It’s not quite “forget the economy,” which will never be a slogan in this White House, but look beyond it, Alex Azar argued on yesterday’s State of the Union. The economic issues themselves have profound public health impacts, Azar tells CNN’s Jake Tapper, which means we are actually balancing between two competing public-health strategies. Do we continue to crash the economy for a virus without any end in sight when the economic crash might well turn out to do more damage than COVID-19? At what point do we cross that threshold?

Furthermore, Azar continues, this is less of a national policy question than it is a local choice:

TAPPER: Let me ask you. Forty-eight states will have eased restrictions in some form or another by tomorrow. It’s unclear how many of these states have actually met the White House task force guidelines to begin phase one. But I want you to take a look at some of the images we’re seeing around the country, a crowded bar in Wisconsin, a boardwalk in New Jersey, another crowded bar in Ohio. Does it concern you, as health secretary, to see these images? Is the U.S. reopening in a way that won’t bring back a spike in new cases and deaths in a few weeks?

ALEX AZAR, U.S. HEALTH AND HUMAN SERVICES SECRETARY: Well, Jake, thanks to the president’s historic response efforts here and the collaborative work of governors and our heroic health care workers on the front lines, we are in a position to be able to reopen now. The president has left it up to states to know their local situation the best. And so it’s very hard to judge in any community whether a bar being open, a restaurant, a school is the right thing. That’s why the local leaders lead this, the states supervise it, and the federal government provides expertise and support from our level. It depends so much on what the disease burden is. In almost half of our reporting counties, we have had not a single death. Sixty-two percent of our COVID cases come in just 2 percent of the reporting counties in the United States.

So, these are very localized determinations. There should not be one- size-fits-all approaches to reopening. But reopen we must, because it’s not health vs. the economy. It’s actually health vs. health. There are serious health consequences to keeping us shut down, whether it’s the suicidality rates, or if it is cardiac procedures not being received, cancer screenings, pediatric vaccinations declining. All of these are critical health needs that are part of reopening the economy.

Azar’s correct to frame the argument this way, and we already have data on that in place. If you haven’t read my earlier post on the shutdown’s impacts on hospitals, be sure to read it now. One stated goal of the shutdown was to conserve health-care resources in order to focus them on the COVID-19 response, especially personal protective equipment (PPE) that was in short supply. The practical impact of that was not just to deny all sorts of routine care and treatment, but also to rob hospitals of the economic resources that keep them in operation. If this continues for much longer hospitals will shut their doors — and what will that do to public health?

Tapper’s concern over irresponsible behavior is certainly a germane point, but this too could be seen as an unplanned artifact of delayed reopening. Americans initially cooperated with the shelter-in-place orders because they had a specific goal in mind — delaying the inevitable transmission of the virus until health-care resources got put in place. As those restrictions got extended, those goalposts got moved to “until the virus goes away,” and many Americans felt as though they’d been taken in by a bait-and-switch. It’s no small wonder that some of them have decided to stop abiding by the restrictions as a result. The slower that states roll out a rational return to normality, the more we will see “irresponsible” actions by people who are simply not going to sit in isolation for an indeterminate amount of time.

That issue isn’t with “reopening” but a refusal to reopen promptly. Shutdowns are unsustainable, and attempts to keep extending them will result in growing rebellions to them. That also isn’t good for public health, in part because it will increase transmission of the disease, but also because widespread low morale and resentment toward authority will create all sorts of other unhealthy behaviors as well. Tapper’s example here isn’t a symptom of a too-early reopening — it’s a symptom of a too-long-delayed reopening.