The United States of America could teach a master class on how NOT to manage a viral pandemic.
We are, in fact, offering it now, free of charge. Tune in to us, pretty much any day at pretty much any time, and class is in session.
To be fair, though, the rest of the world has done little better. Only the rarest, and rather parochial departures exist, hinting at the great possibilities the world ignored. But ignore them, the world at large did- albeit generally with far less delusion and far more coherence than the U.S. Select outliers exist, to their discredit, that are about as bad as we Americans. But few if any deserve the Hall of Fame, and there is ample shame to share.
Northern Italy and New York City showed the world the respect SARS-CoV-2 warrants, by locking down too late. The virus was already widely circulating, a classic instance of closing barn doors after the horses ran out. As a result, these two sites suffered total harm maximization: the full-brunt of uninterrupted viral spread through the population, compounded by the harms of lock-down after it might have done the most good.
The long-term results of Sweden’s approach remain to be determined, but it is rather clear the country failed to protect its frail elderly as well as they might have, and should have.
Countries like New Zealand that locked down most decisively, did so apparently without appreciating that a “flatten the curve” approach with no clear risk-stratified plans for phase 2 does not prevent hospitalizations or deaths; it simply changes the dates. They have the choice now of experiencing a late first wave in an entirely non-immune population any time they open up, or remaining on high alert and entirely isolated from the world until everyone is safely and effectively vaccinated- whenever that may be.
We have bungled this crisis badly, and in a variety of ways, and we are collectively reaping a constellation of consequences. How we did this is important. More important, though, if we are to have any hope of extricating ourselves from this mess, and never replicating it, is: why? I offer here my brief tour through both consternations.
I believe now, as I did at the start, that we should have looked both ways, not just one, before traversing the pandemic thoroughfare. I believe now, as I did at the start, that this should be just about as controversial and provocative as the same homely wisdom applied to pedestrians in traffic. Why on earth would you choose to look for potential calamity in only one direction when it can careen at you from either? Why on earth would you assassinate the character of those equally monocular, equally blinkered, but directionally inclined the other way?
What I mean is this: SARS-CoV-2 can kill us; some of us, in any event. That is now beyond refute, with more than 135,000 attributed deaths in the U.S. alone. We all certainly needed to look in the direction of infection and ask: how best do we avoid getting hit with that?
But we also needed to look at probable impact on health and lives of societal disruption at an all but unprecedented scale. Unemployment claims in the United States have topped 40 million. When I joined with Stanford University economist Nick Bloom in a recent webinar, Nick connected two indelible dots. First, about half the job losses now occurring are expected to persist for the long term; in other words, some 20 million jobs (thus far) are not coming back any time soon. Second, for every mid-life adult who loses a job long-term, a year or more is shaved off their life expectancy.
Here, then, are the dispassionate mathematical implications- at last getting the attention they warranted at the start. If COVID deaths are taking, on average, ten years from each life (I suspect it is less given the average age and health of those most prone to die from the virus, but let’s use that figure anyway), and if 135,000 Americans have succumbed to date, the total “person years” of life lost to the virus is 1.35 million (10 years for each of 135k lives). That is, without question, a tragic loss; let no one dispute it.
However, if 1 year is lost on average for each of 20 million long-term job losses, that is 20 million “person years” of life lost, nearly 20 times as bad. Yes, many of these deaths will happen over an extended timeline, although some due to addiction, violence, and suicide are happening already. But still, this is a colossal loss of life, also tragic, let no one dispute it.
Looking both ways meant respecting both, not just one, of these obviously looming calamities. I believe this was, and is, the right thing to do. And informed by that binary view, we should have made the traverse aiming our steps at total harm minimization. We should not have traded lives lost one way against lives lost another.
If total harm minimization ought to have been the ends, the means should have been risk-stratified (vertical) interdiction methods. We had perfectly clear indications before COVID was first detected in the U.S. that it was a dangerous disease for some, and overwhelmingly prone to be mild for others. We know a whole lot more about that now, but it all reaffirms the original impression. SARS-CoV-2 is not a one-size-fits-all threat, and it is not best managed with one-size-fits-all interdictions.
We should have stratified protection in accord with risk: absolutely meticulous protection of nursing homes (which would, by itself, have cut the national death toll by half or more); careful and consistent protection of the elderly, frail, and chronically ill; routine protections for generally healthy people over 50 or so; and no particular protections for young, healthy people for whom COVID is //medium.com/@DrDavidKatz/colleges-and-schools-can-and-should-open-in-a-way-that-does-the-least-harm-5089b2fd0308" target="_blank" rel="nofollow noopener" style="box-sizing: inherit; margin: 0px; padding: 0px; font-size: 20px; vertical-align: baseline; background: transparent; text-decoration: none; font-weight: 400; border: 0px; color: rgb(102, 94, 208); touch-action: manipulation; overflow-wrap: break-word;">less dangerous than commuting to work or riding a school bus. However, there is an important subtlety: to practice risk-stratified interdictions, the lower risk groups must always accommodate the higher. Our policies could have, should have, and still might allow for that.
We are, in fact, seeing some of that now, as we hear about “record case counts” and witness the differential implications by state. Some states that have opened up rather haphazardly, and are now experiencing their first pandemic wave, have not compounded that misstep by delusion and denial. In other words, the population of say, California, has mostly respected the lethal potential of COVID all along. The result is a rise in case counts- due to a combination of more actual transmission, and more testing to find what was out there all along- but, so far at least, no excessive demand on hospitals and in particular ICUs.
In other states, where the general attitude has inclined against respecting the virus, rising case counts are conjoined with increasing hospitalization rates and ICUs nearing capacity. This likely relates to differing behaviors related to high-risk groups. In the states where those at high risk of bad COVID outcomes remain protected- by the care both they and others take- we may expect to see cases and hospitalizations diverge. Where such cares are neglected, cases and hospitalizations will rise in tandem.
If I happen to be right, and total harm minimization by means of vertical interdiction makes sense; if it made sense to build a “data pyramid” based on a representative random sample and thereby garner the data required for well-informed policy, then why is a defense of these simple concepts required now, so late in the game? If meritorious, why aren’t these policy approaches abundantly defended by real-world evidence at this point?
Because nearly nobody applied the approach, all opting instead to focus on a threat from only one direction at a time. Rare exceptions of enlightened policy have garnered far less media attention than every calamitous anomaly attributable to the virus: Kawasaki-like syndrome; death in a child; death in a young and seemingly healthy health professional. If it bleeds, it leads, and the media coverage of the pandemic warrants a harsh indictment: they have squeezed every drop of blood they could from this crisis in every news cycle since it started. A carefully cultivated dread has fed the native polarities, and given us the toxic admixture of viral contagion and rampant vituperations.
Why? I have a list of ten causal factors. My hope is that understanding the basis of our collective incompetence will empower us to overcome it while there is still time to do some good. And if it’s already too late, well- there’s always the next pandemic.
1) The Internet
This is the first major pandemic of the Internet era, and that has changed everything. Information “goes viral” now faster than any actual virus can. So, alas, does misinformation, only more so. Managing a pandemic carefully, thoughtfully, and cooperatively proved impossible as a divisive “infodemic” infected us before ever the virus did. And then, the virus followed.
2) Media Indulgence
As noted above, “if it bleeds, it leads” is a media mantra; as is “afflict the comfortable.” At every step of this crisis, the media have done more to maximize the drama than cultivate a temperate and full understanding. There are exceptions of course, but they are…exceptional. The prevailing predilection was to milk this mess for every drop of drama it would yield.
3) Polarization plus Amplification
We began this crisis as a highly polarized society in an increasingly polarized world, with encouragement for more of the same from seats of power. With recourse to social media, we are all empowered to append opinions to news, and blur the boundaries between the two. Polarized interpretations of already polarized media coverage were amplified in endless cyberspatial echoes until little hope remained of hearing nuanced truths above the din.
4) Moral Preening and Crowd-Shaming
Our instantly shared views are not just polarized; they are prone to be self-righteous. Take a position at odds with that of some vociferous, cyberspatial clan, and you must expect the digital equivalent of stoning in the public square. The very argument that both the virus and rampant unemployment could cost lives evoked allegations of something approximating heresy, sociopathy, and genocide from the “hunker in a bunker until there’s a vaccine is the only right thing to do” crowd. Conversely, the same in reverse from the “liberate my state, the viral toll be damned” clan. That’s not conducive to thoughtful engagement, constructive disagreement, and policy informed by the vigor of hybrid thinking. Disagreement is the gauntlet all ideas should run so that only the worthy prevail. But when ideas are disfigured into caricatures at the start, good ideas and bad die together, undistinguished.
5) Reductionism in Medicine/Science
Medical science owes much of its modern advance to the reductionism in its methods of inquiry. But when a problem is too big to fit into any one discipline, let alone a test tube or beaker, reductionism can conspire against us, per the precautionary fable of The Blind Men and the Elephant. The infectious disease camp propounded the dangers of the virus. Others propounded the dangers of social determinants. Neither, it seems, was much inclined to take in the view that encompassed both.
6) Isolationist Politics
SARS-CoV-2 does not care what kind of government you have; who you vote for; who issued your passport. You, and I, and everyone else- are all just so much infectable protoplasm of the same basic variety. A viral contagion illustrates as nothing else can the folly of isolationist politics in so small, and so flat, a world. COVID reminds us we are all the same kind of animal, no matter how we bicker over differences we exaggerate or imagine. Permit me to note, accordingly, what an absurdly horrible time this is to exit the World Health Organization. If ever the world needed more, not less, from an organization focused on the species-wide defense of Homo sapiens, it is now.
7) Nature Denialism
We will be grappling with the existential threat of climate change long after this pandemic ends, although because of climate change- this pandemic is less likely to end, and more likely to be followed by another, and another. The prevailing tendency to deny our interdependence on the rest of biology may prove the collective hamartia of all humanity. Our disrespect for natural systems is why we had a pandemic in the first place.
8) Either/Or Thinking
In a world prone to think in sound bites and provoke with clickbait, we are a nation governed by tweets. Is anyone truly surprised that the nuance required for judicious policy in a complex crisis is at risk of extinction here? We are the very kind of society where insults are lobbed between “lock it all down” and “liberate us all,” as the possibility of common ground between the extremes gets scorched by the intemperate exchange.
9) Compensation as Policy
I have the impression- or at least the hope- that many were inclined to nuanced, thoughtful reasoning they never shared from a perch of power. Why? For the reasons made famous by The Emperor’s New Clothes. When reason itself is conflated with…treason?...even those not prone to extremism become extremists, needing to adopt a “for” or “against” platform, rather than the sense they might have spoken in a culture of tolerance, that remembered how to listen before rushing to judgment. We wound up with policy platforms that compensated for opposing policy platforms, with all that might have proven “just right” - left to languish in the middle.
10) Utterly Inept Leadership
There is nothing partisan about flagrant ineptitude; it’s bad when plied by anyone. It’s bad in liberals as in conservatives; in democrats, republicans, libertarians, or any other party anywhere. The combination of almost stupefying incompetence and failure at the highest level of our government, combined with the greatest public health crisis in living memory- is the recipe for a nightmare. We are living in it.
We might, to date, have saved countless lives and livelihoods alike and been well on our way toward life as we knew it before, perhaps with important improvements – notably, reduced abuse of our planet- baked in. All that recipe required- was a very different world than the one we now share. We need to think about why we’ve failed as we have to discern the differences between the world we want, and the world we have.
And then, it’s time to think about getting there from here. It’s time to recall that the single best way to predict the future- is to create it.
Dr. David L. Katz is a board-certified specialist in Preventive Medicine/Public Health
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.