We Have to Explain Risk to People as if They Were Five Years Old
Public Health practitioners keep forgetting to talk about and teach the most important lesson of all.
Humans are notoriously bad at assessing risk. In 2019, aviation authorities around the world grounded the Boeing 737 MAX class of aircraft because of two accidents that occurred in 2018 and 2019. The accidents resulted in 346 deaths, a small proportion of the estimated 8 billion passengers who flew commercial airlines in those two years. (That number includes duplicates, or people who flew multiple flights in those years.) Nevertheless, plenty of people became apprehensive about flying. Even after the investigations into the flights, and the return of the airplanes into service, there are still people out there who do not want to fly in general or in those airplanes in particular.
Instead of flying, people who are looking to travel but fear flying will instead turn to driving or riding a bus. The risk of fatal accidents on the road is larger than flying by orders of magnitude, but being on the ground seems safer than flying. We could extensively discuss the psychology of this. Instead of discussing psychology, I’d rather discuss how to explain risk to a person as if they were five years old… Because I just did it with my own preschooler.
“Safe or Unsafe” Is an Imaginary Binary Option
First, let us understand that risk is not a binary thing. An activity should not be classified as safe or unsafe and then left at that. An activity should be classified along a continuum of risk. For example, drinking water is one of the safest activities you can do. Nevertheless, there are instances in which people choke or drown while drinking water. It does not happen very often, and that is why we see drinking water as safe. Running a marathon is much safer for your overall health than sitting on the couch all day. Nevertheless, training for and running a marathon incurs risks of traffic accidents, injuries, or cardiac events. You can’t tear your hamstring while sitting on the couch, can you? So, there is some risk to running a marathon, but it lowers the risk of other outcomes that are more common in our society, such as overweight, obesity, diabetes, and lung and heart disease.
For many years, smoking was seen as a safe activity until we understood its strong association with lung disease. Then it became risky, but that risk hinged on when you started smoking (lifetime exposure) and how much you smoked. This is the same concept with other activities that are harmful, like using injectable substances, but we in public health seek to reduce harm by recommending that a person who injects substances use clean needles, has naloxone nearby if they’re using opioids, and does it with someone nearby if they overdose. Again, these activities are on a continuum of risk.
Everything Is Absolutely Relative
Next, let us understand the difference between absolute and relative risk. If I tell you that your risk of a blood clot will double if you start using a medication, you might be less inclined to use the medication out of fear of getting a blood clot. But what if that risk was 1 in 1,000,000, and then your risk goes to 2 in 1,000,000 once you start taking the medication? That is a relative increase in risk of 100%, or doubling. Your absolute risk went up by 1 in 1,000,000. Furthermore, you have to look at the other side of the equation: How much is the medication lowering your risk of a bad outcome because you take it? In most cases, medications are licensed for use if the benefits outweigh the risks. In the example above, your risk of a bad outcome should go down by as much as your risk of a clot goes up, or more.
Finally, we need to understand that public health interventions aim to change the dynamics of risk, often without eliminating risk entirely. This is mostly because nothing in the known universe is 100% safe or effective. Vaccines lower your risk of infection, or — if you get infected — will likely lead to a milder course of the disease. (This is true for most people; your mileage may vary.) Other interventions, like needle exchanges or safe injection sites for injectable drug users, are also aimed at reducing risk and not having the user quit completely (though, it would be nice if they did).
Vaccines Will Save Us, but Not All of Us
Many of us who work in public health mistakenly said the vaccines against the novel coronavirus that is causing the COVID-19 pandemic were some sort of panacea. I know I did. I said the vaccines would bring about the end of the pandemic faster than anything else. While that may still be true, it has not been true so far. With the Omicron variant doing what it is doing right now, plenty of people have the right to question the efficacy of vaccines. However, it is my sincere opinion that they are questioning more because we held vaccines to a very high standard a year ago. Had we properly explained that vaccines lower the risk of infection and severe disease if the infection happens, we could have managed the expectations of the public much better than we did.
Perhaps it is time to include a dedicated curriculum on risk in our schools. I’m certainly trying to teach my preschooler about risk by asking her what is the most probable outcome of some of her decisions. “If you fall and are not wearing your helmet, would it be more painful than if you wore your helmet? Yes? So then wear a helmet, please.” Or, “we have gotten up and looked under your bed for monsters many times. What is the probability that we’ll see a monster this time?” We’ll discuss more advanced concepts later.
Program Our Autopilot to Account for Risk?
At the end of the day, we do what we do without thinking most of the time. People who are afraid of flying have an irrational fear of it, so it is difficult to try and rationalize things to fight that irrational fear. Teenagers with raging hormones hand over control of their actions to the more “autonomic” part of their brains. And people for whom life hurts will seek a way to ease that pain. What we do to respond to those fears, those urges, and that pain — and how we do it — will determine the level of harm we cause ourselves and each other. Without understanding the risks of the actions we take to do harm — and especially to reduce it — we will continue to make the same mistakes that end up hurting us.
A previous version of this blog post was first published on my Medium.com page. Go over and check out some of the other stuff I’ve written: https://epiren.medium.com