Defining Our Goalposts

 

During April of 2020, the in-hospital mortality rate from Covid-19 was at 19.7%. By November, it had declined to 9.3%. That is a remarkable testament to the triumph of clinical medicine in the face of a previously unknown disease. The drop in mortality was due to many factors, including the use of non-pharmacological approaches such as patient proning, the use of pharmacological therapies in hospitals such as remdesivir and steroids, and perhaps also due to lower viral loads seen in hospitalized patients because of more universal embrace of mask wearing. Regardless of the explanation, it is clear that our handling of Covid-19 got better quickly, changing dramatically the risk of what should be the ultimate outcome of concern: death.

But this dramatic improvement in mortality did not do very much to change our broader public narrative of Covid-19. Our impression—legitimate as it was—of a new deadly disease that was to be avoided at all costs was fixed quickly in March of 2020, and it did not budge much when the risk of the disease’s feared outcome changed substantially. We were seeing the same dynamic a year later as the widespread introduction of vaccines provided protection for those most vulnerable—the elderly and those with underlying medical conditions—lowering mortality rates and leaving cases to be driven by younger people who have had much less risk of contracting severe Covid-19. Despite this dramatic change in disease profile due to widening vaccination, the public conversation about the state of the pandemic remained driven, largely, by fluctuating case numbers, and state-by-state decisions were informed primarily by case load, even if these cases were milder and posed less risk.

There were many reasons for this state of affairs. In part, our slowness in adapting to a changing Covid-19 landscape was due to the stickiness of our thinking about health conditions. Once we develop an understanding of a particular condition, it is difficult to rethink it. Once we are afraid, it is hard to accept that the factors that made us afraid to begin with have changed, and we should therefore change our level of fear. The media narrative with Covid-19 that used catchy devices like case maps and trend arrows and continued to reinforce infection as the key marker of interest contributed to this mindset. As did our medical approach itself. Hospitalizations, for example, reflected not only disease severity but also availability of hospital beds, meaning that hospitalization for Covid-19 had likely evolved over time; clinicians had taken advantage of more space to hospitalize those with less severe disease.

From the start, we have wanted to reach the point where we vanquished Covid-19 forever. In April 2020, shaken by the chaos of a new virus, with an enormous scientific challenge laying ahead, we wanted some certainty that we could be done with Covid-19. As we went along, it was unclear to us as a society whether our goalpost should be fewer cases, or fewer severe cases and hospitalizations, or fewer deaths. Or perhaps it was all of them? The public conversation, our public actions, repeatedly lagged the clinical progress. It turns out we were better at handling Covid-19 than we were about thinking through what we wished to do with Covid-19.

The lesson we take from this is that it benefits us as a society to have clarity about the goalposts for any health condition. Such clarity comes from official sources, but also from our shared conversation, from a common understanding of what we are trying to achieve. This can point the way to more effective handling of any condition, allowing us to focus more intentionally on getting to those goalposts, and reducing collateral harm from efforts at prevention as our treatment and containment approaches improve over time.

 

Warmly,
Michael Stein & Sandro Galea

As we re-emerge from the pandemic, 2021 stands to be a turning point year for public health. In The Turning Point’s weekly essays, we reflect on what we learned during 2020, and what we are learning during 2021, that can guide us to the creation of a better, healthier world.

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