The Other Side of the Scoreboard

A Series (if a bit aspirational)

I have a metaphor I have returned to frequently during the COVID pandemic. I call it “The Other Side of the Scoreboard.” It refers to the unfortunate tendency to view all of the public health recommendations through the lens of COVID cases. This isn’t wrong by itself, but it is, at best, only half of the story. Any medical intervention must be assumed to have unintended harms, because this is sadly universal to healthcare. All interventions cause harm. Some interventions provide enough benefit to be worth accepting the harm.

This has been hard for some folks to accept. The common analogy is to a parachute. “You can’t investigate the benefit of masks (or school closure, or any of the non-pharmaceutical interventions) any more than you can test the effectiveness of parachutes when jumping out of an airplane.”

This has always been a rhetorical dodge. There are precious few parachutes in medicine. The idea that there have always been simple procedures universally available but left in the metaphorical airplane is both ahistorical and an insult to the intelligence of those who came before us. One of the clues that you have found one of the rare medical parachutes is that you won’t find yourself in Twitter arguments trying to convince people. Parachutes are so obvious nobody mentions them.

So, if all interventions cause harm, how should we account that harm? That’s where the other side of the scoreboard comes in.

The OTOTS is more nebulous, I’ll admit. It doesn’t lend itself as easily to running tallies, it is often subjective, and it doesn’t even follow the same time scale of the pandemic. Take school closure. The educational harms from closed and virtual school are becoming obvious, but there are many confounders than make the attribution challenging. Was it the closure or the pandemic? That simple question is hard to disentangle. Was it all kids, or disproportionally on the most vulnerable? Will it all get better over time, or have we saddled a generation with a legacy of lost potential?

You quickly see why some people might find it easier to wave that side away. But that is always a mistake.

My overall point will be that, in our zeal for minimizing the measurable and scary COVID numbers, we systematically ignored the harms of policy. In fact, we made the fundamental error of placing the public health leaders responsible for coming up with the interventions in charge of the entire policy. Politicians, who had the job of balancing out the risks and benefits, continually deferred to a public health leadership that was predisposed place the emphasis on the medical side, and poorly equipped to judge or even acknowledge the tradeoffs. They had a toolbelt well-supplied with hammers, and it should be little surprise they perceived a society brimming with nails.

This will be my project. To take some of the issues and make the case that public health recommendations took insufficient account of the harms of their approach. My goal is that, taken together, this will be a cautionary tale about how myopia toward COVID cases ended up causing unintended and avoidable harm, so that we never, ever let this happen again.

First up: Friday 12/2 - Visiting Loved Ones in the Hosptial. What You Had, and What You Lost.