Counting the costs of the global north's COVID-19 policies: Lives vs life years

Countries of the global north responded to the spread of COVID-19 typically with mitigation strategies aimed at flattening the curve. The laudable objectives were intended to reduce the number of people requiring care at any given time, as well as to prevent the health care system from collapsing under a tidal wave of sick people requiring intensive care in hospitals. Different countries have employed different mitigation strategies. Most had in common a shutting down of their borders for tourists and business travelers, or at least a dramatic reduction in international travel. Some countries even went so far as to imprison people in their own homes over extended periods of time, China being the paradigmatic examples of this.

The impacts of COVID-19 in the global north were significant. Economies contracted, health care for non-COVID-19 patients was delayed (for some patients irreversibly so), global supply chains were interrupted, schools switched to very suboptimal on-line learning, and so on. Currently reviews of such mitigation efforts both by academics as well as by various kinds of commissions of inquiries are ongoing, effectively comparing the number of COVID-19 deaths a given mitigation strategy has prevented, versus the number of prevented COVID-19 deaths in countries that deployed different mitigation strategies.

The question is, of course, why deaths should be the relevant measure of success or failure, when in pretty much every other health policy instance one would focus on the loss of quality adjusted life years, or of disability adjusted life years. The reason why this issue matters is that these mitigation strategies all had their own costs. No doubt, unless a significant number of lives were directly lost as a result of a given COVID-19 mitigation strategy, a lower number of COVID-19 deaths than alternative mitigation strategies would have to be considered a success, and this is what happens today in review articles looking at these different responses.

Taking an alternative measure, say quality adjusted or disability adjusted life years, could quite conceivably change the outcomes of these reviews quite substantially. So, unsurprisingly, the measure one chooses often determines whether a particular policy response will be considered a success or a failure. Choosing deaths-prevented as the measure to be used is a normative choice that is far from self-evident, unless we decide that people's quality of life can be fully discounted. We would have to disregard then, for instance, the loss of quality learning environments that children encountered, the highest price being invariably paid by children of resource poor families. Equity campaigners who were busy arguing for particular equity considerations when it came to priority groups in the early days of the vaccine roll-outs had little to say about the harms affecting these children quite inequitably, with the greatest burdens being carried by the poorest.

Turning to the global south. Thinking about children, again, in many countries of the global south on-line education – sub-optimal as it is – wasn't even a realistic option in their under-resourced public education systems. There children – that is those of our citizens least likely to experience serious health consequences, if infected – went without anything resembling education for more than two years. They are unlikely to be able make up for this loss of education. A decision was made – by mostly older people – to keep schools closed in order to protect, well, mostly older people. The interests of children were mentioned, but only by way of flagging that they shouldn't be egoistic, and that the protection of the elderly was more important than children's educational and social needs. Their loss of quality-adjusted life-years was never counted, because the measure of pandemic mitigation success was ‘deaths prevented’.

It is well known by now, and it has been much lamented, that vaccine nationalism in the global north resulted in very significant delays in terms of getting vaccine to people in the global south. Under-resourced health care systems like Kenya's struggled with the COVID-19 patient caseloads. But there were other harmful impacts of the global north's COVID-19 policy responses on the global south. For instance, the damage done to global supply lines had immediate consequences on what hundreds of millions of impoverished people in the global south were able to afford. The COVID-19 (policies) caused, in that order, high inflation, followed by a global recession and led to a collapse of commodities prices, forcing more than 30 sub-Saharan African countries to approach the International Monetary Fund (IMF) for financial bailouts. A fair number of countries in the global south have highly tourism-dependent economies. The abrupt absence of tourists over a two-year period devastated these industries and the many workers, and their dependents, who made a living working in them. There is an environmental cost to lament, too, where nature reserves fell prey to increased poaching. Eco-tourism as a solution to environmental preservation has taken a serious hit, courtesy of the global north's COVID-19 policies. The absence of well-heeled tourists, coupled with these societies’ inability to provide a functioning welfare safety net resulted in large numbers of people falling over night into abject poverty. Poverty, of course is a well-known social determinant of health that is directly linked to morbidity and mortality rates in a population. Progress that was made in many countries of the global south in terms of reducing extreme poverty, has been reversed. Reportedly, the absolute and relative size of the number of severely impoverished people has increased for the first time since 1990.1 Much of this was caused by the global north's COVID-19 mitigation strategies. None of these costs feature in the reviews that are supposed to demonstrate the successful nature of particular restrictive mitigation policy responses.

I don't want you to read this Editorial and interpret it as suggesting that all attempts in the global north that were aimed at flattening the COVID-19 curve were misguided, or even that many were misguided. However, I do think that any analysis that measures a policy by its results in terms of lives lost, but only within a nation state, while omitting the harmful impact it had on vulnerable lives elsewhere, is ethically untenable. The price that others had to pay in order to achieve the outcomes in the global north that we see currently celebrated in academic journals should be properly quantified and be part of any serious analysis of COVID-19 mitigation policies. Otherwise, what we are really saying is that the lives of those in the global north count for more than the lives of those in the global south.