There’s nothing to be afraid of…
By: Nathan Davies
Tags: Covid 19, Communication, Risk

What really makes people scared? Leave people to their own devices, and perhaps they will worry about any old thing, even if it is not remotely dangerous. Clowns, perhaps, or friendly British spiders. We know people readily swallow new dangers — Brass Eye’s Cake skit, where celebrities were fooled into giving straight-faced lectures on the danger of the imaginary drug Cake, being a prime example. Can people be trusted to know what’s harmful for them?

The original fake news

A growing group of people seem to believe the same is true of COVID-19 — that the population at large has been spooked into unnecessary draconian measures for a disease that is simply not that harmful. Using Sandman’s formula Risk = Hazard + Outrage, is it true that the outrage surrounding COVID-19 has caused an overblown perception of risk? Are people being irrational by worrying more about COVID-19 than a bad influenza season?

Tl;DR — I don’t think so.

First, let’s look at another example where supposedly unfounded fears were put through the risk wringer — the fears of American parents on guns.

Think like a Freak?

In their hugely influential first Freakonomics book, and in future productions, Steve Levitt and Stephen Dubner talk about the comparative risk to children of swimming pools and guns in the US. Steve Levitt tells us that any given parent that he knows would be more worried about sending a child to a house with a gun in it than a house with a swimming pool.

The kicker; they reveal to the audience that the risk of death to a young child from a given swimming pool is 100 times greater than that of a given gun. “People are terrible at risk assessment generally”, conclude the duo.

It’s a compelling example of something the average person might think of as scary (the loud, violent gun that features heavily in news reports) and what is truly scary (the silent, still swimming pool). There’s an accompanying intellectual rush for those consuming the books and podcasts that they, possessed with this information, are smarter than the average person, and better understand their risk. But do they?

1. Is it a fair comparison?

A 2019 NEJM study looking at CDC and other sources of US data found that deaths from firearm injuries far outweighed those of drowning (note: not just backyard swimming pools, drowning). Freakonomics had played a statistical trick, dividing firearm deaths by the number of individual guns in households (lots of households in the US have gun collections in the tens or even hundreds) and then divided drowning deaths by the far rarer swimming pools, which has the distorting effect of making swimming pools seem much riskier.

Road deaths are a far fairer comparator, but the magnitude of difference between the two is not particularly large. They are the leading contributors to child and adolescent death in the US and are extremely pressing and valid issues for both parents and children to worry about.

2. Different populations, different risks

For children in large swathes of America’s cities, death by garden swimming pool is about as likely as death by asphyxia in space. Few people they know will have more than a few metres of yard, let alone tens of thousands of pounds to put into a monumental garden water feature.

Guns, however, are a real and present risk in their communities. Parents and their children will largely be aware of this. They will likely know of people who have been shot at or people who have shot at others. They may well have heard a gun go off in anger. They and their families shouldn’t face chastisement or mockery for being overly concerned about guns.

The Freakonomics pair were largely thinking of people like themselves when considering how to frame this risk. Risk is different for different populations. And as Hans Rosling argues in Factfulness, if we draw a conclusion about a group or population we don’t know very well that leads us to believe they are idiots, we probably haven’t understood their context.

3. There’s more to life than not being dead

It is often said but equally often forgotten that deaths are not the only thing worth measuring or caring about. The pooled wider effects of guns on the lives of children and young people in America are far beyond anything caused by backyard swimming pools.

· Children lose parents to suicide or murder

· Children lose parents to incarceration for illegal gun possession or misuse.

· Children or their families lose limbs or experience other lifelong injuries due to accidents or deliberate shootings.

· Children fear to travel to certain areas of cities because they will be at greater risk of gun violence.

· The long-term mental health impacts of exposure to guns and gun violence

Just as a swimming pool drowning might not always make headlines, neither do the disrupted and troubled school days of a child whose parent has been incarcerated for illegal possession of a firearm.

4. To COVID-19 — it’s not that simple…

Tim Harford is a bit of an idol of mine; a man who gets across complexities of statistics and risk through the medium of punchy, accessible radio programmes, books and podcasts. Even he has slipped up in COVID-19, comparing the risk of catching and dying of COVID-19 to that of the risk of dying whilst a bath (although, in true Tim Harford fashion, he quickly and fully corrected his own statistical mishap.)

The interesting aspect was how quickly this was picked up and sprayed across newspaper headlines. It highlights the risks of ‘overcorrecting’ what is seen as an overblown public perception of risk. Clinicians and public health professionals often despair at headlines with overblown claims of health harms (Sun Avoidance Is As Risky As Smoking) but this highlights a claim in the opposite direction, particularly for a topic like COVID-19, can prove to be equal media dynamite.

Giving people who are soliciting advice based on research on what may harm seems like a straightforward, common sense idea. But risk communication is a very difficult business. As David Spiegelhalter discusses in the BMJ, this is especially true at population level. There are some easier risks to quantify, backed up with years of evidence; the personal risks of smoking, for example. But most of the time, risk communication is compounded in several ways:

· Where the population faces significantly different risks (US children by neighbourhood and guns)

· Where the risk is not just personal but public (being infected with COVID-19 and infecting others, alcohol abuse and violence)

· Where there is little the individual can do about it (the child living in a high-gun crime neighbourhood does not benefit from being told guns are risky)

· Where the risk communicator does not emphathise with the person they communicate with

· Where benefits of activities are not acknowledged (the fun children have whilst swimming together, the personal enjoyment derived from drinking alcohol)

· The uncertainty surrounding the risk (e.g. drowning deaths are relatively straightforward to monitor and report, deaths related to air pollution much less so, and the morbidity associated with air pollution even less so)

· Quantifying wider harms (emotional and mental health harms

· Deciding whether an activity is “safe” or low-risk (personal and community risk appetite will play a role here)

· Where the risk is emerging (COVID-19 sequelae, reinfection unknowns)

· When a risk may rapidly change (COVID-19 risks to individuals in September will sound reassuring against what they might be in November)

5. Respect and COVID-19

We will glide swiftly by those who use the pejoratives “bedwetters”, “face-nappies” and “mindless sheep” on Twitter.

The more thoughtful and professional members of those who believe the response towards COVID-19 is disproportionate would never use such terms. However, they do sometimes lean towards framing their response as “rational”, even “grown-up”, and contrast this with “emotionally-driven” responses of others.

There are debates to be had on the harms of restrictive measures and how to minimise this. It is also true being worried about the effects of further restrictions on the lives of others should not be automatically be categorised as having a disregard for life. One thing that cannot be brushed aside is the severe psychological impact COVID-19 has had on communities across the country, the 50,000 COVID-19 deaths and associated bereavements, and the longer-term impacts of the disease. Anyone in the UK can justifiably be afraid of COVID-19 — including the young and “healthy”.

Any risks for individuals, populations or given in the public sphere must be carefully thought through, empathetic, emphasise what the uncertainty of the estimate is, and emphasise what is not included in that estimate.

There is a lot left unsaid behind a population ~0.6% infection fatality rate. Think very carefully before telling the world there is nothing to be afraid of.