A doctor on how to make Covid-19 decisions when so much is unknown

This month there are two shoppers at a Target in Los Angeles fought a security guardbroke his arm when he tried to tell them to follow store policies and wear masks. The American Covid-19 response is confusing to say the least; sometimes it seems as if we are confronted with two battles: one against the virus and one against each other.

A central part of this frustration between fellow Americans has been the failure of leadership to unite against a common enemy. With confusion and inconsistency around everything from masks to medicines, it has become more difficult to navigate information and misinformation, find direction, or even know if we are going in the wrong way.

And as much as there is uncertainty among the general public, there are multiple levels of leadership, including the federal government, the Centers for Disease Control, and the World Health Organization.

What is unambiguous is this: we operate under extreme uncertainty. Most of us have never been so directly affected by a pandemic; the best comparisons we have are flu, but it is quite clear that we are dealing with something completely different.

As a physician, I have always had to embrace uncertainty in the hospital when caring for patients, and understand my clinical decisions less as absolute truths and more accurately as careful calculations of risks and benefits. As such, uncertainty didn’t feel as strange to me as it did to many other Americans right now. Uncertain decision-making requires that we be careful enough that our hoped-for benefits outweigh our feared risks, but not so carefully that it prevents us from taking any action at all.

In a March 13 press conference, WHO’s Executive Director of Health Emergencies Program, Dr. Mike Ryan said about a pandemic reaction: “If you have to be right before you move, you will never win.” But what we have seen is not continuing with some critically important decisions from those paralyzed by the lack of perfect information.

Universal mask wear is one example: opponents, including the CDC early on, have said that universal masking has not yet been proven to reduce the transmission of SARS-CoV-2, the virus that causes Covid-19. While it is true that we are not sure what the effect of universal masking will be at the population level, it is because we have not yet had time to study this effect with Covid-19. This does not mean that masks will not help us tremendously – it means that we are not quite sure if and how much they will do.

Here, the practice of weighing risks and benefits can help us realize that masks are worth using. The potential benefits of consistent universal masking, especially when using a mask with a high filtrate equivalent, such as N95, are enormous. We can potentially prevent thousands of deaths, significantly slow down its spread, and eventually drive R0 consistently under 1, causing the epidemic to burn out the epidemic.

If masks aren’t everything they’re meant for, we really don’t lose much. Some have also argued that masks can reduce the risk of people physically distancing themselves (because they think they are safe), but there is no data to support this “risk compensation” argument. The same was assumed for seat belts – the possibility that they would increase reckless driving – and it was turns out not to be true. The CDC endorsed it population-level masking, and many felt they should have done this much earlier.

The decision to close schools was another exercise in the challenge of decision-making under uncertainty. There have been a number of debates on the benefits of closing schools, including some leading academics who argue against it because we didn’t have the data to know if it was worth doing. Now, reports suggest that children are likely to play a significant role in transmissionand that closing schools has in fact been able to reduce the epidemic wave by 40 to 60 percent.

This is a good example of the old adage: the devil you know is better than the devil you don’t know. Close the schools if you are not sure. You can reopen them (or tackle the ripple effects of closing them), but you can’t rewind a runaway outbreak.

The same logic could have been applied at a broader level, since it concerns the establishment of city-wide closures. Data now suggest that the The New York City outbreak alone may have been responsible for most other outbreaks across the country so far. And even early in the pandemic, we had reason to believe that a city-wide shutdown could have a noticeable effect – with Wuhan as our case study. (Even now it’s hard to know how much effect each intervention had, since the closure was one of many.) But we were hesitant to stop the journey to and from our country’s most populous city, while the swift action here may have been has changed the American Covid-19 trajectory.

It’s also important to consider the consequences of moving too fast and being wrong – being wrong can also cause unnecessary damage.

President Trump’s tweets about hydroxychloroquine-azithromycin think as an example. Acting on the preliminary findings of a small French study with some methodological limitations, the president switched to promoting the drugs. In the end, it has not yet been proven that they have a significant benefit for Covid-19 patients, but that is known increase the risk of deadly heart rhythms and have has already led to damage in a number of cases.

Trading without robust data can be reckless and harmful when the risks are as great, if not greater, than the potential benefits. The medicine mantra of “First, do no harm” should dampen leadership build-up to act too quickly and rely on unproven treatments. With masks, the risk of being wrong – that masks don’t have a huge population-level advantage – still leaves us with our remaining strategies of testing, tracking, and isolation, and it probably won’t set us back significantly. But with unproven drugs, there is a much faster way to make life and death calculations. Taking a chance here is a much higher bet.

The preprint publishing sector has also continued this trend from haste to closure. Preprints are studies that are made public before they are formally checked for publication in a printed scientific journal. These early reports allow for rapid dissemination of research, but in a form that has not been reviewed by other experts in the field and can easily be interpreted by non-experts.

It is fueled in part by the insatiable appetite for rapid scientific results, which is understandable in a rapidly evolving situation like the one we are in right now. But they should also be read with extreme caution.

There are some examples of the failure of this system. A prominent one a preprint of early serological data from Santa Clara County, California, which epidemiologists and public health experts quickly identified as problematic.

To add an extra layer of complexity to this, we have to take up the challenge of tackling disinformation, a huge task in itself. As if dealing with uncertainty and complex considerations at the same time is not enough, disinformation is really the “Parallel” epidemic in almost all infectious disease outbreaks; it happened with Ebola and Covid-19 is no exception.

Incorrect information affects confidence and in turn limits the possibility of coordination or cooperation in an outbreak response. It also creates even more uncertainty and makes people less likely to believe robust scientific data when we do.

The antidote to misinformation is a reliable countermeasure from reliable leaders. This can come at the national level. But if not, it should come from trusted professionals with technical expertise working with journalists and communicators who can help translate information to the masses.

As a doctor who works closely with the Covid-19 public health response, I appreciate the challenges of getting the responses perfectly right – to avoid being too slow or too fast, both of which can cause accidental damage and carefully weigh the risks and benefits.

We have to recognize that we operate under uncertainty now – but we always were, even in the pre-Covid-19 world. We just didn’t have to think about it as often, because the consequences of our decisions were less drastic.

It’s not easy, but the world we live in has always been dictated by tradeoffs, with both successes and failures. We must also realize, perhaps most importantly and humbly, that we are wrong and that we may need to correct our course. In the end, we only know with certainty that we must move forward together.

Abraar Karan is a physician at Brigham and Women’s Hospital / Harvard Medical School and is part of the Covid-19 state epidemic in Massachusetts. (Twitter: @AbraarKaran)

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