We Mean Business
This post is rated "H" for "Honest." If you want reassurances that everything is going to be OK, this is not the post for you. If you want a hard-headed assessment of how to approach the problem, read on. Introduction Leadership requires sticking to the fundamentals. People are fearful because leaders both in the U.S. and around the world have failed to articulate the end goal of the COVID-19 response and therefore are imposing their plans on entire societies haphazardly. The leader's job is to determine the goal, formulate a plan, and inspire people to achieve the goal. Without a goal, a plan just leads to useless activity. "We must do something, this is something, therefore we must to this" is not good leadership. SMART goals are a common management and planning tool. Not all goals are equal. Good goals lead to real achievements and results, poorly stated goals lead to useless unproductive activity. The SMART goal technique helps us write goals that drive good choices that lead to the achievement of our objectives. Perhaps the most important feature of SMART goals is that they measure success and failure. We need goals that can tell us whether we won or lost, so that we know whether we've achieved our objectives or whether we need to re-evaluate and try again. Here's the SMART goal technique in a nutshell. SMART is an acronym:
"I will lose 2 pounds per week for 10 weeks. I will weigh myself every Monday morning to monitor my progress." This is much better. It's specific, it's not a general aspiration. It's definitely measurable. For most people, a couple pound weight loss per week is achievable. Let's assume losing weight would be relevant to good health as that would be true in many cases. If the person should not be losing weight, then this goal would not be SMART because it would go against our overall objective of good health. We've also set a deadline for losing 20 pounds. This SMART goal would then lead us to monitor our diet and exercise to lose weight throughout the week. If we are losing too much or too little, we can adjust as we go. If we are failing to meet the goal, we can then re-evaluate whether the goal is in fact achievable or whether we are doing something to keep ourselves from achieving the goal. Now we know a bit about SMART goals. Before we turn to COVID-19, I want to state a couple assumptions about the overall goal I have in mind. The government response to COVID-19 should aim to maximize the health outcomes for as many people as possible within the constraints reality imposes. The goal should not be to stick it to one's political opponents, which has for much of the last few months seemed to have been the actual goal. Good health is the strategic objective, not winning elections. [Yes, I know, I live in a fantasy world.] Applying SMART to COVID-19 Flatten the Curve. In the early response to COVID-19 back in March, experts and politicians told us the goal was to "flatten the curve." Here's Michigan's curve, with the purple line showing the number of hospitalizations, green showing ICU beds used, and blue showing ventilator demand. The straight lines, as indicated, show the capacity for regular hospital beds and ICU beds. The initial concern was that COVID cases would overwhelm the hospitals. People would become much more sick and even die because they could not be treated. Italy and New York City both encountered this problem in the early days of the outbreak. So let's state "Flatten the Curve" as SMART goals.
In April the green line rose above the ICU bed line. That's a problem. There are two ways to keep the green curve below the green line:
Increasing the supply of ICU beds in the short term is difficult, but our goal would suggest certain actions. We could beef up logistics to move patients from hard hit areas to less hard hit areas. We could deploy military mobile hospitals or hospital ships where necessary. All of that pretty much happened last spring. Where hospitals were overwhelmed, like in NYC, extreme steps were necessary to address the crisis. But then something happened. Things got better and the lines fell well-below the capacity lines. Promising treatments were developed. Death rates fell. A vaccine seemed to be just on the horizon. But the lockdowns continued in much of the country. Many people still could not go back to work. Schools remained closed or online. Some people started getting back to normal but others still saw a threat. Masks and various drugs became politicized. COVID fatigue set in. What is the goal now, here in late October 2020? That's not rhetorical, it's a real question. If flattening the curve is not good enough as a goal, what is the goal now? I don't think there's a politician in America who can answer that question. And if they could, they probably wouldn't say it in public. In the final debate, former Vice President Biden pointed to the roughly 220,000 COVID deaths to claim the President failed. President Trump retorted that the initial projections were for more than 2 million deaths. Who's right? No one knows, because no one set total deaths as a metric. Politicians can't say our best case scenario is, just to pick a number, 200,000 dead. We know the realistic number is more than 0, probably a lot more, but candidates for office don't want to be held to a number and anything more than 0 makes them look bad. We're now in a situation where we don't know how good the COVID-19 response to date has been. As we head into winter, the numbers are headed up again. Here's the latest projection for Michigan. The projected ICU line goes above the capacity line which is worrisome. SMART Goals Going Forward
Let's go down each of the SMART factors. Specific. Setting a specific goal is difficult, but I suspect it will be a heck of a lot easier after the election on next Tuesday. The office winners will have a bit of time where they can address the problem without worrying about what they do or say ending up in a campaign commercial for the other side. If anything, at this late date, we don't want to be so specific as to address COVID and nothing else. Many routine tests and screenings weren't done this spring, and some people became sick and even died from things that could have been cured if treated in a timely manner. Kids don't do well when they aren't school. They don't learn as much, get into trouble, and in troubled homes can suffer abuse. Families without their usual incomes face disastrous problems. The financial system will buckle if there are a large number of defaults. Enforcement of various mandates can multiply the number of police contacts with civilians, right at a time when people are rioting in the streets because they feel mistreated by the police. The list could go on and on. I present that parade of horribles to show that decision-makers can't act as if they are racehorses with blinders. They need to see the big picture, not just at COVID. Measurable. What measures can we use to set our goals?
The media focus heavily on the total number of cases. Although on its face that measure seems like a good measure, there are some problems. First, it includes people who have the virus but aren't sick. Second, the number of cases naturally goes up as we test more people. Third, there may be cases where people don't get tested even if they know they might be sick. It's not hard to imagine people not getting tested when they know a positive test will mean lost work and a two week stay in quarantine. Total cases therefore is of questionable value for decision-making. Another statistic I've seen thrown around is the percentage of positive tests. Presumably this is calculated by taking:
Again, this is a measure that's of dubious value because it's not clear what it's measuring. Lastly, we have excess deaths. In a large population, actuaries can predict with a high degree of confidence how many people are expected to die in a given year. One way to determine the danger of COVID-19 is to compare how many people would die under normal circumstances and how many died with the introduction of COVID-19. We can then infer that the excess deaths are related to COVID-19, either the disease itself or the response. Recent reports place the number of excess deaths at about 300,000. Documented COVID-19 cases are about 2/3 of that number. Are those excess deaths actually COVID deaths that weren't diagnosed as such? Or are they people dying of other things because they aren't getting their usual medical care? Are they suicides brought on by the stress associated with the disease and lockdowns? Is it something else entirely? I suspect that one day we may know the answers to those questions, but it won't be soon. I'd probably use this excess deaths number both as a check on the COVID-19 death figures as well as a canary in the coal mine to warn of whether the lockdowns are leading to more deaths. To sum up, the hospitalization figures are probably the best measures that can lead to meaningful action. Of the others, only excess deaths provides some useful information, but even then we probably need more detail to make a meaningful interpretation. Achievable. Here's where I'd really need to rely on the experts. If I were a decisionmaker, I'd want epidemiologists but also other kinds of doctors, psychologists, educators, and economists. I'd want my advisors to avoid tunnel vision and a diverse array of advisors should help provide the big picture. Here's what I'd want to know from my medical experts.
Also, we could change the composition of the people under the curve. If a certain number of people need to get infected, let's minimize the exposure of the most vulnerable. That means we protect the people most likely to need serious hospital care, such as the elderly or those with other serious medical conditions. If the answer is "no," then we need to know how we can manipulate that number. How do we reduce the number of people who get the virus? If a vaccine is just around the corner and will be available in time to make a difference, then our strategy becomes to play for time. We find ways to slow the virus down, perhaps even slow it down more than we would if the metric were only hospital utilization. This is probably where the leaders have the most difficulty. You can't run for office saying "almost everyone's going to get it." However, at some point leaders need to be honest so that people know what to do and what's being asked of them. We don't have that at this point. We also have to weigh a variety of costs. Shutting down businesses ruins the lives of the owners and the employees. Shutting down schools has an enormous long-term cost as we'll have a generation with sub-standard educations. We've seen the social and political costs as unrest spreads on both the left and right. All of these costs are constraints that must be weighed. Are shutdowns even a possibility now? Or will people just ignore them. If they do, are we willing to have mass arrests and incarcerations of otherwise law abiding people. Are we willing to take the casualties that will arise when we multiply police interactions? Would the police even enforce a lockdown if ordered? I'd think that a second lockdown will see far less compliance than we had in the spring. Relevant. Any goal we set has to be relevant to an overarching goal. The leaders need to state what we're trying to achieve. Is it overall health? Minimize deaths? Live with the virus as best as we can and go about life? Without that, it's impossible to set goals to guide action. Timebound. Any goals we set must have deadlines. Waiting for a vaccine to come some day is not good enough. We need to set a deadline for the vaccine and have a plan if it does not appear or proves ineffective. If the vaccine does not save us by then, then we have to proceed accordingly. Conclusion After all that, what goals should we set? If we conclude that in reality "most everyone's going to get it" then we stick with flattening the curve but add that we're going to change the composition of the curve.
What if we believe a vaccine can be deployed in a few months?
If handwashing, masks, and social distancing can get us 80% of the benefit (which might be the case), then don't destroy people's lives and livelihoods and end their freedoms to try to get the last 20%. Pick an achievable SMART goal and find the most efficient way to achieve it.
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Christopher J. EngeEducator. Entrepreneur. Attorney. Author Archives
January 2022
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