In 2020, many Americans told themselves that all it would take to halt the pandemic was replacing the president and hitting the “science button.” In 2023, it looks like we’re telling ourselves the opposite: that if we were given the chance to run the pandemic again, it would have been better just to hit “abort” and give up.
You can see the impulse in declining support for public health, state laws limiting future public-health authorities, revisionist accounts of the early pandemic presented in Congress and the presidential campaigns launched in opposition to Covid policies, in those who now routinely describe pandemic policy as a cure worse than the disease. And you can see it in Bethany McLean and Joe Nocera’s book “The Big Fail: What the Pandemic Revealed About Who America Protects and Who It Leaves Behind,” excerpted last month in New York magazine under the headline “Covid Lockdowns Were a Giant Experiment. It Was a Failure.”
There is, I think, a lot of good in the book: reported accounts of the flat-footed American response and the structural problems with supply chains and health care access, and the privatization of hospitals and old-age homes.
But as someone who has followed the twists and turns of Covid science and pandemic policy very closely over the past few years, I also found much of its analysis intensely frustrating. There are important questions to ask, in retrospect, about the limits and trade-offs of pandemic mitigation. But I also think we can’t simply replace one simplistic narrative, about the super power of mitigation policy, for another, focused only on the burdens it imposed and not at all on the costs of doing much less — or nothing at all.
I spoke with McLean and Nocera in early November. The conversation has been edited for length and clarity.
Let’s start with the title. What is the big failure, as you see it?
McLean: I think it gets at things that had happened in America even before the pandemic hit. And among those things were, I think, a failure to recognize the limits of capitalism, a failure of government to set the right rules for it, particularly when it comes to our health care system; a focus on profits that may have led to an increase in the bottom line but created fragility in ways people didn’t understand; and then our growing polarization that made us incapable of talking to each other.
How big is the failure? When I look at The Economist’s excess mortality data, I see the U.S. had the 53rd-worst outcome in the world — worse than all of Western Europe, but better than all of Eastern Europe.
McLean: I think one way to quantify it is to take all those numbers and then put them in the context of our spending on health care. Given the amount we spend on health care relative to other countries, the scale of the failure becomes more apparent.
Nocera: I would like to focus on one additional thing. It’s not just about death and disease statistics. To me, the most glaring example is the schools. They were closed without people thinking through the potential consequences of closing down public schools, especially for disadvantaged kids.
And then, to compound it, in my view, public health never made the distinction that needed to be made between the vulnerabilities of somebody 70 years old and the vulnerabilities of somebody 10 years old.
McLean: Look at the kids who went missing. At the height of the pandemic, in Chicago public schools, 45 percent of kids were just missing. The numbers in New York and L.A. are comparable. And while kids have caught up somewhat, there are still kids missing from the system. And I think that it’s a huge failure, one that this country is going to be grappling with for decades to come.
In the beginning of the book you write, in what almost feels like a thesis statement for the book: “A central tenet of this book is that we could not have done better, and pretending differently is a dangerous fiction, one that prevents us from taking a much needed look in the mirror.”
This claim, that the U.S. could not have done any better, runs against your other claim, that what we observed was an American failure. It is also a pretty extreme claim, I think, and I wanted to press you on it in part because it is, in my view, undermined by quite a lot of the work you do in the book itself.
Would the U.S. not have done better if it had recognized earlier that the disease spread through the air rather than in droplets? Would it not have done better if it hadn’t bungled the rollout of a Covid test in the early months? You write at length about PPE shortages and the problems of coordinating care between hospitals in the early months — would the country not have done better if it had addressed those problems quickly, or not suffered from them to begin with? Disparities in health care access — is it a dangerous fiction to think we might address that? You guys are big champions of Operation Warp Speed — would it not have been better if those vaccines had been rolled out to the public in nine months, rather than 12, getting shots into the arms of the vulnerable elderly before the first big winter surge?
McLean: Everything that you mentioned — the point of the book is that those were set by the time the pandemic hit. The disparities in health care, for instance, that had been done for decades beforehand.
Well, sure, but what about the Covid test failure? The pace of Operation Warp Speed?
McLean: I think that the test failure was baked into the way that the C.D.C. had come to operate. The fact that we’ve outsourced so much of our PPE manufacturing, you couldn’t then just switch on a dime and say, let’s manufacture PPE in the U.S. so that we can have it ready. And I’m not sure you could have sped up Operation Warp Speed.
There’s a lot of talk now that next time should be even faster, but even this time around, the safety trials were completed by the summer.
But the big question I really want to ask is this one: According to the C.D.C., we’ve had almost 1.2 million deaths from Covid. Excess mortality is nearly 1.4 million. Is it really your contention that there was nothing we might’ve done that brought that total down to 1.1 million, for instance, or even 900,000?
McLean: It’s very — you’re right. If you went through each and every thing and had a crystal ball and you could say, this could have been done, this could have been moved up by a month, we could have gotten PPE …
Nocera: Can I speak?
Nocera: I’ll acknowledge that Bethany wrote that. But this is not throwing her under the bus. When I came to that sentence, I thought of it in terms of human behavior: What will humans put up with? What will humans stand for? How do Americans act? And you’ve written about Sweden being sort of average, and you’ve written about China and the Chinese example. They lock people up for two years and suddenly the society just revolts. They will not take it anymore. They can’t stand it. And as a result, a million and a half people die in a month and a half.
Well, I would tell that story very differently. For me, the problem is that when China opened up, they had fully vaccinated just under two-thirds of their population over 80. So to me, it’s not a failure of lockdowns. It’s a failure of vaccinations. If the Chinese had only achieved the same elderly vaccination rate as we achieved — which by global standards was pretty poor — that death toll when they opened up would have been dramatically lower.
Nocera: But you can’t lock people up for two years in America while waiting for a vaccine.
What do you mean by “lockdown,” though? You use the word throughout the book and suggest that China was the playbook for all countries. But you also acknowledge that what China did is not anything like what America did.
Here, the shelter-in-place guidelines lasted, on average, five to seven weeks. Thirty nine of the 40 states that had issued them lifted them by the end of June, three months in. By the summer, according to Google mobility data, retail and grocery activity was down about 10 percent. By the fall, grocery activity was only down about 5 percent across the country. My daughter went back to preschool. My father-in-law had elective surgery. The N.F.L. launched its season.
Nocera: With lots of games being canceled because there weren’t enough players.
But that’s not a question of lockdown, that’s a question of people being sick and the league’s policy about how to handle those illnesses.
And yes, of course, there were restrictions and impositions. Schools were closed. People didn’t go on trips and were very cautious about seeing family. In a lot of places, you couldn’t eat inside a restaurant. In others, when you went into stores, the store asked you to wear a mask. In some places, not many, you were being asked to provide a negative test to enter a particular event or social gathering. In many cases and in many ways the restrictions were burdensome and painful. There was mass unemployment, too, and an awful lot of anxiety and fear. But this isn’t “lockdown” like there were lockdowns in China or even Peru. It’s how we tried to make it safer to go out and interact during a pandemic that ultimately killed a million Americans.
McLean: I think that you’re absolutely right to focus on the definition of what a lockdown is and how we implemented them here in this country. And I think part of the problem is that we implemented them in a way that allowed people who were well off and could work from home via Zoom to be able to maintain very much of their lives while other people couldn’t. And then you can ask, well, is there a better way to lock down? Is there a way to lock down that we could have protected people in nursing homes? Is there a way to lock down that we could have protected people who live in multigenerational housing? Is there a way to lock down that we could have protected essential workers?
And I think it depends on who you were, whether you would define this as a lockdown or not. If you were a small business who saw your small business closed because of this, you’re going to define it as a lockdown. If you’re a restaurant owner who lost their restaurant because of this, you might define it as lockdown. If you’re a parent whose child missed out on education because they needed the public schools to be open and who was struggling to balance the demands of having a child at home with having to do their own work, you might call it a lockdown. If you were free to leave your home and roam around and you could work via home from Zoom, you might not call it a lockdown.
But it’s also hard to separate a lot of that policy impact from social behavior that would have changed to some degree anyway. You mentioned Sweden, Joe, where they had a lighter-touch pandemic policy: There were some restrictions, and secondary schools did go remote, but it was essentially about advisories and guidance. And yet, by the objective data we have about how people actually behaved, for most of 2020 Sweden was not any more “open” or active than the U.S. was.
McLean: I think you’re asking an essentially unknowable question. What is that interaction between the fear that a population might have and the public health policies that are put in place?
But in the book you’re pretty definitive. You write, “maybe the social and economic disasters that lockdowns created would have been worth it if they had saved lives, but they hadn’t.” How can you say that so flatly?
I think there are still open questions about what worked and how much. But the way that I think about all of this is that the most important intervention that anybody did anywhere in the world was vaccination. And the thing that determined outcomes most was whether your first exposure came before or after vaccination.
Now, at the time, mitigation measures were defended in a few different ways. We talked a lot about flattening the curve to protect the hospitals. We talked about Zero Covid and trying to eradicate the disease. And then we entered into a period in which there was no clear stated goal, which I do think was, as you point out in the book, kind of disorienting and frustrating to a lot of Americans. But in retrospect, what we were doing was to try to delay as much spread as we could until people got vaccinated. All the things that we did in 2020 were functionally serving or trying to serve that purpose. Now, given that, how can you say that none of that work saved lives?
Nocera: Well, on some level, I feel like you’re trying to have it both ways. On the one hand, you’re saying that lockdowns saved lives. On the other hand, you said they weren’t real lockdowns because everybody was out and about.
I don’t think that’s having it both ways. I’m trying to think about these issues on a spectrum rather than in binaries. I think we did interrupt our lives — everybody knows that. And I think they did have an effect on spread, and that limiting spread had an effect by delaying infections until after vaccination.
Nocera: Most of the studies that say lockdowns didn’t work are really less about Covid deaths than about excess mortality deaths. I wound up being persuaded that the people who could not get to the hospital, because they were all working, because all the doctors were working on Covid and the surgical rooms were shut down, the people who caught some disease that was not Covid and died as a result — I wound up being persuaded about that.
But actually, I want to stop you there, because I actually think that that data tells the opposite story.
There was a lot of worry early on about delayed health care, and about cancer in particular — missed screenings, missed treatments. But in 2019, we had an estimated 599,600 Americans die of cancer. In 2020, it was 602,000. In 2021, it was 608,000. In 2022, it was 609,000.
Nocera: See, it went up!
But by a couple of thousand people, in years in which hundreds of thousands of Americans were dying of Covid.
Nocera: I think you can’t dispute the excess mortality numbers.
I’m not. But in nearly every country in the world the excess mortality curves track so precisely with Covid waves that it doesn’t make sense to talk about a massive public health problem beyond Covid. And when you add all of these numbers up, they are nowhere near the size of the footfall of Covid. How can you look back on this and say the costs were too high?
Nocera: I think the costs were too high because you had school costs, you had economic costs, you had social costs, and you had death. I remember Cuomo saying once, if one person dies of Covid, that’s one too many. And no — that’s not true. We’re in a pandemic. People are going to die. And then the question becomes, can we protect the most vulnerable? And the answer is, we didn’t protect the most vulnerable. Nursing homes were a complete disaster.
How would you have liked to see things handled differently?
Nocera: Well, the great example of doing it right is San Francisco. Jay Caspian Kang wrote a really terrific article about this in The New Yorker. They have a large nursing home, and it’s run by the city, and they took appropriate measures, and by the end of 2022, only 11 people died there. The second thing they did though, and this is equally important, is that they reached out to the vulnerable communities. They were able to do this because it’s one city in the country where there’s actual trust between the disadvantaged communities, the Latino communities, the drug-addicted communities, and the city and the public health community because of AIDS. And they were able to reach out, they were able to protect people.
I find the San Francisco experience impressive, too. But it was also a city that engaged in quite protracted and aggressive pandemic restrictions, well beyond just protecting the elderly and vulnerable.
McLean: But are we going to go for stay-at-home orders plus protecting vulnerable communities like San Francisco did? Or simply letting everybody live their lives, but with a real focus on the communities and places like nursing homes that were going to be affected? My argument is that we probably would’ve been better off really focusing on protecting those communities which were likely to be the most severely affected.
I agree that the public certainly didn’t appreciate the age skew, and our policy didn’t reflect it either. But I also wonder what it would mean to better protect the vulnerable than we did. We had testing shortages at first. Then we had resistance to rapid testing. We had staff shortages in nursing homes.
Nocera: This gets exactly to one of our core points. We had spent 30 years allowing nursing homes to be owned by private equity firms that cut the staff, that sold the land underneath and added all this debt on. And the economics matter here. And when Covid comes, they’re completely unprepared, because they spent 20 years gouging the nursing home industry, putting the money in their pocket. And people died needlessly.
I hear you saying both that we could have done a much better job of protecting these people and that the systems we inherited at the outset of the pandemic would’ve made those measures very difficult, if not impossible, to implement.
McLean: I think you’re raising a really good point. We’re making an argument for a policy that might not have been doable given the preconditions that had been set. I’m arguing that there were these things that had been put in place in our country for decades leading up to the pandemic that made it really difficult for us to plant in an effective way, from the outsourcing of our PPE to the distrust in our health care system that had been created by people’s lack of access to health care with the disparities in our hospital system. And then I’m trying to say at the same time, but couldn’t we have done something to have protected people despite all of that?
Nocera: I feel very strongly that if we had done a better job protecting people just in nursing homes, we would’ve saved lives for sure. Maybe even a lot of lives.
I want to talk about the number of lives at stake. In the book, you write about the work of British epidemiologist Neil Ferguson. In the winter of 2020, he says that in the absence of mitigation measures and vaccination, 80 percent of the country is going to get infected and 2.2 million Americans are going to die. He says that 80 percent of the U.K. would get infected, and 510,000 Brits would die — again, in the absence of mitigation measures and in the absence of vaccines.
In the end, by the time we got to 80 percent of the country infected, we had more than a million Americans die. We had more than 200,000 Brits die. And in each case most of the infections happened after vaccination, which suggests that if those infections had all happened in a world without vaccines, we almost certainly would have surpassed two million deaths in the U.S. and almost certainly would’ve hit 500,000 deaths in the U.K.
Nocera: I haven’t read that in a long time, but my memory is that he said that this would all take place by August 2020.
In the absence of any mitigation.
In the book, you write about this estimate, and you endorse Jay Bhattacharya’s criticism of Ferguson’s model. You write, “Bhattacharya got his first taste of the blowback reserved for scientists who strayed from the establishment position early. He co-wrote an article for The Wall Street Journal questioning the validity of the scary 2 to 4 percent fatality rate that the early models like Neil Ferguson’s were estimating and that were causing governments to panic. He believed, correctly as it turns out, that the true fatality rate was much lower.”
Nocera: I know where you’re going with this, because I read your story about the nine pandemic narratives we’re getting wrong. In there, you said that Bhattacharya estimated the fatality rate at 0.01 percent. But if you actually read The Wall Street Journal article, what he’s really saying is I think it’s much lower. I’ve looked at two or three different possibilities, and we really need some major testing to figure out what it actually is, because I think 2 percent to 4 percent is really high.
Well, first of all, the 2 percent to 4 percent fatality rate is not from Neil Ferguson. It’s from the W.H.O. Second, it was not an infection fatality rate [I.F.R.], it was a case fatality rate, which means it was inevitably going to be higher. Third, in the Imperial College report — the one projecting two million American deaths — Ferguson gives an I.F.R. estimate of 0.9 percent. Fourth, in this same paragraph, where you write that Bhattacharya was correct, you have a footnote to the Johns Hopkins I.F.R. estimate, which is 1.1 percent. That is not lower than Ferguson’s estimate. That is higher than Ferguson’s estimate. And Bhattacharya’s? Yes, there is some uncertainty around the estimate he offers. But the estimate he does offer — 0.01 percent — is one hundred times lower than the I.F.R. you yourselves cite as the proper benchmark.
Nocera: In The Wall Street Journal he does not say it’s 0.01. He says, we need to test to find out what it is, but it is definitely lower than 2 to 4 percent.
He says, “if our surmise of 6 million cases is accurate, that’s a mortality rate of 0.01%. That is ⅒th the flu mortality rate of 0.1%.” An I.F.R. of 0.01 percent, spread fully through the American population, yields a total American death toll of 33,000 people. We have had 1.2 million deaths. And you are adjudicating this dispute, in 2023, and saying that Neil was wrong and Jay was right.
Nocera: Hold on, hold on. I’m trying to find his story
I’ll send it to you.
Nocera: You don’t like him, huh?
I think a lot of these guys have raised important questions — about the efficacy of masking and the value of mitigation measures like school closures and the wisdom of boosters. I don’t want to shut down debate. I don’t want Jay Bhattacharya kicked off Twitter, and never did. I followed him on Twitter! I don’t want any of these people silenced.
But I think that fundamentally, at the outset of the pandemic, the most important question orienting all of our thinking was, how bad could this get? And it turns out that almost all of the people who were saying back then that we shouldn’t do much to intervene were extremely wrong about how bad it would be.
The argument then was, more or less, “We don’t need to do anything too drastic, because it’s not going to be that big a deal.” Now, in 2023, it’s the opposite argument: “We shouldn’t have bothered with restrictions, because they didn’t have an impact; we would have had this same death toll anyway.” But the death toll turned out to be enormous.
Now, if we had supplied all these skeptics with the actual numbers at the outset of the pandemic, what kind of audience would they have had? If instead of making the argument against universal mitigation efforts on the basis of a death toll of 40,000 they had made the argument on the basis of a death toll of more than a million, do you think the country would’ve said, they’re right, we’re doing too much, let’s back off?
McLean: I think that if you had gone to the American people and said, this many people are going to die, that would’ve been one thing. But if you had gone to the American people and said, this many people are going to die and a large percentage of them are going to be over 80, you might’ve gotten a different answer. So I don’t think you can make the point you’re making without also asking the America people, where are those deaths going to be and in which populations are they going to be?
Nocera: OK, so here’s the other thing Bhattacharya says in the same article — and you’re right, he said if our surmise is accurate, then the mortality rate is 0.01 percent. But then here’s the key sentence: “Given the enormous consequences of decisions around Covid-19 response, getting clear data to guide decisions now is critical. We don’t know the true infection rate in the U.S. Antibody testing of representative samples to measure disease prevalence is crucial.” To me, he makes some surmises that turn out to be wrong, just as many others did. But he doesn’t say, I know this for a fact. He says, we don’t really know what the answer is and we need to test. And from my point of view, that’s exactly right.
I’m not arguing we shouldn’t have been trying to get a clearer sense of the true fatality rate, or that we shouldn’t have been clearer about the age skew. But Bhattacharya was also offering an estimate of fatality rate that turned out to be off by a factor of a hundred from the I.F.R. that you yourselves cite as correct. And then you say that Bhattacharya was right and Ferguson was wrong.
And you, too, Joe, you wrote an article in April expressing sympathy for Covid skeptics and you said ——
Nocera: This April?
Nocera: Oh, oh. That’s the one where I praised Alex Berenson.
You also cited some Amherst modeling which said that we were going to have 67,000 to 120,000 American deaths. We already had, at that point, 60,000. So you were suggesting, in making an argument against pandemic restrictions, that the country as a whole was going to experience between 7,000 and 60,000 additional deaths from that point.
Now, two things about this. The first is, from there, we had more than a million additional deaths. The second thing is that the reason that we were revising our estimates downward in the spring of 2020 was that our models were very simple projections from recent data. And that recent data was showing case declines, back then, because the initial mitigation measures were working — our staying at home and social distancing was driving cases down.
Nocera: David, I saw one article that you wrote where you said, I’ve made my share of mistakes here. We all write things that turn out not to be true. It was April 2020. I’ll acknowledge that I probably got that wrong. It was very early. I was trying to figure this out like many other people.
But the point is what you’re doing now.
Nocera: No, no, no, no, no, no, no. The point is, our view is that protecting the elderly would’ve maximized lifesaving and also allowed society to operate in a more seamless fashion. That’s my view. I think it’s correct.
But in your book, now, you also say that Bhattacharya was right and Ferguson was wrong.
Nocera: Do we really want to argue about this for the next 20 minutes? I feel like I’m on the witness stand.
Well, you did write a book on the subject.
Nocera: And now I’m on the witness stand!
Let me ask you about the broad economic impacts. You guys have mentioned a number of times that businesses closed, people lost their companies, there was massive unemployment for a period of time. All of that’s obviously quite real and produced a lot of suffering, especially in 2020, with some hangover effects later.
But when I think about the combination of the economic effects of mitigation policies and just of the pandemic itself and the big fiscal response, I look back and I think the U.S. managed this storm relatively well. How about each of you?
McLean: I’m less positive than you for a couple of reasons. In the wake of the financial crisis, the Fed had to step in to save the economy because Congress was deadlocked and wasn’t able to do anything. So we’ve had these couple of decades of super-low interest rates that have distorted markets and created debt bubbles in a lot of places. And by the time the pandemic hit, much of what the Fed had to do when they stepped in to rescue the system wasn’t to rescue the parts of the system that the Fed is supposed to rescue. It was to rescue all of the non-banks that are now part of this large thing called the shadow banking system.
And that raises two questions. It raises the short-term question of why does the Fed have to step in to fix the losses of a financial market that it’s not supposed to be responsible for? And second, what does it mean that every time we have a crisis, the Fed’s rescue has to get bigger and bigger and bigger? And what happens if central banks can no longer come to the rescue? Why do we have this flawed and fragile financial system that necessitates a gigantic rescue when there’s a hiccup in markets?
When you look at the money that the Fed had to throw at the system and who it benefited — it namely benefited big companies that could take advantage of the access to capital markets. And because they had access to capital markets and because of what the Fed did, every trader in the market was like, this is the world’s best buying opportunity. And the people who made the most money from these policies were the already well-off. And the reality is every time you have the Fed have to step in with the rescue package, that’s what’s going to happen. It’s going to make those who own assets a lot richer.
So in this case, Congress did get it together and did come to the rescue. And I agree that made a ton of difference in the short term, but the long-term effects of the fiscal rescue package were to help create inflation. And once again, inflation hits those at the bottom of the socioeconomic distribution much harder than it does those at the top. So I would argue that some of what we did in the pandemic is papering over these long-term issues.
And now with interest rates rising, it’s really unclear what our budget is going to look like. It’s finally becoming an issue. After a couple of decades we’ve had of pretending that money was essentially free and that it didn’t cost anything to keep adding to the bill — the bill is coming due. And if interest rates don’t go back down, the share of our budget that’s going to have to go to making interest payments on our considerable debt is really frightening for the future.
I think as with a lot of the stuff we’ve talked about today, I agree with you about the underlying problems. But if we take for granted for a moment that the pandemic was going to hit us, when it did, under the economic conditions it did, and then think about the more narrow context of whether, given all that, we handled the pandemic well. We returned quickly to prepandemic G.D.P. trends,