. EJPH 2015,25,115) showed age-adjusted relative risk of mortality in unemployed males and females to be 1.85 and 1.51 respectively. Applying these data to the Israeli population, I estimate that if a lockdown reduces employment by 70% then 1,700 lives will be lost to unemployment-related factors during the next 12 months. This exceeds the estimated deaths from COVID that are liable to be prevented.

    If employment is reduced by 50% then there will be around 505 extra unemployment-related deaths. I know it's hard to think across sectors, but we have to at least (as the authors suggest) start combining cross-sectorial data on which to make our decisions.
    CONFLICT OF INTEREST: None Reported
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    Widespread and Prolonged Unemployment Rates as Risk to Democracy: Lessons from the 20th Century
    David Gurwitz, Associate Professor | Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
    This is a superb opinion article that is a 'must read' for public health strategy planning teams globally and others in the health policymaking chain. This includes Parliament/Congress/Senate members in all democratic nations. The aspects discussed in this article must be addressed and carefully taken into consideration when deciding on lockdowns and on financial support systems for assisting unemployed individuals and affected private sector businesses.

    Alas, given our incapacity to predict when an effective and inexpensive vaccine would become widely available, as well as future SARS-CoV-2 mutations and their effects on COVID-19 fatality rate, it is next
    to impossible to calculate numbers of lives saved vs. lives lost due to prolonged lockdowns.

    Moreover, a key aspect entirely absent in this otherwise elaborate article is that widespread and prolonged unemployment rates tend to destabilize democratic nations, which is what fueled the rise of the Nazi Party to power during the period leading to the Third Reich. Such events may lead to far higher numbers of lost lives compared with COVID-19. Sadly, there are already signs that in some nations such events are conceivable.
    CONFLICT OF INTEREST: None Reported
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