No more handshakes

 The history of a pandemic, and its possible futures

3D print of a SARS-CoV-2 virus particle|© National Institute of Allergy and Infectious Diseases (NIAID)
 

In 2002 the Cambridge astrophysicist and Astronomer Royal Lord Rees predicted that, by the end of 2020, “bioterror or bioerror will lead to one million casualties in a single event”. In 2017 the Harvard psychologist Steven Pinker took the other side in a formal bet. As the terms of the wager defined casualties to include “victims requiring hospitalization”, Rees had already won long before the global death toll of Covid-19 passed the one million mark in September. Sadly for him, the stake was a meagre $400.

Nicholas Christakis has given his rapidly written yet magisterial book about the pandemic the title Apollo’s Arrow. The allusion is to the plague the god unleashes against the Achaeans for kidnapping the daughter of his priest Chryses in Book One of Homer’s Iliad. An alternative title might have been Rees’s Bet. In a report from 1998 the US Department of Defense observed that “historians in the next millennium may find that the 20th century’s greatest fallacy was the belief that infectious diseases were nearing elimination”. Pinker was only one of many scholars who subscribed to this belief in the twenty-first century. “Disease outbreaks don’t become pandemics” any more, he argued in Enlightenment Now, because “advances in biology … make it easier for the good guys (and there are many more of them) to identify pathogens, invent antibiotics that overcome antibiotic resistance, and rapidly develop vaccines”.

Pinker was not alone in his complacency. But complacency alone cannot explain the remarkably ineffective response of the US, UK and numerous other developed countries to the virus’s spread. The most Christakis can say in defence of the US response is that “vastly more Americans would have died – perhaps a million – had we failed to deploy the resources we marshaled, belatedly, in the spring of 2020 to cope with the first wave of the pandemic”. He himself was never one lightly to dismiss the potential lethality of Covid-19. And via his Twitter feed (@NAChristakis) he provided an exceptionally illuminating and learned commentary on the pandemic from its earliest stages. He was well placed to do so. Though Christakis’s first degree was in biology, he also holds an MD, a master’s degree in public health and a PhD in sociology. His recent books – Connected: The surprising power of our social networks (2009) and Blueprint: The evolutionary origins of a good society (2019) – established him as a leading authority on social networks and contagion of all kinds. If one graphed the social network of pandemic expertise, the node marked “Christakis” would have very high centrality.

But he is more than just a rare polymath in an academic world of narrowly specialized Fachidioten. Christakis is also a publicly engaged scientist with a notable aptitude for sharing his knowledge with lay audiences. He also possesses the quality – rare in academia – of courage. When, in October 2015, a crowd of Yale students surrounded and harangued him, demanding an apology for a perfectly innocuous public email his wife had sent on the subject of Halloween costumes and the transgressive origins of the festival, Christakis stood his ground, cordially listened – and somehow kept his temper.

In some respects, Apollo’s Arrow is an instant history of an event that is by no means over. This is a hard thing to pull off, but Christakis does it with aplomb. His account of the initial outbreak in Wuhan, which began on December 1, 2019, describes the uncertainty about the new virus’s origin, the local cover up, the lost weeks as the seriousness of the crisis slowly became clear to the Politburo, and the uniquely restrictive “lockdown” imposed not only on Hubei province but also right across China, beginning on January 23. He is a little too kind to the Chinese central government, in my view, and inexplicably says nothing about the shameful role played by the World Health Organization in swallowing Beijing’s early lies. But he is right that Chinese doctors acted with courage as well as competence. And much that we know about what happened in China is due to high-quality research by Chinese scientists.

Christakis’s account of Covid-19 is paradoxical. That the new virus would reach the US was inevitable. “Patient zero” returned to Washington state from Wuhan on January 15, but it was another carrier who first spread it. Numerous infected people were flying into the United States in January and February, not only from Wuhan but from other Chinese cities, from Europe and from Iran. No one knew exactly how many because the Centers for Disease Control and Prevention (CDC) failed utterly to expand testing in the way that its counterparts in South Korea and Taiwan did. This was the first of a woeful succession of failures of public health policy (which had their counterparts in the UK and Europe). Though much media commentary has placed nearly all the blame for the relatively high excess mortality in the US on President Trump, Christakis’s list of culprits is much longer: in addition to Trump, he singles out the governor of Georgia, Brian Kemp, who “explicitly banned cities and counties from enacting rules requiring masks”, and Vice President Pence, who “visit[ed] the Mayo Clinic … without wearing a mask while everyone else around him was wearing one”. Democrats also failed to act quickly, particularly in New York City and New York State. And, as Christakis makes clear, the public health bureaucracy was as much to blame as the elected politicians. “Our nation spends 17.7 percent of its GDP on health care,” he notes, “and this was our level of preparedness?”

What could the US have done differently? Clearly, it would have been better if the White House had not interfered with CDC recommendations on social distancing. Clearly, the president had no business endorsing what proved to be an ineffectual prophylactic (hydroxychloroquine). But, as Christakis gently hints, the administration of Barack Obama had not distinguished itself in 2009 when confronted by “swine flu” – which fortunately proved far less deadly than Covid-19 – and it failed utterly to contain the opioid pandemic, the death toll from which remains higher than the death toll from the new pandemic, and with many younger victims. Christakis clearly thinks that an earlier ramping up of testing and of social distancing would have saved American lives in 2020, though he is surprisingly ambivalent about digital contact tracing (contact-tracing apps, he writes, “do not offer enough epidemiological benefit to justify the privacy trade-off”). He ultimately concludes that the belated imposition of lockdowns “was commensurate to the threat posed by the virus”, even if viewed “strictly from an economic perspective”. I have my doubts about that conclusion. Research by economists as different in their approaches as Austen Goelsbee and John Cochrane suggests that Americans adapted spontaneously to the outbreak, with much social distancing preceding the official shelter-in-place orders. The debate on the costs and benefits of the lockdowns will not be over until we have a full accounting of their economic, social and health costs. The fact remains that there were alternative policy options that achieved better public health results at much lower economic costs, in countries such as Taiwan, South Korea and Sweden. Researchers at the Oxford Blavatnik School have shown the lack of correlation between the stringency of government measures and outcomes in terms of infections. The correlation between stringency and the magnitude of economic contraction is, by contrast, high.

Apollo’s Arrow has three great strengths. Firstly, Christakis clearly explains the nature of the virus and the disease it causes, and shows that social network structures and public policy largely explain the great variance in the pandemic’s impact from country to country. Because of the distinctive role of super- spreaders (the roughly 20 per cent of carriers who for various reasons conduct around 80 per cent of the spreading), controlling the proliferation of Covid-19 depends on testing, tracing and isolating the infected. As he shows, a laissez-faire approach that aimed to achieve herd immunity through uncontrolled spread almost certainly would have led to an intolerable number of premature deaths. (Though Sweden did not impose a blanket lockdown, it banned public gatherings and encouraged social distancing.) Given the high costs of containment, a vaccine will therefore be crucial, just as it was in controlling earlier infectious diseases such as polio and measles.

Secondly, Christakis does an exceptional job of comparing Covid-19 to other major pandemics in history. He chooses to go backwards through time, beginning with the two coronavirus epidemics (of SARS and MERS) that should have served as warnings to everyone and not just to the countries directly affected. Covid-19, he shows, is less deadly than these recent coronaviruses but it has “the ease of transmission of a common cold”. Our pandemic is nowhere near as deadly as the Spanish flu of 1918–19, as some (notably the Imperial College epidemiologists) feared back in March. It is much closer to the 1957–8 “Asian flu”, an episode now largely forgotten and which Christakis describes vividly, noting the crucial difference: the Asian flu killed the very young as well as the very old, along with a significant number of teenagers.

The third strength of Apollo’s Arrow is what it has to say about the future. On the social and psychological consequences of the pandemic, including the silver linings of markedly increased voluntarism and “catastrophe compassion”, Christakis fizzes with insights. Until 2022, he argues, “Americans will live in an acutely changed world – they will be wearing masks, for example, and avoiding crowded places”. This will be “the immediate pandemic period”, to be followed by an “intermediate pandemic period”, when “we either reach herd immunity or have a widely distributed vaccine”, by which point people will “still be recovering from the overall clinical, psychological, social, and economic shock” of what has happened. Not until 2024 will we reach the “post-pandemic period”, but even this will seem only a partial return to “normal”.

What will have changed? Handshaking will be a thing of the past, he conjectures, like spitting in the street. Telemedicine will be here to stay, as will a lot of working from home. Cities will likely be “duller, as many small retail firms go out of business”, and many smaller universities will close. Yet perhaps we shall eventually make it to our own Roaring Twenties, as those who survived 1918–19 did. “The increased religiosity and reflection of the immediate and intermediate pandemic periods”, Christakis suggests, “could give way to increased expressions of risk-taking, intemperance, or joie de vivre in the post-pandemic period.” Here’s hoping.

There certainly seems some chance that, after Covid-19 has been contained, the huge monetary and fiscal measures deployed to offset the shock of lockdowns could have inflationary consequences. Christakis foresees higher wages as a result of a political backlash against inequality. He also joins the many commentators who have argued that “the loss of American economic power and the lack of US leadership could create an opening for China to exert more influence”. My own view is that Western commentators are making the usual mistake of over-estimating the authoritarian competition and underestimating the American system’s capacity for self-repair. Let’s not forget where this pandemic began and why China’s one-party state took so long to admit the truth about it and take effective measures to protect the rest of the world, as opposed to the rest of China. Beijing is paying a price for this, as Pew’s recent report on China’s international reputation made clear. And let’s not exaggerate the scale of the American failure. The excess mortality rate in the first half of this year (23 per cent in the US) was roughly twice as high in Spain (56 per cent), the UK (45 per cent), Italy (44 per cent), and Belgium (40 per cent). Only in one of these four European countries was an incompetent populist in charge, suggesting that incompetent populist leadership may not be the crucial variable.

Of course, this pandemic isn’t over. As Christakis notes, the experience of past pandemics should have led us to expect more than one wave, as opposed to a single curve that had to be flattened. “We are likely to reach an attack rate of roughly 40 to 50 percent by 2022 no matter what we do”, the author concludes. If the infection fatality rate is 0.5 per cent (by no means the maximum estimate in the current literature), that implies at least 660,000 Covid-19 deaths in the US, three times the total to date. Lord Rees has won his bet, and Apollo is still shooting his arrows.

Niall Ferguson is the Milbank Family Senior Fellow at the Hoover Institution, Stanford University, and a senior faculty fellow of the Belfer Center for Science and International Affairs at Harvard. His next book, Doom: The politics of catastrophe, will be published in May 2021

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