Amesh Adalja – COVID-19 Interview

[0:00:01 Speaker 1] Welcome to Policy. Emma Combs, A Data Focus conversation on Trade

[0:00:05 Speaker 0] Arts. I’m Carlos Car value from the Salem Center for Policy at the University of Texas at Austin.

[0:00:19 Speaker 1] So this is Gregory Sal. Mary, Uh, I met the Salem center in the McCombs School of Business at the University of Texas. Of course, literally. Now I’m in my house because we’re all social distancing. The center is conducting a series of video interviews about covert 19 the pandemic with experts from different fields. This is my first time as an interviewer, and I’m happy to have with me today, Dr Emission L. Dr. Adalja is a practicing infectious disease and emergency medicine physician which separates him from a lot of the experts are commenting on this, even who are physicians but also is senior scholar at the John Hopkins University Center for Health Security, where he focuses on emerging infectious diseases, pandemic preparedness and biosecurity. And you all are likely to know him because he’s a very frequent commentator on the media. That is, we’ll see him on pretty much all of the major news networks, and in addition, he’s a personal friend from whom I’ve learned a lot over the past years about infectious disease and more than I could say over the past months is we’ve all been making our way through this crisis, so I’m very pleased to be able to have him here and, uh, to be having this discussion publicly. I should say it’s July 14th, now 2020 and I’m mentioning that because things change so quickly that it’s worth knowing when when this was recorded. So a mish I want to dig in today a little more to the the state of your own thinking as it’s developed over the course of the pandemic and your impressions of the state of the field. There’s often in the news and in political debates we hear like, the experts say, or the science tells us or doctors say this. But of course, science doesn’t speak with one voice there certainly a lot of open questions earlier in the pandemic and still now about different scientific matters. They’re gonna be disagreement sometimes about the biological facts and even where there is agreement about the facts about different policies, because it’s only not only direct questions about biology that go into setting wise policies and wise medical decisions. So you’re one of the few people. Well, let’s start by. Could you, um, maybe say order to about your overall perspective that you bring to this crisis and how you differentiate yourself from other people thinking about it in terms of the background

[0:02:48 Speaker 0] For some? I work at the Center for Health Security, which is the premier think tank focused on infectious disease emergencies. And I’ve been there since I was a training infectious disease physician and spent all my time thinking about pandemics. Emerging infectious diseases Hospital prepared this thinking about out of predicted. He’s been working specifically to try a understand what it is about certain pathogens that allows them to cause of end up what allows them to slip out of control. And how do we prevent that? And at the same time, I worked clinically doing infections, disease, critical care, medicine and emergency medicine. So I’m constantly toddling between what’s going on in the real world versus what’s going on. In the theoretical standpoint, research standpoints and our think tank is very focused on policy, trying to fix policy gaps that might exist that we really interested in, how toe make these things not just as academic exercises, but how do we get better the next time that we face a pandemic? So that gives you a kind of unique perspective. And I really came to light during the 2009 H one n one Pandemic when I was first at the center, thinking about all this from a theoretical standpoint and then in the hospital a couple of hours later, dealing with it and understanding what the implications of policy are right there in front of me because I’m facing that same type of the same type of decisions that are the same types of scenarios that were predicting for a theory standpoint, so that, I think is different, that most people in my field tend to be maybe not clinicians or have decreased their clinical time. But I’m still probably about 50% or more. Ah, clinical. So everything that I see and say on television, I myself am also living it

[0:04:25 Speaker 1] excellent things so as let’s focus for the moment on the part of your being part of the world that was preparing for for this and thinking about what we should do in in case of endemic passenger could you tell us a bit about the state of thinking in this field as of a year ago, or as of before this pandemic hit, what were were there different schools of thought about what we should do? What were the accepted kinds of interventions? What role did, for example, social distancing and other non pharmaceutical interventions play and in particular, what were the questions that were on the minds of the specialists before they had to face them? In the context of this particular pathogen,

[0:05:06 Speaker 0] most people have a general framework that we would want to have very aggressive diagnostics and then use kind of basic, tried and true public health principles to keep this a pay looking Teoh ah, virus that likely emerged from China or some other country where we’ve seen pandemics emerge from before, likely scribe through the respiratory routes and be something that there was no vaccine for no antiviral. Most people thought that was the case. Most people believe that this will be an influenza virus, that we do it because that’s traditionally what Saucepan DeMint’s and we have our eye on multiple different avian influenza B C’s that that actually cause mortality rates that are much, much higher than what we’re dealing with now talking about 50 60% mortality rates. We were looking at that. Although most of us knew that even the 1918 level pandemic with 1 to 2% mortality would be debilitating through the country, most people have just had thought about Corona viruses is important regional threat. We didn’t know that it would be a, but it was on a list of pandemic pathogen, something that we thought we had to prepare for. We always put influenza much higher, but this SARS and MERS or to precursor Corona viruses that didn’t really spread that efficiently from person to person, who were easily halted with simple public health measures. Most of us thought social distancing is something that we would recommend as a voluntary measure, as something that we knew would decrease interaction between people and decrease the force of transmission. It wasn’t really in anybody’s playbook toe. Have this be something forced. Obviously, school closures and things have been debated. They did do school closures during 2009 but full stay at home orders were not something that we’re basically on the list of things that would happen. We thought that we would be able to do very precision guided in public health, which is the way that public health interventions usually are. You you’re really targeting those people who are infected because you know that there, in fact, did you know who’s infected. And you know what activities are likely to contribute just friends and which ones are not. And that’s mostly how people thought that this would this would happen. But that would be, you know, in January or so like that. That’s how we thought this would happen. But clearly things didn’t happen that way.

[0:07:11 Speaker 1] Were there known failing points like if I had asked you and others in your field a year ago, supposing we had a pandemic pathogen, Uh, where the stress points going to be in our system? How what would you guys have said then? And how is that fit with what’s been observed?

[0:07:32 Speaker 0] The biggest dress point people would have said a year ago is hospital capacity because we knew that hospital capacity get stressed even during the severe flu season. So if you take the 20 18 flu season, there were hospitals that were almost in crisis, and we know that the 2009 H one n one pandemic, although it wasn’t very severe, was difficult for many hospitals. And that’s something that always talked about the hospital capacity. Because hospitals don’t they don’t operate with the major margin just based on the industry. They like to be completely full, and they have only certain number of licensed beds, and they want to fill all those beds. And they want to use all idols face because this is an expensive proposition and hospitals, most of them don’t they operate in the black, they’re always operating in the red. So we knew that hospital capacity and the ability to do surge would be very limited. And we also knew, I guess, that the that that we had issues with personal protective equipment and in the strategic national stockpile, being replenished and being up to date and worried about that we were worried about with number of mechanical ventilators, all of those which all kind of fall into hospital capacity. That really been the issue that most of us had identified for a long period of time, knowing that hospitals were woefully unprepared for for anything and we’ve seen it multiple times with many types of surgeons. That happened after Superstorm Sandy, for example, in New York, where hospitals went offline and other hospitals got crushed by the volume, most of us not good. Most of us thought diagnostic testing was going to be something that was a challenge. But not something that was insoluble are not solvable because we have the technology to be able to do that. Many people thought that that private industry as well as major national labs like Question Lab, will be able to absorb this. And, uh, that, I think, is a little bit surprising. How badly what will you do if you some difficulties? But I don’t think anybody fathom that now, sitting in July of 2020 that we’re still talking about diagnostic testing problems in the the most powerful country in the world,

[0:09:19 Speaker 1] I want to talk more about the testing problems a little bit later, when we’re talking about how prepared we were and in what different areas, maybe we should differentiate three United States, in particular certain cities. New York I know you are on a group that was assessing the New York hospital system and other countries. The world is there. Is there anything to say about the states of preparedness of different countries and maybe different regions of America?

[0:09:47 Speaker 0] The U. S. Was definitely considered the most prepared because we had all the resources we have, Ah, very robust health care system that has a lot of resources and a lot of people in in a lot of technology and in a lot of money versus other countries. But I would say that I was part of a team that went to Taiwan 10 years after SARS. Sadly, Taiwan is not able to be evaluated by the W H O for their prepared just because they’re not a member of the W H O. So my colleagues and I went there and I really saw Ah, very I got I guess I was a very complex, A very complex and intricately designed system engineered t detect any kind of infectious disease emergency and treat it very, very seriously, even something as minor as mundane as dengue fever. They take it very, very seriously, and from the top level they have epidemiologist at the highest level of their government. So this is something that they take. They got burned during SARS there, right next to a hostile power that has biological weapons That has, ah lot of issues with avian influenza viruses. So they prepare all the time. And I was just very, very impressed if this was something that they made a national priority, that they thought about this happened, that it was not a matter of of, uh if this would happen. And we went out what happened and they were prepared right from the get go. And you saw this whole system that we evaluated jump in spring right into action. Even in 2019 actually, late December, they were already in action, ready for a pandemic where most of us, Donald for months and months. So I do think there’s definitely differences in states that prepared this with Taiwan being stand out, South Korea as well. Again, the commonality there’s hit with another Corona virus outbreak that time the MERS outbreak in around 2013 or the whole government basically a lot of loss of confidence in the government because off how badly that was handled, the Middle East respiratory syndrome outbreak and they vowed to make changes, and it’s clear that they did make changes because they pounced into action to students. They had cases. And I think that that there is definitely something to learn from those experiences that even though the U. S on paper looked like that the most formidable country for a pandemic, it’s actually turned out to be one of the worst.

[0:11:55 Speaker 1] It’s also, in a way, maybe a hopeful sign, because they were burned by earlier experiences and improved. So there are precedents for countries building this kind of apparatus. Um, in that case, So let’s turn now to what you were mentioning the early days of the pandemic. I wanna know a bit about your thinking early on and your perspective on the first moves that were taken by different, uh, countries both at the time and your thoughts in retrospect. So when did you personally first become aware of this disease and when did you first expect it to be a pandemic or at least an international problem?

[0:12:36 Speaker 0] I first became aware of it, I think, in the early days of January, after the W. H. O notification that there was a novel. Corona Virus initially was described to a seafood market there was about 41 patients, and that’s what we had. The fact that was a novel Corona virus peak Everybody’s years because we were worried about SARS and MERS and the fact that was happening in China. And, you know, the China has always had transparency problems when it comes to infectious disease outbreaks. And the whole story of SARS by SARS circled the world and killed some and kill as much as it did, even though it was only attended was a 10% salary, didn’t it? Wasn’t completely shattering that the world was because China did not report. The case is in. The other countries cannot get you could not get prepared early enough. So this was something that we thought about at least. I thought this was something that was significant, and we were seeing a lot of transparency from China. Early on the sequence of the virus, they notify the W. H. O very quickly, and it all seemed to be clustered to a seafood market. It was a Corona virus. There was 40 cases, and they all said they came from the seafood market, which to me was a little bit suspect on a kind of a moralizing my thinking about my vlog about this, But they that seemed to be a little bit much for a seafood exposure or on animal exposure that suggested that maybe there was some limited human to human transmission going on. We didn’t know we didn’t hear about deaths. And we know that Corona viruses this was this was the seventh human Corona virus that was discovered in four of them are part of our common cold repertoire viruses and some of them are very, very mild. But something cost of your disease as well. Immuno compromised patients, so we still kind of I was trying to fit into that when when it started spreading human to human, and we got confirmation that this was sustainably transmitted from human to human. There was no way that I thought that this virus had only been in that it only was going to remain in China because a virus like that to me that officially transmits from the respiratory route is not going to be containable. So focusing all efforts on people that were from China, I thought was likely to be not fruitful. I thought that even though this was recognized in late December. There probably were cases going on for some time because we know that the clinical symptoms were indistinguishable from cold and flu and this emerged in the middle of the cold and flu season so that there likely were cases that were missed and likely in other countries. And I think that that thinking at least has been borne out when you look, for example, at sewage supplies from Italy. So it’s ah, sampling from Italy that there were cases already there in mid December. There was someone diagnosed in France who had no travel outside of France around Christmas time. So clearly this virus had escaped from China long before we even have took notice of it. And I think that was something that I think that that I was right thinking about that just based on what I knew about what viruses where I thought that the case fatality rate numbers were a little bit skewed when we started to hear about these deaths in China, because there was a lot of severity bias in the data, but people were testing only those who went to the hospital and I saw it. I thought this was going to fall below 1%. And I do think now if you look at the W, H. O and CDC guidance, they are now looking around 00.6, which I think was a number that I kind of, I kind of estimated, which seems to be pretty accurate for the infection fatality rate.

[0:15:38 Speaker 1] I remember your guesstimating that number early based on the South Korean um, data. So the fact that it got out so quickly and you would expect it to through it was expectable to What does that, um, what are the implications of that for? For travel ban policies. Clearly we can’t rely on them or expect them to do everything or to save us. But did they help? In particular? Was America better off than Europe because Trump banned travel from China when some European countries did not Or did that make no difference? Did you ever way of telling that

[0:16:16 Speaker 0] I my biases to think that it probably didn’t make much of a difference because I’m not a fan of travel bans and I don’t think that with a respiratory virus that had already left the country of origin, that you could have really stopped it. And what I think there was. What happened? This You get a false sense of security amongst public health, people among people who don’t know that much about it, saying, Well, it’s taking care of. We’ve got to travel. It’s only in China. We have a traveled man from China. So therefore, we don’t have to spend time fortifying our hospitals, getting diagnostic testing ready. You just gotta focus on this hall trickle of people that are coming from China now because of the ban is in place. So I don’t think it was effective and we had no way of knowing if it was effective because we couldn’t actually do diagnostic testing. So even if you’re gonna grant that it just that it was effective. How do you actually know that our measure that the only way you could do that it’s a diagnostic testing which we could not do very well back then. So I don’t think that this is this was the answer. I don’t think travel bans are are the answer, and they often cause cascading retaliatory travel bans and make it paradoxically harder to get. Resource is and you know that those travel bans, they had to have special flights to bring supplies from China. To hear all of that was could have been avoided. And I just I do think that this was just something that has a lot of face validity to the general public, but really has no validity when it comes to the science behind it. And it’s clear that this didn’t stop this fire from coming because at the same time we had multiple travelers coming from Europe that receding, uh, the New York City area with strain that had landed in Aura.

[0:17:39 Speaker 1] And we know I gather that the New York City outbreak was caused by European travel that occurred even prior to the trying to travel ban about this before he would have known to ban Europe if we were doing. And

[0:17:50 Speaker 0] there was already cases already seating there. You’re talking about the travel ban that occurred already after there were cases in the United States and undetected chains of transmission that were going on in Washington in likely Santa Clara County, California, as well and probably even New York, maybe even other parts of the country. There were one off cases that were going on because there really was no ability to test in no kind of, uh, no kind of thought pattern if this is something that could be in any city based on what we know, based on what the guidance was, despite what we knew about viruses of this. So let’s

[0:18:21 Speaker 1] now talk about this period when were first starting to have a response. February, March, particularly March, even January. What were your expectations personally? And what’s your sense of what people in your field expected for what we would be able to stand up domestically as a response, particularly in terms of testing, eyes tracing, isolating what I’ve been clearly every every one of you now is that there’s been some massive failure in this area. How much of that was expected? Could have been expected. And how much of it? Where did that come from?

[0:19:01 Speaker 0] No, my expectation was that there would be guidance. It says. This is something that we have to think about when you have a compatible clinical syndrome. Despite where a person may or may not have been that you might want to rule out the usual suspects because we’re in the middle of flu season and influence of was still spreading. But this is something that you need to consider. But we got a CDC testing protocol that basically said You can only test people that came from China and only people that had lower respiratory tract disease. If you want to make a program to actually allow undetected chains of transmission to occur, that’s what you would say because we knew it was already outside of China. And then it’s baffling to meet that they didn’t allow you to test mild cases because those mild cases are contagious, actually probably more contagious than the ones that are getting hospitalized because those people were getting put in isolation in the hospital, where someone who’s mild just goes back about their life because most cases are are not going to really interfere that much with people’s activities of daily living. So none of us really suspected that we were. I was pretty vociferous in the beginnings in this testing, but I was wrong. It’s not something that that’s going to do anything except from predictably increase the number of cases you until they become uncontrollable by case contact racing because of your only case contact tracing the severe cases, you’re missing the entire thing, entire. It’s like a nice front. You’ve just seen the tip of the iceberg of the hospitalized cases. If it’s maybe 2% or 5% get hospitalized. Other 90 something percent are out there infecting other people. So you have this this scenario where you have no idea who is infected, who isn’t infected. Who is it? Lewis, who poses a risk, who doesn’t almost by design. And I don’t think that anybody realize that that would happen so badly on and that would be executed. So it’s still to me that feeling how that kind of guidance Scott became codified and how people really adhere to it. And Aiken, I can vividly remember arguing the people over this face. It needs to be tested because it’s likely covert and and it’s just it was just impossible to get the test because it was controlled by that protocol, which all the states that adopted. So this is

[0:20:54 Speaker 1] her arguments you’re having as a practicing physician with a patient in your office who’s showing symptoms

[0:21:01 Speaker 0] were in the hospital, even hospitalized patients. Yes, as well as I’m saying the same thing in the media, and I’m on conference calls saying this doesn’t make any sense. What We’re what we’re doing and, uh, and continue to be that way for a long period time. And at the same time we were being told by the highest levels of government, including the president, that this was going to go away. It wasn’t going to be something that hospitals needed to worry about. And I think that was the wrong message because we wanted hospitals to say, What is your personal protective equipment inventory? How many mechanical ventilators air there, dust off their pandemic flu plans and think about what you’re gonna do for I see you search. What’s the status of strategic national stockpile? What do we need to replenish? All of that should have been happening in January and February, not march and April. And I think if you would have done that, we would have had a much different course with this pandemic, not only in the economic shutdowns that occurred but also preparing the public for what was going to happen. And indeed, in February, when the CDC started saying, This is going to be a pandemic, we need to prepare. You need to think about social distancing. It came as a shock. And the woman who who, um, talk about that Nancy, Miss Sonia, who’s, Ah, very decorated CDC expert She’s been heard of since that time. So this clearly was things that were not. We never thought this would be politicized to the extent that the CDC would be silenced from actually giving the public expert advice. So and I think that compounds the whole issue. And I think this is the of the important questions need to be answered is how did this all go wrong and not what went wrong once the task force started. But what went wrong in January, February and March? That’s that’s where the key decision points. That’s where we lost the battle against fires. So

[0:22:34 Speaker 1] to what extent worthy, the, um, recommendations around testing that were out of that were active in January and February. To what extent was there a contingent of medical expert scientists who thought, wrongly by your life’s And as we’ve now seen, that these were the right protocols? And to what extent was it politicians overriding the contents of the medical field?

[0:22:59 Speaker 0] I don’t think we know the answer to that. I don’t know anybody that believed that that was the best way to approach diagnostic testing and thought that this was going to have any kind of effect that containing the outbreak. I think that this was this was something that was baffling to many people, and it was probably aided by the CDC. So I think that’s an important question. Why did the CDC settled on that guidance on what was driving that guy? Did they think that this was something they could contain? But I don’t No one has asked the CDC director. That question directed it. This is a respiratory virus with a spectrum of illness that’s friends efficiently from human to human. How was that protocol likely to pick up the cases at a rate high enough to prevent the country from being disrupted by this? And nobody’s asked after a question, which is what I would like to ask the CDC who came up with that guy, and it to me is completely goes against everything that I’ve learned from people at the CDC, so I don’t know what we’re that

[0:23:50 Speaker 1] it seems like there’s actually a failure of of science and political journalism here because that’s not one of the questions that where we’re seeing posed to people and seeing posted the administration. Was there a contingency of contingent of doctors who thought this was the best procedure and what was the reasoning? Or was somehow the medical decision override righted by political considerations?

[0:24:15 Speaker 0] It’s one of the biggest questions I have is trying to understand that because that’s if I were to pinpoint a decision where the whole thing went the wrong way. It’s that decision because it really sets the tone for the rest of the outbreak.

[0:24:28 Speaker 1] Fascinating. So now we’re we’re into March and April were into the lock down because it’s often put of the restrictions on motion being introduced, and a one point I’ve heard you make Is that what we had weren’t locked down of the sort that were in China or even in Europe. So how would you characterize the policy that was in place in in California, in New York and eventually in almost all of the nation?

[0:24:54 Speaker 0] So these were why I call them stay at home order economic shutdowns where there was a determination made by governors about what was an essential business or an essential activity and what wasn’t. And they were very broad compared to what you saw in Europe and what you saw in China, where basically there was the full cessation of economic activity that occurred, or where when they started to open up, they kind of got to where we were at the height of our stay at home workers. And I think that that was because ours were explicitly designed not to drive the cases to zero, but to preserve hospital capacity because we were very nervous about what was happening in New York City at that time. And that’s why they were what we call leaky. For example, in the United States, you could go outside and exercise whenever you want to do what you could walk a dog whenever but in England at certain hours will you could walk your dog or exercise. That was not what we had here. And I think that it’s good that we didn’t do that because you have a different understanding of individual rights and liberty, although I think that, um, the shutdown says they were were very damaging to people’s lives and But I think it’s important to remember that the reason why we have these surges now is because we even at the height of our stay at home workers were still getting 20,000 cases a day. That’s not that’s not what they saw in other countries, and that was by design. So I don’t think that people should be surprised that we’re having more cases in other places because our shutdowns and indeed doctor found she just said this yesterday are shutdowns were not driving cases 20 that that’s why we have cases now. It’s a simple biological fact that that’s what that’s the the policy that was pursued here. And I think that that’s an important thing to remember that we were even even when we were using kind of the most aggressive public health measures, they were still targeted. If you look for example, in my home state of Pennsylvania, almost 10,000 exemptions were granted for things that were deemed non essential to become essential, so I think that this is a you know, a misunderstanding of what these the stay at home orders were meant to accomplish hold up with. But that being said during that period of time, states needed to invest in the infrastructure to be able to actually deal with the number. The increase, the number of cases if they would get a soon as a stay at home order is lifted. And clearly, that’s not the case in states like Florida, Arizona and Texas and even California, which is a state that was pretty aggressive with the shutdowns. One of the earliest stay at home order was in the state of California, and clearly they can’t keep up with contact tracing or diagnostic testing. So this tells you that this is a virus that is going to be, ah, major challenge that we have to deal with because it spreads so efficiently and has the spectrum of illness, or many people don’t know that they’re sick.

[0:27:26 Speaker 1] So there was a, um, a spectrum of views about how to handle this, including whether to have shutdowns or restrictions on motions, They and all motors, what level of them to impose. We saw a range of different types of them across different states across different countries. Um, you mentioned ah, Europe’s being stricter than in the United States. You were in general form or freedom of motion. Less imposition of this, Um, how do you could you say something about the state of the arguments within the field and you’re thinking about, uh, about how this should be handled and any ways in which that thinking’s developed over time?

[0:28:08 Speaker 0] I think I’ve always been an advocate of precision guided public that you just can’t have a blanket order on every activity. And it was clear that some of these data mortars have very silly components. That, for example, in Michigan you could not travel to your second home if it was in Michigan. But if your second homeless in Ohio, it was fine to go there. So they’re clearly Western science backing. Some of those blankets likes of orders, and I knew that there was only certain activities that were leading to this spread. Maybe congregation in large groups, indoor settings, churches, maybe bars. That’s where you’re seeing transmission occur. And it wasn’t the fishermen that’s out one or two friends on the lake that’s causing it. So I didn’t think that that was the right way to do it. And I think that there was a paradoxical backlash that if everything is so is permitted is not permitted. Then when you do open up everybody and I said this in the media articles turns 21 all once and there’s a lot of responsibility because people didn’t get hit with. They didn’t get hit hard with the pandemic because of stay at home orders and then all of a sudden they’re out there behaving as if there was no panda. So I think that my thinking is that it has always been that you have to direct activities that what, what’s causing it? And it was very difficult for some governors. I don’t anything the position they were in because they had no ability to know who was infected, who wasn’t. There was no peace contract racing, so we didn’t have all that epidemiological data to know exactly which activities needed to be shut down. Which ones did not. But you could You could come up with that maybe after a to a four week period of time, knowing that this is what what was causing it. I do think some states started to do that. They started to say, Okay, we’re going to permit drive in movies that we’re going to do this, and I think that’s usually you start from that you kind of build your way up to the restricts instead of putting on a blanket order and then peeling away with what was going on. But I don’t think that I think the only way you can understand that is the governors were scared. They had no tool except for that one. And they did not want to be blamed for for lives being lost based on their inaction. And I think it takes a lot of it, takes a lot of courage to say, Okay, we’re gonna peel this away. We’re going to do it very you want, Especially when there was a political narrative going on and you had different opinions from the federal government because my thinking always has to be. It’s always going to be the least restrictive. You don’t you don’t put typhoid Mary on the island automatically. You give her a chance.

[0:30:21 Speaker 1] Are there any states or countries? I know that if we talk about Taiwan and South Korea, a lot of their success had to do with, as you described before the testing and how much they were prepared beforehand. But are there any countries that you know didn’t stand up an excellent testing response right away, or any state that did go into some kind of shut down and mitigation measures and that you think did a good job of it or a better job than the others he would want to put forward as an example?

[0:30:55 Speaker 0] No, I don’t think there’s any great great examples. Think most countries got it wrong. Most places got it wrong. I would think, you know, when you look at it, I think what everybody’s eyes are on New York State because obviously they were hit very hard and they’ve been reopening and their percent positivity of tests, which I think is a very important indicators around 1% and they have not had these surges and I don’t know, it’s so there’s two things that I have iPod. This is one is because New York State was hit so hard that this is really scarred, the people and they’re behaving in a very different manner than other states, and that could be part of the truth. And the other thing is, is that when New York, when they started to quote unquote reopened. One of the criteria was, You have to hire X amount of contact tracers that you have. They actually push them to actually build the public health infrastructure in each of the regions of the state. Not not any it. And I don’t know that any other state had an actual metric of the New York. So I’m very curious to see if New York sees any kind of unmanageable upstarts. They’re going to get more cases, but will they actually get to the place that some of these other states we’re hearing about it? And I think that’s key, because I think to me it’s going back to the bread and butter public health contact tracing. And if you don’t have that in place, you’re not gonna be able to keep these outbreaks from from spiraling out of control.

[0:32:01 Speaker 1] When people talk about less restrictive policies, they often think about Sweden and the plan that was talked about in the UK before the Imperial College report came out. Could you comment on those policies? Differentiating what you’d advocate from from that kind of a policy Perrotto

[0:32:19 Speaker 0] So I think, have to separate Sweden, some parts of Sweden, Sweden has very good public health laws that are really well written and give people a lot of guidance on what can and can’t be done. But I think that with a virus like this, if you’re going to pursue that type of policy, you have to realize that they’re gonna be vulnerable. Populations that are going to get sick and that are going to die. And you can’t just you want a couple it with some amount of testing that’s going t d Limit that and you want to fortify the nursing homes and assisted living centers. And they didn’t do that, so they they while they might have had okay, public health, they had a good public health laws and they had a sort of it wasn’t kind of. Obviously it wasn’t a thoughtless policy. It wasn’t a couple to the right interventions to make it an effective policy. So if they would have said Okay, we’re going, we’re gonna have voluntary social distancing. We’re going toe and they did. They did band mass gatherings of a certain number which were too much of a risk. Then you have to be ableto actually still diagnosed. These cases testament contact trace them and isolate those individuals and at the same time fortifying the nursing home so that you don’t get this virus spreading in there where it can kill it a very high rate. If you would have done that, you might have seen a different approach in Sweden and more of a model approaching. Now, Sweetness chief epidemiologist is saying that they did it for nothing because they actually ended up with the same economic losses because people are not going to go outside and not gonna are taking the same activities. If they’re worried about their safety because they don’t know who’s infected, who is. And I think that’s the important part of this is that it’s not just businesses normal. That’s not the alternative, because people are still going to refrain from from activities if they’re nervous about going outside just like they won’t go outside during a hurricane. He

[0:33:56 Speaker 1] seemed to be returning over and over to this theme of the essence of the proper response is getting the testing capacity and the, um uh up to speed what happened during the stay at home order the restrictions on motion here. Part of the goal was to build capacity and that I think it was hospital capacity but also testing capacity. We had the president saying numbers times that, you know, they’re funny of tests, we but not just the kind of, um bloviating. There were also cases where there were doctors on and different people in ministry talking about how testing capacity had been scaled. What is the state of testing capacity now? Why is it not sufficient? Um, at least in some parts of the country,

[0:34:49 Speaker 0] we’re definitely doing a lot more test in July 2020. Then we were in March, maybe over 700,000 tests for day or being done. But the capacity is much better. Many hospitals, even small community hospitals, have the ability to test on site. But what the problem is now is that it is still very difficult to fear an outpatient somebody that’s not needing to be in the hospital. Did you get a test and you may sitting in a car for eight hours at one of those drive through tests test places in What’s happened is that there is still some scarcity eat in terms or limited supply of re agent, so it’s not just a test kits. It’s a surprise to run the test, and some of that is being run by the White House task force and their prioritized in hospitals as they should be to get this for the sick patients. And there’s still a problem for if you’re an outpatient with mild illness, of getting this test front quickly and it is being rationed that the agent and being prioritized for certain people over other people. And I think that’s what the problem is, that we still don’t have a proper supply tape off that re agent to allow enough testing to be done. And I think that’s why we have to start moving alternative types of testing like an engine testing, and we have to figure out what this problem is, but that’s going to continue to plague us. We can’t do a statement, you know, a little bit this virus, and I agree with that. But we can’t live with this virus if you don’t the only way they were gonna be able to live with this virus. Actually, if you have some ability to know who’s infected, new isn’t so you can actually live on, and I think that’s the That’s the problem that we have to fix. And I think they really have to fix the re agent problem and allow people to be tested just like they are tested for HIV right now, just at the drop of ah ha, you can get an HIV test. You cannot do that with this saccharine virus test, the

[0:36:24 Speaker 1] trouble America’s facing or the United States is facing getting enough free agent simply a function of our size that were such a large country. Or is there why is it Do you have any insight into what makes it such a challenging problem? Why it’s not been solved?

[0:36:40 Speaker 0] I think it’s primarily because there’s one supplier that’s a fire has limited abilities to scale. They’re supplying so many different labs, just a simple capacity problem. And we are doing a lot of testing that requires a lot of re agents. So in hospitals that I work out, we can test for other. I had to test somebody recently for influenza and I had to go through all kinds of bureaucracy because we’re saving that re agent, which is the same reagent used for Corona virus tests on not allowing influenza tests to be done. So I think this is this is a problem with that probably going to plague us for a while until they get to get to the bottom of this problem.

[0:37:11 Speaker 1] Is the supply chain global here and affecting other countries the same Or we hit worse with this.

[0:37:19 Speaker 0] I don’t know the exact answer to that. I don’t know that that I do think it is global and I do think the company it’s hyejin is the main re agent manufacture that they do have other international clients and other demands that are going on. But some tests do. I know our tests are highly dependent upon it. Other tests may not be as dependent upon it, and so it depends on what countries are doing specifically.

[0:37:40 Speaker 1] So that’s another topic that people researching this might, uh, you know newspapers, for example, might be looking into understanding the cause of this prices. Are there other tests we could be using? So let’s talk now a little bit more. We’ve already been in this mode about reopening. Of course, there were a range of opinions as to how wise, very estates re openings were, and they reopened it. Different speeds. But everyone that I have seen every medical expert anyway was expecting. Um, you know, more cases as we reopened is what we’re seeing in states like Florida and Arizona and Tech. And you were saying there would be more cases? Uh, is what we’re seeing in Florida, Arizona and Texas the kind of more cases we were expecting, or is this a kind of a different sort of surge than we could ever should have been predicting?

[0:38:35 Speaker 0] I think it’s a different kind of search because it’s not just that we’re getting more cases. We all expected to share number of cases to go up. We did not expect the percent positivity of test meaning acceleration of the operator to occur, and we didn’t think that we would see hospital to get back into crisis. We’re already hearing about hospitals in Miami running out of I C U capacity. Nobody thought we would make the same mistake again in June and July that we made in January February. But yet again, the same mistake happened.

[0:39:01 Speaker 1] How would you compare the situation in Miami now and in other Sun Belt cities to the situation in New York in March. Is it the same thing all over again? Is it worse in some respects, better another.

[0:39:15 Speaker 0] It’s hard to make direct comparisons. I think early on we thought it wasn’t as bad because the percent positivity of test was 20% in New York. At the height, it might have been 50% because we had such constraint testing. But now that Miami is reporting that they’re in problems with, I see use again that that kind of changes the equation. And I wonder, you know, is it akin to New York? It’s probably not as bad. They’re probably able to decompress. We know that there are still doing other surgeries and there’s other activities going on. They’re in some of those places in in Florida, but I do think it’s approaching a New York style. When you start hearing about hospital capacity being compromised, that that’s that. That’s with the theme of the New York issue, and I think that’s changed the way that we have to think about these random, this pandemic and thinking of in these new hot spots. If these are at risk of becoming like New York, we didn’t think that that could happen. We didn’t think that everything was extrapolate to New York because we thought that people would actually learn from New York and realized, You know, we don’t have the same population density. We don’t have the same multigenerational families there. We don’t have the same public transportation. But if that gets out, weighed by just inaction and ineptitude with testing in contact, not hiring enough contact races in allowing change the transmission to Earth that’s gonna wash out any advantage you might have, because your city isn’t your

[0:40:27 Speaker 1] What are the cities that you know sitting today on the 14th of July, your most or regions you’re most concerned about? The hospital capacity issue arising in Miami is one or the other.

[0:40:38 Speaker 0] Houston eyes another one. Austin is another one. Some parts of California, some parts of Arizona as well on. And then there are going to be other hot spots we’re already hearing, like Delaware is having problems now that they’re percent positivity is above 10% and Iowa all these these places are all this is going to be the standard in the pandemic, that he’s hot spots are going to flare, and it’s just that hospital capacity is going to continue to be a problem because it’s not something anybody tries to pick other than just surge capacity or or just kind of building up a little bit building up. I see you capacity by converting beds. Nobody’s actually think you should have more beds in the hospital that maybe they said I on. We use them for this and I think that’s that. That’s going to be the You know, the controlling factor here, and I don’t think there’s anybody has. Even this is not even in the realm of suggestions to say, Well, maybe we should increase I see your beds and just leave them empty. Nobody no, it’s not what anybody wants to do because of the economic. Some help here

[0:41:34 Speaker 1] just anecdotally. I was in the New York area as you know, living there in February, March, April into May, and now I’m in the Austin area and in terms of the number of people one or two, you know, people removed from me or activities that would have had to been canceled because somebody has covet there’s a lot more of it going on now in my life than was then in part, that might be just because they’re more activities going on now. Them were there, but I’m more aware of people with it here that I was there

[0:42:07 Speaker 0] when the same is true for me in Pittsburgh. Diet More more of my friends are infected now than they were earlier in the height of the endemic here.

[0:42:16 Speaker 1] I want to ask now about a couple of issues that aren’t quite so time dated as the ones we’ve been talking about. One thing that, uh, I’ve noticed in your discussions of the virus that differentiates it from a lot of the other medical things I’ve read, particularly in science journalism on it, or like just in New York Times articles or recent article inbox is you get a lot of reporting on what the virus can. Can it survive on a surface in this condition cannot be spread airborne, etcetera. One thing I’ve become sensitive to from talking to you is the difference between what the virus can do and what it does do, in other words, what’s possible to it and what we should expect to see occasional cases up and what it’s typical behavior is that that drives the epidemiology of it. Could you comment a bit on that distinction and the role it plays in your thinking?

[0:43:08 Speaker 0] I think that what happens is people will have an experiment. Maybe an aero. Biologists will show airborne transmission or show droplets being suspended in the air and then that gets extrapolated into This is an important epidemiological fact that we need to consider in our public health guidance on how we treat patients. And I don’t think they make a leap between what’s possible in an experimental setting. What’s possible and maybe 1% or 2% of the time, or even more so. If you’re using an experimental cough simulator, for example, versus how, what do we actually seem on the ground? How are people getting infected? What is the main way? What is the primary mechanisms? This is transmitting. That’s what I tried to really differentiate because you confined case reports of a lot of things that are odd, that the virus has some kind of odd behavior that occurs, and it’s not necessarily representative of what people do. And I think that sometimes you get very distracted, especially cause the media gets very interested in the 1% but not the 99%. And you could get people very distracted by worrying about something that is a rarity versus something that they normally have to worry. So you’ve got people trying to bleach their male or do what they do things to their male. But that’s not how people are getting infected. So I will say the virus isn’t waiting for people to pick up their mail. That’s not how it’s getting around. It’s getting around people being close together. Yes, there is some. There is some risk there, but I think it’s very negligible and not something that I would spend much time thinking about. Obviously hocked a scenario where someone seizes on your envelope and you touch it and then you get get it. But it’s hot. That’s what what’s going on in the majority of transmission cases. And just because you can find a surface that the virus lives on in a perfect laboratory setting for seven days, that remains viable. That’s not what what normal life is about, and that’s not how that’s not well received with our epidemiology. So I always tryingto put this into the context of what’s relevant for patient care or public health messaging, not what’s in an academic paper. That shows something in the realm of possibility kind of the 1% the 1% of what could happen. Looking at what’s happening, 99% and where is the most impact? I’m almost thinking about the intervention. Where is my most impact? Should I spend time trying to worry about this thing that happens very rarely, Or should I put all the effort into what dropped? What what works for the majority of cases.

[0:45:14 Speaker 1] So if you, um operationalize ing that for an individual, if there’s somebody who’s, um, you should spend less time, you know, again, depending on your your particular context in situation, less time, sanitizing your mail and more time. Doing what? What? What is it that people are doing less of when they’re focusing on more unlikely risks?

[0:45:38 Speaker 0] So I would say it’s limiting your contact with other human beings and trying to stay 6 ft department, washing your hands frequently and not touching your face. And maybe maybe wearing face coverings as required O. R. As indicated in certain areas. That’s much more important than figure out which bleach product to use on your on your mail. And indeed, people who had a record numbers of poison call center costs people getting in, getting it intoxicant flame exposures to to cleaning substances. Because of this, because it was such a misplacing because the media love to talk about male being or how don’t sterilize your groceries and there were so many more. You know, there’s a negative effect of that. If you spend so much time working on the 1% it really distracts people laying in there actually negative consequences that occurred with all the places

[0:46:21 Speaker 1] that’s anything. There was a lot of media attention on people maybe would would take trumps strange comments, and it would lead them to drink bleach and such. And I don’t know if anyone has has done that, But you’re saying that there’s been a lot of danger, not people doing something crazy like drinking bleach with just They have too many cleaners out sanitizing everything, and they get it in there. I or something, uh um, and causing problems himself that way.

[0:46:48 Speaker 0] Yeah, I mean, definitely the people saw tips on how to sanitize, and they were using Clorox bleach And that could be, you know, you could be overcome by those fumes and there were record numbers of also poison centers over there.

[0:47:00 Speaker 1] Oh, um, you mentioned face covering. So I know there’s been of debate about that. There are different. Uh, some people are more pro facemasks and different types of face masks than others. I know you are a little more skeptical of the value of the masks than some and are more of a fan of the face shield. If I if I understand correctly, could you say a little bit about what the issues are that are being debated about the different types of face coverings in their utility

[0:47:29 Speaker 0] So early on independent? There was recommendations of surgeon general in all Caps wrote on Twitter. Do not buy people stop by face mask. Seriously stop buying because people were buying them, thinking that they’re going to protect themselves from getting infected. And there’s no evidence that a face mask protects you because you can get effectively rise. The general public doesn’t wear face masks very well, but what happened was we started to see these cases where people didn’t know they were sick or maybe they were pre symptomatic, never contagious. So that became this like you. Maybe you should put on a face mask in orderto serve a source control for these individuals who don’t know that there’s the problem I found with that is that these were homemade masks that sometimes you’re just a bandanna tied around somebody’s neck, and people don’t wear them properly. They stick their nose out, a paradoxically touch their face more. You get a false sense of security and see social distancing when they’re wearing a mask, and then they let her all over the sidewalk with these mass that other people have to clean up, which could be infectious to them. So that’s what my problem was with it. When face shields started, Teoh become something in vote. They offered the opportunity not only to service source control but also to protect the wearer because they also cover your eyes. You don’t touch your face is much, much easier to comply with. People aren’t taking them off and every five minutes to do much so if you find a face job where they’re more likely to be wearing it correctly than a face mask, Where and what’s happened is that this is also now become politicized. When we have two camps now and again, this is going to what can the virus. But what is possible for the virus to do on what does it actually do it? These aero biologists who have talked about airborne spread and have shown that in some of their experimental studies have said, this really negates the benefit of the shields, but it also negates the benefit of people wearing their face mask on their without their nose in as well. So I think, and you have to think of the what’s the main pattern of transmission and its people closely talking to each other and drop bigger droplets. And I do think that facials work in that situation. So I’m somebody that does favor the use of facials, and I think that we have to think about as you move forward. Facials are going face coverings are going to become the Norman, and it’s going to be almost like the price we pay for reopening, because it is if they do service source control when they’re used appropriately. This is something that will make people feel safer and, uh, and go for, but I think that there’s a lot more nuance to it than people think, and it is not a substitute for the other aspects of social distancing, so you shouldn’t get a false sense of security from it. But I think this is again going to be something that’s completely politicized and in a way that you have two factions and a lot of acrimony between those. So

[0:50:02 Speaker 1] you say this is going to be with us for a while? The, um, the usual line we hear is until there’s a vaccine. I’ve now heard more skepticism about whether there could be whether immunity is lasting. Can you say anything about the prospects for a vaccine and the timeline?

[0:50:20 Speaker 0] I do think that there is not a biological block to having a vaccine. Many people don’t realize that we have coat corona virus vaccines for cows and for for bird species that seem to be effective and not have a major problem. So I do think we can get one. How long the duration of immunity last. If you need boosters, all of that needs to be figured out. We don’t know any of those answers yet. I think the timeline is likely that we’ll start to see vaccine, maybe some small batches at the end of 2020 in the best possible scenarios. Maybe in the early in early 2021 but not enough to be able to vaccinate a substantial proportion of the U. S. Of the world population. I do think it’s probably going to be a two year period before we get enough vaccine and it’s gonna come out in tears and batches based on people’s risk for severe disease, to maybe health care workers and and I risk individuals will be the first here to get the vaccine and then lose to the general population. So I do. But I don’t think that we’re going to see a whole enough uptake. They get the herd immunity threshold, probably for a period of two years.

[0:51:16 Speaker 1] So part of you know, we have that seen candidates that have been shown to be safe and to generate some antibodies I’ve heard people speculating about. Is it just some kind of regulations or fussiness on the part of people that making us go through all the trials were going through rather than charging ahead and giving them to everybody, and then we’ll see what works. Why is it speaking from the perspective of a clinician? It would be prescribing these that it’s important to have controlled trials before we phase out. That released the vaccines more widely

[0:51:53 Speaker 0] because we don’t know how well it works. We know that it’s generating. Analyze. Where are those antibodies effect? Are the antibodies paradoxically, enhancing infection, like we saw with certain SARS vaccine in the experimental studies that people who have the vaccine or not open in a laboratory setting the antibodies generated by the vaccine enhanced the infection? We need to know that you need to know what the doses. How frequently do you have to administer this? What are the side effect profiles you do Those side effects occur more in other, in certain in certain population groups and and in a certain population groups. Is the vaccine Contra indicated? Is the risk being outweighed by the benefit or vice versa? Isn’t working pregnant women? What about his Children? You need a higher dose and elderly individuals all of that needs toe to be really adjudicated in a clinical trial, and then you also know not only doesn’t work because it is the antibodies. But we talked about them being effective. But how effective are they? Do they prevent you from getting infected? Do they prevent you from getting a severe infection? Do they make you less contagious? Do they prevented from getting hospitalized? What is the benefit of the vaccine? I think you’re not gonna know that unless you a placebo controlled trial where you have people that are vaccinated and they’re out with community getting infected versus people that are not understanding what actually is it doing? Is it preventing? Is the infection rate different in the placebo group in the in the treatment group? Or is it the hospitalization rate? Two different types of vaccine. And I think that those are important questions not to know because you’re gonna be prescribing these people. And one of just multiple candidates out there is, I think five candidates Art of Operation works me that there’s probably two dozen candidates in clinical trials. How did the vaccines fair head to head? Which one has a better side of that group? Which one works better in certain age groups? All of that stuff you can’t figure out without doing clinical trials.

[0:53:32 Speaker 1] That’s really clarifying. Um, so let me just close by asking two related questions. One is, what do you expect the next year to look like with respect to to this virus? And what recommendations do you have both? For people who might be in charge of policy for organizations and for individuals of weathering this time,

[0:53:58 Speaker 0] I think the next year is gonna be kind of punctuated by these periodic flare ups and multiple hot spots where hospital capacity gets under stress in one place. Then it moves to another place that we kind of muddle through this in the way that you wouldn’t want toe. Think of infectious disease emergency being handled. And there’s going to be a lot of a lot of politization with people on one camp calling this kind of a fake thing. Other people being very serious about of the truth, sort of being that this is something serious. But we have to find a way to move forward. I think that’s what we’re gonna see. I think that we’ll start to get more treatment, so that will be able to decrease the the mortality rate of people who get hospitalized. We’ll learn more about how to prevent complications to just get more in depth. So the individuals get hospitalized are going to start to fare better, and I think they’re already starting to fare better. We’re getting better handling nursing homes and tryingto to keep them kind of in a state where the virus has not let in because we’ve got very strict visitation policies and infection control policies. But I think for policymakers in an organizational leaders, it’s gonna be very difficult because they’re going to get cases. They’re going to have disruptions to their workplaces. That is going to be hard for them to come up with plans that are not gonna get foiled by this virus. It’s going to be destructive. This is what happens during a pandemic that’s out of control, that you’re going to see many disruptions, your workforce, what activities you plan to travel, what what kind of events you can have. All that’s going to be really bad until we get a vaccine. I think that for an individual, this is going to be something that they haven’t had to deal with, probably since the 19 sixties, or maybe even before that before the antibiotic era, where every time you walk out the door there’s an infectious disease threats looming over you that you can’t take the risk to zero. But what you have to do is try and think about how can you reduce the harm of this virus causes you and the people you care about taking kind of common sense measures by avoiding very crowded places by washing your hands a lot, not touching your face. I like wearing maybe wearing a face show in thinking about how that every activity you do, you have to juxtapose that to your value high Rocketi. Is this important to me? Is this essential is an alternative way. I could do it, and then it’s gonna be different for each person, and you’re gonna have to come up with an individual risk calculus. And most people in this country have not had to do that. When it comes to an infectious disease. I often draw the example of someone who might live in the sub Saharan Africa that every time they step outside, they have the risk of malaria or Ebola are yellow fever or being bitten by then a mistake or whatever it might be. That’s kind of what we’re revealing with you. And I don’t think the people in the United States are very good at that. They’ve taken for granted the advances of civilization and vaccines and antibiotics, and now we’re we’re back to what it was like for our grandparent’s.

[0:56:31 Speaker 1] So the same, which, like what? What, It’s what it’s like for a grand parents has an element of hope in it. As bad as it is, it’s not an unprecedented scenario to be in. Is there wisdom we can recover, I guess, is what you’re getting is to how to deal with this kind of a situation.

[0:56:49 Speaker 0] I do think that we get there is a way forward. I don’t think that this is cataclysmic. This wasn’t the big one. This wasn’t 65% case fatality rate. You know, I talked about the fact that we did great things during eras when there wasn’t a measles vaccine or rubella vaccine. So I do think that this is something that we can get through. But it’s it’s really always been not so much about the virus for people’s reaction to the virus and people taking the wrong actions in response to the virus. Whether it’s the president, whether it’s it, the government, whether it’s a governor or whether it’s an individual who’s acting carelessly, it’s it’s about taking the right actions in the face of the context of keeping in the mind. The context of this fire is being with us, and if there is a way just to live with it, but only if we provided the tools. And government gets good at doing its core function of protecting individuals from becoming infected by just going back to the basics of testing, tracking and isolating, which they failed to do from the beginning.

[0:57:41 Speaker 1] It will. Thank you so much for taking the time to discuss this with me and with our viewers, who I’m sure both on the Web and these videos are gonna be used in classes. So I think we’ll have learned a lot. Thank you again and thank you for everything you’re doing on this. Thanks for listening to Policy.