Should We Lockdown Again?

Episode Summary

In recent weeks, The Great Barrington Declaration erupted the debate about how best to continue the fight against COVID-19. On this episode, we try to have an honest and difficult conversation about the tradeoffs of different strategies for the future, from lockdowns to herd immunity. We also speak to people on both sides of the aisle: Sunetra Gupta, an epidemiologist from Oxford and one of the signers of The Great Barrington Declaration, and Andy Slavitt, former Acting Administrator of the Centers for Medicare and Medicaid Services under Obama and the host of the In The Bubble Podcast.

Episode Transcription

Luigi: In this episode, we’re going to try to do something very difficult, i.e., to think about big strategies, looking at big numbers, and inevitably these are ignoring the pain and suffering of each individual. So, if you have been majorly affected by a loss during this year, our conversation may appear flippant, but we are certainly not flippant. We want to try to understand what is best moving forward.

Bethany: We acknowledge the pain and the horror of the 200,000-plus lives that have been lost to COVID, and the more that are sure to come. What we are trying to do in this episode, without minimizing that in any way, is to have a conversation about the risks on the other side, and the deaths both now and in the future that may be caused by our response to COVID.

I’m Bethany McLean.

Speaker 3: Did you ever have a moment of doubt about capitalism, and whether greed is a good idea?

Luigi: And I’m Luigi Zingales.

Bernie Sanders: We have socialism for the very rich, rugged individualism for the poor.

Bethany: And this is Capitalisn’t, a podcast about what is working in capitalism.

Speaker 5: First of all, tell me, is there some society you know that doesn’t run on greed?

Luigi: And, most importantly, what isn’t.

Speaker 6: We ought to do better by the people that get left behind. I don’t think we should have killed the capital system in the process.

Bethany: So, Luigi and I, with some trepidation, decided to do an episode on what we view should be a debate over how best we proceed with COVID, and as we started to work on this, a group of scientists came out with what’s now known as the Barrington Declaration.

Speaker 7: That declaration, posted by an American economic think tank, promotes focused protection of the vulnerable until we reach herd immunity.

Bethany: As we were working on it, a group of scientists on essentially the other side came out with the John Snow memorandum, which essentially calls the Barrington Declaration immoral.

Luigi: Particularly what we think is very dangerous is when, instead of having a debate on the facts, you have a debate on religion. When you say it’s immoral, you’re not saying that what there’re saying is wrong. You’re saying, I don’t want to hear what you’re saying, a priori, no matter what, you can have the best facts in the world, et cetera, and this is the end of . . . I was about to say end of civilization as we know it, but indeed, it is, a bit.

Bethany: What Luigi and I have found even odder, when you pause to think about it, is that someone’s political affiliation is very likely to be tied to whether or not they’re a supporter of the Barrington Declaration or the John Snow memorandum. The idea that epidemiology and science should be tied to your political affiliation, perhaps that’s not new. Maybe thus it’s ever been, but it is certainly worse today than it’s been in the past.

We thought on this show, we would talk to one of the authors of the Barrington Declaration, so we decided to talk to Sunetra Gupta, who was kind enough to come on our show. She is a professor of theoretical epidemiology at Oxford. We also decided to speak with Andy Slavitt, who was the acting administrator of the Centers for Medicare and Medicaid in the Obama administration, and Slavitt is essentially on the other side of Gupta’s argument. He has, as recently as this summer, advocated for another lockdown harder than the one we went through last spring, in order to shut down the virus. 

One of the things the signers of the Barrington Declaration have highlighted is all the risks that are caused by lockdown itself. Some of those costs are already mounting, whether it’s the line for food banks in the United States, the increased risk of suicide and depression that come with economic collapse, the cost to children of not being able to have an education. Globally, the estimates are huge of the number of people who may suffer from starvation as a result of lockdown. The lack of vaccinations that are taking place that are going to bring back diseases like measles and pertussis as sources of death, but also diseases like cancer that, there was just a piece in the Journal as we were recording this, about the number of missed and delayed cancer diagnoses, and how problematic that’s going to be.

And so, regardless of what your preexisting views on COVID may be, the notion that there are risks caused by our approach to this, I think, is incontrovertible.

So, now we’re going to talk to Dr. Sunetra Gupta, who is a professor of theoretical epidemiology at Oxford.

Luigi: For a nonexpert like me, can you explain what is the nature of the scientific disagreement between you and the rest of the epidemiologist community?

Sunetra Gupta: OK. We feel that there is a good chance that in many settings, a proportion of the population is either immune or resistant, and that is what is responsible for the observation that it did not, in the summer, when restrictions were lifted, you didn’t see it going up in New York, or in Stockholm, or in London. So, let’s say the epidemic has not fully reached its capacity, and once we, as now, the cold months come along, the rise in infections is going to be significant. I personally don’t think we have enough data yet to know that, but what does one do in the face of these uncertainties? The main route that seems to be followed, that people are following, is one where we suppress the infections. The problem with that approach is, it doesn’t seem to have an endpoint, or the endpoint that is often declared, which is a vaccine, is not one that we feel one can have sufficient certainty about to carry on with these extremely costly measures.

So, our proposal is one which, first of all, acknowledges that we cannot afford to carry on with these costly measures. But also, it provides a mechanism whereby we can reduce the risk to the vulnerable without expending lives by shielding those we know to be vulnerable over the short term, the period, the 3-6 months that it takes for those who are not at risk to develop natural immunity, which will then bring down levels of risk to everybody, but particularly the vulnerable population, to the levels that we tolerate for other infectious diseases. Sorry, that was very long.

Luigi: No, no, that was extremely useful, because if I may say, the first one is really a scientific disagreement. Ideally, it could be tested, how much the disease has spread, and reasonable people, of course, can disagree until we have the perfect data. But the second, in my view, is a political decision, in the sense that there are costs and benefits of various strategies. I see the role of the epidemiologist, as the role of the economist in other situations, not in this one, as presenting the political system with the analysis of the cost and the benefits. At the end of the day, where you draw the line is a political decision, in the sense that there are costs to carrying out the suppression strategy. There are costs to carrying out your strategy. Which ones are bigger are not easy to determine, but at the end of the day, there are enormous distributional consequences of either strategy. So, I’m not so sure that there is a science to say what is the right thing to do. It’s more like a political decision, no?

Sunetra Gupta: I completely agree. I think, absolutely. I think what we are trying to do is open up that debate. That’s all that we want to do. I mean, as you said, far be it from us to say this is absolutely right, and I think you’ll find that we are not using that kind of rhetoric. We aren’t saying that we are certain that this is what will happen, and this is the only way to stop it from happening, and I think that I cannot stress more how I think that mathematical modeling of infectious disease only can provide a conceptual framework, and then statistical analyses of data can provide some of the numbers. What I think one needs to do in talking with policymakers is to present those, and then they have to integrate all of that into a workable solution. And that is why I have never engaged in developing models that churn out, throw out policy decisions. I don’t think that’s how it works.

Bethany: I think that that’s exactly the debate we should be having, but somehow this has become a moral debate, instead of a political or an economic one. There are accusations that people like you want to lock up the elderly, and that the only way to protect these vulnerable populations is to limit the spread in the community. So, let’s pause before we get back to mathematical modeling, which I think is a fascinating topic, on that nugget. How do we protect the vulnerable while allowing community spread, or is the only real way to protect the vulnerable by limiting community spread?

Sunetra Gupta: That’s, of course, the crux of the question, and so we’re saying, no, we should not limit community spread and find ways of shielding the vulnerable. The way I think of it is, you need to break the problem down into different parts. Protecting the care homes. That was something we all failed on. And another large part of it is and continues to be hospital-acquired infections. But of course, then there’s that crucial element, and much more difficult to decide, of what do we do in the community? 

So, we’ve got the grandparents, if you like, who live independently of their children and grandchildren. Those people have already been shielding, I mean, staying away from their grandchildren, and that’s already been a heartbreaking kind of situation. But we’re proposing, with regard to those people, something that is a subset of what was endured during lockdown anyway. Just for another 3-6 months. 

Then you come to the really tricky situation, which is multigenerational families. And even within that, there are different categories. There are the multigenerational families where, effectively, the grandmother or the grandparent lives essentially in the same building, in the same home, but they can be, for again that short period of time, kept apart as best as possible. 

And then, there are situations where this is really, really almost impossible. In those instances, again, for that short period of time, surely we can try and think creatively about how to maybe rehouse vulnerable people, or put in place whatever measures are necessary, and I think it’s worth having the discussion, but I think what is wrong is to dismiss it offhand, given the enormous costs of the opposite, I mean, the other competing strategy, which is to make everyone lock down.

Luigi: You keep repeating “a short period of time.” How short is this period?

Sunetra Gupta: We know within 3-6 months, it would run its natural course, and you would achieve enough immunity in the population to bring the risk down to levels that we normally tolerate for other pathogens. So, that’s 3-6 months.

Bethany: Are we agreed upon that, though? It seems to me that at least in the public discourse, part of that is dependent on an agreement around the level at which herd immunity is achieved. Originally, the numbers were as high as 60-80 percent, and there are now people who say it’s as low as 20 percent. And yet, in the public discourse around this, we’re not really allowed to challenge the idea that it’s 60-80 percent, even though reality doesn’t seem to be corroborating the 60-80 percent. So, where do you think we are on agreement about that level?

Sunetra Gupta: The beauty of the 3-6 months is that whatever the level of herd immunity actually is, you would still get . . . it would turn over naturally within that timescale. But, yes, what is the level of herd immunity? What we’re disagreeing on at the moment, or there’s room for doubt on, has that already happened, occurred in places like New York, where we’re only seeing, in May when we did these antibody tests, where we found seropositivities of 20-30 percent in most areas, leaving aside a few pockets.

So, the point of dispute is, when you do these antibody tests, what does the seroprevalence, the readout from these tests, what does it actually tell you about whether herd immunity has been reached or not? We’ve been involved in two ways in this. One is that straightaway in March, Craig Thompson in my lab developed or perfected a neutralizing antibody test, which detected antibodies in the blood of people, and then we tried to use that to do the studies that would settle how many people had been exposed to the virus. We found it very hard to get the samples, but we did get some Scottish samples from Scottish blood banks, and seropositivity was quite low, and that paper is about to be published.

But in parallel, people were doing all these other immunological investigations where they were finding that people actually didn’t always make antibodies when they were infected, and even if they did, they were decaying quickly. Plus, people sometimes just got rid of the virus through other means, or already had established responses, like T-cell responses from other coronaviruses that prevented them from being infected.

So then, that radically changed the picture of what level of antibody prevalence corresponds to herd immunity, and we have a paper on that, which we’re finding very hard to publish, it must be said, which shows that it could come down to very low levels, 20-30 percent. But the truth is, for example . . . These are very simple arguments. If, for example, the basic reproduction number of the pathogen, that is, how transmissible it is, is two, so on average one person would infect two people in a totally susceptible population, the herd immunity threshold by classical formula would be 50 percent. But if 30 percent of the population is already immune because of exposure to seasonal coronaviruses, of which there are four circulating at the moment, then of course, as soon as you reach 20 percent level of exposure, we’ve crossed that herd immunity threshold.

We simply don’t have enough information to know precisely what that threshold is in different communities, but what we do know is that in areas where you do see levels of immunity or seroprevalence to be 20 percent, that the virus seems to be under control, or has been under control over a period of time since lockdowns.

Luigi: Sorry, I’m not an epidemiologist, but I look at the data, the Italian data particularly, from northern Italy, particularly around Bergamo, which was the hotspot in Italy. And then, you see towns where 1 percent of the population died. If you use the mortality rate that has been estimated, for example, in Spain, and Spain and Italy are very similar in many dimensions, you get that those towns had an infection rate around 60 percent. So, I don’t see how this stuff can stop at 20, because in those towns, it didn’t.

Sunetra Gupta: OK, first of all, what happens typically in the first wave of the epidemic is that it crosses the herd immunity threshold. It significantly overshoots it. So, that is an argument that people have been using to say, “Ha, ha, of course the herd immunity threshold can’t be 20 percent. It’s got to be . . .” Because in Manaus, for example, 60 percent of people had antibodies. But that is very typical of, in fact, it’s exactly what you’d expect to happen in a first wave, is that it significantly overshoots the herd immunity threshold.

What that means, in fact, is if you have a 60 percent seropositivity, the other 40 percent may be resistant. We don’t know, but it’s possible that the other 40 percent may actually have been resistant to infection. Now, we don’t expect 100 percent of people to be infected, but these models typically will, whoever runs them and whatever way they set them up, they do give you very, very high rates of infection and exposure in the community. So, those figures are compatible with both the herd immunity threshold being low and also of there being a number of people who are resistant in the population, and also of exposure having been widespread.

The point is that these models are conceptual frameworks. You can use them to say, “Ah, that makes sense, or that doesn’t.” What you shouldn’t do is to say what people are saying, which is, “Oh, we saw a seroprevalence of 5 percent. That means 95 percent of the population is not immune.” That should not . . . Those statements should not be made with that kind of certainty. That’s all you can say.

Luigi: Can I ask you, what is your view on the side effects? Because while now we have pretty good estimates of the fatality rate by age, there is a lot of disagreement, at least from what I can read, I’m not an expert, on how severe and how diffuse the side effects are that might remain in the population after getting the disease.

Sunetra Gupta: Yes, that seems to be a major thrust of the criticism against us, is this phenomenon of long COVID. Long-term effects lasting well over a few months, or certainly at least a few months, are quite common in viral infections, so I think it fits very neatly into that kind of paradigm of many viral infections like flu causing these long-term sequelae, and not just being confined to the one week when you’re absolutely unable to move. So, given that, I don’t understand why we would be thinking about COVID any differently than the flu. Because at the moment, you might see more of these than you would for COVID, because we’ve just had a pandemic, so the risk of getting the infection has been much higher than it would be in an endemic, when it reaches an endemic state. 

So, I certainly would not dismiss that as, if you like, an epiphenomenon of this pandemic, but I don’t understand why we should be altering our policy decisions based on that, other than to perhaps put in some investment into supporting people who have got these long-term effects. So, if someone does have something that puts them in bed for six months, then we should have, again, the public funds to make sure they don’t lose their job, or that their lives are enabled during that period, because we’ve just come through a pandemic. I mean, the scale of the problem to me doesn’t quite match the scale of 130 million people starving to death.

Luigi: I understand that if you are in a developing country and you’re starving to death, that’s a different equation. But in more developed countries where we could afford to, for example, work a little bit less, or close down certain particular businesses, if the side effects are large, then the strategy of waiting for the vaccine seems more appealing.

Bethany: Except I don’t think we can afford it, even in more developed economies, when you look even in the United States at the lines for food banks, and the job losses, particularly among the vulnerable. I would argue it’s an illusion to think we can afford it anywhere, and then in the global economy, the choices that developed economies make affect the choices that less-developed economies have available to them.

Sunetra Gupta: Yeah. I mean, to me, the idea of just thinking what is going to happen in the UK and not worrying about what’s happening worldwide is not acceptable, is it?

Luigi: I know, but from a policy point of view, you can provide monetary support to people who don’t work. There is a cost. We can discuss whether this cost is worthwhile. But imagine that . . . This is obviously not the case, but imagine that half of the population who get infected with COVID becomes unable to work for the rest of their lives. We’re not going to go ahead . . . Waiting for a vaccine makes a lot of sense. So, if it is 50 percent, clearly waiting for the vaccine makes sense. If it zero, it doesn’t make sense. In between, there must be some threshold point. So, I think that this number is very important, in my view.

Bethany: I think you’re thinking like an economist, that all the costs are measurable in dollar terms, whereas even here in the US, by shutting down schools, for example, when you have disadvantaged students—30 percent in Chicago, 40 percent in LA United, whatever the numbers are now—not showing up at all, that is a societal cost and a human cost that is simply not measurable in dollars and cents terms. 

Luigi: Yeah, but you are trading off some cost . . . Imagine it were the case, which I’m not saying is the case, but imagine the case that half of the people become permanently invalid, OK? There is a cost here. There is a cost in not sending kids to school. You need to compare them in some way or another. It is a tradeoff.

Sunetra Gupta: I agree, I mean, that is absolutely true, that if half the people that got infected with COVID became paralyzed for the rest of their lives, that would be a very huge cost. And then, of course, we know that that hypothetical . . . I think we can dismiss that as a hypothetical, because then we would be seeing that. It would be evident. It is important to measure that cost, but I have not seen any good assessment of exactly what proportion of people do develop these sequelae. Perhaps our assumption should be that it isn’t any different from any other viral infection? I mean, I think that would be a good baseline assumption.

Luigi: Let’s now turn to the other side of the aisle, and we’re going to interview Andy Slavitt, who is not only a former White House health advisor under Obama, he’s a fellow podcaster, and his podcast is called “In the Bubble,” and the author of the forthcoming book Preventable, which is scheduled to be released in March 2021.

Bethany: I was thinking, Andy, a way to get into this might be, are you surprised at this point by how much we don’t know, or by how much we do know?

Andy Slavitt: I’m surprised how much we do know and that we ignore. This is basically a function of, are you breathing near another person? Countries around the world have recognized that that’s actually quite a simple thing to combat. Go to Africa. 1.3 billion people on the continent of Africa, fewer than 30,000 deaths. There are extraordinarily low-tech mechanisms that we can use, like mask-wearing, that are highly effective against this virus. This is not chimera. This is not the killer bug of all times. This is, in many respects for the US, it’s a starter bug, and the fact that it has so many properties that make it easy to defeat and we still can’t do it is the puzzling and troubling thing that we should examine.

Luigi: At the policy level, one is to make tradeoffs, and it’s not my role or Bethany’s role to make those tradeoffs, but in analyzing those tradeoffs, how fatal the disease is quite important, because we live with influenza. Certainly, we could do much more to reduce influenza. Influenza is lethal, and we could devote more resources, but nobody has thought about stopping the country for influenza, no?

Andy Slavitt: Well, look, you’re absolutely right on one level that it’s useful to know how many people are dying, and it’s useful to know how much more lethal it is, and generally speaking, the range is between three and 10 times more lethal, probably about six times more lethal. But that’s going to come down. I mean, that’s going to improve. And you’re right, you’d love it to get to the place where it’s very, very close to the flu.

Where I shake my head is, I think people inappropriately use this flu comparison to justify things that don’t make a whole lot of sense, particularly because this doesn’t strike everyone equally. You and I may have a 0.25 percent chance, but someone who works on a farm labor camp or lives in a homeless shelter may have a 10 percent chance. We have to be careful about being so flip with saying, “Well, hey, 50,000 people die from the flu every year, so no big deal.” Three thousand people died in 9/11, and we changed our whole country because of it. There’s no set point at which we say something matters and something doesn’t matter.

Bethany: Backing up to that notion, because it is an argument that while there are better ways to protect people and to protect the vulnerable than lockdowns, when you try to think through that and look at the fact that—and you’ve argued convincingly on Twitter, we’ve really failed our elderly, for instance. Is there a better way to protect protected people, given that, what is it, 30, 40, 50 percent of the deaths have been in long-term care facilities?

Andy Slavitt: Yeah, there are. I mean, you can do a better job with infection control. We have a miserable record of infection control at long-term care facilities. But it’s important to understand that people work inside these facilities that don’t live there. People work inside jails that don’t live there. They live in the community. The level of infection inside a high-risk setting, a nursing home setting, whether it’s a congregate care setting, whether it’s a farm labor setting, is directly proportional, number one, two and three, to the level of community spread in a community. Because it’s very hard to, what scientists call, cocoon for very long times, and we have to remember, we have 35 million people in the US who are under 65 that are immunocompromised. People who have had cancer, people who have had HIV, people who have been malnourished.

And so, at some level, this argument about saying, let’s just protect the highest-risk people, you’ve got to ask yourself a couple of questions. One is, can you do it? And it’s hard. And secondly, is that the society we want? There’s no perfect solutions. This is a perfectly fine debate to have, but this camp that says, hey, just lock up the old people, I think, that’s an argument of convenience, usually. 

Bethany: I don’t think anybody’s saying lock up the old people.

Andy Slavitt: I just had a debate, a public debate, it was one of the advisors to the president, and that’s exactly what he said.

Bethany: I don’t think that’s any more broadly representative, though, of that argument than the idea, on the other hand, of locking down forever, until there is a vaccine.

Andy Slavitt: Scott Atlas, who’s advising the president, believes this. Abbott from Australia, the former prime minister, believes it. The lieutenant governor of Texas believes it. There are lots of people who . . . And, look, it’s understandable. It’s an understandable thought to say, can we find a way to do this? I’m just saying it’s hard to do. But most people want to go on with their lives, and I understand that.

Bethany: OK. I guess my point would be that finding a way to protect old people is different than locking up old people. Locking up old people is one step further along the continuum.

Luigi: No, but even protecting means isolating, and this is, I speak as a true Italian. The Italian family is, for example, much more integrated. Hispanic families are much integrated. Black families are much more integrated. So, often the grandmother is the one picking up the kids, so you can’t . . . and maybe they live in the same house. So, isolating is relatively easy if your elderly live in Florida, and you visit them once a year. Isolating them is not such a big cost. But if you live in the same house, and generally the people that share the same house are not that wealthy, so isolating them really becomes a problem. And then, basically, this means that the rich people get isolated and the poor people die.

Andy Slavitt: Exactly. I agree with you 100 percent.

Bethany: Can we pause on that concept of herd immunity? Do we know that number? Is it 80 percent, as some people have suggested? Is it as low as 20 percent, as other people have suggested? Is there a reasonable answer, or are we still in the midst of all we don’t know with that question?

Andy Slavitt: We don’t know, and there’s no precise answer, because it really has to do with levels of exposure. So, if you’re in San Quentin Prison, in that type of environment, it’s 70 percent, is what we saw. It’s possible that you could be in other environments. And then, of course, there’s a bunch of things we don’t know, like do some people have T-cell cross-immunity from other coronaviruses? It’s possible, but again, I think when people talk about it, they talk about it as a silver bullet. And I get it. We’re clutching to find answers. We don’t know, and the evidence on this suggests that people are mistaking lower transmission rates for T-cell immunity. T-cell immunity doesn’t prevent transmission. 

But there are gaps in our knowledge. I mean, there are things that a year from now, certainly maybe two years, we’ll say, oh my god, we didn’t know that fact. If we would have known that fact, that would have explained a lot, and we’re still trying to discover those things. So, getting the data and studying these things is still really, really important, because we don’t have a clear picture. A lot of people think they do. I don’t think I do, but a lot of people think they do, and that’s an important question. We also don’t know how long immunity lasts.

Bethany: It will be heartbreaking, right? In retrospect, we’ll be able to look back, as you just said, and pinpoint that thing that if only we had known, we could have been better.

Andy Slavitt: Not only will it be heartbreaking, we will blame the scientists. We will blame people for not knowing. We will blame people for being, “wrong.” It is our habit.

Bethany: Is that because, more broadly, we’ve become a society that expects science to have answers it can’t possibly have, and in perhaps a broader sense than the COVID sense?

Andy Slavitt: It’s a first-world mentality. We’re rich. We expect that technological innovations should cause us not to have to deal with any inconveniences. Life should be getting more convenient, not less convenient. That thinking, it creeps into all of our thinking. I’m not immune from that thinking by any means. My grocery store is out of my favorite toothpaste, and I’m pissed off. 

The truth is, that’s not a real clear picture of what scientists . . . Scientists are not supposed to be perfect. They’re supposed to be discovering. They’re supposed to be gathering data. They’re supposed to be doing trial and error. But when we watch them super closely, it looks like they’re making all kinds of mistakes, which is why I would tell people, step back a little bit, play a little tennis, do the things that give you some hope and spirit and joy in your life. If you watch it so closely and expect the scientists to get everything right, right at the right moment, you’re going to drive yourself crazy.

Luigi: Going back to the herd immunity, if your numbers on the infection fatality rates are correct, I mean, I think they are, if you look at the number of people who died in the small towns in the epicenters of the Italian COVID disaster, they suggest an infection rate of 60-65 percent of the population. So, I’m not very hopeful of an early threshold of immunity, because at least there, it didn’t work.

Andy Slavitt: I think that’s right. That’s a very solid data point I’ve seen, which is why I say it may have to do with the structure of the community, the way people live, the structure of people’s households. How many kids do they have? Do they live in a multigenerational household, as you said? And it could be, you take that town in Italy and pop it down somewhere else, or you look at the slums in India, or you look at wherever you pick, you’d have highly different answers, probably.

Luigi: But if was true that there is a fraction of the population that is immune, as people say, that should be true, in principle, everywhere, and you shouldn’t see, in those towns in Italy, infections reaching 60 or 70 percent.

Andy Slavitt: Yes. You’re right. But it could be a matter of degree, though, is all I’m suggesting. So, it could be that some of those 65 percent, if they’d have gotten half the exposure, you would have seen it at 20 percent, and places where it’s at 20 percent, if they would have got twice the exposure, it could have been at 65 percent. Is 20 percent the right answer, or is 65 percent the right answer? It could be, in different circumstances, that most likely it will be 20, because people just don’t live in those circumstances. 

But you’re absolutely right. The premise that there’s some limit that if we were all exposed to it pretty significantly . . . It’s like eating poison. You eat a little bit of poison, you may get a little bit sick. You eat a lot of poison, you get very sick. You eat a ton of poison, you’re going to die. These things are easy to feel they’re black and white. They may not be.

Bethany: Back to this concept of a silver bullet. Are we placing too much hope in a vaccine, in that both that one is going to be available, and one that’s going to work? That it’s going to be available, and that it’s going to be 100 percent effective? Has that become our new silver bullet of choice?

Andy Slavitt: Well, if anybody thinks it’s going to be 100 percent effective, we’ve misled them. People think of vaccines, and at one level they think, their model is an MMR vaccine, which is 97 percent effective among children and lasts a lifetime. Then we have an influenza vaccine, which is, depending on the year, 40 percent or 50 percent effective for some period of time, and sometimes effective is not eliminating, but just lessening the virus. So, I think we should think of a vaccine, first of all, number one, as a very good thing. Huge tool. Secondly, it’s just part of our arsenal. It’s not the entire arsenal. It’s not the entire answer. Thirdly, we’ll need multiple vaccines, and, I think, a combination of factors. 

To beat this thing down and give yourself reprieve, what you want to do is get away from a world where we have to presume guilt, and where we can start to presume innocence again. Right now, we look at each other, and we don’t know. We look at the people we bump into in the street, we don’t know if they have it or not, because there’s wide community spread. Once you can flip that around and say, we can kind of know where the cases are, and most people aren’t infected, then life returns, as it’s done in many, many countries. Sometimes, like in Italy, with some adjustments, like scheduling time to go certain places. Those are adjustments that may have to be made for a while. But over time, I think we build up this arsenal of tools, including our own behavior, and we will see things get closer and closer to normal. I don’t think it’s going to be flip a switch, silver bullet day, though.

Luigi: But then, Andy, if you were king for a day, or for six months, whatever, what would you do to fix the problem?

Andy Slavitt: I think we all wear masks for, call it two months, three months. Whatever we close down, Congress financially supports. So, if I’m king for a day, I want to be able to control the purse strings of Congress.

Luigi: Of course. 

Andy Slavitt: So nobody gets hurt. We can do creative things. We need a lot more food distribution, so I think bars can, if they choose to, get paid for and act as food distribution centers, or they could just get held harmless. But, look, I would not be closing down small businesses. I would say that arenas, probably a no-no. But I would be investing like crazy in testing, in the kind of instant paper testing that are like the pregnancy tests. We’re about a month and a half away from having an 85 percent effective test that can tell you pretty rapidly, and with pretty good probability, whether you have this or not. And once you have that, I think you open up a lot of different activities, and people who have the virus asymptomatically know not to go out, so it stops spreading as much.

What I would tell you still, though, I’ll go back and say it, is if you’ve lost the public, if the public is basically saying, “I’m done. No more. I’m not doing testing. I’m not doing contact tracing,” it’s very, very difficult. So, there’s a soft, intangible side of it here in the US, where we have people . . . our founding principles here. People are suspicious of government. People are not used to sacrifice. They’re consumption-oriented. We. I should say we for all of these things. We really prize our individual liberties, but we don’t often think about what responsibilities come with those liberties.

I’m not saying we have to be perfect. We don’t have to get all these things perfectly right to win this. We need to get many of them mostly right. But I think the hardest part is not knowing what to do. I think we do know what to do. I think that list I gave you, 90 percent of people you talk to could give, and you probably would give, a similar list. But the problem is, we’re not doing it, and that has other challenges attached to it.

Bethany: That list is really interesting. It left out one really key source of debate, which is schools, and you recently tweeted a link to a study showing that kids under 10 do transmit. I thought of schools, and perhaps this is inaccurate, so feel free to argue, but as a place where we’re almost inconsistent, in the sense that the US has been lax in many ways, and yet in most of our major cities, our public schools are not open, whereas countries around the world, their schools are open. So, where do you come down on the school debate? And particularly the damage being done to kids, particularly children of color who, I think, 50 percent of kids in Chicago public schools didn’t show up on day one. Same with LA United, same in New York. We’re losing an entire generation of children, and how do you think about those offsetting risks?

Andy Slavitt: I’ve talked to all three of those school districts’ superintendents. These are not easy. I would be wary of your dramatic statement that we’re losing a whole generation of kids. I think more that we’re already losing generations of kids with our school systems. There are legitimate issues, like we should make sure everyone has broadband, which we probably should have done anyway, kids are getting meals, and that younger kids, kids under 10, probably do need to learn in person, and we need to figure out how to make that happen.

Look, and I’m a parent myself. It’s a very emotional issue with your kids, because you want your kid to have everything you had, and you want them to have everything you didn’t have. But I tell you what, kids growing up today, maybe they’ll learn to be more resilient. Maybe they will learn more compassion. Maybe they’ll get to spend some more time with their parents. And so, we just have to do the best we can. There’s no clean answer. District by district, if you have enough testing and you have a low enough transmission rate, you absolutely can be open, and when you can’t, it has real costs. 

Yeah, I mean, look, on the one hand, I started this podcast by saying how this is not that hard, but I’m going to finish by saying this is hard. It’s hard on all of our psyches. It’s hard to know what to do. It’s hard when there’s all this uncertainty. But we’re living through a certain period of history, we’re living through an era of history that people will look back on. I ask myself one question, with two parts to the answer, I guess. How will people look back on this, and what will we feel like we wish we would have done? How will we judge ourselves?

For me, the first answer is the obvious one. How many people did we lose? What was the cost? On Wikipedia, when they say COVID-19, from which one million people died around the world, or whatever it is, making that toll as small as possible. That’s the goal. 

And then the second, I think, is I want, when someone says to me, my grandchildren, what did you do? Did you help people? Were you helping people who were hurting? There’s an enormous opportunity for kindness. 

Bethany: So, in my view, and this may be far too simplistic, but where I’m not sure Gupta has it right, is in this idea that we can protect the vulnerable without limiting community spread. In other words, this idea that there is a way to protect the vulnerable while the rest of the population achieves herd immunity. And they are, the signers of the Barrington Declaration, it is quite explicit about ways we might be able to do this. But is that really doable? As well as her contention that if you did take this path, that it would move through societies in 3-6 months. I don’t know that we know that. 

But on the flip side, I think that Andy Slavitt is quite cavalier about certain aspects of risk, too, in that he, for instance, was very dismissive about the risks to kids. He said it doesn’t really matter if they miss a couple of months of school. I think, talk to any educator, any parent, just look at the statistics. The risk to children is quite a bit bigger than that. We can’t just dismiss it and say that this isn’t a risk. And so, I’m not sure that I’m 100 percent with either approach.

One of the doctors in the very controversial Barrington Declaration said, “The illusion of a safe strategy is the problem. There is no such thing as a safe strategy. You say that if we all lock ourselves in our homes, that’s safe, but it’s not, because it’s ignoring the risks created by locking ourselves in our home.” And so, to me, one big problem with the public debate we’re allowed to have about this is that it’s as if COVID and preventing deaths from COVID have become this big black spot that obscures all the other risks out there. 

But there are also really immeasurable costs. There was just a piece in the Wall Street Journal today about a huge decline in mammograms and other screening procedures, leading to missed and delayed cancer diagnoses. There is the issue of kids around the world no longer getting vaccinated for diseases that will kill them, like measles and pertussis. So, that’s one framing that I wish we could have a more adult conversation about, instead of pretending that if we stick our heads under the mattress, somehow there’s not going to be any risk, and we can make risk go away. I wish we could have an adult conversation about risks.

And then, the other framing is the practical versus the theoretical. Theoretically, it would be lovely if we could lock down, get rid of the virus, and then test and trace, and keep it contained. Practically, is that doable, when a large number of people in this country won’t cooperate with contact tracing? You might say that’s terrible and they should, but it doesn’t matter if they won’t. And there’s no country, besides New Zealand and maybe Australia, that has really been able to lock down and completely stamp out the virus. The damn thing is pretty sneaky. And so, if a lockdown isn’t going to stamp out the virus, then why are we pretending it’s going to? And so that’s, to me, the what we wish . . . the theoretical versus the pragmatic is the other framing that I think we’re getting wrong.

Luigi: Yeah, but I think that the debate is mostly the extremes, but there are a lot of intermediate solutions. Take Japan. Japan did extremely well by basically trying to limit the super-spreading events, and trying to trace more people, and of course, use the masks. And they have no lockdown, and they have done extremely well. But that requires, for example, closing down factories that we know are super spreaders. So, every factory producing meat, it has been demonstrated now, is a super spreader. So, I think we should close them down, or we should impose conditions that are extremely severe to avoid contagion. I think that big sporting events are crazy, in the sense that we don’t let people go to school, but we let them go to the clubs or to sporting events, and I’m talking about large sporting events. That’s crazy. There is a middle ground. It’s just that nobody wants to discuss this.

Bethany: The more I thought about this, the more I thought that any kind of country-to-country comparison is really fraught, because we know now that this disease is particularly vicious to people with certain risk factors, so to look at America’s population, with, what is the number, 30 percent potentially at high risk due to obesity and other conditions that we now know dramatically increase your odds of having this disease in a severe way, and then to look at a country like Japan that doesn’t have our health portrait, you can’t compare from one to the other. It’s the same thing with the experience of the virus in India or Africa versus the US. It’s almost irrelevant, in the sense that the outcome is dependent on the makeup of the population, not necessarily on what was done.

And then, to come back to your idea, close down meat plants, because it’s clear they’re super spreaders. Yes, that would be fantastic. Is it feasible? Can we actually just say stop to America’s global meat production? What will we do with all the dead animals that no longer have a place to go? What kind of environmental damage happens to the millions of animals that are going to have to be slaughtered with no place to go to process that meat? What do you do then? I mean, again, it’s pragmatic, or practical, versus theoretical. Theoretically, yeah, I don’t eat meat. I’m happy to shut down the country’s meat supply. Is that actually doable?

Luigi: Look, first of all, you’re right that there is a difference across countries, but if anything, the difference between Japan and the United States should make the United States much more aggressive in suppressing the virus than Japan. So, the strategy of Japan is not only good because there’s fewer deaths. They’ve had fewer cases through their efforts. So, if you are saying that the US population is more at risk, and I believe you, then the United States should adopt an even stronger policy than Japan, not a weaker policy than Japan. Your argument goes in the opposite direction, in that case.

Bethany: No, I’m going to contradict you, because once again, it’s theoretical versus pragmatic, right? Of course we should. We should, if we could, but we also in this country have very little of a support system, and very little means of getting, say, meals to those kids that are now going to starve to death because school was their way of getting nutrition. And so, the “we should shut down more thoroughly than another country” also depends on the “and how can we then get aid to the people who are going to be the most crushed as a result of this?” Because, let’s face it, we should shut down. For you and for me? Costless. Pretty costless. For the people who can least afford it? Immense cost of just shutting down. And so, that’s where I get, once again, I want to say, what are the risks on the other side of this? 

Luigi: But Bethany, I divide things that we can address relatively easily, if there is political will, and things we cannot. The issue that some children might be starving because we close down schools, if there is the political will, that can be addressed. I don’t think it’s infeasible, OK? Now, changing the healthcare system overnight, that is infeasible. But again, the other systems make it easier for people to be cured, and so make it less painful to have a spread of the disease. 

So, every argument that you are making is saying the United States should be more conservative than the other countries. More aggressive. Conservative might be a misleading term here. More aggressive in fighting the disease than other countries because the costs here are much bigger. We don’t have generalized health insurance. We don’t have a healthy population. All these things go into a stricter policy. 

Bethany: Theoretically, if there’s political will, we could address all of this. We have no political will. Our system has been mired in dysfunction for at least the last decade, if not longer. So, arguing that we could fix these issues if there were political will is sort of like arguing that if beggars were horses . . . whatever the old saying is. That’s kind of like arguing if pigs could fly. I think we’re right back in that zone of what’s reality versus what’s theory. 

And, look, if we could go back to early January and lock down this country, and not allow the virus in, maybe that would have been the right strategy back then, but also, we are where we are today. And so, I think to get lost in debates about what we should have done, and what would be ideal if we could go back to the beginning, just . . . we are where we are.

Luigi: No, I understand, but imagine for a second that Biden is elected, and the Senate and the House are both Democratic. I think that the political gridlock is finished. What would you do in that situation?

Bethany: What would you do? I’ll let you answer that while I think about it.

Luigi: I think I would try to still limit the super-spreading events. I would try to adopt a Japanese policy, in which I don’t think we should lock down so severely as we did in March, but I wouldn’t be cavalier, especially, maybe because of my ethnic background, but I do believe in intergenerational families. I agree with Andy that it is impossible to isolate, especially among the weaker part of our population, weaker financially, and also health-wise. We are making gigantic progress in fighting the disease with the cocktail, et cetera. I wonder how massively this will be available.

So, we know that President Trump got the royal treatment. I don’t think that the average Joe would get the same treatment. So, I would be very nervous about letting the disease spread like Professor Gupta is suggesting, even if I understand that there are a lot of costs involved in delaying. And at some point, if the vaccine waits three years to come, Sweden might look like the real winner here.

Bethany: That’s the ultimate problem, is that the vaccine is waiting for Godot in many ways, and we don’t know what the timing is, because I agree with you. If you could say, we’re going to have a vaccine that is widely available by, say, January of 2021, then the answer would be pretty simple: let’s just lock down until we have a vaccine. If it’s not going to be widely available, and the vaccines that we get are only going to be 50 percent effective, or whatever the number is, then you have a very different picture. To me, the overwhelming factor here is the timing of a vaccine, and I think that it’s unfortunately, at this stage, just unknowable.