The Conflict of a Global Pandemic 

Atul Gawande, a leading public health expert, reveals how the response to COVID has deepened our countries’ flawed healthcare system and exposed a discomfort with conflict. 

This week marks one year since the first round of major city shutdowns shook the United States as COVID-19 spread throughout the country. Atul Gawande, a practicing surgeon, New Yorker staff writer, and leading public health researcher, made a prediction with a friend of his: the total death toll from COVID-19 will not reach more than 40,000 people, which seemed unimaginable to him at the time.

Over 500,000 tragic deaths later, Gawande retraces his steps. As debates over mask mandates and personal and political freedom suffocated a united COVID response, Gawande traveled to Minot, North Dakota, to understand what was happening in one of the worst-hit counties in the world. Through interviews and council meetings, Gawande found that the community struggles between doctors, small business owners, parents, and politicians went beyond political party. The ability to cope with conflict, he found, was at the heart of the issue. Could we, as people, as a country, accept conflict in order to unite against a virus?

Recorded March 8, 2021

Preet Bharara:

From CAFE, welcome to Stay Tuned. I’m Preet Bharara.

Q&A

So I’ve gotten a lot of questions about this, the fate of Andrew Cuomo and whether or not that affects what happens to any state case brought against Donald Trump. And the easy answer is, the quick answer is that the governor of the state of New York like the governors of other states can pardon someone for charges brought under the laws of that state. The president can’t pardon state charges, but the governor can.

But I hope it puts people at ease to realize that if Andrew Cuomo resigns, the governor becomes Kathy Hochul, who’s also a Democrat and I’m assuring you very disinclined to pardon Donald Trump if he’s charged in New York state. I will also say that given the demographics and the political makeup of the state of New York, the likelihood that there will be a Republican governor after the next election is quite low.

And a Republican governor who would be inclined to pardon Donald Trump, I think is just as low. And by the way, I’ve been seeing these conspiracy theories on the part of the left saying that Donald Trump must be in some way responsible for these allegations against Andrew Cuomo. That’s not true. Let’s stay focused on what’s really happening in the world. Donald Trump is responsible for a lot of bad things. He is not responsible for or behind Andrew Cuomo’s woes.

This question comes in a tweet from @KMChanko1. Does the SDNY and the Manhattan DA share info? Would SDNY assuming that office doesn’t already have such info, be able to get Trump’s taxes and other business records from Vance for any potential investigations SDNY is working on? Yeah, there are circumstances in which law enforcement offices can share information.

They can do that pretty easily with respect to generalized information, interview notes, share theories of the case, et cetera, with respect to grand jury information, stuff that’s been obtained by grand jury subpoena. Depending on the jurisdiction, there are rules for which a judge can issue a court order to allow the sharing of that information. I assume that the Manhattan DA’s office is going to collect its own information with respect to not just the Trump case, which is pretty far along, but also as we’ve discussed on the show before, the case against Steve Bannon, which had been proceeding in SDNY until Trump pardoned him.

This question comes in a tweet from @wisa38 who asks very important questions. One, can voting rights legislation pass the Senate? Two, if it doesn’t, what are the impacts of the current plague of voting restrictions being enacted by GOP legislatures?

So as I said, that’s a really important and vital question I think, for the country. So you appear to be referring to two different bills currently before the Senate, one that we’ve talked about before, that sweeping democracy reform bill called H.R. 1, which just passed the house and the John Lewis Voting Rights Act, which also has gotten a lot of attention.

And that’s a bill that would restore the Voting Rights Act of 1965, which as you may also know, was gutted by the Supreme Court in 2013. So H.R. 1 is a groundbreaking sweeping bill, and I think very important. I can’t summarize it here too easily because it’s 800 pages long. But among other things, it creates a system of automatic voter registration, it restores the franchise to people with criminal records. It expands early voting, voting by mail and absentee drop boxes.

And it does other things too to bring reform to our elections. It requires candidates for president and vice-president to disclose 10 years of tax returns, not leaving it up to their discretion. It establishes a new system for public financing for campaigns. So it does a lot of different things that many Republicans don’t seem to like. So first you asked whether the bill could pass the Senate, well, it doesn’t seem to have much if any Republican support.

And as you know, it’s a razor thin margin in the Senate, 50 Democrats, 50 Republicans with the vice president Kamala Harris available to break a tie. So the fate of H.R. 1 at least at this moment may depend a little bit on the fate of the filibuster. There’s been a lot of debate about the filibuster. Joe Biden himself has suggested that he’s opposed to repealing the filibuster. Joe Manchin seems to be adamantly opposed, although he has opened the door to some reforms and making it a little bit more difficult to filibuster a bill.

But I think it will depend a lot upon what people’s will is. So we’ll just have to wait and see. And you’re right to raise the other question, H.R. 1 and some of the provisions in it are more important than ever before, not just because it would be good for improving democracy and voting, but also because there is a deliberate move in state after state after state, including in Georgia, to roll back access to the ballot.

Republicans are passing measures that would restrict access to absentee voting and early voting and heightened requirements for voter ID. In fact, Michael Waldman, former state team guest and my colleague at NYU who leads the Brennan Center for Justice. This is what he said about these restrictions that are being voted in around the country. He said that this is “the most significant wave of such restrictions since the Jim Crow era.”

And so you’re right to ask these questions. It’s a really big deal. The lesson that some people have learned from the 2020 election is that voting is too easy and voting is too accessible for too many people, including people from communities of color, and the way to stop that is to make some progress on H.R. 1.

This question comes from Twitter user @Fraser1025. After a year of lockdown, what is the favorite board game in the Bharara household and who is the reigning champion?

So we don’t play a lot of board games. There was a time, I don’t think you can call boggle and Yahtzee board games, but they are games that we play. I’ve made it a habit in my home to not let my kids win, even when they were little so that when it came time for them to be able to beat their father, they had a real feeling of achievement, accomplishment.

And I can report to you, they feel that feeling of achievement and accomplishment a lot because I lose a lot to my kids at Boggle, for example. The favorite board game of the moment in my home is my youngest son has become obsessive about the game of chess. I used to be able to beat him from time to time. I haven’t beaten him in some while, but I’ll keep you posted if I make a comeback. It’s time for a short break, stay tuned.

THE INTERVIEW

Preet Bharara:

My guest this week is Atul Gawande. He’s an influential surgeon, writer and public health researcher. Operating at the intersection of medicine and politics, he recently wrote a New Yorker article about a town in North Dakota and their debates over mask mandates. As we cross the one year mark since the first wave of COVID shutdowns, Gawande joins me to discuss his hopes for healthcare policy and the potential for a fully vaccinated America. Atul Gawande, welcome to the show.

Atul Gawande:

Glad to be here Preet.

Preet Bharara:

It’s a real treat to have you. I don’t know if I told you the story last time I saw you, but I just wanted to mention to you and for the hundreds of millions of people listening, how much some of your writing has meant to me. And in particular, when I was writing my own book three years ago, I was at a conference and someone was asking me what my book was about and what the approach was that I was taking.

Preet Bharara:

And they said, “You know what? It sounds an awful lot like another book called Complications,” of which you are the author. And so I picked up your book and it’s a series of stories and meditations on medical cases that you did. And so I just want you to know that was an inspiration to me in the writing of my book. So I thank you for it even though I forgot to put you in the acknowledgements, forgive me.

Atul Gawande:

That’s awesome.

Preet Bharara:

So I’m doing it now.

Atul Gawande:

That’s awesome.

Preet Bharara:

You’re my worst nightmare. Someone who went to medical school to please their parents and then also writes beautifully. So I kind of have some envy.

Atul Gawande:

Indian kids, we all have that scar.

Preet Bharara:

Right off the bat. So one of the reasons I’m really thrilled to have you is we’re recording this on Monday March 8th and a year ago, I feel like March 8th or the week of March 8th was when most Americans began to really fully understand that something terrible was upon us and school started getting canceled and lockdowns seemed imminent. And so let me just first ask you, what were you doing and what were you thinking a year ago this week?

Atul Gawande:

I had as much doubt as anybody else. I was convinced this was going to be not just the flu, but the whole idea that the world would really change. I remember on March 10, I keep little notes of predictions and I-

Preet Bharara:

You do? Wait, why do you do that?

Atul Gawande:

Why did I do that? Someone told me about the idea like you think you’re right. And so write down what you really think is going to happen and the date and when you predict it will be, and then just see how right you are. And I miss a lot. And so I note these things down.

Preet Bharara:

I just find that fascinating because very few people do that.

Atul Gawande:

Well, it includes lots of personal stuff. Like I had a bet on here whether my son who was out of college would have a job by the end of June. Fortunately-

Preet Bharara:

I’m like, “Am I going to lose the seven pounds I’ve gained over the pandemic?”

Atul Gawande:

Exactly.

Preet Bharara:

I don’t know.

Atul Gawande:

Exactly.

Preet Bharara:

I’m not going to write that down. So your prediction was what?

Atul Gawande:

My prediction, I had a medical colleague who said… by then we’d started to see deaths but the notion that would be in the hundreds of thousands was almost inconceivable. And he bet me that the total death count would be less than 40,000. And I remember I took the bet, I remember just pausing for a minute. I thought what he said was nuts, that everything indicates this is a hockey stick heading straight upward and the disease is doubling every 10 days, the deaths are doubling every 10 days and the math just indicates a serious problem.

Atul Gawande:

And yet I paused, I paused about taking the bet. And I remember that pause, everything in it, right? I’ve got my public health training, my epidemiology, my sense that this really was a big deal and a concern and yet the notion… I kept pausing it every moment, right? March 10 was that bet. Within a week later, I was making a bet that we were shutting down, working in person and people would say, “Well, when do you think we’d be back?”

Atul Gawande:

And I’d say, “Well, who knows? Could be April.” And just every of these, even with all of my background is inconceivable. It’s one thing to say the math indicates this is going to get terrible, it’s another to actually take actions and believe that the invisible is going to create this incredibly visible impact.

Preet Bharara:

Well, that’s interesting to me. Given your training and your expertise, you were having a hard time getting your head around what probably in retrospect seems to have been what the likely result would have been. And so what does that say if someone like you had these hesitations and couldn’t wrap your head around it for tens of millions of Americans who don’t have that expertise and also engage in wishful thinking because that’s how human beings are, about how difficult it was for them to really wrap their heads around how serious a thing this was going to be even months into it and hoping that we were going to reopen? And do you think that sort of mental state has been part of the reason why we’ve been in this for so long?

Atul Gawande:

Completely. I think about this a lot. I wrote an article some years back about what I called slow ideas. And my field of surgery was completely transformed in the 19th century by two discoveries and one spread like wildfire and the other did not. The one idea that spread like wildfire was the discovery of anesthesia, that you can inhale a gas and it would make you free of pain so that you could undergo surgery.

Atul Gawande:

And that spread, there was no internet, ideas had to travel across the ocean by ocean liner. And you had to take the Pony Express or whatever to get across the country. And within weeks of publication, ether anesthesia was being used in all the major capitals Europe and across the United States. By comparison, when Lister, Joseph Lister demonstrated antisepsis, prevention of the biggest killer in surgery, which is infections by using antiseptics.

Atul Gawande:

It took a generation for it to be widely, fully adopted by every hospital across the country and adopted around the world. And the big difference between the two was one had an immediate and visible effect, anesthesia stopped pain immediately, and it was very visible. And so you could connect what you’re doing with the actions that you were taking.

Preet Bharara:

And it was visible with respect to the first patient you did it with.

Atul Gawande:

That’s right. You can see my action here has this effect there and then I can fine tune. Antisepsis was stopping an invisible problem, germs that infected a wound in an operation, but don’t kill the person until two to three weeks or four weeks later. And the result was battles for decades over whether germs really matter and whether the infections are a big deal or not big deal, and whether they can be prevented and whether that’s the right thing or… all those wars went on at that time.

Atul Gawande:

And it looks just like the ones we have now, because it’s an identical situation. Something you can’t see or feel, and you feel perfectly fine can spread, and in two to three weeks have created an illness that leads to hospitalization and then to death. And the idea that our actions now lead inexorably to these invisible things happening to create visible effects weeks from now is incredibly politically hard.

Atul Gawande:

I’ll add something that makes this virus particularly politically menacing. We have for people ages 20 to 50, they account for three quarters of the spread. So we have a disease that half the spread comes from people who are asymptomatic, don’t know they have it and most of the spread is from people from people ages 20 to 50, and 93% of the deaths are in people over age 55.

Preet Bharara:

Now I feel bad for my age group, I feel a little bit of guilt.

Atul Gawande:

Well, so the challenge there is from age 15 on up, we all have an elevation in our mortality rate. We’re all worse off, but we all start out with such a low level of death that it doesn’t amount to that much for us, but over the age of 55, that’s where the action is.

Preet Bharara:

I’ve got a question about the psychology of this. You’re talking about the slow idea of dealing with infection and washing. And I would get it if an idea took a long time if it involves some major procedure or sacrifice or dietary change or some other such thing. But it seems to me that this slow idea or this idea that was slow to take root for preventing infection, it was a pretty minimal thing to have to do.

Preet Bharara:

And the reason I ask about it is it strikes me that there’s a parallel between that and mask wearing, which doesn’t seem to be that intrusive. It’s not like putting a shot in your arm even, or under undergoing some medical procedure. Do you have a sense of why even simple things that cause no harm and have a likelihood, or at least a possibility until further proof comes along of being of great benefit, why are people resistant to doing simple things?

Atul Gawande:

Well, you put your finger on one other thing that’s really important to understand about why one went viral and the other one didn’t between anesthesia and antisepsis. Anesthesia was good for the doctor as well as the patient. So not only did the patients love being free of pain. In surgery, you’d have three orderlies to pin a patient down, the average operation had to be done in 60 to 120 seconds because people just couldn’t take it, right?

Atul Gawande:

And it was all about speed and not precision and there’s a limited amount you can do. And so surgeons loved it, right? That was part of what made it go. It was incredibly complicated. It was high risk, you give too much of the anesthesia people died, don’t give enough and they’re screaming. And in fact, it took ultimately creating a whole specialty, putting two people in an operating room to make this go. This is in the 19th century, we had the GDP per capita of India.

Atul Gawande:

We would have said, “This is not scalable. This cannot spread.” And it spread almost by itself. Now the other one required some pain now for the sake of a big gain for the patient. It wasn’t huge, but it required a meticulousness and attention to detail about these invisible germs. It required washing your hands with the antiseptic. And by the way, the antiseptic that he discovered worked, Lister discovered worked was dilute carbolic acid.

Atul Gawande:

And so it was literally… it burned after a while and literally was pain now for gain later. And when you look at the experience with the Coronavirus, a mask doesn’t seem like much, but you’re asking people to be deliberate to take actions, to curtail their lives in certain ways, whether it was where they go, where they travel, whether they eat out, whether they don’t eat out, and then the mask was the symbol of the idea that public health people are telling me what to do.

Atul Gawande:

And those public health people would say, “This invisible thing is going on.” And it drove surgeons crazy to have the people who followed Louis Pasteur’s theory of microbes saying to them, “You are causing people to get sick, that you have to change your actions in order to…” The way you do something as central to their life as how they do their surgery. And it wasn’t hugely complex, the requirements, but it required a level of intention, attention to detail and requiring you to change.

Atul Gawande:

And that felt like an affront, an affront that lasted a generation and continues to be something we have to police and watch because people stop washing their hands, they stopped doing what they need to do in the hospital and it turns out to matter. And I think it’s very parallel here.

Preet Bharara:

So I want to talk about some of those attitudes and what you learned through the prism of a visit you made to a town in North Dakota, and you wrote a New Yorker article about this. And you write in the article, and it’s a place called Minot, North Dakota, Minot, North Dakota, and you write in the article, “I wanted to learn about Minot because it was exceptional. It was in the worst performing county, in the worst performing state, in the worst performing country in the world.” What was special about that place?

Atul Gawande:

Well, in the fall North Dakota was the hardest hit by the Coronavirus at a time when the United States was the hardest hit country in number of cases per capita hospitalizations, per capita ultimately deaths. And Minot, North Dakota was in the county that had the highest rate of spread in North Dakota. And what I was puzzling over is in a democracy as freight as ours, and I started following along with people there in October, I had infectious disease colleagues in North Dakota that are friends, and they describe just trying to get mask wearing in North Dakota, and they were just demonized.

Atul Gawande:

There was absolute opposition to mask requirements, or even to the suggestion that people should be wearing masks out of arguments that this is fear-mongering, this isn’t any worse than the flu. But even among those who had seen that it could be bad, had still kind of sense of don’t tell me what to do. And what I wondered is in the midst of crisis, could the democracy of a city council, how do they cope and keep a city going?

Atul Gawande:

I mean, the hospital in September for the local community started saying that they are seeing cases rising. They’ve had to open extra beds, COVID units, and they were going to run out of staff. And they were begging by the beginning of October for people to wear masks and for some basic restrictions on bars and restaurants and weddings and the like to come into place. And I was interested because the state wouldn’t do it, but the city council had one of its members say, “Well, I’m just going to do it. I’m going to propose that we have a mask mandate here in Minot.” And they had the argument and it was a loud, vocal, painful argument. And people had to be heard from all sides.

Preet Bharara:

And so how did that go?

Atul Gawande:

I mean, part of what was interesting to me is… so I talked to the people like Tom Ross was the most vocal opponent on the other side. And I grew up in rural Ohio, town called Athens. And Tom was a guy I went to high school with. I mean, we’re almost the same age and he’d been a local newscaster then was in sales for farm equipment to large… farming is the biggest industry there. And one of his friends, someone you knew, was the first person to die of COVID in Minot.

Atul Gawande:

He was afraid for what might happen to his mom. But at the same time, he had a child in high school who had his senior year decimated. He had a daughter who’s out of work, she’s a chef. And he saw the pain of it all, eventually got infected himself and remained absolutely opposed to masks. And partly because he hears from lots of folks who will disagree with what I have to say about the data and what it shows, and so has his doubts, but partly because at the end of the day, he was not willing to sacrifice.

Atul Gawande:

After all that we’ve given up in the last year, he was not ready to keep on doing that and he accepted the vote. The vote was five to two against his position. He would propose later to revoke the mask ordinance. In the end the state adopted mask wearing. And I think it’s really telling that in the debate, by the end of it, at the end of November, 89% of North Dakotans put on a mask. They were wearing masks most or all of the time in public.

Atul Gawande:

But I also want to make clear, there was no consensus, there was still strong opposition by folks like Tom Ross or another person I’d written about named Roscoe Streyle who was very active on social media and a former state legislator. And that battle is there. And that turned out to me to be part of what democracy is about in the face of an invisible menace that requires parts of the population to sacrifice for what’s happening for all of us.

Preet Bharara:

It’s an interesting question, maybe more philosophically than medically. And I should note that you were a student of philosophy at one point in your academic career. It’s one thing to decide for yourself how much you’re going to behave in a way that lengthens your life versus the quality of life as you define it. And we can talk about that in a second, because I’m curious about what your thoughts are. But it’s quite a different thing to decide you’re not going to undertake certain sacrifices or engage in certain habits when the effect of not doing that affects other people.

Preet Bharara:

People can make decisions about their diet. And I could decide if the doctor told me you’ll live three years longer, you’ll live to be 87 instead of 84 but you have eat lettuce every day of your life, I might choose and likely would choose to live three years less. I like lettuce, but not that much. But it’s quite different to say if you engage in some activity, it increases the chance of other people dying. How do you think people process that decision-making?

Atul Gawande:

Well, we make those kinds of choices all the time, right? This is not black and white. Case in point would be, I remember the debates over whether we would raise the 55 mile an hour speed limit to 65 miles an hour, knowing there’d be thousands of people who would die, and we did it. Ultimately as a country we decided that… and also all the arguments about energy as well. Carter had brought in the 55 mile an hour speed limit to save on energy, and we did that.

Atul Gawande:

We’re going to come to this choice. There’s going to come a moment, I don’t know if it’s in three months, if it’s in six months, but we will get our hospitalization rates and death rates below flu levels, that’ll be below a hundred deaths a day. And at that moment we will then decide, do we keep everybody locked down, not locked down, but with restrictions like we’ve had, keep on wearing masks, keep restaurants and bars at minimal capacity in order to knock a hundred deaths a day down to one death a day.

Atul Gawande:

I think we already have our answer, right? Whether it’s a Democratic state like New York or a Republican state like Iowa or Texas, you have restaurants and bars opening and people desperately wanting to return to normal. And we’re still at 60,000 plus cases a day and 2000 deaths a day. So we haven’t even come down to the peak of the last surge and we’re already finding that we end up wanting to make these choices.

Atul Gawande:

The question is not, are we going to have trade-offs that we are willing or not willing to make, it’s where is that line for these trade-offs and how do we have a straightforward, honest discussion about that, taking into account all of the pain that people have. Part of what makes it complicated is the virus is boss, as one economist told me.

Preet Bharara:

Right.

Atul Gawande:

The economy does not respond to whether you have restrictions or not. People aren’t restricted from flying, they’re not restricted from going to hotels that while the virus is in heavy circulation, the virus is boss and we are not… Yes, movie theaters apparently can be open 25%. I cannot go inside a movie theater. I don’t care if it’s unrestricted. Knowing that we have millions of people actively infected every day and that there are going to be, there’s going to be someone in that movie theater who is infected, I’ll be in a different place when that’s not the case. But other people, clearly people are going in and they’re like, “Well, I’ll do it.”

Preet Bharara:

I’m guessing since you’re a medical professional that you have been vaccinated.

Atul Gawande:

I have been vaccinated.

Preet Bharara:

And yet you still will not go into a movie theater.

Atul Gawande:

Yeah. Two reasons. Number one, now am I fearful that hospitalization and death are going to come to me? No. Am I fearful that we’re going to keep these viruses circulating? Because we have evidence now that even though you get vaccinated, we’re still capable of asymptomatic or mildly symptomatic infection. And with so many people infected it’s those who are not immunized that I’m concerned about. And also the fact that the more we keep this in circulation, the more likely we are to develop mutations that are resistant, make the viruses resistant to the vaccines we’ve all taken. I have many reasons to be very leery about going into that movie theater right now.

Preet Bharara:

We’ll be right back to my interview with Atul Gawande after this. Is part of the problem for policymakers in trying to decide where the trade-offs are, is on the one hand, at least at this moment, with respect to the pandemic, there are metrics, there’s an infection rate and there’s a hospitalization rate, there’s a number of cases. There’s all sorts of ways to measure how we’re doing. And everyone is looking at the graphs and the charts.

Preet Bharara:

So with respect to the problem of the pandemic and COVID-19, we seem to have a lot of data and metrics, not perfect, but a lot. On the other hand, the problems that are being caused by the social measures we’re taking, increase in alcoholism, domestic violence, depression, more obesity, and a whole host of other things I’m sure you can list, we probably don’t have great data on those things. And so aren’t policymakers and decision makers essentially blindly trying to figure out what the right trade offs are?

Atul Gawande:

Yes, to a certain extent. It’s about leading indicators and lagging indicators, all the things that you have are lagging indicators of where we are. And in that blindness, I think we have pretty solid evidence that people who are not in face to face professions have done well economically, they’re continuing to do okay. Knowledge workers, Zoom workers.

Preet Bharara:

People like us.

Atul Gawande:

And those who are in the face-to-face jobs, which is about 45% of the economy have been hammered and they are disproportionate amount of the job losses, they’re more than two thirds of the job losses, and those are the hospitality industry. It’s also happens to be some of the healthcare industry but also travel and airlines and there’s so many different components here. And we blame the measures more than we blame the virus depending on our…

Atul Gawande:

Well, I should say that there’s a real division over that, right? That you have one party that blames the measures and another party that blames the virus. There’s solid data to indicate that the virus is boss theory is absolutely right, right? That even though restrictions didn’t climb, people’s employment and the economic returns in those face-to-face jobs got worse when the virus got worse. And it was kind of regardless of what the restriction climate was.

Atul Gawande:

And so again, it’s that problem I started with, it’s pain now for gain later, that is incredibly hard. Climate change has this problem in spades. This is a problem where it’s invisible and it has an effect in four weeks and you see the economic effects in eight to 12 weeks. And we have a hard time on that cycle. Climate change where things unfold in years of time are even harder to motivate people to take action.

Atul Gawande:

And you can always… when your politician, you can exploit the group who is making whose lives just changed. The 20 to 50 year olds mostly they’re not getting significantly sick or are asymptomatic spreaders, they’re driving the infection, but they’re not the people who are most afraid of dying. You can exploit their strong desire to get back to normal and say, “It’s just a flu. These guys are pulling the wool over your eyes.”

Atul Gawande:

And we’re seeing this start to crop up in vaccination right now. The strongest indicator earlier on as vaccination was not yet approved and about to happen by whether people would want vaccination, race was the strongest predictor of vaccine willingness or unwillingness. Now, it’s partisan affiliation, party affiliation.

Preet Bharara:

Have you ever seen anything like that before?

Atul Gawande:

No. It’s stunning.

Preet Bharara:

You retweeted a study or a poll, as you just mentioned, that 41% of Republicans say they don’t plan to get a vaccine if it’s available to them and only 33% of Republicans say they do plan to get vaccinated. How did we get to that point?

Atul Gawande:

Well, so part of the interesting thing, and I think we’re only partly through understanding this. So we have in general, young essential workers, and by young, I mean, non elderly, essential workers outside of healthcare have very low rates of willingness to get vaccinated, strikingly low, concerningly low. And then also, if you look at white Republicans, they have very low levels of interest and people of color have also got high degrees of skepticism.

Atul Gawande:

Over time, as people see people around them get vaccinated, though willingness has gone up considerably, it’s dropped a lot for black Americans, for Hispanic Americans dropped a bit less so, but it’s dropping, for white Republicans, that is not dropping, it is… And part of what’s interesting, as I have tried to understand this is that there’s a strong belief among conservatives that business and government could end up mandating them to be vaccinated and a fear that they will be told what to do or that it will be required for privileges like working in certain jobs or to travel.

Atul Gawande:

And there’s a strong desire, belief that this is really a personal choice whether to get vaccinated and not see it as something that’s necessary for the family or community. They are much more likely to believe that COVID is overblown. And that’s the big distinction from the other populations, that rural white population actually has been hit hard by the pandemic in the fall. They’ve seen people who’ve been harmed.

Atul Gawande:

But what’s striking is that where that is something you can tap into as a motivation for people to get vaccinated in the black or brown communities, immigrant communities, et cetera, that is not true in conservative populations. Instead, seeing the elderly get vaccinated persuades people even more that it’s not important that they get vaccinated because of a belief that the virus is overblown as an issue.

Atul Gawande:

Finally, I’d just say that… so the question is what is the motivator that could encourage people to be vaccinated? And when I talk to people polling in this area so far, they say they haven’t found the motivator for conservatives. You could say, “Well, I need to do this because I want life to return to normal, or I need to do this for my family, or I need to do this for my community.” Those are not motivating reasons because almost any message from a public health official saying, “Here’s a reason that you should get vaccinated,” is perceived to be propaganda.

Preet Bharara:

One of the late night comics said the other day that folks who have that line of thinking are basically paraphrasing Patrick Henry’s, “Give me liberty and give me death.” Right?

Atul Gawande:

Well, actually I want to pull a paddle a bit. The argument, which is not totally wrong is okay, if we’re vaccinating… a lot of conservatives argued from the very beginning, we should just protect the elderly, they’re the ones who are at risk. Maybe people who have a chronic illness. Well, now if those people are getting vaccinated, we know we’re over 50% of people over 65, we’ll get up to 75% in weeks I hope and people with chronic illness can get vaccinated, then the argument is why is it important for anybody else to get vaccinated? Why would it be important at all?

Atul Gawande:

We have the reasons why, we don’t want the virus continue to circulate and mutate, et cetera, et cetera. But it’s no longer about give me death or it’s out of a belief that… like some of the folks I talked to in Minot, they weren’t denying that this is… some of them were denying, but many were not denying this is hammering their community. They believed that the damage of not opening up, not moving ahead anyway, is greater and more harmful to America, to society, to their lives than if people were getting sick.

Preet Bharara:

Right. But you can put it this way. You could say, look, to open up, there are a menu of options, right? To make the pandemic become less of a problem, most cumbersome and oppressive is staying home, not being able to work. A little bit less oppressive is being able to go out for essential things and wear a mask.

Preet Bharara:

And by the way, if you get a vaccination and enough people in the community get a vaccination, we can open up completely and fully. It seems that given the menu of choices, that are a reasonable argument, that to get the thing that you want, which is complete opening up and complete freedom and liberty to take this minor step that’s painless and quick, when your turn comes, why not do it? I have a hard time understanding that mindset.

Atul Gawande:

Well, first of all, you put that beautifully. And I actually think that was what made me hopeful in the discussion as I followed it over four months in North Dakota, was that 90% of the population embraced that very idea. North Dakota, by the way, now has one of the highest rates of vaccination in the country. They’ve been able to move the vaccine out and they’ve been committed across party lines to doing that.

Atul Gawande:

There is strong resistance in a portion of the population, and that happens to have a party affiliation associated with it. But in a state that is largely Republican anyway, the fact that they’re at 90% mask wearing and are going out and getting the vaccine, even though there’s a sort of Trumpist/libertarian base that has a disproportionate voice in the legislature or on the media, people have really voted just the way you just described. That sounds very reasonable to many, many, many, many people.

Atul Gawande:

And I think as I said at the top, we’re not going to have consensus. We’re going to argue this out. And there will be people who continue to disagree with your assessment because they will say, “Well, yes.” And we can open fully while also saying, “We don’t need to push the vaccine on everybody if they’re going to be okay.” Right?

Atul Gawande:

That I think is going to be the difference between whether we actually get enough to get to herd immunity and you start seeing the disease eliminated and we simply live with the disease at a hundred deaths a day kind of thing. And I think that what people would say is we can return to normal and there’ll be some deaths, it’ll be low level, it’ll be like the flu and you don’t have to make people take a vaccine they don’t want and they see that as being more important.

Preet Bharara:

Can we spend a few minutes talking about healthcare generally?

Atul Gawande:

Yeah.

Preet Bharara:

And getting access to healthcare. I know you’ve said this and I have this belief as well, how stupid is it… and maybe that’s not the right word.

Atul Gawande:

It’s just a rhetorical question. No, no, no, no, no.

Preet Bharara:

How much of a problem is it to solving for this problem of getting everyone healthcare that in this country healthcare is tied to employment?

Atul Gawande:

That one-

Preet Bharara:

Is that the whole thing?

Atul Gawande:

That is the original sin, our core mistake. Tying where you get your healthcare to your job, which is a artifact of World War II, I can get back to that, has been hugely damaging and made ultra clear during this pandemic when large numbers of people lost their jobs. It first of all, makes it so in a world where people are not tied to their jobs lifelong, it runs completely contrary to what the medical science is doing.

Atul Gawande:

We are developing more and more capabilities, whether it’s as simple as ways of controlling your blood pressure so 25 years from now you’re not having dementia or kidney disease or genetic findings that help us tune your care so that we’re adding years to your life on down the road. This ability to act now and make investments now and do tests now that people pay for, an employer paying for things that occur now that benefit in five years when you’re no longer working with them, gets harder and harder to do.

Atul Gawande:

Case in point, we now had two different companies that devised cures for hepatitis C, a devastating infection shortens your life, causes liver failure, people need transplants, all kinds of things, saves hundreds of thousands to millions of dollars on down the road. But because the cost of the treatment is in the tens of thousands of dollars, you have had an enormous battle over whether people should get treatment for it or not.

Atul Gawande:

And so it was always fought over regarding the cost and the two affected populations, employed populations and poor populations, hepatitis C happens to be much more common in prison populations. Neither wanted to pay now for the sake of a gain years in the future. And that is a big problem by having our employer based system. The most valuable thing that you can have in your life is a steady primary care relationship.

Atul Gawande:

And if you have access to the needed treatments and medications, that gives you your best likelihood of achieving the average 80 plus year life expectancy that you could have. And we have some of the weakest primary care systems in the world in part because of the ways that people are moving in and out of coverage and relationships in health care because of employment.

Preet Bharara:

What’s weird about it a little bit is you think the way it’s set up with the linkage between health insurance and employment, it sets us up for irrational outcomes. But the particular actors, like the ones you’re describing, whether it’s with respect to prisons or other employers on hepatitis C and other matters, it’s not irrational. It’s not economically irrational for them to think about these things the way that they do and that sort of perpetuates the problem.

Atul Gawande:

Completely, completely. The challenge is making the transition from a system that started as core as people getting Blue Cross Blue Shield plans offered to them during World War II at a time when they were wage controls, because so many of the labor force was overseas and unions fought for and got the right to have healthcare benefits as a kind of thing that could be offered to people. And that just seemed like a whole good, right? Nothing bad about that.

Preet Bharara:

Right.

Atul Gawande:

But then we built the whole system around that. Well, we need a system for people who are unemployed because they’re retired, so we got Medicare. We need a system for people who are unemployed because they’re poor and we got Medicaid. We didn’t have a system for the self-employed, we didn’t have a system for people buying insurance on their own and we got the Obamacare exchanges.

Atul Gawande:

And now you’re trying to navigate as you travel across these, and the reality is in your lifespan, you’re going to go from a kid to college student, to a young worker who may be in multiple jobs to someone who might be having your own podcast and needing to figure out how you get healthcare, on and on down the list until you’re retired and then in Medicare.

Atul Gawande:

And we need the way that you can be tied into a consistent set of relationships in your health care and know that it’s seamless and taken care of. And in the American way, we will need to stitch it together. It’s possible we can throw the whole baby out with the bath water and start all over again, but that’s never been how…

Preet Bharara:

Nothing works that way. Nothing ever works that way.

Atul Gawande:

Nothing ever works that way.

Preet Bharara:

Can I ask on these issues of policy? Do we need more medical professionals, medical doctors in Congress, or in otherwise elective office so that we have better policy or do doctors have the same public policy flaws as the rest of us and it wouldn’t really matter? What’s your thought on that?

Atul Gawande:

I don’t think that having… I think that having more doctors in Congress and more nurses and more health professionals to reflect the fact that 20% of the economy is healthcare is a good idea, but I don’t think it magically changes how Congress will fix this set of problems. The problems are not ones where the ideas are unavailable. This is a lot like what we have with the pandemic.

Atul Gawande:

We know what to do, we’ve known what to do since April. The battle is over whether we’re already to pull together and do it. And there are trade offs and there are hard choices and the same goes in spades for healthcare. And there’s been an explosion in the number of healthcare, people in politics probably are more on the Republican side than on the Democratic side who have come from the healthcare background.

Atul Gawande:

And I don’t think anyone on either side would say it’s made it easier to come to conclusions, but you do have people who have more of that frontline experience to argue from, right? But I’ll have my arguments with Senator Rand Paul or others who have that healthcare experience and completely disagree nonetheless.

Preet Bharara:

Further on this question of politics, you address it a little bit in your last article about North Dakota. And you talk about something in the waning couple of minutes that we have, we’re not going to make much of a dent on, but I wanted to raise it, and that is this issue of conflict and the weird reactions people have to this idea of conflict and how we don’t really understand it and we’re afraid of it, although it is what makes democracy work and it’s a part of it.

Preet Bharara:

And you say, “Conflict is also why so many people say they hate politics. We want consensus badly enough and we convince ourselves that it can be created if only we try hard enough.” And then you Gandhi, which is a pretty good person to quote, who said peace is not the absence of conflict, but the ability to cope with it. What’s the lesson of all of that for how we deal with not just the pandemic, but our other problems in the country?

Atul Gawande:

Part of what I love about that Gandhi quote is that then Ronald Reagan went on to paraphrase it in his own way of saying that peace is not the absence of conflict, but our ability to manage it peacefully. And I think there’s a fundamental truth in that, right? Democracy is our ability to have people’s voices heard, bring them to the table and have a place where we can hash it out without coming to insurrection.

Atul Gawande:

And one of the dangers of this moment in my mind is that for things as straightforward as public health. We are in a place where we’re battling over whether people have rights to vote on Sundays and everything from… I think the fundamentals of democracy, about our ability to all have a voice and to encourage and enable that to happen is under threat and a core battle.

Atul Gawande:

My article on Minot, North Dakota was about how that happens and unfolds in a largely Republican state. 84% of the representatives in the legislature are Republican, and yet within themselves, they are completely divided about how to make the state run and city councils run. The heartening thing is that within that atmosphere, there still managed to be a peaceful approach. At the end of the day, Republicans and Democrats condemn the insurrection where having a battle over whether it was Antifa or it wasn’t really Antifa, was it real or not real.

Atul Gawande:

But no one’s saying, “Well, I thought that was a good idea.” Not in the large numbers of conservatives that you would most fear. And so in a funny way, I continue to be hardened and have some degree of optimism that the good ideas, the ones that can keep us moving forward, the ones that can get us through the pandemic and solving these healthcare issues will ultimately prevail.

Preet Bharara:

I appreciate your writing. I appreciate your service. Next time I speak to you I will hope that you have solved the whole healthcare crisis altogether and also the pandemic. Are you going to write that in a prediction no card today?

Atul Gawande:

That’s right. And it’s going to go right alongside the prediction that you’ll have solved the problems with our legal system by then.

Preet Bharara:

Right. Government solved, you and I together, wonder twin powers activate. Atul Gawande, thank you so much. And it’s a pleasure visiting with you.

Atul Gawande:

It’s great to talk to you Preet.

Preet Bharara:

My conversation with Atul Gawande continues for members of the CAFE Insider community. To try out the membership free for two weeks, head to cafe.com/insider. Again, that’s cafe.com/insider. So I want to end the show this week by talking about something that’s not particularly obscure and a lot of other people have been talking about, and that’s Oprah Winfrey’s interview with the Duke and Duchess of Sussex, Meghan Markle and Prince Harry.

Preet Bharara:

And I just want to add my two cents to the course of folks who have said Oprah Winfrey is a masterful interviewer. I’m aware of the commentary from people who say it’s kind of silly to point out the obvious that Oprah is a great interviewer, a couple of examples. This is David Pell on Twitter who said, “You’re writing an article to explain that Oprah is really good at doing celebrity interviews. Stop. Seriously. We know. Oprah is Oprah.”

Preet Bharara:

And then my personal favorite, this was a tweet from Jon Lovett who wrote on Twitter, “Love people giving Oprah notes on interviewing. She’s Oprah. She’s a billionaire from interviewing, that shouldn’t even be possible.” So with apologies to those who say it should go without saying that Oprah is a great interviewer, I’m going to say something about it anyway. I spend a lot of time thinking, teaching and talking about how to get information from people, obviously in different contexts.

Preet Bharara:

There are formal interviews in connection with criminal cases or civil cases. We’ve talked about how senators and members of Congress do or do not elicit information from witnesses at hearings. We talk about how people get information from regular interviews, celebrity interviews, and the like as well. They’re all different, they’re different contexts, they have different goals, they have different purposes.

Preet Bharara:

But in essence, the getting of information from other people, whether they’re willing or reluctant is an art, not a science. And to watch people who are good at it, even in a different context is to help you understand how to do it better in your own life, in your own career. So I have a fascination with interviewing for a lot of reasons, but among them, because I make my living now in part from long form interviewing.

Preet Bharara:

And if you go down the checklist of things that a good interviewer must do, Oprah Winfrey hit each one of them out of the park, preparation, check, a winning and welcoming demeanor, check, focused and from followups, check, eliciting of emotion for entertainment value, and also for empathy, check. Was she patient? Check. Now, granted in Oprah’s favor, in addition to her skill and her artfulness, Meghan Markle, especially and Prince Harry too, they had a story to tell. It wasn’t so much like pulling teeth.

Preet Bharara:

They decided to do a high profile interview in prime time, they were going to get some nuggets out there no matter what questions Oprah asked, though she asked them very well. And second, she had the benefit of a long form interview. As a lot of people have been commenting and noting that podcasts for this opportunity, more than television, generally, you can get somewhere with a long form. That’s why the follow-ups are effective. You can ask them again and again and again, you don’t have to move on to the next topic or the next issue or the next revelation in a minute and a half. You have time.

Preet Bharara:

In fact, the two hour interview is only a portion of the full interview that Oprah did, apparently there’s a lot that we didn’t see. And so I too will say for the record, I bow to the greatness of Oprah Winfrey’s interviewing skills. When it came to that interview with the Duke and Duchess of Sussex, I came for the drama, but I stayed to learn how to do my own job better. Well, that’s it for this episode of Stay Tuned. Thanks again to my guest, Atul Gawande.

Preet Bharara:

If you like what we do, rate and review the show on Apple Podcasts or wherever you listen. Every positive review helps new listeners find the show. Send me your questions about news, politics and justice. Tweet them to me @PreetBharara with the hashtag ask Preet, or you can call and leave me a message at (669) 247-7338, that’s 669-24 Preet. Or you can send an email to staytuned@cafe.com.

Preet Bharara:

Stay Tuned is presented by CAFE Studios. Your host is Preet Bharara. The executive producer is Tamara Sepper. The senior producer is Adam Waller. The technical director is David Tatasciore. And the CAFE team is Matthew Billy, David Kurlander, Sam Ozer-Staton, Noa Azulai, Nat Weiner, Jake Kaplan, Jeff Eisenman, Chris Boylan, Sean Walsh, Jennifer Corn, and Margot Maley. Our music is by Andrew Dost. I’m Preet Bharara, stay tuned.