Social distancing doesn’t cause recessions – pandemics do

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

We’re almost a month into social distancing in our collective effort to reduce the spread of COVID-19. It’s working; models indicate we’ve likely already prevented hundreds of thousands of deaths. But the economic effects of social distancing are tough. Though we haven’t met the official definition of a recession yet, simply because we haven’t been at this long enough, no one doubts that we are in a recession, if not an outright depression. The 22 million unemployment claims in the U.S. since early March are at levels that dwarf even the 2008 Great Recession.

So, naturally, even though public support for continued social distancing remains high, we’re hearing calls from some to relax restrictions. Small protests have broken out in Ohio and other places. Politicians are clearly spooked by the impending decision on when to “re-open the economy,” as some call it. And even though it is easy to make fun of some of their responses to questioning, the decision to relax social distancing in the hopefully near future will clearly be based on some combination of instinct and data. The best data we have on the topic seems to come from more than 100 years ago, during the 1918 influenza epidemic.

Economists Sergio Correia and Stephan Luck of the Federal Reserve and Emil Verner from MIT recently tried to apply lessons learned from the 1918 “non-pharmacologic interventions” for influenza (what we’re calling “social distancing”) like closures of schools, theaters, and churches; restriction on public gatherings and funerals; quarantine of suspected cases; and restricted business hours, to our current situation.

They came to two conclusions: First, areas that were more severely affected by the 1918 Flu Pandemic saw a “sharp and persistent decline” in economic activity. This is no surprise. We’ve seen the devastation COVID-19 has wrought in northern Italy and New York City. Second, the economists concluded that early and extensive use of non-pharmacologic interventions like social distancing had no independent adverse effect on local economic outcomes. Rather, cities that intervened earlier and more aggressively experienced a relative increase in real economic activity after the pandemic was over compared to other cities.

In other words, these three economists concluded that it was not social distancing that caused the most economic pain in 1918. It was the disease.

You can see the relationship between non-pharmacologic interventions and economic activity in the figure below. The green dots are cities with early, aggressive social distancing. The red dots are cities with late or low-intensity social distancing. The vertical axis is the change in employment over the four years before and one year after the pandemic. The horizontal axis is the mortality rate. What the best-fit line shows is that cities that intervened early and aggressively not only experienced more economic growth over time, but also, in most cases, had far lower mortality rates.

social-distancing-effectiveness-graph.png

The United States is not a manufacturing economy today like it was 100 years ago, and these numbers look primarily at manufacturing output, which fell 18% during the influenza pandemic. The U.S. is primarily a service economy now. If that strikes you as a weakness of their analysis, the authors also looked at bank assets over the same time period, according to the intensity of the non-pharmacologic intervention (left; [e]), and the speed of the intervention (right; [f]):

graph-of-economy-growth-following-social-distancing.png

 The cities that intervened earliest and most aggressively were much more likely to experience an increase in wealth through the time of the influenza pandemic.

What lessons can we learn from 1918? We need to take the long view. Social distancing hurts now. Unemployment of 25% or even 30% is unprecedented in the last century, and we need strong actions by federal, state, and local governments, along with good work from charities and non-profit organizations, to get us through the hardest part of this pandemic. But we need to be very, very careful about when we relax social distancing. Many projections, like this one from Morgan Stanley, are already taking into account a “second wave” of infections this fall:

COVID-19-second-wave-graph-1024x532.png

 That second wave of infections is likely avoidable if we do the right thing now.

This paper, nor this blog post, have been peer reviewed. We at KBGH would love to know your thoughts on how and when we should modify social distancing for COVID-19.

Is social distancing...bringing us closer together?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

If you’ve read as much as I have in the last few days about the COVID-19 pandemic, you’ve probably come across ominous-sounding warnings about social isolation or loneliness as a result of social distancing, our preferred short-term strategy to prevent the spread of the SARS-CoV-2 virus. Social isolation is the physical state of being alone, while loneliness is the feeling you get when your social interactions don’t meet your expectations; you can feel lonely in the middle of a crowded room, but you’re only socially isolated when you’re, well, socially isolated.

But both are bad for you. A 2017 systematic review showed that social isolation was associated with a 29% increased risk of death, while subjective loneliness was associated with a near-identical 26% increase in mortality. For perspective, a second meta-analysis in 2010 showed that “…by the time half of a hypothetical sample of 100 people has died, there will be five more people alive with stronger social relationships than people with weaker social relationships.”

As we have ramped up social distancing there has been legitimate fear that we would exacerbate the already-high rates of social isolation and loneliness, especially in elderly people. While it’s too early to say if that’s happening, I’ve been pleasantly surprised at my own experience. Just yesterday this meme came across my phone:

quarantine-meme.jpg

I found it so true. Now that many of us (but not healthcare workers, first responders, food delivery people, restaurant workers, mail carriers, or a hundred other “essential service” professionals and workers) are stuck at home during the day, it seems that we’re finding new strength and resilience just from getting out and moving in our neighborhoods and green space. I’ve talked to more neighbors on walks in the last three days than I had in the last three months, and not just because of warmer weather. Could it be that COVID-19 has begun a small restoration of what physician sociologist Nicholas Christakis calls the “social suite”: love, friendship, cooperation, and teaching, all from six feet away?

The evidence of increased investment in the social contract isn’t limited to the streets in my neighborhood. Young people are volunteering in large numbers to do things like deliver meals. So many retired doctors have offered to re-enter the workforce–at significant personal risk, considering many of their ages–that the Kansas State Board of Healing Arts has begun issuing emergency short-term licenses, and KAMMCO is issuing short-term liability insurance. Manufacturers in cycling, my favorite sport, are pivoting away from bike gear and toward the production of personal protective equipment. Congress is operating at a rare, near-normal level of functionality to give financial relief to millions of people (now if we could only get more testing resources). And I know that many of the readers of this blog, be they human resources professionals, insurance brokers, health administrators, or others, are working steadfastly to save as many jobs at their companies as they can in the face of an impending global economic catastrophe.

While you’re working hard on those things, don’t forget to work on these, too:

1. Look for ways to have “conversation-centric” interactions with people. Talk on the phone. Skype or FaceTime. Talk to people from your porch or from the street. As former Surgeon General Vivek Murthy says, “Smiling at someone–eye contact–is an act of service.”

2. Let kids around you continue to have unstructured play time with friends. Just keep them apart. Let them run around, ride bikes, and throw sand. Don’t let them wrestle or share toys.

3. If you’re still going to work, synchronize your coffee breaks with someone else. Common socializing like this has been definitively shown to be more restorative than snacking or emailing. If you can do it outside, even better.

4. Take time to express gratitude to others. Expression of gratitude is one of the most common indicators of life satisfaction in the US.

5. Volunteer. Organizational volunteering has been shown to be associated with a 24% reduction in mortality risk.

6. If you’re lucky enough to have some money to donate, do it. Spending money on others makes us far happier than spending it on ourselves.

Is “Social Media Hygiene” The Next Frontier In Workplace Wellness?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

Social media takes up an inordinate amount of our time. A recent report by Activate Consulting found that, when multitasking with consumer internet and media activities are accounted for, the new “normal” day is 31.5 hours:

avg-day-by-activity-graphic-social-media-blog-post.png

The amount of time we spend on these platforms is not likely to go down. According to that same Activate Consulting report, the number of social media networks an average person participates in is projected to almost double in the next four years, from 5.8 to 10.2 per user.

And in spite of snarky comments—many of them, yes, on social media—about the habits of millennials or Generation Z, it is Gen X workers in their forties and fifties who are the heaviest social media users, at almost seven hours per week, rising about 17 minutes per year.

All this virtual communication may be bad for us. Studies that are now several years old show that the more Facebook you use, the worse you are likely to feel. As anyone who has ever been accidentally pulled into an email argument that could have been solved with a single two-minute face-to-face conversation can tell you, in email and on social media in particular, we may abandon social norms in response to feedback from other users, since the algorithms that drive the platforms reward content that is highly emotionally charged. Tweets that use the greatest amount of moral-emotional language are the most likely to be retweeted or liked. Facebook posts that display not only disagreement, but indignant disagreement, are more likely to be liked or shared.

Why is this?

Researchers believe that virtual conversations lack the “advanced analogue cues” that in-person, video, or phone conversations have. Without clues like body language, tone of voice, and facial expressions, we have a hard time discerning the true intent or meaning behind innocuous statements.

What can be done?

A randomized trial by Stanford investigators showed that people who were paid to deactivate their Facebook accounts—as compared to people paid to continue their usual activity—were happier and reported increased well-being, decreased political polarization, and increased time spent with friends and family. And, presumably because of the drug-like effect of social media platforms, people who were paid to discontinue Facebook experienced apprehension at re-starting, just as a former smoker may be nervous about going outside around other smokers at break time.

But because of the strong network effect of social media, asking employees to cancel their accounts is probably unrealistic. Instead, we should look for healthier ways to use the platforms. After sifting through the mainstream medical literature, here are some of our tips:

  1. Encourage your employees to use social media as a bridge to in-person connection and real experiences, preferably outdoors and definitely away from screens. Using social media this way to connect to other people you’ve lost touch with may even have profound professional benefits.

  2. Create this bridge to in-person connection by changing the way you approach social media. Do not seek “likes.” Do not like other people’s posts, even though that may seem rude at first. Instead of passively scrolling through your Twitter, Instagram, or Facebook feed and hitting the “like” button, intentionally reach out to people. One study found that even one week of increased composed, directed social media posts to friends and family increased happiness. Another study compared this strategy to simply “liking” or sharing posts on Facebook. People who received targeted, composed messages from friends or family felt better; those who simply got “likes,” status updates, or shared posts experienced no change.

  3. Encourage employees to enforce “sacred spaces” where no devices are used, in order to reclaim conversation and non-verbal advanced analog cues. At home this may mean the kitchen, the dining room, and the bedroom, since even the presence of a device on the table may alter conversations, and looking at bright screens before bed can disrupt sleep (to say nothing of sex). As technology researcher Sherri Turkle famously said, “The greatest favor you can do to your sister, mother, lover, professor, student, is put away your phone.”

  4. While you’re at it, encourage employees to delete all social media apps from their phones and use social media only on a device they have to seek out, like a desktop computer. If that seems too severe a step, encourage them to go to their phone’s settings and kill notifications from all social media.

Are there strategies you’ve tried, either at home or in the workplace?  We’d love to hear them!

Why are there fewer posts on here than there used to be?

In the New Year, I've been trying to severely curtail my internet use. A side effect of this has been far fewer posts on this blog linking to articles or papers or videos that I've found interesting.

This is the next brick in a path I've been headed down for a while now. When I was a first-year med student, a classmate of mine was famously addicted to her flip phone. It would buzz and ring through lecture, and people would give her the stink eye, and as soon as the last Powerpoint slide clicked off the last reaction in the Krebs Cycle, she would bolt from the room and start making calls like a Wall Street veteran. Like Dan Akroyd in Trading Places. What would she have been like if she'd had a smartphone? Well, we know what she would've been like, because most of us are exactly where her trajectory was headed, and we're doing it with almost no social stigma. She would've answered all those calls with texts, right there in the lecture hall, and she would've checked multiple social media accounts to boot.

Needless to say, I was not an early adopter of social media. Once I had a couple accounts, I quickly found that social media made me act differently than I do in other situations or media. The act of trying to market myself for "likes" or "pins" on a platform of someone else's design was an act perfectly designed to produce insincere, awkward content. And thought I'm generally sincere, or at least I try to be, I'm somewhat socially awkward. That is, I'm awkward enough without someone else's help. I found that the effort I put into social interaction on platforms like Facebook and Twitter didn't enrich me. If anything, it impoverished me. It made me feel bad.

I was mystified by people's willingness to give up all the same information that we try so hard in the medical world to keep private. Facebook in particular seemed to be engineered specifically to tweak my smoldering social anxiety. It tried to choose my "friends" for me. But as I accumulated hundreds of "friends," the value of real friendship seemed to be degraded. And the privacy. Lordy. The day I put it to sleep came on my birthday a couple years ago. In spite of my almost religious tending to social media to keep details like the date of my birth off of them, people knew. Just like Wolfram Alpha knew. And I didn't want them to know. So I deleted it.

A year or so ago, I read Cal Newport's book Deep Work as part of a book club. I was still wading around the fever swamps of Twitter at the time, because I thought it was good to stay engaged for work. It wasn't completely by choice. I had suspended my Twitter account at one point, but then I'd applied for work with a company that used Twitter for much of its internal non-secure messaging. So during my grace period with Twitter (they give you a chance to come back for a month after you delete your account. Surprise!), I re-activated the account.

The discomfort with it remained. I started to talk about social media in less-than-flattering terms in posts a few months ago. Then I paused. I thought maybe I was being stereotypical: the middle-aged guy yelling at younger people to get off my digital lawn. But I kept some thoughts in draft form while I thought it over. I even considered getting a Facebook page for Double Arrow Metabolism, just to drive a little more traffic.

When the 2016 presidential election happened and I got glued to the daily outrage of social media as it responded to a shifting political landscape. I was left with two options: 1) master the software, or use it in such a narrow sense that it didn't control me, which seemed unlikely. I'm a reasonably smart guy, but my reptile brain can't outsmart thousands of computer engineers. Or 2) kill the software and get to know myself better. I don't mean blow up Twitter; I mean kill my interaction with it. I chose #2, eventually. I feared it would hurt business, or make me less knowledgeable about the world.

Then I read Newport's "any benefit" argument: we stay on social media because we can't bear the thought that there's some unknown, as of yet unseen benefit to it. In other words, what will we miss out on? It reminded me of what my parents lovingly called this the "unsmelled fart rule" when I was a kid. I'd be told to go outside, away from the party, and when I objected, I'd be asked, "What's the matter? You afraid somebody's gonna fart and you won't get to smell it?" That's exactly what I was afraid of with Twitter. But after I read Newport's book, I just quit. And it hasn't made a bit of difference in regards to my knowledge about the world. If something bad happens, I'm going to hear about it, social media or not. 

So I've been off social media for a little over a year, I think. Scratch that-it's not completely true. I still have a Strava account, albeit with no notifications enabled. And I still have a LinkedIn page. LinkedIn is like social media status post fun-ectomy, though, so I don't really count it. I even experimented briefly with Figure 1, but I didn't think it was useful. If I'm going to look at cases, I want to either get money or CME credit in return. Figure 1 provided neither.

But it wasn't just awkwardness or privacy concerns that bothered me. It was a gnawing sense of unease. And I couldn't quite put my finger on what bothered me until I read Andrew Sullivan's piece about the phenomenon a year or so ago, "I used to be a human being."

"Every minute I was engrossed in a virtual interaction I was not involved in a human encounter. Every second absorbed in some trivia was a second less for any form of reflection, or calm, or spirituality. 'Multitasking' was a mirage. This was a zero-sum question. I either lived as a voice online or I lived as a human being in the world that humans had lived in since the beginning of time.

And so I decided, after 15 years, to live in reality."

Time on social media, and now to some extent time on the internet, was taking away from time in the real world. You might be pointing out right now the apparent hypocrisy of the position I'm in the process of staking, since you're currently reading these words from a screen. Why, you're asking the screen (and by extension me), do you spew forth on this blog if you're so against public sharing? Fair point. But my content has decreased. And whether you like what I have to say or not, I don't make money off of it, even though I do make money off the consulting work that sometimes makes a guest appearance on the site. And I don't spend a lot of time looking at the analytics on my site to see how many of you are reading. So this particular shout into the void is my way of getting what I consider my fairly radical beliefs about health out into the world. But I figure the people reading this blog have at least a passing interest in me or in what I have to say. If you're here, I've in some way earned your eyes on this page. Artificial intelligence did not move Double Arrow Metabolism higher in your feed. So sure, I'll share with you, like the authors of some of my favorite blogs share with me:

Velominati, Kottke, Study Hacks, Wait But Why, Slate Star Codex, Mr. Money Mustache, Red Kite Prayer, Marginal Revolution

But I won't share with a thousand people who caught wind of my birthday through a complicated algorithm and are only posting about it because said algorithm makes it easy to do and makes them feel bad if they forget. I want to generate content that--good or bad--takes me longer to write than it takes you to view. Call it anti-Twitter.

So the fact that I'm not posting as many links is dual purpose: it keeps me off the internet, and it keeps me from turning this site into something I didn't set out for it to be. If what you want is a bunch of interesting links, many, many websites serve that purpose better than this one. One of them is Twitter. But Twitter has a fatal flaw in that it has no end.

Comedian Aziz Ansari, a guy who it turns out was a creep on a date, but who literally wrote a book on how technology has changed romance, has this to say:

"I’ll say, the times where I haven’t read that stuff, the stuff that I normally read on the Internet, just nonsense blogs or whatever, the next day I’ve felt like I’ve missed nothing...Cause you’re not reading it for the information. What you’re reading it for, and this is just my personal theories about this stuff, what you’re reading it for is a hit of this drug called the Internet...Like, here’s a test, OK. Take, like, your nightly or morning browse of the Internet, right? Your Facebook feed, Instagram feed, Twitter, whatever. OK if someone every morning was like, I’m gonna print this and give you a bound copy of all this stuff you read so you don’t have to use the Internet. You can just get a bound copy of it. Would you read that book? No! You’d be like, this book sucks."

Again, Ansari, a comedian whose job seems to have been created in a laboratory to achieve maximum benefit from social media, had this to say to Stephen Dubner of Freakonomics before adopting his new social media, internet-lite life philosophy:

"I never read anything. I’ve never read all these novels that are like these beautiful stories that have continued to have a resonance with people for so many generations, like beautiful works of art that I could read at any point. But instead, I choose not to read them. And I just read the Internet. Constantly. And hear about who said a racial slur or look at a photo of what Ludacris did last weekend. You know, just useless stuff. It’s like, I read the Internet so much I feel like I’m on page a million of the worst book ever. And I just won’t stop reading it. For some reason it’s so addictive."

Aziz quit the Book of Internet. The Book of Internet is a shitty book. Double Arrow Metabolism will not be a chapter. 

Since my departure from social media and my sharp reduction in internet consumption in general, I haven't come across much to change my mind. I read Jean Twenge's Have Smartphones Destroyed a Generation? I read John Lanchester's A Criticism of Facebook. They reminded me of a teaching course I attended at Beth Israel in Boston in roughly 2009, when "teaching the 'millenial learner'" was already a hot topic. They were different than Gen Xers and Gen Yers, we were told, in that they hadn't been quite so "latchkeyed" (a term d'art for what some might consider excessive babysitting as a symptom of absent parents). They also were perceived to want more of a personal touch in their instruction; more feedback. But Twenge notes that in her data, something shifted a few years after my teaching course on millenials. It was in 2012, the year that smartphone ownership in America surpassed fifty percent. So she calls the group at the tail-end of millenials the "iGen." Smartphones and social media have been ever-present in their lives. They've never known a world without tablet devices. Three out of four of them own an iPhone. 

Rusty's Last Chance, a landmark bar in the Aggieville district of Manhattan, Kansas, was a beacon to Kansas State University students and nearby Fort Riley soldiers for decades, but it closed in February of 2017. Bars and restaurants close all the time, but I cannot help but think, based on my experiences in going back to Manhattan in recent years, that students' taste for virtual contact over the real thing didn't have something to do with it. I'm still volunteer faculty at the local med school, and one of the criteria we're expected to evaluate students--med students! Adults!--is their willingness/ability to stay off their phones during sessions.

At this point, if you're still reading, maybe you're ok with all this. Maybe you don't think your time is worth that much, and maybe you've heard if you aren't that bothered by an algorithm guiding you away from your true self, and maybe then that information you've paid to give up is used to reduce you to a set of numbers or yes/no questions that define you, just as medicine so imperfectly tries to define you by race, body mass index, blood pressure, and soon your genetic "fingerprint." After all, teen pregnancy is at an all-time low, and teens' addiction to their phones surely has something to do with that. It's hard to impregnate someone if you're spending your weekends in your bedroom scrolling through Snapchat. And kids are physically safer than ever; it's hard to die in a drunk-driving accident from the comfort of your bedroom, and I've never seen a drinking game whose rules involved immersion in tindr (but, come to think of it, I'm sure it exists). Psychologically, though, kids may in trouble. Twenge notes that since 2011, depression and suicide have "skyrocketed." I'm not sure this is true. I'm too exhausted by the internet right now to go and find the primary data. But it doesn't take a social scientist to watch toddlers engrossed in YouTube Kids at the grocery store and deduce that we're in the middle of a profound change. We're running an uncontrolled experiment on ourselves and our kids.

So how should we handle smartphones with our kids? Based on no empirical evidence whatsoever, my wife and I have decided that 1) our kids will not have their images posted on social media other than in extremely rare circumstances (nobody wants to be the guy that torpedos an entire birthday party, after all). And our kids, upon entry into middle school, will have access to a good, old-fashioned cell phone. But if they want a smartphone, they'll have to earn the money for it themselves.

At home, we try to enforce what I'll call the "White House" rules. I don't know how the White House handles the issue precisely, but I'm fairly certain that unsecured cell phones are a no-no in the White House. So, like a Jack White or Chris Rock or Dave Chappelle show, people are asked to put their phones away upon entering. So I follow the same rules: when family members come into my house, they put their phones in a central location, and we go about our business. 

In case this all just sounds like so much "get off my lawn"-style old man grouchiness, I engage with technology. I help docs run their electronic medical records more effectively and efficiently. I listen to podcasts in my free time. But I can listen to podcasts while I accomplish other things. And EMRs, at least in theory, have value beyond the immediate. 

Sigh. So that's the story. Expect fewer posts on this site than there used to be, because I'll simply have less to post, because I'll have spent less time on the internet than I once did. But I'll probably keep my smartphone. I like the calendar.