#425 — Are We Prepared for the Next Pandemic？
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Summary
In this episode, Dr. Mark Lipsitch joins me to talk about the lessons we should have learned from the co-designated pandemic known as COVID, and why we should be worried about what we didn t learn from it.
Transcript
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Welcome to the Making Sense Podcast. This is Sam Harris. Just a note to say that if you're
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hearing this, you're not currently on our subscriber feed, and we'll only be hearing
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the first part of this conversation. In order to access full episodes of the Making Sense
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Podcast, you'll need to subscribe at samharris.org. We don't run ads on the podcast, and therefore
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it's made possible entirely through the support of our subscribers. So if you enjoy what we're
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doing here, please consider becoming one. I am here with Mark Lipsitch. Mark, thanks for
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joining me. Thanks for having me. I enjoy your podcast and happy to be on it. Oh, nice. Well,
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I am a big fan of the Center for Communicable Disease Dynamics, which is a mouthful, which
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you run at Harvard. Before we jump into the topic at hand, can you summarize your scientific
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background? Sure. I was trained as an evolutionary biologist and mathematical biologist. I'm now an
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infectious disease epidemiologist and microbiologist, so I've moved sideways a little bit. But the
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common thread is that I'm very interested in understanding how, when we give people vaccines
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and antibiotics, how that affects the populations of infectious agents, and then how those changes in
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the infectious agents affect us and our health. And so I work on how that works, how we measure it,
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how we measure whether vaccines are doing their job, for example, how we track antibiotic resistance
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over time, and so forth. And then more recently, I've been involved in two other things. One is the
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response to the COVID pandemic on a bunch of different fronts. And the other is areas of research policy
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and research ethics around potentially risky experiments and human challenge trials for COVID
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vaccines. So I move around a little. Yeah. Well, it's probably been a busy few years for you, I can
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imagine. This has really been, the entire world came crashing into your wheelhouse somewhere around
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the beginning of 2020. Yeah. Let's start with COVID. I mean, obviously, I'm very concerned about
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the Trump administration's apparent assault on American science and scientific institutions. I
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want to get there, but let's start with COVID. What did we learn from COVID? I guess, what did we
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learn that we should have learned? What have we imperfectly learned? And what perhaps wrong lessons
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might we have learned at this point? Yeah. And I think the other pieces, what did we observe and
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probably won't learn even though we should have? There's a whole history of observing lessons and
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repeating the same mistakes. I think what we learned was a number of things, but one really big one is
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the importance of public trust and public solidarity in the response to an emergency like COVID. I think
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that the fact that different parts of the country and different people had very different levels of
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trust in what the government was telling them and in the vaccines and before that, the interventions
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that were put in place to slow the spread meant that it was much more divisive than it was in some
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other places and that our response was worse. I think we also learned that our public health system
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needs an upgrade. It was designed in the 19th century at a very hyper-local level with all the data and all
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the power really in the states and counties. And that makes it very hard to have a unified national
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response. And I think we also learned that, and this is one of those things that we sort of relearned,
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had been already noted a few decades ago, that policies need to be revisited on a regular basis
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with new information. The information is changing very fast in the middle of a pandemic and the
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policies that seemed like a good idea in the past may have lost their value or we may have more new
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information that says they weren't actually valuable and we should stop them. And I think an example of
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that might be, a good example might be school closure, which looked like the right thing to do. I think it was
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the right thing to do in the absence of good information. But we learned pretty quickly that
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young children in particular were not very important in transmission. We learned that those
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schools that stayed open managed to do so pretty safely. And the policy was kind of stuck in place.
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And the U.S. was one of the places that kept schools closed the longest for not very good results
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and for a lot of damage that that did. And that was pretty clear pretty early. But we, for various
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reasons, kept policies in place past their useful life. How would you describe the unraveling of
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institutional trust and actual trustworthiness over the course of the pandemic? I mean, to what degree
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was the loss of trust warranted? I mean, I think everyone who's on the highly
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contrarian anti-establishment side at this point has a litany of abuses they can cite, you know,
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real or imagined abuses, noble lies that were told, you know, masks don't work and masks, you know,
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don't grab all the PPE because they're desperately needed for first-line responders. But, you know,
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also masks don't work. You know, try to square those to that logical contradiction. How would you describe
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the, what happened and the challenge of communicating scientific uncertainty to a public in the middle
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of a global health emergency that the scope of which is still, you're still struggling to understand
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and you're messaging into a highly polarized and fragmented information landscape?
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Yeah. Well, I think we started from a position of very low levels of trust in government among some
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people and some segments of society and in public health, particularly. Public health has been
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underfunded for a long time in the United States and particularly in the least advantaged parts of
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the country. And so we started from a rough position and we also started from a level of enormous
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inequality. And we know that people who were more disadvantaged had worse COVID outcomes within the
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U.S. And so there was already grounds for polarization. I do think that the early communication from the
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U.S. government under the first Trump administration was very confusing and that the promises that it
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would be over by Easter had no basis in any kind of science and were nonetheless made from the White
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House. On the other hand, indeed, as you said, there were comments made by people who were trying to
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induce the behaviors in the population that they thought would be more desirable. And they did come
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out with comments that were not scientifically valid. And that, of course, undermined trust when they
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changed or when people, as you noted, figured out that it actually didn't make logical sense to say,
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don't use all the PPE, which doesn't work in the first place. So I think there's plenty of blame to
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go around, but that the system was in bad shape to begin with. And that's something to remember for
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the future because the people will largely be different the next time, but the system is going
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to be very much whatever we make it or at the moment, however we're breaking it. And seeing the current
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threats to good science and good public health is pretty, pretty worrisome as I think about the
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future. Yeah, we will get to fears of the future because I share them. What is the appropriate
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posture and just rhetorical algorithm to be running as a communicator of, you know, public health
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information in the midst of a, an epidemic like that, where, where uncertainty is real and the
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story is changing. And yet, you know, that you're getting, you know, clipped into social media and
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you've got six minutes on CNN and you're, you're, it's an environment that's hostile to nuance.
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It's hostile to uncertainty on the part of the so-called experts. The very role of an expert is being
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undermined by perceived failures of expertise. And unfortunately, scientific uncertainty, while it
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is the, often the, the only sane thing to confess in the midst of a conversation about the science,
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when you're confessing it on the news, you're, at least to many people's ears, you're, you're failing
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to function in the political role that is also part of the communication of, of science during an
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emergency, right? So you're, you're giving advice to the public and when the story changes or when the
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store or when, when the story is always a probabilistic one, like you, you, you think
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something may be benefit, but you may be it's, but you're not sure. And you're, you're aware that the
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stories might change. How will you want to walk that tightrope next time? Because clearly during COVID
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that just the, the communication burden and the failure to meet that burden was just unbearable at a
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certain point. I mean, we just, we had a society that shattered over the perceived failure of, of
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expertise in the midst of this pandemic is so much so, I mean, the shattering is a little bit of a
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cartoon, but it's not too far from what, what's true. We had half of our society that was absolutely
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terrified of COVID and desperate to get vaccinated at the first opportunity. I mean, I, you know, I,
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I waited in the dark at four in the morning to get, you know, overflow, possible overflow vaccines
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in a ghetto in Maya city. And yet the other half of the country thought COVID was more or less a
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non-issue. It was the flu, but they were terrified to get vaccinated. And that division remained for,
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in some sense, it still remains, right? Still remains. Yeah. Again, how would, how would you, as someone
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who's trying to give an honest account of the best information in so far as you have it, you know,
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hour by hour during a pandemic meet this challenge of communicating nuance and uncertainty in the
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current environment? Because I just think we, we obviously failed somehow last time. And there has
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to be some rhetorical device that authorities can arm themselves with so as to inoculate people against
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their conspiracy thinking and their, and their waiting of when the story changes, that's how science
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is done, right? It's not, there's nothing nefarious about the story changing in principle. And yet
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every time the story changed, it was perceived to be to the absolute discredit, that really the
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everlasting discredit of scientific institutions. Yeah. I think it's a great set of questions you ask,
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and it's not hypothetical. At the Center for Communicable Disease Dynamics at the Harvard Chan School,
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we ran 150 plus Zoom-based press conferences during the course of the pandemic to try to
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do exactly what you're saying, to try to lay out what was known and what was not known. But I think
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from the perspective of government spokespeople and, and experts, this is something that really
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has to start between, during peacetime, during a period when people are hearing about, you know, beach
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safety and avoiding heat stroke and sort of more routine things. And it has to be, come clear that
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science evolves. Most science doesn't evolve as fast as pandemic science. And so it is a special time
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during a pandemic. But when there's a new outbreak of something that's not understood, experts can say,
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look, this is what we think it is. These are the precautions we're taking because we think it may
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be these things. And we're going to keep updating and we're going to keep refining what we know and then
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changing our recommendations as we understand it better, or as the situation changes or both.
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And I think people, people do that in their normal lives all the time. You know, weather forecasts
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are use, use science and, and people are perfectly capable of, uh, understanding that as you track a
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storm, you update what you think about it. They don't say that the weather forecasters are, are
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wafflers or, or incompetent. Uh, we sometimes do think they wish they were more on the ball, but we know
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that it's a probabilistic game. I think people are actually smarter and more able to deal with these
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kinds of things than, uh, they're often given credit for, but they have to be treated as adults
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and, and be used to it during peacetime and during, during periods when, when they aren't also under
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incredible stress from the pandemic itself. Uh, the leader of Singapore actually set an extraordinary
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example. He did a Facebook live post or session in February of 2020 as the pandemic was starting
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and, uh, had come to Singapore already. And he got on, on Facebook live and said, this is what we know.
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We went through SARS one, uh, in the past and, and we have learned some lessons from that because they
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were very hard hit by the original SARS in 2003. He said, this is what we know. This is what we're doing.
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We're going to change what we do and what we know as, as the situation changes. And it was very
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straightforward, all in very clear language. And, you know, I think we have a lot to learn from that
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performance and it's not something that a lot of public health officials are comfortable doing.
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I think there are also ways to build it into the system. Up until the end of last month, I was part of
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setting up a new center within the CDC called the Center for Forecasting and Outbreak Analytics.
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And one of the things that we really tried to do there when designing our public communications was to
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have a regular update. Uh, when there was a, when there was a crisis going on, we would set a regular
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pattern of updating what we said so that people would expect that and wouldn't be, wouldn't think there
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was some kind of emergency if there was a new statement because there was a new statement on some
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regular schedule. And also it would be expected that those updates would come. And so
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if for some reason it didn't come, there would be a demand for it. And that would, uh, insulate
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against potentially political interference. So I think there are ways to do that. That's something
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the UK, uh, really has pioneered, uh, in their public health communications and do very well.
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And so I think building in regular updates of data, building in expiration dates for policy decisions
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and public health guidance, uh, where you say, this is our guide, our interim decision or guidance until,
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uh, say 30 days or 90 days. And then we're going to revisit it helps to unstick the process and
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avoid the kind of policy stickiness that, that really caught us, uh, made our policies worse,
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uh, during COVID. And that's an old lesson. There's a great book by Harvey Feinberg and Richard
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Neustadt on the swine flu affair, uh, when we vaccinated millions of Americans against,
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uh, swine flu in 1976 after three cases. Uh, and then that never became a thing. And we,
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we had a number of adverse effects and their number one recommendation was to make sure that
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policies have off ramps. And that's an example of one of those lessons that we should have
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already had in our back pocket, but we didn't quite. Why do you think vaccines are so uniquely
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terrifying and polarizing? I mean, it seems that people who are, you know, highly, um, uh,
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it are radicalized by vaccines and their use and their mandates and their, et cetera, et cetera,
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aren't radicalized by similarly or even more, you know, even riskier medical interventions,
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right? I mean, you had the spectacle of people who wouldn't take the COVID vaccine under any
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circumstances and would have gone to their deathbeds, praising themselves for not having taken
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it. And yet they'll sign up for something that is the safety of which is far less demonstrated.
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And I mean, even something that's like a therapeutic for COVID. I mean, there, I know people who wouldn't
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get vaccinated for COVID, but the moment they got COVID, they got, you know, monoclonal antibodies
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pumped into them and a bunch of other cocktails just on the, on the chance that it would
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mitigate the illness. This was early on when it was still an illness that people reasonably feared.
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What is it about vaccines in your view? Yeah. I think monoclonal antibodies are also quite safe,
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but yeah, but putting that aside, but I mean, tens of millions of people hadn't taken them at that
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for COVID at this point. Yeah. So I think one part of the answer is that there is a
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sophisticated and widespread campaign to try to make people scared of vaccines,
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vaccines, which has been led in the past by the man who's now our secretary of health and human
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services. And we shouldn't put that aside that some, some people have an interest in making
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radicalization about vaccines. Uh, and why that is we could speculate about, I don't actually
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I do think that, I think that is just also my question, right? It's like, well, so they're doing
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it for vaccines in a way that they're not doing it for other medical interventions. And I, so this
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gets at, it's just another way of stating the question, like, what is so scary about vaccines?
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Is it, I mean, I, to give you just a, um, a shade of an answer that I have rattling around my brain,
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it might have something to do with the fact that we give them to healthy children, right? Like,
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it's not like your child is sick and you have to do something to get him or her well. It's your
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child's healthy. And now you're, you're sticking a needle into, uh, you know, in many cases, an
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infant who can't even understand what's happening. That's disturbing. And the idea that there's some
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risk of a bad effect, which is real, that's somehow intolerable, right?
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I think that's true. But, uh, and I think, yeah, I think that is part of the story. On the other hand,
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as you said, there are a lot of things that are more dangerous, much more dangerous in reality
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than vaccines are. And yes, I think, I think as a, as a matter of human psychology, it is
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more natural to people to intervene when there is a, an immediate problem. So an illness to treat
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rather than to prevent. It's just part of human nature as best I understand human nature.
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But I also think we shouldn't discount the fact that people have chosen to make this
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a toxic issue to use a, perhaps the wrong word, um, a, an issue that is polarizing and that
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where fear is being instilled for no good reason. I think the susceptibility to that fear might have
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something to do with what you said, but, but we shouldn't overlook the fact that this is a big
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industry. So what should we believe about COVID and COVID vaccines at this point? Maybe we can do
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this kind of rapid fire. I'll tell, I'll tell you what's in my head and you, and you can debunk my,
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my, the myths and, and half truths that have gotten there perhaps. I imagine that I know that
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something like 1.1 million Americans died from COVID and probably, I think this is due to still
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mathematical modeling, but something like 300,000 people died who didn't need to die based,
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as a result of vaccine hesitancy. Is it, does that sound right to you?
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Yeah. I think the numbers are a little bigger on the number who died, but that's the right order
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of magnitude. Is there any reason to be more concerned about the risks associated with mRNA vaccines
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as a class of vaccines than ordinary vaccines? And are, is there something riskier about COVID vaccines
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than the other vaccines that people routinely take? On COVID? No, it's, I mean, it's a new virus. So
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we are learning about the safety as hundreds of millions of people get it, but we've learned a lot
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because hundreds of millions, billions of people have now gotten these vaccines. mRNA is a new
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technology. It's understandable that people find it unfamiliar and have questions about it, but the data
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showed that these mRNA vaccines against COVID are extremely safe. They are not 100% without side
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effects. There are side effects. Those have been documented. It's also clear that in the presence of
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COVID circulating SARS-CoV-2 or COVID virus, it is a good trade-off to take the risk of side effects
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for most people compared to the risk of, that it protects you from, from getting COVID and its complications.
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How do you think about the risks for specific groups like teenage boys? I mean, I think that was the,
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the one cohort where it seemed like there, there was real signal of myocarditis risk that was
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looking like, um, in that group, maybe it was a toss-up as to whether or not they should get
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vaccinated given the risks on, on both sides. I don't, I don't know what the current thinking is
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there, but it seemed like it was, you were not completely irrational to think maybe my teenage son
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does not need the COVID vaccine given how benign the disease tends to be in kids that age and the,
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the elevated risk for boys for whatever reason. Yeah. I think that's not irrational. And I think
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people who make that decision or whose kids make that decision with them when they're teenagers are,
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are, are, are making a, an understandable decision. We had our, well, we have girls, but we had,
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we would have, uh, had our teenagers vaccinated had that been who we had as children because,
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uh, had we had boys because the myocarditis while real was not very severe in most cases,
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uh, it went away and the small risk of, of really severe COVID and long COVID, uh, which there's
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growing evidence that vaccines help with as well was enough, would have been enough in our minds.
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But I, I think people, that's part of treating people like adults is there are ways to reasonably
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disagree. And I don't begrudge anybody who makes the opposite decision of that for that group of people.
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I think as you get to age groups, uh, or groups of people like pregnant women who are at very high
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risk or comparatively high risk of complications, that decision becomes harder to justify based on
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numbers and really a matter of being opposed to vaccination more generally. And that, that I think
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is very hard to, to understand, but it's, it's certainly something that some people, uh, view that some
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people hold and the needs to be discussed with them, with their doctors and, and figured out.
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What about now, now that the disease has evolved to be more benign, uh, how do you view the risk
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reward of vaccination? I mean, so speaking personally, I told you that I was waiting in the dark at four in
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the morning, hoping to get an early vaccine. Now for the last, I think at least two years,
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I don't think I've been vaccinated because I I've gotten COVID more or less on schedule once a year.
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And that in my mind has served as my vaccination for that year. How, how, uh, preposterous is that
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road to personal health? The value of vaccination as opposed to becoming infected to build immunity
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is that the risk of long COVID is not there. The risk of, although low of severe illness is not
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there from the vaccine and it is from COVID even, uh, even though the probabilities are low.
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So it's an understandable decision. I think you could improve your odds a little bit of
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certainty of staying healthy by, by periodic COVID vaccination, but it is not the same kind of
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public health emergency that it was in years past. And so I think, you know, people will,
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will have different views. And that's certainly true in the numbers that the numbers of people
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getting vaccinated is, has gone down. Part of the, the main reason why it appears to be a more mild
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illness is that we have a lot of immunity in the population, both from previous infections and from
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multiple rounds of vaccination. So some of it is the evolution of the virus, but yeah, there aren't
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very many people around to test this hypothesis on. But my prediction would be that if you, uh,
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magically made the entire population susceptible again and removed their immunity, uh, there would
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be a lot of severe COVID around. It's just that we, the combination of host immunity and a little
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bit of the evolutionary changes, uh, has combined to make it rarer that people get severe illness.
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So again, just taking my personal case and people can draw whatever lesson, uh, they can draw from it.
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So if I get the flu vaccine every year, because that's what I do and it's a new flu every year
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and I'm not getting the COVID vaccine, do you, uh, detect any cognitive dissonance there? I mean,
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it's in my own mind, the rationale is I remember every time I got the COVID vaccine, it actually
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seemed like I had fairly significant side effects and I felt crappy for at least 24 hours. So it seemed
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like more of a vaccine than a flu vaccine, which I never perceive an effect from. Uh, and that's
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really just my, the source of my bias. If you were me, would you be getting a COVID vaccine every
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year and a flu vaccine every year? And that, that would be the rational way to, to have a sane
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approach. I think so. I mean, these are not the same kinds of truly life and death decisions that
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they were when the vaccines first came out and when COVID was a bigger threat. So, you know,
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I'm not going to spend a lot of time trying to convince you one way or the other, but the COVID
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vaccines are also probably more effective than the flu vaccines on the whole. And so, yeah, you,
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you pay a bigger price and you get somewhat more protection. So on balance, are we any better prepared
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for the next pandemic or do you think we're worse off for, for the stress reversal we experienced?
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