Conversations: Philip Zelikow

 

SYNOPSIS

 

Emily speaks with historian, attorney, and diplomat Philip Zelikow about the investigative report Lessons from the Covid War, authored by the COVID Crisis Group, which examines the U.S. response to COVID and provides valuable insights for how we can do better in the future.

 
 
 

LISTEN

 
 
 
 
 
 

GUEST

 

Philip Zelikow is the White Burkett Miller Professor of History at the University of Virginia. An attorney and former career diplomat who has served at all levels of American government, his federal service includes work in the five administrations from Reagan through Obama. He has also led three bipartisan national commissions: executive director of the Carter-Ford commission on federal election reform, the 9/11 Commission, and the Covid Crisis Group, whose report, Lessons from the Covid War, has just been published.

 
 
 

RESOURCES

Mentioned in the episode:

 
 
 

CREDITS

Hosted by Emily Silverman

Produced by Emily Silverman, Sam Osborn, and Carly Besser

Edited and mixed by Sam Osborn

Original theme music by Yosef Munro with additional music by Blue Dot Sessions

The Nocturnists is made possible by the California Medical Association, and people like you who have donated through our website and Patreon page

 
 
 

TRANSCRIPT

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The Nocturnists: Conversations
Emily in Conversation with Philip Zelikow
Episode Transcript

Note: The Nocturnists is created primarily as a listening experience. The audio contains emotion, emphasis, and soundscapes that are not easily transcribed. We encourage you to listen to the episode if at all possible. Our transcripts are produced using both speech recognition software and human copy editors, and may not be 100% accurate. Thank you for consulting the audio before quoting in print.

Emily Silverman
You're listening to The Nocturnists: Conversations. I'm Emily Silverman.

Today's episode features a truly extraordinary thinker, writer, public servant and patriot. His name is Philip Zelikow. And he is the White Burkett Miller Professor of History at the University of Virginia. An attorney and a former career diplomat who has served at all levels of American government in administrations from Reagan to Obama, Philip has led three bipartisan national commissions, the Carter/Ford Commission on federal election reform, the 9/11 Commission and the COVID Crisis Group. And it's the COVID Crisis Group that recently published a book called Lessons from the COVID War, which is what Philip and I are going to be discussing today on the show. It's quite different from the other books and articles and papers that have been published about COVID over the last few years, and that's because it's an investigative report.

So a little bit of background on the COVID Crisis Group. The purpose of the group was to lay the groundwork for a national COVID Commission, Philip was the leader of this group, and the group included 34 experts across disciplines as diverse as medicine, biology, government, economics, and more. I was really fortunate to be invited into this group, because of the work that The Nocturnists was doing collecting stories and perspectives of frontline clinicians during the crisis. So as a side note, you should know that I am listed as an author on the report. Over two years, this nonpartisan group held listening sessions with nearly 300 people related to everything from the origins of the virus to Operation Warp Speed to the Omicron wave and Paxlovid, and more. A lot was learned during those listening sessions and with all of that research, and when it started to look like Congress was not going to create a formal commission for COVID, the members of our group felt a duty to share what we had found with the public. And this is the report that the group has produced.

I'm still amazed at Philip's ability to synthesize so many different voices and perspectives in this book, which despite the complexity of the topic is actually very plain-spoken and easy to read for any ordinary American citizen. And I was so honored that Philip came onto the podcast today to chat with me about the report's biggest insights and discoveries, as well as some of the solutions that flow from those discoveries, which hopefully will better equip us as a nation to handle the next pandemic when it comes. But before our chat, here is Philip reading a brief excerpt from the report Lessons from the COVID War.

Philip Zelikow
We talked to a key figure in the crisis, one of those who helped originate the successful operation "Warp Speed", that rushed vaccines to Americans, Peter Marks. Marks said it was stunning to him that there was so little understanding of the lessons from this war. Some experiences troubled him, Marks admitted. Sometimes he wished that, like one of those characters in the movie Men in Black, someone could administer Neuralyzer and blank out his memories of certain meetings. But as Marks watched what was happening in the continuing COVID war, it seemed to him at the end of 2022, as if the US government and the country were repeating the same mistakes he remembered from Spring of 2020. We do not promise a permanent cure for Reflection Deficit Disorder. We cannot offer the kind of exhaustive investigative report that a COVID commission might have produced, interviewing layers of officialdom across the country and around the world, and piecing together thousands of key documentary records. What we can offer is our sketch of the whole picture, our sense of how we think the pieces fit together. There are already many books and stories about this war. We step back and appraise the entire landscape, focusing on what we believe mattered most. We have an advantage. Working together, we helped each other make sense of this overwhelming experience. Our take goes beyond some of the stock narratives. Our views don't fit neatly with partisan political arguments on either side in American politics. We believe this is a strength. We wrote this book for our fellow citizens, experts and non-experts alike, who have already read hundreds, if not thousands, of articles about the pandemic as it happened. We will not spend much time just recapitulating what you likely already know. We try to be more analytical; to zoom in on what mattered most. While being analytical, we have tried to write plainly. We are not writing the way we would write up our results for scientific or medical journal. We think you, like us, want to get past the enormous jumble of information and make some sense of it all. What just happened to us, and why? How could we do better?

Emily Silverman
I am sitting here with Philip Zelikow. Philip, thank you so much for being here today.

Philip Zelikow
Glad to be with you, Emily, and it's been great having you as a member of our group these past couple of years.

Emily Silverman
I have been so honored to be included in the group. And I'm really looking forward to unpacking this incredible book that you've written, which synthesizes so many different perspectives and areas of expertise. In some ways, I was shocked reading it, that you weren't an expert biologist. Just the facility with which you're able to tackle things from so many different angles.

Philip Zelikow
Oh, wait! But, I've seen biologists on TV. Oh, and I should say, yeah, I drafted the thing. But, you shouldn't really say that I "wrote" it. It was really a group effort. I just... A lot of it just got channeled through my word processor.

Emily Silverman
And I will say, despite having thirty-four authors, it speaks with one voice, and it's not disjointed. It does cohere. And that's just a testament, I think, to you and your analytical mind, and the way that you wrote it.

So Philip, let's start with you, if you don't mind. You have a very interesting background. You're a lawyer; you have a PhD in International Relations. You've worked as a Foreign Service Officer, and you've been thinking and writing about national security for a very long time - everything from Pearl Harbor to the Cold War, to serving as Executive Director of the 9/11 Commission. So, tell us about the process of getting this group together to unpack the story of COVID. And, for the audience, maybe how was that process similar to, or different from, the 9/11 Commission, which was a similar project?

Philip Zelikow
Well, first of all, this was a privately organized effort. We thought we were preparing for a possible government commission, or a privately sponsored commission, in which the government might facilitate our access to the people and records we would need. But, for its reasons, the government didn't want to create a commission, and it didn't want to facilitate the work of a commission. Those were decisions made by the Congress of 2021-22, and by the Biden administration, for lots of different reasons. So, then, we had done a huge amount of work to get ready. And then, we kind of faced this really interesting choice – the thirty-four of us who had really cohered to get ready for this commission – we could either just hang it up, and say, "Oh well, there won't be a commission. Wasn't interesting that we did all this work?" And, I was actually a little bit discouraged. A number of members of the group got a little bit angry, and said, "Damn it, we know an awful lot about this. We should just write up what we know." And, that was then the genesis of our effort to, then, go from being a COVID Commission Planning Group into what we now call the COVID Crisis Group, and produce this report. Probably, in many ways, it's... I think it turns out to be simpler and clearer than it might have been if we were trying to write an elaborate commission document.

Emily Silverman
And talk a little bit about the process of bringing together these experts and conducting these interviews – hundreds of interviews that you and the team facilitated. What was it like to do that work, and to have that culminate in this report?

Philip Zelikow
First of all, you encounter the cultures of all these different fields. If you work, for instance, on foreign policy or domestic policy, you encountered people who work on political science, or history, or different aspects of government work. But in this area, what you encounter a lot are medical doctors. Then you encounter all these biologists. Then you encounter people who are in the public health world, which is really a different world, with its own kind of academics, its own culture. And then, in a way, there's the biopharma industrial world. Some people have degrees in both and cross from one to the other. But the cultures of these different worlds are markedly different.

And none of them are really historical cultures. They are cultures that are used to analyzing what to do with a version of a scientific method that basically says, "Let's compare the results of A and B, and then do the correlations of which work. And then, well, if A worked better than B, we'll do A as our treatment next time." This is very much a hindsight method, you see, in which you try to set up some sort of clinical trial, you see? Some sort of controlled experiment. And everyone in these fields are used to that culture. And, a lot of the work they do, including in the scholarly world, looks like that culture.

The historical approach is actually quite different. It's not fundamentally a hindsight approach, if you do it well. Because what you're really trying to do is, you're trying to reconstruct what people knew and understood at the time, and the choices they made with the knowledge and tools they thought they had. So, even though you're looking backwards, you're working extremely hard to actually put aside your hindsight. In the 9/11 Commission work, there's a sentence in the report that says, "Hindsight blinds; it is not 20/20. Because, the path of what happened is so brightly lit that everything else falls more deeply into shadow."

The challenge, then, for someone who does the historical reconstruction well, is actually to reconstruct, without being infected by the hindsight blindness. It turns out that, if you go through this pandemic, and try to reconstruct, "Well, what did people think they know, and what tools did they think they had?" That's how you get all the insights about what worked, what didn't work, and what to learn for the future. And actually, the method of trying your A-B treatment and turn the pandemic, and it... Like, "Can't we convert this historical record into a series of pseudo-clinical trials? Let's see if we can kind of get something in which we have proxies for mask mandates or something or another, and then we'll know next time." You see, what I mean is, that you get results from that method that are kind of false.

And so the approach we took was, took people who were very used to doing work with different kinds of methods, but had enormous subject matter knowledge, and all these different cultures, and then work with them in this more historical approach to reconstruct this experience and what worked and what didn't. And this report, in a way, is kind of taking that style and that habit out of the informal shadows, and making it the core of how to understand what happened in this war.

Emily Silverman
And so the product of this, this encountering of different experts, different cultures, different ways of thinking, ways of analyzing – the product is this book. And, the experience of reading it, for me anyway, was very different from reading an ordinary book. We've seen many books come out about the pandemic. Bill Gates had a book; Andy Slavitt had a book. We've also had a ton of journalism about the pandemic. We've had the work of Ed Yong, which is amazing. And many others. And then, of course, there's all the scientific studies that have come out. How is this book different? And, what does it offer the reader that they haven't already gleaned from some of these other books and articles and sources?

Philip Zelikow
Well, first of all, it covers the whole landscape of the crisis, from origins to Warp Speed. So that's the first big difference. Second big difference is, ordinarily, journalists make their living by telling relatable stories. So what you've got then is, is these very colorful individual stories in which you zoom in on some person, and then you work from that person. Oh, and this illustrates something. You know, the beleaguered nurses... whatever, story. But, you do a relatable story in order to kind of highlight a problem.

So, the first thing is, it's comprehensive. The second thing is we're analytical, rather than just telling relatable stories. So when you're analytical, that means you're actually asking all sorts of "why?' questions, and then you're doing the analytical work using historical methods, in part to explain "why?", which requires you then to be very selective. This is actually not the standard journalistic method at all. The journalistic method is not analytical in that way. Also, the journalistic model is mainly meant to spotlight problems. It's not meant to explain choices, which have trade-offs. (And, here's why they did this, and here's why they didn't do that. And then here are the tools they didn't have. Here's the knowledge they didn't have.) Sometimes, you know, really good accounts – and there are some really good accounts, including some of the journalism you mentioned – that we cite, and that casts quite a bit of light on one or another aspect. But in a way, the goal of this book is to cover the whole landscape; synthesize it all analytically. But then, write it up in a plain, powerful, way. So that you can go through this, and like, "Okay, I actually now have a pretty clear narrative throughline about this crisis."

Emily Silverman
I feel like this book hits on many different levels. Reading it definitely led to a feeling of clarity, and, not necessarily a feeling of closure, but just a relief, in finally being able to understand in this broad, comprehensive way, what happened. Like you said in your reading up top, "What just happened to us?" And I felt like this book answered that question for me, in a way that some of the more narrow journalism (which spotlights a little corner here and there) just wasn't able to answer. And so, I really appreciated that. And then from the level of, you know, policymakers and public health workers and clinicians and executives, really serving as a blueprint. Because when you look at the choices that were made, and what worked and what didn't, there are solutions that flow from that knowledge.

Philip Zelikow
I was talking to Charity Dean, one of the members of our group. Charity was the Deputy Head of Public Health in California, during the 2020 phase of the pandemic, and had been a County Public Health Director and was one of the people profiled in Michael Lewis's book, The Premonition. And, Charity loves the book, but she had a really interesting way of expressing it. She was saying, "This book really breaks through the firewalls." And what she meant by that was, not that the book was like a sensational polemic. It was that the book was just plain-spoken and direct. It just kind of cut to the core of things without a lot of bloviating and efforts to be diplomatic, and just kind of called things as they were.

Emily Silverman
So we say in the book, "In October 2019, the Center for Health Security at Johns Hopkins, the Nuclear Threat Initiative and The Economist published a landmark index of health security capabilities. No country received a perfect score, but the authors gave the USA an 83.5, the highest score in the world. And for reference, Spain and Germany had scores of 66; Italy had a score of 56." So we see, in this theoretical experiment, that the US got the best rating, and then the pandemic arrives. So for the audience, compared to the rest of the world, how did we perform? And how do you think about that question?

Philip Zelikow
That's a great... It's actually a great question; yields an absolutely core insight. So, by the way, in the book, we don't do that in order to then make fun of the Johns Hopkins study – "goofy academics" – that's not our argument. You see, they measured what they could measure. And mostly what you can measure is hardware and inputs. "They spent this much money; they have this many hospital beds. They have all the stuff, the stuff we can measure." By those measurements, which are hardware measurements of stuff; we had more stuff. And that looked good. But again, you don't blame them. And so the big point then, we make in the book is: The key to these things is actually not so much the hardware; it's the software. And what we mean by software is: Hardware are the structures and tools that are available for the work, but software has to do with how you actually do the work.

Put it another way. Suppose you're a layperson, and your friend pitches over, and is having a heart attack. You don't know what to do. You know that probably you need to do something really quickly. There is no phone nearby. So a friend comes along, and says, "Your friend's... He's having a heart attack. Help me." Your friend says, "I know just what to do," and hands you this book called Emergency Medicine. It's this 500-page book. You kind of take this book. You know, "Well, thanks a lot." And then the person says, "Oh, here, I'll write you a check. If you'll save that person's life, here's $1,000." And you take the check. Alright, so you've given me a book, and you've given me money, but I still don't know what to do to help this person. Well, that's actually kind of what happened in the COVID pandemic.

We had the best book. We had the best scientific knowledge in the world. We spent more money than anybody in the world. Checks were not problem. We just didn't know what to do. This is what happens in an emergency. Emergencies are not so much about what to do. They're about knowing how to do it. And something called "preparedness". Everybody pays lip-service to preparedness. Like, who's in favor of unpreparedness? But, what does preparedness really mean? Preparedness is not so much, "I've got a goal, which is save people's lives." Or, "I've got a goal that says, develop rapid diagnostic tests." That's actually a quote from one of the playbooks. There was nothing in it that said how to do that.

Take a really good example in the crisis. As everyone remembers, remember that we had no tests. Actually, to their credit, CDC designed a test rather quickly. They had no idea how to produce these tests at scale. They thought that we'll make these tests available to the handful of state public health labs, kind of the way we would do if we had an outbreak of 50 cases of Ebola somewhere. But this wasn't like that at all. But everybody remembers the testing story.

Let's just suppose that we knew how to produce a million tests in a month. (We didn't, but let's suppose we knew how to do that.) Then the question would arise, "Well, what are we supposed to do with the million tests?" Do we use these tests for biomedical surveillance? How would we do that? Do we use this test so that panicky members of the community can go to drive through test centers and get tested? Or, do we use this test so that we can screen people at nursing homes and provide point-of-care testing? Or, do we use these tests so that we can re-open workplaces, and re-open schools, and make people safe? How would we use the screening tests to do those things? How rapidly and where would we need to deploy them, with what kinds of protocols?

So the point is, is that just saying, "I got my million tests in the warehouse," actually does not mean that you're prepared. So, kind of, back to, then, these indexes. These indexes said we had a lot of stuff. We had, so to speak, the books and the money. But we really... We didn't know what to do, and how to do it.

Emily Silverman
You talked earlier about different ways of knowing, different ways of reconstructing the crisis, and how the scientist's brain and the physician brain always has this impulse to look at it scientifically. And to, you know, try to randomize, you know, randomize control trial: A versus B. Compare and contrast. But just to be clear, how did we do? And how do you think about that compared to others? Because, like I said, it's very difficult to compare these sorts of things. In the book, you talk about how maybe one way to do it is to compare the United States to Europe (roughly the same number of people), or even something like comparing Florida's performance with Spain (similar age, similar climate).

So, in the absence of the ability to actually conduct some kind of trials, since that's not how the messy real world works... How did you think about that question in this book? And then, what was the performance (the grade) from an A+ to an F? How did we do?

Especially, I'll just say, because so many people, as is articulated really nicely in the book, view this pandemic as an unavoidable catastrophe. We have this fatalism about it - that it happened and there's really nothing we could have done. So I think, just being really clear about what our performance was, compared to what it could have been, I think, is just very important to state.

Philip Zelikow
Yeah, there are a couple ways to measure this. First of all, people's own felt experience of the crisis counts for something. Frankly, lots of people in America knew we weren't doing very well. They knew we were flailing and floundering. They felt it in all sorts of different ways, and their instinct was we were doing badly. And their instincts were right. It turns out, you need to compare us with other similarly affluent countries, that are not islands. So that Taiwan and Australia are not the ideal comparisons, and they have really good mortality data. The most reliable data is excess mortality, not COVID-delineated mortality, because there are a lot of problems with the data about which deaths are attributable to COVID.

So the most reliable numbers we have is simply excess mortality numbers. And, ideally, you would then control the excess mortality numbers in a couple of ways. The most important demographic variable in COVID is median age. There are others, but the most important one is median age.

So ideally, you would compare populations that are roughly comparable affluence, and then controlling or doing age-adjusted numbers. So we have really good data for a group of the European countries that have excellent mortality data. It's about 300 million Europeans. Not quite as affluent as us, but somewhat. You can do the age adjustments. And, one of the good things about that, too, is you can compare it in different time phases. So you can, like, compare the period before vaccines to period after vaccines, and so on.

And if you do that, the Europeans do way, way better than us. They do better than us, even in the very first phase, like say 30% better. Then in the second phase, let's say, second half of 2020, early 2021, before vaccines are widely distributed. They're doing like 50% better. And then, after vaccines, they do better still, because they have high vaccine uptake, and we don't, on top of all the other things. But it... Then if you say, "Okay, well you had 1.2 million Americans' excess mortality, 7 million hospitalizations, conservatively. That's a lot, by any measure. It's the largest excess mortality since the second World War.

Then, if you break it down, then you can compare, say, the highest large state with a high median age over, let's say, a median age over 40. It's a large state: Florida. Let's compare that to a relatively temperate coastal state in Europe: Spain. (Spain has a larger population than Florida, but Spain's median age is slightly higher than Florida.) Spain did 50% better on excess mortality than Florida. Italy has a still higher median age; 30% better than Florida. So, this also helps, kind of, get us out of the thing that it's all about Germany or Sweden. These are not the most affluent European countries. They still did way better. And they do way better at all phases of the crisis.

Emily Silverman
There's a section of the book that I really enjoy, that gives us a bit of a history lesson. So you talk about how the United States was designed to have de-centralized power. In other words, the states know what's best, and they should have a lot of power and the federal power should be limited to what's absolutely necessary: things like the military, things like public health. And, we talk about how after World War I, the military was federalized. And you would think something similar would happen to our public health system after the flu of 1918. But it did not happen. So talk a little bit about the state of our public health system, and how that set us up for these poor performance metrics, that we're seeing when we when we compare us to Europe.

Philip Zelikow
So, the United States has a really unusual health system, compared to other countries in the world, and we met a 21st century pandemic with a public health system designed for the 19th century. The fundamental design of our public health system is circa 1890, the administration of Grover Cleveland. It was then a mainly state and local system, that was mainly meant to handle dirty water and mosquito-borne diseases – cholera, yellow fever. And you did that with fire and bulldozer. Then you were very fond of vaccinating people for smallpox. And, you know... So, you cleared tenements or did things with water, and that felt like a state and local job. And then, eventually, you created a research entity at the national level, basically a lab that was supposed to provide the lab results to help inform the state and local authorities.

We never really changed that system, fundamentally. So we went into this crisis, and we have no national public health system. The CDC actually thinks of itself as a national public health agency. But in fact, the CDC is really a research entity. It always has been. It's kind of like the national public health university. It's not an executive agency. I mean, it's just not. It is a conduit for a lot of money that goes down to the state and local levels, as state and local governments have increasingly starved their public health entities for money. But it does not have national executive authority.

So, the CDC almost has this image of itself that is an illusion. It thinks of itself, because it, symbolically, it feels like a national public health agency. But in an operational sense, in an emergency, it's just not. There is none. So, then you think, "Alright, that's public health..." Which, by the way, is entirely divorced from the health care system, which is entirely divorced from the biopharma sector, which is making your medical countermeasures. And there's no one above all this, who's conducting the orchestra. All this, then, had to just get improvised during the crisis. And as things get improvised, and people are uncertain what to do, what fills that void is a lot of finger-pointing, and blaming, and culture war stuff.

So one of the things we pointed out in the book is that people think that the red/blue political divides are what caused our poor response. And we think that that is somewhat backwards. The fact that we were uncertain and didn't really know what to do, and didn't have a system ready to respond, created the void and the flailing. And then what filled that is the partisan politics, that took its place. So, in a way operational weaknesses helped feed the partisan politics, rather than the other way around. This is not, by the way, to excuse the behavior of President Trump and a variety of other things. And the book has plenty about President Trump, and the collapse of federal crisis management during the spring of 2020 (during April and May of 2020). We have, I think, very good details on that. As one of our members put it, Trump is a co-morbidity. It's not the underlying disease.

Emily Silverman
The book does such a great job disambiguating this alphabet soup of organizations and departments. We have the Department of Health and Human Services (HHS). And under that umbrella, we have CMS – Medicare, Medicaid. We have the CDC, which, just as you said, is more of an academic ivory tower-style research institution, not really designed to manage or operate or execute. We have the FDA, we have the NIH. We have the ASPR, which is the Assistant Secretary for Preparedness and Response. Then we have the Department of Homeland Security, which has FEMA, which is better at responding to crisis, although it's usually smaller, localized, and time-bound crisis. We have the military, the Pentagon, we have the White House. We had sort of random efforts from Jared Kushner. We have, as you said, the actual healthcare system, biopharma. But the book asks, "Who is conducting the orchestra?" And, I think, you've just stated that there really was no one conducting the orchestra. Hence the void.

And there was a part of the end of the book that I thought was quite funny where you said, "Few things are duller to read than suggestions about how to reorganize government institutions." Also, "the people running all levels of government think they know better than outsiders how to organize what they do, and they are often right." So, what does the group recommend? Who should be in charge? What should be the focal point of operational leadership? Who, or what, do we think should be conducting that orchestra?

Philip Zelikow
To make the answer really simple, and not too dull, we think we should have a national health security enterprise that has the strengths of the federal system, so that you devolve a lot of the operational responsibilities and the situation awareness down to the field. But then, you need someone to write sheet music for the orchestra, including the different sections (public health, health care, biopharma industry for medical counter-measures. And you need an orchestra conductor. That's like... People sort of generally know here's the melody we're playing. And then everybody's got different responsibilities in all of that.

So, you don't have to try to synthesize everything into one giant agency or create a "czar", but you do have to have some national executive guidance. "Alright, here's the general approach we're going to take, but we're going to rely on all these different people to tell us what's going on. Execute." Or, "We're going to give you guidance on and we're going to share information on state treatments; we're going to create networks, you see." And some of this grew up ad hoc during the crisis. People invented this stuff ad hoc. And then, in the book, we kind of noticed what it is people invented that worked and pick up on that. So for instance, some of the infectious disease folks began creating networks, informal networks, where they would share stuff, "Oh, here's a treatment that works. Let's do proning for patients. Let's try nasal cannula instead of ventilators." And ideas, and then they would share tips.

Often these would come out of doctors who were in the big metro center hospitals, or the big research hospitals, where they had lots of cases. And then a few dozen of them would network about the cases that they were seeing, and the practices they were trying out. Then what you need is to spread that information and that guidance out to, like, you know, 3000 health care locations. Like, here's some new tips we've got this week. And also knowing, like, here are the vaccines coming down the line; here are the medications now that seem to be working. Here's the stuff we need to put into clinical trials. With that taken into account, here's an approach then for workplaces and schools. Fundamentally, you begin to see this national health security enterprise, where there is someone in charge, but you leverage the good things about our de-centralized federal system.

Emily Silverman
The chapter about the collapse of the federal response was very striking. We have these anecdotes of, on March 8, President Trump quote unquote, told FEMA to take over and then we have one of them is key operators, whiteboarding what to do, which he called a surreal experience in reorganizing the government in two hours. Also very striking, on March 21, Jared Kushner met in the White House Situation Room with a group of private CEOs, who expected to hear a government plan, and then Kushner tells them the federal government is not going to lead this response. It's up to the states. And then we have a local public health leader, who described feeling like she was watching a giant boulder rolling downhill right at her and her community. Another says it was like The Hunger Games where there was an invasion on US soil by a foreign adversary. And the White House was telling all 50 governors, "Good luck, you're on your own. And now you're also fighting each other for weapons and supplies." So, tell us about the state and local response, because unfortunately, that turned out to be, more or less, the first line of defense: governors, mayors. Do you have some favorite examples of people who improvised well? Success stories? And what did they do well?

Philip Zelikow
Well, first thing to notice is that we saw common patterns emerge again, and again. State and local public health agencies, the formal structure was pretty quickly overwhelmed. So then what would typically happen is governors, and some big city mayors, would then create an entirely new setup for ad hoc governance. And how they did that really varied. Typically, the governors would reach out to their friends, people they knew, you know, business leaders they liked or admired, or were cronies, or medical leaders in some of the big metro center hospitals, kind of according to their likes. They also frantically hired contractors: McKinsey, Bain Company. We interviewed the Chrystal group, which did some really good work, organizing crisis management setups in about half a dozen jurisdictions.

So they would basically invent ad hoc governance structures. And a lot of it then had to do with how good their friends were, and how well they set these up. We call out, actually, that some really good work was done in most of the New England states. The state of Washington actually formed alliances with the private sector, organized by a former governor, Christine Gregoire, and working with firms like Microsoft and Boeing and Starbucks, and others who had a lot of experience and know-how that they could bring to bear.

But what tended to happen then is if you put good people in charge of these ad hoc structures, what they would do is they create all kinds of networks of stakeholders. So they're talking to school district superintendents and business leaders: What do you need? What works? What can you do? And then, they're also forming real-time crisis management setups, so that all the different state and local agencies that have information about what's going on are now pooling that information every day for situation updates. And when they make decisions about what to do, they communicate it out through this network.

So notice what I'm talking about here, is they're bringing in highly competent executives, usually volunteers, including some medical people. If they pick them well, it turns out better. Then they create a crisis management setup in real time to get information about what's going on, and also distribute task teams that organize a lot of the emergency agencies and the capabilities they have. Another thing they're doing in these cases is they're bringing stakeholders into the conversations, at schools, and also in the private sector: people who have know-how or can help, or who can tell people, "Here's what's practical in my world, and here's what's not practical." And they take that advice and act on it, to form toolkits that re-open businesses and schools. Where all this worked pretty well, those states did better. Where all this did not work well, they had a much harder time.

Emily Silverman
Looking at some of the blind spots that we had, as a country, two really stood out to me in reading this. One was about testing. And so, I was wondering if you could say a little bit about the Crimson Contagion Exercise, the pitfalls of using influenza as a stand-in for epidemics, and how we were sort of blindly groping around in those first few months without access to testing. And the second was this, just really striking, misjudgment about how the virus was transmitted. Especially considering, like you said, we had all the brightest minds, all the greatest science... You would think that we'd be able to figure out how this thing moves from one person to another. And this confusion about droplet versus airborne and the hygiene theater of wiping down surfaces and how that really didn't do anything. And it just took us way longer than it should have to figure out how it spreads, and the implications of that for how to, kind of, mitigate. Maybe you can speak to both of those, just briefly: testing and then transmission.

Philip Zelikow
Let's start with transmission. This is a scientific failure. It's an intelligence failure. In the report, we actually analogize it to the intelligence failure on WMD in Iraq, where, you know, we looked to the experts, and the experts got it wrong. They got it wrong at CDC, and they got it wrong, to some extent, in the World Health Organization. Actually, experts in a number of other countries got it right. We call out, for example, Japan.

The nice thing is some good people have done some work on this. Like, why did the experts get the aerosol stuff wrong? This has enormous implications, as you mentioned. The hygiene theater, some of these absurd guidances about outdoor activities, when actually outdoor activities and improving ventilation, were absolutely crucial tools we could have started using very early on to make people safe and re-open stuff. And we didn't utilize those tools as well, because of this intelligence failure.

Rather than just say, "Oh, bad CDC," and call it at that, it's like, "Well, what happened here?" The people who did a lot of the work on this were all working on their experience of science on the spread of respiratory illnesses. If you dig deeply into it, they were all basically using tuberculosis models and versions of tuberculosis models, which turned out to create a whole sort of cultural mindset about how to define droplets, and kind of arbitrary delineations between droplets and aerosols, without really even talking to folks in these other subfields, like occupational health. We're very used to studying these kinds of problems.

This kind of insular culture of particular kinds of scientists, with particular kinds of methods, was fatal in this case. And that's analogous, actually, to problems I've seen in other intelligence failures.

Now, the testing issue is a different set of problems. But it's also revealing. A lot of the media highlighted, basically like "Trump administration, bad" because we'd done this Crimson Contagion exercise. And gosh, if only they'd paid attention to Crimson Contagion, they would have known what to do – wrong. Why wrong? The ASPR office inside the Health and Human Services Office, which is an acronym that stands for the Assistant Secretary for Preparation and Readiness, they ran an exercise before the pandemic, to simulate, you know, the emergency response to a pandemic. They ran the exercise in Chicago, and the hypothetical was a flu hypothetical. In the flu hypothetical, testing and the need for testing didn't figure, because it was a flu outbreak. And they weren't worrying about asymptomatic spread, and the symptoms of flu were very distinctive. The exercise didn't serve as the testing issue to them at all.

The second big problem with the Crimson Contagion exercise, and this is really interesting is, in the exercise, they had the medicine to treat the flu. They had 30 million doses of the medicine to treat the flu. So, in the exercise, all they need to do is slow down the spread of the flu for a few weeks, until they can deploy their medicine from the warehouses, and get the 30 million doses out to the population. Well, in COVID, there are no 30 million doses in the warehouse. There was no medicine to treat COVID that was readily available, and so the notion of "slow the spread for a few weeks until we distribute the medicine" was not a good guide for COVID.

Actually, we didn't really ever slow the spread, but we tamped it down maybe a tiny bit for a little while. But then what? We... There's no medicine that's going to save us, and we can't lock down things for more than a few weeks. And then folks didn't know what to do, and the exercise hadn't given them any advice. So the exercise hadn't cued them to testing. And I hadn't cued them to what to do if you have an extended illness, for which you don't have ready medicines.

Emily Silverman
So March of 2020, the country locks down. There's no medicine in the warehouse. So the question becomes, "Lock down until what?" And then we see this prolonged situation, where trade-offs start to come up, this idea of trade-offs between locking people down, keeping people safe, opening things back up, prioritizing the economy. And we, in the book, talk a lot about this idea of a false dichotomy: saving lives versus saving the economy. The book also talks about how "anyone listening to the noisy debate might have concluded that in May 2020, Republican governors suddenly flipped a switch ended lock downs and reopen their economies, while Democratic governors kept their states in the total darkness of lock downs for many months. This is not what really happened." So talk a bit about this false dichotomy of lock-downs versus opening up, and then tell us what did happen.

Philip Zelikow
Yeah, lock-downs were unsustainable. And both red and blue states, using different rhetoric, by the way, but effectively wound down lock-downs. And both red and blue states reimposed very specific lock-downs when things got really bad, to try to save their healthcare systems. And by the way, the mortality numbers, there are no particular differences between states with red governors and states with blue governors. What happened then is, "Okay, we we shut things down for a few weeks; we haven't stopped the spread. We don't have the medicines. What now?" So one answer is, "Well, maybe if this pandemic is now over, it's just going to be a flu season. We don't need to worry too much about it. Let's just reopen and everything will be fine."

And then the instinct is we need to reopen to save the economy. So let's downplay the problem, and pretend it will all be fine, which was wrong. It was not going to be fine; it was actually going to get much worse, basically downplaying or ignoring the problem, to reopen to save the economy. That's the wrong answer. But then the right hand, you can't lock down indefinitely. If you think the problem is going to get worse, what do you do?

The answer is... is you've got to find a way of reopening society, but making people safe, as safe as you can, safe to the point, where you are as safe in your workplace or your school as you would be at home, occasionally going out to the grocery store, and protecting nursing homes and essential workers in serious ways.

So, effectively, you've got to get your society to function, while using public health so that it can function. That requires really specific toolkits for what to do, for protecting the most vulnerable people, for protecting people in schools, and then ventilation, masks, testing, screenings, so that they not only are more safe, but they feel more safe.

Because frankly, you can have mandates or not have mandates but if people are scared, they're going to change their behavior, so it's very important that people feel like when they go out and do stuff that they are about as safe as that, perhaps, they might be at home. That's what we mean about the false binary. And that's also why we spend a lot of our time In the report talking about the need for better toolkits.

And the big policy failure is it took us much longer than it should have to develop the toolkits to do things like reopening schools. We should have been able to reopen schools, frankly, on a large scale, as the Europeans did in the fall of 2020. Instead, probably we were at least a year behind other countries, in designing the toolkits to effectively reopen schools.

Emily Silverman
You say the goal is to make people safe, and to make people feel safe. And there's a great section in the book that talks about communication, and a little bit of behavioral economics. So, talk about the crisis communication - maybe some examples of success. I think, overall, we probably can all agree that the information communicated was confusing, sometimes contradictory. But there are some communication success stories. So maybe you'd want to talk a little bit about that.

Philip Zelikow
This crisis is almost a model of how not to do crisis communication: many voices ad hoc, without serious deliberation and the kind of methodical work that a lot of people who work in crisis communication think is second nature. We didn't do that. CDC is putting out stuff that's technically accurate, but seems impractical and hard to understand. And of course, the President is making things just much worse every day. It's just like the the textbook of how not to do it.

And actually, the Biden administration's crisis communication was not very good either, at least of 2021. It didn't really give the kind of attention to this that it should have. There were problems in vaccines. And this was also a success story. See, we had this outstanding program to manufacture and deploy vaccines, Operation Warp Speed. Did Operation Warp Speed actually do the work on how to prepare the campaign to convince people that the vaccines were safe, and they should take them? No. So, no one would think of rolling out a giant new product without having a campaign prepared for the rollout, a public campaign. But we did. Because the military is just working on manufacturing and deployment, and there was no real considered deliberate effort to prepare people to use the vaccines. And so, you see the results. We get terrible vaccine uptake and a haphazard campaign. And then a lot of misinformation and disinformation starts filling the void from a thousand different places.

So misinformation and disinformation was also a big problem. This was the first giant national emergency to be plagued by social networks and all their pathologies, which is kind of a Petri dish in which to grow misinformation. But, you start with, on your end at least, if you have really good crisis communication, maybe you have a leg up in combatting the misinformation. And we did that very poorly in the United States. And it showed. It not only shows in some of the health statistics, it shows in general breakdown of trust and confidence. And then that produces the poisonous culture war rhetoric, that then makes everything else harder.

Emily Silverman
One communication success story that stood out to me was the COVID Collaborative and the Ad Council, working with trusted organizations in the community, like the American Farm Bureau Federation in Tennessee, Arkansas, Texas, Florida, and Minnesota, in areas with especially low vaccination rates. That gave me a lot of hope.

Philip Zelikow
It's did. And it's interesting, Emily, to zero in on what worked about that. This was not like, "Okay, Joe Biden's gonna buy an ad, and then go on TV with a public service announcement," or, you know, a lead expert or Tony Fauci (or figure you're a lead expert) makes... cuts an ad. No, you actually have to do the sweat equity of going to communities where people live. And you have to talk to the people who those people respect, in their community, which may be local farmers, local churches. And then also, these nonprofit efforts like the COVID Collaborative made a real effort like in the American Indian community and some African American communities, in some farm communities, not to do the elite messaging, like wagging their finger at people, but actually to reach down and kind of have community leaders talking about why this made sense among peers. And that worked. Where they used those methods, they really changed vaccine uptake. You have this remarkable thing where you go into the crisis with African Americans much more suspicious of all this stuff, including vaccines, than white Americans, and low vaccine uptake to a point like a year after these programs are in effect, where Black American and white Americans have more or less identical vaccine uptake, which saves many, many lives.

Emily Silverman
You mentioned Operation Warp Speed, and I think we would be remiss if we didn't spend a couple of minutes talking about that. In the book, you talk about why it was so successful. You also point out something that, admittedly, I hadn't really thought about, which is, why wasn't there a similar Operation Warp Speed for therapeutics? We got steroids and Paxlovid much, much too late. So, why did Operation Warp Speed succeed? And, specifically, why around vaccines and not so much with drugs and other therapeutics?

Philip Zelikow
Yeah, technically, when they set up Warp Speed, they meant it to cover therapeutics too, and even testing. Just those aspects of it never really got off the ground very well. And we tell a little bit of that story in the book. But it is... it. Really interesting. A couple things about Operation Warp Speed. Everyone generally tends to think that was a success, but hardly anyone really understands it. They don't understand who invented it, at... why it was invented, and why it worked, and what about it didn't work. So one big misunderstanding is people think of Operation Warp Speed as an R&D program, as a Research and Development program. Nah, not mainly. It was mainly a manufacturing and distribution program. Actually, Pfizer refused to take any Warp Speed money, preferring to do its own R&D, and did its own R&D on its own dime, about as fast as Maderna did, which was in Warp Speed. So you've kind of conducted this natural experiment, with and without Warp Speed. And Pfizer's doing just as well as Maderna. Well, above all, Warp Speed turns out to be a manufacturing and distribution effort, and it fails on the public communication side. And it does a lot of the manufacturing and distribution, because it's making these advanced market commitments across this really intelligently designed portfolio. And it was a really well led effort, that was sheltered from the chaos and cronyism of the Trump administration, by... by being substantially in the Defense Department, and sheltered by the Secretary of Defense and Chairman of the Joint Chiefs of Staff. And actually Kushner, to his credit, sheltered a little bit from the rest of the Trump White House. But it doesn't do therapeutics; it's kind of miracle vaccine. And then, this is an area where the Biden administration didn't quite pick up the ball. They felt, during a lot of 2021, that vaccines were going to, kind of, break the back of the crisis. So they had a chance to do a big advanced market commitment on Paxlovid, for example. And they didn't do it; they passed on that. It would have cost billions of dollars, but that's what you do in these situations, is you spend a lot of money, but it turns out that the return on investment for these sorts of portfolio expenditures is really, really good. But they didn't do that with Paxlovid. So, as a result, we're just barely beginning to buy any units of Paxlovid when the Omicron wave hits, in Winter of 2021-2022. And Paxlovid is essentially unavailable for the Omicron wave, which probably causes a lot of unnecessary deaths and hospitalizations. Because folks hadn't really quite understood what Warp Speed had done and hadn't done, and hadn't yet fully bought into the philosophy around Warp Speed. You have to think of Warp Speed as a program of national security preparedness, as like, I'm buying weapons that I hope I don't need, but I have to buy them, because there's not a good market for these weapons, and I have to buy them and prepare them. Which another way of talking about advanced market commitments. And, in a way, you're buying Paxlovid in order to have these potential weapons in the warehouse, if you need it, if the vaccine doesn't take care of your problem. And the vaccine didn't take care of our problem, and we needed those medicines. And we ended up buying many, many doses of Paxlovid, and it helps a lot of people, but too late for Omicron.

Emily Silverman
You talk about the return on investment and one of the numbers that really stood out in this report is the number 5 trillion. Even more so, comparing that number with what was available in the bank when the crisis hit. I jotted down a few of them. We had 29 billion in FEMA, we had 105 million in the Infectious Disease Rapid Response Reserve Fund. And in the public health emergency fund, we had $60,000. And then, in the report, we learned that the federal government deployed more than 5 trillion, and that doesn't include state and local spending or uncompensated costs in economic output, business failure, lost education, unemployment, etc. So, I can't help but ask you to comment a little bit about this idea of spending billions to save trillions: just the scale of what we're talking about here. So, how do we think about that?

Philip Zelikow
Economists used to say things like, "This is one of those cases where you spend billions to save trillions," which sounds like ridiculous hyperbole. But in this crisis, it actually turned out to be true. I mean, the $5 trillion, by the way, is not lost output. That's not a GDP number. That's actually federal fiscal outlays, in either tax rebates, you know, money, we're just scattering around the economy. That's federal expenditure. Lost output is like, at least triple that number, just in the United States. Numbers so large they kind of boggle comprehension. Let's suppose, if you kind of worked out, "Okay, cost of pandemic per day." Per day. By the way, if you start doing the numbers, you get almost like, towards like... It can be in billions per day. It's like, "Okay, if I spent this much more to accelerate deployment of the vaccine, and I shave, you know, like 15 days..." It just turns out that the... the returns on these investments are, are just so colossal, that even what seemed like "Oh, well, this just seems like a marginal, incremental thing." I moved it from 180 days to 130 days. Yeah. And that just saves you $100 billion. I'm just making up these, I'm trying to give you a sense of the scale, actually probably the numbers.. It just turns out that, in these situations, time is everything; deployment and mobilization, speed of mobilization is everything. Time is money on a fantastic scale. Therefore, the investments you make in preparedness, if it even shaves a little time at the margin on the end, you're still going to get a fantastic return on investment.

Emily Silverman
So we've covered a lot of ground. I would encourage the listeners to pick up the book and read it. It's truly extraordinary. But my final question to you, Philip, is: We wrote a book. Is this the end of the story? How do you envision this book being used? And what happens next? Or, what should happen next?

Philip Zelikow
I think anyone who reads this report, anyone who reads this book, is actually going to be reassured a little bit. Because, instead of just kind of hand-wringing and despair, they're gonna say, "Oh, I kind of see some ways you could actually do stuff.” So, in that sense, the book doesn't make you feel hopeless, it makes you feel, "Ah, this is like something that humans can actually work on." So if enough people read it, then you get the possibility of change. Because what happens, and what's happening now, is we're treating the pandemic as this act of God. And we're treating it like... We think of fires and floods as just these things that happen. And it's as if a hundred years ago, people accepted there were fires and floods and cities, and no one had ever heard or thought of something called building codes, or building levees, or dikes, and a bunch of... And it... There are pretty clear, low-hanging fruit that we could take on. That's I think the only chance of avoiding the cycle of panic and neglect that has characterized every one of these big outbreaks is... You get the emergency, and then after the emergency people just, "Oh, well.” And we have not made any fundamental change, coming out of this pandemic. But I think partly we haven't made the fundamental changes because people don't really see clearly, "Gee, what should we do?" I think if you read this report, you'll get a lot of good ideas. Then people, "Oh, well maybe we can do stuff." And I think if enough people read the report, and react to it and comment on it, what might happen is what happened after the 9/11 Commission report came out. In that case, the report was a Number one best-seller. Congress said, "Well, instead of taking our summer recess, we're actually going to convene hearings this summer, on the legislation we're going to write." And, that wasn't the cure-all, but it actually... It mattered. And actually reading the report matters, not just for bureaucratic fixes by the federal government. It matters, because if people actually understand how to do this better, that understanding will seep into all sorts of things, including things that they may do in their hospitals, in their state and local communities, and lots of other ways. And has a chance, actually, of making us safer. The best expertise on this is that the odds of another pandemic, in the next 10 years actually, on a very large scale, are substantial. And the dangers are rising. This arms us with some tools we can use,

Emily Silverman
You talk at the end of the book about this idea of statecraft, or the software that you mentioned at the top; software as opposed to hardware. The art of problem-solving, so to speak. And you say in the book, that the art of problem-solving historically, has been passed along, mainly through imitation, and apprenticeship, and that little has been done to preserve or teach these skills. Unlike the methods taught for engineering, the software is rarely recognized or studied; it is not adequately taught, and there is no canon with norms of professional practice. So maybe just, as a final question... I can't help myself: Could you comment on this idea of statecraft scholarship, and whether we need some kind of formalized container to teach this stuff to people?

Philip Zelikow
I think, actually, the the future of this is not going to rely on people going to schools to get two-year degrees, that it'd be nice if those schools were better than they are. But this is going to be more modular. It's going to be worked into a lot of different professions and disciplines and cultures and organizations, in which we recognize these skills as essential and we value operational skills. We value the ability to apply this knowledge and practice, and we value the talents of preparedness. We concentrate, not just on goals, but a lot more on how to do things. There are actually other countries and other cultures that spend a lot more time on the how-to-do-it part, and that paid off for them in this pandemic. They just have cultures that are very operational cultures, very oriented to results in the field, especially in Europe and Asia. Interestingly, we used to be known as the "can do" culture in the world. We were the guys who weren't too doctrinaire, but we got things done. Oddly, now we're losing that reputation, even though we were once the paragons. Well, we just need to, really, in a way, to recover that...that kind of moxie, again. It's more of a culture shift. It's less about performative symbolism and having the right talking points, and more about whether or not people can actually get stuff done.

Emily Silverman
I have been speaking with Philip Zelikow. Philip was the head of the COVID Crisis Group, which produced this book, Lessons from the COVID War: An Investigative Report. In my mind, this is the book to read about COVID. If at any point during this crisis, you felt scared, or sad or angry, even rageful, I think this book will serve you. It certainly served me and I was really proud to be able to contribute to it even in a small way. So thank you, Philip, for the just absolutely incredible work that you did, amassing this group, synthesizing, analyzing, creating this, because it was a huge ambitious task, and it just came together really beautifully. So, thank you for doing it. And thank you for being here to chat with me about it, and with The Nocturnists audience.

Philip Zelikow
Gosh, thanks.

 
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