Pandemic “Retrospective”

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Zachary Karabell (ZK): What could go right? I’m Zachary Karabell, the founder of The Progress Network. And I am joined as always by Emma Varvaloucas, the executive director of The Progress Network. And we are having a series of engaging conversations with what we hope are engaging members of The Progress Network about some of the crucial issues of our moment, with the perspective of what could go right? The idea that we are faced as always, and as human beings always have been, with a series of existential challenges to the world as we know it, and to the world as we want it to be, but that we are all in the process of trying to create, I think, the future that we hope for and not the future that we fear we are entering into. And one of the things that has clearly been top of mind and top of body and top of every society for the past two years is the challenges of COVID and a global pandemic that multiple societies, including the United States, have either risen to or failed to rise to in the way in which they could have, should have, or would have had things been different.

So we’re gonna have a conversation today with two of the people who really have been front and center in both analyzing what’s going on and in making public policy in response to what’s going on. As a way of provisionally two years in—and hopefully we won’t have this conversation four years in, two years from now—as to what we’ve learned from what’s happened and some thoughts about where that places us going forward. So Emma, tell us a bit about who we’re gonna be talking to today.

Emma Varvaloucas (EV): Okay. So our first guest is Nicholas Christakis. He’s a social scientist and physician at Yale University where he directs the Human Nature Lab and is also the co-director of the Yale Institute for Network Science. His work focuses on how human biology and health affect and are affected by social interactions and social networks. He’s also the author of Apollo’s Arrow: The Profound and Enduring Impact of Coronavirus on the Way We Live. He’s one of the first people that I know of who called that the pandemic will last into 2023, 2024, as we see it doing now. And he made that call in that book.

Zeke Emanuel is an oncologist and a world leader in health policy and bioethics. He’s a special advisor to the director general of the World Health Organization, vice provost at Penn University. He served on the transition COVID task force under Biden and was also an advisor to the Obama administration. He’s the founding chair of the Department of Bioethics at the National Institute of Health. And he’s also the author with other experts of a recently released roadmap to help guide the US to the pandemic’s next normal.

ZK: So with that, let’s have our conversation with Nicholas and Zeke.

So I’m so excited to be having this conversation with both of you, and of course, with Emma today. There has been nothing more front of mind, and front of all of our collective experiences over the past two years, than the COVID pandemic. And one thing that I am chronically struck by and remain struck by, but I don’t think we will digest fully for years, is the degree to which, for all else that this was, it was the first time in collective human history that all humans on the planet simultaneously experienced the same crisis in real time with transparency and visibility into how other groups of human beings were also dealing with the same crisis. You know, not World War II, certainly not the Black Death, all this enhanced by the communication techniques and technologies that have become so prevalent. And that alone has shaped our collective understanding of what all this is in ways that I don’t think we can fully grasp right now, given that we are still partly in the midst of this. And it was such a new thing.

I’m just framing that because I think that’s something, you know, to kind of think about in the back of our mind. And the way in which we are able to compare ourselves to other societies and other societies to each other, you know, all of that is remarkably new, in real time, as well as the fact that our tendency to want to make “insta-conclusions,” right? The sprint rather than the marathon aspect of all this has equally been a problem. Because we wanted to make conclusions, you know. “Sweden Got it totally wrong,” or “the United States got it totally wrong,” or “China got it totally right.” And all of those are just moments in time. And maybe those are the right conclusions.

So my question for the two of you to begin, because it is at least part of the mix as we are having this discussion and likely part of the mix when people are listening to this discussion, is that there is an emerging sense that, whatever a pandemic is, that that phase of whatever COVID is and will be is transitioning into something other than a pandemic. First of all, do either of you agree with that? Do the words even matter [laugh]? Meaning, does it matter whether we call this one thing versus the other, or is the challenge the same? And is the very fact that that proclamation—I think we’re recording this on a day when Anthony Fauci has said that we’re exiting the pandemic phase.

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Is the very need to like, you know, create these moments in time, codify them and put them in neat little boxes, itself an issue in terms of how we deal with these things?

Nicholas Christakis (NC): For me, it’s looking at the history of plagues, and looking at the history of respiratory pandemics. So plagues going back thousands of years and records regarding respiratory pandemics going back at least a hundred—in some cases, 300—years, I actually think there are phases of pandemics. And I think we are, you know, we’re not approaching the beginning of the end of this pandemic, but we are approaching the end of the beginning. And I like to think of these pandemics as having three phases. And honestly, we were talking before we started recording about logging the accuracy of people’s predictions. Here’s a case where I would like to take a win, where in October of 2020, I said there are gonna be three phases, and we’re gonna be in the first phase until 2022. And this is exactly what’s happening.

So the first phase of the pandemic is when we feel the biological and epidemiological shock of the virus, as this new pathogen has an ecological release and spreads and spreads and spreads among us, until we reach herd immunity. Which ideally one does through vaccination. But in the pre-vaccine era we would reach this so-called naturally, by death. People would die and those who survived would be immune. And then the disease would become endemic. And in parallel to that, often the pathogens would evolve to be more benign with time. This is a theory, but it is often true because from the point of view of the germ, it doesn’t, quote, want to kill us. Killing us is inefficient from the germs point of view. It would rather sicken us and have us be ambulating and infecting others. Those variants of the pathogen that do that come to predominate. So for those two reasons, eventually the pandemic becomes endemic and then plateaus, and the epidemic force is nullified. And that’s the opening act, the initial phase.

And then we enter the intermediate phase of the pandemic, which in this case, I think will last from 2022 to around 2024, which is when we clean up the mess: the clinical, social, psychological, and economic aftershocks of the virus. It’s like a tsunami washes ashore and the water spreads inland causing destruction. And eventually that stops and the water recedes, which is great, but now we’ve gotta clean up the mess. And I think that’s the phase we’re entering now. Five times as many people as die of the pandemic will be chronically ill from this. We’ll have some kind of disability, approximately. Those people will need clinical care. Our healthcare system will need to deal with them. We’ll have millions of people who are bereaved and people who lost their jobs. Children—We’re gonna be catching up with the educational deficits of children for a very long time to come. And I think that intermediate phase will take a couple of years, until 2024, approximately. And then finally we’ll enter the post pandemic phase, which I think is gonna be a little bit of a party, a Roaring Twenties of the 21st century, like the Roaring Twenties of the 20th century. I think people will relentlessly seek out social interactions, will spend their money liberally. I think we’re gonna have an efflorescence of the arts and so on.

So I think that’s very typical, and I think we are actually following that path. And I’ll say one more thing and then I’ll shut up—I think that that all is with a proviso that we do not have the emergence of new, more worrisome strains of the virus, that if we were to have new strains that were materially more deadly or materially evaded the vaccines, which I’d put at between a one and 10% chance of that happening, then all bets are off; everything I just said won’t happen, we’ll be back to square one, I think, in terms of coping with the epidemic. So yes, I actually think we are transitioning to a new phase of the pandemic right now, here in early 2022.

Zeke Emanuel (ZE): Yeah, I think… I don’t have a crystal ball the way Nick does. I think he’s predicting all the way to the end of the decade. I’m nowhere near…

NC: Till 2024, Zeke. Give me a…

ZE: You went all the way into 2026 [laughs].

NC: No, I said to 2024. And anyway, I said this two years ago, and it’s been happening as predicted. But go on.

ZE: I do think that we are in a phase transition. How long that transition takes, I think it’s premature to say, you know, we’re in the endemic state. And in part, I’m hesitant because of Omicron. We were all focused on Delta, and then literally out of left field, no one tracking it, comes a completely different viral variant that, you know, spreads much more rapidly, et cetera. And is that possible? You better believe it’s possible again. And we just don’t know. And we have a few Omicron variants—BA.4, BA.5—that could turn out to be problematic. And we have no idea how big that surge is gonna be. Everyone, you know, sort of poo-poos Omicron compared to Delta, but lots more people got it. And as a consequence, you have a lot of hospitalization and death, even though per person it’s not as virulent. And we did overwhelm systems and go into crisis levels of care.

So I’m a little hesitant to you know, declare victory so soon. We’ve been burned before. What I worry about, and here, I’m gonna shift a little, is I think what we’re experiencing now tells you something deep about human nature, which is we can change and put ourselves in a pretzel and really redo our lifestyles, but that can last only a few years. And then we bounce back. And to switch metaphors, from pretzels to rubber bands, we have to go back into social life. And I think, too, you know, I don’t know what it is cause I’m, I haven’t thought it through enough, but there’s something biological about, you know, we can’t have this sort of social isolation and all the other things that we’ve experienced and do it for more than two years without going batty.

And it’s true of me, you know. Two nights ago, he had dinner on our porch with five other people. And it was like, wow, this is feeling so good [laugh]. Because you know, regular conversation, people weren’t crazy, worried. And I think whether the virus comports with us or not, people are just so urgently having to get back to normal that I think even if we had a surge, it would be very hard to get people to adhere to any public health precautions,

NC: Unless it was much deadlier, right?

ZE: Yeah.

NC: And see, this is the thing. Our time in the crucible in the 2020s with our pandemic in our lifetime, it’s sort of a plague lite, right? I mean, it’s not the smallpox or the cholera or the bubonic plague or the Ebola of other historical periods or other groups. It kills half a percent to 1% of the people. But if it mutated to kill 10%, I think there would be a lot of political will and interest to take more stringent measures again.

ZE: I would say that’s right. And even if it didn’t go to 10%—if it went to 1% but affected kids under 12, for example—yes, everything would change. Again, I agree with that.

EV: So hopefully we’re not gonna have such an event occur. But given this discussion of, we’re not sure what variants are gonna do, you know, we’re hoping that the variants are gonna continue to be milder and not be something like, you know, the killer effectiveness of Ebola. But if something pops up that is truly nerve-wracking—Nicholas, you mentioned before that it could happen—where are we, not so much from a cultural perspective of the willingness to go back into extreme measures, but more from a public health perspective, in terms of the infrastructure and even such things as herd immunity and vaccination—where are we as far as dealing with that? Are we in a good place? Are we in a medium place? Are we in a terrible place?

ZE: I would say we’re in a bad place, where bad means we have not had an opportunity to build up the public health infrastructure appropriately, either from a surveillance standpoint or an intervention standpoint. We’ve undercut the trust in the public health health system. And third, we have a completely exhausted, burned-outdemoralized both public health workforce and healthcare workforce. So I actually think if somehow there were another onslaught we would be in bad shape. We’re already to some degree running on fumes. And we would really be… People would be squeezing the last bit of adrenaline out of their adrenal glands. But you couldn’t sustain it for a marathon.

NC: I agree with everything Zeke just said. And I would only add that the one area where we are a better prepared is in the mRNA and adenovirus vaccine technology. So assuming that the rapid prototyping and invention of new vaccines for new variants takes place, which I think is a good bet, and assuming that those vaccines are effective—we got incredibly lucky with the first batch of vaccines that had these 95% effectiveness rates. I mean, most doctors are delighted with vaccines that have 70% effectiveness rates. The Chinese vaccines had 65% effectiveness and people were happy with that. So we got incredibly lucky. So assuming that we can do it, which is likely, and assuming it works, which is unclear that’s different, and to our credit, and might help us. But I agree a hundred percent with what Zeke said about the burnout and, still, the lack of preparedness. Plus, one more thing. With the war in Ukraine, the ongoing supply chain disruptions, it’s unclear we’ll be… You know, let’s say we have to tool up to start making something—tests with particular reagents or more masks or whatever the hell it is that we need to make to combat the virus—it’s really unclear if the global supply chains will allow us to do that again. So it’s a concern.

ZE: But this also goes back to the other thing which, I’d say, of all the things that keep me up at night, this is one of them, which is the urge by American society to move on. And the urge to not devote the resources. And we’ve seen this in Congress, not to devote the resources, the attention to fixing the problems that exacerbated and made this pandemic so much worse. And again, putting in the right infrastructure for surveillance, putting in a better public health effector arm so that we could go to isolated, vulnerable communities with community healthcare workers, and on and on. We have the tendency to [say] “I’m done with that.” And “done” means I’m not paying attention. And the solutions we put into place—other than the mRNA, because it’s been so hugely profitable and incredibly impressive—we haven’t put the infrastructure in place in addressing the problem. We could upgrade indoor air quality, and God willing we will, and that would be an infrastructure change that would be really positive for respiratory viruses. Maybe we’ll put in some aspects of surveillance, coordinated wastewater surveillance that’s standardized. But the whole gamish that we really need, yeah, you know, I’ve thought a lot about what we need, but I’m skeptical America’s got the attention span to do it, frankly.

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ZK: Zeke, you wrote a little more than two years ago about assessing the world’s best healthcare systems. And if you’d looked at your book then, and countries that have done well since, there’s a pretty good correlation there. I mean, you sort of looked at Germany, you looked at Taiwan, you looked at Switzerland. Not all those… Switzerland probably didn’t do as well. Taiwan obviously did exceedingly well. And I guess my question for both of you, and something I’ve thought about during this, is as much as we are, certainly as Americans—and we are in this particular conversation American, although Emma is in Greece, Nicholas, you have that heritage; we all have a different background. But let’s sort of say like, there’s a lot of commentary that says America did this well and that well, or [did] that badly and other countries did better. If you really stepped back, if you were the proverbial Martian looking at the human race, the societies that did, at least as of this moment in time, a bit better in managing both death and cases and social cohesion tended to be either islands communitarian, or authoritarian. Full stop.

ZE: Well, I don’t know about authoritarian.

ZK: I said tended to be one of those.

ZE: Yeah, I’m not sure I agree.

ZK: Well, we’re not sure. Right. And maybe we don’t know how China ended up doing. I would say Singapore has an authoritarian, communitarian quality. But that’s another episode of What Could Go Right? That’s a strength, you know, when you need people to behave collectively, when need them to do what they’re told, when you need them to do all these things. Do you really feel there’s a way in which a society can simultaneously have those strengths and also have the strengths of a messy, angry, chaotic, but often vibrant, innovative democracy. I mean, isn’t some of what we’ve screwed up also, in a different set of circumstances, the things we excel at?

ZE: So Zach, I would say that the example you’re looking for probably is Israel, right? Talk about messy, chaotic, where cacophony is the order of the day. And they have a lot of political divisions, a very strong right–left division. But I would say there are good studies where, you know, societal trust was the key ingredient. And America, for almost all of its history, had huge cacophony but had a lot of societal trust. Political cacophony, cultural cacophony, and trust can go together. We don’t have that at the moment. And we have, I fear, greatly, an institutional structure that is ripping and undermining any possibility of trust. And that’s, I think, a large part of why we did poorly. I don’t think it was our political cacophony, our cultural diversity.

I mean, we had a lot of that cultural diversity at other times, but we had a lot of trust, which we don’t have now. So I would say that, I think, besides [inaudible], which I do think there’s a strong element of that communitarian [element], I think what works is the trust element here. And I think that’s where we have fallen down. Now, there are many things that have contributed to it. But I would put Facebook, Twitter, Instagram Fox News at the center of the process. I think Jonathan Haidt’s article is, you know, it’s not the definitive work, but I think it’s a very good and insightful thing worth reading.

ZK: Zeke’s referring, of course, to the widely read recent Jonathan Haidt article in the Atlantic about why the past 10 years of American life have been uniquely stupid. That’s the title of the article, not my characterization of it. The other question that pertains, given that you’ve looked at the history of plagues and how society’s have dealt with them is, I don’t know, have we actually done that badly? I mean, relative to most of human history, maybe we actually did pretty well. We just underperformed what we actually could have done in the present.

NC: I don’t know. I mean, the United States definitely has underperformed. Our per capita death rate is three times Canada’s. It’s about 10 or 20 times South Korea’s. These are populations of, you know, broadly similar wealth and similar age structure. The fact that Kenya might have a lower death rate than us is not as impressive because their median age is 18 or something. Our median age is in the thirties. And this virus kills the elderly much more. So we have underperformed.

And then if you just look at the intrinsic infectiousness, [which] is measured by the R-naught, and the intrinsic infection fatality rate of the pathogen, which is a God-given property of the virus—that’s how it emerged—and you just did a little envelope calculation on how many Americans would’ve died, we probably have maybe half as many Americans that have died. About a million Americans have died so far; maybe as many as 2 million would’ve died if it had just ripped through our population and we’d done absolutely nothing—if it had been medieval times or something. But even that, with 2 million deaths which is bad, it’s less than 1% of our total population. So I go back to the thing I said earlier. We’re actually lucky in a way that, because of our incompetence, we are facing a kind of plague lite.

Now, one more thing, and then I’ll shut up. In a way, this virus was almost perfectly calibrated, quite apart from the social dynamics that paved the way for the virus to harm us the way Zeke just spoke about, the virus had its own biological dynamics that paved the way for it to harm us with exquisite precision. Because it was just deadly enough to really harm us, but not deadly enough to galvanize us to really do what we needed to do to respond to it. And the virus had a number of other properties as well, which clouded the public health response. Zeke mentioned a moment ago that, you know, the trust in public health institutions in general and in public health actors in particular has been low, partly [because of] self-injury, right? That we’ve not been as forthright with the public. And here, I don’t mean mistakes. I mean public health experts, scientists make mistakes. That’s okay. But we could educate the public about that. Say if I change my mind. I told you that this wasn’t good, but now I’m doing something different because new facts have come in. That’s the way science works.

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If we’d been able to educate the public about how science works. And if we had been able to articulate our reservation, the limitations in our knowledge, all along the way, I think we would’ve preserved credibility better. And if we had been able to tamp down a little bit on some of the charlatans among us this would’ve helped. Anyway, the point I’m making is that, bad as this virus is, it’s not sufficiently bad that we took it as seriously as we could. We were hampered by the public health credibility and institutional limitations. So we did pretty bad, I would say. In my judgment. And some people say, well, what about Germany or England? They also did poorly. And I’m not particularly jingoistic, but, you know, I expect more from the United States of America.

And we had the great misfortune—and I don’t think… For some listeners, maybe this will strike them as political, but I don’t think it is—I think we had the great misfortune in the previous occupant of the White House, who honestly did a terrible job. Now, so did some democratic governors. I don’t think Cuomo or de Blasio did a good job in New York City. And I was saying it at the time. But the president, Donald Trump, was appallingly incompetent as this pandemic was bearing down on us. Not preparing the nation. Not getting ventilators. Not buying PPE. Friends of mine were taking care of patients in garbage bags. I mean, it was ridiculous, not preparing the nation morally and sort of practically saying, “Here’s, what’s gonna happen. Here’s what we need to do. We need to work together to confront it.” None of that was done. Instead, we were told, “it’s going away, it’s going away, it’s going away.” Which was a lie. And which was known to be a lie to any expert. And in fact, it was known to be a lie to the president. We now know that the NSA briefed him back in December of 2019 that this was a gathering threat. And certainly experts in the CDC, all of my friends, all of my epidemiology friends in January of 2020 knew what was gonna happen.

And I’ll say one more thing. I remember in January of 2020, I was sitting here at the desk I’m talking to you from now, pulling my hair out, probably like Zeke, and saying, why aren’t people more concerned? Everyone I’m talking to is very concerned. But the politicians aren’t concerned. The public isn’t concerned…

ZK: Zeke doesn’t have a lot of hair to pull out.

NC: Well, he can pull out the sides.

ZE: Two years ago!

NC: Yeah, exactly. Two years ago, there was more to pull out. That’s why it’s gone. But the point is, I was sitting here at my desk saying, how is it possible that I, Nicholas Christakis, know more about what’s gonna happen than the president of the United States? This makes no sense. And in fact, he did know, and did nothing. And I think, you know, hundreds of thousands of Americans… We would’ve lost 300,000 or half a million Americans, I think, no matter what we did. But I think we definitely had… Several hundred thousand deaths can be laid at his feet, in my judgment.

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ZE: Can I respectfully disagree with Nick on this one point? And I don’t think the larger point we do disagree on, which is, the problem of having this pandemic occur when Donald Trump is president is that Donald Trump is a divider, not a uniter. If we had a president who was a uniter—and I will think of, you know, John Kennedy or Bill Clinton as those kind of presidents—we might have had an opportunity to take this pandemic and bring the country together and overcome the cultural divisions we were having. That the president at the timeDonald Trump, has no such instinct—his entire modus his whole life has been taking advantage by dividing. And that cost the country—I think Nicholas is a hundred percent right—that cost the country three, four, 500,000 additional deaths. And it’s terrible. And not to mention the larger number of cases, the large number of long COVID, and all the other stuff that it caused. And, you know, again, a huge missed opportunity.

EV: I do wonder exactly how much Trump was the cherry on top. Just for instance, you know, thinking about Greece, the prime minister right now, Mitsotakis, is not a divider. He’s not a Trump type of guy, but there are very low levels of social trust in Greece, and Greece is also done poorly. So just to gently push back on, like, how are we to know how much blame to lay at the feet of Donald Trump, if you’re already in an environment where trust in the media, trust in the government is low?

ZK: Combined with the outcomes in 2021, which yes, no one expected Omicron to come with the virulence that it did. I mean virulence in terms of infectiousness, not necessarily virulence in terms of mortality. But it’s not like the United States magically did really well in 2021. Now, you could say, look, the cake had been baked, or the ingredients had been put in place and therefore redirecting that magically in February of 2021 on the heels of the political insurrection and incredible divisions would’ve been kind of impossible. You can’t just like recreate social trust in a month, although societies are weirdly resilient and things actually do—Zeke, you used the rubber band analogy—sometimes snap back extraordinarily quickly. And we didn’t do that in 2021.

ZE: I think you’re right, but I do think there are two things going in. One is I do think the divides were solidified in 2020. Remember, it was a whole year, exactly a year, that he was in office. And I will say the Biden administration came in with a game plan, and they executed on the vaccines and did a really good job ramping it up. If they made a mistake, and I think they did, it was putting all their chips—they were at the roulette table, and they put all their chips on vaccine. And they should have diversified the portfolio more. And that, I think, was their fundamental mistake. You know, all their chips may be a little exaggeration. They had a few chips in other places, but they didn’t have lots of chips in other places. They thought, if we get the vaccine out, we’ll be protected. And it turned out not to be the case. Some of us sort of thought that was likely to be true. Andanyway…

I actually think there’s a lot more to blame Donald Trump and the kind of environment he created and fostered. His resistance to coming out and saying to people that he got vaccinated, it would’ve changed everything if he had done it on TV.

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ZK: So let’s turn this hook of more recent stuff. And I wanna bring up something that remains hugely divisive and controversial in the United States in particular, which is the whole question around masks. And to what degree masks are a potent weapon against the spread of a virus, a potent symbol that you care about whether or not other people get the virus a political flag of sorts that sort of marks out, you know, what side of the angels or the devils you’re on. It’s become all these things simultaneously in a way that’s quite confusing. But I wanna quote from one of your colleagues, Zeke, Michael Osterholm, who, I don’t know if this is a quote from him per se, but it’s a quote from the report that the University of Minnesota put out on kind of looking at masks and efficacy of masks, which came out at the end of 2020.

And for those people who are not aware, Michael Osterholm, as I think you’d agree, Zeke, has been as much a COVID hawk as any human who’s been in the public realm. But the conclusion of this was, “it should be well known by now that wearing cloth face coverings or surgical masks, universal or otherwise, has a very minor role to play in preventing person-to-person transmission. It is time to stop overselling their efficacy and unrealistic expectations about their ability to end the pandemic.” Which seems a rather unequivocal conclusion. And it doesn’t speak to whether or not there should have been and should in the future be a universal K[N]95 or, you know, a high-quality mask mandate that is then enforced.

EV: Zeke is waving his N95. [Laugh.]

ZE: I’m waving the N95. First of all, I think the CDC has got masking wrong from day one, and I think has done a very great disservice to the country, unfortunately, on masking, by not saying that aerosol spread was the method of spread and that we could do a better job, and then say we gotta preserve all these masks for the healthcare workers. The fact is, there is a progression of the quality of masks from nothing to cloth to surgical masks to KN95sto N95s and N95s that are fitted. If both people are wearing high quality N95 masks, right, and one of them’s infected, they can be in the same area for about six hours, right? On the other hand, if both are wearing nothing, it’s about 15 minutes [laugh]. That makes a huge difference, right?

And if I’m wearing an N95, but you’re not, you’re wearing nothing, right, I can be near you for an hour before transmission is likely to happen. So the quality of mask is definitely there. And again, the CDC was slow in recommending masks and slow in emphasizing that quality matters. Cloth is really, I won’t say worthless, but well-nigh worthless. Surgicals are slightly better, but because of the way they put the loops around the ear, it opens up for transmission. You really need a good N95 with a thing around the nose. And you can buy them NIOSH-certified produced in the United States. They’re not that expensive, and the government can send them all out.

EV: It does go back to this question that we were talking about in the beginning of, you know, moving into the intermediate phase of the pandemic, or Fauci calling it moving out of the pandemic phase of the [inaudible]. But how long are we expected to wear KN95 masks out and about in our daily life? Like, until when would we do that under scientifically ideal circumstances?

NC: Well, I think I’d like to answer that question indirectly, which is to bring up this whole notion of the Swiss cheese model of pandemic defense. And this is a model advanced by James Reason about 30 years ago, to talk about the breakdown of complicated sociotechnical systems, like nuclear power or medical error. One of the classic applications is to medical error. Why are patients injured in hospitals? And it’s usually a breakdown of multiple failsafe systems. So each system is good, but not perfect. And he developed this model of… A so-called Swiss cheese model, which is, you have different layers of defense, each of them has a few holes in them. And these holes are randomly situated in the piece of cheese and of random size. And you should have the intuition that if you stack up three or four pieces of Swiss cheese, by the third or fourth slice, none of the holes will align, and you’ll get an impermeable barrier by the time you have four pieces of Swiss cheese stacked, let’s say. One layer is not enough.

So you can think about everything we do to respond to the virus as a piece of Swiss cheese. Vaccination is a layer. School closure is a layer. Border closure is a layer. Testing is a layer. Masking is a layer. Quarantine procedures is a layer. And every one of these is a layer. And no one layer is enough. So vaccination is great, but we all know vaccination is 95% effective. It’s fantastic, the mRNA vaccines, but not a hundred percent. So maybe people might want in this intermediate period to use some additional precautions. So for example, Zeke said earlier he met with his friends outdoors to have a meal. Everyone’s vaccinated. You have an outdoor meal. You’ve got that extra layer of ventilation. You’ve got vaccination, you’ve got high ventilation because you’re outdoors. That’s probably enough, actually, to protect you adequately. It doesn’t reduce the risk to zero, but it’s good enough. So the answer to the masking would be, if you’re using a good mask—and Zeke just summarized the literature quite well, I thought—if you’re vaccinated and you’re getting out of your car to pump gas, I don’t think you need to put your mask on. If you’re going into a rock concert with 10,000 people you don’t know then you know, you might wanna put your mask on. I mean, it just depends, is the way I would put it.

ZK: So my pushback to that would be last week and the week before, in Coachella, California, which admittedly was outside, you had, I don’t know, 250,000 people in a densely, dancey, druggy, bacchanalian, saturnalian haze.

NC: I’m sorry, and you were there?

ZK: No, I was in Los Angeles at the Los Angeles Times Book Festival, which was a non-drunken, non-bacchanalian, non-saturnalian…

NC: Okay. [Laugh.]

But it had 150,000 people, and mask use was not high on the list of things that people thought was essential to their attire. Much more at the book festival, which makes sense, given the demographic, and much less at Coachella, which probably also makes sense, given the demographic. And I guess the question is—the Swiss cheese analogy is a brilliant one, and I think you’ve used it before, and I think it’s absolutely the one to keep in mind. The problem with the mask debate from my perspective has been, it’s a little like the abstinence debate. There’s no question that abstinence works, but it doesn’t work as social policy because people don’t behave that way.

There’s no question that universally enforced high-quality masking in all indoor settings at all times from early 2020 would’ve been a massively advantageous thing for all societies, right? Universal high-quality masking in all interactive situations, all the time. Full stop. But given that human beings don’t behave that way—again, back to the abstinence analogy—and that COVID, particularly in Omicron, was so unbelievably contagious that it was much like if you don’t use it universally, it’s like—and correct me if I’m wrong about this, but the analogy I’ve used is, it would be like saying it’s a good idea to use an umbrella when it’s raining. But if it’s a torrential rain and you go out 10 times and you use your umbrella eight times, you still get completely soaked. Meaning, it didn’t doesn’t matter that you used at the eight times. It matters that you didn’t use it the two times.

ZE: Wait, wait, wait, wait, wait a second. First of all, I think we did not tailor the public health interventions we did to the circumstance and do what Nick said. If we were doing what Nick said, you know—you can probably see in the background, my HEPA filter back there, right? We would have HEPA filters running indoors. We have good data now from Addenbrooke’s hospital in Cambridge about the efficacy of taking the SARS-CoV-2 virus out of the air by HEPA filters. And we would upgrade, that’s the first thingso that we reduce that element of transmission. And then masks in the right circumstances would be advantageous. And when you said society doesn’t work that way, that is false, right? American society with lots of cacophony about my rights. But have you ever been in South Korea or Japan in the winter seasons? Everyone’s wearing a mask.

You are the oddball if you’re not wearing the mask. And what happens then, Zach? You wear the mask. Even if you don’t like it, you wear the mask because none of us—well, I won’t say none of us, but many of us don’t like being the oddball. There are some of us who like being the oddball, but that’s a minority, and we can deal with that minority. Part of the problem is the polarization we put around masks and the bad information that we had. So again, I think that if I had to do one thing on the transmission side of the world, it would not be focusing on masks. It would be focusing on indoor air quality and really souping it up between this and UVC lights. That’ll make a big difference. It’ll make a huge difference.

NC: I think one of the legacies of the pandemic may in fact be a new paradigm of clean indoor air. Just like we had clean indoor water a century ago. You know, expect when you go to a public building that the water that you drink out of the faucets will be clean. But that’s a legacy of public health interventions a hundred years ago. And I think that we may see that increasingly. Especially if we get another pandemic in the next 10 years, I think the public may say enough is enough and be willing to commit resources to it. Or unless the cost of outbreaks… I think we’re at the point now where firms have not calculated or seen adverse enough impacts on their employees or their customers from outbreaks at firms to make it worth their while. If you’re a restaurant that goes out of business because you’re pasted in the local news because there was a COVID outbreak. You might say, “Hey, maybe I should spend some money and get this device.” Or if your employees are constantly missing work because they’re getting sick at the office, you might find that economic calculus to work. I don’t necessarily think we’re there yet, but I think we may get there.

EV: I’d like to go back just for a moment to the social trust and the misinformation conversation. I mean, I think there’s certainly no denying that there is a huge social trust and misinformation problem in the United States, but I was wondering what you both think of there being another side to the story about that, which is just that, for instance, you know, Nicholas mentioned prior in the conversation something about the R-naught with a virus. Two years ago, I would have 0% knowledge of what he was talking about. Now, I’m 80% reasonably sure that, like, I know what he meant. And I have absolutely no background in science. I’m just a normal layperson. And I think there are really large swaths of the American public that, despite the people that fell prey to misinformation, despite, you know, viewers of certain TV networks out there, we all now have a much stronger public education in science and a sort of direct access to scientists in a way that we haven’t had previously. Is there a positive to that? Because I feel like that’s not sort of well-discussed.

ZE: So I would say one of the things it does do is highlight the absolute terrible science education and biology education that educated people like yourself have gotten and can get and can graduate college with. You know, I’m actually… I think, Nicholas, you’re a University of Chicago product.

NC: Well. No, I went to Harvard Medical.

ZE: But on the faculty.

NC: Yeah, on the faculty. Yeah.

ZE: Yeah. You know, I think there’s like a core of education we all ought to have. And knowing something about the biological world, including evolution and how it might work at the viral level, would’ve been really important, had people just had that and understood that the way they understand two plus two. And by the way, it doesn’t require complicated math. I mean, there are some ways in which it requires complicated math, but it doesn’t all require complicated math. In any case, I think we have gotten educated, and you’re right, people know what R-naught is. People understand about viral variance. We understand about mutations better. But you know, we should be getting that in high school and college, I think, as standard fare. And the fact that, I don’t know, it’s now 160 years after publication of On the Origin of the Species, we still have lots of people who don’t understand evolution, who don’t understand it at, you know, sort of a basic DNA, molecular level. It’s 60 years since the publication of the double helix paper, and we should be doing better in this kind of education, which is really important for people to understand, to be facile in the conversation of the kind of things that are affecting our society.

ZK: So Zeke, that is a perfect segue into an issue that I’ve wanted to get into. And that is the question of public health messaging, and public health messaging during the pandemic in a way that we need to learn something about, particularly if Nicholas is right, that look, we could be facing this in 10 years, and this could get worse. And I’ve felt, as someone who is credentialed, but not credentialed in those areas, that there has been kind of a dangerous cult of expertise that was certainly fostered within the media, that there are different levels of expertise. Nicholas, you’ve got a PhD in medicine. Sorry, you’ve got an MD in medicine and a PhD. There’s a difference in, like, I have no idea how to create an mRNA virus, and most people who are not steeped in biochemistry do either. But being able to read and understand statistical analysis, which is part of what epidemiology is, you know, there are a wide swath of people who have that kind of expertise. That is not limited to, you have to have a degree in epidemiology. And the degree to which we siloed inputs into, how do we collectively decide what we collectively are gonna be doing, and that if you didn’t have X letters after your name, you were therefore not allowed to have an informed view, I think made it very difficult… I mean, it made it very difficult to steer a collective public policy. I mean, is there something to be learned from that? Am I wrong in that?

NC: Well, I would say two things about that. I don’t know what you mean by a cult of expertise.

ZK: That was rhetorical and probably hyperbolic, but it was meant to spur a conversation.

NC: No, but I think there is expertise in our society. In fact, that’s how all economies have been organized almost since we invented cities 8,000 years ago. There’s a famous saying in sociology that one man’s occupation is comprised of another man’s disasters, emergencies. You know, when, when your hot water heater breaks in your house and your basement is flooding, it’s an emergency for you, and urgent. But for the plumber that comes to your house to fix it, it’s his routine bread and butter. And you’re delighted to pay the plumber money to fix the problem. Same with the car mechanic, same with a cabinet maker, same with an infectious disease doctor, same with a lawyer, same with everything. That’s how our whole economy’s organized. The exchange of goods and services manufactured by people with specialized knowledge in the division of labor.

And the same holds for epidemiology and knowledge about infectious disease and medical history. I mean, we are a wealthy 21st-century democracy with institutions where there are people who’ve devoted their lives to studying the history of epidemics, or epidemiology or vaccinology or virology or immunology. All of these people who have deep expertise in these areas. So the cult of experts, I’m delighted that we have them, and we’re lucky as a rich nation to have such people and to live at a time when we’ve accumulated all this knowledge, which we can deploy to save our lives. The challenge is to educate the public to the inexorable reality that scientists don’t always agree, that there are experts but they sometimes disagree. And that’s okay, too, right? And this is where we failed.

What we could have done, or should have done, is said, “look, there are some topics about which the experts are in consensus. And not only that, don’t just take their word for it, here’s the evidence that they can educe to support this claim, which you as a layperson can access.” Say, “okay, they’re all saying the same thing. And here’s why they’re saying it. I’m gonna believe them.” Or, “here are experts who disagree. Here’s why they disagree. And now, unfortunately, you either have to pick who you’re gonna put your trust in, or make your own mind up about it, but you should not lose confidence in the notion of expertise as a result.” You know, that’s like, if me saying, “okay, well, one mechanic said this is the problem with my car, and another mechanic said this is the problem, therefore, there’s no such thing as auto mechanics.” That’s false. There is actually a reality of how the car works. It’s just that these two experts happen to disagree on this occasion. And so this is one of the things I think that political leaders could have done and should have done. And it gets back to the point that Zeke made earlier about how we don’t have a kind of consensus capacity, you know, kind of a capacity as a society to put our trust in particular institutions. And so, anyway, that’s my answer to the expertise question.

ZE: Look, we all rely on expertise, whether we’re willing to acknowledge it or not. Right? And we rely on it in all sorts of ways. And so, I think it’s just a fact. And mostly experts agree on 90, 95%. And at the cutting edge, the bleeding edge, there is gonna be disagreement, where we don’t have clear data, where we haven’t experienced this before, where this is a coronavirus pandemic. There’s gonna be uncertainty, and uncertainty is gonna manifest itself in different interpretations of data, different recommendations, et cetera. In any case, I do think we have to have expertise. And unfortunately we know… And this is like old as old can be in America, right? We’re suspicious of experts. We poo-poo experts. This was true in Ben Franklin’s time [laugh]. One of the reasons he was never respected in America as a scientist is because we were suspicious of experts and viewed them as elites. And so that suspicion waxes in wanes, and we’re in one of those populous moments where, you know, we have more of it, and it’s to our detriment.

I don’t think our moments when we’re suspicious of expertise are moments of great success. They almost always end badly. Like the Jackson era ending in the 1837 terrible recession, a very prolonged recession, because he got rid of the federal bank.

ZK: Look, you’ve both given a brilliant—and I mean that actually—a brilliant defense of the vital role of expertise. I was, though, also talking about the degree to way which expertise does not preclude non-experts having profoundly meaningful…

ZE: Totally agree with that. One of the things we called for in our roadmap was more public disclosure of the underlying data, so anyone can actually analyze it and come up with insights. And we’ve seen, in this case, lots of people who aren’t weren’t experts in viral spread or epidemiology coming up with brilliant insights. And by the way, I believe one of the good examples to support your point, Zach, is the Netflix competition to come up with a better algorithm for predicting what people would like when it was run way back when. But the winning team had no expertise in that particular area. They just happened to be really smart people who could develop models and had statistical and modeling capacities. And I think there are lots of things in society where if we put out the data and let people play with the data, obviously with, you know, protections, absolutely. We would get fantastic insights from those people.

EV: So, Zeke and Nicholas, it was wonderful to speak to you. Maybe, perhaps in another conversation, we can get to what Nicholas was talking about, the Gilded Age, the Roaring Twenties, what’s coming after the intermediate phase, because that sounds a lot more fun than what we’re going through now. But for what we are going through now, I hope that we can heed the advice that both of you have given to us during this hour. And we will certainly find out what’s going to happen. Fingers crossed. Thank you both.

ZK: Thank you.

NC: You very much for having me.

ZE: It’s been great. Thanks.

ZK: So Emma, I feel like that was one of those conversations, even more than the other conversations, that needed like another four hours. And there were all these other questions I wanted to get into that we didn’t get into. The expertise one leading into… We’ve collected so much data and information about who’s sick and who dies and who doesn’t and who’s hospitalized and… Which we don’t do for anything else in our lives to the degree that we do with COVID. And I wonder if it creates, like that in and of itself, because it’s so out of context with everything else, right? I don’t have a dashboard of flu cases and automobile deaths and heart disease and heart attacks and multiple forms of cancer, all of which are quite lethal and all of which we could probably do a lot more to reduce the lethality of. So I wondered about that, you know, the degree to which we have so much awareness of this particular thing, but the flip side of that is we are much more focused on every modulation of threat.

EV: Well, I think there’s this weird balance there between… It’s a tension that I think that was actually throughout the whole conversation, where it feels like scientists and experts and people in the public health realm are asking people to behave 100% objectively and rationally. And I think this is what you’re pointing to with the abstinence question, or not the abstinence question, but the abstinence analogy, that people don’t behave like that. They’re guided a lot by emotion. And there is a very strong emotion that comes with, you know, looking online every day and seeing how many people have died of COVID, how many people are in the hospitals; the photos of, you know, bodies stacked up that was happening in New York in the early days. And that doesn’t lead you to “let me go through what everyone is saying and come to a good decision for myself.” That leads to something else. And so I still feel perhaps a little bit like, you know, if we’re supposed to trust the experts, but the experts made a bunch of mistakes, and there’s an enormous amount of information happening in a strongly emotive time, what are we supposed to do with that as sort of laypeople, normal citizens?

ZK: Of course it is equally true that at this moment in time, and we’re having this conversation in the spring of 2022 on the heels of… I’ve been to four or five different countries in the past month. I’ve been to France, I’ve been to Portugal, I’ve been to Saudi Arabia. I’ve been to Oman…

EV: Okay, don’t make us jealous, Zachary [laugh].

ZK: This is not like, “Ooh, look at me.” It’s—and the United States, and different regions in the United States. And it is palpably true that whatever the reality of COVID is as a disease, the reality of human societies in relation to COVID has radically shifted from “this is the most significant threat confronting us today” to “this is not.” Full stop. And that, I mean, that was the vibe in every single place I have been in. And the good thing about expertise, right, is that in any moment there are multiple threats to our wellbeing individually and collectively, and it is a really good thing that there is a cohort of individuals who are attending to them. Like it’s really good that there’s a lot of cybersecurity professionals trying to make sure networks aren’t hacked by Russia or China, or us, at any given time, so that I don’t have to go through my life palpably worried about them, right? It’s really good that there’s people making sure the planes don’t crash and… Go down the list. So I love the fact that there are people like Zeke Emanuel and Nicholas Christakis who are thinking about these things and disseminating them and gaming out worst-case scenarios. Like you want somebody to be prepared for worst-case scenarios. It is equally true that our moment in time right now has moved beyond the palpable fear of those worst-case scenarios, at a collective level. I mean, individuals are and will continue to be all over the place in their risk tolerance or fears. And I assume you feel that in Greece. It’s certainly true in New York. And I think that’s a good thing. You know, I think human beings learning to live with a level of risk that was unfortunate, undesirable, unexpected, and to some degree, not fully preventable, is a good thing. Other people may not agree with that. So that’s my paean to… We might be into the early Roaring 2000s as a collective, Roaring 2020s, a little more quickly than we thought. It’s funny. That was the title of Alec Ross’ book, whom we had one of the first conversations with.

So I’m gonna leave it with the… This is a good moment in time to be having the conversation, albeit we may be in a really bad moment in four months or a much better one. I have no idea.

EV: Yeah, well, hopefully we’re not gonna look back on this conversation and be like [wince] [laugh].

ZK: Ooh, that was a moment [laugh].

EV: Yeah [laugh]. But I think everyone’s hoping along with us, and that’s the point that you’re making. That there is a negative side to that if we’re not preparing for what’s coming in the future, but also, as a species, humanity has to be resilient. We have to be psychologically resilient because, you know Zeke mentioned that, you know, we got through the two years without getting too batty, but actually I think many of us went really batty. It was hard. So we do, we do have to take steps forward even as we prepare for the worst case, like you were saying.

ZK: And that at least is something that can go right.

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