Reflections on Risk

One of the books in my personal library that I’ve actually read is Getting Risk Right: Understanding the Science of Elusive Health Risks, by Geoffrey C. Kabbat. It wasn’t the book on risk that I needed at the time, but it was sufficiently interesting that I stayed with it until the end. Given the many books that I’ve started but never completed, that’s a compliment.

The essential bit of knowledge that I acquired from the book is simply that evaluating risk is seriously challenging. As we plunge ahead, involuntarily, into our third year of the Covid-19 pandemic, we are mostly yelling at each other from our different perspectives on risk. Could we please cut each other a little slack and consider how we each came to our different views of Covid risk.

As re: Covid, I tend to be somewhat forgiving of error because this is a new pathogen. Remember all the talk early on about “R-0” or R-naught” when epidemiologists were just trying to figure out how many new people would catch Covid from one infected person? They were still trying to figure out how it spread (aerosols, not fomites), and had yet to learn that indoors was much more dangerous than outdoors. 

The value of masks, still hotly contested, is one of the most challenging topics of risk assessment. For myself, I just ask if I’d want my surgeon to be wearing a mask or not. Yes? Then I’ll wear a mask, and at least a surgical grade mask if that’s available. Yet the Twitterverse is still alive with digs at people seen alone in cars or outdoors wearing masks. Seriously, there are more things to worry about than that, friends.

If you find masks controversial and an appropriate topic for digs on Twitter, I wonder how you would go about assessing the value of masks in the real world. What sort of double-blind randomly controlled trial would you construct? How would you manage exposure? Which masks would you evaluate? If cloth masks are in the mix, how would you supervise washing them? If surgical masks, or N95 masks, or KN95 masks are included, how would monitor whether or not people actually change them daily? How long would you keep your subjects isolated from the rest of the world in order to assess the efficacy of masks? Seriously? I’m going back to my “surgeon” test, and wearing my mask. 

Let’s suppose you want to evaluate public travel options. What sort of double-blind randomly controlled trial would you construct? I hope, by now, you’re realizing that there cannot be a double-blind trial on any of these questions. Double-blind means that neither the researcher, the medical personnel, nor the subject knows which arm of the trial the subject is in. Clearly, a subject in a clinical trial of masks knows whether they’re wearing a mask or not, as would any observer or data-collector. So, think again about evaluating travel risks or myriad other dilemmas confronting health authorities who actually want to keep us safe. Give them a break. 

OK, now about those experts you’re watching on YouTube, the ones who specialize in snark. “It’s obvious that schools should have stayed open.” “It’s obvious that lockdowns were foolish.” “It’s obvious that wiping off cans and boxes from the grocery stores was a dumb idea.” NO! Nothing is obvious! This is a new game, and discovering the rules is part of the game. Covid did not come with an instruction manual! Stop, already!

Seriously, though, we must apply our 20/20 (or 21/21, soon to be 22/22?) hindsight to this challenge. We must learn from our honest mistakes. This pandemic isn’t over. This will not be our last pandemic. And we have countless examples of jurisdictions that made different decisions on lockdowns, masks, school closures. So studying what worked well and what failed spectacularly will be important. Just remember that most of the evidence will be inconclusive. 

Consider, for example, the matter of school closures. The primary objective, initially, was hindering the spread of the virus. Even evaluating the impact of school closures on that one objective will be difficult, but the “side-effects” of school closures are surely as important to consider as well. Of course, decisions about school closures were often affected by employee fears of disease, not just whether school kids would or wouldn’t affect the overall spread of the virus. 

Let’s say, for the sake of argument, that the first decisions to close schools were reasonable given how little was known about Covid at the time. I believe that this decision, more than any other, should have been constantly subject to intense scrutiny given what we knew about the side effects of keeping kids home. We knew that the impact on learning would diverge along socio-economic lines. We knew that kids at risk of abuse at home would suffer. We knew that play with other kids is important during childhood. And we knew that we couldn’t fully understand the impact of closure decisions on all of these issues for years. What to do? 

The learning curve on Covid was dramatic. Scientists of all sorts were busy applying their skills to assess the incubation period, how deadly Covid was, the impact of Covid on different age groups, which underlying condition created the most risk for Covid patients, the value of existing treatment options, the nature of variants, the impact of Covid restrictions in health care settings on other conditions. And despite our growing knowledge of Covid, schools remained closed. 

Here’s a thought: What if a pandemic of this nature (airborne, mostly mild cases, relatively low death rates, steadily improving ability to treat successfully, vaccines available for those who want them) suggests a two track school policy? Create settings for onsite learning for those willing to work in such a setting and those willing to attend such a setting, presumably vaccinated once vaccines are available. Create another setting for online learning for those unwilling or unable to attend in-person school. Yes, this might involve shuffling kids around, but this could have been done at the beginning of the 20-21 school year, or mid-year at the latest. School districts can shuffle many thousands of kids when faced with unique circumstances. So, doable.

To some degree, we already have these options. Kids whose health prevents them from attending school in person already have an online option. Some kids who can’t/won’t attend school for other reasons, and millions of home-school kids make massive use of online education options. I wonder if we could just look at this two-path option as a more generally available option going forward. 

OK, that was a thought experiment. I just think lots of thought experiments are in order, especially regarding education. But the lockdowns are another policy with widely divergent impact, certainly deserving of their own thought experiments. 

Bottom line: We’ve got to position ourselves to do better going forward and to be better prepared for the next challenge of this nature.

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