Various reactions to the coronavirus pandemic in mid-to-late May raise a disquieting thought: What if the logic model of public-health policymaking is structurally flawed? I don’t claim to have an answer or a solution, but I think the question requires meaningful discussion.
Let’s start the conversation by reviewing CDC guidance about preventing the spread of SARS-CoV-2. Then we’ll explore individual and social risk mitigation, followed by the long-term political risks of over-reliance on public health guidance.
Public Health Guidance: The Dirty Secret
Everyone’s heard the CDC guidelines for staying safe during the Coronapocalypse —
- Wash your hands often with soap and water or use a hand sanitizer of at least 60 percent alcohol before you touch your eyes, nose and mouth
- Avoid close contact and practice “social distancing” of at least 6 feet
- Wear a cloth mask at all times when you’re around others
- Do not wear an N95 mask; that model should be reserved for healthcare workers only
- Clean and disinfect frequently-touched surfaces daily
- Take your temperature
Simple, right? But the devil’s in the details.
Public-health officials reduce the management of complex diseases and medical conditions into a small set of easily comprehended behavioral norms. These rules, because they’re intended to be fully intelligible even to people with below-average cognitive repertoires, often elide the details and the counterfactuals. Doctors and public-health bureaucrats issue directives intended to serve as maxims — as a catechism of sorts — that everyone memorizes and observes. Deviation from the catechism is bad, either for your own health (as with chronic-disease avoidance) or for others. When others come into the equation (as with Covid-19), deviation may even be accompanied by legal sanctions or social shunning. In most cases, though, the maxims are useful and benign.
All these rules offer broad generalizations that won’t be applicable in all circumstances, however. That’s the problem with broad-based, simplistic rulesets: They work at a 60,000-foot level, but sometimes prove incoherent at a 6-foot level of social distancing. But because they’re The Rules™ they’re inviolable, even when a proportion of the population recognizes that a specific application of those rules proves absurd. The reaction in Michigan to Gov. Gretchen Whitmer forbidding big-box stores from selling gardening supplies or from people engaging in recreational boating offers an excellent case in point. She invoked restrictions about essential and non-essential business activities that might, at first glance, enjoy some grounding in Science™ but in context stood in almost perfect contradiction to the best available clinical evidence.
(Turns out, you actually should be outside, and both gardening and boating are great environments to get some sun and to get some fresh air while not being in close proximity to others.)
Let’s go back to those CDC guidelines, developed by public-health officials to serve as an easily understood catechism. What are their vulnerabilities?
- Wash frequently: Frequent hand-hygiene is default best practice. The CDC guidelines for frequent hand-washing with soap and water (normal soap, not the antibacterial kind, I might add) is always called for, as is alcohol-based sanitation in the absence of soap and water. This is a good guideline, but it’s universal — not just applicable to SARS-CoV-2. You should always practice good hand hygiene, pandemic or not!
- Social distancing: Useful in principle, useless in (some) practice. Social distancing has been invoked as some sort of magical talisman to ward off infection, but it isn’t. The six-foot exclusion zone is just an average. Given what we know about the way SARS-CoV-2 spreads, in some cases six feet isn’t enough, but in other cases, it’s superfluous. To be infected, you must be exposed to a certain number of active virus particles. At a clean, well-lit and well-ventilated supermarket, passing within two feet someone who isn’t coughing isn’t likely to materially increase your risk of infection. However, it’s several orders of magnitude worse to stand cheek-by-jowl for 10 minutes to buy Michigan Lottery tickets in a dank liquor store with no active ventilation. And the risk of infection outdoors is almost zero; the infinitesimal number of confirmed outdoor-infection cases in China relate to people who stood in close proximity and talked face-to-face, unmasked, for an extended period of time. Keeping eight to 10 feet of distance from unmasked people in a dark and poorly ventilated space makes a ton of sense; keeping six feet away from masked people in a bright, breezy public park offers comparatively less value. But because the rule must be simple and universal, it doesn’t admit to context-sensitive refinement or prudent situational enforcement.
- Cloth masks: The CDC tweaked its message; nowadays, the rule is to wear a cloth mask to prevent the infection of others, not to avoid infection yourself. To be clear: Wearing a cloth mask doesn’t stop you from being infected. Rather, those masks minimize the transmission of virus particles by infected but asymptomatic or pre-symptomatic carriers. That being the case, after you’ve been confirmed to have antibodies and aren’t symptomatic, you aren’t a transmission risk. Yet the “thou shalt wear masks” rule is considered an absolute, with some stores refusing service if you don’t wear one, even when any individual person presents literally zero risk to others or the environmental context is not favorable to virus transmission. In fact, the CDC recommends masks only when “other social distancing measures are difficult to maintain.” When you read the fine print, you discover that the recommendation is not for all people to wear masks in public at all times.
- Avoid N95 masks: From the beginning, CDC said N95 masks weren’t necessary. This lie (and it was a deliberate lie) was intended to minimize runs on these masks, preserving supply for frontline healthcare workers. And as someone who’s worked in health care for two decades, I totally get it. But an N95 mask, if properly fitted and used according to spec, not only reduces your outbound infection risk, but also your inbound infection risk. Everyone should be using N95 masks, not homemade cloth masks. But because the supply chain proved fragile, the CDC offers guidance that is deliberately inaccurate to distort the market for these masks. No matter how noble, a lie is a lie, and when people know it’s a lie, then why should they trust any of the other guidance? Especially when it breaks down within a specific context? It’s difficult to understate the credibility hit that public-health officials took over this about-face on masks.
- Clean and disinfect: CDC recommends daily cleansing of surfaces. However, different pathogens react differently to different surfaces in different contexts. For example, on copper, SARS-CoV-2 has an estimated life of just four hours. On cardboard, it’s 24 hours. On glass, it’s up to five days—but not glass exposed to direct sunlight. But you don’t get infected from a surface; SARS-CoV-2 doesn’t enter the body through hands or skin. If you practice religious hand hygiene, you will not become infected from surface contamination. That said, obviously you should not allow your stuff to become a petri dish of pathogens. But the practice of ostentatiously disinfecting, say, shopping-cart handles doesn’t really matter as long as you wash or sanitize your hands after shopping but before you touch your eyes, nose or mouth. This surface-disinfection practice certainly helps to a degree (what if you involuntarily touch your eye to remove an eyelash? or absently re-adjust your cloth mask and touch your lips?), so it’s not a useless exercise, but it’s an adjunct practice to limit transmission of the virus through the respiratory tract. Fetishizing the cleansing of surfaces brings diminishing marginal utility, but it creates a false sense of security that makes other precautions seem less urgent. (“I won’t bother with hand sanitizer because the nice lady sprayed my cart handle with something, so I’m safe.”) So, yes, clean your surfaces — but understand that surface contamination in itself isn’t an infection risk.
- Take your temperature: Something like 40 percent to 80 percent of all transmission events are estimated to occur from people who are asymptomatic or pre-symptomatic. That’s the big reason for the “wear a mask” rule — you’re highly contagious early in the infection, before symptoms manifest (if they manifest at all). But you only show a fever when you’re symptomatic, and fevers aren’t restricted to SARS-CoV-2 infections. The practice of some healthcare organizations, TSA and some retail establishments of taking surface skin temperatures is therefore odd. If you’re sick enough to be symptomatic, you’re likely not traveling anyway, and even if you are traveling, an elevated temperature (unmanaged by a fever reducer like acetaminophen, which will fool the thermometer in low-grade cases) could source from any of hundreds of infections, not all of which are transmissible. You’ll get a fever if your appendix is about to burst, but you’re not going to mass-infect people with appendicitis if you’re out in public. Public temperature reads are very obviously kabuki theater — no different from TSA “randomly screening” an 85-year-old grandmother.
Put differently: CDC guidance is directionally useful at a population level, but the value of the guidance — because it must be simple enough for low-IQ people to understand — diminishes as you move from the general to the particular.
This phenomenon always applies to the management of any disease condition. Public-health officials focus on the herd, not the individual. Public-health guidance is replete with “rules” that don’t make sense in specific situations but reduce herd risk in the aggregate. Perhaps the classic pre-coronavirus example relates to HIV transmission. The official guidance is to not engage in unprotected sex (without a condom or pre-exposure prophylaxis or both) with someone who is HIV positive or who is uncertain about his HIV status. Yet a person can be HIV positive but maintain clinically undetectable levels of the virus thanks to modern antiretroviral therapies. There’s almost no risk of contracting HIV through unprotected sex with someone with an undetectable viral load. But that kind of asterisk doesn’t fit on a bus poster and it’s not easily digested by a low-IQ audience, so the high-level rule remains unchanged.
(Obviously, unprotected sex can generate other infections beyond HIV, but that’s beside the point.)
Plenty of problems arise when individuals and politicians maximize the 60,000-foot advice at the expense of useful context, though. People cannot properly account for risk through universal rules, and when they experience the disconnect between the universal and the particular, they may dismiss the universal guidance wholesale as “fake news” or “political posturing.”
This 60,000-foot-to-6-foot scale problem may be a fatal structural flaw with the entire discipline of public health management.
Risk Mitigation for Individuals and Groups
In the WEIRD world, transparent and open access to information is crucial. With information, individual actors price risk effectively. That’s why we’ve got laws against insider trading. The pricing of risk — actuary science — can be arcane, but it’s a critical skill for thriving in a complex environment. Every action entails some degree of risk, from which we protect ourselves with insurance or with behavior modification. High-risk activities tend to require higher premium payments, because the insurer is likely to experience higher or more frequent payouts, or more elaborate safety mechanisms. It’s well known that humans tend to suffer loss aversion and retroactively rationalize predicable but low-frequency loss as a black-swan phenomenon. In other words, by default, we tend to suck at accurately estimating risk on the fly. Actuaries are simultaneously boring and critical.
Risk mitigation works on an individual level, too. We all take various steps to reduce potential harm, often when the mitigation step is minor and the potential cost is very high but the risk is very rare — as with wearing a seatbelt to prevent ejection through the windshield after a high-speed impact. Other forms of risk mitigation incur minor costs when the risk is high but the cost is low, as with frequent handwashing during cold-and-flu season. And sometimes, as with Covid-19, we don’t know enough to estimate cost or risk.
Each person must judge risk for himself, though. The relative risk-to-reward ratio is a subjective assessment. One reason the “don’t tread on me” types rejected both the Affordable Care Act and the wear-masks-in-public rule stems from a sense that they price risk differently from the authorities; mandates that overrule a person’s innate risk threshold are seen as an infringement of liberty. They don’t like that their choice to act or not-act has been taken away from them, that someone else imposed a risk-reduction cost that they wouldn’t have voluntarily accepted. And in a tort-happy legal system, the dial seems to turn ever more tightly into a health-and-safety framework that nowadays results in CPS referrals if a kid plays alone in the front yard. A big part of the modern populist movement is, in a sense, a reaction against costly or invasive mandates arising from irrationally low risk tolerances in public policy.
Think of it this way. Assume that two years from now, a new respiratory virus spreads across America. We know that if you venture into a mass public gathering, you have a one-in-five chance (20 percent) of acquiring the illness, and if you’re infected, you have a 1 percent chance of dying. A public-health expert says that in a nation of 300 million, half the people venture out in public once per year. Thus, they estimate that 300,000 people will die in a year from this new virus without interventions. They deem this risk unacceptable, so they ban public gatherings, driving both the infection rate and the case-fatality rate to very low numbers.
A win for the experts, right? All it cost was 1 percent of GDP from lost economic activity arising from the banning of those gatherings, including the loss of 1 million jobs. (And no one calculates the secondary effects of the solution, including increased rates of alcoholism, drug addiction and diseases of despair that arise from the economic dislocation of the public-health intervention.)
But what if instead of ordering a banning of those events, officials laid out the risks? If you as an individual realized that each mass public gathering you attended translates to a 0.2 percent morality risk, would you still go? Would your opinion change if you realized that the only people who died were those with a defined set of risk characteristics that you either did or did not share? It’s likely that these events would shrink, but they wouldn’t be banned. Some people would likely die that wouldn’t in an outright ban, but the secondary economic and health risks wouldn’t materialize, either. It’s not an easy choice, but it’s a necessary one.
The structural bias of public-health policy is that the average citizen is too disengaged, or simply not capable, to make an informed decision in light of these facts. Thus, they set rules — intelligible at a fourth-grade reading level, and often accompanied by pictures — that easily distill to a few slogans that anyone can understand. Even, significantly, people with an IQ that’s more than one standard deviation below the mean, which therefore necessitates the removal of a lot of context in order to preserve the universality and intelligibility of the rule. Plus, they favor population-level interventions (mandatory masks and social distancing, quarantines) in lieu of targeted strategies for clinically relevant sub-populations.
Perhaps, though, public-health officials ought to focus on risk identification and quantification and risk-cohort stratification, and let the mitigation strategy fall to individuals and elected leaders. Because when the experts in a very narrow field gain control of the levers of power, too much goes awry.
The Long-Term Political Risk of Public Health Kabuki Theater
Remember in March when the primary justification for state-level quarantine orders rooted in a fear of over-stressing the health systems and running out of ventilators? Turns out, people across the ideological divide got behind that argument. Then, when the feared stresses and ventilator shortages failed to materialize, some governors changed their tunes. Now, emergency orders were justified to “bend the curve” or to prevent people from becoming ill.
It doesn’t take a constitutional genius to realize that neither state nor federal governments labor under an affirmative duty to prevent individual citizens from acquiring a respiratory infection, even a particularly nasty one. Offer high-level advice? Sure. Pen emergency orders requiring people to remain in their homes and, in many cases, to lose their livelihoods? Maybe not.
Public health officials throughout this pandemic did what they always do: They offer a maximalist case for applied epidemiology: “To minimize harm, engage in these activities and refrain from these other activities.” Too many political leaders simply parroted this advice without translating it into a broader risk profile that included considerations far removed from the public-health officials’ domain of competence. Like, for example, economics. Political leaders who outsourced policy to the most risk-averse public-health expert didn’t effect a good kind of balance. This dynamic played out — in part, from partisan-media laziness — in a red-vs-blue divide among the governors. The reality is a bit more complex; after all, Gov. Brian Kemp of Georgia (a Republican) was targeted by the media for opening Georgia while Gov. Jared Polis of Colorado (a Democrat) did pretty much the exact same thing at the exact same time and the media didn’t pounce.
A better example might source from a pair of Democrats. In Michigan, Gretchen Whitmer cloaked herself in the righteousness of public-health virtue even as some of her directives offered no meaningful effect on public health but scored Democratic Party talking points. Meanwhile, the attorney general, Dana Nessel, publicly argued with President Trump over wearing face masks at the same time that Whitmer herself appeared at a news conference without one. In Colorado, however, Jared Polis reopened the state using a model that balanced emerging cases relative to economic risks. (So did Brian Kemp. And a few other governors, Republican and Democrat alike, didn’t shut down their states at all.)
It’s not red-vs-blue; it’s holistic vs. outsourced. Governors most averse to pandemic risks tended to maximize vague public-health rules and talk about “safety” while governors most averse to long-term economic and secondary public-health costs tended to blend expert advice from many disciplines into a more comprehensive plan of action.
The effect of the safer-than-thou governors may prove catastrophic in the long run — not from Covid-19 morality figures, but from public rejection of the “we’re in this together” argument that makes early, strong action uncontroversial. If, two years from now, a new coronavirus appears with significantly “worse” clinical profiles to SARS-CoV-2, and Gretchen Whitmer invokes emergency powers to shut down the state, will she get an early bipartisan consensus and public support like she did in 2020, or will a non-trivial chunk of the population trot out the “fool me twice” canard and actively resist from Day One?
Worse, ostentatious compliance or non-compliance becomes a form of virtue signaling. Security guards have been killed because they refused admittance to non-masked store patrons; some store patrons have chased un-masked shoppers out of stores. It’s dangerous that a face mask, which is only contextually useful, absolutizes into totemic status. Yet here we are.
You get one chance to deploy public-health emergency powers. Screw it up politically, and you don’t get a second chance, even if the second occurrence justifies the emergency more strongly than the first chance did. I’m terrified of the long-term repercussions of Gretchen Whitmer’s deferral to public-health authorities and her refusal to work effectively with the Republican-led state legislature. Because the next crisis will be worse. And now, we’ve potentially lost a vital tool because we misused it the first time.
But Whitmer’s fecklessness isn’t the whole problem. Perhaps our public-health officials, who are so sure of themselves and of the principles of their discipline, ought to take a long look at whether they made things worse by offering systemic policies that source from one domain of knowledge only, and which didn’t allow for reasonable tailoring at the 6-foot level where ordinary citizens reside.