I am afraid of a lot of things, though probably not more than the average person. I really do not like small closed spaces, and I have a disproportionate fear that any ache and pain can become a terrible illness. I fear economic insolvency. And I have been thinking a fair bit about these fears in the time of a global pandemic. Fundamentally, I have been trying to ask myself: what role does (or should) fear play in our decision-making? How do we reckon with the role fear plays in shaping our choices?
If you live in the US, your odds of being killed by a foreign-born terrorist on American soil are one in 3.64 million. This places risk of death from terrorism far below that of other causes of death, such as, for example, drowning, which is fifth among leading causes of unintentional injury death in the US. Yet drowning risk has not shaped our politics and society for decades, motivated sweeping legislation like The Patriot Act, or helped provide justification for an annual defense budget of roughly $700 billion. This is arguably because drowning, while more widespread, does not receive the same publicity as terror attacks, allowing terrorism to generate a fear disproportionate to the risk it poses.
The role of fear in shaping our response to threats is deeply relevant to the COVID moment. This fear is understandable. COVID-19 has been a catastrophe. As of this writing, over 28 million people have been infected in the US and over 500,000 have died. As a result of this, new CDC projections show we are facing a one year life expectancy drop in the US. Beyond the numbers are the stories of the infected; the articles about what it is like to get the disease, the frightening specter of long COVID, and the media’s amplification of all of this. Then there was how the story initially unfolded, echoing the narrative of disaster films, priming us to fear by adhering to a script many of us already had in our minds. First, there were the initial rumblings of trouble thousands of miles away. Next, came the growing awareness that this was no minor concern, that it had the makings of a global threat. Finally, there were the signs of COVID’s inexorable spread, including devastation in Italy, the digging of huge burial pits in Iran, and the first reported case in the US.
So, fear has been a big part of this moment, reasonably so. Fear has motivated us to dramatically change how we live our lives; who we see, and what we do. We may prefer to think we have made these changes because we are following the science of the pandemic and adhering to government policies curtailing our actions in the name of health. And, to an extent, we are. But, as we in public health well know, top-down interventions can only do so much. We can provide data that, say, doing such-and-such is good for health; governments can generate policy based on these data, but without motivation among the population, such measures cannot be effective. The speed with which society changed in the face of the pandemic, and the length this change has been sustained, suggest we are, collectively, highly motivated to do right by our health. Data suggest this motivation is best understood as fear. A National Bureau of Economic Research working paper found that the economic decline of 2020 was due much more to people voluntarily choosing to stay home and alter their consumption habits than it was to government restrictions. The study found that while overall consumer traffic fell by 60 percent, legal restrictions accounted for just seven percent of the decline. According to the study:
“Individual choices were far more important and seem tied to fears of infection. Traffic started dropping before the legal orders were in place; was highly tied to the number of COVID deaths in the county; and showed a clear shift by consumers away from larger/busier stores toward smaller/less busy ones in the same industry.”
In the initial months of the pandemic, this fear served as the basis for creating a radically different world. As we are still living in this world, it is worth taking a closer look at fear’s foundational role in bringing it about, and asking whether such a foundation can indeed support a healthy long-term future, as we look to move beyond the pandemic. Fear has served as subtext for all we have done during the pandemic, yet it has been rarely discussed. It is helpful indeed, then, to take a moment to think about how we understand fear and its role in our COVID response.
There are ample data on how the perception of risk shapes our choices. I have written previously on how emotion can shape the decision-making process, often at the expense of rationality and our willingness to take data into account. Consider: a 2016 Frontiers in Psychology study found that visualizing risk consequences of decisions can generate negative affect linked with feelings of stress; these feelings can, in turn, generate higher perceived risk. The study authors noted this further supports a model of decision-making which places significant emphasis on the role of feelings as a counterweight to rational analysis—more than a counterweight, even; data suggest that it is often our feelings which, in fact, drive our choices.
Given this reality, it makes sense we react disproportionately to emotional stimuli. Indeed, if we had responded with complete equanimity to the pandemic, this reaction would have been even more anomalous than the pandemic itself. So, when COVID-19 arrived, it brought with it many examples of what could be seen, in light of human nature, as reactions guided more by fear than reason. Take, for example, the decision of some school districts to cancel outdoor sports. From the perspective of reason, this made little sense. The virus is significantly less likely to transmit outdoors. What is risky, however, is denying young people the chance to socialize in person, particularly during the crucial early years of their development. We are just beginning to learn about the mental health effects of this past year’s isolation, and it is likely the experience of isolation will shape the psychology of today’s young people for a long time. When the tenuous risk of viral spread during sports is compared to the near-certainty of poor mental health outcomes caused by isolation, the choice pure reason would select is clear.
But we are not guided by pure reason. We are afraid. Last year, we learned there is a contagion, we learned it travels by air, and, in a sense, these two data points have trumped all we have learned since. This has kept the prospect of people gathering together under any circumstances a frightening one for many. Given the overwhelming role of emotion in risk calculations, it is unlikely we can ever completely separate such fears from our decisions. What we can do is ask: has our response to the moment been overly controlled by fear? What is the right proportion of response to risk? Have our policies been disproportionately driven by fear? To this last question: in the context of fear, it is all the more important that policymakers apply reason over emotion, helping to lead the public in a measured approach to crisis.
This is especially true at this stage of the pandemic, when we have an opening to end the crisis and the social and economic disruption it has caused. COVID is not just an infectious threat. It also makes us unhealthy through its effects of unemployment, a stalled economy, and in the mental health challenges worsened by the isolation of physical distancing. Addressing these challenges is just as important for health as ending the viral threat through vaccines. Fortunately, the latter has a good chance of helping us do the former. COVID vaccines are safe and effective, and data are starting to indicate they help reduce transmission of the disease. Yet we have been hesitant to embrace the full implications of what this means. President Biden has suggested that we will begin to see a return to something like normalcy in late 2021. It may or may not be the case that this timetable is correct; many variables are still in play which are shaping the pandemic’s endgame. What is certain, however, is that we must take care that our projections are informed, to the greatest possible extent, by data rather than by a tendency to err on the side of fear.
It is understandable that, as we make high-level decisions about the pandemic, we may wish to manage expectations, and sometimes conclude there is little to be lost by suggesting—just to be on the safe side—that the risk to a vaccinated population is greater than it is. The same is true of the push to cancel outdoor sports, despite the data. The problem here is that giving in to our fear, and basing policy on it, is not as costless as it can seem. For example, we have long seen in the US a vocal minority which expresses skepticism of the efficacy of vaccines. A key task for public health is to counter these voices, especially now that robust vaccine uptake has emerged as the key to ending this crisis. However, if we caution against reopening even after vaccination has become widespread, are we not implying vaccines are less effective then we have always claimed them to be? We would not spread such a message, of course. But perception is reality, as the saying goes, and this is the perception we risk promoting when our actions are motivated by fear. While we may not see much short-term cost to this, in the long run, we may well face greater distrust of public health authorities in general, and of vaccines in particular, none of which is to the good.
Are there steps we can take to appropriately mitigate fear? First and foremost, we need to be alert to its influence, so that it does not govern our actions at the expense of the measures necessary to support health. It is OK to be afraid. It is wise to balance risks and trade-offs. It is not OK to let fear completely make decisions for us, or for us to play on the fears of others for the sake of expediency. We should aspire to a level of dispassion about the moment we are in, so we can make the best choices about how to navigate our way out of it. And we need to relieve those who are making key decisions from the pressure of feeling they must play to fear. This means basing our conversation about health, as much as possible, on reason, maintaining a sense of proportion about the issues we face. Emotion may always play a role in our decisions, but it need not be the emotion of fear. Instead, we might embrace compassion as a counterpoint to reason, in the hope this informs the wisdom—on the part of both leaders and the wider public—to act in ways that support a healthier world.
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Thank you to all of you who came to one of The Healthiest Goldfish Conversations this week. I truly enjoyed talking, meeting new colleagues from all over the world. The Conversations left me heartened about the future of health, with excellent people everywhere committed to thinking carefully about what we need to do to improve our health, and creating a better world that generates health. Thank you for for joining the conversations.
I published a piece in JAMA Forum about “The price of health equity” arguing that there is a price to pay for health equity—one that is abundantly justifiable by the fundamental aspirations of health and of a fair society that invests in ensuring that all of its members are healthy enough to realize their potential. However, recognizing that there is such a price to pay should focus the attention of anyone concerned with health and achieving health equity as well as on the forces that militate against it, which requires sharper thinking on the topic than what has occurred in recent public conversations.
And in this week’s The Turning Point, Michael Stein and I ask what lessons we have learned from the COVID-19 moment that may apply to other respiratory disease.