Authors: Leonardo Barbieri, Ludovico Gandolfi, Alessandra Magazzino.
During the harsh and suffered times we are living by, a lot of different issues and topics have been discussed as the abrupt change and all-encompassing damage brought by the spread of the pandemic inoculated a pessimistic view of future trends in both economic and social scenarios. In the same way individuals’ lifestyle deeply changed, due to the necessary abortion of some rights which were considered essential until that point.
In these tough moments, the political arena — committed to facing the crisis — has often held debate between two very different currents of thought: one strictly focused on health results of the pandemic and a second one more centred on its economic drawbacks. Two conflicting views which eventually created the ground for the ideation and emergence of several proposals.
One of the most contentious proposals regards the so-called “targeted lockdown”, it presents a framework of lockdown imposed to defined age clusters — e.g. the elderlies — on which the virus hits stronger and registers higher mortality rates. The bases onto which the resolution has been grounded were strictly bound to a utilitarian view of the issue that easily overlooked ethical arguments.
MatteoVilla, a research fellow at the Institute for International Political Studies (ISPI) located in Milan, draw a thorough review of the determinants which would come into play if the targeted lockdown were to be considered, he ultimately pointed out that there are no “excellent” or “total” answers, everything is now based on weighing costs and benefits, both economic and ethical.
However, the masterpiece on targeted lockdown is the paper by MIT economists Daron Acemoglu, Victor Chernozhukov, Iván Werning and Michael Whinston. With their work “Optimal targeted lockdowns in a multi-group SIR model” (May 2020) they proposed an outstanding model capable of projecting reliable approximations of the effect of various restrictions, ranging from a semi-targeted lockdown limiting elderlies who do not constitute part of the labour force, to a full lockdown as the one Europe experienced in spring. By setting country-specific parameters as the propensity to immune deficiencies and the percentage of elderlies’ contribution to the GDP in form of work and spending, the model delivers health and economic outcomes in form of percentual of lives lost (which could be projected as ICU relative saturations) and decrease in GDP at current prices. What came out from their projections is that a semi-targeted lockdown would hypothetically reach “bearable” consequences in terms of contagion levels and economic losses: implementing a semi-targeted policy would possibly keep fatality rates from 1% to 0.5% and economic losses from 23% to 10%, it is here important to clarify that the model assumes as hypothesis an 8-months length for the said policy.
Clearly, the cited paper is scientifically focused and does not take into consideration how different prospects would reflect on individuals’ self.
For this reason, hereinafter we will try to project the targeted lockdown characteristics on our country: Italy, bringing into consideration all the possible determinants, we aim to offer you the tools to subjectively infer on the issue.
A view from Italy
With a total population just above 60 million inhabitants (60,244,639 by January 1st, 2020), Italy is the third most populous nation in the European Union. It is also the oldest, with almost 14 million people aged 65 or more, amounting to 23% of the national population. More than one in six people is aged 70 or more, and the number of people aged 80 or more (4.5 million) is almost equal to the one of kids up to age 9 (4.9 million).
A selective lockdown (or other age selective restrictions) targeting senior citizens would, depending on the age set as a threshold, directly constrain the daily life of up to almost a quarter of Italians. Given the relevance of family ties, culture and societal structure, many more would be involved indirectly. Policymakers ought to carefully weight the benefits from such a decision.
The numbers of reported deaths from Covid-19 would support age-targeted interventions, as the virus hit disproportionally harder the older segments of population. Data from Istituto Superiore di Sanità, Italy’s most important health institution, show that out of the 41,736 deaths from Covid-19 registered by November 11th (the time of writing this article), 35,692 of them (accounting for more than 85%) came from citizens aged 70 or more. This figure rises to more than 95% of total deaths if the threshold is set at age 60.
Although an age selective lockdown would not delete neither cases nor deaths in the targeted age group, it would certainly reduce them. This distribution may suggest that age 70 would be a reasonable threshold to impose temporary confinement. The principle of caution may even push such threshold down to age 65, or 60. The cost of a policy like that would, however, be enormous. Of all the wide continuum of burdens a lockdown would impose on citizens (from psychological distress to unhealthy lifestyles) the most feared is the economic one, as individuals’ economic activities, if not suspended, suffer from the reduced circulation of goods and clients. Italy’s pension system however offers a sure shelter to senior citizens, who do not need to earn income on a regular basis. Moreover, the impossibility to work would not depress the demand from the elderly, as, again, their income would not drop. As Figure 2 shows, senior citizens (i.e. aged 65 or more) account for less than 3% of total employed individuals. The productive loss from a lockdown on them could be managed without excessive effort.
Despite the aforementioned health and economic considerations, which support the temporary lockdown of the frailest segments of the population, a proper debate on the matter lacks in Italian politics. The few suggestions made in this direction were met by public and political indignation.
How can this be the case? A possible answer lies in politics. The elderly, although more at risk in case of contagion and less exposed to economic uncertainty, constitute a substantial portion of Italian electorate. Although information on electoral turnout by age is not available, data from the Italian National Institute of Statistics (ISTAT) show that almost 20% of citizens that declared to be interested and participate into politics is aged 65 or more.
However, although a selective crackdown on such consistent part of politically responsive citizens would likely backfire, senior citizens alone remain a minority of voting-age Italians, and their (potential) opposition appears an insufficient force to block the debate.
Enlarging the perspective may provide a possible solution. According to ISTAT, the most numerous age group of citizens participating in politics is the 45–64 one. With over 14 million of politically active individuals, this group constitutes 36% of Italians who are likely most responsive to politics. This group lies outside the target of an age selective lockdown, given its low death rate and economic relevance. However, it may interpret a selective lockdown as a signal by political elites that the freedom of individuals of the age they are approaching can be reduced, to preserve the one of younger citizens. In this case, forward-looking voters may punish an incumbent taking this decision. The sum of the potential opposition by two relevant groups (which have average turnout rates higher than younger cohorts and account for more than half of politically active individuals), may be enough to prevent the development of a fully-fledged debate on age selective restrictions.
Ethical dilemma in addressing a targeted lockdown
A discussion about the proposal of a targeted lockdown would be incomplete if some thoughts about its ethical implications were not displayed. The deprivation of liberty of a portion of the population per se brings out issues concerning social equality. Therefore, besides scientific evidence, the academic community has addressed these questions with different views and solutions.
To support the dispute of the selective lockdown, the Journal of Medical Ethics quotes Aristotle’s principles of equality. In the opinion of the Greek philosopher discrimination is not always unjust; it may be acceptable if it is proportional to the pursuit of the common good and if there is a morally relevant difference. Regarding the first point, it is possible to consider “proportionate” a solution whose benefits can exceed the social and economic burdens imposed to a part of the population. In this perspective, coercion of the elderly — the fraction most exposed to the risk of hospitalisation — would guarantee a better distribution of limited resources of the health system while avoiding the collapse of entire economies. About the second argument, this situation is comparable to other conventionalities typical of the health system. In fact, as well as screenings for breast cancer are conducted only for women — the most vulnerable category for this illness –, the different treatment of quarantine and isolation would be addressed only for the oldest part of the population. These principles synthesize the utilitarian point of view.
On the other hand, the “We are all in this together” slogan echoes the reasons of the opposite faction. The selective isolation should not be considered as a “ethically proportionate” welfare measure because this, instead of protecting older people, would worsen their health. This doubt is shown by M. Villa himself in his report published for ISPI. Therefore, in an interview for the Italian journal “La Stampa”, Raffaele A. Incalzi, a geriatrist of the Policlinico Gemelli in Rome, has affirmed that other pathologies could overwhelm the health of the elderly, such as diabetes, depression, renal and respiratory failure. As we could imagine, an effective isolation is expected to give results only if it is avoided any contact with the family and with in-home nurses who typically take care of older adults. In this scenario, not only the elderly could not be assisted by their relatives, but also, they would be rejected from any nursing home — whose reputation of being the “perfect outbreak” is unhappily known — and, of course, hospitals. Moreover, anxiety and anger derived from a lack of social and physical contact, could be partially solved with smartphones and video calls, although they represent unknown tools for the elderly. About that, FederAnziani Senior Italia has started with WindTre a project of digital inclusion with the aim to spread knowledge between the seniors about the basic use of instant messaging programs and online delivery services. However, data about its efficacy are not yet available.
In conclusion, against the idea of an “ethical targeted lockdown”, another issue concerns the example previously shown about screenings on breast cancer. In fact, the two compared episodes are not totally equivalent. Firstly, a screening operation is not costly as much as a long period of isolation, in terms of time and socio-economic impacts. Secondly, a dramatic fight against cancer would come only after a positive result of the screening, while the affliction caused by a lockdown, as a preventive measure, is not necessarily associated with the Covid-19 disease: it negatively hits everybody independently from the infection. All these problematic implications lead to a reconsideration of the benefits previously mentioned.
“There ain’t no such thing as a free lunch”: the pandemic we are all facing does not elude this economic rule. Any form of restriction of the individual is not optimal for the society. In expectation of a capillary distribution of the vaccine — recently announced by Pfizer-BioNtech — it is probably better to invest on the expansion of universal precautions, such as air filtration systems and safer public transit options. Until that moment, however, the reduction of our freedom is a prerequisite to finally reach the moment when we will all physically, and not just virtually, together.
Appendix
References Villa, M. (2020, October 30). Datavirus: il lockdown per gli anziani può servire? ISPI online. https://www.ispionline.it/it/pubblicazione/datavirus-il-lockdown-gli-anziani-puo-servire-28032 Acemoglu, D. et al. (2020, May). Optimal Targeted lockdowns in a Multi-group SIR Model. https://economics.mit.edu/files/19698 Savulrscu, J., Cameron, J. (2020, October 28). Why lockdown of the elderly is not ageist and why levelling down equality is wrong. Journal of Medical Ethics. https://jme.bmj.com/content/46/11/717.info Ferraglioni, G. (2020, October 31). Isolare gli anziani per salvarli e allontanare il lockdown per tutti: l’ipotesi divide gli esperti. Open online. https://www.open.online/2020/10/31/isolare-anziani-lockdown-ipotesi-divide-esperti/ Gruppo della Sorveglianza COVID-19 (2020, November). Caratteristiche dei pazienti deceduti positivi all’infezione da SARS-CoV-2 in Italia. Epicentro. https://www.epicentro.iss.it/coronavirus/sars-cov-2-decessi-italia#2 (2020, July 9). Impatto dell’epidemia covid-19 sulla mortalità totale della popolazione residente periodo gennaio-maggio 2020. Istat. https://www.epicentro.iss.it/coronavirus/pdf/Rapp_Istat_Iss_9luglio.pdf Istat. http://dati.istat.it//Index.aspx?QueryId=37383 (2020, June 24). La partecipazione politica in Italia. Istat. https://www.istat.it/it/archivio/244843
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