Cognitive Illusions and How Not to Write About COVID-19 and Children

A problematic statement

In an interview on May 11^th 2021, Dr. Monica Gandhi said:

Children and young adults are very low risk for severe disease, about one in a million chance of death for a child under 19 from COVID as opposed to 600 deaths [per million] in the U.S. from adults.

These numbers are all wrong. By the time Dr. Gandhi made this statement, at least 500 people younger than age 19-years had died of COVID-19. As there are not 500 million youngsters in the US, her statement is mathematically impossible. She was also wrong about the death rate for adults, which was about 2,200 per million when she made her statement. Sadly, a highly credentialed doctor from a prestigious university making obvious errors about basic facts in a public forum is now so commonplace, it is worth mentioning only to note these errors always understate, but somehow never overstate, the risks of COVID-19. However, even if Dr. Gandhi had stated factual information, I believe it is problematic to frame pediatric deaths in this manner.

The contrast effect

How our brains perceive an object is determined by what surrounds it as much as the object itself. Optical illusions take advantage of this fact to trick our brains, something psychologists call the contrast effect. The two orange circles below are the same size, but they sure don’t look that way. (Interestingly, this illusion, called the Ebbinghaus illusion, doesn’t seem to trick children.)

The contrast effect can similarly affect how we perceive numbers. Salesmen know this. A $30,000 car might not seem so expensive after you’ve been shown one that costs $60,000. Often during this pandemic, “blue circles facts,” as I will call them, have been used to obscure our ability to appreciate the reality of how COVID-19 has harmed children, the “orange-circle facts” in the middle. Some blue-circle facts are that:

1. Children constitute only about 0.08% of the total COVID-19 deaths. They are much less likely to die of the disease than older people.
2. Children are more likely to die of suicide than of COVID-19.
3. COVID-19 kills only 1 in 50,000 (0.0019%) of children who get it. This number is even lower for healthy children.

These statements are all true and potentially quite useful. It is not necessarily wrong to compare pediatric deaths to adult deaths or to other harms that befall children. We are deluged with information and need some way to contextualize the numbers we encounter daily. The infection fatality rate (the percentage of people who die after contracting a disease) is an important statistic. Blue-circles facts are not intrinsically problematic, and though the word “rare” is imprecise, I agree with those who say the rate at which children suffer severe harms from COVID-19 is very low. I’ve said as much myself. Thankfully, the overwhelming number of children who get COVID-19 will be just fine. I wouldn’t have been too worried had my kids contracted COVID-19. However, blue-circle facts by themselves are incomplete and can be used to distort our understanding of how COVID-19 has harmed children.

Some orange-circle facts are that:

1. According to the CDC’s COVID Data Tracker, COVID-19 has killed over 500 children in the US.
2. About 25% of these deaths occurred in healthy children. The most common underlying conditions in children who die are asthma and obesity. As such, these children had their lives shorted by many decades.
3. Even accounting for incidental infections, COVID-19 has hospitalized tens of thousands of children, many needing ICU-level care and mechanical ventilation.
4. At least 4,196 children have been diagnosed with MIS-C, and most of these children need ICU-level care. This number may be a substantial undercount.

Orange-circle facts are independent of blue-circle facts. The number of children killed or hospitalized by COVID-19 does not depend on how the virus affects adults or how many children commit suicide each year. For example, COVID-19 would not be a worse disease for children if adults were completely spared or if only ten children committed suicide annually. Everyone knows and nobody denies that more children die of accidents, drownings, and suicide than COVID-19. However, hundreds of children have died of COVID-19. That’s not nothing, in my opinion. Of course, COVID-19 is different than accidents, drownings, and suicides in that two injections can prevent the disease in adolescents. Predictably there are news reports of parents regretting their decision not to vaccinate their child after they become seriously ill with COVID-19. I expect to see many more such stories in the future.

The fallacy of minimizing one harm by pointing out a more severe harm is called the fallacy of relative privation, and it has been commonly employed to minimize how COVID-19 has harmed children. No one would be taken seriously if they argued against a suicide prevention program because teens are more likely to die in accidents. No one should be taken seriously if they argue against the COVID-19 vaccine because children are more likely to die of something other than COVID-19.

Though the infection-fatality rate is extremely low for children, rare outcomes multiplied millions of times add up to non-trivial numbers. I fundamentally agree with Dr. Saurabh Jha who wisely said early in the pandemic, “the continued obsession with the denominator, when the numerator speaks for itself is bizarre.” COVID-19 has killed 500 children and is the leading cause of infectious deaths in children. These 500 tragedies are independent of the total number of children who contracted the virus. For example, COVID-19 would not be a worse disease if only 1,000 children contracted it, but 50% died. Either way, 500 children are dead. As CDC Director Dr. Rochelle Walensky said, “Children are not supposed to die”.

Additionally, we don’t have all the orange-circle facts yet. The long-term consequences of COVID-19, if any, will not be apparent for some time. I said before that I wouldn’t have been too worried had my kids contracted COVID-19, but I’m also grateful they stayed safe and healthy. I’m glad they are older than 12-years, and I vaccinated them as soon as they were eligible.

Beware of articles that omit orange-circle facts

I’ve read nearly a dozen articles suggesting in one way or another that children should not be vaccinated against COVID-19. Even though it can be done in a couple of sentences, I’ve not seen a single one include all orange-circle facts. Some articles don’t include any orange-circle facts at all. Several doctors have written multiple articles on COVID-19 and children without even mentioning that the virus has killed hundreds of children and sent tens of thousands of them to the hospital. You could read the entire works of some prolific writers this pandemic and emerge knowing zero orange-circle facts. I find this astonishing.

Instead, those who wish to minimize the impact of COVID-19 on children only use blue-circle facts. Statements such as “the old have a thousand-fold higher mortality risk than the young” permeate their writing. This may be correct, but it tells us nothing about how many children have died of COVID-19. I suspect these writers know that many of their readers wouldn’t find 500 dead children and tens of thousands of hospitalized children to be trivial. As such, they only describe the harms to children as “extremely low” or “rare“, rather than explicitly enumerate how COVID-19 has harmed them.

Often these writers feel that policies designed to stop the virus have hurt children more than they’ve helped. They may or may not be right. However, acknowledging orange-circle facts doesn’t suggest any policy positions. One can acknowledge them and still believe that closing outdoor playgrounds was ill-advised or that schools should be open in the fall. I basically feel this way, though I hope schools will make common-sense efforts to prevent students from getting the virus and be willing to adjust if the virus cannot be contained. Based on CDC estimates, around 40 million America children remain vulnerable to COVID-19. If 1 in 50,000 children dies after getting COVID-19, this means that around 800 more children would die if the virus were allowed to spread unchecked throughout the pediatric population. Many thousands more would be hospitalized. This is on par with risks that didn’t shutter schools before the pandemic, but people should be aware of the facts.

What makes this especially sad is that all of this could have been avoided if eligible Americans were willing to be vaccinated. It might not have made that much difference, but I do wonder if more people would have been vaccinated if knew the orange-circle facts and not just the blue-circle facts. Most people have a natural tendency to really want to protect children, even those with underlying conditions.  As I wrote previously it often seems as if children with medical co-morbidities don’t really matter to some people, though of course, the death of a vulnerable child is just as tragic as the death of a healthy child.

Even just a single orange-circle fact can be very compelling. I urge you all to read about Wyatt Gibson, a healthy 5-year old who recently died in Georgia. According to his father,

Wyatt was nothing [but] joy and happiness. We loved having fun and going on adventures together. He loved his momma and his sister so very much, and he was always looking for ways to help.

Behind every statistic there’s a real life that has been cut tragically short and a real family that has been devastated by the loss. We should not forget that.

Doctors writing about COVID-19 and children have an obligation to inform their readers of essential facts. Making informed policy decisions requires acknowledging basic facts and presenting them in a way that doesn’t distort our perception. Articles that omit orange-circle facts actively impair our ability to make informed choices and are scarcely different from those that blatantly misstate facts, though of course many manage to do both (here and here). Thanks to these articles, many people are under the mistaken impression that COVID-19 poses essentially zero threat to young people. As Dr. Andrew Pavia, the chief of pediatric infectious diseases at the University of Utah said,

In any other time, if we had a new disease that killed 300 children, we would be pulling out all the stops, we would be doing everything we could to protect them. And yet people are saying, “well, it’s not so bad, because it’s nothing like what happens to adults.”

If you read an article with only blue-circle facts, ask yourself if the authors are truly trying to inform their readers or if they are instead trying to advance a narrative that would be undermined if they fully enumerated how COVID-19 has harmed children.

I also believe the contrast effect has impacted how some have viewed vaccine-induced myocarditis. Vaccine-related harms can be downplayed because the virus can be so much worse. However, the vaccine has sent hundreds of adolescents and young adults to the hospital. Even though the vast majority of them are back to normal after a short time, this side effect should not be minimized. Notably, many authors who omit orange-circle facts when it comes to the virus are only too willing to enumerate the harms of the vaccine. As Loretta Torrago aptly put it, “Anti-vaxxers love talking about the numerator when it comes to vaccines, but, when it comes to Covid, they fall hard for the denominator.”

My advice: Cover the blue circles

No amount of thought or effort can change how we perceive optical illusions. We can only appreciate that the two orange circles are the same size if we cover up the blue circles that surround them. We can’t do this with COVID-19, or course, but we can try. When considering how COVID-19 has harmed children, I suggest you try to transport yourself back to a blissful time before you heard of COVID-19.

How would you feel then if you knew that a virus would kill 500 American children and hospitalize many thousands more, some intubated in the ICU? Would you wait to voice an opinion until you knew the total number of infected children or how many adults died? Would you wait to form an opinion until you knew exactly how many children die of suicide? Would you shrug and merely say that the harms are “rare”? If you don’t think you would have done any of these things back then, then you shouldn’t do them now.

And if you are the kind of person who writes that “only” hundreds of children have died from COVID-19, consider that normal people won’t benefit from reading your thoughts on children and a deadly virus.