The full video interview between Marian L. Tupy and Angus Deaton can be found here. The transcript is below.
Marian Tupy: When we were getting ready to do this interview, you mentioned that you are quite saddened and pessimistic about COVID itself, but that compared to other pandemics, there is much to be optimistic about. Can you explain what you meant by that?
Angus Deaton: Well, very much for the reasons that you put in your original email. We haven't had a pandemic like this for a hundred years, and people didn't know what they were dying of then, and now we’ve decoded the DNA or at least the RNA of this virus within days, or at least the Chinese have. So it's something you and I have often talked about. The Enlightenment really helped us, and post-Enlightenment, we tried to think about these things and reason them through and over the broad sweep of history, that really works, and you can see it working here.
It doesn't mean that we're going to get a vaccine next week or even next year. It doesn't mean we're going to get a medicine, which would be a terrific thing. I think maybe that would be the most helpful thing. But there's a huge amount of people working on it with a huge amount of scientific knowledge, and our chances of doing that are so much better than they were in 1918, let alone in 1640, when people had no idea what was happening to them. So we have some control. It may not be perfect control, and this is certainly something that will teach us not to be too hubristic about the world. The world is a dangerous place and bad things will happen, and I think a lot of us thought that this would not happen, that the days of these things were behind us. So it's this sort of rude shock, and there's much to be learned from it. But we have just a huge amount of knowledge, a huge amount of technology, a huge amount of good stuff that will help us in a way that just wasn't possible before. That's a reason for being relatively optimistic without falling into the trap of saying that we'll beat this in five minutes.
MT: Would you agree that there was a bit of a psychological shift in the last 200 or 250 years? In the past, when a pandemic occurred, people tried to protect themselves but ultimately felt that there was nothing that anybody could do about it except pray, whereas now we sort of expect this pandemic tackled. In other words, the psychological change I'm talking about is an expectation that we can conquer this.
AD: Yeah, “expectation” is a little strong. We don't have a vaccine for the common cold. We don't have a vaccine that works very well for the flu, and I think that's probably because we didn't care enough. My virus researcher friends say that we could have that if we'd devoted enough resources to do it. So maybe, in the end, that's because we didn't really care about that. But, yes, the expectation is that we should be able to tackle this and that we have a good chance of success. But that's the Enlightenment. People stopped praying, or at least they stopped just turning themselves over to God and actually started thinking for themselves and boy does that work.
MT: Let's talk a little bit about different responses to the pandemic. Let's start with advanced countries, the developed world, and then switch over to developing countries. How would you assess the wisdom and the efficacy of what the developed countries have tried to do?
AD: Well, I think that one shouldn't expect too much. It's very important to start with that and to say that nothing like this has happened for a hundred years. The war metaphor is often useful here because, at the beginning of wars, there's usually chaos, including chaos in the armed forces. You have the wrong generals. You have the generals that led in peacetime, and they're useless when it comes to actually fighting. Then it takes a few years, and you sort that out and you get the people who do this. So I'm not too hard on countries that didn't have perfect responses. People will say, “You should have been prepared. We should have had more ventilators. We should have had more hospital beds. We should have had more ICUs.” Well, it’s completely crazy to have all these ventilators if we won’t need them again for a hundred years. So there's going to be a lot of panic, a lot of stupid things done.
When people are frightened, they don't behave very well and so I think the political response has been very spotty, and it's very easy in hindsight to say what you should have done. So I'm not too harsh on what countries have done. They've been taken by surprise. That said, it’s clear some leaders have come out of this much better than other leaders, and some people seem to rise to those tests and some people are not so capable of doing that. I think it has been very important for rich countries not to try and stimulate the economy. I hate the term “stimulus.” That's not what we're trying to do here. We've deliberately slowed down the economy, and what we need to do is make sure that people don't suffer too much while the economy is deliberately being slowed down. And that is much harder to do in poorer countries, where the resources are not so easily available. The trade-offs are obviously different because there just isn't as much money available. It's been real torture in places like India and in South Africa. There, the losses in terms of people not having enough to eat seem very immediate and very severe, and the risks of the epidemic in the short run look not very severe, but it's very hard to tell whether they're going to go on being severe.
MT: I spent some time living in South Africa and, obviously, I keep in touch with a lot of people there. Among my friends, there seems to be surprise and shock at the government's action, partly because people have been confined to their shacks, where there are a great multitude of people, but also because of some actions the government has taken in terms of food provision. Hunger is really spreading, so I think there is a bit of a shock and panic in South Africa certainly. I don't know much about India.
AD: I think India is rather similar. I've followed South Africa a little bit too, and it's very sharp there. The social distancing just doesn't work for people who live in the shack towns right in Cape Town, so the people who benefit are very different from the people whose rights are at risk, and so there's a big inequality trade-off there. I think the same is true in India. They gave no notice, and they closed down all public transport. The food distribution system depends on you being at home, and so millions of migrant workers had to try and get home after the railways had been closed and the buses had been closed. That seems to be poor decision making. It was done without much thought, without much preparation. That smacks of a panic reaction. I was very surprised that in South Africa, they closed the liquor stores That seems like a terrible thing in the circumstances. In America, the liquor stores are a roaring trade. I don't know why you'd want to do that to people under this circumstance.
MT: There's the added component that the government in South Africa might use the COVID crisis to put further screws on the South African economy and to try to nationalize ever larger chunks of the economy, which I think in the long run would be quite disastrous.
AD: But that's not just in South Africa. The dangers of populist and nationalist takeovers are almost everywhere, and I think these pandemics certainly raise that as a real danger and real possibility, if only because in the short run we do need to have some central direction. This is not a problem that individuals can solve by themselves. The danger is that you've grabbed these temporary parts which are needed and that they turn into a long-term loss of freedom for people, which would be very serious.
MT: Would it be fair to summarize your position as saying that in the advanced countries lockdown or shutdown was probably the best they could do, but in developing countries, they shouldn't have?
AD: I wouldn’t be that strong. I think what I said about India is that there should have been much more preparation for doing that if they were going to do it. On the question of whether they should have done it or not, that is not something I have the data or knowledge to say. One of the big things about the current situation is the incredible amounts of uncertainty. There are all sorts of terrible things that are possible, but they're not very likely. And it could be that 70% of the Indian population could get infected. They're much younger than the population of the U.S., but there will be millions of deaths if that happens. And if that's the thing you think is going to happen, then a lockdown might be a good thing to do. We're also probably exaggerating the effects of the lockdown or the effects of the orders to lockdown, meaning that many people are not very keen on going out right now because they're scared. I'm sure there are some people who respond to the orders, but a lot of people would change their behavior if left after themselves.
MT: Let's talk a little bit about that. How much of the economic pain do you think especially in Western countries advanced economies, in the long run, will be attributable to the sickness itself, and how much of it will be attributable to the lockdown?
AD: Almost impossible to tell, unless we know how long it's going to last. At the beginning, we thought there'd be a V-shaped recession, that this would all be over in a month or two. And these terrible projections that were being sold out of the University of Washington said all the dying would be done by May 1, and I think policymakers paid a lot of attention to those numbers, which I think was a mistake. But if it's for a long time, it's so much harder problem. I don't think we can continue lockdown in this current form for very much longer, and I don't think we ought to. I think we need serious work. There's been no pandemic for a hundred years. We're not living in an economy that is infection proofed as it were. People are beginning to think about it but I don't think there's enough work going on. How do you make an airplane really safe? There are huge incentives for airlines to do that, so maybe they'll get right to it. How do you redesign offices so that people can work in those offices in a way that does not cause them to start another pandemic or continue another one? And I think we all think now that this is something that's likely to happen again.
MT: What do you think about modeling? Part of the reason why we had these shutdowns was that every government ended up with some sort of a model that was showing severe crisis. These models are being constantly reworked. They're constantly changing. Now, I don't want to be too harsh, but I guess the question is - what is a proper role in society for modeling and how seriously should people take them?
AD: I think we have to take it very seriously. They have to recognize the degree of uncertainty and to understand that models are models. The word “model” is being tossed around a lot in ways that I would not use it. For instance, models have to have some basic scientific contact and curve-fitting does not satisfy those criteria because there's no understanding of how this disease is progressing. I think that people who actually know something about virology and how viruses spread have been more accurate and more helpful on this than the people who just fitted curves to the data. That's not to say there isn't a role for that. I download the data every morning, and I peer at the tea leaves and try to see whether the things that people are saying are going to happen. And that's very useful. You absolutely have to look at the data and see whether they're matching what the scientists are telling you. But I think we really have to combine all those sources of knowledge. I think it's very dangerous just simply to accredit the status of modeling to people who are not really modeling at all.
MT: One of the patterns that seems to be emerging - I wonder if you agree - is the beauty of smallness, that small countries seem to be much better at tackling the virus. Now, I don't think that applies universally. There's Belgium and so forth, but most countries that have done a decent job had been small ones. Is there something to it or is that premature?
AD: I hadn't thought of that actually and it's interesting. I do think that the U.S. being so big is problematic because it's so hard to seal borders between states, for example, though there is a certain amount of that going on. Rhode Island has a quarantine for anyone coming from out of state. So does Montana. Other states may do it too. If you're Switzerland, it's much easier to close your borders than if you’re Rhode Island. But I don't know. I haven't thought about that systematically.
MT: Well, one of the things that you are famous for in your research is deaths of despair. What impact do you think COVID will have on these deaths of despair?
AD: Well, there's stuff going around that makes both Anne and me very unhappy. People are saying that the lockdowns will cause enormous numbers of deaths of despair and that the lockdowns are worse than the virus. And they can say that if they want, but there's no basis at all for that in our work. In fact, one of the standard slides we like to show is a picture of deaths of despair – suicide, drug overdoses, and cirrhosis - rising before the Great Recession, rising during the Great Recession, and rising after the Great Recession. And we have a line on that graph that asks, “Where is the Great Recession? Show me the Great Recession in this picture.” And it had no effect on those at all. It was driven by other forces.
And it's certainly true that we think of deaths of despair as linked to economic distress but to a long-run, slow disaster for less-educated Americans, who are being consistently left out of progress over the last 50 years, and also a health care system that's run amok and that’s helping to immiserate them. You can't just jump from that and say that the lockdowns and the huge number of unemployed are going to lead to suicides and overdoses. It may, but not for the same reasons that we're talking about. The following is certainly true: the people who suffer from these deaths of despair, who are less-educated Americans without a university degree, are also the people who are going to suffer from COVID. They are the people who are differentially losing their jobs. They're differentially the people who are risking their lives because they work in occupations that are essential, whereas the educated elite - the people with the BAs - are sitting at home talking to each other on Skype and we're hopefully as productive as we were before.
MT: In a recent interview, you said that during depressions and recessions, mortality rates decline, but suicides increase. What is the reason for both?
AD: Well, I think that's one of those high-level results which comes from a bunch of different mechanisms going on together, and you wouldn't necessarily expect it to be the same everywhere. Also, the recession we're going through right now is different from any other recession we’ve ever seen, and therefore, one has to be very careful of saying that what happened in previous recessions will happen in this recession. Nevertheless, you want to look at that evidence to see what happened. The Great Depression in the U.S. was a time when mortality rates were lower than in any years before it. I’ll come to suicides in a minute. A lot of it is just fairly mechanical stuff. For instance, people are not spending very much money. They are not driving fast cars. They're probably not smoking and drinking as much, and that is something you would expect right now.
New York emergency rooms are typically full of people who've had traffic accidents or people who've injured themselves on construction sites and things like that, and most of that has gone away. That's one of the main reasons why when economic activity slows, some of the accidental consequences of economic activity also slow. I think that makes good sense. People also like to spend money in ways that are sometimes harmful to them, and if they have less money, they'll do less of that. Obviously, you can think of things on the other side. In the Great Depression, there were people jumping out of skyscrapers in New York, but it turns out they're a very small number. Suicides are only 2% of all deaths, and so you could have an increase in suicide, but it doesn't do much to the all-cause mortality, nor does it offset those other more positive forces. Well, they're not positive forces, but they're positive for mortality.
Mortality is not everything, of course. People trade off mortality against other things they want all the time, and so it's a fairly narrow discussion, but it should temper accounts that say this huge recession we're having is going to cause millions of people to die or hundreds of thousands to die who would not otherwise have died
MT: You mentioned the empty hospitals and the fact that a lot of people are not going to hospitals because they are afraid, discouraged and what-have-you. Some people refer to this as “excess deaths.” Do you expect a spike in excess deaths above those caused directly by the COVID pandemic? Are we going to be seeing thousands or tens of thousands of people who for whatever reason didn't get treatments and therefore died in addition to the harm caused by the pandemic?
AD: It's possible and I look forward to researching that some years from now when we have the data. The term “excess deaths” is being currently used in a different way. The CDC is actually looking at deaths on a weekly basis and comparing them with deaths on weekly basis in other years, but that's mostly to get at COVID deaths that are not diagnosed as COVID deaths because a lot of people just found dead at home who died of COVID. So there are a lot of those sorts of deaths, and I'm pretty sure the official COVID numbers are understating the number people who have died from COVID who never got to go to the hospital or who died without being tested. They're typically not testing dead people to see if they had COVID. The other one you’re talking about I suspect is smaller, but I don't know. The question is how many lives you think are being saved by the hospital system on an average day, and I would guess not very many.
MT: Just to make it clear for our viewers, there's a certain baseline that you would expect of people who die in, say, May, and when we look back at that a year from now we'll be able to see the difference between May 2019 and May 2020 and presumably it will be higher. So then the task of smart people will be to determine how much of that excess has been produced by COVID, people not going to hospitals, and whatever else right, right?
AD: Right. I think most of it will be COVID. There's a very good website for the National Center for Health Statistics under the CDC, which shows pictures of that. The only thing you said that you have to qualify a bit is that the deaths in May every year are different. So, in fact, there were quite a lot of excess deaths in the spring of 2019 too, which was actually a bad flu season. A lot of people died of flu in those days, and those are excess over what you would normally expect even in those flu months. So it's going to be hard to sort all this out. I'm sure there are some people who need to go to the hospital and just decide not to and the hospital may have actually helped them, and I know a lot of elderly people, for instance, who made arrangements that under no circumstances will they allow themselves to be taken to the hospital.
MT: A short while ago you noted that the American healthcare system in your view is failing, especially for the people in lower socio-economic strata. In a recent interview which I read, you said that the American healthcare system is both capitalist and rent-seeking. I always thought about these two terms as being polar opposites. Can you explain what you mean by that?
AD: Yeah, I think there's no generally agreed-on definition of what capitalism is. So maybe we shouldn't have put that into the title of our book. I like to think about free competitive markets as wonderful things that deliver goods to millions of people and have taken an enormous number of people out of poverty. These free competitive markets are things that are nearly always good. I would defend those. Capitalism, as we have it in America today, is a mixture of some of that going on and a lot of markets doing wonderful things and other parts of it that are very severely scarred by rent-seeking and other sorts of things that undermine competition. Adam Smith knew from the beginning. You have to protect capitalism. You have to protect free markets because the people who dominate free markets will often try to corrupt them for their own interests and against the public interest.
First of all, and I'm not sure all your watchers will agree with this, but I think health care cannot be delivered by free, competitive markets. I think we've known that for a very long time. Kenneth Arrow, one of the greatest economists of the 20th century, actually proved the Adam Smith theorems for the first time in rigorous mathematical conditions under which the invisible hand does this for us. The great thing about those conditions is not just intellectual curiosity but you can also identify the conditions where they won’t work. He wrote a very famous paper about health care, and I think the phrase he used was that there's no socially acceptable way of delivering health care through free, competitive markets. You can't do it, and no country does it without expensive interference by the state. Now, some people would say, “Okay, let's get the state out of this altogether and let them be free competitive markets,” but I don't think that's sustainable because lots of people are going to die as a result, and I don't think we'd find that socially acceptable. There's no rich country in the world that does find that socially acceptable.
Then what you get is the system we have in America today that sort of pretends to be a free market and uses that rhetoric when it suits them but is in fact just a giant swamp of conspirators trying to rip us all off. The result in America is we spend more than twice as much as any other country. The next highest is Switzerland with 12.5% of GDP we spend 18%. That excess is enough to fund our military and leave 50 percent over, so just the waste in healthcare is more than the total amount we're spending on the military. And that's because we're trying to square the circle. We're trying to pretend that we have a competitive market system and in fact, we don't because the government has to interfere in so many ways. Continuing to pretend it's a free market just leads us into this terrible spot. So there's no good way to deliver health care is the answer, but we have the worst, and it's costing people their lives.
MT: Would you be comfortable with a system that allows for maximum competitiveness in the delivery of services but subsidizes consumption? Would that be something that comes closer?
AD: Everything depends on the details, but yes. Many people think that if you deviate from what we have in America, you have socialized health care, where the government is delivering health care. We don't need that. Britain does that. The Brits love their health care system. I grew up there. My parents had lived in a world where there was no National Health System, and for them, it was one of the greatest things that had ever happened in their lives, but it's not the only way of doing it. And I don't think America would like that, but we've got to get away from what we have now because it's taking money out of the pockets of ordinary people and distributing it to doctors and device manufacturers and pharma companies, not to mention the conspiracy of pharma companies to addict the population and get fabulously rich over addicting and killing people. Other countries don't allow that.
MT: Last question. We hear much about trust between governments and the governed. The Swedes supposedly trust their governments to guide them through the pandemic. Americans don't. What is trust and what role does it play in tackling the pandemic?
AD: Well, trust is part of something that I think is very important. It's like a public good. It's something that we share and that helps us do things that we can't do for ourselves. There are lots of things we can do for ourselves, but sometimes we need to be governed, and it's very good if we can trust the government. The Swedish example is a very interesting one because the Swedes are actually not doing what the government tells them. They're doing what their top health official is telling them, and that to me is wrong. I think that if people are going to trust, they have to trust not the experts but the government. The leaders are some sort of buffer between the scientific experts and the people. They didn't vote for that scientific experts. They voted for the prime minister or whoever, and it's the politics that ought to filter that through.
I'm not sure it's working here either because we have a government that seems to be at war with its own experts, but to me, you need that. It's the politicians that need to be trusted. The scientific advisors are vetted by peer review and various other things, but they have to advise the politicians and the politicians have to make the decisions. Now, in the U.S., people have become very attached to their governors, which is interesting. The governors have stepped up to sort of do that, and they have taken responsibility. They listen to scientific advisory, and that seems to be the right way to do it. I think trust in the U.S. is somewhat of a casualty of this extraordinary polarization that we have, which I think is very unfortunate. I think this crisis might bring us some of that back. I think we have to value science more than we have in recent years. I think we have to value public goods more. There are some things that the market can't do. Public health is one of them and epidemics really show that. There are lots of public health agencies much too involved in things like smoking, which we can perfectly well handle for ourselves, but when it comes to infectious disease, we've got to have trusted institutions there to help and advise us.
MT: In The Great Escape, your book which I read some years ago, you talk movingly about growing up in Scotland, and there’s a great deal of poverty. And indeed, I studied in Scotland and have made some elder friends who had a very similar experience. You obviously saw a tremendous deal of human progress, not just in Western countries but also in developing countries. Are we going to recover? Fifty years from now, is the world going to be more prosperous and happier? Is the engine of progress going to be allowed to go on, or do you see troubles on the horizon?
AD: Well, fifty years is sort of right on the margin. As I wrote in The Great Escape, this was a 250-year horizon beginning with the Enlightenment. But some of the worst things in human history happened in the 20th century. So one thing I have to keep fighting against is people who claim this great progress is steady because it's not steady at all. And I think we're in a very dangerous position right now, so I think if we go 100 years ahead or 200 years ahead, the forces of reason will win out, and we will be happier and more prosperous and more flourishing. In the short run, people compare this with the 30s, for instance, where really bad things happen. Anne and I have been saying together that this might be a moment where we actually get long-needed reform of the U.S. health care system. Look back at the 1930s. There was chaos and America got Roosevelt and Germany got Hitler. And the trouble with the crisis is it's very unpredictable. A crisis is not a good way of reforming things because it's very unpredictable. So we could be in for a bad ten or twenty years, but maybe we'll try for it in the short run. That would be good
MT: In the meantime, we will all keep fighting for the values of the Enlightenment. I'm deeply grateful to you for the time that you have given me and hopefully, our viewers will appreciate our chat as well.
AD: Thank you very much, Marian. I enjoyed it. Bye.
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