The study of risk, the perception of risk and the management of risk is an important area of scholarship that I believe all leaders in positions of authority should study. I am certainly not an expert, but over the years I have invested in some scholarship in this area. There are, of course, numerous ways to categorize risks. One simple exercise is to think about risks kinetically. Risks may be acute, chronic or recurring. The response to each class must be different. In an acute, or one-off event, such as a nuclear accident like Chernobyl, draconian measures may be needed and effected without a great deal of concern about the long-term consequences of the intervention. But for chronic risks, say automobile accidents, or recurrent risks like the winter infectious cycle that happens every year, the response must be sustainable. This means that careful consideration of the long-term consequences of a draconian intervention must be considered. In short, since we know the risk is with us every day or occurs every year, the response must be sustainable, i.e. the “cure” must not do more long-term damage than can be tolerated.
COVID-19 is a newly emergent infectious organism. Unfortunately, such events happen fairly frequently – we deal with a new strain of the flu virus every year. This year in America, the flu is estimated to have caused more than 12,000 deaths by some experts. And winter happens every year, bringing the usual winter infectious cycle with it. So, any response to a newly emergent or a pre-existing strain that for some reason seems more problematic must be sustainable.
We live in an era in which we can identify new organisms almost instantly with powerful information. We also live in a time when we seem to want to zero out some risks. Driving any risk to zero is incredibly challenging and costly. Thus, an important principle in risk management is to put the new risk in perspective and develop a response that is proportionate to the risk and sustainable if the risk is chronic or recurrent.
As an unwilling participant in the extraordinary efforts to quarantine entire populations, below I pose a few questions that perhaps should be a part of the public discourse about the unprecedented response to COVID-19.
- Later this year, we will experience winter. We will be assaulted by the usual pantheon of infectious agents, COVID-19, a new strain of flu and perhaps other emergent infectious organisms. Will our response again be to impose another several months in which the economy of the world be brought to its knees?
- What is the evidence that quarantining the healthy works? The response to COVID-19 is, I believe, the first time we have quarantined the healthy. Did it work? Did it work better than the tradition of quarantining the sick? Of course, we will not have answers, but one can point to examples of different approaches to COVID-19 and some would claim they worked better, but they certainly did not fare worse than areas that engaged in the most draconian responses.
- What are the long-term consequences of the COVID-19 response? They will be literally immeasurable. When the economy is suddenly disrupted, the people who bear the brunt of the economic damage are the working poor. These people live paycheck to paycheck, not because they want to but because they have to. Yet, they still have aspirations, if not for themselves for their children. How many enter the ranks of the impoverished?
- What are the long-term effects of the economic shut down on health care? Again, immeasurable but bad. Among the first expenses that are jettisoned during economic hardship is preventative health care. How many patients have stopped taking their blood pressure medicine? How many no longer take their children for routine preventive care?
- What was the core problem in managing the COVID-19 epidemic? I believe it was matching the supply of health care to demand. At the national level, this should have been straightforward to address by using public health service and military medical personnel to buttress, by managing the necessary respirator and other supplies so that supply met need, by establishing centers in each area to be expert at managing COVID-19. This would have avoided exposing the infected to the sick and frail in our medical institutions and areas like New York City would have had the support they needed.
- Will we develop risk-proportionate responses to newly emerging infectious disease? Will we really try to reduce that risk by taking actions that are so obviously damaging to so many?