Pushkin from Pushkin Industries. This is Deep Background, the show where we explore the stories behind the stories in the news. I'm Noah Feldman. Today we have a return guest, and in fact, he may be the most important guest that we've had this year. It's Mark Lipsitch, whom I spoke to first back in February. He's professor of epidemiology at the Harvard chance School of Public Health. He's director of the Center for Communicable Disease Dynamics there then. He was then and has continued to be one of these central voices in sounding the warning about COVID nineteen and in modeling what good responses look like and figuring out what's going to happen next. With the election coming and the possibility of vaccines on the horizon, I wanted to reconnect with Mark to see how he reads the current situation. Mark, thank you so much for being here. I feel like I've lived a lifetime since we spoke in February when you were in an early warning mode. But I bet you've lived ten or one hundred lifetimes since then. How you've slept is hard for me to even imagine. Let me start by just asking you how are you holding up in this process? Doing okay? It's frustrating to be watching governments, including our own national government, ignoring very clear science, and as we now know, deliberately ignoring it from the very earliest times. It's encouraging that our local and state government are trying much harder to do good things. And there's still a huge amount of uncertainty about what the best approaches given all the trade offs, and so that's what keeps me awake at night right now. There is an enormous amount of uncertainty. But one thing that's sort of remarkable is that a paper that you published with co authors described a model, or of models, of what might happen if we had intermittent shutdowns and reopenings, And to oversimplify it vastly, you showed a kind of sign curve, a kind of up and down curve of how things would go. And sure enough, we had the first loop up of that curve, then we had a decline, then we had reopenings, and now we're on our way back up. So to the extent anything in real life ever matches a model, we seem to be matching, at least so far early stage. The model that you designed. How do you think about that? I mean, do you think that, in fact, that model so far does seem to be fitting the data. When we published that model and Science in March, we stated clearly that it was neither a prediction nor an endorsement, but a description of what might happen and what the consequences might be. And it wasn't an endorsement because it's obviously a miserable process, and it wasn't a prediction because we didn't know how people and governments would risk. And I think it turned out to be a little more true than we really expected in some respects in the general pattern. I think what's less true is that we imagined in that model, or we've made an assumption in that model that each round of control measures would be sort of similar to the previous round in terms of its level of effect. But I think what we didn't factor in was fatigue and the sense that politically and psychologically the same level of control measures doesn't seem to be feasible in many places. That was feasible the first time people were up for one one very intense lockdown in some places, and maybe not too many more. The logical implication of what you just said, Mark, sounds like that there's a real possibility that we're not just headed up for another peak roughly at the point where the peak was last time in terms of number of cases, but that we're actually headed for a potentially substantially higher peak. I think the potential is there. I mean, the population remains largely uninfected and still susceptible. There are pockets that have experienced very intense infection, but much of the country and much of the world remains uninfected, and so at a population level, we're kind of not that much more protected than we were at the beginning of this, and so I think it will be more There will be peaks in more different places at roughly the same time, because the virus has had time to spread out geographically, so it's not mainly in urban centers in the US anymore. It's now in the Midwest and the plains, in parts of the country that are much more rural, and it's just more widespread outside the major ports of entry and places connected to those. So I think it will be more widespread, very likely. But how high a peak we have really depends on the timing and strength of our reaction, and that is so uncoordinated in this country and also between countries, that it's hard to make a general prediction. Deaths are trending obviously in the wrong direction, though they seem to be less as a percentage of all cases than they were previously. Is that because of better treatments? Is it because of a broader awareness of the number of people who have diseases? Ie? More testing the President's favorite line, why the disparity? I think it's very clear that there's more testing and that we're detecting a higher fraction of all the people who are infected with this virus than we were at the beginning. Still a very low fraction, but more, and therefore the denominator swells and the ratio of deaths to known cases goes down. The really interesting question is how much better we're getting at treating those cases that do occur. And there have been a couple of articles relatively limited populations and imperfect methodology, as it always is in this kind of situation, that suggests that when people get to the hospital or get to the ICU, they are more likely to survive, which you would expect given that clinicians learn all sorts of things, not just what drugs they can use, and there's sort of one and a quarter good drugs right now that are available, but also other details of the clinical management that make it more likely that the hundredth patient will survive than that the first one that someone has seen survives. So every expectation is that the death rate of those people who get severe disease would be going down. The data have been very limited so far, two papers that I'm aware of, and some data from Florida that I've seen that maybe suggests the opposite that there isn't a change. So I think it's too early to declare victory, and certainly there are still a lot of people dying per case, but I think there's some hints that we're getting better. It's an absence of evidence mostly right now, and that will be an important question to figure out going forward. I'm almost loath to ask you about the so called Great Bearington Declaration because I know that your view is that it was false and problematic, and you've joined a counter declaration, but it's been so much in the news that we can't completely avoid it. What's wrong with the so called Great Bearington Declaration and the perspective that it takes. I think the Great Barrington Declaration starts from a premise that most of us would agree with, which is that the current state of response is miserable in that it's depriving us of many features of our lives. It's causing unemployment and other harms to humans, and it's no fun at all, and even the details are no fun. Wearing a mask is not pleasant, and everyone wants to get back to normal. The part of it that is insidious, in my view, is not the desire to get back to normal, but the notion that that is consistent with some kind of way of protecting the vulnerable. And there's just no evidence that that is possible. There's no place that I'm aware of that has successfully let the epidemic spread and at the same time protected the vulnerable. Sweden is the sort of most famous example, and they nobody thinks that they did a good job of protecting their nursing homes and the vulnerable people that are less often discussed are immigrants and members of ethnic minorities and racial minorities in this country and in Sweden. Many of the early cases and severe cases were in Somali immigrants and in other less integrated communities. And so when you say protect the vulnerable, people imagine that you can just sort of seal off nursing homes, which is problematic and probably not effective in itself. But the vulnerable is a larger group than just the very old and infirm. It's a mixed group, some of whom we know about and some of whom we don't. So the notion that we can stop transmission to those who are most at risk, first that we can identify them, which is imperfect, and second that we can somehow wall them off from society, which has just not been demonstrated. So as a claim by a group of scientists, this seems to be a lot of aspiration and very little scientific description of how it would be done. You joined a very detailed counter declaration. You're one of the first people to join it. It's now got thousands and thousands of scientists who also joined it. Was what you just said. The essential takeaway for you of that documentary? Does it go beyond Yeah? I think that's why I signed the document. And it's impossible to speak for all the people who signed a document, of course, but in my view, there's a shared desire to get back to some kind of normal and a responsibility if you propose a way to do that, to propose a way that is effective and for which there's evidence. I think what's the next step for those of us who don't think that that's an effective approach, is that we need to figure out how to do it by some other means. And I think the best evidence right now is that a combination of very widespread mask use and consistent mask use, really insisting on social distancing when encountering other people, and increasingly making available cheap and frequent tests so that people can understand their status is in my view, the best combination of measures that will keep things at bay while we search for vaccines and therapeutics. So I think that's the next step is to figure out an alternative plan. But in the meanwhile, we have these blunt instruments of shutting down parts of the economy, which in some cases are necessary in order to slow things down and maintain the integrity of the healthcare system. I want to ask you about both stages of this alternative and that you're describing, and I guess my first one is to ask how alternative it really is. I mean the mask use has been part of the approach thus far, that insisting on social distancing has been part of the approach. They have some limit to how much they're going to be followed. I mean, my kids are in school a couple of days a week, and they report great efforts to adhere to social distancing and mask wearing. But let's say imperfect enforcement and imperfect efforts also by kids. And I can anecdotally report the same of my world, you know, in social interactions. As long as it was warm out, that was a real effort to always be outside and to maintain social distancing. But there's erosion around the edges on that, and so I'm wondering whether that step, that component is different and also if it's practically in the real world sustainable at scale. Well, I think that is a fair question. And the Swiss Cheese image that's been making the rounds of every intervention being imperfect and together you make an impermeable barrier with a lot of holes in each layer is an appealing one because all of these things are both not perfectly effective and not perfectly practical. But having said that, Massachusetts, where you're describing, is on a global scale doing pretty well, and the hospitals are not overwhelmed right now, and that's to a large degree because of both early shutdowns a part of the economy, and then relatively adherent population to those social distancing norms. So I think while cases are rising here as they are almost everywhere, it is important to say that places that have embraced masks and social distancing have on the hole done better than places that haven't. And within the US there's a lot of variation, and of course there are a lot of other factors, and you can argue about the causal relationship, but there are large variations and how much people use masks and large variations and how bad the epidemic has gotten. We'll be right back. Let's talk about a world where we have vaccines, but imperfect vaccines that in any case take a while to roll out and get to reach everybody. But imagine we have some vaccines that work at fifty percent efficacy or above, Leaving aside the technical problem of how long it will take to get them to people, how effective in a process of moving US towards group immunity is it to have a say, fifty percent efficacious vaccine that some percentage of the population is taking How much does that speed up our process or does it actually not make that much difference? But we have to maintain mask wearing, social distancing, and some business closures regardless. If a large faction of the population took fifty percent efficacious vaccine, and that vaccine was efficacious against infection and transmission as well as against symptoms, it would make a huge difference. It would not stop transmission by itself, because we have to get the reproduction number down from probably three or so down to below one in order to stop transmission, and this would be at best a fifty percent hit even if everybody took it, but down to one and a half would mean that even uncontrolled, it would grow more slowly. There would be more time to make control measures. There would be greater effects of things like mask wearing and the less burdensome interventions because you could layer fewer interventions on top and then keep the virus under control. So fifty percent infection blocking vaccine would be obviously worse than a eighty percent, but a lot better than what we have now. Isn't there a dynamic game theory problem, though, which is if vaccine were out there, and if people thought that it worked, that would probably lead many people to be less careful with masks and social distancing. I mean, it's going to be hard to say to people, here's your vaccine, it works somewhat well, but keep on everything you're doing and don't really change your lives that much. I think that's a concern. But I also think that we would be able to get away with a lot less adherence to mask wearing and all those other things if half the population were protected by the vaccine, and if some of the people who weren't protected against infection perhaps were at least protected against severe disease. So I mean, unfortunately, this is a problem that we're trying to solve on a time frame of a year or two, when this kind of problem is typically solved over a time scale of decades. So we're going to be chipping away with a lot of imperfect solutions. But I think even a modestly effective vaccine, if it blocks transmission, will make a huge difference, or if it works in the most vulnerable people, either of those would vastly improve our lives. Once it's distributed. It won't solve all the problems we can't know this for sure, obviously, but it does strike me that among people who will be skeptical of a vaccine, it won't want to take it. The idea that a vaccine only works roughly half the time might be used by critics and skeptics as a reason not to take the vaccine. Yeah. Well, I think that's been true for flu vaccines for a long time, and flu vaccine uptake is not great, although it's better this year, I think because people are nervous about getting something that would get them in contact with the healthcare system. But yes, a better vaccine would be better in many ways, including in public confidence, so we can hope for that. But the fifty percent floor that's been set by the FDA is not the desired level. It's the minimal level. My takeaway from what you've been saying, though, is that if indeed we get a vaccine, even if it's pretty effective and reaches many many people, we're not in a scenario where things will be quote unquote back to normal anytime soon, including at the moment when many many people begin to get the vaccine, which just by a some shit, let's imagine, would be the fall of twenty twenty one, which seems to be the soonest that you could get very very broad uptake. It sounds like we're going to be continuing with some hybrid version of our social distancing and masking. Well beyond that, am I reading you right? I think if it's eighty or ninety percent effective and widely accepted, then we might be back to something approaching normalcy. I also think that we will learn other things in the process. I mean, I think the evidence is accumulating that schools are, if they take basic precautions, not sites of major transmission. They may be sites where people who are infected get together because they've been infected in the community and it looks like their outbreaks. But the frequency of outbreaks in schools with reasonable is low, not zero, but low. So I think that aspect of our society, as we learn more about how to do it safely and keep some level of normalcy, might get back to normal along the way, And that will be boosted by the fact that at least the adults initially will be protected if we have a vaccine. So I think that's an example. But other aspects of our society, we hopefully will learn something about how we can operate them more safely. So I think we shouldn't assume that our knowledge is going to be stuck here. And one of the things that's been really disappointing is as the CDC and to some extent other public health authorities in other countries, but especially the CDC, has been hobbled by interference from above. One of their functions would normally be to very actively be seeking epidemiological evidence on what is safe and what is not safe, and that part of their function has been very limited in this epidemic. So I think we will keep learning things, and I'm somewhat optimistic in that sense that we will as we chip away at the problem, we will find ourselves getting closer to normal. But it's not going to be quick and it's not going to be complete. I agree with that. Are there any country models that are positive models from your perspective still at this moment? I think the models of Germany and Luxembourg and probably some other countries like them, which had big surges at the beginning, got them under control and now have very widespread testing. Still not universal, but Luxembourg has actually tested most of its population at least once, which is a step in the direction of widespread, easily available testing for anybody who's curious whether they're infected. Those are positive, but of course they're also both going up in the number of cases, so it's not a full solution. And then of course New Zealand and Vietnam and some others have had much better outcomes than we and those are two different situations. One we don't really understand what's exactly happened in Vietnam, and with New Zealand it was very very early both lockdown and extremely good contact tracing on an island. So and then thinking about Korea, you know, there was a very very large outbreak and it was brought down through very intense surveillance, test and trace and the like, with some degree of lockdowns, but probably a level of surveillance that is not replicable here. What has happened to surveillance here. At the beginning of the outbreak, there was an enormous amount of discussion in the public square and also in policy circles about contact tracing, and we did episodes on it several and yet as it's turned out, that hasn't functioned as a central prong of the approach. Just about anywhere in the United States. Yeah, tech tracing works in combination with other measures, and it works. I think I've made the analogy of you don't clean up an oil spill with paper towels. Contact tracing is paper towels. So when the number of cases is down to a number where you can detect almost all of them, where you can rapidly get test results because your system for testing isn't overwhelmed, and where you can rapidly make contact with the people who you need to and they are willing to talk to the contact tracers and the like, then contact tracing can make a big difference. It's a mopping up exercise. It's not a large scale control exercise because it's scales with the number the need, scales with the number of cases. And so when you have thousands of cases a day in a jurisdiction of modest size, then you just can't keep up, and you especially can't keep up when testing capacity is limited and the time to get a test result is many days. In New Zealand, by the time they're contact tracing was really in full speed. It was all happening very very quickly, so that people were being found even before they became symptomatic contacts were being found even before they became symptomatic, so that was a measure of how efficiently it worked. But that could work in the tens and even can work in the hundreds, it can't work in the thousands. Mark, what am I not asking you that I should be asking you at this stage of play? I guess the question there's a question of would we do any better than next time? And what would determine if we did any better the next time? And by the next time, you don't mean the next round of this, you mean the next pandemic, if we had it to do over again, or if we have to deal with stars three and some future time, what would determine it? And I mean, I think there are many many answers to that. I think there are two that really strike me. One is leadership and clear messaging from the top of the federal government in our case, or the national government in other countries, that is science based, clear about what we know and don't know, and leads by example by showing on television the practices that are being recommended enacted by the people recommending them. And that was pretty much what we had in two thousand and nine. For H one N one flu and that was a milder illness, but that aspect worked much better. And then the other piece is the information systems are just antiquated by information systems, I mean everything from the ability to test a random group of people in order to estimate how much virus activity there is, all the way through how that gets reported, Having the number of tests available you need at the front end, and having the information systems to report them in meaningful and interpretable ways. I think that's really something that sets the country that have responded effectively apart from those that haven't. And I think that's a huge job for many countries in the world, including ours, and decentralization as a challenge for that. Let's imagine that we get vaccines and over the next couple of years we eventually get stars covy two under control. When we look back from a distance of a decade, are we likely to think, well, we made lots of mistakes, but on the whole we got pretty lucky. The overall numbers of deaths could have been way, way worse. It could have been a worse variant. Or are we likely to think that wasn't really a model of what we should not do of getting it wrong, and we really need to massively improve on that. I think we're going to look back with a lot of regret about how much we let happen that didn't need to happen, and how long we delayed the response, and how little we use our internationally famous biotech expertise to solve problems in the country as a whole. I mean, focusing on the United States, just comparing across states is really remarkable, and comparing across countries is also remarkable, as was done in a recent article by Elisabolinski and zecommanual where they compared the sort of beginning, middle, and recent part of the pandemic. And at the beginning the US was like a lot of other countries. But in the middle and more recently we have just messed it up in a way that most of the rest of the rich world has not. So there's a lot of things that could have gone a lot better. The evidence of that is just comparisons across states and across nations. Mark, thank you for coming back, thank you for being so clear, and above all, thank you for the extraordinary work that you're continuing to do every day. As we continue to come to terms of the pandemic. Thank you for having me. Listening to Mark Lipsitch's take eight months after we first had him on the show was sobering, to say the least. On the one hand, Mark thinks we've made many many mistakes and that when we look back in retrospect, we're going to be emphasizing our failures rather than our successes. It's also true that in the interim Mark and co authors designed a model that now looks eerily prescient with respect to what things look like when you shut them down, then reopen them, and shut them down, and reopen them. Mark was very clear that that model was not intended as a prediction and certainly not intended as an endorsement, but at least thus far, it does provide the best guidance that we can find for thinking about what's going to happen next. That means that the surge that we're facing now may go up significantly, Mark says, but if we respond with strong measures, it will go down again. In Mark's account, our goal is to try to keep things under control until the vaccine comes to the rescue. Like the cavalry. That brings us to the question of what will happen when that vaccine is here. Mark makes it really clear, and to me this is the most significant upshot of our whole conversation that whether we get more or less back to normal is going to depend almost entirely on how effect of the vaccine is and how many people take it. If it only has say, a fifty percent efficacy, then even if everybody takes it, we don't get down to an R zero low enough to eliminate mask wearing, social distancing, and potentially a range of other limits. If, on the other hand, a vaccine is eighty or ninety percent efficacious, and if it were able to reach and be taken by a very very large percentage of the population, we could actually begin to get back to something resembling normal. So there are two questions that we're going to need to know the answers to one, how effective will these vaccines be? To how many people will take them. Almost everything will turn on the answers to those two questions. With respect to effectiveness. We're going to start beginning to know the answer sometime in the winter as we begin to get published results of large scale trials of the vaccines. And as for the second question of how many people a vaccine will reach, will begin to get answers to those questions through this spring and summer and into next fall. It's a long road, it's a painful road. It's not a road that anybody is enjoying, but it is a road on which we do have some guidance, and Mark Lipsitch is a crucial guide for this show, for me and for all of us. On Saturday, we'll be continuing our special series Deep Bench about the right word turn of the Supreme Court. Until the next time I speak to you, full, be safe and be well. Deep Background is brought to you by Pushkin Industries. Our producer is Lydia Gencott, our engineer is Martin Gonzalez, and our showrunner is Sophie Crane mckibbon. Theme music by Luis Guerra at Pushkin. Thanks to Mia Lobell, Julia Barton, Heather Faine, Carlie mcgliori, Mackie Taylor, Eric Sandler, and Jacob Weisberg. You can find me on Twitter at Noah ar Feldman. I also write a column for Bloomberg Opinion, which you can find at Bloomberg dot com. Slashfeld To discover Bloomberg's original slate of podcasts. Go to bloomberg dot com slash podcasts, and if you like what you heard today, please write a review or tell a friend. This is deep background

Pushkin from Pushkin Industries. This is Deep Background, the show where we explore the stories behind the stories in the news. I'm Noah Feldman. Today we have a return guest, and in fact, he may be the most important guest that we've had this year. It's Mark Lipsitch, whom I spoke to first back in February. He's professor of epidemiology at the Harvard chance School of Public Health. He's director of the Center for Communicable Disease Dynamics there then. He was then and has continued to be one of these central voices in sounding the warning about COVID nineteen and in modeling what good responses look like and figuring out what's going to happen next. With the election coming and the possibility of vaccines on the horizon, I wanted to reconnect with Mark to see how he reads the current situation. Mark, thank you so much for being here. I feel like I've lived a lifetime since we spoke in February when you were in an early warning mode. But I bet you've lived ten or one hundred lifetimes since then. How you've slept is hard for me to even imagine. Let me start by just asking you how are you holding up in this process? Doing okay? It's frustrating to be watching governments, including our own national government, ignoring very clear science, and as we now know, deliberately ignoring it from the very earliest times. It's encouraging that our local and state government are trying much harder to do good things. And there's still a huge amount of uncertainty about what the best approaches given all the trade offs, and so that's what keeps me awake at night right now. There is an enormous amount of uncertainty. But one thing that's sort of remarkable is that a paper that you published with co authors described a model, or of models, of what might happen if we had intermittent shutdowns and reopenings, And to oversimplify it vastly, you showed a kind of sign curve, a kind of up and down curve of how things would go. And sure enough, we had the first loop up of that curve, then we had a decline, then we had reopenings, and now we're on our way back up. So to the extent anything in real life ever matches a model, we seem to be matching, at least so far early stage. The model that you designed. How do you think about that? I mean, do you think that, in fact, that model so far does seem to be fitting the data. When we published that model and Science in March, we stated clearly that it was neither a prediction nor an endorsement, but a description of what might happen and what the consequences might be. And it wasn't an endorsement because it's obviously a miserable process, and it wasn't a prediction because we didn't know how people and governments would risk. And I think it turned out to be a little more true than we really expected in some respects in the general pattern. I think what's less true is that we imagined in that model, or we've made an assumption in that model that each round of control measures would be sort of similar to the previous round in terms of its level of effect. But I think what we didn't factor in was fatigue and the sense that politically and psychologically the same level of control measures doesn't seem to be feasible in many places. That was feasible the first time people were up for one one very intense lockdown in some places, and maybe not too many more. The logical implication of what you just said, Mark, sounds like that there's a real possibility that we're not just headed up for another peak roughly at the point where the peak was last time in terms of number of cases, but that we're actually headed for a potentially substantially higher peak. I think the potential is there. I mean, the population remains largely uninfected and still susceptible. There are pockets that have experienced very intense infection, but much of the country and much of the world remains uninfected, and so at a population level, we're kind of not that much more protected than we were at the beginning of this, and so I think it will be more There will be peaks in more different places at roughly the same time, because the virus has had time to spread out geographically, so it's not mainly in urban centers in the US anymore. It's now in the Midwest and the plains, in parts of the country that are much more rural, and it's just more widespread outside the major ports of entry and places connected to those. So I think it will be more widespread, very likely. But how high a peak we have really depends on the timing and strength of our reaction, and that is so uncoordinated in this country and also between countries, that it's hard to make a general prediction. Deaths are trending obviously in the wrong direction, though they seem to be less as a percentage of all cases than they were previously. Is that because of better treatments? Is it because of a broader awareness of the number of people who have diseases? Ie? More testing the President's favorite line, why the disparity? I think it's very clear that there's more testing and that we're detecting a higher fraction of all the people who are infected with this virus than we were at the beginning. Still a very low fraction, but more, and therefore the denominator swells and the ratio of deaths to known cases goes down. The really interesting question is how much better we're getting at treating those cases that do occur. And there have been a couple of articles relatively limited populations and imperfect methodology, as it always is in this kind of situation, that suggests that when people get to the hospital or get to the ICU, they are more likely to survive, which you would expect given that clinicians learn all sorts of things, not just what drugs they can use, and there's sort of one and a quarter good drugs right now that are available, but also other details of the clinical management that make it more likely that the hundredth patient will survive than that the first one that someone has seen survives. So every expectation is that the death rate of those people who get severe disease would be going down. The data have been very limited so far, two papers that I'm aware of, and some data from Florida that I've seen that maybe suggests the opposite that there isn't a change. So I think it's too early to declare victory, and certainly there are still a lot of people dying per case, but I think there's some hints that we're getting better. It's an absence of evidence mostly right now, and that will be an important question to figure out going forward. I'm almost loath to ask you about the so called Great Bearington Declaration because I know that your view is that it was false and problematic, and you've joined a counter declaration, but it's been so much in the news that we can't completely avoid it. What's wrong with the so called Great Bearington Declaration and the perspective that it takes. I think the Great Barrington Declaration starts from a premise that most of us would agree with, which is that the current state of response is miserable in that it's depriving us of many features of our lives. It's causing unemployment and other harms to humans, and it's no fun at all, and even the details are no fun. Wearing a mask is not pleasant, and everyone wants to get back to normal. The part of it that is insidious, in my view, is not the desire to get back to normal, but the notion that that is consistent with some kind of way of protecting the vulnerable. And there's just no evidence that that is possible. There's no place that I'm aware of that has successfully let the epidemic spread and at the same time protected the vulnerable. Sweden is the sort of most famous example, and they nobody thinks that they did a good job of protecting their nursing homes and the vulnerable people that are less often discussed are immigrants and members of ethnic minorities and racial minorities in this country and in Sweden. Many of the early cases and severe cases were in Somali immigrants and in other less integrated communities. And so when you say protect the vulnerable, people imagine that you can just sort of seal off nursing homes, which is problematic and probably not effective in itself. But the vulnerable is a larger group than just the very old and infirm. It's a mixed group, some of whom we know about and some of whom we don't. So the notion that we can stop transmission to those who are most at risk, first that we can identify them, which is imperfect, and second that we can somehow wall them off from society, which has just not been demonstrated. So as a claim by a group of scientists, this seems to be a lot of aspiration and very little scientific description of how it would be done. You joined a very detailed counter declaration. You're one of the first people to join it. It's now got thousands and thousands of scientists who also joined it. Was what you just said. The essential takeaway for you of that documentary? Does it go beyond Yeah? I think that's why I signed the document. And it's impossible to speak for all the people who signed a document, of course, but in my view, there's a shared desire to get back to some kind of normal and a responsibility if you propose a way to do that, to propose a way that is effective and for which there's evidence. I think what's the next step for those of us who don't think that that's an effective approach, is that we need to figure out how to do it by some other means. And I think the best evidence right now is that a combination of very widespread mask use and consistent mask use, really insisting on social distancing when encountering other people, and increasingly making available cheap and frequent tests so that people can understand their status is in my view, the best combination of measures that will keep things at bay while we search for vaccines and therapeutics. So I think that's the next step is to figure out an alternative plan. But in the meanwhile, we have these blunt instruments of shutting down parts of the economy, which in some cases are necessary in order to slow things down and maintain the integrity of the healthcare system. I want to ask you about both stages of this alternative and that you're describing, and I guess my first one is to ask how alternative it really is. I mean the mask use has been part of the approach thus far, that insisting on social distancing has been part of the approach. They have some limit to how much they're going to be followed. I mean, my kids are in school a couple of days a week, and they report great efforts to adhere to social distancing and mask wearing. But let's say imperfect enforcement and imperfect efforts also by kids. And I can anecdotally report the same of my world, you know, in social interactions. As long as it was warm out, that was a real effort to always be outside and to maintain social distancing. But there's erosion around the edges on that, and so I'm wondering whether that step, that component is different and also if it's practically in the real world sustainable at scale. Well, I think that is a fair question. And the Swiss Cheese image that's been making the rounds of every intervention being imperfect and together you make an impermeable barrier with a lot of holes in each layer is an appealing one because all of these things are both not perfectly effective and not perfectly practical. But having said that, Massachusetts, where you're describing, is on a global scale doing pretty well, and the hospitals are not overwhelmed right now, and that's to a large degree because of both early shutdowns a part of the economy, and then relatively adherent population to those social distancing norms. So I think while cases are rising here as they are almost everywhere, it is important to say that places that have embraced masks and social distancing have on the hole done better than places that haven't. And within the US there's a lot of variation, and of course there are a lot of other factors, and you can argue about the causal relationship, but there are large variations and how much people use masks and large variations and how bad the epidemic has gotten. We'll be right back. Let's talk about a world where we have vaccines, but imperfect vaccines that in any case take a while to roll out and get to reach everybody. But imagine we have some vaccines that work at fifty percent efficacy or above, Leaving aside the technical problem of how long it will take to get them to people, how effective in a process of moving US towards group immunity is it to have a say, fifty percent efficacious vaccine that some percentage of the population is taking How much does that speed up our process or does it actually not make that much difference? But we have to maintain mask wearing, social distancing, and some business closures regardless. If a large faction of the population took fifty percent efficacious vaccine, and that vaccine was efficacious against infection and transmission as well as against symptoms, it would make a huge difference. It would not stop transmission by itself, because we have to get the reproduction number down from probably three or so down to below one in order to stop transmission, and this would be at best a fifty percent hit even if everybody took it, but down to one and a half would mean that even uncontrolled, it would grow more slowly. There would be more time to make control measures. There would be greater effects of things like mask wearing and the less burdensome interventions because you could layer fewer interventions on top and then keep the virus under control. So fifty percent infection blocking vaccine would be obviously worse than a eighty percent, but a lot better than what we have now. Isn't there a dynamic game theory problem, though, which is if vaccine were out there, and if people thought that it worked, that would probably lead many people to be less careful with masks and social distancing. I mean, it's going to be hard to say to people, here's your vaccine, it works somewhat well, but keep on everything you're doing and don't really change your lives that much. I think that's a concern. But I also think that we would be able to get away with a lot less adherence to mask wearing and all those other things if half the population were protected by the vaccine, and if some of the people who weren't protected against infection perhaps were at least protected against severe disease. So I mean, unfortunately, this is a problem that we're trying to solve on a time frame of a year or two, when this kind of problem is typically solved over a time scale of decades. So we're going to be chipping away with a lot of imperfect solutions. But I think even a modestly effective vaccine, if it blocks transmission, will make a huge difference, or if it works in the most vulnerable people, either of those would vastly improve our lives. Once it's distributed. It won't solve all the problems we can't know this for sure, obviously, but it does strike me that among people who will be skeptical of a vaccine, it won't want to take it. The idea that a vaccine only works roughly half the time might be used by critics and skeptics as a reason not to take the vaccine. Yeah. Well, I think that's been true for flu vaccines for a long time, and flu vaccine uptake is not great, although it's better this year, I think because people are nervous about getting something that would get them in contact with the healthcare system. But yes, a better vaccine would be better in many ways, including in public confidence, so we can hope for that. But the fifty percent floor that's been set by the FDA is not the desired level. It's the minimal level. My takeaway from what you've been saying, though, is that if indeed we get a vaccine, even if it's pretty effective and reaches many many people, we're not in a scenario where things will be quote unquote back to normal anytime soon, including at the moment when many many people begin to get the vaccine, which just by a some shit, let's imagine, would be the fall of twenty twenty one, which seems to be the soonest that you could get very very broad uptake. It sounds like we're going to be continuing with some hybrid version of our social distancing and masking. Well beyond that, am I reading you right? I think if it's eighty or ninety percent effective and widely accepted, then we might be back to something approaching normalcy. I also think that we will learn other things in the process. I mean, I think the evidence is accumulating that schools are, if they take basic precautions, not sites of major transmission. They may be sites where people who are infected get together because they've been infected in the community and it looks like their outbreaks. But the frequency of outbreaks in schools with reasonable is low, not zero, but low. So I think that aspect of our society, as we learn more about how to do it safely and keep some level of normalcy, might get back to normal along the way, And that will be boosted by the fact that at least the adults initially will be protected if we have a vaccine. So I think that's an example. But other aspects of our society, we hopefully will learn something about how we can operate them more safely. So I think we shouldn't assume that our knowledge is going to be stuck here. And one of the things that's been really disappointing is as the CDC and to some extent other public health authorities in other countries, but especially the CDC, has been hobbled by interference from above. One of their functions would normally be to very actively be seeking epidemiological evidence on what is safe and what is not safe, and that part of their function has been very limited in this epidemic. So I think we will keep learning things, and I'm somewhat optimistic in that sense that we will as we chip away at the problem, we will find ourselves getting closer to normal. But it's not going to be quick and it's not going to be complete. I agree with that. Are there any country models that are positive models from your perspective still at this moment? I think the models of Germany and Luxembourg and probably some other countries like them, which had big surges at the beginning, got them under control and now have very widespread testing. Still not universal, but Luxembourg has actually tested most of its population at least once, which is a step in the direction of widespread, easily available testing for anybody who's curious whether they're infected. Those are positive, but of course they're also both going up in the number of cases, so it's not a full solution. And then of course New Zealand and Vietnam and some others have had much better outcomes than we and those are two different situations. One we don't really understand what's exactly happened in Vietnam, and with New Zealand it was very very early both lockdown and extremely good contact tracing on an island. So and then thinking about Korea, you know, there was a very very large outbreak and it was brought down through very intense surveillance, test and trace and the like, with some degree of lockdowns, but probably a level of surveillance that is not replicable here. What has happened to surveillance here. At the beginning of the outbreak, there was an enormous amount of discussion in the public square and also in policy circles about contact tracing, and we did episodes on it several and yet as it's turned out, that hasn't functioned as a central prong of the approach. Just about anywhere in the United States. Yeah, tech tracing works in combination with other measures, and it works. I think I've made the analogy of you don't clean up an oil spill with paper towels. Contact tracing is paper towels. So when the number of cases is down to a number where you can detect almost all of them, where you can rapidly get test results because your system for testing isn't overwhelmed, and where you can rapidly make contact with the people who you need to and they are willing to talk to the contact tracers and the like, then contact tracing can make a big difference. It's a mopping up exercise. It's not a large scale control exercise because it's scales with the number the need, scales with the number of cases. And so when you have thousands of cases a day in a jurisdiction of modest size, then you just can't keep up, and you especially can't keep up when testing capacity is limited and the time to get a test result is many days. In New Zealand, by the time they're contact tracing was really in full speed. It was all happening very very quickly, so that people were being found even before they became symptomatic contacts were being found even before they became symptomatic, so that was a measure of how efficiently it worked. But that could work in the tens and even can work in the hundreds, it can't work in the thousands. Mark, what am I not asking you that I should be asking you at this stage of play? I guess the question there's a question of would we do any better than next time? And what would determine if we did any better the next time? And by the next time, you don't mean the next round of this, you mean the next pandemic, if we had it to do over again, or if we have to deal with stars three and some future time, what would determine it? And I mean, I think there are many many answers to that. I think there are two that really strike me. One is leadership and clear messaging from the top of the federal government in our case, or the national government in other countries, that is science based, clear about what we know and don't know, and leads by example by showing on television the practices that are being recommended enacted by the people recommending them. And that was pretty much what we had in two thousand and nine. For H one N one flu and that was a milder illness, but that aspect worked much better. And then the other piece is the information systems are just antiquated by information systems, I mean everything from the ability to test a random group of people in order to estimate how much virus activity there is, all the way through how that gets reported, Having the number of tests available you need at the front end, and having the information systems to report them in meaningful and interpretable ways. I think that's really something that sets the country that have responded effectively apart from those that haven't. And I think that's a huge job for many countries in the world, including ours, and decentralization as a challenge for that. Let's imagine that we get vaccines and over the next couple of years we eventually get stars covy two under control. When we look back from a distance of a decade, are we likely to think, well, we made lots of mistakes, but on the whole we got pretty lucky. The overall numbers of deaths could have been way, way worse. It could have been a worse variant. Or are we likely to think that wasn't really a model of what we should not do of getting it wrong, and we really need to massively improve on that. I think we're going to look back with a lot of regret about how much we let happen that didn't need to happen, and how long we delayed the response, and how little we use our internationally famous biotech expertise to solve problems in the country as a whole. I mean, focusing on the United States, just comparing across states is really remarkable, and comparing across countries is also remarkable, as was done in a recent article by Elisabolinski and zecommanual where they compared the sort of beginning, middle, and recent part of the pandemic. And at the beginning the US was like a lot of other countries. But in the middle and more recently we have just messed it up in a way that most of the rest of the rich world has not. So there's a lot of things that could have gone a lot better. The evidence of that is just comparisons across states and across nations. Mark, thank you for coming back, thank you for being so clear, and above all, thank you for the extraordinary work that you're continuing to do every day. As we continue to come to terms of the pandemic. Thank you for having me. Listening to Mark Lipsitch's take eight months after we first had him on the show was sobering, to say the least. On the one hand, Mark thinks we've made many many mistakes and that when we look back in retrospect, we're going to be emphasizing our failures rather than our successes. It's also true that in the interim Mark and co authors designed a model that now looks eerily prescient with respect to what things look like when you shut them down, then reopen them, and shut them down, and reopen them. Mark was very clear that that model was not intended as a prediction and certainly not intended as an endorsement, but at least thus far, it does provide the best guidance that we can find for thinking about what's going to happen next. That means that the surge that we're facing now may go up significantly, Mark says, but if we respond with strong measures, it will go down again. In Mark's account, our goal is to try to keep things under control until the vaccine comes to the rescue. Like the cavalry. That brings us to the question of what will happen when that vaccine is here. Mark makes it really clear, and to me this is the most significant upshot of our whole conversation that whether we get more or less back to normal is going to depend almost entirely on how effect of the vaccine is and how many people take it. If it only has say, a fifty percent efficacy, then even if everybody takes it, we don't get down to an R zero low enough to eliminate mask wearing, social distancing, and potentially a range of other limits. If, on the other hand, a vaccine is eighty or ninety percent efficacious, and if it were able to reach and be taken by a very very large percentage of the population, we could actually begin to get back to something resembling normal. So there are two questions that we're going to need to know the answers to one, how effective will these vaccines be? To how many people will take them. Almost everything will turn on the answers to those two questions. With respect to effectiveness. We're going to start beginning to know the answer sometime in the winter as we begin to get published results of large scale trials of the vaccines. And as for the second question of how many people a vaccine will reach, will begin to get answers to those questions through this spring and summer and into next fall. It's a long road, it's a painful road. It's not a road that anybody is enjoying, but it is a road on which we do have some guidance, and Mark Lipsitch is a crucial guide for this show, for me and for all of us. On Saturday, we'll be continuing our special series Deep Bench about the right word turn of the Supreme Court. Until the next time I speak to you, full, be safe and be well. Deep Background is brought to you by Pushkin Industries. Our producer is Lydia Gencott, our engineer is Martin Gonzalez, and our showrunner is Sophie Crane mckibbon. Theme music by Luis Guerra at Pushkin. Thanks to Mia Lobell, Julia Barton, Heather Faine, Carlie mcgliori, Mackie Taylor, Eric Sandler, and Jacob Weisberg. You can find me on Twitter at Noah ar Feldman. I also write a column for Bloomberg Opinion, which you can find at Bloomberg dot com. Slashfeld To discover Bloomberg's original slate of podcasts. Go to bloomberg dot com slash podcasts, and if you like what you heard today, please write a review or tell a friend. 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