American public health experts are working hard to work out a plan to fight the corona virus in America. And there are indeed many proposals – of academic centers, from think tanks, and from the government.
Although the plans differ, almost all of them rely on a combination of monitoring, mass testing, isolation and contact tracking. Many of them refer to countries like Singapore, South Korea and Germany as examples of how they can respond intelligently to the pandemic.
But what if the successful strategies in those countries just don’t work in America?
This question was asked by Keith Humphreys, a professor at Stanford University who works on addiction and public health policy, in a viral Twitter thread last week. Humphreys argued that many of his public health colleagues did not think seriously enough about the cultural obstacles that could undermine the country’s efforts to test, isolate and isolate Americans. He later wrote a Washington Post column arguments are more detailed.
Humphreys’ basic claim is that any plan we adopt, no matter how sensible, is useless without “broad political consent” from American citizens. And the obsession with individual liberties in America, linked to a general distrust of the governmentis a huge challenge for even the best plan imaginable.
I spoke to Humphreys over the phone about what he thinks public health experts don’t recognize, and whether he believes America is too libertarian to solve a collective action problem like the coronavirus pandemic.
A slightly edited transcription of our conversation follows.
Put the “political-cultural” problem of America before me. Why are you concerned that we cannot deal with this pandemic like other countries have?
Well, I think we are different from the other democracies that have handled this well in our long-term resistance to the growth of the state in general, but also to health. How come every other developed country has government-guaranteed health care and we don’t? The obvious reason is that there is an instinctive aversion to government power in America’s DNA. This is the only major democracy in which a large number of people have fought to prevent a government guarantee of health care for all citizens.
This aversion is now particularly powerful, but dates back to the very beginning of the country, a country founded by people who lived in fear of a king. Our constitution has been drawn up with checks and balances for fear of the power of the state. And that libertarian streak is everywhere with us and also applies in the field of health.
That libertarian instinct has some advantages, and I think you will admit that, but the problem is that it’s just the wrong ideological software to run into a pandemic –
Turn right. I don’t think we want to live [a more authoritarian society] like Singapore for example. But the question is what will you do about an epidemic if we are all really together and there is no way to run, detect and isolate a program without seriously increasing government oversight and accessing many quite intimate personal information? Those libertarian impulses are an obstacle to that.
So I just don’t think we can do what Germany does, where it is higher confidence in the state and more confidence in the state. I don’t think we can do what democracies in East Asia do, with a more recent history of autocracy and much respect for the state. Even though I am a public health person, I admire all the people who work on all the technical issues and think about what we do should to put a stop to this virus, I just believe we underestimate the political and cultural obstacles here.
What exactly can countries such as South Korea and Germany do that we cannot do?
In South Korea, you had an authoritarian regime until the 1980s. The adults in that country grew up in a place where if the government was concerned about a parasitic infection, you had to submit stool samples to the officials – it’s exactly what you did. And these are the people who are currently deciding whether or not to follow their government’s orders or hand over personal information. And what we’ve seen is that most people want to do it.
The case of Germany is a bit different. Unlike stereotypes, Germans are not dependent on their state. For example, they have many concerns about health information. But I think the big difference is that people are relative more confidence in the state. They believe that their state is fundamentally competent. Almost all polls we’ve shown to Americans that many of them just don’t trust the state, and that’s a huge problem if the state asks you to sacrifice so much for the common good.
My problem with libertarianism has always been that it gives us a language of rights, but it cannot give us a language of obligations – it is essentially an individualistic philosophy. What you are actually saying, at least in my mind, is that America is too libertarian to tackle a collective action problem like this.
Is that fair?
Yes, that is a very spicy way to express what I am saying, but it is exactly right.
I should say that I raise all these questions for fear. In other words, I’ll be happy if I’m wrong. But I keep thinking about other times when we’ve been in exactly this health situation, going back to Harry Truman who suggested and hit national health insurance. And I worked for President Obama, so I was there struggling to get a version of the Affordable Care Act passed. I have seen several states reject the extension of Medicaid. And I saw how the ACA couldn’t get a single Republican vote and I don’t think anyone lost their seat because of that, because they voted against.
So I’ve seen this dynamic over and over again in different contexts and I’m afraid this is the thing that limits us in our efforts to eradicate this virus. I don’t think I can say it better than you: I don’t think we can reconcile our libertarianism with the need for a sense of common purpose in times of crisis.
If what you say is true, it doesn’t matter who is the president or which party is in charge, because our problems are fundamentally cultural. And in that sense you define the problem as insoluble.
I think that would be a bit bleak. I would say the president matters. I was talking to a friend the other day and he said if Trump put on a mask at a press conference and said “I’m doing this because it’s smart to do” that would be important for some people who are resistant, that signal of someone they trust is important. So it is not that leadership is irrelevant, but I do think there are real limits to what is possible in the country and its origins go back to our inception.
Okay, Keith, you forced me to play the optimist here. I’ll take all your points and I don’t think anyone can deny our libertarian streak, but here’s my counterpart: A majority of Americans have shown a remarkable willingness to work together and social distance despite the vacuum of leadership at the top – and this applies to all parties.
Does that give you a break at all?
That is a very good point and it is encouraging. And some of the data I’ve seen across the country shows that most people choose to stay at home, even in places that have been blocked, like Georgia. So there is some consensus on that.
The question for me is, does that translate into behavior? The psychologist in me can see that 80 percent of Americans think masks are a good idea, for example, but does that mean 80 percent of Americans actually wear masks? Because I don’t see that and I live in one of the places you expect it.
At least wouldn’t it be fair to say that our cultural capacity may be wider than you suggest? I think we should be careful not to confuse mistrust this one administration with mistrust of the government as such, even though I agree that Americans have unusual mistrust of the government.
Still, there are reasons to think that there is a wealth of goodwill that could be sparked if we had a skilled leader who had a clear plan to deal with this pandemic, a plan that instilled confidence and the sacrifices and inconveniences justified –
Well, there are some places I think you can determine empirically by looking around the country. For example, I live in the Bay Area and the governor, Gavin Newsom, is quite well regarded. He anticipated this and imposed many restrictions that people usually accepted. I suspect that most people will follow their local leaders if the restrictions are sensible and properly explained.
However, I would say that I think a lot depends on whether there is an actual shared interest that is clear to everyone. For example, my parents live in a community of assisted living where everyone is in exactly the same situation, so there is total consensus. They don’t take visitors, they don’t go out. But they can because everyone recognizes the shared risks.
To be even clearer, I recognize that many people are willing to work together and sacrifice. The question we have to ask ourselves, the question that virologists in particular have to ask, is it enough? If 20 percent of the country signs out, or if several states sign out, will that jeopardize our national response? Or is it just enough to keep the pandemic going?
I am concerned that, for all the reasons we have already discussed, we have just enough dissent to keep this matter going. In that case, we might want to include that in our thinking about what is possible here. We need an idea of the level of compliance we need for a plan to work, and if we can’t replicate the levels of compliance in countries like South Korea or Germany, we probably shouldn’t try to replicate their approach.
Those are good questions and I don’t know the answers.
Me neither. But look, when I say we are different from other countries, I am not saying we are bad or worse. I’m only going to judge what we’re good at and what we’re not good at. I mean, if anyone wants to write a book about how much they hate Keith Humphreys, I’d say they should publish it in America, not Britain, because the libel laws here are milder and we value free speech and you can get away with it. So that’s just an assessment based on the legal culture in this country.
We have many strengths in America that can be of incredible value in normal times, but in a pandemic, those same strengths can become liability. That’s all I really say.
You close your thread by saying we probably end up with something like a Swedish corona virus policy by default. What exactly does that mean? How does that scenario end?
One of the drawbacks I got was that our approach will not be as good as Sweden’s because we don’t have universal health care. So I think this means that the virus will continue to spread fairly consistently across the country. I wouldn’t be surprised if the death toll doubles with Labor Day. Of course I would be very happy to be wrong about that.
And there are really only two things that could interrupt this: 1) a vaccine, which is very unlikely for at least a year or more, or 2) an increased development of therapeutics. So maybe we have a breakthrough in our ability to treat the symptoms. What I think is most likely is that a large number of people contract this virus and that we develop immunity over time. If this happens, the virus will decrease over time, but it will not be due to our testing, tracking and isolation efforts.