by Dr. Adam Cifu
I recently spoke with a colleague in another city about how we would adjust our personal behaviors as COVID-19 cases rise once again. I have great respect for this physician, and both of us are well versed in the medical literature concerning COVID-19 and dedicated to the health of our patients and community and have cared for patients throughout the pandemic. But we disagreed on many of the issues we discussed. Our conversation illustrated that disagreements exist not only among members of the public but also among physicians, a group that we assume would be of like mind when it comes to science. In a recent poll, physicians, as well as nurses, were split roughly in half on whether they would continue to wear masks regularly at work.
Many of us have had COVID-19 debates over the last two years. Discussions about vaccination, vaccine mandates, masking and school closings, whether on social media, at school board meetings, in doctors’ offices or in our homes, have been contentious.
As we look back on the pandemic — and forward to future waves or other epidemics — is there a way to find understanding in our disagreements? Would better understanding enable more productive discourse? Can we advance our understanding of risk assessment and decision-making as much as we have advanced our understanding of vaccine science and immunology?
I concentrate here only on disagreements between people and between professionals who are knowledgeable about the COVID-19 scientific literature and dedicated to minimizing the burden wrought by the pandemic. There are those, inside and outside the scientific community, who render dubious opinions to the public. At this point in the pandemic, nobody can seriously argue that older, higher-risk people should not receive a three-shot series of one of the mRNA vaccines. But it is also clear that masking outdoors is unnecessary because the risk of contracting COVID-19 outdoors is low.
Drs. Jerome Groopman and Pamela Hartzband have suggested that we all have a “medical mind,” an individual approach to weighing the risks and benefits of treatments. They suggest that we split into groups of minimalists and maximalists, as well as believers and doubters. J. Eric Oliver and Thomas J. Wood, two political scientists, have suggested similar dichotomies endemic to our culture, seeing us as aligned as either rationalists or intuitionists. Our experience with COVID-19 has taught us that well-informed and well-intentioned people will disagree based on their assumptions about health and health care and how they weigh risk.
On one side of disagreements over the pandemic are “COVID optimists,” who now see the virus as a relatively minor threat. They foresee progressively smaller, less severe waves of disease as our immunity handles SARS-CoV-2 like it does all coronaviruses — imperfectly and impermanently but competently enough. The optimists concentrate on the fact that the large majority of vaccinated and previously infected people will experience COVID-19 as a mild upper respiratory infection. While they acknowledge that the disease can still be deadly, they argue that we must now live with an unavoidable infectious disease, like humankind has done for most of its history.
On the other side are the “COVID pessimists,” those concerned that this highly (and increasingly) transmissible virus will cause recurrent waves of increasing hospitalizations and deaths. The pessimists worry that long COVID-19 is not a prolonged phase of recovery, like we see with other infections, but a new, particularly disabling condition. The pessimists believe that we should continue to employ all the tools at hand, pharmacologic and otherwise, to suppress the activity and evolution of the virus.
Even the same data can be read differently by the two groups. The effect of our treatments and preventions can be viewed as highly effective when viewed in relative terms, such as the originally reported mRNA vaccine efficacy of 95%. The vaccine, however, seems less effective in absolute terms. If the infection fatality rate of COVID is 0.25%, a rough estimate, a vaccine that is 95% effective produces only a 0.24% absolute improvement in death rates, benefiting only 1 in every 425 people vaccinated. Two people, reading the same data but with different perspectives, might come to very different conclusions.
To have productive discussions about COVID-19, whether between physicians debating recommendations or family members discussing whether to mask in a certain situation, we might recommend two steps. First, agree on the facts. We are, fortunately, at a place in the pandemic in which we can agree, at least in a general sense, on many things that were unknown two years ago. We have numbers for vaccine efficacy, the maximum efficacy of masking and the risk of severe illness for various age groups.
Next, place yourselves along the spectrum of pessimism or optimism. How people situate themselves unmasks personal values and risk tolerance, things that should be accepted rather than debated. Recognizing this should allow people to, at least, agreeably disagree.
Like it or not, this pandemic will continue to shape our lives and the practice of medicine. This emergency has catalyzed enormous advances in the biological sciences, with millions of lives saved.
What is not clear is if we have learned the same lessons in bias and communication. Refreshing our knowledge of communication and complex decision-making is critical because we can all agree that the next virus is waiting.
