Epidemiology is the study of impacts on human populations.
There is nothing in the etymology (the study of word origins) that requires exclusive application of the term to health impacts, but that is the custom in practice. That seemingly reflects our tacit consensus: those are the only impacts, encompassing both body and mind, that truly matter.
The epidemiology of COVID19 so obviously warrants our respect and a coordinated crisis response that pausing to say so should be unnecessary. A collective pause to commemorate those the contagion has claimed was long overdue.
My own respect for the pandemic was never in question, and has been informed by a front line view, and now a new, particular intimacy. As I write this, I almost certainly have COVID. My son, two of my daughters, and my wife are all sick and have tested positive, and we all have much the same array of symptoms (none too bad, I hasten to note). I await my confirmation by test result, but you know what they say when it flaps like a duck and swims like a duck and quacks like a duck.
I respect this contagion and have from the start. I also resent the drama.
While public policy and coordinated crisis response have been wanting, the media response has been a veritable feeding frenzy, and the systematic extraction of every droplet of drama to keep it going. As the saying goes: never waste a good crisis. My contention is that a thick overlay of drama where unencumbered data ought to be is among the reasons we have so horribly wasted this one. We are mired in the dramademiology (my own neologism) of COVID. If there is to be a field of COVIDramademiology- and there should be, when this crisis is subject to its post-mortem exam- it will require us to study the impacts of pandemic distortion on human populations. They will, when we finally look back with clarity and dispassion, prove quite massive.
Pandemic dramademiology has been rampant and diverse, ranging from inadvertent to cleverly crafted in increments of sound bite and clickbait. There are innumerable examples, some quite shameful, but I will stick to just two: inconsistency, and want of context.
Nothing means much in the absence of context, and here’s an example: nearly 3 million die in the United States! Is that a calamitous headline? Not if the report is about total mortality for a prior year, because nearly 3 million people die every year in the United States, most at old age in the fullness of time. We are mortal; we all die eventually. In a population of 330 million with our age distribution, the annual mortality that makes room for all the annual births in the “great circle of life” – is just under 1%.
I was moved and relieved when the presidential transition here in the United States offered us a collective moment to mourn the loss of 400,000 to the pandemic. Following months contaminated with misguided refutations and allegations of hoax, this was balm, redemption, and reality check.
But it was also a moment to rue our predilection for the new and shiny, our contempt of the long familiar, our complacency in the face of crises too profitable to protest, our inconsistency, and our inattention to context.
Consider that well over 650,000 people die of heart disease in the United States- this year, and every year- and that those deaths are as often tragic and premature as deaths to COVID. Certainly, they leave behind a bereft family just as inexorably. Can we say why we don’t have a national moment of silence, annually, to honor these preventable losses? A list of conditions for which we might say much the same- cancer, diabetes- could readily follow.
True, the conditions populating that list of leading “causes” of premature death here in the United States are for the most part not contagious, at least not in the ways that SARS-CoV-2 is, but that does not seem to be germane. We were not mourning losses because of cause; we were, I believe, mourning losses because of consequence- because of hurt. Those other causes cause the same kind of hurt; gouge holes in households and families.
Some 1800 people die of heart disease in the US every day. How do we wax sanctimonious about the need to prevent every death, about every death as a tragedy- while thoroughly neglecting 1800 deaths on average every day, all year long, year in and year out? That is more than mere inconsistency; it borders on hypocrisy.
I rue the inclination either way. That much more so because these neglected causes of death by other means are means of death by COVID, too. When COVID kills other than the very elderly, it mostly kills those with a burden of entries from that very list of chronic conditions: heart disease, hypertension, diabetes, obesity. The conditions we routinely disdain explain much of the COVID toll.
So much for our glaring inconsistencies. There is, as well, the essential matter of context.
We have all heard- and all of decent conscience mourn- that COVID has caused over 400,000 deaths now in the United States; more than 2 million worldwide. There is no context that can challenge the dire significance of such milestones.
But context is required to evince understanding. We could, for instance, just report that 3 million people died last year in the United States, provide no context, and leave everyone to infer that the world is coming to an end. The context- that the population turns over at approximately that level every year- completely transforms our interpretation.
For COVID, the transformation is not complete, but it is considerable.
The best available estimate for flu deaths in the US in the 2019-2020 season I can find is roughly 22,000; this is lower than other recent years by many tens of thousands, and lower than a severe flu season by more than 100,000. So far, the 2020-2021 flu season is seemingly on pace to be lower still. We are rather complacent about tens of thousands of deaths to flu every year; so complacent, in fact, that antivax sentiment seemingly dominates the narrative. Apparently, a very considerable portion of deaths to COVID would, in any other year, have been deaths to flu- along with an array of other viral infections we are not currently seeing. What I fail to understand amidst the rush to append drama to data is why these deaths are calamitous if by COVID, unprepossessing if by flu.
I also fail to understand how, if every death that happens matters as indeed it should, deaths that don’t happen fail to matter. If we have lost as many as 200,000 fewer than usual of our loved ones to influenza these past two years, that is news half as good as the pandemic is terrible. These lives also matter.
A non-pandemic analogy may help here. Imagine if we actually “cured” cancer so that no one died from it anymore, as nearly 1600 people currently do in the U.S., every day. And imagine if, as a result, people who would have died of cancer back in the bad old days, now live longer, get older, their hearts wear out- and they die of heart disease instead. So, now, instead of 1800 people dying daily of heart disease, the figure rises to 2200.
How should this statistic – which harbors 1200 premature deaths averted daily- be reported? If you wanted to maximize the macabre drama, you would simply report the mortality figure without context, with an emphasis on the recent cause-specific increase. “Ever More of Us Dying of Heart Disease!” would make a perfect, technically “true,” and utterly misleading headline.
Such reporting would reveal nothing at all about the number of people who were dying daily before, and would not mention the decline in countervailing causes of death- cancer in this hypothetical case.
But if those critical elements of context were provided, would it be a reason to respect heart disease less? Of course not. Would it be cause for disregarding the tragedy of loved ones lost prematurely? No, that is absurd. Would it be an invitation to take greater personal risks related to heart disease? Not for anyone with just a bit of sense. Rather, it would simply allow for more complete and genuine understanding- concern informing purpose, rather than despair informing panic.
I contend all of this pertains to COVID, too, where to borrow from Billy Joel, we have offered ourselves a choice between the desperate sadness and helplessness of calamity, or the deluded euphoria of denial.
Overhyping and distorting what is already intrinsically dramatic does not garner more respect for the menace, it garners distrust of the message. A consistent, willful want of context that amplifies portents of doom propagates anxiety and dread among those predisposed to take the bad news seriously, and disdain among those predisposed to suspect deceit. Harm is actually done in both directions, to both camps.
This is the toll not of COVID’s epidemiology but of the overlay of drama. This is the toll of dramademiology, of the superimposition of context-lacking drama as insult to the injury immanent in the data.
To be clear, the matter of competing causes is just cause to reject drama devoid of context; it provides no reason to disrespect data. The data we have, assembled thus far in haste and lacking the reliability and precision time will require, suggest that all-cause mortality for 2020 was considerably elevated in the United States. All-cause mortality aggregates causes and thus is not subject to offsets.
But there is a still a catch. Even before COVID, mortality was rising and life-expectancy declining in the U.S. due principally to the opioid crisis. There is evidence that the pandemic has revived and amplified that crisis.
So, is the surplus in total mortality due to SARS-Cov-2 infection, to pandemic exacerbation of our antecedent crises, to both, or to something else still obscure in the data compilation? We don’t know, and won’t for a while. As we wait, the safest supposition is that both the direct consequences of infection and the indirect consequences of policy missteps are contributing. Such thinking reminds us to look both ways before crossing what remains of the pandemic, and to aim at total harm minimization. However the pandemic harms someone is bad; however we defend against that harm and prevent it - is good. We should achieve all such good we can.
In the reckoning that COVID19 will demand of us, we might, I suppose, convene a multidisciplinary group of experts in psychology to autopsy our public handling not just of the virus, but of ourselves in response to it. How might we best have exchanged information and guidance that inspired cooperation rather than conflict? Would more civic-minded behavior have been inspired by invitations to opportunity than by provocations of dread?
I think we might save ourselves a lot of trouble by invoking the summary judgment of Sir Isaac Newton instead: for every action, an equal and opposite reaction. Newton wasn’t meaning to be a psychologist, but from my view across 30 years in medicine and public health, he was just the same.
When the action node was to lock everything down, the reaction node was to oppose that blunt response. When the action node was opposition to lockdown, the reaction node by even the most responsible authorities and media was to append drama to data- to expostulate on COVID as if nothing else killed anyone otherwise; to declare every death a tragedy, but only when COVID is the cause; to withhold any information about epidemiology in general, the context of other causes, the seasonal variation in hospital quotas. When drama over data became the action, the reaction was some amalgam of distrust, disgust, and disdain- and an amplification of the rebellious opposition. And so, now - here we are, mired in both contagion and discord. Just look around.
If we do embrace Sir Isaac as the True North of pandemic psychology and attendant public health communication, the extractable lesson is all but self-evident: tell the truth, nothing but the truth, and…the whole truth.
The whole truth would have conceded that the pandemic is bad and deserves respect, but that the risk is very variable. It would have conceded that during the pandemic, many other causes of death- flu salient among them- have seemingly declined by large numbers. Nothing in the whole truth degrades the respect SARS-CoV-2 deserves; this pandemic is some multiples worse than even a very bad strain of influenza. Thus far, though, it is also more than a hundred-fold less bad than the pandemic of 1918. The whole truth preserves all lessons in the data, but expunges the drama populating empty spaces where context ought to be.
The whole truth also admits uncertainty. That is of enormous value in any effort to mend society’s torn seams. Why? Because the “equal and opposite reaction” to “maybe” is “maybe not,” which is not a disagreement. “Maybe” allows for “maybe not;” “maybe not” allows for “maybe.” The equal and opposite reaction to “I’m right, you’re wrong” is “you’re wrong and I’m right.” The one is a war; the other, just a conversation.
I surmise that Sir Isaac, our panel of psychologists, and perhaps even you and I might agree that one among the most universal of psychic blights is helplessness. Little leads more reliably to desperation and despair than helplessness. Looking at this the other way around, the words of Holocaust survivor, Viktor Frankl, come to mind: “Those who have a ‘why’ to live, can bear with almost any ‘how.’”
Helplessness is the antithesis of both “why” and “how.” When you are made helpless, there is nothing for you to do. There can be no “why” attached to nothing; there can be no “how.” There is just desperation, and its expression in dysfunctions.
The varied expressions of that desperation have been a deafening dissonance in this pandemic from the earliest days of excessively confident action, and unjustifiably certain reaction. As opposition to the blunt and unnuanced thinking of “lock it all down” and just flatten the curve” burgeoned, the case for those same tactics grew more strident, more self-righteous, and more extreme. As “this is a serious pandemic that deserves respect” started sounding ever more like “this is the apocalypse,” there were only two ways to express the attendant helplessness: submission or revolt. Revolt has given us the uncivil disregard for the wellbeing of others that has fed the contagion, while submission has given us anxiety, depression, dread- and the grim consequences of these.
We might have given people a far better “why.” We might have talked about differential risk, and how to take control. We might have talked about modifiable risk factors, means of attenuating them. We might have inaugurated whole new channels for Zoom-mediated health promotion.
Variation in risk means one size does not fit all, and that in turn means empowering individuals to respond appropriately to the threats in their particular circumstance. I can’t help but think that more Americans would have embraced their obligations to the body politic if validated in their perception that not every body was at the same risk for the same reasons.
Among the many potential advantages in matching remediation to risk was a demonstration that we could respect the pandemic, and one another, at the same time. There was, in it, an opportunity for hierarchical responsibility that invited individuals, along with institutions and government – to contribute a share of effective, collective action. My contention is that drama and distortion conspired against just such solidarity of opportunity and purpose.
Here we are, now- contending with a proliferation of mutant viral strains. This was inevitable the moment our management of the pandemic required this many months. Pathogens and our immune system are opposing sides in an arms race; random mutation deals arms to both, but vastly faster to the virus. The more viral generations, the more hosts populated, the greater the chances of advantageous mutation. Those come to prevail, because that’s the nature of the advantage.
The only practical way to constrain the impact of mutation with an airborne pathogen that can take refuge in animal reservoirs…is risk-stratified exposure. I won’t belabor this point, because it is now a case of “coulda’, shoulda’, woulda’” of limited practical value. But intentionally high, early exposure among those reliably at the lowest risk of adverse outcomes, followed by those at next lowest risk, and so on…was a way to let the original viral strain produce widespread immunity with minimal harm.
The alternative to that- whether with a “lock it all down” slant, or a “liberate it all” slant, is much the same: haphazard exposure in the absence of risk stratification and risk management. The wait for the vaccine, though rewarded with such prizes in record time, nonetheless accorded the virus far more time than required for innumerable mutations, and for those favoring more viral propagation to disperse and predominate. So, again, now: here we are.
The only way pandemics end- whether by means of natural exposure or immunization- is herd immunity. In our overheated rhetoric, we have turned that topic into heresy. Where there is heresy, there is unholy war.
A pandemic post-mortem will one day reveal that drama and distortion fanned the flames of discord and contagion alike.
That SARS-CoV-2 demands our respect should be self-evident. Instead, we have aided and abetted viral spread in our disrespect of one another and for the admixture of humility, uncertainty, accommodation and nuance an intact truth requires.
A post-mortem will one day reveal that. For now- here we are.
David L. Katz, MD, MPH, FACPM, FACP, FACLM, is the Founding Director (1998) of Yale University’s Yale-Griffin Prevention Research Center, and former 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.