I am a person who works at a health department. I agree with all these points -- as do many in my office. But we are so hamstrung by the lack of any power or ability to do things. For political reasons, we cannot provide any support essential workers. For political reasons, we cannot keep the schools closed. For political reasons, we cannot contradict the CDC.
I read this whole article and I feel ashamed and sad to be part of this fucked-up response - but the only other option is not being part of this response, so.
Also - everyone is so mad at us, all the time. I don't know what to do. We have so little staff; we are all doing everything we can. We know the messaging is bad. But what can I do? How can I change it?
I worked a vaccination POD last week; I was signing someone up for her second dose appointment. She asked if she could have her second dose this weekend as she was going on vacation next week and wanted it before she flew. I don't know.
Alison, please don't feel ashamed of working harder than should be asked of you and all health departments trying to fill expectations that are impossible and often make little sense. I work at a college, volunteering for testing students and staff, and between my experience with our campus healthcare providers and people I know at our local health department I have nothing but the highest respect for the work you all are doing. Endless thankless hours of service. Thank you. Thank you. Thank you.
I'm not kidding when I say that in our region we saw our county health directors replaced one after another. In our county it was a quick and silent change. In a neighboring county it was a public "hell no I won't go" response by the valiant director. Guess what? He went. Our schools are open. It appears to me that not everyone in our county health departments share the same understanding as Alison. That saddens me. And I am sad for you Alison. Hang in there. I respect and value you like I can't even begin to describe.
We went through three county health directors within the year -- not replaced; they mostly left due to complete lack of support and even resistance from elected political leaders. We ended up with the most recent one who had retired years ago but at least is willing to step in and knows a lot of the personalities and dynamics he has to contend with.
This would be a wonderful opportunity to utilize the professional skills of senior workers/experts in communications who may be retired or working part-time. As volunteers, e could help amplify, hone and multiply consistent messaging. Our current health agencies are underfunded and understaffed and can't do it all.
There is almost nobody whom I’ve been more grateful for througout this than our county health department, who have done an incredible job and their best with too few resources and no political support. You should not feel ashamed.
I am a school bus driver who has chosen to take unpaid leave instead of returning to work at this time. In our region we have literally seen public health directors driven from their positions. It is disgraceful. I won't cooperate with the wrong solution. I would be happy to cooperate with the right one, however draconian it may seem. I never understood why we didn't see the national guard used to shut us the f down. Now there are 500,000 plus less Americans and we continue our march forward into the withering fire.
OK, I haven't read the article yet. But when the coronavirus first appeared, I wrote on Facebook that it was "almost perfectly designed to exploit the ways America is messed up". Like you, I had a list of five. I look forward to reading your article to see whether we have the same list.
- Large number of people without health insurance, who will avoid the healthcare system.
- A culture that emphasizes individual rights over the common good will have trouble getting people to comply with the rules to curb the spread of a disease that transmits from people without symptoms.
- healthcare culture of focusing on cure rather than prevention.
- uncoordinated government structure - federal vs states and divisions between different government departments. I thought there was little hope, for example, of proper management of borders given the differing priorities of different government departments.
- a President who never leads by example or by asking people for sacrifice.
Careful, you may be committing some of the messaging problems that Zeynep highlights in her article, which is that COVID spread cause people were bad. If only people have followed rules! She lays out how people were getting it simply by going to work or being at home or fulfilling very human needs. You can’t control a pandemic through individual willpower alone.
Fair point. But whether they were rules or guidelines, my point stands. In America we really look at things from the point of view of personal risk. Especially in the early stages of the pandemic, when case counts were low, the point of most of the precautions was not to prevent risk TO ME (and after all, if I am not in an at-risk group, the risk of serious harm to me is low), it was to reduce the risk of me being part of the chain of transmission. We still hear this in the debate on schools. Parents ask: “ Is MY CHILD safe?” Teachers ask: “ Am I safe?” No one really says “Does this contribute to the risk of a huge outbreak?” I’m an immigrant who has lived here 20 years, and I have still been surprised at the way Americans seem quite incapable of thinking like this.
Thank you! I have shut down my life for the last year. Personal safety of course. But I have also seen it as my duty to not become a link in a chain. I feel reasonably certain I could throw back beers and handle my own infection with the best (wrong word) of them. I won't. I am one of a handful of employees in my school district who have taken leave this year. And the stated reasons for my taking leave (to protect myself and particularly my wife -who I could not forgive myself if I infected) are easily accepted by my superiors. But the argument that they are wrong to be reopening the schools ahead of vaccinations is just not something anyone seems willing to embrace. Thank you so much for your post.
In no other country was all this energy spent on asking people to stay home and only do non-essential activities for a full year! We asked individual willpower to stand in for public health measures, and personal virtue to stand in for mobilizing a society.
Indeed. I was surprised to discover that I WANTED to be told what to do. And I WANTED that to be enforced. I suspect I am one of millions who have tried for over a year to “do the right thing” and follow guidelines that others have ignored. I know too many people who feel doing anything is “safe” - but are only able to do those things safely only because of the millions who are staying home, restricting their movements wearing a mask, etc. I came into the pandemic expecting to feel a sense of “We are in this together, and we will get through this together.” That dissipated quickly.
Enforcement has proved impossible in our culture. I am intrigued by the comparison of our unruly states U.S. (mine is Texas) with Australia, which has a rather unruly history. It has been able to do gun control and now covid control. What is different?
I had a conversation recently with an Australian friend who just moved back to Perth from the UK. I observed that whenever I had been to Australia, I had observed two things: (1) their public service messaging is superb, and (2) they are, surprisingly, some of the most rule-compliant drivers in the world. He confirmed that they have great respect for authority, and rules are strongly enforced. No one speeds because “it’s not worth it. Not worth it at all.” The speed cameras WILL get you. I will also tell you that they are as proud of not being America as they are of not being Britain!
I had a similar response, just shared with family and friends, that this was going to be a stress test for what climate change will bring more of. The results are mostly not encouraging, though my own small community’s resilience showed.
Are you familiar with Margaret Klein Salamon? She does a lot of work around the hidden psychological toll of our subliminal awareness of the coming climate emergency and the need to work through these complex emotions, and engage fully with the harsh realities, while being compassionate with ourselves and processing this suppressed grief and fear together with others with the ultimate goal of being in a better position to take action.
The pandemic of course is a different situation, and maybe less about acknowledging the sheer scope of everything, but in some ways not entirely different since it is as you say a dry run. I feel like we could have benefited at times from a larger set of voices stressing this more empathic dimension (Julia Marcus does this at times, and of course Zeynep in a different way).
I guess there's many others who have written on existential coping in the Anthropocene and so on, but she was a clinical psychologist so she comes a bit from that perspective as well, which I appreciate.
Despite the occasional nod by writers to parallels between this pandemic and the climate crisis, I would really like to have these two linked up more systematically; both in terms of how we are internalizing them (sometimes simultaneously, sometimes in parallel), and also with a mind to lessons we can learn from one to the other.
I still think the fundamental attribution error is one of the most useful things I learned about in college and I've thought about it a lot during the pandemic, especially in the context of grandma-killing rhetoric. Not exactly the same, but an imputation of very bad motives to ordinary people committing the unforgivable sin of wanting to see their loved ones.
My mother is an epidemiologist and I learned a lot about public health intervention from her, but my trust in official channels of expertise in this pandemic is utterly gone, even though I'm myself a credentialed member of their class (university professor). There are a few different reasons for this, but the three most basic: 1) Being told not to wear masks (I'm in New York) and it made no sense to me but I thought well, I'm not the expert here. 2) Total absence of harm reduction messaging. I do some work on the history of the AIDS crisis and the rhetoric and scolding was eerily similar, despite the absence of the sexual element. In fact, the trope of the careless disease spreader goes back at least to medieval times. To make people guilty for breathing in the presence of others... that's really hard to come back from. Which is connected to 3), the acknowledgement in your article that sociality is a human need and itself an essential component of health. I think we made a fundamental error in not focusing on just how basic a need we were asking people not to indulge.
The people we think of as pandemic deniers aren't necessarily stupid. They may have different assessments of risk, different values, and they may know - which is correct- that 'elites' are lying to them. That is apart from the horrible and of course completely culpable contribution Trump made to all this.
But there's other cognitive issues too: that a successful intervention would seem overkill in retrospect, and that familiarity doesn't read as danger, and that cause-effect relationships are often distant and out of sight. The cognitive load of generating decisions so contrary to fundamental processing structures in our brains is costly. Thinking more compassionately instead of treating people like naughty children might have helped.
re: To make people guilty for breathing in the presence of others... that's really hard to come back from.
I sense that you're right about how that makes people feel. But to use the efficient messaging of Dr. Michael Osterholm, this virus does result from "swapping air" with infected people. It makes me wonder if that phrase had been used from the start, would anything have been different?
Good messaging without shaming and blaming feels like the dream, and also much more likely to give folks a sense of being in it together. Instead we all feel like others are either trying to kill us or steal our lives and happiness away. It's a good phrase! And there are many practical small risk-reduction things we can do as more are vaccinated that are compatible with something much closer to normal life. I wish we were explaining them all.
I think there's been a repeated "you can't handle the truth" approach to public health communications which has really contributed to public skepticism. See: "masks don't help" when it could have been "Some people need masks more right now, and we're not sure..." I'm so frustrated by the ... I'll say misinformation .. around the amount of vaccine doses and when they'd be available. V-E (vaccines for everyone) day was never coming until May or so, I'm not sure why this wasn't made more clear. Also, there's something I've called data idolatry before. Yes, RCTs are the only way to be sure about a scientific fact, but in life, you often have to make the best call you can with the (incomplete) data you have. It might very well be a good call to postpone second doses in order to get single shots in arms before new variants arise. We don't have conclusive data on this yet, but we have pretty good data, and we shouldn't dismiss it.
I guess I'm pulling out specifics where this article is more concerned with trends... but I don't think I can overstate the effect that being yelled at in all caps by the Surgeon General had, on all public health messaging I received after that. https://www.nytimes.com/2020/02/29/health/coronavirus-n95-face-masks.html
(Some context: I still don't quite understood who is a political appointee and who is not; and I most strongly associate the Surgeon General's "brand" with the extremely warranted, frightening messages that got added to cigarette boxes from when I was a kid... which means there was a certain amount of recognition and trust, maybe even gratitude, that I brought to my understanding of what their role would be, in decision-making about my health and the health of those around me.)
I felt wounded, honestly: first by a tone meant to convey how stupid my impulse was, to want to protect my family from a virus that had enough obvious priors/analogues even by February 29th to warrant mask use. Then by collapsing my very sane and normal impulse into a kind of panic reduction by gaslight; presumably (but not obviously) meant to address price gouging and hoarding. And finally by invoking frontline workers' need for PPE... all but the worst of us would prioritize their huge needs over our own modest ones... and it only served to underline that we were probably correct in assessing those needs. Yeesh. I still can't shake it, an entire year later!
Can I just say that I really like these sharings of anecdotal, personal experiences about what was or wasn't helpful for a particular individual and/or their friends, what felt alienating, what confused or aided their understanding? I feel like this is a really important part of the data and one of the most valuable things about the blog, that it provides a space for these kind of concrete stories and situating them together vis-a-vis the larger issues being dissected. (The more analytical and conceptual posts are great too - I just like that we're seeing both.)
That early messaging was horrible. I had the time to closely follow the news and the politics and the science. (The early medial preprints from China were wonderful. They were wonderfully readable and informative.). I am still angry at the estimable Dr. Fauchi, who said the same things the SG did.
In my view, both were lying about the medical facts. You could look at the news from Europe and Asia and see whole populations who had feared SARS and who had dealt with Swine Flu wearing masks and having better statistics than the U.S. did.
Also in my view, Dr Fauchi and Dr. Adams were trying to accomplish the part of the message you picked up, to save PPE for medical responders. But they and their agencies failed completely to put out messaging on how to make effective masks. Many other countries did better. The U.S. process did finally get a mask pattern on the internet and in the newspapers. But they completely failed to publicize the materials that should be used and the use of the nose clips to improve the fit.
Meanwhile, all over the world, Australia and Hong Kong were telling us about materials (using scientific studies), and individuals and companies started churning out masks, but the government and other trusted agencies (whatever those might have been) did not tell us how to choose.
Thank you for sharing your response. As you can see from my post, I haven't shaken it either.
Could not agree more. I'd purchased a few boxes of N95s years ago (more for wildfires and earthquake preparedness than biological threats, but that was in the back of my mind as well) and started wearing one to the grocery store at the beginning of March (along with nitrile gloves that I ditched after a month or so when it became obvious that they didn't really do much).
It was shockingly hard to do it! I'd never been in the position of being semi- publicly shamed/embarrassed routinely before. For weeks, I was the only person wearing a mask in the store, and other people would give me that "what a weirdo" look (and that's the most charitable accounting). It's surprisingly unsettling, even though intellectually I know that I'm never going to see these people again and have absolutely no reason to care what they think.
The lies (some "noble" and some not), misdirection, and manipulations from public health officials during this pandemic have been absolutely unforgivable, and it cannot all be laid at Trump's feet (although he certainly did his share and I think also led journalists to rally unthinkingly around any and all of his opponents, when in a more normal time they likely would have exhibited a bit more journalistic skepticism---see Cuomo, Andrew M. and Newsom, Gavin C.).
Ironically, the anti-mask messaging did more to convince me, personally to wear a mask early on than probably anything else they could have done. Based on the level of concern for rationing supply, it was pretty evident that these N95s must be pretty good protection. Kind of like in the Soviet Union, if there was a line forming somewhere, you joined it. You didn't even need to know what the line was for, just that something was about to go horribly wrong, and you'd best get there early. And if heaven forbid the authorities shouted that there was no need to get in the line, you ran there.
Zeynep, further to this, from your wonderful Atlantic piece:
"The difference lay not in the level of evidence and scientific support for either theory—which, if anything, quickly tilted in favor of airborne transmission, and not fomites, being crucial—but in the fact that fomite transmission had been a key part of the medical canon, and airborne transmission had not."
In addition to your Popperian observation of weak evidence that matches the paradigm case out-competing strong evidence that does not, there is also the value of various adaptations as signals, not just as counter-measures.
Institutional consumers of public health advice, in the absence of clear Federal or state mandates, were left to signal to consumers that visiting their establishments was safe. Hand sanitizer is cheap and visible, while HEPA-compliant HVAC systems are expensive and invisible. The fact that the former is ineffective and the latter effective does not solve the merchant's primary problem, which is not limiting viral spread but rather not going out of business. (To this day, there is a stall in my farmers market, open on 4 sides and bathed in glorious UV rain or shine, that makes me sanitize my hands before entering.)
More speculatively, I wonder if there is a heuristic for people involving precaution, especially where it is engaged around questions of cleanliness and purity, where evidence to start a practice is easier to internalize than evidence to stop it?
Alternatively, I wonder if there is a heuristic that overweights early signals and underweights later ones, as humans build implicit mental models, analogous to the way parents of babies take much longer to realize their children have stopped liking certain foods, than they did to react to the moment when their children started liking it.
This is such an excellent question, Clay. After last year, I have decided that I've... not given sufficient respect to: Kuhn, Popper, Michel, Weber, Janis among others. Paradigm shift, group think, "iron law of oligarchy" in the sense of organization inertia, etc. I mean, not that I didn't know of these things but the strength with which they happen, the speed of the transition and the ensuing amnesia... As if it didn't just happen. Incredible. What else did we forget, historically, that is there to be understood? What is there to learn? It's been incredible.
Yes, and I'll add the Iron Cage Revisited and institutional isomorphism to that list.
And the amnesia is indeed extraordinary. Despite knowing, for 100% certain, that fall will not be 'back to normal', both as a practical matter and as a desirable outcome, I hear people slipping into that language all the time.
though sideline it seems parallel to climate change mitigatiion-- it was always easier to convince orgs to do the visible and demonstrative but less effective actions(personal recycling, using recycled paper (not bad but not as big an impact as folks think) eg) than the effective but less visible (lowering energy use, fixing HVAC etc).. Seems parallel.
Zeynep, First of all, thank you for your coverage during the pandemic. You have been right so often since the beginning, and it blows my mind that you are not in some higher up position in the government public health response or the CDC. America would have been better off this way. At this point, I typically check in on what you have written and Fauci when I'm making decisions on how to proceed based on new information. Along those lines, I would greatly appreciate if you could write a future article on your thoughts on pregnancy and getting vaccinated. (Although I'm sure this is such a loaded topic...)
There are a lot of points that I think are right on in this article. Public health officials have failed to help individual citizens focus on ways that they can mitigate risk (ie- socializing outdoors safely and staying mentally healthy), and not focusing enough on providing evidence based guidelines to businesses and schools on ventilation. How is it that at this point of the pandemic, it is basically mandated that hand sanitizer be readily available in every corner of a store, but most stores keep their doors and windows closed even if they could be easily opened? An incredible failure in the public health messaging for sure...
I'm so beaten down right now that I just keep re-reading your point that life will get better with vaccines. It's so obvious that the vaccine dramatically reduces transmission and yet...FEAR MONGERING IN EVERY HEADLINE. Widespread PTSD is sure to be the next phase of this pandemic.
Thanks again, and looking forward to reading more of your work.
Yeah, the way we cling to hand-sanitizer (which isn't bad! but not that necessary for this!) while still not doing more for healthier indoor air (which is great! even after this pandemic is over!) is .. disappointing and the one thing to push for. Indoor air quality is really important, even without this coronavirus stalking us.
I see the reluctance to improve ventilation as a function of how expensive it would be. Both my university and the public schools in my region have lots of dreadful HVAC "systems" (if they even deserve the name) that would honestly need to be fully replaced rather than merely improved. Such institutions need more info on how to do the best with what they've got. Sure, some HEPA filters have been installed. Not all systems even permitted that.
We also have far too many leaders, at every level and in every sector, who don't even begin to understand how ventilation is the key issue. The baffling directions from WHO didn't help. CDC was wayyy too slow on getting the word out - even though the case of the Washington choir was an absolute klaxon. I wonder how many millions were spent on sanitizer and plexiglass?
Thanks for your work, Zeynep. Your early article about beach shaming helped me understand both the difference between indoors and outdoors with regard to transmission, and the susceptibility of our leaders, health officials, and the general public to grasp at solutions that distracted us from interventions that would actually help save lives.
Ventilation improvements are expensive, and I agree that they are critical for many reasons beyond the pandemic. However, opening a window or a door is free. To your point, if the public was actually effectively educated by public health officials on how this virus spreads, they would at the very least make an effort to open windows in lieu of expensive upgrades.
Indeed, you’re right about windows! But a great many classrooms lack windows. The majority of the ones I’ve taught in are I that category. Ditto for nearly all classrooms at my kids’ high school. I wish this were a rarity.
Remember that because of the epidemic of school shootings, there are often strong policies about keeping doors and sometimes windows closed at all times.
.We are spending the money already. It is what you might call expensive technology, no question. So the question to ask is is it worth it? Assuming it functions as expected, absolutely. But moving beyond concerns about price and profits and patents who cares how much the company hopes to sell them for... if the device can be produced it needs to be produced and distributed and put into service regardless of who pays the cost. Were it the US we would be talking about the defense production act. I don't know the Canadian equivalent and of course we need an international approach anyway. Airborne detection strikes me as akin to the holy grail. As I mentioned DARPA has been chasing it. So my goal here is simply to let you know it exists. I do that because I sense that it is a story not fully told yet and feel compelled to share it. I am glad you took the time to look into it, Yes, the unit price is not a minor consideration. And the cartridge replacement cost is not nothing. But I would suggest given the value of early detection that cost, compared to the cost of testing is insignificant.
The real question, in my opinion, is would something like this be effective in controlling the spread of the virus? Certainly it would be. There is skepticism from some in the Canadian scientific community who question the proven effectiveness of the device but acknowledge the need for it. That question is being faced now. Were the story more widely known there would surely be more skepticism here.
Because, after all, how is it this Canadian company beat the world to this? Well, it seems to be in the wheelhouse of CEMSI which develops an array of sensitive electronic monitoring systems.
Moving beyond doubts about whether it works, which obviously need to be dispelled first. Moving beyond the current unit price, which is steep but surely will be able to be brought down. Think about how you would use an airborne detection system as part of the response to the pandemic. And finally (and I am so proud that I am on topic now) how much of a mistake would it be to dismiss such a possibility so readily?
One last note: I just learned Spokane, WA is experiencing the exact scenario I have been describing to anyone who would listen for some time: a breakout of exposure on the buses. Eighteen positive cases among drivers. Another eighteen exposures. Bus company claiming it happened offsite. Parents not buying it. Bus drivers claiming safety measures not being followed. Buses being overloaded with kids as they consolidate routes due to missing drivers. And do I need remind anyone of the average age (and I hate to say it, weight) of the typical American School Bus Driver. This is not a moment where I enjoy being right but I warned my own school board this was coming. Now it has come to bear in Spokane. It will happen the same way everywhere. And everyone in America will all of a sudden care and have an opinion about pupil transportation beyond platitudes about how important bus drivers are. Now imagine an airborne virus detector on a bus.
Okay, sorry, that was a heck of a long post. I am very close to this issues - as we all are. Cheers!
Perhaps the above is an updating of the colloquial concept of ‘public-health’?
Taleb quotes Popper in Black Swan:
“Genuine philosophical problems are always rooted outside philosophy and they die if these roots decay.”
That is sorta your role?; you’re one of the few American-based philosophers who can reason in an informed and fruitful way about some of the hyper-dynamics at place. Wonderful!
Targeting these fallacies makes sense; there is an opportunity for us to do a better job illustrating them; we put a lot of effort into making dynamic graphics for network television, and yet it’s hard to see the dynamics you explain. So, something like, better versions of nicky case’s work (but static stuff too) with opportunities for conversation and reflection.
As a writer, you cue us in to more tangible illustrations of the fallacies considered. Let’s do this visually. We need the public health officials working more closely with storytellers better accustomed to the tools of the times. It may help to SEE these fallacies side by side. A few core visual ways; adapted as templates for specific communities.
As you know, the ‘research debt’ problem is acute in Machine Learning; folks have some early ideas on how to address the matter. Worth a (-nother?) glance. https://distill.pub/2017/research-debt/
Forgive me Zeynep, but this all seems so intellectualized; which seems appropriate, but I’ll politely suggest that the emotional realm is quite important regarding public response, coping and the action issues.
We are all having to sit with a lot of discomfort. Updating and better distributing our tools for being with emotions and following their relation to thought, seems pertinent. Your point about awareness matters here.
Ex. ‘I am feeling ____”, . ..why? Because I am worried that ____ will occur”.
We know a lot about how cognitive load, acute and prolonged stress, and trauma, affect thinking, behavior and learning. We have to bring these insights to bear upon our current encounters.
Meditation, mindfulness, our heuristics around social emotional learning, matter here; and not in a hand wavy-way. Being in nature. Islands of competence etc.
I want to also emphasize your nod to the time boundary; which seems important.
Part of your audience seems to be the explicitly mentioned ‘officials’ and ‘media outlets’; perhaps we could expand this to include product managers?
Dewey and Addams always emphasized how democracy being embedded in social practice was crucial.
So on this. Yes, yes, yes. This is also the problem with a lot of our tech coverage/criticism now. We need to make the philosophical roots of our disagreements more explicit. "“Genuine philosophical problems are always rooted outside philosophy and they die if these roots decay.”
On the emotional responses: of course. We're humans. Sitting with discomfort and uncertainty is difficult, and there's just no avoiding it in a situation like this.
Second, messaging is hard, especially for public health officials. Often arbitrary standards are the best they can do. I am reminded that in the jewish tradition, on Passover you are forbidden from eating leavened bread. So why not corn tortillas - there are no yeasts that can naturally leaven corn flour? Don't confuse the simple. Much easier to say "just eat Matzo".
If you are a public health official, is it better to say "stay six feet apart" or "don't get too close"?
Is it better to say "if you are socializing outdoors, wear your mask anyway" or "it depends on the wind's direction and velocity and how close you are to each other"?
Of course, our public health messaging could have been much better, but if we foster risk adverse public institutions then we should not expect sophisticated messaging.
Indeed. "Just eat Matzo" work well for one day of the year, and for a ritual/religious gathering. It is easier. It makes sense when the solution is universal, one-time and works.
@jlb, I can only speak for people who teach public health on a university faculty, but yes, there is a widespread sense that the messaging has been terrible. However, it seems hard to separate the communication effects of politicians in the previous Presidential administration, and state and local politicians loyal to him, from general weaknesses in messaging.
"6 feet" is the "just eat Matzah' of this crisis. (You can tell because in Europe the advice has been '2 meters', not '183 centimeters'.) The 6' Rule has no basis in epidemiology, was based on rules of thumb from decades ago, and was quickly superseded by actual studies of transmission, but a year into the U.S. epidemic, that 'rule' remains stubbornly encoded.
It's infuriating that resources like this (https://www.microcovid.org/) have been created by random volunteers and not the CDC. Apparently their "evidentiary standards" would never allow them to create something like that. Which means we really need to start over from scratch with the public health field after this catastrophe.
The right approach isn't to give black-and-white advice, it's to tell people honestly what the risks are to themselves and others. It seems like most public health people have a shockingly negative view of the population---as if everyone is an anti-vax dropout. Kind of like how we berate children into being terrified of "strangers" when, in fact, it's like 99.999% likely that, if they're in trouble, a random stranger will help them (obviously, the calculus is different if a stranger is approaching the child unprompted).
This cynical, paternalistic disdain for the population among academics and these public health people is really counterproductive. Get off Twitter! It's a funhouse mirror that distorts the fact that the vast majority of people are decent, hardworking, caring and of perfectly average intelligence.
re: seem to have a negative view of the population? IDK, seems they have to. they cannot afford to lean too far forward and found later to be wrong - would destroy trust.
Excerpt: “You got to juggle all these guidelines,” he said. “I told everybody, ‘Give us the playbook. Tell me exactly what we need to do, and we’ll do it.' ”
The day this newsletter and the article came out was the same day I received my second dose of vaccine. As many sources had warned me, my immune system kicked into overdrive with an industrial-strength migraine headache, chills, and the inability to sequence thoughts enough to write meaningful comments here. 48 hours later, I’ve returned to normal.
While I appreciate the fascinating discussions about Scientific Method and public health rhetoric that have dominated the comments, there’s more than that going on that’s differently important.
I survived my zombie state with some degree of sanity not because of Scientific Method, but because of tribal knowledge. Had I not read or heard anecdotes of how awful it can feel when the immune system is working so hard, I would have been terrified that I had contracted some other deadly disease. As it was, I was only discomforted, not panicked. The public health information gave me a partial list of some possible symptoms; tribal knowledge was more phenomenological, telling me what it *felt* like, and that was paramount.
It’s clearly necessary to distinguish the valuable tribal knowledge from the recommendations of ingesting or injecting bleach, or popping hydroxychloroquine. There’s an interesting dividing line between worthwhile and damaging advice. But figuring out what to accept as possibly trustworthy and what to dismiss is not simple. For future pandemics it will remain as necessary.
This speaks really well to how there is always a gap between the official scientific guidance, however responsible and up-to-date -- the "party line" if you will -- and the anecdotal realities of how things really look on the ground. It is simply not possible for formal institutional/scientific knowledge to keep up with tribal (or "folk?") knowledge: what the former *can* do is synthesize, refine and explain all this messy emerging folk knowledge, while carefully weeding out what turns out to be false or distorted.
My own anecdote is that a friend who apparently had the virus exactly a year ago at the outset of the pandemic had such a severe overreaction to the first shot of Moderna that she presented with bizarre and concerning symptoms and ended up being hospitalized for a few days (in the end she opted not to get the second shot, though she is still a big advocate for others taking the vaccine). During this entire period she shared running updates on social media about her condition and the phenomenology of what she was going through, as a point of reference for anyone else who might have a pronounced reaction. If I had not read her posts, and all the comments from others reporting very bad experiences, I would have *no* idea this was normal. All this tribal knowledge from below *combined* with scientific credibility from above helps me feel more empowered to choose the vaccine in spite of side effects.
It is hard to find, but there is good information out there. I knew about 2nd shot reactions in Jan from the weekly physician update on the podcast This Week in Virology. I highly recommend everyone spend the 45 min each weekend to get up to date.
TWiV 724: COVID-19 clinical update #51 with Dr. Daniel Griffin
My concern is not that I had no idea what I was in for, but rather that tribal knowledge (or narrative descriptions, more accurately) were another aspect that I thought should have a place in Zeynep’s overall framework.
The Atlantic article you mention was a great source. I had read it before the experience, and it was a help precisely because it got me to understand what might go on and why. Neighbors who are docs and had bad dose 2 reactions also gave accounts.
But not everyone is a highly educated reader living among professionals. The tribal knowledge I encounter is somewhat more rarified than the typical. The content and source of tribal knowledge varies, I believe, along many demographic dimensions. Your suggesting a This Week in Virology podcast is itself an instance of passing tribal knowledge, but it passes usefully only to a subset of people. Other communities have different sources, which may be just as accurate, yet pitched in other ways.
As ever, since tribal knowledge is not peer reviewed, the opportunity for malicious (or even well-intended) misinformation remains enormous.
Thanks for your wonderful article, Zeynep. As a student of rhetoric, I really appreciated this analysis, and especially the points you made in the section on "Rules in Place of Mechanisms and Intuitions."
The failures of the public health rhetoric is a clear example of the growing chasm between experts and non-experts, or even people who think of themselves as educated and how we educated folks think of uneducated folks. The world is more complex than an 8th grade reading level! It's dangerous to write about an extremely nuanced issue while imagining a public audience that you assume can't understand any nuance.
Throughout the pandemic, I've been frustrated and confused by close family members basing their behavior on rules and what kinds of public spaces were allowed to open rather than on knowledge of how the virus spreads (e.g., "restaurants are open now so it must be safe to eat inside a restaurant," or a holiday meal where everyone ate inside together but were careful to avoid sharing serving utensils). I know that I'm privileged to have postgraduate training, but from my perspective, being able to visualize how the virus spreads has made it much simpler to mitigate my family's risk without completely sacrificing our social needs.
Thank you. I agree, "restaurants are open now so it must be safe to eat inside a restaurant" is perfectly reasonable a conclusion if no other information is provided—extra problem since it rarely takes into account the restaurant workers.
I wonder if the circular logic you point to in the restaurant example could be additionally explained in relational or emotional terms rather than a cognitive judgment of risk, where the new social norms don't just function to rationalize, but help the person feel less deviant or exposed to judgement by others (as well as their internal critic). Now it is not only physically "safe" to dine at a restaurant, but socially and morally safe.
Thank you for your thoughts throughout the pandemic. One of my favorite articles that I read is the interview that you did with Eric Topol -- "The Remarkable Value of Thinking Broadly: A COVID -19 Trifecta."
One piece that I have been very focused on, during the pandemic, is how data is gathered, what the definitions are, how it is reported at a county, state, federal level, and if those data match. There are many articles in The COVID Tracking Project Blogs, on how they do not, as well as an article from KHN in September, describing how each state was determining whether to report antigen tests/if they did. There is still no federal standardization of data reporting. Each state can report PCR pos/neg, or PCR pos/neg + Antigen pos/neg or PCR pos/neg + Antigen pos. Not every state deduplicates people that have already been tested, hence, in some state 1 person can equal 5 cases. This reporting of "cases" became especially problematic, when the 150 million Abbott Binax Now started to arrive in mid-September. The Government Accountability Office Report from January 28, 2021 details out the lack of a plan on testing, and how there are no federal reporting standardization, and how the data should not be used to compare and contract, as the data are not equal.
The WH Coronavirus Task Force, led by Dr. Birx, put out this inconsistent data, never scaled it as testing changed, and then made dire warnings about how "All Americans must change their behavior now", all through November and December. Had this task force/Birx realized that the data was inconsistent and not scaled, the picture would have been very different. It continues to this day with Dr. Walensky's warning, yesterday, as quoted in a STAT News piece that the last 3 days of cases are a "somber warning". The Director of the CDC did not realize that a winter storm that knocked out almost all of Texas, and other states, was creating a data artifact, and then making judgements and communicating them as facts -- that's a problem, for me. This challenge of the data artifact is even listed in the Community Profile Report that HHS/CDC/ASPR puts out daily, with data notes. When things like this happen . . . does she not understand statistics/data, or is the messaging for another reason?
Regarding the school metrics that the CDC put out, if one goes back and calculates the "Blue" metric, the last time the U.S. hit that metric, at a total was March 19-20, and that was on 1/70th of the testing that we do, today. For yellow, the last time it was hit was in June, on 1/7th of the testing.
I went through the 3,006 U.S. Counties, Territories, Municipalities, a week ago, 241 (8 blue, 233 yellow) would have been achieved, of those yellow counties, 203 of the 233 counties had a population of 50k or less, only 2 had populations of 500k - 1.0 million, Honolulu County, HI, and Washington County, OR. None had a population of over 1.0 million. Of those meeting the Blue Standard, only Hawaii County, HI had a population over 100k at 202k. The 7 remaining counties had a population of 46k or less.
Add in the difference in reporting, and for example, any state/county that reports PCR pos/neg only, is always going to have an advantage for "reopening" based on cases per 100k, simply because they do not report antigen tests. Doesn't mean the spread is less, just means the reporting is different. But, that isn't how the CDC/HHS is calculating it, they have applied a standardized opening metric to non-standardized data.
When hearing messages and metrics that the CDC/Dr. Walensky has put forward, coupled with Dr. Fauci on December 24th, referencing how many more people were going to be need to vaccinated to reach herd immunity, as that is what he, now, thought people were "ready to hear", based on his gut instinct, and new science -- however, no scientific reporting/research was referenced, that leaves me with questions of judgement and intent.
There has never been a push to establish serological testing for all, to see who may have already been exposed to COVID-19, to calculate what levels of exposure/natural immunity might exist. I know the CDC has done studies, they are with many caveats, and the sampling leaves a lot to be desired. People are not being tested prior to vaccination, to establish whether the 2 dose regimen is appropriate, Francis Collins wrote about this in his NIH DIrector's Blog on 2/23/21.
Couple this, with as your coauthor, Michael Mina, from the NY Times opinion piece, had written in the Lancet this past week, that 50-75% of the PCR positives are not infectious/transmissible virus. The Ct values, are too high. His preprint with James Hay, that they put out in October and updated in February, could have made such a difference, had the Federal Government adopted an approach to record these Ct values and/or delta values, to establish where the virus was most infectious. There are many quotes all over the CDC Conference Call notes/pages, that most that are seeking samples want the samples of Ct values of around 28 with a maximum of 33. The FDA as of 12/10/20, in their frequently asked questions, said that "currently there is no consensus as to whether or not particular Ct values correlate with a person being or not being infectious or risk level for disease severity". Yet, the scientists on the CDC Conference calls ask for samples at Ct values at a max of 33, and a preferred 28 -- why would that be? Hence, leaves a lot of questions of what we are trying to determine, diagnosis for an individual, that they may have had COVID-19, that they are infectious, now, and should quarantine/leave work, or are we using this as a public health measure to see where the spread may have been? So many unclear answers from the public health authorities.
I think the public health authorities forgot that a relationship involves two people. If, for example, they don't respect the person they are talking to (the public), they most likely will not get the same respect back. I know that they were/are in the position, to then "blame the public" for their behavior, but is that solving the problem? Why were they not looking at age and income stratified risk, why were they not putting a focus on protecting the nursing homes/LTCFs as (35-40% of the deaths have come from the 1% of people that reside here. Why were they not supporting them with staff, PPE, and instead threatening to fine them (based on positivity rates that are not standardized) per the CMS/HHS guidelines?
These are the questions I ask myself, as I try to wade through the information that is put before us.
Thank you for your thoughtful pieces, I learn so much, and many times causes me to dig/investigate further.
Thank you so much for your work on this, Professor. I'll just throw a little personal anecdote into the mix, for what it's worth. When the pandemic first broke out, late in 2019, I was teaching in International and English Language Programs at University of Washington (the UW IELP program has since been shuttered, for budgetary reasons, and I myself have now retired). I was teaching a Special Program with a focus on science, technology, and engineering, for an all-Chinese group from the PRC. Class opened on January 3rd, 2020, by which time it was already possible to get enough information to know that something big and scary, but not unexpected, was happening. My students and I drilled down deep on multiple sources--mainstream media, including an article or two by you; technical articles, mostly open-source pre-prints; official pronouncements from WHO; politically-motivated misguidance from you know who, etc. etc.--and treated them ALL with a healthy dose of skepticism. It helps a lot that I already had some experience teaching global public health, had mentored and been mentored, working in a program where we took hits from SARS, MERS, Ebola, HIV/AIDS, you name it, all of them in the 20+ yrs I worked there. In this latest crisis, we exercised critical thinking, in the broadest sense, not in the limited and mechanistic form that it is so often presented, but where context is in the foreground, as you discussed just the other day. Just for example: when the WHO said there was no evidence for human-to-human transmission, let's just say we took that with more than a grain of salt! What's that saying? "Absence of evidence is not evidence of absence!" When the advice was NOT to mask (right!), we masked up. The messaging on that was a debacle, and your work called it out. Thank you again! When the debate was all about the size of the droplets and the definition of an aerosol, we exercised the precautionary principle and assumed the worst. Only took like more than 6 months for the science on that to really catch on. Everything we did was done in the first 3 weeks of the breakout! We did it by studying the problem, talking about it, making up our own minds about what practical measures to take, and how to sift the flood of information and misinformation. As you have pointed out, scientific literacy is so fundamental, but it doesn't exist apart from socio/cultural/political awareness. If a person can developed a modicum of that, even on the fly, they can make well-informed judgments in fast-moving and fluid circumstances like these. The failure of much of the modern educational establishment to cultivate those habits of mind is itself of epic proportions, but these are habits of mind that really need to be instilled from day one. I always tell my students, young adults, university-bound, when we are working on 'critical thinking': "Look, it's too late!" And they get it.
I'm in the habit of only talking about things I don't like within an argument, so bear that in mind as you read this:
Risk Compensation
Here you talk about various government agencies doing what normal non-substack non-twitter people would call "lying". All these problems stem from an assumption that truth is some sort of optional and usually sub-optimal thing to be avoided when desired, necessary or just 'cause.
This doesn't seem to be a problem for you; you mention only that it produced less than great outcomes in this situation, and that seems to be your only complaint. It's very, very common for people on the left to criticize people on the right for not "trusting science", but it's so normal for science to lie at this point that you don't even think it's worth mentioning that this is what's happening.
So immediately I'm struck by two conclusions here, the first being that I need to carefully evaluate everything science says with a strong prior towards them lying to me if it suits their immediate needs. The second is that I need to carefully evaluate everything Zeynep says about science, since she's apparently fine with going along with a lie so long as it might produce good results; at the very least she won't be so provincial as to call someone on lying as if it might be wrong.
Harm Reduction:
This section misses its own point so hard it's almost unimaginable.
Harm Reduction in practice is a bunch of people screaming at those who will only accept "perfect" solutions at any level of cost to the to the good that they should be willing to compromise to reduce risk where it's not possible to eliminate it. You do capture this bit.
You then go on to miss the big implication - you talk about things like kids being able to play at parks instead of having to hide it; these things might have had a small but real effect, it's true. But how in the world do you not mention that we could have had working vaccines in May or June if we were willing to accept a small risk on a super-proven technology (vaccine production). Or if we were willing to do challenge trials?
The things you choose to talk about might have worked or might not have; people might have been content with the slight increased freedoms mentioned and obeyed in other ways, and this obedience may or may not have had a large effect. Let's be generous - would we have seen 20,000 lives saved? 40,000?
Meanwhile we are hemorrhaging hundreds of thousands of lives because harm reduction philosophy isn't being pursued by the FDA in the slightest; we must take a year to produce and test a vaccine. We are in a world where we might plausibly need completely new vaccines to combat virus mutations, and the FDA/WHO very plausibly might make you wait another year to gain access to vaccines that are probably in existence right now, fully functional and waiting for use.
Why ignore the huge and definite benefit harm reduction philosophy promises in this case to focus on a small, uncertain benefit?
The balance between knowledge and Action
See above; same problem. Why ignore vaccines here? Why not mention the one place a better balance would be sure to produce massive benefits?
I think there's a difference between "lying" and unfounded beliefs! Challenge trials have other issues, though. First question is how do you make sure you have the coverage you need without randomization? Testing stuff on young/healthy folks isn't a good way to do this. Two, how do you ensure you got all the routes of exposure covered? Three, how do you deal with trust issues when/if someone from a high-risk group suffers severe illness or death? Challenge trials sounds better on paper then on giving us either the answers we need or the trust we absolutely require.
You are conflating two things here: the first is that they had an unfounded belief that people would act poorly if provided with the truth. The second is that the truth was withheld or that lies were provided because of this unfounded belief.
Holding a paternalistic unfounded belief is bad in one way, but holding a bad belief in no way frees you from a moral responsibility to be truthful. From your link:
"One of the key problems is that our public health efforts continue to suffer from paternalism toward the public. Rather than focusing on risk mitigation—giving the public every tool to reduce the chance of transmission—many leaders have fallen prey to the fear of risk compensation—that giving people better tools will lead to them behaving more carelessly. This mistake was made with masks early on, with some officials worried that public masking would lead to less physical distancing."
If you believe Karan there (I'm assuming you do, you linked him) then he's referencing our highest-level public health officials blatantly lying about the efficacy of mask use for reasons unrelated to the efficacy. That's not something you get to dodge by saying "well, we had an unfounded belief, so we lied to you" if you think lying is wrong.
That's what I'm talking about here - you seem to think lying is wrong only because it didn't work very well this time; thus you bring up the unfounded belief, because if it was founded the lies and paternalism would have been A-OK. Most (or, hell, some; we are in trouble but it's probably not most anymore) people think lying is wrong, full stop.
Regarding the vaccine testing:
You don't! You don't do those things! That's kind of the point!
We have a great idea of how vaccines work; we have a great idea of how vaccines for this particular disease work. We are really good at making them! We made one in February that was in production in march that works great, just as we knew it would!
But instead of taking a tiny, almost insignificant risk on it by doing some basic effectiveness testing, we did what you are doing: we demanded absolute surety at the cost of 3/4ths of a year and several hundred thousand deaths. And if we need a new vaccine because of mutation, we will produce a working vaccine for it in a few days, and then let hundreds of thousands of people for-sure die so we can avoid a very small chance of a vaccine not working very well.
Even some of your object-level objections don't make a ton of sense. Are you worried about exposure routes? Run a slightly bigger challenge trial; problem solved unless you just won't consider anything but "the perfect". Worried about trust issues? Work on a reputation of truthfulness (see above), and explain honestly both before the trial and after that some level of inefficacy/reaction is to be expected, and that this will potentially save 100,000-300,000 lives at the cost of perhaps a few in the volunteer group, which you still expect to be net-positive in terms of lives saved even within the group.
But instead we have the worst-possible situation: hundreds of thousands of avoidable, unnecessary deaths, and most health intellectuals going "Well, of course it had to be that way; god forbid we grappled with the minor problems any other method would present - let's just let a quarter of a million people die so we can say later that we were very cautious".
I'm falsifiable on this, of course: If you can explain how the new method was as likely to kill a quarter of a million lives as it was to save them, I can back off of this view.
Although I’m not a Virologist or epidemiologist expert and although I’ve to admit that when I was young I’ve been educated with a Philosophical approach that would sound exactly as
“You don't ! You don't do those things ! “
I think that the idea of Challenge trials must at least being taken in consideration .
Of course with all the due randomization, safety checks etc etc .
Although I don’t think that the path that they choose with the available Vaccines, especially with the mRna ones is so different .
Putting it very simple, Phase 1 has been shortened consistently,
Phase 2 and 3 kind of “fused” together (continuous-phase trial etc),
and Phase 3 is continuing now in real time .
(talking about this I’m thinking how it could be addressed to the Population @zeynep ?
I mean “empowering the public with information”, or just informing telling all the truth about the meaning of Emergency procedure and approval to the main Population, and expecting to be fully understood and approved in a compliant way .
Meaning that the Population will anyway take the Vaccine in a way that is not even less enthusiastic and numerically consistent hat the one that we’re already experiencing in many part of the Western World at least . )
Then, Phase 3 again combined with Phase 4 AKA real World experimentation .
Talking about Challenge trials (Human challenge study) I’m not sure that what happened with AstraZeneca and Sinovac Phase 3 in Brazil (and some other Countries) is so far from this,
maybe they didn’t intentionally expose the test subjects to the Virus,
but for all the rest that Challenge trials imply I can’t see so many differences …
I honestly don’t want to be polemic about all of this,
I kind of approve the Trials approach that had been mostly adopted,
but at the same time there are many things that only 6 or 12 Months would have considered scientifically and ethically unconceivable .
And I personally still don’t know where to place all this doubts .
About shortening the timing for a Global Health Emergency :
Maybe (sigh) Boris Johnson’s call at the G7 about “100 Day Target to Create New Vaccines”
I do have to take exception to the idea that what we did "isn't all that different" from challenge trials. Challenge trials are much, much faster and we didn't seriously consider using them as a tool.
Think of it this way: We just recently got our vaccines. They are much less effective against the mutations, from the data we can tell. We might get lucky and not need new vaccines, but that might not be the case. This leaves us with two scenarios we can follow:
1. Acknowledge that we are pretty good at making vaccines and that it's very likely any vaccine made with the current science will work and work well, just as every vaccine designed for the current pandemic works and works well with zero tweaks after initial design
Run a quick challenge trial with the initially produced doses to verify basic safety and efficacy. In this scenario, you have the vaccine tested and in production in a matter of a few months.
OR
2. Be maximally careful about the vaccine and close your eyes to the definite danger of the disease you are fighting. Do mostly-useless testing for 9 months; let hundreds of thousands of people die.
There isn't much in-between here. Even the most pessimistic of people didn't think that a botched vaccine was particularly likely, or that if it was botched it would kill 400,000 people. But to prevent a vaccine accident that's enormously unlikely to happen in the first place and would only effect a few people, we are supposed to be comfortable condemning hundreds of thousands of people to die. This is weird. I don't understand this stance and I probably never will - it's just throwing your hands up and saying "This is the way it's always been done! We have zero other options!".
Challenge trials might have gotten us a month at the best. Pfiizer and Moderna were still in phases 1 and 2 in early July, so it wasn't the lack of challenge trials that kept us from having a vaccine in the spring. Phase 1 is a safety test, but since it involves the immune system, it takes weeks to determine safety, and one needs to test a large enough cohort. The immune system is full of surprises.
Phase 3 started in late July and took two or three months. Challenge trials might have shortened this by a month, maybe, but phase 3 was a lot shorter than anticipated thanks to the rising case count starting in late summer.
Challenge trials aren't magic. You still need a good number of subjects, and you need to spend some time calibrating the challenge. How much virus comprises a suitable challenge? Does the concentration matter? What are the mechanics of a realistic inoculation? All those things and more have to be found out to create a realistic and useful challenge trial.
Just vaccinating people and telling them to carry on avoids a lot of work and guarantees a realistic result.
(This ignores the problem of collating and analyzing the data, ramping up production, arranging for refrigerated transport, setting up websites and clinics and a host of other things.)
This whole argument assumes you go the full, unnecessary and death-ensuring FDA process knowing that doing so represents sure, mass death to mitigate an almost non-existent risk. This assumes you need the full FDA battery of tests to ensure a reasonable efficacy level - you really don't. We do those things because we are used to them, and because job number #1 of the FDA is "We only get in trouble for stuff we approved".
The Pfizer vaccine was finished in it's current form in JANUARY. Recruiting a battery of test subjects and running them through the weeks you need to determine basic safety could have been done by March; at that point every single other thing you do is extra when dealing with a pandemic we always knew would have a spectacular kill count.
It shocks me that given the millions of people who have died, the 10k or so who die a day, that I really have push the basic intuitive math here: Rushing the vaccine and pushing it out to incrementally larger groups - a few thousand, a few tens of thousand - over the course of a month could have potentially killed a few hundred or a few thousand people; to prevent this risk, we knowingly accepted the deaths of several hundreds of thousands.
The fact that the vaccine was produced in its final form should tell us something, but we ignore it: We are pretty good at making vaccines. We have very few if any sizable testing disasters with vaccines in our history; I haven't been able to find any. Nobody seriously expected that the Pfizer vaccine wouldn't work or wouldn't work well; we are just married to absolute surety on drug safety/efficacy even where it makes sure we kill far more people by doing so.
And because of this, we are stuck; we already have pretty reasonable evidence the new mutations don't respond as well to the vaccine. If tomorrow a new strain emerges that the vaccine doesn't handle, we will waste another year and kill a few million more people to save a few thousand in the absolute worst case. This is insanity; it's "But this is the way we've always done things!" with a price tag of the population of a small country every time we do it.
I don’t have enough expertise in the field for giving an accurate opinion .
Although being a Professional Musicians and a Financial Investor with some background in the area of Tech,
I studied Medicine when I was young .
But the Immune system is so complicated and yet with many unknown aspects, the Virus field so articulated and mostly the Vaccine’s sector so specialised that I don’t feel able of giving a pertinent opinion .
I didn’t have any background, despite my studies, in the Vaccine’s sector before this Pandemic .
But I’m grateful that you opened a window on Challenge Trials possibilities,
It seems like so much of the moralizing and absolutist messaging stems from the fact that US public health systems -- the basic testing, contact tracing, and quarantining-- were totally inadequate. In some areas, half of the patients reached by contact tracers give any contacts at all. Those who are told to quarantine or isolate are asked to do so voluntarily, without aid or checks to ensure compliance. Meanwhile every country that beat this virus had a managed quarantine and isolation program. In Australia, they did call and check to make sure you were isolating at home. International travelers must spend two weeks in quarantine. China built thousands of field hospital beds to isolate even mild cases. Yet at the height of the epidemic in New York, a New Yorker could get on a plane and fly anywhere else in the country without any testing, quarantining, or tracing involved, spreading the virus across America. If you were exposed and had to go to work or lived in overcrowded housing, there wasn't much help coming for you. Is it any wonder that when the basic measures of testing and tracing weren't working, health officials could only urge people to stay home harder, and wear a mask harder?
Good article. A few thoughts on vaccines and why they have not been greeted by dancing in the streets.....
- A lot of the population doesn’t believe the virus is serious, and some have behaved as though nothing is going on. Why would these people rejoice about a vaccine?
- Whoever delivers a message in America is likely to be disbelieved by 40% of the people. Trump told us we’d have mass vaccination by the end of 2020. I instinctively didn’t believe him. It turns out he was exaggerating, but not terribly. The roll-out has been far quicker than expected. But who wants to give the Trump administration credit for supporting the development of the vaccines?
- Poor messaging by Biden. He reacted to Trump’s pretense that the virus is nothing serious by saying relentlessly how awful things are going to be. This is not what people want to hear. We’ve had a long, hard year. Tell us that if we stick with this a bit longer, success is on the horizon. When you’ve been losing a game, and the game starts to turn in your favour, you don’t take your foot off the gas and let your opponent back in the game. But you also shouldn’t dwell on the negative. (The only messaging I've seen that got this right was a commercial for the Ford Motor Company. How strange is that?)
- Media desire to look for the negative. We are vaccinating 1.4 million per day. That is fantastic. We are far ahead of most countries in the world. But if you read certain sections of the media, the sole focus is on the “inequity” of who gets vaccinated before whom. Distribution has been far from perfect. But with an infectious disease, each person vaccinated helps the whole community.
- Complacency. Most of the population has little memory of times when infectious disease imperiled whole societies. We just expect these things to be fixed.
I think it's also important to take into account her larger message which is to appeal to people's better instincts as a necessary resource in all this, not just the realist view of our negative tendencies. I.e. people are usually distrustful or cynical for a reason, and restoring trust can help counter this.
Martin, these are valid observations along with your 5 initial ones in the earlier post and definitely a part of the story, with the possible exception of complacency: maybe at the very beginning of this, but I don't think most people have been complacent for a very long time. I think you're mostly targeting a different level of analysis than Zeynep though (aside from media looking for the negative where you both overlap) - my sense is she was focusing on categories of strategic errors in public health messaging and fallacious logic or self-defeating patterns in our general approach to the pandemic; not the background/structural conditions, political environment or "bad attitudes" that hampered our response.
You are right. My comments here were strictly focused on Zeynep’s first para about how there seemed to be no rejoicing about the vaccine. I have friends and family in the UK, and what I hear from them sounds very different. They have also had a tough and crappy year, but I’ve not heard from anyone who isn’t impressed and grateful for what the country has done with vaccination.
As for complacency, think about the anti-vaxxers. They are able to take the position they do precisely BECAUSE VACCINES WORK! I don’t think people grasp the scourges that have been beaten - and how speedily we have come up with the means of beating this one.
I do agree that there's psychology to all this as well as sociology and policy, and it's really important to try to get inside people's heads to imagine what's motivating (or not motivating) them.
Can you explain more what you mean by the luxury of taking the anti-vax position precisely because vaccines work? I think I understand what you're getting at, but not sure if I'm reading this correctly. Do you mean they are complacent in the sense that they still benefit from society benefiting from the vaccines, so they can get away with not taking them in the short term and still maintain the illusion this leaves them better off? If vaccines weren't effective, how would this work to undercut their vaccine denial?
I think you’ve got it. Infectious diseases were once a major problem everyone knew about and feared. Earlier rounds of vaccines were a miracle that removed these scourges from everyday life. Neither the fear of infectious disease, nor the relief of vaccination are any longer a part of most people’s lived experience. For that we can be grateful to earlier scientists, and to officials who implemented mass public vaccinations.
So today’s anti-vaxxers have the luxury adopting a posture of denying the science, or indulging in conspiracy theories, unaware that they have that luxury only because of the previous efforts of scientists and administrators - and because most people DO get vaccinated.
Now we are faced with a new disease for which we do not yet have herd immunity. Maybe I should be optimistic. Maybe this will end the complacency and denial, and give us all a renewed appreciation for what science and public health can do for us.
I am a person who works at a health department. I agree with all these points -- as do many in my office. But we are so hamstrung by the lack of any power or ability to do things. For political reasons, we cannot provide any support essential workers. For political reasons, we cannot keep the schools closed. For political reasons, we cannot contradict the CDC.
I read this whole article and I feel ashamed and sad to be part of this fucked-up response - but the only other option is not being part of this response, so.
Also - everyone is so mad at us, all the time. I don't know what to do. We have so little staff; we are all doing everything we can. We know the messaging is bad. But what can I do? How can I change it?
I worked a vaccination POD last week; I was signing someone up for her second dose appointment. She asked if she could have her second dose this weekend as she was going on vacation next week and wanted it before she flew. I don't know.
Alison, please don't feel ashamed of working harder than should be asked of you and all health departments trying to fill expectations that are impossible and often make little sense. I work at a college, volunteering for testing students and staff, and between my experience with our campus healthcare providers and people I know at our local health department I have nothing but the highest respect for the work you all are doing. Endless thankless hours of service. Thank you. Thank you. Thank you.
I'm not kidding when I say that in our region we saw our county health directors replaced one after another. In our county it was a quick and silent change. In a neighboring county it was a public "hell no I won't go" response by the valiant director. Guess what? He went. Our schools are open. It appears to me that not everyone in our county health departments share the same understanding as Alison. That saddens me. And I am sad for you Alison. Hang in there. I respect and value you like I can't even begin to describe.
We went through three county health directors within the year -- not replaced; they mostly left due to complete lack of support and even resistance from elected political leaders. We ended up with the most recent one who had retired years ago but at least is willing to step in and knows a lot of the personalities and dynamics he has to contend with.
This would be a wonderful opportunity to utilize the professional skills of senior workers/experts in communications who may be retired or working part-time. As volunteers, e could help amplify, hone and multiply consistent messaging. Our current health agencies are underfunded and understaffed and can't do it all.
There is almost nobody whom I’ve been more grateful for througout this than our county health department, who have done an incredible job and their best with too few resources and no political support. You should not feel ashamed.
I am a school bus driver who has chosen to take unpaid leave instead of returning to work at this time. In our region we have literally seen public health directors driven from their positions. It is disgraceful. I won't cooperate with the wrong solution. I would be happy to cooperate with the right one, however draconian it may seem. I never understood why we didn't see the national guard used to shut us the f down. Now there are 500,000 plus less Americans and we continue our march forward into the withering fire.
OK, I haven't read the article yet. But when the coronavirus first appeared, I wrote on Facebook that it was "almost perfectly designed to exploit the ways America is messed up". Like you, I had a list of five. I look forward to reading your article to see whether we have the same list.
- Large number of people without health insurance, who will avoid the healthcare system.
- A culture that emphasizes individual rights over the common good will have trouble getting people to comply with the rules to curb the spread of a disease that transmits from people without symptoms.
- healthcare culture of focusing on cure rather than prevention.
- uncoordinated government structure - federal vs states and divisions between different government departments. I thought there was little hope, for example, of proper management of borders given the differing priorities of different government departments.
- a President who never leads by example or by asking people for sacrifice.
Careful, you may be committing some of the messaging problems that Zeynep highlights in her article, which is that COVID spread cause people were bad. If only people have followed rules! She lays out how people were getting it simply by going to work or being at home or fulfilling very human needs. You can’t control a pandemic through individual willpower alone.
Fair point. But whether they were rules or guidelines, my point stands. In America we really look at things from the point of view of personal risk. Especially in the early stages of the pandemic, when case counts were low, the point of most of the precautions was not to prevent risk TO ME (and after all, if I am not in an at-risk group, the risk of serious harm to me is low), it was to reduce the risk of me being part of the chain of transmission. We still hear this in the debate on schools. Parents ask: “ Is MY CHILD safe?” Teachers ask: “ Am I safe?” No one really says “Does this contribute to the risk of a huge outbreak?” I’m an immigrant who has lived here 20 years, and I have still been surprised at the way Americans seem quite incapable of thinking like this.
Thank you! I have shut down my life for the last year. Personal safety of course. But I have also seen it as my duty to not become a link in a chain. I feel reasonably certain I could throw back beers and handle my own infection with the best (wrong word) of them. I won't. I am one of a handful of employees in my school district who have taken leave this year. And the stated reasons for my taking leave (to protect myself and particularly my wife -who I could not forgive myself if I infected) are easily accepted by my superiors. But the argument that they are wrong to be reopening the schools ahead of vaccinations is just not something anyone seems willing to embrace. Thank you so much for your post.
In no other country was all this energy spent on asking people to stay home and only do non-essential activities for a full year! We asked individual willpower to stand in for public health measures, and personal virtue to stand in for mobilizing a society.
Yeah, will power in place of public health measures has been a good portion of what we did too much of.
We asked. We didn't enforce. We failed.
Indeed. I was surprised to discover that I WANTED to be told what to do. And I WANTED that to be enforced. I suspect I am one of millions who have tried for over a year to “do the right thing” and follow guidelines that others have ignored. I know too many people who feel doing anything is “safe” - but are only able to do those things safely only because of the millions who are staying home, restricting their movements wearing a mask, etc. I came into the pandemic expecting to feel a sense of “We are in this together, and we will get through this together.” That dissipated quickly.
We are brothers Martin. Thank you!!
Enforcement has proved impossible in our culture. I am intrigued by the comparison of our unruly states U.S. (mine is Texas) with Australia, which has a rather unruly history. It has been able to do gun control and now covid control. What is different?
I had a conversation recently with an Australian friend who just moved back to Perth from the UK. I observed that whenever I had been to Australia, I had observed two things: (1) their public service messaging is superb, and (2) they are, surprisingly, some of the most rule-compliant drivers in the world. He confirmed that they have great respect for authority, and rules are strongly enforced. No one speeds because “it’s not worth it. Not worth it at all.” The speed cameras WILL get you. I will also tell you that they are as proud of not being America as they are of not being Britain!
I had a similar response, just shared with family and friends, that this was going to be a stress test for what climate change will bring more of. The results are mostly not encouraging, though my own small community’s resilience showed.
Are you familiar with Margaret Klein Salamon? She does a lot of work around the hidden psychological toll of our subliminal awareness of the coming climate emergency and the need to work through these complex emotions, and engage fully with the harsh realities, while being compassionate with ourselves and processing this suppressed grief and fear together with others with the ultimate goal of being in a better position to take action.
The pandemic of course is a different situation, and maybe less about acknowledging the sheer scope of everything, but in some ways not entirely different since it is as you say a dry run. I feel like we could have benefited at times from a larger set of voices stressing this more empathic dimension (Julia Marcus does this at times, and of course Zeynep in a different way).
Ooh, no I hadn’t but will now go look up her work. You are right—having more voices talking openly about this would have really helped.
I guess there's many others who have written on existential coping in the Anthropocene and so on, but she was a clinical psychologist so she comes a bit from that perspective as well, which I appreciate.
Despite the occasional nod by writers to parallels between this pandemic and the climate crisis, I would really like to have these two linked up more systematically; both in terms of how we are internalizing them (sometimes simultaneously, sometimes in parallel), and also with a mind to lessons we can learn from one to the other.
^^Yes all of this
it is ironic that with climate change, the old have showed unconcern for the young, but with covid, ...
That had actually never occurred to me. Good point.
I still think the fundamental attribution error is one of the most useful things I learned about in college and I've thought about it a lot during the pandemic, especially in the context of grandma-killing rhetoric. Not exactly the same, but an imputation of very bad motives to ordinary people committing the unforgivable sin of wanting to see their loved ones.
My mother is an epidemiologist and I learned a lot about public health intervention from her, but my trust in official channels of expertise in this pandemic is utterly gone, even though I'm myself a credentialed member of their class (university professor). There are a few different reasons for this, but the three most basic: 1) Being told not to wear masks (I'm in New York) and it made no sense to me but I thought well, I'm not the expert here. 2) Total absence of harm reduction messaging. I do some work on the history of the AIDS crisis and the rhetoric and scolding was eerily similar, despite the absence of the sexual element. In fact, the trope of the careless disease spreader goes back at least to medieval times. To make people guilty for breathing in the presence of others... that's really hard to come back from. Which is connected to 3), the acknowledgement in your article that sociality is a human need and itself an essential component of health. I think we made a fundamental error in not focusing on just how basic a need we were asking people not to indulge.
The people we think of as pandemic deniers aren't necessarily stupid. They may have different assessments of risk, different values, and they may know - which is correct- that 'elites' are lying to them. That is apart from the horrible and of course completely culpable contribution Trump made to all this.
But there's other cognitive issues too: that a successful intervention would seem overkill in retrospect, and that familiarity doesn't read as danger, and that cause-effect relationships are often distant and out of sight. The cognitive load of generating decisions so contrary to fundamental processing structures in our brains is costly. Thinking more compassionately instead of treating people like naughty children might have helped.
re: To make people guilty for breathing in the presence of others... that's really hard to come back from.
I sense that you're right about how that makes people feel. But to use the efficient messaging of Dr. Michael Osterholm, this virus does result from "swapping air" with infected people. It makes me wonder if that phrase had been used from the start, would anything have been different?
Good messaging without shaming and blaming feels like the dream, and also much more likely to give folks a sense of being in it together. Instead we all feel like others are either trying to kill us or steal our lives and happiness away. It's a good phrase! And there are many practical small risk-reduction things we can do as more are vaccinated that are compatible with something much closer to normal life. I wish we were explaining them all.
I think there's been a repeated "you can't handle the truth" approach to public health communications which has really contributed to public skepticism. See: "masks don't help" when it could have been "Some people need masks more right now, and we're not sure..." I'm so frustrated by the ... I'll say misinformation .. around the amount of vaccine doses and when they'd be available. V-E (vaccines for everyone) day was never coming until May or so, I'm not sure why this wasn't made more clear. Also, there's something I've called data idolatry before. Yes, RCTs are the only way to be sure about a scientific fact, but in life, you often have to make the best call you can with the (incomplete) data you have. It might very well be a good call to postpone second doses in order to get single shots in arms before new variants arise. We don't have conclusive data on this yet, but we have pretty good data, and we shouldn't dismiss it.
I guess I'm pulling out specifics where this article is more concerned with trends... but I don't think I can overstate the effect that being yelled at in all caps by the Surgeon General had, on all public health messaging I received after that. https://www.nytimes.com/2020/02/29/health/coronavirus-n95-face-masks.html
(Some context: I still don't quite understood who is a political appointee and who is not; and I most strongly associate the Surgeon General's "brand" with the extremely warranted, frightening messages that got added to cigarette boxes from when I was a kid... which means there was a certain amount of recognition and trust, maybe even gratitude, that I brought to my understanding of what their role would be, in decision-making about my health and the health of those around me.)
I felt wounded, honestly: first by a tone meant to convey how stupid my impulse was, to want to protect my family from a virus that had enough obvious priors/analogues even by February 29th to warrant mask use. Then by collapsing my very sane and normal impulse into a kind of panic reduction by gaslight; presumably (but not obviously) meant to address price gouging and hoarding. And finally by invoking frontline workers' need for PPE... all but the worst of us would prioritize their huge needs over our own modest ones... and it only served to underline that we were probably correct in assessing those needs. Yeesh. I still can't shake it, an entire year later!
Can I just say that I really like these sharings of anecdotal, personal experiences about what was or wasn't helpful for a particular individual and/or their friends, what felt alienating, what confused or aided their understanding? I feel like this is a really important part of the data and one of the most valuable things about the blog, that it provides a space for these kind of concrete stories and situating them together vis-a-vis the larger issues being dissected. (The more analytical and conceptual posts are great too - I just like that we're seeing both.)
Absolutely. These details are so crucial to our understanding. The view from 30K feet has its uses, but absolutely has its significant limitations.
That early messaging was horrible. I had the time to closely follow the news and the politics and the science. (The early medial preprints from China were wonderful. They were wonderfully readable and informative.). I am still angry at the estimable Dr. Fauchi, who said the same things the SG did.
In my view, both were lying about the medical facts. You could look at the news from Europe and Asia and see whole populations who had feared SARS and who had dealt with Swine Flu wearing masks and having better statistics than the U.S. did.
Also in my view, Dr Fauchi and Dr. Adams were trying to accomplish the part of the message you picked up, to save PPE for medical responders. But they and their agencies failed completely to put out messaging on how to make effective masks. Many other countries did better. The U.S. process did finally get a mask pattern on the internet and in the newspapers. But they completely failed to publicize the materials that should be used and the use of the nose clips to improve the fit.
Meanwhile, all over the world, Australia and Hong Kong were telling us about materials (using scientific studies), and individuals and companies started churning out masks, but the government and other trusted agencies (whatever those might have been) did not tell us how to choose.
Thank you for sharing your response. As you can see from my post, I haven't shaken it either.
Could not agree more. I'd purchased a few boxes of N95s years ago (more for wildfires and earthquake preparedness than biological threats, but that was in the back of my mind as well) and started wearing one to the grocery store at the beginning of March (along with nitrile gloves that I ditched after a month or so when it became obvious that they didn't really do much).
It was shockingly hard to do it! I'd never been in the position of being semi- publicly shamed/embarrassed routinely before. For weeks, I was the only person wearing a mask in the store, and other people would give me that "what a weirdo" look (and that's the most charitable accounting). It's surprisingly unsettling, even though intellectually I know that I'm never going to see these people again and have absolutely no reason to care what they think.
Also, let's remember that the CDC recommended that people not get tested after possible exposure IN LATE AUGUST! (See here: https://arstechnica.com/science/2020/08/cdc-loses-its-mind-says-people-exposed-to-covid-19-do-not-need-testing/)
The lies (some "noble" and some not), misdirection, and manipulations from public health officials during this pandemic have been absolutely unforgivable, and it cannot all be laid at Trump's feet (although he certainly did his share and I think also led journalists to rally unthinkingly around any and all of his opponents, when in a more normal time they likely would have exhibited a bit more journalistic skepticism---see Cuomo, Andrew M. and Newsom, Gavin C.).
Ironically, the anti-mask messaging did more to convince me, personally to wear a mask early on than probably anything else they could have done. Based on the level of concern for rationing supply, it was pretty evident that these N95s must be pretty good protection. Kind of like in the Soviet Union, if there was a line forming somewhere, you joined it. You didn't even need to know what the line was for, just that something was about to go horribly wrong, and you'd best get there early. And if heaven forbid the authorities shouted that there was no need to get in the line, you ran there.
Zeynep, further to this, from your wonderful Atlantic piece:
"The difference lay not in the level of evidence and scientific support for either theory—which, if anything, quickly tilted in favor of airborne transmission, and not fomites, being crucial—but in the fact that fomite transmission had been a key part of the medical canon, and airborne transmission had not."
In addition to your Popperian observation of weak evidence that matches the paradigm case out-competing strong evidence that does not, there is also the value of various adaptations as signals, not just as counter-measures.
Institutional consumers of public health advice, in the absence of clear Federal or state mandates, were left to signal to consumers that visiting their establishments was safe. Hand sanitizer is cheap and visible, while HEPA-compliant HVAC systems are expensive and invisible. The fact that the former is ineffective and the latter effective does not solve the merchant's primary problem, which is not limiting viral spread but rather not going out of business. (To this day, there is a stall in my farmers market, open on 4 sides and bathed in glorious UV rain or shine, that makes me sanitize my hands before entering.)
More speculatively, I wonder if there is a heuristic for people involving precaution, especially where it is engaged around questions of cleanliness and purity, where evidence to start a practice is easier to internalize than evidence to stop it?
Alternatively, I wonder if there is a heuristic that overweights early signals and underweights later ones, as humans build implicit mental models, analogous to the way parents of babies take much longer to realize their children have stopped liking certain foods, than they did to react to the moment when their children started liking it.
This is such an excellent question, Clay. After last year, I have decided that I've... not given sufficient respect to: Kuhn, Popper, Michel, Weber, Janis among others. Paradigm shift, group think, "iron law of oligarchy" in the sense of organization inertia, etc. I mean, not that I didn't know of these things but the strength with which they happen, the speed of the transition and the ensuing amnesia... As if it didn't just happen. Incredible. What else did we forget, historically, that is there to be understood? What is there to learn? It's been incredible.
Yes, and I'll add the Iron Cage Revisited and institutional isomorphism to that list.
And the amnesia is indeed extraordinary. Despite knowing, for 100% certain, that fall will not be 'back to normal', both as a practical matter and as a desirable outcome, I hear people slipping into that language all the time.
Just to save other folks the search, here's a summary of what Clay's referring to, with a link to the full paper:
https://acawiki.org/The_iron_cage_revisited:_Institutional_isomorphism_and_collective_rationality_in_organizational_fields
though sideline it seems parallel to climate change mitigatiion-- it was always easier to convince orgs to do the visible and demonstrative but less effective actions(personal recycling, using recycled paper (not bad but not as big an impact as folks think) eg) than the effective but less visible (lowering energy use, fixing HVAC etc).. Seems parallel.
Zeynep, First of all, thank you for your coverage during the pandemic. You have been right so often since the beginning, and it blows my mind that you are not in some higher up position in the government public health response or the CDC. America would have been better off this way. At this point, I typically check in on what you have written and Fauci when I'm making decisions on how to proceed based on new information. Along those lines, I would greatly appreciate if you could write a future article on your thoughts on pregnancy and getting vaccinated. (Although I'm sure this is such a loaded topic...)
There are a lot of points that I think are right on in this article. Public health officials have failed to help individual citizens focus on ways that they can mitigate risk (ie- socializing outdoors safely and staying mentally healthy), and not focusing enough on providing evidence based guidelines to businesses and schools on ventilation. How is it that at this point of the pandemic, it is basically mandated that hand sanitizer be readily available in every corner of a store, but most stores keep their doors and windows closed even if they could be easily opened? An incredible failure in the public health messaging for sure...
I'm so beaten down right now that I just keep re-reading your point that life will get better with vaccines. It's so obvious that the vaccine dramatically reduces transmission and yet...FEAR MONGERING IN EVERY HEADLINE. Widespread PTSD is sure to be the next phase of this pandemic.
Thanks again, and looking forward to reading more of your work.
Yeah, the way we cling to hand-sanitizer (which isn't bad! but not that necessary for this!) while still not doing more for healthier indoor air (which is great! even after this pandemic is over!) is .. disappointing and the one thing to push for. Indoor air quality is really important, even without this coronavirus stalking us.
I see the reluctance to improve ventilation as a function of how expensive it would be. Both my university and the public schools in my region have lots of dreadful HVAC "systems" (if they even deserve the name) that would honestly need to be fully replaced rather than merely improved. Such institutions need more info on how to do the best with what they've got. Sure, some HEPA filters have been installed. Not all systems even permitted that.
We also have far too many leaders, at every level and in every sector, who don't even begin to understand how ventilation is the key issue. The baffling directions from WHO didn't help. CDC was wayyy too slow on getting the word out - even though the case of the Washington choir was an absolute klaxon. I wonder how many millions were spent on sanitizer and plexiglass?
Thanks for your work, Zeynep. Your early article about beach shaming helped me understand both the difference between indoors and outdoors with regard to transmission, and the susceptibility of our leaders, health officials, and the general public to grasp at solutions that distracted us from interventions that would actually help save lives.
Ventilation improvements are expensive, and I agree that they are critical for many reasons beyond the pandemic. However, opening a window or a door is free. To your point, if the public was actually effectively educated by public health officials on how this virus spreads, they would at the very least make an effort to open windows in lieu of expensive upgrades.
Indeed, you’re right about windows! But a great many classrooms lack windows. The majority of the ones I’ve taught in are I that category. Ditto for nearly all classrooms at my kids’ high school. I wish this were a rarity.
Remember that because of the epidemic of school shootings, there are often strong policies about keeping doors and sometimes windows closed at all times.
Biocloud airborne virus detector... look it up. They could be in our schools by next September. If we tried hard enough I mean.
At $20,000 USD / $15,000 CAD per unit and per the Kontrol brochure, schools would need one device per classroom. That's just not going to happen.
.We are spending the money already. It is what you might call expensive technology, no question. So the question to ask is is it worth it? Assuming it functions as expected, absolutely. But moving beyond concerns about price and profits and patents who cares how much the company hopes to sell them for... if the device can be produced it needs to be produced and distributed and put into service regardless of who pays the cost. Were it the US we would be talking about the defense production act. I don't know the Canadian equivalent and of course we need an international approach anyway. Airborne detection strikes me as akin to the holy grail. As I mentioned DARPA has been chasing it. So my goal here is simply to let you know it exists. I do that because I sense that it is a story not fully told yet and feel compelled to share it. I am glad you took the time to look into it, Yes, the unit price is not a minor consideration. And the cartridge replacement cost is not nothing. But I would suggest given the value of early detection that cost, compared to the cost of testing is insignificant.
The real question, in my opinion, is would something like this be effective in controlling the spread of the virus? Certainly it would be. There is skepticism from some in the Canadian scientific community who question the proven effectiveness of the device but acknowledge the need for it. That question is being faced now. Were the story more widely known there would surely be more skepticism here.
Because, after all, how is it this Canadian company beat the world to this? Well, it seems to be in the wheelhouse of CEMSI which develops an array of sensitive electronic monitoring systems.
Moving beyond doubts about whether it works, which obviously need to be dispelled first. Moving beyond the current unit price, which is steep but surely will be able to be brought down. Think about how you would use an airborne detection system as part of the response to the pandemic. And finally (and I am so proud that I am on topic now) how much of a mistake would it be to dismiss such a possibility so readily?
One last note: I just learned Spokane, WA is experiencing the exact scenario I have been describing to anyone who would listen for some time: a breakout of exposure on the buses. Eighteen positive cases among drivers. Another eighteen exposures. Bus company claiming it happened offsite. Parents not buying it. Bus drivers claiming safety measures not being followed. Buses being overloaded with kids as they consolidate routes due to missing drivers. And do I need remind anyone of the average age (and I hate to say it, weight) of the typical American School Bus Driver. This is not a moment where I enjoy being right but I warned my own school board this was coming. Now it has come to bear in Spokane. It will happen the same way everywhere. And everyone in America will all of a sudden care and have an opinion about pupil transportation beyond platitudes about how important bus drivers are. Now imagine an airborne virus detector on a bus.
Okay, sorry, that was a heck of a long post. I am very close to this issues - as we all are. Cheers!
Perhaps the above is an updating of the colloquial concept of ‘public-health’?
Taleb quotes Popper in Black Swan:
“Genuine philosophical problems are always rooted outside philosophy and they die if these roots decay.”
That is sorta your role?; you’re one of the few American-based philosophers who can reason in an informed and fruitful way about some of the hyper-dynamics at place. Wonderful!
Targeting these fallacies makes sense; there is an opportunity for us to do a better job illustrating them; we put a lot of effort into making dynamic graphics for network television, and yet it’s hard to see the dynamics you explain. So, something like, better versions of nicky case’s work (but static stuff too) with opportunities for conversation and reflection.
As a writer, you cue us in to more tangible illustrations of the fallacies considered. Let’s do this visually. We need the public health officials working more closely with storytellers better accustomed to the tools of the times. It may help to SEE these fallacies side by side. A few core visual ways; adapted as templates for specific communities.
As you know, the ‘research debt’ problem is acute in Machine Learning; folks have some early ideas on how to address the matter. Worth a (-nother?) glance. https://distill.pub/2017/research-debt/
Forgive me Zeynep, but this all seems so intellectualized; which seems appropriate, but I’ll politely suggest that the emotional realm is quite important regarding public response, coping and the action issues.
We are all having to sit with a lot of discomfort. Updating and better distributing our tools for being with emotions and following their relation to thought, seems pertinent. Your point about awareness matters here.
Ex. ‘I am feeling ____”, . ..why? Because I am worried that ____ will occur”.
We know a lot about how cognitive load, acute and prolonged stress, and trauma, affect thinking, behavior and learning. We have to bring these insights to bear upon our current encounters.
Meditation, mindfulness, our heuristics around social emotional learning, matter here; and not in a hand wavy-way. Being in nature. Islands of competence etc.
I want to also emphasize your nod to the time boundary; which seems important.
Part of your audience seems to be the explicitly mentioned ‘officials’ and ‘media outlets’; perhaps we could expand this to include product managers?
Dewey and Addams always emphasized how democracy being embedded in social practice was crucial.
So on this. Yes, yes, yes. This is also the problem with a lot of our tech coverage/criticism now. We need to make the philosophical roots of our disagreements more explicit. "“Genuine philosophical problems are always rooted outside philosophy and they die if these roots decay.”
On the emotional responses: of course. We're humans. Sitting with discomfort and uncertainty is difficult, and there's just no avoiding it in a situation like this.
First, wonderful article.
Second, messaging is hard, especially for public health officials. Often arbitrary standards are the best they can do. I am reminded that in the jewish tradition, on Passover you are forbidden from eating leavened bread. So why not corn tortillas - there are no yeasts that can naturally leaven corn flour? Don't confuse the simple. Much easier to say "just eat Matzo".
If you are a public health official, is it better to say "stay six feet apart" or "don't get too close"?
Is it better to say "if you are socializing outdoors, wear your mask anyway" or "it depends on the wind's direction and velocity and how close you are to each other"?
Of course, our public health messaging could have been much better, but if we foster risk adverse public institutions then we should not expect sophisticated messaging.
Indeed. "Just eat Matzo" work well for one day of the year, and for a ritual/religious gathering. It is easier. It makes sense when the solution is universal, one-time and works.
Do we know what public health officials in the different layers of government think about the COVID messaging?
Would they say:
we've learned that nuance never works, or
we've always done it this way, or
this is the only message we could all agree on, or
we might be silenced at any time so let's go with something easy for the public to remember.
Or do they even share our opinion that the messaging has been terrible.
@jlb, I can only speak for people who teach public health on a university faculty, but yes, there is a widespread sense that the messaging has been terrible. However, it seems hard to separate the communication effects of politicians in the previous Presidential administration, and state and local politicians loyal to him, from general weaknesses in messaging.
"6 feet" is the "just eat Matzah' of this crisis. (You can tell because in Europe the advice has been '2 meters', not '183 centimeters'.) The 6' Rule has no basis in epidemiology, was based on rules of thumb from decades ago, and was quickly superseded by actual studies of transmission, but a year into the U.S. epidemic, that 'rule' remains stubbornly encoded.
It's infuriating that resources like this (https://www.microcovid.org/) have been created by random volunteers and not the CDC. Apparently their "evidentiary standards" would never allow them to create something like that. Which means we really need to start over from scratch with the public health field after this catastrophe.
The right approach isn't to give black-and-white advice, it's to tell people honestly what the risks are to themselves and others. It seems like most public health people have a shockingly negative view of the population---as if everyone is an anti-vax dropout. Kind of like how we berate children into being terrified of "strangers" when, in fact, it's like 99.999% likely that, if they're in trouble, a random stranger will help them (obviously, the calculus is different if a stranger is approaching the child unprompted).
This cynical, paternalistic disdain for the population among academics and these public health people is really counterproductive. Get off Twitter! It's a funhouse mirror that distorts the fact that the vast majority of people are decent, hardworking, caring and of perfectly average intelligence.
re: seem to have a negative view of the population? IDK, seems they have to. they cannot afford to lean too far forward and found later to be wrong - would destroy trust.
Did you read https://www.washingtonpost.com/business/2021/02/26/du-quoin-covid-nursing-home ?
Excerpt: “You got to juggle all these guidelines,” he said. “I told everybody, ‘Give us the playbook. Tell me exactly what we need to do, and we’ll do it.' ”
The day this newsletter and the article came out was the same day I received my second dose of vaccine. As many sources had warned me, my immune system kicked into overdrive with an industrial-strength migraine headache, chills, and the inability to sequence thoughts enough to write meaningful comments here. 48 hours later, I’ve returned to normal.
While I appreciate the fascinating discussions about Scientific Method and public health rhetoric that have dominated the comments, there’s more than that going on that’s differently important.
I survived my zombie state with some degree of sanity not because of Scientific Method, but because of tribal knowledge. Had I not read or heard anecdotes of how awful it can feel when the immune system is working so hard, I would have been terrified that I had contracted some other deadly disease. As it was, I was only discomforted, not panicked. The public health information gave me a partial list of some possible symptoms; tribal knowledge was more phenomenological, telling me what it *felt* like, and that was paramount.
It’s clearly necessary to distinguish the valuable tribal knowledge from the recommendations of ingesting or injecting bleach, or popping hydroxychloroquine. There’s an interesting dividing line between worthwhile and damaging advice. But figuring out what to accept as possibly trustworthy and what to dismiss is not simple. For future pandemics it will remain as necessary.
This speaks really well to how there is always a gap between the official scientific guidance, however responsible and up-to-date -- the "party line" if you will -- and the anecdotal realities of how things really look on the ground. It is simply not possible for formal institutional/scientific knowledge to keep up with tribal (or "folk?") knowledge: what the former *can* do is synthesize, refine and explain all this messy emerging folk knowledge, while carefully weeding out what turns out to be false or distorted.
My own anecdote is that a friend who apparently had the virus exactly a year ago at the outset of the pandemic had such a severe overreaction to the first shot of Moderna that she presented with bizarre and concerning symptoms and ended up being hospitalized for a few days (in the end she opted not to get the second shot, though she is still a big advocate for others taking the vaccine). During this entire period she shared running updates on social media about her condition and the phenomenology of what she was going through, as a point of reference for anyone else who might have a pronounced reaction. If I had not read her posts, and all the comments from others reporting very bad experiences, I would have *no* idea this was normal. All this tribal knowledge from below *combined* with scientific credibility from above helps me feel more empowered to choose the vaccine in spite of side effects.
I’m sorry you went through that.
It is hard to find, but there is good information out there. I knew about 2nd shot reactions in Jan from the weekly physician update on the podcast This Week in Virology. I highly recommend everyone spend the 45 min each weekend to get up to date.
TWiV 724: COVID-19 clinical update #51 with Dr. Daniel Griffin
https://www.microbe.tv/twiv/twiv-724/
Also, please check The Atlantic weekly. You would have seen this article from Feb 2nd titled
The Second COVID-19 Shot Is a Rude Reawakening for Immune Cells, Side effects are just a sign that protection is kicking in as it should.
https://www.theatlantic.com/health/archive/2021/02/second-vaccine-side-effects/617892/
My concern is not that I had no idea what I was in for, but rather that tribal knowledge (or narrative descriptions, more accurately) were another aspect that I thought should have a place in Zeynep’s overall framework.
The Atlantic article you mention was a great source. I had read it before the experience, and it was a help precisely because it got me to understand what might go on and why. Neighbors who are docs and had bad dose 2 reactions also gave accounts.
But not everyone is a highly educated reader living among professionals. The tribal knowledge I encounter is somewhat more rarified than the typical. The content and source of tribal knowledge varies, I believe, along many demographic dimensions. Your suggesting a This Week in Virology podcast is itself an instance of passing tribal knowledge, but it passes usefully only to a subset of people. Other communities have different sources, which may be just as accurate, yet pitched in other ways.
As ever, since tribal knowledge is not peer reviewed, the opportunity for malicious (or even well-intended) misinformation remains enormous.
you said: tribal knowledge was more phenomenological, telling me what it *felt* like, and that was paramount.
good point
Thanks for your wonderful article, Zeynep. As a student of rhetoric, I really appreciated this analysis, and especially the points you made in the section on "Rules in Place of Mechanisms and Intuitions."
The failures of the public health rhetoric is a clear example of the growing chasm between experts and non-experts, or even people who think of themselves as educated and how we educated folks think of uneducated folks. The world is more complex than an 8th grade reading level! It's dangerous to write about an extremely nuanced issue while imagining a public audience that you assume can't understand any nuance.
Throughout the pandemic, I've been frustrated and confused by close family members basing their behavior on rules and what kinds of public spaces were allowed to open rather than on knowledge of how the virus spreads (e.g., "restaurants are open now so it must be safe to eat inside a restaurant," or a holiday meal where everyone ate inside together but were careful to avoid sharing serving utensils). I know that I'm privileged to have postgraduate training, but from my perspective, being able to visualize how the virus spreads has made it much simpler to mitigate my family's risk without completely sacrificing our social needs.
Thank you. I agree, "restaurants are open now so it must be safe to eat inside a restaurant" is perfectly reasonable a conclusion if no other information is provided—extra problem since it rarely takes into account the restaurant workers.
I wonder if the circular logic you point to in the restaurant example could be additionally explained in relational or emotional terms rather than a cognitive judgment of risk, where the new social norms don't just function to rationalize, but help the person feel less deviant or exposed to judgement by others (as well as their internal critic). Now it is not only physically "safe" to dine at a restaurant, but socially and morally safe.
Zeynep,
Thank you for your thoughts throughout the pandemic. One of my favorite articles that I read is the interview that you did with Eric Topol -- "The Remarkable Value of Thinking Broadly: A COVID -19 Trifecta."
One piece that I have been very focused on, during the pandemic, is how data is gathered, what the definitions are, how it is reported at a county, state, federal level, and if those data match. There are many articles in The COVID Tracking Project Blogs, on how they do not, as well as an article from KHN in September, describing how each state was determining whether to report antigen tests/if they did. There is still no federal standardization of data reporting. Each state can report PCR pos/neg, or PCR pos/neg + Antigen pos/neg or PCR pos/neg + Antigen pos. Not every state deduplicates people that have already been tested, hence, in some state 1 person can equal 5 cases. This reporting of "cases" became especially problematic, when the 150 million Abbott Binax Now started to arrive in mid-September. The Government Accountability Office Report from January 28, 2021 details out the lack of a plan on testing, and how there are no federal reporting standardization, and how the data should not be used to compare and contract, as the data are not equal.
The WH Coronavirus Task Force, led by Dr. Birx, put out this inconsistent data, never scaled it as testing changed, and then made dire warnings about how "All Americans must change their behavior now", all through November and December. Had this task force/Birx realized that the data was inconsistent and not scaled, the picture would have been very different. It continues to this day with Dr. Walensky's warning, yesterday, as quoted in a STAT News piece that the last 3 days of cases are a "somber warning". The Director of the CDC did not realize that a winter storm that knocked out almost all of Texas, and other states, was creating a data artifact, and then making judgements and communicating them as facts -- that's a problem, for me. This challenge of the data artifact is even listed in the Community Profile Report that HHS/CDC/ASPR puts out daily, with data notes. When things like this happen . . . does she not understand statistics/data, or is the messaging for another reason?
Regarding the school metrics that the CDC put out, if one goes back and calculates the "Blue" metric, the last time the U.S. hit that metric, at a total was March 19-20, and that was on 1/70th of the testing that we do, today. For yellow, the last time it was hit was in June, on 1/7th of the testing.
I went through the 3,006 U.S. Counties, Territories, Municipalities, a week ago, 241 (8 blue, 233 yellow) would have been achieved, of those yellow counties, 203 of the 233 counties had a population of 50k or less, only 2 had populations of 500k - 1.0 million, Honolulu County, HI, and Washington County, OR. None had a population of over 1.0 million. Of those meeting the Blue Standard, only Hawaii County, HI had a population over 100k at 202k. The 7 remaining counties had a population of 46k or less.
Add in the difference in reporting, and for example, any state/county that reports PCR pos/neg only, is always going to have an advantage for "reopening" based on cases per 100k, simply because they do not report antigen tests. Doesn't mean the spread is less, just means the reporting is different. But, that isn't how the CDC/HHS is calculating it, they have applied a standardized opening metric to non-standardized data.
When hearing messages and metrics that the CDC/Dr. Walensky has put forward, coupled with Dr. Fauci on December 24th, referencing how many more people were going to be need to vaccinated to reach herd immunity, as that is what he, now, thought people were "ready to hear", based on his gut instinct, and new science -- however, no scientific reporting/research was referenced, that leaves me with questions of judgement and intent.
There has never been a push to establish serological testing for all, to see who may have already been exposed to COVID-19, to calculate what levels of exposure/natural immunity might exist. I know the CDC has done studies, they are with many caveats, and the sampling leaves a lot to be desired. People are not being tested prior to vaccination, to establish whether the 2 dose regimen is appropriate, Francis Collins wrote about this in his NIH DIrector's Blog on 2/23/21.
Couple this, with as your coauthor, Michael Mina, from the NY Times opinion piece, had written in the Lancet this past week, that 50-75% of the PCR positives are not infectious/transmissible virus. The Ct values, are too high. His preprint with James Hay, that they put out in October and updated in February, could have made such a difference, had the Federal Government adopted an approach to record these Ct values and/or delta values, to establish where the virus was most infectious. There are many quotes all over the CDC Conference Call notes/pages, that most that are seeking samples want the samples of Ct values of around 28 with a maximum of 33. The FDA as of 12/10/20, in their frequently asked questions, said that "currently there is no consensus as to whether or not particular Ct values correlate with a person being or not being infectious or risk level for disease severity". Yet, the scientists on the CDC Conference calls ask for samples at Ct values at a max of 33, and a preferred 28 -- why would that be? Hence, leaves a lot of questions of what we are trying to determine, diagnosis for an individual, that they may have had COVID-19, that they are infectious, now, and should quarantine/leave work, or are we using this as a public health measure to see where the spread may have been? So many unclear answers from the public health authorities.
I think the public health authorities forgot that a relationship involves two people. If, for example, they don't respect the person they are talking to (the public), they most likely will not get the same respect back. I know that they were/are in the position, to then "blame the public" for their behavior, but is that solving the problem? Why were they not looking at age and income stratified risk, why were they not putting a focus on protecting the nursing homes/LTCFs as (35-40% of the deaths have come from the 1% of people that reside here. Why were they not supporting them with staff, PPE, and instead threatening to fine them (based on positivity rates that are not standardized) per the CMS/HHS guidelines?
These are the questions I ask myself, as I try to wade through the information that is put before us.
Thank you for your thoughtful pieces, I learn so much, and many times causes me to dig/investigate further.
Best,
Jean
Thank you so much for your work on this, Professor. I'll just throw a little personal anecdote into the mix, for what it's worth. When the pandemic first broke out, late in 2019, I was teaching in International and English Language Programs at University of Washington (the UW IELP program has since been shuttered, for budgetary reasons, and I myself have now retired). I was teaching a Special Program with a focus on science, technology, and engineering, for an all-Chinese group from the PRC. Class opened on January 3rd, 2020, by which time it was already possible to get enough information to know that something big and scary, but not unexpected, was happening. My students and I drilled down deep on multiple sources--mainstream media, including an article or two by you; technical articles, mostly open-source pre-prints; official pronouncements from WHO; politically-motivated misguidance from you know who, etc. etc.--and treated them ALL with a healthy dose of skepticism. It helps a lot that I already had some experience teaching global public health, had mentored and been mentored, working in a program where we took hits from SARS, MERS, Ebola, HIV/AIDS, you name it, all of them in the 20+ yrs I worked there. In this latest crisis, we exercised critical thinking, in the broadest sense, not in the limited and mechanistic form that it is so often presented, but where context is in the foreground, as you discussed just the other day. Just for example: when the WHO said there was no evidence for human-to-human transmission, let's just say we took that with more than a grain of salt! What's that saying? "Absence of evidence is not evidence of absence!" When the advice was NOT to mask (right!), we masked up. The messaging on that was a debacle, and your work called it out. Thank you again! When the debate was all about the size of the droplets and the definition of an aerosol, we exercised the precautionary principle and assumed the worst. Only took like more than 6 months for the science on that to really catch on. Everything we did was done in the first 3 weeks of the breakout! We did it by studying the problem, talking about it, making up our own minds about what practical measures to take, and how to sift the flood of information and misinformation. As you have pointed out, scientific literacy is so fundamental, but it doesn't exist apart from socio/cultural/political awareness. If a person can developed a modicum of that, even on the fly, they can make well-informed judgments in fast-moving and fluid circumstances like these. The failure of much of the modern educational establishment to cultivate those habits of mind is itself of epic proportions, but these are habits of mind that really need to be instilled from day one. I always tell my students, young adults, university-bound, when we are working on 'critical thinking': "Look, it's too late!" And they get it.
I'm in the habit of only talking about things I don't like within an argument, so bear that in mind as you read this:
Risk Compensation
Here you talk about various government agencies doing what normal non-substack non-twitter people would call "lying". All these problems stem from an assumption that truth is some sort of optional and usually sub-optimal thing to be avoided when desired, necessary or just 'cause.
This doesn't seem to be a problem for you; you mention only that it produced less than great outcomes in this situation, and that seems to be your only complaint. It's very, very common for people on the left to criticize people on the right for not "trusting science", but it's so normal for science to lie at this point that you don't even think it's worth mentioning that this is what's happening.
So immediately I'm struck by two conclusions here, the first being that I need to carefully evaluate everything science says with a strong prior towards them lying to me if it suits their immediate needs. The second is that I need to carefully evaluate everything Zeynep says about science, since she's apparently fine with going along with a lie so long as it might produce good results; at the very least she won't be so provincial as to call someone on lying as if it might be wrong.
Harm Reduction:
This section misses its own point so hard it's almost unimaginable.
Harm Reduction in practice is a bunch of people screaming at those who will only accept "perfect" solutions at any level of cost to the to the good that they should be willing to compromise to reduce risk where it's not possible to eliminate it. You do capture this bit.
You then go on to miss the big implication - you talk about things like kids being able to play at parks instead of having to hide it; these things might have had a small but real effect, it's true. But how in the world do you not mention that we could have had working vaccines in May or June if we were willing to accept a small risk on a super-proven technology (vaccine production). Or if we were willing to do challenge trials?
The things you choose to talk about might have worked or might not have; people might have been content with the slight increased freedoms mentioned and obeyed in other ways, and this obedience may or may not have had a large effect. Let's be generous - would we have seen 20,000 lives saved? 40,000?
Meanwhile we are hemorrhaging hundreds of thousands of lives because harm reduction philosophy isn't being pursued by the FDA in the slightest; we must take a year to produce and test a vaccine. We are in a world where we might plausibly need completely new vaccines to combat virus mutations, and the FDA/WHO very plausibly might make you wait another year to gain access to vaccines that are probably in existence right now, fully functional and waiting for use.
Why ignore the huge and definite benefit harm reduction philosophy promises in this case to focus on a small, uncertain benefit?
The balance between knowledge and Action
See above; same problem. Why ignore vaccines here? Why not mention the one place a better balance would be sure to produce massive benefits?
I think there's a difference between "lying" and unfounded beliefs! Challenge trials have other issues, though. First question is how do you make sure you have the coverage you need without randomization? Testing stuff on young/healthy folks isn't a good way to do this. Two, how do you ensure you got all the routes of exposure covered? Three, how do you deal with trust issues when/if someone from a high-risk group suffers severe illness or death? Challenge trials sounds better on paper then on giving us either the answers we need or the trust we absolutely require.
On "unfounded beliefs":
You are conflating two things here: the first is that they had an unfounded belief that people would act poorly if provided with the truth. The second is that the truth was withheld or that lies were provided because of this unfounded belief.
Holding a paternalistic unfounded belief is bad in one way, but holding a bad belief in no way frees you from a moral responsibility to be truthful. From your link:
"One of the key problems is that our public health efforts continue to suffer from paternalism toward the public. Rather than focusing on risk mitigation—giving the public every tool to reduce the chance of transmission—many leaders have fallen prey to the fear of risk compensation—that giving people better tools will lead to them behaving more carelessly. This mistake was made with masks early on, with some officials worried that public masking would lead to less physical distancing."
If you believe Karan there (I'm assuming you do, you linked him) then he's referencing our highest-level public health officials blatantly lying about the efficacy of mask use for reasons unrelated to the efficacy. That's not something you get to dodge by saying "well, we had an unfounded belief, so we lied to you" if you think lying is wrong.
That's what I'm talking about here - you seem to think lying is wrong only because it didn't work very well this time; thus you bring up the unfounded belief, because if it was founded the lies and paternalism would have been A-OK. Most (or, hell, some; we are in trouble but it's probably not most anymore) people think lying is wrong, full stop.
Regarding the vaccine testing:
You don't! You don't do those things! That's kind of the point!
We have a great idea of how vaccines work; we have a great idea of how vaccines for this particular disease work. We are really good at making them! We made one in February that was in production in march that works great, just as we knew it would!
But instead of taking a tiny, almost insignificant risk on it by doing some basic effectiveness testing, we did what you are doing: we demanded absolute surety at the cost of 3/4ths of a year and several hundred thousand deaths. And if we need a new vaccine because of mutation, we will produce a working vaccine for it in a few days, and then let hundreds of thousands of people for-sure die so we can avoid a very small chance of a vaccine not working very well.
Even some of your object-level objections don't make a ton of sense. Are you worried about exposure routes? Run a slightly bigger challenge trial; problem solved unless you just won't consider anything but "the perfect". Worried about trust issues? Work on a reputation of truthfulness (see above), and explain honestly both before the trial and after that some level of inefficacy/reaction is to be expected, and that this will potentially save 100,000-300,000 lives at the cost of perhaps a few in the volunteer group, which you still expect to be net-positive in terms of lives saved even within the group.
But instead we have the worst-possible situation: hundreds of thousands of avoidable, unnecessary deaths, and most health intellectuals going "Well, of course it had to be that way; god forbid we grappled with the minor problems any other method would present - let's just let a quarter of a million people die so we can say later that we were very cautious".
I'm falsifiable on this, of course: If you can explain how the new method was as likely to kill a quarter of a million lives as it was to save them, I can back off of this view.
Although I’m not a Virologist or epidemiologist expert and although I’ve to admit that when I was young I’ve been educated with a Philosophical approach that would sound exactly as
“You don't ! You don't do those things ! “
I think that the idea of Challenge trials must at least being taken in consideration .
Of course with all the due randomization, safety checks etc etc .
Although I don’t think that the path that they choose with the available Vaccines, especially with the mRna ones is so different .
Putting it very simple, Phase 1 has been shortened consistently,
Phase 2 and 3 kind of “fused” together (continuous-phase trial etc),
and Phase 3 is continuing now in real time .
(talking about this I’m thinking how it could be addressed to the Population @zeynep ?
I mean “empowering the public with information”, or just informing telling all the truth about the meaning of Emergency procedure and approval to the main Population, and expecting to be fully understood and approved in a compliant way .
Meaning that the Population will anyway take the Vaccine in a way that is not even less enthusiastic and numerically consistent hat the one that we’re already experiencing in many part of the Western World at least . )
Then, Phase 3 again combined with Phase 4 AKA real World experimentation .
Talking about Challenge trials (Human challenge study) I’m not sure that what happened with AstraZeneca and Sinovac Phase 3 in Brazil (and some other Countries) is so far from this,
maybe they didn’t intentionally expose the test subjects to the Virus,
but for all the rest that Challenge trials imply I can’t see so many differences …
I honestly don’t want to be polemic about all of this,
I kind of approve the Trials approach that had been mostly adopted,
but at the same time there are many things that only 6 or 12 Months would have considered scientifically and ethically unconceivable .
And I personally still don’t know where to place all this doubts .
About shortening the timing for a Global Health Emergency :
Maybe (sigh) Boris Johnson’s call at the G7 about “100 Day Target to Create New Vaccines”
https://www.gov.uk/government/news/pm-announces-100-day-target-to-create-new-vaccines
or
Tony Blair report on preparing for the next pandemic ?
https://www.theguardian.com/politics/2021/feb/26/blair-says-collaboration-on-covid-could-have-cut-three-months-off-crisis
https://institute.global/policy/preparing-next-pandemic
I do have to take exception to the idea that what we did "isn't all that different" from challenge trials. Challenge trials are much, much faster and we didn't seriously consider using them as a tool.
Think of it this way: We just recently got our vaccines. They are much less effective against the mutations, from the data we can tell. We might get lucky and not need new vaccines, but that might not be the case. This leaves us with two scenarios we can follow:
1. Acknowledge that we are pretty good at making vaccines and that it's very likely any vaccine made with the current science will work and work well, just as every vaccine designed for the current pandemic works and works well with zero tweaks after initial design
Run a quick challenge trial with the initially produced doses to verify basic safety and efficacy. In this scenario, you have the vaccine tested and in production in a matter of a few months.
OR
2. Be maximally careful about the vaccine and close your eyes to the definite danger of the disease you are fighting. Do mostly-useless testing for 9 months; let hundreds of thousands of people die.
There isn't much in-between here. Even the most pessimistic of people didn't think that a botched vaccine was particularly likely, or that if it was botched it would kill 400,000 people. But to prevent a vaccine accident that's enormously unlikely to happen in the first place and would only effect a few people, we are supposed to be comfortable condemning hundreds of thousands of people to die. This is weird. I don't understand this stance and I probably never will - it's just throwing your hands up and saying "This is the way it's always been done! We have zero other options!".
Challenge trials might have gotten us a month at the best. Pfiizer and Moderna were still in phases 1 and 2 in early July, so it wasn't the lack of challenge trials that kept us from having a vaccine in the spring. Phase 1 is a safety test, but since it involves the immune system, it takes weeks to determine safety, and one needs to test a large enough cohort. The immune system is full of surprises.
Phase 3 started in late July and took two or three months. Challenge trials might have shortened this by a month, maybe, but phase 3 was a lot shorter than anticipated thanks to the rising case count starting in late summer.
Challenge trials aren't magic. You still need a good number of subjects, and you need to spend some time calibrating the challenge. How much virus comprises a suitable challenge? Does the concentration matter? What are the mechanics of a realistic inoculation? All those things and more have to be found out to create a realistic and useful challenge trial.
Just vaccinating people and telling them to carry on avoids a lot of work and guarantees a realistic result.
(This ignores the problem of collating and analyzing the data, ramping up production, arranging for refrigerated transport, setting up websites and clinics and a host of other things.)
This whole argument assumes you go the full, unnecessary and death-ensuring FDA process knowing that doing so represents sure, mass death to mitigate an almost non-existent risk. This assumes you need the full FDA battery of tests to ensure a reasonable efficacy level - you really don't. We do those things because we are used to them, and because job number #1 of the FDA is "We only get in trouble for stuff we approved".
The Pfizer vaccine was finished in it's current form in JANUARY. Recruiting a battery of test subjects and running them through the weeks you need to determine basic safety could have been done by March; at that point every single other thing you do is extra when dealing with a pandemic we always knew would have a spectacular kill count.
It shocks me that given the millions of people who have died, the 10k or so who die a day, that I really have push the basic intuitive math here: Rushing the vaccine and pushing it out to incrementally larger groups - a few thousand, a few tens of thousand - over the course of a month could have potentially killed a few hundred or a few thousand people; to prevent this risk, we knowingly accepted the deaths of several hundreds of thousands.
The fact that the vaccine was produced in its final form should tell us something, but we ignore it: We are pretty good at making vaccines. We have very few if any sizable testing disasters with vaccines in our history; I haven't been able to find any. Nobody seriously expected that the Pfizer vaccine wouldn't work or wouldn't work well; we are just married to absolute surety on drug safety/efficacy even where it makes sure we kill far more people by doing so.
And because of this, we are stuck; we already have pretty reasonable evidence the new mutations don't respond as well to the vaccine. If tomorrow a new strain emerges that the vaccine doesn't handle, we will waste another year and kill a few million more people to save a few thousand in the absolute worst case. This is insanity; it's "But this is the way we've always done things!" with a price tag of the population of a small country every time we do it.
Thank you for your very articulated reply .
I don’t have enough expertise in the field for giving an accurate opinion .
Although being a Professional Musicians and a Financial Investor with some background in the area of Tech,
I studied Medicine when I was young .
But the Immune system is so complicated and yet with many unknown aspects, the Virus field so articulated and mostly the Vaccine’s sector so specialised that I don’t feel able of giving a pertinent opinion .
I didn’t have any background, despite my studies, in the Vaccine’s sector before this Pandemic .
But I’m grateful that you opened a window on Challenge Trials possibilities,
I didn’t have a deep thought on that until now .
Cheers
It seems like so much of the moralizing and absolutist messaging stems from the fact that US public health systems -- the basic testing, contact tracing, and quarantining-- were totally inadequate. In some areas, half of the patients reached by contact tracers give any contacts at all. Those who are told to quarantine or isolate are asked to do so voluntarily, without aid or checks to ensure compliance. Meanwhile every country that beat this virus had a managed quarantine and isolation program. In Australia, they did call and check to make sure you were isolating at home. International travelers must spend two weeks in quarantine. China built thousands of field hospital beds to isolate even mild cases. Yet at the height of the epidemic in New York, a New Yorker could get on a plane and fly anywhere else in the country without any testing, quarantining, or tracing involved, spreading the virus across America. If you were exposed and had to go to work or lived in overcrowded housing, there wasn't much help coming for you. Is it any wonder that when the basic measures of testing and tracing weren't working, health officials could only urge people to stay home harder, and wear a mask harder?
Good article. A few thoughts on vaccines and why they have not been greeted by dancing in the streets.....
- A lot of the population doesn’t believe the virus is serious, and some have behaved as though nothing is going on. Why would these people rejoice about a vaccine?
- Whoever delivers a message in America is likely to be disbelieved by 40% of the people. Trump told us we’d have mass vaccination by the end of 2020. I instinctively didn’t believe him. It turns out he was exaggerating, but not terribly. The roll-out has been far quicker than expected. But who wants to give the Trump administration credit for supporting the development of the vaccines?
- Poor messaging by Biden. He reacted to Trump’s pretense that the virus is nothing serious by saying relentlessly how awful things are going to be. This is not what people want to hear. We’ve had a long, hard year. Tell us that if we stick with this a bit longer, success is on the horizon. When you’ve been losing a game, and the game starts to turn in your favour, you don’t take your foot off the gas and let your opponent back in the game. But you also shouldn’t dwell on the negative. (The only messaging I've seen that got this right was a commercial for the Ford Motor Company. How strange is that?)
- Media desire to look for the negative. We are vaccinating 1.4 million per day. That is fantastic. We are far ahead of most countries in the world. But if you read certain sections of the media, the sole focus is on the “inequity” of who gets vaccinated before whom. Distribution has been far from perfect. But with an infectious disease, each person vaccinated helps the whole community.
- Complacency. Most of the population has little memory of times when infectious disease imperiled whole societies. We just expect these things to be fixed.
I think it's also important to take into account her larger message which is to appeal to people's better instincts as a necessary resource in all this, not just the realist view of our negative tendencies. I.e. people are usually distrustful or cynical for a reason, and restoring trust can help counter this.
Martin, these are valid observations along with your 5 initial ones in the earlier post and definitely a part of the story, with the possible exception of complacency: maybe at the very beginning of this, but I don't think most people have been complacent for a very long time. I think you're mostly targeting a different level of analysis than Zeynep though (aside from media looking for the negative where you both overlap) - my sense is she was focusing on categories of strategic errors in public health messaging and fallacious logic or self-defeating patterns in our general approach to the pandemic; not the background/structural conditions, political environment or "bad attitudes" that hampered our response.
You are right. My comments here were strictly focused on Zeynep’s first para about how there seemed to be no rejoicing about the vaccine. I have friends and family in the UK, and what I hear from them sounds very different. They have also had a tough and crappy year, but I’ve not heard from anyone who isn’t impressed and grateful for what the country has done with vaccination.
As for complacency, think about the anti-vaxxers. They are able to take the position they do precisely BECAUSE VACCINES WORK! I don’t think people grasp the scourges that have been beaten - and how speedily we have come up with the means of beating this one.
I do agree that there's psychology to all this as well as sociology and policy, and it's really important to try to get inside people's heads to imagine what's motivating (or not motivating) them.
Can you explain more what you mean by the luxury of taking the anti-vax position precisely because vaccines work? I think I understand what you're getting at, but not sure if I'm reading this correctly. Do you mean they are complacent in the sense that they still benefit from society benefiting from the vaccines, so they can get away with not taking them in the short term and still maintain the illusion this leaves them better off? If vaccines weren't effective, how would this work to undercut their vaccine denial?
I think you’ve got it. Infectious diseases were once a major problem everyone knew about and feared. Earlier rounds of vaccines were a miracle that removed these scourges from everyday life. Neither the fear of infectious disease, nor the relief of vaccination are any longer a part of most people’s lived experience. For that we can be grateful to earlier scientists, and to officials who implemented mass public vaccinations.
So today’s anti-vaxxers have the luxury adopting a posture of denying the science, or indulging in conspiracy theories, unaware that they have that luxury only because of the previous efforts of scientists and administrators - and because most people DO get vaccinated.
Now we are faced with a new disease for which we do not yet have herd immunity. Maybe I should be optimistic. Maybe this will end the complacency and denial, and give us all a renewed appreciation for what science and public health can do for us.