1. Fortress and Frontier: Different but Not Less
  2. Fortress and Frontier: A Second Conversation with Temple Grandin
  3. Fortress and Frontier: What the Data Say About COVID-19
  4. Fortress and Frontier: The Narayana System and Innovations in Healthcare
  5. Fortress and Frontier: Healthcare’s Reluctant Revolution
  6. Fortress and Frontier: Price Transparency in Healthcare
  7. Fortress and Frontier: The Disruptive Innovator
  8. Fortress and Frontier: Healthcare Policymakers Should Worship Change, Not Stasis


In this third installment of the Fortress and Frontier series on Discourse Magazine Podcast, Robert Graboyes, a senior research fellow at the Mercatus Center, speaks with Dr. Pradheep Shanker, a radiologist who focuses on health policy. They discuss the course of the COVID-19 pandemic, the different policies implemented by various national and state governments, and the outcomes of those policies. They also talk about pandemic politics and speculate on COVID-19’s long-term effects.

Previous installments of the Fortress and Frontier series are two conversations between Robert Graboyes and Temple Grandin. The first can be found here, and the second can be found here. The fourth podcast with Devi Shetty is about innovations in healthcare. The fifth talk with Eric Topol is about medicine’s slow progress and machine learning in healthcare. The sixth with Keith Smith focuses on price transparency.

Editors’ note: This podcast was recorded on March 11, 2021, and the situation in India has changed significantly since then. On April 29, we asked Dr. Shanker if he wanted to omit his comments about India and COVID, and he said unabashedly, “It was my opinion at the time!” Dr. Graboyes commented, “One of the things I’ve enjoyed most about Pradheep’s pandemic posts has been his intellectual honesty and willingness to highlight where his predictions have not been borne out.”

ROBERT GRABOYES: Glad to have you with us today, Pradheep. I’ve been wanting to do this for quite a while.

PRADHEEP SHANKER: Oh, thanks for having me. I’m excited about it.

GRABOYES: I am, too. As Twitter has descended into an insane asylum of angry political people, I have often been tempted to delete my account. There are a few reasons I don’t, and one of them really is your stream. You have been, I have found, one of the most informative people out there on the COVID crisis, both on the end of observations on policy and the way things are going, but especially your massive amount of statistics that you’ve posted. I think you’ve done a real service to humanity in posting those, and my thanks, and I know a lot of other people out there who’d make the same quote.

I will say that though you are a self-described conservative/libertarian, I’m always impressed you’ve aimed your rhetoric and your facts at both sides of the aisle, and one of the things I like best about reading your writing is its unpredictability. When I set out to read one of your pieces, I don’t know in advance what you’re going to say, and that’s what I value most in a commentator. That’s what I aspire to do in my own writing. With that, let’s get started on the conversation.

Throughout this pandemic, as I said, you’ve posted vast amounts of international, national and state-by-state data, and you’ve provided running commentary. What are a couple of the most interesting or surprising findings to emerge from the data over the past year?

Looking Back at the COVID Data

SHANKER: First, I want to thank you for your compliments. That was really kind of you. Twitter to me has been a lot of fun all along, as long as you can ignore the hate. I think the COVID crisis, because we were all locked down for so long, it was a very useful method for us to interact with other medical professionals on a day-by-day basis trading information. A lot of these things couldn’t be published immediately, so a lot of them were just anecdotal, but we were able to spread information and data around very quickly. For that, Twitter was great.

GRABOYES: Yeah, it is.

SHANKER: Yeah, absolutely. That’s a Twitter strength, obviously. I think the other nice thing is, for me personally, I don’t delete almost any tweets, so I can now go back a year ago and see the things I got right and wrong. I think most of the more respectable researchers and stuff will do this. They’re pretty honest about, “Yeah, I screwed up here. I screwed up there.” A few weeks ago I went back and went and looked at some of my old tweets, and I tweeted out, “Look at how much I screwed up here and how much I screwed up there.”

That’s the only way I think we can really improve on our response for the next time. The next time is going to come eventually, and it gives me a good ability to look back and say what things I did right, what things I did wrong. I think for a lot of people on Twitter, that’s one of the benefits.

GRABOYES: I agree. That’s another reason I stay on it, too.

SHANKER: Yeah. It’s just really helpful, as long as you’re not, “Oh, I’m embarrassed that I said this.” I’ve said a lot of dumb things, just like everybody else said, and then come back and said, “That’s not right.”

I do think as for the data, to me the most surprising thing was, when we go back and look a year ago, how many assumptions we made that were just completely wrong. I’m talking about the smartest of smart people, from Anthony Fauci, who I’ve met and I respect, all the way on down to everybody else. We all made huge mistakes. We knew that early on the elderly were susceptible because of what was happening in places like Italy. Unfortunately, we didn’t have data about China, but once Italy and the U.K. started getting hit, we knew that the elderly were especially susceptible.

That one fact was consistent all the way through. But everything else that we looked at and ways we approached things during the pandemic, really, so many of them fell by the wayside as we learned more and more about the pandemic. I think it goes to the point that we have to be a little more careful about making assertions on something that’s completely new that we don’t really have a good grasp of.

The one other thing, I think, that going back and the data really surprised me is I think most of us expected a lot of these poor countries to have mass devastation. Some of the Indian experts out there were talking about millions of dead people on the street. Countries like India actually haven’t done too bad. We can question their data to some extent, but their excess deaths haven’t increased as much as any of us expected.

We expected them to get hit, while we expected the West to do better because we have better healthcare systems, but exactly the opposite happened. The West got pummeled, even though our healthcare systems were dramatically better and we had the money and ability to do all kinds of things. Again, a lot of our assumptions fell by the wayside as time went on.

GRABOYES: Just as an aside, let me just ask, I’ve never done this: You’re a radiologist. How did you end up doing all this writing for public policy journals and becoming a world-class data expert on public health data?

SHANKER: I was always involved peripherally with political issues. I was involved with some public health stuff, but my first love before I even went to college was education policy. I really loved education policy. My sister and I were very involved in setting up mentoring programs for inner-city kids and those kind of things. Eventually, I had a charity that was running for a while, giving scholarships and stuff. That was my first love in public policy.

I was peripherally involved with some of the researchers that talked about the Clinton healthcare plan in ’93 and ’94. So, I was a little bit educated on that, but that wasn’t really my love. Then, in 2008 then-Sen. Barack Obama, then-Sen. Hillary Clinton both come out with healthcare plans—massive overhauls of the healthcare system. I had a couple of friends that were working for politicians that were asking, “Well, what do you think?” I had a lot to say like I always have. I have a lot to say about everything.

I ended up starting writing. Then they asked me to write a white paper for them. I ended up writing something like an 80- or 100-page thing about, well, here’s all the data I could find on the things they’re doing. That got sent around a little bit. Then I got asked to give updates and things to different people. Really, the ACA Obamacare event was the one that really propelled me more into public health than the other fields I was more interested in before that.

GRABOYES: Interesting. Actually, we share some of that. From the early ’80s until the early ’90s, I did international economics or macroeconomics. At some point, my wife noted that I didn’t seem very interested in it at that point—I had liked the international, but I wasn’t doing that anymore—but that I seemed to be always absorbed in healthcare issues. This was during the Clinton debate, and she said, “Well, why don’t you do that for a living?” That actually is what got me to switch over into healthcare. It was a fascinating time.

SHANKER: Yeah, it really was. It’s funny how these external events change our path because we just don’t expect it.

GRABOYES: Then the lead-up to the ACA is what got me to move to Washington and get into the policy world. So that was the other event.

SHANKER: Yeah. That’s right.

Masks, Lockdowns, School Closures, Vaccines

GRABOYES: Diving into all the data you’ve been looking at over the last year, what would you say the data looking back tell us about, I don’t know, wearing masks, locking down businesses, closing schools and getting vaccinated?

SHANKER: Let’s take it one by one. Wearing masks is one thing that’s become very political for silly reasons. I think the evidence is quite clear that universal usage of masks is going to reduce transmission. Now, how much it reduces transmission for COVID, I think that’s still debatable. To me, when I look at the data, I think it’s a significant but marginal benefit to wear masks, and considering the cost is almost zero, wearing masks seems like an easy, simple thing that we should all be doing.

We’ll talk about the vaccinations, but even once vaccinated, I plan on wearing a mask. I wouldn’t force that mandate on other people, but I think there’s a lot of benefits to that. We can talk about that. Yeah, I think the evidence shows that masks are at least somewhat beneficial.

As far as locking down businesses, when we were talking about last March, almost exactly a year ago when everything hit the fan and we were in really big trouble—New York hospitals were getting flooded—we really needed to lock down. What we saw in New York, the catastrophic deaths that we saw in March of last year, we would have been seeing all over the country if we had not locked down. New York has a lot of good hospitals, a lot of capacity, and they were overflooded. I can’t imagine what the rest of the country would have looked like if we had not locked down.

So short term, the lockdowns were necessary and prudent. I think where we get into a problem with the lockdowns was all the experts were saying, “Okay, we need to bend the curve.” That was the thing that we talked about. They were talking about, “We need two to four weeks to bend the curve and save hospitals.” Then four weeks came, and then they’re like, “Well, we need four more weeks.” And then, “four more weeks” after that.

The public is pretty reasonable about these things, but after some point, a lot of these people were missing mortgage payments and not able to pay rent. They’re looking around and saying, “Well, you told us ‘four weeks’ 10 weeks ago.” I think as a short-term effort, the lockdowns were smart and prudent. Going longer than that, I think it basically backfired because at some point the lockdowns were going to be fought against by the public. The public was not going to be able to sustain a 6-month, 12-month lockdown.

And you look at even countries in Europe, where they’re a little bit more willing to do those things, even there they’ve seen pushback on the lockdowns. There was no way we were going to sustain lockdowns for months and months and months on end.

As for school closings, I think that’s one of our biggest failures. Even early on, you saw European countries and Asian countries keeping schools open. France, except for very limited times, was open all the way through. Most of Europe stayed open for most of the year. We shut down everything last March, and there’s kids that are only going back to in-person schooling this week [the middle of March]. The cost of that to kids is something that’s going to be immeasurable for years and years. It may take decades for us to understand the full damage we’ve done to kids on that.

Now, some of that was necessary. Early on, I said the lockdowns were necessary. I think, yeah, short term they were necessary, but when we got to this fall or even now into January, and we’re still—as of today, some of the teacher unions are still fighting the CDC recommendations. The economic and societal costs to this are going to be with us for the rest of our lives.

GRABOYES: Some health costs as well in terms of mental health of the kids.

SHANKER: Absolutely. Well, mental health, I don’t even know how we’re going to approach that. Kids that do not have the support systems of wealthier parents, what have they been doing for a year? We have no idea. There’s a lot of estimates on this, but there are people saying that there’s 3 or 4 million kids that have just dropped off the face of the earth as far as the government is concerned, and we don’t have any idea where they are. They’re not on online learning. They’re not being tracked by anybody. The damage is going to be incalculable.

Then, as far as vaccines are concerned, if you had asked me last summer would we have had vaccines by the end of 2020, I would have laughed at you. Anthony Fauci basically said there’s no way we’re going to have vaccines by 2020. Then here we are in December vaccinating people. It is truly one of the great scientific achievements of modern history, being able to get the vaccines produced safely and then inoculating people.

It was a remarkable feat. There are a lot of people to credit, both public and private, for that, but they should be thanked dramatically. They’ve saved tens of thousands of lives by the speed and efficiency of their system. Anybody out there thinking twice about getting vaccinated, please get vaccinated. It’s going to save lives.

GRABOYES: That’s certainly the thing that I got most wrong a year ago. I assumed that there was no way that we were going to have a vaccine for two, three years at least. I thought it’d be longer. So, I’m delighted to be wrong.

SHANKER: It was a remarkable achievement.

What Should We Have Done Differently?

GRABOYES: I’m delighted to be wrong. Deborah Birx was the White House coronavirus response coordinator under President Trump. She said early on in the pandemic that if we did everything right, U.S. deaths were still going to exceed 200,000. We’re now at about 500,000 in the U.S., 2.5 million worldwide. Looking back, do you think we really could have kept COVID deaths anywhere near 200,000? If so, what were the mistakes that prevented us from doing that?

SHANKER: Honestly, I don’t really know. This is a game that some of us data nerds on Twitter have been playing for months. Was there a singular moment, a singular decision by Trump or somebody else, a policy change, that could have shifted the entire course of the pandemic and saved 200,000, 300,000, 400,000 lives?

I’m really not sure. I keep telling people if China was honest in early December, when they knew at that point that it was probably transmissible, and if the WHO had told us early—they knew by the end of December of 2019 that this was coming up—maybe we could have done anything.

By the time the WHO comes out and calls it a global pandemic, which is January 24 of 2020 basically, at this point there was already community spread in New York. Could we have halted that spread? Maybe we could have. But if you look at the countries that really succeeded this past year or year and a half, they are countries that closed down their borders, had strict quarantines for anybody that came in and out of the country, and then tested heavily.

We did not ever put a strict quarantine on our borders, so we never really had a limit on what new virus was coming in and out. Even early January and February of 2020 when New York was getting hit badly, there were people that were suggesting maybe we should quarantine New York, which is kind of a crazy thought. There’s a lot of constitutional issues with that, but I don’t want to get into the legal thing because I’m no lawyer. But if you do that, does that stop the spread of COVID? Because we know for a fact a lot of COVID virus spread from New York to the rest of the country. New York was the gateway.

Places like China, they could just order Hubei province, with a population of 60 or 70 million people, closed off. They were able to control it because they just closed the borders completely. We had more trouble because, first of all, we don’t have the constitutional power to easily do that, but as a free country, free travel is one of the things we truly appreciate. Quarantines were the one thing that might have really stopped this, and our country is just not built for that. It’s not just our country. You look at Europe; they had the same problem.

A lot of things were out of our control. If we had earlier detection, we would have maybe made some better decisions. If we had ability to quarantine areas with high infection rates, we might’ve been better off. But considering everything, I’m not sure any person in the Oval Office was going to make a dramatic change that would have changed the course of the pandemic.

The Federal Government’s Successes and Failures

GRABOYES: You’ve already mentioned Operation Warp Speed, the rapid deployment of the vaccines. Other than that, can you name something that the federal government really got right and maybe something the federal government really got wrong?

SHANKER: Let me start with what we did wrong. The biggest mistake early on was not closing the border, like I said. We could have closed the foreign border completely, enforced quarantines of everybody, which is what countries like Australia, South Korea and Taiwan did. Ironically, this was the one place all year long that Trump’s instinct was absolutely right and everybody else was wrong. His instinct was to close the border, and in retrospect, he was right on that one thing.

The second thing the federal government failed was with the CDC. The CDC early on, they were ahead of the curve, actually. They were trying to get an easily usable test for COVID. Their scientists basically made a mistake. It was an honest mistake. It wasn’t something that was easily prevented by any politician or any external thing. It was one of those things in science where you go, “Oops,” and people die because of it. It was horribly unfortunate. I’m sure the researcher in charge feels horrible, but it’s just one of those things in science that sometimes it doesn’t work. So we were way behind on testing for several weeks or maybe even months, while Europe and others were testing really well.

The third thing is, again, I talked about quarantines. We needed more ability to quarantine people early on. We’ve kind of become resistant to those kind of acts because we’re kind of libertarian, but if we were going to control the pandemic, we had to do that. Now, I don’t think that was a federal power necessarily. Maybe it had to go to states and localities. But that was one thing: We were never able to control the spread.

Even if we had had testing from the CDC early on, I’m not sure we could have controlled much. It would have told us more about where the virus was going, where we’re seeing new infections, those kind of things, but I’m not sure it would have helped us actually control the spread.

As far as successes, we talked about Operation Warp Speed. The Trump administration, to their credit, made it the priority to get the vaccine done as fast as possible. That was their priority over everything else. They didn’t worry about red tape. They didn’t worry about all these things. They said, “Get us a vaccine that’s safe as soon as you can.” The private companies answered the call—Moderna, Pfizer and then later on the others.

You look at where Europe is, and their red tape really has hurt them on the vaccinations. You even compare Europe to the U.K. The U.K. had a very similar plan to Trump. They were just like, “We’re just going to get the vaccine going.” Europe, because of their resistance to streamlining this process, now you’re looking at some of those red tape decisions costing lives now.

The Trump administration and the U.K. did a really good job streamlining those efforts. It’s one thing I chuckle about. Trump was audacious enough to say last July that we’d have a vaccine by the end of the year. In retrospect, you think about all the smart people—Fauci, Birx, the current CDC director, the current White House chief of staff—they all got it wrong, but somehow Trump got it right. It’s just one of those things you shake your head at.

GRABOYES: I guess for any listeners who aren’t familiar with your work, I doubt that you are in the top five favorite writers for either Donald Trump or Joe Biden.

SHANKER: No, I’m not making any friends of late. Yes.

GRABOYES: Right. That’s what I enjoy about your writing. You call them as you see them, and I don’t always know which way you’re going to call them.

State Governments’ Successes and Failures

GRABOYES: Okay. We talked about the federal government. You’ve also been very vocal on the states. In fact, the data that I looked at most from you through the year was—just on a constant basis, you were pouring forth, state by state by state by state, data and analysis about it. Let’s address the same questions. Which states look best in hindsight? Which look worse? What policies that they implemented seemed to work, and which didn’t?

SHANKER: I have spreadsheets upon spreadsheets of data going all the way back to last year about what states were doing and this and that. Now looking back, I think the evaluation of how states did, how governors acted, is so, so hard because there were so many variables on how to control the virus and how they were being impacted.

There’s no question that New York and the Northeast got hit really hard in the first wave. They were just unprepared. It’s hard to blame even Cuomo or Murphy of New Jersey or any of those guys for what they did early on. If you go back and see my comments, early on, I really complimented Cuomo. He was trying to mobilize the healthcare system to focus on the people that he thought needed to be focused on, which were ICU patients. He wanted ventilators, and he needed PPE to protect his healthcare workers. He was the voice of reason from the localities.

I think states that acted early did slightly better. Ohio, for example, Gov. DeWine was one of the first to close schools. Early on, he was one of the ones that saw the risk of prison populations, so he tried to close off prisons. He took a lot of heat for that, being a Republican. But it certainly saved a lot of lives when you look at it, when you compare, say, Ohio to Michigan, who did a lot worse early on because they took a little longer to get moving.

That being said, all these things—and then, if you go look to March, April, May, a lot of these states kept their lockdowns going. Then in April, May, what you had was Republican governors saying no—Georgia’s Kemp, DeSantis in Florida, Abbott in Texas—and they started opening up. At that time, again, you can go and look at my comments. I was very hard on them. I was like, “This is a terrible decision. I hope it doesn’t cost lives.”

In retrospect, it probably didn’t cost a lot of lives, which, again, it went against the conventional wisdom that all of us were saying. The ways they opened up were mostly outdoor venues. They kept indoor stuff closed for the most part. Then they mandated masks, which we’ve already talked about shows evidence that it protects from transmission. Then they kind of let the rest of the people feel their way and try to use common sense.

Now, in hindsight, that method actually wasn’t terrible. Maybe there were certain things they should have done that would have helped infections in certain places and others. Like DeSantis, for example, he opened up very early. I was very critical of him early on. But he did do one thing that Cuomo didn’t do, which was, he focused on nursing homes and elderly and said, “We are going to protect these people.”

Meanwhile, Cuomo, of course, now we know, had been sending people that were sick from hospitals to nursing homes and infecting all the nursing homes. That happened in a lot of states. It happened in New York. It happened in New Jersey. It happened in Michigan. DeSantis was kind of libertarian, in a sense, for the general population, but on the most susceptible populations, he actually did a pretty good job.

We have these kind of diverging—mostly it was political, but also philosophically—there were these diverging concepts about how a population or community confronts an unknown threat. It was like a real-world test of big states doing large-government things versus other states letting people more decide with guidance.

Even after one year’s time, what you see is it’s really hard to say, “Oh, this state did really, really well, and this state did poorly.” New York did poorly because they got hit early on. Then their summer was okay, and then they got hit again. California was doing good all year. Newsom was another guy I complimented all the way through. Then you get to the fall, and Southern California gets hit really bad. Northern California actually still is doing relatively okay.

Then you have states that basically have done well all the way through, like Washington. Their Democratic governor has done a really nice job, but was it luck or was it policy? It’s so hard to tell, even now, one year after the pandemic’s gotten going. I think it’s going to take years to filter through the data and decide, “Oh, this policy really made an effect. This policy didn’t.”

GRABOYES: As an economist, I always told my students to keep in mind that we still haven’t actually figured out what caused the Great Depression. We’re still debating it.

SHANKER: Right. Or what got us out of the Great Depression, for that matter.

GRABOYES: Right. I expect that careers will be made from start to finish on analyzing the data from this thing.

SHANKER: Oh, thousands of Ph.D. theses.

The Politicization of the Pandemic

GRABOYES: Actually, it’s funny. I wrote down a quote of yours just because it was optimistic and in hindsight just sounds quaint. You said—and this was in April [2020]—“Trump has managed to maintain decent relationships with a handful of high-profile Democratic governors, from Newsom to New York’s Andrew Cuomo, both of whom have had their disagreements with Trump but also complimented him at times. The president has praised both of them in turn.”

I will have to say I wrote something very similar at the time, and I viewed it quite optimistically, but in hindsight that seems rather antediluvian. You wrote a lot, starting in April. In fact, that article was you writing of the sharp political schism in how liberals and conservatives viewed policy actions.

My view is that the political schism probably was rather deadly. We wasted a lot of time and a lot of effort in pointing fingers at R’s and D’s. I don’t know how much damage was done simply by delays, inaction or inappropriate actions taken because of the politicization of the pandemic. What do you tease out of the data on that?

SHANKER: Yeah, I agree with you a lot. Quaint is such a nice word. I would call it, in retrospect, probably naive. Like you, I was hoping for our leaders to reach for a higher calling at a moment of national crisis. That’s really what I was hoping.

Now, I knew who Trump was. I left the Republican Party because of Trump, so my hope that Trump was going to raise the bar was always marginal. At the time, I was never a big fan of Cuomo even before the last year. With Newsom, I didn’t know him that well, but I was really hoping these guys would find some way to work with Trump.

Now, maybe that was always hopeless because Trump is Trump. He’s always looking at his own career more than anything else. But definitely the politicization all across the board damaged the entire response. The inability of the federal government to work cohesively with states—it certainly must have cost lives, I think. The onus on that is mostly Trump’s. The federal government just wasn’t willing to coordinate with local states, even Republican states. So the lion’s share of that responsibility belongs to Trump.

I think it really started once the states like Georgia and stuff started opening up. Then these other governors felt like they were being pressured to open up when they didn’t really believe in it. Once that happened, then these governors like Cuomo and Newsom saw a political cost to staying locked down.

Once that happened, now they’re all looking in their own best interest. “You guys are risking lives while I am trying to save lives.” That was just incorrect. They should have tried to let each state guide their way through the storm. Certain states, it made sense to open up. States like Florida, in retrospect, really were okay opening up. Other states have not done so well because they just didn’t have the ability to open up safely.

Of course, on top of all this, this was a presidential election year, which compounded all the hatred and all the anger. And, of course, Trump stirs the pot on top of everything else. I would hope that under a different president with a different political environment, if we have this problem in the future, we do better. I’m not overly optimistic that is the case. I don’t think this was a Trump-centric issue. I think our political divides are really hurting us right now. In this case, they cost us a lot of lives.

GRABOYES: One of the things that I found most disturbing was the politicization of the public health community itself, people who were supposed to be scientific and neutral ending up on the political sides of the issues. Any thoughts on that?

SHANKER: Let’s be honest. Most of them tend to lean Democrat in the public health community. Most of them I thought did a pretty good job. I think there are certain ones that got overly political. I think it was more true in the medical community than the public health community. There’s a lot of doctors I know that definitely lean Democrat. I think their partisan views hurt them when looking at these things more objectively.

But I think you look at people like Fauci and Birx and now Walensky, who runs CDC, or Redfield, who ran it before her. I think these people were well meaning. I think they honestly were dealing with terrible realities on the ground. They were dealing with horrible politics, where people were making death threats against them. Amy Acton here in Ohio, she was the head of the Department of Health here. She did an excellent job. She’s a Democrat. DeWine’s a Republican but hired her. She did a really great job. Then she started getting death threats and people with guns sitting on her lawn.

So these people were facing terrible, terrible repercussions for just trying to save lives and do their job. Again, the politicization definitely hurt us. There are people that now attack Deborah Birx for being overly political because she was being more friendly or more positive to Trump, but she was working within a system where Trump was the commander in chief. I think she was trying to run the gauntlet, where maybe she knew certain things weren’t right, but she was trying to get Trump on the right page.

I don’t think people were very sympathetic to her position inside of government, where she’s been working for presidents—Republican, Democrat—for years. If people had given these people a little more leeway, I think, it would have been better for everybody.

Sympathy, Empathy and Humility

GRABOYES: In the years that I was teaching medical professionals in graduate school, I had a stock phrase that, more than anything else I wanted them to learn from the class, I wanted them to learn to be skeptical of everything they hear, “including the sentence that I am uttering at this very moment. Be skeptical of my skepticism too.”

You did a really interesting piece sometime during the year in which you wrote, first of all, the need for sympathy and empathy. Then you added the need for humility and described the role of a devil’s advocate, or—and it was a phrase I had not heard before—“the 10th man.” Could you elaborate on these? I really liked that piece.

SHANKER: Well, first, sympathy, empathy and the humility part, too. Again, just like I was saying with the previous health directors and stuff, there was so little empathy for what was going on with others, what they were dealing with. Everything was about politics. Even with people like Trump and people like Cuomo early on, I was like, “They’re going to make mistakes. They’re human. This is a horrible situation where nobody knows what the right thing to do is.”

Every time a mistake was made, people were like, “Oh, wow. Look at this Republican. He made a terrible mistake.” There was no ability to give people enough leeway, to say, “They are trying their best. We have to allow them to lead.” Right from the beginning, people were starting to root for, “Oh, this blue state is doing good,” or “This red state is doing good,” or vice versa. That really, really bothered me, and that’s why I talked about sympathy and empathy. But then the humility part is another part of that because we had so many experts, even to this day, so many experts that made horrible, horrible mistakes.

Anthony Fauci initially said, “Oh, we don’t need masks.” Now you look back and that’s just a ludicrous statement. Was he ill-meaning when he said that? No, of course not. He was trying to do the best he could. Did he screw it up? Yeah, he screwed it up. He’s human too. At the same time, people like Fauci or myself or anybody that’s in this business has to say, “Look, we may be wrong. What we’re telling you right now is the best we can do right now, but the data could change tomorrow. It could change next week.”

Early on, people forget. Last March, what were we all talking about? We were talking about ventilators. We were producing tens of thousands of ventilators. General Motors cleared out one of their factories and started building ventilators. What we now discovered is we didn’t need that many ventilators—not even close. We spent a month talking about ventilators as if they were the holy grail of curing this problem, and it ended up we didn’t really need those.

There is not one single physician or public health policy person who has not made a mistake—a significant mistake—in claims in the last year. There’s nobody, including myself. I can go through a full list of things that I screwed up. That ability to be humble as an “expert” would have gone a long way to convince the public, “Oh, you know what? That guy has always been honest with me.”

I think the problem with a lot of the public, they feel like these guys are out there and they’re saying they’re the expert, then they get stuff wrong and they don’t say that they’re wrong. That ability to be humble actually gives you more credibility with the general public, I think, in the long run.

The devil’s advocate, this also leads into the humility thing. Devil’s advocate is obviously a Christian or Catholic concept, where we have to be skeptical about what we view as the truth or reality. The 10th man is an interesting offshoot of that. It actually originates in Israel. If you go back and look, what it was is during the Yom Kippur War, they had many, many data points showing that the war was coming, and they ignored all of them. And they were almost pushed into the sea.

After that, they came up with the concept of a 10th man, which was not really a rule, per se, but it was more like a philosophical thing. Again, it’s not a rule, but the idea is if there’s nine people in a room that all have the same response to a question, the 10th man has a duty to take the opposite position. Again, that’s a devil’s advocate position. Basically, “Okay, you guys are all saying X, but I think it’s Y. Tell me why I’m wrong about Y.”

Now, in this past year, we didn’t have very many good devil’s advocates. When people said, “Oh, we don’t need masks,” where were the big leaders saying, “Oh, yeah, we absolutely do need masks. Tell me why we don’t need masks”? Anytime somebody stepped out of line from the common narrative this year, they were ostracized.

That’s a very poor way to confront science because science is always evolving, and you should be able to confront somebody that has a different position and say, “Well, okay, that’s your position, but let me tell you why you’re wrong.” Saying, “Oh, no. You’re an idiot. Get out of here,” is not a useful scientific process. That’s why the devil’s advocate to me is very important in, not just public policy, but scientific policy and how we approach these issues.

COVID and Other Countries

GRABOYES: We talked about states and the federal government. We talked a little bit about some other countries. Are there any observations on specific countries? Of course, people talked a lot about Sweden, which was in some sense a big outlier in their policies because they basically didn’t shut down. They were sort of the Florida or Texas of Europe. Now we can look back at the data. There were other countries—France, Italy, U.K.—that made a lot of news, and, of course, China. Any observations on any of those countries, again, good or bad points?

SHANKER: I think what is fascinating about Europe is in many ways they have analogs to U.S. states, which you just alluded to. Italy and the U.K. got hit in the first wave very much like New York did. They then improved over the summer and then got hit again. That’s exactly what happened in New York. France was in the middle, where they got hit a little bit early on. Then they struggled with it later. That’s true of a lot of the Midwest states if you look at it. Sweden—they had some boundaries, but they took a more libertarian approach. You could call it like Florida, you said.

So you have all these countries doing little bit different things, but here again, this is where it’s so hard to decide what policies are when you come after one year. Yeah, the U.K. did worse than most of these countries. Italy did worse than most of these countries. France did slightly better, but not much better. Sweden did about the same as France.

So what you have after a year, I’m not sure which policies helped and which policies didn’t. Even when you get to Germany—remember, early on last year, Germany was heralded as the European success story. They did great. Then they got hit. They missed the first wave for the most part. Then they got hit hard in the second wave. They look like they’re going to get hit now in a third wave. Well, after a year, Germany doesn’t look like so much of a success. They look like just everybody else. The successes—we talked about this earlier—the successes were, again, countries that were able to lock down, quarantine and then test.

China, because of being a communist state, was able to do that with a 70 million population province, which is just incredible. The smaller countries that succeeded—the New Zealands of the world, Taiwan, South Korea—it was the quarantines that made the difference. They stopped the virus from coming in, and then they tested, tested, tested.

Europe and the U.S. basically did about the same, I think, when you look at everything. They failed for similar reasons. China is unique, and we don’t really have good data from them. Of course, now the ongoing problem is going to be Brazil, where they’ve lost all control. Their public health system’s a mess, and their leaders have not promoted masking and distancing enough. Brazil is going to be the hot spot for a while.

GRABOYES: Interesting that some of the really good examples that you named happened to be islands, or effectively islands. Taiwan, New Zealand, Japan all did well. South Korea is not an island, but it may as well be.

SHANKER: Right. They have a border that’s closed. That’s exactly right. Again, when they were able to close off and quarantine themselves, those are places that were successful. Now, you go back and look at Hawaii. Early on, I thought Hawaii might be able to escape, but then they had enough travel back and forth that they still got hit. Had they stopped all travel or had a really harsh quarantine the way Taiwan did, they might’ve got away with not much. But again, the mixing of travelers—once you did that, you had lost the battle.

Preparing for the Next Pandemic

GRABOYES: In October, you wrote about steps we need to take in order to prepare for the next pandemic. What kind of steps would those be?

SHANKER: Well, I wrote a long piece, also, with my wife, who helped me a lot with that piece. I think part of it is, first of all, looking honestly at what failures we had. The first failure was an international failure. We could talk about China, but China’s a bad actor and that’s who they are. Where was the WHO? They knew early on something was wrong. Once they knew something was wrong, they should have been hitting all the alarm bells. But they didn’t. Instead, they kept quiet because they didn’t want to upset the Chinese.

A system where it’s going to be that partisan and political is always going to fail. It’s always going to fail because nobody wants to be, “Oh, the next pandemic started with us.” They don’t want to be that. So they’re not going to be honest about it at all. The WHO’s responsibility, first and foremost, should be to the science, not to the politics. If they’re going to be to the politics, then they’re a useless organization. So, they failed us, first of all.

Then we have the CDC. I talked about their testing mistakes. I think the other thing they failed in is they relied on the WHO to give them intelligence on what was going on. Honestly, at this point, I think we cannot trust the WHO, unless there’s massive reforms there, and I don’t think there’s going to be massive reforms.

In that case, the CDC and maybe some other organizations, like some of the European organizations and others, need to join together and have some kind of early-alert system or intelligence system, where they start ringing alarm bells when they see these kind of things. The CDC and others really missed the boat. They had warning signs early on, but they were like, “Well, the WHO is looking into it.”

Here’s the other thing. It’s kind of strange, and I only know this because of my parents. My parents spend the winters in India usually. In winter of 2019, they were in India. Then in November, my mom calls me and says, “Oh, a lot of these students in India, they traveled to Wuhan to study, but they’re all starting to come home.” I said, “Why are they coming . . .?” They said, “Oh, there’s some sickness going on.” This was in November of 2019. I was like, “I haven’t heard anything about it.”

Then my mom calls me a couple months later—I think it was early January—and she’s saying, “India TV is saying that there’s thousands of dead in China.” I’m like, “I haven’t heard anything about it.” If people were looking for a problem, they could have found it, but the CDC obviously wasn’t even looking. When news in India is able to find stories like this, the CDC should be able to. We can’t rely on other people. Yes, we should work with the WHO, but we have to have our own separate intelligence system on these things because they’ve proven that we can’t depend on these foreign ones.

I think the last thing that is going to be one of the biggest positives out of the COVID thing is that these new mRNA vaccines have the potential to basically stop many, many of these pandemics in their tracks. Now that we have a mechanism that we know is safe, we can clip an RNA piece from any virus that we think is a problem, stick it in a vaccine and start inoculating.

As time goes on, we should be able to produce vaccines in weeks, not months, which is just an incredible thing. The only thing is, this is where the public and private need to get together. Government needs to find a way to have facilities where we can produce these type of vaccines very quickly. But this is a very costly thing. Private companies aren’t going to want to have factories just sitting idle for years and years. We have to have a system where the government and these private companies work together, where we have production facilities ready to go when they’re needed. I think those kind of things are going to cost money, but it’s very feasible.

GRABOYES: Just the chemistry of what they did is just astounding.

SHANKER: Yeah, it’s incredible.

How COVID Has Changed the World

GRABOYES: The last thing I will ask you is, this virus, its effects are lessening. We can deal with it. It’s not gone. Two questions out of it: Do you think this particular virus is just here to stay, that it’s something we’re going to be managing permanently going forth? Secondly, somewhere about a year ago, I published 32 conjectures about permanent societal changes that might result from COVID. Can you think of some things you think are never going to be the same as they were before? So, is COVID-19 going to be around, and what has it changed that will never return?

SHANKER: As for COVID-19, I guess nobody really knows. My guess is that it will become endemic. I think every population on the planet will eventually be exposed to it. Because it mutates so much, we may have to get vaccines regularly the way we do with the flu vaccine. That’ll take time to see. If we can control the replication of the virus among humans, we might be able to stop it so that we don’t see a lot of mutations. With the flu vaccine, the virus mutates in pigs and other things, and that’s what complicates the new flu species that we get through different years.

With COVID, we might be able to control it, but my guess is it will be around in some manner forever. What people kind of forget, in 1969, we had the H3N2 flu pandemic. It was called the Hong Kong Flu back then, which now is kind of inconvenient. It killed about a million people worldwide at that time. What people don’t realize is we still see that flu every few years. It’s a bad flu. It’s an influenza virus strain. It goes and hits older people. That flu has never gone away. That’s 1969. My guess is that COVID will be something similar. Hopefully, we’ll get it under control. It won’t be a major issue because of the vaccines, but it’s here to stay, I think.

As for your conjectures about societal changes, I think at least American society has dramatically changed. I think there’s a few certain things, like Zoom calls. Our kids, my kids, are so comfortable with Zoom calls now that they are probably willing to do almost anything online. That’s a remarkable shift from what we were doing before.

Working from home is going to be the standard, I think, especially in an IT economy. The way our country is moving, so many people can work from home. I already do work from home. It’s going to definitely have a major transition on society as less people are going to be traveling to downtowns and office buildings to work. It’s going to have a lot of effects.

I hope cleanliness, in a way, or mask wearing becomes more common. You see we have not seen almost any flu in the last year. That’s because everybody’s wearing masks. If everybody wore masks like this all the time, we’d almost never see the flu. Flu kills tens of thousands of people a year. We could save a lot of lives if we were more careful about transmission and stuff. So, I hope people continue the washing the hands—which may or may not help with COVID, but it helps with everything else—and may start using masks if they’re sick. Those kind of things could really save lives.

One funny thing is I think a lot more people own pets now. I know my dog kept me sane the last year. He was a godsend. Everywhere I go now, people have new pets. I think that’s another new thing. A lot more people owning dogs and cats, so it’s fun to see all the new little rascals running around.

GRABOYES: A couple of the things I had written about were that I think telehealth is here to stay. It’s something that I had been, let’s say, touting for a number of years. I’ve used it myself. I’ve written a lot about it. I wrote fairly early on—sometime around June, I think—I wrote that I had seen more innovation in the delivery of healthcare services in a couple of months than I had seen in the rest of my career.

SHANKER: Oh, absolutely. No question.

GRABOYES: Things changed rapidly. The other thing that I speculate at the end, and I think it’s going to be an interesting thing to see whether it happens. As someone who spent eight years in New York City, one of the things I was most thankful about was that I was not living in New York City. I don’t just mean because of the early arrival of the virus, but simply, I can’t imagine what life would have been like there trapped in an apartment.

Here, in the suburbs, I can go and sit out in my yard under a tree and be happy. To be living in a high rise with elevators and to be dependent upon public transit, I’m just very thankful I wasn’t. I suspect that the idea of living in high-density cities will, at least for some segment of the population, become a lot less attractive an option. I also wonder whether the use of large-scale mass transit is going to be less attractive going forward.

SHANKER: I think definitely there’s going to be trends. It’s so hard to predict. New York is so appealing for so many people for so many reasons. I think New York will come back. San Francisco, I think, will come back, but they won’t be the same. That’s the thing. They’re going to transition or adapt to a new reality. I wonder if people like middle-age or older are going to be like, “This isn’t worth it anymore for me.” Or people with young kids just say, “Forget it.”

All over the country, we’re seeing— I know it’s true in Columbus, where I live. My sister lives in Albuquerque, New Mexico. I know it’s true there. There’s tons of people moving from California and New York to these places. House sales are going nuts here, which they never do. That’s just not how things are here.

Clearly, something is happening. I think it’s going to take a long time to figure out exactly what is happening and who it’s happening to, but this is a societal shift I don’t think we’ve seen since World War II probably. It’s that dramatic, where the effects are so deep that it’s going to be hard to really see it for many, many years.

GRABOYES: Any final words you want to say?

SHANKER: No, not really. I really enjoyed this. Any time you want to talk, I’m always here. I do recommend Twitter, as long as you can stay away from the haters. Always like to see more people on Twitter.

GRABOYES: That’s a good way to end the session. I wanted to thank you, Pradheep. This has been everything I had hoped it would be. I want to talk to you soon about accumulating some of your data in writing. I think it needs to be preserved in places other than Twitter, too.

SHANKER: Okay. Well, thank you for your time. I really enjoyed it.

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