Saturday, August 15, 2020

Fighting the flu

Some people, perhaps more towards the beginning of our pandemic than now, have said that we wouldn’t have a shutdown for seasonal influenza, and COVID-19 is not much worse. Our best mortality data shows that this argument is unsound: COVID-19 is much worse. But still I wonder if there isn’t something to do the idea of turning the argument around to conclude that we should be doing more about the flu—and the common cold, while we’re at it—than we are.

The flu isn’t nearly as deadly as COVID-19, but it does kill many. It causes significant suffering to a much greater number than it kills, and it is very disruptive to the economy. The kinds of public health measures taken against COVID-19 have apparently been extremely effective against the flu, apparently leading to a seven-fold decrease in flu-like symptoms in Australia around April of this year as compared to last year. Of course, for economic reasons, it would not be prudent to shut down businesses and schools to prevent the flu, especially since economic impact is one of the reasons for fighting the flu. And, in my sample of one, I continue to delight in the fact that since spring break, I haven’t had any flu or cold—five months without coughing is completely new to me, and wonderful!

But some of the measures taken against COVID-19 carry little economic costs, and yet might significantly decrease flu transmission. Specifically: voluntary individual social distancing and masks. Prior to the pandemic, comfortable personal space in the U.S. was said to be at least 1.5 feet for good non-romantic friends, four feet for strangers and three for co-workers and casual acquaintances. We could modify our etiquette to increase all these distances to six in those circumstances where it is not seriously inconvenient to do so. And we could also make it a part of our social etiquette that we wear good quality masks (which we could presumably make in large numbers at relatively low cost if we put more resources into it in the long term) when we are with those who aren’t very close to us, again when this is not seriously inconvenient.

Of course, there would be many circumstances where distancing and masking would be seriously inconvenient, and our etiquette could take those into account, just as it already allows for exceptions to personal space requirements on public transit and on crowded streets. And in cases where facial expressions are important, or when communicating with members of the Deaf community, one would need to take off one’s mask or use a mask with a window.

And there might well be some bonuses:

  • covering up a significant portion of the face could result in greater social equality for two reasons: (a) decreased lookism because of covering up of much of the face (one of my teens mentioned acne in this connection!) and (b) decreased barriers to social participation by those with serious social anxiety (for instance, I have noticed that I feel more comfortable in social interactions when covered up)
  • potential for avoidance of being the victim of street crime, in that non-accidental violation of one’s personal space would provide an earlier warning of bad intentions (with lots of false positives, of course) and allow earlier evasive and protective action.

It would require research whether such partial measures would have sufficient effectiveness against the flu (and the common cold, which is still pretty unpleasant) to outweigh their inconvenience, at least when any bonuses are added.

Nonetheless, I am kind of thinking of unilaterally implementing some variant of these measures once the pandemic is over. The idea of being on an airplane or in a car with strangers and not wearing a mask—even if flu and common cold are all that one has to worry about—now seems rather weird or even repugnant to me. And I’ve wanted more personal space for a while—I can see myself continuing to step back from people not in my household when having conversations to ensure six feet of separation.

(And of course getting vaccinated for the flu goes without saying. I didn't even bother to write it because it's so obvious until my wife reminded me of how many people don't do it.)


Helen Watt said...

Flu is a bad thing, so good it’s gone down (though some doctors are reminding us too much shielding is bad for our immune systems!) But I think you may be underestimating the significant social costs of increasing distancing and especially wearing masks.

Masks are not just physically miserable for many of us to wear, but socially alienating to see on other faces: exchanging friendly glances of acknowledgement with passers-by is not really possible with masks, though with acquaintances you can of course raise your hand. For some of us this may not be such a problem – but what about young people, for example, who need to be meeting new faces (literally), and maybe doing a bit of flirting and setting up dates?

Those with social anxiety may feel happier participating in groups, that's true, but they may have to try harder to be noticed at all, especially if they naturally speak less than others in the group. Will they even be recognised next time by those they meet (especially if wearing a different mask)? Yes, masks hide the acne, but they also hide the smile, and generally delete half the information the face is communicating. Communication is what the face is for.

Also, there’s already a problem with over-anxiety in relation to infection (one little boy who’d been locked down offered the thought that ‘bad things happen outside’). Children and young adults will need to learn or re-learn how to socialise, after too much time on their screens. They will do this best by talking to human beings with fully visible faces, on which they learn to pick up helpful clues.

Alexander R Pruss said...

I kind like the idea that masks should be socially expected to have a name or other tag or avatar on them. :-) That would fix the recognition problem, and also increase social equality between those of us who are good at recognizing faces and those of us (like me) who are not.

As for communication, it may be that what we just need is better transparent or windowed masks. Something like this MIT mask would hide some information but not that much:
Or even better:

We do lose the benefits with respect to lookism and social anxiety, though.

I assume many young people still manage to flirt and set up dates in cultures where women's faces are largely covered.

S. F. Griffin said...

Can you provide a link, or links, to our best mortality data?

Alexander R Pruss said...

This isn't my field. But this seems to me to be a reasonable discussion:

Here's my understanding of the situation: Roughly, the case fatality rate for the flu is about 0.1%. But just as for COVID-19, we have good reason to think that there are a lot of unreported cases of the flu, including asymptomatic ones. It's estimated that about 50% of the flu cases are asymptomatic, which makes for an infection fatality rate of about 0.05% for flu. The infection fatality rate estimates I've seen from reputable sources for COVID-19 range about 0.1% to about 1% (with most of them in the upper half of this interval), so it's about 2-20X seasonal influenza. I think the current CDC estimate is pretty much in the middle of that range, so about 10X.

Australian data from 2019 looks like there is a flu fatality rate of 0.2% of the lab-confirmed cases ( But as of April 2019, there were about 20X as many people in Australia reporting flu-like symptoms than having lab-confirmed flu ( Let's suppose that half of those with flu-like symptoms have something else (allergies, common cold, pneumonia, etc.). Still, that means that there are 10X as many people with flu-like symptoms as with lab-confirmed flu. Thus, the flu infection fatality rate would be 0.02%, which is about an order of magnitude lower than the lowest serious estimates for COVID-19. Maybe, Australian flu deaths are underreported as one of the news reports above suggests. Let's say it's a factor of 2. That raises the flu infection fatality rate to 0.04%. That's still way lower than COVID-19. There is a lot of handwaving here, of course, but the distance is sufficient large that it shouldn't matter much.

S. F. Griffin said...

Thank you.

Helen Watt said...

Alex - Flirting is not encouraged in countries where women cover their faces :) though I'm sure some expert flirters manage as you say.

Thanks for the mask links - yes, I can see that would be better though it's still like socialising through a window. See-through masks would however allow charming people to use their charms, whether they were also goodlooking or not.

Not everyone is goodlooking OR charming of course but shouldn't we allow the world to be a beautiful and charming place? We can't compensate for all natural deficits after all.

I'm not good at faces either but feel I should practise! Avatars sounds a bit like cheating... And with social anxiety, isn't it better to build resilience? There might be the social equivalent of an overprotected immune system that gets worse with more distancing maybe?

Alexander R Pruss said...

Helen: All good points. But is the benefit worth the flu? I guess that's a question for a prudent judgment. I've been living with respiratory illnesses several times year--mostly probably just the common cold--and it's been very, very nice to be free of that. I am not quite sure what I will do once the pandemic is over. I am socially awkward, and I have good reason to think that I need my frequent smile to compensate for the awkwardness--that my smile is a crucial part of what makes people not dislike me.

One might be able to have some in-between solution that could significantly reduce flu rates. For instance, one could have a very strong social expectation that if one is the least bit sniffly or coughing, one wears an effective mask, unless one has good evidence that it's allergies. Or maybe people past a certain age wear a mask. Or maybe it's worn indoors only.

Another bonus: it's harder to guess people's ethnicity with a mask (though less hard if it's see through); so, maybe less ethnic discrimination?

But as you point one, one shouldn't neglect the potential mental health harms, such as increased irrational fear of infection. Another one is irrational disgust (until recently, I haven't thought about the fact that prior to masking and distancing we routinely inhaled total strangers' secretions, such as saliva; I now find this really disgusting; is it rational or irrational to be disgusted?).

I am inclined to think that after the pandemic I will continue wear a good filtering mask on public transportation (including airplanes and taxis). But definitely not while teaching or advising students. I feel that it would be a really good idea to wear a mask in church, but if I am the only one doing it, it might distract others from worship (they may worry that I have some nasty contagious disease, or maybe I have some nefarious reason to disguise myself, rather than just acting from an abundance of caution).

Walter Van den Acker said...


I think you are right, to some extent. If you e.g; have a "common" cold, one might ask if it is your duty to protect others from the virus your are carrying.

One of the leading virologists here in Belgium suggested that it should be common sense to stay home from work if you feel ill.

Now, I have never done that. I admit that I have even mocker people for staying at home for the slightest cough. But, since covid, I am wondering if those people weren't right after all.

Unfortunately, I don't think my boss would be too happy if everybody stopped working if they felt (a little) ill.

Alexander R Pruss said...

I think I've always stayed away from work when I had a fever. I don't want to infect colleagues and students. But since I have chronic congestion and--apart from the last five months!--I have a cough very regularly, it wouldn't have been practical to stay from work without a fever.

JCarver said...

Useful info!

Hawk said...

If enough people in a population are vaccinated against the seasonal flu, then there shouldn't be much of a need for masks and social distancing. Maybe in certain areas, but not necessarily in the general population.

The real threat is when there's an antigenic shift and a novel flu virus emerges. If this happens, it could end up being as bad as or worse than our current COVID pandemic. And there'd be no vaccine.