An interesting commentary in the BMJ global health by Meyerowitz-Katz and others looks at this issue.
During the pandemic, there has been ongoing and contentious debate around the impact of restrictive government measures to contain SARS-CoV-2 outbreaks, often termed lockdowns.
The authors define a lockdown as a highly restrictive set of non-pharmaceutical interventions against COVID-19, including either stay at home orders or interventions with an equivalent effect on movement in the population through restrictions of movement.
Whilst necessarily broad, this definition encompasses the strict interventions embraced by many nations during the pandemic, particularly those that have prevented individuals from venturing outside of their homes for most reasons.
The claims often include the idea that the benefits of lockdowns on infection control may be outweighed by the negative impacts on the economy, social structure, education and mental health.
A much stronger claim that has still persistently appeared in the media as well as peer reviewed research concerns only health effects: But there has been a large toll of deaths and disease attributable directly to Government action against COVID-19, a toll larger than that of COVID-19 itself. The tagline of this claim is that the cure is worse than the disease!
The authors consider the claim that lockdowns cause more harm health than
COVID-19 by examining their impacts on mortality, routine health services, global health programmes and suicide and mental health.
They examine the evidence regarding whether government interventions are to blame for negative health consequences, or whether the lethality and infectiousness of SARS-CoV-2 is as much or more of a driver behind adverse health impacts.
The grave harms from ineffectively mitigated epidemics have been clearly seen in places such as India and Brazil. Given the benefits from government intervention against COVID-19 – slowing spread and preventing COVID-19 deaths. The authors explore whether the harms of lockdowns are likely to exceed the harms of COVID-19, or if the health harm sometimes attributed to lockdowns may instead be explained directly by the pandemic itself.
Short Term Mortality
The world mortality data set is the largest international data set of all causes of mortality, including many countries that have imposed and not imposed restrictive measures against COVID-19.
This project has accumulated excess mortality data on 94 nations from the onset of the pandemic, with the most recent data being reported up until mid-2021. The project defines excess mortality as mortality greater than the anticipated model number of deaths given existing trends. Using this data set, the authors examined a range of locations that both have and have not imposed lockdowns in terms of their potential damage to population health.
Using these data, they saw that New Zealand and Australia, two countries that imposed severe lockdowns and heavy restrictions experienced no excess mortality during 2020.
Similarly, South Korea, Taiwan and Thailand had either no excess mortality or only very modest increases in mortality during lockdown periods when there were few or no COVID-19 cases.
Indeed, there are no locations in the dataset that experienced both excess mortality and lockdowns concurrently with low numbers of COVID-19 cases. This is what would have been expected if lockdowns were independently causing large numbers of short-term deaths.
Conversely, places with few COVID-19 restrictions such as Brazil, Sweden, Russia, or at times certain parts of the USA have had large numbers of excess deaths throughout this pandemic.
This pattern indicates that whilst there may be multifaceted impacts of intensive government restrictions, including social and economic costs, these are not apparent in short term increases of mortality.
In fact, the world mortality data set appears to show that countries with concerted COVID-19 restrictions have had fewer deaths than in previous years, with the authors estimating that lockdowns may reduce annual mortality by 3-6% from eliminating influenza transmission alone.
This finding is supported by data from Peru that shows that lockdowns are likely reduce deaths from common sources such as automobile accidents in the short term, resulting in a reduction in the immediate mortality when implemented.
The high excess mortality in countries with few restrictions, or less voluntary behaviour change may not be surprising given the high infectiousness and fatality rate of COVID-19.
For example, in Manaus Brazil COVID-19 spread was largely unmitigated and as of March 15th 2021, more than 10% of the entire population aged over 85 years had died of COVID-19.
Similarly, in the United States, where highly restrictive sets of non-pharmaceutical interventions were not imposed to contain the spread of SARS-CoV-2 in autumn and winter, COVID-19 became the leading cause of death several months in late 2020 and early 2021.
However, the excess mortality data does not refute the position that lockdowns have caused harm in some instances.
Comparing the UK and Sweden for example, it does not show a clear benefit of lockdowns in terms of excess mortality.
The UK imposed three national lockdowns yet both countries have had very severe impacts. It is impossible to determine from this evidence whether lockdowns have a net benefit, especially given the very high excess mortality in many nations that did pursue such strategies.
What is clear, however, is that locations that locked down without experiencing large epidemics of COVID-19 such as Australia and New Zealand did not have large numbers of excess deaths.
Disruptions to Health Services
Another common claim is that government interventions themselves are responsible for reduced access to and use of healthcare services, which in turn causes harm to health in the long term.
However, the available evidence to date does not reliably or consistently support this assertion. There is clearly an association between large outbreaks of COVID-19, government interventions and reductions in attendance for vital non-COVID health services. Thus the connection between lockdowns and missed contact with health systems is very well established.
However, this association may be related to lack of capacity of healthcare services or impacts of the pandemic itself rather than measures taken by governments to reduce cases. It may also simply be caused by the public perception of risk due to fear of the pandemic for example, people may fear becoming infected by SARS-CoV-2 in the healthcare setting and thus they stay at home rather than attend health services.
Suicide and Mental Health
In many parts of the world there are substantial lags in reporting of deaths from suicide due to the time it takes for coroners to determine the cause of death.
However, despite these lags, there is consistent and robust evidence from many countries that government interventions to control COVID-19 have not been associated with increased deaths from suicide.
Indeed, some evidence suggests that the number of deaths from suicide may have dropped in some age groups, particularly children, during the pandemic.
Whilst government intervention has not been associated with an increase in deaths from suicide, changes in other mental health conditions are a far more complex issue.
There is abundant evidence that mental health has declined in the population since the onset of the pandemic, which may provide evidence that lockdowns cause mental health problems.
However, research into this area is fraught with no limitations of confounders, meaning that it is extremely challenging to ascertain whether government intervention causes or is simply associated with mental health clients, perhaps both driven by the underlying factor of the pandemic itself.
Global Health Programmes
Surveys conducted by multilateral health agencies found that services for a variety of conditions – including HIV, tuberculosis and malaria were disrupted by the pandemic. For example, a survey by the Global Fund to Fight AIDS, Tuberculosis and Malaria found that 80% of HIV programmes and 75% of TB programmes reported disruption to service delivery.
By May 2020, childhood vaccination campaigns had been disrupted in 68 countries. However, these disruptions have been caused by multiple complex direct and indirect consequences of COVID-19, not just stay at home orders.
Lockdowns: Costs and Benefits
Public health ethicists and practitioners have long known that stringent control measures aimed at reducing disease mortality and morbidity will be accompanied by negative consequences in many sectors of the economy.
These harms are real, multifaceted and potentially long term, and are therefore important factors for policymakers to consider when choosing which intervention packages to implement.
However, this cost benefit view must also recognise harms caused by large and ongoing epidemics of COVID-19, and it is often extremely difficult to separate the potential impacts of lockdown from those of the pandemic itself.
Most crucially, many harms are not mutually independent; negative consequences arising from interventions are also present during generalised COVID-19 epidemics.
The reality is that whether knockdowns and other government interventions have a net benefit is a challenging question which requires evaluating social, economic and health aspects.
Furthermore, the question poses a false dichotomy.
Governments were not faced with the choice between the harms of lockdown and the harms of COVID-19, but rather sought to find the means to minimise the impact of both.
When looking at secondary health impacts in particular, often the most that it is possible to say is that there are harms associated with both large COVID-19 outbreaks and government interventions to prevent the disease.
It is also important to consider voluntary behaviour change, with evidence that some economic and social harms of the pandemic can plausibly be explained by individual responses to rising infection numbers.
The authors concluded that from the evidence to date, government interventions, even more restrictive ones such as stay at home orders are beneficial in some circumstances and unlikely to be causing harms more extreme than the pandemic itself.
However, the authors have not considered the evidence of vaccination and in particular, in countries such as Australia and New Zealand who locked down heavily but did not implement a vaccination programme.
The London General Practice, the leading London doctors’ clinic in Harley Street commends the Government on its vaccination programme and encourages all those eligible to be vaccinated.
Dr Paul Ettlinger
BM, DRCOG, FRCGP, FRIPH, DOccMed