“Covid, two years later: Looking back and looking forward” – with Emily Oster

Dr. Emily Oster and Dr. Fox review their predictions about Covid-19 from the pilot episode of Healthful Woman. They review how things have changed, the unknowns that remain, and the mistakes and successes we’ve seen in the past two years.

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Welcome to the Healthful Woman Podcast, the fastest growing podcast in women’s health. Today is Monday April 11 2222, in honor of our we decided to drop both with Emiy Oster. Emily was our first guest in the land of corona. It was interesting to hear about our conversation two years ago when Emily agreed to come back
Where did we get it right? Where did we go wrong? And finally when can I take my mask off an airplane? Lots of good stuff.
As a reminder to you, we have a second podcast that drops, called High Risk Birth Stories. If you enjoy this podcast, you’ll probably enjoy High Risk Birth Stories as well. Enjoy any of the older episode, etc.

Dr. Fox: 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. Emily, welcome back to the podcast. Our favorite guest, how you doing?
Emily: I am good. I love to be here.
Dr. Fox: You were the first guest on the podcast, “The Maiden Voyage,” the very first guest two years ago. Last week, as I told you offline, we did re-drop our first podcast so people can hear our predictions about COVID. Now, people don’t do that. Like sportscasters, they don’t go back and, you know, say, “Oh, this is what I predicted for the NFL season.” Because they’re always wrong but we were right. We nailed it. Good work.
Emily: And that’s why we’re re-releasing it.
Dr. Fox: Yeah. And we said, “Nah, this COVID will be gone in two weeks.” We would never re-drop that. So it’s interesting. I mean the things, you know, we when speaking about it, I know that you have had a lot of conversations in your life about COVID in the past two years. So you may not remember this one in particular, but clearly, there’s some things that are very different now compared to then. I would say most notably the vaccines, which is a game-changer obviously. But the interesting thing is, you know, I was listening to it. There was arguments, you know, about masking, about lockdowns, and restrictions, about, you know, data surrounding who gets it and who doesn’t. And this is like two weeks into it. And now we’re two years into it and we’re arguing about the same things.
Emily: True. Although I was reflecting on sort of how the spring of 2020 felt relative to now. And on the one hand, I’m constantly thinking, “I wish we knew more now.” Like, we could have better data. There’s information that we’re missing, but that reflection also reveals there’s a lot that we know now that we didn’t know then. So we did the same hike that we had done sort of in kind of March of 2020 last weekend. And my husband was reminding me that when we did that a hike in March of 2020, like, everyone was wearing a mask outside on the hike. And like, at some point we encountered some other, you know, small child and my then four-year-old yelled, “Social distancing.” When the kid got too close. And so I feel like, okay, look, we have sort of evolved some of our understanding since then about things like outdoor transmission but there’s a lot we don’t understand. And as you say, a lot of these debates feel like the same debate that we were having two years ago.
Dr. Fox: Yes. I’m curious. How do you feel about COVID now compared to let’s say a year ago when the vaccines were first coming out and two years ago when it was just starting? Like, what are the major things that you think are, you know, different and how you think about it?
Emily: I think that the enormous uncertainty that they inhabited basically every moment of the sort of March of 2020 seems dialed down. I will say relative to March of last year, in some ways more existential angst or worry about the long-term effects of the pandemic. You know, I was looking at my vaccine card for something. I got my first dose of the vaccine on March 11th and my second on April 1st of 2021. I sort of remember that moment as feeling like, “Okay. Like, we’re gonna move to the next phase.” Parts of that feel true now. I mean, I think even more true because vaccines are better and because more people have natural immunity and all kinds of other things. We have better treatments. But I think it’s coming into focus very much for me all the ways in which society is going to be experiencing the impact of this pandemic for a very long time. Not just the impacts of the people that we lost but the impacts of some of the social breakdown. So in that sense, I almost am more worried even if I’m thinking less about the virus if that makes sense.
Dr. Fox: Yeah. I mean, what do you mean specifically by the social impacts? You mean like school closures and sort of that type of stuff?
Emily: So yes, sort of. So I mean, you know, the impacts of school closures on kids but I also mean the mental health impacts of this kind of state of heightened alert for so long and the conflicts that have arisen about how people are dealing with this. And, you know, maybe I see more of this or you and I see more of this because of where we are. And so I sort of wonder if I were in a place that had been less COVID careful like, you know, Oklahoma or North Dakota, like, maybe I would not feel like this. But here it feels very much like, you know, as my kid’s school takes off their masks, we sort of reveal the vision, the frisher [SP], whatever the word I’m looking for. We reveal the fractures between the people who are not ready to do that and the people who are. And those reflect a lot of other fractures in society and I don’t know, feel very anxiety-provoking.
Dr. Fox: Yeah. I mean, I remember talking about this, I mean, probably about a year ago, plus how when the virus came out, it’s a serious situation, obviously. Like, this is like a big deal. This virus. Like, it was not to be ignored, right? It was very dangerous to people. A lot of people died. It had a really, really big impact. And so sort of at the beginning phase, the messaging is always focused on, we need everyone to know that this is serious. And so all of the messaging is focusing on the dangers, the dangers, the dangers, and that’s both on a sort of strategic level, from healthcare, from government. You know, people need to know that like, you guys stay indoors or you could be, you know, killed. You know, like, these are really important. And then sort of the media picks up on that. Well, this is like, this is big stuff. This is juicy.
You know, everyone focuses on all the horrible dangers of it. And while, you know, there’s reason to do that, obviously, because maybe it’s gonna save lives, maybe it’s gonna get people who wouldn’t otherwise take it seriously. You know, I think of the movie “Independence Day,” when these big aliens are hanging over city and people are like partying underneath the ships and [inaudible 00:06:19] “Dude, this is not safe. Like, get out of there.” And so there’s importance to that but there’s a massive, massive repercussion to that in that you’re gonna freak people out forever. And so when people think they’re gonna drop dead if they get near the virus, yeah, there’s a lot of people who are gonna never wanna take off their mask. And there’s just no getting around that. It’s very hard to balance making people aware of how serious this is with, okay, maybe there is a time when we could take off our masks and go on side and shake hands and hug again. And since there’s, you know, so many people who have different, you know, psychologies, you’re not gonna get it right. And some people are gonna be not scared enough and something are gonna be too scared.
Emily: Yeah. And I think part of what I find a little, you know, frustrating about some of the messaging that sort of some of the evolution of the messaging is there is a sense in public health sometimes that we have this one lever, which is trying to make people say things seriously. And that’s a lever that we use with frequency and a lever we’re very comfortable with. And when we observe population at large not doing all the things that we think would be important, there is a tendency to just ratchet up that lever. But what happens then it is that the people who are already very anxious are then doing more. Whereas the people who weren’t listening in the first place are not listening any more than they would. And that’s how you get to a situation where there’s a lot of people…You know, and this was true certainly, maybe it’s less true now because so many people had Omicron but the sort of in the kind of period in which we were sort of pre-Omicron, there was a real opportunity for a lot of people to get vaccinated. And getting vaccinated really would’ve saved a lot of people from dying. And yet the messaging, in whatever way the messaging came out, one of the results was those people didn’t get vaccinated. But some people who were already vaccinated a bunch of times became afraid to, you know, leave their house again and are still afraid to leave their house or to go to the grocery store or to eat inside a restaurant. Even though at this point, you know, those risks are really small.
Dr. Fox: Yeah. That’s really interesting. I agree with that, that people are already fearful of getting more fearful. And I think one of the other are things is, and this is something that you mentioned again two years ago when the pandemic was just starting, was that one of the issues with restrictions is there’s almost like a breaking point that you can sort of do a certain amount but once they get too restrictive, people then blow it off. They just say, “I’m not doing any of this stuff.” And so if you give people sort of like a small endorsed reasonable restrictions, you may get, you know, people are gonna follow you. They’re gonna, you know, comply or whatever it might be. But if you say, “All right. You can never leave your house for the whole year.” People are gonna say, “All right. Screw it, I’m leaving. I’m walking out.” And it’s hard because you have to know exactly where the right point is. And I do think that we probably as a society went overboard and that’s same thing. Like, why did so many people not get vaccinated? And I think, you know, there’s always conspiracy theorists but they’ve always existed. We’ve always had people who didn’t vaccinate and they were this small segment of society. But I think once the government comes in and says, “We’re gonna mandate it, everyone’s getting it. We’re going door to door and inoculating people.” People dig their heels in and they’re like, “Nuh-uh, not me.” You know, and then it becomes a fight as opposed to just, “All right. Listen, we think everyone should get vaccinated. It’s available everywhere.” I think the numbers would’ve been higher.
Emily: I agree with that. I mean, it’s hard to know in some sense, if I think about sort of the two biggest failures, the two things that we did, you know, that we should have done differently or could have gone better, I guess. You know, one is testing infrastructure, which took a very long time to sort of ramp-up to where we needed it to be. But the other is the kind of not the development of the vaccine, which was extraordinary, or the initial rollout, which I thought was very good, but the way that it got politicized. And I’m not sure how much of that was an error of messaging or how much of that was, you know, the fault of, you know, particular individuals. But I don’t think that pushing people or shaming people wasn’t especially helpful message. I also think, you know, the reality is that there’s a lot of variation in risk across individuals. And we probably did too little boosting in nursing homes and too much emphasizing of, you know, additional doses for like lower-risk groups. That feels to me like a continuation of a failure we had all along, which was not taking the age gradient enough into account. Not recognizing that the number one comorbidity for serious illness from COVID is being old. Just like that’s just so vastly the number one above any other thing. You know, that often didn’t get as much attention as it should.
Dr. Fox: Right. And we knew it immediately because again…
Emily: Immediately.
Dr. Fox: …we were talking about this, you know, in the end of March of 2020, like, literally like, risk factor being older. And in terms of everything, vaccinating, in terms of restrictions, masking, all these things, when you do it, you know, to everybody, again, some people you’re not doing enough and other people you’re doing too much. And, yeah, I agree. I think that was a pretty big mistake and it wasn’t that hard. I mean, it’s not so hard to differentiate by age, right? Everyone knows their age. It’s not that complicated.
Emily: No. One of the most interesting things that happened in the pandemic was looking at the initial rollout of the vaccine across states. So, you know, if you think about back to, you know, a year ago, a little bit more than a year ago now, when states had to make decisions about who to prioritize for vaccinations, there was a lot of distinction between, you know, were you gonna prioritize people who had, you know, a lot of in-person contact or older people, and how were you gonna titrate that? And I remember talking to, you know, one of the most impressive people I work with in the last year who was the kind of head of everything COVID-related for the State of West Virginia. Who, basically, I think knowing that he was gonna get a fair amount of kind of vaccine resistance and they had a huge amount of hesitancy, he went in initially with just this message of like, old people, old people, old people. And just telling people, you know, like, “If you’re 80, like, your risk is, you know, 1200 times as high as someone who’s 20.” You know, and just emphasizing that over and over again and kind of getting at their nursing homes that actually their initial vaccine rolled out to old people was really extraordinary. Then they ran the kind of left, right bent on their state and things went worse but it was initially good.
Dr. Fox: It was initially good. I’m curious, does the virus concern you moving forward?
Emily: In the same existential sense that I think it probably concerns almost everybody, which is like we could get a new variant, the new variant could be different. I will say that the virus has evolved tremendously since the sort of wild type. And it’s kinda amazing that the vaccines, particularly the mRNA vaccines and, you know, prior infection has provided such good protection in serious illness, even in the face of vaccine, the virus may just suggest that like, T-cell immunity is pretty good. That like, the sort of COVID funding appears to be disappearing, which seems, like, bizarre given that like, all-season of respiratory viruses. We should expect to see a spike in the fall and winter of next year. I mean, even without a new variant with waning immunity, everything else, I mean, that’s gonna happen and it probably would be good to be like, prepared, I think.
Dr. Fox: I don’t know. That’s the girl scouting. You coming out.
Emily: Yeah. Exactly. I know, I was like…
Dr. Fox: It’s probably good to be prepared. Someone said that once. It’s so interesting. I think that Omnicron in a certain sense was kind of like a big bummer because its variant came out and all these people are getting COVID, even those who had it before, even those who are vaccinated, even those who are young and healthy. But on the other hand, I think it really shifted so many people’s perspective about the virus to, “Oh, like this could be something that behaves like a cold, a flu, where a bunch of people get it and then a blows through and most people are perfectly fine afterwards.” And I think that it actually kind of, you know, people like loosened up a bit after Omnicron went through and it wasn’t the same thing as like the Delta wave last summer.
Emily: Yes. I think at that point, also a lot of people who had been very, very cautious leading up to that point who had effectively done, you know, everything, like had been really cautious about avoiding the virus, had been, you know, boosted and fully vaccinated and everything then got it. And I think it partly sort of reveals some of just the inevitability of respiratory viruses. And I think partly it revealed to people that, “Okay. Like, you know, I’m lucky there was a frame there, which was like, I’m really lucky that I was vaccinated and also, you know, this happened and like, it wasn’t great. You know, I had COVID, it was like not a great week but it was okay. It behaved sort of like a flu, maybe a mild flu.” And I think that that changed a lot of people’s mindset around both the inevitability and just, you know, the reality of what it would be like once you are vaccinated.
Dr. Fox: Yeah. I mean, listen, we’re in the hospital, 100% of people are vaccinated and wear masks and it blew through the hospital. I mean, so many people got Omicron. For the six months prior, no one got anything. And it just shows you that there’s only so much you can do for these things. I was on a flight. I flew to Israel last week and the whole process I’m like, “What are we doing here? Like, who is in charge of all this? This is like the most ludicrous thing ever.” Everyone, before they got on the plane, has to get a PCR test in the U.S. All right. Fine, you don’t want someone get on the plane as active code, whatever. I mean, okay. Everybody on the plane has to wear a mask the entire time, except when you’re eating and drinking because at that time COVID can’t be spread.
Emily: COVID actually does…It knows if you’re eating. Yes.
Dr. Fox: Yeah. When they serve the drinks.
Emily: I mean, COVID knows that’s really the [inaudible 00:16:39]
Dr. Fox: Yeah. It’s a break. It’s like when you’re playing tag. It’s like a safety, you know. And it’s like, “No, no, I’m on safety. I can’t be tagged. I can’t be hugged.” Same thing like the airport, everybody does wear masks in the airport, except when all the people are sitting down and eating. So 20% of the people in the airport don’t wear masks on. You can’t get COVID that way. And then we land in Israel and you have to get a PCR when you land so that you’re not in lockdown. And then to come back to the U.S., you have to get an antigen test. And then the same thing with the masking and the this on the plane, except you’re eating and drinking. And I was like, “This is the biggest waste of time for everybody. Like, why isn’t it just optional?” Like if you wanna wear a mask to protect yourself, wear a mask. God bless you. Put on an N95, put a shield over your head, do whatever you want. But if someone’s like, vaccinated, I was like, “Why are they wearing a mask, you know, 85% of the flight?” It doesn’t make any sense yet we’re all doing this.
Emily: I mean, I think the counter to like, you know, to push back on that, I think that the counter that people would say is, look, you know, the world contains vulnerable people, whether it is, you know, immune-compromised individuals or, you know, kids who are not vaccinated, who I think we both agree are not in the vulnerable space but you know, this is kind of the argument. That then, you know, this is all sort of they’re making it…What you’re advocating in some ways is really a kind of like, totally individualistic approach to say, “Look, now we have good vaccines. Everybody has access to like, a well-fitting N95 mask and full vaccines and you can choose to protect yourself to whatever degree you want. And you know, that is an individual choice the way there’s a million individual health choices.
Like you choose, you know, whether what kinda day you eat or you choose, you know, what kind of other, you know, healthcare you get. But then there’s this piece of it, which is, well, what about the immune compromise? What about people who need your protection? You know, for me, in some ways I find that argument compelling but I also think it puts an awful lot of onus on individuals that should be on some sort of broader governmental body. That it’s not really the job of individuals to be fully responsible for protecting, you know, vulnerable people. I also think that, you know, the marginal impact of kinda you wearing a mask on the airplane, except when you eating and drinking. And, you know, deaths in a nursing home is pretty minimal at this point. But I think that’s kind of where we could do better to try to either make clear to people or, you know, think about how we’re protecting these other groups. And by the way, that is a problem that was true before. If you were like, a sort of late-stage cancer patient who’s on immunosuppressants, you were vulnerable to infection before COVID.
Dr. Fox: Oh, yeah. Yeah.
Emily: Like many other things COVID has revealed like, boy, it, you know, great if we had better ways to protect people in those situations but it’s not different than it was before really.
Dr. Fox: Yeah. No, I think that’s one of the big changes that if you look at, you know, like you said, someone who’s vulnerable because of whatever medical conditions, because of the medications they take, because of their age, you know, two years and a month ago when they got on an airplane, same problem. They could get a cold, they could get a flu, they can go get adenovirus. They can get anything, you know, potentially. And we weren’t telling everyone then to wear mask. And so I think now sort of mass became sort of acceptable in a certain sense. And now it’s hard to take these things away, but the real question sort of scientifically is, “All right, so I’m someone who’s vulnerable and I’m vaccinated and I’m wearing an N95 mask, what is the relative risk to me if the person next to me is or isn’t wearing a mask?” And it’s probably pretty small. Again, if they’re wearing a mask 85% of the time, except when they’re eating and drinking or something like that. What is the benefit to that person versus, you know, the inconvenience to 400 people, you know, on the plane? And you know, there’s no right answer to how you balance those things. I’m not claiming there is. I’m just saying that’s a complicated calculus that’s been made forever and this is just different. We’re falling on a different side of the line now than we ever did before and I think that’s jarring to people.
Emily: Yeah, I agree. And I think, you know, maybe part of the answer is, we were kind of in the wrong place on the line before and, you know, we should have been more conscious about this. And I think it will be true almost indefinitely that people are gonna be more conscious about the choices they make that would spread illness to other people in a way that is probably really good. So, you know, the kind of like Sandra came to school when they’re a little bit sick or go to the office when you’re a little bit sick, my guess is that would be dialed way down now. And it just the sort of social acceptability of saying, you know, “Look, I have a little bit of a cold.” I’m like, “Let’s Zoom the meetings today.” You know, two and a half years ago, people would’ve been like, “Sorry, you have a little cold and you wanna like move our meetings to the phone. You know, what are you talking about?” Whereas now people be like, “Oh, thanks so much. Like, that’s great.”
Dr. Fox: Yeah. Well, some would say that’s great and some would say, “All right, now this person just doesn’t wanna come to work.” [inaudible 00:21:52] both.
Emily: Of course, there’s a mix there but I think that there is a sort of…We will see more of that, whether it’s because people are shocking or not. And I think we’ll see more masking in those, we’ll see more masking times with respect to the flu and all kinds of other stuff.
Dr. Fox: Yeah. I mean, people have argued a lot about the effectiveness of masking and there’s arguments to be heard there in both directions. But I think also one of the interesting questions is there’s the difference between the effectiveness of a mask versus the effectiveness of a policy that requires people to mask. Because those are very different and…
Emily: Absolutely.
Dr. Fox: Yeah. Because you can say there’s something like a vaccine, for example, a vaccine could be, and it is remarkably effective, but how effective is it, you know, to have a policy about a vaccine? Well, that depends how well it’s adhered to and all these other variables that come into it. And I think that’s a lot of these arguments also center around that.
Emily: Yeah. I agree. I mean, I think that basically like, two things could simultaneously be true and probably are. One being that if you wear a well-fitting N95 mask, you are much, much less likely to get COVID or anything else because, you know, there’s mask filtration. And you can see that in the lab, you can see that in, you know, the way like you can be in a patient room with somebody and, you know, they can be sick and you don’t get it because you’re wearing this high-quality mask. So that could be true and it could also be true that as implemented mask mandates make very little difference in terms of spread of COVID, which, you know, I think probably is true, whether it’s no difference or a small amount of difference, it’s certainly not anywhere close to as large as the difference between you wearing a high-quality mask versus not in an environment with somebody who’s sick. So somehow like, we’re having trouble separating those two things in the data.
Dr. Fox: Yeah. You could also look at the data different points in time. So, you know, if you have, for example, like two states, one of them has a mask mandate and one of them doesn’t. Let’s assume they were similar at baseline, which is also not true but let’s assume they are. You can look at the data in the first month and maybe show that the state with the mask mandate had fewer infections, but then if you waited six months, it may have caught up to everybody that eventually blows through. And so there’s so many ways to manipulate this which is why, you know, people have these sort of preconceived beliefs about mandates, about mask, about whatever. They can cherry-pick data that’s gonna support what they believe based on where they take it from or at what point in time they take it from or how they interpret it, which has always been true in science. We’ve never really had these debates in public about these scientific things and putting them on CNN. And so I think it’s just gotten real ugly with the data.
Emily: That has been very interesting for me and I agree it has gotten ugly, you know, that all of a sudden everyone is much more in principle…Like, people are much more interested in data and much more willing to sort of think about data and to engage with data and they understand more what charts are and the idea that you would do some kinda analysis. You know, that’s been a huge move in the last two years that I have seen, you know, as a person who kind of writes about this. But at the same time, we’re in such a sort of evolving and in some cases, quite data, poor environment, that it is very easy for people to cherry-pick the particular piece of evidence that they want that supports their thing. And, you know, as you say, with something like masks or really almost any of the kind of non-pharmaceutical interventions we thought about during COVID, there are ways to cut the data that show one thing and ways to cut the data that show that just gets weaponized in all of the different directions. And because our data literacy is actually at its fundamental core quite bad, it is hard for people to parse like which of these two charts should I believe? You know, there’s two similar-looking people with two different charts and two different television channels. And like, how do I know that like, the blonde guy with this chart on “Fox News” is like, more or less reliable than the other guy with the chart on the “MNBC.” Like, how do I differentiate those things? That’s really hard.
Dr. Fox: Yeah. I mean, this is partly what you do. Actually, it’s a good segue because I wanted to do the sort of we’re gonna let Emily go back in time and make all the decisions for everybody.
Emily: Amazing. Okay. I’m ready.
Dr. Fox: On the one hand you could look at it, you know, where did we go right? Where did we go wrong? I’m not doing this like, to be judgemental about anything because okay, whatever. I’m gonna say based on your understanding of the data and what you’ve seen and what, you know, you’ve read, if you could go back in time, I’m asking if you would do things the same or different. So the first I’m gonna ask about because it’s sort of the first thing that happened was the lockdowns. Sort of all the same…
Emily: Just so I understand. I get to choose based on what I know now?
Dr. Fox: Yes. Oh, yeah, yeah. You know, based on what you know now, based on everything you know today, if you could…
Emily: So we got to make a deal over. Okay.
Dr. Fox: …get in the time machine and go back two years.
Emily: All right.
Dr. Fox: So what would you have recommended first in the initial phase when the virus, you know, first hit the scene and then sort of over the next, you know, year or two, with lockdowns, both, you know, home and then also with schools?
Emily: So I think when we sort of think about that initial period, actually there was something we did really right was with this idea of like flattening the curve, which put a lot emphasis on the idea that we need to build hospital capacity. And so I think that wasn’t wrong. I think part of what happened was we sort of build the hospital capacity and then in some ways, like never let up on the kind of lockdown, well, we let up eventually but we didn’t sort of let up link to hospital capacity. So I think that, you know, building out the hospital capacity and having a period of pretty extensive lockdowns while sort of hospital capacity was built out was a good idea. I think it’s pretty clear we did not do anything close to the amount of lockdown that we needed at nursing homes. So things like nursing homes, assisted living facilities needed much more testing and much more kind of like, restricted access at least for this initial period until we understood a little bit more about the virus.
I think looking back to expose, it was a mistake to close schools certainly for as long as we did. I also, you know, think that it would’ve been quite hard to continue sort of having schools open for at least some of the spring. So, you know, it wouldn’t have been a good idea to reopen schools in, you know, May or June of 2020. I think some people say yes. I’m not sure. Maybe, depending a little bit on how we were doing on other things.
Dr. Fox: But come the fall of 2020.
Emily: Oh, come the fall of 2020, yes. So come the fall of 2020, we should have had all schools open fully in-person, regular school, five days a week with masks.
Dr. Fox: And is that because looking back in hindsight, I know that was actually your opinion at the time also, but looking back in hindsight is that because we’ve realized better that the risk to kids from the virus is very low or because the harm of closing school was higher than we thought it would be?
Emily: So I think it’s both of those things plus a third thing. So I think, you know, if we think about what we learned over time, you know, one is that the kids was low. Although I think to be fair, we pretty much knew that in almost like in March of 2020.
Dr. Fox: Yeah, we did.
Emily: I don’t think we learned very much about that over time. Well, I think what we learned is that the spread in schools was extremely limited. So based on the sort of, you know, some of the data we collected but more than that the like careful contact traces studies in a bunch of places showed that just very very limited spread in schools particular during the kind of like whole 2020, 2021 school year. There was just not much spread at all.
Dr. Fox: Do you think because there was masking and all that stuff or just because it’s not spread so well in kids?
Emily: Probably both. So I think, you know, most of the sort of really, really limited spread stuff we have did involve kids in masks. And so I think separating out, you know, like was there more places with more limited masking? You know, we did masking in most schools in the U.S. But I don’t think it’s just the masking. I think it was more that, you know, this is a controlled environment and you know, people were being careful and, you know, kids are just not super high risk and you know, they weren’t spreading as much or whatever was the reason, schools were just not places of a lot of spread.
So I think there was that. And then the other thing we’ve learned over time is just how damaging school closures were for student learning, for, you know, family’s ability to kind of put food on the table, for kids’ mental health, like all these things, the sort of implications of school closures, which people thought somehow we would be able to mitigate and somehow just because we’re not mitigated, they were bad.
Dr. Fox: Yeah. And then what about masking and social distancing?
Emily: Having spent a bunch of time talking to the guys who are obsessed with aerosolizing and ventilation and so on, I think we missed the boat on the kind of ventilation versus social distancing business. So we spent a lot of time on like, be distant from people, but actually physical distance is not important and to that to [inaudible 00:31:29] the social distancing, which really became part of that. We should been investing more in ventilation of the door spaces probably. You know, on the masking, I think we don’t totally know. The [inaudible 00:31:42] trial data suggests probably some small…That, you know, mask mandates like in the Bangladesh data suggests that masks mandates had some positive impact, you know, but not enormous
Dr. Fox: If states were calling you in the summer of 2020, and they said, “Should we go like Florida? Should we go like New York with masking?” Right now, knowing what we know, which way would you go?
Emily: In the fall of 2020, I would’ve said go like New York. Like, I would say now the choice that I would’ve suggested in the fall of 2020 was go like New York. But I think we failed to write sufficient off-ramps for that.
Dr. Fox: Like if rates drop or if the vaccine comes out, things like that.
Emily: If rates drop the vaccine comes out. Yeah. I think part of what made masking, you know, so contentious was the feeling that it would never end and this sort of feeling like, you know, as we said, take them off, then we put them back on. And then the feeling of like, well, no matter what, we’re always gonna need to do this. And I think that people really push back on that. So, you know, again, it goes back to, you know, I guess I think some of what we must have talked about, you know, two years ago, which is to sort of meet people…You can’t ask people to do everything all the time. You know, you’re gonna need to pick a set of things that are doable. You know, I think that masking probably is one of the more doable of the non-pharmaceutical interventions and, you know, with good quality mask can have some impacts. So that seems like something to do but we made it something that was like, you’re gonna have to do this forever. And then I think people got past that.
Dr. Fox: Yeah. And I think also when there were this potential for off-ramps and we’ve spoken about this before, they were sort of illogical that they’re doing it based on like positive rates or total cases. When like, we said really they should have focused on hospitalizations or deaths or, you know, something that matters. Whether someone tests positive or not, is not as relevant to whether they’re sick. And also the data is more poor because it depends who you test. If you test everybody, you know, you have more numbers, you have more total cases and a lower percentage. And so everyone was doing it differently and none of it made a ton of sense. And it was very frustrating. Like, you know, I’d be like, “All right. There’s many more cases.” Like, well, everyone’s going to school they’re all getting tested. Of course, there’s more cases but this is ridiculous. So, which is what I want to ask you about the next one because I know that you feel very strongly about this. What should we have done with testing?
Emily: So I think with testing, we should have invested way more heavily in antigen testing. So we got totally like focused on PCR testing as a sort of gold standard. And I think that’s because from a diagnostic standpoint, you know, PCR testing, you know, is sort of the gold standard to detect small amounts of the virus and so on. But I think it was also very clear early on that these antigen tests have these lateral flow checks which are easy to use, which you can use, you know, in your house are very good at detecting contagious levels of the virus. Those were developed pretty early on. It took, I don’t know, a year, more than a year between the sort of initial development of things that you could have used in your house and you’re even being allowed to use them in your house. It was many months before we even used them in schools. Like, this just became a kind of total failure and a total failure of messaging. If we had done that faster, this would’ve been a place where we could, you know, help on the nursing home staff.
Like how do we get antigen test? So everybody who comes into a nursing home is antigen tested like, every day before they come to work. That would have really improved our situation. And similarly, you know, giving people confidence to do things like going back to school. You know, we wanna open all our schools in September of 2020, like tell everybody, you know, everybody has antigen tests and, you know, figure out how you’re gonna implement that. It wouldn’t be impossible. The idea that it wasn’t until February of 2022 that the government started sending these to people in the mail. It’s crazy. Particularly because, you know, like all these universities, with all this testing, it felt like we just really fell apart there for a few different reasons but we definitely [inaudible 00:36:05]
Dr. Fox: The university is where everybody’s young and healthy, they’re getting tested twice a week but it was, yeah…
Emily: With PCR test.
Dr. Fox: Yeah, with PCR test but a nursing home they’re not doing that.
Emily: With PCR test and it’s insane. Exactly. Like that we really need to protect so like, you know, the students who are only leaving their apartments to get their, you know, twice-weekly PCR tests, but yeah, we’re not somehow to put antigen or full testing into nursing home settings. I mean, just it was a really, you know, bizarre organization of resources.
Dr. Fox: Yeah. I also don’t think it would’ve been too difficult for there to some, you know, effort to get random sampling, random testing to say, “What is the COVID rate in the community?” Like, because it was all over the place. Nobody knows what it is because, you know, people are home, they’re not getting tested or everyone’s getting tested and, you know, it’s not that hard they do this with polling. Right?
Emily: Yes.
Dr. Fox: You know, they do it all the time to eat sample of, you know, 400 people and you know, what’s going on in the entire city. It’s really not complicated from a logistical standpoint. I don’t know why they didn’t do it. It doesn’t make any sense to me.
Emily: I’m not sure what happened. I think that they, you know, there were some sort of political stuff around testing inside the CDC. I think there were some feelings that, you know, people had about accuracy versus, you know, different kinds of errors. You know, I think also a lot of these organizations were pretty, you know, like, not great at pivoting. And I think that that was an issue. And then, of course, remember like in the sort of summer, fall of 2020, even the early winter, you know, the administration was not, you know, super focused on identifying cases of the coronavirus.
Dr. Fox: Yeah.
Emily: And it wasn’t like their jam. And so I think, you know, while by the Biden administration coming in, didn’t sort of fix everything the way that some of us maybe thought that they would using a magic wand. Definitely, I think that, you know, things would’ve looked a little different had there been a different set of people sort of with a different set of incentives in the 2020 period.
Dr. Fox: Right. Maybe if we’re not in an election year.
Emily: Maybe if we’re not in an election year. Exactly.
Dr. Fox: Yeah. It’s so interesting, all these things play into this because I mean, it changes everything. It changes people’s perceptions, which changes, you know, their responses and the reality. It’s really interesting stuff. What do you think is gonna happen moving forward? Now we’re doing prediction, Emily. Now we’re going forward so we can drop this podcast in two years. What do you think is gonna happen in the next couple of years with all of this? Is this just gonna sort of fade away into the sunset and it’ll be like, you know, a flu where we get a booster or a new vaccine every year and we just sort of like move about our business, or is this gonna like annoy us and irritate us that we’re gonna argue about this for the next, you know, 2, 4, 10 years?
Emily: I think that for me, that lies in whether you’re talking about in the next two years, in the next century. So I think what will happen is, you know, I think this part I’m basing on, you know, what people on sort of smarter people than I do kinda viral evolution. I think the kind of expected half is something like, you know, continued sort of winter surges like with, you know, like with any respiratory virus, like with the flu and probably, you know, a sort of moving towards a kind of booster in the fall system. And whether that booster is specific to the variant, you know, that’s in circulation or not, you know, we’ll have to see. I mean, actually, in the summer of 2020, I did an interview in my newsletter, of all places, with the CEO of Moderna. And he basically was like, “Okay. You know, we’re gonna have a vaccine, an mRNA that does like flu RSV and you know, dominant COVID variant and you’re gonna get it every fall and that’s gonna be great.” And so like, maybe we’re going there. Like then you’re not gonna have a job, you know. You’ll still have a job. Some people will be out of a job.
Dr. Fox: Yeah.
Emily: I think there’s something like that but we’ll sort of see these surges. I think that will be true, you know, almost forever. We’re not moving to having no COVID. Over the next couple of years, I think this will be a significant source of sort of discussion and angst as these waves come in. And also as we work through a lot of the things that are gonna come out of the social impact and also the health impact over the last year. You know, I think there’s probably more discussion among COVID than there needs to be, but there’s no question that a reasonable number of people have been experiencing this sort of longer-term disability effects of infection. Much more so people who got it unvaccinated and that’s something the healthcare system will be dealing with. So there’s a bunch of these like knock-on effects that I think will mean that this occupies more mental space over the next two years than it will, you know, seven years from now.
Dr. Fox: All right. And when are the airlines gonna tell us we don’t have to wear masks going back to my [inaudible 00:41:06]
Emily: I think that will be next week.
Dr. Fox: Oh, really?
Emily: I think that’ll be very soon.
Dr. Fox: Yeah. I just think that. I guess it’s a federal mandate, isn’t it?
Emily: Yeah. There’s no…Like, it’s a federal mandate. I think that the federal government is not…So like going back to the issue of politics, you know, I think that the Democrats are quite worried about midterms. And for better or for worse, I think perceive that some of these COVID restrictions, particularly the most visible ones are not likely to serve them well in the midterm elections. And they’re therefore, I think going to be eager to remove some of them sooner rather than, like, later.
Dr. Fox: Fascinating. Wow.
Emily: That’s my like sort of social science political economy hat.
Dr. Fox: Wow. Thank you so much for agreeing to come on the podcast again. We love having you. It’s always great to talk to you. My listeners love hearing from you and most of them are, you know, followers of you anyways, but it’s really interesting. And I just think that this has been so cool and yeah. And I think it’s gonna be awesome to play this back to back with us two years ago because honestly, they sound almost exactly the same. It’s really remarkable.
Emily: I don’t know. Like, do we think it’s good? I don’t know. You know, it’s like maybe that’s good. Maybe that’s not good.
Dr. Fox: It’s good for you. It’s, you know…
Emily: It’s good for me perhaps. Perhaps.
Dr. Fox: Awesome.
Emily: Yeah.
Dr, Fox: Well, thank you so much.
Emily: All right. Thank you so much. It’s always really great to talk.
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 healthfulwoman.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. The information discussed in “Healthful Woman” is intended for educational uses only. It does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan. Paid sponsors of the podcast are not involved in the creation of the podcast or any of the content. Support for our sponsors should not be interpreted as medical advice from the podcast, the host, or the guest.