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Editorial
June 4, 2020

Thinking of Risk in the Era of COVID-19

Author Affiliations
  • 1Dr Bauchner is Editor in Chief and Dr Fontanarosa is Executive Editor, JAMA
JAMA. Published online June 4, 2020. doi:10.1001/jama.2020.10242

Society remains in the grip of the worldwide coronavirus disease 2019 (COVID-19) pandemic. As each town, city, and country attempts to restore some aspect of normal life, they are confronted with 2 nearly identical questions: What is the individual risk of acquiring severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and ultimately COVID-19? What is the risk for the population that renewed activities will fuel a surge of new cases of disease and potentially overwhelm the health care system? Neither of these questions can be answered with precision, and yet they have come to dominate everyday conversation.

Some data are helpful to understand the risk. Overall, since March 1, 2020, the overall cumulative hospitalization rate for COVID-19 in the US was estimated at 67.9 per 100 000 or about 0.068%.1 In addition, the major risk factors for mortality related to COVID-19 are now well-defined—age and underlying comorbid conditions.2-4 About 50 million individuals in the US are older than 65 years of age.5 Based on various data sources,6-9 about 75% of the more than 100 000 COVID-related deaths in the US to date have occurred among these older individuals; thus the risk of death in this population is about 1.50 per 1000 or 0.15%. One-third to half of the deaths in some US states have involved residents in nursing homes or other long-term care centers.10 Approximately 1.5 million individuals live in these facilities in the US,11,12 and if approximately one-third of the 100 000 deaths in the US have occurred among individuals from these facilities, the risk of death in this population is about 22 per 1000 or 2.2%.

In contrast, the rate of SARS-CoV-2 infection among children thus far appears to be relatively low, and when children do become infected, they are less likely to develop serious COVID-19 illness; however, a new entity, multisystem inflammatory syndrome in children,13 has been identified and is of concern to parents and clinicians, and others, including teachers. Yet even with this new entity, it is unclear if the risk of infection or severe disease is 1 in 1000, 1 in 10 000, or 1 in 100 000.

Despite these differences in risk, a general approach has emerged involving the mandatory wearing of masks and physical distancing when indoors, with greater flexibility when outside. However, it is not possible to accurately define the risk of becoming infected while walking or jogging outside or going to the beach. The precise benefit of wearing masks and physical distancing in preventing disease is unknown, although it is quite clear that these are effective behaviors, with virtually no individual consequences.14

Individual Risk

Some people are risk averse, whereas others are willing to assume far greater risk (eg, the individual who lives a sedentary life vs the individual who rides motorcycles or climbs mountains). Combined with behavioral research, risk analysis can help explain why reasonable people sometimes make different decisions.15 With COVID-19, a person’s perceptions and decisions involving risks involve consideration of at least 3 questions.15 How much disease is in the community? What is an individual’s risk of exposure to COVID-19? How much can individuals do if exposed to SARS-CoV-2?

However, in the coming months, differences in risk-taking behaviors will play out every day. Each person will decide whether and when to travel by plane, visit with friends, shop, or eat in restaurants. What will complicate this further is that individuals will interact with others who may not share the same sense of risk, potentially straining relationships between family members, friends, and colleagues. Regardless, there will be risk, and it will not be possible to accurately define that risk.

Societal Risk

Some individuals are willing to assume risk and are not willing to have their individual freedoms curtailed. This has emerged as a central debate in the US, and poses numerous and substantial challenges for public officials, particularly mayors and governors, who must make decisions about restoring normal activities in their cities and states. Most of these officials consult public health experts, ask for their best estimates, but then must balance the risk to society vs individual rights. This issue of individual freedom vs the common good has always been a central debate in the US. What rights and privileges do individuals surrender for the common good? How should individuals balance their rights against their responsibilities and ensure that their choices and actions do not impose risks on other members of society or their own family members?

Risk Assumed vs Risk Imposed

Some individuals, even if they are willing to assume personal risk, are not willing to have risk imposed on them or their family. This issue will emerge as an important question in the coming months as businesses begin to reopen and schools and colleges consider whether and how to open and resume classes in the fall. Some businesses may continue work-from-home arrangements, whereas other businesses may require that their employees return to the workplace. For some businesses, employees cannot work from home, and many businesses will implement changes that will reduce the likelihood of employees being exposed to and acquiring SARS-CoV-2 infection, but the risk will never be zero. The question of risk is even more complicated for schools.16 Even though schools can make various changes, the risk of exposure to SARS-CoV-2 to students, their families, and teachers will never be zero. Most families and most teachers will likely be willing to assume some risk, but others may not, leading to substantial logistical complexities and potential legal challenges.

Another debate involving assumed vs imposed risk is likely to emerge in the US about mandatory vaccination. Many experts agree that preventive and therapeutic treatments, including measures such as physical distancing and wearing of masks or therapies such as monoclonal antibodies, are only a bridge to the ultimate goal—an effective vaccine. Vaccines against non-COVID diseases are overwhelmingly safe, and it will be incumbent that federal agencies ensure that any new vaccine against SARS-CoV-2 is safe, and the potential adverse effects are well-defined. It is possible that many people who are willing to assume individual risk will not want the risk of vaccination to be imposed on them. How to reconcile this tension between individual rights and privileges vs the common good is unclear.

Lingering Risk

For the foreseeable future, the risk of acquiring SARS-CoV-2 may decrease but will persist. Professional sports teams could quarantine their athletes in isolated hotels, conduct events in venues without fans, and adopt new rules; colleges could create individual dorm rooms, test students twice per week, and end classes before Thanksgiving; businesses could ensure appropriate work spaces, require employees to wear masks, and insist that workers who are ill stay home; but none of these mandates can ensure zero risk of disease exposure and transmission—it simply is not possible. Every discussion about return to school, college, work, or other activities must start with the acknowledgment of this fact, and individuals need to be mindful that everyday life has risks. For instance, each year in the US, there are approximately 35 000 motor vehicle–related deaths, 40 000 individuals die from firearms, and hundreds of thousands of deaths are attributable to smoking cigarettes.17,18 Admittedly, most individuals perceive they have some control over how they drive a car, are exposed to firearms or smoking, whereas being exposed to COVID-19 seems more random and less controllable. Yet in 2018-2019, the US Centers for Disease Control and Prevention (CDC) estimated that approximately 500 000 hospitalizations and 34 000 deaths were associated with influenza,19 but this recurrent morbidity and mortality had almost no effect on normal activities.

In the era of the COVID-19 pandemic, there is a greater discussion to be had—and it is far more difficult. What is the risk to individuals, families, and society with such a radical change in everyday behaviors and activities? How does society balance the risk of COVID-19–related death or serious disease with the short-term and long-term consequences of nearly 40 million people being unemployed; 55 million children home from school; and millions of families, friends, and colleagues kept apart without the ability to touch, feel, laugh, or cry with one another. Is there a way to protect the most vulnerable, or at least reduce their risk of disease, without a total disruption of everyday life? Is there a way to make patients feel safe enough to return to health care facilities for care? What will be necessary for people to feel safe enough to return to work? There are answers to some of these questions, and the CDC and others have offered substantial guidance for many of these issues.20,21

However, without more direct, definitive, and evidence-based guidance from the appropriate federal agencies, primarily officials from the CDC, the National Institutes of Health, and the US Food and Drug Administration, individual states will be left to chart a course forward, and this is likely to create additional uncertainty and political discord. Perhaps most important, rigorous scientific evidence and epidemiological assessments must serve as the basis for objective discussion, fact-based decisions, and optimal determination of the best path forward for individuals and for society.

For the foreseeable future, the risk of acquiring COVID-19 will never be zero. Grappling with and balancing risk, personal choice, and freedoms against individual responsibility and the common good must be part of the discussion of how each person as well as how towns, cities, and countries decide to return to work, school, play, and other activities.

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Article Information

Corresponding Author: Howard Bauchner, MD, JAMA, 330 N Wabash Ave, Chicago, IL 60611 (howard.bauchner@jamanetwork.org).

Published Online: June 4, 2020. doi:10.1001/jama.2020.10242

Conflict of Interest Disclosures: None reported.

References
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US Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19). Accessed May 28, 2020. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html
2.
Wu  Z, McGoogan  JM.  Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese center for disease control and prevention.   JAMA. 2020;323(13):1239-1242. doi:10.1001/jama.2020.2648PubMedGoogle ScholarCrossref
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Richardson  S, Hirsch  JS, Narasimhan  M,  et al; and the Northwell COVID-19 Research Consortium.  Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City Area  [published correction appears in JAMA. doi:10.1001/jama.2020.7681].  JAMA. 2020;323(20):2052-2059. doi:10.1001/jama.2020.6775PubMedGoogle ScholarCrossref
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Grasselli  G, Zangrillo  A, Zanella  A,  et al; COVID-19 Lombardy ICU Network.  Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy Region, Italy.   JAMA. 2020;323(16):1574-1581. doi:10.1001/jama.2020.5394PubMedGoogle ScholarCrossref
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Administration for Community Living; Administration on Aging; US Department of Health and Human Services. 2017 profile of older Americans. Accessed May 28, 2020. https://acl.gov/sites/default/files/Aging%20and%20Disability%20in%20America/2017OlderAmericansProfile.pdf
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Michigan.gov website. Coronavirus: Michigan data. Accessed June 2, 2020. https://www.michigan.gov/coronavirus/0,9753,7-406-98163_98173---,00.html
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Massachusetts Department of Public Health. Dashboard of public health indicators. Accessed May 28, 2020. https://www.mass.gov/doc/covid-19-dashboard-may-25-2020/download
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Illinois Department of Public Health. COVID-19 statistics. Accessed May 28, 2020. https://www.dph.illinois.gov/covid19/covid19-statistics
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US Department of Health and Human Services; US Centers for Disease Control and Prevention. Long-term care providers and services users in the United States, 2015-2016: analytical and epidemiological studies. Accessed May 28, 2020. https://www.cdc.gov/nchs/data/series/sr_03/sr03_43-508.pdf
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Pillemer  K, Subramanian  L, Hupert  N.  The importance of long-term care populations in models of COVID-19.   JAMA. Published online June 4, 2020. doi:10.1001/jama.2020.9540Google Scholar
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Kaiser Family Foundation. Total number of residents in certified nursing facilities: 2017. Accessed May 28, 2020. https://www.kff.org/other/state-indicator/number-of-nursing-facility-residents/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
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Howley  EK. Nursing home facts and statistics. Accessed May 28, 2020. https://health.usnews.com/health-news/best-nursing-homes/articles/nursing-home-facts-and-statistics
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US Centers for Disease Control and Prevention. Multisystem inflammatory syndrome in children (MIS-C). Accessed May 28, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/pediatric-hcp.html#anchor_1589580133375
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Pan  A, Liu  L, Wang  C,  et al.  Association of public health interventions with the epidemiology of the COVID-19 outbreak in Wuhan, China.   JAMA. 2020;323(19):1915-1923. doi:10.1001/jama.2020.6130PubMedGoogle ScholarCrossref
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Fischoff  B.  Making decisions in a COVID-19 world.   JAMA. Published online June 4, 2020. doi:10.1001/jama.2020.10178Google Scholar
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Sharfstein  JM, Morphew  CC.  The urgency and challenge of opening K-12 schools in the fall of 2020.   JAMA. Published online June 1, 2020. doi:10.1001/jama.2020.10175Google Scholar
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    2 Comments for this article
    EXPAND ALL
    Risks & Responsibilities...
    David Fessell, MD | University of Michigan
    Thank you for this informative and thought-provoking summary. Individual risk, societal risk, lingering risk, and our responsibilities as citizens and human beings....much to consider and reflect upon.

    "Grappling with and balancing risk, personal choice, and freedoms against individual responsibility and the common good must be part of the discussion." Indeed! The distinctions and clarity you provide are very helpful. Please do read this article! I expect it will elevate many upcoming discussions.
    CONFLICT OF INTEREST: None Reported
    Post-Covid19, will failing to accept the need for major change represent the most harmful risk of all?
    Stephen Green, MD | Sheffield Hallam University & University of Plymouth, United Kingdom
    Bauchner & Fontanarosa are correct that balances need striking between the rights & responsibilities of human beings vs individual & societal needs. 

    With COVID-19, a lethal transmissible virus, one should really be including all individuals' “right to live” in discussions.

    Put starkly, for any human being there is nothing more harmful, personal & final than their own death. Given that some people’s personalities lead them to more readily accept & even enjoy risk taking, the potential for the actions of some to lead to the deaths of others must be pondered. Many of us find the
    fact that others would not only be prepared to put themselves at risk but simultaneously also risk our lives too to be highly unacceptable.

    So, where to from here? In a crisis, balancing freedoms with responsibilities has to start somewhere. It requires philosophical, legal & political foundations. It also demands leadership. Politicians cannot sidestep that challenge. It comes with the job.

    But what represents the good heroic political leadership needed in a crisis? Bob Dylan’s view seems a good starting point - "I think of a hero as someone who understands the degree of responsibility that comes with his freedom."

    Ergo, it is leaders who must provide that understanding & render judgement as to where the balance between rights & responsibilities lies.

    Useful inspiration may come from the world of medical ethics. The principle of “primum non nocere” – first do no harm - has served medicine well for millennia, & in our current situation wider societal application of this notion could - seen from the perspective of a “reasonable person” - be deemed “reasonable”(1). So, if collective changes in behavior are judged necessary for the common good & the only way to best ensure that those in society who don't wish to have their lives cut short as a consequence of actions by others do not then so be it. This way forward arises naturally out of a broader application of “primum non nocere.”

    But more risks have to be considered. As Fyodor Dostoevsky wrote, “Taking a new step, uttering a new word, is what people fear most.” We have to recognize that effecting even essential change is tough. But, change can itself be seen as risky. That said, nothing is fixed in stone, & and COVID-19 has enormous potential to force change.

    While some leaders may seem intent on pushing everything on the economic, trade & international travel fronts back to December 2019, that may mean we return to a world where unnecessary & harmful risks are imposed on the human beings who have to live in it. So, maybe it is time for our political & economic systems to accept that our world has changed, quite possibly forever, & instead seek out new less harmful ways forward (2). For example, should a requirement to design infection prevention & control – including safer social distancing – into all aspects of human life, including how we work, travel & relax, be non-negotiable? After all, the next zoonotic pandemic could be even worse. (3)
      
    Albert Einstein said “Insanity is doing the same thing over & over again & expecting different results." Facing up to the fact that turning the clock back to patterns of human behavior & expectations from the pre-covid 19 era may in itself be an act of insanity is vital, & failing to change may be the biggest risk of all.

    Authors: ST Green MD & L Cladi PhD

    REFERENCES
    1. https://aeon.co/ideas/legal-st&ards-invoke-the-reasonable-person-who-is-it
    2. https://www.bmj.com/content/369/bmj.m2056/rr
    3. https://doi.org/10.1016/j.jinf.2020.05.015
    CONFLICT OF INTEREST: None Reported
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