The recent COVID19 surge has triggered widespread discussion about what went wrong, who’s to blame, and what lessons we can draw about re-opening society and schools. As a bioethicist and general egghead, I am happy to talk about all these things.
But I am writing to say that whatever you think about these issues, what really matters is what you do. In the end, what you do largely determines your health. And what the people around you do largely determines public health.
It’s a basic truth of medicine that our health is related to what we do. Are you wearing a mask when you’re in public? Staying 6 feet away from friends when you see them? Disinfecting hands with soap or sanitizer regularly? If yes, then you will likely not get COVID19.
No guarantees, of course. You might do everything right and still get sick, for sure. But your chance is low.
Many people have high risk due to things they can’t change about their work (checkout clerk, daycare teacher, healthcare worker) or living situation. A tragic part of this virus is that some are forced into high risk behavior, and many are getting sick and dying because of it. It’s the grimmest reminder of the link between behavior and illness.
Admittedly, your behavior largely determines your health, not absolutely determines it, as always in life. People at low risk, who do everything right, can get sick, and people who take all the risks in the world may stay healthy. That’s luck. But you determine how much luck you need. “The harder I work, the luckier I get,” the film producer Samuel Goldwyn said (supposedly). The more consistently we wear a mask, wash our hands, and physically distance, the less lucky we need to be.
If you get COVID19, the risk of getting very sick or dying is higher for some people than for others. Some of the recent surge has come from young people who don’t wear masks or physically distance the way they should due at least in part to feeling invulnerable.
This is unfortunate, for so many reasons. First, COVID19 causes severe illness and even death in at least some people with low risk. And, second, wearing masks, washing hands, and physically distancing are done to protect those around us, who might have higher risk, as much as it is for ourselves.
Of course, there’s nothing new in saying that behavior largely determines health. What mostly determines if you get lung cancer? Basically, whether you smoke. Yes, yes, we all know someone who smoked till they were 90 and never got sick. And I had a friend who died of lung cancer even though he never smoked a day of his life (it was the rare type that isn’t linked to smoking). But your chance of getting lung cancer is (something like) 1% if you never smoked and 10-15% if you’re a smoker.
What largely determines if you get gonorrhea, or chlamydia, or HIV? Again, your behavior: who you are having sex with, in what ways, and if you are using condoms.
Does this mean that sick people are to blame for getting sick, if they did something that raised their risk? Well, it’s not simple, in the yes and no kind of way. There’s some responsibility, sure: As we I tell my kids, you can make good or bad choices, and you have to take responsibility for them.
But this responsibility also has limits. Doing the right thing – what’s best for our health – requires personal traits of insight and resilience, and relies on social and economic resources. We often don’t have those traits or resources, at least at a moment, through no fault of our own.
My patients who work two jobs and are poor are usually not going to exercise regularly. My patients with extreme anxiety and PTSD from their childhood trauma are usually going to keep smoking. Genetics and family history make drug addiction more or less common.
Let’s put it this way: The responsibility that individuals bear for their bad health doesn’t mean that they don’t deserve sympathy and healthcare. A person with lung cancer from smoking, or heart disease from obesity and lack of exercise, deserves affordable health care and empathy as much as anybody else. Acknowledging personal responsibility does not mean assigning blame in some mean way.
The bigger picture is that individual behaviors that determine individual health and illness eventually result in public health, or illness. Public health is just individual health times thousands and millions. Smoking and having unsafe sex gets individuals sick, which becomes an epidemic of lung cancer and sexually transmitted infections. Millions of individuals with opioid addictions add up to an opioid epidemic.
It’s sort of like voting. You think your vote doesn’t count? Well, a winning candidate has only a whole bunch of single votes.
In medicine, we sometimes pretend there’s a sharp distinction between individual healthcare and public health. Clinics and doctor’s offices take care of individuals, and the public health department takes care of the population.
But, of course, the split is not so clear. Much of public health involves convincing people to do the right things for their health. And improved treatment of individuals, making them healthier one at a time, adds up to a whole population with better health.
And doing the right thing – wearing a mask, washing your hands, and physically distancing – is the ticket to being able to go out, see friends, and play (certain) sports, without getting sick or causing a spike that kills people, overwhelms hospitals, and shuts everything down again.
What matters is not whether the government imposes a rule requiring masks, it’s whether you wear the mask, whether or not there is a law that you should do so.
We should not pretend this is easy. Masks, physical distancing, and cleaning our hands obsessively are new and a bit weird. Changing our own behavior is hard. Masks are sweaty, they make breathing uncomfortable (though oxygen levels are unaffected), they make us look weird and feel rude at times. Also, it’s hard to always have to remember a mask and a small bottle of hand sanitizer when you leave the house.
Like with so many health behaviors, these will only become standard when they become a habit, something we do without thinking. Until they are habits, we have to work to remember to do them. But know that these can become habits, and can become regular. When they’re regular parts of our lives, they will be easier.
We know what we have to do. We can do this. You can do this. We have to.