“COVID – Three Years Later: Looking Back, Part Two” – with Emily Oster

Dr. Fox: Welcome to the “Healthful Woman Podcast,” the fastest-growing podcast in women’s health. Today’s Monday, April 24th, 2023. As you all know from our podcast two weeks ago, we recently celebrated the three-year anniversary of the “Healthful Woman Podcast.” In honor of this milestone, I asked our very first guest, Emily Oster, to come back and talk about COVID, where we went right, where we went wrong, and what lessons we can learn for the future.

Last week was part one of the podcast, and this week is part two. So, if you have not yet heard last week’s podcast with Emily, be sure to listen to that one before this one. Last week, Emily and I talked, in general, about looking back on COVID, and today, we’re gonna talk about specific things like lockdowns, masking, school closures, and vaccines. Thanks, Emily, for being our first guest and for always agreeing to come on the podcast. We do appreciate it. Reminder for all of you listening on Spotify or on Apple, we would appreciate it if you could rate this podcast, preferably with five stars, and leave some comments. Thanks for listening. See you next week.

Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness.

All right. So, let’s get to the nitty-gritty here. Let’s talk about specific decisions, first specific decisions that were made to sort of reduce either infection or the spreading. The first I wanna talk about is lockdowns. So, what are your thoughts looking back on all of the lockdowns that happened, particularly in the first year or so?

Emily: Yeah. I mean, this is a…that’s, like, a pretty loaded question.

Dr. Fox: That sounds like “60 Minutes” here. All right. Well, you could answer it any way you want. We could talk about it any way you want.

Emily: I think what’s challenging about this question is that it is much easier to sort of think about optimization in hindsight than it was in the moment. And even in hindsight, I think it’s difficult to be certain about what was the right choice and the set of options that were actually available to any individual sort of location or setup were very different. So, I almost think this question is unanswerable. I almost think it’s unanswerable.

Dr. Fox: I think that’s fair. I think that it’s…the reason it’s such a tough question is I think that this was the…this is the thing that really initially affected everyone’s lives. And, you know, everyone says, “Listen, we got this virus, we don’t know what’s going on. It seems to be pretty dangerous. Like, stay home. Like, don’t get infected, don’t go out, don’t be around people.”

And I think that that made a lot of sense and it makes a lot of sense sort of in the initial stages. I think that part of the reason it became such a controversy is not the initial decision. I think it’s sort of all those subsequent decisions, which is, okay, you know, we’ve done this for two weeks, for three weeks, for four weeks, which, you know, again, we were told was meant to, like, flatten that curve, that not everyone gets infected at the same time. Even if you’re gonna get infected, let it spread over time.

And then all these decisions about, okay, now what do you do? And who makes those decisions about when can you go out, who can go out, for how long can you go out? Why is someone allowed to tell me not to go out? How can they say this person can go out and I can’t go out? And that sort of gets to become very complicated and people got very angry over that. And the reason I think about it is, I happened at the time and in hindsight to disagree with a lot of the rules, but okay, that’s fine, no big deal. I don’t know what we’re gonna do moving forward. Like, is the experience that we had with lockdowns one that’s gonna make everyone think, “Great idea, let’s do it again,” or, “Bad idea, let’s not do it again?”

Emily: I think it will make people think both of those things. I mean, in a sense, this is maybe one way to articulate why I think this is so hard is that it is very difficult for people to make decisions which have significant downsides. So, when we are making our choices, we usually like there to be a choice that we think is good. And this is a place where there are no good…there was no good option, right? There was like no…

I mean, sometimes I talk about this as like there’s no secret option thing. Like, there was no, like, secret option that meant nobody got COVID and everybody got to go about their regular life. Like, that just, like, wasn’t available. And so, every choice here was hard and had some significant trade-offs. I think part of what made these conversations so challenging is that people were talking about their preferences without talking about the fact that what they were saying was that they were weighing these trade-offs differently.

And instead of saying, “You know, I see this trade-off this way, you see it this way,” it was, “You know, you wanna kill people.” Well, actually both sides, you know, you wanna kill people. And so, I think that made the conversations, like, you know, difficult to have in any objective way. And I understand. It was, like, an extremely broad time. I’m not criticizing people’s, like, desire to have angry conversations, but I think it got in the way of thinking about this carefully. My guess is that the kind of overall picture will be…would produce fewer lockdowns in a future pandemic, maybe some optimally fewer. I’m not sure.

Dr. Fox: Yeah, no. I also don’t know how I feel about it. I am sure that the lockdowns saved some lives, particularly those who are elderly and you know, really just stayed away from people. And I’m sure it kind of ruined some lives in terms of not so much, like, lethality in the same way, but people’s businesses or people’s social structures and, you know, people’s mental health. And it is pretty tough. I think that maybe the experience will let us fine-tune it a little better the next time around in terms of timing, in terms of exactly who.

This is really the first time I can think of, at least in my lifetime, that this really happened. And so, I think it was really one of those, like, kind of all or none phenomenon. And I agree. And I do think that that’s probably the hardest. I think some of the others…because that’s why we don’t really have data. It’s hard to have data on that so much.

I mean, you could look at states that relaxed earlier versus other states and it didn’t seem to make a huge difference. But pretty much everyone locked down for the beginning and that was really the most critical time period. And so, it’s hard to know what would’ve happened if a certain state didn’t lock down at all, ever. Like, what would’ve happened there? We just don’t know in that sense, because it was always done, at least initially. The differences were really sort of after that initial wave, how and when, and for whom did people relax those lockdowns.

It didn’t seem to make a difference in retrospect. Like, the states that were different, the countries that were different, all the strategies seem to end up with similar infection rates and mortality rates. But I don’t know, it’s tough stuff. I do think though that social distancing is an interesting thing that is probably going to fall by the wayside moving forward. I don’t know if you have any thoughts about that.

Emily: I mean, social distancing and hygiene theater turned out to be, like, two things that were wrong. And I actually…I think it’s completely understandable why we got into that place because, you know, like many of these things we were thinking about this like flu and that those absolutely would’ve been effective and, in effect, were quite effective metrics to get rid of the flu. That’s why we didn’t have any flu during the pandemic were very low, low levels. But it turned out like those just…that was just not…that was not true. Like, those were not… Because of the way that COVID was spread, because it was airborne in, you know, a particular way, actually, like, standing six feet from somebody is really not very helpful. You’ll get the flu.

Dr. Fox: When I think about social distancing, it was predominantly comical. But whatever. It was an interesting and odd experiment that I agree is probably not gonna happen again for something like this. Masking remains a controversy so much later and people are still disagreeing on this. I think part of the reason the data is interpreted differently by different people is it depends on the mask.

For example, in the hospital, once everybody got the N95s and wore them well, pretty much none of the healthcare workers got infected. They really got infected prior to that. The N95s were extremely effective if they were worn at all times, sort of in the proper way. And that was born out sort of in hospital workers. But sort of all the other masks out there did not seem to stop the spread of COVID, unfortunately, and they’re still quite ubiquitous.

Emily: Yeah. I mean, I think part of what’s hard about the masking data for people actually even in the kind of in some of these studies and sort of how people interpret them is there is an important distinction between the question of like does a well-fitting N95 mask work to protect you from viruses? To which the answer is yes. And were mask mandates an effective approach to this? To which the answer is, you know, at least based on the Cochrane Review, you know, probably no or, at most, very, very small effects.

And, you know, the reason for that is of course, like, there’s a difference in uptake and there’s a difference in the kind of masks. And so, I think what’s harder…what I always find hard about this conversation is I think almost people are talking past each other, that there’s a set of people whose view is, like, basically if we force everybody to wear a well-fitting N95 mask all the time, that would lower transmission rate. I think that’s probably true, but that’s also, like, impossible to achieve.

And so, when we’re trying to do policies in the world, we can only do policies that we can actually achieve. We can’t do, you know, imaginary policies. And so, that… But on the other hand, like, if you are really, really concerned about protecting yourself from COVID and you are willing to wear an N95 mask at all times around other people, like, that is gonna lower your risk of getting COVID. So, I don’t know.

Dr. Fox: Yeah, no. I mean, I think that was part of, you know, the argument against masking policies, was they’re not that effective because not everyone’s gonna adhere to them properly. And then you start getting into the whole, like, policing the masking, which is, as a whole, separate layer of problems and anger and, you know, in both directions.

But ultimately, for the people who were really in favor of masking and masking policies and were very upset for the relaxation of masking policies, you know, I was involved in some of these decisions at work and, you know, sort of my community and the thing I never understood, I said, “Well, if you’re so concerned and you really want the mask, just put on an N95 mask. Like, just walk around with one, and then you’re basically protected.” And at the time, you’re also vaccinated and it’s like it shouldn’t matter to you if you’re vaccinated and sitting with an N95 mask if the person next to you has a mask on or not. It probably won’t make any difference whatsoever. And so, people have a hard time, like, understanding that conceptually that those are both true, that, you know, your mask can protect you and it doesn’t matter so much if the person next to you has a mask on or not and it’s not worth yelling at them about it.

Emily: Yeah. And I think it became…and the other thing is this became a sort of marker of a sort of particular…became a marker of type, like a social signal in a way that, in either direction, became a social signal in a way that, you know, was served by the polarization of one of these topics.

Dr. Fox: Yeah. I’m Jewish and I always…I said, you know, those wearing the mask, it’s like wearing a yarmulke. It’s like, “I’m a believer. I got it, you know. It’s on my head. Here we go.” And it’s sort of like the same way with the mask, “You know, I’m one of you, I’m one of the mask people. You’re not one of the mask people,” and I’m opposed to that concept. I think that that’s a problem when people use it to sort of indicate who they are. I think it’s much more helpful if you really think it’s gonna help. Now, let’s talk about schools because I know this was your passion and we spoke about this early and often and I know that you wrote about it a lot. So, here you go, here’s your chance.

Emily: I mean, I think that… So, here’s what I would say. I think it was very understandable that schools were closed in March of 2020. I am not sure if knowing what we know now, that we necessarily would do that again. If we said, you know, we’re gonna go back to the beginning. It’s exactly what…you know, COVID is exactly what it is, I’m actually not sure that I think it would be a complicated question. But I think, at the time, in March of 2020, it was absolutely understandable that that was a choice that was made. We didn’t really know what was going on.

I also feel that in September of 2020, we should have opened all of our schools. We should have done whatever is the appropriate, you know, the best amount of mitigation that we could have, better ventilation, whatever testing we could ramp up would be great. But we should have had kids in school and we should have had them in school even if we couldn’t do those things. Because the reality is that the risks, and we knew this, I think we knew this, at least a lot of this by spring, by September 2020, that the risks to kids in school were low.

We knew it from some European data, we knew it from some things that happened with camps. We knew it from some schools that had remained open. Like, I think we should have understood this. And I think we should have understood better at the time that the downsides to kids from being out of school were very large. My instinct is we will look back on this as one of the biggest mistakes that we made in the pandemic.

Dr. Fox: Yeah, I agree. I think the masks, for example, if we think it’s a mistake, it was an annoyance to maybe wear a mask we didn’t have to, or, you know, try to mandate them when it was sort of impossible. But this with the schools is much more than an annoyance. I mean, there are kids who literally did not learn for a year, could not learn for a year or more, and are behind. And that’s just the academic side.

Then there’s a massive social impact on kids who are out of school and didn’t have the socialization that they would have normally had. And there’s a mental health component to it, to being isolated, to being alone for anybody, but also for children and for teenagers. And I think that we don’t know what the long-term effects are gonna be of all these things, but we have to know that there are gonna be long-term effects for a significant number of kids who went through this for X amount of time. And it’s a problem.

Emily: Yeah. And I think it’s…I mean, there are kids who dropped out who aren’t gonna come back. I mean, this is something that is a…I think a generational effect. And, you know, I don’t wanna… I think there are things we can do to try to make this better to sort of catch this off the stem, but, you know, it’s not an easy…this is not an easy fix problem.

Dr. Fox: Yeah, it’s tough. We’re still working back from it. I mean, I think that the schools that were able to open definitely have an advantage. And I think that there’s definitely some annoyance that people had with their schools, like whether the schools required masks or didn’t require masks. But ultimately, there were some schools that basically remained closed the entire time and that was a big deal. I mean kids on Zoom for example, for a year, I just think that it’s…there’s so many downsides to that. It’s even hard to enumerate them.

Emily: And I think this is a…some of this is a little bit lost in some of these conversations. We’ll occasionally see people say, “Well, I don’t know why everybody thinks there’s a big deal about this. You know, your school is closed for two months.” Like, no. Like, if you were enormously lucky, you know, maybe half the country or something, your kid’s school was closed for two months, and then in September, they went back. And whether they were wearing masks or other things, like, they basically went back fairly…you know, fairly normally.

But there are districts, there are kids in the U.S. who did not see the inside of a classroom, who could not have. Not just that their parents chose for them not to, but like they did not have the option to be back in a classroom from March of 2020 to September of 2021. And, you know, you can’t have Zoom first grade. Like, nobody learned Zoom first grade. That’s not a way that we teach kids. And so, I think it’s just…so just that’s a lot of time.

Dr. Fox: Yeah, no I agree. The last thing I wanna talk about are the vaccines. And I think that there’s sort of a few subcategories and I think the simplest one, which I think was a huge win, was the development and production of the vaccine. That was so rapid compared to what we would’ve predicted. And I think that it was a massive success basically from the time the pandemic hit to have a vaccine available for nearly everyone within a year is almost unheard of with other vaccines. It was really, like, so much faster than you would’ve guessed.

Emily: I mean, it was extraordinary. So, I heard at some point, Bancel, the Moderna guy, on a podcast where he explained that they had the vaccine before the first case was identified in anyone in the U.S. Like, as soon as they had the sequence from China, which happened in January of 2020 before anyone in the U.S. had COVID, as soon as they had that, they had the vaccine. It’s the same vaccine that, like, went out in, you know, December of 2020. And I mean, that’s just an absolutely extraordinary technological feat. And just, yeah, like I think not to be forgotten in terms of, you know, how many lives were saved and just in general how impressive that is from a client, which is like, it’s very cool.

Dr. Fox: And also, I think that it has to be stated with pretty much medical certainty that the vaccine worked in terms of reducing the risk of severe infection and death. I mean, people who got vaccinated were much less likely to have severe infection and to die. And this was basically true across the board. It was more pronounced in people who were at higher risk, right?

So, in the elderly, you know, people with medical conditions, since their baseline risk of severe illness and death was much higher then if you lower it, you know, by X percentage, it’s gonna be more evident, whereas, like, let’s say in a teenager where their baseline risk is very, very, very low, it’s hard to sort of prove that it makes it lower. But, basically, across the board, the data was that it lowered your risk, and that was really quite impressive.

Emily: Yeah. I mean, I think the… And that protection was pretty…has been quite durable actually. So, the protection and in serious illness and death of, you know, having a sort of full complement of shots has seemed to be fairly durable.

Dr. Fox: Yeah. I remember the time we were talking about the vaccines, there was a question that we had which was about transmission, right? And the question was, okay, so how does the vaccine work? Does it prevent you from getting the virus or does it, you know, somehow kill all the virus on you, in which case you will not transmit it? Or does it work such that you’ll get the virus, you’ll have the virus on you, but you won’t get sick from it? And we said, in which case, you’re not gonna prevent transmission, you’re just gonna prevent illness. And it wasn’t really known at the time.

And I think that, like we said earlier, one of the big mistakes was that very early on, the sort of marketing or sort of the messaging was not only does this prevent you from getting very ill, it’s gonna prevent you from passing on the virus to your loved ones and to your community, which was not really proven, and has been shown not to be correct actually. But it wasn’t proven at the time. It was sort of theorized or, you know, it was possible that that was the case. You know, it’s not unheard of that that could be the case, but it wasn’t.

And I think that that’s where a lot of the skepticism came about, especially because if the first is true, that it prevents you from getting sick but doesn’t prevent transmission, then really it makes a lot more sense, like, all right, personal choice. You know, you want to get a vaccine and not get sick. I think most people would, right? Fine. But if the second is true, and not only do you not get sick, but you don’t get everyone else sick, now it’s like, all right, you don’t get a vaccine, you’re a bad person because you’re killing everybody. All right. You’re walking around giving COVID to everybody. And I think that that is part of the reason it got so ugly with the vaccines and the mandates and whatnot.

Emily: Yeah. I think that’s right. I mean, one of the…you know, we talked earlier about this pandemic amnesty piece that I wrote, and one of the things that a lot of people wrote back to me was, and I didn’t read most of these because they contained death threats. But when I did read the parts that were not like that, you know, one of the things that really came out was sort of the feeling of, like I lost my job because of this vaccine mandate. And the motivation for that was that, you know, I was going to be a risk to spread to other people. But actually, it turned out, like, I am no more a risk to other people than, you know, somebody who is vaccinated. And so, that is like…that is unfair.

And I think that…I think there are…you know, there potentially are reasons for mandates, but that turned out not to be one of them. And, you know, the reality is that the case for a mandate in general, like in economics, the case for a mandate of anything is based on externalities typically. So, we usually like to mandate things when there is an externality reason, when there’s some reason why your behavior would affect other people. Without that, it’s much harder to defend sort of forcing people to do something if the main beneficiary is them.

Dr. Fox: Yeah. I wasn’t a big fan of the mandate for a few reasons. First, I just thought that from a strategy, it really… When you make people sort of dig their heels in, it’s a lot uglier than if you just sort of like, “Okay. Listen, here’s a vaccine. It’s available for everyone, it’s free, come and get it. It works. Don’t get COVID. You know, great thing.” But that was my first problem with it.

But I get it. If it’s something that’s really gonna reduce infection amongst everyone else, like, there’s some sense to it. But the data was poor on that. And also it did not take into account people who had antibodies from getting COVID and it wasn’t clear, you know, in those people, was the vaccine, again, gonna protect them or others any differently.

And I thought that one of the real sort of sad ironies that occurred, at least in New York, when the pandemic first hit, all these healthcare workers, the essential workers, the heroes, right, who got applauded every day because the nurses, the doctors, healthcare workers, everyone in the hospital, literally there was a…every evening, they got applauded at 7:00 at night because they were the ones going to the hospital and taking a risk. And many, many of them got COVID.

These are the same people who then all got fired for not wanting to get a vaccine as a mandate after they already got COVID. And it’s like, so all the heroes are now the criminals. And it was just such a…it was such, like, a bad taste that it left. You know, even if you could kind of logically come up with a reason why might be the way to go, it just…it has such a bad look to do that. And a lot of people left town, a lot of people quit, a lot of people got fired, a lot of people moved states. And I just think that there’s a lot of resentment left over because of that. And it’s unfortunate because it really wasn’t based on great data. And that’s really…that’s, I don’t know, that’s a big problem, in my opinion.

Emily: I mean, I hear what you’re saying. I think the flip side of that is, like, there wasn’t any reason not to get vaccinated. Like, so I think maybe we fell down on explaining to people the benefits of being vaccinated. And maybe your view was like, well, actually, like, there really aren’t that many benefits if you’ve already had it and you’re young and so maybe that’s…you know, maybe that’s true. But I don’t think that there was a lot of evidence of cost either. And so, somehow there was a…I mean, I guess what I would say is I can see why people would turn to mandates if you thought it would help people protect themselves.

Like, to give you the other side. So, if you think about, like, mandating vaccines for kids in school. So, we do that even though, like, most kids are vaccinated, we make all the kids get vaccinated. And that’s, like, for some externality reasons, but it’s also like we think it’s good for them. And it turns out when the best way to get kids to do that is mandates, at least in, you know, some places like in California had some kinda opt-out.

They basically turned to a mandate and then all these schools that had 35% of kids with the measles vaccine, now they have 89% of kids with the measles vaccine. So, I mean, mandates do tend to move behavior. I actually don’t think they moved it much in the case of COVID, which was very different than what we might have expected from other settings.

Dr. Fox: Yeah. I think part of it is, again, just sort of the way it rolled out. I think that, you know, measles and whatnot have been…these have been very slow developing changes over time and I think most people will get on board with these things when it’s a little more deliberate and thoughtful and, you know, they get to go through their process versus, “We have a new vaccine, you have to take it.” And that just is very jarring for people. And I get it.

Again, were it something that would prevent transmission to others and prevent other people from getting sick, like, I understand the reasoning, but it’s not the same as someone who’s thinking about a measles vaccine, which has been around forever. And I just think that when it happens like that, like, literally. We have a new vaccine, it’s now approved, everyone has to get it. That’s just a very shocking thing for a lot of people.

I mean, for me, I was great. Like, let’s do it. You know, signed up. My kids got it. I don’t have a problem with it personally. I was all on board. I got vaccinated, got boosted. I think it’s great. But I can see why a lot of people who are just maybe more skeptical by nature with these things were very squeamish about it and then put their foot down and then you develop, like, a swell where you find your people online who agree and then it just…then all the conspiracy theories come out and then it just goes bananas, obviously.

Emily: And I think it’s right that we didn’t always meet people where they were on this and that there was a lot of, like, messaging that was in this space of, you know, if you don’t wanna get this vaccine, are you some kind of like dumb-dumb? As opposed to saying like, you know, I hear your…I hear the things you’re concerned about, can we try to like…can we try to talk about them? And maybe if we had taken more of that tack at the beginning, we might have made more progress with more people.

Dr. Fox: Yeah. Nope, I agree. All right. Well, it is good to be here three years later rather than there three years ago. I do feel that, again, this isn’t behind us, obviously. There’s a lot of PTSD from this. There’s a lot of repercussions from this. There’s a lot of people still very angry about this. But I do think that the more time we have sort of in normalcy or semi-normalcy, it is gonna become something we can, like, think about and analyze a little bit closer and maybe develop more strategies as a country, as a community, whatever, for the next one that hits. And hopefully, that’ll never come, but if it does, hopefully, it’ll be a little bit more, I don’t know, evidence-based and sane the next time around.

Emily: I hope so.

Dr. Fox: Well, hopefully, you’ll still be around to write about it and keep us updated.

Emily: Yeah. Let’s see. Let’s see what, I hope. But yes, yes.

Dr. Fox: Emily, thank you so much for coming on the podcast. Thanks for being my first guest. Thanks for always agreeing to come on when I ask you. I know you have a busy schedule. And my listeners love hearing from you, so I really do appreciate you taking the time.

Emily: I always like to talk. Thank you so much for having me.

Dr. Fox: Thank you for listening to the “Healthful Woman” Podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s H-E-A-L-T-H-F-U-L W-O-M-A-N.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@healthfulwoman.com. Have a great day.

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