I have no expertise relative to when or how to come out of lockdown and “reopen the country.” But I do see a huge risk communication problem in the way this question is being framed. All too often, the question is framed as when it will be “safe” to come out of lockdown, or what it will take to make sure the process is “safe.”
For 40-plus years I have advised clients never to claim that any course of action is “safe.” If you have decent evidence, you can sometimes claim that X is safer than Y, or safer than it used to be, or safer than some standard, or possibly even “safe enough” that you’re willing to take the risk. But not “safe.”
And if there were ever a time to avoid claiming any course of action is “safe,” it’s in the middle of the worst pandemic since 1918.
If you ask people why they’ve been told to stay home, most people can come up with the answer “to flatten the curve.” But if you ask them what flattening the curve is for, a lot of them get hazy. All too many think it has to do with reducing the number of people who get infected, get sick, and die. Similarly, many hear that we have reached or are about to reach “the peak,” and think that means we’re headed for a time –maybe in May, maybe in June –when it will be possible to resume something like normal living without much risk of getting infected. We see news stories that explain that when that time comes, we’ll need to do a lot of testing and contact tracing, and maybe we’ll still have to wear masks and stay six feet apart and wash our hands a lot. But these stories seem to be telling us that if we don’t jump the gun, if we listen to the experts about when and how to reopen the country, not very many of us will get infected.
All this is mistaken. The purpose of flattening the curve is to spread out the infections so hospitals won’t be overrun. A flattened curve doesn’t mean fewer people get infected. It means fewer get infected at the same time, so the ones who get seriously ill have functioning hospitals to try to save them (and also so people with cancer or heart disease or broken bones have functioning hospitals for their medical needs too).
In other words, if we follow the experts’ advice, and if the experts’ advice turns out sound, COVID-19 will become a slow-moving pandemic instead of a fast-moving pandemic. That’s a big improvement, but it’s nothing like “safe.”
Here’s what almost nobody understands yet. As many experts see the situation, the goal of reopening the country is to regrow the economy as quickly as possible, restore normal life as quickly as possible, and move toward herd immunity as quickly as possible – all without overrunning hospitals. If the hospitals are only half-full, that will mean we haven’t relaxed the lockdown enough; we want the hospitals nearly at capacity but never beyond capacity. We want the curve to stay flattened, but no flatter than it needs to be. We won’t be aiming to infect as few people as we can. We’ll actually be aiming to infect as many people as we can – hopefully young and healthy people – as long as we don’t end up with more really sick people than our hospitals can cope with properly.
Fewer than 600,000 Americans so far have tested positive for COVID-19. Let’s guesstimate that ten times that many –six million –have actually been infected. And let’s make the optimistic assumption that all six million will recover, and that once you’re infected and recover, you’re immune, at least for a while. So six million Americans so far are immune, and therefore genuinely “safe” vis-á-vis COVID-19. If we’re at the peak more or less, maybe another six million will be infected and recover before the experts release us from lockdown. That’s 12 million total. With a U.S. population of 328 million, that leaves 316 million to go.
Not all 316 million will need to get infected before the pandemic is over. At some point before then, enough of us will have been infected that the virus will have trouble finding somebody new to infect –especially if we’re still wearing masks and keeping our distance and washing our hands. That's herd immunity. And if we’re really lucky, an effective vaccine will be developed and mass-produced, so a lot of us can become immune by getting vaccinated instead of by getting infected.
In the meantime, reopening the country will not be “safe.” A lot of people are going to get infected after we reopen the country, and some of them are going to die.
One reason why the public needs to understand all this is to help make it a bit safer for officials to reopen the country without getting blamed for the resulting deaths. If they do it wrong, the pandemic will speed up again, hospitals will get overrun again, and we’ll need to go into lockdown again. If they do it right, we can transition to a New Normal –a New Normal in which a lot of us will s-l-o-w-l-y get infected and some of us will die. We need to understand that going in.
Keeping the country locked down isn’t “safe” either –not even purely in terms of health. Someone with early-stage breast cancer didn’t get her mammogram today because of the pandemic. Someone who lost his job and can’t support his family will commit suicide next year because of the pandemic. Millions of us are frightened and miserable, emotional states that are guaranteed to do well-documented damage to our health.
Still, perpetual lockdown is less deadly than reopening the country will be. We need to understand that going in too.
Literally perpetual lockdown isn’t feasible, of course. But we could decide to stay more or less locked down for more or less time –maybe even for a year or two, in the hope that by then we’d have an effective vaccine. Even if we do it right, following the very best expert advice, the decision to reopen the country without a vaccine is a decision to accept more illness and more death for the sake of resurrecting our economy sooner.
Like most difficult decisions, this is a tradeoff. Framing the choice as saving lives versus saving the economy is a false dichotomy in some ways. But it is a genuine dilemma nonetheless.
Moreover, it is not fundamentally a scientific question. It needs to be guided by science, obviously. But all that scientists can tell us –albeit with high uncertainty –is which pandemic policies are likeliest to keep the pandemic from speeding back up and infecting more people more quickly than our hospitals can handle. That’s surely relevant, but not necessarily dispositive.
Imagine that this were an individual decision rather than a collective decision. What increased probability of disease and death would each of us accept in order to keep our job, our savings, or our home; or for our children and grandchildren to keep their educations, jobs, savings, homes, and prospects?
What policymakers have to decide, guided not just by scientists but also by the public, is what the tradeoffs are between saving the most lives and saving the most of our way of life. That’s not a scientific question. It is a political question. The politicians who have to make this incredibly difficult decision will be guided –and should be guided –by public opinion as much as by expert opinion.
So it would help if the public had a better understanding of what’s at stake.
Two Added Complexities
Several readers have pointed out that I'm assuming people who recover from COVID-19 will be immune (at least to some extent and at least for a while). If infection doesn’t lead to immunity, obviously, there can be no herd immunity no matter how many people get infected – in which case there will be no point in trying to maximize infections just below the level where hospitals become nonfunctional.
Under that worst case scenario, the goal will be to find the best compromise among rebuilding and sustaining a viable economy, keeping hospitals functioning, and minimizing mortality and morbidity – while waiting and hoping for effective treatments and/or vaccines.
Most experts believe some kind of post-infection immunity is likelier than not. But like so many COVID-19 questions, this one is yet to be answered.
Another complexity: It is not yet known what sorts of medical problems may confront people after they have recovered from COVID-19. If these problems are widespread and serious, that too would call into question the wisdom of trying to infect lots of people in pursuit of herd immunity.
Copyright © 2020 by Peter M. Sandman
