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Calling for benefit–risk evaluations of Covid-19 control measures (thelancet.com)
51 points by mrfusion 12 days ago | hide | past | favorite | 67 comments





Unicef and others have compiled reports but they have gotten very little press coverage for instance. There's many stats and models there.

>An additional 6.7 million children under 5 could suffer from wasting in the next 12 months.

https://data.unicef.org/covid-19-and-children/

> Almost 200,000 additional stillbirths could occur over the next 12 months due to the impact of COVID-19


Why do so many articles use the phrasing "due to COVID-19" instead of "due to the lockdowns"?

It's much more acceptable / justifiable creating positive perception (brain washing) in broad audience. Old repetition marketing rule.

In advertising, the effective frequency is the number of times a person must be exposed to an advertising message before a response is made and before exposure is considered wasteful.

https://en.wikipedia.org/wiki/Effective_frequency


Probably because that’s in accurate and reductionist:

> While children appear to be largely spared the direct mortality impacts of COVID-19, the indirect effects stemming from strained health systems and disruptions to life-saving health services such as immunization and antenatal care, can result in devastating increases in child deaths. The pandemic threatens to reverse decades of progress made around the world toward eliminating preventable child deaths. According to a study covering 118 low- and middle-income countries by the Johns Hopkins Bloomberg School of Public Health, an additional 2 million under-five deaths could occur in just twelve months due to reductions in routine health service coverage levels and an increase in child wasting.

Children are suffering because of strained healthcare systems, which isn’t because of their city being locked down. Reduction in routine healthcare could be caused by lockdown but it’s just as likely that parents are choosing to put off care out of fear (as a personal choice, not mandated) or because they can’t get it because the place they would go to is too busy because of Covid patients.


You cherry-picked an exception and ignored the common case. Consider these ones instead:

> families lose their sources of income due to COVID-19

> Approximately 150 million additional children are living in multidimensional poverty – without access to education, health care, housing, nutrition, sanitation or water – due to the COVID-19 pandemic

> At least a third of the world’s schoolchildren – 463 million children globally – were unable to access remote learning when COVID-19 shuttered their schools.

> COVID-19 is increasing global poverty and the nutritional status of the poorest people will deteriorate further.

> COVID-19 is disrupting women’s access to nutrition services.

> violence prevention and response services have been disrupted due to COVID-19.


If a road accident victim dies due to not getting ICU because all are full, one could say he died of secondary causes of covid. No Covid and he'd have survived.

But those aren't the kinds of things I'm talking about. I'm talking about things that only happen because we locked down, and that wouldn't have happened had we let the virus run completely unchecked.

I really feel that at some point in the future, we're going to look back on lockdowns with a highly critical eye, and the people who were most vocal about supporting said lockdowns will be coming up with excuses as to why they supported them in the first place.

I supported contact tracing, testing, and forced quarantines, as well as strict lockdowns to reduce cases to the point where contact tracing and quarantines were feasible. That strategy seems to have worked in much of the Asia-Pacific, successfully returning society to normal.

What I absolutely oppose is half-hearted “flatten the curve” lockdowns which prolong the pandemic over a long period of time while putting stifling restrictions on people. It’s the worst of both worlds, and simply letting the virus run wild would be preferable.

I’m fairly confident that an analysis of population-wide QALYs will back up my view.


Excuses like “protectng human life in the face of uncertainty” seem valid. History should look back more fondly on someone who tried to save lives in the face of unknowns rather than gamble them.

Not to mention there is a gray are. You be a supporter of lockdowns but also believe the government did not sufficiently protect people/businesses.

This is a multi-faceted issue, not a binary one.


I'd like to take a minute and add an important factoid that both sides should know.

Humans are REALLY bad at responding to "highly unlikely" risk.

With the corona virus, there is a really small chance (~2% depending on factors) that you die after catching the disease. Some people look at this and say "well, I probably won't even get enough viral load to get sick". There are sone people say "wait, I might survive, but then spread it to someone else, with X% probability - and EACH OF THEM might die".

Both groups are EQUALLY INCAPABLE of properly assessing the likelihood of living a healthy life or dying (or something in the middle). BOTH GROUPS are responding out of "gut feelings" and emotion and VERY LITTLE LOGIC.

I say this not to condem you - in fact I have been in both parties. I say this so that we can find common ground and MEET TOGETHER and acknowledge that is IS HARD, and we should try to work TOGETHER AND NOT DIVID.


I think this was a valid mindset last March when we had little trusted data, limited mitigation strategies, few treatments, and no vaccines.

A year later, to have all those things and follow the same policies implies we either a) nailed it from the start or b) are not applying what we've learned. One of those is unlikely and the other unacceptable.


> I think this was a valid mindset last March when we had little trusted data

Ordinary people had little trusted data.

Experts had data from cruise ships showing a low infection fatality rate [1], data from the first quarantined cities in Italy showing 60% of asymptomaticity[2], data showing that the average Covid victim is 80 years old and has three comorbidities[3].

[1] https://www.nature.com/articles/d41586-020-00885-w [2] https://www.repubblica.it/salute/medicina-e-ricerca/2020/03/... [3] https://www.bloomberg.com/news/articles/2020-03-18/99-of-tho...


>data from the first quarantined cities in Italy showing 60% of asymptomaticity[2]

Asympomaticity or pre-symptomacity?

>Experts had data from cruise ships showing a low infection fatality rate [1], data from the first quarantined cities in Italy showing 60% of asymptomaticity[2], data showing that the average Covid victim is 80 years old and has three comorbidities[3].

Yet Italy had crowded ICUs and Sweden had to beg neighboring countries to take some ICU patients from them. It'd have been all much much worse without lockdown. Your CFR assumes good critical care.


I’m not sure the US has been applying what we’ve learned, if we’ve learned anything at all. There’s no follow through on restrictions, people have been travelling and partying, etc... Hospitals are still overwhelmed in some cities, health care workers are tired and over-worked, etc... There isn’t enough political capital to end the pandemic or to provide meaningful economic support, so we’re left picking up the pieces of both at the same time.

> Excuses like “protectng human life in the face of uncertainty” seem valid.

Terrorism was the excuse last time, and we were told to support the troops. Now it's a viral infection, and we are told to follow the science.

This should not ever be a valid excuse, especially since one doesn't have to be that old to remember the last time these sorts of excuses were made - to justify the West's horrific and brutal Middle East occupations. We knew better, and in the face of those facts this excuse is either made out of ignorance, or to cover up for remarkable amounts of incompetence. Neither should be acceptable justifications to the citizens of those countries who hide behind that excuse.

> Not to mention there is a gray are. You be a supporter of lockdowns but also believe the government did not sufficiently protect people/businesses.

Under what circumstances would a government be able to lock their people down and shutter their businesses, while also sufficiently protecting those people and those businesses? Which governments would have the resources to actually achieve success using these strategies?

Governments have a responsibility to operate within their own laws and any country whose legal code allows for the government to overreach into the movement of individual people as they have over the past year, are at grave risk of morphing into the sorts of evil regimes we haven't had to deal with since the end of the second world war.

EDIT: Programmers should have better social intelligence than this. Most people in this world do not want to live like programmers, locked up in a room looking at screens all day, transporting bits of electricity from one place to another. In fact, I would reckon many would rather die than live like we do. If people want to live this way freely and of their own choosing, fine - but to impose this on others as the only answer to a multi-faceted issue is just cruel to the broader public.


I get the sense that time is now that reasonable, logical people have realized we screwed up with the overreaction. Back in late March people were already questioning the lockdowns once the unemployment numbers started rolling in. Every day since, we've just been piling up the data that suggests the reaction to covid-19 has been worse than the virus itself.

Destroying a generation of kids is going to have significant long term effects over the next 50+ years.


There is a very unlucky band of kids that've been irreparably screwed over by teachers looking to completely abandon any pretense they're essential to society or have any responsibility to work, liberals looking to avenge Trump and otherwise anti-science, monomaniacal anxiety-ridden adults. It's heartbreaking.

If this round is any judge, it'll be about a century, and we can do it all over again!

dibs on not being the guy doing laps of my garden.


Living in Melbourne, Australia, where we went through some pretty brutal lockdowns, I think they’ll be viewed very positively. Life here is pretty normal now (I’m going to a concert with thousands of people this week), and there’s no vaccine resistant “Australian strain”. To me, these are good results from proactive lockdowns.

> Life here is pretty normal now

Except for last week where you were under your third lockdown? I work with people from Melbourne and I feel like a lot of them suffer from at least some mild PTSD. This was re-ignited when the 3rd lockdown was announced with worries that it would last months again (luckily this was not the case!). The mental health aspect/general population wellbeing seems to be largely ignored in Victoria.

> I’m going to a concert with thousands of people this week

Unless there's another leak and you go back into a snap lockdown. There's always uncertainty under such a system! Again, not great for mental health. (and yes, you can argue that there's always uncertainty under a pandemic, but the levels of uncertainty differ between geographies)

I am sure a lot of work from home office people without kids will view these lockdowns rather positively. But I doubt business owners, hospitality workers and artists will appreciate them as much.

The article makes some good points and we really need to look at the wider issues around the disease and its countermeasures.


Sure! Everyone was freaking out on Friday. But then it actually only lasted five days and the state government is taking steps to reduce risks of outbreak from hotel quarantine.

I agree lockdowns are awful. But what if we didn’t do the snap lockdown last week? I don’t think that would be better.

I also disagree with your statement about mental health not being taken seriously. I think it’s difficult to talk about, but I believe mental health resources have been made broadly available. I’m not really sure how much more seriously it can be taken without making mental health checks mandatory.


> the state government is taking steps to reduce risks of outbreak from hotel quarantine.

Stopping the system entirely is certainly a way to reduce the risk ;)

> I also disagree with your statement about mental health not being taken seriously. I think it’s difficult to talk about, but I believe mental health resources have been made broadly available. I’m not really sure how much more seriously it can be taken without making mental health checks mandatory.

I was mostly thinking of the way the pandemic has been handled in general by the Victorian government. Locking people inside for 22-23 hours a day, curfew, etc. There is very little if no scientific evidence that these drastic measures, which severely impact mental health, have a measurable effect on getting numbers down. Not all lockdowns are the same, NSW's North Beaches lockdown allowed people to picnic outside for example (and made gathering exemptions on Christmas day). This again points to the benefit-risk evaluation mentioned in the article.

Similarly, banning Victorians out in regional NSW from returning home: forcing them to make a dangerous dash across half of the country to get back within the day. Again this could have been handled with a much stronger emphasis on benefit-risk but instead the wellbeing of Victorians was disregarded.


Meanwhile, I have now lived through two multi-months complete lockdowns, have been under a curfew since the beginning of October which prevents me from being out after 6pm and there now is rumors of a third lockdown with no end in sight. Initially I thought we were doing this so our government got time to organize a trace and isolate strategy and then that we were waiting for a vaccine but apparently a year wasn't enough for them to properly put something in place and the vaccination strategy is nothing but a sad joke so I'm starting to seriously wonder why we are accepting this.

I’m sorry to hear that, that sounds very rough.

It sounds to me like an ineffective broader strategy by your government. I definitely wouldn’t be voting for those people again, and maybe legal action around their incompetence could be an option. I think the examples set by Australia, New Zealand, Taiwan, China, Singapore, Vietnam, and South Korea show that effective responses are possible. Lockdowns were an important part of these responses, but of course a lockdown by itself will not solve the pandemic.


I actually mostly agree. I don't even know why I'm grumbling like that. I guess it's juste getting long and I somewhat despair at the obvious ineptitude of my government (but to be entierely fair they had already been shown to be extremely incompetent before the pandemic).

Tangentially, my personal takeaway from the situation is that Europe is doomed. The combination of an ageing population, young voters absenteeism and political clientelism means that policies are now strictly geared towards pensioners. I fear a victory of the far right at the next election in France and fully expect a severe brain drain once the crisis is over.

> I think the examples set by Australia, New Zealand, Taiwan, China, Singapore, Vietnam, and South Korea show that effective responses are possible.

If we remove China whose statistics are dubious, I find it remarkable that apart from Vietnam, all these countries are islands or can be considered as such with regards to immigration.


How is Australia evidence that lockdowns work when every country in the world had them, and almost all of them worked out much worse than Australia?

I think countries like Australia, New Zealand, China, Taiwan, Singapore, Vietnam, and South Korea show that lockdowns can be very effective at stopping spread. However, I think countries like Germany are currently showing us that just because it’s called a lockdown, doesn’t mean it’s effective. See also, California ending lockdowns while still having a high positivity rate.

Because Australia (and Wuhan) had strict lockdowns and finees whereas other countries had barely any enforcement or punishments.

Also

‘What’s the Point?’ Young People’s Despair Deepens as Covid-19 Crisis Drags On

Experts paint a grim picture of the struggle with lockdown isolation — a “mental health pandemic” that should be treated as seriously as containing the coronavirus.

https://www.nytimes.com/2021/02/14/world/europe/youth-mental...


Could we have done this before we destroyed a significant percentage of small businesses with lockdowns?

And what's the mortality rate for otherwise healthy people? Greater than 99.9%?


The infection fatality rate overall in the US is around 0.65%, meaning a 99.35% survival rate. For ages below 50, the survival rate is ~99.99% (https://www.nbc26.com/news/coronavirus/cdc-estimates-covid-1...). And it seems that controllable personal lifestyle choices like maintaining a balanced diet and getting outside may have played a role as well since Vitamin D deficiency increases chance for fatality from COVID-19 by 3.7x (https://www.medscape.com/viewarticle/942497).

I do think there is an injustice in draconian coronavirus measures because this is a low risk event ultimately. So by making everyone change their entire lives, we are making it so everyone gives something up so that those with a higher (but still low) risk can continue to go outside and partake in business, leisure, etcetera to a limited extent. This was the alternative to instead having just the risk averse or vulnerable quarantine themselves if they feel the odds are not agreeable (they could just self isolate and face nearly no risk). Put another way, lockdown measures and other mandates or restrictions trade the freedoms, leisures, financials, mental health, and stability of the young, healthy, and personally responsible to reduce the risk exposure of other people to an amount where the other people can live a slightly more normal life than otherwise.

When I see children losing a year of socialization and education so that a small proportion of the very elderly can live slightly longer, I feel like we are making a disastrous tradeoff.


Yea you've got the intelligent and right response imo. Politics, anxiety and tribalism obscured the obvious picture you've laid out.

Upvoted and adding relative story from a week ago

It's middle of winter in Europe, old jacket got broken and you can't buy winter jacket because the non-essential shop are closed....


Nothing like a good crisis for the political-bureaucratic class to usurp power without debate on drawbacks and second order effects.

Note government bureaucrats and politicians continued to collect a steady paycheck. Small businesses, RIP.


The still unspeakable one is it may turn out that the public’s widespread belief that cloth or surgical masks are protective may, on net, have led many to use them in situations where they would have otherwise simply have stayed home. Given the increasing evidence that a single, loosely fitting, or non-medical grade mask provided less than perfect protection, it could turn out a message like “stay home unless you had a N95 or kn95” may have been much better. (Along with a federal manhattan project to make and distribute these to as many as possible.) Given the literal lies we were told early on that masks were not effective at all, due to concerns about PPE supply, I worry that those same concerns may have led to messaging on mask that downplayed the difference between good PPE and non n95 masks. The second order consequences of this seem possibly quite bad.

Long overdue. Should have been started last April, after the initial "flatten the curve" had been achieved.

Restrictions were rolled back in April, at least in much of the US. Not fully, but we have had a lot more variation that people complaining that it's a lockdown would have you think.

Eventually we will probably be able to make some comparisons, what happened in Florida vs say, Los Angeles, and so on.


I wonder if discussion of this article will get banned on Twitter.

Hell hath no fury like a bureaucrat scorned.

For all the calling for "follow the science", I don't see much scientific behavior in how the crisis is handled. I see lots of politics instead.

For example, Dr Fauci says we won't achieve herd immunity before fall. But he also says vaccinated people should keep wearing masks, because they could still get infected and be infections.

But that would mean herd immunity is impossible. Herd immunity totally relies on vaccinated people not being infectious.

For another, Congressmen are outraged that some rich people are buying vaccines at $10,000 a dose. But Congressmen moved to the front of the line in December to get vaccinated, including the young & healthy ones.

Politics.


> But he also says vaccinated people should keep wearing masks, because they could still get infected and be infections.

I wonder if, like when he "pushed" the numbers for the herd immunity threshold higher to push people to vaccinate he's deliberately omitting the data coming from Israel, which says that a full vaccination reduces the transmission of the virus and even prevents infection.

This is what irks me of the current public health policies worldwide. Every "good" news must be buried under a pile of terrorizing, negative news, because those in charge foolishly believe that hope for an improved situation might lower compliance with non pharmaceutical interventions.

In the end, they're either covering up for their failures (botched EU vaccine rollout) or just going to increase vaccine hesitancy (why bother, when everything stays the same?).


We need people to keep wearing masks until there is herd immunity for the simple facts that a) you can't tell who is vaccinated or not by sight, and b) social pressure to wear them in public will collapse if X% of people stop wearing them.

That argument is political, not scientific. Exactly my point :-)

I don’t think behavioral psychology counts as politics.

It doesn't really count as science either.

Politics is behavioral psychology.

Coronavirus policy has really helped me understand David Hume's point that you cannot derive and "ought" from an "is".

You can't follow the science on something as complex as pandemics and lockdowns. There are too many tradeoffs that people will weigh differently.


What they forgot is that pressure to get the vaccine has collapsed because the average person thinks there is no point. Public policy has to be smart.

> pressure to get the vaccine has collapsed

Uh, no it hasn't. We don't have vaccines laying around going bad with nobody who wants them, but we do have plenty of people who want the vaccine who can't get it.


Look at the surveys. Is that percentage high enough to achieve herd immunity?

As long as we are constrained by vaccine supplies, it is rational to prioritize mask compliance rather than vaccine uptake.

I would rather have policy push for interventions that have a better impact on transmission. While the latest ECDC report[1] says "use them, can't hurt", it acknowledges the lack of evidence of masks (and thus effectiveness) in preventing transmission in a community settings.

[1] https://www.ecdc.europa.eu/sites/default/files/documents/cov...


It's likely a matter of weeks at this point, the messaging on masking shouldn't be undermining messaging on vaccination when that is the case. Maybe 60 million doses shipping in March vs a total of 75 million from the start through today.

(Pfizer believes production rate will about double over the next couple of weeks, Moderna has been steadily increasing, J&J likely to get approved).


60 million doses is only enough to vaccinate 10% of the American population. Vaccines likely won’t be available for every adult who wants one until well into May.

Sure, I was pointing to the velocity increasing there more than thinking it was enough for everybody. Is the idea that if we have a couple months until wide availability we should have mask focused messaging for half the period regardless of how it impacts vaccination? Because in my mind, shots in arms are a lot more valuable than marginal mask behavior (which is already not that good because people have decided it's a serious infringement on their freedom).

>> 'Herd immunity totally relies on vaccinated people not being infectious.'

That's not accurate. Herd immunity only requires a vaccine reduce transmission rate sufficiently that R0 < 1. It doesn't require that R0 = 0.

If the R0 for a vaccinated person = X, such that 0 < X < 1, wearing a mask likely puts it < X. Which is a desirable characteristic.


Not knowing the transmission rate means one can not make any predictions of herd immunity.

To be clear, it requires R < 1, not R0 (which is the initial rate of spread). More importantly though, we don’t really need herd immunity - once everyone has had a chance to get vaccinated, the virus ceases to be an issue, as contracting covid is no different from contracting the cold or at worst the flu.

>For example, Dr Fauci says we won't achieve herd immunity before fall. But he also says vaccinated people should keep wearing masks, because they could still get infected and be infections.

An effective vaccine can mean 1, 2 or 3 different things. The first is that you don't get infected, the second is that if you do get infected that your disease course is mild, the 3rd is that you don't transmit it if you are infected.


If the vaccine just protects you and doesn't keep you from infecting others, then why are perfectly healthy 23-year-old healthcare workers getting it while there's still so many people over 65 waiting for it? And if it does keep you from infecting others, then why do you need to keep following the mask and social distancing rules even after you get it?

The answer is that we don't know. We think it works but we don't know for sure, only time will tell.

We need to get to this point:

(number of people vaccinated) * (vaccine effectiveness) > (herd immunity threshold)

At this point, the R0 drops below 1 and the pandemic dies out by itself.

However, if everyone keeps wearing masks, it looks more like this:

(number of people vaccinated) * (vaccine effectiveness) + (mask effectiveness) * (number of people vaccinated) * (1 - vaccine effectiveness) > 1

This makes it easier to get R0 below 1 with fewer societal restrictions. Given that it's trivial for most people to wear masks, this seems like an obvious choice.


Why isn’t the answer just “those who are afraid of the virus can stay inside indefinitely” and no one else has to wear masks if they don’t want to? I don’t think it is “trivial” to wear masks - it makes breathing harder, it affects mental health (by not seeing people’s emotions), it makes communication harder for those with certain disabilities, and it makes every activity less enjoyable. After all if we really think there is no negative impact from wearing masks why not permanently require it all the time including at home?

So then this comes down to a fuzzy tradeoff, which seems more like a values or politics based determination than a mathematical or scientific one.


Most vaccines are less than 100% effective at preventing infections. Vaccinate 10,000 people and intentionally expose them to the thing vaccinated against and you will get some infections.

When there are significant numbers of infected people in the population, adding other measures to the protection provided by vaccines decreases the spread of the infection.

I think the problem Fauci has is that he is confident that it is better to provide an answer than to hedge. It would be pretty reasonable for him to say something about getting vaccinations done as quickly as possible and evaluating what other measures are necessary once a larger percentage of the population is vaccinated.


We self-isolated just as hard as anyone from March - May. I was looking at my Amazon orders and I'm coming up next week on the 1 year anniversary of when I bought a pair of pulse oximeters as a diagnostic early warning measure.

In the summer, we started slowly going out more and doing things with people more. At this point, I think the country just needs to get on with life.

Everyone around here knows a dozen or two people who have had it, and a handful of elderly people who died from it. It's a tragedy, but so is their treatment this past year. My Grandma is 98 and has gone downhill so significantly this past year from lack of interaction. At least now she's allowed to talk with the other residents of the nursing home. She spent six months locked in her room. And they all caught coronavirus anyway last fall.

It's been clear since late Spring of last year that politics was driving the lockdowns far more than any real hard science.


It was obvious when Cuomo was doing a victory lap book tour during the summer declaring that masks work and he figured out how to fix things, only for infections to pick up again when the season changed.

I expect it'll be obvious in retrospect that human interventions had much less effect than thought, and the largest factors were a mix of demographics like obesity and nutrition, as well as geography (which influences sun exposure, humidity, etc.).




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