On Aaron Carroll's Coronavirus cap-and-trade

It feels odd for me to take issue with recommendations from Aaron Carroll on how to deal with the risk of coronavirus infection, individually and collectively. In March, Carroll was prescient on what we as a country needed to do (and, with Trump in charge, inevitably failed to do) after we'd already let community transmission run rampant -- reduce infections via shelter-in-place, and use the breathing room to ramp up testing. He is a trusted source on nutrition, medicine and healthcare policy, able to sift through piles of published studies and assess the evidence, as he did on core nutritional questions in The Bad Food Bible.

But I feel there's something off about Carroll's approach in today's column to risk balancing in response to the pandemic. No one should have any beef with the main point: when you give up one major form of risk mitigation (e.g, when you go back to school), don't give up all others (e.g., by congregating in basements). But how, then, to balance risks? Envisioning our individual conduct as "piles" of risk-mitigating and risk-enlarging decisions, Carroll writes:

To keep the [safety] pile big enough...we need to be willing to trade some activities for others. If someone wants to play on a sports team, for instance, they should consider giving something up to do so. Increasing their risk by participating in a group activity should prompt them to reduce their risk the rest of the time.

This idea of making personal trade-offs-- offsetting one desired risky behavior with renunciation of other activities, as with carbon offsets, or the medieval Church's sale of indulgences -- gives me pause.  I am more comfortable with the way Anthony Fauci and a handful of other public health and infectious disease specialists describe their approaches to personal risks in this collective q-and-a:  I wouldn't eat in a restaurant or fly in a plane just now, but no, I don't feel I need to wipe each grocery before putting it away. That is, assess each risk individually, on its own merits.

In practice, I guess we all balance our wants and needs against the risks, and if we're driven to take what seems like an inadvisable risk, might somehow compensate. But I don't think there's any meaningful ledger to keep a running account and "spend" within our means.

The problem fades but doesn't go away entirely when Carroll turns to our collective conduct:

From a policy perspective, we’ve been just as unwilling to sacrifice. Almost everyone thinks that opening schools is extremely important (myself included). But too few people have been willing to discuss what we might be willing to shut down to make that happen. If we want to make it safer to send kids back to school, we might need to consider reducing the number of people who can drink in bars or eat in restaurants, for example.

For sure, opening schools should be a higher priority than opening bars and restaurants indoors -- and in the U.S., it hasn't been. But a time element is missing here (though emphatically not in Carroll's other writings public coronavirus response). Policy needs to be sequential: give up the non-essentials like restaurants/bars, and when infection rates hit benchmarks, allow more essential things like school.

Money is also part of the equation. Germany made its factories safe for work early. We didn't. School return should require adequate ventilation in every school opened.  Carroll does address our failure to invest:

If Americans were willing to invest in bigger-picture solutions, we could all have nicer things. A massive testing scheme would require spending increases and many more public health personnel than we currently employ, but it could make many activities much safer. Providing more people with the means to stay home instead of going to their workplaces in person would significantly reduce close contact. Ubiquitous and affordable high-speed internet would make online education easier.

In the public domain, the choices are between investing and not investing in infrastructure that makes core activities safer, as well as in prioritizing what risks are worth taking versus what risks aren't. (The Trump administration will always make the wrong -- and in fact manifestly depraved -- choice.)  Here too, though, it's not really about trading credits of equal value: closing gyms and opening theaters, say. Each risk needs to be assessed on its merit versus societal reward -- and cost of making the activity less risky.

P.S. The carbon offset approach to personal coronavirus risk management might resonate a bit more with me if I had children at home.

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Photo credit: Chetan Hireholi on Unsplash