Imagine it is February 2016, the WHO just declared the Zika outbreak in South and North America a Public Health Emergency of International Concern and you and your significant other were planning to start a family. In addition, the CDC just published a report that suggests that “[a]lthough local transmission of the Zika virus has not been documented in the continental United States, […] imported cases might result in a human-to-mosquito-to-human spread of the virus” in some areas with “the appropriate mosquito vectors.”
Should you get pregnant? Given the WHO’s and CDC’s warning and what we know about the effect of the virus on pregnant women and their unborn babies, this may seem like a question with a fairly straightforward answer. Unfortunately, there are often pathologies in public health policies that are the result of perverse incentives built into path-dependent institutions.
To illustrate, consider how you would seek good medical advice if you were unsure about whether or not the WHO’s warning and CDC guidelines really apply to you. You might simply go to your doctor, but this incredibly complex question may be more than your doctor is qualified to answer. You could consult the CDC to find out what the risk of getting bitten by a Zika-infected mosquito really is in the US, or the local county health department for the more specific risk in your community.
It turns out that no matter where you turn, however, you will likely get the same answer. This does not imply, however, that people are out to deceive you. It does not take a conspiracy theory to explain the fact that medical professionals and health care workers are unlikely to deviate from WHO and CDC guidelines. Incentives faced by individual actors create artificial and potentially foolish consistency. In the case of the Zika virus, the WHO declared the end of the outbreak in November 2016 and there were a mere 224 cases of presumed local mosquito-born transmissions that were limited to Florida and Texas.
Guidelines are usually based on scientific evidence. But the scientific process is incredibly complex. In a paper we recently published in Public Choice, we outline why settled opinion in an area is loath to update in response even to legitimate challenges from outsiders. This is the case because science is a social enterprise and individual scientists have a strong incentive to conform with the existing scientific consensus.
The institutions that connect projects, teams, and the definition of problems bind individuals together in pursuit of common goals. Unfortunately, those goals are not scientifically antiseptic. Scientists don’t leave their politics, religion, and bad habits at the rack when they put on their lab coat. Dynamism suffers. In addition, behavior in one area of research has a systematic effect on other areas and a reckless politician can damn 10 years of research in an area by tweeting about it and calling its credibility into question.
Science is very much a turf battle, and so much the worse for science. Those that hold dominant scientific positions train the next generation of future thought leaders. The best professional positions are filled by those conforming with the status quo. Science is conservative, and this is not good for science under normal circumstances.
Path dependence creates barriers for the creative and innovative processes. Larger groups representing the more static scientific consensus dominate the formal institutions that, at least in public health, make recommendations to the public. These recommendations become focal points for public opinion and for smaller institutions.
Recall the Zika advice we started with. Once the CDC has published guidelines, every doctor and every state and county health department now has a choice to either adopt the expert advice from the CDC or to deviate from it. But deviations from the consensus opinion can have serious legal ramifications.
If the medical advice that a particular doctor gives is too permissive, and that advice leads a patient to suffer harm, the doctor may face criminal negligence charges for failing to follow the public health guidelines the CDC issued. If the doctor’s advice is too restrictive, on the other hand, there is no such liability threat. The only consequence of exceeding government guidelines in terms of strictness is a potential loss of revenue because the doctor might lose patients to another, more permissive doctor.
As a result, health care professionals have an incentive to adhere strongly to the advice from government agencies, even if this comes at the expense of scientific innovation or accuracy. The use of guidelines creates gravity around particular solutions. This isn’t a conspiracy, it is a reflection of the incentives health care researchers and practitioners face. Further, the consensus gives the false veneer of settled truth as to what should continue to be a hypothesis we have, so far, failed to reject.
But government guidelines should never be interpreted as settled science whether there is a consensus or not. In the case of the novel coronavirus, a large public health organization like the CDC faces significant pressures to respond quickly and accurately. But accuracy is difficult to guarantee in this situation because the scientific consensus is still evolving. It is actually a good thing for an agency to honestly update their position as knowledge evolves.
But it is important to acknowledge that the legitimate desire for a rapid response undermines the sort of consistency and coherence of settled science. Government guidelines issued with respect to newly emergent and understudied viruses should be taken with a grain of salt and we should continue to be open to new evidence and perspectives. We should continue to question and discuss government guidelines, particularly with respect to novel health threats.
In the movie, And the Band Played On, the CDC team continues to return to their basic mantra, “What do we think, what do we know, and what can we prove,” suggesting a strong resistance to arriving at the final answer about how HIV and AIDS function. This is the deep sort of skepticism that is needed for science and knowledge to advance. This idealized version of scientific skepticism is abandoned in favor of a naïve, progress-defying path dependence when skepticism is sacrificed for expediency and public health institutions are seen as providing settled scientific answers. It makes us wonder if the response to new information can really be handled in an institutional environment designed to communicate authority and certainty.
CDC guidelines regarding the use of cloth masks have seen a complete 180-degree inversion over the last two months. With rapid changes like this we see the human side of science, we see the social and political aspects of the scientific process. Any contradiction in guidance from the WHO, the Surgeon General, or other public health bodies immediately creates a crisis of confidence. This skepticism of easy answers to complex social questions helps to discipline the temptation to more heavily weight expediency.
When autumn plans are considered, guidelines are issued suggesting school children should be required to wear masks in order to attend school. Expediency leads to idealism presented with the authority of science. Realism dictates that we discount our belief that kindergarteners can be asked to use a mask in a way that actually slows the transmission of a disease, especially one that we don’t yet know much about. Let’s continue to ask questions rather than rush to the outright acceptance of guidelines that does not take implementation, effect on childhood behavior, or educational outcomes into account.
During this pandemic more so than ever before, science has somehow been linked to politics and public policy in a way that is not good for science itself. When scientific consensus changes in a world of emergent knowledge, a corresponding change in policy is neither required nor constructive, at least not in a direct cause and effect sort of relationship.
To ask science to remain robust and efficient when conflated with politics and policy-making is to weaken each of these institutions. Public policy should be robust and reasonable, seeking creativity without the limitations that come with “settled science.”
More than ever before, we need to be open-minded, and allow scientific and entrepreneurial creativity to take its course without condemning others for disagreeing with us, because we are all in this together and we all want to know how to protect ourselves and those around us in the best, but also in the most efficient way possible.