The Counterlife of COVID-19: What Might Have Been – MedPage Today

"There is only this way that we have established over the months of performing together, and what it is congruent with isn't 'ourselves' but past performances -- we're has-beens at heart, routinely trotting out the old, old act."

-- Philip Roth, The Counterlife

The counterfactual is a term for what would have happened if not for some intervention, action, or policy. Here, I want to explore the COVID-19 counterlife. What would have happened if. Obviously, this is an act of imagination, but anchored by over 10 years of studying science, medicine, and policy, and how people respond.

So, what would have happened if...

Twitter and Facebook Did Not Exist

If social media did not exist, the pandemic would have been fundamentally different. The selection of "experts" given airtime on popular media, such as cable news and newspapers, would have been turned on its head. Instead of the current cast of characters, researchers with longer histories and reputations would have been chosen. Op-ed submissions would have swelled even more, and successful writers would have been featured on TV.

Instead, in our world, there is a strange reciprocity. News outlets select visible Twitter personalities whose inclusion leads them to retweet the story. The paper gets the clicks, the Twitter personality gets the exposure, and polarizing and illogical views that get likes and retweets drive the conversation. Nuance and reflection die; sensationalism and groupthink thrive.

Without social media, the news itself would have been less extreme and drifted to consensus. Without the seduction of clicks, the media would have acknowledged trade-offs. Centrist policy positions, such as those espoused by former FDA Commissioner Scott Gottlieb, MD, would be favored. Zero-COVID and vaccine passports would have gotten little airtime -- as these are positions driven by one extreme worldview.

Extreme feelings on vaccines, including staunch opposition, would likely have been diminished. These poles have been fueled by social media platforms for years. Finally, there would be much less public discussion of long-COVID, and instead it would be viewed principally as an ongoing research topic. This is because long-COVID gained traction from social media advocacy.

Trump Had Not Been President

I am not here to judge former President Trump, but merely to point out that he generates strong feelings. Some love him, others loathe him. And, we must acknowledge that a sizable subset of the academy is strongly opposed to him, and vocal about it. This fact alone affected the pandemic in numerous ways, apart from the specific decisions made during his presidency.

Although it is clear that Trump played a role in popularizing hydroxychloroquine without good evidence, his advocacy also generated a backlash, and the harms of hydroxychloroquine were broadcast loudly, and at times exaggerated. Both unjustified optimism and unnecessary pessimism diminished interest in clinical trials. Some wanted the drug, and others wanted no chance of getting it. Ironically, the best path is always to be quiet about investigational agents while trials are ongoing.

School closures would have been dramatically different had Trump never advocated to reopen them. Some opposed this (sensible) policy simply because he said it. Indeed, we saw school closures disproportionately in liberal strongholds and regardless of virus-related factors such as cases per 100,000, hospitalizations, or deaths.

Countless other decisions may have been different with a different administration, and I imagine entire books will be written on this topic. I wish to highlight just one more: Had former President Obama, a Democrat, been in office at the time, I imagine that far left progressives would have felt differently about restrictions without resources. Lockdowns protect the rich more than the poor; had a Democrat enforced these restrictions, a vocal backlash would have emerged from within the academy. But because Trump was reluctant to advocate for prolonged use of these measures, many progressives demanded more restrictions, perhaps in part to oppose him.

In short, replacing Trump with a more typical politician would have led to different policy decisions, and also, would have changed the academy's response. Those who opposed his recommendations merely because he said so would not have done so in the counterlife.

There Was No Uber, Amazon Prime, or Zoom

Many hail these technologies as services that allowed us to survive the pandemic, but were it not for their existence, we might have fared better. If COVID-19 were COVID-99 or even COVID-09, the use of telework for more than a year would not have been tenable for most white-collar workers (Internet was too slow!). Layoffs would have resulted, and as such, white-collar workers would have rebelled against continued restrictions. In fact, many workers would have embraced the harm-reduction philosophy. We would have gone back to work in the summer of 2020 in larger numbers, with rotating schedules, ventilation, and masks. Anxiety and depression would have been lower, and we could have been open about trade-offs.

Ironically, the upper-middle class would not have been able to construct a delivery service moat around their castles, and as such, the well-being of the poor, the marginalized, the destitute, and the neglected would have been more on their minds. Their own lives would be more tied to that. I imagine we would have spent far more on resources. Free hotels for folks with fever. Better paid sick leave. We would truly all be in it together. We might even have had fewer cases and deaths.

The services that many hail as our salvation accelerated our doom. They allowed folks with money to separate further, grow more anxious and angry, and more indifferent to the well-being of the least well off. Long-lasting school closures were only tolerated because of these services. If adults had to go back to work twice a week (with mitigation) then schools would have to perform their duty as well.

Ironically, these technology platforms censored the opinion of legitimate scientists who were critical of some aspects of lockdown or who favored loosening restrictions. This is a fundamental conflict of interest. If your product is addicting people to their screens and stopping them from being participants in the world, you are not the best arbiter on the truth in matters of policy that would keep people glued to their screens and as non-participants in the world.

We Reacted Proactively in January 2020

The biggest COVID-19 question might be, what if we reacted strongly in early January 2020? What if we were able to deploy a multinational team of experts into China. Could we have stopped the virus before it escaped? This technical question has no easy answer, and will likely also be the topic of many books. I wish only to suggest that the answer is not immediately obvious. It is not "we definitely could have stopped spread" or "it was hopeless from day one," but something that requires a great deal of detective work. A mix of science and investigative journalism from a place of open-mindedness. We are not ready to do this work right now.

What If Anthony Fauci or Scott Atlas Did Not Exist?

Many lament that national policy would have played out differently if not for Scott Atlas, MD, or Anthony Fauci, MD; the Great Barrington Declaration or the John Snow Memorandum; if we didn't have Deborah Birx, MD, or Robert Redfield, MD. The truth is that all these people were secondary characters, and if you remove any of them, the void would be filled by other people. I doubt any of them uniquely changed policy.

After it became clear that this virus has a massively steep age gradient of risk -- the risk to an 80-year-old is thousands of times greater than it is to an 8-year-old -- it was only a matter of time before someone argued that our policies should leverage this difference, an idea at the center of the Great Barrington Declaration. It was also inevitable that other scientists would oppose this view, believe it impossible to target this age group, and advocate that the risk to younger age groups is intolerable and broader measures are needed (the John Snow View).

Recognizing that these characters are replaceable -- and the bench is a thousand deep -- can provide humility. There is no need to have strong emotions about any of these people. Pick whomever you wish, without them, we'd be right where we are today.

We Did a Cluster RCT of Masks

Early in the pandemic, Margaret McCartney, MD, writing in The BMJ, said we need better evidence for non-pharmacologic interventions, such as face shields, masking, plexiglass, and other restrictions. Imagine if we did this. What if the U.S. did for restrictions what the U.K. RECOVERY trial did for drugs? What if we performed a cluster randomized controlled trial (RCT) of regions (or even a stepped-wedge roll out), and tested all of these interventions?

I believe that these results would have defused the mask polarization bomb. The mere fact that the trial was ongoing would have relaxed some of the most ardent proponents and opponents of these interventions. It's harder to become an impassioned anti-masker (indoors in a grocery store) or a zealot masker (outdoors, with a rare passerby, on a run) if one knew that randomized data was coming to show if one is right or wrong. The mere presence of a well-done, large, clean study would result in temperance and humility. Contrary to the many vociferous and passionate critics of RCTs, I believe that a meaningful cluster trial could have been conducted. If launched in early March 2020, contamination (use of mask in the control group) would have been so low, it would be a non-issue. Instead, we settled for mannequin mask studies a year into the pandemic -- a.k.a. a useless study.

The Counterlife

The COVID-19 counterlife illustrates that so much of our unique and unprecedented response to the pandemic was contingent on our times. Technology was supposed to liberate us, but it divided us and chained us to this response. Changing leadership might have changed outcomes, but it so easily might have shifted allegiances and tribes and resulted in different battles and partnerships. I am confident that had we had a Democratic president, the left-most progressives would have viewed these choices differently. And, at last, if one can rewind the tape to the early days in China, could we have stopped the virus before it was too late? That is the toughest question of all, and I have no answer for now. Instead, I merely ponder what might have been.

Vinay Prasad, MD, MPH, is a hematologist-oncologist and associate professor of medicine at the University of California San Francisco, and author of Malignant: How Bad Policy and Bad Evidence Harm People With Cancer.

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The Counterlife of COVID-19: What Might Have Been - MedPage Today