Episode 75: Prof. David Cutler - the economics of Long Covid

[Music] Hi, my name's Noreen Jamil and this is Emily Kate Stevens. Both of us have been diagnosed with Long COVID. And we've created this podcast dedicated to the condition. Welcome to the Long COVID sessions. Hi Noreen, how was your week? Not too bad Emily, thank you. I have been relatively well, except for my insomnia and bad stomach, but I think that's down to me just crunching iron tablets like those smarties. Right, so I thought you were supposed to be getting an infusion. Oh yes, but I did say it was on the NHS, so it will be sometime next year. I'll get one. But you're going to persevere with the iron tablets even if they cause you horrible stomach. Yes, because my hair is falling out and handfuls and I'm just really tired and I really think it's down to the iron right now. Yeah, but do you say to me about four days ago that you thought you were heading into a crash? Did you stave that off? No, I had a mini crash, but it was more just breathlessness and just feeling like, you know, it's an idea a few years ago, but it didn't debilitate me. I mean, I kept going. Yeah, I've definitely been through a bit of a. That's weird, isn't it? Because I just said my week was fine. I didn't even remember. Yeah, you said that's what I found really weird, because I think it was Friday. You text me saying, I think I'm heading for a crash. So I read about you. No, I did have one. But I've just kind of blanked it out. You've got my. I was going to say in some way, what's the worst? What's that thing that I have? You're. What's the thing when I forget everything? I can't remember everything. We can't remember. We can't remember the word that means that we can't remember anything. That's good. Amnesia. My long name is. Amnesia, there we go. Yeah, no, I totally have. I just power through now. But what I have found this week, because I've got so much on my plate, is that I've got no patience whatsoever. For anything or anyone. Is that from the insomnia? Yeah, I think it's. I think it's everything. And I'm never like that. I can normally just keep taking whatever I take from people and from things without ever losing my temper. But now you're really feeling it. If you cross me. Is that what it is? You're losing your temper? Not so much losing my temper, but I'm not being diplomatic. So if someone is just. absolutely just being stupid around me, I will just tell them, like. I don't have time for this. Like, just. go away. Does that include your children? Yes. But they have not been very well, so I can't really. I can't really be mean to them. And it's not even being mean. It's just I'm not being as nice as I normally am. But I normally have an abundance of patience for bullshit and for stupid behaviour. But I don't anymore. It's gone. I might just watch it. Maybe it's because I'm old and don't have any shits left to give. Yeah, I think it just sounds healthy, babe. Cutthroat, but healthy. I don't think that's necessarily long COVID insomnia. How's your week been? So I could just say the same as you. I've been good. I've really been crashing recently. I've had quite a crappy period, to be honest with you. And I've really felt like I'm back two years. Today, my headache is like having a hot poker going through my brain. It is worse when I change positions, so standing to sitting, sitting to standing, there's something to do with blood flow. It just pounds. Moving my head is painful. It's quite difficult to keep your head immobilized, though I find. So it's not great. My stomach is terrible. But I had three good days before that. Obviously, I went to the gym. I got back into my handstand training. I really tried because I feel disgusting when I have these periods where I am completely taken out by it. So then I like to ramp it back up, as we know. I'm a kind of boom or bust girl. Which is obviously completely not what we need with on COVID. But in honesty, I was feeling a little bit shaky yesterday. So I tell that off, I did some light yoga. And I've been sleeping really well, Norina. I'm really trying to get to better, just a decent time. I've been really getting good sleep. It doesn't, none of it makes sense. I tell you what doesn't make sense. I slept for eight hours last night and I woke up. I couldn't get on a bed in the morning. I was so tired. But you sleeping is an amazing thing. Talk about burying the lead. Why didn't you tell me that? I've not known you to sleep for about four years. I know, but I feel worse. Your body just needs to catch up now. You're going to need to sleep for about six years to make up for the deficit. I'm afraid. You can't actually catch up on sleep, can you? But yeah, I think your body needs to repair a little bit from the end of some now. You know, and the funny thing is, is that, you know, I keep saying I'm powering through and it's fine. It's fine and fine. But all my stats have taken a nose dive. Your HIV and things. Yeah, my HIV has been the lowest now for two years. Ever since I started monitoring. But I just, I get up and I just get on with things. And when you look at my face, I've got these really dark circles now that I can't get rid of. My hair's falling out and I just don't feel well. But, I'm just, you know, I'm all right. I'm fine. There's some kind of status quo that you've reached that you think this is acceptable because I ask you how you are. You say I'm fine. And when we dig slightly deeper, turns out you're not that fine. But yes, I think one of the things where there is four years in, if this is what life is, we've got to just keep moving along. Whatever people say about pacing and things. And they can say that with the best well in the world. And we definitely want to try and recover. But we have kids. We have financial responsibilities. We have all of these things that fall to us. Yeah, and it's hard. It's hard to keep that balance. It's hard to stay sane sometimes. Because I do feel on the verge of hysteria at the moment. Do you? Yeah. That's interesting because actually throughout all of this, I've been very, very open about my mental changes, my big dips. And you've actually always remained relatively level, even when you've been having really scary symptoms and times when you found it kind of terrifying. You haven't really ever suffered from the anxiety that I've spoken of. Or that kind of mental toll. And there have been a few times that you've said you're pretty down. But not in the same kind of oscillating way that I've been back and forth between being happy and not being able to take these knocks. Yeah. So the things finally ground you down, hasn't? Finally. It finally has. I guess it really, and maybe it has. It's tough trying to keep up with everything and trying to, trying to maintain keep all of the balls in the air. It's also tough to listen to other people complain. Oh, you know, this and that's going. And I think to myself, well, you don't know how lucky you are. This is absolute. You're just being stupid. Then I remember, you know, everything's relative and their worries are just as valid as mine. But I'm like, I've been sick for four years. And I've been, I've kept going and everything I'm still here, everything's still going. And yes, the house is a bit messier. But we manage. And then when I hear other people complain about just stuff, I get really annoyed now. That is definitely showing the erosion of your patients because you've never really got annoyed by those people before. You don't normally let things like that bother you. No, they definitely do at the moment. No, it's just it's everything state of the world state feels very bleak. It's really bleak, but I'm also finding that it just seems like really crappy things are happening to a lot of people. Yeah. In terms of health, but in terms of finances and in terms of mental health and in terms of relationships and in terms of life circumstances, it feels pretty bleak out there at the moment. More people I speak to who are just going through really tough times. I felt like this year has been particularly, I keep throwing out the hashtag #20204 because I just feel like this is not a great year. No, what more can it throw at us? Yeah. Well, plenty. Yeah, plenty. And it turns out from this week's guest that economically the future is not looking particularly bright with long COVID. No, so this week we. spoke to Professor of Economics at Harvard University, David Cutler, who did a very widely cited paper that talked about the enormous cost of long COVID on the economy with regards to the US and then broadening it out to global economics. But we really wanted to speak to him, hadn't we, for a while, because this number kept being thrown up time and time again. Yeah, and we wanted to just find out what really is encompassed within the figures that are being bandied around and how can you actually put a cost on human life essentially? How can you put a cost on this illness? Historically, your work has not only looked at the economic cost of pandemics and the health system, but can you talk to us about how you decided that COVID and non-COVID was something that we needed to consider in terms of the economics? Yeah, so the world was right, we focused on COVID. It was a big, big deal for the world. And a lot of the world was focused understandably on the immediate death rate from COVID. So we were judging whether COVID was over or not over based on how many people were dying, what was the share of people in ICUs and so on. It was kind of focused on immediate events. And then there was all these stories about people with long COVID. And that made me more acutely aware that thinking about COVID is just a short term like, okay, can you prevent death in COVID? It is not the right metric here. And that COVID wasn't going to be over when death declined. And we shouldn't think of the needs to address COVID as simply being, okay, fine, vaccinate people, try and prevent them from getting COVID and dying of COVID. And then we're sort of done with what we need to do because the long-term impairments can be consequential and unfortunately affect a lot of people. So I was interested in that. And as an economist, you then start to ask questions like, well, how big is that? What does that mean for people? What does that mean for the economy? What does that mean for the impact of medical treatments and what we should be doing with respect to medical research and employers should be doing all of that? So it sort of led me down there just the sense that if you were framing the battle is too easy, not that anything about COVID was easy, but we're declaring victory too soon. When was the moment statistically that you saw the number of people affected by long COVID that it might have an impact on the overall economy? Because it's a numbers game, I believe. It is a numbers game, but actually I think in this case it was less than numbers than it was the personal stories. So like everyone, I know people who have long COVID. And I would listen to their stories and talk with folks and then you sort of hear about the various Facebook groups devoted to it and the various calls for more research and so on. And so I think it was, in my case, less the numbers, although as an economist, I'm quite used to dealing with numbers and usually I do, than it was the sense that there's something there and people are very, very upset and concerned as they ought to be. And so as an economist, maybe there's some things that economics can contribute to discussion about this. Well, that's really interesting that you came to it before even the huge amount of people that we now know suffer from long COVID just in the United States. So that's really interesting that you came to it early in that way just through friends and family. And you first started putting the figures together. Am I right in thinking it was late 2020? That's correct. That you really began to see the impact. Although your recent update suggests that things have shifted quite considerably. Do you want to talk us through what you first started to see? The difficulty with anything that's new is it's very hard to get good data on it. So we had some guesses from the US, the UK actually had better data. So we had some data from the UK about things like prevalence because we had household surveys. I say the data are okay because the response rate to the surveys is not super high and there are a bunch of issues with the definitions and things like that. So we had some data, but in terms of then thinking about well, what are the economic consequences? Long COVID for everybody is not equally disabling. Some people are more disabled. Some people are less disabled. Some people can continue work. Some people can't. Some people can continue some work, but not other work. So it's getting information on what the consequences of long COVID were is actually very difficult. I was trying to piece that together. And then of course a very big thing which at the beginning of the epidemic is really very hard to do is how long will people with long COVID have the condition for? Because that's going to influence what the costs are. Some people have it forever, but for other people it disappears over time and certainly early on in the pandemic we didn't have a very good guess about how long people would be disabled for. So I looked at the SARS experience two decades ago. And as best I could tell from SARS based on very small samples, the median person seems to recover in about five years. So half recover before half recover after with the median person is about five years. When I was doing the first estimates of long COVID, I said, well, I don't know why don't we just assume that the median person will have long COVID for five years. Thankfully I think that was too pessimistic. So it looks like the based on the data that we have, which again is not perfect, but based on the data that we have, it looks like people are recovering somewhat more rapidly than that. So that's a good sign, but that's the kind of information that you can only get over time. I guess the other thing that feeds into this and that possibly we don't yet know is that on your best estimates of the people that recover, we still cannot establish the trajectory in terms of people developing long COVID again in the future or continuing because for some people the pandemic is deemed over. However, the figures for long COVID are not suggesting that at all. How do you factor into your data, the fact that this may be a recurrent or continuous process? It's very, very difficult to do. What I tend to do in my data is just look at population surveys about what share of people report that they have symptoms of long COVID. And so look at, for example, the trend in that, which has been coming down slowly in the US and that's good. And that's trying to put everything together recovery and nuance said and recurrence and so on. And they sort of all get bundled together into a kind of share of the population with long COVID. I haven't seen any good micro models that go out and say, okay, let me model the transition probabilities from having acute COVID to long COVID to recovery to recurrence and so on. Shall we talk through the costs that you anticipate and give a picture of what you think the costs are going to look like? Now, I believe that your figures in your recent report, they're the costs over five years. So those were the lifetime costs based on cases that we knew of as to that point or that bigger forecast as of that point. The five year part comes because I assume that the average person has long COVID for five years. Okay. That's why they get carried out for five years. And so for some, you're going to overestimate the cost of for others you're going to underestimate the cost, but on average, you'll get it right. So talk us through what you came up with. The first way to think about this is who are you trying to estimate the costs for? And so in this case, we're trying to estimate the kind of the social costs. And so what social costs come from is basically people not getting to enjoy life as much as they would have. How do you put a cost on that? What is it encompassing that? Yeah. So there are basically three parts to it. The first part is people are less healthy and people like to be healthier. So it's not a dollar cost particularly. It's an I'm impaired cost. The common way that economists get that is that there are a number of circumstances where people either pay to reduce their risk. So for example, pay for safer cars or travel or something or people have to be compensated to work in riskier jobs. And so from that, you can back out a typical value of health to people. And those are real circumstances people taken. They say, no, I'm not going to work in this job. It's got a higher risk of death or injury and I'm not being paid enough for it. So that's the first part, which is not a monetary cost, but it is a, if you will, a utility cost or an enjoyment cost. The second and third are dollar costs. So it's the income that we're not earning as a society because people are not able to work as much. And the medical spending we have to undertake as a society because people are ill with long COVID. So those are resources we don't get to use for other stuff. So when people are not working as much, we don't get the benefits of their labor as society. When we have to spend money on medical care, those are medical resources that can't be used for other things. And does that also encompass the cost on social care, the increase in people claiming disability benefits or unemployment? So I start off by saying these are social costs. Disability insurance and unemployment insurance, they're hugely important, but they're slightly different in the sense that let's take one person who doesn't have long COVID and one person who does. So we want to transfer from people who do not have long COVID to people who do. So that's kind of taking money from the bank accounts of people who don't have long COVID and putting it in the bank accounts of people who do. That's not a loss of resources. That's just taking money from one pot and putting it in another. The real loss of resources is that person who is long COVID can't work as much and so therefore doesn't earn as much. Or I have to if you will, waste resources in the medical sector that I'd rather use for something else. So those are the social costs. They're all sorts of private costs like the person with long COVID has lower income even with the transfer person without long COVID has to give up money to help out the person with long COVID. Those are all shifts of money which are very important but they're not social consequences. There's not a social change in resources. To recap. So it's social costs, the quality of life, lots of earnings and higher spending on medical care. What I then did was I estimated those costs and altogether those three costs I estimated for the US would be about three and a half trillion dollars which is a huge amount of money which just tells you kind of the scale of the number of people of long COVID and how disabling it could be and both in terms of their health and in terms of their incomes, their ability to work and how much medical spending is involved. So it's a lot of money in there. Have you done this kind of trajectory on other conditions or illnesses? I know that the way that you approached the project was looking at the way that you had studied ME/CFS. Are there any other illnesses with comparable costs? I had estimated the cost of COVID itself to the principally acute COVID itself to the US economy. I had done that even earlier when we were trying to make first guesses about what COVID would mean. And there with my colleague Larry Summers using a similar type of methodology, we had estimated that the cost of COVID would be about $16 trillion to the US economy. Obviously, the mortality rate from COVID was higher than mortality rate from long COVID and number of people affected was greater and so on. But that's also just such an immense number. The reason I did numbers like that both for long COVID and COVID is not because you think about, "Okay, the dollars and cents, I really need to know exactly the dollars and cents," but it gives you a scale of how big the problem is. And if it's really big, then that implies you really need to be doing a lot about it. And so the thing about both of those numbers, the 3.5 trillion on long COVID and the 16 trillion on COVID, is they're so big that they really imply that governments have to be taking that seriously. You can't ignore the problem. The 3.5 trillion, of course, it's not perfectly right, but anything around that means it's such a big deal that you have to be spending a lot of time, money, resources, effort trying to figure out how to address the issue. We haven't seen much, many people taking notice of that figure, though, have we? And in terms of the UK government and the US government? I think there's been pushes. So in the US government, the NIH was allocated $1 billion, just over $1 billion to study long COVID. There's been very, very slow going in the US government. The money has not been used as rapidly as people had hoped it would be with results as quickly as people had hoped we would have results. It gets attention. I don't hear people say, oh, we don't need to study long COVID because it's not a problem. So in that sense, it's been successful. And the question is just like, what should we do about it? There are obviously issues of what can we afford and stuff. But hopefully it's cut down some of the line of argument, which is this isn't such a big deal. It's not worried about it so much. That runs counter to how the government's behave in terms of their pandemic is over policy right now where CDC just said there's no quarantine period now if you have COVID. They're just trying to get people back out to work and consequences be damned, really. It's a very delicate balancing act and our official agencies have not always been good on it. There of course also cost the various policies too. The quarantine policy is particularly difficult because a lot of people really have to work to earn money and with pandemic relief ending, that's a big deal for a lot of people. When I think about policies for long COVID, I think of probably three of them separate from quarantine policy. But I think of three really important policies. Then is basic biomedical research into what's going on and how can you prevent it? This is sort of the NIH version of it. How do you prevent the foggyness that comes with long COVID and how do you prevent the cardiovascular implications and the respiratory implications and so on. The second set of policies I think are really important are about employers that as many workers are able to work some but they can't work as hard or as physically demanding or as mentally demanding jobs as they used to. When example I read someone told about it on one of these long COVID check groups was, I can generally work but I find it difficult to go up and down stairs. Well, okay, so an employer knowing that can say, "I'll tell you what, let's make it so that you don't have to go up and down the stairs. We'll get someone else who can do that easier. We'll just switch your job around a little so you don't need to do that." So making kind of basic job accommodations so that people who can work some but not do everything can still be productive on the job. So there's really about awareness within the workplace. Is that something that actually needs to be driven by government policy? Do you think that we need to have more messaging surrounding that awareness? Yeah, labor markets are tight in many areas so employers are really looking for more workers and I think if the government can come in and say, "You know, there's actually a bunch of people with long COVID who would be happy to work." For that matter, lots of people with disabilities can work more than they used to, particularly with remote work and so on. So figure out how to take advantage of people who can work partly and that would be a great benefit to you and then here's some strategies you can use. I think the third area is we have to get primary care physicians used to being able to treat people with long COVID the same way they can treat people with diabetes or people with other chronic diseases and I think many primary care physicians don't feel comfortable doing that now because they're not sure enough about it. But imagine if we had to send everyone with diabetes to a specialist that would just be this enormous waste of specialist resources and things. So we need to help primary care physicians be able to treat most cases of long COVID except for very severe cases which clearly will need specialists. That's not a bad idea. Is it really that if you could go to your GP to get some symptom relief without having to persuade them that you're actually suffering from long COVID because a lot of primary care physicians have no knowledge of long COVID whatsoever. It's really in our experience. Yeah. Yeah, they've no knowledge of it and it would be great if they could handle at least routine cases of it just like they handle routine cases of all sorts of conditions. And then sometimes the condition gets too complicated and you say, "I need a specialist then that's totally fine." And that's the way it should be. But sometimes it's like, "Okay, yes, I understand how to handle this type of case." So let's work on this type of case. Yeah. We have come up against a lot of primary care doctors who have very little awareness of the condition let alone. Obviously none of us really know how to treat it yet. We haven't found treatments more than symptomatic relief. But a lot of them are still not willing to sort of entertain it as something that exists. So I think there's still a lot that the government needs to do and then feeding down into the various systems that we have nice here and throughout the NHS, throughout all the different countries, medical systems to actually get that message to primary care because we're not getting people are not getting help by primary care. The most closely related conditions, ME/CFS chronic fatigue syndrome, people in the US derisively sometimes call it "yepi flu" so that classic presentation would be someone who works very hard and then they could go to the doctor complaining of fatigue and well, you know, it's just the "yepi flu." And of course that's just so terrible because the people are ill. And we don't say, "Oh, you have the insulin flu because your body doesn't produce insulin." We have to get over the labels of this is pejorative in one way or another and get down to the fact that people have a condition and that condition deserves to be treated. Many years ago it was the same with mental health illnesses. I hope you just got yourself in shape. You wouldn't have these issues know that's a serious issue and you need medical treatment for it. So we need to get past that and I think part of that is going to be educating primary care physicians and the public that these are real serious medical conditions and that people need to be treated for them. Can you just compare the projected costs against two of the things that you have mentioned, one diabetes, two ME CFS and three are current costs of mental health. Can you put into context what the $3.7 trillion looks like compared to those? I haven't done it with respect to those. My sense is that the mental health and the diabetes would be significantly greater because the prevalence is so much higher but I haven't done it and I haven't seen anyone do it but I would be surprised if the cost of poor health from those conditions isn't even greater. Okay. There are also lifelong conditions that require lifelong treatment. In some cases like the diabetes, the mental health can be somewhat more episodic. I mean family and I four years in feels like a lifetime doesn't it? That's long COVID. So the $3.7 trillion are the social costs altogether. Do you have a figure that just looks out the economic impact on the country's GDP for example? Yeah. So the GDP impact would be the one on the lost income and that's about a half a trillion dollars call it a little bit more than half a trillion dollars. So it's well worth the government trying to get people like Emily and I back to work. Oh absolutely. There's nothing about this that says this is small we should just ignore it. Try saying the same thing about HIV. Oh it's not that many people it's just ignore it. It's just crazy. There's just no there's just no way that that's right. I just wonder what happens though to your costs. If with the AIDS pandemic we became aware of it and we put measures in place to try and mitigate it. With the COVID pandemic we put temporary measures in place which are now no longer in place and I wonder about the long-term implications if we just let the COVID keep running through societies. What happens to your models? It's interesting because HIV for various reasons doesn't mutate as much and once you treat someone you can reduce the viral load to undetectable. You can't cure HIV but you can make the person be as best we know perfectly healthy just with continuous treatment and not able to pass the disease. So effectively you can end the epidemic by treating people. COVID mutates much more rapidly. The vaccine is not perfectly effective and so on and of course there's a bunch of hesitancy about taking it. So one of the fears of the epidemiologists is that we go through cycles of COVID where sometimes COVID looks like it's down but then it makes a resurgence or resurgence in some population groups or a different form of COVID that may be resistant to the vaccines and so on. And so how that's going to play out it's going to require much more active biomedical science I think than some other condition. I'm not HIV I think still requires a lot of biomedical science but it's going to require a lot more active biomedical science to keep up with what's going on with COVID and what new vaccines we need and what we're learning about efficacy and stuff like that. But you think with that we could prevent it getting even more out of control, the cost getting more out of control. I don't know for sure but and some of it will surely depend on how good the world is at spotting things and doing stuff. The irony of COVID is that in many ways we dodged a bullet because COVID wasn't more fatal. It really was fairly low on the fatality scale. So the folks I know and I'm not an expert in this area are both worried about what happens to COVID and they're worried that there will be another COVID that will be even worse in terms of case fatality rates. And so COVID I think teaches us the need to be prepared and to continue to be vigilant and working on it even after you think that oh okay we've solved this case of it because you never eliminated the possibility of mass viral disease. Actually we spoke to a risk analysis who was not very optimistic about the future because the likelihood of a mutation coming along that has a higher fatality rate than SARS-CoV-2 is fairly likely at some point because there are mitigations that we had in place were temporary as Emily said and now it's being let run through society. But what was really interesting is that the biggest failure is in messaging in terms of for example vaccines you know the messaging was so poorly done that people would have turned away from vaccines now. And so the you know the likelihood of something much worse in the in the future or near future is quite high. I wonder if you have when you look at your models have have affected that in. A number that gets tossed around a fair amount is that we should expect something like COVID that is a mass viral outbreak maybe every 20 to 25 years. And of course sometimes it's going to be mild and sometimes it'll be severe but that's roughly the time frame to think about. The best thing that happened in COVID is that we learned how to produce a vaccine very quickly. The time between recognizing COVID and the vaccine for COVID was far and away the shortest on record by orders of magnitudes for any other disease ever. So that's great. My hope is that hope in quotations marks is that part of the hesitancy about COVID vaccines is that COVID itself wasn't that fatal. So therefore people were willing to risk it or to put it another way that if a new version of a mass viral outbreak came that was more fatal that maybe more people would be willing to get vaccinated because the consequences of not being vaccinated would be so high. Economically if we look at this coldly is it worse for an economy to have excess deaths or to have excess chronic illness as in is it actually more disabling to the economy to end up with the chronically disabled than for everyone. I'm not saying I wish anyone to have died in the pandemic but I'm just asking on a pure economic basis. It depends on how you count if you will the loss from the people who have died. So among people who are not affected you're better off if there are fewer workers competing with you for jobs. So let me give you an example. One of the biggest boost to incomes of poor people in human history was the bubonic plague which invaded Europe for a couple of centuries in the Middle Ages. Waked out I don't know the third of the European population and so those who survived suddenly there was the same amount of agricultural land but fewer math to feed landlords needed more workers cities you know towns needed more blacksmiths and so on. So that was an enormous economic windfall to those who survived. Now for all the families that were affected which most families were affected that was a terrible situation but relative to having to care for more people care feed the same number of mouths with fewer workers feeding fewer people with greater income per person is much higher standard of living. On the other hand it's not great in terms of you know people have died and you've lost loved ones. Isn't that the mouth of history? Oh yes so and there's in fact you know a number of stories about how European urbanization was to a great extent or to some extent driven by the bubonic plague and the end of futile life was driven by that because when workers are so scarce all of a sudden you have to be much nicer to them and you can't just say no you're going to sit here and do agricultural work for me and so on you have to actually treat them well and pay them more there's demand for workers and stuff so so whenever you're in a situation of a labor shortage that's great if you're a worker. Just have to survive the plague. You just have to survive the plague. But people didn't survive the plague and the big difference here is that people are surviving and not able to contribute to the economy in the same way are drawing money from government's healthcare systems. So actually the human cross-decide in terms of what it is to lose people you are worth ending up with a master-sabling event than a mass killing event economically purely economically. Well as an economic matter I count the lost if you will utility from people have died that is an economic loss it's not a dollars in sense loss so I think a better statement would be if you're talking about per capita income it's better if people die than if they survive and are disabled but per capita income is not synonymous with economic benefit. Okay but I'd feel like if people could understand that it's not only the death rate that we need or need to worry about it's the people that are left disabled from it that actually has a huge economic impact and three points $7 trillion is a terrifying figure. - Mass data again are terrible. - We don't have any contingency in governments to deal with that. We maybe have some disaster preparedness funds, but not to deal with the long-term implication. - No, we don't. And those are sort of big, if you will, uninsurable shocks. But as what's insurable is, we know that one out of every 100 people will develop a certain condition. So we're willing to all pay into a pool so that we treat that. And that's insurable. We buy insurance for that all the time. We buy health insurance and life insurance and auto insurance and homeowners insurance and so on. What's not insurable is that the state of the world will change so that everyone or a lot of people are much sicker. So we're good at risks where the risk is known. We're not very good at risks where the probability of developing the things unknown and changing over time. And that makes it very, very difficult for government. A lot of governments like the US government and the British government borrowed a lot during COVID. So that's good. That's what they should have done. Now they have to pay it back. So the hope is that we'll make it through that okay, but you really need to have a plan in place so that just stumbling through is not the norm. - Well, it's very sobering, isn't it Emily? - It unfortunately exposes a lot of weaknesses in society. What are strengths too? That is the vaccine process and what many employers are doing and so on and we'll learn more about disease and so on. But it certainly exposes a lot of fault lines in society too. And those fault lines, it would really be good if we addressed them before the next version of this. - Yes, because the wealthier amongst us were able to move out of the cities and go and live in their second homes and not have to go out to work every day in order to make money, not deliver them in parcels or food deliveries or, and it's those people that got COVID and then subsequently ended up as a greater proportion of society getting long COVID. - And the healthcare workers. - And the healthcare workers and those people are facing huge uphill battles against their local councils and governments trying to get disability benefits and especially when there's no diagnosis or biomarker available for long COVID. - One of the things in addition that's happened in the US and I don't know how much it's happened in the UK is there were some cities in the US where almost the entire downtown was given over to business and so people would commute a long way to come into business. So I think about San Francisco because housing prices were so high that very few people could live there. And then of course during COVID people didn't come into business. So then people would move out and they would stay out and they would work at home. And then this city center itself would become barren and it would go downhill because then there would then be homelessness and restaurants weren't open and buildings weren't open. And then that feeds on itself. Well if other people aren't going in to the city then I shouldn't go in. So maybe I should work at home more and plus there's now all this homelessness and despair and poverty on the streets, not the vibrant city. So I shouldn't do that. And so it really has this potential to kind of have a big, big change in life because we used to all agree yes we'll commute a while and come into San Francisco and that'll be nice and we'll commute a lot but it'll be fine. Now it's like well great I don't want to commute a lot because it's not even fine to be there. And so that discourages other people from being there. And the whole thing has this house of cards feel to it a little bit. And so some cities in the US are really struggling to not to survive but to really come back because they don't have that base of people around the people that actually make a city go. So this baristas and the people out on the streets and the people in the buildings and so on that sort of make the city go. And once it's there and then it's very hard to get people to come back. - Yeah, that just perpetuates itself. And particularly bad in, not even from a social point of view but particularly bad in the healthcare system where we've got more and more people being out of work with long COVID from the healthcare system and yet more and more burden on the healthcare system with not just long COVID but COVID related illness and disease. - And that's another thing that feeds on itself that is when some workers are out then the other workers have to work harder and they burn out. And then they need to take time off too. And so without a new flow of workers coming in or workers coming back, it becomes really problematic because you're asking fewer people to do even more at a time where they have loved ones who are in difficulty and the whole system is very difficult. And so in healthcare that's been a really, really big issue. - Emily, any last thoughts? - Thank you for doing this. - No, thank you. - It's quite terrifying when you put it into that quantitative data mode, though rather than being just speculative on more about how people feel, how people feel when people they love die. When you actually put the financial figures on it, you'd hope that maybe someone will take some notice. (upbeat music) - Actually, at the end of the day, it's not necessarily down to the specific figures that he's citing or what he has or hasn't included, but rather that he is pointing out the enormity of the problem. And I think that's what these kind of studies do. It's a little bit different to some of our other, we are so medically focused a lot of the time in our interviews. So it's a little bit different in what we're discussing, but I think the thing that is really highlighted is just how huge this is. - It's good to take a wide of view sometimes, especially when so many people with long COVID are struggling to get financial help and the governments are struggling themselves. I mean, it does feel that as a community, not only is the wider medical world struggling in terms of getting help or grants, it's just individuals as well. - Yeah, and it feels like we need to approach this on a governmental and strategic level to be able to help people. I, as a family, we are feeling the economic pinch of my reduced capacity to work massively. And we're in a relatively okay situation compared to millions of other people. I was not the primary earner at the time that I got this illness, but there are so many people who are, who were. And the implications going forward really don't look great, particularly as we tried to push him on that point of we actually have no idea what the future holds in terms of recurrent sickness and people actually continuing to get long COVID or getting worse. And the ONS data came out last week suggesting that it's not a good trajectory that we're on in terms of the number of people with long COVID. - Yeah, it's going up. - Yeah, not such a sunny ending for today's episode, but we're still here bringing you the sunshine even if we are kind of so but slightly by the reality of everything this week. - Yeah, and we still will be arranging our gathering and I promise not to be too cross with everybody. (laughing) It's good cut back up, remember anyway, Noreen. So if you come feeling a little bit grumpy, I'll be on the up that day. We're just trying to balance each other out, you know, 'cause on the bits where I feel really crafty, you're always the one that pulls me out. - That's what we can offer other people as well, I guess. That's what we hope to offer with this podcast, sharing our dirty linen. (laughing) - Yeah, really getting it all out there. We're never shy, are we? - We're never shy of the tree. - It really shocks me when people write to us and say, "Oh, you're so open, I'm thinking, oh my God, what is this?" - I'm so honest. - I know, I think that's the thing though, we record these and then let them out there into the ether. Our time stamp of this illness is out there for all to see, whereas we have this delightful amnesia with it. - Yeah. (laughing) - Until next week, Emily. - Yeah, look forward to it. (soft music) (upbeat music) Join us next week as we hear others' experiences of long COVID. Share your stories and questions at TLCSessions.net. 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