WEBVTT - The Road out of the Pandemic 0:00:15.396 --> 0:00:21.676 Pushkin from Pushkin Industries. This is Deep Background, the show 0:00:21.716 --> 0:00:24.916 where we explore the stories behind the stories in the news. 0:00:25.356 --> 0:00:29.476 I'm Noah Feldman. Today we have a return guest, and 0:00:29.596 --> 0:00:31.996 in fact, he may be the most important guest that 0:00:32.036 --> 0:00:35.396 we've had this year. It's Mark Lipsitch, whom I spoke 0:00:35.436 --> 0:00:39.396 to first back in February. He's professor of epidemiology at 0:00:39.396 --> 0:00:41.876 the Harvard chance School of Public Health. He's director of 0:00:41.916 --> 0:00:45.556 the Center for Communicable Disease Dynamics there then. He was 0:00:45.636 --> 0:00:48.596 then and has continued to be one of these central 0:00:48.676 --> 0:00:52.716 voices in sounding the warning about COVID nineteen and in 0:00:52.836 --> 0:00:57.076 modeling what good responses look like and figuring out what's 0:00:57.076 --> 0:01:00.516 going to happen next. With the election coming and the 0:01:00.556 --> 0:01:04.636 possibility of vaccines on the horizon, I wanted to reconnect 0:01:04.676 --> 0:01:09.436 with Mark to see how he reads the current situation. Mark, 0:01:09.516 --> 0:01:12.196 thank you so much for being here. I feel like 0:01:12.636 --> 0:01:15.836 I've lived a lifetime since we spoke in February when 0:01:15.876 --> 0:01:17.756 you were in an early warning mode. But I bet 0:01:17.796 --> 0:01:20.276 you've lived ten or one hundred lifetimes since then. How 0:01:20.276 --> 0:01:22.916 you've slept is hard for me to even imagine. Let 0:01:22.996 --> 0:01:24.996 me start by just asking you how are you holding 0:01:25.076 --> 0:01:29.316 up in this process? Doing okay? It's frustrating to be 0:01:30.036 --> 0:01:36.836 watching governments, including our own national government, ignoring very clear science, 0:01:37.076 --> 0:01:39.636 and as we now know, deliberately ignoring it from the 0:01:39.716 --> 0:01:44.636 very earliest times. It's encouraging that our local and state 0:01:44.676 --> 0:01:48.836 government are trying much harder to do good things. And 0:01:49.236 --> 0:01:52.036 there's still a huge amount of uncertainty about what the 0:01:52.076 --> 0:01:55.876 best approaches given all the trade offs, and so that's 0:01:55.916 --> 0:01:59.196 what keeps me awake at night right now. There is 0:01:59.196 --> 0:02:01.676 an enormous amount of uncertainty. But one thing that's sort 0:02:01.716 --> 0:02:05.396 of remarkable is that a paper that you published with 0:02:05.516 --> 0:02:09.876 co authors described a model, or of models, of what 0:02:09.996 --> 0:02:14.556 might happen if we had intermittent shutdowns and reopenings, And 0:02:14.836 --> 0:02:17.996 to oversimplify it vastly, you showed a kind of sign curve, 0:02:18.036 --> 0:02:20.996 a kind of up and down curve of how things 0:02:20.996 --> 0:02:24.276 would go. And sure enough, we had the first loop 0:02:24.316 --> 0:02:26.676 up of that curve, then we had a decline, then 0:02:26.676 --> 0:02:29.876 we had reopenings, and now we're on our way back up. 0:02:30.036 --> 0:02:33.396 So to the extent anything in real life ever matches 0:02:33.556 --> 0:02:36.276 a model, we seem to be matching, at least so 0:02:36.316 --> 0:02:40.236 far early stage. The model that you designed. How do 0:02:40.276 --> 0:02:42.036 you think about that? I mean, do you think that, 0:02:42.116 --> 0:02:44.356 in fact, that model so far does seem to be 0:02:44.356 --> 0:02:48.316 fitting the data. When we published that model and Science 0:02:48.356 --> 0:02:51.956 in March, we stated clearly that it was neither a 0:02:51.996 --> 0:02:54.836 prediction nor an endorsement, but a description of what might 0:02:54.916 --> 0:02:59.436 happen and what the consequences might be. And it wasn't 0:02:59.476 --> 0:03:04.076 an endorsement because it's obviously a miserable process, and it 0:03:04.196 --> 0:03:08.196 wasn't a prediction because we didn't know how people and 0:03:08.236 --> 0:03:11.796 governments would risk. And I think it turned out to 0:03:11.876 --> 0:03:15.716 be a little more true than we really expected in 0:03:15.756 --> 0:03:19.356 some respects in the general pattern. I think what's less 0:03:19.396 --> 0:03:22.836 true is that we imagined in that model, or we've 0:03:22.836 --> 0:03:25.236 made an assumption in that model that each round of 0:03:25.636 --> 0:03:28.116 control measures would be sort of similar to the previous 0:03:28.196 --> 0:03:30.876 round in terms of its level of effect. But I 0:03:30.916 --> 0:03:34.116 think what we didn't factor in was fatigue and the 0:03:34.196 --> 0:03:40.036 sense that politically and psychologically the same level of control 0:03:40.316 --> 0:03:44.156 measures doesn't seem to be feasible in many places. That 0:03:44.316 --> 0:03:46.716 was feasible the first time people were up for one 0:03:47.196 --> 0:03:50.676 one very intense lockdown in some places, and maybe not 0:03:51.316 --> 0:03:55.316 too many more. The logical implication of what you just said, Mark, 0:03:55.476 --> 0:03:58.196 sounds like that there's a real possibility that we're not 0:03:58.276 --> 0:04:00.636 just headed up for another peak roughly at the point 0:04:00.836 --> 0:04:02.996 where the peak was last time in terms of number 0:04:03.036 --> 0:04:05.396 of cases, but that we're actually headed for a potentially 0:04:05.436 --> 0:04:09.796 substantially higher peak. I think the potential is there. I mean, 0:04:09.956 --> 0:04:14.516 the population remains largely uninfected and still susceptible. There are 0:04:14.516 --> 0:04:17.716 pockets that have experienced very intense infection, but much of 0:04:17.756 --> 0:04:20.396 the country and much of the world remains uninfected, and 0:04:20.876 --> 0:04:24.636 so at a population level, we're kind of not that 0:04:24.716 --> 0:04:29.076 much more protected than we were at the beginning of this, 0:04:29.716 --> 0:04:31.996 and so I think it will be more There will 0:04:32.036 --> 0:04:35.356 be peaks in more different places at roughly the same time, 0:04:35.636 --> 0:04:39.156 because the virus has had time to spread out geographically, 0:04:39.196 --> 0:04:42.756 so it's not mainly in urban centers in the US anymore. 0:04:42.796 --> 0:04:46.556 It's now in the Midwest and the plains, in parts 0:04:46.556 --> 0:04:49.276 of the country that are much more rural, and it's 0:04:49.316 --> 0:04:52.556 just more widespread outside the major ports of entry and 0:04:52.796 --> 0:04:55.676 places connected to those. So I think it will be 0:04:55.756 --> 0:04:58.556 more widespread, very likely. But how high a peak we 0:04:58.636 --> 0:05:02.676 have really depends on the timing and strength of our reaction, 0:05:02.796 --> 0:05:08.036 and that is so uncoordinated in this country and also 0:05:08.116 --> 0:05:11.116 between countries, that it's hard to make a general prediction. 0:05:11.836 --> 0:05:15.756 Deaths are trending obviously in the wrong direction, though they 0:05:15.756 --> 0:05:18.196 seem to be less as a percentage of all cases 0:05:18.196 --> 0:05:21.556 than they were previously. Is that because of better treatments? 0:05:22.116 --> 0:05:24.396 Is it because of a broader awareness of the number 0:05:24.436 --> 0:05:27.316 of people who have diseases? Ie? More testing the President's 0:05:27.356 --> 0:05:31.556 favorite line, why the disparity? I think it's very clear 0:05:31.556 --> 0:05:34.396 that there's more testing and that we're detecting a higher 0:05:34.436 --> 0:05:37.116 fraction of all the people who are infected with this 0:05:37.236 --> 0:05:39.996 virus than we were at the beginning. Still a very 0:05:39.996 --> 0:05:43.596 low fraction, but more, and therefore the denominator swells and 0:05:43.636 --> 0:05:48.756 the ratio of deaths to known cases goes down. The 0:05:48.836 --> 0:05:51.516 really interesting question is how much better we're getting at 0:05:51.596 --> 0:05:55.916 treating those cases that do occur. And there have been 0:05:55.956 --> 0:06:02.156 a couple of articles relatively limited populations and imperfect methodology, 0:06:02.196 --> 0:06:04.476 as it always is in this kind of situation, that 0:06:04.636 --> 0:06:07.236 suggests that when people get to the hospital or get 0:06:07.236 --> 0:06:10.276 to the ICU, they are more likely to survive, which 0:06:10.276 --> 0:06:13.716 you would expect given that clinicians learn all sorts of things, 0:06:13.756 --> 0:06:17.076 not just what drugs they can use, and there's sort 0:06:17.076 --> 0:06:20.476 of one and a quarter good drugs right now that 0:06:20.556 --> 0:06:24.996 are available, but also other details of the clinical management 0:06:25.036 --> 0:06:28.476 that make it more likely that the hundredth patient will 0:06:28.516 --> 0:06:31.396 survive than that the first one that someone has seen survives. 0:06:31.836 --> 0:06:35.956 So every expectation is that the death rate of those 0:06:35.996 --> 0:06:39.116 people who get severe disease would be going down. The 0:06:39.236 --> 0:06:42.596 data have been very limited so far, two papers that 0:06:42.636 --> 0:06:46.396 I'm aware of, and some data from Florida that I've 0:06:46.436 --> 0:06:49.836 seen that maybe suggests the opposite that there isn't a change. 0:06:49.916 --> 0:06:52.956 So I think it's too early to declare victory, and 0:06:53.036 --> 0:06:56.116 certainly there are still a lot of people dying per case, 0:06:56.676 --> 0:07:00.036 but I think there's some hints that we're getting better. 0:07:00.436 --> 0:07:04.236 It's an absence of evidence mostly right now, and that 0:07:04.276 --> 0:07:06.436 will be an important question to figure out going forward. 0:07:07.676 --> 0:07:10.276 I'm almost loath to ask you about the so called 0:07:10.276 --> 0:07:13.036 Great Bearington Declaration because I know that your view is 0:07:13.076 --> 0:07:16.796 that it was false and problematic, and you've joined a 0:07:16.916 --> 0:07:19.196 counter declaration, but it's been so much in the news 0:07:19.236 --> 0:07:22.316 that we can't completely avoid it. What's wrong with the 0:07:22.676 --> 0:07:26.516 so called Great Bearington Declaration and the perspective that it takes. 0:07:27.356 --> 0:07:29.916 I think the Great Barrington Declaration starts from a premise 0:07:29.956 --> 0:07:32.556 that most of us would agree with, which is that 0:07:33.316 --> 0:07:37.796 the current state of response is miserable in that it's 0:07:37.796 --> 0:07:41.636 depriving us of many features of our lives. It's causing 0:07:41.916 --> 0:07:47.236 unemployment and other harms to humans, and it's no fun 0:07:47.356 --> 0:07:49.876 at all, and even the details are no fun. Wearing 0:07:49.916 --> 0:07:53.316 a mask is not pleasant, and everyone wants to get 0:07:53.356 --> 0:07:57.476 back to normal. The part of it that is insidious, 0:07:57.476 --> 0:08:00.116 in my view, is not the desire to get back 0:08:00.156 --> 0:08:03.596 to normal, but the notion that that is consistent with 0:08:03.756 --> 0:08:08.396 some kind of way of protecting the vulnerable. And there's 0:08:08.396 --> 0:08:11.636 just no evidence that that is possible. There's no place 0:08:11.676 --> 0:08:16.276 that I'm aware of that has successfully let the epidemic 0:08:16.356 --> 0:08:20.596 spread and at the same time protected the vulnerable. Sweden 0:08:20.756 --> 0:08:23.916 is the sort of most famous example, and they nobody 0:08:23.956 --> 0:08:26.436 thinks that they did a good job of protecting their 0:08:26.516 --> 0:08:30.516 nursing homes and the vulnerable people that are less often 0:08:30.596 --> 0:08:35.116 discussed are immigrants and members of ethnic minorities and racial 0:08:35.116 --> 0:08:38.116 minorities in this country and in Sweden. Many of the 0:08:38.156 --> 0:08:41.756 early cases and severe cases were in Somali immigrants and 0:08:41.796 --> 0:08:46.956 in other less integrated communities. And so when you say 0:08:46.956 --> 0:08:50.436 protect the vulnerable, people imagine that you can just sort 0:08:50.476 --> 0:08:53.236 of seal off nursing homes, which is problematic and probably 0:08:53.276 --> 0:08:57.356 not effective in itself. But the vulnerable is a larger 0:08:57.396 --> 0:09:00.636 group than just the very old and infirm. It's a 0:09:00.676 --> 0:09:02.436 mixed group, some of whom we know about and some 0:09:02.476 --> 0:09:05.156 of whom we don't. So the notion that we can 0:09:05.316 --> 0:09:09.516 stop transmission to those who are most at risk, first 0:09:09.556 --> 0:09:12.276 that we can identify them, which is imperfect, and second 0:09:12.276 --> 0:09:15.036 that we can somehow wall them off from society, which 0:09:15.076 --> 0:09:19.196 has just not been demonstrated. So as a claim by 0:09:19.396 --> 0:09:22.596 a group of scientists, this seems to be a lot 0:09:22.636 --> 0:09:27.116 of aspiration and very little scientific description of how it 0:09:27.116 --> 0:09:32.956 would be done. You joined a very detailed counter declaration. 0:09:32.996 --> 0:09:34.396 You're one of the first people to join it. It's 0:09:34.396 --> 0:09:38.276 now got thousands and thousands of scientists who also joined it. 0:09:38.316 --> 0:09:40.756 Was what you just said. The essential takeaway for you 0:09:41.196 --> 0:09:44.316 of that documentary? Does it go beyond Yeah? I think 0:09:44.396 --> 0:09:46.836 that's why I signed the document. And it's impossible to 0:09:46.836 --> 0:09:49.516 speak for all the people who signed a document, of course, 0:09:49.556 --> 0:09:52.836 but in my view, there's a shared desire to get 0:09:53.036 --> 0:09:56.556 back to some kind of normal and a responsibility if 0:09:56.556 --> 0:09:59.076 you propose a way to do that, to propose a 0:09:59.076 --> 0:10:03.756 way that is effective and for which there's evidence. I 0:10:03.796 --> 0:10:06.516 think what's the next step for those of us who 0:10:06.636 --> 0:10:10.836 don't think that that's an effective approach, is that we 0:10:10.876 --> 0:10:14.716 need to figure out how to do it by some 0:10:14.756 --> 0:10:17.996 other means. And I think the best evidence right now 0:10:18.156 --> 0:10:22.276 is that a combination of very widespread mask use and 0:10:23.036 --> 0:10:28.796 consistent mask use, really insisting on social distancing when encountering 0:10:28.796 --> 0:10:35.556 other people, and increasingly making available cheap and frequent tests 0:10:36.076 --> 0:10:39.396 so that people can understand their status is in my view, 0:10:39.436 --> 0:10:43.596 the best combination of measures that will keep things at 0:10:43.596 --> 0:10:48.556 bay while we search for vaccines and therapeutics. So I 0:10:48.556 --> 0:10:50.916 think that's the next step is to figure out an 0:10:50.916 --> 0:10:54.116 alternative plan. But in the meanwhile, we have these blunt 0:10:54.156 --> 0:10:58.436 instruments of shutting down parts of the economy, which in 0:10:58.476 --> 0:11:02.076 some cases are necessary in order to slow things down 0:11:02.116 --> 0:11:06.036 and maintain the integrity of the healthcare system. I want 0:11:06.076 --> 0:11:09.196 to ask you about both stages of this alternative and 0:11:09.236 --> 0:11:10.876 that you're describing, and I guess my first one is 0:11:10.916 --> 0:11:14.036 to ask how alternative it really is. I mean the 0:11:14.156 --> 0:11:16.796 mask use has been part of the approach thus far, 0:11:17.556 --> 0:11:20.196 that insisting on social distancing has been part of the approach. 0:11:20.396 --> 0:11:22.876 They have some limit to how much they're going to 0:11:22.956 --> 0:11:25.116 be followed. I mean, my kids are in school a 0:11:25.116 --> 0:11:29.196 couple of days a week, and they report great efforts 0:11:29.276 --> 0:11:32.716 to adhere to social distancing and mask wearing. But let's 0:11:32.716 --> 0:11:37.476 say imperfect enforcement and imperfect efforts also by kids. And 0:11:37.556 --> 0:11:41.356 I can anecdotally report the same of my world, you know, 0:11:41.556 --> 0:11:44.436 in social interactions. As long as it was warm out, 0:11:44.476 --> 0:11:46.196 that was a real effort to always be outside and 0:11:46.196 --> 0:11:50.116 to maintain social distancing. But there's erosion around the edges 0:11:50.156 --> 0:11:55.236 on that, and so I'm wondering whether that step, that 0:11:55.356 --> 0:11:59.836 component is different and also if it's practically in the 0:11:59.916 --> 0:12:04.076 real world sustainable at scale. Well, I think that is 0:12:04.356 --> 0:12:08.156 a fair question. And the Swiss Cheese image that's been 0:12:08.196 --> 0:12:11.836 making the rounds of every intervention being imperfect and together 0:12:11.956 --> 0:12:15.316 you make an impermeable barrier with a lot of holes 0:12:15.316 --> 0:12:19.196 in each layer is an appealing one because all of 0:12:19.196 --> 0:12:23.956 these things are both not perfectly effective and not perfectly practical. 0:12:24.516 --> 0:12:29.916 But having said that, Massachusetts, where you're describing, is on 0:12:29.956 --> 0:12:33.956 a global scale doing pretty well, and the hospitals are 0:12:33.956 --> 0:12:37.156 not overwhelmed right now, and that's to a large degree 0:12:37.196 --> 0:12:40.636 because of both early shutdowns a part of the economy, 0:12:40.676 --> 0:12:46.636 and then relatively adherent population to those social distancing norms. 0:12:47.156 --> 0:12:50.916 So I think while cases are rising here as they 0:12:50.956 --> 0:12:55.756 are almost everywhere, it is important to say that places 0:12:55.796 --> 0:12:59.716 that have embraced masks and social distancing have on the 0:12:59.756 --> 0:13:03.436 hole done better than places that haven't. And within the 0:13:03.516 --> 0:13:05.636 US there's a lot of variation, and of course there 0:13:05.676 --> 0:13:08.036 are a lot of other factors, and you can argue 0:13:08.036 --> 0:13:11.836 about the causal relationship, but there are large variations and 0:13:11.876 --> 0:13:14.756 how much people use masks and large variations and how 0:13:14.796 --> 0:13:28.316 bad the epidemic has gotten. We'll be right back. Let's 0:13:28.316 --> 0:13:31.796 talk about a world where we have vaccines, but imperfect 0:13:31.876 --> 0:13:34.276 vaccines that in any case take a while to roll 0:13:34.316 --> 0:13:36.476 out and get to reach everybody. But imagine we have 0:13:36.516 --> 0:13:38.996 some vaccines that work at fifty percent efficacy or above, 0:13:40.236 --> 0:13:42.516 Leaving aside the technical problem of how long it will 0:13:42.556 --> 0:13:46.756 take to get them to people, how effective in a 0:13:46.836 --> 0:13:51.356 process of moving US towards group immunity is it to 0:13:51.556 --> 0:13:55.836 have a say, fifty percent efficacious vaccine that some percentage 0:13:55.836 --> 0:13:57.996 of the population is taking How much does that speed 0:13:58.076 --> 0:14:00.996 up our process or does it actually not make that 0:14:01.076 --> 0:14:04.116 much difference? But we have to maintain mask wearing, social distancing, 0:14:04.116 --> 0:14:08.116 and some business closures regardless. If a large faction of 0:14:08.156 --> 0:14:13.196 the population took fifty percent efficacious vaccine, and that vaccine 0:14:13.276 --> 0:14:17.676 was efficacious against infection and transmission as well as against symptoms, 0:14:17.796 --> 0:14:20.556 it would make a huge difference. It would not stop 0:14:20.596 --> 0:14:24.276 transmission by itself, because we have to get the reproduction 0:14:24.356 --> 0:14:28.916 number down from probably three or so down to below 0:14:28.996 --> 0:14:31.676 one in order to stop transmission, and this would be 0:14:31.716 --> 0:14:35.436 at best a fifty percent hit even if everybody took it, 0:14:35.476 --> 0:14:37.956 but down to one and a half would mean that 0:14:38.636 --> 0:14:41.396 even uncontrolled, it would grow more slowly. There would be 0:14:41.436 --> 0:14:45.196 more time to make control measures. There would be greater 0:14:45.476 --> 0:14:49.596 effects of things like mask wearing and the less burdensome 0:14:49.636 --> 0:14:54.516 interventions because you could layer fewer interventions on top and 0:14:54.556 --> 0:14:59.556 then keep the virus under control. So fifty percent infection 0:14:59.596 --> 0:15:03.676 blocking vaccine would be obviously worse than a eighty percent, 0:15:03.756 --> 0:15:06.836 but a lot better than what we have now. Isn't 0:15:06.836 --> 0:15:08.876 there a dynamic game theory problem, though, which is if 0:15:09.236 --> 0:15:11.676 vaccine were out there, and if people thought that it worked, 0:15:12.036 --> 0:15:14.636 that would probably lead many people to be less careful 0:15:14.676 --> 0:15:16.436 with masks and social distancing. I mean, it's going to 0:15:16.476 --> 0:15:19.036 be hard to say to people, here's your vaccine, it 0:15:19.076 --> 0:15:22.596 works somewhat well, but keep on everything you're doing and 0:15:22.596 --> 0:15:25.756 don't really change your lives that much. I think that's 0:15:25.796 --> 0:15:28.356 a concern. But I also think that we would be 0:15:28.396 --> 0:15:30.916 able to get away with a lot less adherence to 0:15:30.956 --> 0:15:34.116 mask wearing and all those other things if half the 0:15:34.156 --> 0:15:38.196 population were protected by the vaccine, and if some of 0:15:38.196 --> 0:15:41.156 the people who weren't protected against infection perhaps were at 0:15:41.196 --> 0:15:44.956 least protected against severe disease. So I mean, unfortunately, this 0:15:45.036 --> 0:15:48.556 is a problem that we're trying to solve on a 0:15:48.596 --> 0:15:51.796 time frame of a year or two, when this kind 0:15:51.836 --> 0:15:55.036 of problem is typically solved over a time scale of decades. 0:15:55.636 --> 0:15:57.836 So we're going to be chipping away with a lot 0:15:57.916 --> 0:16:02.636 of imperfect solutions. But I think even a modestly effective vaccine, 0:16:02.676 --> 0:16:05.636 if it blocks transmission, will make a huge difference, or 0:16:05.676 --> 0:16:08.796 if it works in the most vulnerable people, either of 0:16:08.836 --> 0:16:12.556 those would vastly improve our lives. Once it's distributed. It 0:16:12.636 --> 0:16:15.916 won't solve all the problems we can't know this for sure, obviously, 0:16:16.036 --> 0:16:18.196 but it does strike me that among people who will 0:16:18.196 --> 0:16:20.276 be skeptical of a vaccine, it won't want to take it. 0:16:20.916 --> 0:16:23.636 The idea that a vaccine only works roughly half the 0:16:23.676 --> 0:16:27.756 time might be used by critics and skeptics as a 0:16:27.796 --> 0:16:31.036 reason not to take the vaccine. Yeah. Well, I think 0:16:31.436 --> 0:16:34.196 that's been true for flu vaccines for a long time, 0:16:34.396 --> 0:16:37.476 and flu vaccine uptake is not great, although it's better 0:16:37.516 --> 0:16:40.716 this year, I think because people are nervous about getting 0:16:40.756 --> 0:16:43.356 something that would get them in contact with the healthcare system. 0:16:43.916 --> 0:16:47.756 But yes, a better vaccine would be better in many ways, 0:16:47.796 --> 0:16:51.676 including in public confidence, so we can hope for that. 0:16:51.756 --> 0:16:55.076 But the fifty percent floor that's been set by the 0:16:55.116 --> 0:16:59.276 FDA is not the desired level. It's the minimal level. 0:17:00.356 --> 0:17:02.716 My takeaway from what you've been saying, though, is that 0:17:03.236 --> 0:17:06.316 if indeed we get a vaccine, even if it's pretty 0:17:06.356 --> 0:17:09.996 effective and reaches many many people, we're not in a 0:17:10.036 --> 0:17:13.196 scenario where things will be quote unquote back to normal 0:17:13.956 --> 0:17:17.276 anytime soon, including at the moment when many many people 0:17:17.436 --> 0:17:19.636 begin to get the vaccine, which just by a some shit, 0:17:19.716 --> 0:17:22.916 let's imagine, would be the fall of twenty twenty one, 0:17:22.916 --> 0:17:24.436 which seems to be the soonest that you could get 0:17:24.556 --> 0:17:27.356 very very broad uptake. It sounds like we're going to 0:17:27.436 --> 0:17:31.596 be continuing with some hybrid version of our social distancing 0:17:31.596 --> 0:17:34.636 and masking. Well beyond that, am I reading you right? 0:17:35.596 --> 0:17:38.596 I think if it's eighty or ninety percent effective and 0:17:39.076 --> 0:17:44.196 widely accepted, then we might be back to something approaching normalcy. 0:17:44.796 --> 0:17:47.276 I also think that we will learn other things in 0:17:47.316 --> 0:17:50.876 the process. I mean, I think the evidence is accumulating 0:17:50.956 --> 0:17:55.756 that schools are, if they take basic precautions, not sites 0:17:55.756 --> 0:17:58.596 of major transmission. They may be sites where people who 0:17:58.636 --> 0:18:01.996 are infected get together because they've been infected in the 0:18:01.996 --> 0:18:05.876 community and it looks like their outbreaks. But the frequency 0:18:05.876 --> 0:18:10.596 of outbreaks in schools with reasonable is low, not zero, 0:18:11.356 --> 0:18:15.316 but low. So I think that aspect of our society, 0:18:15.476 --> 0:18:18.476 as we learn more about how to do it safely 0:18:18.516 --> 0:18:22.156 and keep some level of normalcy, might get back to 0:18:22.236 --> 0:18:25.236 normal along the way, And that will be boosted by 0:18:25.236 --> 0:18:28.476 the fact that at least the adults initially will be 0:18:28.516 --> 0:18:32.436 protected if we have a vaccine. So I think that's 0:18:32.476 --> 0:18:36.116 an example. But other aspects of our society, we hopefully 0:18:36.116 --> 0:18:39.516 will learn something about how we can operate them more safely. 0:18:39.556 --> 0:18:42.116 So I think we shouldn't assume that our knowledge is 0:18:42.116 --> 0:18:44.356 going to be stuck here. And one of the things 0:18:44.356 --> 0:18:49.316 that's been really disappointing is as the CDC and to 0:18:49.356 --> 0:18:51.716 some extent other public health authorities in other countries, but 0:18:51.796 --> 0:18:55.196 especially the CDC, has been hobbled by interference from above. 0:18:55.716 --> 0:18:59.156 One of their functions would normally be to very actively 0:18:59.236 --> 0:19:03.196 be seeking epidemiological evidence on what is safe and what 0:19:03.396 --> 0:19:06.636 is not safe, and that part of their function has 0:19:06.676 --> 0:19:10.476 been very limited in this epidemic. So I think we 0:19:10.556 --> 0:19:15.076 will keep learning things, and I'm somewhat optimistic in that 0:19:15.156 --> 0:19:18.156 sense that we will as we chip away at the problem, 0:19:18.196 --> 0:19:22.076 we will find ourselves getting closer to normal. But it's 0:19:22.076 --> 0:19:23.476 not going to be quick and it's not going to 0:19:23.516 --> 0:19:26.916 be complete. I agree with that. Are there any country 0:19:26.956 --> 0:19:29.876 models that are positive models from your perspective still at 0:19:29.876 --> 0:19:35.756 this moment? I think the models of Germany and Luxembourg 0:19:35.876 --> 0:19:41.836 and probably some other countries like them, which had big 0:19:41.956 --> 0:19:45.156 surges at the beginning, got them under control and now 0:19:45.196 --> 0:19:50.916 have very widespread testing. Still not universal, but Luxembourg has 0:19:50.956 --> 0:19:54.796 actually tested most of its population at least once, which 0:19:54.916 --> 0:19:58.316 is a step in the direction of widespread, easily available 0:19:58.356 --> 0:20:03.076 testing for anybody who's curious whether they're infected. Those are positive, 0:20:03.116 --> 0:20:05.396 but of course they're also both going up in the 0:20:05.476 --> 0:20:09.236 number of cases, so it's not a full solution. And 0:20:09.276 --> 0:20:12.596 then of course New Zealand and Vietnam and some others 0:20:13.196 --> 0:20:17.356 have had much better outcomes than we and those are 0:20:17.356 --> 0:20:21.116 two different situations. One we don't really understand what's exactly 0:20:21.196 --> 0:20:24.476 happened in Vietnam, and with New Zealand it was very 0:20:24.596 --> 0:20:29.396 very early both lockdown and extremely good contact tracing on 0:20:29.436 --> 0:20:33.236 an island. So and then thinking about Korea, you know, 0:20:33.276 --> 0:20:35.796 there was a very very large outbreak and it was 0:20:35.836 --> 0:20:40.876 brought down through very intense surveillance, test and trace and 0:20:40.996 --> 0:20:44.116 the like, with some degree of lockdowns, but probably a 0:20:44.196 --> 0:20:47.836 level of surveillance that is not replicable here. What has 0:20:47.876 --> 0:20:50.516 happened to surveillance here. At the beginning of the outbreak, 0:20:50.516 --> 0:20:52.836 there was an enormous amount of discussion in the public 0:20:52.836 --> 0:20:56.996 square and also in policy circles about contact tracing, and 0:20:57.036 --> 0:21:00.076 we did episodes on it several and yet as it's 0:21:00.116 --> 0:21:04.116 turned out, that hasn't functioned as a central prong of 0:21:04.356 --> 0:21:09.116 the approach. Just about anywhere in the United States. Yeah, 0:21:09.156 --> 0:21:13.436 tech tracing works in combination with other measures, and it works. 0:21:13.556 --> 0:21:16.116 I think I've made the analogy of you don't clean 0:21:16.196 --> 0:21:18.636 up an oil spill with paper towels. Contact tracing is 0:21:18.676 --> 0:21:21.156 paper towels. So when the number of cases is down 0:21:21.196 --> 0:21:24.716 to a number where you can detect almost all of them, 0:21:25.516 --> 0:21:29.556 where you can rapidly get test results because your system 0:21:29.596 --> 0:21:33.996 for testing isn't overwhelmed, and where you can rapidly make 0:21:34.076 --> 0:21:37.156 contact with the people who you need to and they 0:21:37.196 --> 0:21:39.876 are willing to talk to the contact tracers and the like, 0:21:40.756 --> 0:21:43.276 then contact tracing can make a big difference. It's a 0:21:43.436 --> 0:21:48.116 mopping up exercise. It's not a large scale control exercise 0:21:48.156 --> 0:21:50.676 because it's scales with the number the need, scales with 0:21:50.716 --> 0:21:53.316 the number of cases. And so when you have thousands 0:21:53.316 --> 0:21:56.876 of cases a day in a jurisdiction of modest size, 0:21:56.956 --> 0:22:00.596 then you just can't keep up, and you especially can't 0:22:00.676 --> 0:22:03.276 keep up when testing capacity is limited and the time 0:22:03.316 --> 0:22:07.076 to get a test result is many days. In New Zealand, 0:22:07.516 --> 0:22:10.756 by the time they're contact tracing was really in full speed. 0:22:11.436 --> 0:22:14.396 It was all happening very very quickly, so that people 0:22:14.436 --> 0:22:17.716 were being found even before they became symptomatic contacts were 0:22:17.716 --> 0:22:20.716 being found even before they became symptomatic, so that was 0:22:20.756 --> 0:22:23.196 a measure of how efficiently it worked. But that could 0:22:23.236 --> 0:22:26.156 work in the tens and even can work in the hundreds, 0:22:26.156 --> 0:22:29.436 it can't work in the thousands. Mark, what am I 0:22:29.636 --> 0:22:31.276 not asking you that I should be asking you at 0:22:31.276 --> 0:22:35.276 this stage of play? I guess the question there's a 0:22:35.356 --> 0:22:37.756 question of would we do any better than next time? 0:22:38.116 --> 0:22:40.156 And what would determine if we did any better the 0:22:40.276 --> 0:22:42.316 next time? And by the next time, you don't mean 0:22:42.836 --> 0:22:46.516 the next round of this, you mean the next pandemic, 0:22:46.556 --> 0:22:48.836 if we had it to do over again, or if 0:22:48.836 --> 0:22:54.156 we have to deal with stars three and some future time, 0:22:54.676 --> 0:22:57.556 what would determine it? And I mean, I think there 0:22:57.556 --> 0:23:00.756 are many many answers to that. I think there are 0:23:00.796 --> 0:23:06.476 two that really strike me. One is leadership and clear 0:23:06.716 --> 0:23:11.476 messaging from the top of the federal government in our case, 0:23:11.916 --> 0:23:17.316 or the national government in other countries, that is science based, 0:23:17.996 --> 0:23:21.196 clear about what we know and don't know, and leads 0:23:21.196 --> 0:23:24.916 by example by showing on television the practices that are 0:23:24.916 --> 0:23:29.316 being recommended enacted by the people recommending them. And that 0:23:29.396 --> 0:23:31.236 was pretty much what we had in two thousand and nine. 0:23:31.276 --> 0:23:33.876 For H one N one flu and that was a 0:23:33.916 --> 0:23:38.676 milder illness, but that aspect worked much better. And then 0:23:38.836 --> 0:23:43.116 the other piece is the information systems are just antiquated 0:23:43.556 --> 0:23:47.076 by information systems, I mean everything from the ability to 0:23:47.076 --> 0:23:50.716 test a random group of people in order to estimate 0:23:50.996 --> 0:23:54.436 how much virus activity there is, all the way through 0:23:54.756 --> 0:23:58.716 how that gets reported, Having the number of tests available 0:23:58.756 --> 0:24:01.796 you need at the front end, and having the information 0:24:01.876 --> 0:24:06.076 systems to report them in meaningful and interpretable ways. I 0:24:06.116 --> 0:24:09.476 think that's really something that sets the country that have 0:24:09.916 --> 0:24:15.196 responded effectively apart from those that haven't. And I think 0:24:15.276 --> 0:24:18.156 that's a huge job for many countries in the world, 0:24:18.196 --> 0:24:22.236