When Do We Stop Counting? | The Turning Point

All over the country, over the course of a few months, there were about 21,000,000 symptomatic cases, 290,000 hospitalizations, and 37,000 deaths.  More than 25,000 of the deaths were in the 65+ age group. 

It seems likely that this type of case and death count recitation is familiar to the reader, seen through the lens of Covid-19, where we have assiduously documented cases and deaths for the greater part of two years. But these numbers were not Covid-19 numbers. They were cases, and deaths, from flu, during the 2010-2011 influenza season, one of the worst seasons in the past decade. We wonder: how many of us were aware of the daily case and death count during that flu season more than a decade ago?  And, perhaps more importantly, would we have behaved differently as a society if we had beenkeeping track of cases and deaths the way we have been during Covid-19?

In some ways Covid-19 case and death counting, 18 months into the pandemic, has taken on an uncomfortably familiar role, with tallies being reported in all media in much the same way as, say, the weather, which is also reported daily. But what impact does this abundance of reporting have on how we think about the pandemic? 

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How sunk-cost bias can obscure our vision of a post-COVID world | The Healthiest Goldfish

In science, it is customary for researchers to disclose any potential bias, as part of the process of publishing work. While this is often considered in the realm of financial biases, I have previously suggested that our other biases—our mental architectures that shape how we think, why we do what we do—matter as much, or perhaps more than, easily quantifiable other biases. With this in mind, I will here disclose my own bias, one which has relevance for how I see, and write about, the COVID moment. My bias is this: if presented with a choice between, on one hand, absolute safety at the cost of the interactions and experiences that make life worth living, and having these experiences with the understanding that doing so entailed some amount of risk, I would choose the latter.

Let us call this the sunk cost bias. This bias is our tendency to continue with a given approach to health not necessarily because the data support it, but because we have already invested much in pursuing this approach. The sunk cost bias echoes the sunk cost fallacy, where we continue with a behavior or investment because it is something we have long done. The sunk cost bias is the last in a series of three biases I have discussed in recent columns, as part of the lead-up to the November 1 launch of my new book, The Contagion Next Time, which aims to help us see the true causes of health during a pandemic, which our biases can obscure.          

In some ways, I think my bias is a product of being an immigrant, one who has—like many immigrants—worked to construct a life in a new country, often in the face of uncertainty and risk. While my journey from Malta to Canada to the US has been far less difficult than the journey of other immigrants, I nevertheless know what it is like to experience the challenges that are ever-present in the life of the immigrant. I also know what it is to choose to undertake such challenges in search of a better life, to willingly accept uncertainty and risk because moving forward seems to demand it. This perhaps helps counter the sunk cost bias—I may have a particular perspective on the status quo we have traded in exchange for a feeling of greater security during COVID-19, understanding that it was never as certain as it perhaps seemed. This sense of permanent uncertainty, and the ability to live with it, can help us avoid persisting with approaches that seem to lock down a sense of security which is, in fact, more illusory than we may care to admit. Once we recognize this uncertainty, we are that much closer to realizing that life always entails some measure of risk, and the challenge is to learn to coexist with, rather than eliminate, it.   

Read the full post at The Healthiest Goldfish.

Can Contact Tracing Work Here? | The Turning Point

One of the disappointments in our pandemic response has been the limited ability of our contact tracing—one of the fundamental activities of public health during an infectious disease outbreak—to control Covid-19 transmission. Hong Kong and Singapore initially contained their outbreaks by deploying thousands of public health workers to track down every person with a newly positive test, figure out whom they had been in contact with, and quickly get those people to quarantine. The United States did not. Which raises the question: have we now learned something about how to better perform this ancient public health function to make us confident that we could do better the next time around?

The US public health system faced three challenges in its attempt to make contact tracing work. First, we had inadequate Covid-19 testing early on: we could not identify all positive cases. The testing system failed—long waits to get tests and then more waiting for results. Without being able to readily identify and test those who have been in contact with an infected person, the chain of infection continued. By the time testing was readily available, rapid, and mostly free, the number of people infected far outstripped the supply of contact tracers.

Even if we had accurate testing available soon after Covid-19 was identified, workforce limitations was our second problem. Four months into the pandemic, in May 2020, we had only a fraction of the public health workers needed to launch an effective national contact tracing effort. At that time—with only 30,000 persons having tested positive—public health experts told Congress the country needed to increase the number of contact tracing staff tenfold to 100,000 or more. Yet even in December 2020, at the peak of US case load, there were still only 70,000 contact tracers nationwide.  Widespread community transmission across the country occurred within a few months of Covid-19’s arrival; it is unclear that any number of contact tracers could have kept up. The numbers grew too big too fast.

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The problem of positional bias | The Healthiest Goldfish

In last week’s Healthiest Goldfish, I discussed how our individualist bias can stop us from seeing the full picture of what matters most for health. Today, I would like to talk a bit about how our positional bias can do the same. I do so as part of a series of columns leading up to the November 1 release of my new book, The Contagion Next Time, which aims to help us look past our biases to see the true causes of health during the pandemic, so we can prevent the next one.  

Positional bias is, broadly speaking, when our vision of health is blinkered by our socioeconomic status—when we cannot see past the confines of our own immediate circumstances, to recognize the true drivers of health. I recently wrote about a form of positional bias when I touched on the suburban impulses that helped shape attitudes towards COVID policies, as stricter lockdowns were more widely embraced by the populations most able to easily navigate them.

For today, I will use a different example, that of vaccine hesitancy and the challenge of understanding it. As I write this, the US is currently undergoing the delta wave of COVID-19. What is distinct about this wave is that nearly all COVID deaths are among the unvaccinated. While the vaccinated can still be infected—although this is rare—we have seen a dramatic decoupling of infection rates from death rates. This speaks to the effectiveness of vaccines and the danger posed by vaccine refusal. On April 19, 2021, the date by which President Biden said all adult Americans would be eligible for the COVID-19 vaccine, there were 567,314 total COVID deaths in the US. On October 15, there were 742,008 total deaths. While the 174,694 deaths which occurred between these two dates cannot be laid entirely at the feet of vaccine hesitancy, it is undeniable that mistrust of vaccines informed the conditions that made these deaths likelier.

Read the full post at The Healthiest Goldfish.

Why did we Keep our Schools Closed? | The Turning Point

By March 2020 the Covid-19 pandemic had taken hold in America, and within a few days the country had moved to an unprecedented slowdown of civic and professional life in an effort to limit the spread of the virus.  As part of this general shutdown we closed K-12 schools. In spring of 2020, 48 states required or recommended the closure of public schools; more than 50 million children and their teachers stayed home. In the face of a new, poorly understood virus, our collective shut down was entirely reasonable, and to a large extent remarkably successful.  

And yet, by the summer of 2020, data were emerging that showed that children were less likely to contract Covid-19, and if they did, their disease was mild, and they had a low probability of transmitting it. Data quickly accumulatedshowing that children were unlikely to be an important cause of viral transmission. This, coupled with other data showing the educational and social developmental losses that were being incurred due to persistent school closure—often affecting marginalized children more than others—made a strong argument for re-opening schools in the fall of 2020.  

And yet, schools continued to remain closed, affecting as many as half of allchildren in the US in the fall of 2020 with only about a quarter of schools remaining fully open for in-person learning. Why did schools stay closed when we knew that the risk of them staying closed probably outweighed the risk of them re-opening?  Of course, societally, we are always particularly tentative if we can imagine even the smallest risk of children dying. But we suggest that there were three additional reasons, and that we might do well to learn from each of them.

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Looking beyond our biases | The Healthiest Goldfish

The 1999 film, The Matrix, is about a man who discovers the world as we know it is actually an elaborate simulation created by intelligent machines who use it to control humanity in the “real” world—a dystopian future where the machines have taken over. In the decades since its release, the premise of the film has become an established metaphor for realizing that the world as it is can sometimes be radically at odds with the world as we perceive it. As one close-to-home example of this, I can recall the moment when I realized that health is more than doctors and medicines; that health is, in fact, an emergent property of the world around us, and that working to improve health means working to improve the context in which we live, and that it is that world that we should be focusing on to improve health.

Much of my career in public health has been an effort to make this very case—a vision of health that only sees health care is incomplete, that we need to talk about far more when we talk about health than treatment alone. In the post-COVID era, this strikes me as more important than ever. The dominant sense of the last 20 months is that what we just lived through was fundamentally a story about a virus. This, I would argue, is wrong, or at least incomplete. True, a coronavirus was the precipitating factor in what we experienced. But the nature of that experience was deeply, decisively shaped by the same factors that always shape health—politics, culture, the economy, the places where we live, work, and play, our social networks, and other structural forces that shape our world. Preventing the next pandemic means engaging with these forces, to shape a healthier society. To do that, we must first be able to see them clearly, to take the measure of their influence on health. Helping us do so is the aim of my forthcoming book, The Contagion Next Time, which will be released on November 1. The book argues that the pandemic was, at core, a story about how structural forces in our society left us vulnerable to the virus. The title is a tribute to James Baldwin’s book, The Fire Next Time, which helped readers better see the challenge of racism, and to insist this challenge must be faced in order to avoid future catastrophe. Contagion aims to shine a spotlight on forces in our society that shape health by examining them through the lens of the COVID moment, and in so doing cast light on the world as we should perceive it, rather than the world that dominates in the public narrative.

Recognizing then that we need to see the world somewhat differently has me asking often, what is it that keeps us from seeing the right world? It seems to me that we see the world the way we do through our biases. 

Read the full post at The Healthiest Goldfish.

Does Today Matter more than Tomorrow? | The Turning Point

Covid-19 has shown us that the present—the today—can be, at times, overwhelming in its salience, and there is little that we can do, or indeed should do, that does not focus on the needs of the moment. At the beginning of the Covid-19 pandemic, in the first terrifying few months of a disease that we did not understand, it was appropriate that we invest every bit of our effort in mitigating the immediate threat we faced. But at what point does tomorrow matter more than today?

There are multiple ways in which one can approach this question. Economists approach it through time discounting, the study of how the value of rewards is shaped by their temporal proximity. Benefits that accrue in the present tend to matter more than those that may accrue in the future, losing value the more distant they become from the present moment, simply because, all things being equal, we put more value on the bird in the hand. There are, of course, alternative perspectives. If we prioritize the needs of future generations-- any parent who invests their money into college funds for their children rather than buying a new car does this—we are valuing the future more than the present.

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Inefficiency in the pursuit of excellence | The Healthiest Goldfish

Among the lessons I am trying to learn, as we navigate the COVID-19 pandemic, is how best to learn from inefficiency. Let me explain. It seems to me that at our best, as a society, we aspire to efficiency in pursuit of excellence. This pursuit entails looking for ways to maximize our time and resources; a focus on improving skill sets and finding ways to enhance productivity. In public health, we pursue efficiency towards the aim of shaping a healthier world. This lends itself to a particular worldview in which we tend to see events through the lens of the conditions that shape health and our commitment to improving these conditions.

This perspective informed our response during COVID, yielding both success and some shortcomings. It allowed us to get much right, helping us provide the public with effective recommendations as we navigated the pandemic. But a fair assessment of our performance during COVID would have to concede that we also had some blind spots, areas which fell outside our perspective, exposing the limits of our collective focus. We did not always account for the degree to which partisan politics mediated how populations engaged with public health recommendations, nor were we always effective at seeing our own biases and how they informed mistrust among the populations we serve. Instead, we did what we do—focused on the core aims of our field, worked to refine our methods, and proceeded from there.

This suggests that there is more to getting better at our mission of supporting health than the efficient pursuit of our core focus to the exclusion of all else. There is also the richness that comes from the interstices, from seeming inefficiencies, from the detours which ultimately take us to a different, perhaps better, destination then where we thought we were going.

Read the full post on The Healthiest Goldfish.