A way forward: Considering the sustainability, equity and unintended effects of social control measures as a response to the <scp>COVID</scp>‐19 crisis

In Canada and many other countries public health leadership, healthcare professionals and political leaders have known for a long time that, even in the absence of a public health emergency like COVID-19, health care systems are unable to handle a sudden upsurge of patients. The evidence was clear: patients needed more channels for accessing healthcare services, not less.1-6 Yet, less access and services were what patients got as part of the healthcare systems' response to the COVID-19 crisis. Globally circulating images of overwhelmed health systems in high income societies produced a climate of fear, which undergirded the need to make bold decisions to avert catastrophe.7, 8 The absence of a vaccine and effective treatments against COVID-19 resulted in widespread demand and support for radical non-medical measures of social control. Variously labelled and applied, these "social/physical distancing" recommendations, law-enforced mass-scale restrictions of sectors of economy and society, and societal-level lockdowns, ultimately resulted in the reduction of health services.9-11 In this context, mathematical models made a compelling medical and moral case for the widespread and months-long implementation of radical social control measures.12, 13 These models looked like science,14 and theorized – not proved – that such measures could supress or even eliminate the virus. This in turn justified a short-term all of society sacrifice until an effective and safe vaccine, faithfully positioned on the visible horizon, could be found.8, 15-17 The pathway ahead, although uncharted, was simple: the population would be sent home for a few weeks, the "curve would be flattened" and eventually the virus would be supressed. As medical resources were diverted to COVID-19 responses, hospitals ended up working under capacity, as patients waited for needed clinical services broadly understood as "elective" and piled onto already long waiting lists.18 Despite the initial success of these measures in reducing the COVID-19 transmission rates and the associated morbidity and mortality across all social groups, the continuous threat to vulnerable groups remains high and may continue to do so for the foreseeable future. This is the case because on the one hand the measures are unlikely to be sustainable in the long-term, as children and youth need education and training for their full human development, and the general public requires meaningful social interactions and employment opportunities, which are essential for physical and psychosocial health and wellbeing.19-22 On the other, the historic problems in policy infrastructure to care for the most vulnerable, for example the elderly within long term care homes, has created significant care vacuums that produce ongoing risks for this population.23, 24 The risks posed by these policy vacuums remain unaddressed by mass scale lockdowns.25 In short, the indiscriminate and universal application of these policies of social control have not provided effective long-term solutions to protect the most vulnerable. Despite these shortcomings, the public so far has supported these highly restrictive measures26, 27 to protect lives. The widespread public support for a policy direction, particularly in times of augmented existential fears, should not imply that such policy preferences are automatically scientifically sound or morally good.28, 29 On the one hand, one should interrogate the policy options presented to the public under the climate of uncertainty and fear created by COVID-19.30 On the other, and perhaps more importantly, the history of the public's responses during other health crises should serve as a reminder of the importance of cautious application of restrictions on autonomy and freedom in the service of public health.31 Examples from our history that we can draw upon include the moral panic and stigmatization of AIDS and HIV patients and IDU users,32, 33 the politicization and moralization of LGBTQ and women's health rights, including abortion rights,34 and the racialized moral panics surrounding other recent zoonotic disease outbreaks.35 This is why it is essential to look at the collateral harms that radically disruptive measures of social control may produce, harms that affect the health and wellbeing of entire generations and may last for decades. Yet, with few exceptions,36 many in the health professions are still vocally advocating for the re-implementation of mass-scale restriction policies as the solution to bring down COVID-19 cases and avert a potential crisis.37, 38 Considering the limitations of this policy pathway in providing long term protection for the most vulnerable, this virtual consensus from health experts and scientists is nothing less than surprising since focused critique and debate are the hallmarks of science. The epidemic response has reached a critical decision point. Ongoing unfettered social behaviour and interaction (eg, full COVID risk tolerance) increases the risk of broad COVID-19 transmission in the community. Ongoing mass restrictions such as closures of entire economic and cultural sectors (eg, zero COVID risk tolerance) cannot be sustained indefinitely given the importance of social interaction for societal functioning and human health and wellbeing. Neither path is acceptable or sustainable, and the path we forge ahead must understand, accept, and balance the risks of disease transmission against the harms from universal or mass-scale restrictions. To be sure, while they lasted, mass restrictions dramatically reduced the spread of the virus across all population groups. However, as the necessary "re-opening" of society has taken place, step and widespread infection trends have come back. In addition, USA's CDC data suggests that the risk of morbidity and mortality vary by 1000-fold along population age groups.* In the face of these emerging realities we must ask: What are the objectives of these radical measures of social control in relation to the well-being of the entire population? Are these measures best suited to accomplish such objectives? Are they equitable, that is are the trade-offs and the unintended effects of such policy-making experiments on differently resourced population groups justifiable – both clinically and morally? Are they sustainable in the long term? These are questions of central import for evidence-informed decision-making, health equity, and effective resource allocation. Societies across the world are experiencing a feared second wave of infections, and perhaps many more in the months and years ahead, as we wait for effective vaccines and treatments to be developed. It is paramount, therefore, that health professionals become more critically informed and explore alternative and calibrated pathways of action. In order to do so, it is important to assess the evidentiary base available before the crisis hit, the emerging evidence on harms and benefits and their scientific and moral implications. Historical and localized instances of a wide variety of non-medical or non-pharmacological interventions, such as quarantines, "social/physical" distancing mandates, and closures of social venues to manage viral outbreaks have been conceptually debated and empirically analyzed in a multiplicity of health fields for decades.39-47 It is surprising then that their limitations and the direct and collateral effects on equity in healthcare and socio-economic life were not fully considered for the mathematical modelling that served as the "scientific" evidence to push for radical measures of social control. As argued elsewhere,48 this vacuum did not allow for an informed public debate on the long-term costs and benefits of the measures vis-à-vis the mathematical models projecting COVID-19 deaths, which made the medical and ultimately the moral case for lockdowns. For example, reputable medical historians have pointed out, while in the short-term quarantines and "lockdown" policies can be effective to manage viral outbreaks, they are unsustainable when extended over long periods of time. This is because they are socially disruptive and pose clear threats to economic viability and community life in the long term.49 The relationship between the economy and health has been widely studied.50-57 Social determinants of health scholars in fields as diverse as sociology, economics and gender and race studies have found that economic downturns are strongly associated with net negative health effects, including the onset of chronic conditions, long-term disability and early mortality.58-61 These effects are unequally distributed and tend to deepen health inequities along the lines of class, race, age and gender.62-67 In short, policies that cause unemployment and poverty are not health outcome neutral, nor are they sound public health policy. "At the outset, we talked very much about sustainability, and I think that's something we managed to keep to. And also be a bit resistant to quick fixes, to realise that this is not going to be easy, it is not going to be a short-term kind of thing, it's not going to be fixed by one kind of measure. We see a disease that we're going to have to handle for a long time into the future and we need to build up systems for doing that."68 As is broadly known, the Swedish approach continues to serve as fodder for much epidemiological and moral debates, and the making of controversial political and scientific claims. It remains unclear whether this approach can lead to sustainable and equitable population outcomes in the midst of this crisis. However, the purpose in citing the words of the architect of such a contentious public health approach is to underscore the fact that, even at the beginning of the crisis, some experts recognized that quick solutions are not well-suited for complex public health problems. " …indiscriminate policies to reduce contacts that are not optimally tuned may not satisfy the creed 'do no harm'. A relative loss of welfare can potentially occur from non-targeted policies, compared to decentralized decision making, because designing policies for the 'average' individual may impose a strong constraint that erodes welfare more than incomplete markets for disease prevention."74 "…up to 25,000 could die from delays to treatment in the same period and a further 185,000 in the medium to long term-amounting to nearly one million years of life lost … there could be 500 more suicides during the first wave, and between 600 and 12,000 more deaths per year resulting from a recession which had a significant impact on GDP."‡ 75 These numbers are mathematical projections - similar to those provided by the original Imperial College Model in the UK. They also look like science,14 but somehow, they do not get the same limelight in public debates. Clinically and morally, however, the numbers in these projections are sobering and should give pause to consider the kinds of medical and human harms that are still preventable. This is so because these harms are the outcomes of scientists' and health professions' advocacy and human made policies, not the outcome of a novel virus. To be clear, the numerical alarms and the empirical horrors of the realities posed by an unchecked COVID-19 pandemic should not blind us to the unintended – yet clear - long-term costs in human suffering, human development, and human lives of the policies we design. The morbidity and mortality risk profiles of COVID-19 are becoming more clear (mortality ranges from 0.00003 for the 0-19 years group to 0.054 in the 70+ years group).§ Considering these vast differences across population groups, we need to ask: what are the clinical and moral bases for denying the full spectrum of human development opportunities in terms of socialization, early education, hands-on training, jobs and so on to generations of children and youth? On what basis are some human harms, forms of suffering and casualties medically and morally intolerable while others - those that accrue over time as the outcome of health policies based on narrow evidentiary sources - are ignored or accepted? These are central questions in the context of the health and social crises unleashed by COVID-19. They are also important questions for health professions education,76, 77 as current and future public health leaders, clinicians and healthcare managers must be trained to integrate the social determinants of health in clinical and population health decision making. We do not know how long the COVID-19 crisis will last. Sustainable policy directions that are enshrined in broadly informed decision-making processes and health equity are required. Robust, transdisciplinary and collaborative decision-making models are necessary to avoid unintended harms. These models cannot exclusively focus on the impacts of social control measures on COVID-19 related morbidity and mortality; they must incorporate the wealth of available scholarship and emerging evidence on the impacts of these measures on the full spectrum of human health and development. Only then can we truly understand the costs and benefits of public health interventions, allowing principles like transparency, democratic community participation, informed consent and individual autonomy to enhance human rights and dignity. It may be that a more sustainable solution to COVID-19 risk management lies in enabling differential social participation based on individual-level risk. Community and universal risk mitigation measures may be applied temporarily and under strict criteria, such as health system capacity exceedance or rising unexplained mortality. However, such criteria are scientifically and morally legitimate only when the full spectrum of societal harms and benefits are understood, integrated into modelling and disclosed to the public. In an era of "precision medicine," it is our responsibility to avoid damaging "sledge-hammer" approaches when precision tools can be developed that minimize harms while maximizing health, social and economic gains. The author declares no conflict of interest. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.

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