Establishing criteria for dealing with pandemics

The Quarantine Zone
1

Experience in business and running shops has taught me to establish criteria to base my decisions on so as to minimize delays in making decisions. when it comes to human life it becomes much more difficult. I made up a few questions I would have to ask myself if I were in a position of authority making decisions that would affect peoples lives such as the shutdown.

  Suppose we used a very bad flu season as a baseline for criteria. We used a number like 100,000  projected deaths life goes on like normal, 200,000 deaths we implement some social distancing recommendations, 300,000 deaths we tighten up a bit on social meetings etc. 

 How do we rate human lives at stake? Is everyone the same or do we prorate based on life expectancy of those at risk. Anything below 90% would be considered a full person. If a person 70 years old was expected to have 7 years left he would count as 1/10 of a person and 80 year old with 6 months to live he might count as 1/100 of a person etc.

How would we deal with extreme risk cases being primarily because of bad life choices? Smoking, obesity etc? Would this be a consideration or would that automatically lower the influence they had on decisions that would affect us all and our economy? Should they automatically be rated at a lower number say for example 1/5 of a person. 

We do need a criteria here, how could we go about establishing that?
2

100,000, 200,000 where? In the US? The world? And are these deaths evenly distributed or clustered? The federal government can guide or make strong recommendations, but decisions re: shutting down are still up to the states, so who is “we”?

Finally, the idea of designating people as fractions of a person is not going to go well. We tried it once before with a segment of our population, and it was pretty awful.

I get what you’re trying to do here. I just think you need more information and a different approach.

3

I don’t have any information, the post was just intended as an example to think about. Any numbers I proposed were strictly hypothetical.

4

The problem isn’t the proposed numbers; it’s the system of counting some people as worth less than a whole person.

5

Suppose a situation where we have now where about 40% of the deaths are in skilled nursing homes and basically very close to the end of their natural lives. Another very large segment of the deaths could be attributed to bad life style choices. I think these circumstances need special consideration when deciding what to do with the general population.

6

The key here is your sentence, “I don’t have any information.”

Scientists spend lifetimes studying diseases in populations. They use contact tracing to follow the disease spread, and collect mortality and morbidity figures to enable them to project outcomes. Further study allows them to model changes in behaviors to vary the outcomes.

Simply pulling numbers out of the air doesn’t work too well. People who do that are called “novelists.”
~VOW

7

Not sure why you would say that. The only premise I am proposing is that we need to establish criteria based on something tangible. Forget the numbers they are hypothetical. We currently have a circle jerk going on. Decisions are being made based on emotional responses.

8

Yes, every government has left the successive government a pandemic preparedness playbook which was ignored. Here’s Bill Clinton’s, George W Bush’s, Obama’s.

Inside America’s 2-Decade Failure to Prepare for Coronavirus for a detailed article about how every change in administration leads to a loss of institutional knowledge about how you need to treat pandemics seriously and a subsequent relearning of the same expensive lessons.

9

And here’s the WHO version published for the first time on September, 2019.

10

A good discussion of how economists attach dollar values and how that applies to the current circumstance.
https://www.google.com/amp/s/www.forbes.com/sites/theapothecary/2020/03/27/how-economists-calculate-the-costs-and-benefits-of-covid-19-lockdowns/amp/

Counting a likely 60 future years of disability free life as of different worth to invest in than a likely 2 of bed ridden, is pretty standard for medical intervention cost analysis, FWIW.

Problem still is poor inputs. What are the lives quality and dollar costs downstream from different actions? It’s unclear. That still does not mean that those who have the best tools to use to make those analyses shouldn’t be trying to rough it out under ranges of assumptions.

11

I puke at the thought that some economists will determine my worth as a human being, and decide whether or not I qualify for life saving treatment.

I’m 67 and have several co-morbidities, so that means I’m standing at the edge of my grave until some bureaucrat gives me a good shove. The fact that I worked my entire adult life is meaningless, I guess.

Someone else had that idea. His name was Hitler.
~VOW

12

Although you are correct that many decisions on how to deal with the COVID-19 pandemic are “being made based on emotional responses”, it is clear from your previous history that what you mean by this is that the decisions you disagree with, i.e. those recommending isolation and closure of non-essential business. In fact, it is the appeals to ‘reopen the economy’, being made by people who are arguing from ignorance that this is just an ‘old peoples’ disease’ that are making the emotional argument. The rational argument is that we should gather data and make cautious, well-monitored incremental efforts to relax isolation measures rather than just open everything up at once and let ‘nature’ takes its course.

The recommendations by epidemiologists and public health experts are based upon empirical science and experience with previous infectious epidemics. These recommendations are geared toward minimizing the loss of life from the pandemic which does have to be balanced against the economic and social impacts that those recommendations will have because the lost of employment, mobility, social contact, et cetera also has an effect on population morbidity and mortality. Because the SARS-CoV-2 virus is novel (never previously experienced in the human population, and thus, there is no acquired immunity, a poor understanding of the dynamics of this contagion, and no prior knowledge of pathogenesis of the virus or treatments for it) those experts have recommended very conservative infection control measures that are unprecedented in living memory. As we are learning more about the SARS-CoV-2 virus and the COVID-19 syndrome it causes, it is apparent that such caution is warranted, because what was originally believed to be ‘just’ a respiratory infection that only affected the elderly and those with severe co-morbidities has been discovered to affect healthy adults with no underlying conditions, attack the heart, kidneys, and other organs and extremities, and even severely impacting some children presenting a Kawasaki-like vasculitis via a mechanism that is not understood.

We currently do not have effective pharmacological prophylactic treatments or interventions that have been shown to be substantially effective in reducing mortality across any age group (although a few drugs have shown some degree of promise). The normal intervention of mechanical respiration for patients experiencing ARDS has had surprisingly low efficacy compared to normal influenza-like and pneumonia diseases, and the severe lack of reliable testing means that even several months after the start of this pandemic we do not have reliable numbers on the percentage of the population infected or the infection fatality rate, nor do we really understand the long term impacts of people with seemingly mild infections but persistent debilitating sequelae. We do not know when a vaccine will be available (the frequent promises of “in a year” are still at this point magical thinking until one of the candidates manages to get through a Phase II efficacy trial with success) and we don’t even know the degree of immunity conveyed by prior exposure or how long it may last.

As for the notion of making the response proportional to some kind of metric like financial loss due to isolation measures compared to the valuation of a hypothetical reference person at different stages in their life, this might have some ethical merit in a constrained sense if we actually knew what the end result would be of a free fire contagion versus the efficacy of various restrictions. Unfortunately, we have neither adequate knowledge of the effects of the virus in the long term nor a good way to make high confidence estimates of the efficacy of the graduation of isolation measures. Since the basic reproduction number and other figures of merit of the infectiousness have been repeatedly revised through the past couple of months, any kind of simulation of the efficacy of such measures would have to be revised repeatedly and the results interpreted with a statistically large uncertainty notwithstanding the variable compliance of the public with any stated measures.

If we had taken non-conservative measures we would have likely seen more incidence of the kind of outbreaks that were observed in New York City, Detroit, and New Orleans, and we may yet see those as measures are lifted to abruptly with no controls or any attempt to assess the effects on localized populations first. Since we do not have the information to make very accurate predictions of how a novel pathogen will spread and behave, trying to make any kind or opportunity cost estimates is fraught with the potential that a wrong decision could cost an order of magnitude more deaths that could potentially be savable not withstanding the inability to calculate the cost on the economy of a free running epidemic, which is a point all of the ‘damn the virus, America wants to be free’ populists either obtusely or willfully miss.

All of that being said, epidemiologists and public health experts are cognizant of the costs of keeping states or regions shut down to prevent epidemic spread, which again have real health and welfare consequences that can be estimated and measured. This is why the CDC put a lot of effort into developing criteria for when a state should consider opening up, how they might perform a gradual relaxation of measures, and what kind of testing and monitoring to perform to prevent flareups that would overwhelm health services. Unfortunately, the White House has tried to block these detailed recommendations and many state governors don’t seem to care about them, or even the less detailed measures the White House published when electing to relax or remove business and social restrictions. So, we’ll see how that goes. I’m guessing that spikes in mortality and ICU wards overflowing in the Midwest are not going to be too great for the economy.

Stranger

13

The metric you may be looking for is what is alife worth. Generally in the US we consider a life worth about $10mm. So it’s worth spending $10mm to prevent a person from dying. This can be applied to pandemics in that each person we prevent from dying can cost the Country or State up to $10mm before the pain isn’t worth it. Generally, that number isn’t divided to make granny worth less than junior but you could probably come up with a metric that somewhat useful.

If we use the Imperial College London worst case/best case numbers we could save 1.1mm lives by taking preventative measures so it would be worth it for the governments in the US to spend $11T to prevent that loss of life or about $600B/month over the 18 months to develop a vaccine. How that $600B should be spent to maximize the results is a different question of course. Though preventing economic pain while locking everyone inside would have probably made the most sense. It would have worked out to a cash payment of $1,800/ month to every person in the country.

14

Why are you only considering mortality?

Even if only a handful die, many more will be hospitalized, or will be off work for possibly extended periods due to illness, and some of them are going to have a very long road back, a road that for some is likely to detour through short- or long-term disability.

Then there are the knock-on effects of having a bunch of people off sick. For example, the meat processing plants are closing not because so many employees have died, but because so many are ill; most will recover, but in the meantime they’re not able to work. At the state prison in northeast Kansas, illness and quarantine among staff are exacerbating their long-term staffing issues; it’s bad enough that they have the National Guard taking inmates’ temperatures and overseeing property distribution. “Only” two staff (plus three inmates) have died, and they’ve all been men aged 50+, but neither guard was decrepit: they were both at work as recently as mid-April. (Hearing about guards dying isn’t likely to improve staff morale or aid staff recruitment efforts, either.)

15

LOTS of someone elses had that idea. Every aspect of your life is affected by decisions made by people weighing lives against other considerations. People die in car accidents, too. Fewer people would die if we had a nationwide speed limit of 55 MPH, or 35. Why don’t we have those lower speed limits? Because there are other costs to having speed limits that low, and those costs must be weighed against the cost of lives.

16

There’s medicine you can use for your hyperemesis, because whether you think about it or not it is done ALL THE TIME. Not your worth “as a human being” but how much should be spent to save a full “quality” year of life. It is something that is obviously true, even if it is not always done in consistently rational ways. People do it even valuing their own lives … pay the extra thousand for the extra safety package on the car or not?

As the article I linked to discusses, on the medical side it is often referred to as Quality Adjusted Life Years (QALY), and the ranges that seem to get settled into are $100K to 150K/QALY. There are a variety of variations of it but on the medical side a public health intervention that say saves 10,000 eighteen year olds lives to likely live to average life expectancy might be funded at a cost of $50B while one that saves 10,000 eighty year olds to live to average life expectancy would probably not be funded at that cost.

Again though the bigger difficulty are the unknowns that such calculation would need.

The issue of net lives or QALYs saved directly from COVID by way of one or another intervention, as unknown as it is how effective each individual intervention is, is a relatively minor part of the calculation.

How many are disabled from the disease and how does that get valued? How many deaths do the harms of the interventions cause? Do you value the deaths caused in low income countries by the hunger pandemic and childhood vaccine preventable disease increases that will predictably occur the same as American lives? (I do but our society does clearly does not.) The actual costs of different course of action, assuming one can agree on how much to value which life, are guesswork.

The best we can do is recognize that some interventions are much more costly across various metrics (including non-COVID-19 deaths), and some that are less. Some that have solid reasons to believe they do a lot of good, and some that have little evidence for this specific germ. Ideally we the criteria includes easing off on the ones that are most costly for the least proven benefit first, and the interventions that provide the most benefit for the least costs get done well for the longest. That should be specific for each pandemic as the specifics of the germ and its behaviors are determined.

17

Now please apply that reasoning to the OP, specifically:

HoneyBadgerDC: How do we rate human lives at stake? Is everyone the same or do we prorate based on life expectancy of those at risk. Anything below 90% would be considered a full person. If a person 70 years old was expected to have 7 years left he would count as 1/10 of a person and 80 year old with 6 months to live he might count as 1/100 of a person etc.

How would we deal with extreme risk cases being primarily because of bad life choices? Smoking, obesity etc? Would this be a consideration or would that automatically lower the influence they had on decisions that would affect us all and our economy? Should they automatically be rated at a lower number say for example 1/5 of a person.

18

I think we already have it. The concern is whether or not the health care system gets overwhelmed. So 100,000 evenly spread out over a year not as serious as 20,000 in 1 city in 3 months.

19

Recognising that you may get to a point where you do have to make value-judgements about the relative worth of different lives, for example which of the 10 people you allocate to the 5 ICU beds and which 5 will likely die, and that this will be a severe, irreversible, morally challenging decision, surely the first question to ask is - What can I do to NOT get to that point, because any answer at that point cannot be satisfactory. This is completely missing in your pseudo-objective quantification process.

To me, the original post is couched to say the solution is a cost-benefit formula that absolves us from moral culpability in the outcome. We are probably already doing that far too much in the current situation, where doctors are being left at the pointy end to make decisions about whether people live or die, for which they are held responsible, so that society can avoid the psychological angst of having to be part of a morally invidious decision.

The answer is to be more proactive and intrusive in isolation early on, but from your commentary here and elsewhere you’d rather swallow your own tongue than entertain that.

20

My personal feeling about this virus is that it will be well above the 100,000 mark so does deserve special attention. I am not opposed to shutdowns to slow the virus. I do feel the shutdowns have slowed it a bit too much and in many states and was applied to soon. I realize that is a hard call because of the two week lag and not knowing how many were infected that will be hitting the hospitals in two weeks. Once we became aware of who was primarily at risk I didn’t see much effort in educating the public and those at high risk about their true risk factors and things they could do to mitigate this. It seemed it was just stoking as much fear as possible to keep everyone in. I see lots of decisions being made on the fly.

   I feel establishing more criteria would save lives in the long run and consider everything that was at stake. I believe we are still in the very early stages of this virus and learning more everyday. Hopefully we are establishing counter measures that will save lives and allow folks to get back to living as normal lives as possible.