It is wishful thinking to pretend we can return to pre-pandemic norms. The time has come to decide what kind of society do we want to live in
This article was originally published at openDemocracy.
“I hope we will be one of the first major economies to demonstrate to the world how you transition from pandemic to endemic,” Nadhim Zahawi, a UK government minister, stated last week. “We are moving to a situation where it is possible to say that we can live with COVID and that the pressure on the NHS and on vital public services is abating,” echoed Michael Gove, another senior minister.
When it comes to COVID-19, the message resonating from the UK government is loud and clear: the virus is here to stay, and the time has come to learn to ‘live with it’. The prime minister, Boris Johnson, is expected to announce details of such a plan within the coming weeks.
That COVID-19 is not going to disappear anytime soon is undoubtedly true. As long as large parts of the world remain unvaccinated – a problem created in large part by the refusal of countries such as the UK to support waiving patents on COVID vaccines – it is likely that new variants of the virus will continue to emerge in the months and years ahead. Vaccines, which to date have been designed to fight the original strain of the virus that emerged in Wuhan in 2019, may struggle to keep up. As an editorial in The Lancet medical journal recently noted:
The window for pursuing the elimination of SARS-CoV-2 has closed. Moving towards a so-called post-pandemic world will be far more complicated than scenarios such as “Zero COVID”. The challenge now is to determine the level of COVID-19 that is acceptable for individual nations in a fundamentally interconnected world.
Learning to safely ‘live with’ COVID-19 presents many challenges. It is foolish to pretend that the social and economic disruption experienced over the past two years can be attributed to government restrictions alone. Instead, we must focus our attention on the root cause of the disruption: the circulation of the virus itself. The challenges engulfing England right now are a case in point: employers were recently advised to plan for staff absences of up to 25% resulting from rising infections, while more than 600,000 people cancelled flights at Heathrow airport in December alone – despite a relative absence of government restrictions. As long as the virus remains in widespread circulation, a degree of social disruption is inevitable.
As the Professor of Global Public Health at the University of Edinburgh, Devi Sridhar, recently noted: “Yes the world needs to figure out how to ‘live with COVID’. Unfortunately, no country has yet figured out how to do this well over time without crashing health services, social life, the economy, or having widespread disruption.”
If COVID-19 is here to stay for the foreseeable future, then answering this question should be an urgent priority. In order to attempt to do so, however, we must first decide what we really value.
Throughout the pandemic, the question of how to optimally balance public health, economic and other social concerns when shaping policy has loomed large, but hasn’t yet been adequately answered. In part this is because we have been swimming in uncharted waters – as a new disease, robust data on the health impact of COVID, as well as the side effects of policies such as lockdowns and social-distancing rules, have only recently become available.
However, the challenge of making informed trade-offs between health outcomes and wider socio-economic factors is not new. Undertaking these kinds of assessments has formed the basis of how resources are allocated to health problems for decades. In the UK, the established approach to undertaking this kind of assessment uses something known as ‘Quality-Adjusted Life Years’ (QALY).
Born in university economics departments in the 1970s, QALY is a framework used to assess the costs of medical interventions such as new drugs, procedures and other technologies against the health improvements that can be expected to result from them. An intervention that can be expected to deliver one year of additional perfect health provides one QALY; whereas if it provides a year of life in a state of less than this perfect health, for example through a disability or chronic condition, then it provides only a fraction of a QALY.
Crucially, because health services typically operate under constrained budgets, monetary values are attached to each QALY in order to establish whether interventions can be justified as being ‘cost effective’. In the NHS, the typical maximum threshold value for treatments is between £20,000 and £30,000 (although this can be significantly higher in the case of highly specialised treatments) per quality-adjusted life year. This means that if the cost per ‘QALY gained’ for any given intervention is below £30,000, it will typically be deemed as ‘cost-effective’ and will be offered. But if a treatment costs more than £30,000 per QALY gained, it will typically not be offered.
The idea that the state would ascribe a monetary value to something as sacred as life will likely come as a shock to many. Never mind that a value of £30,000 is, on the scale of government finances, surprisingly low. But for the past three decades this principle of attaching monetary values to life-years has underpinned how resources are allocated in the NHS.
The QALY system is not administered by the NHS, but by a little-known organisation called the National Institute for Health and Care Excellence (NICE). NICE was established in 1999 with the aim of making what were previously ‘opaque’ decisions about resource allocation in the NHS more transparent and consistent.
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Like many concepts in modern economics, although the QALY framework is presented as an objective tool, in reality it is underpinned by a range of political and ethical assumptions. Primary among these is that in a world of limited resources, healthcare provision must be rationed, and that this should be done on the basis of how many additional ‘quality life years’ a medical intervention can be expected to deliver. Because treatments that provide more ‘life years’ are assessed as being more effective, interventions that help older patients with shorter life expectancies are typically rated as less cost-effective than interventions that help younger people. Similarly, the system is based on the assumption that someone in a perfect state of health is more ‘valuable’ to society than someone with a disability or chronic condition. An inevitable result is that patients sometimes do not receive treatments or drugs that could technically prolong or improve their lives, on the basis that buying certain treatments would not be ‘cost-effective’.
Although these ethical issues mean that the QALY system has at times attracted controversy, it has survived as the backbone of resource allocation in UK healthcare for decades. Until COVID-19 came along, that is.
Despite the longstanding use of QALYs in medical decision-making in the UK and elsewhere, when the COVID-19 pandemic hit the system was not used to guide the public policy response – much to the dismay of some health economists. Instead, after a long period of denial and delay, the UK government eventually recognised the threat posed by the disease and reluctantly introduced unprecedented measures including lockdowns and social-distancing rules. The aim of the response was not to maximise quality-adjusted life years under a fixed-budget constraint, but to prevent the NHS from being overwhelmed, save lives and do ‘whatever it takes’ to see the UK through the crisis.
The reasons for departing from the QALY framework were sound: COVID-19 was a dangerous new disease that epidemiologists knew very little about. Calculating the scale of the health impact, and the costs of measures such as lockdowns, was highly challenging due to the unprecedented nature of the crisis. Embracing the precautionary principle, whereby a risk-averse approach is taken in the face of great uncertainty, was therefore justified. Moreover, the fiercely infectious nature of the disease meant that there was a real risk that health systems could become overwhelmed. The priority was therefore to manage the spread of COVID cases through social distancing and lockdowns to ensure that this did not happen to the NHS. This strategy has proved to be essential at preventing more deaths, even if it was implemented reluctantly and far too late.
The significance of departing from the established QALY system should not be understated. Were it used to guide the response to COVID, it is likely that many more deaths would have occurred. Whereas the QALY system typically does not endorse interventions that cost more than £30,000 per QALY gained, studies have estimated that each QALY saved from COVID-19 measures has ended up costing much more – ranging from hundreds of thousands to millions of pounds – due to the high costs associated with lockdowns and other pandemic measures. Given that those dying from COVID-19 tend to be older (and therefore have fewer ‘quality-adjusted life years’ left), this cost would not normally be justified.
Some critics have latched onto this discrepancy, claiming that the UK and other countries have in essence been operating a two-tier system when it comes to health resource allocation. In September 2020, Tony Abbott, the former Australian prime minister, claimed that COVID restrictions were costing the Australian government as much as A$200,000 to give an elderly person an extra year of life – substantially beyond what the government would usually pay. For similar reasons, some economists have used calculations based on the QALY framework to urge governments to ease COVID restrictions.
However, there are good reasons why the QALY framework may not be effective when society is battling a lethal infectious disease. This is because the system focuses on quantifying the effects of interventions on morbidity and mortality and does not adequately capture many of the other harmful effects of COVID and government restrictions beyond deaths. These include, for example, the impact of social distancing, isolating and travel limitations on social wellbeing and loneliness; the loss of education due to school closures; and the knock-on effects on wider healthcare provision. If we care not just about whether people live or die, but also the kind of society we live in, then we ought to try and capture these dynamics in any decision-making framework.
For this reason, researchers have already begun to devise alternative frameworks to QALY, such as ‘well-being-adjusted life year’, which attempt to capture these wider social factors. Whether these alternative measures represent a superior framework to QALY remains to be seen. But whatever framework is ultimately used to inform policy on COVID-19 will play a key role in determining the kind of society we live in going forward.
As with all models, however, the outputs delivered are driven by their underlying assumptions. If we are going to try and ‘live with’ COVID-19, we must have an open and engaged debate on what those assumptions should be.
Deciding how to weigh up public health risks against wider economic and social priorities is a fiendishly difficult task. As well as requiring large amounts of reliable data, the task is inherently bound up in political and ethical questions.
Periodically lurching into lockdowns or semi-lockdowns is clearly not a desirable path. The toll of lockdowns on mental health, loneliness and other health issues has now been well established, as are its significant economic costs. But if the government wants us to ‘live with’ COVID-19, it must be prepared to answer some difficult questions.
How many deaths, if any, is the government willing to tolerate in order to allow social normality to resume? What sort of pressure are we willing to see placed on the NHS before new restrictions are considered? Should keeping schools open be a higher priority than keeping the hospitality sector afloat? What priority should be placed on minimising instances of ‘long COVID’ and other non-fatal but nonetheless serious consequences of the disease? Are we willing to accept lower, or even negative, economic growth, if it means saving more lives?
These may be challenging questions, but in practice they are impossible to avoid. Before attempting to ‘live with’ COVID-19, we must first decide what kind of society we want to live in.
Whenever the government has decided on a course of action during the pandemic, it has implicitly made a series of value judgements on these issues – although the precise assumptions, and the evidence underpinning them, have not been openly revealed or debated (even if the government’s pro-business bias has at times been painfully obvious).
Going forward, it is critical that the values and assumptions underpinning government decisions are made open and transparent, so that they can be scrutinised, debated and challenged.
A health-centred economy
While being clear about the trade-offs underpinning government decisions, and establishing a robust framework for evaluating them, is vital, this by itself will not answer the question posed by Devi Sridhar: how do we ‘live with’ COVID-19? The disease has changed everything, and it is wishful thinking to pretend that we can simply return to pre-pandemic norms and carry on as before.
Trade-offs between public health and wider socio-economic factors are not fixed, but can be altered by reorganising how our economy operates – and in whose interest. What might this look like?
Firstly, living with COVID means doing everything possible to roll out a rapid distribution of vaccines globally on the basis of need, not corporate profitability. This means overriding the intellectual property regime and providing financial and technical support to develop local supply chains, as the South African and Indian governments and groups such as the People’s Vaccine Alliance have called for. As openDemocracy’s Anthony Barnett and Peter Geoghan recently put it: “Never in the history of humankind has the blindingly obvious been ignored with such obviously high risk.”
Secondly, it means maintaining the suite of relatively painless measures that control the spread of the virus and reduce serious illness and death. Most obviously, this includes regular testing and tracing, mandating mask-wearing indoors, providing adequate ventilation in offices and public spaces, and mandating home-working where possible.
Thirdly, it means viewing health and economic policy not as separate domains, but as inherently interconnected. In an age of escalating public health and environmental crises, traditional economic goals must be replaced by a wider ambition to maximise social and ecological well-being, with health and care placed at the centre of all policymaking. Such an agenda has already been articulated by groups such as the Women’s Budget Group and Wellbeing Economy Alliance, but has yet to be fully embraced by governments. In practice this means putting the needs of people and planet ahead of economic growth, and assessing prospective policies against holistic criteria that put social, economic, environmental and public health impacts on an equal footing – rather relying on traditional economic impact assessments.
Fourthly, it means investing to create more capacity inside national healthcare systems to cope with future outbreaks, and providing a stronger social safety net to ensure that people can isolate without fear of facing financial hardship. The pandemic has shown that government finances are not as constrained as politicians have often claimed, and health and social spending could be further supported by levying new taxes on wealth that has been amassed during the pandemic. That the UK still has the lowest level of statutory sick pay in the OECD, as well as the lowest levels of unemployment benefits, is a problem that must urgently be addressed. Proposals such as Universal Basic Income, which provide a basic standard of living that nobody can fall below, should be closely examined.
Finally, it means taking proactive steps to reshape the labour market to serve different ends. If COVID-19 has taught us anything about our economic system, it is that the link between social value and financial reward is fundamentally broken. When the pandemic hit it rapidly became clear which type of work is truly ‘essential’ for society to function, and which is not. ‘Key workers’ such as frontline health staff, teachers, food and warehouse workers began to be celebrated as national heroes, despite in many cases being classed as ‘low-skilled’ and chronically underpaid. Meanwhile, hedge funds and other financial speculators have made vast profits during the pandemic while contributing little in the way of social value. Creating a health-centred economy therefore means taking proactive steps to rein in activities that contribute little to the common good, and reallocate labour towards socially important work.
COVID-19 has inflicted tremendous pain and suffering on the world, and many of us may long for a future without it. But it cannot simply be wished away. We can choose to reshape our economies around it, or we will continue to be shaped by it.