What would you do?

By Kevin Roche

The title of this post is a fair question, which I am occasionally asked and I am sure many others are as well.  And it is a timely question given the case surge in many states.  One thing I learned in  my early career as a lawyer (a calling which I hereby renounce, since most politicians appear to be attorneys) and a litigator was that most questions have unstated assumptions in them and that when you answer the question you may be affirming the unstated assumption without meaning to do so.  So I am always very careful to parse questions for those unstated assumptions.  This question has several very large unstated assumptions and a couple of smaller ones.  One of the small ones is that “you” actually means the government.  As individuals we all can, and all have made our varying choices about how to respond to the epidemic, which is a good thing and a reflection of democratic freedom. And then of course the government imposes limitations on that freedom of choice in how to respond. And only government, not individuals, can enforce restrictions on freedom, usually in the name of the greater public health good. So I take the question to mean, if you were in charge of the government response, what would you do.

A bigger unstated assumption is that we should “do” something and an equally big assumption is that whatever we might “do” has on balance a more beneficial than harmful effect on the population as a whole.  And of course the really big assumption is that there is something we can “do” that actually will have an effect on the course of the epidemic, and that effect will be to lessen the morbidity and mortality imposed by CV-19.  Just thinking about all those assumptions mentally wears me out, but then I am old, my neurons are likely full, and they are definitely tired.

I honestly struggle to answer the question, because I don’t think the answer is do nothing, just let it take its course, but I also have difficulty identifying measures that meet that criteria of being more beneficial to the population than harmful.  I believe strongly in the concept of hubris, so I believe that we need to be willing to accept the limitations of human action and not imagine that we can control or fix everything.  Sooner or later a large meteorite is going to hit the earth and there is nothing we can do about that right now.  Other catastrophes are equally likely and out of our control such as the big one hitting California, but Gov. Newsome assures Californians that as long as they are wearing masks, stay in their homes all the time and don’t interact with any other people, they will be fine.  And epidemics happen and will happen.

Any decisions made now also have to deal with all the decisions made since the start of the epidemic and the consequences of those decisions. From a big picture perspective, it seems to me that we would have been better off to not try to suppress spread to the extent we did, and we certainly  should not have engaged in heavy suppression during the summer months when the environment was less favorable to the virus.  Spread in the summer would naturally have been lower and would have led to fewer transmission targets for the virus now.  Schools should have been opened and run all summer long.  But I understand, to some extent, that at the start of the epidemic people may have been less confident in the relatively non-lethal nature of the pathogen to the general population.  And we now how the benefit of much more science and data about transmission of the virus than we had at the start.

So without meandering too much, what would I recommend now.  One thing the current administration doesn’t get enough credit for is the efforts made to find and improve treatments and care guidelines.  At the start of the epidemic we were killing people by putting them on ventilators; we are much more cautious in their use now. We have some ability to identify patients most likely to develop severe disease.  We have identified some drugs that appear to make a difference in severity and mortality.  We are developing vaccines at a very rapid pace.  So I would continue to place a very heavy emphasis on those efforts–develop risk markers for severe disease, get a good, safe vaccine and get better therapeutics.  I would insist that schools be kept open, the risk to children is low and the damage we are doing to their development cannot be justified.  We can do the best we can to protect teachers and staff but they may have to accept some risk for the greater good of protecting our children’s development.  Colleges should definitely be open and those students should be kept on campus and allowed to go about their usual activities but confined to the campus space.  That is a large pool of people with very high contact levels with low risk of serious illness.  If they develop high prevalence, that is very protective of the rest of the population.

I think businesses should generally be open, with appropriate mitigation measures, mostly avoid crowding for any length of time.  People can make their own judgments about their comfort level in patronizing public businesses.  What to do about vulnerable populations is trickier.  We are killing the elderly with isolation.  So the best I can come up with for vulnerable populations in congregate care settings–nursing homes, assisted living, behavioral health homes–is to give the patients and their families a choice, and segregate the population accordingly.  Those who want to be able to have visitors and see people can be in one section.  Those who want maximal protection can be in another.

And since I believe in individual freedom, I also believe strongly in the flip side–individual responsibility.  It is incumbent on all of us to especially get tested if we have symptoms or know we have been in close contact with someone who is positive.  If you are positive or have symptoms while awaiting test results, avoid others and stay home.  Follow basic hygiene practices.  Personally, I would avoid crowds with strangers and lots of close contact.  If you have clear risk factors, be extra careful.   Seems like a pretty minimal list of measures, but they can help slow spread, at low cost.  All of this is predicated on my perception that there simply is no easy way to stop transmission of this virus.  Really extreme lockdowns, which might slow transmission somewhat more, have an incredibly high cost that I don’t believe can be socially justified.

This is a pretty modest approach, but given the actual risk to the general population, and the harms done by more extreme measures, it is about the best I can come up with.  Always welcome other opinions.