Covid-19 has turned life into an endless series of risk calculations. Can I take my child to see their grandparents, even if it means getting on a plane? Is it okay to begin seeing friends or dating? Should I attend religious services even if they are held inside? Do I have to wear a mask around my roommates? The profusion of these questions reflects public health failures, but we live in the wreckage of those failures. So how do we live our lives?
Julia Marcus is an epidemiologist at Harvard Medical School and a contributing writer for the Atlantic who has penned a brilliant series of essays about how to think about risk in the midst of this pandemic. Marcus’s starting point, which emerges from her previous work on HIV prevention, is that an all-or-nothing approach is blindly unrealistic: Everything is a trade-off. Shaming is a terrible public health strategy. And we can’t have a conversation about risk that ignores the reality of benefits, too.
In this conversation on The Ezra Klein Show, Marcus offers a framework for making key life decisions while at the same time managing coronavirus risk. We also discuss what the risk calculation for someone living in Germany or South Korea looks like, how the US government’s abdication of responsibility has shifted the burden of risk management onto individuals, the kinds of activities we tend to underestimate and overestimate the riskiness of, the principles that should guide us in the age of coronavirus, how long we can expect this pandemic to last, and much more.
In March, if I’d ask you to predict what kinds of risk decisions we would all be making today, would you have predicted something like this?
I don’t think I would have predicted where we are now until sometime in April. In March, I was still in the camp of hopefully we’ll get this sorted out pretty quickly.
In early April, it became obvious not just to me but to everybody that this was not going away anytime soon. And that really shifted my thinking. I think there was a big shift societally around needing to think about sustainability. It took some time, and I think we still have not actually fully caught up to that in terms of the way we’re thinking about navigating our everyday lives.
What haven’t we caught up to in terms of that everyday thinking?
If we think back to March, there was some very binary thinking going on around two options. One was: Let’s just stay home until there’s a vaccine. And the other was: Let’s just go back to business as usual. Of course, there’s a million things in between; risk is not binary. I think we’ve gotten out of some of that binary thinking. But, in a way, I think we have unfortunately continued to apply binary thinking, not just to staying at home versus business as usual, but also to masks to schools to Sweden, you name it.
Any hot button topic right now has become dichotomized in a way that I find really concerning, especially around scientific decision-making and also for people making everyday decisions who are trying to navigate this. There has to be nuance in all this, and I feel like nuance died sometime in March.
The conversation I want to have today is about how to think about risk in this era. It strikes me that the question of risk has been shunted far more onto individuals than I would’ve hoped a couple of months ago. We are living in the void where an effective policy response should have been. If our contact tracing and quarantining and testing was where it should be, the question of risk management for individuals would be very different; risk that would have been shared between individuals and government is now risk that individuals have to bear the bulk of themselves. Do you think that’s a reasonable way of looking at this moment?
I think that’s exactly right. The burden of decision-making and risk in this pandemic has been fully transitioned from the top down to the individual. I think it started with basically being transitioned to the states, and then transitioned to the local school districts, for instance, and then down to the individual.
I think you can see it in the way that people talk about personal responsibility and the way that we see so much shaming about individual-level behavior. It’s true that individuals have responsibility in an infectious disease outbreak, and more than usual in the sense that our choices affect other people. But there’s been a total abdication of responsibility at the top to create an environment in which individuals aren’t burdened with that much risk and have to make those decisions entirely on their own.
And it’s not just a policy gap. Compounding that is a public health messaging gap. The CDC has been silent or silenced. And without that unified public health voice, I think there’s so much more confusion than there has been in similar situations in the past when we have had a well-respected, trusted public health voice that we’re hearing from on a regular basis. You can see the difference in other countries where there really is that voice — it makes a difference in terms of public trust and people’s willingness to make sacrifices that are really difficult right now.
What often feels so hard about this moment to me is that it’s one thing to manage a risk that primarily falls on you as an individual, but for many of us who don’t have co-morbidities and are not in an at-risk age band, the bigger danger is not the risk to me but the risk of me passing it on to someone for whom it’s even more dangerous. I find that much harder.
Could you talk a little bit about that difference and how it changes our conception of risk in this conversation?
I think this is very salient on college campuses right now where people who are somewhere between the ages of 18 and 22 are being asked to make enormous sacrifices to prevent something that is a very distal risk for them. They are also at risk of infection, and some of them may or will have bad outcomes, but for them it’s a much lower risk than, say, older people in the surrounding community or their families who they live with.
And we’re not asking people to just make a slight shift in their behavior — this is not just a seatbelt we’re talking about. We’re talking about asking people to make radical changes to their behavior that may be really counter to what they need and want in their everyday lives. And we’re asking them to do it not for themselves but for others. It’s a big ask.
I’m not saying it’s not something we shouldn’t ask, but it is something that we need to consider when we make these asks. We need to find ways of making it easier for people to make that decision without just saying, “If you really cared about other people, you would do this, and you’re selfish if you don’t.” There has to be some give there and some recognition of what we’re really asking and what’s realistic and what’s sustainable.
Does social shaming and scolding work as a communication strategy around public health?
I generally try to stay away from absolutist responses, but my instinct is to flat-out say no: Scolding and shaming are toxic to public health. Almost full stop, with very few exceptions.
I think it’s a natural instinct to want to shame somebody for several reasons. One is we’re watching people do what we perceive as risky, and it’s not just putting themselves at risk — we’re watching them potentially put others at risk. There’s a lot of frustration and anger that comes up in that situation. But from a public health perspective, trying to shame somebody into changing their behavior just doesn’t work. It doesn’t deter the behavior generally. For some individuals, it might, but on a general population level, what it will do is actually just deter disclosure of the behavior. So if we think about what shame is doing, it’s essentially saying you’re a bad person for doing this.
Going back to the colleges right now, we’re seeing plenty of examples of administrators saying you are selfish and reckless and irresponsible — that doesn’t put somebody in a place of action to change their behavior. And it also doesn’t solve the root problem. An alternative approach is to say, “What’s actually going on here? Why are students partying or why are people not wearing masks?”
If you take a step back and ask that question, you might come up with a very different approach. In the case of college students, you may conclude that they really need to socialize and have fun. They’re like 19 years old — this is what 19-year-olds do. So then the question becomes, how do we help them meet those needs in a way that’s safer? And that is far more productive in public health. We see it for HIV prevention, for substance use. It’s the same situation here with Covid where we really need to be thinking about how we can help people meet their needs, not how we can shame them into changing their behavior.
Let’s talk a bit about what we’ve actually learned here. What are behaviors or activities where we tend to overestimate their coronavirus risk, in your experience? And what are things where we tend to underestimate the danger? What is off in our social and societal risk perception?
That’s a hard question to answer in a generalized way. I think everyone is assessing risk differently, and policy-level decisions about risk differ wildly depending on the setting because we don’t have a national response — we have many local responses that look very different.
At the policy level, we see situations like a few weeks ago in Hawaii where there were indoor restaurants and gyms open, but public outdoor spaces like beaches and hiking trails were closed. That struck me as really backwards.
We see some of that on an individual level as well, where we have some people who are still disinfecting their groceries, even though there has been little to no evidence of fomite transmission. I would not say it’s impossible, but it appears to be a low risk. And then we have people who are having crowded indoor gatherings with family because they feel like family is probably pretty safe and they’re not registering that as potentially risky.
So I don’t think there’s one way that we are assessing risk in the wrong way. I think there’s a variety of myths and misperceptions around risk. And that’s normal. I see it in HIV as well. We are not robots, we are human beings. And we’re not going to assess things perfectly all the time.
It strikes me that it would have been good from the beginning to build out a couple principles that seem to apply to everything. One is that anything that can move outdoors should. We know people are not going to stay in their homes all the time. If we can get them outside as opposed to inside, that will be better. I think we should be permissive with outside activities and really urge it so people are not driven inside. Also, if you’re going to be seeing people, which is a reality for most at this point, I think it would be better if that was a stable set of people. And then, of course, there’s masking when you’re around other people.
It seems like there could have been like five or seven things like this that should have been the principles that we should have been almost restructuring society around for a while. And instead, we’re just fighting over every individual case endlessly with no resolution and a billion different plans in a million different places.
You summed it up beautifully. I think that’s exactly what’s happening. And I couldn’t agree more about outdoor spaces in epidemiology. When we talk about relative risk and we look at various causes and effects, we rarely see relative risks above like 1.5 or 2 — like twice the risk in this setting versus that setting or this drug versus that drug. When we talk about outdoor risk of transmission versus indoor, we’re talking about like 20 times difference with indoor risk being 20 times higher. So it’s just a huge prevention opportunity.
And, as you said, we are not going to stop interacting as human beings. So let’s find ways to keep our contacts at a minimum and keep them outdoors. If we work with that framework, I think there’s a lot we can do. That is more sustainable than the approach we’re currently taking, which is fragmented and unproductive.
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