June 9, 2020
By Dr. Murray Feldstein
The New Yorker recently published a fine article by Atul Gawande, entitled Amid the Coronavirus Crisis, a Regimen for Reentry. A surgeon at the Massachusetts General Hospital, a researcher in public health, and an expert in the science of viral transmission, Gawande outlined the methods to successfully keep viral transmission at very low levels. He found that hygiene measures, viral screening, social distancing, and wearing masks reduced transmission, and he found that organizational culture was important in effectuating these policies. I agree with Gawande’s recommendations and follow his advice.
Gawande also asserted that some jurisdictions are opening prematurely. In his opinion, they have not satisfactorily implemented regimens to reduce viral transmission. Gawande is using the viral transmission rate as a surrogate, a convenient measurement, or endpoint, to decide when to safely open. But there are other endpoints we could measure. I would argue that in the light of everything we know (and don’t know), the ultimate decision of when and how to open the economy cannot be based solely on scientific data. We should consult with appropriate experts to understand the implications of any policy, but, for better or worse, we will be stuck with what is ultimately a political choice.
For example, the transmission rate wouldn’t be important if the virus didn’t harm anyone. Viral transmission is just one many factors that have to be considered: Viral lethality, viral load, occupational exposure, pre-existing medical conditions, socio-economic status, regional transportation, population density, and cultural practices are just a few of many other factors that determine harm.
We could more directly measure harm by using one of several mortality rates as the endpoint. The disease-specific mortality rate is the death rate caused by the viral infection itself. We might use the relative mortality rate to ascertain the relevance of pandemic—this compares the total death rate during the pandemic to the death rate in a control population that was unexposed to the virus. We might use a net death rate that takes into account the deaths caused by the interventions we use to suppress the virus. For example, a lockdown might lead to deaths from spousal abuse, suicides from being unemployed, or cancers whose treatment was delayed.
There are other chilling endpoints. Actuaries could calculate not only the numbers of lives lost, but also the years of life lost. The death of an older person might count for less using that endpoint. Everyone’s quality of life could be arbitrarily but mathematically described on a scale of 1 to 10. A terrible quality-of-life score of 1 might be defined as a chronically sick person dependent on others. The best quality-of-life score of 10 could be assigned to a healthy person responsible for a family. Statisticians then calculate an endpoint commonly known as the Quality Adjusted Life Years (QALY) to develop prediction models for policies maximizing both the number of years and quality of life in the population.
The prioritization of endpoints introduces bias. At age 79, I worry more about how a lockdown impacts the lives of my 11 grandchildren than my own. Some people tolerate more risk than others. We normally don’t worry about the risks being taken by skydivers or mountain climbers when their behavior doesn’t affect others. In a pandemic, one foolish partygoer can cause the deaths of hundreds. Science cannot be expected to take the aspirations, fears, and activities of more than 300 million Americans into account.
We are told by the press, by scientific experts, and by politicians that we are fighting a war against an invisible enemy. In wars, many people die—some needlessly, all prematurely. But, as Peggy Noonan writes, “we cannot commit suicide out of a fear of dying.” Winston Churchill was under tremendous pressure to pursue peace with Hitler after France fell in order to save lives. Churchill inspired his countrymen to fight on, because to him the survival of the British way of life was more important than even death.
Is not the American way of life threatened by this war on the virus? We elect imperfect people to decide what is the least imperfect course to follow. Some people value liberty over their lives. Others regard a loss of liberty the price we pay for a greater good. To disagree is to be human. We expect our leaders to shoulder the burden of making public policy. Let us hope they regularly consult experts like Dr. Gawande to get their opinion, but not accuse them of malign intentions if they do not prioritize any expert’s particular endpoint as the most important one. If we are unhappy, we elect different leaders.
And let us fervently hope that there are still some Churchills around to inspire us despite our disagreements.
Dr. Murray Feldstein is a Visiting Fellow at the Goldwater Institute.