Now that we have a new president-elect and can look forward to a new approach to the management of Covid-19, how will Joe Biden appeal to those citizens who see it as their constitutional right to intentionally disregard public health measures? A right they define as being able to assert their liberty and individuality. And, more important, how will Biden create the national will and cooperation that is required to change the course of this accelerating pandemic?
We Need a National Strategy and Nationalized Implementation
Over the last eight months, we have seen the results of a state-led response to a national problem and it has been a serious failure. Although few western countries have had an exceptionally good response to Covid-19, the per capita death rate in the U.S. is comparable to the worst rates in the world. It is dozens of times worse than where a central government has asserted real authority regarding testing and mitigation ( consider China, New Zealand, Australia, Taiwan, South Korea, and Japan).
The absence of a national health structure to address a national public health crisis is foundational to the disaster unfolding. So, what to do?
We will need national plans for diagnostic testing, assurance testing, quarantining, contact tracing, vaccine distribution and administration, and the associated compliance with each step to get this ship on course. But nationalized plans needs nationalized messaging.
What new arguments can we bring to the national discourse? I have several ideas.
Cooperation Must Be Earned, It Cannot Be Mandated
Simple mandates won’t work without scientific proof of efficacy. Asking people to wear a mask failed as one of several mitigation tactics. Wearing a mask was first perceived as a sign of individual weakness in the face of a minor flu-like illness. Subsequently, the wearing of masks was turned into a political statement that overwhelmed the scientific data and that aligned face-coverers with weak globalists and mask-less individuals with America First-ers.
But even achieving 100 percent compliance with mask wearing will not turn around the currently diseased ship of state. We need major education initiatives.
Our Constitution Requires Us to Promote the General Welfare
First, we need to debunk the concept that national mandates and policies, associated with big government, are bad to the core. There is always tension between individual rights, states’ rights, and federal responsibilities. But on occasion federal responsibilities must take precedence. According to Thomas E. Ricks’s new book, First Principles: What America’s Founders Learned From the Greeks and Romans and How That Shaped Our Country, the framers of the Constitution used the term “promote the general welfare” dozens of times in the run up to their final draft which includes the phrase twice, including the opening sentence. This makes efforts to define and achieve the common good one of the foundations of our government.
Avoid the Tragedy of the Commons
Another concept, overlooked in our consideration of Covid-19, and a foundation of Western Civilization, is the principle of averting the tragedy of the commons. This means that individuals, acting in their own self interest, behave in a way that is contrary to the common good and to the benefit of society as a whole. In the case of a national pandemic, medical resources (hospital beds, professional staff members, ventilators, and medications) represent “the commons.” Misuse of those resources through willful ignorance or wanton neglect represents the selfish over-use of the commons that has incited communities to anger and action throughout history. As I have written before, overburdened hospital systems will ration treatment and overburdened doctors and nurses will make medical mistakes. These will cause deaths in people that were otherwise not destined to die.
First, Do No Harm: Protect Yourself to Protect Others
Two medical concepts, familiar to healthcare professionals but less so in the general public, should also be introduced into our discussion of the current pandemic: 1. primum non nocere (first do no harm) and 2. the unpredictability of disease. The first is a principle that medical practitioners learn early in training and actively practice – the concept that a medical action must offer more benefit than harm. The second is a hard learned truth that no matter how much medical professionals learn about an illness, there is always the threat of unexpected consequences. I.e. when a disease spins out of control and, in the case of a pandemic, the otherwise young and healthy patient is killed or permanently disabled by a usually manageable and, ideally, avoidable infection.
I have to protect myself to protect others.
With respect to primum non nocere, I, as a medical professional, do not want to give the disease to anyone else. The principle that I am living by is that I prefer to cooperate with enhanced mitigation than live with the guilt I would feel if I was the source of a cascade of infections, particularly if that cascade resulted in someone’s death. That means that I have to protect myself to protect others.
In my mind, my social responsibility to protect others is more important than my individual right to express myself. The challenge is to convince the minority, renegade, and mask-less segment of the population to embrace that perspective of social responsibility. Because, if we all embraced primum non nocere, the spread would stop.
My social responsibility to protect others is more important than my individual right to express myself.
With respect to the unpredictability of disease, every medical professional has seen unpredictable complications from illness. Therefore, we must know that when we invite a tidal wave of illness by embracing disease-driven herd immunity we are inviting a torrent of complications. The trick is to prove (and then convince a skeptical populace) that vaccine-driven immunity causes fewer deaths and complications than the disease itself.
Support of Our Economy and Mitigation of Disease are Not Irreconcilable
With a new team of leaders in pandemic management, with fresh concepts in mind about disease and personal responsibility, let us sacrifice for the general welfare. We should support our economy where it is safe to do so and mitigate where we must. This way we can turn the prospect of a dark winter into a brighter than predicted spring.
IMAGE: As of Nov. 9, 2020, Maine was elevated for the first time to a risk level (red) of active or imminent outbreak of COVID-19, according to CovidActNow.org.
CDC supports wearing masks to protect yourself as well as others (Nov. 10, 2020)
Houston, We Have a Problem: A Retired Physician Remembers Fatal Mistakes
You accept uncritically the assertion that non-pharmaceutical interventions (masks, distancing) make a difference. No RCTs (randomized control trials) support that claim to any degree of certainty, and the observational results are at best inconclusive. Masks as used by the general public are certainly completely ineffective, and given the low incidence of this disease in the general population and the extremely low risk of outdoor transmission, masks outdoors are merely virtue signaling. This isn’t crazy talk – this is studies published in NEJM, BMJ, NIH, NBER, Lancet, and other peer-reviewed journals. I can send you links…
You also argue for a “National Strategy and Nationalized Implementation” – but wouldn’t we benefit from some experimentation? Isn’t the world better off from the lessons learned in Sweden and Florida, which have pretty much the same morbidity and mortality as places that imposed much more severe restrictions? Should New York City have the same protocols as, say, rural North Dakota?
Mortality from Covid-19 is closely tracking that of the 1968-1969 Hong Kong flu – remember that? We were in high school. Hong Kong flu killed 0.028% of the world’s population. Covid-19 is halfway to that number – 0.014% – but our reaction to Covid-19 has driven nearly a billion people to desperate poverty, kills more than 10,000 children a day (per Oxfam), erased many human freedoms – and probably makes not a whit of difference to the disease.
Jonathan, thank you for these cogent comments.
I do accept, but not completely uncritically, that non-pharmaceutical interventions make a difference, largely because, as a physician, I have practiced them my entire career. I have seen, both in person and in studies, how gowns, gloves, masks, and hand washing prevent disease spread. I recognize that what we can do and document in hospitals will not translate directly to pandemics and the public health space, but I do believe there is a role for masks and other non-pharmaceutical interventions.
What I do believe (from worldometers.info) is that there are 735 deaths per million in the US, 595 deaths/million in Sweden,137 deaths/million in Germany, 65 deaths/million in Finland, 52 deaths/million in Norway, 35 deaths/million in Australia, 14 deaths/million in Japan, 9 deaths per million in South Korea, 5 deaths per million in New Zealand, and 0.3 deaths/million in Taiwan. I suggest that we should choose the model or models that work in those countries that are performing well and apply them nationally or regionally as best we can in the U.S.. This is the kind of experimentation that I can endorse.
Finally, I believe that as long as our regional health systems can handle the disease burden we have time to discuss this. When our systems are overwhelmed people will die unnecessarily. Then we must admit failure and change course. That’s just the doctor in me.
Deaths/million is a problematic statistic… It is a factor of pre-existing immunity (a probably factor in East Asia, especially Taiwan and South Korea), the course of the virus (maybe Australia and New Zealand have merely delayed the inevitable), record-keeping, and other factors including, for example, botched management like Cuomo’s nursing home orders and Italy’s nosocomial outbreaks.
I’ve been reassured by John Ioannidis’s work on infection fatality rates – early on, he and others tried to work out the denominator – the number of total infections – to try to deduce how dangerous this disease really is. His “Infection fatality rate of COVID-19 inferred from seroprevalence data” published in Bulletin of the WHO comes up with a mean IFR of 0.27 percent but with a very steep age gradient – crude and corrected medians of 0.05% in people under age 70 – meaning that the disease is much less dangerous than influenza, and less dangerous than the lockdown orders.
A very interesting feature of this disease – echoed in your post, I think – is an idea that Faye Flam of Bloomberg wrote about in “Covid Spread Can’t Only Be Explained by Who’s Being ‘Bad’”. The passage of this virus through a population is cast in moral terms: will power brings the virus “under control;” while bad behavior – eschewing masks, even when hiking alone in remote parkland or standing on a windy beach – is sinful and is punished by the disease. Given our knowledge of this virus, this falls far short of any certainty. And isn’t it a fundamental position of modern medicine that disease is not a sin?
Sam…..I have found your postings very informative, so I am interested in your thoughts about this open letter to Dr. Fauci. This was forwarded to me by a doctor I have great respect for. Sorry, it is quite long, but it seems to provide strong support for an early intervention “cocktail” for high risk people that might significantly reduce deaths…..but unfortunately a medical topic that became very politicized.
Don, thank you for your question. Unfortunately, we are unlikely to come to a mutually agreeable conclusion on the benefits of the medical cocktail referenced here.
You respect the physician who sent you the open letter. Having spent 32 years in DC observing the work Dr. Fauci has done, I have great respect for him. I can think of no reason that he would suppress valid information about the benefits of the zinc, azithromycin, hydroxychloroquin cocktail.
After decades of practice, I observe that it is easier to promote a treatment than to withhold it owing to a cautious concern about it.
In my own practice, I have seen a patient suffer from complications of hydroxychloroquin and another patient die of complications from azithromycin use, though neither were related to the Covid epidemic. I have also seen many unsubstantiated claims about the benefits of zinc and azithromycin used in more benign circumstances.
Putting this all together, and recognizing the likelihood of some confirmation bias on my part, I am comfortable following Dr. Fauci’s advice until other medical scientists can tease the truth out of this politicized morass. Given the numbers involved, that might take some time.
I am sorry to be unable to offer real clarity. Sam
Good column! Yes indeed! Good to see this. In fact, I mention the coronavirus epidemic in my book ‘First Principles’ in connection with the idea of the general welfare, on page 287:
The coronavirus pandemic of 2020 reminded America of a lesson it had forgotten about the public good—a phrase that occurs over 1,300 times in Founders Online. Health is a public good—which is one reason everyone should have access to health care. In the longer term, so are education, transportation infrastructure, the environment, and public safety. These are the things that come under “the general welfare” of the people that is mentioned twice in the Constitution—the preamble and Article I, Section 8. The idea has its roots in an assertion by Cicero that “salus populi suprema lex esto”—that is, “Welfare of the public is the supreme law.” Salus was the Roman goddess of “health, prosperity, and the public welfare.” John Adams wrote in 1766, “The public Good, the salus Populi is the professed End of all Government.”
Tom, thank you for this. Your comments are clarifying and Founders Online is a resource that is fascinating and new to me.
I recently came across your article from 2014 comparing Eisenhower’s speech on the Military Industrial complex to the current medical industrial complex, Which I found interesting, so looked up more of your articles. Imagine my surprise to see you now wholeheartedly believing in and consuming what you’ve been fed by the very ones you were concerned about just a few short years ago.