On Friday, March 13, 2020, I invited a few friends over before we all went into lockdown. We did not stay six feet apart—the norm of social distancing had not yet been fully absorbed—but in a nod to good hygiene we washed, used disinfectant, and avoided shaking hands or hugging. That evening of food and drink was the last time anyone other than me has been in my living space.
At that time, restrictions were just beginning to roll out. Two days later, our governor closed schools for a two-week period, and the CDC recommended against gatherings of fifty or more over the following eight weeks. It would be another week before all non-essential businesses were closed in our area. That evening, we were all in a state of shock and unable to process what was happening. One of my friends turned to me and asked, “Do you think we will be back to normal in April?”
I’m the kind of person who copes with bad news by doing as much as I can to understand it. By Friday the 13th of March, I had already been obsessively reading about the new coronavirus for a couple of weeks. I had already heard Harvard epidemiologist Marc Lipsitch’s estimate that 40–70 percent of the world’s adult population could be infected and that one percent of symptomatic people could die. I’d also heard about the difficulties in developing vaccines. So, I said to my friend, “No. I think life is going to be different for a long time.”
In the subsequent months, we all went through a difficult process of accepting the loss of normal life. Much has happened since those early days, and people are now understandably frustrated and anxious to gather together again in all the usual places. Even more urgent are the cries of parents who are at home trying to work and raise children at the same time or, worse, need to leave home for work without the benefit of face-to-face school or childcare for their children. Households with children at home have also suffered the greatest economic impact of the pandemic (Armantier et al. 2020).
All of this tends to make people impatient. For good reason. Whenever there is a gap between where we are and where we want or expect or used to be, people get desperate, and that gap has never been so large in most people’s lives as it is right now. Unfortunately, the impatience of these desperate times can lead to serious mistakes.
The Tyranny of Now
Many of humanity’s worst problems are caused by what could be called the tyranny of now. Smaller rewards in the present are chosen over larger ones in the future. The most obvious example is climate change. Many decisions made out of convenience today are quickly guiding us toward an uninhabitable planet tomorrow. In the area of health, we often enjoy tobacco, drugs, alcohol, and caloric foods at the expense of good health in the future. In our economic lives, we buy things with a credit card, paying more later in order to have something now. The list goes on. It appears that Homo sapiens evolved in environments that gave great value to immediate rewards and punishments. The bird in the hand. Unfortunately, as we have expanded our ability to alter the future, we have not adequately adjusted our relationship with the now.
The coronavirus pandemic has exposed many examples of this kind of short-term thinking. Delayed effects have been given less weight than immediate ones, sometimes with deadly results. Here are just a few examples:
Delayed Effects of Public Health Interventions
One of the most frustrating aspects of the fight against SARS-CoV-2 has been the imposition of substantial changes in our lives, only to have to wait for weeks to see any benefit of our sacrifices.
In the case of New York State, the governor ordered a statewide lockdown on March 22, but New Yorkers had to wait nineteen days until the number of new cases began to fall and two full months, until May 23, before the number of daily cases fell below what they were on the first day of the lockdown. Fortunately for New Yorkers, COVID-19 fatalities, which reached a peak of 1,025, began to fall just days after the new cases curve bent downward.
As the pandemic progressed, another, more confusing effect of delays emerged in the United States. In mid-June, after having maintained a rate of approximately 20,000 new cases per day, new infections began to rise. The lockdowns that had been in effect in the West and especially the Northeast had greatly diminished the number of new cases in those areas, but in June and July, states in the South and Midwest that had been largely spared began to show increasing levels of infection. This ripple effect created conflict—or what seemed to some to be a conflict—between the new cases curve and the death curve. At the national level, cases were back on the rise, but deaths continued to fall. President Trump blamed the increase in cases on increased testing, and at his ill-fated rally in Tulsa, Oklahoma, on June 20, he said, “I asked my people to slow the testing down, please.”
Why does the Lamestream Fake News Media REFUSE to say that China Virus deaths are down 39%, and that we now have the lowest Fatality (Mortality) Rate in the World. They just can’t stand that we are doing so well for our Country!
— Donald J. Trump (@realDonaldTrump) July 6, 2020
When you get a mix of good news and bad, it is natural to accentuate the positive, and in 2020, we are desperate for anything positive. In addition, there is still much we don’t know about SARS-CoV-2, and our lack of knowledge provides cognitive wiggle room for optimistic speculation. Of course, if you are a politician, you have an even stronger incentive to push positive news. In June and July, some people suggested that the original form of the virus was mutating and becoming less lethal. Vice President Pence tried to paint a rosy picture by pointing out that a larger percentage of the infections were in younger people, who were less likely to develop serious symptoms. On July 6, the president claimed success based on the lower death rates, but speaking a day later, Dr. Anthony Fauci, the nation’s top infectious disease expert, said it was a “false narrative to take comfort in a lower rate of death.” As early as late June, Dr. Fauci pointed out that deaths lagged weeks behind infections and predicted that the country would soon be seeing more deaths.
Undeterred, a number of southern governors continued to open their states despite rising infections. By July 9, daily infections in Florida had quadrupled over recent weeks, but deaths had not yet started to rise. As a result, Governor Ron DeSantis, echoing the president, claimed that additional testing had caused the rise in confirmed cases, and he pressed for the schools in his state to open. On July 16, as infections were soaring in Georgia, Governor Brian Kemp sued Atlanta to stop the city from implementing some of its coronavirus public health policies. But, as should have been expected, Dr. Fauci was right. By August 1, U.S. deaths from COVID-19 had surged back up to over a thousand a day.
Bars and Restaurants before Schools
When states under lockdown orders had driven the infection rate low enough to consider reopening, another example of short-sighted reasoning took hold. In an unfortunate bit of timing, the move to reopen occurred after most schools had already closed for the year. People were anxious to go out, and much attention was placed on reopening bars and restaurants. For example, Indiana began to reopen on May 1, but schools remained closed. On May 11, indoor dining at restaurants reopened at fifty percent capacity, and on June 12, as the state entered its Phase 4, restaurants opened to seventy-five percent capacity. Bars, nightclubs, movie theaters, and bowling alleys opened at fifty percent. But after bottoming out at a seven-day moving average of 297 new cases per day on June 24 (Wordometer.com), infections began to rise sharply. As of this writing, the seven-day average of new cases in Indiana is at 935, over three times what it had been two months earlier and 25 percent higher than the peak during lockdown. On August 1, the governor introduced a statewide mask mandate for the first time, but by then school openings were close at hand.
Of course, there were economic reasons to open bars and restaurants, but there are arguably even greater economic and social reasons to open schools. Furthermore, some of what happened after the reopenings might have been predicted. Back in May, 119 new infections were traced to one patron who visited several bars in a single night in Seoul, South Korea, and today reports are coming in from the United States suggesting that restaurants and bars are an important source of new cases. In an August 12 article titled “The Nation Wanted to Eat Out Again. Everyone Has Paid the Price,” the New York Times reported—in a quote that could sum up the main point of this column—“short-term gains have led to broader losses.” States throughout the country have tracked a substantial portion of new cases of SARS-CoV-2 to restaurants and bars.
I am fortunate to live in Connecticut, a state that currently has one of the lowest rates of infection in the country. Schools in my area are making plans to return to some form of in-person instruction, and as is true all over the country, it is impossible to predict how well the school openings will go. But it is much easier to think about sending your child back to school in a state, like mine, that is averaging seventy-two new infections per day and has a test positivity rate of less than 1 percent, than it would be, for example, in Indiana, where they are currently averaging over 900 new infections a day and have a test positivity rate of 9 percent. Indiana’s population is approximately two and a half times that of Connecticut, but adjusting for population does not do much to close the virus gap between the two states.
School openings will be another big test of our national, state, and local responses to the coronavirus crisis, and soon we will have the benefit of hindsight. At that point, we can take stock of how much we paid later in order to go to bars and restaurants earlier.
Clinical Trials and the Tyranny of Now
As described in an important New York Times Magazine article by Susan Dominus, some of the most dramatic examples of the tyranny of now have been playing out in intensive care units throughout the country. At the beginning of the epidemic, doctors knew almost nothing about this disease and how to treat it. They gave basic supportive care—oxygen, hydration, antibiotics, and ventilation—but they had no idea what therapeutic drugs might be effective in treating hospitalized COVID patients. ICU doctors were overwhelmed, stressed to their limits, and desperate to do something for their COVID patients. Based on informal reports of other doctors’ experiences, both here and abroad, many physicians tried “off label” uses of drugs that had been approved for other conditions and were considered safe. At the same time, a variety of double-blind randomized control trials (RCTs) were launched to test drugs that seemed promising. At the height of the outbreaks in New York and New Jersey, ICU doctors were well aware of the on-going RCTs, but each time they prescribed a therapeutic drug for their patients, they eliminated a potential participant from studies that could establish which drugs were actually effective.
The case of the antimalarial drug hydroxychloroquine was particularly instructive. In March, President Trump started praising the effectiveness of hydroxychloroquine, and that same month, the Food and Drug Administration approved it for emergency use with COVID-19 patients. Unfortunately, the excitement about the drug was largely based on a small study done in France that was not sufficient to convince most scientists. In the hope of providing a more definitive test, Steven Libutti, director of the Rutgers Cancer Institute of New Jersey, got approval to start a larger RCT, but he found it difficult to enroll patients in the study. As Dominus reported, by the time a nurse spoke to patients about participating in the RCT, most had already taken hydroxychloroquine, making them ineligible for the study. In the end, England was the first country to produce a good test of hydroxychloroquine because their doctors had been instructed not to use it until more was known about it. The results: hydroxychloroquine was not found to be effective in the treatment of COVID-19.
The plight of ICU doctors is quite understandable. Many have extensive experience and are likely to rely on their clinical judgment in difficult cases, but decades of research have shown that physicians sometimes make predictable decision errors (Elstein 1976). During the current pandemic, doctors have also had to contend with patients’ families, many of whom have heard the president praising hydrochloroquine and were anxious to have it prescribed for their loved ones. Finally, being in an RCT means understanding that you have a chance of being assigned to the placebo group. The only way to prove a drug works is to compare it to a group of similar patients who get an inactive placebo. In a recent talk in the Center for Inquiry’s Skeptical Inquirer Presents series, Dr. Paul Offit, pediatrician and expert on vaccines, said that in order to test a vaccine for COVID-19, it would be necessary to have approximately 150 people in the placebo group who eventually come down with the disease to compare with the people in the vaccine group. Without an adequate placebo comparison group, we will not know if any of the vaccines under development actually work. But for both the person who already has COVID and his or her attending ICU physician, there is undoubtedly a strong temptation to just try something now. Meanwhile, the scientists running clinical trials would argue that there will be many more patients coming in the future. More lives will be saved in the long run by doing the science as efficiently as possible. Of course, when it is you or your patient, it is hard to think about the big picture in strictly utilitarian fashion. It’s even harder when it is your mother, father, or child.
Thinking Beyond Now
Delays are difficult for us. Somebody once said, “If the hangover came first, no one would drink.” Immediate things fill our thoughts and tempt us. In contrast, the future is largely out of sight and mind. But in the face of a deadly global pandemic, we should be able to focus on the much larger long-term goals that may actually bring us back to normalcy in less time. A number of other countries have been more resolute in their efforts and aggressive in finding and rooting out the virus, and in return for their sacrifices they now enjoy much more freedom of movement than we do. New Zealand managed to go over 100 days without any community spread, during which they could gather in large groups without masks and engage in normal activities. In response to an outbreak in Auckland, Prime Minister Jacinda Ardern recently returned the city to lockdown, but New Zealand now knows how to beat back the virus. The Kiwis have benefited from the geography of an island nation, but a number of other countries are doing well and returning to work and school.
If the United States wants to be able to control the virus and bring back economic activity before a vaccine is widely available, it will take a commitment to choosing the larger rewards of the future over the smaller ones we can have now.
- Armantier, Olivier, Gizem Koşar, Rachel Pomerantz, and Wilbert Van Der Klaauw. 2020. The disproportionate effects of COVID-19 on households with children. Liberty Street Economics (August 13). Available at https://libertystreeteconomics.newyorkfed.org/2020/08/the-disproportionate-effects-of-covid-19-on-households-with-children.html.
- Elstein, A.S. 1976. Clinical judgment: Psychological research and medical practice. Science 194(4266): 696–700.