Denial, alarmism and the COVID-19 crisis

One theme I've seen play out during this pandemic is that the political divisions and culture wars that have increasingly characterized our modern society are getting in the way of us working together as a society during this crisis to get it under control and move past it.

This is so tragic and unnecessary. In the end we all want the same thing. No one wants more people sick, hospitalized or dying, and also no one wants society to be locked down, with schools and businesses closed and people stuck at home with devastating consequences to the economy and society at large.

Also, it is not that difficult -- from what we have learned, if we all agree to follow a few basic precautions, we can keep this virus under control, live our lives as close to normal as possible, and live with the virus until hopefully we have an effective vaccine broadly disseminated.

It is sad that in the USA, past crises have served as rallying points to unite us against a common enemy that have solidified our society, but this one has not.

Another related theme I see at work in this crisis is a struggle to find balance between competing extremes -- between denial and alarmism, glass half full or half empty, between paralysis by irrational fear and careless lack of vigilance inviting disaster.

We might classify people at the two extremes in their viewpoints towards this crisis as "deniers" and "alarmists".

Denial

The "deniers" are skeptical about whether this crisis is as bad as the media portrays and others believe, and there are certain facts that they hold on to and focus upon:

• They realize that a high proportion of people infected with SARS-CoV-2 never develop severe symptoms or are at risk of death.

• They acknowledge that the risk of death is concentrated in older patients with preexisting conditions -- that >1/3 of USA deaths were from mismanagement of the virus in nursing homes, and that the risk of death for young adults and children is minuscule -- lower than flu -- and the heightened risk is in a set of well-defined vulnerable subpopulations.

• They note that increased testing leads to increased case counts, so just because cases increase doesn't mean there is a "surge".

• They acknowledge the imprecision in all of these data measurements, that some places conflate antibody tests with viral tests, some states count individuals multiple times when they have multiple tests, and that death attribution is an inexact science.

• They note that while cases surge, the death rate nationally has continued to decline.

• They acknowledge that we were initially told that masks would not help prevent the virus, and that the viral particles were too small to be stopped by cloth masks.

• They acknowledge that we were told that once this virus reached community spread, there was no controlling it and so the goal of the initial lockdowns was to flatten the curve so hospitals were not overwhelmed with too fast a surge of cases.

• They acknowledge that hospital ICU capacity can be expanded by surge capacity in many places so to say ICU capacity is full doesn't mean that there is literally no place to put patients needing ICU, and that by and large hospitals have not been completely overwhelmed in the USA during this crisis.

• They see the arbitrary nature of some of the mitigation guidelines and are skeptical about where the precise numbers come from (Why 6 feet? 50% capacity? Walmart open but not clothing stores?)

• They note that the media has a financial incentive to create alarm, since the data show this generates viewers, readers, and clicks, and also see a leftward lean in the media's perspective so if conservative, are inherently distrustful of the media's messaging.

• They see inconsistency in the media's messaging, emphasizing the danger of gatherings until there are major protests and other gatherings, e.g. high profile funerals, during which the media does not even seem to note potential for outbreaks from these gatherings or the need to take caution.

• They understand the devastating effects that society-wide lockdowns have -- on the economy, on mental and spiritual health, on education and child development, and some even acknowledge that this damage, which goes largely unmeasured, disproportionally affects some of the most vulnerable and underprivileged populations in society.

• Regarding schools, they note that there are reports that children may have lower viral loads and exhale lower volumes of air, so may be less prone to spread the infection.

• Because of these doubts about its seriousness, mitigation strategies including major ones such as business closures and stay at home orders as well as minor ones including capacity limits, social distancing standards, and mask wearing seem foolish and unnecessary, and compliance with these directives makes one an "alarmist sheep".

• They view the push to slow reopening of the economy or schools or push to expand mail-in voting as damaging, foolish, and politically motivated.

There are at least elements of truth supporting all of these facts, and focusing on these facts at the exclusion of others reinforces their viewpoints.

Alarmism

The "alarmists" are scared to death of this virus, are frustrated that others do not seem to be taking it seriously enough, and are ready to take any step to prevent viral spread, and there are certain facts they hold on to and focus upon:

• They have seen images from Wuhan, Northern Italy, and in New York about what happens when we allow it to grow out of control, horrified with images of patients left to die in hospital hallways, refrigerator trucks as makeshifts morgues, and rationing of care deciding who gets to live and who is "left to die".

• They recognize the power of exponential growth inherent to the mathematics of infectious disease -- that even if raw counts are relatively low, if allowed to spread unconstrained, a virus can quickly surge to overwhelm a community and its healthcare system.

• They recognize that this virus spreads alarmingly fast if left unconstrained, and thus that mitigation strategies must be taken to get it under control.

• Many want to "kill the curve" and tend to want to keep strong mitigation strategies in place until the counts are decreased near 0.

• One key contributing factor to its alarming spread is its ability to spread from asymptomatic infected for relatively long periods of time, which also means anyone we encounter may be infected. For some, this thought makes them not want to leave their house and think that any degree of reopening is reckless and dangerous.

• They know that the virus can stay alive on various surfaces for long periods of time, raising the possibility of infection through contaminated surfaces, and requiring that we be careful what we touch, disinfect often, avoid touching our face, and wash our hands vigorously and often.

• They have heard that the virus may be "airborne" and can spread over longer distances than 3-6 feet, and are concerned that even social distancing is not enough to be safe.

• They recognize that since most of the viral spread is respiratory and much of it from asymptomatic infected, mask wearing is a key mitigation strategy that reduces the amount of virus exhaled by these asymptomatic infected so can reduce spread, and that epidemiological and scientific evidence support the primacy of mask-wearing as a key mitigation strategy.

• They see that our management of the virus as a country has been substandard relative to most other developed nations, with east Asia seemingly gaining rapid control of the virus, and even European countries with outbreaks finally gaining control with rapidly decreasing case counts, yet the USA is experiencing a second surge that looks out of control and expanding in scope.

• They note that even if a given outbreak is focused on young people with lower risk of severe complications or death, allowing the viral numbers to increase will also invariably lead to increased cases, hospitalizations and deaths in older and more vulnerable populations.

• They recognize that cases have surged in the south and west, and this surge indicates a real increase in infections and not an artifact of testing, as evidenced by increasing testing positivity rate, hospitalizations and deaths.

• They note that this surge produces large numbers of infected people who, as they move about, can seed additional outbreaks and surges in other locations.

• They understand that unconstrained viral spread devastates all parts of society, and these effects disproportionately affect the most vulnerable and underprivileged populations in society.

• They acknowledge the unique complications that can arise in severe cases, far worse than anything we see with flu or other common viruses, including inflammatory cytokine storm that can result on oxygen-starving major organs that can lead to multiple organ failure and death, or blood clots that have been found all over the body and leading to death by stroke or embolism. While these complications are more common in older people, they also occur in younger people infected with the virus.

• They recognize the horrific side effects that this virus can produce in some, even among survivors who recover, including potentially life-altering conditions such as permanent damage to lungs, heart, kidneys, or brain damage, and these can affect young as well as old.

• They see reports of a multi system inflammatory syndrome in children after SARS-CoV-2 infections that produce horrifying life-threatening complications.

• Regarding schools, they have seen super-spread events in crowded indoor locations, especially with poor ventilation, and wonder how crowded schools filled with children in enclosed areas, some of which may have poor ventilation, could possibly be safe. They think reopening schools may be a recipe for disaster. While the children may not tend to have a high rate of severe disease or deaths, there is concern they will spread it to their teachers and bring it home to their more vulnerable members of their family and increase the spread.

• They see the single-minded focus to "reopen the economy" and "reopen schools" by some and opposition to expansion of mail-in voting and consider this reckless, harmful, and politically motivated.

There are at least elements of truth supporting all of these facts, and focusing on these facts at the exclusion of others reinforces their viewpoints.

The straw man on the other side

People who are entrenched on one of these two sides clearly see the folly in the other side and are thus emboldened in the veracity of their beliefs. The deniers see some people having irrational fear or seeing to propose long-lasting extreme measures like lockdowns until there is a vaccine, and this reinforces their viewpoint is correct. The alarmists see people who seem to deny the very threat of the virus and are unwilling to take even the basic steps to prevent its spread, and this reinforces their viewpoint is correct. Both sides tend to minimize information that feeds the viewpoints on the other side, and instead focus on the information that reinforces their own beliefs.

Ditches on both sides of the road

It seems to me that either extreme brings with it certain dangers.

• Alarmism can lead to overly strict mitigation strategies that will eventually produce a great deal of societal and economic damage, and much of this damage is abstract and unmeasured so perhaps not taken into account enough. On an individual level, alarmism can lead to irrational fear that prevents people from feeling safe doing anything in public, keeping them from seeking required medical care or engaging socially which can lead to many problems down the road for them.

• Denial can make people unwilling to go along with even basic mitigation strategies and lead to outbreaks and surges that can overwhelm hospital systems, produce unnecessary deaths and long-term health conditions in some survivors, and lead to high viral prevalence in society that would cause policymakers to institute stricter mitigation strategies that will produce the collateral damage that these people are hoping to prevent. On an individual level, these attitudes raise the risk of infection, that even if not producing devastating effects on the individual, could easily result in them spreading it to vulnerable family members or friends, and even if not getting infected directly, by actively opposing mitigation strategies, one may influence others to let their guard down contributing to infections for them and their vulnerable family members.

Finding the middle ground

It is clear to me that the sweet spot is in the middle of these two extremes. Clearly, describing these two extremes as discrete groups of people is an oversimplification, since in reality there is a continuum between them and an individual may lie at any point on the continuum between these extremes. But I would argue that people tend to lean heavily towards one side or the other and very few people acknowledge and consider the merit of the facts emphasized by the other side.

My view is that one key factor in the polarization in our society is that given the current Information Age in which we find ourselves living, we have unlimited information literally at our fingertips about nearly any topic, and this is overwhelming. Since it is too difficult or time-consuming to try to synthesize and process all of this information to inform their own viewpoint, many individuals tend instead to find groups of people with whom they share a common perspective and world view and adopt that group's view on truth. The problem is that any single perspective is incomplete, and will tend to focus on certain facts at the exclusion of others, or spin certain facts in a way that supports their viewpoint, and so blind adoption of the narratives from any group is going to lead to incomplete knowledge an natural opposition to those with other viewpoints.

In politics, these narratives are purposely formulated and promoted, and the opposite viewpoints and their adherents are caricatured and vilified for political purposes. Many times the opposing viewpoints are distilled into a weak straw man that is portrayed as weak and perhaps even morally repugnant, and the obvious ignorant and repugnant nature of this straw man reinforces people of the veracity and even moral superiority of their own viewpoints.

As we buy into this narrative-based political groupthink, we can fall into this way of thinking in a broader sense, and this leads to us vilifying a huge portion of our fellow Americans, leading to extreme division and disunity. This problem can become so severe that both sides can't come together and cooperate even when it is very obviously in their best interest, and when they both, in fact, want the same things.

This is what I see going on during this pandemic crisis. No one wants more people to be sick, for hospitals to become overwhelmed, or people to die unnecessarily, and no one wants to destroy the economy, children to receive substandard education, or to isolate people and increase mental illness and substance abuse. Yet, rather than come together as a country to face this crisis together, we fall into our new habits and focus our thoughts on distrust and vilification of "the other side", and fuel all kinds of conspiracy theories and imputing evil motives to others without direct evidence. We have let these characteristics of unhealthy, dysfunctional individual relationships seep into our societal collectives and produce an unhealthy, intolerant, dysfunctional society.

There is middle ground between these two extremes, and if we can find it as a society we can work together to navigate this crisis.

• Acknowledge that this virus spreads alarmingly fast, and if left unconstrained the mathematics of infectious disease means it will spread out of control, and then can overwhelm hospital systems.

• Acknowledge that when it leads to severe disease, this virus does nasty things to people that are far more horrific than what we see in common cold or flu.

• Because of these two facts, it is imperative that we take some mitigation steps to slow its spread and keep it manageable -- we can't just ignore it.

• However, acknowledge the collateral damage that overly strict mitigation strategies can and will produce in society, economically, psychologically, educationally, and socially.

• Acknowledge that while this virus spreads easily, it is not like nuclear fallout such that we the only safe strategy is to stay in our bomb shelter for extended periods of time -- we can engage in society safely if we follow basic precautions.

• Acknowledge that while the virus does nasty things to people, for a vast majority of people, they will not experience severe symptoms and are not at significant risk of death, especially younger people without preexisting conditions. We don't have to consider this disease like the plague that will lead to certain death to anyone who is infected..

• Acknowledge that, although some aspects of guidelines seem arbitrary and have changed over time, this is to be expected in a novel virus in which we are learning on the fly, and in recent months we have learned a great deal about how it spreads and what strategies are effective in limiting its spread.

• Given these facts, the middle ground is to find targeted mitigation strategies that put into practice what we have learned, specifying a minimum set of guidelines that can keep the virus from spreading out of control yet allow us to live our lives as fully as possible while we wait for a vaccine. Steps that retain most of the mitigating effect of lockdowns, yet minimize their collateral damage to the rest of society.

• These key targeted mitigation steps individuals can practice include spending as much time as possible outdoors, when going indoors, avoid settings that are (1) crowded, (2) enclosed and/or with low ceilings, (3) with poor ventilation, or (4) with people singing, yelling, or talking loudly. When indoors around other people, (1) practice social distancing, (2) wear a mask, and (3) try to minimize exposure time. Avoid touching shared surfaces, and be conscious not to touch your face, and disinfect surfaces, but you probably don't have to become obsessive-compulsive in these steps as we have learned these are secondary to respiratory spread. If these steps are followed, the risk of infection is minimal. And stay at home if you have symptoms to avoid spreading in case you are infected.

• At a policy level, these safe behaviors can be encouraged with minimal guidelines including: limitation of occupancy capacity and gathering size at indoor locations, social distancing guidelines, mask wearing directives especially for indoor settings, and perhaps limited closures of settings that are unavoidably risky, such as theaters, bars, and perhaps workout clubs unless adaptations can be made to incorporate the guidelines above to make them safe. By the way Deborah Birx and the White House Pandemic response team have worked behind the scenes in constructing and promoting such guidelines, which is the content behind some recently publicized memos -- this will be a topic of a future post I will write.

• Key provisions need to be made to protect the most vulnerable populations at most risk of severe complications and deaths, yet other less vulnerable populations need to also be vigilant so that the virus does not spread so much that it is out of control and thus impossible to keep from reaching the vulnerable populations.

• If we can agree to work together to follow these basic precautionary steps, the current surges can be brought under control and we can prevent such surges in the future. This will allow maximal reopening of businesses and schools and enable a "new normal" that is as close to our regular lives as possible while we wait for development and dissemination of (hopefully) effective vaccines. This will keep hospitals from being overwhelmed, will prevent unnecessary deaths, and also obviate the need for more extreme mitigation steps that produce the greatest collateral damage to society. Our PolicyLab modeling of targeted mitigation scenarios suggest that these targeted mitigation strategies can retain much of the benefit of lockdowns and get these surges under control -- another topic of a future post.

• School reopening is a really tricky issue and highlights this idea that there are ditches on both sides of the road. If we restrict schools to online learning in the fall, it will likely continue all year, and although we have exceptional and dedicated teachers who can creatively make it work as well as possible, there would clearly be devastating consequences for children's intellectual and social development as a result, and these will inordinately affect certain populations exacerbating existing disparities. An overly scared alarmist way of thinking could produce these outcomes. However, if we carelessly open schools without accounting for the realities of this virus and how it spreads, we are asking for massive outbreaks and surges that may cause the virus to spread even more out of control more than we have seen to date, with commensurate overwhelming of the medical system and needless deaths, and may lead to the requirement of imposition of extreme measures like lockdowns again. A careless, overly-optimistic denial-based way of thinking could produce these outcomes. Threading the needle and finding a middle ground on this issue is trickiest of all, given the unavoidable crowding, indoor setting, long period of time together, and in some places poor ventilation that characterizes the school setting. There are some indications that children spread the virus less efficiently than teens or adults, but it would be foolhardy to bank on this fact as being sufficient to prevent school-induced surge (that has already happened in Israel). I may get more into the school decision in a future post, but this is a huge test for our society's ability to come together and find a balanced solution accounting for all concerns, and I must say I am concerned about whether we are up to the task at this point in time.

A Call to Action

We need to come together NOW to combat this crisis. As individuals, I think that whichever way we lean, we need to each try to understand the meritorious points on the other side, and find ways to find points of common ground and come together in the middle.

I urge you even if you have doubts about the seriousness of the virus and think it is being blown out of proportion by the media, follow the basic precautions just in case you are wrong — they will cost you almost nothing even if you are right, and if you are wrong and don't then you may influence others and contribute to devastating consequences for society.

If you are pushing for extreme measures like societal lockdowns and business and school closures and haven't thought much about the collateral damage they produce, then I encourage you to consider that perspective and assess whether strategies that do less damage can get the job done, and if your viewpoint is that they are necessary to get things under control to avoid more collateral damage later, try to patiently explain that perspective rather than vilifying those who don't see it that way.

For all of us, let's not impute nefarious motives to people whose perspectives differ from our own. People who you think are deniers are not heartless people who don't care about others -- they may just not see the seriousness of this crisis as clearly as you do. People who you think are alarmists are not people wanting the government to take over control of our lives or trying to create a false crisis to affect the upcoming election -- they just might just be more concerned about the virus than you are and think that stronger steps are necessary to get it under control. Let's think the best of each other, and try to find common ground.

There is still a chance to come together in combating this crisis, for us to start to move beyond the division that has increasingly characterized our society, to use this crisis as an opportunity to unite against a common enemy and to respond together as a people as has been done in many national and international crises in the past. To let the crisis inspire the best out of us, not expose the worst.