In the hospital, postmortems are often sought to answer an uncomfortable question: Might this death have been prevented? That inquiry—whether we could have prevented more COVID-19 deaths—is notably absent from Stephen Macedo and Frances Lee’s list of “large and ferociously controversial questions” about the pandemic. In contrast, their postmortem focuses on how we could have disrupted lives less. That question is also important, but it cannot be responsibly answered in isolation from clear-eyed reckoning with the magnitude of viral death.

The true horror and scale of the pandemic was largely invisible for most people, particularly the most advantaged. Of course, everyone saw and felt the pandemic response—school closures, holidays spent apart from family, shuttered storefronts, mass layoffs, even sidewalk dining. But the epidemic itself—the severe respiratory disease that made this the deadliest pandemic in a century—was mostly visible only within the sealed walls of hospitals, and intensive care units (ICUs) in particular. Neither photos nor videos do justice to its terrible toll.

Closer attention to the pandemic itself might have led Macedo and Lee to more nuanced analysis—and in particular, to more careful weighing of costs and benefits. They point out that policies like school and business closures had a disproportionate impact on disadvantaged populations, including minorities and the working class. And they suggest that policymakers and the public health establishment led the public astray because, as members of “the laptop class,” they were blind to or insulated from the negative impacts of pandemic restrictions.

But this turns reality on its head. The true “disproportionate impact” of the pandemic was working-class people and people of color being killed at high rates by the virus itself. The community hospital system where I work as a critical care physician, situated north of Boston, is a catchment area for many working-class immigrant communities. In the pandemic’s first wave, our ICUs became so full so rapidly that at times we were transferring critically ill patients to other hospitals as fast as we possibly could to make room for incoming catastrophes.   

Perhaps this helps to explain why working-class people and people of color were actually more in favor of school closures, afraid to send their kids to school only for them to bring the virus home to a sick parent or grandparent. They were, after all, far more likely to have lost a loved one to COVID-19.

Macedo and Lee also suggest that the sacrifices we made in response to the pandemic were for nought, since control measures may not have accomplished anything. But is that true? Quantitative study of the effects of individual non-pharmaceutical interventions (NPIs) using observational data is difficult due to enormous regional variation, not just in the timing and magnitude of outbreaks and policy responses but also in health care access, urban density, partisan affiliation, chronic disease prevalence, and beyond. Peer-reviewed studies come to different conclusions. What is clear is that aggregate comparisons between U.S. states, like Macedo and Lee’s, reveal little in themselves. Many other factors besides state policy determined mortality outcomes, and these factors are difficult if not impossible to fully control for.

Other kinds of evidence, however, provide additional insights. In the first year of the pandemic, infections due to other respiratory viruses that spread like the novel coronavirus—including influenza and respiratory syncytial virus—basically disappeared. In joint work with my colleagues David Himmelstein and Steffie Woolhandler, we found that COPD and asthma exacerbations, which are often provoked by such viruses, plummeted during the pandemic. (Others have found similar results.)

The takeaway is clear: the abrupt change in human contact that suppressed the transmission of these respiratory viruses—which spread similarly to SARS-CoV-2—must also have at least incrementally reduced coronavirus transmission. According to one antibody-based study, four out of five Americans had still not been infected by SARS-CoV-2 as of May 2021. Even assuming sampling bias in that study (which was based on blood donors), there is little question that by the time vaccines were rolled out, most Americans had not been infected. Had they been, far more would have died.

To be sure, the abrupt changes to society were painful. Policies like business closures were accomplished not with a scalpel, but a shotgun—the only weapon we had in a rampaging epidemic. But even here, Macedo and Lee neglect critical elements of what happened.

For one thing, some of the hardest things we did were largely voluntary, like going long stretches without spending time in the company of our loved ones and cherished friends. These changes—this widespread social isolation—would have been every bit as difficult had our governments done absolutely nothing.

Additionally, many of the adverse economic consequences of pandemic policies like workplace closures were substantially mitigated by expansive and solidaristic economic policy. The number of Americans without health insurance fell after February 2020 legislation to keep patients continuously enrolled in Medicaid who might otherwise be dropped. A federal moratorium on evictions prevented people from going homeless. The child poverty rate plummeted to a record low in 2021 due to emergency legislation that provided unemployment insurance, stimulus checks, and child tax credits. Chaos did not reign: we helped the disadvantaged in new ways, and we could have done even more. Macedo and Lee suggest that all this economic stimulus was short-sighted, since it contributed to inflation. But pandemic-era inflation was a global phenomenon, striking major economies in tandem, mostly reflecting a supply crunch rather than the consequences of fiscal policy in one nation.

Admittedly, almost everyone was eventually infected by the virus. As early as December 2022, a modeling analysis concluded that 98 percent of the U.S. population had been infected at least once. In retrospect, we should have prepared more robustly for this eventuality. Given this tendency to universal infection, the “herd immunity” strategy of the Great Barrington Declaration was absurd on its face. It was not possible to “selectively” expose those with very low risk of severe disease. But even if it had been, doing so would not have protected others: nearly all would have been infected anyway.

Consequently, had this plague occurred a century ago, “social distancing” and other restrictions likely would have made no difference to ultimate lives lost. But this pandemic happened at a time when scientific progress permitted the rapid development and deployment of vaccines. Vaccines did not stop us from ultimately being infected, but they dramatically reduced the risk of death when we encountered the virus. Every sacrifice that broke a chain of transmission meant that someone, somewhere may have avoided a terrible death, giving them time to be vaccinated before infection.

None of this means that we should not discuss—and more importantly, rigorously investigate—which policies made a difference in slowing transmission and which were not justifiable or even counterproductive. Like many others, I think that wholesale closures of outdoor public spaces like beaches and parks did more harm than good (thanks to impacts on mental health and low risk of outdoor transmission), and I opposed anything reeking of the punitive or carceral. Hospital policies that prevented family visitation, even for dying patients, were wrong, and I regret not saying so earlier.

But we should also acknowledge where we could have gone further. It was clear early on that COVID-19 is an occupationally transmitted disease, yet comprehensive, national occupational safety standards formulated by the Occupational Safety and Health Administration were never implemented. Universal paid sick leave was never enacted. Fragmentation and inequities in our health care system led to overload in some ICUs even as others had excess capacity, which could have been mitigated by national policy. We (wisely) made vaccines free, yet our fragmented, non-universal health care system still impeded vaccine uptake—possibly because so many Americans lack long-term relationships with primary care physicians whom they trust (and who help to address so-called “vaccine hesitancy”). Nor do Macedo and Lee say anything about the chronic underfunding of public health that left states and localities with inadequate resources to face the pandemic—a particularly notable omission given the Trump administration’s eviscerating attacks on public health agencies today.

In short, where Macedo and Lee suggest that government should have done much less, I think we should have done much more. Yes, the (non-viral) pain of the pandemic was real: the simple absence of contact with others is, after all, inconsistent with our basic needs as human beings. And yes, both these needs and the biological realities of respiratory infections have to be acknowledged. But keeping COVID-19 at the gates as long as possible until modern science could sap it of much of its lethal potential made a critical difference—and could have made a larger difference still. That should be the focus of our inquiry and our ire.

The fate of one of the many patients I saw with COVID-19 drives this point home. He was vaccinated in 2021 as soon as he was eligible, but almost simultaneously he got sick—too soon, unfortunately, for the vaccine to protect him. His lungs became inflamed. He could not breathe, and he died. Had he been infected only a week or two later, he would probably be alive today. People like him should be at the center of our postmortems, not pushed—if mentioned at all—to the periphery of the discussion.