How to Reopen America Safely

A much-needed perspective is clearly conveyed in today's Op-Ed piece in the NY Times by Marty Makary, a surgeon and professor of health policy at Johns Hopkins.

His perspective is that lockdowns were the right call 2 months ago, and have had a positive effect, but they have also caused unbelievable harm to people in many ways, some of which he lists. He makes the point that "lockdown vs. full opening" is a false dichotomy, and we have to find a balance between the two, that lockdowns CANNOT continue, but that we also need to be careful. He thinks that based on what we have learned so far, we know several of what I would call "targeted mitigation steps" that will work well, including:

1. Universal mask wearing

2. Spend more time outside

3. Business must adapt to mitigate spread

4. We must prioritize safeguarding nursing homes

5. Protect those at high risk by limiting their interactions.

My commentary: I fully agree with his perspective, and hope his opinion gains traction. I think he is 100% correct, and the false dichotomy of "lockdown vs. fully open" is extremely destructive to society and HAS TO GO. We all need to realize that we MUST find a middle ground right now.

Why do people go to these extremes? I see some people still downplaying the risk of the virus, seemingly not understanding how easily and quickly it spreads and the devastating damage it can do. I also see a lot of discourse (including by some senators and governors) suggesting we can't lift "lockdowns" until it is "safe" to do so that many times comes across as an extreme viewpoint depending on their definition of "safe"

The key is what is a reasonable definition of "safe". Some define it very strictly, with most extreme being until we have vaccine or effective treatments, or some extreme high level of testing and contact tracing in place -- with these types of criteria the lockdowns would continue indefinitely. Others define it more moderately based on some reduced incidence or effective reproductive rate. These might be reasonable, but data subtleties can throw off these strategies as well, e.g. if we increase testing like we should then incidence will rise even if the spread is slowing, which would again serve to extend the lockdowns for potentially long period of time. People need to think carefully about what is a reasonable goal and then set the conditions accordingly. Assuming we can test, track and isolate 100% of the cases is unrealistic in a country like the USA, so while we should strive to do so, waiting to lift lockdowns until we are able would also extend lockdowns indefinitely. People proposing these types of conditions are making a de facto recommendation of indefinite lockdowns whether they realize it or not.

I see two errors of thinking in people whose rhetoric is a de factor recommendation of indefinite lockdowns: 1. status quo thinking and 2. a variety of "identified victim effect"

Status Quo thinking: There are two ways to think about a decision -- one is to symmetrically consider each alternative, weight pluses and minus of each, and then decide which option seems best. I'll call this symmetric decision making. The second is to start with a status quo, and then assess other alternatives and only move off the status quo if there is strong enough evidence. This second way of thinking gives the status quo "favored status."

Status quo thinking is what is used in our criminal justice system, in which "innocence" is the status quo, and evidence of guilt is provided, and guilt is only concluded if overwhelming evidence is provided. Thus, if there is any question, the status quo of "innocence" prevails. This is considered appropriate for the criminal justice system, since putting an innocent person in jail is considered a far worse outcome than freeing a criminal. Thus the asymmetry and bias towards the status quo. In civil court, this status quo thinking is not used, and the case is considered more symmetrically, with preponderance of evidence in either direction enough to sway the decision making.

Many people are affording the current lockdowns with "status quo" privileges, which makes it very difficult to move off of that policy absent overwhelming evidence of "safety" that may be difficult to provide. Why should a lockdown strategy be given status quo status? To do so downplays the risks and damage of lockdowns, and heightens disease control over all other factors. Lockdowns have their own strengths and weaknesses, as do other strategies that involve more moderate mitigation measures.

I think a major reason leading to the status quo thinking is a variant of a well known "Identifiable Victim Effect": The idea behind this is that someone is much more likely to offer aid to a specific identifiable person experiencing hardship, even over other (potentially larger) groups of people who are suffering potentially more but who are not concretely identifiable.

The variant of this effect in play here is that we KNOW how nasty this virus is, and we've seen stories of it tearing some people's insides apart, and seen the horrific setting of overcrowded ICUs and the prospect of care rationing. This makes the suffering of severe covid-19 patients identifiable, and something we all are trying to minimize. Even if the steps we are taking (e.g. lockdowns) against this potential harm causes even greater harm to a larger number of people, that damage is more abstract and less identifiable, so we don't take it into account very much in our thinking. In this case, someone might suggest it is "immoral" to recommend lifting lockdowns if it leads to even 1 more death to COVID-19, since that is identifiable suffering, because they view the only benefit of lifting the lockdowns as "economic", which to them is abstract and impersonal. But they don't recognize that the lockdown may be causing great damage to a large number of people, not just inconvenience.

This article above paints a picture of some of the damage caused by lockdowns -- damage to public health with neglected prevention and care, damage to mental health from loneliness and isolation, damage to education of children, and of course economic damage. The economic damage is not just temporary damage that will reverse course once lockdowns are lifted -- the longer the lockdowns last, the damage at some point becomes nonlinear, irreversible damage, as businesses go under never to return, people's savings over many years are lost, and people go into debt that they cannot easily recover from. This economic decay can have significant impact downstream in public health capacities and dealing with hunger and poverty, which affects many lives as well.

My strong view has been that states and municipalities need to view various mitigation strategies, including lockdowns as well as other less extreme strategies, in a symmetric way, bringing to bear the knowledge we have attained and weighting pros and cons of each strategy. If they are considered in a symmetrical way, I would argue that most people would conclude that it is time to move off of total lockdowns, immediately in most places and soon in the others.

Given the widespread reach of the virus at this point and the long timeframe for viral control through vaccine or treatment, it seems to me that we need to accept that the virus will continue to spread to some degree and do what we can to slow its spread and manage it in a way that allows many other elements of society damaged by the lockdown to begin to recover. The balance of risks need to be weighed not ONLY considering viral spread, but also getting expert knowledge from economists, psychologists, and educators to take into account the other less obvious factors affected by lockdowns.

We need to increase testing, institute some form of contact tracing and isolation of cases, and need to push certain mitigation measures such as mask-wearing, avoidance of big crowds, and establish procedures for hygiene and social distancing, while taking extra care to protect the most vulnerable.

It looks like we are getting there, but I am still frustrated with the false dichotomy and extreme positions on both sides that I see many espousing.


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