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Brian Lehrer: Brian Lehrer in WNYC. Thanks to the Delta variant of SARS-CoV-2. Where much of the word awaits any vaccine availability at all, countries like the US, Israel, the UK, and France are wavering between further reopening, reimposing restrictions, and debating whether vaccine boosters are warranted. The pandemic has exposed fault lines between rich and poor, the politically powerful and the vulnerable, and along ideological lines, both between states and within societies. How this all plays out in whether you put on a mask when you leave home or top up your J&J vaccine, or even get your vaccine is both a question of public health and personal health of science and ethics.

To talk more about some of these fault lines and how our political leaders and public and private health systems are responding, we're joined by Laurie Garrett, Pulitzer, Peabody, and Pulitzer Prize-winning health and science journalist, who has been at the front of studying how we handle public health crises. From her first classic book, The Coming Plague: Newly Emerging Diseases in a World Out of Balance from 1994 reissued last year, to Betrayal of Trust: The Collapse of Global Public Health, and I Heard the Siren Scream: How Americans Responded to the 9/11 and Anthrax Attacks. Welcome back to the show, Laurie Garrett.

Laurie Garrett: Brian, it's always a pleasure to be with you.

Brian: Laurie, you were on a recent episode of the podcast This Week in Virology. I will tell the listeners that I happened to catch. You spoke about the state of public health here in New York and globally. I wanted to follow up on something you said because it doesn't get much mainstream media coverage. This is the kind of thing they talk about in a science nerd podcast about virology, [chuckles] but I think it has an impact. We seem to be in a moment where we're getting mixed messages.

I think the reason has to do with what lens you look through. A medical doctor, you argue in this podcast, might see a reason to get vaccine booster shots when an epidemiologist might not, for example. Is that an apt example of how the lens you look through public health or medicine affects policy recommendations?

Laurie Garrett: Well, Brian, going all the way back to the days when Herman Biggs created the first great Public Health Department in the entire world located ta, ta, in New York City at the turn of the 20th century. From there on, you can see, you can just map an arc that shows this constant tension between individually-oriented organized medicine versus population-oriented public health. It's a conflict that's never been resolved. Maybe it's never will be, but it has always ended up deciding in terms of power and money on the side of individual care and organized medicine, not on the side of public health.

The person who protects a million lives a day by cleaning your drinking water supply, unless you're in Flint, Michigan, gets paid maybe $50,000, $60,000 a year. You don't know that person's name, they have zero political influence on anything. Whereas the individual who's a famous open-heart surgeon and saves perhaps 100 lives a year or what have you, is Dean of the school of medicine, has earnings in excess of 400,000 a year, and can call the mayor and say, "I think you should do X, Y, and Z about people wearing masks."

We have this very skewed situation where the people that actually are saving your life every single day and are largely invisible and you never think about them, they're the ones making sure that there's as little toxic compounds in your air and water as possible. They're monitoring for disease outbreaks, they're trying to make sure the food sold in restaurants is safe to eat and all that. Those folks have no influence, no power, but they actually save more lives.

Then you get into an outbreak or as we're in now, a completely full-fledged out of control, no end in sight pandemic. You see it play out all the way to the global stage where influence is driven by what is in the best interest of the wealthiest countries' individuals versus what is in the best interest of society as a whole, of the world population as a whole, of the poorest person in the worst slum in Nairobi, Kenya, and the richest person living in the Hamptons. We've never resolved this debate. It just ends up deciding in favor of the 2% and their doctors.

Brian: How would it look if it came out the other way if we treated everybody's interests equally in the context of COVID?

Laurie Garrett: Everything would have been quite different from the very beginning because what was the absolutely most important thing we needed to know? Before we had a vaccine, before we knew how to treat anybody, we were being deluged. We all here in New York can put on our memory caps and remember what it felt like on March 18th, 2020 to live in this city. The level of fear and the knowledge that there wasn't a particular set of things that a doctor could do for you if you made it into a hospital with COVID that would be deciding factors in your survival because the toolkit was so limited. It's still fairly limited.

What would have made the biggest difference? Well, the first thing would have been an effective, rapid, easy to use, not requiring a laboratory, super cheap way of telling who had COVID, who was infected with the virus. Then to have used it, not just to diagnose people individually, which by the way, remains the primary use of all our available tests, but it would have been to do well-designed studies rapidly, super fast to figure out what percentage of our nursing home populations are infected? Who's getting it and how? What's going on with spread inside the hospitals? Are healthcare workers getting infected from the patients?

If we had been taking interventions and developed the technology appropriate and high priority at that end, way back then, we would be in a very different epidemic today.

Brian: I think a lot of people are confused, Laurie, when they hear the mayor of New York City say like he did on this show on Friday, that he won't require masking indoors, in public spaces for everyone again now. Even though cases are on the rise and they're doing this in LA, and most people have heard of someone who's fully vaccinated, but have tested positive. If no immediate friends or family members, those Yankees players, or those Texas lawmakers but the mayor says the fact that this summer we have vaccines means cases don't inevitably lead to hospitalizations so no further restrictions.

When talking about the homeless, when I asked him this on Friday, he said, "Yes, we can put people back into congregate shelters again because they can choose as individuals to get vaccinated." So far, what does the data support and your opinion about grouping people together again, or another indoor mask mandate?

Laurie Garrett: What the data is telling us, and we don't have to just look at New York, we can look at the whole world experience and see even a highly vaccinated society like Israel is still struggling. Definitely sees moments when they want certain populations to put masks back on, when there are people that refuse to get vaccinated. What we can see around the world is that the vaccines are not going to be our exit sign from this pandemic if they're not used universally and if they're not used strategically.

It is crazy that we got as far as we did into the rollout of vaccines in New York City without really asking who are the most vulnerable populations that also are exposed to large numbers of people? Can we get them vaccinated? For example, we know that a lot of people who work in the nursing home industry work at multiple sites, and a lot of people who do home health care work at multiple sites. They move around quite a bit, they go from one nursing home to another, they're surrounded by highly vulnerable people, in many cases, living in substandard conditions, crowded, not your fancy Beverly Hills nursing homes.

Those individuals that are the moving labor force should be a primary target for vaccination. They should have been offered it immediately and they should be more than just encouraged to be vaccinated. They are potential vectors of disease. There should be a mandate. There should be some sense of social obligation. There's a social contract in public health, and there's a contract that says, "I, as a health practitioner agree to do everything possible to not spread disease, to not make your potential health worse than it was before you interacted with me." Now, mistakes can get made, but you can't just say, "Oh, it's okay for doctors, nurses, and healthcare workers to decide that they can interact with large numbers of people and never get vaccinated because they personally don't want to do it."

Brian: Our vaccine resistance rates in this country are about what? 30% of Americans and incredibly to me and I guess to you, it's like 30% of healthcare workers even. I'm curious if in all your years of covering viral pandemics, and listeners, if you don't know Laurie Garrett's work, she's traveled the world to look at things like this over a period of decades. Have you ever seen a situation of resistance like this to a vaccine, not to mention the ones as highly effective as what we have for this if they are almost universally distributed?

Laurie Garrett: Yes, I think the best example [beep] that would correlate with what we see right now is what happened in the later years of the Soviet Union. I saw this up close and personal. They had a spectacularly huge diphtheria epidemic that spread across much of the Soviet Union, especially Russia and Ukraine. I think if I remember the numbers right, more than 250,000 children got diphtheria. I realized that for most Americans, the word diphtheria is meaningless because we're all vaccinated.

You don't see kids dying of diphtheria, but when you do see a child literally suffocating because of a bacterial membrane forming in the back of their throat and they can't breathe and you watch them take their dying gasps, it's a terrible thing to imagine that there would be a large conspiracy theory that somehow all the diphtheria vaccines are contaminated and that it would have reached such a level, and this is, of course, long before social media, that in the most educated elites of Moscow and St Petersburg, the vaccine refusal rates for their children were as high as 80 to 90%, refusing.

There was a direct correlation between a moment when the state began to lose support. More and more people in the Soviet Union opposed the existence of the state. They doubted its validity. They didn't trust the state, which is why my second book is called Betrayal of Trust because trust is key to everything in public health. As you saw the trust in the Soviet system began to deteriorate then everything that the Soviet health authority said came under suspicion.

You saw more and more conspiracy theories about everything from drinking water to vaccines, but it was especially effective in attacking vaccines, and what was the result? Boom, this huge, huge epidemic that spread across a region of thousands of miles [beep] multiple today countries. It all came from an unvaccinated population in Afghanistan and Soviet soldiers that were exposed in the war then in Afghanistan bringing it home.

Brian: Wow. I had no idea. Now President Macron of France just instituted a vaccine mandate for health professionals over there plus people wanting to participate in public life will need proof of vaccination or a very recent negative test result. I think that's even for going into restaurants and things like that. It's drawn protests from both the left and the right in France. That's not something anyone could contemplate here politically, could they?

Laurie Garrett: It would be a very tough thing to enforce even in a relatively blue progressive city like New York and certainly very difficult in much of the red state regions of our country. We have a situation. Let me give you the reverse of that horrible Soviet diphtheria story for a second. It was in New York. The year was 1947, a tourist came from Mexico, traveled to New York, went to every single tourist site that you want to go to when you visit New York and didn't realize it, but had smallpox. Smallpox spread in New York City. There was great concern that overnight there would be a spectacular return of a disease that had virtually disappeared from the United States.

At the time in the post-World War II period, there was so much trust and faith, and pride in America. Patriotism was so high and support for the city government in New York was so high that when the city health commissioner went on, guess what? WNYC and told the people of New York, "We are faced with a catastrophe. I want all the boy scouts, all the girl scouts, all the YMCA, all of you organized immediately. We're going to get every single New Yorker vaccinated." They did it. People lined up for blocks and totally there was no substantial anti-vaccine effort at all. The entire city was vaccinated against smallpox in a matter of days, something we just absolutely couldn't accomplish today for entirely political reasons.

Brian: That's a great story. This Week in Virology podcast that you were on, you were particularly critical of Mayor De Blasio for putting people who weren't trained in public health in charge of the pandemic response. You said 30% of the city's public health professionals, and again, we're making a distinction between public health professionals, largely MPHs, master of public health and DRPHs, doctor of public health. We're not talking about MDs and that's the distinction you're making, that they weren't putting trained public health people in charge of the city's public health response to the pandemic. I hadn't heard that figure before that 30% of the city's public health professionals have left the health department. Remind us what happened there?

Laurie Garrett: We saw a real tidal wave and frankly, morale issues that persist today. We once had the greatest public health department on the planet, and I used to love with great-- get all puffed up when I went overseas and brag about New York City's Health Department with really remarkable efforts and tremendous leadership, one health commissioner after another. What we've seen under De Blasio in the COVID response is a total deterioration of the health departments leadership by public health professionals, indeed the firing or forced resignation, depending on who you want to talk about, of our last health commissioner, Oxiris Barbot and replacement with a physician who came out of the hospital corporation.

What we've seen is contact tracing all the essential toolkit of [beep] test and trace for controlling an epidemic was stripped out of the health department and put in the control of the hospitals. We've seen this once great health department suffer such deep morale crisis as they heard nothing from city hall, but attacks, criticism, refusal to accept their analysis of what was going on.

Brian: Let me jump in because we're going to run out of time. Make your case. Why would the public health response be worse under MDs? I don't want to pounce on MDs who are also going into health.

Laurie Garrett: Wait, correction. It's not that they're MDs. Most of our health commissioners have had MDs, but it's that if you are working as a physician, your duty is to individuals, to the person right in front of you who is sick. If you're working in public health your duty is to the whole city at once, the whole state at once, whatever that constituent is.

Brian: You think that's even true of the people who run the public hospital system?

Laurie Garrett: Public hospital system's primary duty is to its hospital patients.

Brian: We're almost out of time. I'll just say by way of maybe a lighter note that as someone who you may know in my secret life, I have a master's in public health and I was amused by a comment you made on that This Week in Virology episode about the lack of funding and respect that we give the public health schools. I think you said that the public health schools are relegated by the major universities to some stucco building versus a marble hall for the school of medicine. In our last 30 seconds, how does that play out on the ground in a pandemic like what we're dealing with?

Laurie Garrett: I think in general, you will see that that plays out in terms of how the professionals see themselves and work together. Public health people tend to be pretty meek. They tend to see themselves as government employees, very obedient, not terribly wild looking for official approval to say anything. Then you look at what's happened with so many of the MDs that have stepped into the center stage, particularly when Trump was in power. You see that some guy whose training was radiology, he's never dealt with an infectious disease case ever, becomes the number one advisor to the President of the United States and says, "Oh, we'll have instant herd immunity. We can stop vaccinating, forget about it." That was Scott Atlas.

Brian: There we leave it with Laurie Garrett, science journalist and the author of several books including the recently reissued classic, The coming plague. Laurie, thanks so much.

Laurie Garrett: Thank you, Brian.

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