“In evaluating the US efforts against the coronavirus pandemic, do you consider the number of US fatalities from coronavirus so far to be . . . acceptable or unacceptable?”
That was one of the questions on the CBS News Battleground Tracker poll of registered voters on Aug. 19-21. The question struck me as doubly provocative, asking respondents to evaluate not only our attempt to control the epidemic but also what they would consider a success.
Overall, 31 percent of all respondents said the American death count, which was then 176,000, was “acceptable.” That included a majority of Republicans — 57 percent — but only 10 percent of Democrats. What were people saying with their answers?
The respondents likely evaluated acceptability in terms of any of three implicit comparisons.
First, “acceptable” could mean that compared to other illnesses that cause massive numbers of deaths each year, a few hundred thousand lives lost does not seem so bad. In this we-all-die-of-something view of the world, acceptable suggests “bearable” or “tolerable.” In 2020, about 600,000 Americans will die of cancer, and about the same number from heart disease. Sure, the COVID-19 number far exceeds the average annual mortality from influenza, which kills 12,000-60,000 Americans each year, but COVID-19 is simply a new addition to the list of causes of death, a once-in-a-century mishap that we will surely be able to control by next year. And after all, 10 years ago we didn’t have 70,000 Americans dying of drug overdoses annually, and now we do. This fatalistic understanding of “acceptable” is a conversion of the question of how many people will die to how they will die.
Second, “acceptable” could mean that the COVID-19 fatality level is low compared to what we were expecting when the first cases were reported in Washington state at the beginning of 2020. If we were expecting 2 million deaths as suggested by the early epidemiological models (which did not include any preventive behaviors like wearing masks), and we end up with only half a million dead, then we did something right. In this view, coronavirus is as “acceptable” as any other natural disaster — a hurricane, a tornado— where damage is expected and we hope along the way that the storm changes course. Some people will unfortunately die, but the event will be survivable. Disasters are unavoidable, but if we do our best to protect ourselves, our efforts are acceptable.
Third, one could imagine the question to be asking how 176,000 dead compares to some lesser number, perhaps tens of thousands, who would have died even if we had mandated and enforced stay-at-home orders lasting for months. In this trade-off view, “acceptable” suggests “defensible”; more severe restrictions would have produced even greater unemployment than the nearly 30 million unemployed today. The military makes acceptable loss assessments for every proposed operation. Casualties represent the price for protecting a larger ideal: a better future, freedom, security. Perhaps deaths from COVID-19 are acceptable because our livelihoods are at stake. Someone with this viewpoint does not necessarily accept the notion that better viral control also would have led to fewer business closings and lost jobs.
But the poll question is less about death than an evaluation of the current administration’s effort to prevent death. Ninety percent of Democrats (and 43 percent of Republicans) presumably believe we haven’t done our best. Americans had been warned of a viral pandemic by biodefense experts for a decade and hadn’t prepared adequately. We had inadequate surveillance and supplies. These deaths could have been avoided with competent governance. If COVID-19 is a kind of natural disaster, other countries suffered the same one but didn’t have the US outcomes.
Would any number be acceptable? What if the COVID-19 deaths occurred only among children and teenagers? Would our acceptance level change? Can death rates that are unequal across income or ethnic groups or states ever be acceptable? And acceptable to whom? Each person killed by COVID-19 is someone’s child, someone’s friend, a mother, a cousin. Acceptable deaths seem unquantifiable.
To “accept” deaths from an infectious disease even when we know well how to limit transmission seems not only a failure of determination, but also a failure of imagination as to how we could have done better. Shockingly, partisan politics has now even undermined that ability.
As we suffer through COVID-19, we also need to plan for the next pandemic, which could be even more transmissible and deadly. The relevant next questions should be: “What will it require to save more lives?” “How do we quickly identify the highest-risk populations and protect them?” For now, COVID-19 remains a threat and misery to be endured, one final definition of “acceptable.”
Dr. Michael Stein is chair of Health Law, Policy, and Management at the Boston University School of Public Health, and the executive editor of Public Health Post. Follow him on Twitter @mdsteinmd.