We need a better understanding of the human costs of our containment efforts for COVID-19
When stories of mathematical models dominate the headlines, it is a sure sign that we are living in uncertain times. In 1976, British statistician, Dr. George Box, famously stated that “all models are wrong, but some are useful.” Today, in the throes of the most comprehensive pandemic since the Spanish Flu of 1917-18, Dr. Box’s observation seems particularly apt.
The purpose of models is not to predict the future. They simply help us to imagine things we don’t yet know, based on related observations we have already made. They are tools to help us assemble new knowledge about complex phenomena in a structured and deliberate way. They are dashboards. They are valuable not because they tell us what will happen, but because they can help us to better prepare to ask the right questions, collect the right data, and put in place the right management strategies for the things we are likely to see.
And if we’re lucky, the models will help us understand the role of variables that might be in our power to control, such as social distancing.
Models require data. And data require investment. No one questions the value of financial market models or weather forecasts. And for all the questions and controversy that have surrounded the interpretation of the major models being used to manage the COVID-19 pandemic, no one has questioned the significant investment in data generation, computing infrastructure, education, or the staggering hours of human labor that have made these complex modeling efforts possible. There is no debate about the value of efforts to forecast the demand for ICU beds and ventilators, or the likely death toll, or the ultimate duration of the pandemic.
But other important questions attract less attention and less investment.
Independent of the associated mortality, morbidity, health system distress and economic catastrophe, COVID-19 represents the most extensive case of human containment, quarantine and isolation in world history. The scale and scope of the human burdens associated with these practices literally boggles the mind. But there is little evidence that we are investing in the generation of systematic knowledge about the implications of these complex human experiences. Journalists have produced moving and illuminating stories about the experiences of individuals, families and communities, but there is no evidence of advocacy for more systematic investment in data to support robust modeling of these human experiences on a societal scale.
What would be the value of data and modeling of the aggregate human burden of COVID-19?
On Feb. 13, 2020, as COVID-19 cases began to spike in South Korea, two weeks before the first death in the United States, public health legal scholars Larry Gostin and James Hodge wrote in the Journal of the American Medical Association about the pending legal and ethical challenges ahead. They argued that “during crises, government has a special responsibility to thoughtfully balance public health protections and civil liberties.” The power to impose and enforce public health containment measures is an awesome one precisely because it deprives individuals of fundamental freedoms — freedom of movement, freedom of assembly, and non-interference to pursue important life interests, such as running a company, earning a salary, pursuing an education, meeting in a local coffee shop, attending religious services, or attending the funeral of a loved one.
Public health ethics and public health legislation lean heavily on four core principles to guide public health decisions that restrict civil liberties.
The “harm principle” requires that the only grounds for a government to infringe people’s fundamental liberties is if they pose a risk of harm to others.
The “least-restrictive means principle” requires that when quarantine or isolation decisions are deemed to be necessary by public health authorities they should be implemented using strategies that impose the least restriction or burden possible on those affected in order to achieve the public health objective.
The “reciprocity principle” recognizes that people have a general duty not to infect others and that, in some circumstances, they may require assistance to execute this obligation.
And the “transparency principle” requires that the evidence, rationales and processes that led to quarantine and isolation decisions are clearly communicated with the public.
Has the reasoning reflected in these principles of public health ethics become obsolete? Or are they simply inoperable at the scale and scope of the COVID-19 pandemic?
Mass containment strategies seem almost certain to be necessary to save thousands, and perhaps millions, of lives. And so, our alarm at the unprecedented restrictions of personal freedoms must be tempered by cooperation, humility, tolerance, understanding and generosity. But these are not simply attitudes of resignation. Without a deeper understanding of the full scope of the human costs — how many people died alone? How many went hungry? How many suffered domestic violence? How many critical life opportunities were lost and what were the implications? — more epidemiological and economic data alone simply cannot tell us whether the same reductions in transmission could be achieved with less restrictive means or whether the reciprocity efforts are adequate.
With trillions of dollars appropriated by Congress for the response to COVID-19, a pressing ethical question is whether any of these funds will be invested in research to answer these questions so that we can be better prepared to minimize the human costs next time. Without this kind of evidence, we also run the risk of losing an unprecedented opportunity to advance a more robust and realistic value proposition to shore up public investment in the health system, and all the related social support systems, that we systematically under-value, even as we commodify them unfairly.
We don’t need models to know for certain — there will be a next time.
Jim Lavery is professor and Conrad N. Hilton Chair in Global Health Ethics at the Hubert Department of Global Health, Rollins School of Public Health, and Faculty, Center for Ethics at Emory University in Atlanta, Ga. Follow him on Twitter @LaveryJim