by Jorge Guira
Sunday night, President Trump declared in an emphatic tweet, “WE CANNOT LET THE CURE BE WORSE THAN THE PROBLEM ITSELF”, then announced that at the end of a fifteen-day period he may ease the measures and restrictions designed by the CDC to safeguard public health. He doubled down on this Tuesday night with a message that he is intending to have THE US open for business by Easter. This came on the back of a warning by Fox News commentator, Steven Hilton, that the harm of continued economic decline, leading to vast unemployment and economic collapse, may be greater than the Covid-19 virus, itself. Which in turn was something that many leading public health commentators such as Dr. David Katz set out in the New York Times this weekend.
The losses hitting Wall Street and Main Street are real. They are measured in falling equity prices, bond market selloffs, a dash for cash. Fear is the currency of the moment punctuated by certain days of hope, and it is driven by the idea that a life’s work should not die within a short time. In order to combat this, the Fed has gone “all in” with a raft of measures. The Congress still fiddles, stymieing the precious commodity of hope and confidence that is so needed, although that appears to be remedied and a deal seems close to closing. The overall aid package is estimated to be about 6 trillion US dollars, nearly 30% of the US economy GDP. Meanwhile, we are left with the question of what the government’s response ought to be.
Do we continue to prioritize, at least in the short term, the preservation of life at the expense of the economy? Or do we ease restrictions on movement and trade, hoping for an improved economy, but at the cost of American lives?
Logically, life should be prioritized.
But this is perceived to be at conflict with livelihoods.
So, the choice is presented as one where perhaps some small percentage of the population (1 to 2%) may have to suffer and die at the cost of preserving the economy. But that this may be worth it, as it is keeping with American norms such as traffic fatalities and other flu’s, where business goes on, as usual, without impairing business and finance and the livelihoods of Main Street.
But is this a real choice, or part of a larger plan to deflect blame and politically come out ahead? Turning a losing situation into one where Trump can claim victory, no matter what.
And what of Boris Johnson and his team? What is their approach, by contrast, and how forthright have they been in explaining it to the British public?
The analysis begins with examining the premise about that most elemental of concerns, what is the value of a life?
This is at the heart of cost benefit analysis, which is crucial in debates about health care rationing. The UK has implicit rationing, the stuff not talked about in polite conversation, or if so, obliquely. And the US has, as well depending upon various ethical and monetary considerations and considered by ethicists in the NIH and beyond.
The initial question therefore is if you genuinely have such a trade-off between economy and health, what criteria do you use? Should value decisions be based upon utilitarianism, egalitarianism, or the idea that you should prioritize the rights of those most vulnerable. Efficiency, equity, and John Rawls concepts also may be used. So, as to the latter, for example, if you do not know where you would rank to access health services how would you feel about the trade off? Would your position change if you do not know beforehand how you would fare in getting quality care-and in your own odds of survival, and those you hold most near and dear?
The lens we choose gives us our answers.
And that in turn is based upon the stories we tell ourselves about our own lives, and our own societies. Which in turn are always based upon mythologies and archetypes as well as more elusive truths which we may find as facts.
The news from Spain yesterday is telling. A doctor openly talking about favoring the young and relatively healthy versus the old in choosing who will live and die. The care home where workers abandoned the elderly to look after themselves and many died are another reaction. These very different impulses, the first case, born of rationality and triage criteria, and the second based on the perception of what is needed to survive and fear. These are all present in the air.
To someone who has worked hard all his life and he sees his or her savings dwindle, he says it’s the economy, stupid — a sentiment shared by many businesspersons, who are attached not so much to money but the identity of success, and the security it brings, and the fear of its evaporation.
To someone who is focused on the health of a loved one or cares for others in his or her role in a family system, the core identity they have may be a different one. They may care about economics, even deeply, but place greater emphasis on life and its quality. They may even view that those who value economics over health reflects the path of someone who knows the price of everything and the value of nothing. And hope against hope that that they do not have to see the face of unbearable loss.
We all traffic in value preferences and society has different views about moral priorities and responsibilities, and this is reflected in law and in tough decisions about medical ethics. This sometimes falls exclusively within the province of self-interest depending upon how the question is framed. So, there may be others who hold humane values most dear and some who would agree to economic pain and those for whom this is an unacceptable cost.
When the question is simplistically posed this way, there is a third possibility, that the question itself is based upon a false premise. Because there often multiple ways to align the interests of those who hold such diametrically opposing views. This includes what may be known as the direct approach and the deflection one.
And this applies to means as well. Let’s take the case of medical equipment and ventilators, for example. An American of a certain stripe will think of public private partnerships and scale, because that is what he knows, especially if in Silicon Valley. A Brit may invoke the Dunkirk spirit and think about how a plucky vacuum cleaner company can make ventilators to specification rapidly and get it out to people before the suffocating reality of breathlessly perishing becomes a casualty of rationing. Or a mass call for volunteers to the NHS, answered emphatically, reflecting solidarity with wartime spirit.
Let’s look at how public health strategy works links up to this and walk through it. Some will argue for total lockdown, and some will favor a differentiated approach, with targeted protection for those most at risk while restricting broader contact strictly, at the right time. The latter is seemingly where the UK is at now. This latter strategy seemingly conceals what may have happened as the early behavioral approach of developing herd immunity was used and apparently due to its risk and predatory impact on the most vulnerable was that it was in practice, abandoned. The perception was that it was discarded in an apparently somewhat farcical muddle in a pivot to a more humane approach focusing on tougher incremental measures reflects the public posture of policy development.
Herd immunity essentially allows greater spreading to the general population, which has typically mild symptoms but is much less likely to contract the disease in future, but with the possibility of major losses. A report from Oxford University reckons that over 50% of the UK population now likely has coronavirus. So, judging by this apparent result, it seems that perhaps it was not actually abandoned at all but allowed to run its course. And only stopped when it was too politically controversial. If so, then Boris and his team could claim that they were direct but abandoned it early as directed by opaque medical strategy driven by still unpublished “behavioral fatigue” data and “the science”.
Communicating this clearly in the UK, with full transparency was problematic and perhaps muddied as a result. But this allows Boris to look like he did his best, was tough with stricter measures when needed, and still manages to preserve much more of the economy while seemingly prioritizing life over livelihoods. He therefore has the best chance to preserve his core base of business, and still reach out to those who value social interests more that he has just won over in the North of England. It is, quite possibly, a classic triangulation by deflection artifice.
In the US, consider this. Trump has played a perhaps similar game but adjusted it to the different constellation of interests and political base he must fight which make up the correlation of forces for and against him. So, as above when this essay began, Trump announces he will save the economy by getting people back to work after the 15-day voluntary lock down period. So, by acknowledging the urgency and severity of the public health problem he positions himself as a person who is acting to preserve life.
And this of course helps scale up economic rescue packages based upon market signalling due to horrendous and visible interruptions of cash flow, which violently shake the markets. Despite criticism, his polls show no dip and his handling of the crisis while still low, is steady and holds up, with his base remaining solid. But to his right he hears that business interests are clamoring for even more relief. And as an ex-hotelier, his own’s life work and legacy, and that of his family may be at peril.
What’s a deflector and secret triangulator to do then? He has two choices, one to be direct, and the other, to say he is now going to open the economy, and perhaps as the crisis escalates and bodies pile up at hospitals, he pulls back when the 15 day period ends and claims, I can’t do it now based upon the advice of health experts. That way he can blame the experts for any further negative and extended fallout from the economic carnage and claim to be someone who in the end puts life first.
He has therefore craftily used deflection, as he does time and time again to triangulate and to align his own interests, especially after initial denial and missteps that were made. He can use the Democratic Governors who oppose him as useful foils who are too soft, while he balances a difficult situation handed to him. The Chinese misled him and started it, the science kept changing, and he always put America first, business and the people, his administration can and may argue. And if anyone disagrees with this clever employ of deflection: plausible deniability as to his real underlying strategy.
The nature of this challenge for both leaders is defining as well as divisive by its nature and is especially interesting as the debate is one where time frame to contain the disease is a variable from both a public health and economic standpoint. To consider soberly what the time horizon is for the disease to be contained and for the economy to return to functionality is a complex question. And what is the existential value of what we seek to preserve is something which may be obscured by political interests including the need to position oneself in a certain way and to have wiggle room to adjust as circumstances change.
In the case of pandemics, one conventional view is that early containment is crucial, or it can grow exponentially. Rather than have 1 person infect 2.3 people who then infect nearly 60,000 in a month’s time, it can be reduced to 1 person who inflects 1.3 people who then infect 3,000, as one example. That is a 95% reduction rate. And that is even without underscoring the issues that arise in treatment given the limited medical capacity in treatment which all countries have, if faced with exponential numbers. Rather than say we need to prioritize the economy, it is more likely the case that failing to contain the virus raises the costs of care exponentially and lengthens its duration, according to this view. Distasteful as it is, the seemingly discarded herd immunity approach certainly raises the costs of care in the short term, but arguably may shorten its duration but with the risk of uncontrollable loss of life. It may also result in savings, as a result of all the dead “boomers” out there, in the medium to long term.
The true enemy of the economy in present circumstances is thus calibrating the response correctly and applying the right decision rules in a three-dimensional game of chess with public health, economics, and politics at play. The trade-offs that are made if insufficient containment is made, restrictions are eased, and the disease runs more rampant seem to have put transparency itself in the cross hairs.
And therefore, in the final analysis, we must all reckon with this new reality and reflect upon our values. And how to rationally allocate resources and set decision rules that make sense of these two, when they do indeed conflict. And this arguably requires more honest conversations about trade-offs and uncertainties that plainly exist.
Speaking of such trade-offs is uncomfortable in the public square.
And should be.
Social and political consensus will be tested as society confronts these questions and seeks to move on and save itself and do the right thing, however that is defined.
Victor Frankl writes, in the grimness of the Holocaust, of those who find meaning by telling themselves stories of hope and purpose. And those who do not, degenerate and become lost and defeated. This is ultimately a false choice between economy and health. The exponential math of pandemics makes public health a priority over economy in the shorter term. However, in the longer term, there is no provision for public health without an economy.
Preservation of both is the chicken and egg problem redux.
Crafting the solution is not reducible to some magic formula.
Or easy transparency.
Clarity about the task, and how we can have better and more civilized discourse about this, the most uncivil of viruses is needed more than ever.
It is interesting how the arts of deflection have been used on both sides of the Atlantic to preserve and maximize political capital.
And at what cost, and for whom it will toll, is an ever-present reality.
[You may contact me on firstname.lastname@example.org. I am an Associate Professor of Law at the University of Reading, UK]