Dueling petitions about what to do about COVID19 -- the and the -- are circulating online amongst physicians, public policy makers, and academics. I am not against policy statements, consensus building, or even petitions, but both of these documents trouble me. They are the dropping anchors when we should be open to sailing where the wind blows.
Let's start with the obvious. SARS-CoV-2 kills people. When infected, older people and those with serious comorbidities are more likely to die than younger people. This age-gradient (extra risk of death among older people) is steep. At the same time, dramatic interventions to halt SARS-CoV-2 -- such as closing schools, business, travel, economic activity, normal hospital functions -- also kills people. Some of these deaths occur immediately -- a person with a heart attack is dissuaded from seeking care, an uncontrolled tuberculosis epidemic in a low income nation, or even depression and suicide -- and some of the downsides take a long time to kill: loss of upward mobility and economic potential for the next generation will shorten lives.
Downsides to lockdowns can also be hard to predict. Harms may include destabilizing democratic governments, civil unrest, and political turmoil. The goal of policy in each and every place on earth is to minimize the total harm to the people who live there. It may vary by place and even moment based on viral spread, age of population, safety nets (or lack there-of), and a number of other factors, including values and preferences.
First, consider the Great Barrington Declaration. It's just 540 words long, and outlines a strategy of focused protection. Based on the idea that the risk of death varies dramatically with age, it proposes we shield and protect the vulnerable while allowing the young, and others at lower risk, to get on with life as normally as possible. It offers some ideas about how to guard nursing homes, which have experienced massive causalities, and endorses simple measures like handwashing. It nods to the idea that the herd immunity threshold (fraction of people in a population who have become immune before viral spread abates) is not a fixed value: it depends on the way in which populations mix and interact and on simple measures we choose to take, such as improved hygiene. It recommends that schools, universities, bars, and restaurants be allowed to open fully.
Limitations to the statement are its lack of guidance as to who exactly the vulnerable are, how they should shield themselves, and the fact that it lumps together very different things -- such as bars and schools. Open bars can be replaced with drinking beers in the backyard with a friend seated at a distance with little loss of pleasure, but education, particularly for the poor, is one of the few ladders left in American society for a better life, a place to feed children, and a vehicle for detecting abuse. Another limitation is its lack of acknowledgement that in moments of explosive spread, temporary measures likely need to be taken to prevent, for example, hospitals from overflowing. Surely, policy responses must depend on the specifics of the time and place.
The John Snow Memorandum was filed in response. It's longer, at 930 words. It calls Great Barrington's suggestions to achieve immunity through naturally occurring infections a "dangerous fallacy unsupported by scientific evidence." Instead it advocates for continued restrictions, along with social programs to minimize the harms of these restrictions. Signers believe this would lower viral spread to very low levels where contact tracing can be utilized to eliminate outbreaks. Finally, the strategy ends when we have an effective vaccine, which it predicts will occur in the coming months.
Limitations to the Snow memorandum include: How exactly will one create social programs to minimize the harms, and what exactly will those programs look like? What will you do in places like the U.S. where even basic economic stimulus talks have stalled? Millions of people are entering poverty in this country, and many more may face starvation globally. How precisely and quickly will you help them? Those who criticize the Barrington authors for not providing a plan to protect the vulnerable from the virus, must criticize the Snow authors for not explaining how they will shield the vulnerable from the harms of restrictions. Additionally, calling for contact tracing is easy, but practically, this faces severe limitations in a nation like the U.S. when many individuals contacted are reluctant to share information. Here too the Snow memorandum falls short on specifics.
The declaration and memorandum are both online and taking signatures, but is this how complex policy should be decided? I find the idea that the fate of the globe will hinge on who garners the most signatures to be Kafkaesque.
Worse, the dueling petitions further divide us, when we should be talking together and working together. It does not escape me that many forces seek to tie these petitions to the Republican and Democratic parties -- a dangerous but growing movement to equate pandemic policy with politics.
Signing these petitions may already be a form of identity or virtue signaling, letting others in our political circles know that we are on the virtuous team. Moreover, having signed them, we may be less likely to be willing to change our mind: To think one moment "we ought to open universities," and the next moment, "let's consider alternative policies, if hospitalizations rise."
Instead of these divisive petitions, surely there are things we can all agree to. There is a hierarchy of importance to activities and events in life. Bars, strip clubs, conferences for work -- fall on the low end. Schools for young kids, particularly public schools in poor or minority communities, and hospitals are among the most important. There are simple interventions that we can test in controlled trials and implement in the meantime, such as face-shields, plexiglass barriers, widespread hand sanitizer, and masks. We must prioritize schools over bars, and policy must remain individualized (to specific nation/state/county and local preferences) and fluid -- able to scale up and down, as we balance the harms of the virus with the harms of closure.
Finally, we have to separate rules from behavior. You can allow restaurants to open, but it won't help the economy if no one eats there. And, you can close everything, but you won't slow the spread if people have backyard barbecues with dozens of people. What are the best ways to encourage desired behavior? That's a harder problem.
Finally, there is no one-size-fits-all solution. What works in a remote island nation with a strong safety net, that can cut off contact with the rest of the world, may not work in a nation with hundreds of millions who face the threat of starvation if the economy grinds to a halt.
We need fewer pompously named petitions and instead, a COVID policy response that engages with people who hold views and perspectives different than our own; which acknowledges the lives lost from the virus and lost through the response; which is nimble and responsive to new data, new facts, and new perspectives; which engages values and preferences and local norms and the messy reality of the world as it is, not as we wish it were.
And, almost most importantly, one which is bipartisan, spanning political ideology, which unites rather than divides us.
And no, I don't need your signature.