A Conversation With Robert Redfield

Thursday, December 10, 2020
Alex Edelman/Pool via REUTERS

Director, Centers for Disease Control and Prevention


Correspondent, New York Times; CFR Member

Dr. Robert Redfield discusses the CDC’s response to the COVID-19 pandemic.

FINK: I'd like to welcome members to today's Council on Foreign Relations meeting with Dr. Robert Redfield. Thank you very much for joining us today. I'm Sheri Fink, and I'll be presiding over today's discussion. And we're going to try to get as many member questions as we can today. So, CDC Director Robert Redfield has presided over a period of time that has been historic, and I understand that he will make some opening remarks. So, let's start with that. Dr. Redfield, over to you.


REDFIELD: Well, thank you very much, Sheri. And thank you all for giving me the opportunity—I look forward to our discussion. I thought I'd start just by emphasizing, I think what we all know, that this pandemic is the most serious public health crisis that's confronted both our nation and the world in more than a hundred years. And we are now at this moment in time, really, at a very significant moment in the pandemic, particularly in the United States, where we're seeing widespread transmission throughout our nation.


Just to highlight, we had over four million cases in the month of November alone—more than a million a week. And we're consistently seeing between 175,000 and, say, 225,000 cases a day. It's also very sobering to realize in the United States today that COVID-19 now is the leading cause of death, surpassing heart disease and other causes of death. I've said that the next three months in the United States, in particular, is going to be really rough. And I've actually said, it's my own personal belief, it's going to be the most difficult time in the public health history of this nation.


This is why we're really asking people to really double down on the mitigation steps that we do know work. There's really no value in the debate about whether these mitigation steps work or not—they work. We have the data to show that. We're asking people to wear a mask. They work, they help contain the virus from the individual infected so they don't spread it to others, but they also can impact whether or not someone who is not infected, gets infected. And it's critical that we embrace mask wearing, social distancing, excellent hand hygiene, smart about crowds. Recognizing that outdoors are better than indoors.


Ventilation is really important. This virus doesn't do well in highly ventilated spaces in terms of its ability to transmit. We're also asking people to be very circumspect this holiday season about traveling. We believe the safest place for people right now, at least in the United States, because of the extent of the pandemic, is to seriously reconsider travel plans. We do have these powerful tools. I mention masks—really an enormously powerful tool as we continue to confront this.


We've tried to really stress for the American public and public at large now the real risk and why we have such a pandemic, even in rural areas—Idaho, North Dakota, South Dakota—I mean, they're having over 30 percent of people tested are positive in all the rural counties there. This is really happening because the transmission cycle now is really much more dependent on transmitting in household gatherings, small household gatherings, as opposed to the public square. And so it's really important for people to realize not to let their guard down just because they're around family members who come to celebrate a holiday.


Obviously, globally, you know, this pandemic is huge. We're over sixty million cases, over a million four [hundred thousand] deaths. The United States leads in cases, followed by India, Brazil, Italy, and then European nations. I just, you know, want to echo that the CDC was involved in this from the beginning. I got my first contact related to an unexplained pulmonary illness on December 31 last year. And in 2019, CDC had its first report on this new mysterious illness on January 1.


We briefed the National Security Council on January 2. I had extensive discussions with my counterpart, head of CDC China, George Gao, all through that period of time and offering our assistance. Unfortunately, that assistance wasn't accepted by the Chinese government. I think it could have made a big difference. We had a team of over twenty people ready to go in and help try to define this pandemic, which at the time was felt to be not transmitted human to human and not to be an illness that could be transmitted in the absence of symptoms. Both of those facts, the sooner those were known, it would have had great, great impact on the public health response.


You know, on the other side, it's an exciting time. As you know, Great Britain has approved already. Canada, Bahrain, a number of countries now have approved the first COVID vaccine. The United States is reviewing it to the FDA. And many of us expect that they'll authorize it in the EUA [emergency use authorization] in the next several days. It's going to be a game changer as our nation embraces vaccine, but they got to embrace vaccine with confidence. Something, I know, Sheri's a very big proponent to help build confidence for vaccination.


I will say it's one of my greatest priorities right now as CDC director to continue at this moment in time to try to help move more and more of the public to vaccinate with confidence and try to change the narrative from vaccine hesitancy. Really, it's not going to help us to have delivered a vaccine in record time, and I am on the board of Operation Warp Speed, to think that, you know, from the time the sequence was in January 10, within a year, we actually have two vaccines that are going to be deployed.


It's really remarkable in terms of the impact of the innovation that came to bear and to see that then somehow sit on the shelf for a percentage of our population and eventually the world, initially in our country because of hesitancy, and many parts of the world as we ramp up availability. But to see hesitancy and it become a major reason why individuals don't get vaccinated, I think, continues to be one of the really serious challenges that we have in the remaining time that I'm CDC director through the middle of January to keep pushing for vaccination with confidence.


We've been working with every state in our country to develop their own, what we call, micro-distribution plans. The vaccine will probably be delivered this weekend or early next week to sixty-four different jurisdictions. And they have worked since July with the CDC developing their own individual micro-distribution plans for the populations that they believe should be prioritized for vaccine. It will take us probably 'till the end of the second quarter or the beginning of the third quarter before there's enough vaccine that all of the American public will have access to it. And I know our country will be committed to working to do what it can to then provide vaccine availability to the broader world.


I'll probably close with just saying that we are turning a corner, but I want to come back to reality that this is going to be, I think, a brutal time for us. As I said, I think, it will be the most challenging time in the history of our nation from a public health perspective. And I want the public to really understand that despite what I said, that's not written in stone if people really would embrace the strategies that we've asked. The problem with this virus is it's really infectious. I'm a virologist by training. It's interesting that we're seeing record lows of flu.


So the mitigation that we're doing, at the level we're doing, is having an enormous impact on the respiratory pathogen influenza, but that same degree of mitigation is not having any impact of any degree, as I mentioned, that our nation now is at the highest threshold of this pandemic. And unfortunately, we're continuing to see cases rise as a consequence of the Thanksgiving surge combined with the surge that we're having in general. But we do know that if you do, in fact, wear a mask, it really works. We did a MMWR [Morbidity and Mortality Weekly Report] in Kansas where the governor issued a voluntary mandate—counties could either do it or not do it.


You know, say, a little less than half did it and a little more than half didn't do it. The follow up period, it turns out, if the county had a mass mandate—didn't do any investigation of how well it was exercised—but if a specific county issued a mandate, those counties had a 6 percent decline per hundred thousand cases over the observation period. And the counties that decided to ignore the mass mandate, they had over 100 percent increase. So there was over 106 percent difference in the number of cases that were spread just by that simple decision, whether to send a leadership perspective and in recognizing that masks were important. So I'll leave it at that. I'm happy to answer questions and see what other questions that the audience has.


FINK: Thank you so much, Dr. Redfield. And I'm really glad that you started with that question of what can we do to protect ourselves because there are over 650 members on this call. Many are leaders in their communities, and, I think, you know, we're going to get into lots of questions, but there's probably nothing more important that we could address today then this question of how to how we can protect ourselves, how we can protect our communities. So I hope that everybody's taken those words to heart. You did talk about today being a momentous day. Yesterday, we, as a nation had reported over three thousand deaths. It's a record. Many news outlets have pointed out that that puts the coronavirus toll for one day higher than the 9/11 toll for the first time, the September 11 attacks. There are some other statistics that really bring this home. We've had nearly 300,000 deaths now in total. That is half the expected cancer deaths in a year according to a government web site that expects over about 600,000 cancer deaths in a year, and we haven't even reached the year mark.


Flu deaths are estimated at 12,000 to 60,000 deaths a year, so we can see that comparison. If you do the jumbo jet comparison, the, you know, four hundred seat jets, that's seven and a half of those in just one day in terms of deaths. And then just the comparison to the world, as you pointed out, we are leading the world. Actually, just in recent statistics, the New York Times, where I work, maintains a lot of statistics, and according to our site, a third of the world's new cases were in the U.S. and a quarter of the world's new deaths. And we have the highest deaths in the world. And if you look at deaths per capita, we're still in the top fifteen. So my question for you is why is the U.S. leading the world in deaths?


REDFIELD: You know, it's obviously an excellent question. It's kind of a sad answer, and I'm going to give you the answer. I do think your point is important as I was talking to the Chamber of Commerce the other day. We are in the timeframe now that, probably for the next sixty to ninety days, we're going to have more deaths per day than we had in 9/11 or we had at Pearl Harbor. I mean, this is really, as I said, this is a real, it's going to be a real unfortunate loss of life as all that we've had so far. And the reality is the vaccine approval this week is not going to really impact that, I think, to any degree for the next sixty days.


And this is why we have to really do everything we can. When you look at the mortality of this virus, this virus has really—it's very unusual. Like influenza can cause death for children. It can cause death for adolescents. It can cause death for adults. The spectrum of illness is pretty, you know, across every age group. This virus is very different—really hard because if there's any illness in individuals, say, under the age of forty-five and fifty and even between fifty-five and sixty, most of the illness it causes is dependent upon comorbidities. And then, of course, the elderly, again, associated with comorbidity.


So, people may not like the answer that I'm going to give why the Americans are at greater risk for death. It's because we're an unhealthier nation. When 30 percent of our nation is obese, we have a very significant number of people in our nation with chronic comorbidities. The other thing I think it's done, I've spent a lot of my life worried about this, about health equity, prior to coming to CDC, and I really do believe viscerally that one of the greatest social injustices in our world today is lack of health equity. Whether it's in my own city where there's a twenty-year lifespan difference depending on what zip code you were born in.


So, I do think one of the reasons we're having more death is that we, unfortunately, have more obesity, more diabetes, more renal disease, that the population is less healthy at large. And this virus really does exploit certain comorbidities—kidney disease, obesity, heart disease—and, I think, that's actually the reason. I think our medical treatment is really very good. And as we've gone from April when it was a 25–30 percent mortality if you're seventy years old and admitted to a hospital, today that mortality is probably somewhere between 3 and 8 percent. So, a lot of improvements based in just health care facilities, understanding how to take care of these patients better, the timing of oxygen support, how to do it, when to ventilate, when to not ventilate. Obviously, the advancements in Remdesivir, understanding the role of steroids in advanced disease, and then, of course, now with the monoclonal antibodies and the potential for convalescent plasma, particularly as outpatients.


I mean, most of the therapies that we have really pushed forward, the monoclonal antibodies and convalescent plasma, these are therapies that are based on antibodies, and they really need to be positioned and given to people before they get sick enough to go into hospital. You know, the steroid therapy is for the post-inflammatory response. That needs to be given when people are getting sicker in the hospital. But I think the basic reason is that we have more people that have comorbidities and this virus really does exploit comorbidities.


FINK: Yes, it does, and I should say for people who are in their thirties listening, I have in my reporting in various hospitals have seen people die in their thirties. So, it is less common, but this can be brutal when it's bad. I've seen so many—


REDFIELD: Yes, when we see—it can cause death to anyone. I would say some people I've seen that died under thirty, many of them had, you know, fairly significant body mass indexes, but—


FINK: Heavy. Yes.


REDFIELD: —just, you know, but this virus definitely has a differential fatality rate built into it. And, you know, as opposed to, say, if I was to look at people with a bad influenza pandemic, between the ages of zero and the age of fifty, it would be pretty equal across that group. And as I look at this virus, it's quite different as you know.


FINK: Right. And in terms of the U.S. being the leader, I mean, it's not just in death, it's also in cases. So, I think there may be something more there than just our comorbidities, obviously reported cases, and we're testing a lot, but they're still, you know—


REDFIELD: Sheri, I think it's important and you're right. I mean, I think, different cultures have embraced public health recommendations with different degrees of rigor. And I do think that, you know, this nation may not be as rigorous when someone says we're going to, you know, do the following things, say, as we saw maybe in Germany, or what we saw in Korea, or we saw in Singapore. This is where I want to come back when you say what can all of the leaders do that are on the phone and listening, you know, one is to really recognize that these mitigation steps that we've been recommending since the late winter, they really do work.


They really are lifesaving. Wearing a mask really does matter. You may get infected as a young person, say, twenty-eight years old and not get sick, but while you're running through the park or doing whatever you're doing, you may infect an older couple sitting on the park bench, and they end up having a fatal outcome because of the fact that you decided not to wear masks and you got infected.


The second thing I would ask people to do is really try to help join the choir on the idea of vaccination with confidence. You know, it really was disappointing to see that, maybe it was from your newspaper, I don't know, but I saw the firefighters in New York—55 percent, I think, said they would take the vaccine. Well, that's not great. And then, you know, one of the nursing groups, just a third of the nurses, said they wouldn't take the vaccine. That's not great. You know, the rigor that this vaccine has been through and what the FDA is doing, you know, there were no shortcuts taken on this vaccine.


The reason we got it so fast are two reasons. One—the platform. This is the first time we've used this messenger RNA platform. It is a very exciting platform, because it can go from finding a new virus to having a vaccine within weeks as opposed to the old platforms that take, you know, months to a year. And the second was there was a decision right up front to basically simultaneously figure out if this vaccine worked and build production and start producing it. And so there was a huge financial risk that was taken, but it was decided that, you know, we needed to move in parallel with the idea of proving whether this vaccine was safe and efficacious and at the same time building the manufacturing so that if, in fact, it was determined to be safe and efficacious, we already have millions, you know, tens of millions of doses already manufactured.


FINK: Right.


REDFIELD: It's not that—


FINK: That was an incredible decision. And certainly, we're seeing the benefits of that now. And I think one of the things that you said about, you know, young people and taking risks, you know, that in so many ways, this virus is a test of, you know, our ethics, our humanity. I mean, even when it comes to the vaccine and how will that be rolled out in an equitable way not just within our country but internationally. But I want to go back to just this question of why we're the leaders and, you know, you've talked about a few important factors and maybe, I'm just wondering, whether there is anything in terms of your agency in the CDC that is, you know, may also be a factor?


And I, you know, I just want to say obviously, everybody on this call knows, the CDC has been subject to intense scrutiny, relentless reporting, accountability journalism. And it's not just journalists writing stories about, you know, the CDC, things that have been critiqued, mistakes or—but it's public health experts, as well, saying some of those things. And I can only imagine what it feels like on the inside to be, you know, fighting the war on this pandemic and also to be critiqued at every turn. So I guess I wanted to give you a chance to, to say two things. One is, if you could have a do-over, what is one thing that you would do differently? And then, on the other side, what is one thing that you and maybe people in the agency feel that the public really isn't getting about what the CDC has accomplished?


REDFIELD: You know, I would start by just acknowledging that there's, you know, right now almost eight thousand men and women from CDC that are working 24/7 on this pandemic out of our entire team. And they're highly dedicated and very professional. And they've worked hard to get data and science to create over forty-one hundred documents to try to provide some advice and guidance to government's business and the American public. I've deployed over twenty-seven hundred people, two hundred thirty cities to try to provide technical assistance at the ground, because really the way CDC works is by working public health group to public health group providing advice and trying to get the data to understand what are the mitigations.


We were able to actually get out about $12.3 billion to the states to help them start to build their infrastructure. So I'm very proud of the men and women at CDC and what they did. I got my first projection of the impact of the pandemic, I think, in late February, and it was a difficult evening that evening, because it projected up to 2.2 million people would be dead by September. This pathogen, it was going to be a big problem.


You know, when you get to what I would have loved to have done differently, I think I would have loved to have been able to convince President Xi to let CDC in the first week of January so we could have helped define some of the key scientific questions, which at that time were it's not human-to-human transmitted, these are all zoonotic-acquired cases, and the virus causes symptomatic illness. I think if we had been able to get in with that team of great experts, we could have helped answer these questions probably in the month of January, as opposed to learning them in late February, early March. I think that would have made a big difference.


Obviously, second thing I would have done, and again this is totally misreported in the press, I suspect it will continue to be, but the truth is CDC's diagnostic test was not botched. The sequence became available on January 10, and my team had a workable test, I think, by the seventeenth-eighteenth of January, which is really a historic speed. And we published it so anybody could copy it. We didn't patent it or anything. And that test at CDC is how we began to get eyes on this epidemic and diagnose the first case, I think, on the twenty-first of January. That test worked then and the test works now. It never had a problem.


The problem was to get that test you had to send blood to CDC. And some of the people at CDC felt they could help the health departments and manufacture that test. Now, I think, if there was a do-over, it would be that CDC is not going to manufacture a test. We developed it. We turned it over to a group to manufacture it. And when they manufactured the test, one of the three reagents didn't perform when we sent it out to the states. We brought it back. It took us about four to five weeks to figure out the problem working with the FDA—it was the third reagent. Some people say it was contaminated.


It may have been contaminated, but it also is scientific. It's how that primer happens to dimerize on itself. I'm not going to argue one way or the other, because as we looked at it, there was some of the newer people in the laboratory had violated some of the standards of how we work when we do PCR tests. But, I think, if I could have done that over, we wouldn't have manufactured because, although CDC created a great test that works today, it didn't get totally mired in this argument of a botched test and they didn't do the test right. And all they were trying to do was get the tests to the hundred-plus health departments around the country.


FINK: But if it dimerizes, if that third probe dimerizes, it wouldn't matter who made it.


REDFIELD: That's right, when it doesn't work. And it's no longer in the test.


FINK: Right. So to say it's a perfect test isn't quite—


REDFIELD: But I mean, when we first did the test at CDC, the one we used, we didn't use that primer. When they decided to manufacture it, they wanted to be overly cautious so they added a third primer, all right, and that third primer—


FINK: Who is the "they”?


REDFIELD: Well, the CDC, it's—


FINK: Oh, okay. All right.


REDFIELD: So, but I want to say the diagnostic test that we develop works well. We use it today, and it's the basis for most of the diagnostic tests that were developed subsequently around the country. If I had a real do-over, and then I'll end with a quote, I would have had this nation invest in public-health core capability over the last thirty years. Because when I inherited CDC, I was shocked to see the data systems that we had. I was shocked when we did the measles outbreak to have some health departments sending me data by fax machine, all right. That this nation has failed to invest in the core capabilities of public health data, data analytics, predictive data analysis, we really need to make that investment.


It failed to invest in laboratory resilience of our public health labs. The reason we developed the lab test on the platform we did—the flu platform—is because that's the platform that public health labs could do a test in. And it's a low-throughput platform, it would never meet the needs of an expanding epidemic. We should have invested over the last ten, twenty, thirty years in these public health labs, so they have resilience in their platforms and resilience in their technical people so they could accommodate a search. We need to invest in public health workforce. I had some states that had less than fifty people that could do contact tracing, right. So there is a real do-over.


I'm going to take that do-over all the way back, you know, thirty years from now. And I've argued in Congress, and I'll continue to argue as I get out back into civilian life, that this nation needs to invest in core capabilities of public health. I say now is the time to give this nation the core capabilities of public health, not only that it needs, that it deserves, I would argue beyond this nation. You know, public health is not some extra thing you do if you have a few bucks left over. Public health is in my view, and one of the reasons I was originally excited as I got to CDC, I thought we were about to go through a transition from building a disease system, which I have been part of in my professional life as a doctor, that we actually were now going to start to invest in building a health system.


You know, keeping people healthy rather than a system that's designed for illness, let's design a system for health. So, I would say that and finally about, you know, whether people think it's good or whether people think it should have been better or what the missteps are, there's going to be a lot of time to go through this pandemic when we get it behind us. But what I've kind of lived by is, "It's not the critic who counts. It's not the man or woman who points out how the strong man or woman stumbles, comes up short, or where the doer of deeds could have done better. The credit really belongs to the man or woman that's actually in the arena, their face marred by dust and sweat and blood. They strive valiantly, they err, they come up short again and again, and they spend their life for worthy cause. And, at best, they know at the end, the triumph of high achievement, and at worst, if they fail, they fail while daring greatly, so their place shall never be with the cold and timid souls and never know victory nor defeat."


I've been in the arena on this one, and there's a lot of critics one way or the other. I think at the end of the day, I'm proud of the response that CDC has done. I'm proud of the thousands of people that have worked 24/7. I'm proud that we've been able to work collectively, I think, and have some impact on the number of human lives that were lost, although I'm very sad of the number of human lives that we have lost. I do think there's some scientific information if we could have learned in January, it would have made a huge difference. But unfortunately, this pandemic, by the very nature that it's not flu, it's not SARS, both of those viruses transmit by sick people, this virus is a silent spreader. It's a silent epidemic. And the traditional public health measures of identifying sick people and contact around them doesn't work.


FINK: Right.


REDFIELD: And we got to lead into the pandemic to, you know, to learn that. If we could have learned that in January, I think we'd be in a much different position.


FINK: It's a fair point; it's a wily bug. And certainly it would have been great if the U.S. and other public health experts from outside could have gotten in early, but honestly, we have had that information for many, many months. And there are some countries that have been able, as you pointed out, more than the U.S., to be able to take that information and take actions perhaps, and really, in some cases, it has been because they did invest in public health systems because they faced other pathogens and, you know, sometimes, unfortunately, it takes that to, you know, for us to make those investments and now we have a real case to do that. But—


REDFIELD: I would just say one thing, Sheri, on this before we go because you'll be, you know, in the arena and many of the people listening will be—


FINK: Well, they're going to have a chance to ask you some questions. We're not going to just yet.


REDFIELD: I know, but I wanted just to say that it's just really important that we don't lose that understanding, that we have to invest in the core capability of public health.


FINK: Well, that's what I'm saying is that we can see examples around the world where those, in fact, as you can see, it's nighttime where I am now and I'm looking at some of that now as well. And I think it's a very valid point that you make and certainly there has been such a disinvestment in the—


REDFIELD: What I meant, though—what I meant by it is we're about to have a vaccine, and the vaccine is probably going to make a big impact if people take it. And I don't want that to then have people to forget that we need to invest in public health.


FINK: Correct. And that too often happens. Absolutely.


REDFIELD: I would say it always happens. I'd never know, where we, you know, we've spent $6-$8 trillion because of this pandemic, people talk about investing in infrastructure or public health—it really hasn't happened yet. And I'm excited about the vaccine, but I don't want people to forget that lesson. When you asked me what's the one thing, that's the biggest lesson. We have to invest appropriately, proportionately in our public health infrastructure, not just in the United States, but in the whole world.


FINK: Journalists don't usually express opinions, but I would say you're absolutely right just from all the reporting I've ever done on emergencies that investment, that preparedness is so key, and we so often, you know, very quickly let those lessons lapse. So this will be a real test if we do make those investments. There are a lot of members who have questions for you. As we prepare to go to them, one last thing just to ask you, which is this whole question of the politicization of the agency.


You know, today in the headlines, there are some allegations that this person heard from this person, that heard from this person, that you had asked for an email to be deleted. That had, you know, that was going to the, you know, allegedly some political interference or attempt at that with the MMWR, the Morbidity and Mortality Weekly Report, which is a very highly regarded scientific publication of CDC. And there's this House Select Subcommittee on the coronavirus crisis that wants to interview you, so I want to ask, will you go, will you do that? And, you know, policymakers, of course, have to balance a lot of, you know, science with implementing things and I don't envy people who have to make tough decisions about policy, but is there a role for politics in the agency and how has the political pressure affected—


REDFIELD: Yes, a lot of stories, a lot of stories. A lot of speculation and clearly on the one that you referred to that—I would never delete an email. Plus my email can't be deleted. It's archived forever at CDC—


FINK: Arguing that you had told somebody to—


REDFIELD: Right and I would never tell somebody to delete an email. What I did tell people, I instructed CDC to ignore Dr. [Paul] Alexander's comments and they didn't need to reply to his email. And as I testified before Congress, I've always been fully committed to maintaining the integrity of the MMWR. It is a jewel, it's an independent publication. It doesn't work at the pleasure of the CDC director. It has its own independent group. So I stand by that. It doesn't mean people won't try to accuse. It doesn't mean people won't try to make up their own point of view. But I can say that on my watch, it's science-based data driven. The agencies maintain their integrity.


I will concur with you, it's not always easy. And I don't think these agencies should be politicized. You know, I had my druthers—the CDC director, the NIH director, the FDA director would be appointed like the FBI director for ten years, it served multiple things. These agencies should not be, I think, in the political mix. You know, myself personally, I'm not political. I'm a doctor, clinical researcher, then when I was asked to serve the president and the nation, having come out of twenty-three years of Walter Reed in the Army, I said yes. But I don't think these science-based agencies need to be, as I believe CDC is today and was during my tenure, grounded in science, grounded in data.


This has been a complicated response. It would have been a lot nicer if it was more limited like the Ebola response that my predecessors did where CDC had total lead. But this became very rapidly from CDC, where I did our incident management in our Center for Respiratory on January 7, all of CDC. Toward the third week in January for [inaudible] structure, the secretary decided to move it up HHS at the end of January. And then of course, the president moved it up to the vice president. And it went from a CDC response to an HHS response to an all of government response.


FINK: Do you think it should have stayed a CDC response?


REDFIELD: I'm not going to get in and speculate. I'm just saying that we really needed all of government. We needed the Defense Production Act. We needed to be able to send ships to help. We needed to build hospitals where they needed them. So it really needed to be in all of government response. And to get beyond to get all—I'm just saying it was it was harder because of that.


FINK: Yes, certainly. Yes. But you're right, CDC doesn't have the power to do all of those things. So I would love to now open the Q&A session to invite our members to join our conversation with their questions. So a reminder to everybody that this meeting is on the record, and the operator will now tell you how to join the question queue.


STAFF: [Gives queuing instructions.] We will take our first question from Sonya Stokes.


Q: Sonya Stokes, Mount Sinai Icahn School of Medicine. Thank you, Dr. Fink and Dr. Redfield for all your efforts protecting our public health. My deepest gratitude to you both. My question is about how we can improve our approach to disease surveillance. I asked this because many of us working in emergency medicine in New York City, we're seeing a sudden increase in flu-like illnesses towards the end of February, while the ILI [influenza-like illness] data was demonstrating a decrease in flu percent positives.


But despite this, we could not get our patients tested. Not because of a lack of testing kits or an intrinsic problem with the test itself, but because of the case criteria limiting testing to patients with significant travel history or close contact with a confirmed case. What were the reasons for this strict case criteria leading up to our index patient in New York City? And how can we better utilize what we are seeing on the front lines to make our disease surveillance more dynamic for future outbreaks? Thank you again.


REDFIELD: Thank you, Sonya, and a very important question. Obviously, when the initial outbreak was recognized, as we do many times, and I know you do, it was grounded in an epidemiological link. And that epidemiological link was linked to Wuhan, China. While there was no absolute restriction, there clearly was guidance and it was left to the discretion of the health departments to whether they send samples to us, and some of them said, well, they can't send them or we wouldn't take. We always opened it to any clinician that felt that they should get it. But I will say it was a restricted definition initially, epidemiologically, like many things would be, say, if it was, say, suspecting rabies, or what—and I think, you know, the lack of recognition that most of this infection was coming in asymptomatically was a real challenge.


As you know, we set up screening multiple airports, we screened hundreds of thousands of people, but we screened them for symptoms. I remember calling Howard Zucker, because I saw the same stuff you saw. And I saw that, you know, influenza was going down, but influenza-like illness was going up. And I remember calling Howard and I said, "I think there's a problem in New York City." And, of course, they began to look at it more aggressively and we began to unfortunately rapidly see that there was substantial seeding.


So, I do think the one thing that could help do this is if we invested in core capabilities of public health, so our public health labs had greater laboratory resilience and capacity. New York did a great job. Howard was the first state lab to actually develop their own tests, they cross-filed an [inaudible]. And they were the first one to actually have it on a high-throughput machine. Your comment is factual. I do think it had an impact. It was not until I think the fifteenth and sixteenth case when we clearly saw patients that had no link that we recognized that we had to expand this to, you know, anybody who had concerns or suspected they may have someone with Wuhan. But that's January, early February timeframe to the end of February. I do think that restriction, then therefore, did have an impact on whether certain cases were identified.


But I think the big answer to your question is a significant investment in laboratory resilience of our public health labs. And the other thing I would say is expansion from great institutions like yours, because there was no reason why Mount Sinai couldn't develop their own laboratory developed test and be able to expand the use of this test for whatever patient population they wanted to look at, particularly influenza-like illness. But it did take, you know, a lot of the academic institutions didn't jump to make their own laboratory developed test. One of the reasons we published the—actually how to do it, we were hoping that major medical centers would just develop their own lab test and then be able to use it more broadly, particularly after we had the two cases in California that were clearly community acquired.


FINK: Right. That's really interesting that you say that because there was this case in Washington that we wrote about where that did happen, but because they didn't have the CLIA certificate, they were actually stopped from using that test. So I think it's not always that simple. And I think the caller is right. I remember as a reporter hearing from a lot of doctors who really wanted to test patients early on, and it was very, very hard to get exceptions to those rules. So thank you for acknowledging that that was an issue. Let's go to the next question.


REDFIELD: I think the other side, I just want to reemphasize, too, because I acknowledge that is that really the major medical centers could have made that test available to the people in their hospital too and we really did try. I got the FDA at the end of February to give regulatory discretion so that laboratory tests could be developed. But there didn't seem to be a lot of institutions to jump to developing. They have molecular labs. We strongly encouraged them to develop those molecular labs so they could expand diagnostics. It took a while, but it took too long.


FINK: Let's go to the next question,


STAFF: We will take our next question from Donna Shalala. Please accept the unmute now button.


Q: Yes, I have. Dr. Redfield, all of us have said that we ought to reinvest in the public health infrastructure. But I hope you don't mean the existing infrastructure and that we've learned something through this pandemic about taking a fresh look at what we mean by infrastructure, including the closer integration of the medical community with the public health community. And I thought you might want to talk a little about that.


REDFIELD: Well, Congresswoman, Secretary, I couldn't agree with you more. When I said that, you know, it's our chance to build a health system, not a disease system. And fundamental to that is exactly what you said. The worst thing we could do is just do more of the same. There has to be a much more aggressive interaction with the entire medical community, and beyond that, as you know, the community, and really between the community and the medical community, build a health system. I was always disappointed as a young student of medicine of the Flexner Report, which in 1929 decided we needed to pull public health out of medical schools. We need to have a public health school; we need to have a medical school. And I've been a big advocate that we need to reintegrate public health and medicine into a health system.


And in addition to that is the community is going to be central in it. So, I mean, I know you have great skills in this, I'm sure you will also be a great voice as our nation tries to transition. I'm disappointed in institutions that have gone on to population health and figured they can just put their public health programs right in the same structures that they developed for a disease system. The answer is they can't do that. We do need to develop a new comprehensive [inaudible] that brings together practice of medicine to practice to public health to community, you know, a number of the issues that you know are so important in terms of the social determinants of health. So, I look forward to some of your leadership in this space.


FINK: Let's go to the next question. And thank you for that one.


STAFF: We will take our next question from Eric Schwartz.


Q: Thank you. Dr. Redfield, could you please comment specifically on your attempts to convince our political leaders to locally endorse the use of masks as a public health risk mitigant?


REDFIELD: Well, I can say that since we formally made our recommendation on April 3, that we finally recognized that source control was really important even for people with no symptoms, and we put out the recommendation for masks. I've echoed that, obviously, at all of our task force with the leadership of our nation. You know, I do think that as you look at where I think we could have done better as a nation is actually had more consistency in messaging among all the American public. Not just our political leaders, not just our governors, but all the public.


And I can say that, you know, we've pushed the data, we've shown the data, we've done by example, but it's very disappointing when I have governors basically feel that masks don't work. Both Ambassador Birx and I have made trips to go and talk and share data and happy when we're able to change people's minds as we have—some. But I can just tell you that we have aggressively reiterated that we want all Americans to embrace face masks. And we will continue to do that in every chance that we get. Probably the most important way is by on our own example and making sure that we're wearing them independently even when we see others maybe not.


FINK: Okay, let's go to the next question, please.


STAFF: Our next question from Desiree Cormier Smith.


Q: Hi, thank you. I have a [inaudible] related question. It's in regard to the vaccination and the, sort of, public mistrust and wariness over it. You know, there are certain communities and especially the black community and other communities of color that have legitimate and historic reasons to be wary of a vaccine that, you know, has been approved so quickly. What are the CDC's plans for public education campaigns or other campaigns to allay those fears?


REDFIELD: Yes, very important question. I will say, you know, when I was given the opportunity to be CDC director, one of the things that was important to me was to challenge the vaccine hesitancy. Obviously, I think, it started early with the measles outbreak, which was again driven by people. We had some schools in this country that had less than 25 percent of the students vaccinated against measles. I just couldn't believe it. And so Nancy Messonnier had really started a program back then as we tried to go from what we call vaccine hesitancy to vaccinate with confidence, obviously targeting both the African American community and the Hispanic as well as Native American.


And we have made progress, originally in flu vaccination. I mean, it's very disappointing to me that in any year, you know, less than 50 percent of American public take the flu vaccine and the reality is in, say, the last decade when I did it, I think was [inaudible] and back ten years. We had lost 360,000 people from flu. And my first year as CDC director, we lost 80,000 people to the flu. And then I find out that, you know, only 28 percent of Hispanics take the flu vaccine. It was that time we were in the high thirties for African Americans. We've made some progress. We're now in the 40 percent for both, but it's not enough progress. So we're going to continue with that campaign, expand that campaign.


Obviously, the way we've tried to do that campaign is have trusted sources. So, we've reached out to different trusted sources in the African American community and the Hispanic community to help continue the campaign of vaccine hesitancy, I mean, vaccine with confidence and try to counter about that, both with flu and COVID. Obviously, that's going to expand and trying to get, you know, community influencers to really be the voice. But people's concerns are grounded in events that have occurred, that are that are based in reality. And we have to address them.


We have to take the time. It doesn't help me when a person comes in and ask a doctor [inaudible] do they want the human papilloma vaccine. They say no, and then he just moves on. I mean, unless you can sit there and talk to the [inaudible] of why don't you want? Do you understand it's a cancer vaccine? Wouldn't you want your children vaccinated against cancer? What are your concerns? Why don't you come back, you know, in two weeks, we'll talk more about your concerns. You have to have a much more proactive approach to help listen to people's fears. I would say that most people are worried, you know, they don't want to do something to hurt their children. And I happen to have six children. My oldest son died at birth. People don't want to make a mistake. So you can talk to them and help them understand their concerns. There's another group that are truly misinformed, you know, by individuals that I think try to misinform people.


That takes a little longer to listen to their misinformation, not to criticize them or you're stupid, why do you believe that? No, to listen to them and then spend the time over the next week, month, couple months trying to get them to understand that they've been misinformed. And there's a very small percentage of people just are anti-vaxxers. So, I think, you know, you're going to see that continue and get expanded and not just for COVID, but for vaccination in general. As I said, it's the most important contribution of science to modern medicine. And it's really, really, really sad to see it left on the shelf by so many people.


STAFF: We'll take our next question from Peter Katona. Please state your affiliation before your question.


Q: Good afternoon. I'm an infectious disease physician. I run infection control for UCLA and I have worked at CDC on emerging viruses. My question has to do with the reporting of antigen versus PCR testing. And we know that antigen testing is not as accurate. But amongst the two million tests that are done a day, how does antigen testing fit into the mix? And what percentage of the testing that's reported is antigen testing?


REDFIELD: Those are good questions. You know, and I would have to, I would say right now, antigen testing is probably, oh, at this point, maybe 30–40 percent of the testing, but it's going to go up. Some of the antigen tests, you know, have built in reporting capacity to the cloud, and they're going to expand obviously. I would like to make one comment, though, because I think this is mispresented in the press about whether antigen tests are less sensitive. PCR was the first test and I don't think PCR is the gold standard—it was the first test.


And the PCR test is going to be positive if there's an active live replicating virus, but it's also going to be positive if there's remnant nucleic acid. We've done studies at CDC where we really do what could be considered the gold standard. Well, that is virus isolation. And when you look at virus isolation, correlating with PCR, it really correlates with those PCR tests that have cycle numbers under thirty or cycle numbers under twenty-five. When you look at antigen tests, they correlate with PCR with cycle numbers under thirty, under twenty-five. And when you look at antigen tests, they have a much higher correlation with positive viruses.


So I would suggest this, and this is still being worked on, but I think this is how it's probably going to evolve, we'll wait to get all the data, that the antigen test is much more accurate in defining someone who has infectious virus. It doesn't define people that have nucleic acid remnants. The nucleic acid test defines people that have infectious virus, and it also finds people that have nucleic acid remnants, which may stay around for two weeks, three weeks, four weeks, five weeks.


So I would just suggest that I think antigen test, and again, all antigen tests aren't the same, so you really need to look at the FDA in terms of the ones we really know, for example, like the bionics now, these I think are really very accurate tests for us in defining whether people are currently likely to have infectious virus. And I wouldn't be surprised that over time, that you see that there'll be testing that comes out that's really going to distinguish whether someone's currently infectious, not whether someone was recently infected.


FINK: Thank you, that's a very clear translation of the science at the end there. I want to just thank you and thank everybody for joining this meeting today. And also just to amplify something that you said, Dr. Redfield, which is to acknowledge how incredibly hard people in the public health world, from CDC to every level of government and really all over the world, have been working. How, you know, personally pained they are by the state that we're in right now. As well as everybody working in healthcare, too.


It's such a tough time, and I know for many of our members it's a tough time. For everybody it is. So just to acknowledge that. Thank you for being here today. Maybe if you want to go out with just—the president-elect has revealed who he's intending to be your successor, Dr. Rochelle Walensky, who's an infectious disease specialist. Would you like to, in thirty seconds, tell us what is your biggest piece of advice to your successor?


REDFIELD: Well, I think she's a great choice. I had a chance to give her a call and congratulate her after President-elect Biden nominated her. The other thing what I would say to you and the people on the call and to her and in the nation is, you know, there's only three of us leaving CDC in this transition. You know, you're going to be left with over twenty-three thousand dedicated men and women, many of which have done this for ten, fifteen, twenty, thirty years of their life. For me personally, it's been a great privilege to work with them. And they're really pros.


And my replacement, she's outstanding. I think she's going to do great work. You know, my advice, you know, to her will continue if she asks me. You know, we're here to help her succeed, and I'm sure she will. She's going to be leading really a group of extraordinary individuals. Many people don't know how big CDC really is. There's five campuses in Atlanta alone. You know, there's two in Washington, in Hagerstown and then you have Cincinnati, Morgantown, Pittsburgh, and you have Fort Collins, you have Spokane, then you have forty-five offices around the world. It's a big organization. It's a great organization.


And these dedicated men and women, when I had a meeting with many of them and I asked everybody in the room that had been at CDC longer than ten years to stay standing, I think 85 percent of room was still standing. And when even when I got to, like, thirty years, I still had over 25 percent of the room standing. It's just a great group of dedicated public servants. And the American public should have confidence in this transition, because the reality is there's only three political appointees down there.


And I've reorganized that with really a group of six really unbelievable deputy directors and I'm sure my replacement is going to come in and I hope we get the pandemic behind us so she can really start to enjoy the other enormous potential we have to impact public health.


FINK: Thank you very much, again. I just want to remind everybody that the transcript and the audio of this conversation will be available on the CFR website. So thank you, everybody. Thank you, Dr. Redfield.


REDFIELD: Thank you very much.



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