Public Health Threats and Pandemics
Speakers discuss the measures necessary to eventually reopen the country to public life, including the proliferation of contact tracing and increased, widespread testing.
Visit Contact Tracing: Part of a Multipronged Approach to Fight the COVID-19 Pandemic for more information.
Senior Fellow for Global Health, Council on Foreign Relations; President and CEO, Resolve to Save Lives; Former Director, Centers for Disease Control and Prevention;@DrTomFrieden
Vice Dean, Public Health Practice and Community Engagement, Johns Hopkins Bloomberg School of Public Health
WOODRUFF: (In progress)—on Foreign Relations conference call with Tom Frieden and Joshua Sharfstein on how to reopen society as soon and as safely as possible. I’m Judy Woodruff. I’m the anchor and managing editor of the PBS NewsHour. I’m going to be presiding over today’s discussion for the next hour. I want to thank everybody for joining. I’m told we’ve got a large number of participants. And I just want to remind all the members that this conference call is on the record.
We’re very fortunate to have these two speakers with us today. I’m going to give you a brief introduction. They both—neither one is a stranger to you.
First, Dr. Tom Frieden. He is the senior fellow for global health at the Council on Foreign Relations, former director of the Center for Disease Control and Prevention. He’s also the former commissioner of New York City’s Health Department. He is the president and CEO today of Resolve to Save Lives. This is an organization that aims to prevent epidemics and cardiovascular disease. He is—Tom Frieden is a physician with advanced training in internal medicine and infectious disease, in public health, and epidemiology.
And our second speaker is Dr. Joshua Sharfstein. He’s a vice dean for public health practice and community engagement for the Johns Hopkins Bloomberg School of Public Health. He previously served as the secretary of state of Maryland Department of Health and Mental Hygiene. He was the principal deputy commissioner of the U.S. Food and Drug Administration, and also the commissioner of health for Baltimore city. So very lucky to have both of them.
And I’m just going to plunge right in with questions to both of you. And I’ll start with you, Tom Frieden: If you were to sit down this afternoon with either the president or any one of the governors, what is the guidance that you would give them about what to keep in mind as they make decisions about when and how to open the country back up again?
FRIEDEN: Thanks, Judy. And thanks, Josh. It’s great to be with you. And thanks to CFR for hosting this. It’s great to be part of this organization. I want to emphasize that these are hard decisions. This is an unprecedented pandemic. We’re still learning about it every day. And there’s obviously a challenge between trying to make sure that we’re as safe as possible and the economic devastation that we’re living through. That’s why we really want to focus on opening as soon and as safely as possible. And that means recognizing that there are things that we have to do, and data that we have to follow, to do that as effectively as possible. And I put that really into two large groups: what we’re doing about the virus and what we’re doing more broadly in society.
With the virus, we want to make sure that we’re seeing a consistent, steady decrease in cases and in deaths for at least two weeks. We want to make sure that our health care system is robust, so that health care workers are not getting infected and not dying because of the infection. And we want to make sure that our public health system is ready to very proactively address cases which do arise by the box-it-in strategy. The quarters there, or corners, of: test, isolate, contract trace, and quarantine. If you do those four things, you can keep the virus in a box.
Those are the three things that we look at in society to track, but in the viral—in the virus response to track. But in terms of society more generally we need to think about sheltering those who are most vulnerable—the elderly, those with underlying conditions, those in congregant facilities like nursing homes, shelters, and prisons, and jails where we can have explosive spread.
Second, we want to think about gradually loosening faucet. Not opening the floodgates, but step-by-step resuming and starting a new normal with that being very different in some ways. More physical distancing, hand sanitizer at entrances, facemasks on if there is widespread transmission—lots of changes to how we’re going to resume activity. And understanding that we need to be ready to go back to a more stringent physical distancing situation if there’s an increase that could overwhelm either the health or the health care system. That’s why it’s—health or public health system. That’s why it’s so important that we have that box-it-in capacity strengthened, so that we can open as soon and safely as possible.
But the last point I would say is, whatever you do, do it one step at a time. Because if you loosen today and there’s a lot of spread, you’re not going to know that for three, four, five, or six weeks. So if you loosen it this week and then again next week in two different steps, you could get a really very rapid and widespread transmission that’s very hard to turn off and would require you to distance again for a long time. Because bad as this has been in New York City and elsewhere, it could get a lot worse because there are still many people who are not exposed, don’t have any natural or acquired immunity to it.
WOODRUFF: Dr. Sharfstein.
SHARFSTEIN: Sure. Well, that’s a great answer. And thanks also for having me.
I would add two points. First, that it’s really important to keep your eye on the virus at all times. It is—you know, it can, like Tom just said, cause a huge problem. And by the time you figure it out, you’re basically powerless to prevent a surge in cases for at least a few weeks. So you have to really focus on the virus. And that means to the exclusion sometimes of the some maybe more narrow political considerations. Like, you have people who—there will always be people in pretty much every epidemic who say you’re overreacting. And it’s just very important, and often sometimes people say you’re underreacting. But definitely overreacting. It’s very important for leaders to be able to keep focused on what the virus is doing. The virus that doesn’t know politics, or party, or geography.
And the second point is that this is not going to be easy. You know, we want to get back to the way our lives were. But, absent a miraculous treatment or a vaccine, it’s going to be a while. And people will get frustrated. People—if you’re successful, people will wonder why you didn’t go faster.
And the most important thing for a leader to have in that situation is credibility and, you know, honesty and transparency. And it’s very important that the governors, other leaders at every level, mayors, are honest about what they know and what they don’t, that they share the basis for their decision-making, and that they can inspire people by doing that, to do the things that they need to do.
You know, it’s a lot more than just what the leader does. We need people to practice social distancing for a longer period of time. We need people not to, you know, be sending their kids out for huge groups on the playground. And, you know, the employers have to redesign their workplace.
All those things have to happen. Success is going to require a huge social effort. So by maintaining credibility, you know, inspiring people to understand the basis of what’s going on, those are really critical elements of putting a successful strategy into place.
WOODRUFF: There are clearly things that we don’t have right now. We’re told we’re at least a year away, if not much longer, from a vaccine. We don’t have a treatment yet; a lot of work on that, but nothing there. What are the things that we have to be able to do, have to be able to measure, in order to safely tell people, OK, you know, you can open up your physical-fitness center or your hair salon or your restaurant?
I mean, what are the musts? Because right now we don’t have the testing capacity to know who does have, who has had, and who hasn’t had COVID. So what are the—I guess I’m asking what are the measuring steps? How do you measure what’s the right thing to do and what’s not? And let’s start with Dr. Frieden.
FRIEDEN: Well, I think we’re all looking at what are the most important measurements to track. I don’t think it’s necessary the number of tests that are being done. I do think it’s how much testing we’re doing and the proportion we’re reaching of hospitalized patients, of health-care workers with symptoms, of people in nursing homes and other congregate facilities who have symptoms, because those are the people who, if we miss infections there, we can have explosive spread.
And then, just to go into the box-it-in strategy, that’s the testing component. But that’s just one of four corners of the box. We also need isolation, contact tracing, and quarantine. All four of those corners need to be intact or the virus can escape.
And for isolation, that means better infection control in our hospitals so patients and health-care workers aren’t getting infected. There are really shockingly high numbers of health-care workers infected in the U.S., as well as in many other countries. We also need to look at the nursing homes and at home isolation.
We’re seeing that this virus is quite infectious. And if you’re living alone with your ninety-two-year-old mother and you have COVID, you probably—either you or she should not be there. I don’t think people should be forcibly removed from their homes for this, but I do think it’s the responsibility of each community to offer an attractive alternative for people who want to not risk their family getting infected, and possibly severely ill. So isolation also needs to be strengthened. And do you have that capacity?
Contact tracing is a tried and true method of finding out who has been exposed and warning them of their exposure. And Josh Sharfstein and Hopkins and we are working together on this with many other groups around the country to scale up this traditional public-health approach to the kind of numbers that are actually needed in the COVID response.
Now, if we look around the world, those numbers are quite large. In the city of Wuhan, China, they had nine thousand contact tracers for a population of eleven million. In Singapore, they had a thousand contact tracers even before they had a huge increase in cases. In South Africa they’ve hired twenty-five thousand; in Liberia, six thousand. So these are large numbers. And it’s not a simple thing to do. It requires specialized skills, people skills, confidentiality, medical knowledge, crisis counseling, really skills in eliciting information from people and gaining and maintaining their trust.
And then quarantine is something that we really do have to think about more. If someone has been exposed and they become ill, they really shouldn’t be out and about. They need to be home for fourteen days. And again, if we look at best practices from around the world, there are a lot of good incentives that places have used to make sure people stay home. If they don’t have a way of getting food or sustenance or income or access, they’re going to need support or they’re going to come out.
So I think we have to go back to one of the fundamental concepts here, which is that in infectious diseases, the patient should be the VIP of the program. And by structuring the program with that in mind, we have a greater likelihood of making sure that they do what’s needed to protect themselves, their contact, and the community.
WOODRUFF: Dr. Sharfstein, you want to pick up on that?
SHARFSTEIN: Yeah. I want to go back to the question of what is it that people need to be looking at as they’re making decisions. And I think you could imagine that communities should be thinking of—imagining a dashboard with four major categories. One is the number of cases that are being identified. And we want to build enough testing capacity so that people who are sick can be tested rapidly. And that will be very helpful to track over time.
Number two, you want to look at the consequences. So even though this is a later manifestation, you want to make sure you are watching the number of people going to the emergency room with respiratory symptoms, the number of people hospitalized with COVID, the number of people in the intensive-care unit, because that’s really one major factor that you’re trying to avoid is a catastrophe there.
Third, you want to look at essentially red flags, things that are a little bit earlier on but are indicative of the potential risk that’s there. So you may have—for example, just like Tom said, what are your prevention policies for nursing homes? Are they able to be followed? Are you able to maintain the distancing or successfully implement policies for people experiencing homelessness? Or has the jail been able to follow through on an actual strategy to reduce the contact that people have?
You could even go so far as to look at mask wearing, whether people are really wearing masks. So, you know, if you suddenly find people stop wearing masks, that might be a warning sign that people have sort of let up on some of these things, and that would be a reason for concern.
And then the last area of tracking is the response. And that is to talk about the box-it-in strategy that Tom’s saying, that each of those things can have metrics associated with them. For each case, are we able to find contacts? For each contact, are they able to be successfully quarantined? That’s a really important thing to be tracking.
And when I talked to the head of the Ebola response in Liberia, you know, at a time he took over when the country was really—people were wondering whether Liberia would survive as a country. And I know he worked very closely with Tom and the CDC then. You know, he said one of the most important things was to watch not just the number of cases, but was the system working to respond? Were they finding contacts? Were they quarantining contacts? And when he saw that they were able to reliably do that, he felt more comfortable and he saw how the curve was able to really bend then.
So it’s really like a few key sets of measurements that correspond to the different aspects of the response.
WOODRUFF: I want to ask one more question of each of you and then open it up to the members. But—and just to be very specific here, a lot of people want to know about schools, about colleges and public schools, K through twelve, and about schools. If you’re the head of a school system or a president, a leader, at a university, how should you be thinking about this? I mean, clearly not all these decisions are in your hands, but you do have decisions to make in the coming weeks about how to open up.
What do you think about in terms of, I mean, having younger population of students, of young people, coming into class, into the classroom? Do you think about reducing the number? What do you need to take into consideration as you make this decision? Dr. Frieden?
FRIEDEN: Sure. And I look forward to hearing what Josh has to say about it.
I think the first thing I would say is wait as long as you can. And I know that’s a very frustrating thing to say. But we are learning more every day, and we’re seeing what the trajectory is of the virus every day. So the longer you can procrastinate in this case and put off your decision, the more informed that decision will be, and understanding that there are deadlines. People have to make decisions.
Still, for example, we don’t know to what extent children spread the disease. We know that kids get infected and we know that rarely they get severely ill, but generally kids are much less hard hit by this for reasons that no one understands. So if we found out that very few infections are spread by kids under the age of twenty, that would really change our thinking some about how safe it is to open schools.
Second, recognize that you are going to have to protect the vulnerable indefinitely, and that means that people over sixty and those who have underlying medical conditions are going to have to be accommodated for the indefinite future—until we have a vaccine or there’s some dramatic change here. And that means tele-school, telecommuting is going to have to be a continuous reality for many people.
Third, recognize that you may need to be flexible and there may be times when you’re going to have to tighten up on the distancing and timed solutions. That’s also frustrating, but it’s the reality that we’re entering into.
And fourth, recognize that when you come back it’s not going to be normal. It’s going to be a new normal with hand sanitizer at building entrances, possible with facemasks, possibly temperature checks.
And in all of that, think about societal benefit. So if you can do it without risk, without being in person, by all means that’s something you should consider. If it’s daycare, and the risk is low, and you are protecting the vulnerable, and it allows parents to work, that is something that has a greater societal benefit, potentially. So you have to look at both the risk and the societal benefit.
SHARFSTEIN: So I’ll jump in. This is Josh.
I, for universities, would definitely recommend a podcast episode that we just recorded with Dr. Preeti Malani, who’s the chief health episode—the chief health officer at the University of Michigan. This is part of the Public Health on Call podcast. And she is really responsible for thinking through will and how the University of Michigan will be open in the fall. And some of the issues that she raised were, you know, mass gatherings, which you have for a number of things on many campuses, you know, are probably not in the cards if we are where we think we will be in the fall. But mass gatherings would include large lecture classes. Like, those may not be possible, at least in person. The idea that people could get tapped on the shoulder and asked to quarantine because of exposures during the semester was one that has occurred to her, and they’ve thought about having dorms empty just for people who are quarantined, and making sure that every class has the ability to go online if it needs to, or somebody could be—you know, basically, have to dial in to that class because they are quarantined or isolated. The appropriate testing capacity, and how to assure that people can get tested very quickly, and that any outbreaks can be contained very, very fast, and all the cleaning protocols that need to be done. So, basically, there’s a lot to rethink about how campuses might ordinarily work.
But one of the things as you think about elementary schools and daycares is just the massive amount of mixing that kids do with each other. And I totally agree with Tom’s point; hopefully we will learn a lot more, and hopefully there will be some good news about kids passing the virus on. But if it is like we fear and that there’s a lot of transmission, it will be better if, say, there’s a class of twenty kids, that that class kind of sticks together throughout the day and that kids aren’t mixing with the other five hundred kids in the school. Similarly, for daycare, if there are, like, four rooms, but there was, like, party time when all the kids play together, it’s better to keep the kids in their own rooms so that if there is a problem it can be more quickly isolated to that room. And these are things that will disrupt the normal function of schools at all levels, but may be necessary to be able to—be able to open in sort of a staged way.
WOODRUFF: Well, I’m so glad I asked that. I get more questions about this than anything else, so I really wanted to get that on the table. Thank you both.
Now it’s time to open this up. I want to invite members to join the conversation. I am told we were expecting over nine hundred of you to join us, and we are going to try to get to as many questions as we can. Just another reminder: the conference call is on the record. We ask you to state your name, your affiliation, and please limit yourself to one question—one concise question—so we can get as many members as possible. Now, the operator is going to be calling on you. And I’m going to turn it over to the operator.
OPERATOR: Thank you very much. Ladies and gentlemen, at this time we would like to open the floor for questions.
(Gives queuing instructions.)
Our first question will come from Congresswoman Donna Shalala, U.S. House of Representatives.
Q: Hi. Just a quick question.
And that is, we know—at least, we have the outlines of what to do. You’ve all told us. It’s testing. It’s contract tracing. It’s quarantine. It’s infection control. I mean, there’s a long list. And the CDC put out a list. But the president has simply decided: You know, it’s the states that are going to have to do this. But there’s no thinking through what the role of the federal government is, what is the role of states, what’s the role of local health officials. We actually have a bill that we’ve introduced that says the states have to come to HHS and get a sign-off on their—on their health strategy, and the federal government will fund it. We need something so that my state of Florida, which wants to open tomorrow, doesn’t infect the state next to it. And how are you thinking about who’s responsible for what?
FRIEDEN: Secretary Shalala, it’s a great question, as always. And not one that’s easy to answer at this time. I do think that the opening up America framework that the White House released is a sensible framework. What’s lacking is the next step of specific measures that would allow the clear assessment of whether a state has reached those measures. And also, a real national discussion about some innovation, and how to open in a safer way. Because there are some sensible things that states are proposing to try to get economic activity back on track. That’s going to require, I think, a real national conversation. But in reality, as you know, the states have a lot of autonomy when it comes to health issues.
However, if I look around the world, I’m really amazed by what we’re seeing in places like Canada and Australia, and what we could conceivably see in the United States. If one area, a province or a state, doesn’t control the infection and another does, then it’s almost inconceivable that the place that’s having fewer cases wouldn’t want to keep people from the places having more cases out. And so we’re seeing concrete barriers between provinces in Australia. We’re seeing travel restrictions within Canada. And it’s unthinkable that that would happen among American states, and yet potentially inevitable if there isn’t a minimum level of control in many different places, or something surprising happens with how the virus spreads.
SHARFSTEIN: Yeah. I mean, I agree with that. And I would say I completely agree with the premise of Secretary Shalala’s question, which is that I think the federal government needs to play a critical role here. And it’s not enough just to say: Here are some guiding principles and good luck out there. I think it’s very important for the federal government to be very clear about their expectations for states. I think the idea of having states have concrete plans and getting resources based on effective plans is a very good one. And I would love to see that pass Congress.
WOODRUFF: OK. Next question.
OPERATOR: Thank you. Are you ready for the next question?
WOODRUFF: Yes, please go ahead.
OPERATOR: Thank you. Our next question will come from Daniel Gilmer, Pfizer.
Q: Hello. Thank you both for the clear, concise guidance you provided.
I have a question for Dr. Frieden. So, we’ve heard plenty about individuals potentially carrying proof of immunity from serological antibody testing. Could you comment on both the feasibility and the ethical hurdles potentially regarding this approach, including perverse incentives to get the disease and potential consequences of having a bifurcated workforce?
FRIEDEN: Right now in the United States serology testing is not standardized. So there are many very low-quality serological tests on the market, and I would not trust any results. Furthermore, even if someone has a good test and a good quality test, and is found to have antibodies, we don’t know if that’s protective against repeat infections. And if it is, we don’t know how long that repeat infection will last. It’s tempting to want to have some sort of immunity passport. And it’s possible that we’ll be going in that direction, and some countries are already doing some form of that. But right now neither the science nor the practicality are there to provide it. And I think anywhere the infection is spreading we have to assume universal precautions. In a way, you can’t assume that it’s safe anywhere. You have to maintain the physical distancing and prudent measures to reduce the risk of infection. This is one of the things that may develop in the future.
The perverse incentive that you mentioned is something that a lot of people are quite concerned about. By the same token, there are some things that, to be very frank, we do wonder about. For example, how are we going to protect our nursing homes? Unless we do something very differently than what we’re doing today, we’re going to see this infection go to most, if not all, nursing homes in America. We could see one hundred (thousand), two hundred (thousand), or three hundred thousand deaths in nursing homes in the next year. And maybe we should be trying to prioritize for staffing nursing homes people who have recovered, who may have some degree of immunity if they wish to volunteer there, and trying to cocoon nursing homes, which is really our ground-zero, as I called it in early March, in this country. So on the one hand, a lot of challenges. A lot of things we don’t know. On the other hand, something that definitely bears continuing to monitor, and maybe something that provides some sort of a resource for us.
OPERATOR: Thank you.
WOODRUFF: OK, next question.
OPERATOR: Our next question will come from Chloe Demrovsky, Disaster Recovery Institute International.
Q: Hi. Can you hear me? Hello?
Q: OK, great.
It seems to me that the first thing everyone’s going to do when these measures are relaxed is run out and get a haircut. (Laughs.) But it also seems to me that, like, barbershops, for example, salons, gyms, some of these first businesses that states were talking about opening, notably Georgia, are the kinds of places where contact is very close. So is it even possible before we have something like vaccines to do that safely? And what measures would you recommend for those kinds of businesses that are thinking about opening up in the next couple of weeks? Thank you.
SHARFSTEIN: This is Josh. I don’t necessarily think that those are businesses that should open up in the very first phase. And as—you know, one of the questions with Georgia is whether it is even ready to start. But putting that aside, you want to have a phased approach with the lowest risk first so you can demonstrate that we can open up and not have a surge in cases. So if you had the ability to, you know, show that cases are still going down, you’re gradually opening things up, you have a tracking and quarantining capacity, then each business as they start to open up will have the ability to think about reengineering the process, and what they can do.
And so there are different things that could be done in any business to make it less likely to be—to transmit the virus. But like anything that requires that kind of close contact, we’ll not be able to eliminate the risk altogether. So it will be sort of on the basis of how much virus is out there. You know, if there’s a lot less virus, it will make it less likely. All the precautions and redesigns that could be done, including potentially protective equipment. But even when you do all that, it’s still some risk. And people may eventually choose to do that. But I wouldn’t do it necessarily on the first day that you’re starting to reopen, got get a haircut.
OPERATOR: Thank you.
WOODRUFF: Dr. Frieden—go ahead. Let’s go ahead.
FRIEDEN: No, I think Josh said everything I would say. Thank you.
OPERATOR: Excellent. Our next question will come from Fred Hochberg, Heyday.
My question is: What about utilizing OSHA, which is often used to certify and set standards for workplace safety, which would also indicate whether the workplace is safe for workers and, on some establishments, for customers? I don’t hear OSHA being thought of or deployed in any fashion in this crisis.
SHARFSTEIN: Well, I would say that OSHA could potentially play this role, but OSHA has not been very active on anything, really, for quite some time. Maybe that’s a tiny bit of an overstatement, but probably not much. I do think, though, that NIOSH, which is part of the CDC family, is—could play a very important role in the short term. And OSHA could—if it were able to kind of awaken—you know, help to enforce good standards. But NIOSH is really the science of the standards. And I think NIOSH could play a very important role. And NIOSH has done some very important work in setting some of the guidances that CDC has put out for different types of workplaces.
Tom, is there anything you want to add to that?
FRIEDEN: Just on—thank you, Josh, for that. In fact, NIOSH does have really deep and broad expertise here, ranging from having done some of the studies that showed mask wearing dramatically reduces the spread of infection to studies that show that elastomeric half facepiece respirators—which are reusable N95 masks that can be safely sterilized, or at least disinfected, I should say—are really important in this response. NIOSH is a scientific organization. OSHA is a regulatory organization. And as Josh said, in the current context I don’t think may expect to see a whole lot from OSHA. But I do think we need to think about worker safely and workers at all levels. Health care workers, most apparently, there are some home workers, grocery attendants, delivery people. We have to think of everyone who, through their work, maybe more exposed and may also expose more people, and what can we do to maximally protect them.
SHARFSTEIN: If I could just jump back in for one second, just to say that there are a couple of very good reports that the Center for Health Security at Johns Hopkins has put out. One of them has links to all these key guidance documents from different places for different types of workplaces. And it is a very specific guide to reopening. And it talks about some of the standards and approaches that people take to evaluating the risk in different workplaces. And another that just came out this week is all about antibody testing, from every angle. So both of those might be of interest.
OPERATOR: Thank you. Our next question will come from Joseph Bower, Harvard.
Q: First, thanks very much.
It seems in some sense—this is an exaggeration—that there are kind of—there are two United States’ which are being affected by the disease. And a lot of the things we say about social distancing, wearing masks, and how to manage that, are being done by one group. But there’s a whole other sector that has been exposed to microparticles intensively. They also tend to be many of the essential workers. They live in very, very close quarters. They live in circumstances in which it’s extremely hard to do the things you’re talking about. And they are the ones who are actually working right now. How, as we talk about opening, do we think about what to do with that second group of people, who just, it seems to me, are in a very, very vulnerable state, and we’re not really doing much to help them?
FRIEDEN: Great question. Maybe I’ll start and if Josh wants to—oh, go ahead, Josh.
SHARFSTEIN: No, no, go ahead. Go ahead, Tom. (Laughs.)
FRIEDEN: I’ll just comment, and then let Josh take it on, that there’s an important lesson to be learned here from Singapore.
Singapore has been pointed to, with reason, as having one of the best COVID responses anywhere in the world, with—pretty much anything that should be there has been there, including transparent communication from the head of state, ample testing, excellent infection control—so very few if any health-care workers infected, despite having many cases—vigorous contact tracing done the old-fashioned way, by having a thousand contact investigators calling and talking to and doing videoconferencing with people, a real social and community engagement. So they stopped their first wave, but then they had a lot of people coming back to Singapore from around the world and they had a second wave of infections, and they stopped that wave. And then infection got into their migrant-worker population, of whom there are about a quarter of a million—two hundred and fifty thousand people—who live in very close quarters, apartment blocks with twelve people to a room. And they have thousands, now, of cases in that environment, and they’re working very hard to try to control that outbreak, and bringing out people who are sick—a thousand a day—to facilities around Singapore where they can be more safely house; by trying to cohort so that people on one floor stay on that floor, people in one room stay in that room so they can try to prevent the explosive spread.
But what we’re seeing, whether it’s nursing homes or shelters or jails or congregate facilities in this way, is that infectious diseases tend to be a guided missile aimed at the poor and disenfranchised. And we have to do special—make special efforts to both prevent entrance of the infection into these communities, detect it rapidly, stop its spread if at all possible, and also begin addressing the substrate, if you will—the underlying conditions—which enable that kind of rapid spread.
SHARFSTEIN: Yeah. I would—I would follow on that and say that, you know, the virus seeks out not just the—anybody who it can jump to, but it seeks out weaknesses in societies. And so what happened in Singapore was it was—you know, everybody was focused on the core public-health response and they had this massive outbreak among immigrant workers who may live ten or fifteen to a room. I’m surmising that’s not the most, you know, big focus of the political system on a regular day there, and that’s where the virus went. And I think we have profound inequities in our society in part because our political system can’t address them, and yet those inequities make us all less safe with the coronavirus. That’s why you see such stark racial disparities in deaths, particularly for African Americans and also in some areas for Latinos. And it has to do with not only the fact that many are low-wage essential workers who haven’t gotten sufficient protection at work; also, the issue you raised about living conditions, and maybe there are—it’s impossible where they live to follow social distancing as instructed even if they have symptoms; but also, the fact that people have higher rates of chronic illness in certain groups—(inaudible)—and maybe have less access to health care.
So these are things that we can’t look away from if we’re going to try to really take on this challenge. And if we do that, we’re vulnerable to major outbreaks that really weaken the health system and everybody’s security. And so I think the solutions are both to have very good infection control, like Tom said, and like he also said try to rethink some of those underlying issues. And you know, that can be as simple as rethinking the idea of congregate shelters for the homeless, which a lot of cities are now starting to rethink. It can be about really trying to support essential workers—low-wage essential workers—in ways that we haven’t yet, you know, often done. And then, for health-care access, it’s important to think about not building our response to COVID simply on top of a health-care system that is very inequitable.
And so, for example, in Baltimore, the health systems got together and launched a call line that anybody can call in. Even if they don’t have a primary-care doctor, they can get to a doctor at Hopkins or the University of Maryland through telemedicine and get arranged for a test. They can, you know, get care super-fast, not requiring people to have to find, you know, a new doctor if they don’t have one. So we really have to think about working around a little bit, but hopefully fixing some of these problems if we’re going to be able to be successful.
OPERATOR: Thank you. Our next question will come from Emma Court, Bloomberg News.
Q: Hi. Thanks for taking the time here.
I wanted to go back to this kind of question earlier about kind of the states versus the federal government, whose job kind of coordinating this response is. I wanted to ask you specifically regarding testing, you know, what your sense is in how kind of—how hard anyone has tried to develop sort of a cohesive, meaningful strategy on testing, and also what role the state versus the federal government should be playing, particularly on this question of testing. We’ve seen this sort of issue of shortages come up a lot and people saying the federal government should play some role in coordinating these kind of shortages of key supplies. Thank you.
SHARFSTEIN: Maybe I’ll jump in on that part, which is I think it is imperative for the federal government to play a bigger role on supplies. What’s going on now is it’s a travesty that every health system, every state is competing against each other looking for supplies. I did an interview for the podcast that hasn’t aired yet with the head of the microbiology lab at Johns Hopkins, and she short of took me on a virtual tour of the lab. And she said there are five machines they have that they’ve gotten that can run tests, but she doesn’t necessarily know which one will be running tests until she figures out where she can cobble together the supplies, and they’re constantly trying to find supplies for at least one of the machines. I mean, it just seems absurd that that’s the case. And the nursing—(inaudible)—and medical colleges wrote a letter to the White House basically begging the federal government to take a more active role so that people can actually be running tests and not just engaged in this crazy game of searching for supplies.
Now, recognizing that there’s a limitation just by how much is available, but that—just because there’s a limitation of how much is available, you know, doesn’t mean that you need all these entities to be so inefficiently spending time trying to find what’s there. And you know, it’s been contemplated that the federal government will play a very important role in logistics in a crisis like this, but it’s not a role that the federal government is playing now. So I think on the supply-chain side it’s been extremely disappointing for people who know what the federal government is capable of to see the chaos that has existed. And the chaos that exists when people are talking about, you know, different kinds of masks and protective equipment, that is one major reason that testing has been so dis-coordinated.
And maybe, Tom, I’ll turn to you for the part about what a good testing strategy would be.
FRIEDEN: Yeah. One of the things that has been frustrating to me is that when you get past all the rhetoric, it’s very, very clear we don’t have anywhere near the testing capacity we need. And let’s just accept that. It’s not easy to scale up testing. People are working really hard on it. Let’s now be transparent about what’s being done and when we might see more testing capacity. Let’s take the world as it is today and do the best we can with our limited resources, and that means prioritizing.
And so what I would have hoped to see from the federal government is a sense of here if how we’re going to prioritize testing. And what we would recommend—and we’ll probably put something out along these lines in the next few days—is simply we should do this as—prioritize by how can we save the most lives and how can we prevent the most spread of COVID. And that means you start with people who are being hospitalized or people who are older, who have underlying conditions, and who have symptoms of COVID. You make sure that anyone in a cluster gets tested or clusters get evaluated to see if they’re COVID. You make sure that symptomatic health-care workers get tested. You make sure anyone in a congregate facility who is symptomatic gets tested. And ideally, you would want every patient hospitalized to get tested because that’s going to prevent spread of the infection in our hospitals.
That alone is far more tests than we have, probably about three times as many tests as we have, even if we only tested those people. And then when you have more you can think about testing contacts who are asymptomatic. You can think about testing health-care workers who are asymptomatic. You can think about testing people with symptoms of COVID who don’t have underlying conditions who, ideally, all should be tested. And then you can think about testing some of these other groups that are being discussed in various papers of asymptomatic health-care workers, public-safety/essential workers symptomatic and asymptomatic, nursing-home workers who are asymptomatic. You can go down a long list and you can get to about twenty million a day.
If you really tested everyone you’d like to test as often as you’d like to test them, that’s about twenty million tests a day. And we’re doing a hundred and fifty thousand a day. So we’d better prioritize. And even if we just did those first few groups I mentioned—people with symptoms, at high risk, people in clusters, health-care workers, people in congregate facilities, hospitalized patients—that’s about three times more. That’s about four hundred thousand to five hundred thousand a day.
So I would make clear what the prioritization is, and then I would establish some form of tracking. What proportion of our inpatients are we testing? And we can track that over time and try to improve it rather than, as Josh says, this kind of free for all.
OPERATOR: Thank you.
Our next question will come from Stephen Koonin, New York University.
Q: Thank you.
You know, we’re starting to see, over the last couple of weeks, a number of antibody studies that indicate that there’s been quite a broad exposure of people in certain areas and many cases of even asymptomatic or mildly symptomatic. And just this morning Governor Cuomo announced that preliminary results show that 21 percent of New York City people tested show antibodies, and perhaps then some level of immunity.
In areas where the number is that big or in areas where the number might get to be that big, how does that change the implementation of efficacy of contact tracing and quarantine, which seem to me to be best suited when the number is far lower?
FRIEDEN: Maybe I’ll start and Josh can continue.
First off, the antibody testing has not yet been well standardized, and I haven’t seen any truly population-based studies. But it wouldn’t be surprising if at least a million New Yorkers have been infected by now. That’s 15 percent plus.
And on the one hand, that indicates that there is a lot more asymptomatic disease or mildly symptomatic disease, and that’s something we’re seeing in some of the other studies, though it will be interesting to determine whether some of that variation is from different sub-strains of the species..
But it also means it could get a whole lot worse. Even if one (million) or two million New Yorkers have been infected, that leaves 6 million plus who haven’t. That means that, terrible as this has been in New York City—and for those of you who haven’t been following, it really is horrific. We’ve had already more than fifteen thousand COVID-associated deaths in less than two months. And that compares with the worst health disaster of the past hundred years, the 1918 flu pandemic, when there were thirty thousand reported deaths in two years. So this is devastation on really an almost incomprehensible scale.
So, bad as it is, it could get worse. But it doesn’t change that we can really make a difference by finding the people with symptoms, warning their contacts, getting their contacts to isolate. We don’t know how much spread there is from asymptomatic people to others. It undoubtedly exists. How much it exists is a question of debate.
But just because you can’t solve all of the problems doesn’t mean you shouldn’t solve any of the problems. And the box-it-in strategy of testing, isolation, contact tracing, and quarantine has been effective in the countries and communities that have used it, and needs to be scaled up here in conjunction with other things, like continuing to physical distance, using hand sanitizer, facemasks, and other things that can tamp down the spread of this infection.
The only thing we know that works really well is for everyone to stay home. And we can’t do that forever. So we have to figure out a way to come out as soon and safely as possible.
SHARFSTEIN: I don’t think I’d have anything else to add. This is—maybe I’ll just say this. This is a challenge. In scaling up a good contact-tracing effort that is going to be fast enough to get as many cases as possible is going to be a real challenge, which is a challenge that is necessary to embrace in order to be able to have more options as a society. But it doesn’t have to be perfect to be successful and to be meaningfully slowing the number of infections that would then allow for more social opening.
OPERATOR: Thank you very much.
Our next question will come from Arlene Getz, CNN.
Q: Hi. Yes. Thank you for this.
I wanted to ask about air travel. At what point do you think that airlines can—people can start safely flying? And do you see a situation where it would be mandatory that you have space between you, seats between you, you know, given that we’ve all seen that rather frightening graphic out of China about the infection from the air conditioning in a restaurant? I wonder if you could comment on the air situation.
FRIEDEN: I’ll start, and Josh may want to continue.
There’s a long tradition of epidemiologic investigations on airplanes that shows that a couple of rows before and a couple of rows after, there can be spread of some respiratory pathogens. I think a broader issue is we’re likely to see travel bans and quarantines for a long time. So if you’re coming from a place that’s relatively more affected and going to a place that’s relatively less affected, you may need to quarantine for fourteen days when you get there. That is what the future may well hold.
In terms of the safety of air travel, I think there’s going to be some risk. The universal use of masks is a good idea. Extensive cleaning, because we know that this virus spreads like a super SARS and can be on contaminated surfaces, is going to be important.
I’ll turn it over to Josh. I suspect we probably only have time for about one more question. But Josh?
SHARFSTEIN: I won’t add anything to that. I agree.
OPERATOR: Thank you.
Our next question will come from Jon Andrus, Center for Global Health, University of Colorado.
Q: Thank you, both speakers.
My question is about quality and meaningful impact. In a situation where you’re doing contact tracing and relying on the person you’re interviewing to identify contacts to follow up, versus a situation where you have the capacity for the investigators to call each of the contacts, is that a deal breaker? Would that be an Achilles heel in making meaningful impact? I’ll stop there.
FRIEDEN: I’m not sure I understood the question, Jon. We expect contact tracers to interview the index case, usually by video conference, or at least by phone. And then we expect them to try to reach each of the people who have been potentially exposed to warn them of their exposure.
The CDC just put very good guidelines on its website on the principles and criteria for effective contact tracing. This is a big effort. We’re still learning about it in the U.S. and globally. But quality is crucially important in making sure that you—we have a system that supports patients and their contacts so that they can isolate and quarantine, respectively.
Josh, did you want to say more?
SHARFSTEIN: No. I think that’s fine.
OPERATOR: Thank you.
Q: You answered my question.
OPERATOR: Thank you very much.
Our next question will come from Ellen Futter, American Museum of Natural History.
WOODRUFF: And this will be the last question.
Q: Thank you. And thank you for the wonderfully thoughtful responses and questions.
We seem to be morphing over to travel. Being from a high-density location in New York, there’s an awfully lot of consideration that’s been articulated and given to how we return and how it might function in the workplace. I’m rather focused on how people are going to move around New York City in the transportation system, in particular subways and buses, and how that would be controlled so that you really can stand up the economy again.
FRIEDEN: Could I let Josh take that first, and I’ll—and make any last remarks. And then I’ll close up because I think we’re at the end of the hour. Josh?
I would say that’s a very important question, because obviously public transportation was not designed with a pandemic in mind. And it also appears that there is very much the possibility of transmission in public transportation.
I think the public-transportation world, which I’ve had a chance to interact with a little bit, is very worried about their employees and the safety of passengers. And figuring out how to make it safer for physical distancing in this world that we’re in is going to be a major issue, while keeping these systems that we depend on solvent.
I would just say that it probably hopefully will involve more people teleworking so less people on public transportation. It could involve different kinds of screening for symptoms for people. It certainly, I think, will involve masks in the—in the short term, at least. And much more frequent cleaning. And then we’re going to have to study very carefully what’s going on and try to find new ways to protect people in particularly the public transportation, where there are a lot of people together.
And in general, I’ll just say thank you very much for the opportunity to participate in this. And I really think that the—in this, knowledge is power. Science is our best weapon. And people informing themselves at all levels is just absolutely critical. And I hope everyone on this call is able to turn to your own communities and be a source of good information. Thank you.
FRIEDEN: Thank you, Josh.
And I’ll just closing saying this is an example of a really tough question about the new normal that we’re going to have to return to when we go back out again. Certainly, universal masks, extensive cleaning, more social distancing are going to be parts of the equation. But this is a really tough one. And there aren’t going to be simple answers. And that’s why being open about the information, being transparent about what we know and don’t know, accommodating those who are more vulnerable because of age or medical conditions will be crucially important.
And as we go out to this new normal, I think we can both look at the past and what we’ve learned and look toward the future of what we need to do in both protecting the most vulnerable, but also working together in a real solidarity within communities, within countries, and globally, because we have an enemy here. The enemy is a dangerous microbe. And working together to learn more and do more, and learn how we can make progress against it, we can make—we can help people be as safe as possible and help restart our economy as soon as feasible.
WOODRUFF: All right. With that I want to thank Dr. Tom Frieden and thank Dr. Josh Sharfstein. Thank you both so much for participating. I would note—and thank you all members for being part of this. The audio and the transcript of today’s call will be posted on the Council website. So you can look for it there. But, again, thank you to everyone. I hope you have a great afternoon.