Recently, a friend and East Coast professor called me upset after watching cable TV news (a rookie mistake).
“I am sick of hearing the ill-informed opinion of an <insert specialty> doctor.”
I had a hearty laugh. Indeed, it sometimes felt like those doctors dominated the news cycle, and some parroted a position they thought was a consensus view but was too often riddled with internal inconsistencies. As he continued to specialty bash, I had to point out that some terrific people, friends of ours, were in that field.
“Be fair, though,” I said, “Some folks in <insert specialty> are pretty sharp. What about…,” and I rattled off a list of names. He agreed and walked back his statement. It wasn’t the field, he admitted, it was a few specific comments made by a few people.
The Spectrum of COVID-19 Beliefs
Throughout the COVID-19 cycle, there has been a broad spectrum of thinking. At one end is denial: COVID-19 doesn’t exist or is no worse than a cold or flu; go out and live! On the other extreme is fear: COVID-19 is apocalyptic. We can’t let people say goodbye to dying loved ones. We all must seal ourselves at home, close borders, ban school, and did I mention the variants are coming? The truth is most of us are somewhere in the middle of this spectrum. And we have our public policy ideas and our personal tolerance of risk.
For instance, a middle point of view might be that COVID-19 is a serious threat, and folks who can work from home should be empowered to do so, but schools have to stay open — as they mostly did across Europe — just like hospitals have to stay open. Vaccination is great, and we should encourage it, but vaccine passports might not work or have unintended consequences.
In our personal lives, we also exist along the spectrum. Some were happy to meet select people for dinner and drinks this whole time — mostly outside and distanced, but perhaps not always. Others might have been reluctant to lower their mask even at a park, or may have been completely unwilling to meet with anyone not in their household. And others might have taken greater liberties — met new people, spent times indoors. As the pope might say, “who am I to judge?”
No matter what your policy views are or where you fall personally, we have all been frustrated with ideas and points of view we disagree with. Some people are too risk averse, and others too risk tolerant. It’s like the old George Carlin joke, everyone driving slower than you is an idiot and everyone driving faster is a maniac.
It is natural in these situations to assume that your set point is right, and that others are wrong. But it is also inevitable that there will be a distribution of views, and we will each have our personal set point for COVID-19. Now, let’s turn to the experts.
Personal Views Versus Good Policy
So many hours have been wasted on debating who is a COVID-19 expert, but it generally boils down to this: we all like people who share our set point. On social media, you can almost intuit someone’s personal risk thresholds. I feel I can tell the person who has holed themselves up in their apartment, wearing an N95 alone in their car, from the person who is holding a backyard BBQ (limited to three households), from the person having dinner parties in a dimly lit dining room, saying they don’t believe in masks. And, sure, I also gravitate to the person with views closest to mine.
From a policy standpoint, we do the same thing without knowing it. We like people who promote policies we think are sensible, reasonable, and pragmatic, but not those who go too far, or are too cavalier. On social media, and in New York Times articles, we ask, what do epidemiologists, infectious disease physicians, pediatricians, pediatric infectious disease doctors, front line physicians, virologists, intensivists, and Tony Fauci, MD, think? But none of these ‘tags’ or symbols is synonymous with good policy.
In fact — and I hate to say it — unlike your internal ‘personal’ risk thermostat, the policy thermostat actually does have a right answer. We might not know it, but there are surely policies that maximize human well-being and ones that do not. The problem is there is no set of credentials that predict the people who advocate for good policy from those who advocate for bad policy. The folks who are reasonable in this space can come from art history or epidemiology, but what unites them is understanding a set of core principles and thinking. Let me take a stab at what those principles are:
1. Amid unprecedented threats, governments can use unprecedented powers, though they must do so judiciously. All good policy people get this. When you face a threat unlike historical or common threats, a response may require using unprecedented powers like diverting vaccines, breaching contracts, expediting regulation and shutting down movement, or mandating interventions. But you have to use these sparingly. You can’t become an oligarch or dictator. You have to appreciate what people are willing to sacrifice, and what is inviolable. You have to pick and choose your interventions. Choose wisely! Do what works, and abandon what doesn’t. Don’t close outdoor ice-rinks, but do consider improving ventilation, providing N95s for people who work in slaughterhouses and factories, and offering paid sick leave for everyone working in person.
2. What works in theory doesn’t always work in practice. Good policy analysis recognizes that the gap between theory and practice is the Grand Canyon. A mannequin study on masks has nothing to do with actual humans and certainly should not shape policy. If you think something works in theory, ask yourself how much benefit it provides. Vaccines provide 95% relative risk reduction — let me assure you, every other intervention provides less than that. Now, whatever effect or benefit you imagine from an alternative intervention, cut it in half. As two months roll by, cut it in half again. Good policy is knowing that medical and public health interventions that run counter to human nature have modest impact and diminish as people fatigue. Don’t lament it. That’s the way of life. Accept it, and plan accordingly.
3. Everything has tradeoffs, and you only see some of the consequences. Every single thing you do has trade-offs. You can close schools for more than a year in California, but you will pay for that. There will be loss in educational outcomes; there may even be more drop outs, violence, or teen pregnancy. And you may destabilize society in a way you cannot imagine. You may have paved the path for the political success of a despot or tyrant. Good policy means having the humility to know what is unknown. Assuming it is unfavorable, would you still act like you do? This means good policy should consider someone’s age as it decides who to prioritize for vaccination.
4. Human beings are primates. And primates have needs. Good policy people never forget people need food, clothing, company, sex, intimacy, dialog — and policies that preclude or prevent this have a short shelf life. The writer William Faulkner said that all good stories contain “love and honor and pity and pride and compassion and sacrifice“…”the old verities and truths of the heart.” Good policy means understanding that people will be people. You have to empower them to make better choices, and you will never succeed by asking them to deny who they are.
5. Public health is a service industry. Public health is not a law enforcement agency. It is meant to serve those who suffer the most from plagues and toxins and the crushing gears of our financial systems. Public health must abandon judgement and morality, and instead bend down to serve those who are ill and suffer. Good policy people never forget this.
6. Smart people — and group consensus — is often wrong. The greatest lesson in medicine is that many things the brightest minds thought were immensely plausible failed miserably when tested in larger and better studies. If you want to shape policy, you must never trust the opinion of the masses or those who are celebrated. Instead, on every issue you must seek the primary material, read it yourself, and make up your own mind. Folks who offer counter-perspectives should be engaged with, and not ostracized. Reportedly, Antonin Scalia used to hire a clerk who disagreed with him to point out blind spots in his reasoning. Good policy people always seek out the opinion of those who disagree. Even if they overrule them, it’s good to know the limits or pitfalls.
7. Good policy means sometimes you are unpopular. The popular thing is not always right. Sometimes people need to be pushed. But, at the same time, good policy people know that unpopular interventions cannot be sustained forever. They must be abandoned as soon as possible, if not earlier.
8. Good policy means you meet people where they are. Throughout this pandemic, I have grown tired of listening to pundits scold or shame the public for not doing this or that. People who do not comply with policies have to be factored into deploying them. We must meet people where they are.
9. Measure and experiment. Anyone who has any experience designing systems or policies knows that you cannot know the right answer from just theorizing. You have to implement things, often in staggered or randomized fashion, and measure outcomes. You have to continually learn. By this measure, it is a catastrophic failure that we went the entire pandemic and have little idea which restrictions work, and which do not.
These are just nine principles that separate good thinkers from bad ones. I wish there was some credential — background in infectious disease, epidemiology, etc. — that separates folks who use these principles from those who do not, but there isn’t. That means specialty bashing and credentialism are futile endeavors. Good policy does exist. It is what works. We would all do better to remember that and be careful not to fall in love with folks who simply share our personal risk assessment.
Vinay Prasad, MD, MPH, is a hematologist-oncologist and associate professor of medicine at the University of California San Francisco, and author of Malignant: How Bad Policy and Bad Evidence Harm People With Cancer.