I have been wanting to write something for a few weeks in response to what I keep seeing as spurious arguments against the escalation of COVID restrictions in Victoria, and around the world, which use “mental health” as a reason to suggest we should not be increasing social restrictions.
As I understand it, the argument goes that the mental health consequences of the damage to the economy, job losses, unemployment and social dislocation resulting from enforced economic and social lockdown will exceed the impact of COVID infections themselves. Suicide rates will rise and the resultant loss of life may exceed that associated with COVID related deaths, or at least mitigate the reductions in death we achieve through tighter restrictions.
I think this is just a somewhat more complex extension of the binary argument that has been presented now for several months: that we have a simple choice. We shut down the economy to fight the virus with harsh economic consequences (and effects on mental health) or we do the opposite to support the economy at a cost to physical health / higher rates of viral infection and COVID deaths.
This is a completely false choice.

Let me repeat that as many just don’t seem to get it: we do not have a choice. The economy, and peoples mental health, is going to be dramatically effected whatever we do.
As we are shutting down the economy, restricting economic and social activity this is having important and damaging mental health consequences. Every day I am seeing patients whose mental health has dramatically worsened during the pandemic and social isolation and unemployment are playing a significant role in driving these problems.
However, it will be no different if we don’t impose the lockdown measures required to get COVID under control. A society with more shops open and more businesses operating is not one that is going to result in better mental health outcomes.
First, this will not necessarily support better economic outcomes. The reduction in GDP in Sweden has been similar to that in other Nordic countries, at a much greater loss of life[1].
Second, more widespread COVID infections will directly worsen mental health outcomes. COVID infection leaves lasting mental health consequences[2]. These can arise directly from viral brain infection or the trauma of the illness experience itself, let alone the impact of chronic post viral physical illnesses that seems to characterise this disease. This is before we even consider the effects of grief as many would lose cherished love ones and the impact of the fear in the community that widespread viral spread will have.
Finally, what about the mental, as well as physical health, of healthcare workers. Hospitals around Melbourne (and in many places in the world) have growing numbers of infected workers, and many sidelined due to possible exposure. The job of caring for the community, people presenting with COVID as well as with strokes and heart attacks, is falling on the shoulders of a shrinking workforce, who also have families at home worried their family member will fall ill, or bring COVID home.

Increased rates of infection resulting from relaxing restrictions will have direct impacts on the mental health of individuals, their families and marked adverse consequences for health care workers. And the status quo is also unacceptable. The current rate of daily new cases in Melbourne (400- 700 per day), pales by comparison to some places in the world but is not sustainable for the health system or society in general.
For these reasons we have “simply no choice”. We have to act aggressively and with the cooperation of everyone in the community. The government has no choice but to impose strict sanctions on all of us, especially constraining the behaviour of those who cannot see the impact of their actions on others.

Regardless of what we do we are going to end up with a major hit to the economy and significant widespread mental health issues. However, one option leads us to also have an overwhelmed healthcare system, deaths and illnesses in healthcare workers and higher rates of physical and mental health illnesses directly related to COVID infection. I don’t want to be part of a society that chooses this option in the misguided belief that it is the pathway to sustain corporate profits and the share market. Or in the mistaken, but perhaps more well intentioned belief, that it is the way to support mental health.
To support mental health we need generous financial supports to mitigate income loss, extensions of health care programs to ensure all members of society have timely and affordable access to mental health support and a united society dedicated to finding all the innovative ways we can to support one another. We would be much better off channelling our energy in these directions than in these debates.
[1] https://www.nytimes.com/2020/07/07/business/sweden-economy-coronavirus.html
[2] https://www.sciencedirect.com/science/article/pii/S0889159120316068

The Prime Minister gathered all his expert advisors around him. He had just been told that finally a vaccine was available for the terrible disease that afflicted the country. But there were not enough doses for everyone: what was he to do?
“Vaccinate the doctors first, we have to treat all the patients” said his chief medical officer.
“Vaccinate all the epidemiologists first, you need us to understand the disease” said his top public health officer.
“Vaccinate all the economists first, without us you won’t be able to understand the financial problems this disease is causing” said the head of the Treasury.
“What about the factory workers”: said the Industry head, “without them we wont be able to make anything”.
“STOP” shouted the PM, exasperated and at his wits end. What do you think he said to the junior aid who was trying to avoid his gaze. “What would you do?”
“I…I..” stammered the aid. “I don’t want it, I don’t care who you give it too first, I am not a fool — I have read about these things on the internet — these vaccines, they do more harm than good”.
The PM pondered this for a while and then commanded. “Find everyone who doesn’t want to be vaccinated. Find a way to persuade them to have it: they are the ones we need to have vaccinated first”
So I think pretty much everyone sees the development of an effective vaccine as the way we get out of the predicament of the COVID-19 pandemic. Whether you are for locking down for the long term, graded reopening or want to open the economy and damn the health consequences, I think pretty much everyone now accepts we don’t get back to a world that resembles anything like the one we all used to know without an effective vaccine. Sure some places, New Zealand being the outstanding example, have effectively eliminated the virus for periods of time. But for how long can countries remain isolated. Like personal isolation this will eventually take its toll: on the economy and on the individual desires and freedoms of the population. This is not a long term future we desire.
There is fortunately, a remarkable effort going on around the world to develop an effective and safe vaccine. In fact, given the number of competitive development programs it is quite feasible that we might end up with more than one, and possibly even quite a number of useful vaccines. It is sobering to realise that we haven’t ever successfully developed a vaccine in less than 5 years before — imagine what it would be like living in a COVID prevalent world for half of the next decade — but the intensity and breadth of the vaccine efforts at the moment gives me optimism that we won’t just beat, but will obliterate, this record.

However, the successful development of a vaccine will not be the end of our problems and will pose a series of issues which as a community we need to start thinking about and discussing now. If we wait until a vaccine is available it will be too late. We will be left making decisions on the run: we all know how well that has turned out in this pandemic so far!
The first issue relates to how we are going to ensure enough of our population is open to accepting vaccination. Vaccine skepticism, driven by the divisive rantings of often charismatic but misguided individuals on the internet, fringe religious groups and polarising political actors has never seemed to be so prominent. This is especially the case in the US — a recent poll reported that 35% of the population does not plan to be vaccinated but also pervades other countries, including Australia. Campaigns against mask wearing and other public health pronouncements have also acted to undermine trust in public health recommendations. They have fostered an atmosphere where what you believe or accept in regards to health recommendations has become more influenced by your politics than what is the received wisdom of experts.
This unfortunately, is just one nasty consequence of an increasing mistrust of expert opinion in society in general.
As American Historian Richard Hofstadter stated way back in 1964,
“However, in a populistic culture like ours, which seems to lack a responsible elite with political and moral autonomy, and in which it is possible to exploit the wildest currents of public sentiment for private purposes, it is at least conceivable that a highly organized, vocal, active, and well-financed minority could create a political climate in which the rational pursuit of our well-being and safety would become impossible.”
He has also described anti-intellectualism as the view that intellectuals are “pretentious, conceited… and very likely immoral, dangerous and subversive”.
I don’t think it is hard to make an argument that things have only worsened since the publication of these works and events during the current pandemic have brought this home with considerable force.
There is also fairly clear evidence of the link between general anti-intellectual views and opposition to scientific recommendations. Erick Merkley in a recently published study found a clear relationship between anti-intellectualism and opposition to scientific recommendations on issues such as water fluoridation and climate change. Importantly, this study showed that individuals with anti-intellectual views are likely to hold more firmly their opposition to ideas presented as a result of expert consensus.
This is a really important finding. We are clearly not going to convince the vaccine skeptical proportion of the population through appeals to expert opinion, no matter how strongly these ideas are supported by scientific evidence. Instead, we need to reconsider how we promote the hopefully soon to come COVID-19 vaccines.
Given that Merkley also found that anti-intellectualism seems to be connected to populism, perhaps we need to come up with novel ways to promote vaccine adherence turning this finding on its head. Should we promote vaccination through aggressively jingoistic appeals to patriotism? What about if we promote vaccination through advertising where compliance with vaccinations is positively associated with certain class affiliations, even if these groups are more commonly vaccination skeptical?
I don’t know the answer to these questions but they are ones we need to be addressing now. Research to address this will only take a minor fraction of the funding been pumped into vaccine development itself, but if we don’t tackle this immediately, vaccine resistance has the capacity to dramatically undermine our capacity to establish true herd immunity. Waiting until we actually have a vaccine will be too late.
The other conversation we must begin to have now relates to the process of vaccination roll out when it becomes available. Clearly there is going to be a process of escalation of vaccine availability such that systematic decisions are going to have to be made in regards to how we prioritise vaccine delivery.
It makes rather obvious sense to have some groups at the top of this list. Health care workers, especially those in the front line of helping patients with this illness, clearly need to be protected as soon as possible, really in the interests of everybody. There are a variety of other so-called essential workers for whom it would make sense to prioritise early access to vaccination.
It is less clear, however, how we roll out vaccination after we address these initial groups. For example, the elderly are clearly the most vulnerable to the most serious health effects of COVID, and a sensible argument could be made to progress with vaccination from the elderly downwards across the age groups.
A meaningful counterargument can be made, however, that viral spread appears to be driven by younger people and so perhaps we should do the opposite.
It can also be argued that the younger members of society are actually bearing the greatest long-term burden arising from the pandemic. Compromised education will have a profound generational impact on health, earning potential and quality of life.
I must admit though, that I find it hard to envision a situation where the interests of the young are prioritised in many western societies. This would be so inconsistent with our recent history where successive generations of leaders, and those who vote for them, have been quite happy to mortgage the future for the profits of coal miners and lucrative real estate price escalation.
I think that how we address this issue will have impacts not just in the coming years but for decades to follow. We already have young generations priced out of the housing market, with derailed educational and career progression and who will be saddled with the future societal debts we are rapidly accumulating as we battle not just to overcome COVID but prevent complete economic meltdown (and to support the stock and real estate portfolios of predominately the older generations of our societies). Open acknowledgement of these disastrous consequences, and their broader context, would be a sensible component of the discussion and one that should be approached proactively to try and help mitigate intergenerational resentment and conflict.
The abiding message here is that we need to start thinking about these issues now. We need the type of mature considered conversations that our polarised societies most struggle with. We need to engage people widely: across social, generational, political and ideological lines. We need to understand the whys to get to the hows. In doing this we need to treat people with respect, to understand and engage rather than to judge and pontificate. We are all in this together — whether we like it or not — it is up to us all to work out how we are in it and how we can come together lest this be yet another reason to further drive us apart.