Wednesday, 1 April 2020

COVID-19: The public health emergency and the disproportionately disadvantaged

Good sense and social justice in the control of Australia’s COVID-19 epidemic

Bruce Armstrong

Bruce Armstrong explores the trade-offs ‘flattening the curve’ will require for Australians living in poverty, and provides some practical suggestions on how to counterbalance the adverse effects managing the COVID-19 crisis will have on the most disadvantaged members of our society.

In the space of less than 12 months, Australia has been beset by a nationally disastrous 2019-2020 bushfire season and an epidemic (now pandemic) of COVID-19.

As of 30 March 2020, 720,117 cases of and 33,925 deaths from COVID-19 have been reported worldwide. Unchecked, each infected person transmits the disease to two uninfected people and, typically, the number of people who have been infected has doubled every two to every ten days, depending on the country, the time since the epidemic began and the control measures implemented. COVID-19 has an estimated case fatality rate (percentage of infected people who die from the infection) of 2.3 per cent in China .

Managing the pandemic
High-income countries are managing their epidemics of COVID-19 by: (a) educating citizens about the disease and its impacts; (b) mandating social distancing; (c) quarantining (for 14 days) those known to have been exposed to infected people; (d) isolating infected people for a similar period; and (e) tracing and testing those with known or probable exposure to infected individuals for presence of the infection. In high-income countries, social distancing is the most variably applied of these measures. South Korea attributes its turnaround in the growth of COVD-19 infections to widespread testing for infection, and contact tracing.

The major objective of these measures, as illustrated below1, is to slow the evolution of the epidemic. In this way, health services are able to keep pace with the burden of treating large numbers of often seriously ill people suffering from COVID-19.

The left side of the graph shows the epidemic without intervention: it passes comparatively rapidly but leads to overloading of the health services, increasing the likelihood of many deaths. The right side shows the epidemic with substantial intervention: it requires twice the time to pass, but results in less pressure on the health services, decreasing the chances of a high death toll.

It is important to note that in these, somewhat hypothetical, examples, intervention does not reduce the number of people infected in this first epidemic wave. The truth of this statement depends on assumptions that: (i) no vaccine preventing COVID-19 becomes available; and (ii) no herd immunity comes into effect in this first wave. Neither assumption is certainly true or untrue.

In any case, flattening the curve will mean prolonged restrictions placed on the overall population, such as social distancing, quarantine and self-isolation, which in turn will have a much bigger impact on the economy.

It is important to note that in these, somewhat hypothetical, examples, intervention does not reduce the number of people infected in this first epidemic wave. The truth of this statement depends on assumptions that: (i) no vaccine preventing COVID-19 becomes available; and (ii) no herd immunity comes into effect in this first wave. Neither assumption is certainly true or untrue.

The Rule of Rescue
The intervention illustrated in the graphs above is an application of the Rule of Rescue , which is “the imperative people feel to rescue identifiable individuals facing avoidable death” . Examples of applications of this rule have valued saving life very highly. The cost of retrieving solo yachtswoman Isabelle Autissier from her dismasted yacht in the Southern Ocean in 1995 was estimated at over A$1million. A year’s course of on-patent, modern chemotherapy for cancer can cost as much as US$400,000 .

The trade-off
In the present context, it is easy to neglect two words in the above statement of the Rule of Rescue: “identifiable individuals” . Being comparatively few, the circumstances of infection of these identifiable individuals may be known: the individuals may be known personally to many in the community, and prominent figures may express concern about their welfare. Less well known are the identities and lives of a much larger group in the community whose health and lives are being traded off against the health and lives of those suffering (or soon to suffer) from COVID-19.

How large is this group and how will they suffer? Their numbers and their suffering depend on how successful we are in flattening the curve. Simply put, the flatter it is, the greater this group’s size. The flatter the curve, the longer the Australian economy will lie in recession, and the deeper into recession it will go. More of those already disadvantaged and living in poverty will fall into deep disadvantage; more of those who are “just struggling” will in turn become disadvantaged.

The health impacts of COVID-19 epidemic in impoverished Australians
The consequences for the health of these Australians will be huge. In the short term, increases in anxiety, depression and suicide are likely to have the biggest impact on Australians in poverty. Infectious diseases will follow hard on their heels due to increasingly unsanitary living conditions and exposure to cold during the approaching winter. Risk of COVID-19 will be greatest in Australians living in poverty because of overcrowded living spaces and weakened immune systems.

Government aid to impoverished Australians
While assistance for industry and Australians “in jobs” has been dominant in the Australian Government’s aid announcements, little has been said about aid to the already disadvantaged. Direct and urgent action is required to support them – it should not be left to what may “trickle down” from industry and the still-employed or recently unemployed. Nor should aid to the already disadvantaged be delivered by those for whom it would be another opportunity to monetise human misery.

There are three practical proposals that stand out on the basis of this analysis.

First, a simple piece of policy, borrowed from several European countries, will help enormously, namely the speedy designation of social and care workers alongside frontline volunteers. This will have a major bearing on the ability to shelter the most fragile in our society as the next stage of restrictions is debated by Australia’s National Cabinet.

Secondly, Australian governments should designate a high proportion of the funds allocated to relieving the COVID-19 epidemic to Australians in poverty, or at high risk of falling into poverty. In 2015-16, 13.2 per cent of Australians were in poverty. This fraction could easily double or treble during the COVID-19 epidemic. Any delay in responding to the economic shock of epidemic-control measures will fall quickest and heaviest on the most disadvantaged, who are already suffering serious economic stress.

Finally, Australian governments should massively increase testing for COVID-19, and target initially those at greatest risk of being infected, isolating those shown to be infected, and tracing and testing their contacts. How quickly such a program will reduce new infections and, in consequence, permit relaxation of social distancing measures and the revival of economic activity, is not certain. But its main rationale rests on a different pillar: that the adverse economic consequences of COVID-19 control measures for poorer Australians will mainly come from the wholesale suspension of economic activity (both locally and globally) that social distancing measures entail.

Bruce Armstrong is a retired public health physician and researcher. He has been, among other roles, Commissioner of Health for Western Australia and Director of the Australian Institute of Health and Welfare.



UWA Public Policy Institute