Coronavirus Grab Bag: deaths vs qalys, safety vs safety theater, ‘all in this together’, and more.

This post is by Phil Price, not Andrew.

This blog’s readership has a very nice wind-em-up-and-watch-them-go quality that I genuinely appreciate: a thought-provoking topic provokes some actual thoughts. So here are a few things I’ve been thinking about, without necessarily coming to firm conclusions. Help me think about some of these. This post is rather long so I’m putting most of it below the fold.

I. Deaths vs ‘life-years’ lost, with or without ‘quality adjustment’.
I have pretty much been looking at ‘deaths’ as a key metric for the severity of the pandemic, but I’m not happy with it. A big issue is that all deaths are not equal: on average, the older the victim the smaller the tragedy. Here’s how I think of it: I have about 30 years of expected life ahead of me. A 20-year-old has about 60 years of expected life ahead of them. If each day of my life is just as precious to me and to society as each day in the life of a 20-year-old, if I die the net loss is half as many of those precious days as if the 20-year-old dies. Certainly I’d have a hard time arguing that each of my remaining days is _twice_ as valuable as that of a randomly selected 20-year-old. And how about a 90-year-old with dementia who has just been diagnosed with pancreatic cancer? If there’s a fire, and a fireman has a choice between saving this person vs a 12-year-old, would anyone seriously argue that it should be a toss-up? I hope not.

Rather than ‘deaths’, or in addition to it, I’d like to see ‘life-years lost’. When someone dies, you can use actuarial tables to determine how many expected years of life have been lost. Sum that over everyone who has died of covid-19 and you’ve got a number I would rather see than the raw count of deaths.

There are various options, like whether to adjust for the ‘quality’ of the years lost (that 90-year-old with dementia being assumed to get less out of each day than a healthy 20-year-old)…my personal preference would be to _not_ have someone do the quality-adjustment for me, I’d rather have just life-years. But QUALYs would be much better than just ‘deaths’.

Why isn’t it happening? Is there any news outlets that routinely reports on life-years lost?

On a related subject, I wonder: to what extent are differences in opinion about the pandemic response related to differences of opinion about either the importance of life-years lost or the appropriate ‘quality adjustment’ for an old person’s life? To come back to Sweden, which I have discussed in an earlier post, the Swedes seem very happy with their choice of doing mostly just voluntary measures to control the pandemic, in spite of the fact that their death rate is among the highest in the world. As with every country, most of the people dying are quite old; they’ve had about 3200 covid-19 deaths, which is 320 deaths per million population; the U.S. is officially 240 per million, although we surely have a bigger undercount here than they do. Still, they’re probably 30% higher than us, but they don’t seem bothered. Should they be? It’s not like a randomly selected 320 people per million have died in Sweden: nearly 2/3 of the deaths have been people 80 years old or older, and only about 5% have been under 60.

II. Safety vs Safety Theater.
This is on everyone’s mind one way or another. There are rules that make sense to me and rules that don’t, and I wonder whether the ones that don’t are just supposed to make us _feel_ like they’re doing something, or whether they serve a purpose I don’t know about?

For instance, here in California you are allowed to take a walk in the park with members of your household. But you are not allowed to have a picnic in the park. A walk in the park is said to have an important health purpose — gotta get your exercise! — so it’s allowed in spite of whatever virus transmission risk is associated with it. A picnic is said to serve no vital purpose and thus to be unjustified. This doesn’t make much sense to me.

I accept that either activity does involve some risk of viral transmission. Most people who drive to the park will do so in a car that needs gasoline. All those people driving to the park means more stops at gas stations, gotta touch the pump, maybe someone else is nearby, etc. If the park has other people then you’ll walk past some of them and inhale or exhale some air they exhaled or inhaled.

And if you were to picnic at an actual picnic table, well, you’re touching the table and the people who come after you will touch the same table, so there’s that. Also, if people are picnicking then they’ll generate trash, which means you need trash pickup, and that trash has to be dropped off at a transfer station, and all these things — having people driving garbage trucks and manning transfer stations etc — all increase the number of people exposed to other people.

So, OK, have a million people go on picnics in the parks over the period of a month and the number of additional transmissions won’t literally be zero. But c’mon, how many additional transmissions would happen this way compared to the number that happen anyway from people going about permissible activities like shopping for groceries? And to the extent that having a picnic in the park with your family is good for one’s mental health, especially as an alternative to being cooped up in a small apartment together, does it really make sense to deprive people of this minor pleasure?

I don’t think picnicking in the park with one’s family should be illegal, or even discouraged. But: I could be wrong. Seeing people picnicking in the park as life is normal, maybe that gives people a false sense of security and would nudge people towards dropping their guard on more consequential behaviors? Or maybe the governor or his advisors think the risk of transmission to another household is higher than I think it is; for instance, maybe they think children from different families will inevitably intermix because in practice their parents won’t be attentive enough to stop them.

This is just one example of something that I think isn’t actually significant when it comes to slowing the spread of the virus, but that with which we are expected to comply. I am not a scofflaw on this stuff: I think it’s safety theater and doesn’t actually improve safety, but I don’t know for sure and I’m not going to pretend I do. I just hope these decisions are being made by someone who is paying attention to reality of the risks rather than the ‘optics.’

III. Are we all in this together?

Boy, am I lucky: so far my work is unaffected by the pandemic. My annual income in 2020 will be pretty close to what it was in 2019. My wife’s might be down a bit, but not a lot. We are doing absolutely fine. But some of our friends and neighbors are (already) out of work, and our friends who are out of work are in a much better financial position than many or most people in the country who have lost their jobs. 

I’m sure my circumstances influence my view of the response, in the direction of making me want to ‘err on the side of caution’ when it comes to relaxing government regulations. I see news articles about people complaining about the enormous sacrifices being required, how much it’s crushing the economy, etc. etc., and I think “jeez, if you think this is ‘sacrifice’ what do you think about World War II, when millions of people were drafted and sent off to fight, while back home there was rationing of meat and gasoline and rubber?”  A friend mentioned how unreasonable it is to expect people to go for months without being able to hang out with friends or see their girlfriend, and I pointed out that the men storming the beaches at Normandy also had to go for a long stretch without seeing friends or girlfriends, and that many of them never got to do those things again at all. As sacrifices go, what is being asked of us now is huge, but in the past people have been asked for much, much more.  To which a perfectly appropriate response is: “Sure, Phil, easy for you to say.” And it is. I’m not suffering. 

It isn’t fair. I’m not a big fan of the sentiment that ‘life is unfair; get over it’. The world would be a better place if it were a bit less unfair. Maybe a lot less unfair. What are some politically feasible ideas for spreading the pain? Anyone got any ideas? 


This post is by Phil.