Salmon Upstream, LLC

Developing and implementing real-world community solutions.

Social Policy - Simplfied

This is intending to explain the complexities of public health. The most important lesson: it’s complicated.


There are a lot of diagrams out there trying to make complex stuff easier to digest. It’s got benefits, but one of our biggest problems is this need to have everything explained in a headline or fit on a single slide, and the world just doesn’t work like that. To explain, I made my own diagram.

Actually, I stole someone else’s and modded it. (Maybe that Fast and Furious marathon wasn’t such a good idea).

This is intending to explain the complexities of public health. The most important lesson: it’s complicated.

On the left you will see a wonderful rendering of blue and green peeps participating in increasing restrictions to prevent the spread of COVID. The first modification I made was to remove the numbers as the original diagram had percentages that were supposed to be the exact risk of transmission in each of these scenarios. I did this because these numbers were not what we would call in the scientific world “significant figures.” I am taking a lot of license with that term here, but let’s just say there is no way anyone should regard the reported figures as factual for a couple dozen different reasons. But don’t worry, because no one will deny that we have ranked our blue and green citizens in decreasing order of risk of transmission, starting at no-holds-barred rock concerts ad nauseum and ending with our unfortunate neighbors hermetically sealed in their homes.

The original document also attempted to discriminate between uninfected and asymptomatic carriers, a distinction which is theoretical at best in the real world. On this, let’s just agree to disagree and instead recognize that one cloth mask between our subjects is better than none, and not as good as two. And with a few quick clicks in Microsoft’s ubiquitous Paint, we have arrived at a universal consensus, at least as it applies to the transmission of virus.

But, as I stated, it’s complicated.

The next column refers to the social mandates required in a free society to achieve these scenarios, and then a list of major categories of repercussions: public fear, the public impression of the government, the economic impact, the psychosocial impact, the impact on education within the community, and the impact on the management of all of the other disease processes like cancer, heart disease, and diabetes.

The goal with our decisions is supposed to be the best overall outcome. The problem we often face with a complicated chart like this is that you can’t just look at one column and select the best answer, because you have to balance the real-world repercussions of that choice. Furthermore, we have to let go of the ideal: regardless of what anyone thinks should happen, it’s what does happen that matters. So even if you believe that everyone should get on board with a particular idea, if that’s not going to happen, then it doesn’t matter why, it’s just not going to happen.

There has been a lot of discussion of public fear. I want to point out something on this little chart: note that I estimated fear higher in the situation where we do nothing. That’s because the scary ship has sailed. People are already afraid, so if we just shrugged and said, “Move along, please, nothing to see here!” That would actually make things worse. People want guidance and reassurance, and things like masks make some people feel more comfortable. That’s real, and we shouldn’t pretend there is no risk when there is risk.

Well then, what is our leadership to do? We are now slipping below the murky surface in the turbulent sea of politics. I often say that we need to stop looking to our government as a source of solutions. That doesn’t mean that no one in government is a good person or wants to do good things or has great ideas, it’s that politics is truly two big parties that are entities in their own right, and individuals are no more capable of controlling those entities than an individual cell in your body. Which means these parties are going to act in their own collective self-interest regardless, which is extremely unfortunate, because it’s times like these when we need to have truly effective leaders.

If you really want good outcomes, then you want everyone (or as many people as you can) united, and that’s the problem with our current system. When the pollical party’s primary objective is to win an election, then the outcome only matters as it relates to that election. We all know that a massive disaster can be a huge boon for a pollical party so long as the public blames the devastation on the opposition. Our current situation has become political, so what our leaders do has an effect, not just because of the policy itself, but because of the public reaction. That reaction is real and it has to be considered in the equation. And no, you don’t get to say, “but this way is the right way!” Because it doesn’t matter. If a policy is going to result in rioting in the streets, then the rioting and the resulting destruction has to be included in the discussion. If locking people in their houses slows the spread of disease but results in a violent divide of the people, then these factors have to be weighed.

I am not going to spend much time on the economic component in this, except to say that if you are reading this from the comfort of your own secure home, you are probably going to need some empathy to contribute in a meaningful way.

The social – or really psychosocial – impact is one that is hard to quantify but may be the most important of all. If you look at societal issues like poverty, you come to the realization that a lot of measurables – incomes, cost of living, resources, employment rates – these don’t necessarily correlate with happiness. But if you think on the goals of the founding fathers, it was prominently featured: life, liberty and the pursuit of – you guessed it – happiness. This is so hard to achieve in the real world, where people’s views and perspectives differ, and it’s all been muddled by the insertion of for-profit social media platforms that capitalize on our innate attraction to issues that resonate with our fundamental beliefs, profiting from our texted, emoji-laden conflict.

Public schools and small businesses have a lot in common: both are major cogs in the machinery of society, and they both struggle in the best of times. Neither is capable of successfully adapting to the pressures we have placed on them. If you don’t understand what I mean, go to your favorite establishment and watch them try to modify their business model from one of multiple servers waiting on a variety of customer tables to a single input of a phone line while attempting to manage curb-side or delivery service as a primary mode of business when it represented a sliver of what they did in their prior life. I am going to vehemently disagree with the people who think the failure of restaurants is just part of the circle of life, but when it comes to schools, a lack of appreciation of the importance of having an educated society marks you as a irrecoverable dullard. Schools already have an impossible task, but forcing measures like a continuous maintenance of six feet between students at all times will render them completely ineffective, and the most severely impacted will be those already at the bottom of the pile. The repercussion of this will be almost irrecoverable.

The other health concern column is intended to include things like cancer screening and care, which has been supplemented by our focus on the care of patients with COVID. If we keep you safe from this virus only to have you die of some other (potentially preventable) disease like suicide, what do we put on the scoreboard?

When you put it all together, you start to see why a little compromise goes a long way. Again, if you just focus on one issue and demand an extreme – everyone should wear a mask all the time and I just don’t give a damn if you don’t like it – there are very real and devastating repercussions that come when you force the issue. It all depends on whether the best public health outcome is your goal, or whether you absolutely have to win this particular issue, no exceptions.

So, what’s it gonna be?

By the way, there are times when you don’t really want to be right, and this would be one of those times. In the 36 hours since the completion of my last blog where I discuss at length the risks of ineffective facsimiles, my father had a routine screen prior to being transferred from his current spot in an assisted living center to a true memory care center where his dementia – markedly exacerbated by isolation – can be better managed. And he tested positive for COVID-19. Which landed him immediately in the lock-down ward in the hospital, which will turn this isolation thing up to eleven. Though it might be that his condition, his rapid decline, and the lost social interactions – like my being able to explain to him that I published the app I envisioned to help him have a better life – these were insignificant loses next to the need to protect his vulnerable neighbors. Perhaps, but these are very real to me and I want them to be reflected on that hypothetical scoreboard.

Whereupon you scream: How is this even possible, his facility was locked down!

No, it just looked like it was locked down – an ineffective facsimile – because we don’t do real lock-downs here, it’s just not possible.

Well, you say, who is to blame?

Who the actual-F cares? Policies were put in place – relative isolation – in an attempt to protect the very vulnerable inhabitants, but these only delayed the inevitable. To truly stop the spread of a virus in society, we have to literally stop society – see the bottom row on the chart – and that’s not compatible with life. If you fixate only on one column and ignore the rest, you lose sight of all of the devastation that happens as you fail to achieve your goal.

But someone must have violated a policy!

Yeah, I imagine they did, but only because the plan wasn’t realistic. At the end of the day, it doesn’t matter what you are trying to achieve, the only thing that matters is what actually happens.

The better plan is to accept the realities of the risks and dangers inherent in life and try to establish practices that do the most good while causing the least amount of damage.

There are no guarantees in life, but letting people live as they want to live is generally the safe bet.