The US AIDS Memorial Quilt in Washington, DC in 1996. (Photo: Evan Agostini/Liaison)
The US AIDS Memorial Quilt in Washington, DC in 1996. (Photo: Evan Agostini/Liaison)

OPINIONSocietyMay 17, 2020

Covid-19 and the common good

The US AIDS Memorial Quilt in Washington, DC in 1996. (Photo: Evan Agostini/Liaison)
The US AIDS Memorial Quilt in Washington, DC in 1996. (Photo: Evan Agostini/Liaison)

Call it unity, or solidarity, or kotahitanga, Covid-19 made us realise something we’ve known all along: we are all responsible for one another. There is a chance we can now act with common purpose to address intergenerational inequality. For older people, this means curtailing some of our choices, writes public health expert Charlotte Paul.

As an over-70, I am grateful for the unstinting way young people have protected us in the current pandemic. Their solidarity in staying at home and breaking the chains of transmission has saved lives, primarily in my age group.

Everyone over 70 is at greater risk of death from Covid-19, even though some imagine it is only those with underlying health conditions. New good data from the UK show this starkly. Compared to people in their 50s, people in their 70s have five times the risk of dying, and people in their 80s 13 times the risk, even taking into account all the other factors. Men have twice the risk of women and people of black or Asian ethnicities have nearly twice the risk, adjusting for multiple factors. The authors speculate that people in minority ethnic groups in the UK are more likely to be frontline workers.

Even so, these data show that old age is overwhelmingly the most important factor. And these old people who died were mainly not at death’s door, or in death’s waiting room. They would, on average, have lived another 11 years if they hadn’t died of Covid-19. Eleven years is time for a grandparent to be in a child’s life for a while, for volunteers to make a decent contribution, and for the old to look out for the old-old as well as the young.

Of course, it is also fortunate that old people are most affected. We have had the opportunity to live full lives. But our government and people have acted as if all lives are worth protecting. That sense of solidarity, that we are being cared for, helped us care for ourselves in a time when we might have felt useless.

What the younger generation has done matters a great deal. In fact, it has always been so. Infectious diseases bring to light the way solidarity and reciprocity work. Pandemics simply make it obvious. Take the HIV/Aids pandemic.

Have you seen an Aids quilt? It was both a real object and a metaphor. Each square of the quilt, lovingly made, represented an individual who had died of Aids. Each square was stitched to four other squares, or fewer at the edges. The joins represented contact between people. This could represent the number of sexual contacts the person with HIV had infected (R0, in the early exponential phase of the Aids epidemic among gay men, was estimated to be higher than four.)

But mainly the stitching represented unity. Primarily, unity among gay men. Unity spurred common action which led to preventive measures, so that growth in new cases levelled off; R dropped to around 1.0. Even so, the prevalence of HIV among gay men was high, so the chance of becoming infected was also high. It was obvious that everybody’s behavior was influencing risk for everyone else.

It turned out that there was less risk of acquiring HIV through an “unsafe” sexual partnership early in an epidemic than later, when prevalence was low versus high. Hence there was a community interest in HIV prevention.

Modelling showed that small changes in the average number of sexual partners could push R over 1.0, such that epidemic spread occurred, and that would lead to a major increase in prevalence. This has been described as an example of the Tragedy of the Commons. The increment in individual risk from a slight increase in contact rate is negligible, assuming the individual acts alone. But if most individuals make this choice, the aggregate impact is a phase shift in the dynamics of the disease, dramatically increasing everyone’s risk. Avoiding tragedy depends on shared restraint, not just on individual choice.

Collective responsibility also applies, of course, to immunisation. For diseases that are spread person-to-person, when immunisation coverage is high, the disease will die out (because of “herd immunity”) such that even the unimmunised are protected. More widely, it is a truism in public health that the population level of a behaviour affects the proportion of people who are at the extreme end of the distribution. In the case of alcohol, a drinker’s risk of becoming a heavy drinker depends on the “wetness” of the drinking culture. When social risk factors change, their distribution tends to shift as a whole, reflecting the interrelated nature of society. Prevention calls for collective responsibility. To quote Dostoevsky: “We are all responsible for all.”

Covid-19 made us realise we have known this all along. Despite years of focus on individual choice and freedom, we know we are all in this together. During lockdown, younger people have protected older people and those with chronic conditions by staying home. They have also safeguarded Māori and Pacific people who are likely to be at higher risk at younger ages. Each young and healthy person had a negligible risk of dying from Covid-19, so they didn’t act for their own benefit, but for everyone’s benefit. Avoiding tragedy depended on following new shared norms of social distancing, not on individual choice.

For most people, this realisation has played out in daily life during lockdown. People have offered to help others in all sorts of ways. It doesn’t feel like a “do-gooding” altruism, it feels more like recognising a basic human need. Everyone has an interest in eliminating Covid-19. It may be that the interest is personal: to start up a business and earn some money, or get a job back. But we are all pulling together, not apart. Call it unity, or solidarity, or kotahitanga.

It is true that the early lockdown did much more than protect old people. It also held out the chance for everyone to avoid the chaos other countries have seen, with health services overwhelmed, massive economic recessions, and no end in sight.

The steps out of the pandemic are going to be very difficult, especially for younger people and those in insecure jobs. All round the world it is becoming clear that the economic burdens are falling most heavily on those with least resources. And many of these people have been essential workers during the pandemic.

Can the pandemic really teach us something? The younger generations were already worse off and will bear the brunt of climate change, and inequality could widen further. Yet now we have seen equality at work, we have shared the same lockdown, the young have looked after the old. We have seen what unity of purpose can do. We have seen that the government and the opposition can act jointly to safeguard everyone. There is a chance we can now act with common purpose to address intergenerational inequality. For older people, this means curtailing some of our choices.

Philosopher Tim Mulgan has already suggested that people over 65 retire and people in well-paid work take a 20% pay cut. Susan St John believes that many older people agree they should be sharing the costs of a Covid-19 recession. She had already proposed a universal New Zealand Superannuation grant alongside a progressive tax regime for additional income as a way of sharing costs across generations. Economists serious about reducing inequality have already proposed various measures including a wealth tax, a more progressive income tax, and inheritance taxes.

Rebekah White has asked: “Can we hold on to the present mood of solidarity so as to produce more equal outcomes and a more generous understanding of the common good? Are we united only in lockdown, or can that value frame a vision of our future?” Older people now have a special role in promulgating the common good. The principal virtue implicit in this acknowledged dependence on others is just generosity.

Charlotte Paul was a director of the Aids Epidemiology Group for 20 years. The Group is responsible for monitoring the HIV/Aids epidemic in New Zealand.

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