The Year of COVID-19
This article is part of an ongoing collaboration between the Colorado School of Public Health, the Denver Museum of Nature & Science, and the Institute for Science & Policy. Find all of our previous COVID-19 webinars and recaps here.
From economics to epidemiology to psychology, COVID-19 has profoundly altered our society and will likely continue to do so well into the new year. 2020 has challenged us both as decision-makers and as human beings, forcing a collective reconsideration of what it means to live in a time of plague.
In our final COVID-19 webinar of the year, the Institute for Science & Policy’s Director Kristan Uhlenbrock chatted with Nicholas A. Christakis, Sterling Professor of Social and Natural Science at Yale University, who has studied the progression of the novel coronavirus across a range of disciplines and chronicles them in his new book Apollo's Arrow: The Profound and Enduring Impact of Coronavirus on the Way We Live.
This transcript has been edited and condensed for length and clarity. Watch the full recording of the session here.
KRISTAN UHLENBROCK: I’m extremely grateful to have Dr. Nicholas Christakis, author of the new book, Apollo’s Arrow: The Profound and Enduring Impact of Coronavirus on the Way We Live, joining me today. Dr. Christakis is a social scientist and physician who conducts research in the fields of network science, biosocial science, and behavior genetics. He directs the Human Nature Lab and is the Co-Director of the Yale Institute for Network Science and the Sterling Professor of Social and Natural Science at Yale. In 2009, Christakis was named by Time to their annual list of the 100 most influential people in the world. In 2009 and in 2010, he was listed by Foreign Policy magazine in their annual list of Top 100 Global Thinkers. His list of accomplishments is remarkable, and I’m not doing him justice right now. But I’d love to spend time talking with him instead of about him.
NICHOLAS CHRISTAKIS: Thank you, Kristan. In another life, I would have come to Denver, where I've been many times, and seen you in person.
Let me just try to set the stage by making a few remarks about the pandemic. Because we happen to be alive at a moment when something very unusual has happened to us as a species, namely a new pathogen has been introduced into our midst. And this pathogen, this SARS-CoV-2 virus, is going to be with us forever. It's never going to go away. And in fact, we know at this point quite a bit about the pathogen. We know how lethal it is, something that wasn't so obvious from the very beginning. We now know that between 0.5 and 0.8% of the people who get infected with this pathogen will die. Now that's not a trivial pathogen. That's at least 10 times deadlier than the flu.
On the other hand, it could have been much worse. There's no God-given reason that this pathogen isn't much deadlier even than it is. We know of course that the likelihood of death varies with age and in some sense that's quite nice actually, that the young tend to be spared. On the other hand, I don't think there's any reason for us to be nonchalant at the fact that people who are older are at greater risk of dying from this disease.
We can look at this pathogen’s mortality compared to prior global pandemics, for example, bubonic plague, which would kill 30-50%. In some cities, 80% of the people in the city would be wiped out within a couple of months from an epidemic of plague. Or smallpox, when introduced into Native American populations in our society here by the settlers, can sometimes wipe out 95% of the population. We’ve been annihilated by cholera epidemics, or yellow fever epidemics, things that have stricken human beings for centuries. This pathogen isn't that bad, but it's still not trivial, I need to emphasize.
We also know how infectious this pathogen is. Many listeners are now familiar with this notion of the R0, popularized even in the movie Contagion, which actually is quite realistic in describing our current predicament, except the pathogen in that movie probably killed one out of three people that it infected compared to the one we're facing, which only kills about one out of 100.
So anyway, the infectiousness of this pathogen is characterized by this R0 number, which is somewhere between two and a half to three and a half. That means that the ability of the pathogen to infect new people — the intrinsic property of how spreadable it is, or the basic reproduction number — means that for each case, in a non-immune population where the host is interacting normally, creates three new cases. If you take these two numbers, the mortality and the infectiousness, and plot them on a graph and look at all the respiratory pandemics for the last 100 years all the way back to the 1918 Spanish influenza pandemic, you can get a sense of how serious this disease is. The most lethal and the most infectious previous pathogen was the 1918 influenza pandemic, which led to a major global catastrophe. Previously the second worst respiratory pandemic of the last 100 years was the 1957 influenza pandemic, which killed 110,000 Americans back then, which would be equivalent to about 220,000 today.
And then you have all the other respiratory pandemics including the 2009 H1N1 pandemic, which most of you don't remember because it wasn't so fatal. Many people got it but it was down low here on the curve. The COVID-19 pandemic is the second worst respiratory pandemic we've had in 100 years, worse than 1957, almost as bad as 1918. Before this pandemic is over — and it will take a year or two or three before it all sort of dies down — this germ will have killed at least half a million Americans, and maybe as many as a million Americans. This is a catastrophe.
Former Treasury Secretary Larry Summers and a colleague of his, David Cutler, recently published a paper on the cost of the virus. From the moment this virus leapt our species and arrived on our shores, it would do $8 trillion in economic damage, and a trillion dollars furthermore in damage in terms of our health, the deaths, the sicknesses, and the disability that will ensue from this pathogen. So, our world has changed. It's very important for people to understand this. There's this new deadly pathogen that has been released into our midst. And it's had these dramatic effects. I want people to understand that what's collapsing our economy is not our response to the virus so much as the virus itself. It's not the government that's causing the economy to collapse. It's the virus. And if you go back hundreds of years and look at descriptions of plagues, even in medieval times, you will see that people talk about how the economy ceased when there was a deadly epidemic afoot. Even 1,500 years ago, descriptions of the Plague of Justinian talk about how everything slowed and ceased and the economy stopped.
There's debate among scientists whether viruses are living things or not, but from my perspective, you can think of the virus as a living thing. It's found untouched territory and it's exploiting it. Our bodies are the untouched territory for this virus. It's just spreading and spreading and will continue to spread forever.
Now, I want to emphasize that this way that we are living right now, which seems so unnatural and alien, is actually not new to our species. It's just new to us. We think that it's so weird and odd and unfair and unjust that we have to live this way. But what I want to emphasize is that people for centuries, for thousands of years, have been confronting this ancient threat. Plagues are in the Bible. They're at the opening of Homer's Iliad, which is where the name “Apollo’s Arrow” comes from. They’re in Shakespeare. Plagues are not new to our species, they're just new to us.
Take the death of healthcare workers for example. The plague of Athens talks about how all the doctors were dying. The blaming of others, this feeling of grief and loneliness, fear...all of these phenomena that we are witnessing, these social and economic phenomena, have been described for hundreds of years, and I think it's very important for us to take that in if we're to really better confront this enemy that we're now facing during our time in the crucible.
And in fact, if anything, we're lucky, not only because this pathogen is less deadly than these other ancient threats, but also because we are the first generation of humans ever to be alive who could, in real time, invent a specific countermeasure to the disease. Up until now, we've been using primitive means to respond to this primitive threat, wearing masks, physical distancing, avoiding gatherings, closing schools and businesses and so on, which are tools that have been at our disposal for hundreds of years.
Previous generations of humans have thought that they could use elaborate pharmaceutical treatments, you know, rub yourself with dead snakes and onions, for example, as a treatment for the bubonic plague. But those treatments didn't actually work. We, on the other hand, have been able to invent a vaccine in 10 months, which is just astonishing. Now, the vaccine will help us a lot. But I want to emphasize that it's not a panacea. And it's not going to be anywhere near as quick as many people in the popular media are describing.
Let me give you a short little description of how I think the pandemic is going to unfold for the next few years. The vaccine: it's amazing that we've invented it, but it's gonna take time to manufacture hundreds of millions of doses to distribute it, which is not an easy challenge for many of these vaccines, and perhaps most important, to persuade a majority of Americans to take the vaccine. We have to get to something known as the herd immunity threshold, which for this pathogen is at least 50% of people who need to be vaccinated.
But meanwhile, while we're engaged in all those activities of manufacturing and distributing and accepting the vaccine, the virus is still spreading. Right now, probably only 13 to 14% of Americans have been exposed to the virus. And so we're only about a fourth of the way to herd immunity. So my feeling is that, either way, 2021 will be consumed with this pandemic and it won't be until the beginning of 2022 or the end of 2021 before we put the epidemiological and biological force of the epidemic behind us when we reach herd immunity, either artificially because enough people are vaccinated, or naturally because enough people have acquired the infection.
And then we're going to have a period of time — judging from previous pandemics and epidemics going back thousands of years — of recovering from the psychological, social, and economic impacts. Let's not forget tens of millions of Americans are out of work, millions of businesses have gone out of business, millions of children have been denied schooling opportunities. Furthermore, we're also going to have millions of Americans that are disabled. Whereas between half a million and a million Americans are going to die. We don't know for sure yet, but perhaps five times as many will have some kind of long term disability. I'm not talking about long COVID, people who, once they recover from the acute illness, still have some disability like pulmonary fibrosis, cardiac problems, renal insufficiency, neurological deficits. And those people might number perhaps two and a half million Americans, so that will also have to be coped with, plus all the economic aftershocks.
So my thinking is this gets us to about 2024 before we're finally able to put the social, economic, and psychological impact of the virus behind us, and then come 2024, I think we're going to have something like the Roaring 20s of the 21st century, similar to the Roaring 20s of the 20th century, which ensued after the 1918 pandemic. During pandemics, people get more religious. People become more abstemious. They save their money, they become risk averse, and so on. But at the end of the pandemic all of these things will reverse. I think people will relentlessly seek out social opportunities and nightclubs and restaurants, for example. No one will be wearing masks anymore by then. In the next couple of years, people will still be wearing masks, we will have intermittent school closures, people will be avoiding mass gatherings. But then, you know, when we get into the post pandemic period, people will now have this pent up demand for social interaction. We may see changes in sexual practices and sexual licentiousness. People will spend a lot of money. We'll see risk taking, joie de vivre, and we may see an renaissance of the arts. We'll see a lot of changes, I think, at that time.
Now, I don't want to overdo the analogy to the 1918 Spanish influenza pandemic. Of course, that was confounded with the existence of the First World War. But I do think that, you know, people right now who are living in this very constrained way will experience this kind of release at some point in the not too distant future. So now I'm happy to talk more generally about anything you're interested in with respect to this pandemic.
KU: That was a wonderful opening, and really, each chapter in your book could probably be a whole episode. So we're gonna touch on a few things and see where the conversation goes. Was there something shocking to you as you were going about researching this book, something that maybe you weren't expecting when you were coming in?
NC: I get that question sometimes, and it's always awkward for me because it makes me feel very immodest to say that no, I was not surprised. Perhaps it's because I've spent so much of my life studying contagions. I think that from a broad sweep of history and from a basic understanding of epidemiology, there's very little that has been surprising. I like to tell people that we have done embarrassingly badly as a nation coping with this epidemic, especially given the fact that we have the CDC, which is the envy of the world. The CDC and the White House have for decades periodically released documents called a national preparedness plan for pandemic influenza. The pathogen is different now, but the planning and response would be basically the same.
No experts have really been surprised by this. I mean, Tony Fauci was writing articles about respiratory pandemics when I was in elementary school! So to people who had expert knowledge back in January, honestly not much has happened that is surprising, except perhaps our incompetent response, and perhaps the rapidity with which we've been able to develop a vaccine. But by the time I wrote the book, it was obvious to me that we would have a vaccine in the first quarter of 2021. We're a little early. It was approved in December, but not much earlier than I expected.
Part of my motivation for writing the book was that I started working on this topic in January. I was kind of paying attention to what was happening in China. Not a lot, but I had these Chinese colleagues with whom I done some scientific research for the last five years, and they contacted me in middle of January to discuss doing some work related to coronavirus. We were using phone data to track the movement of people through China in January into February, and thereby tracking the intensity of the epidemic. And as a result of this, I was really paying attention.
When China, on around January 24 or 25th, imposed its own lockdown, I became aware of the fact that the Chinese government required 930 million people to stay in their homes. The Chinese judged the nature of this threat as sufficiently severe and basically detonated a social nuclear weapon. 1 billion people were locked down in their homes, before the end of January. And this really got my attention. I was very concerned that the American public was not mindful of this. What were we thinking on the other side of the planet, there are a billion people in their homes. Why on earth would we would be spared this fate? And it's in the nature of these pathogens that they just spread. It's very difficult to contain them.
In February, I thought we still weren't paying adequate attention. And so by March, I thought I would write this book. I mean, it sounds pathetic — how can a book help? — but I wanted to sort of try to help people to understand what was it that we were facing, and would face. And so I sat down in the middle of March to write it, and I worked nonstop for four months, 220 days, and I delivered it to the editor in July, and it was printed in August.
KU: Here in the US, we've had a lot of focus on criticism of our federal response to the coronavirus. I'm wondering what would have been a better, more ideal federal response from your perspective?
NC: Well, I couldn't believe the things that the President of the United States was saying, because from my desk, it was obvious. By the end of January, I was very concerned and most of the expert epidemiologists I was in contact with were very concerned. We were getting these very fanciful statements from the high levels of the federal government. And I was like, this can't be possible. There's just no way that I'm more in the know that the President of the United States, because that's an absurd statement. In fact, the President was briefed back in December about the likely pandemic potential of this disease, which is of course as it should be. The NSA works for him, the CDC works for him, he should have better information than the average person on the street.
So they knew what was happening, but for whatever reason and we can speculate as to the reasons, they didn't take proper action and proper action would have included manufacturing more PPE. The fact that we did not have enough supplies for our health care workers, and for our citizens to the point where Americans died alone. Hundreds of thousands of Americans died alone. One of the reasons that was that we didn't have PPE to spare to give their family members to come visit them in the hospital. We didn't have enough ventilators and other equipment. We didn't have testing built. We had successfully and rapidly done testing for respiratory pandemics for decades, but not in this case. There were a number of goofs, and even after the goofs were discovered we were slow in building our response.
Most importantly, we weren't preparing the American people. I think public health messaging is a crucial part of a public health response. It's very challenging, because epidemic growth is difficult for people to understand. In exponential growth, one becomes two becomes four becomes eight becomes 16 and 32 and 64, 128, 256 and on and on. But it's slow at first, and nothing seems to be happening for a very long time and then all of a sudden, a lot is happening. So it's very difficult for leaders to go out to the public and say, we know it seems to you that nothing is happening, but actually the situation is very serious. But see, that’s the duty of leadership, especially during challenges like pandemics to explain to people that look, I understand that you're not seeing people dying around you. I understand you can't see this virus. I understand it seems to you that these responses I'm recommending are extreme, but they're not, and here's why.
And even if we thought somehow we would escape the fate that occurred to China and Italy, let's not forget that Italy, a wealthy Western democracy, collapsed in February. I mean, what were we thinking? Then in March, it was New York State and New York City and elsewhere. It’s on both right wing and left wing politicians to be honest, although I hold the President to special account for this. They were releasing very benign statements. And right behind the germs trail denial and lies. Lies and denial are parts of epidemics going back hundreds of years. The President was saying that hydroxychloroquine would be a miracle drug. There was no evidence for that. No reputable science supported that belief. It was like a snake oil, and that's not a responsible thing to tell the public. So anyway, the gist that that we felt that we, despite our wealth, despite the openness of our society which should have allowed for information to spread and around the country, you saw hospital systems that tried to stop doctors and nurses from talking, which is exactly the wrong thing to do. You’re not going to beat the virus with denial and lies in silence. We did not capitalize on our strengths and the price of that is death.
KU: It seems like our political response always struggles in the face of pandemics.
NC: It does. I mean, we didn't do so great with the onset of HIV, and in part that's also because during times of plague, people don't want to believe this bad thing is happening. It's very tempting to blame others. During bubonic plague, it was anti-Semitism - the Jews were responsible. Or there was one poor case in Italy where four hapless Spaniards were in the city and they were blamed and they were tortured to death because they were thought to be the bringers of the plague.
During the HIV pandemic, men who have sex with men were blamed, or Haitians were blamed, or IV drug users were blamed. At the beginning of this pandemic, there was a desire to blame the Chinese. There’s always this desire to blame someone else, which interferes with the capacity to forthrightly confront what's happening.
There is a classic paper that was published 20 years ago now on how to plan for respiratory pandemics early on. You can get some assessment of these quantities and then you put them on this graph and you can see if it’s a big one or not. Well, people had already done this back in February. It wasn't hard for experts to do this. So, an expert could put forward serious evidence and we could have had a less ideological conversation about what was facing us
It is hard, but there are countries that have done much better than us. The rich island nations of Taiwan, New Zealand, and South Korea (which is basically an island because the border with North Korea is closed). Other islands like Iceland did not do so well. Even Greece did really well at the beginning and still is doing okay. Germany did well. I'm an American and I'm proud of our country. I just want us to do well in confronting this. I don't want my fellow citizens to die.
Let’s be clear: some deaths were unavoidable. But I think we've had needless deaths and more than we should have. And so I think we could have done better. And I think I still think we need to do better. I need to emphasize to listeners that the imminent arrival of widespread vaccination within a year should increase our resolve to behave well because there is light at the end of the tunnel.
KU: We actually haven't spoken a lot about about death and dying and grieving during this series, and I don't know if our audience knows this, but you are a hospice physician. And so there's a psychological aspect, of course, to this pandemic which is huge when it comes to grief and how people approach that and it's quite complicated. So I'm wondering about your own personal experience and how that shapes your perspective.
NC: There’s a famous saying that nothing human is alien to a doctor. I mean, I think if you're a good doctor, you acquire a kind of reverent gentle appreciation for our frailty. And if you're a hospice doctor, and you see death up close, it highlights for you our common humanity and our vulnerability. And you'll acquire certain commitments to the proper care of patients near the end of life. And this is one of the reasons that my blood was boiling when people were dying alone in March and our hospitals were closed down. I mentioned the lack of PPE, but that wasn't the only reason. It was the inundation of our hospitals that also contributed to the problem.
A well-functioning hospital can make arrangements for loved ones to be with the terminally ill person because the nurses are not exhausted, the rooms aren't packed, they're not putting people in the hallway. When an epidemic is afoot, one of the reasons you don't let family in is you don't want them to acquire infections from other people in the hospital and therefore create more cases. And you also don't want them to bring infections in. But this is all made worse by the fact that you don't have PPE and the hospital is packed to the gills and so people are prioritizing caring for patients. All of this could be avoided if we do our part to flatten the curve to reduce the intensity of the epidemic at any given moment so our doctors and nurses can do their jobs more effectively in our first responders.
I subscribe to the philosophy that we should take good care of the dying. We're fools, we're just fools, that we have not properly prepared. And I need to emphasize, it's not just the healthcare systems that need to prepare. The citizenry really needs to prepare. People need to understand why, when the pandemic struck China, the Chinese had to build a 1,000 bed hospital in 10 days with something like 10 or 20 ICUs. Italy collapsed in February, New York in March, and now we see other parts of the United States, their healthcare systems collapsing and people are shocked and surprised. Why? I mean, what makes any city think that they're special? And do you really want that for your city?
Avoid crowds, engage in physical distance, get testing when you can, obey quarantine guidelines, minimize your shopping trips. Go out once a week to buy your supplies. Do all of these basic things to thin out social interactions, so that those among us who get sick can be properly cared and if, heaven forbid they are dying, they can be visited by their families.
KU: You write that truth is another casualty of the plague. I'm wondering if you could just elaborate on that concept.
NC: I think that's a famous saying about warfare, right? Truth is the first casualty of war. I think it’s true of plagues as well. I think in communicating factual knowledge, you say, here’s what I think is the case. Here's why I think there's evidence for this. And here's my degree of certainty or uncertainty. And then also, owning your mistakes. So if two months from now, you say no, two months ago, I told you this for these reasons, and I wasn't 100% sure. Now I'm back to tell you that in fact, I was wrong about that. Here's what I know now, and here's the reason I've changed my opinion. That can enhance credibility.
As we alluded to earlier, an enormously important part of responding to a pandemic is public health messaging and credibility. I think we can have beloved figures like Tom Hanks or Dolly Parton or Linda Ronstadt or other people who the public sees favorably who could play a role in helping people take it seriously, let alone scientists like Tony Fauci and so on.
Now, in your everyday interactions with other people who hold beliefs that are plainly false, there are wonderful tools that Jonathan Haidt, the social psychologist, has described. There's an old saying that you can't reason a man out of a position he hasn't been reasoned into. So with people who hold beliefs that are unreasonable, it's not facts that they need. It's an emotional connection. So you have to first join them. Why are they saying this? Maybe they're afraid? So they're denying the existence of the plague because to accept the existence of the plague would mean that they have to accept the legitimacy of their having lost their job, and losing your job is a devastating consequence for an adult. People don't want to lose their jobs, so rather than having to engage with that topic, they say, well it's all bogus or a hoax.
So first, you have to engage them where they're at emotionally, and then you have to look for points of agreement. What do we agree about? We agree that people are dying. Maybe there's a debate about how many are dying, but what would you like to talk about that? You look for points of agreement with your interlocutor. And then finally, you recognize it's not a one off conversation. It's a sustained interaction that slowly chips away at people's beliefs.
KU: Do you have any thoughts on changes you’ve seen that you think are going to stay with us after this pandemic is over, toward that 2024 time horizon?
NC: One of my examples of this from the 1918 pandemic is spittoons. Around the turn of the last century, people were really concerned about public spitting because of tuberculosis outbreaks. And so there were big moves afoot to get people to stop spitting in public. And in those days, many restaurants or saloons would have spittoons in them. When the 1918 pandemic struck, the impetus to stop public spitting was really heightened. They did not come back after the pandemic. I've never in my life been to a restaurant that had a spittoon, nor have I ever met anyone who says, you know, it's really is awful that we don't have spittoons anymore. It's just a permanent change in our society.
Not related to epidemics, many listeners might remember smoking sections of airplanes. Even as a child, I remember how odd it was that the smokers were way in the back because of course, the smoke would come to the front. I didn't really understand. Now nobody asks you why isn't there a smoking section on this plane. So there are certain things like that, little things that may change. Our tolerance for these types of Zoom meetings, for example, or working from home. I think business travel is going to be different. Many people have made these observations.
But there are also some other things that might be a little bit more subtle that aren't so obvious. Let’s consider a stereotypical heterosexual couple (conscious of course that there are homosexual couples single heads of households, and so on). Stereotypically, though not always, men make more money than women in the labor market. It’s also stereotypically the case that women have a higher interest or tolerance for taking care of young children than men. In this example, such a couple now is sitting around their kitchen table, and the epidemic has hit the labor market and people are losing their jobs, schools are closing, and they're deciding what to do that's best for their family. So they decide that the husband should continue to participate in the labor market because his wages were higher than the wife's and the wife is more interested in spending time with the children, which they are of course entitled to do.
But meanwhile, millions of other families are making the same choice, and as a result, we may see a regression — a loss of 10 to 20 years of progress — in women's labor market participation. Because of this, at the other side of the pandemic and five years from now, we may see that women are less prevalent in many occupations. We may see greater wage inequality We may see all these socioeconomic ripples in the gender dynamics of the economy because of a germ. So this is another way in which the virus may reshape our society, not like a little physical thing like whether we shake hands or how many people still wear masks in five years. There will be such people who say wait a minute, I wore a mask for a couple years and I didn't get an infection, so I'm going to keep wearing a mask. You see that in many Asian countries, for example. We are also borrowing against the future right now, basically printing money. All kinds of things might change macroeconomically and macrosociologically because of a virus.
KU: To wrap up, is there a silver lining or a way that this has brought out the good in us?
NC: I mean, I love human beings and I love our species. My prior book was called Blueprint: The Evolutionary Origins of a Good Society, which tells you everything you need to know about my feelings about who we are. And so, I see a tremendous good in human beings and I see tremendous good in our society. And it is absolutely the case that the way in which we are going to beat the virus is by exploiting some of these good qualities: our ability to cooperate and share information and work together. And we've seen scientists around the world collaborating and volunteers volunteering for the trials of the drugs, and people contributing to soup kitchens, and collaborating to do the things we need to do. So honestly, I find more to admire in human beings than to despise them and I see a lot of evidence for that as well, even in this modern plague.
The Institute for Science & Policy is committed to publishing diverse perspectives in order to advance civil discourse and productive dialogue. Views expressed by contributors do not necessarily reflect those of the Institute, the Denver Museum of Nature & Science, or its affiliates.