Pandemics and Democracy

I want to start by asking you, George, to help us establish some context about where we are with COVID-19. We know that about 350 people continue to die each day in the U.S. from COVID or complications related to COVID. How do COVID mortality and morbidity compare to the flu or other diseases?

George Rutherford: It’s incomparable to anything since 1918. It’s huge. COVID is the third leading cause of death in the United States overall. It’s the seventh leading cause of death in children and it’s the only one of these major causes of death that’s vaccine preventable.

From a mortality standpoint, we haven’t seen anything like this in the last 110, 115 years. We’ve lost two years of life expectancy at birth in the United States, which didn’t happen during any of the wars. It’s a big, big, big, big, big, big deal.

It’s amazing how normalized it has gotten, how used to death society can get.

George Rutherford: As long as it’s not your death. I think we’ve forgotten how devastating this was off the bat.

Kim Yi Dionne: There hasn’t been a lot of leadership on how to navigate the pandemic. The response has been really decentralized and a lot of people as individuals are carrying the burden. That’s part of the reason why people are so fatigued because, as individuals, they have to take on so many protective behaviors because the state hasn’t been doing that for us. For example, one of the greatest ways to stop [an airborne disease] is to make sure we have better and stronger air filtration in buildings where people congregate. That’s an expensive ask. And rather than do that, people are like: “oh, well, if everyone just wore masks.” [But] the U.S. Centers for Disease Control and Prevention are not encouraging us to wear masks anymore. Anyone who does is carrying an individual burden because there isn’t a collective response. George is right that, if you’re not the one dying, if you’re not the one with an immunocompromised health condition, then you just want to move on.

The U.S. midterm elections are next week, and COVID seems to barely register as an issue, which is in one sense really astonishing, given what an emergency this continues to be. Benjamin Wallace-Wells wrote in The New Yorker this week, “Nearly two years later, pollsters rarely ask about ask voters about COVID policy, it’s no longer front of mind, but the coronavirus and the methods and emotion of its management have supplied the fuel for just about every turn in politics since Biden’s inauguration. This is the pandemic backlash election.”

What role do you think COVID is playing in this election cycle, if any?

Kim Yi Dionne: The claim made in The New Yorker is a bit overblown. The most recent said that health care was mentioned by 10 percent of a national sample of U.S. adults as being the most top-of-mind issue in this year’s elections.

But the economy, the state of democracy, abortion rights—these are the top three issues that voters are thinking about. I think those [issues] are crowding out COVID.

George Rutherford: It’s definitely not there as an election issue. In Europe, where I’m living now, the war in Ukraine is far and away, [the] number one [issue], because of the threat of nuclear war that hangs over it. They’re feeling the war in Ukraine and they’re feeling the pinch of inflation and the economy.

I totally agree with you guys that there are so many other issues that swamp COVID these days. But in a sense, the pandemic has created some of the circumstances that we’re seeing in this election. So, for example, it’s interesting that some of the candidates who have been the most permissive and who’ve made it a rallying cry to be permissive about COVID restrictions—Governor DeSantis in Florida, Governor Abbott in Texas, Governor Kemp in Georgia—all seem to be doing quite well. We’re also seeing candidates who have risen politically as anti-vaccine, anti-restriction, anti-mask voices. Even though COVID may not be the thing they’re talking about right now, it has been very effective for them politically.

How do voters evaluate the effectiveness of their governments in a pandemic? You would think that the most compelling thing that any government can do is to preserve and assure the safety and health of its citizens. But what we’re seeing seems to suggest that something else is going on, that citizens are more concerned about their economic security.

George Rutherford: Public health in the United States is very complicated because it’s not mentioned in the first nine amendments to the Constitution or in the Bill of Rights. Therefore, under the 10th Amendment it devolves to the states. So, we have 50 states plus Puerto Rico, D.C., and the Virgin Islands, all making their own policies. That doesn’t really happen in other countries.

It’s a checkerboard and it means that different politicians run things in different ways. California devolves it even further to the county level. So, you have 58 counties plus three city health departments (Berkeley, Pasadena, and Long Beach). In Northern California, the Bay Area Health Departments, meaning everything that touches the San Francisco Bay, have tried to do things together. When the stay-at-home orders were issued, they all issued them at the same time, using the same language.

In places where the government acted early and acted as cohesively as possible, the mortality is a fraction of what it was [elsewhere]. In San Francisco in 1918-1919, when the city was 350,000 people, there were 3,000 deaths from influenza. It gives you an idea of what careful management can do. Now, there’s also a lot of luck involved in that. A lot of people can stay home and commute in San Francisco and stuff like that. But still, those are very telling numbers.

The U.S. healthcare system is very fragmented, as you said. Why leave choices about pandemic management to each fragmented geographical location?

Kim Yi Dionne: You do that on purpose, right? It’s by design. Politicians know from past experience that they’re not going to be able to claim any credit for saving lives. So they want to avoid any blame. Gavin Newsom, the governor of California, locked down the whole state in March 2020 and he’s suffered a lot of backlash. No one wants to suffer backlash. The only people who can afford to make unpopular policies are people who don’t have to face re-election. This is one of the challenges of democracy.

In the research I’ve done in southern Africa, the politicians who responded the strongest to HIV in the early years were dictators. HIV is one of these interesting infectious diseases where, without treatment, you can be HIV positive but not ill for 8 to 12 years. Only dictators would presume that they would continue to be in power for that long. I’m not saying I want to live in a dictatorship. I’m saying that there are some interesting challenges in democracies for dealing with issues like health, where no one wants to give credit, but people love to assign blame.

Some of the governors that you brought up, Greg Abbott in Texas, DeSantis in Florida, are Republican governors in states that are largely Republican. I’m not surprised that they’re likely to win reelection and the reasons why have less to do with COVID or even their COVID response and more to do with the fact that they’re in majority Republican states where there are rules that suppress Democrat voters. And it’s in an election year where economic indicators would predict more Republican than Democratic success up and down the ballot.

But there’s something interesting about party politics in America today, as it relates to the COVID-19 response. Since early in the pandemic, before there were vaccines, That’s why we see a divergence in the population, largely according to partisan identification. We see a divergence in how willing people are to engage in health-promoting behaviors. There’s a new book out on this written by Shana Kushner Gadarian, Sara Wallace Goodman, and Tom Pepinsky, called Pandemic Politics: The Deadly Toll of Partisanship in the Age of COVID, that explores this partisanship in depth.

I want to pull on a thread there about how Republicans framed the COVID-19 pandemic from the very beginning. One of the ways it was cast and continues to be cast is as a government encroachment on individual liberty. I mean, there have been comparisons to Nazi Germany.

And although a number of people might call claims like that ridiculous, and might point out that we as a society have placed restrictions for the public good on lots of things—like we have to wear seatbelts, we can’t smoke anywhere we want—I suspect that even among people who did get vaccinated, who did wear masks where they were supposed to, there is probably a lot of sympathy for resistance to government mandates.

Public health, by its very nature, is very command and control. But in order for public health directives to be effective, they have to be adopted widely by ordinary people. What have you learned about these tensions between the command-and-control nature of public health and the growing resistance to being told by experts and institutions what we’re supposed to do?

George Rutherford: It’s about enlightened self-interest. And, if you take the example of [which had one of the lowest vaccination rates in California and now has one of the highest] going from worst to first—when people really are worried about things, they want to be directed. People seize on things they think are solutions.

And Kim Yi I hate to pick on you, but I’ll use you as an example. You’re an incredibly smart person who’s fixed on the idea of indoor air circulation. That’s a very minor thing. Yeah, you can fix it, but you’re only going to take about 5 percent of all the transmission out of play by fixing that. It’s really about people being right up in each other’s faces and coughing and sneezing. Yeah, we should do it—we should fix it. It’s probably the most important for hospitals. But it’s not going to make a big difference [outside of the hospital or long-term care facility setting].

The point is, people will grab onto things that seem to be reasonable solutions and that fit within the stuff they think they can control. So this is something that a local government could take on to change the air filtration systems in schools. But the bottom line is that you can get 95 percent of the way there if everybody wore masks.

I also think that we need to give the Republicans some credit here. The vaccine, Operation Warp Speed, was a complete administrative initiative of the [Trump] administration. We paint this as Republican versus Democrat because of vaccine uptake but we would not have had the vaccines without a huge investment by a Republican-controlled federal government. That’s what’s broken the back of transmission.

Vaccination, having people wear masks, those are important. But at the end of the day, people have to go do it. The way we’ve gotten around childhood vaccinations in California is that there’s a law—not a regulation—a law that says that if you don’t have your kids fully vaccinated for X number of diseases, they can’t come to school and you have to home-school them. And that extends across public and private schools. That’s pretty coercive. But it was deemed at the time, given how high rates of immunity you need to get herd immunity for very devastating diseases like measles, worth the effort to push that through.

We’re not seeing that with COVID.

Basically, the dictum of public health is that you need to achieve your aims through the least restrictive way possible. And that’s what the county councils and state attorneys general will insist on. Which is why a lot of [public health] remains in the land of advice. The other lever we have is through the big state insurance programs like Medi-Cal, where we can say: if you want to get paid, you have to do this, and this, and this. Like, all women need to be screened for cervical cancer over a certain age, for example. But by and large, public health is at the level of the individual or the family. People need to want it.

Kim Yi Dionne: When I think of public health, it’s public health, right? My first book, Doomed Interventions: The Failure of Global Responses to AIDS in Africa, made this argument about how interventions to improve the human condition, including health interventions, ultimately rely on individual choices about whether or not to uptake certain policies. I was thinking in particular, for example, of male circumcision to prevent HIV infection. It ultimately depends on a man deciding he’s going to part with his foreskin to protect himself from getting HIV. And that’s a really big decision. But the individual is not the only person. There’s a whole chain of actors before we get to the level of citizen.

George Rutherford: Yeah, and somebody has to pay for it.

Kim Yi Dionne: I’m not fixated on indoor air quality because I think it’s the best solution or it will reduce the most transmission. It’s a public thing. And as someone who knows that things fail at the individual level, if I know that people as individuals are not going to take up these tasks, like masking, then we have to come up with broader solutions that don’t require individuals to take that step.

And I agree with you, it was the Trump administration that invested in this, but that doesn’t mean Republicans are taking up the battle.

George Rutherford: No, I know. I’m just saying to give a tiny bit of credit.

Kim Yi Dionne: Here’s the other thing. Part of the reason we’re facing this problem is that nerds like me who work at universities aren’t sharing expertise in a way that’s accessible to regular, everyday folks. And so there’s suspicion about people like me—that we’re liberals who have an agenda and not that we’re actually people interested in understanding what’s at the root of problems. And we’re trying to use systematic methods to uncover that and share that with others. That’s what science is. But we’re not communicating that, and that’s why I love that IGCC has this podcast because I really think it’s important that more and more scientists are thinking about how the work we’re doing matters for people’s everyday lives and sharing that with people.

Trust really matters. And we as a scientific community need to build more trust with the general population and we do that by being transparent about what it is we’re doing and what we’re interested in.

George Rutherford: I think you’re completely right. We want people to live longer and happier lives. And I think that’s what they want too—they want their families to grow up and everybody not to die prematurely. That’s what people want. And you’re right that communication is huge. I spent a huge amount of the last two and a half years talking to the media, talking to citizens groups, talking to the League of Women Voters.

Yeah. You were in the trenches, George.

George Rutherford: Trying to give some consistent advice. And it’s a question of consistency and clarity and actionability.

Kim Yi Dionne: Lindsay, there was one more thing I wanted to say in relation to the initial question about control versus liberty. There’s a great book that came out a couple of years ago by the late anthropologist and medical doctor Paul Farmer, Fevers, Feuds, and Diamonds: Ebola and the Ravages of History. He looks in depth at the Ebola pandemic in West Africa between 2013 and 2016 and he talks about how so much of the way we respond to pandemics is control. And what he argues for is to focus instead on care. Because if we care for people when they’re sick, if we really, truly care, and give them all that they need to get back to health, that’s going to encourage people to seek out the care they need so that they don’t get other people sick.

If we were to extrapolate the findings from that book to what we’re seeing here in the U.S., if we did a lot more caring for people when they got sick, I think there might be better trust in those who are providing that care.

George, it’s interesting what you said about Marin County, and the fact that people will be directed, but we have to want it deeply. In the U.S., it hasn’t felt like there’s a strong sense of public responsibility, like that we have responsibility for each other. Instead, it’s more that we are on our own and responsible for ourselves. This feels like a very American problem. Do you guys agree with that?

George Rutherford: Totally. It’s very different in Europe. I testified last week in the European Parliament. Don’t get me started on layers of government, but it was an interesting experience. And they’re talking about having a European Health Union with a treaty that would tie all [27 EU countries together]. That’s how they’re responding to this. The U.S. just isn’t going to go there. We’re too individual.

Kim Yi Dionne: The cross-national data analysis supports this claim. Societies where citizens promote a collective ethos have had lower COVID mortality than societies that prioritize individual liberties. In a society like the U.S. where we’re really into our individual liberties, we’re one of the places pulling that regression line [up], with our massive mortality, not just in pure numbers, but per capita.

Individualistic societies are not doing well in this pandemic.

The hard part about that finding is: I’m not sure what we do about it. I do have some faith in younger people, and the way they’re facing these kinds of really big collective events like climate change. There’s much more of a collective ethos among the younger generation in the United States, and that gives me hope. But, yeah, it’s a pretty big hurdle.

George Rutherford: Climate change is a good example of everybody trying to get together and row in the same direction.

You wrote a Kim about the ways in which pandemics are used to marginalize already marginalized groups. You looked at everything from smallpox in the late 19th century to the 1918 flu to plague to HIV to SARS to COVID. And it’s very consistent: throughout all these pandemics across time, people do the same thing. They point the finger at the Chinese. They point the finger at whoever it is. It happens everywhere. But what’s different about the time we’re in now is that we have an ability to spread that kind of misinformation and harm so much faster and at such a wider scale than we’ve ever had before through social media.

What do we know about why political candidates peddle dis/misinformation during public health emergencies and pandemics? What is the benefit to them? And do they ever get punished for it?

Kim Yi Dionne: I don’t think there’s a lot of punishment for anyone who peddles in falsehoods. I’m not even talking just about politicians. There are actual news media organizations that will peddle in falsehoods. Politicians are incentivized to engage in misinformation or in the marginalization of already marginalized groups during pandemics because it works to galvanize their base. It works if your voters are not marginalized groups. In a time when racial resentment is high in America, that can motivate your voters to go to the polls or may discourage people of color or marginalized groups from voting at all.

Something being truthful is not a necessary requirement for an elite to say it out loud. And [that’s true] whether we’re talking about political elites or celebrities. They actually have significant power to shape people’s perceptions. And those perceptions matter a lot more for how people make decisions in a polling booth than the realities that exist.

George Rutherford: We live in this age where there’s instant replication of all sorts of stuff that may be wonderful or may be horrible. I’m reminded of the doctor, Andrew Wakefield, who was a big advocate of childhood vaccination being associated with autism and was eventually sanctioned by the British Medical Association and had his license taken away. The other thing is when state actors deliberately inject disinformation. We know that the Chinese intelligence agencies have done this. We certainly know that the Russians have done this. You have to be cognizant of that when you have unfettered access to whatever you want to say to whomever you want to say it, others will take advantage of it. Outsiders will take advantage of it.

What would you like to see in the U.S. in terms of the politics of the COVID-19 pandemic? After the midterms, attention will turn inevitably into an early presidential election cycle. It remains unclear whether Trump will run again, but I don’t think politics in this country are going to get less contentious any time soon. Putting aside politicians who will always exploit things for their own interest, let’s talk about the public servants who are interested in the well-being, prosperity, and equity of Americans. Talk about them. If you were God of the universe, what do you want them to know?

George Rutherford: I think people need to have a moral compass and they need to be saying that they’re working for the betterment of society. Different people have different triggers to get there. Some will see it as economic growth. Clearly, the richer countries have better health in the indices and the poorer countries don’t. With the exception of Cuba, which has prioritized health care over everything else. And so you have to let the electorate decide whether they want a complete reliance on economics. And you saw what happened to Ms. Truss in the UK the week before last.

People need to know that you have a moral compass and need to hear that what we’re trying to do is to improve the health and well-being of society rather than to get reelected.

Everett Koop, who was the surgeon general under Reagan, was very conservative. I mean, very conservative. He was a chief of pediatric surgery at Children’s Hospital of Philadelphia, and he was asked a question about gay men and HIV. And he said, “I didn’t notice that anybody appointed me to be surgeon general for everyone who was not a gay man. I am the surgeon general for everyone. And my bailiwick, my remit is everyone.” I thought that was the right response. And that’s something that everybody needs to keep in mind as they try and balkanize and marginalize certain groups.

Kim Yi Dionne: I’d want public servants to know that I really appreciate the service that they’re doing for the sake of others. And they should know that there are a lot of people out there who really do appreciate their work. I think it’s important for them to think about why they originally got into their line of work. You know, I’m sure that it was motivated by an interest in helping others or making a contribution. It’s important to remember that because, in a difficult and dark time, you need that as your light to guide you through it.

I also hope that they might share with friends and family and others around who are willing to listen to the actual work they do. One thing that I struggle with is when people say: government is too big.

Well, who do you want to fire? Do you want to fire the public school teacher who makes like $36,000 a year? Do you want to fire the person who sends you your water bill every month? Public servants exist to serve the public. They actually have work to do every day. They help us access public roads; they make sure that the food we’re eating is not contaminated or spoiled. These are not people freeloading for a pension.

More broadly, we have to think about how we’re connected to other people and how what we do is important for other people. And if we can start thinking about those connections, then we might get to that point in the future where we really are worried about not just the people who live in our house, but the woman at the grocery store who we can’t tell is immunocompromised and really needs us to wear a mask because we might be asymptomatic carriers of some infectious disease. We need a different ethos about how we interact with other people, that we actually care about them, even if we don’t personally know them.