Why Our COVID-19 Risk Assessments Are Wrong

What comes to mind when you think about COVID-19? Statistics, news stories, political claims? Or do you think about a friend who caught the coronavirus and developed COVID-19? Your risk assessment of catching and suffering from COVID-19 will be driven by what comes to mind. And that means we may not be making the correct assessment.

I’m writing about how we assess risk. For that reason, I want to tell three very short stories. These are the stories that come to mind when I think about COVID-19. You probably have similar stories. The stories and thoughts that come to mind are critically important, so let’s consider a few.

First, we live in the Pacific Northwest, very close to the early COVID-19 outbreak. The first horrific outbreak occurred in a senior living center in the Seattle area. Almost every resident and staff member caught the coronavirus and developed COVID-19. As I write this, at least 45 people associated with that care center have died from COVID-19. The coronavirus also spread quickly to the town where I live. Residents in several local care facilities have also caught COVID-19, with one facility having more than 20 deaths. And here’s the personal part: My mom lives in a local assisted living center. So far, we’ve been fortunate. Her facility has avoided COVID-19. But the story about nearby centers with cases and large numbers of deaths is often in my head when I think about COVID-19.

Here’s my second story. We have a good friend who caught the coronavirus in early March. She developed a serious case of COVID-19. Never so severe that she landed in a hospital, although she was close a few times. But she ran through all the symptoms. Breathing issues, loss of smell, heart problems, clotting factor increase in her blood, COVID toes, and a serious mental fog.

Now, five months later, she has not recovered. She’s exhausted constantly. Her heart remains strangely erratic and over-reactive, accelerating just from sitting up. She can’t walk up a flight of stairs without needing to rest. And she continues to experience cognitive challenges. She was previously healthy. She had none of the pre-existing conditions that would make her more vulnerable.

I’ve learned that her experience isn’t unusual. Perhaps as many as 30 percent of people continue to have problems months after supposedly recovering from COVID-19—most of these people were never hospitalized. The challenges experienced by these COVID long-haulers are now being studied (see this clear article by Ed Yong in the Atlantic Monthly). You may have heard that few people die from COVID, and most have mild cases. But I’ve got this story of my friend who may never return to normal. And I know that many people are having these long-term consequences. That’s the second story that comes to my mind when I think about COVID-19.

And my third story concerns the daughter of a family friend. She is a young woman in her 20s who caught COVID at work. Her case has been extreme. She spent more than two weeks in the ICU and days on a ventilator. Although she is starting to recover, her kidneys still aren’t working properly. She has been in the hospital for over a month. Her family is hoping she can go home soon. But she’ll be months in physical therapy trying to regain strength. I hope that this young woman doesn’t become a long hauler.

These are the stories that come to mind when I think about COVID-19. COVID running through an assisted living center. A friend who may never regain her strength, may never return to normal. Another friend’s daughter who spent weeks in the ICU and is still in the hospital. These stories come to mind and they guide my assessment of risk. The risk that I’ll catch COVID, that I’ll become very sick, that I may never fully recover, or that I’ll pass COVID to my mom in assisted living.

When I think about COVID-19, I am incredibly cautious. We’ve been as isolated as possible, we wear masks whenever we shop. We only do takeout food. We’ve seen some friends, but only outside, with physical distance, and while wearing masks. I see COVID-19 as very risky.

My situation and risk assessment is a classic example of the availability heuristic (Tversky & Kahneman, 1973). Tversky and Kahneman described the availability heuristic a long time ago, and it is part of the work that led to the Nobel prize awarded to them. Simply stated, we make decisions based on the information that comes easily to mind. COVID-19? I think about these cases, these stories I’ve described. When I think about COVID-19, all that I have in my mind are horrible risks.

You’ll have different information come to your mind when you think about COVID-19. Maybe you also have friends, family members, and local community people who have caught the coronavirus. If you know stories of suffering and loss, then you may have become risk-averse like me. Or perhaps you’ve known people who had very mild cases. Or maybe you don’t know anyone yet. If mild cases and no cases come to mind, then you may not see COVID-19 as a very big deal. You may not be particularly worried.

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But either way, we are guided by the availability heuristic. We are making risk assessments based on the information that comes to mind. And often the information that comes quickly to mind are the stories of people we know personally. (I will note that other heuristics, such as framing effects, also affect how we assess risk and how we respond.)

Is this the wisest way to assess risk and make decisions? No. A few cases isn’t very complete information. The few cases we know are probably biased too. We are more likely to hear and remember more extreme cases. We should instead be guided by overall risks.

For example, the percentage of your local population determines your risk of actually encountering someone with COVID-19. But the odds of encountering someone add up dramatically as the size of a group increases—probably faster than you realize. Interacting with one or two people may be low risk if fewer than 5 percent of your local community is currently infected. But the numbers add up fast. Hang out with a group of 10 or 20 people, and the odds climb to almost 50-50 that someone is infected. The likelihood of transmission also depends on a variety of factors: indoor or outdoor, length of exposure, are people wearing masks, physical distance, the circulation of air for indoor events. Actually, computing the risk for any possible gathering is complex. Even epidemiologists are challenged by the complexity, although they agree on the factors that increase risk.

The risk of complications can also seem small. The death rate, in general, is low. Obviously, this depends on other factors such as age and underlying health. So, if you’re young and healthy, you may believe that you won’t die if you catch COVID-19. And you’re probably right.

But there is another number that is seldom presented in discussions of risk—the odds of developing long-term consequences. Although the risk of death is low, the chance of becoming a COVID long-hauler is much higher. How high? How likely is it that you’ll continue to suffer months later? I don’t know and I’m pretty sure no one else knows at this point. The reports indicate potentially as many as 30 percent of people who catch COVID-19 develop long-term problems—even for people with supposedly mild cases. But this data isn’t really clear at all right now.

In assessing my COVID-19 risks, I could do the math. I’m pretty decent at basic math and statistics. I’m not an epidemiologist, but I can probably use some publicly available information to calculate the odds of catching COVID in a variety of different situations. I am, however, not confident my calculations would be accurate. I can estimate my risk of dying if I catch COVID-19. Here, even if my odds are only 0.1 percent (1 in 1000), I’m not wild about that risk. And I simply don’t know the risk of long-term consequences, but I worry they are high.

But I don’t do the math. The math is hard and not all the relevant information is clear. I’m just like everyone else. I judge risks based on the availability heuristic. Based on what comes to mind easily.

Knowing numbers isn’t as important as knowing stories. And the stories in my head are horrible. So, my evaluation is that this is very risky.

I’ll continue to stay mostly isolated. We’ll rely on physical distancing, even when seeing family and friends. And if you see me, I’ll be wearing a mask.