Douglas MacArthur was one of the finest military leaders the United States ever produced. John Gardner, in his book On Leadership described him as a brilliant strategist, a farsighted administrator, and flamboyant to his fingertips. MacArthur’s discipline and principled leadership transcended the military. He was an effective general, statesman, administrator and corporate leader.
William Addleman Ganoe recalled in his 1962 book, MacArthur Close-up: An Unauthorized Portrait, his service to MacArthur at West Point. During World War II, he created a list of questions with General Jacob Devers, they called The MacArthur Tenets. They reflect the people-management traits he had observed in MacArthur. Widely applicable, he wrote, “I found all those who had no troubles from their charges, from General Sun Tzu in China long ago to George Eastman of Kodak fame, followed the same pattern almost to the letter.”
Do I heckle my subordinates or strengthen and encourage them?
Do I use moral courage in getting rid of subordinates who have proven themselves beyond doubt to be unfit?
Have I done all in my power by encouragement, incentive and spur to salvage the weak and erring?
Do I know by NAME and CHARACTER a maximum number of subordinates for whom I am responsible? Do I know them intimately?
Am I thoroughly familiar with the technique, necessities, objectives and administration of my job?
Do I lose my temper at individuals?
Do I act in such a way as to make my subordinates WANT to follow me?
Do I delegate tasks that should be mine?
Do I arrogate everything to myself and delegate nothing?
Do I develop my subordinates by placing on each one as much responsibility as he can stand?
Am I interested in the personal welfare of each of my subordinates, as if he were a member of my family?
Have I the calmness of voice and manner to inspire confidence, or am I inclined to irascibility and excitability?
Am I a constant example to my subordinates in character, dress, deportment and courtesy?
Am I inclined to be nice to my superiors and mean to my subordinates?
Is my door open to my subordinates?
Do I think more of POSITION than JOB?
Do I correct a subordinate in the presence of others?
BORN in San Gabriel, California, in 1885, George S. Patton, Jr. was the general deemed most dangerous by the German High Command in World War II. Known for his bombastic style, it was mostly done to show confidence in himself and his troops, says author Owen Connelly.
On December 21, 1945, Patton died in Heidelberg, Germany. The following day the New York Times wrote the following editorial:
History has reached out and embraced General George Patton. His place is secure. He will be ranked in the forefront of America’s great military leaders.
Long before the war ended, Patton was a legend. Spectacular, swaggering, pistol-packing, deeply religious, and violently profane, easily moved to anger because he was first of all a fighting man, easily moved to tears because, underneath all his mannered irascibility, he had a kind heart, he was a strange combination of fire and ice. Hot in battle and ruthless, too. He was icy in his inflexibility of purpose. He was no mere hell-for-leather tank commander but a profound and thoughtful military student.
Everyone is to lead in person.
Commanders and staff members are to visit the front daily to observe, not to meddle. Praise is more valuable than blame. Your primary mission as a leader is to see with your own eyes and be seen by your troops while engaged in personal reconnaissance.
Issuing an order is worth only about 10 percent. The remaining 90 percent consists in assuring proper and vigorous execution of the order.
Plans should be simple and flexible. They should be made by the people who are going to execute them.
Information is like eggs. The fresher the better.
Every means must be used before and after combats to tell the troops what they are going to do and what they have done.
Fatigue makes cowards of us all. Men in condition do not tire.
Courage. Do not take counsel of your fears.
A diffident manner will never inspire confidence. A cold reserve cannot beget enthusiasm. There must be an outward and visible sign of the inward and spiritual grace.
Discipline is based on pride in the profession of arms, on meticulous attention to details, and on mutual respect and confidence. Discipline must be a habit so ingrained that it is stronger than the excitement of battle or the fear of death.
A good solution applied with vigor now is better than a perfect solution ten minutes later.
We find the questions, “What makes a great leader?” and “What does great leadership mean in practice?” to be really interesting.
We have seen, for example, the following types of people as leaders: (1) people who appear to have been born to lead and excel as leaders, (2) people anointed as leaders or future leaders who had bold personalities, a certain presence and/or great charisma disappoint completely as leaders, (3) hardworking, organized people without bold personalities who organizations may not have expected to be top leaders grow into their roles and lead organizations to great results.
The greatest leaders leave an organization better than they found it. They leave it in a position to thrive long after they are gone. They have the ability to deliver results today while improving and preparing the organization for tomorrow. Great leaders, as stated by some, have a vision and plan, can build great teams, can motivate the team to pursue and achieve the plan, can take in feedback and adjust the plan as needed.
Here are seven thoughts on great leadership.
1. Great leaders are engaged, excited and passionate about success. Great leaders remain excited about what they are doing and what their team is trying to accomplish. Teams sense whether a leader is engaged or not. It does not take long to detect. It is the unusual leader who can stay enthusiastic and in top form in a position for more than 10 to 20 years; for many, the attention span is less. The phrase “lame duck leader” often applies to those who are still in office despite losing their spark. When leaders find they are losing excitement or engagement, it is time to step down from leadership or take time to rediscover themselves. An excited and engaged leader is critical to success.
We should not confuse passion and excitement with a huge or “rah-rah” personality. A great leader can have a winning personality, and most have excellent people skills, but those two things are only part of the picture. Great leaders are more than mascots or faces of a company — they are engaged with their teams. They are constantly talking to, communicating with, seeing and visiting their teams. They know what is going on with their teams, they know what is going on with their key customers, and they know what is going on with the business.
2. Great leaders build teams and the next level of leaders. The greatest accomplishment of a leader may be building the next level of leadership in a way where the leader is less needed. This is so important to the organization and requires tremendous energy from current leadership, yet it’s not always a leader’s first and foremost goal.
An elite team can go exponentially further and accomplish a great deal more than an elite leader. Anyone who has built an organization beyond a few people understands the importance of great teams and colleagues. When a high-performing team is built, the leader remains important. However, more and more, you can identify a great leader or manager by how special their team is. When a team is magnificent, it is a lot easier to be a great leader or manager. A core concept in Jim Collins’ Good to Great is to build great teams and then set plans. If one has great people, a company or team can then accomplish all kinds of things.
There is a common misconception that leaders welcome their team’s elite performance because it means the leader can work less. We find this could not be further from the truth. Great leaders know that nobody likes working harder than their boss. This adage holds true whether a leader has been in the field for five years or 50. The scope and role of the leader may change as the team grows more adept, elite and accomplished. Exceptional leaders give others space to lead, opportunities to shine and chances to succeed, but this should not be misinterpreted as leaders stepping away out of ambivalence or putting their feet up.
3. Great leaders have big goals and set clear plans. Great leaders set goals for their teams and organizations that are exciting, interesting and far bigger than themselves. The leader needs a goal that one can point to as, “This is what we are trying to be,” or, “This is what we are trying to accomplish.” There’s nothing worse than leaders who transparently appear to get ahead for themselves or accomplish their own goals versus the organization’s or team’s goals.
The late Apple CEO and co-founder Steve Jobs and former GE CEO Jack Welch are examples of great leaders who set big goals. Mr. Welch had the core goal to be No. 1 or No. 2 in any market — or not be in the market at all. It is also critical that the goal is well communicated to the team and that key decisions are consistent with the goal. No plan or strategy is perfect. However, most organizations and teams do far better with a plan and strategy than without. Often, the plan is imperfect but adjusted over time. Either way, in nearly every situation, an imperfect plan is far superior to no plan.
4. Great leaders generally don’t micromanage. High-caliber leaders develop great leaders and teams and allow their teams to excel, perform and grow. They constantly look at benchmarks, hold people accountable and follow up with them. However, on a day-to-day and moment-to-moment basis, their teams are given lots of latitude and autonomy. This is coupled with follow-up and looking at what is accomplished. Warren Buffett may be the world’s best example of a leader who has great CEOs, holds them accountable and doesn’t micromanage them.
Some of the best leaders we have seen recognize when they have an amazing leader working with them. In those situations, the best of leaders can set their egos aside and largely allow the next in line to take credit and lead.
5. Great leaders praise often and recognize contributions. A great leader understands that part of team-building is constantly looking for what people are doing well and encouraging more of it. Great leaders provide praise, recognize what is done well and motivate more of that to be done. They look for what people do exceptionally well, and they look to promote those doing great things. They are constantly looking for the next opportunity for people.
6. Great leaders are not afraid to make hard personnel decisions. The best leaders understand that not everyone is a fit for every job. They are not willing to tolerate mediocrity or toxicity. This doesn’t mean they have a quick trigger. It does mean that they constantly compare current performance to great performance and try to fit people in spots where their performance can excel. For example, someone who is not great at something might be given another try at a different role where they may shine. One of the best leaders I ever witnessed subscribed to the view that it was very hard to change people. He counseled to be fair and patient, but that it was easier to change the person than change a person. In essence, sometimes it’s easier to replace a person than change how a person behaves.
7. Great leaders are emotionally mature. Great leaders do not fly off the handle or make rash decisions, but they do follow their instincts. A remarkable leader does not react to every issue with a great deal of stress. Rather, he or she can take things in, move forward and keep a team on board. A leader’s ability to manage emotions — both his or her own and those of team members — is critical. While great leaders often act with urgency and intent, they too embrace common sense approaches of “sleep on it” or “no sudden movements” when faced with volatility, uncertainty, complexity and ambiguity. They recognize the repercussions of their decisions and movements, and in turn give them the time, thought and reflection they deserve.
Here in Washington, the conversation about politics is often framed as a spectrum, a straight line with poles at the end that are hard-wired opposites. Team Blue to the left and Team Red to the right. But in reality, the chatter might more accurately be framed as a loop, with the far ends bending back on themselves like a lasso. Eventually, the far-right voices and the far-left voices meet at the weird spot where Rand Paul supporters find common ground with The Squad.
It’s often at the knot between the two ends of that scale that we find some of the loudest voices on any given issue: foreign aid, vaccine mandates, the surveillance state. Right now, as Congress is considering a massive spending package on roads and bridges, pre-K and paid family leave, lawmakers have been debating a point on which political opponents agree: drug prices are too high.
Drug pricing is one of those rare sweet spots where it seems everyone in Washington can agree that consumers are getting a raw deal. The motives behind that sentiment differ, of course: liberals want to make medical care more accessible and to curb the power of big pharma, and conservatives see drug prices divorced from pure capitalism. But everyone can rally around the end goal. No one gets excited to tuck away pennies on the paycheck to control acid reflux or prevent migraines.
The package under consideration tries to fix drug costs by ending the ban on feds negotiating with pharmaceutical companies. In a deal hashed out among Democrats, Medicare would be allowed to negotiate directly with drug companies on the prices of the 10 most expensive drugs by 2025. That number would double to 20 drugs three years later. Only established drugs that have been on the market at least nine years in most cases would be eligible, giving pharmaceutical companies almost a decade of unrestricted profitability. (Start-up biotech companies would be exempted from the process under the guise of giving newcomer innovators a leg-up.)
For individuals on private insurance, their drug costs would be tied to inflation, meaning no spiking costs if a drug becomes popular. Seniors, meanwhile, would have a $2,000 cap on what they’d be responsible for at the pharmacy.
Democrats have been working for years to make drug companies the enemy. In the current environment of woke capitalism, they’re an easy target for lawmakers in Washington to come after. Drugs, after all, aren’t luxury goods. They’re necessary. And for the government to give them a pass in ways few other industries enjoy, that just seems wrong to the far-left wing of the Democratic Party that has flirted with elements of socialism.
It turns out, maybe that messaging isn’t working. New polling, provided exclusively to TIME from centrist think tank Third Way, suggests the way the conversation is framed matters more than you’d think. In a poll of 1,000 likely voters in September, costs were their biggest hangup about the healthcare system, regardless of political identity. Almost 40% of respondents cited healthcare costs as the biggest flaw in the system.
What didn’t seem to bother people much? Fairness. That’s right. The spot where the far-right and the far-left tines of the political fork meet is usually seen as an objection to a system rigged against the consumers. But a meager 18% of respondents to the Third Way poll say profits were what’s wrong with the system. Grievance isn’t the most grievous of problems.
And if you dig a little deeper, you find other reasons Democrats might want to reconsider how they talk about drug prices in the twin infrastructure plans parked in Congress. In fact, there’s a 12-point gap in two competing reasons to address healthcare; lowering costs draws the support of 72% of respondents while making things fair wins backing from 60%.
“This is kitchen table economics and it’s not a morality play,” says Jim Kessler, a co-founder of Third Way and its policy chief who is advising the Hill on messaging on the twin bills. “Those are winning messages, especially on healthcare. You’re going to keep the exact same system, but you’re going to get some help with costs.”
In other words, the chatter in the purple knot might feel most fulsome when talking about justice and weeding out the super-rich exploiters of capitalism. But, really, people just want to hold onto their cash. Protections against healthcare bankruptcy are super popular, suggesting the fear of losing everything to a hospital visit is real. Capitalism may well be exploitative but it’s tough to argue that a few extra bucks in the bank can make falling asleep easier at the end of the day.
So as Congress gets ready to move forward with drug prices in its infrastructure talks, lawmakers can find some comfort that the whole of the political spectrum agrees costs need to come down. And they don’t really care if it’s done in a fair way — as long as their savings doesn’t take a hit every 90 days.
A lot of communication in the workplace is conducted electronically. However, it is essential for hospital and health system leaders to have face-to-face conversations with employees in some situations.
Becker’s asked healthcare executives to share the interactions they prioritize when they’re in person at their organizations. Many expressed their preference for the deeper connections in-person interactions allow, citing inspiration and team building as reasons to facilitate face-to-face communication. Below are their responses:
Russell F. Cox. President and CEO of Norton Healthcare (Louisville, Ky.): Healthcare, by its very nature, requires in-person interactions.
With the onset of the COVID-19 pandemic, we made a quick and successful shift to virtual visits for the safety of our patients and providers. This enabled patients with a variety of time and transportation constraints to receive convenient care from a trusted provider. However, telemedicine will never completely replace in-person visits, and the opportunity for our patients and community to interact in-person with our patient care providers is very important to me, and to our team.
And, although the pandemic created the need for virtual meetings, I have always prioritized in-person interactions and meetings with all team members. Whether that be rounding in our hospitals and facilities, holding in-person meetings, celebrating employee accomplishments or milestones, or dropping by one of our community vaccine or testing centers — web meetings will never replace what can be accomplished face to face. It became even more important to interact in person with our caregivers and employees during the pandemic. It was important to show my support for their hard work and extraordinary sacrifices during this time. I’m thankful that with the vaccine, more in-person events, with proper safety precautions, are resuming.
Our motto has been and continues to be: Stay safe. Keep the faith.
Jim Dunn, PhD. Executive Vice President and Chief People and Culture Officer of Atrium Health (Charlotte, N.C.): Recognition is part of our organizational DNA, and in-person delivery is an essential component of that — especially as we continue working through the COVID-19 pandemic. One thing our teammates love is the “Surprise Patrol,” which we employ for some of our most special and meaningful awards, such as our annual Pinnacle Award — the highest award given by our organization to those who best exemplify our Culture Commitments: Belong, Work as One, Trust, Innovate and Excellence. Executives, leaders, teammates and loved ones come together to celebrate honorees with balloons, cupcakes, cheers and even a few happy tears. Our honorees are shocked, uplifted and proud to be recognized in-person for their outstanding accomplishments, and our “Surprise Patrol” participants are honored to be a part of such a special moment. Whether we’re celebrating small wins, personal successes, birthdays or prestigious awards, in-person recognition — where and when possible — is a vital part of the teammate experience and culture at Atrium Health.
Robert Gardner. CEO of Banner Ironwood Medical Center (Queen Creek, Ariz.) and Banner Goldfield Medical Center (Apache Junction, Ariz.): Over the past few years in particular, I’ve spent some time reflecting on the differences between motivation and inspiration. More often than not, it seems like leaders don’t know the differences and often confuse the two as being synonymous or interchangeable. Put in overly simplified terms, I see motivation as being the metaphorical carrot or the stick. We can motivate with reward (aka the carrot) and with discipline (aka the stick), and both are used frequently in life. Motivation tends to be more surface level. However, inspiration is something much deeper, more intimate, and therefore much more complex. Inspiration is getting to a point of genuinely desiring to change, do more, be better, etc.
For me, knowing the differences is critical when it comes to prioritizing being in person in the workplace. Virtual meetings, emails, newsletters and other forms of electronic communication can work incredibly well when it comes to items of motivation; and believe me, there are plenty of these items. However, when it comes time to inspire the team, I heavily prioritize these meetings to take place in person. Items that fall into this category will be mission-critical initiatives and overall reminders on living our mission, purpose values, etc. It’s so ironic to me that despite the increasing complexity, regulation, bureaucracy and proverbial red tape that healthcare has become famous for, that an inspirational dose of simplicity has more effect on change than any other bestseller leadership book on how to motivate performance through some sort of complicated multistep process.
Brian Koppy. Chief Financial Officer of Cano Health (Miami): As a rapidly growing primary care provider, we have found that face-to-face interactions at our offices are as essential as they are in our medical centers. Our providers provide the best care when they see patients in person because it builds lifelong bonds that improve patient outcomes. In our offices, our team members feel more connected and integrated into the Cano Health family when we are together, both formally and informally. This, of course, does not mean we do not have a flexible work environment, which we do. It simply means our priority is on the employee benefits and outcomes that come from working in the office.
At the beginning of the pandemic, we moved many corporate employees to remote work and moved about 95 percent of our patient interactions to televisits. That did not last long, however. Within a month or two, our employees were asking to come back to the office. Our medical centers never closed their doors, and our visits rapidly returned to mostly in person.
It’s the seemingly inconsequential daily interactions that often have the greatest impact on a company’s employees and their connection to the mission, values and culture of the organization. The quick stop-ins to someone’s workstation, the chance hallway encounters, the team lunches — these are so important in developing relationships and, in turn, maximizing efficiency. Employees who know and personally interact with each other work better together. They discuss ideas, they strategize freely, and they execute on the company’s goals together and more effectively.
At Cano Health, our high-touch approach to primary care is key to our success. And we believe that daily face-to-face interactions among employees are equally important to create a rewarding experience for our employees, but also expanding Cano Health’s services across the country.
Christopher O’Connor. President and incoming CEO of Yale New Haven (Conn.) Health:We are prioritizing one-on-one meetings and small groups. With our vaccination mandate, we feel it is critical to have that in-person contact and fill that void that video can’t replicate. This is a relationship business, and spending the time to build and nurture those relationships is critical.
Thomas J. Senker. President of MedStar Montgomery Medical Center (Olney, Md.): Before and especially during the pandemic our priority has been the well-being and engagement of our front-line staff and essential personnel. And while in-person activities have been limited, our executive team makes regular rounds visiting each unit, expressing gratitude, providing snacks and refreshments, and sharing important hospital updates directly. We believe these face-to-face interactions are critical opportunities to gain feedback and focus on areas of improvement across different areas of MedStar Montgomery Medical Center’s operations.
Exactly 300 years ago, in 1721, Benjamin Franklin and his fellow American colonists faced a deadly smallpox outbreak. Their varying responses constitute an eerily prescient object lesson for today’s world, similarly devastated by a virus and divided over vaccination three centuries later.
As a microbiologist and a Franklin scholar, we see some parallels between then and now that could help governments, journalists and the rest of us cope with the coronavirus pandemic and future threats.
Smallpox strikes Boston
Smallpox was nothing new in 1721. Known to have affected people for at least 3,000 years, it ran rampant in Boston, eventually striking more than half the city’s population. The virus killed about 1 in 13 residents – but the death toll was probably more, since the lack of sophisticated epidemiology made it impossible to identify the cause of all deaths.
What was new, at least to Boston, was a simple procedure that could protect people from the disease. It was known as “variolation” or “inoculation,” and involved deliberately exposing someone to the smallpox “matter” from a victim’s scabs or pus, injecting the material into the skin using a needle. This approach typically caused a mild disease and induced a state of “immunity” against smallpox.
Even today, the exact mechanism is poorly understood and not much research on variolation has been done. Inoculation through the skin seems to activate an immune response that leads to milder symptoms and less transmission, possibly because of the route of infection and the lower dose. Since it relies on activating the immune response with live smallpox variola virus, inoculation is different from the modern vaccination that eradicated smallpox using the much less harmful but related vaccinia virus.
The inoculation treatment, which originated in Asia and Africa, came to be known in Boston thanks to a man named Onesimus. By 1721, Onesimus was enslaved, owned by the most influential man in all of Boston, the Rev. Cotton Mather.
Known primarily as a Congregational minister, Mather was also a scientist with a special interest in biology. He paid attention when Onesimus told him “he had undergone an operation, which had given him something of the smallpox and would forever preserve him from it; adding that it was often used” in West Africa, where he was from.
Inspired by this information from Onesimus, Mather teamed up with a Boston physician, Zabdiel Boylston, to conduct a scientific study of inoculation’s effectiveness worthy of 21st-century praise. They found that of the approximately 300 people Boylston had inoculated, 2% had died, compared with almost 15% of those who contracted smallpox from nature.
The findings seemed clear: Inoculation could help in the fight against smallpox. Science won out in this clergyman’s mind. But others were not convinced.
Stirring up controversy
A local newspaper editor named James Franklin had his own affliction – namely an insatiable hunger for controversy. Franklin, who was no fan of Mather, set about attacking inoculation in his newspaper, The New-England Courant.
One article from August 1721 tried to guilt readers into resisting inoculation. If someone gets inoculated and then spreads the disease to someone else, who in turn dies of it, the article asked, “at whose hands shall their Blood be required?” The same article went on to say that “Epidemeal Distempers” such as smallpox come “as Judgments from an angry and displeased God.”
In contrast to Mather and Boylston’s research, the Courant’s articles were designed not to discover, but to sow doubt and distrust. The argument that inoculation might help to spread the disease posits something that was theoretically possible – at least if simple precautions were not taken – but it seems beside the point. If inoculation worked, wouldn’t it be worth this small risk, especially since widespread inoculations would dramatically decrease the likelihood that one person would infect another?
Franklin, the Courant’s editor, had a kid brother apprenticed to him at the time – a teenager by the name of Benjamin.
Historians don’t know which side the younger Franklin took in 1721 – or whether he took a side at all – but his subsequent approach to inoculation years later has lessons for the world’s current encounter with a deadly virus and a divided response to a vaccine.
You might expect that James’ little brother would have been inclined to oppose inoculation as well. After all, thinking like family members and others you identify with is a common human tendency.
That he was capable of overcoming this inclination shows Benjamin Franklin’s capacity for independent thought, an asset that would serve him well throughout his life as a writer, scientist and statesman. While sticking with social expectations confers certain advantages in certain settings, being able to shake off these norms when they are dangerous is also valuable. We believe the most successful people are the ones who, like Franklin, have the intellectual flexibility to choose between adherence and independence.
Truth, not victory
Perhaps the inoculation controversy of 1721 had helped him to understand an unfortunate phenomenon that continues to plague the U.S. in 2021: When people take sides, progress suffers. Tribes, whether long-standing or newly formed around an issue, can devote their energies to demonizing the other side and rallying their own. Instead of attacking the problem, they attack each other.
Franklin, in fact, became convinced that inoculation was a sound approach to preventing smallpox. Years later he intended to have his son Francis inoculated after recovering from a case of diarrhea. But before inoculation took place, the 4-year-old boy contracted smallpox and died in 1736. Citing a rumor that Francis had died because of inoculation and noting that such a rumor might deter parents from exposing their children to this procedure, Franklin made a point of setting the record straight, explaining that the child had “receiv’d the Distemper in the common Way of Infection.”
Writing his autobiography in 1771, Franklin reflected on the tragedy and used it to advocate for inoculation. He explained that he “regretted bitterly and still regret” not inoculating the boy, adding, “This I mention for the sake of parents who omit that operation, on the supposition that they should never forgive themselves if a child died under it; my example showing that the regret may be the same either way, and that, therefore, the safer should be chosen.”
A scientific perspective
A final lesson from 1721 has to do with the importance of a truly scientific perspective, one that embraces science, facts and objectivity.
Inoculation was a relatively new procedure for Bostonians in 1721, and this lifesaving method was not without deadly risks. To address this paradox, several physicians meticulously collected data and compared the number of those who died because of natural smallpox with deaths after smallpox inoculation. Boylston essentially carried out what today’s researchers would call a clinical study on the efficacy of inoculation. Knowing he needed to demonstrate the usefulness of inoculation in a diverse population, he reported in a short book how he inoculated nearly 300 individuals and carefully noted their symptoms and conditions over days and weeks.
The recent emergency-use authorization of mRNA-based and viral-vector vaccines for COVID-19 has produced a vast array of hoaxes, false claims and conspiracy theories, especially in various social media. Like 18th-century inoculations, these vaccines represent new scientific approaches to vaccination, but ones that are based on decades of scientific research and clinical studies.
We suspect that if he were alive today, Benjamin Franklin would want his example to guide modern scientists, politicians, journalists and everyone else making personal health decisions. Like Mather and Boylston, Franklin was a scientist with a respect for evidence and ultimately for truth.
When it comes to a deadly virus and a divided response to a preventive treatment, Franklin was clear what he would do. It doesn’t take a visionary like Franklin to accept the evidence of medical science today.
An argument for humility in the face of pandemic forecasting unknown unknowns.
“Are we battling an unprecedented pandemic or panicking at a computer generated mirage?” I asked at the beginning of the COVID-19 pandemic on March 18, 2020. Back then the Imperial College London epidemiological model’s baseline scenario projected that with no changes in individual behaviors and no public health interventions, more than 80 percent of Americans would eventually be infected with novel coronavirus and about 2.2 million would die of the disease. This implies that 0.8 percent of those infected would die of the disease. This is about 8-times worse than the mortality rate from seasonal flu outbreaks.
Spooked by these dire projections, President Donald Trump issued on March 16 his Coronavirus Guidelines for America that urged Americans to “listen to and follow the directions of STATE AND LOCAL AUTHORITIES.” Among other things, Trump’s guidelines pressed people to “work or engage in schooling FROM HOME whenever possible” and “AVOID SOCIAL GATHERINGS in groups of more than 10 people.” The guidelines exhorted Americans to “AVOID DISCRETIONARY TRAVEL, shopping trips and social visits,” and that “in states with evidence of community transmission, bars, restaurants, food courts, gyms, and other indoor and outdoor venues where people congregate should be closed.”
Let’s take a moment to recognize just how blindly through the early stages of the pandemic we—definitely including our public health officials—were all flying at the time. The guidelines advised people to frequently wash their hands, disinfect surfaces, and avoid touching their faces. Basically, these were the sort of precautions typically recommended for influenza outbreaks. On July 9, 2020, an open letter from 239 researchers begged the World Health Organization and other public health authorities to recognize that COVID-19 was chiefly spread by airborne transmission rather than via droplets deposited on surfaces. The U.S. Centers for Disease Control and Prevention (CDC) didn’t update its guidance on COVID-19 airborne transmission until May 2021. And it turns out that touching surfaces is not a major mode of transmission for COVID-19.
The president’s guidelines also advised, “IF YOU FEEL SICK, stay home. Do not go to work.” This sensible advice, however, missed the fact that a huge proportion of COVID-19 viral transmission occurred from people without symptoms. That is, people who feel fine can still be infected and, unsuspectingly, pass along their virus to others. For example, one January 2021 study estimated that “59% of all transmission came from asymptomatic transmission, comprising 35% from presymptomatic individuals and 24% from individuals who never develop symptoms.”
The Imperial College London’s alarming projections did not go uncontested. A group of researchers led by Stanford University medical professor Jay Bhattacharya believed that COVID-19 infections were much more widespread than the reported cases indicated. If the Imperial College London’s hypothesis were true, Bhattacharya and his fellow researchers argued, that would mean that the mortality rate and projected deaths from the coronavirus would be much lower, making the pandemic much less menacing.
The researchers’ strategy was to blood test people in Santa Clara and Los Angeles Counties in California to see how many had already developed antibodies in response to coronavirus infections. Using those data, they then extrapolated what proportion of county residents had already been exposed to and recovered from the virus.
Bhattacharya and his colleagues preliminarily estimated that between 48,000 and 81,000 people had already been infected in Santa Clara County by early April, which would mean that COVID-19 infections were “50-85-fold more than the number of confirmed cases.” Based on these data the researchers calculated that toward the end of April “a hundred deaths out of 48,000-81,000 infections corresponds to an infection fatality rate of 0.12-0.2%.” As I optimistically reported at the time, that would imply that COVID-19’s lethality was not much different than for seasonal influenza.
Bhattacharya and his colleagues conducted a similar antibody survey in Los Angeles County. That study similarly asserted that COVID-19 infections were much more widespread than reported cases. The study estimated 2.8 to 5.6 percent of the residents of Los Angeles County had been infected by early April. That translates to approximately 221,000 to 442,000 adults in the county who have had the infection. “That estimate is 28 to 55 times higher than the 7,994 confirmed cases of COVID-19 reported to the county by the time of the study in early April,” noted the accompanying press release. “The number of COVID-related deaths in the county has now surpassed 600.” These estimates would imply a relatively low infection fatality rate of between 0.14 and 0.27 percent.
Unfortunately, from the vantage of 14 months, those hopeful results have not been borne out. Santa Clara County public health officials report that there have been 119,712 diagnosed cases of COVID-19 so far. If infections were really being underreported by 50-fold, that would suggest that roughly 6 million Santa Clara residents would by now have been infected by the coronavirus. The population of the county is just under 2 million. Alternatively, extrapolating a 50-fold undercount would imply that when 40,000 diagnosed cases were reported on July 11, 2020, all 2 million people living in Santa Clara County had been infected by that date.
Los Angeles County reports 1,247,742 diagnosed COVID-19 cases cumulatively. Again, if infections were really being underreported 28-fold, that would imply that roughly 35 million Angelenos out of a population of just over 10 million would have been infected with the virus by now. Again turning the 28-fold estimate on its head, that would imply that all 10 million Angelenos would have been infected when 360,000 cases had been diagnosed on November 21, 2020.
COVID-19 cases are, of course, being undercounted. Data scientist Youyang Gu has been consistently more accurate than many of the other researchers parsing COVID-19 pandemic trends. Gu estimates that over the course of the pandemic, U.S. COVID-19 infections have roughly been 4-fold greater than diagnosed cases. Applying that factor to the number of reported COVID-19 cases would yield an estimate of 480,000 and 5,000,000 total infections in Santa Clara and Los Angeles respectively. If those are ballpark accurate, that would mean that the COVID-19 infection fatality rate in Santa Clara is 0.46 percent and is 0.49 percent in Los Angeles. Again, applying a 4-fold multiplier to take account of undercounted infections, those are both just about where the U.S. infection fatality rate of 0.45 percent is now.
The upshot is that, so far, we have ended up about half-way between the best case and worst case scenarios sketched out at the beginning of the pandemic.