ML: You have any clever ideas about how to fix that?
RH: John Bell, who is the Regius Professor of Medicine at Oxford, has an interesting idea. Most of the poorer countries don't have adult vaccination programs. They're not vaccinating adults for shingles or pneumonia or flu. His idea is that this is really an opportunity to introduce adult vaccination programs globally. If you have those capabilities in place in the long term, that helps.
ML: You're a student of pandemics and of the history of vaccination programs. Did it surprise you how resistant to vaccination the American population is?
RH: Yes, it did. Vaccine hesitancy has been a major concern in the public health community for many years. But the pandemic accelerated it in a variety of ways. We were talking about developing vaccines at record speed. For anyone who has any suspicion of pharmaceutical firms, suspicion of government, suspicion of medicine, that creates a very fertile environment for doubt to creep in—even among people who are kind of in the middle, not just the hardcore anti-vaxxers. And the hardcore anti-vaxxers now have instruments in the form of social media for amplification of their message and for sowing doubt. They have used those tools very effectively.
And then you had an overlay of politicization in the U.S. in particular where it got tangled up with political identity issues. That’s remarkable in some ways, because President Trump had every right to stand up and crow about delivering a vaccine in record time for the American public. You could easily imagine that having been the signature success of his presidency if he had embraced it and told everybody to go out and get vaccinated—but, for whatever reason, he didn't do that.
This is a weird virus in terms of differential rates of risk—high risk in the elderly and the almost negligible risk in the young. You've got a lot of people who have the luxury of being anti-vax or being skeptics, or feeling kind of immune, whether they get the vaccine or not. You can imagine a different scenario where you had some lethal bug, like the 1918 virus, that really hammers young people. That might have led to a different dynamic. My sense is when the threat is salient, people are going to go get the magic bullet. Their willingness to skip the magic bullet depends on their assessment, right or wrong, of their own risk.
ML: Knowing what you know now, if I put you in a time capsule and sent you back to the Bush White House, what would you have done differently?
RH: I’m not sure what I would change. The work we did to develop a pandemic plan, and particularly the work we did to rehabilitate non-pharmaceutical interventions, was important. At the time, nobody was thinking how to systematically use non-pharmaceutical interventions. These are tools that can be used intelligently, in a targeted way, to reduce transmission when countermeasures aren’t available. We need to incorporate using them in a highly targeted way into our planning. It can't just be, “Oh, we're going to do a bunch of stuff.” We had to relearn that lesson with Covid, unfortunately. The way lockdowns were applied initially was not targeted. Lockdowns were effective but came with a huge cost. Our use of such interventions has become more targeted and our ability to adapt to changing epidemiologic conditions has improved over the course of the pandemic.
ML: Would you have done anything to the institutional structure of the American government? What should be the mechanism for trying to coordinate society and a response to any kind of new pathogen, whether it's another variant after omicron or another pathogen?
RH: When you have a new pathogen, it requires decisive action and a tolerance for risk that our institutions are not configured to create. What you need are institutions that have a culture that is designed to produce both the autonomy and the understanding of the need to take risks when you face a threat and have very limited information. The problem is that means a lot of false alarms. If you get it right, you prevent a pandemic—but you pay for success with a lot of false alarms.