Somewhere along the line we have lost a sense of proportion about the COVID-19 pandemic. At the beginning, we were rightly concerned that a novel virus, to which human populations had never been exposed, might represent an existential threat to our species. This justified rapid, and often poorly-evidenced, actions to interrupt transmission of the infection. With hindsight, many of these seem arbitrary and ineffective but they appeared to make sense at the time. One result, however, has been to create levels of fear and anxiety in some populations that make it difficult to contemplate any kind of return to what we have thought of as a normal life. This applies as much to politicians as to publics. We seem to be constrained to discussions of a ‘new normal’, an impoverished human existence that will last until such, uncertain, time as we get a vaccine that will protect us. Never mind that we have been unsuccessfully seeking an HIV vaccine for 40 years or that most adult vaccines are considerably less effective than those given in childhood.
This distortion of public debate comes from two sources. One is the understandable desire of politicians not to seem insensitive to the cumulative individual tragedies represented by the deaths from COVID-19. Death makes for dramatic stories in the media and, as David Altheide has shown, feeds a ‘fear industry’ of interests that derive commercial or political benefits from anxiety. The second is the dominance of biomedical-industrial stakeholders in both the characterization of the pandemic and its solutions.
In the UK, at least, we have lost the vision of the 2007 pandemic plan that saw this as a societal, rather than a public health, challenge. For the biomedical world, health, and the preservation and prolongation of life, tend to be considered as absolute goals, for both ethical and commercial reasons. (This is not necessarily true of experienced clinicians who often have a good sense of the limits of medicine and the inappropriateness of futile interventions – but they are not the dominant voices in public communication.) COVID-19, however, has distorted that understanding. The biomedical-industrial complex has become locked into the single issue of COVID-19 at the expense of all the other conditions that might affect human lives. It has also become an advocate for investment in itself at the expense of other things that we might consider to be socially desirable, like liberty and the pursuit of happiness.
This is true even of the World Health Organisation, for whom the pandemic is an opportunity to push back against the Trump administration’s criticism of its operations. It is worth recalling the definition of health in the WHO constitution: ‘Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.’ This does not identify ‘health’ with any single disease and considers it in a wide social and psychological context. WHO should be taking a lead in asking about the importance of the COVID-19 pandemic relative to other causes of mortality, morbidity and human distress – and leading discussion of the proportionality of control measures that have negative impacts, now and in the future, on other dimensions of physical, mental and social well-being.
Six months into this pandemic, we have learned that it is not going to wipe out human life on this planet. This means that it is time for a public policy reset. Our focus needs to be on the overwhelming fact that 80-85 percent of people who contract this infection never need to go near a hospital – and of those who do, the majority will come out alive. Those who do die come from readily identifiable risk groups – there have only been a handful of truly unanticipated deaths. In general, COVID-19 brings deaths forward rather than killing otherwise healthy people, unlike the 1918 influenza pandemic or the 2003 heatwave, for example. Of course, a reasonable person would prefer to live a longer life than a shorter one, other things being equal. However, if we wish to protect those who are truly vulnerable, then we cannot have a society and economy that is driven solely by minimizing the risk of infection to the 95 percent who will survive. Protecting the vulnerable is a charge on everyone else and can only be met from the proceeds of a functioning economy.
If we consider COVID-19 alongside other influenza-like illnesses, we can see that it is more severe, although not greatly more contagious. While most people experience a mild to moderate illness, not requiring the intervention of the health system, others do need high levels of care and significant long-term rehabilitation – like most people who have had extended stays in intensive care. Even some of those with a moderate community illness seem to suffer extended consequences – but post-viral syndromes are not exactly unknown. We could provide for these needs by an increased investment in health system capacity, allowing a background level of COVID-19 to be accommodated without severe disruption, much as is the case with seasonal influenza. This might involve the development of new specialist facilities – dedicated infectious disease hospitals or wings – and the planned rotation of professionals through intensive care units to maintain a cadre of expertise that can be called upon to meet a surge of demand. It might also involve a better integration of domiciliary social care and nursing homes into the health system, something that has long been thought to be desirable anyway.
For public policy, the critical statistic is not the infection fatality rate – the probability of dying once infected – but the population fatality rate – the probability of dying for the entire population. As the pandemic has evolved, it has become clear, that the latter is quite small, to the point of being barely detectable, for people under 45, relative to other causes of death in that age group. Although the risk increases beyond that age, it looks more dramatic as a proportion than as an absolute figure. The risk of death in the next 12 months for the 628,000 English men who share my age and health status appears to be about 0.015 percent, according to University College London modellers. COVID-19 with no mitigation increases this by about one-third to 0.02 percent. How much social and economic damage are we justified in inflicting to achieve this reduction? How easily would this be offset by excess deaths from untreated, or inadequately treated, strokes, heart attacks, attempted suicides and other emergencies? How many ‘deaths of despair’ will result from the impending recession?
It is time to stop ‘following the science’ and to recognize that what we are doing is making political choices about the sort of society and economy we want to live in. These must be informed by the science – but we must be offered the chance to trade off the biomedical focus on health at any cost against all of the other things that make human lives worth living. We cannot eradicate COVID-19 with current technology but in attempting to do so, we may find that we have eradicated industry, commerce, trade, travel, arts, leisure, learning, sports, culture, liberty, and privacy. We have imprisoned ourselves in our homes, too scared to venture far, to mix with others, to learn from diversity, to have new experiences and discover new ideas.
We have never thought it necessary to do this in the face of influenza, whether seasonal or pandemic. Could we live alongside the COVID-19 virus as we live with the influenza virus –as a ‘second influenza’? Maybe we do want to crawl into our bubbles and hide our faces from one another – but let that be a positive choice rather than an unexamined one.