key: cord-0726618-q0oqcr4g
authors: Watkins, Johnathan; Maruthappu, Mahiben
title: Public health and economic responses to COVID-19: finding the tipping point
date: 2020-05-23
journal: Public Health
DOI: 10.1016/j.puhe.2020.05.025
sha: 77a18824f4465b06f727bbc54f82c70e760306d5
doc_id: 726618
cord_uid: q0oqcr4g

Abstract We shed light on an under-reported dimension of the pandemic and its response: namely, the trade-off between early deaths from the virus and potential deaths arising from the economic fallout. Our previous research has shown that recessions and austerity as an economic response to a recession are associated with rises in cancer mortality and all-cause mortality, respectively. We believe it is important to highlight the considerations in this tradeoff.

As the COVID-19 pandemic unfolds, governments around the world have been grappling with their dual responsibility to save lives and safeguard livelihoods. This has comprised a public health response and an economic response. Governments continue to attempt to find the tipping point between them; the deployment of public health measures that save lives from COVID-19 in the short-term, and safeguarding livelihoods in the medium term, which has the potential to save lives from subsequent economic crises.

The direct public health mandate to COVID-19 has been clear, averting deaths from the disease by: i) suppressing the peak of healthcare demand through non-pharmaceutical interventions; ii) expanding health system capacity to detect and manage new cases; and iii) developing and deploying pharmaceutical interventions such as vaccines and antivirals.

The first of these points, the so-called 'flattening of the curve', has generated considerable debate. A range of measures have been attempted including case-based self isolation, social distancing and banning of mass gatherings. However, the most drastic of these have been the regional and national lockdowns that have been enacted in nearly every continent 1 .

Emerging evidence from Asia and Europe has shown that such actions do appear to be working 2 .

One anticipated effect of measures such as lockdowns is unemployment and economic recession. The number of individuals claiming for unemployment benefits in the US during the six weeks up to the end of April 2020 totalled over 30 million. For comparison, the net number of jobs lost in the US during the recession of 2008/09 was 8.7 million 3 . In the UK, a report from the Office for Budget Responsibility projected a 35% fall in real GDP next financial quarter as a result of the pandemic and lockdown 4 .

Our research and that of others has shown that rising unemployment negatively affects health outcomes. Suicides 5 , child mortality 6 and deaths from 'treatable' cancers such as breast and prostate 7 have all been demonstrated to rise with unemployment. The putative mechanisms behind these associations range from increased mental health issues arising from unemployment to inadequate access to the care often enabled by employment packages, especially in countries that lack universal health coverage. Features of this recession may well exacerbate these issues: enforced home isolation and shuttering of whole sectors of the economy could contribute to a net rise in mortality that could run into the thousands or more globally.

Governments also face the challenge of how to respond economically during and in the aftermath of the pandemic. We see the goal here as not merely the safeguarding of livelihoods by supporting people financially during the pandemic and stimulating a sustainable economic recovery, but also the saving of lives by preserving access to highquality health care during subsequent economic challenges, which may threaten health spending.

In response to a recession, fiscal policy can typically go one of two ways: austerity whereby spending is reduced and/or taxes raised, and expansion whereby spending is increased and/or taxes lowered. Putting aside the economic arguments, it has become increasingly apparent that austerity accompanied by a reduction in real-term public health & social care spending is associated with a relative rise in all-cause mortality 8, 9 . The magnitude of the effect is substantial and could lead to hundreds of thousands or more 'excess' deaths globally over a period of several years. Therefore, the number of lives lost due to COVID-19 has the potential to be eclipsed by the number of lives lost as a result of maladaptive responses to the pandemic. Governments have already enacted measures such as lockdowns and social distancing with some positive results starting to emerge. Now is the time to consider how to maintain public health & social care spending levels, while ensuring robust access to services by the unemployed, to ensure the health of the population is preserved long after the COVID-19 pandemic has passed.

Estimating the number of infections and the impact of nonpharmaceutical interventions on COVID-19 in 11 European countries

Unemployment insurance weekly claims

UK Office for Budget Responsibility. OBR Coronavirus analysis

Impact of 2008 global economic crisis on suicide: time trend study in 54 countries

Effects of economic downturns on child mortality: A global economic analysis

Economic downturns, universal health coverage, and cancer mortality in high-income and middle-income countries, 1990-2010: a longitudinal analysis. The Lancet

Effects of health and social care spending constraints on mortality in England: a time trend analysis

Austerity and old-age mortality in England: a longitudinal cross-local area analysis