A differentiated, responsibilities-based approach to living with the Covid-19 pandemic

Rosa Graham Thomas – in UK lockdown

The United Kingdom has among the worst COVID-19 infection and death rates in the world (see Financial Times, 28th May 2020).  This is in part because of very serious errors of judgement made by the UK Government (see my list of questions to which they must answer, 27th April 2020), but it is also a result of the behaviour of substantial numbers of UK citizens during “lockdown” who, for whatever, chose not to self-isolate  (including the Prime Minister’s Senior Advisor, Dominic Cummings).  The UK government at the end of May also made another serious error of judgement, relaxing the restrictions, even for those who had previously been told to shield themselves, when  daily numbers of new infections and deaths were very much higher than they were when other countries had begun to “open up” (BBC, 31st May 2020).  This is despite the advice of many senior scientists who said that it was too early to relax the restrictions (BBC, 30th May 2020).  Estimates by the Office for National Statistics (28th May 2020) suggested that there were then at least 8000 new cases a day in England, excluding those in care homes or hospitals.  The daily average number of deaths from COVID-19 in the UK to the week ending 31st May was 242 (gov.uk, 31st May 2020).

Countries cannot stay locked down for ever, though, and it is essential for people to go back to work; indeed, it may well be that a vaccine or cure for COVID-19 will not be found in the short term, and societies may have to learn to live with this coronavirus for the foreseeable future.  Difficult decisions will therefore need to be made about how to manage daily life and reduce the number of deaths caused by SARS-Cov-2.  These decisions will need to vary depending on the specific contexts of each country, including its demographics (see my post of 7th May 2020) and environmental factors (see my post of 3rd May 2020).  In the UK, the government has used fairly crude measures, trying to ensure that large numbers of people stayed at home (even though most of them would not be seriously ill if they caught COVID-19), rather than varying the strategy according to risk.  Most actions and discussions have also adopted a human rights based approach to considering how decisions should be made (see for example Morley et al.’s paper on the ethics of tracing apps, or Lord Sumpton’s discussion of why lockdown is despotic).  Instead, I suggest here that we need to adopt highly differentiated strategies, based on our responsibilities (or obligations, as Onora O’Neill suggests in her 2016 book Justice Across Boundaries).

Differentiated risks of COVID-19

There is increasingly sophisticated analysis in various parts of the world to suggest that different groups of people have substantially different risk factors.  While anyone can die from COVID-19, the following generalisations about who is most likely to die seem to have widespread support:

• Older people are more at risk of having serious complications or dying from COVID-19.  Public Health England (PHE) in their early June 2020 report on disparities in the risk and outcomes of COVID-19, showed that “Among people with a positive test, when compared with those under 40, those who were 80 or older were seventy times more likely to die”.   Dowd et al. (2020) likewise show that “Currently, COVID-19 mortality risk is highly concentrated at older ages, particularly those aged 80+”.  Case Fatality Rates (CFRs) generally increase significantly with age, especially for those over 60; in Italy 96.9% of deaths by the end of March were for those over 60 (Istituto Superiore di Sanità, 2020).  In South Africa 80% of the COVID-19 deaths reported by 2nd May were for people over 50, with a quarter of deaths being in the 60-69 age group.  There is, though, still uncertainty as to whether there is something specific about age itself, or whether these figures are because older people are more likely to have other comorbidities.  It is also interesting to note that the UK’s Office of National Statistics (ONS) Infection Survey pilot suggested that the highest percentage of those testing positive in the UK between 26th April and 24th May were in the 20-49 year age group.
• Men are more vulnerable than women.  This may well be because women have two X chromosomes (The Guardian, 7th June 2020), although there remains some dispute about the influence of gender on infection and mortality.  The PHE report cited above shows that in England “Working age males diagnosed with COVID-19 were twice as likely to die as females”.  Most surveys seem to suggest that men are more at risk than women, but the ONS survey of those testing positive interestingly indicated that “there is no evidence of differences in the proportions of men or women testing positive for COVID-19”.
• People with comorbidities are much more likely to be seriously ill or die from COVID-19 than are those who are otherwise healthy.  Data for March reported by the US CDC indicates that almost 90% of all patients hospitalised that month had one or more underlying conditions, with 49.7% having hypertension, 48.3% being obese, 34.6% having chronic lung disease,  28.3% having Type 2 diabetes, and 27.8% having cardiovascular disease.  These five health problems are associated with higher death rates in most places where the data have been studied, although precise percentages vary quite considerably between populations (for a review of underlying metabolic health see Lancet, 2020; for a useful South African perspective, see Cullinan, 2020).  The UK authorities have defined clinically vulnerable people as follows:
  • “aged 70 or older (regardless of medical conditions)
  • under 70 with an underlying health condition listed below (that is, anyone instructed to get a flu jab as an adult each year on medical grounds):
    • chronic (long-term) mild to moderate respiratory diseases, such asasthma,chronic obstructive pulmonary disease (COPD), emphysema orbronchitis○chronic heart disease, such asheart failure
    • chronic kidney disease
    • chronic liver disease, such ashepatitis○chronic neurological conditions, such asParkinson’s disease,motor neurone disease,multiple sclerosis (MS), or cerebral palsy
    • diabetes
    • a weakened immune system as the result of conditions such as HIV and AIDS, or medicines such as steroid tablets
    • being seriously overweight (a body mass index (BMI) of 40 or above)
    • pregnant women
  • As above, there is a further category of people with serious underlying health conditions who are clinically extremely vulnerable, meaning they are at very high risk of severe illness from coronavirus”
• Ethnicity does appear to have an effect on the seriousness of health impacts of COVID-19, even taking other factors into consideration, but the precise reasons for this are not yet known.  In the UK, more people from Black, Asian and Minority Ethnic (BAME) backgrounds have been seriously ill or died from COVID-19 than have people of white ethnicity, but this could be partly explained by deprivation, cultural factors (such as religious and family interactions), and comorbidities (such as obesity, hypertension and diabetes).  England’s PHE report concludes that “An analysis of survival among confirmed COVID-19 cases and using more detailed ethnic groups, shows that after accounting for the effect of sex, age, deprivation and region, people of Bangladeshi ethnicity had around twice the risk of death than people of White British ethnicity. People of Chinese, Indian, Pakistani, Other Asian, Caribbean and Other Black ethnicity had between 10 and 50% higher risk of death when compared to White British”.  More recently, the ISARIC CCP-UK study has shown convincingly that: (i) “Ethnic Minorities in hospital with COVID-19 were more likely to be admitted to critical care and receive IMV than Whites”, and (ii) “South Asians are at greater risk of dying, due at least in part to a higher prevalence of pre-existing diabetes” (see Harrison and Docherty, 17th June 2020).  Insufficient detailed studies have yet been undertaken in other parts of the world, particularly in Africa and Asia, to see whether ethnicity is indeed also a risk factor there.
• The risk of being infected is higher indoors than out of doors.  This is mainly because there is generally more air movement to disperse SARS-Cov-2 outdoors (although air conditioning systems indoors do spread it in the direction blown by a fan), and people are usually in closer juxtaposition for longer indoors than outside.  It is also easier to maintain sufficient distance between people outdoors than indoors (see inews, 11th May 2020).  However, there is still some uncertainty about this.  Thus, the UK ONS survey claimed in late May 2020 that “Individuals working outside the home show higher rates of positive tests than those who work from home”.  This is, though, probably because those self-isolating and working at home simply don’t come into as much contact with potentially infectious people outside the home.

Much of the research on which these conclusions are drawn is based on early evidence from China, as well as more recent evidence from Europe and the USA where the infection and death rates have been so high.  A particularly interesting issue is therefore whether these generalisations may also apply in other parts of the world, and especially in countries in Africa and South Asia which have yet to experience very serious rates of infection (see my previous post on On ageing populations, “development” and Covid-19).  It may well be that their governments could learn from the mistakes made in the UK and the USA and develop a more nuanced approach as outlined below.

A differentiated risk- and responsibilities-based approach to managing COVID-19

This post makes two core suggestions: states need to adopt nuanced and differentiated responses to living with COVID-19 in the foreseeable future, and that human rights considerations should be balanced by a responsibilities agenda.

A differentiated risk-based approach to COVID-19

Most governments have adopted stringent lockdown policies in response to COVID-19 that have been applied to everyone, regardless of their health risks.  This has caused considerable damage to their economies, as well as other serious health issues.  Many deaths resulting from the existence of COVID-19 are thus not actually being caused by the SARS-COV-2 coronavirus.  Numerous businesses are failing, and fit elderly people have complained vociferously about not being permitted to partake fully in “normal” society.

Now that more is known about the health risks of COVID-19, it makes considerable sense to develop context specific solutions that take into accont the risk factors noted above.  Governments must first ensure that they have an adequate and robust health service capable of dealing with the number of people who are likely to get infected, but wasteful fiascos such as the construction of new Nightingale Hospitals in the UK that were never really needed, or the numerous projects across the world to create novel designs for new venitlators for which not enough nursing staff are available (and when many people on ventilators actually die), must not be repeated.  The hospital services in some countries will come near to being overwhelmed (as in Italy), or may indeed collapse (see recent reports from Brazil, India and Pakistan which seem near this point).  However, even where countries are unable to manage the health requirements of the majority of people affected, it is still vital that what services are available are used to treat those most in need and most likely to survive treatment.  Is is also crucial that a responsibilities approach is inculcated and adopted at all scales from the state to the individual if the impact of the pandemic is to be mitigated.

It would thus seem wise to introduce comprehensive risk-based schemes through which everyone can evaluate their likelihood of being seriously ill from COVID-19 and their risk of infecting other vulnerable people, so that they can take appropriate actions to reduce such risk.  At present, and as noted above, the key risk factors seem to be:

• age,
• gender,
• comorbidities,
• ethnicity, and
• location

Put simply, and based largely on European and North American evidence, elderly men with comorbidities from BAME backgrounds spending all their time indoors would seem to be most at risk, and we should all do what we can to help protect them.  Young, fit, active white women spending most of their time outdoors would seem to be least at risk.

This has implications for work, transport, and social life, and carefully nuanced schemes should be introduced to enable as many people as possible to live the lives that they wish to.  For example, where resources are constrained, working-at-home policies could first be made available to the most at risk, encouraging those least at risk to stay at work, or indeed to return to work as previously.  Tourism, travel and entertainment is much less risky for the fit and young, so they should be allowed to take those risks if they want to, while alternative arrangements are put in place for the most vunerably elderly Bangladeshi men (such as support for online tourism or special take-away meals for celebratory occasions).

Responsibilities- rather than rights-based approaches

For too long, rights-based approaches have dominated global and national policies, and insufficient attention has been paid to the responsibilities that are essential to ensure the extstence of well-functioning societies  (see my Prolegomena on Human Rights and Responsibilities).  All too often when a “right” is claimed, it is uncertain who has the “responsibility” to deliver it.  Many, for example, have commented on the human rights aspects of COVID-19 (see Human Rights Watch, 19th March 2020; Bonavero Institute of Human Rights, 6th May 2020; The Guardian, 29th April 2020) , but rather fewer on the human responsibilities dimension.

This is particularly reflected in the tension between individual privacy rights and communal responsibilities in terms of the imposition and use of tracking apps to identify COVID-19 contacts (Human Rights Watch, 13th May 2020; Privacy International, no date; Morley et al., 2020).  However, it also lies at the heart of discussions about wearing masks: all to often such usage is criticised for not really protecting the individual, which completely misses the point that their main use is to protect the community from infected individuals.  People thus have a responsibility to wear masks so that if they are asymptomatic their chances of infecting many others are reduced (see my Face masks and Covid-19: communal not individual relevance).

Two main implications of a shift to a more responsibilities-based approach are important:

• The first is that governments have a fundamental responsibility to care for their most vulnerable and at risk citizens.  The shocking way in which the UK government placed its focus on “saving the NHS” above “saving vulnerable people” is an all-too-visible example of a failure to adhere to such a principle.  It was a serious injustice for UK policy to have sent elderly people with COVID-19 back into care homes and the community from hospital, as a result of which many of them died, many others were infected, and many more certainly died sooner than they would otherwise have done.  This principle, though, is also of crucial importance in countries where the health services have difficulty, or will have difficulties in the future, in coping with the COVID-19 crisis.  It is absolutely the responsibility of governments to recognise that many low-risk people will survive COVID-19 with little or no lasting health implications, and that they should be allowed to continue if they wish to in the productive economy.  However, at the same time, governments must put in measures whereby those at risk are protected, and given the wherewithall to sustain themselves.
• The second, and closely related principle is that individuals also have fundamentally important responsibilities to others.  Some positive evidence of communal responsibility and action has been visible in countries across the world during COVID-19, but support for at-risk people has been less than many had hoped for or expected.  Moreover, there have also been substantial numbers of explicitly negative communal actions: digital-attacks on health care organisations have proliferated during the pandemic, and doctors and nurses have been victimised for spreading the coronavirus in countries as diverse as Mexico and Pakistan.  Almost always, the emphasis has been on the rights of the individual (to enjoy the beach or to party) rather than on their responsibilites to others (to protect others from the actions of the self).  Put simply, all of us have responsibilities to protect everyone else from being infected, and to enable as many people as possible to continue to live active and fulfilled lives.

Is it too much to hope for that one of the results of COVID-19 may be the creation of societies where we shift the focus more to our responsibilities towards others than attention on ourselves?  In the short term, this would mean that we should all be:

• Thinking that we could be asymptomatic carriers of COVID-19, and take actions to prevent us from infecting others;
• Caring for and serving vulnerable neighbours who cannot benefit from the freedoms that we enjoy; and
• Taking action to self-isolate and get tested immediately we think we might be infected with COVID-19.

Whilst this is written primarily from the perspective of someone living in a country that is now coming out of lockdown, these principles apply globally, and if adopted in countries that have not yet encountered serious outbreaks of COVID-19 might help them escape some of the more serious impacts of economic shutdown.

Masai children learning in Tanzania

[Updated 19th June 2020]

 

On ageing populations, “development” and Covid-19

There is increasingly clear evidence that older people are more likely to die from Covid-19 than are younger people: on 17th February,  the China CDC weekly report showed that among the cases known in China by then, the ≥80 age group had the highest case fatality rate at 14.8% (with the 70-79 age group being 8% and the 60-69% age group being 3.6%); and in early April, the WHO Regional Director for Europe highlighted that over 95% of Covid-19 deaths occurred in those over 60, with more than 50% in those aged 80 years or older.  In the UK, the Office for National Statistics (ONS) reported in mid-April that mortality from Covid-19 increased consistently with age, with only about 13% of deaths being of people under 65.  Significantly, though it noted that men had a death rate double that of women; more recent ONS reports have also shown that (when taking into account age) Black men and women were more than four times as likely to die from Covid-19 then were those of White ethnicity, and that such differences in mortality were partly a result of socio-economic disadvantage.  These data are stark, and are as yet still not fully explained.  As people grow older, they generally have greater comorbidities, and it may be the impact that Covid-19 has on these other health problems that is more significant than age itself.

However, this is an important reminder that Covid-19 is primarily an old-people’s disease.  It is striking to recall that in 1951 life expectancy at birth in England and Wales was only 66.4 for men and 71.5 for women; in 1901 the figures were 48.5 and 52.4 respectively (ONS, 2015).  Put simply, people born 70 years ago were not expected to live to the age at which most people are now dying from Covid-19.  This has important ramifications, and raises very difficult questions.  Have people, perhaps, become over expectant about longevity?  Will Covid-19 temper our aspirations to live for ever?  Will it be a check on the ambitions of companies such as Novartis, Alphabet and Illumina to extend life well beyond 100 years (CNBC, 2019)?  Is the main problem of Covid-19 that most people living in the richer countires of the world have become too cosy in their expectations of living to a ripe old age?

Implications for Europe and north America: too many old people

Thought experiments can be a helpful means of highlighting challenging issues.  Suppose, for example, that there had been no lockdowns in Europe and North America.  It seems very likely that substantial numbers of elderly people would have died already (see projections by epidemiologists at Imperial College which suggested that without mitigation strategies Covid-19 would have resulted in 40 milllion deaths globally in 2020).  If a vaccine or cure is not found, then it still seems likely that large numbers of elderly people will indeed die in Europe at an age well short of what they and their families have grown accustomed to expecting.

However, think of the impact that this will have on the economy and health services.  Once large numbers of elderly people have died, national pension bills will fall, the burden on health services will be reduced, the percentage of people within the economically productive age range will increase, and the economic vitality of their countries will be revitalised.  If Covid-19 (or its successors) become an everyday part of life, the economic “burden” of older people will be dramatically reduced.  It is scarcely surprising that rumours  circulated about the intentions of UK government policy in early- to mid-March.  As Martin Shaw noted at the time, it had been credibly reported that the “Government’s strategy was ‘herd immunity, protect the economy and if that means that some pensioners die, too bad’; or as summed up even more succinctly by a senior Tory, ‘Herd immunity and let the old people die’”.  Whilst the government strenuosly denied this, there is a realistic logic to the idea that letting large numbers of old people die would have clear economic benefits, and would avoid the very considerable costs that are accruing as a result of economic shutdown.

I should stress that this is definitely not a scenario that I would want to encourage or endorse, but in the early part of May, the balance of popular opinion (or the influence of the business community and mainstream media in the UK) does seem to be swinging towards a view that the costs of lockdown are too high to continue to protect the elderly, especially in those countries where there have already been very high death rates (as in Belgium, the UK, France, Italy, Spain and the USA).  Yet, the 20th and latest Imperial College Covid-19 report  concludes for Italy that “even a 20% return to pre-lockdown mobility could lead to a resurgence in the number of deaths far greater than experienced in the current wave in several regions”.

Implications for Africa and South Asia: youthful countries

The real purpose of this reflection, though, is to consider the implications of the above arguments for some of the economically poorest countries in the world.  Data about Covid-19 infections and deaths in Africa and Asia are likely to be even less reliable than they are in Europe, and the countries in these continents are in any case much earlier in their encounters with Covid-19 than are those of Europe.  Recent reports, for example, suggest that the real number of deaths related to Covid-19 may be many times the number that are currently reported (see The Guardian‘s recent report on Somalia).  Nevertheless, we do have relatively accurate data about the demographic structures of most countries in the world.  The chart below therefore shows the relationships between current density of Covid-19 deaths and the percentage of population aged ≥65 for a sample of countries.[i]

This graph is striking, but difficut to interpret (and can be misleading), mainly because most countries in Africa and Latin America are only at an early stage in their Covid-19 outbreaks.  We simply do not know how many deaths they are likely to witness, and few models have yet been published that predict the likely outcomes.   However, with the very notable exceptions of Japan, Greece and Germany, it re-emphasises that high percentages of Covid-19 deaths are mainly found in those countries that have more than 15% of their populations aged ≥65.  Even Brazil, where the death rate is currently growing rapidly, is still nowhere near at the level of mortality that has occurred in Europe and the USA.  The quite remarkable achievement of Greece, with only 147 deaths by 7th May, is also highly noteworthy because despite a fragile health service and an elderly population it has managed to achieve something that most other European countries have been unable to do.  Most commentators suggest that this is mainly because it imposed a dramatic lockdown even before the first deaths were recorded.

Most countries of the world have intiated lockdowns, and these are having particularly significant impacts on the poorest and most marginalised who can least afford it. An obvious question therefore arises: if Covid-19 mainly affects the elderly, should countries with young populations (such as most of those of Africa, Asia and Latin America) follow the “older” countries in imposing strict lockdowns that will have damaging effects on their economies and the livelihoods of those who can least afford it?  Put another way, are the mitigating actions of European and North American countries, where more than 15% of their populations are ≥65, relevant to economically poorer countries with less than 10% of their populations in this age group?

It is far from easy to answer this.  Perhaps the very small numbers of people reportedly dying in Africa at present is only because the coronavirus has not yet gained a grip, and any loosening of the mitigating measures would unleash the pandemic at a scale similar to that seen in Europe.  The WHO, for example, has warned  that the Covid-19 pandemic might kill as many as 190,000 people in Africa in the year ahead (Al Jazeera, 8th May), with many more dying subsequently.  This may well be true, but there is at least a chance that the youthful populations of Africa will be better able to deal with Covid-19 than have done the older populations of Europe.  It must, though, be emphasised that many younger people who are infected with Covid-19 do indeed have serious illnesses, and some die.  We also do not yet know the long-term health impacts of this coronavirus.  Moreover, the evidence that socially disadvantaged people are also more likely to die than their more affluent neighbours further suggests that the poorest and most marginalised in these countries may well have higher death rates.

As I have illustrated elsewhere, there is some (but by no means conclusive) evidence that environmental factors may also play a role in limiting the spread of Covid-19.  If the environments of Africa and South Asia are indeed not particularly conducive to the spread of Covid-19, then their youthful populations might not need to endure the very tight lockdowns imposed in many European countries. That having been said, the rapidly increasing number of infections and deaths in Brazil (with 121,600 cases and 8,022 deaths as of 7th May), which has physical environments and climates similar to many parts of western and southern Africa, does not bode well for the future spread of Covid-19 in Africa.

Conclusions

In conclusion, there remains much that is unknown about how Covid-19 spreads and who it affects most damagingly.  The evidence from Japan, Greece and Germany shows that even when countries do have a high percentage of elderly people, it is still possible to contain and limit the spread of Covid-19, thereby preventing very large numbers of deaths.  The abject failures of governments in countries such as the UK and Belgium to manage the pandemic and save lives likewise indicate how not to respond to the pandemic.  The governments of African and South Asian countries, with their youthful populations who appear less likely to suffer severe symptoms, may well therefore have an advantage over their European counterparts.  If they can draw lessons about what has worked and what has failed, then they are also in a good position to bounce back swiftly from the economic harm caused by economic and social lockdowns.

 

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[i] The selected countries included the ten most populous countries in the world (in descending order of total population, China, India, USA, Indonesia, Pakistan, Brazil, Nigeria, Bangladesh, Russia, Mexico), a selection of European countries with mixed trajectories (listed alphabetically, Belgium, France, Germany, Greece, Italy, the Netherlands, Spain, Sweden, Switzerland), and a diverse sample of African (alphabetically, DRC, Egypt, Kenya, Rwanda, South Africa, Tanzania), and other (alphabetically, Iran, Japan, South Korea, Turkey) countries.

Short guides to literature on technology use in education: both the positives and the negatives…

Infant school in Cocody, Abidjan, Côte d’Ivoire

Far too many initiatives using technology in education fail to learn from the experiences of others as they seek to be innovative and novel.  Consequently, the same mistakes tend to be replicated over and over again.  Far too many researchers likewise fail to read but a fraction of the vast literature that has been published on technology and education, and bibliographies in PhD theses in the field are increasingly often only sketchy at best.

In 2017 and 2018 I had the privilege of being asked to write a report for UNICEF on how the organisation might respond to the future interface between technology and learning.  This involved reading hundreds of reports, interviewing numerous people, and drawing on my experiences across the world over the last quarter of a century.  It made me realise how little I know, and how much still needs to be done.

However, in order to help others on this journey of discovery and learning, I thought it might be helpful to share a shortened version of the footnotes (34 sides) and a short summary bibliography (10 sides) that I included in that report.  Many of the links to the original literature or examples are included (please let me know if any are broken so that I can try to update them!).  Not least, I hope that this might reduce the flow of questions I receive from people beginning to get interested in the field, either for research or because they have a great idea that they would like to introduce in practice on the ground – most of whom have never actually read much before asking me the question!  These are but starting points on a lifetime of learning and discovery, but I hope that people may find them useful.

• References and links for understanding the use of technology in education, especially in deprived contexts
• A short bibliography of important literature on ICTs and education

I have previously posted summaries of some of the content of my UNICEF report elsewhere on my Blog as follows:

• Why we don’t really know very much about the influence of ICTs on learning and education
• Interesting practices in the use of ICTs for education
• The dark side of using ICTs in education

I must stress that these are very much my own views, and in no way represent the opinions of UNICEF or those with whom I have previosuly worked.  They are offered here, though, to get us all to ask some of the difficult questions about ways through which some of the poorest and most marginalised can benefit from the use of technology in education, if indeed that will ever truly be possible (at least in a relative sense).