Summary
If it works, the UK Government’s Covid-19 (C-19)[1] control strategy will cost over £300 billion and save half a million lives, most of them elderly. According to the International Monetary Fund, this level of expenditure will tip the country into recession and require levels of domestic borrowing not seen since the Second World War. Younger generations fear that it is they that will be left paying the price. Whether they deem this price worth paying depends on what value they are prepared to put on human life.
On the basis that each British citizen’s life is valued at somewhere between £5 – £9 million, that each life-year saved is consequently worth about £248,000 and that each victim loses an average of 14.6 life-years from C-19, this article argues that the price is worth paying. At least, for now.
“Yes, there is a high price to pay. But how do you put a price on life?”
(Michael Gove, UK Minister of State, 29 March 2020)
Over the longer-term, Britain’s youth might instead ponder the social and political, rather than economic, ‘price’ involved and prepare to drive a new agenda for change which re-engineers democracy, re-defines civil liberties, puts Climate Change front and centre, and ensures redistribution of wealth through enlightened corporate responsibility.
Whether the “world’s beauty will be revealed afresh” is in their hands.
Introduction
The UK Government’s C-19 suppression strategy and its demands for extensive country-wide social isolation and ramping up of NHS critical care capacity may result in between 35,000 and 70,000 excess deaths[2] across the country by the end of December 2020 (University College London). This is in addition to the 30,000 that would die anyway from Acute Respiratory Infections such as seasonal Flu (Public Health England). Against the number of premature deaths predicted by ‘zero option’ (do nothing) modelling where up to 560,000 UK citizens would die (Imperial College) this represents the saving of around half a million lives.
However, this will come at great social and economic cost, leaving some to wonder whether such draconian disease control measures are worthwhile? Could the social and economic consequences of the virus be deadlier than the virus itself?
The answer, at least over the short term, appears to be ‘No’. The saving of 500,000 lives is deemed to be worth the billions of pounds committed by the UK Government. But how was that conclusion reached? And in what context does it hold good when the question has yet to be tested against society’s assumption that “every life is priceless” when, from a risk management perspective, they are not?
With the peak of transmission estimated to be in late May / early June, estimates of predicted mortality remain uncertain. But one aspect is crystal clear: The length of the epidemic and the numbers that die are, to a major degree, dependent of the public’s psychological resilience and their ability to break the chain of transmission through sustaining physical distancing from one another for at least three months, possibly longer.
Much clearer is that the strategy now underway will tip the global economy into recession. Most of this money will need to be borrowed now and repaid by future generations.
Are those future generations, some of whom are not yet born, willing to pay such a price, especially when most of those who die are elderly men with pre-existing chronic illnesses (co-morbidities) and who, according to some public sentiments, “only have a few years left anyway”? After all, as the Chief Economist of the UN’s World Food Programme recently put it, “There is only so long an economy can be locked down without inflicting lasting damage.”
The ‘damage’ he is referring to is not measured in short-term mortality alone – a few years from now this disease will be endemic and treated much the same as seasonal Flu or a common cold is – but the long-term consequences of global economic shut-down.
To answer this question, we need to know how much a life saved – or, more specifically, a life-year gained – is worth to society. Only later on, will we need to know what the potential social, economic and political benefits might be in terms of, say, climate change, democratic accountability, and corporate responsibility.
The Humanitarian Dilemma
Whatever control strategy is applied to the C-19 pandemic, two things are clear: A lot of people will die prematurely – many unnecessarily – and the social and economic cost will be enormous. Leaving aside the ethical considerations, society is faced with the same ‘humanitarian dilemma’ faced by disaster managers when coordinating responses to international calamities where resources are never enough, the data unreliable, and uncertainty the norm: Is the predicted gain in terms of avoidable deaths averted by any one intervention ‘worth it’ in terms of the financial cost involved? How does one balance the cost of the prevention against reducing the risk of a premature death that may never happen? If there are not enough resources to do both, is it more cost-effective to improve access to safe water in a cholera epidemic or vaccinate the children? Is it better to distribute the full value of cash grant required to keep a family in Northern Syria alive to half the families that need it, or half the amount to all the families?
The answer to ethical conundrums like these are not as difficult to work out as they appear, and, although away from public view, disaster managers make such life-and-death decisions all the time. So do insurance companies, government transport departments and NHS economists. Each uses a form of cost-benefit analysis (CBA) to help in their decision-making. And each involves the difficult moral question of how to value human life.
The Value of a Life
Although the concept of placing a monetary value on human life is controversial, the ability to do so is essential when making informed and rational decisions on resource allocations. Understandably, for ethical, religious or philosophical reasons, many people oppose valuation of something commonly perceived as priceless and argue that no monetary figure could possibly compensate entirely for the loss of a human life.
Nevertheless, comparing different options requires a common metric against which to measure impact. Usually, this is money. This immediately poses a challenge to planners as it requires a value be put on the direct effects on people vis-à-vis ill-health, injury and death. The UK’s Department of Transport uses a Value of Statistical Life (VSL). Disaster managers in the World Health Organization use Quality Adjusted Life Years (QALYs). Others use ‘Micromorts’ or ‘Judgement Values’ (J-values). Underpinning each approach are the triple concepts of life expectancy, earning potential and quality of life where a monetary value on future years of life is calculated based on discounted income (e.g GDP per head) and work-life balance (the ratio of time spent working to time not spent working). This is part of the Calculus of Calamity[3].
Although many would argue that the value they place on their life is infinite, reality reveals that this is not the case. There are limits to the amount we are prepared to pay for marginal increases in longevity – for example, to have expensive safety features fitted in our cars – and increases in occupational risk of death are often acceptable if the monetary compensation is substantial enough, as evidenced by the existence of ‘hazard pay’.
Another challenge is that most people have great difficulty in understanding the varying levels of risk to which they’re exposed. This is especially true when the impact is intangible and far off, as it is with a deadly pandemic like C-19. Yet another is that any attempt to put a figure on the value of human life has to take age and disability into account. Most people agree that it’s reasonable to suggest that the life of a new-born baby should carry a far higher value than that of someone in their eighties. Equally, people usually recognise that a double amputation might save the life of the patient but that this would mean additional years of life gained would be subject to a greatly reduced quality of life.
To accommodate such value judgements, health professionals and disaster managers use something called a ‘statistical life year’ (SLY) when making life and death decisions. Improved life expectancy in terms of ‘life years’ is a much better characterisation of the benefits to be gained by mitigating risk than ‘lives saved’. This is because, in fact, nobody’s life can ever be saved: the best that can be done is to return an individual’s life expectancy back to what it was before the hazard occurred. The SLY calculates the value to each individual of one additional year of healthy life gained by a particular intervention, adjusted for disability.
In the UK, where each citizen’s lifetime value to society is estimated to be worth between £5 – £9 million, the SLY value is estimated to be £248,209 (Thomas, 23 March 2020). This analysis is informed in part by a well-known economic effect called ‘The Preston Curve’ which demonstrates that we get to die earlier as we grow poorer[4] (Preston, 1975).
This implies that the government would be justified in spending about a quarter of a million pounds on any intervention that would extend a single citizen’s life expectancy by one year. With each victim losing 14.6 life-years on average and, in the best case, 500,000 lives being saved, the cost of control measures must be lower than £1.8 trillion … which, at the moment, they are[5].
C-19 as a Natural Hazard
Dividing the cost of the intervention by the aggregated number of life-years expected to be gained by the intervention allows disaster managers to calculate the relative risk of each intervention without having to bring unnecessary value judgements into the equation. Assessing cost-benefits in this way allows railway safety to be put on the same footing as medical treatments, natural hazard risk reduction and public health.
In this sense, our response to the C-19 pandemic is no different to our response to natural hazards such as Earthquakes or Tsunami; various response options, each with different risk parameters and expected outcomes, have different social, political and economic costs against which the short- and long-term implications on life expectancy and quality of life have to be considered.
All options have to be considered against the ‘Zero Option’, the ‘business as usual’ counterfactual of doing nothing. In the UK, modelling suggests this would lead to the C-19 epidemic peaking in late May/early June and being over by September 2020. But this would lead to roughly 550,000 lives being lost i.e a loss of life comparable to that suffered by the UK throughout the entire course of the Second World War.
Other options are equally unenviable. For example:
A 12-month lockdown during which fully equipped hospital capacity was prepared, followed by an additional four-month shutdown a few months later could cut fatalities by two thirds.
A 12-month lockdown during which a vaccine was developed and a large-scale immunisation programme was carried out would reduce fatalities to less than the average toll on people caused by seasonal influenza each year i.e about 13,000 premature deaths, being less than the average number of 17,000 influenza-related deaths in the UK per year (Public Health England, 2019).
Cost to Society
Meanwhile, the constraint which all but the ‘zero option’ have to consider is that C-19 countermeasures should not decrease GDP per head so much that the UK population as a whole loses more life-years than it gains from such measures. Public health protection schemes should not be put in place if their costs are large enough to cause the nation’s economic output to fall so significantly that it will cause more loss of life and if the scheme had never been implemented in the first place.
It is likely that a recession resulting in a general fall in economic output of 6.4% per person over a prolonged period would cost more life-years than would be restored by current and future C-19 countermeasures. This observation is based on comparisons from the economic recession of 2008-2009 where GDP per head fell by 6% and did not recover until 2015, and its negative impact on life expectancy. Under the scenarios mentioned above, modelling suggests that each victim suffers about 14.6 life-years (years of healthy life) lost.
Current macro-economic analysis suggests that planned countermeasures will severely dampen economic activity. Both the International Monetary Fund and the Centre for Economics and Business Research now predict that the pandemic will cause global GDP to decline twice as much as during the financial crisis of 2008. Furthermore, it raises the prospect of a 1930s-style recession. Such an outcome, if it were to come about, would cause a loss of life-years to the UK population that would far exceed the predicted toll under the ‘zero option’. It would be worse than doing nothing, in other words.
Thus HMG faces health and economic challenges of equal severity. It needs to institute reasonable countermeasures against C-19 but it needs, at the same time, to attempt to restrict the coming recession to not much worse than the 2008 financial crisis.
The Future
Whatever lies ahead, it is already becoming clear that the impact of C-19 will be deep and lasting; not just in the UK and Europe but in poorer and conflict-affected parts of the world which are woefully unprepared and lack the capacity to respond. Imperial College in London estimates that over 40 million people from such areas might die.
We can only hope that Alexander McCall-Smith was right when he said, “Our world, though diminished, will be much bigger, its beauty revealed afresh.”
© James Shepherd-Barron
30 March 2020
References
Thomas: J-Value assessment of how best to combat Covid-19; Unreviewed manuscript, 23 March 2020
Social Value UK: Valuation of a life, 9 June 2016
Ferguson
et al: Impact of non-pharmaceutical interventions to reduce Covid-19 mortality
and healthcare demand; Imperial College, 16 March 2020
[1] C-19 is the name given by WHO to the disease caused by the virus SARS-CoV-2
[2] Excess Deaths are those that occur over and above those that would occur anyway over the same period, based on previous data.
[3] Calculus of Calamity – A Stochastic Risk Optimisation Model for Managing Disasters; James Shepherd-Barron, KissyFish Books, 2019
[4] The Preston curve indicates that individuals born in richer countries, on average, can expect to live longer than those born in poor countries. However, the link between income and life expectancy flattens out. This means that at low levels of per capita income, further increases in income are associated with large gains in life expectancy, but at high levels of income, increased income has little associated change in life expectancy. In other words, if the relationship is interpreted as being causal, then there are diminishing returns to income in terms of life expectancy.
[5] UK Government control measures for the three months March-May 2020 inclusive are estimated at £320 billion