What went wrong during the COVID-19 pandemic? A team of public health researchers recently outlined some of the crucial policy mistakes we made and explained how we might avoid them in the future.
After recognizing SARS-COV-2 as a global threat last spring, the pandemic response quickly devolved into an ideological war. Most people lined up on either side of an oversimplified debate and filtered every new piece of evidence through their preexisting beliefs. Neither side tolerated dissent. Late-night host Jimmy Kimmel ghoulishly illustrated the problem with this mindset during a now-infamous bit about refusing treatment to the unvaccinated:
Vaccinated person having a heart attack? Yes, come right in. We'll take care of you. Unvaccinated guy who gobbled horse goo [ivermectin]? Rest in peace, wheezy.
In contrast to Kimmel on one side and the ivermectin warriors on the other, the authors of a July 2021 review published in BMC Infectious Diseases represent a far more sensible perspective that stresses the importance of avoiding false dichotomies in our policy debates and recognizing the trade-offs that go with mitigating a new viral threat:
We urge a nuanced understanding of the science and caution against black-or-white messaging, all-or-nothing guidance, and one-size-fits-all approaches. There is a need for meaningful public health communication and science-informed policies that recognize shades of gray, uncertainties, local context, and social determinants of health.
Between vaccines, new antiviral drugs, and infection-induced immunity, the pandemic may be nearing its end. But there are lots of nasty microbes in the world, and the chances are good that one of them will trigger another global crisis at some point. It's vitally important, therefore, that we learn to combat infectious diseases while avoiding the harmful mistakes we made in the wake of COVID-19.
The cost of lockdowns
Perhaps the most troublesome of these mistakes was minimizing the consequences of lockdowns. Early on, critics of shelter-in-place orders were dismissed as selfish consumers who would sacrifice their grandmas to get a haircut. The suffering many people experienced was also portrayed as an exclusive side effect of the pandemic; our response to SARS-COV-2 wasn't at fault. Research has since shown why that's a misleading analysis. And the review authors agreed that battling the virus wasn't a cost-free venture:
Adverse effects of stringent public health measures include financial downturn, unemployment, mental illness, child abuse, domestic violence, hunger, and disruption to education, child development, immunization programs, contraception, and family planning [8, 27, 89–95]. Discontinuation of clinical services and prevention efforts regarding chronic non-communicable diseases [96, 97] and infectious diseases other than COVID-19 (e.g., HIV infection, tuberculosis, malaria) has been reported [88, 98, 99].
There was another serious adverse effect, though. Officials often implemented these restrictions “without appropriate communication,” the authors noted, and left the public to confront the consequences with limited or no “social, mental, and financial support,” fueling intense opposition to the lockdowns.
This messy pandemic response drove many disaffected people into the arms of fringe commentators like Mike Adams and Joe Mercola, who eagerly capitalized on their frustrations to sell “alternative” COVID treatments and books. Journalists and fact-checkers spent a lot of time fretting about Mercola and his cohorts in the “Disinformation Dozen,” though few of them stopped to ask why so many people were interested in what they had to say. Answer: their conspiratorial rhetoric appeals to individuals who feel powerless and disillusioned.
Uncertainty and “pandemic shaming”
With the above observations in mind, recall that the media has routinely ridiculed anyone who expresses doubts about masks, lockdowns, or vaccination. This commentary only engendered more intense skepticism, as I've argued previously, and the reviewers made the same point in very clear terms:
Scolding and moral outrage are counterproductive to the COVID-19 response and can perpetuate stigma. Casting shame and blame on people violating public health measures should be avoided [29, 134, 135]. Incentivized messaging works better than 'pandemic shaming' and condescending messaging (e.g., #covidiots, #dontbestupid, #letthemdie) [77, 134–136].
Previous research has also shown that acknowledging uncertainty is one of the best things academics can do to earn the public's trust, but this basic lesson of science communication was often ignored during the pandemic, especially when it came to masking. While masks offer some protection, especially in certain settings (e.g., health care facilities), their limitations were often glossed over as universal masking advocates “omitted nuances regarding viral transmission dynamics, risk communication, and sustainability,” the reviewers wrote. In contrast, some experts took a more nuanced stance on masking; for this, they were shunned:
It is monumentally frustrating that academics both supporting masks and calling for well-crafted messages, nuanced (not universal) guidance, and further evidence have been misrepresented as anti-mask and accused of flagrant disregard for human lives by some universal masking advocates.
Harm reduction: the way forward
Instead of a “social abstinence-only” infection control policy, the authors endorsed a strategy based on harm reduction, which aims to minimize adverse outcomes associated with risky behavior. In the context of the COVID pandemic, this means “enhancing awareness about SARS-CoV-2 transmission and infection risk mitigation, self-assessment of risk related to personal activities, and engagement through alternatives of safer socializing,” the reviewers wrote.
But "abstinence-only" thinking generally prevailed in 2020. For example, some public officials and commentators sternly warned the public not to go outdoors; remember the guy who roamed Florida's beaches dressed as the Grim Reaper? Certain jurisdictions even prohibited entrance to recreational spaces like playgrounds, beaches, hiking trails, and ski parks. As the reviewers explained, the problem was that concerns about outdoor transmission “were mainly based on studies with no virological considerations and limited environmental assumptions.” Of course, we now know that transmission is greatly reduced outside.
This review won't settle our disagreements about masks, vaccines, or any other pandemic-related policies. Our deeply held beliefs inevitably color these disputes, all but ensuring that the fighting will continue long into the future. What the reviewers have advanced, however, is a much more constructive way of approaching these discussions—a proposal to replace the “absolutism” of the last 18 months with “science-informed policies that recognize shades of gray, uncertainties, local context, and social determinants of health.”
Dr. Kevin Escandón, lead author of the review and an infectious diseases researcher at Universidad del Valle in Colombia, summed up this approach in an email to ACSH:
We should: 1- acknowledge uncertainty, embrace it, and expect it. 2- discuss nuance and prefer gray zones or middle-ground decisions by understanding the whole of the evidence and the complexities of science, policy, and pandemic topics in general.
By doing 1 and 2, we enhance public trust, gain literacy, stick to facts more accurately, and build on public health policies that make more good than harm at the point they're issued and over time when new evidence emerges and these need to be updated swiftly. Also by doing 1 and 2, we could tackle (to some extent) disinformation, grifters, and the extreme polarization that are so damaging.