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Brian Lehrer: It's the Brian Lehrer Show on WNYC. Good morning again, everyone. Coming up in a little bit, AO Scott, New York Times film critic on what to watch for at the Oscars on Sunday night. First, this weekend will be the third anniversary of the country beginning to shut down when COVID first hit. It was March 11th, 2020, when a player on the Utah Jazz of the NBA tested positive and pro basketball immediately shut down. Major League Baseball followed suit the next day. Three days later, the New York City Public Schools suspended in-person learning along with schools around the country.

For those who lived through it, whether you were an 8-year-old who suddenly had to stay home from school or an 80-year-old suddenly afraid for your life, this period of mid-March will always bring those memories, right? As we remember the backlash began almost immediately, so did research on a vaccine. Different states and different countries approached the virus differently. Now, three years later, we can ask how'd we do, or since the virus is still with us, how'd we do so far?

That's exactly what physician and New Yorker magazine contributor Dr. Dhruv Khullar has done in the magazine and with David Remnick on the New Yorker Radio Hour, comparing countries and also comparing liberal and conservative states. We wanted to bring them on here and have some of this conversation on our live show. One stat to tease this conversation before we bring them on, there have been around seven million deaths worldwide from COVID, more than a million of them in this country. We have around 4% of the world's population, but we've had around 15% of the deaths. That doesn't sound like a job well done.

Dr. Dhruv Khullar is a physician and med school professor at the Weill Cornell Medical College. He also has the interesting title of Director of Policy Dissemination at the Physicians Foundation Center for the Study of Physician Practice and Leadership. In what must be his copious spare time, he was recently a senior research fellow for the New York City public hospital system. Somehow he is finding time to donate to us today. Dr. Khullar, we really appreciate it. I love your work in the New Yorker, thanks for coming on WNYC.

Dr. Khullar: Thanks so much for having me.

Brian Lehrer: Can we start with that stat that I cited? If the US has 4% of the world's population but we've had 15% of the COVID deaths, does that mean we failed compared to other countries?

Dr. Khullar: It's a great question. I think the first thing to realize is that seven million stat may not be what it appears at first glance. There are some estimates by The Economist magazine and others that actually suggest that there may be as many as 20 million deaths from COVID-19 across the world over the past 3 years. As we know, not all countries report their deaths accurately or their cases accurately. We've seen this in China, in Russia, in India as well, so we're not exactly sure what that top-level number is.

Even given that uncertainty, I think no one would say that the US had a stellar response. Even though at the outset of the pandemic according to Johns Hopkins and other reports, we were one of the best countries in the world to address the pandemic. We clearly didn't live up to that reputation.

Brian Lehrer: Some of the countries you say did the best were South Korea, Australia, New Zealand, Japan. Those are all in the same part of the world, maybe no coincidence. Plus Denmark and Norway. When you cite those countries, how are you measuring success?

Dr. Khullar: The principle measures of success that we look at there, and that's something that we should talk about as well, are some combination of cases, and importantly, deaths. I think no one would dispute the fact that COVID-19 mortality is a really important marker of how countries did. Those are the countries that did really well, and they have some things in common. When you think about some of the countries in East Asia that you mentioned, a lot of those countries had recent experiences with other coronavirus pandemics, actually.

If you think about the first SARS pandemic in 2002-2003, Hong Kong, Taiwan, Singapore, all these countries had really high mortality rates from that. South Korea had a recent experience with MERS in 2015. All these countries, I think those experiences have imprinted themselves on their psyche and they've taken steps to be more prepared this time around.

When you look at what's happened in the US with political polarization and misinformation and the divisiveness with which we've approached this pandemic, it doesn't give you the same level of confidence that during the next pandemic, and we will have another pandemic, we will similarly be better prepared, but that's what we should be looking to, is that you can really update your response and be more effective the next time around.

Brian Lehrer: Yes. Scandinavia is really interesting to me because I noticed that you said Denmark and Norway were among the most successful countries at managing the virus for the lowest death rates, but Sweden wasn't. Sweden tried something really different from a lot of other places. Can you remind us of that?

Dr. Khullar: That's right. Early on in the pandemic, it's been so long now people may not remember everything at the beginning, but there were some countries, the United Kingdom, Sweden, that took a different tack in Europe. They really had a much more laissez-faire approach to the pandemic. They didn't have as stringent of social distancing measures, lockdowns, business closures, these types of things early on in their pandemic. They actually quickly pivoted back to a more mainstream response along with the other countries in Europe. That was because they did have substantially higher morbidity and mortality from the virus early on, so they had to correct course.

It is the case that it's not just enough to live in that part of the world, these policies really did matter. One other thing that I think is really helpful to add into this conversation, both when you think about some of the Scandinavian countries and the East Asian countries that we talked about, social cohesion and trust in both one another and in institutions seem to be a really important part of what created the success in those places. That's another thing that the US and some other countries are lacking in right now, but it's not just this airy-fairy thing, having trust in one another, having trust in institutions, it really makes a difference in terms of how effectively you can respond to a viral threat.

Brian Lehrer: Is there any way for you as a doctor or a scientist to measure the counterfactual of how badly would we have done if Hillary Clinton as opposed to Donald Trump had been president?

Dr. Khullar: A counterfactual is really hard to walk through. Certainly, there were missteps early in the pandemic. Some of those were communication failures on the part of the Trump administration, but others of them were more inbred bureaucratic failures. If people might remember that early in the pandemic, the CDC and the FDA struggled to get a coronavirus test that was effective out into the field early on enough. There was mixed messages coming out about whether to mask or not at that time.

It's hard to say hypothetically how things would've turned out differently had Hillary Clinton and not Donald Trump won, but I think the take-home message is that whoever is in office, we need to have a more robust public health response going forward.

Brian Lehrer: You also referenced liberal and conservative states in your conversation with David, more vaccine and mask requirements like in New York versus much less of those in Florida, for example. The ultimate COVID death rates however were maybe not that different as we in New York might like to believe. Can you go into how similar and maybe why?

Dr. Khullar: That's right. There's no doubt that there's huge variation actually across states. If you look at a state like Hawaii or Vermont and compare it to one like Louisiana or Mississippi, something like three or four times as many people per capita died in those latter states compared to Hawaii and Vermont and some of the states that had a different response.

There is variation, I don't want to mask that, but it's also the case that big states with very different political cultures and very different approaches, you think about California, Texas, Florida, and New York, when you adjust for things like comorbidities and age of the population, they actually did not end up with that different of death rates from COVID-19. Some of that is that there are so many factors that differ in these states, so it's hard to make apples-to-apples comparisons.

Some of it is also vaccination rates and particularly vaccination rates among older people. If you look at the vaccination rate in Florida among older Floridians, it's actually pretty good compared to other states in that part of the country. If I could say one thing that was most important for much of the pandemic after we got vaccinations, masks were important, social distancing was important, but really getting shots in arms was so, so important. That I think narrowed some of the discrepancies that you might've seen even if you had divergent other policies during the pandemic.

Brian Lehrer: Is that to say that mask mandates and social distancing were less important than we've thought? There's an article in the New York Times just today showing data on the ongoing effectiveness of masks.

Dr. Khullar: That's right. I think there's been a lot of controversy in this area. obviously. Some of your listeners may have seen this Cochrane report recently, which came out, which is basically a group of studies that they analyzed together. The upshot of that report, which leaves a lot of consternation among public health officials, is that mask mandates were not effective. Now, there's a lot of problems with that report. A lot of the studies they look at didn't actually measure adherence to masks. It measured whether or not people had masks available or were given masks. Some of the studies they looked at were before the pandemic, not during the pandemic.

I still think that the upshot of a lot of the mask research is that masks are protective, particularly high-quality masks like KN95s and N95s. They are effective, particularly for the people that are wearing it and the people that if they are ill, it prevents you from spreading it to others. Mask mandates are a different question because it's very hard to enforce mask mandates. A lot of masks, the efficacy of masks is actually wearing it and wearing it appropriately. When you think about whether a mask is effective versus whether a mask mandate is effective, those are actually two very different questions.

Brian Lehrer: Let's take a phone call. Here's Maaza in Durham, North Carolina. You're on WNYC with Dr. Dhruv Khullar from Weill Cornell and the New Yorker. Hello, Maaza.

Maaza: Hi. Thank you so much for having me. I'm so excited. I'm a huge fan of the show. I was just listening with interest to your segment. I work for an alliance called the People's Vaccine Alliance, which is a coalition of over 100 organizations and networks around the world working on vaccine equity and also equity in terms of tests and treatments. I just noted that your guest at the beginning was talking about The Economist figures and the fact that we think there are actually many more deaths.

I wanted to highlight that part of the reason why deaths are being underestimated is really because of lack of access to diagnostics around the world. So many people have not seen a rapid test in many African countries and don't have access. The tests are quite expensive for the PCRs. I just wanted to highlight that and also recognize that March 11th is also the three-year, in quotes, I'll say, anniversary of the pandemic. That was the date that the World Health Organization announced that COVID-19 was actually a pandemic.

We have members of our alliance all around the world having actions and bringing light to the fact that part of the reason why we've had so many deaths is really because of pharma profiteering. There's been 1 preventable death every 24 seconds, we've estimated. I just wanted to make sure that your listeners, Brian, who I know are interested in global issues, are also aware of that.

Brian Lehrer: Thank you.

Maaza: Thank you.

Brian Lehrer: Thank you. I suspect there's nothing she said you would disagree with Dr. Khullar, correct?

Dr. Khullar: That's right. I think that's great and such an important point. I think in the US, we think there was a real shortage of testing and difficulty getting access early in the pandemic, and that really changed over time, but in much of the world, that did not change in the way that it has here. It's important to recognize that that's still an important part of responding to the virus in many parts of the world.

Brian Lehrer: Do we learn from these three years and looking around the world that it's really hard to find the sweet spot? Sweden and arguably the US were too loosey-goosey with their COVID rules and we had high death rates. China was at the other extreme with its zero-COVID policy and much longer and more severe lockdowns, as we all know, but ultimately that has now crumbled and they have this massively deadly epidemic right now.

What do we learn? Even with that much isolation of people, they did not eradicate the virus. Remember at the beginning, people were saying, "Well, if everybody would just stay in their shelves for two weeks, the incubation period, then the virus would go away." Well, China did it for three years and the virus didn't go away. What's the lesson there for future contagions as you see it?

Dr. Khullar: Another really good question. I think one thing to recognize is it actually may not be the case that there's one response that is the right response for all countries across the world. Different cultures, different societies have different values and they place different values on how restrictive or not restrictive to be. I do think that there are certain principles that many countries around the world can take. Those are technocratic solutions that we should be looking for to prepare.

Some of the things are obvious. You cannot manage a pandemic if you don't have testing, tracing, and surveillance. The ability to test people regularly should be a bedrock principle of responding to a pandemic, as well as gathering that data and providing it to public health agencies so that they can respond. People might not know that in the US actually, the CDC can't require states and localities to report certain forms of data, it has to basically rely on voluntary encouragement. Those are the types of things that can limit its response.

A second principle really is making sure that you have both vaccine development infrastructure in place and then vaccination deployment infrastructure in place. We know that there are certain groups of pathogens that are most likely to cause the next pandemic. Those are respiratory pathogens. They fall in a number of families of viruses. We can already have pipelines for therapeutics and for vaccinations for those types of pathogens going forward.

The third thing is having support for vulnerable populations, that's both populations that might need financial support to do things like socially isolate during a pandemic, that may need paid family leave or paid medical leave. Also, I think we have just looked away from the crisis in long-term care facilities like nursing homes. There are points during the pandemic where 30% to 40% of all COVID deaths were occurring in nursing homes. Nursing home population is only 1% of the US population. You can just imagine enormously disproportionate impact on that group of people.

I think those are the types of things that all countries in the world should be looking at. As to how restrictive, what type of enforcement the government has on some of these policies around social distancing, masking, and vaccine mandates, I think that really depends on the values of that particular country.

Brian Lehrer: Well, further to that point, are there different ways of measuring success from a public health perspective? We could stick narrowly to minimizing COVID deaths and maybe that should trump everything, or we could take into account other medical conditions that didn't get treated, or the toll and mental illness, huge one, or other secondary health effects of forcing the economy to shut down. I don't know how we make a formula that equates death to any other health effects, but have you or anyone you know of tried? I think that's been the conservatives' argument. Shutting down has caused all these other health problems that we don't take into account when measuring COVID success.

Dr. Khullar: That's right. It's going to be impossible, really, to equate something like death or severe disability from a virus like COVID to other factors. So many people have different perspectives on how to weigh those types of things. I do think we can look to a more global impact of some of these policies. There was, for instance, a report that came out a few months ago from a more right-leaning group of researchers, what they tried to do was, within the United States, they looked at death rates for different states, but they also tried to look at economic factors.

What did unemployment look like during the pandemic? How does your GDP change? Then they looked at educational things like how much time did children spend outside of the classroom. I think these are all the types of factors that we need to think about as we come to kind of societal decisions on what the right types of policies are. When you look at those broader factors, actually, the states that seem to rise to the top of the rankings, they're not the same as the ones that exist if you only look at COVID cases or COVID death rates.

Brian Lehrer: One more call. Matt in Brooklyn, you're on WNYC with Dr. Dhruv Khullar. Hi, Matt. We've got about 30 seconds for you, right to the point.

Matt: Hi. I just want to know, I never see any data presented very simply from the last year or so that specifically talks about secondary or two-way masking. It seems to always gloss over that. Even you, when you spoke earlier, you said masking-- Well, particularly for those who are wearing the mask, is there good, easy-to-read data on that?

Dr. Khullar: Yes. I think earlier in the pandemic, there has been data that certainly suggests in lab studies and other types of studies that if both parties are wearing a high-quality mask, that's much more protective than if just one person is wearing a mask, particularly if that's not a high-quality mask. Both the grade of the mask matters, a cloth mask versus a surgical mask versus a N95 mask, and also whether both parties are wearing that mask correctly, or if only one of those people are wearing a mask. That is an important point, and I'm glad you brought it up.

Brian Lehrer: Last thing and very important, I think, you did a fellowship at the New York City public hospital system known as Health and Hospitals. Of course, the virus had its worst effects on poor people of color statistically because of vulnerabilities like crowded housing, less access to vaccines and treatments, more so-called essential workers, who were forced to be exposed, more underlying conditions that COVID preyed on like heart disease and diabetes, which are themselves functions of poverty, those higher rates.

Assuming you agree with all that, what have we learned about protecting the socio-economically vulnerable as we go forward in this period where COVID is not gone, 400 Americans are still dying every day from it?

Dr. Khullar: I think at the beginning of the pandemic there was this idea that COVID or viral threats are somehow great equalizers because they affect everyone and no one's really safe. That is obviously only half the truth. The other part of it is that it lays bare all the inequities that exist in our society, particularly health inequity and social inequity. There are policies that we have taken and can extend and take further if we want to reduce those inequities. During much of the pandemic things like vaccinations were free, access to therapeutics and testing were free as well. There's a real effort to care for people who couldn't afford it.

As the pandemic emergency is coming to lapse, a lot of those protections are going to go by the wayside. We're going to be left with a situation, as you said, the virus is still killing 300, 400, 500 people a day, as these emergency precautions are being allowed to lapse, there may be a return of a even more disproportionate impact on certain groups of people when you think about that going forward.

Brian Lehrer: Dr. Dhruv Khullar is a physician and med school professor at the Weill Cornell Medical College and a contributor to the New Yorker. Thank you so much for joining us. We really appreciate it.

Dr. Khullar: Thanks so much for having me.

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