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Reader Opinion
COVID Revisionism to
Public Health Intelligence
 

Author: M.A. Stoto, PhD
November 10, 2025

Five years after the start of the pandemic, In Covid’s Wake: How Our Politics Failed Us by Stephen Macedo and Frances Lee compellingly argues that the American political system failed to take collective actions in response to COVID that balance the benefits and harms of public health interventions.  This analysis has gotten a lot of attention, for instance in the New York Times Daily podcast, where the focus became "Were COVID-19 lockdowns worth it?" (their answer was “no”).  To some, this book has come to define the conventional wisdom about public health: “intellectual malpractice and authoritarian impulses infecting governmental, scientific, academic and media institutions.”

Macedo and Lee’s revisionist history, however, is seriously biased.  While their analyses have a kernel of truth, the public health science side is not clearly presented.  This is unfortunate because their larger point about how the challenges of developing public health policies and some thoughtful solutions they propose may be lost to epidemiologists and public health scientists. 

Summarizing, updating, and expanding on my detailed analysis of In Covid’s Wake, this commentary addresses the problems in the book, but also proposes a public health strategy to implement Macedo and Lee’s call for a policy process that recognizes uncertainty, respects evidence and its limits, and acknowledges legitimate differences in values and preferences. 

Did non-pharmaceutical interventions work?

Macedo and Lee argue that U.S. policymakers abandoned evidence that non-pharmaceutical interventions (NPIs) did not work and implemented widespread lockdowns without consideration of the social and economic costs.  Nowhere in the U.S., however, were restrictions as severe as in China or Italy, and the most severe restrictions were eased by the summer.  Moreover, the NPI literature did recognize that well-chosen combinations of NPIs could limit the speed with which a pathogen spreads through the community and discusses the practical feasibility of implementing NPIs and their potential social and economic side-effects.

The authors provide a simple statistical analysis to show that lockdowns (their shorthand for all NPIs) did not work.  However, the global literature now shows that stringent implementation of combinations of NPIs were effective in some countries in reducing the transmission of COVID-19.  In the U.S., approximately 300 thousand deaths could have been averted before February 2021, when vaccines became widely available.  This suggests that public health interventions – generally short of lockdowns – did save many American lives.  State-level disparities in mortality rates are shaped by multiple variables — ranging from demographic, socioeconomic, and racial-ethnic characteristics to access to health care and the prevalence of health behaviors and preexisting conditions — but these calculationsshow that partisan choices made by state policymakers and the public are likely to have contributed to substantially higher mortality during the pandemic. 

Did public health policymakers ignore social and economic consequences?

Macedo and Lee’s argument about the failure of the American political to adequately consider the harms of public health interventions is largely based on the response to the Great Barrington Declaration.  This document emphasized the harms of lockdowns and called for a “focused protection” strategy emphasizing the most vulnerable, but offered no concrete plans for implementing these ideas.  According to Macedo and Lee, a consensus emerged among Blue state policymakers and opinion leaders against those who argued for greater attention to the costs of businesses and school closures and hardened into dismissal of dissent.  The authors maintain that Blue state policymakers and opinion leaders gave little consideration to these costs, in some cases hardening their positions into dismissal of dissent. 

It is true that intemperate language from some government officials can be cited.  But the response to the Declaration cannot fairly be characterized as a broad dismissal of the costs of NPIs or as a “jeremiad” against its authors.  Rather, public health officials and scientists explicitly recognized the social and economic costs.  Moreover, their position papers critiqued the Great Barrington Declaration on scientific and practical grounds, making the case that limited restrictions – not “lockdowns” – could reduce transmission rates until a vaccine was available.   

I closely followed the experience of several states and local areas as well as universities in developing responses to the pandemic.  In contrast to Macedo and Lee’s contentions, Blue state policymakers and opinion leaders seemed acutely aware of the harms of restrictions on social gatherings and sought to identify the least restrictive policies that would meet public health goals.  They also sought to address the inequities that were amplified by the pandemic.  The Trump White House, on the other hand, seemed to be concerned only with social and economic costs. 

Macedo and Lee do have a compelling case when it comes to schools, which were slower to re-open in Blue states and cities.  The authors attribute this to Democratic politicians and the undue influence of teachers’ unions, but the scientific and general literature published in the summer of 2020 is remarkably well balanced, with the likely harms and limited public health benefits both clearly identified.  And survey data suggest that while Democrats were slightly more concerned than Republicans about academic and social harms, they were far more concerned about their children getting sick while attending in-person school and supportive of online learning.  It is also easy to understand that Democrats might not trust a White House that consistently downplayed the threat of COVID-19, and promoted horse medications and bleach.  In other words, decision makers were trying to balance of benefits and harms in the face of uncertainty, just as they should. 

Declining trust in public health
What could explain the partisan difference in perceived risks Leonhardt documents when the actual risks could not have been substantially different?  One possibility is that, starting in the summer of 2020, rather than facing up to the challenges of choosing public health policies that balance benefits and harms, some Republican leaders gave more credence to experts who minimized the risks of COVID-19 and questioned the efficacy of NPIs and later vaccines.  It was easier, for instance, to say that “masks don’t work” than “the inconvenience does not justify the benefits.”  Or that vaccines are ineffective and unsafe rather than the benefit to the community is not worth the loss of “freedom.”  Experts who supported mask requirements or vaccine mandates were not to be trusted.

As Francis Fukuyama wrote at the beginning of the pandemic, when confronted with a novel virus for which there is no treatment or vaccine, the most effective way for a government to protect its citizens is by convincing them to take measures to protect themselves and one another.  Compliance with government guidance depends on citizens’ confidence that the government is trustworthy, that it knows what it is doing and is acting for the common good, and that public health programs will be administered fairly and competently.  But as the pandemic progressed, we argued about the science rather than facing up to value choices, undermining trust in science and public health. 

In support of this hypothesis, Oreskes and Conway note that the public's level of confidence in science has been falling slowly for decades, with Republicans and Democrats having similar attitudes.  During the first years of the pandemic, however, the parties diverge sharply.  This suggests that conservative hostility toward science is rooted in conservative hostility toward government regulation of the marketplace, which has morphed in recent decades into conservative hostility to government across the board.  Science – particularly environmental and public health – became the target of conservative anti-regulatory attitudes.  Distrust of science therefore, is mostly collateral damage, spillover from carefully orchestrated conservative distrust of government.

Since the pandemic, the view of public health captured in Macedo and Lee’s book has been used to justify efforts to dismantle public health agencies and limit their authority, sometimes with words far harsher than anything uttered against the Great Barrington Declaration.

From “follow the science” to public health intelligence

Macedo and Lee are right that “we must not forget the deepest values of liberal democracy: tolerance and open-mindedness, respect for evidence and its limits, a willingness to entertain uncertainty, and a commitment to telling the whole truth.”  Going forward, policy makers and public health officials need to better communicate the need for collective action and develop processes to engage with the community about the value tradeoffs involved, especially when the benefits and costs are unequally distributed.  Public health scientists must understand that “follow the science” is not enough.

Beyond differences in values, however, public health policy design should also reflect uncertainty about transmission risks (e.g aerosol vs. droplet transmission) or intervention efficacy (masks) and differences in the epidemiological context (New York City vs. Idaho in March, 2020, or nursing homes vs. schools).  Optimal policy, therefore, requires better “public health intelligence.”

There is always uncertainty about how a pathogen is transmitted, the efficacy of control strategies, their social and economic costs, and other factors, and how these facts change over time.  However, during the pandemic, we spent far too much time and energy arguing about whether SARS-CoV-2 was transmissible through aerosols, whether masks and vaccines “worked,” and the potential benefits and harms of control policies.  The lingering uncertainty created an opportunity to argue about the science rather than address the balance of benefits and harms, or how they were distributed.  To address this problem, public health agencies should be more proactive in creating and updating risk assessments to clarify what is known and unknown.  And rather than simply analyzing existing studies, or waiting until uncertainties subside, they should conduct or commission laboratory and epidemiologic studies to fill in gaps.

Furthermore, the Centers for Disease Control and Prevention (CDC) should work with state health departments, hospitals, and others to provide accurate, standardized surveillance systems for outbreak detection and situational awareness.  In addition to better integrating existing data, this effort should include developing and fostering systematic implementation of population surveys, wastewater surveillance, and other new systems to track both epidemiologic trends and social and economic consequences. 

Public health intelligence requires resources and perhaps enhanced legal authorities.  Monitoring the avian influenza now circulating in America’s poultry flocks and dairy herds, for instance, demands more than voluntary case reporting; public health agencies must have the authority to survey agricultural workers as well as conduct bulk testing of milk.  This will not be easy to achieve in the current political environment, but reframing public health as an information agency rather than a policymaking body might provide a path forward.  Although this shift in emphasis will not convince everyone, at least it might lead to better informed policy decisions for those who recognize the need for better intelligence.  ■

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