key: cord-0904293-8y7nwlas
authors: James, James J.
title: Of Lives and Life Years: 1918 Influenza Versus COVID-19
date: 2021-07-15
journal: Disaster Med Public Health Prep
DOI: 10.1017/dmp.2021.230
sha: 95016989f24bce72c947d119b679d1abc3ca6483
doc_id: 904293
cord_uid: 8y7nwlas

nan

mitigating morbidity and mortality. Rather than being divisive, both perspectives need to be addressed and optimal solutions formulated to better our overall lives; we cannot maximize 1 at the expense of the other.

To better optimize our policies, we need to first accept the fact that every derivative intervention has some cost in terms of direct and indirect negative health impacts, and, in many cases, those impacts can be quite profound. 6 Second, we need to develop a more objective way of assessing the benefits of a given intervention versus the overall costs in terms of some common measure of overall mortality impact. As the impacts of the interventions cover a broad spectrum of conditions (suicide, overdoses, delayed diagnoses, socioeconomic damage, etc.) over individual life spans, a measure of life years lost versus those lost to the pandemic would afford a comparable measure. The overall life years lost from the pandemic can, in most cases, be readily calculated from available epidemiological data. Calculating the effect of individual interventions is much more complex because of inconsistencies in definitions and data collection as well as the extreme variation in their application and enforcement. The result is a mass of data that can be used to support conflicting positions and policies that are more reflective of individual bias than science.

What we can calculate with increasing accuracy over time is the negative health impacts associated with specific interventions, such as school and business closures and stay-at-home orders, which have been manifested in well-documented increases in mental health issues, drug and alcohol abuse, limited access to acute and chronic medical care, lost academic years, and, often, severe, socioeconomic injury to our most disadvantaged. All of these negative health outcomes will have some impact on overall mortality, some immediately measurable, but most in terms of future life years lost leading to decreased individual life expectancy for a significant component of the population. If such interventions are to be used to control and mitigate future pandemics, we must be able to make a reasonable assessment that the overall benefits achieved outweigh the cumulative harm done and that we are protecting individual lives without undue injury to the public health.

To be able to accomplish this with some degree of validity, we need to have a compilation of studies that assess the individual impacts of specific interventions and allow a reasonable estimate of actual or projected life years lost. One such study recently published measured the increase in opioid-involved deaths in Cook County during the pandemic lockdown period and reported that they increased to a mean of 44 deaths from 23 for the pre-lockdown period and declined sharply in the weeks following. 7 Age data were not reported but can be extrapolated from national estimates provided by the CDC. 8 Another recently published paper estimated excess mortality from drug overdoses, homicides, unintentional injuries, motor vehicle crashes, and suicide for the first 6 months of the pandemic. 9 Following the first publication of this paper an additional study addressing the overall morbidity and mortality impacts of our interventions from a global perspective has been published and should be of interest to the reader. 10 Going forward, a compendium of such studies would be an extremely useful decision-support tool to inform policy development and implementation in future events.

Of course, the intervention that should not need such justification is vaccination, and, despite the strong vaccine hesitancy and refusal that we have seen with the COVID-19 vaccines, there has been a clear demonstration of their effectiveness with the result that most other interventions have been discontinued or scaled down. This is certainly a welcome relief from the anxieties and stresses of the past year, but we must not become too complacent regarding either the current pandemic or the next one. From a global perspective, with vaccine supplies in short supply, COVID-19 continues to be a major killer and the only available defense for many continue to be the non-pharmaceutical, social-distancing interventions. In addition, the virus continues to produce new variants, 1 or more of which might become vaccine-resistant and result in yet another wave.

Finally, we must be wary of the next pandemic and not assume that we will be able to replicate producing a safe and effective vaccine in little less than a year as we have done for COVID-19. Even if we could accomplish that same feat, other interventions would be required to control and mitigate well before the availability of a vaccine. As a case in point, we can juxtapose the COVID-19 vaccine timeline on the epidemiological mortality curve for the 1918 influenza pandemic. As noted, it took just under a year to have an approved vaccine, but it took an additional 4 months (mid-Dec 20 to mid-April 21) to even partially vaccinate 50% of the US population. 11 As seen from the graph in Figure 1 , 12 this timeline, as rapid as it was, would have had essentially no effect on the 1918 pandemic mortality. If we are again faced with a major event, such as COVID-19, and we must depend again on non-pharmaceutical interventions awaiting vaccine fielding, hopefully, we will be better prepared to optimize saving lives and protecting public health while mitigating self-imposed, debilitating, socioeconomic impacts.

Conflict(s) of Interest. The author declared no potential conflict of interest with respect to the research, authorship, and/or publication of this paper. 

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Pandemic influenza: three waves. Last reviewed May 11

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