Ross Douthat, a columnist for The New York Times, has long advocated for a brand of reform conservatism that stands in stark contrast to Trumpism. His latest book, The Deep Places: A Memoir of Illness and Discovery, chronicles his long struggle with Lyme disease.
In this week’s conversation, Ross Douthat and Yascha Mounk discuss why the expert consensus sometimes fails, when to listen to outsiders, and whether the failures of the establishment help to explain the rise of populism.
This transcript has been condensed and lightly edited for clarity.
Yascha Mounk: You've just written a book which astounded me, because it shared the fact that you have been very sick for a number of years, and I, as a regular reader of your column, had absolutely no inkling. One of the interesting things about this was your slow discovery of the limits of an establishment consensus, and finding yourself having to rethink what the consensus view is.
Ross Douthat: It’s a very interesting thing, in my case, what a painful education you can get in the dynamics of consensus and expertise from having a mysterious chronic illness that nobody knows how to treat. It’s a zone of human experience that is less political than most of the things that you and I write about.
Basically, about six years ago, in the spring, my family and I were moving from Washington, DC, to a house in the countryside of Connecticut. And while we were in the process of making the move, I became very, very sick. That was extremely mysterious. I was having terrible body pain, phantom heart attacks, crippling insomnia, this whole extraordinary range of symptoms all around my body. And there was nothing showing up on any kind of blood test to say what was actually wrong with me.
After months and months of this—and after we had finally made the move to Connecticut, somehow—I basically figured out that I had what a lot of people in the northeast of the United States know well, which is this condition called Lyme disease. But it's a devastating illness and also an incredibly controversial one, because most people who get sick with it take four to six weeks of antibiotics and feel much better. And then some contested percentage—anywhere from 5 to 25%—doesn't get better. Officially, at that point, the American medical establishment has very little to offer them.
Mounk: Does it have little to offer them because it doubts that it’s the bacterium that caused the illness? There's a prevailing consensus, or at least a widespread belief, that this is psychosomatic in some kind of way?
Douthat: Right. There are a bunch of different competing theories of what is going on. There is a more scientifically-grounded theory that says that it's not an infection itself—it's just your over-triggered immune system that has cleared the infection, but which can't stop freaking out. In that sense, chronic Lyme disease would be seen as an autoimmune disease.
But then there's also, I think, the more casual and widespread view that it’s psychosomatic, that people have talked themselves into the idea that they have an illness that they don't really have. And as you move through the medical system, you get all kinds of different responses from different doctors, but also this sort of confidence in a medical consensus that, in both my research, but also just my personal experiences of being treated, is just wrong, basically.
There is, in fact, lots of solid scientific evidence that Lyme disease, like other infections, can persist in the human body, and can be suppressed and flare up and so on. The reality is that there isn't a clear-cut way to treat that kind of condition. But the doctors who do treat chronic Lyme disease essentially use a mixture of antibiotics and other things over extremely long periods of time. They treat for months, or even years. And this is what I ended up doing. Over this very long period of time I was largely incapacitated—except, as you very kindly pointed out, my mind still worked well enough that I continued to write newspaper columns, for better or worse.
Mounk: That's a pretty big caveat.
Douthat: Yes, right. One of the many strange things was that there was a very long period of time where I was being simultaneously told that my body was fine and my mind was causing my illness, when it was perfectly clear to me that my body was not fine, and that my mind was the only part of me that still worked. Of course, that's not incompatible with certain psychosomatic theories of disease. You can imagine someone who is capable of writing newspaper columns, even as their mind is causing them problems in other ways. But in practice, the experience was a very convincing lesson in the fact that there are situations where something happens in life and you very quickly reach the edge of expert knowledge, the edge of medical consensus. You're dealing with a disease that is literally destroying your life, day by day, and you just have to go beyond that consensus in order to figure out what to do and how to get better.
Mounk: I think your experience of Lyme is a really interesting window into these larger dynamics. What do you think explains why the medical establishment ended up holding onto a set of views that you believe were wrong?
Douthat: I've thought about that a lot, and I think there are a few dynamics at work. One is essentially that, once you've established any kind of “establishment versus outsider” narrative, it tends to be self-reinforcing. And then, because medical science is bureaucratized, that has downstream consequences. If you narrow the range of things that you're saying count as a particular disease, then you narrow the range of grants that people have, the things that people apply for to study this disease, cases that insurance companies are willing to cover. There are all these feedback loops between the decisions the CDC makes, the decisions that individual doctors make, the decisions that insurance companies make—and they tend to ratify each other in a sort of enclosed circle of accepted knowledge.
There are these generational dynamics, which you also see in politics, where there's a set of doctors who treat Lyme disease, and who settled on this initial consensus that you should only treat it for four to six weeks. They became influential figures. A lot of people who I know and talk to who want to change the way Lyme disease is treated assume that it basically changes with generational turnover.
Mounk: What about the institutions? There’s this motto, “First, do no harm.” And it seems to me, when I look at our response to the COVID pandemic, that this did a lot of damage. It's still striking to me how long it took us to do human challenge trials [in which healthy volunteers are exposed to a pathogen to learn more about the disease] early in 2021. In the end, we were quite lucky with our vaccines, and we managed to develop them reasonably quickly. But that could have cost months and months of time and tens or hundreds or thousands of lives.
Douthat: It's a strange dynamic with the vaccination debate, because on the one hand, we gained the vaccine incredibly quickly... relative to what? Well, the conventional wisdom a few months into the pandemic was that, in part, you have to stress just how fortunate and lucky we were and how well parts of institutional science worked in terms of actually getting them.
That being said, the vaccine itself was literally developed—it didn't take a year, it took weeks, right, for the first mRNA vaccines to be developed in some form. You can imagine both things like human challenge trials, and also, in the last few weeks before the vaccines were approved, expedited FDA procedures that could have delivered us vaccination two months early. That could have headed off not just last winter's wave, but part of the Delta wave as well. And that very clearly reflected safety-oriented, bureaucratic healthcare procedures.
Mounk: I've been thinking a lot about the usefulness and the limitations of utilitarian—or more broadly, consequentialist—political thought. I wonder whether this sort of deontological principle of “don't do any harm, first of all”, of “safety first”, creates the danger of losing sight of more straightforward, consequentialist considerations. For example: “A human challenge trial might kill some people who voluntarily agreed to take part who otherwise would not have been harmed. But if predictably it will save the lives of tens of thousands, perhaps hundreds of thousands of people, then we should be able to do that.” Now, I think some of what you've been saying seems sympathetic to that point of view. But I also take you to be somebody who, in general, is not especially consequentialist.
Douthat: I'm definitely not a hard utilitarian. At the same time, I think there's a way in which a kind of soft utilitarianism is just an inevitable part of political decision-making. You can't avoid asking “how many people does this help?” versus “how many people does it hurt?” in politics.
When I read the bioethical objections to challenge trials, I can understand where they're coming from. The idea of the government paying people to potentially harm themselves is obviously morally questionable. At the same time, the same people who hold those views tend to be extremely supportive of all kinds of COVID-era interventions that severely limit the liberties of other people, and do potential damage of various kinds to people who don't have any say in the matter. It seems to me intuitively implausible that it is wrong to pay a healthy person to try a vaccine in the context of a global pandemic, but that it is fine to, for instance, close my childrens’ school for nine months, with all the potential damage that that inflicts on many people's lives for the same general goal of reducing overall death rates.
Mounk: We do seem to be in an era in which the belief in consensus and science, and in the political establishment, is becoming increasingly polarized. We seem to have a tribe of people who say we must always trust the prevailing consensus in a way that actually can itself be unscientific. I have become, I think, more attuned to some of the failings of institutions and expert consensus over the course of the pandemic. But I'm also aware of this as a huge danger—everybody starting to freelance epistemically, making up their own views on the basis of much more limited evidence and much less time investment than the experts possess.
Douthat: It's a really, really hard problem. And I feel like we witness the challenge of resolving it every day on the internet.
I'm not going to claim to have a perfect solution. Here are a couple of ideas, though. One idea: you want there to be a distinction that people bear in mind between theoretical and practical knowledge. Maybe those are the wrong terms, but let me try and draw out the distinction. Take something like the COVID lab-leak hypothesis, which for a long time was considered a bizarre conspiracy theory that social media networks were supposed to censor if anyone brought it up. And then, suddenly, it became an acceptable part of the discourse. There is a form of expertise about the nature of viruses, and what a virus looks like if it might have been engineered in a laboratory, versus what kind of virus looks like it was just transmitted from a bat to a human being—I, as a decently-educated generalist, am never going to have that expertise unless I shift all of my focus to just trying to understand that particular issue. You have to defer to some kind of expertise. When experts disagree, you may not necessarily be able to choose between them.
But there’s the question of whether the pattern by which COVID-19 entered the world in Wuhan, and spread from Wuhan to China and the rest of the world, looks kind of suspicious—that's not a question that you need a degree in molecular biology to assess. The fact that this outbreak happens next door to a research facility that is conducting research on these kinds of diseases, and also a long way away from the places where the most likely animal-to-human transmission would have happened; and the fact that the Chinese government has behaved really suspiciously around it—all of this is knowledge that is readily available to a reasonably thoughtful layperson looking at the world. I do not write columns claiming to be an expert in exactly the way that an infectious disease spreads. But as a generalist and a citizen, I still have the right to opinions about how you strike the balance between liberty and safety and those kinds of things.
It may seem like people who step outside the expert consensus and become anti-establishment are just rejecting the idea of authority. But in many cases, they just seem to be searching for an alternative authority. And what often seems to happen is that you have an expert consensus—that consensus suddenly changes or gets something wrong, or it swings wildly from saying “don't use masks” to “always use masks.” Some people say, “Alright, this authority’s discredited, now I'm going to go in search of a different authority”—but then they end up subjecting themselves to an outsider authority or an outsider consensus that gets all kinds of things wrong, itself. It requires a certain kind of work to situate yourself outside of, or between, circles of authority.
Mounk: Do you think that skepticism of experts has played into things like the Brexit vote in Britain, and the rise of Donald Trump, Bolsonaro in Brazil, or Modi in India? There are two versions of the story. In one, the experts did get a lot of important things wrong, and that's what gave an opening to those trying to rebel against the status quo. And then there's a slightly different way of thinking about this, which rejects that there is any amount of serious establishment failure that helps to explain the strange political convulsions we've gone through in the last decade.
Douthat: I'm very much in the first camp. In the second camp, you get different versions of the argument ranging from figures like Tom Nichols to Anne Applebaum, who tend to stress that there's a kind of resentment of meritocracy, resentment of intelligence, resentment of experts—that this is an ineradicable part of human nature, which just happened to leverage some contingent events in order to gain power in places from Hungary to Washington, DC.
I agree that even in a perfectly run technocracy there will be resentment of experts which will feed into politics in some way and create the possibility for convulsions. But the truth of the matter is that I went to college in the late 1990s and came of age in a post-Cold War era of peak expert confidence. You went to college and you had the sense that you didn't even have to take an economics class because Robert Rubin and Alan Greenspan had figured out how to manage the global economy. There was this unipolar moment where the world was gradually democratizing and getting richer, and American military power could help push countries along that path when necessary. The US economy was doing really well. US military interventions under Bill Clinton had seemed to go reasonably well.
The next fifteen years of my adulthood featured a disastrous response to 9/11. Then you had the global financial crisis—there were some experts who saw it coming, but not very many. You had the Eurozone convulsions that followed the financial crisis, where the expert consensus about fiscal and monetary policy seemed to be disproven by events.
And then lurking behind them you had this expert-blessed opening to China that was supposed to deliver liberalization to China and greater prosperity for both the US and East Asia. Yet it delivered increased geopolitical power without liberalization. And in the US, it turned out that while there were winners and losers from the opening to China, the losers were more numerous than a lot of economists had perceived. I could go on, but that's a fair catalog of the major problems and crises of the last fifteen years where the expert consensus was not a reliable guide to what was going to happen and what could go wrong. And I think it's not surprising that out of that, you would get a populist reaction.
Mounk: How do you hold experts, established institutions, and politicians to account without jumping to the opposite conclusion, which is that all of these people are corrupt and in it for themselves?
Douthat: I'm not particularly optimistic about this. I think that we are in part living through a dynamic that was very accurately predicted by the British writer Michael Young, who coined the term “meritocracy.” He wrote this somewhat satirical book called The Rise of the Meritocracy that imagined a future where you have politics polarized between a very intelligent but out of touch technocratic elite, and this populist alternative that had legitimate grievances, but couldn't find the leadership to express itself effectively, let alone to govern the country. I think that really is the dynamic of Western politics.
In some cases, very literally, you have these movements like the gilets jaunes in France that have no leaders at all, and who have this array of grievances that span the political spectrum, many of which are reasonable, but which don't condense into a governing program. Or you have figures like Trump and other populist leaders who sometimes manage to take power but are fundamentally grifters, rather than figures trying to translate populist grievance into governance.
But I think right now, you would have to say that Boris Johnson has been the most effective Western politician in terms of channeling populism without being consumed by it. It's hard to see figures who embody a populist alternative, while also channeling that back towards effective governance. One reason that conservatives like Viktor Orbán in Hungary so much is that he seems really ruthlessly effective, in a way that other populist leaders aren't. The problem is he's also, as far as I can tell, terribly corrupt. So where is the non-corrupt, highly competent, civic-minded, populist leader in the Western world? I don't have an answer for you.
Mounk: How do you assess the American political situation now, and how dangerous do you think Donald Trump is to democracy at this point?
Douthat: Trump is dangerous, but not as dangerous as you think. The way that Trump's narrative of voter fraud has played out and taken hold means that, in spite of having lost the election to Joe Biden, he is clearly the front-runner for the Republican nomination next time. And the biggest danger with Trump is a more extreme version of what we saw play out in the last electoral interregnum in the US—where he loses the next election very, very closely, and he or the Republicans who support him find a way to basically pitch the country into a constitutional crisis, where a state refuses to report its electors, or sends dueling slates of electors to Congress.
I don't think that's at all the most likely scenario for 2024. I think it's more likely that the Democrats win easily enough that this isn't an issue, or Trump runs again and wins, or someone else is the Republican nominee. What I struggle with are the arguments that American democracy will collapse and Trump will become an Orbán or Erdoğan-style figure—if not worse, a dictator—and America will become a fascist country. Those scenarios still strike me as very, very remote. Trump is a fascinating but weak figure relative to other populist strongmen who have taken power, and I think that liberals tend to underestimate their own power.
Mounk: What would a second Trump term in office actually look like?
Douthat: My maximally provocative view is that Trump would be more dangerous to American democracy by losing the election incredibly narrowly in 2024 than he would be by winning it. That is to say, I find the constitutional crisis scenario, in some ways, more worrisome than another four Trump years, which may be totally naive and foolish of me. As president, Trump didn't really have a program that he wanted to pursue—yes, he had certain ideas on trade, immigration, and so on that he would reach for, but Trump mostly wanted to be president: to just exist and occupy the presidency and dominate the media conversation.
Don't get me wrong, if he is elected again, there will be a kind of cultural meltdown in America that would be very dangerous, and I definitely don't want to live through it. But in terms of consolidating power in an illiberal manner, I'm just really skeptical. Trump was already president during the greatest opportunity for consolidating illiberal presidential power that anyone's had since 9/11, which was a global pandemic that started in China—Trump's alleged great enemy. And instead, he just followed the libertarian wing of his party, and basically just downplayed it and tried not to take emergency measures.
It doesn't seem to me that an aging, instant lame duck Trump—who would undoubtedly lose the House and the Senate in the next midterm election—would have this appetite for consolidating power that he did not successfully manifest during his first four years. You would have to tell me more about who his vice president is, who his key advisors are in that scenario. Could there be illiberal-leaning Republicans who use a second Trump term to consolidate their own position as leaders of the party? That, I think, would be the more important place to focus, rather than Trump. Trump is not going to pass a constitutional amendment to allow himself to run for a third term. There are things that are just not going to happen in a second Trump term that could happen in a different country. I'm sure I haven't persuaded you not to worry. But I hope that's a provocative place to end.
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🎧 Ross Douthat on the Trouble with Experts