The time has come to vet whether our government officials, Republicans or Democrats, leaders at the CDC, leaders at the NIH, leaders in public health, and talking heads have made an egregious mistake in response to the coronavirus.
In rational decision making, we make choices among alternatives that have been tested to see if one is better than another at reducing the occurrence of some non-valued outcome. This is not a simple sentence. The premise is this, to engage in choosing, we must first know that one option provides benefit over another. Benefit is a difference, one alternative reduces unwanted outcomes more than another. It is a number, it is a difference in the probability of outcomes we don’t want between compared alternatives. This truth about choice, then, means, also, that options that do not provide benefit over others should not be used, nor paid for.
For example, as an oncologist, I offered chemotherapy in order to reduce the chance of a cancer’s untoward events. I only did this if it was proven that the chemotherapy was beneficial versus no treatment. In fact, if I gave chemotherapy knowing it did not provide benefit, or, worse, without the knowledge that benefit is possible, I would be acting unethically.
But, the choice of treatment for a patient with cancer, or any malady (an epidemic), while it must start with knowing benefit, does not end there. Chemotherapy, for example, has specific complications, called, harms. Harm is added complications caused by the treatment that provides benefit over another, not the disease. In a rational decision making framework, the added benefit of the chemotherapy against the disease must be balanced against the added harms of the chemotherapy. This, also, is not a simple concept. Some patients might choose to forgo the benefit side, the side of the decision process that offers some value to gain, because the value to their life they might lose if complications occur looms worse than any potential gain.
Rational decision making is a balance, then, of the value to gain should benefit occur versus the value to lose should complications occur. These values are informed by knowing the size of the benefit difference and the size of the harm difference. All components of a rational choice must be available to a patient who must decide. This the best way to choose, because if allows patients to understand the probabilities of outcomes, and assess, from their perspective, what is the balance, for them.
This decision making framework for an individual is, also, the perfect way to decide for a population’s care. Any application of a social, public health treatment (shutting down schools to slow virus spread, social distancing, for examples) must have an estimate of benefit over an alternative, and an evaluation of the potential to gain and the potential to lose. As an example, what if social distancing led to a 10% increase in unemployment (harm difference) for a 10% decline in transmission of an infectious agent (benefit difference)? If we knew these numbers as facts, we could have a rational public discussion about the balance of our actions for our society.
So, this blog is my attempt to engender a focused discussion of the presence or lack thereof of rational decision making for the COVID-19 epidemic. You see, our public policies against the coronavirus violate every principle of rational choice. We don’t know benefit, we don’t know harm, we have not even had a rational discussion in any forum of what goals we have for outcomes, and there has been no ability for the public to engage in determining the balance of values to gain from reducing the virus transmission versus the social disruption of the interventions imposed upon us.
Here are few of my concerns. First, we don’t know what outcomes matter to our decision makers. We talk about “flattening the curve” but why? To save lives? But, the same number of people die under the falsely apportioned, pointed curve and the flattened curve in the depictions we see. So, if we are following our public health interventions to flatten the curve in order to save lives, did we miss measure a valued outcome? Are we focused on short term outcomes, like flattening, hoping for a vaccine, or for the virus to burn out in warming environs? Hope is a wonderful human characteristic, but it is not public policy. We don’t know if treatments will be forthcoming, or needed.
Do we know the efficacy/effectiveness of social distancing, or does an epidemic wane on its own? We are clearly not applying that idea systematically. Stay at home orders in Illinois are to April 7, while in Kansas City, it is April 24. The communication of the value of interventions is even worse. For example, wear masks, don’t wear masks, don’t gather in groups of 50, no, wait, don’t gather in groups of 10, no, wait, stay at home, no, wait, cluster transmission, isolate family members. This is like saying in a study, we will give some people the full dose and others less. This haphazard application of the social distancing policy will render it ineffective raising questions if the harm to our society is worth it. And any change, now, with the horse out of the barn, would likely be ineffective.
We are usually socially distanced at home. Yes, we go to sporting events, group gatherings, but data from school closings as a proxy of group social distancing in the 2009 H!N1 epidemic found that if schools closed during the epidemic, or if they closed greater than 6 weeks after a first event, that transmission did not decline. We closed our institutions in these windows of time raising concern for efficacy, and hence, no benefit and only harm. Do any of the public health interventions proposed for us have any semblance of an accurate estimate of the efficacy of the interventions? I see models being published with worst case estimates for outcomes but best case estimates for the efficacy of the intervention. These biased models are inadequate for making choices.
We are presently arguing, even, about just one component of rational choice, the severity of the virus’s outcome. We have not included a discussion of alternative causes of death and “excess mortality” of the virus versus just mortality. Excess mortality (specific to the virus) is hard to measure. Excess mortality in the H1N1 epidemic, for example, was much less than the estimated total mortality. Over 7000 people die in the US daily. Over a two-week period of isolation, then, about 100,000 die. Presently, we estimate 700 (March 25, 2020) COVID-19 deaths during that period of time. This means, we still don’t yet know the consequences of this contagion, yet we are acting as we do.
When decisions are made out of fear and panic, rational choice is buried in biased rhetoric. If we do not have all of the items of rational choice in check, trouble follows. Even if we finally agree on the outcome and its number, that number, alone, will not be enough for rational choice.
I hope to see a transparent, unemotional, non-fear based debate soon. We need it so the public can decide if the harm being imposed is worth the benefit. This is an opinion of course, but, in my view, the public, once informed, usually outperforms their leaders sooner or later.
Perhaps, as we do a postmortem on this epidemic and our response, we may learn a better way of communicating and measuring risk, and a better model of transparent, trade-off based rational decision making. In my view, the public deserves better than what we are getting.
