In my previous post ^[1], I noted that there seemed to be no appreciable difference in fatality rates for US states that instituted lockdowns early or late, or among European countries whose social-distancing and lockdown measures varied significantly. Hong Kong, South Korea and Taiwan seem to have managed the crisis without tough lockdowns as well as Australia and New Zealand have with lockdowns.

The quality of government decision-making and the capacity of healthcare systems to respond quickly may have been more crucial than rigorously enforced sheltering in place.

On 24 April, Australia’s chief medical officer, Brendan Murphy, conceded that the effective reproduction rate of the virus—the rate of new infections relative to the number of patients known to be infected—was under 1. Below that level, the infection wanes.

That was the situation in every Australian state and territory in mid-March, before the stage 3 lockdowns took effect on 30 March. Does that mean that the economically less damaging stage 1 and 2 restrictions were working well enough that Australia didn’t need to go to stage 3 lockdowns?

Murphy’s answer ^[2] was that, until then, about two-thirds of Australia’s Covid-19 cases were imported. Once that wave had died down, there was a risk that a rapid acceleration of community transmission would take the reproduction rate above 1 again and cause an exponential explosion of fresh infections.

There are trade-offs within health as well. Total coronavirus deaths in Australia are so low that, thanks to the lockdowns, the reduction in the number of road fatalities may exceed the number of Covid-19 deaths averted.

The Wall Street Journal reported ^[3] that many hospitals and doctors in the US were grappling with an unexpected side effect: a financial squeeze that could deplete the healthcare resources needed to meet local surges in cases and threaten the operations of some financially struggling hospitals. Staff were laid off and clinics and outpatient facilities closed as elective procedures were suspended in many hospitals. Thus, a policy designed to protect the health system from being overwhelmed has instead partially crippled it.

Meanwhile, expenses soared as hospitals sought scarce supplies to cope with the anticipated surge in Covid-19 patients. Doctor visits fell by 50% on average. Hospitals were losing US$45 billion a month ^[4]. According to Dr Jonathan Geach ^[5], tens of millions of patients are failing to receive the medical care they need in a timely manner. At the Mayo Clinic, 65% of hospital beds and 75% of operating rooms are empty. How many of the nearly 2 million new cancers ^[6] each year in the US, as well as heart, kidney, liver and pulmonary illnesses, will go undetected for months because routine screenings and appointments have been put on hold?

In the UK, one estimate ^[7] puts the number of planned and elective operations cancelled in the past three months at 2.1 million. This is in addition to the 4.5 million people who were on hospital waiting lists before the crisis. The UK has recorded a sharp rise ^[8] in the number of people dying at home, including from cardiac arrests, because people are reluctant to call for an ambulance. They fear that beds may not be available, or that they might contract the virus in hospital. Fresh research ^[9] shows that, owing to deferred consultations and suspended treatments of other diseases as the UK focuses on the coronavirus pandemic, almost 18,000 cancer patients could die.

A report in the Financial Times ^[10] references an internal British government estimate that ultimately, without mitigation, up to 150,000 people in the UK could die prematurely of conditions other than Covid-19 because of the lockdown. Preliminary figures indicate that between 23 March and 10 April, 35,817 of the recorded 46,000 deaths in Britain were not directly linked to Covid-19. That’s an 18% increase in the number of deaths compared with the same period in 2019.

A report in Lancet Psychiatry says measures taken in response to Covid-19 could have a profound and pervasive impact on mental health ^[11]. US authorities and experts too are warning of an approaching ‘historic wave’ of mental health problems ^[12] caused by the months-long Covid-19-related ‘daily doses of death, isolation and fear’. Lockdowns also put women at much greater risk of domestic violence ^[13]. It will be interesting to watch the rates of divorce and births in the year following the great lockdown. In earthquake-prone countries, disaster preparedness has suffered ^[14] from the nearly exclusive focus on coronavirus.

What of Australia? Ben Mol and Jonathan Karnon, professors at Monash and Flinders medical schools, confirmed ^[15] that significantly fewer people have been presenting with acute heart problems and stroke and some cancer screening has also ceased.

Many life-threatening situations are discovered during routine annual check-ups and screening, which is why tests are mandated for particular age groups. Some years ago I had a stent inserted. The entire cycle from initial sense that something was wrong, to emergency consultation with the cardiologist, referral for an angiogram and emergency surgery, took about five weeks. With the same symptoms in this lockdown, it’s very likely I’d have died before getting the stent.

How will citizens react to the stress of indefinite lockdown? There’s a danger that some governments will take advantage of the pandemic to tighten controls to an unnecessary extent and for some police to enforce them overzealously. Jonathan Sumption, a former UK Supreme Court judge, warned, ‘This is what a police state is like ^[16]’. Amnesty International Canada ^[17] demanded oversight protections for human rights during Canada’s Covid-19 response.

UN Secretary-General Antonio Guterres warned that the coronavirus pandemic was becoming a human rights crisis ^[18], with authoritarian responses, surveillance, closed borders and other rights abuses.

A serious weakness in epidemiological models comes from data that are uncertain and behavioural relationships that are unstable. Human nature being what it is, increasing numbers of people will gradually begin to resocialise and governments will face a choice between tightening coercion or a collapse of their authority.

It would seem better to control the timing, sequence and pace at which restrictions are eased, with built-in flexibility to bring some back should infection numbers shoot up again, than to lose control of the agenda.