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A Sociologist’s Methodology for Pandemic Predictions and Public Health Messaging – An interview with Dr. Zeynep Tufekci, Open Forum Infectious Diseases, Volume 8, Issue 3, March 2021, ofab117, https://doi.org/10.1093/ofid/ofab117
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The audio file is also available at:https://academic.oup.com/ofid/pages/Podcasts
In episode 35 of the OFID podcast, OFID Editor in Chief Paul Sax, MD, is joined by Zeynep Tufekci, PhD, sociologist and associate professor at the University of North Carolina, to discuss the logic behind her prescient COVID-19 pandemic conclusions, and her use of op-eds in prominent news outlets to amplify her findings.
Hello, this is Paul Sax [MD]. I’m editor in chief of Open Form Infectious Diseases (OFID) and this is the OFID podcast. And that’s a reminder, that’s O-F-I-D and not “Oh-fid.”
One of the silver linings about living through a pandemic has been an introduction to certain brilliant thinkers outside of medicine, thinkers I might otherwise not have known. A prime example is Dr. Zeynep Tufekci [PhD], associate professor at the University of North Carolina, sociologist and computer programmer and writer for The Atlantic and The New York Times. If ever someone embodied the word prescient, meaning having knowledge of events before they take place, this is the person. So I’m thrilled that she’s joining us today. Zeynep, welcome.
Thank you for that very kind introduction. I’m blushing through the podcast.
Anyway, you deserve it. So tell me a little about yourself, how you ended up in your current, very interesting role.
Well, I think the one thing that really characterizes what I do is interdisciplinary crossing between borders. I started on the computer science side of things. I grew up in Turkey, but I was very quickly impressed by the social implications because in Turkey, we had a lot of censorship and I had started working for technology companies. I was working for IBM in fact, and even before the internet came to Turkey, which was late, IBM had a little intranet, which is a little internet. But IBM’s a big global company and it blew my mind because I couldn’t get more than one TV channel, but I could just talk to thousands of people on these forums. I thought, “This is going to change everything,” so I switched to sociology to study the social impact before it was a thing.
So my career, academically speaking, has been very...
Diverse.
Yes, diverse, let’s say, and before some of these fields, they just didn’t really exist as we understand it now. You either did sociology or you did technology, the idea that technology would have these social impacts wasn’t just something you studied like that.
Thinking about crossing borders, I’m from Turkey. I’ve lived in Europe, I’ve lived in U.S. I lived in lots of different cultures and I spent a lot of the pre-pandemic year in Hong Kong doing research on the social movement there because that was very interesting for the things I was looking at in technology and internet, which as we’ll probably get to, when the pandemic hit turned out to be a significant entry point to information and points of view.
Exactly, but there must have been something about pandemics that drew your interest because you say you’ve always been interested in them. Why is that?
Not only have I always been interested in them, I’ve been using them to teach introduction to sociology, partly because for the average first-year student, things like race, gender, class, sound interesting but globalization can sound a little more abstract. And I would use pandemics to explain a lot of concepts that I thought were important, like how connected we are, how travel works. I would try to explain why the global institutions are necessary, why you need surveillance for new diseases.
And of course, there’s also these nice concepts like exponential growth that you can really explain best with pandemics. In my previous writing career, the one time I did write about pandemics, was with the Ebola scare, not this years’, of course, and I just went back and read it a month ago. It was basically, “We’re failing this and it really doesn’t bode well for the future pandemics. If we can’t really devote resources to do what we need to do in this particular case and instead freak out about the wrong thing, like Ebola coming to the U.S., rather than how do we respond to an emerging outbreak where it’s happening.” I was like, “We should worry about this.”
It’s just a fascinating, interesting topic for human sociology history. They’re a constant part of human society. They occur and reoccur, and they change history all the time. So as someone who has always been interested in history and big dynamics, and plus of course, memory. I’ve always asked my students, “Do you know about the 1918 Spanish flu?” when I would teach pandemics, and almost nobody knew about it.
Which brings us, of course, to early 2020. And you realized before many others that a pandemic was about to occur. If you were to think back and go over when you knew with certainty that it was going to happen, there must’ve been some point when you just knew this is real, it’s not something that can be contained, it’s coming here.
It’s weird, my Amazon purchase history is kind of like a timeline. Like many others, I first heard about the mystery viral pneumonia on I believe January 1st, when we first got the warning.
Yeah, ProMed-Mail.
Yeah, we got the Promed-Mail. But, relevant to my own field, we got the word that a few doctors, like Dr. Li [Wenliang, MMed] in China, were trying to warn others through WhatsApp and had been censored and police had shown up and there was the sort of ripple, so to speak, in cyber space about this attempt to warn. My example in the past of a pandemic to teach often was SARS [severe acute respiratory syndrome]. I knew a lot about SARS because of that, so to me, a viral pneumonia in Wuhan – immediately ears perk up.
By January 7th, I thought, “Oh, let me order some masks’” because I also wanted to go back to Hong Kong. At that point, I still don’t know what the depth of the crisis is, but I thought, “I’m going to order some masks and I’m just going to get my own pandemic readiness going.” In fact, people who know me were like, “Why are you ordering hand sanitizer?” because I’m not particularly hygiene – polite word there – obsessed. And I was ordering these supplies and people around me were like, “What are you doing?” And I’m like, “Well, you hear viral pneumonia coming out of Wuhan and you hear censorship – for anybody who’s lived through SARS, it’s two and two, right, that something’s going on. But what?”
The week I knew for sure was the week of January 20th because two things happened. One, China shut down Wuhan, a city of 10 million. With studying authoritarians, a really good rule of thumb is – look at what they do, not what they say. Another rule of thumb that people might recognize from evolutionary biology is always look at costly signals. If you’re shutting down a city of 10, 11 million, you’re not just doing this randomly. This is a very costly thing to do and it’s not the kind of thing a country like China, which is fairly competent in how it handles dissent and problems, is going to take lightly because it’s a huge headache to them.
And at that point, I thought, “If they are doing this, and there are all the rumors swirling around from Hong Kong, from Taiwan, other places, this must be a big deal. This is a huge deal.” For me, that was a key sign it is out of control there.
The second sign for me was that they probably just learned about it themselves. I thought Wuhan authorities had lied to central authorities because it happens all the time. If they had the political will to shut down Wuhan on January 20, they probably would have done some things earlier. And I thought, it’s plausible that the Chinese leadership realized the depth of the problem in the past week, which would fit with the censorship of the local doctors.
And after that, of course, they had a great incentive to prevent the epidemic from becoming a pandemic in China and the world. Then we had this amazing, miracle week of papers coming out of China, it was January 20th and until then, they were lying or covering up. But at that point, their incentive structure had flipped. They wanted to prevent this and they were telling us the truth. I think Chinese foreign ministry spokesperson, before even a paper, he was literally giving press conferences saying there’s pre-symptomatic and asymptomatic transmission.
It was amazing how quickly the science came out of China all of a sudden.
Yes. So the January 20th week there was a New England Journal of Medicine paper that said atypical clinical presentation. They were telling us in press conferences, “This is spreading without symptoms.” And I knew, because I knew SARS, that we had contained it partly because infectiousness and contagiousness coincided. You got fever, you were infectious, you could have a temperature gun and catch people at the airport. So that week I said, “Okay, this is done.” It got out of hand to the point they had to close down Wuhan, which is very costly, and now they’re telling us atypical clinical presentation and pre-symptomatic, asymptomatic contagion, that’s it.
So I knew. I started telling people, “We’re going to get a pandemic.” In my personal life, I started sort of re-arranging, canceling travel, doing all of those things. That’s why I started tweeting about it, but not being a medical person, I never thought I would be doing more. I just started getting ready personally because I was sure this was going to happen.
Let me take you to March and you started tweeting about masks and then you ended up writing a piece in The New York Times that really tipped the scales for many, including me, on this issue. We had been messaging the public that masks weren’t necessary except for healthcare professionals to keep us safe and to keep us from spreading infection to others, but you didn’t buy it. And how long had this been brewing, this thought of yours, and what was your inspiration? And also I’d be curious what the pushback was after you wrote it.
So the first piece I wrote was at the end of February, I wrote a, “We have got to get ready, we have got to flatten the curve,” piece because I couldn’t find any. I wrote it for Scientific American because I owed them a blog post and I thought, “How about this?” Because I was watching. I mean, February 2020 was like an out of body experience for me. I was watching people continue to travel and hold conferences and do all of those things, and we have all these pictures coming out of Wuhan and I’m like, “What do you think is going to happen? This is going to happen.” So I kept trying to find an article to send to people to say, “This is how you get ready. This is why flattening the curve is something you have to do.”
These have become everyday concepts now and they’re obviously not my concepts, these are very basic epidemiology, which I knew, but nobody was saying them. As far as I know, my February article explaining flattening the curve, is the first mainstream media article explaining the concept. And again, if you read it now, it’s very basic. It says hospitals will get overloaded, you want to fill up your prescription medication, things will get closed down. You want to do your shopping, you want to get ready to stay out of crowded places, stop traveling. I wrote the thing I wished was written so I could tell people around me to start getting ready. The media was still saying things like, “Beware of the pandemic panic, the real problem is you panicking and being irrational,” late into February. So I got very frustrated. I wrote that, and I linked to it list the things to get, one of which was masks. It was just a generic list, it wasn’t specific, but if you’re preparing for potential epidemic or something, it’s a very obvious thing to have in your house.
And then I started getting this enormous pushback from healthcare officials, health communicators. Not really a lot of doctors, but a lot of medical people, health journalists, who were saying things like, “How dare you link to a list that says masks,” and I’d even waved the mask question. I was like, “All right, there aren’t that many left. So don’t worry about it.” But the link I listed just put them there and then people were saying, “Well, they’re dangerous. If you wear them, they’ll cause infection and increase your risk of infection.” I was like, “You’re kidding. How? What is the mechanism by which this is going to happen?”
I understand the shortage. And I put in, “If there’s a shortage, of course we’re going to prioritize medical workers, no question about that, but we can tell people to make cloth masks and we certainly don’t need to tell them that wearing a mask increases your risk of infection, because then why are medical people wearing it? This makes no sense.” People would say, “Well, they’re trained.” I’m like, “Come on. There’s a limit. People aren’t going to buy something like a mask is so complicated that we can train medical professionals, but we could never teach you and it’s going to cause you harm.”
So I started having a lot of back and forth with people who were mad at me. They started sending me articles showing allegedly that masks were harmful. And I would read the articles and I’m like, this is not an article showing masks are harmful. They’re showing ceteris paribus, if everything is equal, wearing a mask better is better than being careless with it. Or if you’re in an actual medical facility, taking it off incorrectly is worse than taking it off better, right? None of them were comparing to not wearing masks.” I was like, “This is not making sense.” Then people started arguing things like, “Well, what if you touch the outside of your mask?” And I’m like, “If the outside of your mask is contaminated, that is very, very good news. Because you didn’t breathe in [the contaminant]… How on earth is the outside of my mask getting contaminated a problem?” It blew my mind.
I started tweeting about this too. I started saying, “Look, we have pre-symptomatic transmission. You cannot tell people to wear a mask when they’re sick, because social theory says the stigma will prevent them from wearing a mask.” You already have Asian Americans getting attacked for wearing masks. So even if you didn’t have pre-symptomatic transmission, there’s no way you can tell just the sick to wear a mask in a pandemic.
I kept tweeting every argument and waiting for anyone but me to write this because I’m like, “I want this to come from a former director of CDC [U.S. Centers for Disease Control and Prevention], some Harvard professor in the medical school. I want this to come from somebody with overwhelming credentials because public health messaging needs authority behind it and I’m nobody, right. I cannot just weigh into this.”
I waited until March 15th, and then I went to The New York Times and said, “Nobody’s doing this, I’m going to do this.”
And I got lucky. I got an editor who didn’t make me hem and haw. I just put it very straightforwardly saying, “Here’s why this message doesn’t make sense. Now I understand the concern about shortages in which case we have to appeal to people and say that we’re going to get cloth masks, we’re going to increase the production, we’re going to preserve medical masks and respirators for medical personnel, but here’s what we’re going to do.” And then prepared to end my career because I was contradicting the CDC and the World Health Organization. And never in a million years had I thought I would go into my very first pandemic opposing the CDC and the World Health Organization. That’s not the side I’m normally on in anything.
But I just had to do it.
I waited for the backlash. Some came, but instead of getting the pushback, I got a lot of people saying, “Yeah finally, thank you. Somebody said it,” including from medical people. I heard from the CDC people that it was pivotal. It just created the argument within the agency that finally tipped over shortly.
It was great.
I can tell you, it had a big effect on me personally because I was invited to be on a clinician’s panel and they were presenting some sample cases. This is mid-March, right after you wrote your piece, and they were making fun of someone who was hoarding masks. And I said to them, “There’s a lot of good points to be made for use of masks when you have pre-symptomatic and asymptomatic spread.” And I alluded to the piece and I said, “This is a really brilliant summary of why we should be wearing masks.” So well done.
Shifting now to something also I enjoy hearing you discuss, which is something that you’ve alluded to several times as beach scolding. Maybe explain what that is and why it might have unintended consequences.
After the masks, I was like, “Oh, wait, am I going to write my way through this pandemic?” I just quickly realized there’s going to be a lot of need for sociology and one of the earliest things I wrote after I wrote about masks was the closing of parks. Because I started seeing all these places closing parks and telling people to stay home, and this was April 2020.
So I wrote this piece saying, “You realize it’s a pandemic. It’s going to be about a year if we’re lucky.” So you can’t just tell people to stay home for a year. I mean, I understand in March we know nothing, everything’s up in the air, you don’t really understand what’s going on. You’ve got hospitals getting overwhelmed so you just tell everybody to stay put. I get the first week, I get the second week.
But in April we started getting epidemiology out of China to a degree, we started getting some of the epidemiology out of Northern Italy, and a couple of things became clear. One of them was that there was basically no outdoor transmission, which of course made sense – UV [ultraviolet], air. Another thing is the aerosol spread was already accepted in Japan, maybe there was overdispersion, which didn’t really make sense except through aerosol spread. And there was no outdoor transmission.
One of the first papers I read, which had thousands of cases and they had one outdoor transmission and that was two people jogging together, breathing into each other, very close, “Huff, huff, huff, huff, huff,” the whole time. And even that I think had some indoor components. So it was kind of like, “All right, we don’t have a lot of outdoor risk.” Modeling, theory wise, it makes sense for a virus not to be very contagious outdoors, especially if it’s an aerosol carry thing because it’ll just dilute in the air, and we’re already seeing this epidemiology.
Plus if people are not allowed to go to parks, and if this is going to take a year, which in April I thought this was at least going to take a year, you don’t get out of a pandemic in a week, right? We need a sustainable way for people to socialize because they’re going to otherwise socialize indoors, in poorly ventilated places, breathing in close contact and that’s just obviously much worse.
And I thought, “This is crazy, we can’t do this.” So I wrote a piece in April saying we have to not close the parks. If congestion is a problem, you tell people, if your house number is odd, you come out on these days or have a ticket system in which you just count the people coming in. There’s 50 million different ways to manage congestion. We’re in a pandemic, we can figure this out if that’s the problem, but this closing parks absolutely made no sense.
I wrote that article in April. And then what happened is the weather got better and the scolding of parks and beaches got worse because the photographers could go take pictures and say, “Oh, look at these people on the beach.” And I’d just be looking at the picture, this Australia Bondi Beach, and there’s like seven people on the beach. And nobody breathes right next to each other wearing bathing suits. It’s naturally a distanced thing and it’s a vast beach – probably the safest place you could be in the whole city, and you shoo them away from there. They’re going to go indoors.
So I was like, “Stop this. This is crazy.” I started writing articles about this. I started collecting some examples and there the contrarian risk compensation thing reared its ugly head again. And people started saying things like, “Scolding the beach is good because it’s going to prevent them from going to…
Bars and restaurants.
... the restaurant near the beach.” I was like, “Well, if you want people not to go to a restaurant near the beach, tell them not to go to a restaurant near the beach. You don’t tell people not to go to the beach if what you’re trying to communicate is don’t go to an indoor restaurant near the beach.” I mean, this is insane. So I got, “What about people traveling to the beach?” I’m like, “If you don’t want them to take a bus, then tell them not to take a bus. Arrange something so you don’t deal with these secondary things.”
Yesterday Australia’s paper of record had, I swear, photographs of these five young people sprawled way out on the beach saying, “Here, people defying the lockdown.” And I mean, you could tell they just refused to be interviewed. And I’m like, they’re probably doing the safest thing they possibly can. I understand rules are rules, perhaps, but these are stupid rules. You have beaches, let people go to the beaches.
Yes. It’s so sad the playgrounds with the police tape around them and the beach.
Again, the first month I understand. The first week You don’t know what on Earth is going on. Do we have measles? Do we have Ebola? What on earth is going on? So you’re afraid of fomites, you’re afraid of this. So the first two weeks I forgive everything. You max everything and also you don’t want your hospitals overwhelmed, but a month in, you can start figuring things out. Instead, what happened is whatever we did the first two weeks to crush the curve and then we got stuck on whatever messaging we did there, which I think has been terrible to be honest.
Which brings us to another area where contrarians have had their field day, which is with our vaccines. What is your opinion of the vaccines, the rollout, the response to them? General thoughts.
Okay. So my general thought is we have something that’s neither terribly necessary nor very effective, which is disinfection that is still high up on our recommendations, and schools are closing…
Hygiene theater.
Yes – the hygiene theater. I’m not against disinfecting high touch surfaces or wash your hands, that’s always sensible, but obviously it’s a little out of hand with schools closing a whole day just to do what? I don’t know. And there’s no RCT [randomized controlled trial] showing disinfection works, it’s not like there’s any big science behind it. I’m not even sure the theory works because the school is closed on say 5 p.m. and then there’s nobody in it until 9 a.m. tomorrow, which is probably more than enough for any virus to stop being very viable. And then we’re going to clean it up. And then there’s another 12 hour... It doesn’t strike me as... There’s not a lot of science, there’s not a lot of reason …
On the other hand, we have some of the fastest, most amazing vaccines we’ve ever had with their efficacy against just the symptomatic disease blowing my mind and I’m just [now] writing an article about it. So I went back and looked at The New York Times front pages. So Pfizer, when it gets announced, it gets a single column saying 94% efficacy. Where are the church bells ringing? This is amazing news. And then we got Moderna a week later. And when Pfizer came, I was thrilled, but part of me was like, “Okay, wait for confirmation, wait for confirmation,” because it came out before the paper. And then Moderna came out and said 94.5%. At that point, this was independent confirmations, the same mRNA technology, a competing company, almost identical efficacy. And I just checked The New York Times headline, they’ve got two columns saying, “Another vaccine appears to work.” Talk about understating it. Moon landing may have happened.
And the news since has been amazing. We got the asymptomatic infection reduction in December from the EUA [emergency use authorization]. Pfizer did the swabbing and found two-third reduction. We’ve had really, really good news, but what did we start with? We start telling people what they can’t do. There was literally viral articles telling people what they can’t do, even if vaccinated, before anybody got vaccinated. I’m like, what is the hurry? We don’t even have any vaccination in their near future, December, we’ve started barely vaccinating healthcare workers, and The New York Times starts publishing articles on what you can’t do after vaccination.
And there’s these viral threads on, “I’m not going to stop social distancing.” I’m like, “All right, fine. I get it. We’re going to be cautious for a little bit, but what’s the hurry? Nobody got the vaccine to be scolded.” And again, we don’t trust people. We feel like if they’re vaccinated, they’re going to go, I don’t know, get sick and cough on people. I don’t know what the mental model of scolding is, it makes no sense to me.
I’ve been trying to message it as follows – that once you’re vaccinated and your guests in your home are vaccinated, it doesn’t make sense anymore to wear masks. And even that concept strikes people as being a little overly optimistic. And yet I’m thinking, well, this virus is never going away. We have to give people some way to exit this. Do you think that some people are sustaining the negative messages just because they want to make sure that they’re not wrong again?
So I can’t read people’s minds, but I have a bunch of theories on this. Part of it is the overly cautious, better-to-be-wrong thing, but that’s not good because that backfires in its own way. The second thing is confusing we don’t know yet with we don’t know anything yet. “We don’t know for sure yet how much,” is perfectly valid. “We don’t yet know how much they’ll blunt transmission.” But, “We don’t know yet if they do [or] whether they do,” that’s nonsense. We know, from the day the Moderna two-thirds asymptomatic reduction came out ...
You’re talking about between the first and second doses?
Right. So as soon as you got some initial data, and also the idea that you could have this great drop in symptomatic cases, you cut them by 95% and you cut all severity basically down this much and have no reduction in transmission…
It’s very biologically implausible.
Yeah, that was very implausible, but there’s also the vaccine’s own efficacy. So the thing we’re worried about right now is the transmission, which I think will happen to some degree, because that’s how it works. It will be a leaky vaccine of a bit, but probably greatly blunted. So the transmitter is going to be less likely to transmit, is going to have a lower viral load if that happens.
And then the receiver is being exposed to a lower infectious dose and plus they’re vaccinated. If you add those things up, I’m not saying make policy on my back of the envelope calculation, but it’s pretty clear that the risk is going to quickly dip below something like driving.
Absolutely.
Look at the risk factors. If you look at the math a little bit, it is so clear that you being hospitalized because you interacted mask-less-ly with another vaccinated person when you two have been fully vaccinated, the ideal scenario, is very quickly going to dip very, very low. In that particular case when you have that, it becomes a tradeoff, because I saw a really sad question from a 90 year-old woman saying, “Can I hug my grandchildren?” And the answer was, “No.” And I’m kind of like, have you looked at actuarial statistics? I don’t want to be grim here, but telling a 90-year-old to wait another year is not a lightweight thing to say. That human need there is not something to brush away and say, “Why can’t you just be a little bit more patient?”
And people who’ve been isolated for a year…
So once the risk becomes low enough I think it becomes almost inhumane not to tell people that the risk is not zero, but you can even tell them, “One in this,” from based on what we got, this is what it looks [like], and let people have sort of a graduated risk. Now, personally, I would be for a policy of wearing masks in public, in grocery stores, places like that for a long time because once again, the stigma.
I don’t want to have a grocery store having arguments with who is vaccinated, who is not. The sociology of, “When do we all take our masks off?” is probably community-based, when community numbers go down, when hospital numbers go down, so that’s based on everybody else. But when can a grandma hug her grandchildren is when the grandma is vaccinated. To me, if I were advising my own grandma, that to me would be the bar and now what’s the risk there? There’s the unvaccinated kid, and I feel that we can sort of tell people here’s the risk numbers as far as we can see, and here’s what to do.
And it doesn’t seem like a huge problem to me to develop guidelines and the problem with not developing guidelines is that were undermining the most amazing vaccines. We’re scaring people with what you can’t do and you can’t do this and you can’t take off your mask, but we’re not giving different public-private guidance. We’re not recognizing that especially the elderly cannot just wait another year without risking not being able to survive that year. I’ve seen all the sort of anti-vaxxers, they’re going to town with this and saying, “See the public health officials? They’re moving the goalpost again.”
Even vaccines are going to change. This is all good because the vaccines are great. Yes, there isn’t enough, access is important, I want them to be global, I want equity, I want a faster rollout, I want to go to the neighborhoods, I want to do all those things. But I really don’t understand why on Earth we’re crouching them in this negativity.
Yes. Well, I agree with you and I’m trying to make the same message. Most infectious disease doctors are, but some of us are on the other side saying it’s too soon. Since our audience consists of ID doctors mostly, quickly, if you could tell us your thoughts on how our preparation for an influenza pandemic might have derailed us on this one and you’re welcome to use overdispersion, we can handle it.
Right, we can handle it. So these skewed distributions are sociologically pretty important in internet settings. In social media and digital media, there are parallels everywhere. If you look at it, a few blogs get all the hits and everybody else gets a little bit of hits. These over disperse phenomena are familiar to me and I find them quite interesting from a systems perspective because they create very different stable dynamics. They’re not your usual Gaussian normal distribution and very often we have no idea how to think about that. That kind of long tail, it’s something I’ve known about in other contexts.
So when this pathogen started to show, I started reading the epidemiology just because one, it was interesting. Two, I started thinking about how do we make this public health measure sustainable for a year? So I was reading about the epidemiology to understand the risk, so we could do better risk management, which made me realize, “Ooh, this is over dispersed. This is super-spreader driven.” By March and April, this was pretty clear it was a super-spreading driven thing, and that’s partly how I got into it, because I think about sustainable public health measures. To think about that you need to understand risk. And then I started reading epidemiological documents of places like Japan, it was completely based on this idea. They were not even doing a lot of testing, partly because they also didn’t have a lot of tests, kind of like us, that it was a problem for them. But they dealt with it by realizing that they should direct the tests they did have to try to identify clusters because 80% of the people weren’t...
Weren’t transmitting at all, yeah.
Yeah, at all. But some people were transmitting a lot. So a transmission event was important. A case was not. So they were really focused on finding the transmission events rather than finding every last case, because if somebody has transmitted once, the odds are they’ve transmitted many times. So once you find somebody who’s transmitted, then you want to go and find all their contacts. You want to do all this backward contact tracing. There were all these really interesting optimization strategies that they deployed along with recognizing airborne transmission and ventilation guidelines and they had the “Three C” messaging – close contact, crowds and [closed spaces].
It worked better than most things that were a lot more severe in nature but did not have the right target. So I started thinking, “Why aren’t we doing this?” Why on earth, because you have to react to the risk you have and then I realized that a lot of the Western pandemic playbook, not completely unnecessary or unwarranted, is based on the flu pandemic that will come and hit us. And with the flu pandemic, there isn’t much to do. It is not similarly over dispersed. Kids are super spreaders.
Definitely..
So you do close schools, in fact that’s probably how we got rid of the flu partially by doing the wrong thing for the kids and we don’t have the flu much anymore. So there are a lot of these things that once it gets into this flu-like spread, you just wait for the vaccine, there’s not that much you can do if people do transmit a lot more. It’s half fatalism, you just kind of let it burn out until the vaccine comes and the vaccine comes I think the flu timeline is what, six months, nine months. And it’s like your vaccine, there’s a ceiling to how effective it’s going to be at 60%, 70%, although with mRNA it may change in the future.
I hope so.
Yeah, I know. I felt like, okay, we’re doing the flu playbook here, but we should do a SARS/MERS [Middle East respiratory syndrome] playbook – aerosol, airborne. Flu is also airborne, but just the infectiousness pattern is different. It’s not over dispersed. And the countries like Japan that were doing the SARS/MERS playbook, as I would call it, were doing much better.
Part of it is, yes, we didn’t have a huge SARS experience in the U.S., but Canada had it. So it’s not like Canada was completely outside of that. And they even had healthcare transmission and all that, so it’s not like they’re completely naive. And the second thing is there is all this expertise in Japan and Hong Kong and Taiwan that had been through similar threats before, and I am flabbergasted that our playbook did not get updated.
And I think there’s a tendency to blame a lot of the U.S. response failures on Trump and there’s no doubt that he made many, many things worse by meddling with the CDC, by constantly misinforming and misdirecting. So there’s no doubt that he was a really harmful influence on the course of the pandemic. But that doesn’t explain the Western European pattern, or what the U.K. [United Kingdom] is doing, which is lots of things wrong except perhaps the vaccination part.
So I think there was the broader Western problem with not switching to the correct playbook early enough. And again, the first weeks, first month I forgive everything from everyone.
It was terrifying.
And you don’t know what you’ve got. You’re just trying to plug all the holes. But if you read Japanese epidemiology documents, the ones I’ve read from February have every important aspect of this nailed.
There are three things that are important. One is the pre-symptomatic transmission. If you don’t put that into your playbook, nothing is going to work. For example, there’s a paper out now there’s no way for contact tracing to work at scale if you have pre-symptomatic transmission.
I saw that paper.
It’s not going to happen because the numbers are not going to work. The second thing is the aerosol transmission. You have to understand that, because otherwise you don’t have the correct guidelines. The third thing I think is the overdispersion. Because if you have those three elements, you can devise proper guidelines and then you need the sociology to try to make them sustainable. But if you read the February documents from Japan, they have it and they have everything, which makes me think it wasn’t impossible. It wasn’t unknowable.
They looked at the Diamond Princess and they saw some of the people who were going in with droplet precautions were getting infected. And I spoke to Dr. [Hitoshi] Oshitani [MD, PhD, MPH] who is a Japanese top epidemiologist and a professor. And he was like, “Look, those people were professionals. They went in with droplet precautions. They got infected. That’s a signal, those are not minor things.” So I don’t know why we didn’t switch. Somebody will write a great book of what happened in the European health agencies and the U.S. and Canada.
It was also harmful to have this dichotomous split between droplet and aerosol when it’s obviously a gradation. So I have a couple more questions for you, one is how you think this will “end.”
I don’t really predict a lot of things. I know you started by saying I’m prescient, but I actually read the papers and say them. The things I say, by the time I say them, they seem obvious to me.
But that’s the skill.
Thank you, but I don’t feel like I’m predicting. When I say, “There’s pre-symptomatic transmission,” I’m not predicting this. When I say, “This vaccine is going to blunt transmission,” especially since I’m not a medical person, I’m actually cautious. I read every paper I can find, and then I go ask everybody I can find, “What am I missing? What am I missing?” So I really second guess myself with all of those things and I try to argue with myself.
The reason I’m saying all of this is that everything I’ve spoken about, everything about ventilation in July I’ve written, the clusters days before the White House pandemic, I did the parks, all of those things. Literally, they were all there for almost anybody else to say, “We have to pay attention to ventilation.” By the time I wrote that piece, it was pretty obvious. I’m not saying I’m not doing anything, but I’m not making stuff up.
All right.
That’s the prediction part. Okay. So my feeling is that in countries like the United States, which have an ample supply, if we can crack the hesitancy bit, especially for younger people, it’s going to end very quickly, much quicker than people think. I have no predictions for March, because we do have the variants and we do have vaccination and we have seasonality. With things that are exponential in different directions, you could miss a week and it could go either way. You’re a week early and it goes this way, you’re a week late... so I don’t really know how March is going to play. Completely possible that this will continue on this downward slide because we are vaccinating fast enough and seasonality is helping us. I think that’s plausible.
It’s also plausible that the transmissibility is established right now, and for the remaining unvaccinated population, it could cause enough outbreaks to persist. You’re seeing this in the Israel data right now, even with enormous vaccination, because the variants, especially the U.K. one, took off there earlier so I don’t really know the March timing. But, looking at the numbers, I think sometime this year, we’re just going to stop having vast hospitalizations in any large numbers…
Hurray.
... partly because I think people are either going to get vaccinated or we’re going to get some outbreaks among the young and natural infection. Now what happens in the fall depends on if we have convinced the vulnerable populations, because we are going to have the supply by then, and we’re even going to have a kid vaccine probably by the end of summer. So going into fall when we start facing seasonality come against us again, I think it will be a question of what percentage of the vulnerable population, the elderly, have been left out of this.
That’s a nice way of framing it without having to bring it into any magical powers of prediction by looking at the data. Okay. Last question. Have you ever been wrong on anything?
Oh my goodness. Of course, I’m wrong on so many things all the time. Now the thing is though, by the time I write something in The New York Times or The Atlantic, I only write them after I’m really past the point of having kicked the tires. If anything, I have a newsletter and in my newsletter I got a little worried because people were liking it a little too much because they subscribed to my newsletter.
I subscribe.
Thank you. But the problem is it’s people who like me. I actually hired some people to try to take my arguments down because I really am a strong believer and everybody’s usually wrong about stuff. And what you want to do is you want to be wrong about them before you write for The New York Times.
Yeah. That’s great advice.
Yeah. The thing is and this is what’s been so frustrating to me is that people are like, “Oh my gosh, look at your record. Why have we been so prescient?” And I’m like, it’s actually more like a failure of the system that I get to do this because I feel I’m overly cautious by the time I did it, there should have been 20 other people with better credentials than me to write that article.
You tell me, there’s something about the way the medical profession public health messaging works, where it’s very hard for people to speak out of turn is what I’ve gathered. The people are very smart and very educated and I think they’re just wary of speaking out of turn, but in a pandemic, you have to go ahead of things, you can’t just wait. If the CDC is slow, you’ve got to push it because late is really dangerous against exponential growth. So I haven’t really figured out how. Once things slow down, I’ll think about how did this happen? That’s a question for you – you tell me.
Okay. Well, listen, I really appreciate you taking the time to talk with us today.
My pleasure.
It’s been fascinating. I think we’ve set a record for an OFID podcast for both insights and for duration, which is appropriate. And so once again, I’ve been talking to Dr. Zeynep Tufekci and she’s an associate professor at the University of North Carolina, a sociologist, a computer programmer, and a brilliant writer for The Atlantic and The New York Times. Thanks so much for joining me.
Thank you for inviting me.

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