No one is questioning that “flattening the curve” yields benefits. In cities where hospital capacity cannot match the dramatic rise in coronavirus cases, a two- or three-week clampdown provides a window for hospitals to expand capacity, improve testing, allocate medical personnel and bolster supplies. If treatments become available, then delaying infection may save lives. The case for shutting down society further strengthens if summer weather reduces viral spread and a fall return is muted.
But how are we to balance the short-term gains for COVID-19 management with the long-term devastation imparted by an economic downturn?
If the current economic shutdown continues much beyond a few weeks, the long-term health consequences will far exceed the acute havoc of the coronavirus. We must, therefore, manage both the COVID-19 health crisis and the long-term crisis that has already begun.
The COVID-19 has taken 1,046 lives in the U.S. to date, and it will take many more. In the worst case, 81 percent of the population becomes infected over the course of the epidemic, resulting in 2.2 million deaths in the United States. By contrast, when the Diamond Princess cruise ship experience is projected onto the age structure of the U.S. population, it gives us a mid-range death rate among the infected of 0.3 percent. If we assume, as with the Diamond Princess, that 20 percent of the population becomes sick with coronavirus, then the expected number of U.S. deaths would be about 200,000. In this plausible scenario, total COVID-19 deaths is equivalent to six years of deaths from flu. Death from coronavirus is a tragedy, to be sure, but it won’t be our greatest.
The adverse health effects from the broader social and economic crisis will be far greater and longer lasting if we continue to shut down much of the U.S. economy. The nation’s health depends on people working, earning income and learning. With demand falling off the cliff, businesses in most sectors face insolvency risk and, no surprise, are laying off employees. The dramatic increase in unemployment claims — new filings rose 30 percent last week — is probably understated because unemployment offices are understaffed. We are on a path to depression-level unemployment, which is bad for health.
Sociologists have consistently shown that education level correlates directly with health status. With schools shut down, some students are learning online. But those without access to technology are not. Families that have suffered losses of income and retirement savings will not be able send their children back to college. There’s no question that losses of income, reductions in education and increases in stress lead to bad health outcomes.
The long-term health consequences of our present economic downturn are real. Heart disease, already the leading killer of Americans, will doubtless take more lives. Home confinement restricts exercise and access to fresh foods, which in turn lead to increased rates of obesity. Isolation increases depression and despair. Death by suicides have been increasing steadily in the U.S. over the past two decades; there’s every reason to believe that they will increase. Moreover, if 2018 was the first year in three decades that opioid deaths dropped slightly, coronavirus-era containment measures are sure to reverse this. Adverse health effects are manifestly clear at the individual, family, team, community and national levels.
Why are government officials taking draconian steps to flatten the curve without taking into account the devastation that will follow?
Our survival instincts play a role: when faced with death, humans aspire to do whatever it takes. No elected official wants to oversee chaos at local hospitals or be judged as doing too little. In this context, the most aggressive politicians are rewarded and others follow. Even New York Gov. Andrew Cuomo (D) yielded to the view that saving “just one life” makes government restrictions worthwhile. It is far more difficult — ask British Prime Minister Boris Johnson — to set a less aggressive short-term course that accounts for longer-term risks.
Unfortunately, misconceptions and false hopes are also fueling the flatten-the-curve efforts. Many on the receiving end of media reports believe that a flatter curve will reduce the total number of COVID-19 deaths. Yes, the South Korean experience is preferred, but it recently reported a daily increase of 74 cases, has new clusters of the disease, and is bracing for a resurgence. China reported zero locally transmitted cases over a recent period, but whether China’s curve will remain flat as the country gets back to work is, of course, a major unknown.
Although a flatter curve may reduce deaths in particularly overburdened health systems, the net number of lives lost may not substantially differ over the course of the disease. The extent of long-run adverse health consequences, however, will increase with the extent of damage to the economy from prolonged efforts to flatten the curve.
As we seek to flatten the curve, therefore, we must work to thwart future adverse impacts on health from blunt economic policies, definitive increases in national debt and losses of personal freedoms threaten future health.
What then can be done?
We must first accept the fact that there will be a loss to human lives that we cannot control. We nevertheless should continue to work to mitigate such loss through individual precaution taking, community efforts to assist the elderly and immunocompromised and support of health care institutions.
But we must also look to societal long-term health by restarting the economy — not through bailouts that could easily reach $3 trillion, or $15 million for each of the possible 200,000 lives lost. Governments, enterprises and institutions should develop best practices for resuming our lives. We must allow people freedom to contract — to work and to hire without coercion or restriction and without stigma of irresponsible behavior. We also should allow individuals to decide whether to go to the gym, eat at partially occupied restaurants or go to bars. We should dispense with narratives about irresponsible millennials socializing and then infecting grandma, ignoring both the possibility that the millennial can act responsibly and that a lonely grandmother may invite a visit even at her own peril.
If the 1918 influenza epidemic taught us anything, it’s that compliance with top-down orders for containment is nearly impossible. It also should teach us that the economy can adjust to a far worse pandemic, one that killed 675,000. Without government edicts reasonable people will take necessary steps to protect themselves.
Many say that we are in a war against COVID-19, perhaps an apt metaphor. But the battle to protect our nation’s health has two fronts. We must not devastate long-term economic and social health for short-term gains.
Edward A. Snyder is the William S. Beinecke Professor of Economics and Management at the Yale School of Management. L.S. Dugdale, a physician, is director of the Center for Clinical Medical Ethics at Columbia University Vagelos College of Physicians & Surgeons.
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