Moral dilemma of choosing between lives and livelihoods

In 2011, a research team at Columbia University’s Mailman School of Public Health, led by Sandro Galea, MD, DrPH, chair of Epidemiology, estimated the number of US deaths attributable to social factors using a systematic review of the available literature combined with vital statistics data.

“The investigators found that approximately 2,45,000 deaths in the United States in the year 2000 were attributable to low levels of education, 176,000 to racial segregation, 162,000 to low social support, 133,000 to individual-level poverty, 119,000 to income inequality, and 39,000 to area-level poverty. Overall, 4.5% of US deaths were found to be attributable to poverty—mid- way between previous estimates of 6% and 2.3%,” the study concludes. “Social causes can be linked to death as readily as can pathophysiological and behavioral causes,” points out Dr. Galea.

“For example, the number of deaths the researchers calculated as attributable to low education (2,45,000) is comparable to the number caused by heart attacks (1,92,898), which was the leading cause of US deaths in 2000. The number of deaths attributable to racial segregation (1,76,000) is comparable to the number from cerebrovascular disease (1,67,661), the third leading cause of death in 2000, and the number attributable to low social sup- port (1,62,000) compares to deaths from lung cancer (1,55,521)”.

As per the Columbia University study, in a rich country like USA, the number of deaths caused by poverty, unemployment, low level of education and other social fac- tors are in the same range as the number of deaths caused by familiar health causes such as heart attacks, strokes and lung cancer.

No such credible study is available to look at the contribution of social factors to Indian mortality. But one can safely assume that in a low-middle income country like India, the number of deaths caused by social factors and poverty will be sever- at times more than the number of deaths caused by familiar diseases in the US.

“Even when we take the rich countries (like USA), poor people know from history that every time there is some great struggle, whether it’s the Great War, or the Spanish flu, or the recession of 2008, they are hit the hardest,” said Rev. Dr. William J. Barber, president of the non-profit organization, Repairers of the Breach, in a video debate held by The New York Times Magazine. The COVID-19 pandemic is the defining global health crisis of our time and the greatest global humanitarian challenge the world has faced since World War II.

The New York Times Magazine held the debate with experts from different fields on the issue of a trade-off between saving lives and saving the economy. “I hope we will not have to continuously try this trade-off or balance between saving lives and livelihoods,” said Rajiv Kumar, Niti Aayog Vice Chairman, at a global webinar on ‘COVID-19 - Fallout & Future’, organised by Bennett University’s Times School of Media. But India is indeed facing this difficult and heart- wrenching option to choose between “lives and livelihood”.

India has moved decisively to check the spread of virus, by implementing a nationwide 21-day lockdown, with the objective of flattening the curve and using the time to plan and step-up the medical infrastructure.

Health care sector experts, public policy makers and upper-class intellectuals had warned about the consequences of an exponential increase in the number of COVID-19 cases if the 21-day lockdown was lifted on April 15. Economists, entrepreneurs and left-wing leaning intellectuals had warned about the collapse of the economy, rampant unemployment and poverty, now that the nationwide lockdown has been extended for a longer period.

“The pandemic highlights the divide between workers with paid sick leave and without. Only 47 per cent of private-sector workers in the bottom quarter for wages have paid sick leave, compared with 90 per cent in the top quarter. COVID-19 is further revealing the country’s profound inequali- ty and structural racism (in USA),” said Vanita Gupta, former head of the US Justice Department’s Civil Rights Division, on The New York Times debate.

In a society like India – like those in many poor countries – where most workers are informal and have no right to unemployment insurance faces a higher “income” cost per life saved than one in which all workers are covered for the unemployment benefits or have the right to paid sick leave for the entire duration of containment or have a vibrant social security net. A vast majority of India’s working population, 90% of them, work in the informal sector and have none of the income protection covers.

Again a high per cent of the informal sector workforce in India is migrant workers, who do not have access in their host states even to the limited ration supplies or food security provided by the government. “Yes, restarting the economy has to be done in stages, and it does have to start with more physical distancing at a work site that allows people who are at lower risk to come back.

Certain kinds of construction, or manufacturing or offices, in which you can maintain six-foot distances are more reasonable to start sooner. Larger gatherings - conferences, concerts, sporting events - I think those things will be the last to return,” said Zeke Emanuel, Director of the Healthcare Transformation Institute at the University of Pennsylvania, on the debate.

The bottom line is that a trade-off between lives and livelihoods is a necessity and the terms of such a trade-off are not fixed in stone. A moral dilemma is a situation in which a person is faced with two mutually exclusive choices. A calibrated, pragmatic and balanced approach to minimise both the risks is always better.

(V Venkateswara Rao is a retired corporate professional and a freelance writer)