What We Got Wrong (and Right) About COVID-19
Three public health professionals assess America's response to the crisis—and how we should prepare for the next one.
Since early 2020, when COVID-19 began its rapid spread around the world, we’ve been told that everyone must “follow the science.” But science is a method, not a monolith. Scientific assertions change with the arrival of new information. Science resists dogma and tribalism. Some of these principles seemed to get lost in the aftermath of the arrival of COVID-19 and the policy response that ensued.
Early in the pandemic, I began following on Twitter a number of distinguished public health professionals who increasingly had views that questioned the public health “consensus” that long-term mass lockdowns and school closures were crucial for stopping the spread of COVID-19. They were advocating for more targeted protection of the most vulnerable while allowing other parts of society to continue functioning. They raised questions about the reluctance to modify restrictions in the face of new data. They said that many people were harmed while the most comfortable were cosseted.
I got together with three of them recently on Zoom to discuss what was right and what was wrong about our policies, and what lessons the public health profession should learn from the pandemic. All are physicians and hold master’s degrees in public health. They are:
Monica Gandhi, a professor of medicine at the University of California San Francisco School of Medicine. Her expertise includes infectious diseases, epidemiology, and biostatistics;
Vinay Prasad, an associate professor in the Department of Epidemiology and Biostatistics at the University of California San Francisco. He is a hematologist-oncologist;
Stefan Baral, an associate professor in the Department of Epidemiology at the Johns Hopkins Bloomberg School of Public Health.
All described themselves as people of the left, but they spoke of their concern about how politically polarized their profession became during the pandemic, and how this—and other issues—should be addressed before the inevitable next public health crisis.
[The conversation has been edited for concision and clarity.]
Emily Yoffe: In the U.S., is the pandemic over?
Monica Gandhi: I think that the public health emergency is over. And what that means is that hospitals are in no way overwhelmed. In the U.S., I think the question is going to be: When do you downgrade it from an epidemic to an endemic? Epidemic means it causes excess hospitalizations; it’s a problem for the healthcare system. And endemic means you are just going to live with these low rates of a viral infection. And I think we’re getting very close to it being endemic. I think at this point, tracking hospitalizations and deaths is the right approach. And understanding that “zero COVID,” or complete eradication of an infectious disease, is likely not achievable.
Vinay Prasad: I think the worst is over. The better way to judge how much of a public health threat is happening is the number of people who are hospitalized, the number of people who are dying. And maybe cases won't be the best metric going forward, because many people might have mild, very mild infections.
EY: When you say we should look at hospitalizations, not cases, I think for a lot of the public that is not a clear distinction. For more than a year, we’ve been seeing a running banner of cases on cable news. I think a lot of people think that means serious illnesses. Can you explain the difference between cases and hospitalizations, and elaborate on why the emphasis on cases is not a good idea?
VP: A case is really anybody who, for whatever reason—whether they're going to Hawaii on vacation, or whether they have a runny nose, or whether they're really sick—had the swab inserted, and the swab came back PCR-positive for SARS-CoV-2. So it’s a huge gamut from somebody who didn’t even know they had COVID-19, to somebody who may have mild symptoms, all the way to somebody who’s in the hospital.
Stefan Baral: We teach this in class: An epidemic is when you have more cases than you would otherwise expect. What’s going to have to happen is ensuring that we’re adjusting our expectations, so that we can make decisions in a thoughtful way. In the U.S. there should be an expectation that there will be increased cases of COVID-19 come this winter. But if we say that we expect the same number of cases that are happening now to be happening in December, and then cases go up, we’re going to declare that we’re right back in the thick of it. I worry that yo-yo-based approaches are going to be very difficult for people, and would suggest we update our expectations with a focus on actual health outcomes, and not just test results.
EY: If you three were tasked with writing the after-action report for your profession about the lessons we need to learn from our response to COVID-19, what are the major ones?
SB: We applied a uniform intervention strategy to something that was disproportionately affecting particular communities. We locked down society, but transmission doesn’t happen at the level of society: It happens at the level of households and workplaces. And we didn’t really do a lot in those places, so a lot of the workplaces declared “essential” continued, and we didn’t provide those people options in terms of their households. For example, we could have made temporary living spaces available, especially for people in multi-generational households.
With HIV, we don’t provide pre-exposure prophylaxis to everybody. We don’t provide birth control to 70-year-old women. We have targeted interventions for folks who really will benefit from them. And we just didn’t do that here, to the harm of all of us.
VP: Another great failure is that we didn’t learn a lot. We did so many different interventions, but we didn’t actually study many of them. For example, there are still questions about how much to wear masks, and under what circumstances. We don’t know much more about that than when the pandemic began.
The other kind of failure is the cultural failure, which I view as several interlocking things. One is when you have a very polarizing political figure making statements, some of the response from the public health community was to oppose the polarizing figure because he’s polarizing, not necessarily because what he says is always wrong. As bad as Trump is, as much as I personally disliked him, he was probably right on opening schools.
I think the social media environment was an abject failure. If you had the same pandemic without social media, you would have naturally, I think, had a consensus towards centrist risk reduction—a harm reduction philosophy. But in the era of social media, it’s so easily skewed into two diametric policy positions, both unhelpful. One [extreme] was that the virus doesn’t exist, or “it’s just the flu, bro”—a totally bizarre and farcical view. And the other extreme was, all you needed to do to exterminate the virus was for everyone to be a good person and wear their N-95 mask for four weeks and we get to zero COVID.
The last thing I would say is sort of a core failure is Zoom. I think many people think Zoom is what liberated us—were it not for Zoom, how bad would this pandemic have been? But my counterfactual is different. Zoom allowed a lot of upper-middle-class white-collar people the ability to work and make money and not lose their jobs, and to exclude themselves from society. That fundamentally changed the pandemic. If you went back 15 years ago, and you didn’t have Zoom, you would be facing unprecedented layoffs of wealthy, upper-middle-class people. I think a lot of businesses would have had staggered schedules and improved ventilation. Schools would have pushed to reopen. Amazon Prime and Zoom and all these things in our lives allowed a certain class of people to be spared the pains of COVID-19, taking them out of the game, and making them silent on many of the issues that affected other communities.
MG: I think all three of us on this call are very—well, I describe myself as left of left. But we exacerbated disparities, and we made the rich richer through our approach. And that wasn’t talked about by the left.
EY: You’ve all written and spoken about your concerns about school closures. Can you talk about this and about the legacy of what we’ve done? Are we failing to pay enough attention to the poor, the minority, the rural kids who’ve disappeared from their school systems? You want to be forward-looking, so what do we need to do to address all this?
MG: Children under 14 years old are threefold less likely to get the virus than adults. If they get exposed, they are one-half as likely as adults to spread it. And they have profoundly less severe outcomes. Those three points are facts, and you can’t argue them away. And because of those facts, let’s just be clear that we did close schools to protect adults, when we had other ways to protect adults through the mitigation strategies of masking, distancing, and ventilation. So, in terms of the schools question and long-term legacies, there are two aspects. One is that 3 million children have already been estimated to have never logged on during this virtual school year. So that means 3 million at least—who knows if there’s more—just entirely didn’t get an education when school was online. That could have true long-term impacts on your ability to catch up and be a learner later in life. And the second is the mental health impact. We have a paper that we are circulating to journals right now about the increase in suicides among children, while there was a concomitant decrease in adults. So that means something happened with adolescents. But if you talk about school closures having long-term effects, the anger that you're attacked with—well, that’s just a whole other topic.
Being forward-looking, I would declare an emergency in terms of children’s mental health; some states, like Colorado and Connecticut, have put resources into this. I would call that the next emerging emergency: what we did with children. So now it is our duty as a society, if we treasure children, to make it up to them, if we can.
VP: I think one fact that often gets forgotten is we didn’t close schools for everyone, actually. I have many wealthy doctor colleagues, and most of their kids were in school because they just paid the money to send them to a private school that was happy to have the kids in person. The people I know who didn’t have their kids in school are [the ones whose kids go] to public school. The closing of those schools doesn’t have a relationship to the spread of the virus, or the hospitalizations, or the deaths. It’s only really related to the political valence of the town, and the strength of the teachers union. Strong union towns that are left-leaning were far more likely to be closed than right-of-center places that have weaker unions. What sense does that make? That’s certainly not a virus driving that decision. It’s a policy decision. It’s playing politics with kids.
What we’ve done with school closure is that the one tattered, ratty rope ladder to help people rise and to improve their life, their wellbeing—we’ve cut that ladder. I think in the years to come, the stories will come out about what happened to these missing kids. And I think even the most ardent proponents of school closure today will look in the mirror and ask themselves what they had done. What did we do this for? The change in viral spread by closing schools is at best very, very incremental—and to no benefit at all, in some analyses. I hate to say it, but the moment Donald Trump said he was for schools reopening, I think a lot of people turned their brains off, and they opposed it totally to thwart him. And I think that is one of the worst things that has happened.
SB: The lack of socialization is a fundamental concern and risk as it relates to mental health. And then there’s that whole separate dynamic of upward mobility, and it’s scary to see what the effects are going to be. And by the way, that’s going to take ten years to play out—when we start understanding differential achievements of folks, depending on whether they were able or not to continue school.
EY: Let’s talk about models. Some in public health have raised concerns that policymakers relied on alarming and supposedly predictive models that were not predictive, not reliable—and that had an enormous effect of distorting policies. Many people, certainly in the media, treated models as facts, not projections—no matter that many models were proven wrong. What needs to be done going forward regarding using models as the basis of policy?
SB: Historically, mathematical models would get integrated into a framework of evidence. So models can be part of that decision-making process. But using them as a primary form of decision-making concerns me greatly. It’s not that they're all useless. It’s not that they’re perfectly useful. They are useful in their context and interpreted within their limitations. But I think the ones that were media-worthy were indeed the worst ones. There were lots of models being proposed, but the ones that really got covered in The New York Times and The Guardian were ones that were just truly catastrophic. I would say that how we use and integrate models into our decision-making process needs to be one of these elements we assess moving forward.
EY: In early June the Centers for Disease Control issued a report about the increasing COVID-19 hospitalizations among teens, and the head of the CDC said she was deeply concerned and emphasized the need for adolescents to get vaccinated. But critics pointed out that the data they were using was out of date and the statistics about teen hospitalizations actually were not at all alarming. This was cited as an example of officials deliberately misleading the public for virtuous purposes.
MG: That was clearly deliberate, and that’s not the right thing to do. It’s not okay to scare people. Someone asked me recently, “Wouldn’t it decrease the public trust and make you less likely to want to vaccinate your child if you feel manipulated, and that there is a propaganda element to the advice?” And I said, “Yes, a fair human response is to feel distrustful of that.”
VP: I liken it to when [Dr. Anthony] Fauci spoke to Donald McNeil, then of The New York Times, and McNeil asked, “What’s the herd immunity threshold and why do you keep raising it?” And Fauci admitted that he intentionally gave a lower number at first because he didn’t believe the public was ready to hear what he really thinks. I guess a noble lie by definition is when an official withholds some truth or deceives you because they want you to do something that they believe is best. But that’s playing with fire. The moment you get caught once doing it, you’re going to lose a lot of people who will never trust you again. I think these noble lies are one of the greatest poisons in the profession.
EY: Before we put in place a mass lockdown, should there have been more public discussion, and more discussion among public health professionals?
MG: I think actually it was indicated at the very beginning: There was so much that was unknown. But so many people were fighting against Trump that, as it went on, we didn’t look after the interests of who we used to look after on the left, which was the poor. That’s where we went wrong.
SB: If you ask most epidemiologists now, they will say lockdowns are lifesavers for everybody. Over time, it'll be interesting to see how that evolves with more data and more clarity, because we can’t ignore the outcomes of, say, Florida and South Dakota. [Florida’s governor ordered a short lockdown; South Dakota’s governor never issued one.] We’ve seen disconnects where outcomes haven’t been as bad as had been projected from a modeling perspective. It’s not that I agree with the strategy of these states. But we have to at least talk about the fact that there isn’t as clear of a relationship between how much you lock down and the benefit from it.
EY: Lots of media outlets have interviewed many epidemiologists over the course of the pandemic, asking what they are willing to do, and not do, to feel safe. Many have said some version of, “I will never give up my mask. I didn’t get a cold or flu this past year; my kids didn’t get it. Going forward, I’m going to be masking in public and people should use masks and not get sick.” I’ve seen a minority of people saying this approach may not be a good idea because people, and especially kids, have to be exposed to novel viruses to keep their immune systems working. Can you talk about that?
MG: We take risks every day, in everything we do. But we have to put those risks in perspective. I want to address the fear people have that they will get COVID-19 after being fully vaccinated and that’s why they want to continue to mask. Your chance of being in a car accident is higher than your chance of getting sick from COVID-19 after a vaccine. And importantly, when there are low case rates in your community, the risk of your unvaccinated child getting COVID-19 is very low, too. Population immunity means children are so much less likely to be exposed to the virus.
There's a principle in infectious disease that if you avoid all infections, what’s called your microbiome—your degree of diversity of how you respond to other pathogens—is decreased, and it’s actually very important to have some exposure to mild pathogens. I personally want to get some colds. So I won’t be wearing a mask unless someone makes me.
SB: I agree that it is important, particularly youth with their developing immune systems, to be exposed to different pathogens when they’re young and healthy. It’s amazing that this idea has become controversial, but it has. I similarly am not going to wear a mask unless somebody forces me.
EY: Any other points that you think the public and your profession need to know?
SB: We’ve still yet to see a really clearly delineated CDC national plan for a pandemic that has key performance indicators that then can be adapted at the state and local levels. And a year and a half into this, the absence of this kind of plan is hard for me to comprehend. We need to really think about having one of those earlier in the pandemic next time, so that we can make decisions in ways that aren’t so responsive to public pressures and pressures from social media.
Emily Yoffe is a contributing writer at The Atlantic and a member of Persuasion’s Board of Advisors.