With Australia’s Therapeutic Goods Administration (TGA) expected to approve the vaccine imminently and the roll out set to begin next month, this development might seem like cause for concern around the safety of the vaccine.
We haven’t seen this issue reported in any other countries which are rolling out the Pfizer vaccine.
Norway has reported about 45,000 people around the country have been vaccinated against COVID-19 so far. Their vaccine program has mostly focused on residents in nursing homes.
In other countries, there may be more of a focus on frontline health-care workers in the first instance. So if there is any association between deaths in the elderly and this vaccine, it may not be apparent as yet.
It also depends on surveillance. Norway may have an especially rapid surveillance and reporting system in place, efficiently tracking everyone who has been vaccinated and quickly reporting any adverse outcomes.
We would expect surveillance reporting from other countries with an active vaccination program soon, increasing data critical to building a more accurate picture of vaccine safety across different populations.
Norway’s reports will sensitise other countries to monitoring vaccine recipients closely, particularly those in nursing homes who are older and vulnerable. We may see further reports on this coming through in coming weeks from other countries.
But we also may not. We have limited information regarding these cases in Norway. The people reported to have died were elderly and very frail. Many had significant underlying health conditions common in the very old, and may have been nearing the end of their lives independent of the vaccine.
Though they are under investigation, it’s important to note the deaths have not been linked conclusively to complications from the vaccine. Meanwhile, Australian experts have called for calm.
Vaccines and the elderly
In the recent history of vaccines, we haven’t seen any trends showing deaths in elderly people following vaccination. For example, there’s no evidence the annual influenza vaccine has been associated with deaths in older people — or people of any age.
It’s important to note though, that in making a comparison with the flu shot or another vaccine and the Pfizer vaccine for COVID-19, we’re comparing apples and oranges.
The Pfizer vaccine is based on mRNA technology, which is completely new in a human vaccine. This technology introduces part of the genetic material of the SARS-CoV-2 virus in the form of messenger RNA (mRNA). This instructs your cells to make part of the virus which stimulates an immune response that inhibits infection and protects against disease.
All vaccines are designed to generate an immune response — albeit in different ways — to prepare our bodies to fight the virus if and when we encounter it.
Creating an immune response leads to inflammation in the body. Some people will experience no side effects from a vaccine, but the inflammation can manifest in different ways in different people and between different vaccines. This may mean a reaction at the site of the injection, or fatigue, or feeling unwell.
The deaths in Norway were reportedly associated with fever, nausea and diarrhoea, which, while at the severe end of the spectrum of vaccine side effects, would be tolerable for the vast majority of people.
How different people will respond to the mRNA is what we’re starting to understand now. It’s possible this vaccine will have more serious effects in older, vulnerable people where the initial inflammatory response could be overwhelming.
Side effects show a vaccine is generating an immune response
Vaccines need to generate an immune response in order to work, and side effects are a byproduct of our bodies mounting an immune response.
While the deaths are sad, they shouldn’t be cause for alarm. This actually tells us the vaccine is stimulating an immune response. For most people that response will be entirely tolerable and lead to development of immune memory that protects you from severe COVID-19.
The big challenge for any vaccine is generating enough of an immune response so you’re protected from the disease in question, but not too much that you experience serious adverse effects. Where this line in the sand exists will vary across different people, but the oldest and frailest vaccine recipients are likely to be most at risk of severe, potentially life-threatening reactions.
So for those who may be more susceptible, we may want to be a little more cautious. In approving the Pfizer vaccine, the TGA may consider advising against this particular vaccine for people who are very elderly and frail, particularly those who have other conditions and are potentially nearing the end of their lives.
Ideally, the vaccine should be considered on a case-by-case basis for this group, carefully weighing up the risks and benefits in each situation, based on the best available data.
The COVID-19 death toll is reported every day by state and federal governments. These numbers are often used, alongside case numbers, to assess how public health policies are faring in controlling the pandemic, and to gauge the success of various drugs or interventions.
There’s been confusion, however, over whether reported death statistics reflect those who’ve died from COVID-19, or those who’ve died with the virus. Often it’s hard for medical practitioners to determine which of these categories a death falls into.
But the COVID-19 death toll publicised daily on Australian state and territory government websites and reported to the press does not differentiate between the two. It includes all people who’ve died with SARS-CoV-2 (the virus that causes COVID-19) in their body. It’s unclear if the federal government currently makes this distinction or not.
Lumping these statistics together makes it hard for the public to understand the true impact of the virus. Clarifying what’s being counted as a COVID-19 death is necessary for understanding the impact of the virus, and for informing public health and clinical responses to the pandemic. If we know who is susceptible to dying with COVID-19 because of pre-existing conditions, public health responses could more effectively target and protect potentially vulnerable people and communities.
We are not suggesting this is a reason to downplay the seriousness of the virus, but rather that successful public health engagement requires open communication of death causation data, especially in a pandemic. Therefore, we need a transparent approach to counting and reporting coronavirus deaths in Australia.
Cause of death is not straightforward
Federal Deputy Chief Medical Officer Nick Coatsworth acknowledged that determining cause of death is complex when questioned by reporters on Tuesday, saying:
I remember as a junior doctor trying to do death certificates – it’s not always an easy thing […] I don’t, by any stretch of the imagination, think it’s a reason to underplay the severe impact that COVID has on people who have [pre-existing] conditions.
Indeed, distinguishing between dying with and dying from COVID-19 may require a more complex investigation into the cause of a death, beyond citing a positive SARS-CoV-2 test that was completed prior to the person’s death.
For example, Victoria’s coroner is currently investigating the death of a man in his twenties, who was widely reported as being Australia’s youngest coronavirus death. The coroner is investigating whether his death was primarily caused by SARS-CoV-2, or whether the virus contributed less substantially to his death.
While this death was reported on August 14 in Victoria’s daily death toll, according to The Sydney Morning Herald, as of August 28 it wasn’t counted in the federal COVID-19 death tally. It remains unclear whether the death has been added to the federal count as of today.
Generally when a person dies a medical practitioner is responsible for indicating the cause of death. The doctor will complete a “medical certificate of cause of death”, and inform the Registry of Births, Death and Marriages in their state or territory.
In some circumstances, the cause of a death can also be reported by a coroner, but they typically investigate deaths that are sudden, unnatural, violent or accidental, or which occur during or after medical procedures. The cause of death may be initially unclear at the beginning of a coronial investigation. Sometimes, the determined cause of death may be multiple, while other times it may change when more information is revealed, for example through a post-mortem examination or toxicology tests, or when new information comes to light about how a virus affects the body.
For example, on August 31 Victoria recorded only eight COVID-19 deaths from the previous 24 hours, but also added 33 historical deaths to the toll. According to the state’s Chief Health Officer Brett Sutton, this backlog was due to changes in how aged care providers reported COVID-19 deaths, and differences in reporting methods between the state and federal governments.
On September 4 there were six deaths recorded over the previous 24-hours, but a further 53 historical deaths were added to the daily toll, 50 of which were related to aged care.
There is a lack of transparency about why there is a discrepancy between how Victoria and the Commonwealth count COVID-19 deaths.
The Australian Bureau of Statistics this week released a provisional tally of the changes in Australia’s overall death rate amid the coronavirus epidemic.
The figures record 33,066 doctor-certified deaths in Australia from January 1 to March 31, 2020 – compared with an average of 32,249 during the corresponding months during the years 2015-19.
What’s more, the final week of March 2020 featured the highest weekly death rate of the entire three-month period, with 2,649 recorded deaths. That week also featured the highest numbers of deaths from respiratory diseases, diabetes and dementia.
Australia has had 103 known COVID-19-related deaths, with 21 reported before the end of March. The ABS death counts for respiratory diseases do not include these known cases, but might include COVID-19 deaths that were not recognised or confirmed as such at the time.
Overall, there were more than 800 “excess deaths” in the first quarter of 2020, compared with the average of the previous five years. The 103 confirmed COVID-19 deaths represent just a small fraction of these deaths. But my analysis shows that even in the early days of the pandemic, there are some signs that the impact of COVID-19 on Australia’s death rate may be bigger than the official tally suggests.
Death data allow us to monitor death rates by age, gender, location and cause, and to assess how death rates are changing over time. “Excess deaths” – those that exceed the long-term average – are particularly important to understand, not least during a pandemic but also because they could be due to preventable causes.
The coronavirus death toll has become a feature of media coverage during the COVID-19 outbreak. Unlike in many other countries, the epidemic has stayed within the capacity of Australia’s health system, so we might reasonably expect all COVID-19-related deaths to have been counted accurately.
However, analysis of sewage and swab samples in Europe suggest SARS-CoV-2 (the coronavirus that causes COVID-19) may have been responsible for infections as early as December, before the world became aware of the emerging crisis in Wuhan.
Given the uncertainty about when the coronavirus actually entered Australia, it is possible Australia had COVID-19 cases before official counts began. If so, they may have been recorded as a death from another cause in the death register, most likely as pneumonia.
A death can only be officially attributed to COVID-19 if that patient had been tested for the coronavirus. Australia had a limited supply of test kits initially, and the rules for testing were strict in the early days, mainly focused on returned travellers and their immediate contacts. Testing rules did include hospitalised patients with community-acquired pneumonia, but this recommendation may not always have been followed.
What do the new data show?
The newly released ABS data are raw counts that only include deaths which occurred in January-March and were registered by the end of April. On average, 98% of deaths are reported to the ABS by the end of the following month.
The data compare the weekly death rates against the five-year average death counts for those same weeks from 2015 to 2019. There has been some population growth over this time, which in itself might lead to a rise in expected deaths, but is not yet factored in here. These counts only relate to the deaths that a doctor has certified (in home or hospital), but this is likely to include most deaths directly associated with COVID-19 patients, diagnosed or not.
The 33,066 recorded deaths in the first three months of 2020 is well above the five-year average of 32,249. But overall, the 2020 deaths follow a similar pattern to previous years, with the count rising as we enter the cooler months.
We do expect death counts to increase with population growth and population ageing. These changes will not be particularly pronounced from year to year in Australia, but certainly could account for the small rise in overall deaths seen in these three months. There are no obvious differences between states, but the smaller population in the Australian Capital Territory and Northern Territory actually show slight declines.
Australia reported its first COVID-19 death on March 1, and has 103 confirmed COVID-19 deaths so far – a small proportion of the total number of deaths. Can we learn more by breaking down the new data?
Delve deeper into the data
One possible way to spot significant changes is to focus on groups known to be at most risk of dying from COVID-19.
First, let’s consider age at death. Older people are most vulnerable to COVID-19, but also have the highest death rates in normal circumstances too.
Differences from week to week are subtle, but we do see a slight trend by the end of January for the 2020 count to exceed the average. This could simply represent other factors contributing to the slight increase in all deaths, but will be worth watching over subsequent weeks.
Focusing just on those 65 and older in the ABS data, we see once again that 2020 counts are generally higher than average for all weeks for both males and females. Male deaths spiked in the final week of march, which is interesting as males represent 65% of confirmed COVID-19 deaths in Australia.
These are preliminary numbers, but there is no clear evidence of COVID-19 deaths in Australia before March 1, or before the first known incursion of SARS-CoV-2 into Australia. However, this might be obscured by the “noise” of looking at deaths from all causes at the same time.
It is therefore worth taking a closer look at deaths attributed to respiratory causes (the ABS states that these counts do not include the confirmed 103 COVID-19 deaths). The ABS data split the total respiratory deaths into two categories: chronic conditions such as asthma, and acute infections like influenza and pneumonia. It’s in this latter category (shown in the lowermost set of lines on the graph below) where any excess, uncounted deaths due to COVID-19 should be evident.
So far this year there have been 43 excess deaths due to influenza and pneumonia, relative to the average, and the ABS notes that most of these are pneumonia deaths. The excess deaths were mainly in the final two weeks of March, with the preceding weekly fluctuations largely cancelling each other out. This compares with 21 COVID-19 deaths reported by March 21, and 48 total by the end of the first week of April (ABS data are recorded by date of death; COVID-19 counts by the day publicly reported).
Some of these extra deaths may indeed be due to factors such as population growth, but it does open up the possibility of unaccounted COVID-19 deaths in the early days of the epidemic in Australia that might match, or exceed, those confirmed cases we know about.
The issue of undetected COVID-19 deaths is not the only important question. Has the deferral of elective surgeries affected the death rate? Has there been a death toll associated with people being discouraged from visiting clinics or hospitals for other illnesses? Have the stresses of lockdown and financial uncertainty led to a rise in domestic violence or suicide?
We don’t know the answers yet. But hopefully the forthcoming ABS data will reveal the answers as 2020 continues to unfold.
You probably know the details of the death of George Floyd. He was a doting father and musician. He was killed when a police officer, Derek Chauvin, knelt on his neck for nearly nine minutes while he cried out “I can’t breathe!”
Do you know about David Dungay Jr? He was a Dunghutti man, an uncle. He had a talent for poetry that made his family endlessly proud. He was held down by six corrections officers in a prone position until he died and twice injected with sedatives because he ate rice crackers in his cell.
At the end of a long inquest that stretched to almost four years, the coroner declined to refer the officers involved in Dungay’s death to prosecutors (who might consider charges) or to disciplinary bodies.
When I heard [George Floyd] say ‘I can’t breathe’ for the first time I had to stop … My solidarity is with them because I do know the pain they are feeling. And as for the Aboriginal deaths in our backyard … it’s not in the public as much as it should be.
A perception Indigenous deaths in custody are expected
Many people on this continent know more about police and prison violence in the US, another settler colony, than the same violence that happens here. Both are deserving of our attention and action, so what’s behind the curious silence on First Nations deaths in custody in Australia?
Aboriginal and Torres Strait Islander people have raised this concern long before today in the media and social media.
Why do we have to? The reasons are complex, but boil down to a system of complicity and perceived normality in Indigenous deaths at the hands of police and prisons. The settler Australian public simply does not see Indigenous deaths in custody as an act of violence, but as a co-morbidity.
The choice of language is important: it evokes a certain response in the reader and shapes our understandings of events. In the case of Palm Island, the often-repeated meta-narrative of so-called ‘dysfunctional’ and ‘lawless’ Aboriginal communities served to justify further acts of colonial violence.
In my 2018 pilot study on a sample of 134 Indigenous deaths in custody since the Royal Commission into Aboriginal Deaths in Custody, I found coroners considered referring just 11 deaths to prosecutors and only ended up referring five. Of those, only two made it to court and both resulted in quashed indictments or acquittals.
These are monumental figures. They are also stories of deep systemic complicity, both before and after death. And they are full lives, with loved ones who mourn and fight for them.
The scale of devastation is unthinkable – and violent, and racist.
What makes Australian silence about deaths in custody so especially bizarre is that, unlike the US, we have a mandatory legal review of every death in custody or police presence. Each case, regardless of its circumstances, goes before a judge called a coroner.
Just as public political will is always changing, so is law and legal strategy. Compared to the campaigns for justice for black people killed by police in the US, which have made relative gains, many families here are working in a complex space of honouring their loved ones, proper cultural protocols around death and the dead, and securing CCTV footage to mobilise the public for justice.
Coroners have offered mixed responses, and each state and territory’s coroner approaches the question in a slightly different way.
After the death of Ms Dhu, a Yamatji woman, in police custody in Western Australia in 2014, persistent advocacy from the families and media organisations prompted the coroner to release footage of her treatment before her death. Coroner Ros Fogliani did so
in order to assist with the fair and accurate reporting of my findings on inquest.
However, last year, NSW deputy coroner Derek Lee initially declined to release footage showing the circumstances of Dungay’s death, citing cultural respect, sensitivity for his family and secrecy over prison procedures.
Members of Dungay’s family, who had applied to have it released, responded with exasperation. It was eventually shown on the opening day of the inquest, although the fuller footage requested by the family remains suppressed from public view.
Other ways families are silenced
There are other transparency issues that give a legal structure to silence about Indigenous deaths in custody. Recently, there appears to be a new push in non-publication or suppression orders being sought by state parties in coroners courts.
In Dungay’s inquest, for instance, the media was ordered not to publish the names, addresses or any other identifying features (including photographs) of 21 NSW corrections staff members.
There have been other suppression orders in deaths in custody matters before criminal courts, such as the identity of the officer facing a murder charge in the death of Yamatji woman Joyce Clarke in Western Australia last year.
Officers in South Australia are also going to some strategic effort to avoid testifying before the inquest into the death of Wayne Fella Morrison, a Wiradjuri, Kookatha and Wirangu man, or even speak with investigators on the grounds of penalty privilege.
investigations surrounding the cause of death in prisons can have a great impact for our grieving families to at least get an account of what happened to our loved ones in the absence of our care. It can also raise the spotlight on the behaviours of correctional and police officers – like those that piled atop of my brother’s body.
Outside of coroners courts, there is the threat of subjudice contempt, when media coverage may pose a prejudicial threat to a potential trial.
This carries a risk for families who speak out about their loved one’s deaths in a way that even implies something happened or someone did something. Subjudice contempt poses liability to them personally when they speak out, but also could jeopardise their push for justice.
This puts First Nations peoples at the mercy of what can be raised before a jury, judge or coroner. With lengthy procedural delays, this can also mean a case is hard to talk about publicly for years.
This is problematic given that timely publicity about deaths in custody is what drives attention. Taleah Reynolds, the sister of Nathan Reynolds, who died in custody in NSW in 2018, said,
We’re coming up to a year since he died and we still don’t know anything more.
I feel like they don’t have any remorse; they hide behind the system. No one’s held accountable, that’s the most frustrating part.
All of this leaves our public discourse full of blak bodies but curiously empty of people who put them there.
The power of public campaigning
Prosecution or referral seems to come only from cases where First Nations families have strong public advocacy and community groundswells behind them and strategic litigation resources (not just inquest legal aid).
As the late Wangerriburra and Birri Gubba leader Sam Watson said of the campaign for justice for the death of Mulrunji Doomagee on Palm Island:
Unfortunately, the government had to be dragged to this point screaming and kicking every inch of the way. Every time there’s been a breakdown in the procedure, the family and community on Palm Island are being subjected to more trauma, drama and unnecessary grandstanding by politicians.
Right now, three deaths are either before prosecutors or in their early stages of prosecution. All have been part of growing, public campaigns driven by their families and communities — although many others, like Dungay’s family, have done the same and still been faced with institutional complicity.
Clearly, there is much legal structure that supports this silence, but the basis of the silence itself is colonisation and white supremacy. As Amy McQuire writes:
Their wounds also testify to this violence. But while this footage has been important for mobilising Aboriginal people, non-Indigenous Australia is still complacent and apathetic.
They are not ‘outraged’ because they are not ‘shocked’. There is nothing shocking about racist violence perpetrated by police, because it is normalised.
When we do hear about the Indigenous lives lost in custody, it is undoubtedly because of the persistence, expertise and courage of their families and communities who mourn them. But it is not enough to hear about justice, justice must be done.
Australia’s chief medical officer Brendan Murphy told a senate inquiry earlier this week our COVID-19 public health response had avoided about 14,000 deaths.
This is in contrast to his deputy Paul Kelly, who estimated on March 16 that Australia might have 50,000-150,000 deaths, depending on the percentage of Australians infected.
Then an article by Tony Blakely from the University of Melbourne and Nick Wilson from the University of Otago on March 23 used modelling from Imperial College, London, to estimate that even with “flattening the curve”, there would likely be 25,000-55,000 deaths.
The UK National Health Service has been struggling well before the COVID-19 pandemic, mainly due to an ageing population, difficulty in recruiting staff, higher costs, and population pressure. And even with its higher number of deaths, the UK has still not closed its borders.
A much better comparison is with Sweden, which has a good health system, but took a very different approach to Australia.
Sweden did not put into place any formal social distancing measures. Instead of lockdowns, it encouraged citizens to use common sense, work from home if possible, and not gather in crowds of more than 50 people.
Primary schools are open, as are bars and restaurants and businesses. As a result, Sweden has had more than 35,000 cases and 4,220 deaths in a population of just over 10 million.
This is much higher than neighbouring Scandinavian countries, and in fact tops Europe on a per capita basis.
If we want to compare death rates between Australia and Sweden, we need to calculate the cause-specific mortality rate. The cause-specific mortality rate for COVID-19 is the number of deaths from COVID-19 divided by the population. For Sweden, the cause-specific mortality rate for COVID-19 is 4,220 divided by 10,343,403, which is equal to 40.8 per 100,000 population.
If we now apply this to the Australian population of 25,700,995, we arrive at 10,486 expected deaths from COVID-19, assuming we had taken the same approach as Sweden.
Take away the 103 deaths we actually have, and we have saved 10,383 COVID-19 deaths as a result of our strategy.
So, our chief medical officer wasn’t really too far off the mark.
So what was behind those earlier figures?
The earlier predictions were based on the premise that a significant proportion of our population would be infected, which simply has not happened.
In fact, with just 7,139 cases, only about 0.03% of our population has been diagnosed with COVID-19, compared with the 30-60% predicted in the previous estimates.
But it’s not quite so simple
Unfortunately, the story doesn’t end there. No matter which way we calculate these “avoided deaths”, we also need to factor in additional likely deaths from our public health response.
The impact of our business closures and massive job losses, as well as enforced isolation, might well have increased our rates of suicide and mental illness.
At the same time, many cancer patients and those with other chronic conditions have been staying away from medical check-ups and appointments.
These might lead to more deaths. However, I doubt these people’s death certificates will mention COVID-19.
On the plus side, fewer cars on the roads will almost certainly lead to fewer motor vehicle accidents, and because of social distancing, we are already seeing a huge drop in the number of Australians diagnosed with influenza.
Does it really matter if estimates of deaths saved are a bit out? Well, it probably does to economists. They can cost the value of someone’s life, add up the value of all the lives saved, and then demonstrate we have actually saved money from the billions spent. The government would obviously like the number of deaths saved to be as high as possible to justify its strategies and expenditure.
But for the ordinary person, probably not. For us, we are simply relieved our loved ones have been spared.
As Australia begins to relax its COVID-19 restrictions there is understandable debate about how quickly that should proceed, and whether lockdowns even made sense in Australia in the first place.
The sceptics arguing for more rapid relaxation of containment measures point to the economic costs of lockdowns and appeal to the cold calculus of cost-benefit analysis to conclude that the lives saved by lockdowns don’t justify the economic costs incurred to do so.
Their numbers don’t stack up.
To be able to weigh the value of a life against the economic costs of forgone output from lost jobs and business closures, requires placing a dollar value on one person’s life. This number is called the value of a statistical life.
What are the benefits of the shutdown? This is the value of lives saved plus any indirect economic or health benefits. Lives saved are those excess lives that would be lost if government relied on a strategy that allowed enough people to get infected to result in so-called herd immunity.
How many extra lives would be lost under this second strategy?
To answer this, we need assumptions about the virus.
The lives lost if we let it rip
The initial reproduction rate of the virus, R0, was thought to be about 2.5. This means that every 2 people infected were likely to infect another 5; producing an average infection rate per person of 2.5.
Herd immunity for COVID-19 is estimated to require roughly 60% of the population be infected before the curve begins to flatten and the peak infections fall.
This happens when the reproduction rate, R0, falls below one. Because of subsequent new infections, the total number infected over the course of the pandemic is closer to 90%.
Given a population of 25 million people and assuming a fatality rate of 1%, this would produce 225,000 deaths.
An assumption of a 1% fatality rate is low from the perspective of those making decisions at the onset of the pandemic, at a time when crucial and reliable data were missing.
Those lives are valued at $1.1 trillion
Converting those fatalities to dollars using the Australian value of a statistical life of A$4.9 million per life yields a cost of A$1.1 trillion.
In rough terms, that’s the amount we have gained by shutting down the economy, provided deaths do not skyrocket when lockdown measures are relaxed and borders re-open.
It is about three fifths of one year’s gross domestic product, which is about A$1.9 trillion.
What are the costs of the shutdown?
These are the direct economic costs from reduced economic activity plus the indirect social, medical, and economic costs, all measured in terms of national income.
A starting point is to take the lost income that occurs from the recession that has probably already begun.
What will the shutdown cost?
Let’s assume that the downturn results in a 10% drop in gross domestic product over 2020 and 2021 – about $180 billion – consistent with IMF forecasts of a fall in GDP of 6.7% in 2020 and a sharp rebound of 6.1% growth in 2021, and comparable to the Reserve Bank of Australia’s forecasts in the latest Statement on Monetary Policy.
Comparing this cost from shutting down – about $180 billion – to the benefit of $1,103 billion – makes the case for shutdown clear.
But this calculation grossly overestimates the costs of the shutdown.
The recession is a consequence of both the shutdown and the pandemic.
We need to attribute costs to each.
Most of the economic costs of the recession are likely to be due to the pandemic itself rather the shutdown.
Many costs would have been borne anyway
Even before the shutdown, economic activity was in decline.
Both in Australia and internationally air travel, restaurant bookings and a range of other activities had fallen sharply.
They were the result of a “private shutdown” that commenced before the mandated government shutdown.
Even in a country such as Sweden, where a shutdown has not been mandatory, there has been a more than 75% reduction in movement in central Stockholm and a more than 90% reduction in travel to some domestic holiday destinations.
To be generous, let’s assume the costs attributable to the government-mandated part of the shutdown are half of the total costs, making their cost A$90 billion.
In reality, they are likely to be less, one important study suggests much less.
It is hard to imagine a much bigger private shutdown not taking place had the government decided to simply let the disease rip until its spread was slowed by herd immunity.
Support is not a cost
It is also important to note that the government’s spending of A$214 billion to support the economy during the shutdown is a transfer of resources from one part of society to another rather than a cost.
It creates neither direct costs nor benefits for society as a whole, other than the economic distortions coming from raising the revenue to service the spending.
With long-term government bond rates near 1% (less than inflation), the total cost of distortions is likely to be tiny.
Of course, this discussion simplifies what are incredibly complex social, health and economic questions. There are clearly further costs, from both relaxing restrictions and keeping them in place.
Other costs are not that big
These costs are worthy of serious study and should rightly be part of a comprehensive public policy discussion. But looked at through the lens of a cost-benefit analysis these combined effects are likely to be small relative to the value of preventing mass death.
Among them are the incidence of mental health problems and domestic violence under lockdowns. They are important concerns that should be addressed by targeted and well-designed programs.
Weighing against that is evidence that economic crises are associated with declines in overall mortality rates.
While suicides rise, total mortality, including deaths from heart attacks and workplace and traffic accidents, falls.
In the specific case of this pandemic there is survey evidence based on respondents from 58 countries suggesting that strong government responses to the pandemic have been reducing worry and depression.
Also, we have to acknowledge that recessions and educational disruption have health and economic costs that are unequally spread.
The shutdown disproportionately impacts more-disadvantaged people including short-term casual workers, migrant workers, those with disabilities and the homeless.
The most-disadvantaged suffer, either way
This skewing will also be present in the herd immunity option. As New York City makes clear, a rapid spread of the disease also disproportionately impacts disadvantaged communities. One can only speculate about the disease burden should some of our remote indigenous communities get exposed.
To this we should add further achievements of the shutdown:
elimination of mental trauma and grief from losing our loved ones
avoiding the costs of possible longer-term implications of the disease, which we still know little about
avoiding a collapse in the capacity of the health system to deal with other emergencies through the sheer numbers of COVID-19 infected combined with staff shortages due to illness
Those advocating cost-benefit analysis of this kind have to apply the principle systematically. It is difficult to see how the total of these sorts of considerations on each side of the ledger could compare to the benefit of lives saved. They will be an order of magnitude, if not two, smaller.
$90 billion, versus $1.1 trillion
In the cold calculus of cost-benefit analysis, a highly pessimistic view of the economic costs of Australia’s shutdown comes to around $90 billion.
It is a small price to pay compared to the statistical value of lives the shutdown should save, around A$1.1 trillion.
The question we now face is how quickly to relax restrictions. Here, too, there are costs and benefits, and we need to be mindful of the economic cost of a second-wave outbreak, plus mortality costs of disease spread before effective treatments or vaccine become available.
And in all of this bean counting, we should remember that putting a price tag on human life is sometimes unavoidable – such as when a doctor with access to only one ventilator has to choose between two patients.
But we shouldn’t mistake necessity for desirability. We should seek to avoid needing to make such wrenching choices whenever possible.
Dr Jen Schaefer of the Royal Children’s Hospital Melbourne assisted with the preparation of this piece.
Will the number of lives saved as a result of the COVID-19 restrictions be outweighed by the deaths from an economic recession?
This is a vital question to answer for governments responding to the current global tragedy.
Without numbers, there’s no obvious way of working out whether the economic impacts of the lock-down could be more harmful than the virus.
With health economics consultant Daniel West, I have attempted to estimate the numbers involved in Australia.
In order to provide a strong challenge to the status quo of lock-down the estimates we have used for increased deaths from a lockdown-induced recession are at the high end of the likely scale. The estimates we have used for deaths from COVID19 if the lockdown ends are at the low end.
Our analysis suggests that continuing strict restrictions in order to eradicate COVID-19 is likely to lead to eight times fewer total deaths than an immediate return to life as normal.
Lives the lock-down could cost
The most obvious deaths likely to follow from a lock-down-induced recession are suicides.
Studies in 26 European countries over four decades suggest that increases in unemployment of more than 3% are associated with increases in suicides by 4.45%.
A similar relationship was found in Australia during the global financial crisis.
The projections for increases in unemployment if the lock-down continues are grim, some pointing to an unemployment rate of up to 15% which might not return to normal for up to a decade.
To account for the prospect that the coming recession will be more severe than most, we have used double the highest European estimate of the relationship between increased unemployment and suicide.
This estimate suggests that an increase in the unemployment rate to 15% followed by a gradual decline over ten years would produce a distressing 2,761 extra deaths due to suicide.
Loneliness takes lives too
Continued restrictions could also significantly increase loneliness, which, for those who are lonely, can increase deaths from all-causes by between 15% and 29%.
Research suggests that quarantine can increase the number of people showing psychological distress by about 20%, an estimate we have used as a proxy for the effect of loneliness, even though the lock-down restrictions are less severe than quarantine.
This points to an additional 4,015 deaths associated with loneliness from a lock-down of six months.
Although it would be reasonable to assume that a recession would increase the number of deaths from other causes, studies show this isn’t the case. Research into “all-cause mortality” consistently shows declines in deaths during recessions, due in part to a reduced number of heart attacks.
The current lock-down might also increase deaths in specific ways, such as deaths from alcohol abuse.
On the other hand, if hospitals are overwhelmed by COVID-19 cases, deaths from non-COVID-19 injuries and illnesses will increase as people cannot access health care.
Because we have no data on these offsetting possibilities, we have assumed they are roughly matched in size.
It is also worth noting that although we assume lock-down restrictions will hurt our economy more severely, cities that implemented more severe restrictions during the 1918 Spanish flu had economies that bounced back faster after the pandemic.
Lives the lock-down might save
We have estimated the number of deaths from COVID-19, suicide and loneliness under three different scenarios
an immediate return to life as normal, while still quarantining suspected cases
an easing of restrictions that allows the virus to slowly spread in order to achieve so-called herd immunity
the maintenance of restrictions until the virus is contained, followed by extensive tracking and tracing aimed at eliminating the virus
Scenario 1. Return to normal
With no lock-down measures other than the quarantine of suspected cases, the government believes 68% of people would contract the virus. Our estimates suggest this would result in more than 287,000 deaths from COVID-19 as the health system could not cope with the volume.
We assume this would produce a recession lasting five years instead of ten, with 10% initial unemployment and an associated 753 extra deaths from suicide.
Scenario 2. Herd immunity
The government says that to achieve herd immunity, about 60% of people would need to eventually contract the virus. If it is done slowly, intensive care units will not be overwhelmed, keeping the death rate per infection low.
Our estimates suggest the strategy would lead to 141,000 deaths from COVID-19.
We assume this would result in a deep recession of ten years with 15% initial unemployment and an associated 4,015 deaths from loneliness and 2,761 deaths from suicide.
Scenario 3. Eradication
Under the eradication scenario, 11.6% of people would be expected to contract the virus, resulting in 27,000 deaths from COVID-19.
As with the herd immunity strategy, we have assumed a deep recession over ten years with 15% initial unemployment and an associated 4,015 deaths from loneliness and 2,761 from suicide.
Note that given Australia’s current success, it is very possible that with continued prudent restrictions, the number of deaths due to COVID19 will be well below 27,000.
The calculus of death
Regardless of the strategy, the estimated number of deaths from COVID-19 far exceeds the estimated number of deaths from suicide and loneliness.
Despite assuming that an immediate return to life as normal would prevent all further deaths from loneliness and 70% of deaths from the increased suicide rate associated with high unemployment, the life as normal scenario is predicted to result in by far the highest overall number of deaths: 288,000.
This is almost twice the number of deaths predicted for the herd immunity scenario (148,000) and more than eight times as many as eradication (34,000).
The Brain and Mind Centre at the University of Sydney has reported larger estimates for suicides from increased unemployment: an extra 750 to 1,500 suicides per year for five years. The top end of this range projects an extra 7,500 suicides, almost three times our estimate.
Even using this higher estimate, the number of lives that would be lost from COVID-19 without lock-down measures would dwarf the number of extra suicides.
One of the most confronting impacts of climate change is the risk of more deaths from hot weather. Heat stress can exacerbate existing health conditions including diabetes, kidney disease and heart disease. Older people are particularly vulnerable.
It may then surprise you to learn a fewrecentstudies have suggested climate change will decrease temperature-related deaths in Australia. And a related study published in The Lancet found the cold kills more people in Sydney, Melbourne and Brisbane than the heat.
How do researchers measure temperature-related deaths?
An important part of the process is estimating the proportion of deaths that occurred during cold weather and hot weather.
To determine this many studies use a reference (or baseline) temperature. This reference temperature should be a day where people in a region feel comfortable and their health is unlikely to be affected by cold or heat. Temperature-related deaths falling below this temperature are classified as cold-related, and deaths above will be heat-related.
We use statistical techniques to distinguish temperature-related deaths from deaths due to unrelated causes.
For example, estimates should adjust for the severity of seasonal factors, including flu seasons. Flu and pneumonia deaths do rise in winter, but they’re not directly caused by the cold.
Temperature-related death estimates vary depending on the underlying assumptions made, and the modelling techniques used. But a key issue causing a discrepancy between results is the use of different reference temperatures. This influences the proportion of deaths classified as being related to cold and heat.
The relationship between temperature and death can be shown as a curve of the risk of death from high/low temperatures in relation to the reference temperature.
The figure below shows how the estimated curves, called temperature-mortality curves, can differ when the reference temperature is changed. It compares temperature-mortality curves from my latest study (the bottom row), to those from the study published in The Lancet (the top row).
Red and blue shading show the parts of the curve defined as heat and cold. Arrows point to the reference temperature used to estimate the curves.
Numerous studies, including the Lancet study, have estimated the number of deaths attributable to heat and cold using what’s called a minimum mortality temperature (MMT) as the reference temperature.
The MMT is the lowest point of a temperature-mortality curve and is often interpreted as the daily average temperature at which there’s the lowest risk of death.
Based on the findings for Australia, I’m concerned the reference temperature (the MMT) used in The Lancet study was too high. For example, a reference temperature of 22.4°C (shown in the figure above) meant almost 90% of Melbourne’s historical daily average temperatures were classified as cold. This could be equivalent to a day with a maximum of 31.4°C and a night minimum of 13.4°C.
I’ve used a different reference temperature in my latest study. I used the median of historical daily average temperatures as the reference temperature. For example, in my study cold days in Melbourne are those below a daily average temperature of 14.7°C. All daily average temperatures above 14.7°C are considered hot.
Using the median as the reference temperature creates a 50/50 split between what’s considered hot and cold.
Comparing the results
As well as using a different reference temperature, I used national death record data to estimate temperature-related deaths for six climate zones. They range from areas with a “hot humid summer” in the north and areas of “mild/warm summers and cold winters” in Tasmania, the ACT and parts of NSW and Victoria.
The other studies I mentioned used data for many cities from around the world, but only included the three largest Australian capitals (Sydney, Melbourne and Brisbane).
In my study, I estimated 2% of deaths in Australia between 2006 and 2017 were due to the heat.
In the three warmer climate zones this number was higher, ranging from 4.5% to 9.1% of deaths. However, as the majority of the population lives in the second coldest climate zone (warm summer, cold winter), this brings down the national estimate.
In the coldest climate zone, 3.6% of deaths were due to the cold and the heat was less dangerous.
These estimates are notably different to those in The Lancet study where the total for Sydney, Melbourne and Brisbane had 6.5% of deaths associated with cold temperatures, but only 0.5% of deaths due to the heat.