America’s public health experts are working hard to map out a plan to combat the coronavirus in America. And there are indeed many proposals — from academic centers, from think tanks, and from the government.
While the plans differ, nearly all of them rely on some combination of surveillance, mass testing, isolation, and contact tracing. Many of them point to countries like Singapore, South Korea, and Germany as examples of how to intelligently respond to the pandemic.
But what if the successful strategies in those countries just won’t work in America?
This question was posed by Keith Humphreys, a Stanford University professor who works on addiction and public health policy, in a viral Twitter thread last week. Humphreys argued that a lot of his public health colleagues weren’t thinking seriously enough about the cultural obstacles that might undercut the country’s efforts to test, trace, and isolate Americans. He later penned a Washington Post column drawing out his arguments in a little more detail.
Humphreys’s basic claim is that any plan we adopt, no matter how wise, is useless without “widespread political consent” from American citizens. And the obsession with individual liberties in America, coupled with a general distrust of government, poses an enormous challenge to even the best conceivable plan.
I spoke to Humphreys by phone about what he thinks public health experts are failing to recognize, and if he believes America is too libertarian to handle a collective action problem like the coronavirus pandemic.
A lightly edited transcript of our conversation follows.
Lay out America’s “political-cultural” problem for me. Why are you worried that we can’t deal with this pandemic the way other countries have?
Well, I think we’re different from the other democracies that have handled this well in our long-term resistance to the growth of the state in general, but also in the domain of health. Why is it that every other developed country has government-guaranteed health care and we do not? The obvious reason is that there’s an instinctive aversion to government power in the DNA of America. This is the only major democracy in which a huge number of people have fought to prevent a government guarantee of health care for all citizens.
This aversion is especially potent now, but it goes back to the very beginning of the country, a country founded by people who lived in fear of a king. Our Constitution was set up with checks and balances out of fear of the power of the state. And that libertarian streak is with us through everything and it also applies in the domain of health.
There are some advantages to that libertarian instinct, and I think you admit that, but the problem is that it’s just the wrong ideological software to be running in a pandemic—
Right. I don’t think we want to live in [a more authoritarian society] like Singapore, for example. But the question is what do you do about an epidemic when we really are all in it together and there is no way to run a test, trace, and isolate a program without seriously increasing government surveillance and having access to a lot of quite intimate personal information? Those libertarian impulses stand athwart that.
So I just don’t think we can do what Germany does, where there’s higher confidence in the state and higher trust in the state. I don’t think we can do what democracies in East Asia are doing, where there’s a more recent history of autocracy and a lot of deference to the state. Even though I’m a public health person and I admire all the people working on all the technical problems and thinking about what we should do to halt this virus, I just believe that we’re underestimating the political and cultural obstacles here.
What, exactly, can countries like South Korea and Germany do that we can’t?
In South Korea, you basically had authoritarian rule up until the ‘80s. The adults in that country grew up in a place where if the government was worried about a parasitic infection, you had to submit stool samples to the officials — it’s just what you did. And these are the people deciding, right now, whether or not to follow the orders of their government or whether to hand over personal information. And what we’ve seen is that most people are willing to do it.
The case of Germany is a little different. Contrary to stereotypes, Germans are not deferent to their state. They have a lot of concerns about health information, for example. But I think the big difference there is that people have comparatively more trust in the state. They believe their state is fundamentally competent. Virtually all the polling we have on Americans shows that many of them simply don’t trust the state, and that’s a huge problem when the state is asking you to sacrifice so much for the sake of the public good.
My problem with libertarianism has always been that it gives us a language of rights but it can’t give us a language of obligations — it’s fundamentally an individualistic philosophy. What you’re really saying, in my mind at least, is that America is too libertarian to deal with a collective action problem like this.
Is that fair?
Yes, that’s a very pithy way to express what I’m saying, but it’s exactly right.
I should say that I’m raising all these questions out of anxiety. In other words, I’ll be delighted if I’m wrong. But I keep thinking about other times where we’ve been in precisely this situation around health, going back to Harry Truman proposing national health insurance and getting beaten. And I worked for President Obama, so I was right there as we struggled to get some version of the Affordable Care Act passed. I watched several states turn down Medicaid expansion. And I saw how the ACA was unable to get a single Republican vote and I don’t think anyone lost their seat because of that, because they voted against it.
So I’ve seen this dynamic play out over and over again in different contexts and I worry it will be the thing that limits what we’re able to do in our efforts to stamp out this virus. I guess I can’t put it any better than you: I don’t think we can reconcile our libertarianism with the need for a sense of shared purpose in a time of crisis.
If what you’re saying is true, then it makes no difference who the president is or which party is in charge, because our problems are fundamentally cultural. And in that sense, you’re defining the problem as insoluble.
I think that would be a little bleak. I would say that the president does matter. I was talking to a friend the other day and he said that if Trump put on a mask at a press conference and said, “I’m doing this because it’s a smart thing to do,” that would matter to some people who are resistant, that signal from someone they trust would matter. So it’s not that leadership is irrelevant, but I do think there are real limits to what’s possible in the country and the origins of that stretch back to our founding.
Alright, Keith, you’ve forced me to play the optimist here. I take all your points and I don’t think anyone can deny our libertarian streak, but here’s my counter: A majority of Americans have shown a remarkable willingness to cooperate and social distance in spite of the vacuum of leadership at the top — and that’s true across party lines.
Does that give you any pause at all?
That’s a very good point and it is encouraging. And some of the data I’ve seen from across the country shows that most people are choosing to stay home, even in places that have lifted their lockdown, like Georgia. So there is some consensus on that.
The question for me is, does that translate into behavior? The psychologist in me can see that 80 percent of Americans think masks are a good idea, for example, but does that mean 80 percent of Americans are actually wearing masks? Because I’m not seeing that and I live in one of the places you’d expect to see that.
Wouldn’t it, at least, be fair to say that our cultural capacity might be wider than you’re suggesting? I think we have to be careful not to confuse distrust of this administration with distrust of government as such, even though I agree Americans are unusually distrustful of government.
Still, there are reasons to think that there’s a reservoir of goodwill that could be marshaled if we had a competent leader who mapped out a clear plan to deal with this pandemic, a plan that inspired confidence and justified the sacrifices and the inconveniences—
Well, there are some places where I think you could establish that empirically by looking around the country. I live in the Bay Area, for instance, and the governor, Gavin Newsom, is pretty well-regarded. He was out ahead on this and he imposed a lot of restrictions that people mostly accepted. I suspect most people will follow their local leaders when the restrictions are wise and explained decently.
I would say, though, that I think a lot depends on there being an actual shared interest that’s obvious to everyone. My parents, for example, live in an assisted living community where everyone else is in exactly the same situation, so there’s a total consensus. They do not take visitors, they do not go out. But they can do it because everyone recognizes the shared risks.
To be even more clear, I recognize that a lot of people are willing to cooperate and sacrifice. The question we have to ask, the question that virologists, in particular, have to ask, is will it be enough? If 20 percent of the country opts out, or if several states opt out, will that compromise our national response? Or will it be just enough to keep the pandemic raging on?
My worry is that we’ll have just enough dissent, for all the reasons we already discussed, to keep this thing going. In that case, we might want to factor that into our thinking about what’s possible here. We need some idea of the level of compliance we’ll need for any plan to work, and if we can’t replicate the compliance levels in countries like South Korea or Germany, we probably shouldn’t try to replicate their approach.
Those are good questions and I don’t know the answers.
Neither do I. But look, when I say we’re different from other countries, I’m not saying we’re bad or worse. I’m just making an assessment of what we’re good at and what we’re not good at. I mean, if someone wanted to write a book about how much they hate Keith Humphreys, I’d tell them to publish it in America, not Britain, because the libel laws are more lenient here and we value free expression and you can get away with it. So that’s just an assessment based on the legal culture in this country.
We have lots of strengths in America that can be of incredible value in normal times, but in a pandemic, those same strengths can become a liability. That’s all I’m really saying.
You conclude your thread by saying we’ll probably end up with something like a Swedish coronavirus policy by default. What does that mean exactly? How does that scenario end?
One of the pushbacks I got was that our approach won’t be as good as Sweden’s because we don’t have universal health care. So, I think what this means is that the virus will continue to spread fairly consistently across the country. I wouldn’t be surprised if the death toll has doubled by Labor Day. I would, of course, be incredibly happy to be wrong about that.
And there’s really only two things that could interrupt this: 1) a vaccine, which is very unlikely for at least a year or more, or 2) increased development of therapeutics. So maybe we’ll have a breakthrough in our ability to treat the symptoms. What I think is most likely is that a huge number of people contract this virus and we develop immunity over time. If that happens, the virus will diminish over time, but it won’t be because of our test, trace, and isolate efforts.
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