It is quite amazing how everything gets turned on its head so rapidly these days. Up becomes down and black becomes white. While it seems like years, it was only 4 months ago that no one was wearing masks, schools were shutting down, and Floridians were afraid of New Yorkers traveling south. Now our very own President said to wear (but didn’t actually put on) a mask, kids are starting to buy supplies for the fall, and New Yorkers run in fear from any senior citizen with a tan who is wearing colorful golf pants.
One of the major changes that I have noticed is that we have not been talking about the fear of ventilator shortages for some time. I remember sitting at COVID-19 emergency planning committee meetings back in March where we were scrounging to find every machine that could be jerry rigged to ventilate a patient. I was in contact with companies who make CPAP machines to see if we can rent them to ventilate COVID patients in an emergency. We were even coming up with crazy and unthinkable plans to put multiple patients on a single ventilator. The fear of having to choose who goes on a ventilator was in the forefront of all of our minds. These challenges dominated the news as well and motivated the government to invest $3 billion to build more ventilators as part of the emergency response.
What is most interesting is that we knew from the beginning that ventilators were terrible at prolonging lives and that spending that much money to make more of them would likely do little to improve survival. This was because of the very high mortality when people go on the ventilators (possibly caused by the ventilators themselves). At the same time, government funding for testing and the development of contact tracing was woefully insufficient. That $3billion could have saved many more lives if it was diverted to these tried and true public health interventions. In spite of the fact that most experts knew that a large investment in ventilators would likely not make a large impact on lives saved, it was supported almost universally by the public.
Why? If it is clearly proven that that money could save more lives if spent elsewhere, why was the support for buying ventilators so unanimous. At the same time that universal support for building more ventilators crossed political and cultural ideological boundaries, we had a brewing culture war over masks. If people would have died because of a shortage of ventilators there would certainly have been a public outcry yet there has not been a commensurate outcry about failures to implement more effective contact tracing – an intervention that would have saved more lives.
This discrepancy exposes inherent cognitive biases that impact our decision making and risk assessment. These biases are not just in relation to the pandemic but also impact almost every aspect of our lives. We human beings make the same predictable mistakes on a surprisingly consistent basis. This, unfortunately, has thrown gasoline on the fire of the pandemic. The worst part about these errors in judgment, aside from the fact that we all make them, is that most of us are unaware they are happening (if you want to learn about them in depth read Thinking Fast and Slow by Danny Kahneman).
We, as human beings, make the same predictable mistakes on a surprisingly consistent basis.
These errors distract leaders from making sound policy. They also keep us individuals from getting out of our own way. To quote Tommy Lee Jones in the first Men in Black movie, “A person is smart. People are dumb, panicky dangerous animals and you know it.” Let’s delineate some of these biases.
The Identifiable Victim Effect
Economists have described a bias they call the “identifiable victim effect”. The identifiable victim effect is a tendency to offer greater assistance to an identifiable individual as opposed to a larger, unnamed or statistical group of people. In other words, people respond much more to threats against an individual than statistics reported in the news or a scientific journal, even if those threats are to a far greater number of people. When we can put ourselves in the shoes of the victim or imagine someone we care about in that position it impacts us very strongly. As Joseph Stalin famously and sadistically said, “One death is a tragedy, a million deaths a statistic.” In reality, the statistical information is much more valuable because the individual could be a fluke or a minority case. Unfortunately, we cannot imagine ourselves as a million people.
We are hardwired to predict outcomes that are consistently and systematically better than they are likely to be. This is to our benefit on a population level as all great advances have come from people taking great chances. We even glorify those who take great risks (think explorers, military heros, and entrepreneurs). As a whole this benefits the group even if it puts the individual at great risk.
A great example is in business. Data from the Bureau of Labor Statistics show only about 25% of new businesses survive 15 years or more. In spite of that Over 627,000 new businesses open each year according to estimates from the Small Business Authority. Assuming the business owners are rational, this would mean that 100% of those new business owners feel that they are part of the 25% even though there is a 75% chance they are wrong.
While this is good for the economy as a whole it is not good for public health policy. We have been overly optimistic about all aspects of the pandemic – the likelihood the virus would hit the US in February, the benefits of medications such as hydroxychloroquine in April, the likelihood the virus will spike if things opened up in June, etc. We were also overly optimistic that the ventilators would help.
Humans prefer immediate benefits to future ones even if the future benefits are much larger. If you’ve ever failed a diet, had trouble quitting smoking, chosen a new car/article of clothing/vacation over your retirement plan you’ve fallen victim to this one (i.e. all of us). Ventilators save lives in the present – other interventions save lives in the future. This is also true of masks, quarantine, and social distancing.
Humans prefer both consciously and unconsciously to have something bad happen by not doing something than by doing something. This explains why some parents are biased towards the harm of giving a vaccine over the harm of not giving the vaccine (actually, anti-vaxxers check off all the above cognitive bias boxes. See if you can figure out how for each one and put it in the comments below). The fear of having to withhold a ventilator from an individual is so great because one is actively deciding whether someone should live or die. This was not the case with policies that worked to suppress viral spread. If the virus spreads, people aren’t actively doing something, they only failing to stop it by not doing something.
There are other biases that are in play with COVID-19 – and everything else in our life for that matter. Fortunately the ventilator shortage crisis never came. The curve flattened (at least for a time) which eased the strain on the healthcare system; We got better at treating the disease; and we started using alternatives to ventilators that actually worked better. I myself have treated dozens of critically ill COVID-19 patients but only have had to intubate one (for the treatment plan I adopted read: Good News From the Front Lines).
These cognitive frailties cannot be removed. They are hardwired into our thinking. They can, however, be overcome. The first step to overcome them is to identify them. The second is setting up systems to protect us from them. This can be on the personal level. For example, setting a budget helps overcome the present bias from sinking your finances and having a sound back up plan to account for business setbacks helps prevent optimism bias from bankrupting you. On the societal level, well designed public policy can protect us when we let it. This should be driven by evidence and not by emotion. We have no rational choice but to put our faith in experts, even if they are fallible. The CDC may get things wrong on occasion but our odds of a good outcome are better listening to them than to the screaming youtube videos or conspiracy theory touting facebook posts.
We have a long way to go before this thing is over but, even before we have our vaccine parties, these biases will find new and annoying ways to trip us up. For now, the best thing to do is hunker down and stop letting social media fuel our anxiety and drive our public policy. Our leaders need to stop politicizing sound policy. The media needs to stop feeding off our cognitive frailty. We must do all of these things. I am confident that it can and must be done but, then again, that may be my own optimism bias.
For more read:
Cognitive Bias and Public Health Puolicy During the COVID-19 Pandemic. JAMA 2020; 324(4) 336-7.
Special thanks to Raffi Billek for editing help. Check him out at www.baltimoretherapycenter.com