Michael Tackett of the Associated Press noted we are experiencing a “historic referendum on risk” in a recent article. He quotes Peter L. Bernstein.
“The revolutionary idea that defines the boundary between modern time and the past is the mastery of risk: the notion that the future is more than a whim of the gods and that men and women are not passive before nature. Until human beings discovered a way across that boundary, the future was a mirror of the past [and] the murky domain of oracles and soothsayers…”
Tackett notes we know the risk of some common causes of death: dying from heart disease 1 in 6; dying in a car crash, about 1 in 106, etc. He notes we do not yet know the risk of SARS-CoV-2 infection, because the data are incomplete. I agree, but I predict the worst-case scenario is the death rate is going to be around 1%, or comparable to risk of dying in a car crash. Presently, we are all anxious about going out in public but think little of driving our cars when we decide to do so. So why does the risk of driving our cars seem so much less than the risk of dying of the coronavirus? I would argue the difference is one of familiarity, but it might also be that the car is visible, and the virus is not. There is also the notion that you control your car, but not the virus. Statistically the notion of control is the illusion, of course, but it does engender some comfort.
You might argue the pandemic is worse because the deaths are being concentrated in a short period of time. I would respond that the analogy is to airplane crashes. They always make the news because of the large number of deaths, but statistically, flying is much safer than driving.
Practicing physicians, of course, are accustomed to discussing risks and benefits of proposed courses of treatment with patients. Five years ago, during an influenza epidemic, I wrote about risk and reasons patients don’t follow medical advice, noting that only 40% of the population was vaccinated against the flu, even though we know there will be a spike in cases every winter. I quoted Lisa Rosenbaum, who had published an essay on how people feel about taking medications for heart disease. She identified several categories of barriers, including perceived risk, the difficulty visualizing benefits, the idea that taking medications meant they were “sick,” a desire to avoid dependence, and emotional intelligence. In the case of responding to the pandemic, we are asking people to make changes not only for their own health, but for the health of their communities. Is it any surprise it is a hard sell?
We are now coming out of what to my knowledge is the largest effort at quarantine ever attempted, lasting from four to six weeks, depending upon the jurisdiction. While I have not talked to the experts, I suspect most of them would say this massive experiment worked as intended—the curve was flattened, and deaths were avoided. The latter point is harder to prove, of course. Measuring what did not happen is always harder than measuring what did. Now we are seeing what the side-effects and risks of our giant experiment in mass quarantine will be.
Tackett also quoted Professor Zach Finn of Butler University in Indianapolis.
“I have become increasingly concerned that we are taking a very powerful medicine, in the form of social distancing, without a proper list of side effects. I liken social distancing to chemotherapy. I am so grateful for the health care professionals who have developed both. However, we do not recognize chemotherapy, or any medicine, as a panacea without risks and/or side effects. While it is true that chemo destroys cancer cells, it is known that it also destroys healthy cells.”
Said differently, every intervention has a benefit and a cost. Calibrating the “right” degree of benefit for the right degree of cost is difficult both individually and as a society. Yet our public debate continues to be framed in a “us-them,” or maybe “lives v. money,” duality. I suspect many of our political actors would be horrified if they realized they had adopted a dialectical view of the world compatible with the ideas of Friedrich Engels and Karl Marx. In truth, it has always been about “us.” We each must decide to engage in social distancing and decide how much of it we are prepared to do. And there is no right answer.
I have noted a curious phrase creeping into the advertising on commercial television. The serious-voiced announcer begins by saying: “In these uncertain times…” we should buy a meal, a car, or shop at a particular store. What is curious, of course, is the notion that the time before, say January 2020, was a “certain” time. I suspect at some level we do think that, but risk is always with us, even if we, like our patients, choose to stay in denial and grasp at the illusion of certainty.
As we seek to restore our institutions (and our markets) after our mass quarantine, I wonder if we can recognize life is always conditional and always uncertain, other than death and taxes, of course. I wonder if we can build organizations with more flexibility and more resilience, recognizing the most “efficient” or “economic” way of doing things today is a transient convergence of forces, not an immutable law of nature? I have said before our focus on today’s economic balance sheet is too narrow for healthcare organizations. Is it too narrow for any organization? Are we taking proper account of other costs, environmental, human, or societal, that we should try to include? These are questions I am not qualified to answer, but that does not mean the questions are not important.
We can easily look up the number of coronavirus cases or deaths in our area, but it does not tell us what do. It does not even reliably tell us what the risk is, unless there are no new cases being found. This could be an opportunity to recover a truer perspective on life. Unfortunately, I suspect we will succumb to the lure of certitude, no matter how illusory.
25 May 2020
 Tackett M. As Nation Reopens, a Historic Referendum on Risk Begins. The Jackson Sun, 23 May 2020, p. 6D. [The article was posted online 21 May 2020 at https://apnews.com/4038455e0483a9da7ea651c580a08981. Accessed 25 May 2020.]
 Bernstein PL. Against the Gods: The Remarkable Story of Risk. (New York: John Wiley & Sons, 1996.)
 Rosenbaum L. Beyond Belief—How People Feel About Taking Medications for Heart Disease. N Engl J Med 2015;322(2):183-187. doi:10.1056/NEJMms1409015.
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