Public Health Threats and Pandemics
Adjunct Senior Fellow, Council on Foreign Relations
Affiliate Assistant Professor of Health Metrics Sciences, Institute for Health Metrics and Evaluation, University of Washington
FASKIANOS: Good afternoon and welcome to the Council on Foreign Relations Local Journalists conference call series. I’m Irina Faskianos, vice president for the National Program and Outreach here at CFR. As you may know, CFR is an independent and nonpartisan organization and think tank focusing on U.S. foreign policy.
This call is part of CFR’s Local Journalists Initiative created to help you connect the local issues you cover in your communities to global dynamics. Our programming puts you in touch with CFR resources and expertise on international issues and provides a forum for sharing best practices. We know that as journalists you have an important responsibility to keep the public informed about COVID-19 and its implications, both in the short term and the long term. And we thank you for taking the time from your deadlines, reporting deadlines, to be with us. I want to remind everybody that the call is on the record, the audio and transcript will be posted on our website after the fact, at CFR.org/localjournalists.
We shared full bios for our speaker, Dr. Vin Gupta, and our host, Carla Anne Robbins, prior to the call, so I’ll just highlight a few things from their bios. Dr. Vin Gupta is an affiliate assistant professor of health metric sciences at the Institute for Health Metrics and Evaluation at the University of Washington. His research interests include pulmonary and critical care medicine. Dr. Gupta holds an active commission as major in the United States Air Force Reserve Medical Corps, and he recently served as the primary public health consultant on pandemic emergency financing for the World Bank. He is also an NBC News and MSNBC medical contributor and a term member of the Council on Foreign Relations.
Carla Anne Robbins is an adjunct senior fellow at CFR. She’s faculty director of the Master of International Affairs Program and clinical professor of national security studies at Baruch College’s Marxe School of Public and International Affairs. Previously she was deputy editorial page editor at the New York Times and chief diplomatic correspondent at the Wall Street Journal. So welcome to you both, Vin and Carla. Thank you very much for being with us. And I’m going to turn it over to Carla to have a conversation with Dr. Gupta, and then we’ll open up to you for questions.
So, Carla, over to you.
ROBBINS: Great, Irina. Thank you so much. And I wanted to thank all the reporters who are on the line today and thank you all for doing the work that you’re doing under incredibly challenging circumstances. In fact, I can’t even imagine how you’re doing what you’re doing. It seems like a very different world from a few years ago when I was doing this. So as Irina said, conversation on the record. Dr. Gupta and I are going to chat for about fifteen minutes or so, and then we’re going to turn it over to you all for your questions.
So the federal coronavirus social distancing rules expire today. And the president said on Wednesday it is now going to be up to the governors to decide what rules to follow. We’re seeing a wide variety of responses around the country. In fact, there’s a really good interactive map at the New York Times today. And you see states—it ranges everything from Georgia, where the gyms, and bowling alleys, and the famous tattoo parlors, as well as theaters, and stores, and restaurants with limited service are reopening. Texas, retail stores, restaurants, movie theaters, and malls will be reopening with limited numbers.
Tennessee, people are eating in restaurants again, retail stores and gyms are about to reopen. Florida will be allowing restaurants and stores to operate at 25 percent capacity on May 4. Oklahoma, people and pets can get their hair cut—damn, I’d love to get a haircut—restaurant dining, movie theaters, gyms, houses of worship, and sports stadiums are opening tomorrow, with some restrictions. Colorado, people can get haircuts.
So here is my first question for you, Dr. Gupta: How do we know if a state or city is ready to reopen?
GUPTA: Thanks, Carla. And thanks, Irina, for having me back. And for everybody joining this call. I second everything Carla said in terms of all the great work that all of you are doing. And please keep that up. We really need truth and honestly as much as we can, facts, to help inform health policy. So thank you.
Carla, it’s an important question, and something that I know myself, as an epidemiologist and as a clinician my colleagues at the Institute for Health Metrics have been wrestling with, because there is a concern that how can you possibly know what’s happening when it comes to case detection rates if we’re only testing about a percent of the population currently. And if the goal here that the president laid out just a few days ago was, well, the aspiration is 2 percent of a state’s population, again, the same problem arises. How do we actually know what’s truly happening with infection rates in a given locale? We don’t. There’s a lot of blind spots here.
And so either we say to ourselves: We’re never going to know the answer because, practically speaking, we’re never going to get to mass testing, as Dr. Birx said on Meet the Press on Sunday. Or we say, how do we—how do we navigate the unknown as safely as possible and move form an essential/nonessential paradigm of opening up—so let’s go away from what we think as essential workers and non-essential workers to what’s safe and unsafe, and how do we engage with each other again in public in a way that’s safe and science-based?
I think we’re headed towards the latter. And the reason why is there’s a lot of skepticism on models, like the one that IHME has produced. There’s a lot of haggling between academics about what’s the right model. And I think the appetite, as you’re seeing, from the president, his administration, and large segments of the American public is we’ve had it with these models. We’ve had with public-health individuals like myself prescribing doomsday scenarios. Nobody wants—people are tired out. They want to see—I was just on an ICU shift last night. I was working with nurses caring for COVID critically ill patients. And even they were saying: We just need to see what happens and be smart about it. So I think the focus of this conversation is going to be less about let’s get mass testing and contract tracing in practice, even though that’s what everybody’s preaching. In practice, it’s going to be: How do we open up safely?
ROBBINS: And so you’re making a really interesting distinction, essential versus nonessential, as well as safe versus not safe. If we’re going to go back there, what can we open up safely, knowing that, you know, if the numbers spike we’re going to have to potentially shut down again? So are there certain businesses that can be reopened more safely than others?
GUPTA: You know, I think this is something that you and I, and everyone on the call, could probably iterate on. What is—what do we think is safe? I think, for example, we would never think of a carwash service as essential, but is it safe? And do people’s livelihoods matter on carwashes being open? Yeah, I think it’s safe. I actually think it’s OK that we’re having people drive through a carwash, for example. And that’s been kind of the cited example of an industry that we could open up. It’s small, of course, but that’s the example. How do we—can businesses that by definition have some degree of distance between the customer and the company, or the person selling the product, can we open those businesses up and have a little bit more flexibility?
And I’m sure you and I and others can come up with a list of what that could look like. Do I think tattoo parlors in Georgia constitutes essential—an essential need? No. Is it safe? No, it’s not, even if we try our best to adopt evidence-based public health practices. So there is—this is where common sense is going to help guide some of these greater discussions that our governors across the country, our mayors across the country, are having. But it’s not difficult to understand, you know, in a broad sense, OK, if proximity is not our issue then maybe we can consider opening up national parks. You know, Gavin Newsom, for example, just closed down beaches because people were given a leash to say, OK, let’s see how this goes, and there wasn’t any strict moratorium against you can’t walk on a beach, for example, or at least on the outside of a beach. And then people didn’t follow the rules. And so now he’s just issued a moratorium against congregation at beaches or at state parks.
Could that be relaxed as, you know, we’re seeing that because of local or state reporting people are adopting rules like wearing masks, they’re willing to download apps from big tech companies that allow for contact tracing, they’re abiding by social distancing rules at the ice cream shop? If we’re seeing some degree of cooperation with ostensibly voluntary asks, then I think that changes the nature of the discussion too. It’s going to be incremental, but it’s going to require a lot of cooperation on the part of Americans to rules and regulations that some will interpret as voluntary, but that are absolutely essential to abide by to keep us safe. And I think if people are willing to abide by these thing—masks, social distancing even when things normalize, contact tracing as informed by tech companies and as facilitated by tech companies—then I think we can have a different conversation.
ROBBINS: So if you’re saying that we don’t have anywhere near enough testing to really know, are you saying that the decisions on reopening is not going to really be metric based? It’s going to be solely politically based?
GUPTA: Practically? Yes. The academic in me would say of course it needs to be testing based. Of course that’s what everybody on the public health side is testing, testing, testing, contact tracing. We probably haven’t had an hour go by if you’re watching the news where those phrases have not been uttered repeatedly. But specificity here is important. And right now—and this is Dr. Birx saying this, not me; I’m paraphrasing her—as currently constructed our testing infrastructure is not going to get us to mass testing, however you want to define that. To five hundred thousand tests a day, as identified by my colleagues at the Chan School up at Harvard, is that thirty million every week, as identified by Rockefeller, what is it? So that’s a moving target. Everybody has a different definition.
But we’re just having the wrong conversation when it comes to testing. We’re diagnosing that this is a need, but what’s the solution? This is where the mixed messaging, the unfortunate messaging coming from the very top at the White House, has caused us to not have the right conversations at these White House press briefings. So instead of talking about disinfectants or why isn’t Vice President Pence wearing a mask, we should be talking about saliva testing at home, because saliva testing is out-performing nasal pharyngeal testing—that’s swab into your nose—by a large margin, as identified by Yale scientists, and as first discovered by Rutgers scientists, who actually had the first commercially available saliva-based test in the United States that was approved by the FDA in the middle of April.
We don’t—correct me if I’m wrong, have you heard Dr. Birx or Dr. Fauci even have the opportunity to talk about that specific test? I haven’t because they’ve been defending the indefensible. And so that’s a problem. And so we need to be talking about—if we’re really talking about mass testing as an informing a return to work or a return to normalcy strategy, we need to be having the right conversation. We need our public health leaders to talk about how do we get to scaled mass testing using saliva, maybe at home, and mailing it back? All the ingredients are there. I won’t rabbit hole. I can if there’s interest. But we could get this done quickly. We’re just not having the right conversation.
So, yes, as a result I think it’s going to be political. You’re already seeing states open up in the absence of data. So it’s already political.
ROBBINS: So just two other questions, then I want to turn it over. One is, are there lessons to be learned from how South Korea, or China, or Germany, or other countries are reopening, both positive lessons and cautionary lessons, as we go about doing this?
GUPTA: I don’t think we’re going to want to hear it. Certainly, our current administration’s not going to want to hear it. But, yeah, there are many positive lessons. So South Korea—basically, we got the same intel from the WHO that South Korea did in the middle of January. They gave technical guidance on what testing should be done, how to do it. And one country adopted it, South Korea did, and one country didn’t, we did not. And their per capita testing rates went through the roof. Ours, as you know, are lagging in the bottom twenty of the most developed economies in the world. And so part of this is we should be humble. We should be willing to listen to experts, even if they’re the much-maligned WHO. Turns out there were—there were elements of what they did that were right. Obviously, elements of what they did that were wrong. So that’s one.
From China, again, this is going to be a hard lesson for us, but every model—one of the big criticisms of the IHME models is that its premise—all its forecasts on what happens if social distancing gets relaxed on May 7 in Georgia versus May 14 is premised on social distancing looking like what it looked like in Wuhan. And I think we can all agree, we’re not—we do not have a homogenous approach to social distancing, much less in the—much less across—certainly not across the country, but even within the state, you know, within certain parts of the county. I’m in Seattle, the first epicenter. I see different things just on a ten-mile drive to and from the hospital.
And so we need to be real. And I think we need to be honest about our shortcomings as a country when it comes to adopting these really difficult policies. And so, yeah, I think there are very important lessons about how to do effective containment of an outbreak that are just hard for a large country like the United States to adopt, because it requires a lot in the way of personal sacrifice, and strong leadership, and strong messaging.
ROBBINS: So in states that are reopening, what do we, as reporters, need to be writing about?
GUPTA: I think the most important thing is are people cooperating—are you noticing in your communities that these linchpins of the successful return to work strategy that are not testing based, i.e., they’re wearing masks, there are people cooperating with social distancing norms even as we normalize, there is maybe public perception of contact tracing and how it’s going and whether people are willing to adopt app-based technologies that may infringe on their perception of personal privacy? Those are critical linchpins of—if the answer to that is everybody is willing to sacrifice and do what’s prescribed, then we return back to normal more quickly. And it’s not based on testing. It’s just based on us all doing the same thing for the greater good.
But understanding what’s happening and variabilities across communities with respect to those three big buckets would be extremely helpful, because then we know how effective policies are. There’s some level—there’s some measure of accountability to local and state government about what is and is not effective. And does there need to be greater regulation, what have you? So I think that qualitative sense of what’s actually happening when it comes to adoption of these guidelines—in some cases, they’re just guidelines and suggestions depending on the state—would be critically helpful.
ROBBINS: And what’s the timeframe? I mean, between reopening and knowing whether or not it’s working—you know, they’re taking enough steps, or that we’re going to spiral back into a profound problem? Is it two weeks, three weeks? I mean, how do we—how do we denominate the time frames here?
GUPTA: Carla, it’s a tough question but it’s an important question. I would—you know, I guess this comes down to what’s practical. Inslee, for example—Governor Inslee—laid down a pretty strict order in terms of the lockdown on March 23. And we noticed an immediate change, my wife and I are both physicians, on the next day, on March 24, driving into work. And so I think this is going to be ultimately in the eye of the beholder, in the eye of the journalist in your communities.
But what’s the immediate impact? And then what’s the immediately—what’s the change a week out? Are you noticing the line is not holding a month out? So I think some time series component to this is what happened the day after X social distancing was liberalized, and a week out, and a month out, helps give a good frame for all of us on the public health side to see what’s working, what’s not, are people cooperating, are they not.
ROBBINS: And just the lag on infection rates, and when we talk about a potential spike or, you know, a W-image, or whatever, on infection rates and death rates. I mean, is it two weeks, three weeks? I mean, when—if we know it’s failing or we know it’s working, should we be looking two weeks out, three weeks out, four weeks out? What’s the timeframe on that?
GUPTA: I like—so where I think there’s no distance between those in public health on the academic side and on the government side or on the task force is two weeks is a great metric, because we know that if you’re going to develop symptoms from COVID-19 after an exposure it usually happens within two weeks. If you’re going to develop evidence of virus in your body, it usually—if it hasn’t occurred within two days, frankly, it’s unusual. But by two weeks if you’ve been exposed and you haven’t been infected, then you’re likely not going to ever be infected.
So two weeks is a good number, because it allows us to see amongst those that have a likely exposure who’s truly infected, and you’re not likely to miss anything if you extend out to two weeks. Every two weeks getting a reassessment of infection rates, looking at what’s happening with testing, so we can have some quantitative assessment of what’s actually happening is going to be helpful. But that two week—every two weeks what’s the infection rate or how have things changed on that timeframe makes clinical sense, just given how COVID-19 behaves in the body.
ROBBINS: Great. Thank you.
So, operator Brandon (sp), can we throw it open to all of our colleagues on the phone?
OPERATOR: Yes, ma’am. At this time we will open the floor for questions.
(Gives queuing instructions.)
Caller your information was not captured. If you would please identify yourself before asking your question. Your line is live.
Q: Yeah. This is John Hancock. I’m the editor of data and interactives at the Dallas Morning News.
And I have kind of two questions, really. One, here in Dallas County we’re seeing the county officials really moderating hospital stays and critical cases. Is this a good data point, given that the lockdowns are really trying to avoid asymptomatic spread? And the second question I would have is when we’re trying to moderate—or, trying to look at infection rates, one of the problems we have with Texas is that at a country level about 25 percent on a daily basis, when they release the county-level testing, the county is unknown. So it’s really hard for us to kind of good a good gauge on what a county’s infection rate is. Is there a way around that, or are we just kind of waiting on the state to catch up?
GUPTA: Thanks for the question. So I’m going to tackle question two first and then ask just a clarification on your first question. So we are—IHME at the University of Washington is working towards county-level estimates. So we should hopefully be able to get some visibility on what’s happening at that level soon enough, just because we’re beholden to the data that gets sent to us, and right now it’s aggregated at the state level. But we’re expecting it to be reported at the country level in the next few weeks. So hopefully we should be able to address that problem pretty quickly. And I can make sure that that’s a point of follow up.
In the interim, this is a question back for you, is the county department—is your county department of health able to directly report figures, or are they funneling that up to the state department of health and not directly to media outlets? So here in Seattle we’re able to get King County figures specifically just for King County.
Q: Yeah. On the testing level they’re funneling that up to the state. We get, like, daily case and death numbers from the county, but the county just a couple days—or, the state just a couple days ago started releasing county testing figures on a daily basis. Before they were doing it every week or so. But even as of yesterday with three hundred thousand tests having results in Texas—results of tests in Texas—seventy-six thousand of those have yet to have a county assigned to where that test came from. So, you know, one of the things we’re trying to look at is the infection rates by counties, especially given by that some are rural but have industries that are ripe for infections, like meat packing industries or something like that. But there being such a large number of those tests that haven’t been assigned to a county, I personally don’t feel safe saying, you know, positives divided by tests gives us an infection rate when there are so many tests that have yet to be assigned.
GUPTA: Yeah. No, and that’s good of you not to call that out and to be mindful. You are, as you’ve already figured out, you’re captive to how the data’s being reported. And the denominator here in key. So in our—the data that we would be providing you directly is only as good as the data that we receive in. So this is—it sounds like it’s an issue with data categorization and kind of identifying these uncategorized tests, which no one’s going to be able to do outside of Texas. So I hope that’s going to be circumnavigated, but the last thing you want to do is—you know, and to me we model a lot. But I think this is not something you would want to model and build an uncertainty around an estimate for how many tests are happening.
So I’m happy to kind of help offline if you’d like to kick tires about how we can—we have multiple contacts, as I’m sure you do, in local and state departments of health, if there’s a way for us help standardize data definitions and make sure things are cleaned up, because it only helps us to provide a more aggregated picture of what’s happening at the national level.
Q: Thank you.
GUPTA: I know you had a first question too and I just wanted to make sure I answered that. Would you mind just paraphrasing? Because I just want to make sure I’m answering the right question.
Q: Yeah. So Dallas County is putting a lot of emphasis on I guess how well they’re doing by moderating length of hospital stays and critical cases in the hospital. How strong a data point is this if the whole purpose of the lockdown was largely to prevent asymptomatic spread?
GUPTA: Yeah. No, I’m with you. I’m surprised to hear that. I mean, I think it’s important to understand what’s happening on the inpatient side, but we know nine—you know, in some cases nine of every patients, people that are transmitting COVID-19, are asymptomatic, never touch a hospital setting or interact with a provider. So I think—I think that’s a metric to be monitored, length of stay inpatient for—so that’s important to understand what’s your capacity in Dallas. So as you open things up, and I know Dallas is opening things up, are we—if you got it wrong, or if your governor got it wrong, state leaders got it wrong and you open up too quickly, what’s the surge capacity look like? And so having some sense of what’s open—how many open beds you have, and modeling that out, is going to be critical. But it’s not super effective to understand the effectiveness of social distancing, which is what I think you’re getting at.
What’s better for that, and I’m going to see if I can—I’ll send this to Irina. We had talked about this on the first call, which was the best way to determine the impact of social distancing is to look at fever density. And a fever across the Dallas ZIP code, what are you seeing? And there’s actually connected devices, connected thermometers that people use across the country that provide this data. And the CDC is co-opting this data to basically demonstrate that fever activity across all ZIP codes in the United States is dramatically less than it usually is this time of year in a typical flu season. And you can look down at the Dallas County level or, you know, at the national level.
But that’s the metric you actually want to look at, is—and it doesn’t get to your question of symptomatic versus asymptomatic because who really knows what’s going on with asymptomatic transmitters? But a good surrogate of that question, a metric to see what the effectiveness of social distancing is to see its impact on fever density, because it’s virtually impossible to look at—you know, to see what’s happening with asymptomatic transmission in this type of environment, other than to do mass testing and to see what’s really happening with your cases which, as you know, is an aspiration at this point.
Q: Thank you.
OPERATOR: Thank you for the question.
ROBBINS: And, Brandon (sp), can we have another question?
OPERATOR: (Gives queuing instructions.)
We are currently holding for questions. Oh, we have a question from Allison Schaefers with Honolulu Star-Advertiser. Please go ahead.
Q: Aloha! Because of its isolation Hawaii had a unique opportunity to control its borders and collapse tourism. The state is still talking about continued quarantines for out-of-state passengers and implementing tracking devices, like ankle bracelets, GPS tracking, facial recognition, and more. What’s your sense of what other states are doing about travel as the country reopens? And what discussions do you think should be taking place about how travel is handled as it played an early role in the pandemic spread, and not all destinations are equal in their public health recovery or policies?
GUPTA: It’s such a good question. Thank you for that question. So this is complicated, and I’ll just admit it, talking about the debate on travel bans. So travel restrictions has its antecedents in the post-SARS world, where the WHO came out with something called the International Health Regulations. And one of the tenets of that which every country, including us, signed onto was we don’t put border restrictions. Border restrictions, travel bans just don’t work. And the data right now bears itself out. I’m going to go global and then come local. Globally the countries that implemented travel bans against China right as things got out of control in Wuhan actually have more per capita cases than the countries that kept flights going in and out of Wuhan, or allowed—basically, the countries that didn’t preemptively stop flights coming in from China have less per capita rates of infection from COVID than the countries like us that at some point decided we’re not accepting any more flights.
So that’s one piece. Bans just don’t work. Pandemics—disease with pandemic potential find a way, especially respiratory diseases. They just find a way. That’s one. Number two, practically bans don’t work because forty thousand Chinese Americans and Chinese citizens have traversed the Pacific Ocean between China and the United States since our administration put the ban in place back in February. I don’t remember the exact date. So there’s leakage. And it’s all to say that I don’t like bans because they promote lack of collaboration, especially across countries but even within states. And what you really want is data transparency in this data void that we currently live in. And if we start implementing bans from New York, or initially there was thoughts to quarantine all of Seattle, and then there’s the fear will Seattle and our leaders here in Seattle feel comfortable sharing data more broadly? Or are they going to be worried about the economic consequences of being perceived as a—as a hot zone and being further curtailed and quarantined off for who knows how long? This is the calculation that many countries have determined is the right calculation, i.e., bans will lead to—data transparency will lead to bans, therefore let’s not be transparent. Let’s minimize collaboration.
So it gets to your question, which is I’m—I can understand why people think Hawaii can ban its way out of new cases. I’m a skeptic, but many people may disagree with me. I think COVID has obviously found a way to everywhere, every pocket of the world. And it’s better to index on collaboration and a joint effort and full transparency than it is to do otherwise. I don’t think we’re ever going to get to the point where we’re going to have sort of central areas of quarantine, like they did in China. It just doesn’t—we can’t even adhere to a homogenous approach to social distancing, which is, you know, Wuhan lockdown-light. So we’re never going to get to the point, I think, politically where we’re going to do central areas of quarantine. Do I think we’re going to get to hopefully a point where we’ll do some degree of containment and quarantine individual cases, or maybe quarantine individual houses or nursing homes? That, yes. But I don’t think entire cities. I don’t know if that answer your specific question. I’m happy to clarify.
Q: I’m just wondering too, as we get back to traveling as a public, what different recommendations would you have for the travel industry to accommodate public-facing concerns as well as just to try to prevent any spread—additional spread, as we were covering?
GUPTA: So I’ll say this is a pulmonologist, that the messaging on masks has been—and I’ll just be frank—has been atrocious from the highest levels. There’s been mixed messages when the data is clear. And the data is clear that even—if was having this conversation with you in person and I was infected but asymptomatic with COVID-19, and you didn’t have a mask on you or if I didn’t have a mask on me, I would be spraying you with droplets if we were within three feet of each other, filled with COVID-19. Normal speech, we know now, has the capability of emitting droplets that carry millions of COVID-19 virus particles. So I was a skeptic about masks initially as well, but now there’s great data published in the New England Journal of Medicine that says that’s key.
So any air travel, frankly any type of public engagement, going to a restaurant, what have you, until we feel confident that coronavirus is no longer disseminating at high rates—again, we don’t know what’s truly happening right now because we don’t have enough testing—until we feel confident we all need to be wearing masks. And so Jet Blue, for example, has required that every passenger needs to have a fabric mask or something—at minimum, a fabric mask. And you know, the last thing we want to do is encourage uptake of medical PPE. So some type of face covering is going to be absolutely mandatory whenever out in public, where there’s a chance to be socially incident with other people.
And I think, you know, this is going to seem pretty obvious, but it can’t be said enough times, infection control more broadly has to be top of mind. So whereas Carla mentioned she really wanted to get a haircut, I really want to get a haircut. I probably wouldn’t have washed my hands before and after a haircut in a pre-COVID world. Now I have—now I’m going to. And now we should all be doing that. And so we’re going to have a different ethos when it comes to public health, and how we consume health care too. I think that’s going to be more technically connected devices and through telemedicine. I think people are going to self-regulate their willingness to engage with others anyway. So we’re going to live in a different world.
But practically speaking, getting on a flight to go on a vacation is going to require masks, it’s going to require infection control, common-sense things being top of mind. And I think when it comes to restaurants and other public establishments, there’s going to have to be—every restaurant, every store, is going to have to implement some type of social distancing measure, whether it’s a Costco or a Home Depot, where I’m sure all of you—or a grocery store—where many of you have seen only a certain amount of people can go into a store before—you have to have certain egress before entry of just individuals, and control density. I think that’s going to be a common—a more common theme as restaurants start opening up, just so we can all be safe.
ROBBINS: Thank you. Brandon (sp).
OPERATOR: Thank you for the question.
(Gives queuing instructions.)
The next question will come from Alessandro Sassoon with Florida Today, Gannett. Please go ahead.
Q: Hey, yeah. So I’m a reporter with Florida Today which is Gannett newspaper, part of the USA Today network, in Brevard County, Florida.
Brevard County is a very, very, very deep red suburban country in central-eastern Florida. We’re home to the Space Center. We’re having the big first manned launch on May 27, which while NASA has said please don’t come to see the launch, back during the shuttle days manned launched would attract tens if not hundreds of thousands of spectators. All this is happening right as the state of Florida is starting its opening plan on Monday. Restaurants and beaches are reopening. Restaurants are opening with 25 percent indoor seating capacity, with six feet spacing and outdoor seating is OK. All this also to the backdrop of in Florida there’s a huge question of how much we can believe the numbers, and what do the numbers really mean. We know both through reporting I’ve done and now gained traction nationally after the Tampa Bay Times picked it up, but data that the Department of Health collects doesn’t align with data that the medical examiners collect.
And what’s more we know that contact tracing is really barebone. We only have four contact tracers working at the Department of Health, serving this county of six hundred thousand people. And we have several hundred confirmed cases. Testing, of course, continues to remain a problem. And private entities don’t really transparently report their testing data, and they’re now doing the majority of testing on antibody tests, which are completely unregulated. We know that there’s huge reliability issues from other reporting. So I guess my question is, you know, and given also the sort of demographics politically of the country, when I go outside there’s not people wearing masks all that much. I’d say maybe 20 percent of people wear masks. And there’s a lot of kind of—it’s a hoax thinking, I think, is very prevalent. And so given the inability to actually make sense of numbers, because the reliability of those numbers is questionable, and the other dynamics of the county, I’m curious to sort of hear what you think the approach should be on covering things.
And I kind of came onto the call a little late due to some technical difficulties, but you were mentioning something about length of hospital stays being an indicator. And I wanted to just ask you if you could restate that comment because I have some information on length of hospital stays, and I want to make sense of it. Sorry for that long-winded question.
GUPTA: No, sure. No, thank you for the question. And I’ll try to answer a few pieces to it and let me know if there’s anything outstanding. To your first point—to the last point first, I was just conversing with a gentleman from the Dallas Morning News who was talking about length of hospital stays, and whether that would be an effective metric to engage whether social distancing, in effect, was keeping apart asymptomatic individuals with COVID-19. Could you use that specific metric, length of hospital stays, to monitor the effectiveness of this broader policy? And the answer was no. The two are very different. Social distancing, as was appropriately mentioned, is meant to keep all of us that are generally pretty healthy apart from each other because we know COVID-19 is transmitted overwhelmingly by asymptomatic individuals who wouldn’t otherwise come to medical attention.
The length of hospital stay metric is useful because as we—as states invariably adopt their own return to normalcy strategy, our—we need to know what’s capacity at all the major medical centers in all these states, and all the states in our country, because if we don’t have enough capacity and people have long length of stay, that’s problematic. Because if we got this wrong, and we’re opening up the country too soon—and a lot of us think we are, and this is too patchwork, too messy—we’re going to need hospitals to be the failsafe again. And if length of stays are really high, then that’s a problem. So that’s—I’ll stop there.
To your larger question, you know, I think the data is the data. And there’s always going to be contrarian views. And it’s not my—I prefer to avoid sort of the train of politics and just focus on the data. But I will say that these conspiracy theories of hoaxes, masks, you name it, we wouldn’t have to be fighting that battle nearly as much if there was more alignment between our elected leaders and our public health experts. And so I guess I will leave it at that.
OPERATOR: Thank you. The next question will come from Ryan Blethen with the Seattle Times. Please go ahead.
Q: Yeah, hi. Thanks for taking the time today. I’m going to ask some questions about contract tracing. How effective is contact tracing given the high number of people who are asymptomatic with this virus? Usually with contact tracing you actually have to kind of know who—(laughs)—who’s been exposed. And with the high number of people we, you know, just don’t know right now. And then how important, you know, is contact tracing when considering reopening, given that, you know, we don’t have broad-based testing, you know, here in Seattle, or really kind of anywhere across the country? Thanks.
GUPTA: Thanks for the question. And it’s a really, really—it’s a really important one for us to be talking about more of, and I wish we had more of a national debate on this. So contact tracing is relevant to all of us, whether we have symptoms or not. And here’s—and this is—speaks to the larger point about how we—this notion that we can train an army of manual contact tracers to do the job that tech could do more easily, or in parallel, is fanciful, in my opinion. The problem here is, to your point, the way contact tracing works, in theory, is you have an individual who tests positive. And you can go back, and that individual could then identify where they’ve been, who they’ve interacted with within three to six feet in the prior two weeks.
Imagine going about your daily lives, would you ever be able to do that? Would you be accurately able to capture everyone that you interacted with in passing, or more intimately, in the prior two weeks? I certainly know I would not be able to do that. It’s a little—and so I think there’s just recall bias, there’s memory issues, there’s all types of just, you know, human error. So that’s going to limit the efficacy of a manual contact tracing effort. The Google, Apple, Amazon solutions, name the company, are trying to circumnavigate that through the technology that you may have heard of. So Google and Apple have done a lot of publicity about what they’re trying to do. And the idea here is—and it gets at this question that you’re talking about I think pretty innovatively.
It basically says: If you download this app and comply with having Bluetooth GPS monitoring of your location for an undetermined period of time, you have control over it, then it requires basically everybody in a community to buy in and say, yes, we’re all going to agree to being—to having our location monitored over, say, the prior two weeks. What then happens is if you or I were to become ultimately diagnosed with COVID-19, in the presence or absence of symptoms, this app will then say, under certain criteria, whether you were—it will prompt the person that was diagnosed positive to say: Were you experiencing fever, shortness of breath, or cough, or sore throat—I know the CDC has enumerated more symptoms as of yesterday.
If you were feeling any of these symptoms in the past two weeks, it would then ping anybody—it would give them a push notification to say: You were in contact with somebody who just got diagnosed with COVID-19 that had symptoms or didn’t have symptoms. And the push notification would depend on how close you were to that individual. So if that person was symptomatic, if you were within six feel of that individual at any point in time in the last two weeks, you would get a push notification to get potentially tested. If you—if that person was asymptomatic but came—but tested positive, you would had to have been within three feet.
I’m giving you an example, but this is now tech is trying to build in precision into an effort that is otherwise very complicated. Manual efforts are part of the solution but, I mean, just in me walking you through what Google and Apple are trying to do in this space, imagine a human being being able to do that. The recall issues on both—on the person that is a potential—is potentially exposed are enormous. And so I think that’s the piece here where tech—you know, Singapore and others are trying to leverage tech. We have to, to scale this up quickly.
To your last question, is this important? I think it’s vital. Once we move from mitigation, where we’re all separate from each other, to containment, and presuming we can get more testing—so that’s the key piece here. Presuming we can get a better handle on what’s happening with true infection rates over time—hopefully, we will—we’ll be able to more confidently move into that phase of trade, identify, and quarantine. Tracing is going to be just absolutely essential to that strategy. It’s going to be the first point of action for any public health official. If they have a positive test, or an individual who’s positive, who was that individual proximal to in the prior two weeks? Identify those individuals, test them to make sure that, you know, we don’t have an outbreak that gets out of hand. So this is—this is vital. But it’s also dependent on testing. As you said, there’s no way to say otherwise.
OPERATOR: Thank you.
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The next question will come from Brad Schmidt with the Oregonian. Please go ahead.
Q: Hi, Brad Schmidt at the Oregonian. Thanks, Doctor, for your time.
I think at the beginning of the conversation you had suggested that essentially some of the reopening decisions are largely political absent key metrics. Here in Oregon, you know, we have a low infection rate of about 5 percent, but we’re also lagging pretty substantially in our rate of testing around the bottom half of the country. And as we look to reopen, the state has said that they’re looking for maybe fifteen thousand tests per week, which is, you know, less than one half of a percent of our overall population. And the state has also said that it’s looking to add six hundred contact tracers, which is about half of the rate, based on population, that we would need under the hundred-thousand model that was proposed by Johns Hopkins.
And I’m just curious if it speaks specifically about, you know, whether metrics even matter at this point, if we’re all going to head towards some form of reopening, saying we don’t have enough tests based on capacity, or saying we don’t have enough contact tracers. Are we just at the point where we should be trying something, or do the numbers that I’ve given you give you pause that Oregon is going to reopen without testing capacity or tracing capacity? Thank you.
GUPTA: Thanks for the question. And it’s an important question. I think we’re at—from what I’ve see—so I’ll answer this two ways. Let me preface this by saying upfront: In an ideal world, I think we would all agree if we had mass testing we would be talking about saliva in-home self-collect options—commonsense things that already exist. We should be talking about how we scale them quickly because I think solutions already exist. I think there’s tech solutions to bolster manual solutions for contact tracers. Are these being widely adopted and discussed in mass? They’re not. And there’s not unity. There’s certainly not a federal—you know, we lack some of the leadership here in terms of messaging on the right issues and bringing consensus.
So given all of that, the answer to your question is I’m not sure—I think metrics is—I come from the Institute for Health Metrics and Evaluation. So I love metrics. And every decision I make is data driven, clinical or otherwise. Do I think we’re—that’s the way the country is approaching this? Absolutely not. And this is not my opinion. This is just—I mean, you go to the New York Times front page, and somebody already mentioned, there’s heat map showing people are opening up in a data-free zone. We have no idea what’s happening with case detection rates. We only have 1 percent of the picture.
So I think the answer is already there, to your question, which is: We are already playing politics, or our governors are, our president is. Some governors I think are on the right side of this and will be viewed as being on the right side of history. Others will not be, who are taking a risk that I don’t know if it’s exactly calculated. So I think the cat’s out of the bag, and now we are going to be racing, myself and others, my colleagues, to how do we convince people to adhere to basic tenets of infection control, knowing what we know now about transmission of COVID-19? How do we convince people to wear a mask, even though the vice president went to Mayo and was the only person in a picture of thirty people to not wear a mask—surrounded by COVID positive patients?
These are the challenges that become frustrating for the rest of us that are trying to say, OK, we recognize we’re headed toward—there’s an unstoppable train. We’re going to open up some of the biggest states, the most populous states are opening up. How do we—how do we try to get a handle on this? And so I think the short answer to your question is I don’t know if it matters. I don’t think metrics are—I think reality is showing metrics tell a nice story, and it can provide some degree of accountability. But clearly they only have so much impact when it comes to influencing policy.
Q: Thank you.
OPERATOR: Thank you for the question.
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The next question will come from Meredith Cohn with the Baltimore Sun. Please go ahead.
Q: Oh, hi. So I wanted you to talk a little more about those models. I mean, how much should the public be looking at them, how much should governors be looking at them? You know, we see them in the state and, you know, across the country. And within the state, we see different models. In Maryland, you know, closer to Washington, and in Baltimore the models seem to show that we’ve kind of plateaued. But the Eastern Shore, where there are chicken houses, they seem to still be rising. So, like, how do you make decisions based on that? And what should the public be taking away from these models?
GUPTA: It’s an important question. At a high level how should the public consume these models? And I can rabbit hole into specific details of it. But I would love to see the public look at these models and say: Wow, we are—all of these models are conditional upon a set of actions that the American public—that we all have to play a role in to ensure that the American public is safe, and that we’re acting in unison to really maximize the impact of all these sacrifices all of us are going through right now. And these models, the take home that sometimes probably doesn’t get clearly conveyed every time they get shown on a major news organization’s, you know, broadcast is sixty thousand deaths, or whatever is the new number, is contingent on actions being taken through—in this specific case, through the end of May, through example.
IHME has said repeatedly, we need social distancing to continue through at least the end the May broadly to eliminate virus transmission between individuals that’s being estimated. We want that number—the ability of one person to infect another individual—in infectious disease epidemiology it’s called—it’s a statistic called R0. We want that number to be less than one before we start opening up the floodgates. And so the idea here is that the models say we’re not going to really get to that number, that important statistic in infectious disease modeling, until people adopt broad scale social distancing at the country level by the end of May.
And so one of the things that gets lost in these headlines is I don’t know if that comes across clearly. I certainly don’t—when I hear people talk about the models, if I was otherwise blind to the models or the design of it I wouldn’t know that that meant, oh, I actually have to stay at home until the end of May, and whenever I go to the grocery store I need to wear a mask. And so there’s some key gaps in communication that all of us need to own, I think, on the academic side, and then just, you know, it terms of how it gets communicated to media, and how it then gets distributed to the public.
So that’s one piece, that anything that—whatever model gets thrown around, or whenever that word even gets said, what are the assumptions that are being made? And we need to make sure the public understands that this number that we’re saying, X deaths by this time, means you stay put until X date. And I think we haven’t done a good enough job, and I’m saying whole of society, in making that—in clarifying that message. And so that’s one piece.
I will say, some of these models now have—the IHME model has looked at the state—at state-level efforts, and then specific cities that have been really hard hit, like New York City, and try to model out different policy forecasts. And so if you’re a hard-hit state, you can look at the models online and say to yourself: OK, under various policy scenarios this is when I would feel comfortable using data from one of the leading statistical organizations in the world to consider a phased opening up. And based on what, at least, I’ve seen, it doesn’t seem like the governors that have decided, hey, I’m going to open up, are following the models that are out there, whether it’s the University of Washington model, the model out of Northeastern or Georgetown. I mean, there’s a lot of different models out there. I don’t—it doesn’t strike me that Governor Kemp in Georgia is looking at any of these models to inform his decision.
So to answer your question directly, it would be, you know, spending any time looking at these models and asking probing questions, seeking meetings, maybe seeking clarification from the people that are doing it Perhaps the White House or state governments should be convening virtual sessions. I mean, we do these all the times with interested parties. Rarely are there elected leaders on the other side of the call. So that infrastructure and that muscle memory perhaps needs to be built into how people—or, how our elected leaders decide to open up, and when—and when they open up. I don’t feel like those conversations are happening nearly as much as they should.
OPERATOR: Thank you.
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ROBBINS: Sorry about that. I got dropped from the call. That was my—I didn’t mean to interrupt you in the middle of your answer there.
So I have a question. So you were talking about a pretty significant lifestyle change for a prolonged period of time, potentially, here. And I mean, we can talk about the politics of it, and the resistance to it. But for a reasonable person looking about this lifestyle change—I mean, it’s going to be very hard for restaurants to survive economically with, you know, a quarter of the people there. But for a reasonable person, this lifestyle change goes on for six months, a year, eighteen months? Or do we have no idea?
GUPTA: Right now—I mean, and I’m—there’s no distance between you and I on that. We have to start messaging and thinking reasonably about this, not just saying we don’t have enough testing or have enough contact tracing. I think we probably all had our fill of hearing those specific talking points. So I’m with you. How do we get back to life safely, and how do we protect livelihoods? The best answer I have for you for how long is contingent on two things. One is, once we get a handle on testing, and hopefully that’s going to be the case over the next three months where we’ll get a better picture through a combination of PCR and antibody testing what’s the true prevalence rate, what are we really dealing with here. We have somewhat of a picture, but not really.
That will give us a sense, a crude sense, and using these models, of what’s actually happening more broadly. So we can build in—we don’t have to test 100 percent of the country to really know what’s happening. We just need to test maybe 10 percent of the country to then let the models take over and say: This is actually what’s happening. We have more confidence in our models projecting out: This is what’s happening with infection rates. So once it gets to that point—I think hopefully in the next three to six months we’ll get there—that’s one off-ramp from social distancing being onerous for restaurants and potentially us feeling a little bit more comfortable truly normalizing life economically if things are heading in the direction that we want them to head.
The other off-ramp is a vaccine or a therapeutic. We’re hearing headlines now all day every day, now there’s headlines out of Oxford that they have a vaccine that’s going to go under the clinical trials almost immediately and will be deployed as soon as the summer. If that occurs, that’s a deus ex machina event, and that changes things quickly, in which, you know, if we can scale that specific vaccine that’s a whole different discussion. That’s a geopolitical discussion, that’s a sourcing discussion, that’s a quality and safety discussion. But let’s say you can scale it quickly, then we can liberalize things, and feel like we have a failsafe because at least that—now we know that even if we get socially intimate again, we’re protected.
The other is a therapeutic. As the Gilead remdesivir—you know, I just came off a shift where six of my patients were getting it infused into them. I don’t know if I’m doing something that’s hurting them or harming them, you know, irreparably. Is it saving their life? Dr. Fauci cited studies that I’m sure you’ve seen on the headlines yesterday that suggest maybe there is a therapeutic benefit. So if that turns out to be true, that’s huge, because then this big issue—we talked about the length of stay in hospitals. The reason all of this matters—it call comes down to can our hospitals handle a surge of critically ill patients if we get this wrong? And if that becomes less and less important because we either have a vaccine or we have a therapeutic that’s going to save people’s lives more quickly, then we can take more chances.
Then we can be a little bit more risky in, OK, well, let’s open up and see. Right now we’re just going into the blind and saying: Well, we don’t really know what’s happening. We only have 1-2 percent of the population tested. We have no off-ramp. We have no fail-safe. And that’s the reason why all of us on the public health side are raising alarm. That’s why we’re upset when two California doctors are contrarian on faulty data. But if we had a failsafe, that would give us a little bit more confidence to say, OK, let’s see. And so that’s why I’m saying in this very—there’s no data—there’s minimal data. There’s no failsafe that’s hard, and concrete, and available. That’s why we need to be incremental, even though it’s, you know, seemingly unreasonable to expect people to wear masks and sit six feet apart in a restaurant for the undetermined future. So that’s the thinking behind it. And I think if we message along those lines, maybe it makes those in public health seem reasonable as well.
ROBBINS: Well, thank you. This has been fabulous. I suppose some of my takeaways are, if I were going to go and report this, is I’d like to see how states open up, how people are following or not following the public health guidelines as they adapt to this. But I think also we’re going to have to be going back and reporting some of the things we were reporting when this first started, which is how capable are our hospitals, our health care systems to potentially handle another surge. And because—and particularly because things will be moved around the country, including personnel and ventilators, and all those other things. So some of the reporting that we saw in the beginning we’re going to have to be doing again because if we calculate wrong on this, we could be—we could be going back into this. Let’s hope that doesn’t happen.
Am I reading that right?
GUPTA: You said it beautifully. Couldn’t have said it better myself.
ROBBINS: (Laughs.) Good. I can write a lede.
Dr. Gupta, thank you so much. And thank you so much, Irina. And to all—everyone who called in, thank you for all your great questions. Be safe out there. And we look forward to reading what you have to write.
GUPTA: Thank you.
FASKIANOS: And this is Irina. You can follow Carla on Twitter at @RobbinsCarla. And you can follow Vin Gupta at @VinGuptaMD. We’ll put together some resources to share out with you all, but do follow us on Twitter at @CFR_org. We have a lot of resources that we’re sharing out on our Twitter feed, as well as going to our website, CFR.org, Think Global Health, and ForeignAffairs.com. So check out all three of those websites for resources on the pandemic as well as much more beyond COVID-19. And please send us an email at [email protected] if you have suggestions for focus—of any areas that you want us to focus on in coming calls. So thank you all again and stay well.