"If the C.D.C. had recommended better
masks from the beginning, how many people would have worn them and for how
long? If the Biden administration had flooded stores with cheap rapid tests,
would people have used them? If boosters had been pushed earlier, and more
loudly, would the United States no longer trail peer nations in vaccinations?
Put differently: How much would
getting our pandemic policies right have mattered?
It’s easy to speak as if policy
smoothly reshapes reality. I’m more guilty of that than most. But policy lies
downstream of society. Mandates are not self-executing; to work, policies need
to be followed, guidance needs to be believed. Public health is rooted in the
soil of trust. That soil has thinned in America.
That isn’t to absolve policymakers
of responsibility for their mistakes, but it is to wonder about the power they
actually wield, in a country that led the world in vaccine development but lags
Chile, Vietnam and Brazil in vaccine deployment. A recent interview with
Michael Bang Petersen, a Danish political scientist, drove that point home for
me. “In Denmark, people are in favor of vaccines, with more than 81 percent of
adults doubly vaccinated, but also very opposed to vaccine mandates,” he told
The Atlantic’s Derek Thompson. “There are no political parties in Parliament
that are loudly advocating for vaccine mandates.”
You know what’s better than a vaccine
mandate? A society that doesn’t need one.
We began this pandemic by asking the
wrong questions, and thus we got the wrong answers. Rewind to October 2019. The
Johns Hopkins Center for Health Security and the Nuclear Threat Initiative
release the Global Health Security Index. It ranks 195 countries on their
pandemic preparedness. Each country is judged on prevention policy, on
detection capabilities, on response infrastructure, on health system capacity,
on international cooperation and on underlying risk. The news is reassuring, at
least if you live in the United States: We’re No. 1!
Then, only months later, we get an
actual, once-in-a-century pandemic. The United States fails the test. We have
more infections, more deaths, more pain and suffering and division and grief.
Our performance doesn’t just fall short of rich countries like Germany and
Denmark. It falls short of far poorer countries, too. The Global Health
Security Index was measuring the wrong things. The researchers later noted that tucked
inside the report was a finding about the United States that would prove more
predictive of our response: “It had the lowest possible score on public
confidence in the government.”
But that leaves the question: What were
the right questions? What did we miss?
A paper published on
Tuesday in The Lancet tries to unravel the mystery — and not just for the
United States. It’s built atop new data that tries to adjust for differences in
testing and gaps in reporting to paint a clearer picture of case numbers and
fatality rates across 177 countries from Jan. 1, 2020, to Sept. 30, 2021. (I do
want to note that the data here remains far from perfect, and there is
inevitably noise, randomness and distortion in these comparisons. We live in a
fallen world, and yet still we try and understand.)
Looked at in an international
context, the magnitude of America’s failure comes clear. So too do the successes
of other countries.
The United States had 545
coronavirus cases per 1,000 residents. Uruguay had 472. The United Kingdom 374.
Canada 346. Germany 188, Switzerland 164. But it’s our peers in Asia that
really put us to shame. Japan had 67 cases per 1000. Singapore 59. South Korea
28. Taiwan seven. These numbers are so low as to be baffling.
The United States does better when
you measure the ratio of cases that lead to death. There, our performance is at
least middling. Our infection fatality rate was 4.55 per 1,000 cases. That’s
lower than Germany (6.34) and Switzerland (5.56) but higher than South Korea
(3.24) or Singapore (0.68). Still, our far larger number of cases mean we’ve
grieved far more loss. And we’re not the only ones.
“One reason this pandemic is an
epidemiological mystery is because you see a surprising amount of variation
among nations in close geographic proximity,” Thomas Bollyky, director of the
global health program at the Council on Foreign Relations, and one of the
paper’s authors, told me. “Bulgaria, Namibia and Bolivia have fatality rates
twice as high as their neighbors, Turkey, Angola and Colombia.”
The researchers tested everything
they could think of for predictive power. They looked at G.D.P., population
density, altitude, age, obesity, smoking, air pollution, cancer rates, exposure
to previous beta-coronaviruses like SARS and MERS, health insurance coverage,
pandemic preparedness ratings, trust in government, trust in fellow citizens,
hospital beds per capita and more. It’s a dizzying suite of possibilities, and
they run the numbers one by one.
When it comes to deaths caused by
infections, no single variable explains everything, or even all that much, with
the exception of age. The coronavirus strikes the old with particular viciousness,
and so the age of a population explains 47 percent of the variation in fatality
ratios between countries. This helps explain why richer countries have seen a
disproportionate number of deaths: Richer countries are older.
But age was alone in its ability to
predict fatality rates. Nothing else — not body mass index, not smoking, not
air pollution, not cancer prevalence, not universal health care, not hospital
beds — explained very much.
More unexpected was what the
researchers found when they looked at the factors that predicted how many
people got infected. Some of the obvious candidates — population density,
G.D.P. per capita, and exposure to past coronaviruses — failed to predict much
in the way of outcomes. But both trust in government and trust in fellow
citizens proved potent.
This yields the paper’s most
striking finding: Moving every country up to the 75th percentile in trust in
government — that’s where Denmark sits — would have prevented 13 percent of
global infections. Moving every country to the 75th percentile of trust in
their fellow citizens — roughly South Korea’s level — would have prevented 40
percent of global infections.
“When confronted with a novel,
contagious virus the best way for governments to protect their citizens is to
convince them to take the measures to protect themselves,” Bollyky said.
“Especially in free societies the success of that effort depends on trust —
trust between citizens and their government, and trusts between citizens
themselves.”
When Bollyky told me that, I thought
back to an essay I’d read in The Times by
Hitoshi Oshitani, a key adviser to Japan’s government, that had been nagging at
me.
The Japanese government, he said,
understood that the virus was airborne, and they made sure their citizenry knew
it. The message became that “People should avoid the three C’s, which are
closed spaces, crowded places and close-contact settings. The Japanese
government shared this advice with the public in early March, and it became
omnipresent. The message to avoid the three C’s was on the news, variety shows,
social media and posters. ‘Three C’s’ was even declared the buzzword of the
year in Japan in 2020.”
What struck me about this, when I first
read it, was what it left unsaid. Japan was much quicker to understand airborne
transmission than the United States, but we knew it soon enough. We certainly
knew it by the time of the Delta surge, when Japan again performed far better
than we did. We know it now, and Japan is still performing better than we are.
It is what we do with what we know that matters.
Trust is regularly polled in
international surveys, and so the researchers had access to those numbers. But
I suspect trust is only a cousin of what we’re really trying to measure here.
Solidarity is perhaps closer to the social sentiment the pandemic demanded.
Poring over this data left me
thinking about something my colleague Zeynep Tufekci told me:
If you’re in the 19th century, and
you’re just puzzling over yellow fever, and you don’t even have germ theory,
and you don’t understand mosquito vectors — it’s hard. It’s really hard. I read
those histories, and I want to give them clues. But right now, we have
everything in place. And it’s our dysfunction that’s holding us back. It’s the
global, political dysfunction; our U.S.-specific dysfunction.
There are lots of policy
recommendations that work to curb the coronavirus: Masking, social distancing,
vaccinations, testing, quarantining and so on. But for any of them to work,
they need to be followed. This has been, certainly, the Biden administration’s
insuperable challenge. It can make vaccines available, but they can’t make
people take them. They can make masks available, but they can’t make people
wear them. The context for the Biden administration’s entire response was a
Republican Party divided over the legitimacy of the 2020 election, and aware
that the road to 2024 ran through opposition to Biden’s coronavirus policies.
So what if you assume political
polarization and media disinformation are here to stay, and you need to work
around them, rather than ignoring them?
When you reframe the question, other
possibilities reveal themselves. As an example: Only 36 percent of
Republicans trust Anthony Fauci. I think the Republican campaign against him
has been largely unfair, but that he is particularly polarizing among the
people the Biden administration most needs to reach is simply a fact, and one
it has chosen to ignore. Perhaps new voices were needed, including high-profile
ones chosen for their appeal to those most inclined to doubt Biden and avoid
vaccination.
I asked Ron Klain, Biden’s chief of
staff, about the absence of messengers with credibility among Republicans, and
his response struck me as understandably but depressingly fatalistic. “I think
this question of polarization around vaccinations is very, very complicated,”
he replied. “I mean, you saw President Trump get booed when he himself
advocated people getting booster shots. So this isn’t as simple as ‘Can you put
more conservatives out there talking about vaccinations?’”
That’s certainly true. And I don’t
mean to single out Fauci, or overestimate the value of replacing him. Any
Republican who joined the Biden administration would be seen as a traitor by
much of the conservative base. But improvements are made on the margins.
That our political and social
problems are maddeningly difficult to solve doesn’t make them any less
necessary to at least try and ease. Whatever basket of pandemic policies the
Biden administration tries — be they the vaccine mandates the Supreme Court
just gutted, or new testing infrastructure, or variant-specific boosters — will
not work if the social context in which those policies play out continues to
deteriorate. And it is deteriorating: 88 percent of Americans say the pandemic
has left us more divided, which is higher than in any of the other 16 countries
Pew surveyed.
We erred this time by believing
ourselves not just more capable, but also more united, than ultimately proved
true. Now that we know the truth about ourselves, and the havoc our divisions
will wreak on any pandemic response, the problem we need to solve becomes
clearer.
What does good pandemic policy look
like for a low-trust, high-dysfunction society?"
