We are a polarized society; I have not surprised you by saying so. We are a society with a low tolerance for nuance. We tend to favor: yes/no, right/wrong, good/evil, left/right kind of thinking. We are not the better for it, but it is what it is.
Even so, I want to discuss the essential place for nuance in pandemic policy responses. It is not required in the “what,” but it essential to the “how.” The distinction is vital.
Consider, for instance, the idea of seeing a Broadway show; Hamilton, perhaps. For you, that’s a yes/no decision. You could make it a step more complicated by considering alternative shows, and choosing whether, which, and when. But still, the “what” is a rather blunt decision.
But now, imagine needing to create the show: write the music, choreograph the dances, design the sets. Should you be involved in that? Are you qualified?
Apply the same kind of thinking to anything you like, from watching a movie to riding a bike. You should decide “what” you do, but we all routinely rely on others with dedicated content expertise to address the inevitable nuance of “how.” By its very nature, “how” runs on nuance.
Just one more generic consideration, and then on to COVID. Your decision-making about “what” must account for the decision making of others. If, for instance, you are deciding about a movie or show, and you plan to see it with someone else- their schedule, their preference must be factored in. You should be involved in the “what,” but that does not mean it is entirely or exclusively up to you. As an ethicist memorably declared at a conference I convened some years ago, “my right to swing a stick ends where your nose begins.” My COVID corollary has been that “my obligation to wear a mask may begin where my nose ends.”
I think we, the people, should all have been invited into a national dialogue about the “what” of our pandemic response at the beginning of all this. That decisional axis involves a discrete set of choices, mostly devoid of nuance. At one end of this axis is “lock it all down” in the service of keeping virus and people apart, and saving lives otherwise lost to infection. At the other end is “liberate it all” in the service of keeping people and livelihoods together, avoiding disruptions and ruin, safeguarding civil liberties, and – presumably- saving lives at risk via social determinants of health.
Had grownups been in charge of our country during any of this, we might have heard thoughtful, fair-minded characterizations of the pros and cons of each of these. I like to think that had that happened, more of us might have wound up on the patch of real estate I have favored from the start: in the middle.
Total harm minimization is to our pandemic response what looking both ways is to a busy street.
Sure, it is “simpler” to look only left, or only right- but it isn’t much simpler, and it is much, much riskier. The toll of unidirectional safeguards will mount high and fast via the onslaught from the neglected side. In the case of COVID, that would be the toll of infection for those inclined to “liberate,” and the toll of social determinants for those inclined to “lock it down.”
Informed by these months of experience, I reject both now as I rejected both at the start. We might have looked both ways and aimed at total harm minimization. Perhaps we may yet, although the window of opportunity to get any part of our pandemic response right before it is over and the toll is the toll…is closing fast.
We might have gotten “what” right without bogging down in anything remotely like nuance. We did not, and I think one reason might be the failure to acknowledge that “what” is for all to consider, but “how” is for experts. Failure to unbundle the two encumbers considerations of “what” with the complexities of “how” – and all but guarantees that we will gather at our native poles of opinion and hurl insults at one another.
Imagine this. A national Town Hall featuring a diversity of experts – diverse disciplines, politics, ideologies. Positions are presented and defended. Discussion ensues. A team-of-rivals panel offers perspective, and a recommendation. Might this not have landed us on total harm minimization as a national strategy? I think so, and wish we could go back in time to give ourselves the chance.
But also imagine if the “how” of total harm minimization were debated at the same time. This is a very nuanced matter. What I have called “vertical interdiction” requires predicating our policies on differentiated risk tiers in the population, an example of “precision public health.” What, exactly, is required to provide the requisite protection of nursing homes? How do we handle multi-generational households? What about a family with a chronically ill child? What about…
You get the idea. The nuance of “how” gets very recondite very fast. And those innumerable difficulties would sound the death knell of public debate. And so, to our poles we once again withdraw- vitriol for one another at the ready.
Even if our country had good pandemic response capability- which we did not, having systematically dismantled that capacity in the name of “small government”- we might not have been able to manage the nuance of a fully risk-stratified response right at the start. That would not have precluded identifying the risk differentials associated with this particular pandemic, and establishing a risk-stratified set of policies as the ideal means of achieving total harm minimization. We might then have mobilized the resources necessary to “pivot” over whatever span was needed from general lockdown as an initial defensive posture- to vertical interdiction.
If, instead, we consider only the extremes of “what” for want of any willingness to attempt the nuance of the best “how,” we know exactly what we get: mass casualties from the virus; mass devastation to livelihoods; and a culture war into the bargain. Tell them what they’ve won, Johnny!
This, then, is the crux of our pandemic dilemma: the inability to unbundle “what” from “how.” How is the purview of experts; the general public need not apply.
This is not dismissive of us- it is just reality. I trust you favor safe drinking water in your home, and community. Now, shall we talk about how to provide it? Are you qualified to design a water treatment plant? Almost every expression of public health is complex and nuanced in the “how”- even such simple matters as basic sanitation. You can know what you want without having any notion at all about what’s required to get there from here. The nuance of that is the realm of those with pertinent expertise- in providing water, choreographing a dance, or orchestrating the national response to a pandemic.
The “what” axis for COVID decisions runs from “lock down” to “liberate.” The “how” axis runs from “crude” to “refined.” Yes, refined is harder; but that’s what expertise is for, to do what is hard but better. Yes, the many nuances of practicing a risk-stratified approach to total harm minimization would likely be a 1500-page policy manual written by a small army of suitable wonks. But what do you care? How many pages is the operational manual of your local water treatment plant? You don’t know, and you don’t want to know. You just want clean water when you turn on the tap.
We all wanted, I trust, to save all possible lives and quality of life during the pandemic. But by encumbering the simple considerations of “what” with the subtleties of “how,” we never gave ourselves that chance. The crux of our pandemic dilemmas is where two separate decisional axes cross.
Where decisions cross, at the crux of “what” and “how,” we meet the enemy. It is not nuance, which rightly populates one axis but not the other. It is not even the virus, which we invited into our midst. X marks the spot where the enemy is, inevitably, us- unwilling to debate the “what,” or delegate the “how.” If we can learn from the follies of this history we are making, perhaps we will manage to look both ways before crossing the next crisis. Or better yet, with the application of that better vision - prevent it before it begins.
Dr. David L. Katz is a board-certified specialist in Preventive Medicine/Public Health.
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David L. Katz, MD, MPH, FACPM, FACP, FACLM, is the Founding Director (1998) of Yale University’s Yale-Griffin Prevention Research Center, and current President of the American College of Lifestyle Medicine. He has published roughly 200 scientific articles and textbook chapters, and 15 books to date, including multiple editions of leading textbooks in both preventive medicine, and nutrition. He has made important contributions in the areas of lifestyle interventions for health promotion; nutrient profiling; behavior modification; holistic care; and evidence-based medicine. David earned his BA degree from Dartmouth College (1984); his MD from the Albert Einstein College of Medicine (1988); and his MPH from the Yale University School of Public Health (1993). He completed sequential residency training in Internal Medicine, and Preventive Medicine/Public Health. He is a two-time diplomate of the American Board of Internal Medicine, and a board-certified specialist in Preventive Medicine/Public Health. He has received two Honorary Doctorates.