 We're going to go to the expert, Bill Hanage, Assistant Professor of Epidemiology at Harvard. Welcome back to the show. Hi, Mark. How are you doing? I'm very well. How are you? I'm all right. Although, you know, I have been better. I think our world's been better. So this is the second time we spoke. At the beginning, we sort of gave a bit of an introduction to coronavirus, the challenges it faces. Much has happened since then, both in terms of what we now understand about the virus and also, you know, a very different position to assess the records of both the British and the American government in response to this challenge. You being a Brit in America, obviously perfectly placed to comment on both. Again, I'm going to apologize. I always apologize to guests when I show them a Trump video, but we are going to kick off our discussion with this because he is the President of the United States. And this was a pretty phenomenal interview with Jonathan Swan, who is a national political correspondent for Axios on Monday. Take a look at some of these charts. I'd love to. We're going to look. And if you look at death, yeah, start to go up again. Well, right here, the United States is lowest in numerous categories. We're lower than the world, lower than Europe, in what, in what? Take a look. Right here. Here's case death. Oh, you're doing death as a proportion of cases. I'm talking about death as a proportion of population. That's where the U.S. is really bad. Well, much worse than South Korea, Germany, et cetera. You can't you can't do that. You have to go. You have to go by. You have to go by where. Look, here is the United States. You have to go by the cases, the cases. Why not as a proportion of population? What it says is when you have somebody that has it where there's a case. Oh, OK. The people that live from those cases. It's surely a relevant statistic to say if the U.S. has ex-population and ex-percentage of death of that population versus South Korea. You have to go by the cases. Well, look at South Korea, for example, 51 million population, 300 deaths. It's like it's crazy. You don't know that. I do. It's on the list. You think they're faking their statistics? South Korea? I won't get into that because I have a very good relationship with the country. But you don't know that. And they have spikes. Look, here's Germany low, 9000. Here's one right here, United States. You take the number of cases. Look, we're last. Meaning we're first. I don't know what we're first in. Take a look. Again, it's cases. And we have cases because of the testing. 1,000 Americans are dying today. But I understand on cases it's different. No, but you're not reporting it correctly, Jonathan. I think I am, but. If you take a look at this other chart. Look, this is our testing, I believe. This is the testing, yeah. Yeah, we do more tests. No, wait a minute. Well, don't we get credit for that? And because we do more tests, we have more cases. In other words, we test more, we have, now take a look. The top one, that's a good thing, not a bad thing. The top, Jonathan. If hospital rates were going down and deaths were going down, I'd say terrific. You deserve to be praised for testing, but they're all going up. You know, they very rarely talk. 60,000 Americans are in hospital. If you watch the news, they read the papers. They usually talk about new cases, new cases, new cases. I'm talking about death. Well, you look at death. Death is way down from where it was. It's a thousand a day. It was two than half thousand. It went down to 500. Now it's going up again. Excuse me. Where it was is much higher than where it is right now. Went down and it went up again. But now it's going down again. It's going down in Arizona. It's going down in Florida. It's going down in Texas. Take a look at this. These are the tests. It's going down in Florida? Yeah, it's going, it leveled out and it's going down. That's my report as of yesterday. So most of us, I suppose, the world watched that sort of half finding it hilarious, half finding it quite terrifying. We can't miss the opportunity to get the take from that interview from a professor of epidemiology at Harvard. What did you make of that bill? I'll be honest, there's also, pardon me, that felt like I could be a teeny tiny bit responsible because back in March, I was very vocal about how much testing was necessary and how it's really important to have good testing without having good testing. You cannot tell what's going on. And in the way that, you know, soft as the case, the United States lost that battle with testing early on and so decided to go all in on testing. And it's decided now to keep talking about how much testing is being done rather than how effective the testing is being at preventing new infections and preventing deaths. You know, the interviewer, John Swan, was absolutely right to hold the president, you know, to make him realize that the proportion of cases that, you know, the number of tests you're doing related to number of deaths is not the right statistic if you're trying to view the overall impact of the pandemic. That would be, as you said, her capita mortality. And at the moment in the United States that's closing in on about 500 per million people. And remember, a lot of the country hasn't really experienced much of the pandemic yet. You know, in contrast, Australia, that's 10 per million people, which kind of shows you the difference between, you know, the, you know, what often likes to think of itself as the greatest country in the world with huge resources, huge smarts, extraordinary companies, extraordinary expertise and, you know, pretty good universities. And, you know, what that actually means when it comes down to it in the face of a pandemic with this sort of leadership. So, I mean, obviously he was talking nonsense, but there was a point that he was making that is true, which is that the deaths per cases is going down. And I know he doesn't really understand the significance of that, but it does seem like a sort of significant stat to start a conversation. And I want to get up a couple of graphics before going to you to sort of explain what's going on. So the first one is the number of cases reported by day in the United States at the peak of, back in April, you're seeing sort of 30,000 cases a day. Now you're seeing over 60,000 cases a day. And then we can go next onto deaths. Obviously the massive peak was in the middle of April where you had above 2,000 deaths a day for many days. And then now it's just over a thousand. So I suppose there's a bunch of different interpretations you can have of that mismatch, the fact that cases are going up and deaths aren't going up by nearly the same amount. One, it's just that more testing is going on so we're finding more cases. Two, it could be that different people are getting infected. So before the virus was moving around care homes, now it's moving around bars on the beach or whatever. Or is it that we've got better treatment or potentially that we've got a less deadly strain of the virus even if it's more contagious? That's actually a pretty good start to thinking about this. Most important thing to remember is that back in March and April, we were completely on the back foot when it came to testing. It's my view that in almost all places, you start off with an outbreak which is mostly undetected because it's mostly not making people terribly sick among younger age groups. And quite a lot of them come infected and they're not really going to be showing up in your statistics because if you don't have many tests you only use them on the people who are really sick. And then eventually it rolls into more vulnerable populations and then they start getting really sick and they start dying. So right now we're getting more positive cases because of the fact that there are more tests, the president was correct there and it's good that there were more tests but that means that we're getting an x-ray of an outbreak in a completely different way from what we were able to do back in the spring. Now what I think is going to happen now is just like we saw in the spring there's going to be this long, slow period where the virus has managed to get up to high levels of community transmission and this is a virus that spreads via the respiratory route. It doesn't sit there in the bay borders. It doesn't sit there and stick within particular networks. It will leap from one to the other and it will spread through them and there'll be a long, slow plateau. I want to point out that as in the spring surge we expect the people who are most at risk to be those who are labeled essential workers. We call them essential workers now up until recently we've called them underpaid workers and exploited workers. And these are often people of lower socioeconomic status. They are bearing the brunt of the racism which is in society and they are because they have to go to work to get a paycheck, they are disproportionately exposed. And then they tend to live in communities which has got more cramped and there's less opportunity for social distancing. And so if you look at the social epidemiology of the first stage of the pandemic you can see it really, you can see this sort of awful halo of the outer boroughs of New York City as opposed to Manhattan. The outer boroughs were really hit hard and we expect the same kind of thing to be happening across the South now. As for the near future, I think we need to be thinking carefully about Midwest because these things start off in metropolitan areas because there's lots of people and they make lots of contacts but eventually they move into rural areas. This has this kind of, this has this thing we called over dispersed transmission parameters which means a few infections infect a lot more people than others. And if one of those comes into your small town then you have a big problem going forward. I think that's probably what happened in Aberdeen. Do you think we will see peaks of the size that we saw in somewhere like London or New York again? Or do you think that that is only a feature of the first wave when we really didn't understand what was going on at all, when we didn't understand what treatments worked when people weren't social distancing at all. So do you think that we will probably until a vaccine comes along I suppose, keep seeing sort of bumps and rises here and there but never that sort of 2,000 people dying a day that we saw in New York back in April? I'll be honest, I don't know. I hope we don't, but I have to say that I'm not completely competent in that. The reason for that is that we have the fall and the winter coming, sorry, autumn and winter coming because at the moment, one of the things we know a great deal about transmission of this is that it's more likely indoors. And so if people are gathering together indoors more there'll be more opportunities for transmission. And there's going to be a far larger population than was initially exposed. If you take just the simple, if you take the simple per capita mortality rate of New York City back there in the spring and you roll out over the entire country, you get really very, very large numbers of deaths. And we should also remember on top of that there's not only deaths which are outcomes. We also have to consider chronic health outcomes which are only beginning to come into focus now. If even a small fraction of people who have been hospitalized need to have continuing treatment, for example, kidney disease, then that's something which is going to be causing big problems to healthcare for a long, long time to come. At the moment in the UK, I don't know how closely you're following how it's all going back in your home country, but we've got Boris Johnson who is now saying, you should go back into the restaurants. It's your patriotic duty to get back into the office to start buying sandwiches again from Pretamonjay. And so we're really being encouraged basically to do unnecessary things and then trying to coax us out of our homes. Do you think this is a historic mistake or do you think that they're being guided by the science and this is kind of reasonable? What's your take on the latest term in government policy? I keep one eye on the United Kingdom because of the fact that I have folks there. I have been looking at what happened in the, I've been looking at Johnson's most recent suggestions. They seem to me to be really not guided by the science of which I am aware. Here in Massachusetts, we've got a very phased, very careful reopening plan. By the way, I hate the phrase reopening. We should say pandemic management instead. It's much more honest. While in the UK, there's been this sort of nonsensical suggestion that things will be normal by Christmas. I can guarantee you they won't. In the absence of the vaccine which magically becomes available to everybody in the world, they will not be normal by Christmas, just period. Forget it. It's irresponsible in my view to suggest otherwise because the first step of dealing with it, something like this is to be honest with people. So being honest, I will say that are things that can be done. I think that being cautious going forward is really paying dividends. I mean, look at the likes of Italy in comparison with where you are. You're beginning to see these local lockdowns. You're beginning to see these, what happened in the Northeast recently. But I'll be honest, I don't want to be too critical of that because a U-turn of that kind is what you want to see. You have to respond quickly to something like this. The real problem has been the suggestion in my view very irresponsible that this is somehow passed and that you can expect to get back to normal sometimes. What we're seeing, I've been reading a few articles that kind of talk about disinfecting theater, like disinfection theater and how this kind of sense of, oh, well, I'm going into a restaurant but people are wiping things down. It's getting deep cleaned. But obviously, as this is primarily respiratory, it's passed through the air, through breathing that that kind of is all a way to make people feel much more comfortable than they should be given the circumstances. So I kind of wanted to get your view on that kind of idea of the so-called reopening but with this big sort of theater about how we're reopening in a safe way. But also I wanted to, and I don't know if given your last answer, if this is like, I'm pushing you on this, but this kind of approach of we're going to reopen and then when necessary, do these kind of local lockdowns. Again, this sounds like something to someone who has no understanding of really what's going on. That sounds like something that could make sense. Is that something that actually does make sense from a scientific perspective? That kind of local lockdown approach. The whack-a-mole approach. The whack-a-mole exactly, that's what's called here. Well, the difficult thing with a whack-a-mole approach is that you have to be careful that you don't let a huge amount of transmission build up somewhere and then it immediately leaks out to other places and so you're whacking a heck of a lot of moles. It's a very, dealing with an infectious disease is a truly challenging problem. What you can do, and some countries have done this, is if you have a sufficiently strong, I hate the phrase lockdown, it sounds punitive. We shouldn't use it. We should say shut down at minimum. If you say, so also local lockdowns is not something that's helpful. If you have a shutdown, which is such that you then get things down to a sufficiently low level, with sufficiently good testing, you can manage to really limit this. You can look at Australia, as I mentioned earlier. Now, I was at the moment, sure, but it's extraordinary what they're able to do. Look at Hong Kong. They have had six deaths per million inhabitants since the start of this. This is, these are things which are capable of sufficiently coordinated and prompt action early enough on. And at the moment, you've got this situation where, I feel like the pandemic management piece has come out as sort of saying, well, we want to allow this much stuff to go on and we're just going to try and do it in a very reactive way. And not really have, it doesn't appear to have very much in the way of a very clear strategy. We don't have many people who are PhDs or professors in science on the show. Normally people are political commentators. So I want to take advantage of this opportunity to sort of ask you about what scientific developments have happened over the past five months. Because, I mean, it seems to me that in lots of cases, people are quite, I suppose, negative, depressed about the political responses to this and how it has been managed, so many failures along the way. But it can seem like in terms of biomedical science, in terms of treatments, vaccines, and our general understanding of the disease, it seems to be moving quite quickly. Do you think people are right to be hopeful about a vaccine sort of being ready quite quickly? And how, I suppose, how does that reflect on our scientific establishment? It almost seems like it's going quite well, but I feel like maybe you're now going to sort of abolish. I'm not going to completely ran on your parade, but I'm going to put it a bit of a slight correction here. I think we may have evidence, we have positive evidence from many vaccines actually looking for the initial trials that have been done and regrettably, I'm looking forward into the autumn and the winter, we can readily expect that there are going to be lots of opportunities to test them. And some of them are likely to be, some of them, if they work out pretty well, we are likely to know about that probably towards the end of the year. Now, the difficulty here is understanding what happens going forward from then, because once you've got one that you want to use, you have to make enough of it and get it out to enough people that they're going to be able to take it, and that's a whole different kettle of fish. So I think we might have positive news on a vaccine towards the end of the year, which is going to be a point when we expect that to be a lot of transmission, but actually getting that going is going to be something else. Now, I was talking to somebody the other day who was sort of trying to chime to me and say, oh no, these are really good people, they'll be ready and they'll be on top of it. Well, I hope they were right, because something which is going to be a positive thing going forward is a thing that the whole world could use a heck of a lot at the moment. There was a very influential article in the Atlantic saying the pandemic has shown that America's failed, none of the lessons are being learned, and that our societies aren't really built in such a way that they can learn from these kind of things. Yeah, I think that was from Ed. It's an excellent article if anybody's not read it. I personally feel that I'm hoping that the pandemic is going to cause in the end a lot of reflection. Some of it is going to be scientific. I mean, you know, my favorite scientific thing I'm going to hope that folks are going to learn is that pandemics don't always look like influenza. You know, and they don't necessarily announce themselves with the neon sign saying, oh, look, I'm a pandemic. You've got to be very careful and responsive. And you know, you had the experience back in 2009 of saying that swine flu or H1N1 was a pandemic. It was, it just wasn't very severe. This is much, much, much more serious and it's taken us time to sit up and notice that from a sort of societal viewpoint, I think that what you realize is exactly, this really shows the fractures in society. It's extraordinary. And hopefully more people will be aware of them and be keen to try and work to fix them because they're pretty obvious now in a way that they've rarely been up there in my life.