New York governor Cuomo recently spoke and justified his actions in putting the whole state on lock down: “All this is worth it if saves one life.” That approach seems laudable and the logic bulletproof. Who wouldn’t want to save a life? But in reality, this approach is sentimental and displays some ignorance about how the world actually works. Economist Thomas Sowell said, “in the real world there are no solutions, only tradeoffs.” In the real world, taking major action in one area effects change in other areas. My concern here is not to evaluate the decisions of the governor, but rather this logic, which I believe is dangerous. Many of his decisions are good and justified. So please don’t hear this as a criticism of the shut down orders. But across the country this kind of thinking is leading some officials to ignore (or justify) the damaging implications of policy decisions as if we are playing a game with a simple scoreboard consisting of coronavirus deaths.
This concept of tradeoffs is fairly obvious in other areas. When the police pursue a deadly criminal in a high speed chase in order to keep the public safe from a dangerous criminal they put the public at risk in other ways (10,000 injuries and 321 fatalities in 2002) Widespread use of mammograms to detect breast cancer has led to an estimated 30% over diagnosis of the cancer, and all the problems that come with that diagnosis. The real word is not a simple financial ledger with one column measured in coronavirus deaths. It is more like a teeter totter where moving one side up or down affects the other side.
As an example, following the terrorist attacks of Sept 11, 2001 many Americans opted to drive instead of fly on commercial airlines. The reason was presumably fear. Airplanes can get hijacked. Driving a car would seem to be safer. But it wasn’t. Use of air travel by Americans fell 12-20% in the year following the attacks, while automobile deaths increased around 1,595. That number is about half the number that died in the terror attacks. Americans unknowingly embraced the real danger of automobile accidents to avoid the potential danger of terrorist attacks. The tradeoff was there, but not as obvious as those who died in the twin towers.
In another example this author attempts to track “indirect deaths” from the Japanese earthquake in 2011. “Following the March 2011 Great East Japan Earthquake, which left more than 18,000 dead or unaccounted for, roughly 3,700 people have been recognized as victims of indirect death, including 2,250 in Fukushima Prefecture, where large numbers of people were forced to move from one evacuation shelter to another due to the radioactive fallout from the meltdowns at Tokyo Electric Power Co.’s Fukushima No. 1 nuclear power plant.” The choice to move out of earthquake damaged buildings into shelters took lives as well.
These kinds of numbers are the domain of public health and epidemiology. However, panic and widespread fear can distort our perceptions of reality. Fear can make us focus on one danger so intensely that we don’t see the speeding car that is about to hit us.
The massive an unprecedented steps we are taking to save lives from the coronavirus may indeed reduce deaths in this one area (and we should pursue that), but we should not be ignorant or indifferent to the impact of our actions. It may end up that the response to the coronavirus is the largest and most coordinated disaster in US history. Bringing entire cultural, political, economic, and healthcare ecosystems to a halt will cost lives as well.
In my estimation this is an important part of the equation that we are not talking about. After listening to a podcast with Dr Marty Makary a public health expert from Johns Hopkins, I was concerned that the tradeoffs were given very little consideration. To be fair, he admitted that half of Americans have less than $400 cash available. This is far less than a person needs to purchase 3 months worth of food (his recommendation) to allow one to shelter in place. Experts are asking us to deliberately cause one very certain disaster in order to avoid another very scary potential one based on the projections of experts. We cannot carefully make these decisions without seeing the cost on both sides.
Here are some areas where there will be a price to pay in lives. I have posed them as questions:
What is the life/health impact of shutting down all nonemergency medical and dental care for months? I worked in EMS as a paramedic in Los Angeles and San Bernardino Counties from 1995 to 2006. We ran emergency calls at doctor’s offices constantly. People come in for routine care only to find out they had a serious problem. What would happen if we shut down the regular non-emergency healthcare of for the whole nation (330 million people)? And this is exactly what has already happened in California. The shelter in place order that was issued affected around 23 counties without a confirmed case of the virus at the time of the order.
What is the health impact of a potential worldwide depression/recession on personal health insurance, stress, and nutrition?
What is the health impact of millions people losing their jobs, retirement savings & homes? Especially among the lower income poor and self employed? This can lead to huge amounts of stress and all the poor outcomes that come with it (addiction, PTSD related to disaster, suicide).
What is the health impact of people staying away or delaying care from the ER for serious illnesses out of fear of infection? (This has been happening in our town) A person with an infected appendix or gall bladder that waits an additional 12 hours to get help can become much worse off.
What is the impact on pregnancy stress from our response on maternal and newborn health in pregnancy? It is known that miscarriages, premature births and neonatal deaths all go up in time of national disaster. This can be related to stress and/or women not getting routine preventive care. This article discusses the effects after hurricane Sandy.
This 2015 article suggests 4.4% loss of male fetuses (which are more sensitive to stress) following the Taiwan earthquake.
I want our government officials to take action. But let’s not pretend that the only thing that matters is saving lives from Coronavirus. There is much more going on here. We need leaders that can see and acknowledge the whole situation, including the devastating impact of their own policies.