David Remnick: One weekday morning, just about three years ago, our team on the Radio Hour and all of the New Yorker staff got an email right as we were heading to work, and it said turn around and go home. The lockdown had begun. The pandemic reshaped all of our lives, and many did not survive it. Well over a million people in the United States have died, around 7 million globally according to the World Health Organization. The pandemic has eased considerably, but it is by no means over. We have yet to assess the consequences for long-term health, mental health, education, politics, so many things.

Dhruv Khullar began writing for The New Yorker during the pandemic's most terrifying days, describing his experience as a physician in a New York City Hospital. He spoke recently with senior public health officials, including the head of the CDC, about what we know now. Dhruv it's almost three years since the pandemic began, and it's time to assess what worked, what didn't, who got it right, who got it wrong. Can you tell from here, and now, what countries got the pandemic response right?

Dhruv Khullar: Yes, it's a great question and an incredibly important question. There's a number of caveats I think we should have front. One is we don't have reliable data from every country. If you think about China, even today estimates say that in the last few months they've probably lost one to one and a half million lives, and the official count is somewhere in the tens of thousands. The other thing to notice that their response and who got it right changes over time. If you look at a snapshot from a year ago, it might look different from today.

I think three years into the pandemic we can draw some conclusions. The countries that got things right, the ones that spring to mind are many of the East Asian countries. Japan, South Korea, Singapore, Taiwan, there's also countries like New Zealand, Australia, that did very well. Then you have maybe Denmark and Norway. It really comes down to a few principal factors. The first thing is, you have to know where the virus is. The countries that were able to test early, have a test and trace program in place and have reliable reporting of that data, they were able to mitigate the initial surges.

Along the way, make sure that when a surge did come about, they were able to respond quickly. The first thing is, you got to know where the virus is and how to track it. The second one, I think, is something that's really been overlooked, but incredibly important, and this is idea of trust, both interpersonal trust, but also trust in institutions. That is something no one will be surprised to hear that the US is tremendously lacking right now. If you look at some countries like Japan, or South Korea.

Japan's constitution actually makes it very difficult for it to implement the types of mandates that we've been seeing in the United States, lock downs are out of the question, because of Japan's constitution. They rely really on peer pressure. Another way to think about that is social cohesion, social trust, mass became known as face underpants. You wouldn't want to be in public without your underpants on, you wouldn't want me in public without your mask on.

David Remnick: You're saying that social cohesion may be a lot more important than mandates and even work better than mandates? That doesn't really bode well for us, does it? Did other places try to forego mandates? Did they turn out to be effective?

Dhruv Khullar: There are other countries early on the United Kingdom, Sweden, that took a much more or less fair approach to the pandemic and they did not fare well during the early phase of the pandemic and actually pivoted to do more mainline response in which they did rely on some of these things. The question of mandates is a really complicated one. On the one hand, vaccine mandates, for instance, seem to work. More people do get vaccinated when you mandate.

It also has a lot of downstream social and economic consequences. Some people lose their jobs because of it. Trust in public health institutions may go down and may be more difficult to address the next pandemic. With masks, the issue is even more challenging, whether you wear a mask and how well you wear a mask and what type of mask you wear actually makes a huge difference if the willingness to properly adhere to a mask mandate or mask encouragement is actually more important than the mandate itself.

David Remnick: Mandates seem to have encouraged political division here in the US, blue states typically favored mandates along with more stringent lockdown measures. Conservative leaders tend to focus more on the health of businesses and keeping kids in school. What can we say now about the success of those various approaches?

Dhruv Khullar: What states were most successful depends on the metric that you're going to use to define success and park. It might be helpful or might be instructive to look at two different reports that they came out in recent months. One is from the Commonwealth Fund. It's a prestigious well respected health care philanthropy. It ranks Hawaii as number one, it ranks Massachusetts as number two places that few people would dispute that they have low death rates, and they have an excellent public health system.

David Remnick: Those are the bluest of the blue states, Hawaii has a certain geographical advantage.

Dhruv Khullar: I think there's a couple of interesting wrinkles here. One is that Utah also ranked very highly--

David Remnick: Not a blue state.

Dhruv Khullar: Not a blue state at all. Then if you look at other studies, and there's a big study from a more conservative-leaning group of researchers from places like the Heritage Foundation and the University of Chicago, what they try to do is put COVID death rates in a broader context. They've said, "Look, we're going to take COVID death rates, we're going to adjust them for things like obesity and diabetes, we're going to introduce economic factors.

How much did your GDP shrink or grow during the pandemic? What was your unemployment over that time." Then importantly, we're also going to look at education, in their analysis, Hawaii drops down to something like 40. The reason for that is, as you said, Hawaii is an island, it has certain geographic advantages, but its economy also took a hit, because it's so reliant on tourism. A lot of students spend a lot of time out of the classroom in Hawaii. When they come up with their calculation, they again, they find Utah is the place that is the number one state, at least according to their analysis.

David Remnick: Why Utah? What did you do that made it successful?

Dhruv Khullar: Well, I think one of the most interesting things about Utah is, we think of it as a red state, but it's actually a unique, red state. If you look at the current governor, for instance, Spencer Cox, he has described himself as a liberal Republican, I think a lot of their policies during the pandemic actually reflected that type of more moderate atmosphere. I came across a survey a couple of years ago that I thought encapsulates some of this.

The survey basically found that Utah was probably the best state in the country to lose your wallet in. The idea there is that there's a very high level of social trust in Utah, and other work from Oxford, for instance, has found that the countries that have the highest levels of social trust, actually had some of the best pandemic responses. We see that in a microcosm here.

David Remnick: What did we learn about schools, opening them, closing them, what should we do next time?

Dhruv Khullar: The main takeaway is schools should be the last thing that close during any emergency, including a pandemic. Overall, there was some risk of transmission in schools, but it was relatively low. There were states that had relatively short school closures, and they did quite well when it came to pandemic related outcomes. I think the school conversation is one that's so important because it affects so many lives, and has a huge bearing on how students do in the short and the long term.

David Remnick: You got a lot of resistance from teachers and teachers unions.

Dhruv Khullar: Yes. Part of that is, we didn't know as much as we do now, it's totally reasonable to in the moment, Omicron is the most infectious thing that's come around in decades, if not more than a century, and to be alarmed and be concerned that a lot of that transmission may occur in school. That impulse is by no means something that I would dismiss. Now we have the benefit of hindsight and we should think about it differently.

David Remnick: Ron DeSantis is going to run for president almost surely, and beyond the issues that he hammers away in terms of cultural issues. He also hammers away at COVID and claims that he had a fantastically great record on COVID in the state of Florida, is he right or is he wrong?

Dhruv Khullar: The unsatisfying answer is that he's partially right and partially wrong. Florida is by no means an outlier in terms of a brilliant pandemic response. Neither is an outlier in terms of horrific pandemic response. They took a different tack from states like New York and California, but ended up in a similar state. If you look at things like deaths from COVID per capita or infection rates, I think some of that is actually driven by the vaccination rates. Florida, as a state in the southeast actually has relatively high vaccination rates, and it's particularly true around older people.

David Remnick: The US, globally speaking fared pretty badly in its response to the pandemic. We all remember the lack of preparedness, the lack of PPE and ventilators, and more, and the really, I'm sorry, but the unhinged rhetoric of Donald Trump, we remember that all too well. The Centers for Disease Control came in for a lot of criticism too. You spoke recently with Rochelle Walensky, who took over the CDC about a year into the pandemic.

Dhruv Khullar: What are the kind of concrete steps that you feel CDC needs to take and is taking to transform its culture to be more effective in the next pandemic?

Rochelle Walensky: I came as a consumer to CDC, a consumer of CDC guidance. That was how I spent the first year of the pandemic. Really have now taken this opportunity to do a full review. Among the things that we learned is we need to move our science faster. Not only are we clearing our papers faster, we've decreased our average clearance time by about 50% since I got here, but we've also been releasing our data really in real-time so that people can really understand upon what data our guidelines are based.

We need to have guidance that is implementable on the ground sometimes with options for how to implement because in fact, it may work differently in Manhattan than it needs to work in Indian country. That our communication has to be more targeted in plain language to the American people because all of a sudden people were coming to us. Where CDC prior to the pandemic was communicating largely with academic partners and with state health officer partners, and public health partners. We at CDC have to be sure that we are delivering our information in digestible plain language because our audience has changed broadly.

Dhruv Khullar: I want to get the tension there. Trust in public health is so incredibly important and getting out ahead of your skis, so to speak does that undermine trust in some ways, if you get it wrong on the first pass?

Rochelle Walensky: I've published enough of my share of papers to know that you generally know the answer before the ink is dry on the publication. We need to find that sweet spot where we believe this is as good data as we're going to have for some period of time, that it is as close to the right data as we are going to get in this moment. I can tell you from my vantage point there's nothing more frustrating than needing to make an important decision knowing that the data exists, but I can't see it. That I would make a better decision if I had more data at my fingertips upon which to make that decision. Right now it's not well known, but CDC relies on voluntary reporting from these jurisdictions.

Dhruv Khullar: I do want to ask you about trust and about polarization as well. How do you contend with the fact that we are a deeply polarized society when you're also trying to be nonpartisan?

Rochelle Walensky: I have never walked at a patient's bedside and asked them how they voted before I delivered care. [chuckles] It is the case that this country right now is my patient. Noble scientific discussion that is generally reserved for scientific meetings plays out on the evening news and is consumed by audiences that don't necessarily understand the intricacies. What they want is a unified voice and a unified message. That has been one of the challenges of this time.

Dhruv Khullar: You have people with real power. Marjorie Taylor Greene now sits on the house committee that's in investigating the COVID response and she has spread vaccine misinformation. How are you thinking about contending with that type of thing?

Rochelle Walensky: I think miss and disinformation is something that we're addressing here at CDC. I think it's larger than CDC. I think it's larger than the US government. One of the things I will tell folks is these are the data that are out there, these are data that CDC has published, but importantly, these are data that have been peer-reviewed in the New England Journal of Medicine independent scientific review processes. Oftentimes when people don't necessarily want to trust or don't feel as if they can trust a government source, I will send them to another independent source, a medical society, or someplace else that is sometimes largely consistent, but not always 100% consistent with where our guidance is.

Dhruv Khullar: I want to ask a couple of questions about vaccines. Given some of the backlash to vaccine mandates and mass mandates, were in your mind mandates the right way to go? Is that something that you would've implemented again, in hindsight?

Rochelle Walensky: Hindsight's hard because you're operating with the data that you had at the time. If we rewind where we were at that period of time, I was working in a hospital that had an extra morgue sitting outside the hospital that I walked by. I know many New York healthcare workers were doing the same. When you think about where you were at the time and what we were working to do incrementally to get more and more of society able to be opened, those were extraordinary times and they merited extraordinary measures for those times. We are in a different place right now, and so I think having conversations about mandates is a different kind of conversation.

David Remnick: Dhruv, I don't think we heard a very clear answer from Rochelle Walensky of the CDC about the political consequences of mandates or how to tackle vaccine misinformation. Can we defeat a pandemic if people innately don't really trust the public health system and refuse vaccination?

Dhruv Khullar: I don't think the CDC or really anyone has a clear sense of how to address those factors, which played a huge role in our ability to respond to a crisis like COVID-19. One of the people that I spoke to during this reporting was Zika Emanuel. He's a really well-known policy walk. He's on the COVID-19 advisory board for Biden's transition team. He really emphasized to me that this mistrust has a lot of serious downstream consequences, and they go much beyond just how high your vaccination rate is.

Zika Emanuel: We are in a phase in American life. We attack experts and we pretend like we don't need them. Unfortunately, it's a dangerous idea, especially in a more technical, technological complex world. You need expertise. It's also dangerous at the bureaucracy level because people who are technically experts get attacked. This is extremely extremely dangerous for the country's ability to respond to future emergencies.

Also just future normal operations you need a lot of experts and a lot of expertise whether it's demographics, it's modeling, it's vaccine evaluation and development. You just need lots of different people with different skills. You see it in the attacks on Tony Fauci. Here's a guy who's given 50-plus years of his life to the federal government. He could have easily left at any time for prestige positions, whether in academia or in industry, and he didn't. He kept working. [chuckles] I think if we keep attacking people like that it's going to be hard to have civil servants who are going to want to work hard and be dedicated.

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David Remnick: That's Zika Emanuel, an expert in public health policy talking with the New Yorkers, Dhruv Khullar. Dhruv is a physician at Weill Cornell Medical College here in New York City. You can read him on the Pandemic and much more at newyorker.com.

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