Vinay Prasad MD, MPH is a hematologist-oncologist and Professor in the Department of Epidemiology and Biostatistics at the University of California San Francisco.
In this week’s episode, Yascha Mounk and Vinay Prasad discuss the impact and efficacy of mask mandates and lockdowns; how the stifling of dissenting views among doctors and scientists harmed decision-making; and how we can improve our readiness for the next pandemic.
The transcript and conversation have been condensed and lightly edited for clarity.
Yascha Mounk: Now that the beginning of this pandemic is about four years away, how do you assess, on the whole, our response to it?
Vinay Prasad: I think our response was very poor. In general, we made two types of errors. There are lots of things we could have done that we didn't do and that we neglected, particularly around the elderly. Our response towards young people and people in their 20s and 30s was heavy-handed and overbearing and violated some of the norms of Western democratic free societies.
Mounk: It strikes me that when we talk about this topic right now, we often talk about various ways in which the response was heavy-handed or overly restrictive—I'm sympathetic to some of those arguments. But the more basic failure is a different one: The Centers for Disease Control was built to stop and control epidemics, right? And at the beginning, when we started to hear about the spread of this viral disease, the hope was that we would quarantine people and isolate them in such a way that the disease wouldn't end up infecting most of the population.
Was that something that a better public health system would have actually succeeded in doing, or do you think that given the particular nature of this disease we were never going to be able to control it?
Prasad: Could this disease ever have been contained? Maybe, but only if China had been cooperative early in December of 2019. I think by January and February, the horse was out of the barn. It's a highly contagious virus. It had seeded the entire globe. By March, I think we had widespread transmission in every continent. And so I think containment was always not possible. There are some people who believed in Zero-COVID even in June and July in 2021. They thought we could stop all transmission. I think that was incredibly naive. COVID-19 has animal reservoirs; we had data that it infected the majority of white-tailed deer, for instance, in Michigan. It's affected other animal species. Containment, I think, was not an option from the moment in which US policymakers took it seriously.
There's a lot of people who are infected who are only mildly or asymptomatic. That's one difference from other viruses. Number two, it's extremely transmissible. It's highly contagious, unlike other viruses. Number three, it's spread by breathing, by aerosol, rather than something like Ebola, which is much more able to be contained. SARS-1, for instance, might be a similar comparison, but, of course, the majority of people who get it get very sick, and there's a period of time in which you can quarantine them.
Finally, China did not let us know that the outbreak had even occurred. And so there was all these kinds of obfuscation that made it harder. But I'm of the belief that, even in January of 2020, we were unable to contain the virus.
Mounk: Let’s assume you’re right. And, of course, the problem was that that wasn't completely obvious early on. I remember even when people first advocated social distancing—and I was one of the early advocates of social distancing, writing in The Atlantic on [March 10] of 2020—the idea was to “flatten the curve,” to reduce the number of people who are in need of immediate treatment in hospitals long enough to ensure that the hospital system is not overwhelmed in the way it clearly did get in Wuhan and arguably in some parts in Northern Italy and other places; that would then drive down the number of fatalities. But then it turned into this much more long-term policy.
Where would you argue that we started to go wrong?
Prasad: Social distancing means two things. One is voluntary social distancing. And in the United States, from cell phone tracking data, we know that when people see cases going up, there is a massive voluntary behavioral change that occurs. People are less likely to go out and less likely to see people and they take risks in different ways. We did something beyond that. Of course, in the United States, we used the power of the police state to enforce lockdowns. And that I think was a bad policy decision that was not in line with prior public health guidance. It was learned from a totalitarian regime. There's very little evidence that it actually improved things beyond voluntary changes. And it led to a lot of resentment. And I think it was an infringement on freedoms. You talked about flattening the curve—that made a lot of sense to prevent healthcare collapse. If you get a huge flood of patients to the hospital all at the same time, and they're inundated, you get healthcare collapse and then the fatality rate can balloon because you can't provide basic healthcare measures.
But ironically, we had healthcare collapse or near collapse in New York City, but besides that, we flattened the curve in places that had essentially very low healthcare utilization; the hospitals were empty. So we weren't flattening the curve to prevent healthcare collapse. We were having lockdowns instituted with the authority of the police state and there was nobody in the hospital. And then finally, when we relaxed those pressures by the summer of 2020, places like South Dakota, who had been fatigued and fed up with this sort of top-down restriction, they had outbreaks and epidemic spread and they were not able to institute politically those kinds of measures again, or even to change the minds of people. So in many ways, I think most of the lockdowns in early 2020 were too much and at the wrong time.
Mounk: I think one useful thing to do in politics always is to distinguish between mistakes that were knowable at the time and mistakes that are obvious in hindsight. There was a strange creep of these pandemic measures.
When I wrote that article called “Cancel Everything,” I was not saying we should use the force of the state in order to tell people they're not allowed to leave their house or access beaches; it was really about shifting behavior so that employees are allowed to stay at home rather than having to go to the office, and to call off some of these mass events that would quite likely spread the virus very quickly. That then turned into state-imposed curfews and other kinds of measures that really restricted the freedom of movement of people. And I think that in hindsight, it's frightening how quickly we did that. But we were seeing the collapse of the healthcare system in parts of New York, and there were at the time understandable fears that the same was about to happen in all of these other kinds of localities.
Is this a mistake that is obvious in hindsight, or should it have been obvious in March and April of 2020?
Prasad: I just want to be clear: My criticism is not a referendum on your involvement in all this, it's not about your article, which I think was perfectly reasonable to have written at the time. And it's really a criticism of the people who are in charge of the policy. I think Francis Collins and Anthony Fauci were aware that many scientists disagreed with their point of view. They held zero debates on the topic. They refused to entertain those opinions. We have emails from Francis Collins saying, when he read the Great Barrington Declaration, “We need a quick and devastating take-down” of this. He didn't write an email saying, “Maybe we should have some public discussions and put these on YouTube and let people hear the pros and cons to this.”
I think there were plenty of people at the time who were opposed to these measures. Jeff Flier and I wrote some articles critical of this early in the pandemic saying that we need to listen to scientists from different points of view and we need to think about all the negative consequences of lockdown. We had data from China very early on that it essentially had no lethality in young people. There is a rate of death in people under the age of 18, but it is so fleetingly low it makes no sense to restrict their movements and restrict their school given the value of school. But the bigger point is that it seems like Monday morning quarterbacking because the people who set the policy squelched all attempts at any dissenting opinion and did not allow the public to hear the points of view of people who disagreed at the time.
Mounk: What mistakes should have been obvious at the time? What are mistakes that are obvious in hindsight? And then why did we not have a debate about these ideas? Why was the instinct of public health officials to squelch debate about whether or not we should have school, but also of course about questions like what the origin of the virus might be?
Why is it that so many journalists came to understand the job as being to corral the public into following government guidance rather than being the sort of independent-minded interrogators with a healthy dose of skepticism towards anything that a government says? Tell us a little bit about the way in which that space for debate was closed down, both in the broader public and in the medical and scientific community that you are part of.
Prasad: I want to draw a distinction between when Trump was in office and when Biden was in office, because I think things changed dramatically. When Trump was in office, Trump and the media are not on the same team. Okay, so I think there was a natural tension between Trump and the media. So Trump famously didn't want to wear masks. The media suddenly made it that cloth masks were the greatest thing since sliced bread. And of course, now we know cloth masks don't work. Donald Trump, like a broken watch, he's right twice a day. Donald Trump wanted to reopen schools in the summer of 2020. There's public opinion data that shows very clearly the public supported school reopening the moment he said it at the end of June 2020. One week later, there was a massive flip and it was almost exactly partisan lines: Democrats were much more likely to support school closure. Famously, Apoorva Mandavilli, the New York Times reporter, said that even to entertain the idea of lab leak was a racist idea. Meanwhile, it's not clear to me that entertaining the idea that people are eating exotic animals is any less racist than entertaining the idea that there was an accidental lab leak. I think most of the people in the media championed the establishment public health view, which tends to be on the political left because people in public health tend to be on the political left. And the establishment public health view in 2020 was lockdowns—more is better. School closure, that's good because the virus is bad for kids. Masking, great. Masking two year olds, even better.
We didn't talk about one of the structural problems I see in the pandemic, which was the man on television every day, Anthony Fauci, whom I believe has made numerous errors, including obfuscating the origin of the virus in part because he may have funded it. Also, his statements on masking were inaccurate at the time that he said it. He opposed DeSantis reopening schools in 2020, famously on TV. He made a lot of errors. Many people I know in infectious disease and epidemiology wanted to be critical of him. But they weren't. Because he has two roles. One, he was the public spokesperson for pandemic policy. And two, he is the person in charge of everybody's grant-funding from NIAID, the National Institutes of Allergy and Infectious Disease. So you have the same person who controls our research budget and is the public face of policy. And I think that is a huge structural problem.
Mounk: One of the things that I found striking about the public debate is how easily the consensus flipped back and forth between different positions. What we remember about masking is that it was encouraged and that now some of the scientific evidence about paper masks, at least, is calling into question how useful that was. But if you actually zoom back a little bit more, the story is even wilder than that, because in February and early to mid-March of 2020, the concern understandably was that a lot of medical personnel didn't have access to personal protective equipment. And so therefore people didn't want ordinary citizens to go out there and buy up all of the sparse mask supply because hospitals needed them. And so at the time, a lot of the messaging from the CDC and other health officials was, if you’re not a nurse or doctor, not to bother wearing these masks. And then the consensus sort of flipped a month or so later into taking it seriously and saying that everybody has to wear masks.
What I'm struck by is not just that we ended up in these argumentative silos where partisan polarization governed what people were going to think and (in some ways) how journalists covered this whole thing; it's that the nature of the beliefs within these silos flipped, and very quickly people were consistent within their ideological camps in adopting the new belief that a month later they thought was characteristic of the other team.
Prasad: Yeah, that's a superb point. And I just want to talk a little bit about the mask point. We all know what happened: Fauci famously went on 60 Minutes and said masks don't work; you might touch your face and cause some countervailing harm. So it doesn't work. Don't use it. And then six weeks later, he said masks do work. And then later, when asked to explain that flip, he said, “Well, I didn't want you to buy up the mask for the healthcare providers. That's why I lied to you initially.”
But to me, that explanation is itself a lie. Because when he came back six weeks later, he didn't say use a surgical mask or an N95. He said we still have a PPE shortage, so use a homemade cloth mask: “Cut your socks, cut your t-shirt,” etc. And then from 2020 until 2021, most people on the street were wearing a cloth mask. But if he was going to come six weeks later and say, don't use a surgical or N95 mask, use a cloth mask, why wouldn't he have said that six weeks sooner? You still had the t-shirt, you still had the sock.
Mounk: How strong was the evidence at the time that these paper masks don't work?
Prasad: It was extremely strong, so strong for instance that the Cochrane Review was negative. You can read the account by Tom Jefferson, the Cochrane reviewer, that cloth masks certainly didn't work. And then there's a second issue: Does an N95 mask work? And the answer is in some ways yes. But does a community recommendation for people to wear an N95 actually work? And the answer to that is probably no. Because nobody can wear it correctly. Nobody can sustain it hour after hour.
The reason he went on initially and said it didn't work was that multiple randomized studies showed it didn't work. That was the consensus. I'm not convinced that masking did much in the entire pandemic.
Mounk: Explain to me what your theory of mind about Anthony Fauci is. I have the instinct to assume that people aren't malevolent, so I have a relatively straightforward way of making sense of his flip: He thinks, look, these masks probably have some benefit. We don't know how much benefit they have. Certainly, we need to be able to give doctors and nurses some of these masks, and so in [March] of 2020, he sort of engaged in what he thought of as a noble lie.
I don't think a public health official should tell a noble lie. I think that he's on the hook for having made that mistake, but that makes sense of his motivations in a kind of straightforward way.
What's your story? If it was that obvious that masks didn't work in March 2020, why then did he lie?
Prasad: He says that’s what happened. Here's, I think, my story. We have to think about what his mentality was when this happened. So just now we know from a lot of leaked documents that he actually probably did worry that a lab leak was the culprit origin of the virus. He had been funding, through NIH grants, the EcoHealth Alliance, which was conducting gain-of-function research in Wuhan. I think he's worried that he's on the hook for this thing. Then in February, when he goes on TV the first time, he says what he genuinely believes, which is in accordance with the Cochrane Review, WHO, CDC—it's not just him, every public health authority globally says masks don't work because that's what multiple randomized studies show in community settings, that masking doesn't work. We never recommended it for influenza, et cetera. Then what happened was in the next six weeks, and this is nicely depicted in an article by Jacob Hale Russell [and Dennis Patterson] called “The Mask Debacle,” there is an organized campaign among scientists to push the idea that cloth masks work. The idea is driven by aerosol studies, by mechanistic science, and that campaign has a lot of signatories. It's called #masks4all. When he goes back in March and flip flops and says cloth masks, he's doing it to capitulate to what he thinks people want to hear. And I think he's not doing what he thinks is a scientific thing. He's just saying, “Okay, I tried to tell them the truth about masks and now they really want them. And you know what? Screw it. It doesn't do anything anyway. So let them have it. Cloth mask, cut your sock off and put it on.” So I think he's lying the second time.
Mounk: Why are these scientists on Twitter and so on campaigning for masks? So they're motivated by stopping the disease or by saving people's lives and they just get it wrong, and they don't have a nefarious purpose?
Prasad: Nobody has a nefarious purpose. They're in their house, they're scared, they're panicking. And then the other thing is many scientists put too much weight on mechanistic studies: Yes, if you spray aerosol through the cloth, some of it will be trapped. But that's different from making policy recommendations where you ask people to wear cloth masks and measure the impact of that policy. So I think they don't study policy. Most of the people who are on these signatories are like mechanistic scientists. But no, I don't think anyone's nefarious in the sense that they're trying to recommend masks as a scam.
In my mind, the bigger policy errors were made in the Biden administration. So I hope we come to that, but let's talk about school closure.
Mounk: So there was a moment when we were holding people back from school in places like New York where the health system was really being overloaded, where perhaps, in March of 2020, we didn't quite know with certainty what the fatality rate might turn out to be for young children.
But then by the summer of 2020, we can see that hospitals are not overloaded. At that point, there's much better evidence of how strongly age-correlated fatality for COVID is. So at that point, the argument for opening schools becomes much, much stronger. I'm not a public health expert or an epidemiologist, so I always had some difficulty figuring out the different sides of that trade-off. I think it's hardest when there's a trade-off and there's genuine costs on both sides to figure out what is the right course of action.
What I was struck by in the discussions at the time is the confident claims that little children wearing masks all through the school day, or children going to school via Zoom rather than in person, was essentially costless. And it always struck me that in order to make this argument for school closures, people were willing to discount the costs on one side in a way that I've always found to be intellectually dishonest, whatever your view might be about how the different costs overall stack up.
Prasad: First, I think it's important to have some global perspective. Sweden never closed elementary schools, not even one day. And Sweden only closed middle and high school for six to eight weeks. Switzerland, six weeks. France, like 10 weeks. Everybody gets to me a pass for the first ten weeks of 2020. From March 2020, everybody gets a pass, closed schools for 10 or 12 weeks. That's fine. Only Sweden made the right decision around elementary school kids.
But in San Francisco, Los Angeles, Washington DC, Chicago, schools were closed for 18 months. They were closed all the entire next calendar year. And that to me is the part that's absolutely unjustified. What do we know at the time? We knew from the Swedish experience by the summer of 2020 that schools could safely be run in elementary school settings. What do we know about masking kids? The European CDC suggested no child under the age of six should ever wear a mask. The Americans went down to two years old. Now that's an American delusion to think that cloth masking a two-year-old will work. And that was an extremely controversial and misguided policy that I think created backlash. In terms of schools, there's a huge benefit to children being in schools in terms of their upward mobility and their education. And we see massive learning losses now. The downside was we thought that, even if it wasn't so deadly for kids, that school closure would slow the spread of virus in communities. But by the summer of 2020, there were some elegant economic papers, one from Germany that asked if you close and reopen the school, what's the change in transmission in that county? And that study found no change in transmission in the county from opening or closing schools. We have another study by the USC investigators that showed, by the fall of 2020, very tiny or no difference in transmission from school closure.
So here on one side of the ledger, you get massive learning losses and all the attendant harms of closing schools. On the other side, you're getting no change in transmission and kids aren't affected that much. To me, reopening schools by the fall of 2020 was a no-brainer. That was fought vehemently. Biden ran a campaign where he had political ads that said, “Donald Trump wants to put your kids back in school, that's dangerous.” Famously, Randi Weingarten and the teachers union stubbornly opposed school reopening.
School reopening in the fall of 2020 is not linked to cases or hospitalizations or anything. It's linked to the strength of the teachers union and how liberal a city is. So to me, school closure is the great domestic policy failure of 2020, at least in the fall.
Mounk: We haven't yet really talked about the vaccine. That is, in a sense, the big success story, the one thing that has allowed us to get out of this pandemic faster than we might have done otherwise. And the one way in which human ingenuity really was incredible during the pandemic was the record speed at which we developed these vaccines. We did learn quite early on in the rollout of the vaccine that they did not stop transmission in the way that we had hoped a little bit earlier.
So are vaccines the big success story here? And where do you think we went wrong in terms of how we rolled out the vaccine and encouraged people to get it?
Prasad: Your summary is pretty accurate. I'm 100% persuaded that an older, unvaccinated person who did not have COVID-19 definitely benefited from the vaccine in January, February, and March of 2021. So for a 70-year-old person who had never had COVID, that vaccine dramatically reduces their risk of severe disease and hospitalization from COVID-19. And that was the biggest success story of the pandemic, the development of such an effective vaccine. Now, what I'm not sure about is if a 20-year-old who already had COVID-19, do they benefit from getting the dose of the vaccine? The way to answer that question would have been to ask Pfizer to do a special study in people who had recovered from COVID-19. They didn't do that study. Now the reason that's important is later they're going to mandate that vaccine in people who've had COVID-19 and they're gonna fire them if they don't do it, okay?
Mounk: When it comes to this question of firing, I think that's where basic liberal principles like the harm principle come in. I certainly understand why, if we think that the vaccine impedes the transmission of the disease, there would be a very strong argument for doctors and nurses to get the vaccine, for example. You obviously don't want to subject patients who presumably already have compromised health to the additional risk of contracting a disease because the doctor or the nurse isn't taking the vaccine.
Those arguments become a lot less compelling when you have data that shows that getting the vaccine doesn't reduce the likelihood that you transmit the disease, because then we're really in the realm of a potentialist state where we're saying in order to reduce your risk of mortality, we are taking these very, very heavy-handed measures to force you to take an action. For me, that is the key distinction.
Prasad: That's exactly the key distinction, which is that as a general rule of public health, we think it is a prerequisite to mandate a personal health intervention if and only if there is enough benefit to third parties that it outweighs my loss of autonomy. There has to be that third party benefit. And what I'll point out to you is that every single mandate in the United States, from the federal government mandate to the school mandates, to the college mandates, to the hospital mandates, they were all implemented after we knew the vaccine does not and cannot halt transmission. No mandate was implemented in early 2021. They all came when we already knew that the vaccine does almost nothing to stop transmission.
If we wanted to know if the vaccine slowed transmission, we could have asked Pfizer to take people in the study and swab their family members randomly every few months to see if it slows transmission. The FDA has repeatedly not asked Pfizer to generate data that might lend some value to these debates. We can talk about the booster. Now they're saying that you have to get a booster every year and every six months. So the company is not being made to generate data to support these claims. And so we've kind of fallen down this path where, actually, you need a shot every six months for the rest of your life. We are getting to the point where it's got taken on absurd qualities in my mind. But your distinction is absolutely right. To mandate someone, you need to show benefit to third parties. They never had that, so that to me is problematic.
Mounk: What are the lessons for the next pandemic and do you think we're going to heed those lessons?
Prasad: The result of this pandemic is massive political division. If there is a pandemic in the next 20 years, you're going to see two states. You're going to see the red states doing something completely different from the blue states. And what you're also going to see is they may both make mistakes. The red states are likely not to do anything, even if doing some things would be valuable, because it would be a different virus. And the blue states are likely to do everything, even if that's unnecessary as well.
You'll also see migration probably more than you saw in this pandemic. People who don't like blue state policies will move. I will move to Florida, for instance, if I think the policies are heavy-handed in my state of California. And then I think you'll get more and more division and bitterness. And I think implementing things like mask mandates and vaccine mandates will lead to more backlash. I think we're extremely vulnerable to any threat that requires a coordinated action because we're more polarized than ever before. In the United States, we ran zero studies of community masking. We did no studies. Anthony Fauci said to do it, he controls the budget to run the research and to do it, and we ran zero studies. We didn't study school reopening and school closure. We didn't study social distancing. We don't know the right distance; six feet we made up.
We actually are no smarter about how to handle the next pandemic because we didn't do any studies. So I think we have both a crisis of evidence and a crisis of confidence. And I think those two will not serve us well going forward.
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