Assistant Professor of Global Health, Institute for Health Metrics and Evaluation
Vice President for National Program and Outreach, Council on Foreign Relations
Adjunct Senior Fellow, Council on Foreign Relations
Vin Gupta, public health physician, professor, and health policy expert, discusses the recent surge of COVID-19 cases in many parts of the United States. Carla Anne Robbins, CFR adjunct senior fellow and former deputy editorial page editor at the New York Times, hosts the webinar.
FASKIANOS: Good afternoon to all of you. Welcome to the Council on Foreign Relations Local Journalist Webinar. I am Irina Faskianos, vice president for the National Program and Outreach here at CFR.
As you know, CFR is an independent and nonpartisan organization and think tank focusing on U.S. foreign policy. This webinar is part of CFR’s local journalist initiative created to help you connect the local issues you cover in your communities to global dynamics. And our programming connects you with CFR resources and expertise on international issues and provides a forum for sharing best practices. It’s great to see you all. We’re shaking up the format a little by showing video, so we’ll look forward to your feedback. I want to remind everybody this webinar is on the record. And the video and transcript will be posted on our website after the fact at CFR.org/localjournalists.
I’m delighted to have returning with us today Vin Gupta. He was with us several weeks ago, or months, I’ve lost track as we’re all in lockdown. Vin Gupta is an affiliate assistant professor of Health Metrics Sciences at the Institute for Health Metrics and Evaluation at the University of Washington. His research interests include pulmonary and critical care medicine. Dr. Gupta holds an active commission as major in the United States Air Force Reserve Medical Corps, as you can see. And he recently served as the primary public health consultant on pandemic emergency financing for the World Bank. He’s an NBC News and MSNBC medical contributor and is also a term member of the Council on Foreign Relations.
Carla Anne Robbins is an adjunct senior fellow at CFR. She is faculty director of the Master of International Affairs Program and clinical professor of national security studies at Baruch College’s Marxe School of Public and International Affairs. Previously she was deputy editorial page editor at the New York Times, and chief diplomatic correspondent at the Wall Street Journal.
So, Vin and Carla, thank you very much for being with us today to talk about the resurgence of COVID-19, and if we’re still in the first wave or second wave. We’ll discuss that. I’m going to turn it now to Carla to have a discussion with Vin, and then we’ll open up to all of you for your questions and comments. So, Carla, take it away.
ROBBINS: Thank you so much, Irina. And thank you to all the journalists who have joined us. I know it’s an incredibly challenging time to be a journalist, and we really appreciate all the work that you’re doing on the ground. And, Dr. Gupta, welcome back. Thank you so much for what you’re doing. I said I wasn’t going to say thank you for your service, but I’m going to say it. It’s great to have you back with us.
So this week, and this is the only arcane moment I’m going to have today, but this week as I was listening to Vice President Pence’s brief on the pandemic and talking about early indications of positive tests flattening in Arizona, Florida, and Texas, I remembered one of my favorite quotes from graduate school. And Thucydides wrote that during the Peloponnesian War words had to change their ordinary meaning and to take that which was now given them. And so I suspect that for many Americans coronavirus numbers are losing their meaning.
We’re bombarded with data, we’re constantly being spun—being told this one matters, the other one matters, don’t pay attention to this, pay attention to that. So can we start with a quick overview on where we stand today nationally, regionally, and what numbers we really need to be watching the most closely and why? Is it new infections? Is it emergency room visits? Is it hospitalizations? Is it deaths? Is the age of those infected? Is it the percentage of people with antigens? I mean, I have a PhD and I’m utterly and completely confused.
GUPTA: You’re not alone, Carla. And I want to say thank you, again, for everyone coming to this event, for Irina for inviting me back, and Carla for moderating. It’s a privilege. I did have to just do a disclaimer. I’m in uniform. We’re actually—I’m an ICU doc with the Air Force Reserves. And we’re getting alerted occasionally that we may get sent out, just given everything that’s happening. So I’m not speaking on behalf of the Air Force even though I’m in my fatigues. And so I apologize for being in the car in fatigues.
So with that all aside, my opinion is the following. You know, there are so many metrics out there. And the metrics themselves have gotten politicized. And it’s sad, frankly. And I’m going to speak candidly here. I think what I saw yesterday at the White House press briefing was diminishing urgency, flattening of curves, that if you go to COVIDActNow.org, for all the journalists in the room—I’m going to try to give you as many directed pieces of advice from my own biases as I can. They’re all going to be evidence-based in my opinion. COVIDActNow.org is a great repository of information on metrics that matter. One of which is the positive testing rate.
If you go to—if you’re in front of a computer I’d urge you to go there right now. Go to Florida. And you’re not going to see anything that’s flattening, at least the way I think about flattening. I don’t think of a sharp curve up as flattening. The vice president was messaging as such. And I think that’s dangerous. And I’m going to get into Carla’s question in just a bit. But saying things that are not true in real time is dangerous because it puts our guard down. It makes the vice president, and the president, and the secretary of defense potentially say, well, we don’t need to active the critical care transport team in the U.S. Air Force—I happen to be in that team—where we could rapidly deploy portable ICU capability in Houston, in Tucson, in Florida, places that need it.
You can’t just flip a switch tomorrow and say, hey, we need dialysis nurses. We’ll get them tomorrow. I can’t do that if I’m here in Seattle in an ICU. If I need dialysis on a patient with COVID, which is a frequent need, I can’t sometimes get that in my own hospital when there’s open beds, because there’s staffing issues. There’s all types of things. So we need a proactive approach and how we talk about data really matters, because it keeps your guard up or puts your guard down, which is concerning.
Positive infection rates. What’s the test positivity rate? You hear a lot about that. That is critical. And that’s really—I’m going to give you a few metrics that I think matter. That’s an important one because no matter how much we’re testing, if the outbreak is not getting out of control it’s not like that number should be dramatically spiking, and you shouldn’t be seeing such dramatic growth rates in that specific test positivity number, the percent of tests that are positive. You know, they should remain—if the outbreak is not out of control that should not be an exponential curve, as you’re seeing on COVIDActNow.org.
And it is. It is an exponential curve. It was flat and then it just immediately peaked up. That is concerning. So I would pay attention to that. And the threshold that you really want to focus in on is 3 percent or less. With below 3 percent, and then we think—and the WHO has sanctioned this, the CDC to some degree has sanctioned this although I don’t know—the CDC has become so politicized that it’s hard to honestly trust what comes out of the CDC anymore. Yesterday was a prime example. I don’t want to rabbit hole there.
But anyhow, WHO has said 3 percent or less on that positive testing rate is key. And why is that important? It’s important because then if you are below that level you can feel reasonably confident to move from a mitigation, we’re going to—everybody needs to shelter in place, we need to minimize what we’re doing in public, there’s such disruption to normal life—to containment and contact tracing. One thing that has gotten lost in all the hullabaloo and all the mixed messaging is contact tracing right now is utterly useless because, one, the positive testing rates—or, the test positivity rate in Florida is 18 percent. It’s way too high for contact tracing to be effective.
Because at that point we think the outbreak is out of control. You’d be contact tracing everybody. And we think you need five tracers for every confirmed case to do it well. How can you do it if an outbreak’s out of control? So you want that test positivity rate, the number of tests that turn out positive out of all tests done, to be less than 3 percent, because then you feel like maybe you can manage the number of positive cases that are being detected by isolating those individuals and then tracing their contacts. Anything higher than that, and tracing becomes impractical and cost ineffective. So that’s one.
Hospitalization rates, to me, is self-evident. What’s your ICU bed capacity? Those are key. And I think for self-evident reasons. Because who cares what’s happening with cases and how we’re debating whether cases are rising because we’re just testing more, which is just a nonsensical argument, it doesn’t really—all those things are very proximal indicators—how many tests are happening, what’s the test positivity rate. Those things matter but they’re proximal indicators of the outbreak, meaning those are early—that gives you an early sense of what’s actually happening.
The later indicators of, oh my gosh, Americans may die, are hospitalization rates and ICU bed availability—also available, to some degree, on COVIDActNow.org. You want to look on websites that aggregate data like that. You also want to look at the state health department’s website, especially in places like Florida, Arizona, that are in the midst of the worst of it, to see they sometimes will break down at the county level how many ICU beds are available. I should note that in Florida they’ve done some pretty astonishing things. They are now not even reporting accurately, supposedly, the number of ICU beds that are now available. They’re just defining—they’re listing beds by acuity, either it’s high acuity or low acuity. They’re not even talking about intensive care beds anymore in certain counties, which is problematic because it’s an effort to, in my opinion, manipulate the data so we don’t actually know what’s happening, which is extremely dangerous to planners and hospital administrators when they need it figure out workflow. When the governor needs to figure out if he needs to call the National Guard or beg the president to deploy somebody like me and our team members to come out and help.
Data manipulation and trying to massage the data to make it seem like there’s not an emergency is a problem. And just I wanted to flag that for all of you. Some states, namely Florida, are trying to fudge definitions and trying to mask reporting availability of ICU beds. And it’s bad. But that matters. That’s a late-stage indicator. So just like hospitalizations, hospitalization rate, ICU bed availability, and then of course death rates, which I can get into in a bit.
So one’s positive testing rate, which matters. We talked about the threshold. The other thing that matters on the proximal end, to get a sense of where are we headed, is the number of tests per confirmed case. So I’m not going to throw twenty different metrics at you. I’m just going to try to give you a few. The number of—so, test positivity rate, and the second one I would urge you to pay attention to is not how many tests are we doing in the country every day. That’s meaningless. But it’s the number of tests done per confirmed case. And why does that matter? We do about twelve tests per confirmed case. That’s pretty bad.
Countries that have gotten it right, Australia does about eighty tests per confirmed case. New Zealand does 370 tests per confirmed case. Taiwan, South Korea, about ninety to a hundred tests per confirmed case. We do twelve. That means we don’t have to look too hard. We don’t have to test too broadly to get a confirmed hit. Said another way, we have a ton of cases and we’re still limiting who we test. I’ve been in the ICU to some degree since March. Because I’ve never had symptoms I don’t qualify for a test. My Air Force colleagues, some of them are anesthesiologists on the outside, none of them have gotten a test. And we’re actively caring for these patients. It’s absurd.
Other countries don’t do that. You have to have symptoms. Really and you’re seeing in Houston and in other geos and even in Los Angeles, we’re back to where we were in March. Very narrow criteria on who can get tested. You have to be high risk, over sixty-five, living in a communal facility. You have to have symptoms, et cetera. We’re not testing broad enough. So that’s why look past the headlines on aggregate number of tests being done. It’s meaningless. We’re not testing broadly enough. And confirm—the number of tests per confirmed case.
Our World in Data, if you Google that, I don’t believe that’s the actual URL. But Our World in Data, if you Google that, that will actually get you to a website that shows you the number of tests done by confirmed case. It’s a bar graph. It’s beautiful. And will compare it against other countries. That number needs to be quadruple what it is now for us to feel like we have adequate testing. So in summary, I would say on the proximal end the number of positive tests, and using 3 percent as a threshold, the number of positive tests done over all tests, number of tests per confirmed case.
And then on the later end, so called non-lagging indicators—so gives you a sense of what’s actually—you know, how are people being affected. Look at hospitalization rates, ICU bed capabilities, and then of course death rates. And one last thing on death rates. We still think we’re underestimating the number of deaths nationwide. One, because COVID—you know, sometimes—first of all, there’s a huge epidemic of people just dying at home because of deferred care in places like New York City that were hard hit.
And it wasn’t clear what they died from, but in many cases COVID-19 was either suspected or confirmed. But that was not lodged as the primary cause of death in an autopsy report in all cases. So there was a sense that there was some misreporting, not intentional necessarily, of deaths, especially amongst those that died at home in hard-hit areas back in March and April, and to some extent even now—especially in hard-hit areas down in Texas and Florida—because either a diagnosis was never rendered or was highly suspected but never confirmed. So there’s a sense that we’re still underestimating the number of deaths that are occurring because of COVID-19 in the United States.
I’ll stop there.
ROBBINS: Thank you so much. I have many more questions to ask you, but it’s not all about me. So let’s—why don’t we turn it over to the group, and I will follow up with my own questions. Irina, do you want to?
FASKIANOS: OK, so Ray Stern, you go first.
Q: Hi, there. Thanks for your time today. I appreciate it. It’s very helpful.
I’m from Arizona. And as you know, there’s been a lot of attention given to my state because of what’s happening with the surge. I have a couple of questions for Dr. Gupta. Basically, I’m wondering how much blame, you know, should we fairly put on our leaders for this? You know, there seems to be mistakes just made all over the place. And the right decision, you know, often has consequences for the economy. At the same time, you know, our governor has seemed to follow the Trump plan. And there’s been already some accusations of covering up the data, just like you talked about in Florida. So I’m wondering if you look at Arizona, just how serious do you think the leadership problem is here?
And then of course, the surge is the other extreme problem. I just looked at the COVIDActNow site. They’re putting us at 99 percent for ICU beds. You know, I guess I’m wonder how worried should I be about that? You know, is there a surge capacity that will come in, hopefully? And also we’ve got a governor who isn’t placing a mask enforcement requirement on the state. Should that be done? And what else can Arizona do to try to flatten this new curve? Sorry for the long question, but we’ve got a lot going on here.
GUPTA: No, no. That’s a really important question. Thank you for that. And first of all, I hope you and your family are safe. In Arizona, I know from colleagues, that’s a really difficult situation. I won’t mince words here. We’ve had failed leadership. And it’s been, in some cases, catastrophic. And I think if I did—if I willingly—here’s the analogy I like to think about. There’s a lot that’s not being done that we know could save lives. And if I withheld lifesaving treatment intentionally as a physician in the ICU, my license would get pulled. I probably would get sued. Other bad things would probably happen to me.
So where’s the accountability? So let me start there with Governor Ducey in Arizona, not to pick on him but since you asked the question. Basic things are not being done. And you can only reason to think that maybe it’s political, that he doesn’t want to fear upsetting the president. The mask issue to me is mystifying at this point. Why are we even debating this? There’s plenty of data at this point that suggests masks cannot be recommended because, unfortunately, a citizenry like ours—which is diverse, which is opinionated, is not used to wearing masks—we can’t reliably expect us to comply with that at scale. We need 90 percent mask adoption, otherwise it’s not going to work. That’s what we know is effective. That’s what we’ve learned from our peer countries in the Asia-Pacific, where this is not a problem, cooperation with masks. They readily do it.
But how can we encourage that? There’s no—we can’t just encourage it. The time for encouragement is done. That’s why mandating—a national mandate on masks is important. But when I even hear leaders that I think have gotten this largely right talk about it they say, well, we need to mandate masks. Well, where’s the enforcement mechanism? To your point, there needs to be an enforcement mechanism.
What I’ve seen here in Seattle and elsewhere—I’m from Ohio originally—is essentially there’s a sign at the door: You must wear a mask. But what happens if you don’t wear a mask? And I’ve seen a lot of people just skirt the rules and not wear the mask. It falls to either me, with my toddler son, saying something to somebody, which I may or may not do and risk who knows what could happen afterwards. So I think it relies on our fellow Americans to enforce it, which is dangerous, or security guards to enforce it. That’s just not right. It makes no sense.
So mandating masks at the state level, since the president’s not going to do it, makes a lot of sense. Governor Ducey should do it. But he should fine—there should be a fine. Just like we do with indoor smoking. And that, the threat of a fine, compels people to do the right thing largely. We need that. It’s very basic. And we should make it happen. Yes, people are going to be upset, but tough luck. That’s just how it needs to be. We’ve had success with indoor smoking. We should do it there. That’s one.
Indoor dining needs to stop. I don’t know how much more evidence now we need out of Wuhan or other places that have studied indoor dining or other indoor gatherings in poorly ventilated air-conditioned facilities, but the transmission rates are twenty times higher, in some cases, than outdoor dining, outdoor gatherings where there’s distancing, at the very lease. If I was the governor I would stop indoor dining now. And Governor Murphy and Mayor DeBlasio have done it. To some degree you’re seeing some counties adopt that approach.
But again, this county-by-county, municipality-by-municipality approach is not going to do anything for us as a country. It’s why we have a surge and Spain, and all these other countries, have continued flattening. We have fifty different approaches, multiple different approaches even within a state. It’s not going to work. So that’s number two.
And to your other—to your last question about surge capacity, I’m deeply worried about all of you in Arizona, because 99 percent capacity in an ICU in the setting of COVID is a really terrible signal because it’s not like you have throughput of these patients through an ICU. These patients can take up to upwards of forty-five to fifty days to come off a ventilator. I just got off the ICU last week. I was caring individuals from Yakima who were in their early thirties who were there for forty days, intensive care. I mean, the definition of intensive care. I was in there for hours. My nurses were in there literally nonstop. Turning patients over from their back to their belly, continuous dialysis, twenty different drips, changing IVs out, big IVs in your neck almost—you know, every few days.
This is serious stuff. And so it’s not like that number’s going to change anytime soon. Unless you deploy the military, unless you get the National Guard to do its job. I mean, one thing I think the military does do a good job of—again, I’m saying this—I know I’m saying this in uniform and so I want to be clear this is my opinion this is not the opinion of the Department of Defense—we know what we’re doing when it comes to portable ICU capabilities. That’s what we get trained to do. That’s what the taxpayer expects us to do. There’s a lot of money that goes to the training and keeping this mobile capability ready. Why aren’t we deploying it? It doesn’t make any sense.
We deployed it readily for Ebola. Why are we not deploying it now to Florida, and Texas, and Arizona, and California? It does not make any sense. And yet, we continue to sustain the capability. Again, I think deploying active duty and reservist branches of the military—Air Force, Army, Navy—would give us some relief. Oh, sorry about that. It would give us some relief. But it would also mean that it would be some degree of admission of failure on the part of the president, that now we have to bring in the calvary, which, you know, if this—if the right thing was being done, again, to answer your question, that would be the right thing. And if I was Governor Ducey I would beg the president to do that.
FASKIANOS: Thank you. Let’s go to Rosemary Westwood.
Q: Thank you so much for doing this. I have two quick questions, I hope.
The first, on ICU bed capacity, what is your understanding of, you know, the percentage of beds that are being used after that point at which it’s a big problem. Like, we’re seeing some regions in Louisiana have, say, eighteen beds, one of the most worrying regions right now. And as a percentage, I think that’s at about maybe 60-70 percent of the ICU capacity. So how can I measure, as a journalist, when I’m looking at this data, what threshold should cause us to think that we might overwhelm that system?
And then the other question I have for you is can you just delineate between percent positive and what you call the number of tests to get a positive test? I think I’m sure not the difference between those two.
GUPTA: Sure. No, no, I’m happy to elaborate on that. So on the first, anecdotally this is what I’ve seen, and working now in a few different ICUs in the COVID era and then before COVID. What I’ve seen is we never fill up—we never fill up every single bed because the rate limiting step often—is never the bed. It’s the number of beds you can staff. And staffing, especially nurse staffing, is always a bottleneck, especially now. So what I would urge you to do, and it’s probably different in your zip code than it is in my zip code. But what I’ve seen, to your point, about two-third to maybe 75 percent of so-called surge capacity is the most I’ve seen us actually operate in.
It’s the rare time when you can call in reinforcements and everybody on a second call, third call, to come into the hospital. Its happens, but it’s in the rare circumstance when it’s all hands on deck. In my—what you really want to key in on, and the question you would want to ask your administrators at major health systems in your zip code, is what’s staffing look like? What’s ICU nurse, and respiratory therapist, and dialysis staffing look like? Double click on it, because it’s so easy to just talk about ICU beds.
But I can say as a practitioner, it’s never the bed that’s the rate limiting step. We can always find a bed. We can—we can find a bed. What we can’t find necessarily is—can you find the twenty-four-hour nursing coverage, the highly skilled nursing coverage to take care of that individuals? And maybe—and in most cases a dialysis machine? Those are the rate limiters up front. So I would say typically speaking 75 percent bed capacity usually—if you’re going on the bed side, once you hit about 75 percent bed capacity from what I’ve seen, again, anecdotally, that usually correlates to 100 percent max capacity when it comes to your human health care workforce. And so that’s where I would really key in on when you ask probing questions to the CMO or the leader of the hospital administrators in the major health systems in your geo, because that’s the critical piece.
To your second question, let me know if I didn’t answer your question, to the second question, so percentage positive tests. So just at a basic level, if you do 100 tests how many of those are positive? That—so the percentage of tests done in the prior twenty-four hours that are positive, and trend that out. That’s basically what COVID Act Now is reporting in Florida I think on a daily basis, if not a forty-eight-hour basis. So the number of tests done in a state or in a specific geo, and of those tests how many turned out positive. That positive infection—that positive test rate is key. And again, above 3 percent, you know, basically you worry that the outbreak is on an exponential growth pattern and it’s potentially going to get out of control.
And it also means that contact tracing is effectively useless because there’s just too many positive tests that are out there. And in the absence of a technological innovation or broad adoption of technology to inform tracing—which we as a country are just not willing to engage in for a variety of reasons, unlike the U.K. and Germany—there’s no way we can do a manual contact tracing effort right now in the United States at scale. It just doesn’t make sense.
The number of confirmed—the number of tests per confirmed case, so basically it’s—the way you would want to think about it is take the number of total tests done in you name the state and divide it by—or in the country—and divide it by the number of confirmed cases identified in that way. So it’s almost the inverse of what the positive infection testing rate—positive infection rate is. That inverse ratio, so number of cases per confirmed test, almost—again, it’s almost the opposite. It’s the reciprocal—is one way to think about how broadly or how narrowly we are testing, because if that number is small you basically means you don’t have to search too far and wide before you get a positive hit. So in our case, it’s twelve tests before you get a positive hit. In Australia, you have to test 370 individuals before you get a positive hit.
There’s two applications for that. Again, just to make sure we’re—just to make sure I’m being clear. Maybe this point’s already come across, but if it takes 370 tests before you get a confirmed case, that basically means either you are testing everybody—symptomatic, asymptomatic, and people you don’t think likely have the disease. And that means anybody who wants a test can get a test, in other words. Or it just means you don’t have an outbreak. In our case, we’re only—twelve tests done before you get a confirmed hit, that either means we’re narrowly defining who can get a test, which is the case. You really can only be symptomatic. Don’t believe what they’re saying. You can—only if you’re symptomatic are you a high priority for tests still, all these many months later. There’s some exceptions, but that’s generally the case.
Or it means your outbreak’s out of control. We have a combination of both. We have narrow testing and our outbreak’s out of control. In Australia they have broad-based testing. If you want a test you can get it. And they just don’t have that many cases. So that’s why that rate—you have to test many more people before you get a positive hit. I don’t know, is that clear? Was that—on either part of that question?
Q: Yes. Yeah, they’re connected though, so that’s I think why I was confused. But that makes sense. Thank you.
GUPTA: No problem.
ROBBINS: Thank you. OK, so—
Q: Can I get that website again, where that information shows up, Dr. Gupta?
GUPTA: So COVID Act Now will do the positive test rate, I believe. And then Our World in Data I believe is the name of the website. Or if you just Google “confirmed COVID”—or, “tests per confirmed COVID cases” it should pop right up. And then you’ll see actually a really nice histogram that compares this against other countries.
FASKIANOS: Thank you. Let’s go to Marie Albiges. I hope I’m pronouncing that correct. If not, please. (Laughs.)
Q: It’s Albiges. I’m a reporter in Virginia at a daily paper.
And so every day, you know, we put together the story of all the data, the confirmed cases, confirmed, you know, number of tests, et cetera. But I’m wondering just how much we really should be writing about the data on a regular basis when, A, the state has made mistakes in reporting in the past when it comes to coronavirus data and sometimes they’re unreliable. And, B, like you said, people have become kind of desensitized to what the numbers mean. So I’m wondering, you know, how much we should really be reporting on that data every day, or if there’s a better approach to how we’re writing about the data.
GUPTA: So thank you for the question. And I think you’re appropriately concerned about the data, and how to best report on it. I would love—you know, I still think it’s important to present some of the data that we talked about, for the reasons mentioned . You know, there’s still value, even though there’s some concerns about how Florida is reporting ICU bed capability, if you—if that’s part of the story, it’s still a critical part of the story to tell because trends matter here. A snapshot in time is less useful, but trends do matter. So I would—I guess I would push you to, say, report on trends.
And that’s key. And report on them—don’t report on absolute anything. Report on relative data metrics. So everything I’ve just mentioned here what you want to report on is trends in the positive infection rate, trends—by definition the number of tests per confirmed case is a relative metric. ICU bed availability, all these things. Trends over time, longitudinal data is what we really care about. I think that’s what you want to really focus in on. So whether it’s week over week or every three-day averages, that is very helpful.
What I think is really useful, and I think this gets back to a prior question here, is just double clicking on what are the major health systems in your—you know, in—wherever, in your region of Florida. And then speaking to the hospital administrators there directly, and not relying on the data the government’s reported out on the state of Florida’s Department of Health website, because I think you’re going to—it’s important to hear directly from the COs, the CMOs about their pain points. And it’s usually going to be, again, as I mentioned, on staffing, on the need for PPE, or what have you. To me, that’s the type of data, especially at the local and the municipal level, is really key to surface, because then national attention gets brought to it, and then potentially enough pressure gets made on state officials that they’re forced to act.
But if you can balance—I think the best reporting at the local level is a combination of trends, quantitative—you know, looking at trends on these aggregate numbers, but then also seeing to the extent that you can get real data, actionable data from hospital officials and other leaders of major health systems. I think that’s going to be the most useful. So I don’t know if that’s helpful, but that would be my—what I’m—what I found to be really helpful when I try to message on some of these issues, you know, for certain elements.
Q: Thank you.
FASKIANOS: John D’Anna. And you need to—yes, thank you.
Q: Sorry about that. I wonder, Dr. Gupta, if you could comment on the importance of timeliness in receiving test results. We’re talking to people here in Arizona who are waiting a week to ten days to receive their results. And as a follow up to that, are there any tracking systems that you’re aware of, or resources that you could point us to, that give us an average length of time to receive test results?
GUPTA: Such an important question, especially as we think about this broader debate on returning to school. And so right now the delay—the most commonly available test is from Quest and LabCorp, and major lab-based companies that do lab-based tests. And these are the classic nasal swabs that you stick into your nose, and then somebody—some technician will then send it back to a Quest or LabCorp type facility to get run. On average, the best-case scenario is a seventy-two-hour turnaround on that test. What I’ve seen typically is five to seven days on average, just in the health systems I’ve work in, anecdotal reports. I’ve seen as bad as almost a month, just because things got messed up in transit.
And it’s totally unacceptable and it makes testing virtually useless if we’re thinking that testing is a bridge to something. It’s all fine and well to know that you’re positive or negative, right, but we think it’s a bridge to then determine who needs to be quarantined, but then importantly who needs to get their contacts traced. And if we’re saying there’s a seven-day potential lag between finalization of the positive result and then notifying your exposures, then that doesn’t make any sense. We need point of care testing.
And so I think this is where this synchs in with the larger debate on the CDC guidelines on school re-openings nationwide, and then the president’s pushback on that. One thing you’ll notice, a common thread, is that neither the CDC nor the president stipulated testing for children or adolescents going back to school as a requirement. And it’s—myself and colleagues were sitting here wondering, haven’t we been messaging on testing every single day since early March? And now suddenly it doesn’t matter, and we’re going to have fifty-six million school-age children go back to school, and they don’t need to get tested?
This is the type of inconsistent messaging that ruins the trust—that trust compact between the American people and then I think people like myself, that have been trying to—and my colleagues—who are trying to message on the importance of masking, testing, et cetera. If we’re now saying we’re going to just restart a huge part of our economy and we’re not going to do anything with testing, if I was—if I was listening to that not living and breathing this reality every day I would say: What is happening here? Why are we doing that? And so the reason why they’re not messaging on it, it cuts to the heart of your question. Oh, sorry about that.
Which is, we don’t have the right testing. They don’t want to message on it because you can’t have a seventy-two-hour lag between—or, a week lag—between testing and then saying you can go to school. We will, though. Importantly, we will have that testing capability, we think, by late fall/early winter. Becton Dickinson, Quidel, these are two companies that have a direct—a certain type of test that’s point of care, that’s going commercial in the next few months, and to the tune of multiple millions of units of supply in circulation, you know, we think September/October, and then tens of millions thereafter.
These are the types of tests that you stick something in your nose, with a clinician watching over you, and then within fifteen minutes you get a result. Within fifteen minutes. And there’s other innovations that are in the pipeline, we think by late fall/early winter, will allow for not just same day but same hour, or even within the same half-hour finalization of the result. That’s the type of innovation that the government should subsidize for every school district in the country. That’s the responsibility. They should make sure they—every school has the proper clinician to administer the test or supervise it. And that’s the infrastructure unfortunately we need until we get a vaccine or there’s herd immunity.
That’s what we need. And it’s going to cost money. That’s what the taxpayer dollars—federal taxpayer dollars should be funding, or at least partly subsidizing so it’s not on schools. But that’s what we need to reopen schools. And until we get that, this notion that we’re going to just stagger schedules, we’re going to thermal scan folks, we’re going to make sure there’s adequate ventilation, it’s all just nonsense. And it’s—us not messaging consistently is going to ruin—further erode trust between public health officials, people who are on the front lines, and the American people. They’re not going to trust us.
So sorry I rabbit holed there and went a little bit in a bit of distraction, but I don’t know if that was helpful.
FASKIANOS: Vin, what about saliva testing? Are those—is that an effective means? Are those tests being developed?
GUPTA: They are, Irina. Right now what we understand internally is that saliva testing captures the right—the cases you want—i.e., the cases that are—there’s enough of a concordance between saliva and sticking something up your nose that—it depends on the organization, but Major League Baseball, other major organizations are adopting it. There is a chance that saliva—what we’re seeing is there’s about one in ten cases where saliva misses a positive hit that you would otherwise detect on a nasal test. But those tests we—that one case usually is a case of an individual that had the infection but is no longer infectious. So in other words, saliva captures the cases that matter.
And you know, I’ve gotten some push back. Well, you know, how can you expect a six-year-old to assent to a nasal test, because they’re not going to like that. It’s going to be super traumatic. And I agree. Some of these point of care tests will allow you to spit into a tube instead of sticking something up your nose, but they’re not going to go online, Irina, until we think November/December, at scale in Q1 2021. But it makes this notion of a fall reopening of schools broadly I think terribly unsafe. And it’s creating an expectation that’s wrong for parents. I think parents need to be prepared, unfortunately, to hunker down yet again through the fall semester, with relief starting hopefully in the spring semester.
But that’s the messaging that we need, not oh we’re going to start things up to September. Because now it’s going to create all types of disagreements, it’s going to create false expectations, and then people are going to get upset.
FASKIANOS: Thank you.
Let’s go to John Wotowicz next.
Q: Yes. Thank you so much. And this is a terrific conversation. And, Dr. Gupta, thanks for all of your observations and answers here.
I’m going to take it just—down a different path here, which is it would be great to get your thoughts on the extent to which this whole global pandemic is revealing some real structural flaws in the United States kind of devolved system of state-level health policy, health regulation, health reporting of data. Because when you look at, you know, larger places—you know, such as Germany—where, you know, it’s a substantial population, but where obviously all of these issues are being ultimately decided and directed at the center and at a national level. It’s hard not to at least raise that question. And just to identify, I’m with The City, New York’s local nonprofit—local news platform.
GUPTA: Thank you for that question, which is a really important one. You’re right, the lack of a unified—all fifty states are sort of—you go at it alone approach to our health care system and financing of our health care system has been a huge problem for decades. And I think COVID-19 has really unearthed inequities in access to care. Until May, to give you an example, if you wanted to get a test—until May you had to—and all you could do was access a physician or an ARNP through a tele-environment, you had to—you actually had to own a smartphone, because they did not allow—CMMS did not allow you just to call your doc and say: Doc, I need a test. Or if you were working with a nurse practitioner, same thing. They didn’t allow that. They didn’t allow someone to get reimbursed on the provider end to communicate over phone with somebody to then, you know, prescribe a test.
So basic things like that, where the essentially the common motif here is you have to be affluent, and you have to access to broadband technology. Otherwise, you’re going to get a prescription. It was a huge problem in the initial months where this epidemic, now this pandemic, took root. So I think there’s been progress. So what I will say is, and I hope there’s continued permanence of some of the changes I’ve seen, at least in a temporary fashion, when it comes to, for example, telehealth.
There has been ninety pieces of legislation in the last three months to telehealth to broaden access to make cross-border licensing—to strengthen cross-border licensing arrangements, so I can be a doc here in Seattle and care for you in New York, who needed it. I didn’t have to be licensed in New York. I can how physically go to New York City, if needed, and practice medicine and get a license within twenty-four hours. Previously it would take months. Those changes—let’s hope they become permanent because that’s going to rapidly increase the ability to deliver access to health care in a tele-environment, regardless of if you’re sitting in an urban, densely-populated area or if you’re in a rural/exurban area. So that’s one. And I think that’s important.
What I fundamentally think is a problem in our health care system that has not been addressed is we just have the wrong types of health care workers at scale. We have a—yes, we don’t have enough doctors. Yes, we don’t have enough nurses. But we don’t actually have enough medical assistants. And those are the types of individuals that do the type of work that allow me to practice at my top of license. So I’m not doing care coordination. I’m not calling in meds. I can focus in on the patient in my fifteen minutes I may have with him or her in clinic, try to deliver the best quality care so they can come in less often to see me, and it’s less of a charge to the system, but then they can interact more with the medical assistant, who can focus in on coordinating the care with social services, getting your medications refilled on a timely basis, making up those phone calls.
Do you know what happened in the months right after COVID-19? Most MAs got furloughed, and then fired. So now we don’t have the connective tissue in our health care system that we need. We have nurses. We have docs. But they’re all being overstretched. There is a lot of unhappiness in our health care workforce right now—either because a lot of them have been laid off, and they have untenable bills, student debt, et cetera. Or, because we’re doing work that’s quote/unquote, “beneath” our license, that’s stressing—we’re expected to do top of license work, because we’re in charge of a patient’s care, ultimately, we’re guiding their overall care trajectory. But then we also have to make sure we’re care coordination. We also have to make sure that they have a safe discharge. All these things where we need more people that can strengthen the connective tissue of the health care system.
I don’t know if that directly answers your question, but to me that is the dire lack—the key need for American health care moving forward. We need greater access to care. And broadening telehealth is going to be a key piece of that, making permanent some of these legislative changes. But then we also need a rethink on how we can incentivize roles like medical assistants, and more broadly. How do we make that a career that’s worth saving, and worth investing in, and that people feel like they want to actually continue in on? Without that, we’re just going to have a bunch of expensive clinicians, whether they’re nurses, ARNPs, or MDs, who are going to be doing nurse that they shouldn’t be doing.
It’s going to create a bunch of waste with the health-care system. And it’s going to have these trickle-down effects, where you’re going to have Republican administrations come in every four to eight years and want to block grant Medicaid and create haves and have nots among states. And it’s just not right. But the proximal causes of that are waste, inefficiency. And part of—and a big drive of that, I don’t think we talk enough about, is who are—who are the people delivering our health care in and what proportion? We just don’t have that right.
Q: Thank you so much.
FASKIANOS: So we’re waiting for more questions, so Carla I know you’ve got questions.
ROBBINS: I have a question. So if you look around the country, are any leaders getting it right? Are there any models for how to do a measured reopening? Or are we all just going to have to hunker down and wait for a vaccine or herd immunity to set in?
GUPTA: So I—it’s a great question. I love what Governor Murphy has done. I think what Governor Cuomo and Mayor DeBlasio are doing now in terms of messaging in the setting of a very complicated situation is laudable. They’re taking action on indoor dining. They’ve been as strong as I think I’ve seen on masks. And they went through the worst of it and had the humility to call in reinforcements. And so they had humility. They’re operating with evidence. And so I think they should be praised accordingly.
Truth is, I don’t think this is a state-level approach. So you know, this notion—and this is where I worry about their false sense of creating these regional approaches here. It’s not going to matter what Connecticut, New Jersey, or New York do if Arizona and Governor DeSantis in Florida decide, hey, we’re going to go our own way, because we’re all one country with one set of contiguous borders. The state-level approach has limitations.
Just like if you’re a mayor, or if you’re the mayor of Miami, and I understand the president’s about to go to south Florida tomorrow. And the Mayor has said: You have to wear a mask. Turns out, the mayor doesn’t have any discretion or jurisdiction if the governor says, well, you know, what? You don’t have to wear a mask. We’re not going to mandate—especially if—and if the president comes in and says there’s not going to be a federal penalty even if state law says—if there’s one way or the other on masks. If there’s not a federal penalty for not wearing a mask, then it’s even further weakening messaging on the city level.
And so I think it just goes to say there’s only so much that can be done at the city, municipal, or state level. We need federal leadership. We certainly need governors to be aligned with that federal leadership. But I feel for governors like Governor Murphy, Governor Cuomo, I thought Governor Whitmer withstood a lot of angst, a lot of conflict, but stood firm with a very strong shelter in place order, which I thought was right. I thought Governor DeWine actually initially—my native Ohio—was great, with Dr. Amy Acton, in terms of messaging, shutting everything down early.
But unfortunately I think Governor DeWine’s a cautionary tale of somebody who has let that initial strength essentially completely dissolve, and you’re noticing a very clear uneven response now to the second wave or this extended surge, where now he’s saying, hey, we’re going to do masks in a few counties, but not statewide. Again, it does not make any sense. So I think governors—
ROBBINS: But I understand what you’re saying about it can’t be piecemeal and all of that, and you know shutting down borders obviously is not possible. We’re not East Germany during the Cold War. (Laughs.) I suppose the question that I’m asking is: What do you think is a reasonable series of steps for reopening that when the numbers become—like, New York, in which the numbers are flattened after the horrors that we went through earlier. I mean, Cuomo’s talking about reopening malls, you know, there’s all of these things that are going on. What are reasonable re-openings that can take place once the numbers are, and at what level? I mean, what’s the pacing that you’re comfortable with that the government—that the government—a government that has good public policy should be doing?
GUPTA: So, no, I appreciate that. What I would say at a high level is that to enter any phase of reopening moving forward a jurisdiction, however you define it—but I think we have to do this at the city level or at the county level—has to have an infection—a positive infection rate—that’s the most important metric in my opinion. That’s an early indicator of where things are at with the outbreak—has to be less than 3 percent, for re-opening. And the only reason I say that is because that’s when, it hit on the theme mentioned earlier, that’s when we can actually do something about it prospectively. If you have new cases, you have some hope of maybe containment because you can scale contact tracing.
So I think, number one—one criteria here—and this is, again, my opinion. The infection rate, positive infection rate, has to be less than 3 percent. You have to have—you have to speak with local health system leaders about what’s the true ICU bed capability, not just what’s—not absolute number of beds, but how many can you staff? If that’s 100 percent of all beds, great. In most cases, it’s not. But assuming that you feel like there’s enough elasticity in your health system capability to handle a surge, and that—in my opinion that means only a third of beds are filled at any period of time—if ICU beds—3 percent less—or, percent or less on your infection positivity rate, one-third of less ICU beds filled. Then you can enter a phase where you’re opening up outdoor dining, where you can reengage in public in groups of less than ten, if there’s social distancing and, you know, universal masking precautions in public areas. That’s where that makes sense.
And then I think the critical piece here that we just need to—if we really want to normalize life and get back to normal, until before a vaccine hits, we have to accept that we need app-based technology to guide contact tracing. That’s what the U.K. has done or is about to do. That’s what Germany’s about to do. There’s ways to do it that can protect data privacy issues. There’s ways to do it that could be, I think, sensitive to communities of color and other underserved areas, where there’s going to be even greater sensitivities to the adoption of technology to facilitate tracing.
But let’s be real, we’re not going to be able to do a manual contact tracing effort at scale quickly. But we can do it with the assist of technology. So I think if we have a community that hits those metrics, less than 3 percent on the infection rate, we have adequate ICU capabilities—as defined by what administrators are telling you not what numbers are saying just in some database—and if there’s an appetite and an acceptance of broad downloading of an app, or what have you, or another non-app based technologies that could facilitate tracing, then I think we can think about outdoor dining and outdoor activities upfront. Of course, you’re assuming that you have mandatory mask enforcement as a part of that legislative approach. But that would be how I would think about a reopening process that may actually have some hope of curtailing any new infections from becoming niduses for new outbreaks.
ROBBINS: And of course, those things are—many of the things you’re talking about are already happening in New York City, without contact tracing and without mandatory masks. I mean, certainly not with enforcement of masks.
GUPTA: Well, I think those are two—those are two critical gaps that need to be rectified because—but New York is, again, far ahead of the curve. I think you had—and New York is—that’s why I highlighted it, because I think if you’re thinking about indoor dining and stopping that, the messaging on masks has been excellent, at least from elected leaders in New York state and City. So those are two things that most of the country doesn’t have.
MR. RUBENSTEIN: Let’s try to sneak in Ray Stern before we close.
Q: Thanks so much. Just wondering if you can talk about death rates just a little bit more. On one of the conservative sites that I was looking at they talk about how the CDC says this this is barely an epidemic at this point, according to the CDC. And I looked that up and it’s true, basically, though, they say that that could change. How do we explain this in full context to people? And the last question is, New York, of course, had this big first wave surge. A lot of doctors and nurses got sick. Are these people getting sick again or have they achieved immunity as far as we know, at this point?
GUPTA: I think the death rate debate is—it’s so easy to mis-message on death rates as it’s 0.6 percent, why—or, the true death rate we think is 0.6 percent, even though we think the case fatality rate—how many people are actually dying right now in the United States out of those confirmed cases is about 5-6 percent. The question, and you’re seeing that sort of death rate curve level off and it’s decreasing consistently. So it’s causing people to wonder, what’s all the fuss about?
And there’s a few reason why we’re all fussing. Number one is, this outbreak—if we continue to open up the way we’re opening up, if it continues that, you know, young people continue to be vectors for transmission, the median age of—that the majority of newly infected individuals in Florida is thirty-five, versus sixty-five in March. Similar findings in Arizona, in your home state, where younger people are now the predominant focus of the infections.
You know, these are individuals that are—as long as COVID-19 is still circulating in an environment, it poses a threat to us as we enter the fall with flu. That’s the concern, because you can still end up in the ICU if you’re young, number one. But then you can still transmit it to older individuals, number two. As older individuals resurface and are now, you know, potentially going out, because we can’t have them shelter in place forever. So there’s going to be a tendency to want to normalize life. And as long as we have this circulating, it’s going to still pose a threat to those that are the most vulnerable.
So that death rate, one, is a lagging indicator, deaths now probably are largely occurring from infections that occurred four weeks ago. And so there’s nothing to say that we’re not going to see an uptick in deaths as we continue to let our guard down. And I worry that our guard is being let down, based on scenes from July 4, based on core messaging from the White House. And if schools do reopen because the president’s blackmailing school districts nationwide with funding, which is, I mean, just completely dangerous to do, you’re going to see—there’re all the ingredients for a repeat surge and more potential risk to those that are the most vulnerable. That’s one reason.
Number two, and I know I’m going over time. I’ll say this quickly. My colleagues and I have gotten better at saving lives at ICUs. We know things that we didn’t know in March. It doesn’t mean then that we should be playing Russian Roulette with ICU bed capacity. Yes, we can save more lives now because we know steroids work. We know that you should put everybody on blood thinners. We know that you should probably put somebody on their belly instead of keeping them on their back on a ventilator. These things we didn’t know in March.
And so is that helping with the death rate and we’re saving more lives? Yes, potentially. But is that a pop-off valve we can rely on at scale? No, because as we’ve talked about ICU bed capacity staffing is such a limited—it’s still in such a limited supply there isn’t a lot of room there. And I wouldn’t bank on it. So that’s a key piece here. And then, number three, we’re testing more. And so we’re seeing that most of these new cases are happening among young people. Again, not a cause for celebration. Young people are transmitters of the disease. They can still end up in the ICU. There’s still a lot of risks.
So that’s how I would—I guess I’ll close there, just in the interest of time.
FASKIANOS: So, Vin, I just—one question came over chat. Natalie Megas. She can’t ask her question out loud, so I’m just going to read it. But going back to the school systems reopening safely: Is testing, in your opinion, the only indicator to reopen safely? Many states are leaving it up to parents to decide between virtual and in-person instruction. How can I report on this to help parents make an informed decision? And she’s a freelance reporter in Virginia. And that will have to be the last question.
GUPTA: And sorry, just to paraphrase, it cut out a bit, the question is safety of going back to schools and balancing needs in terms of virtual versus brick and mortar.
FASKIANOS: Yes. If testing’s the only indicator—if schools are not doing testing, are there any other indicators that would help parents make the decision of whether it’s safe to send their kids back to school or do virtual. So is testing—if we’re not doing testing, would you say then don’t send you kids?
GUPTA: My opinion is: don’t send your kids. Because it just doesn’t make—I don’t understand the argument for why we’re saying testing doesn’t matter. It just doesn’t make sense. I know the American Academy of Pediatrics, the CDC, and the president are all aligned that we need to restart schools. We all want schools to restart, but it’s just what are we then basing a return to school strategy on? That’s where I would really ask your school district. Here in Seattle they’re talking about thermal scanning, which makes no sense. And I love our elected officials here in Seattle. They’ve been leaders on this issue.
But looking for something, fever, amongst individuals that we know that if they were positive adolescents they would not have a fever—we’re looking for something we know is not going to be there. It doesn’t make any sense. So we have to—testing has to be the backbone. If it’s not, I would encourage parents to wait and not take the risk. Because even if your child may not be at risk, you would be at risk, or your grandparent—or, your parents might be at risk, if you’re a parent. So I would be very cautious.
FASKIANOS: Well, with that, Carla, any final words?
ROBBINS: Just actually one quick list here. The Times did this extraordinary things, they asked 511 epidemiologists what they would and wouldn’t do, what normal activities they would return to, and in what timeframe. What are they—are you doing any normal activities, or are you going to wait for the vaccine? Getting your hair cut? Going out to dinner outside?
GUPTA: Outdoor dining, absolutely. And I think that is something that we call still can enjoy. And I’ve seen a lot of restaurants innovate with community spaces, and I think there’s going to be more of that. So outdoor dining, I’d highly encourage it. And I think that’s fine. And that’s the only thing I would say that I’ve done that’s been true normalization.
ROBBINS: It looks like you got your hair cut too.
FASKIANOS: It does look like you got your hair cut. Or was that a home cut?
GUPTA: It’s my wife’s incredible cut. But, no, so I guess yeah. Sort of semi-normal.
ROBBINS: Thank you so much.
GUPTA: Thank you for having me.
FASKIANOS: Thank you, Carla Anne Robbins and Dr. Vin Gupta. This is fantastic. We really appreciate it. We will be sharing out the recording and transcript of the webinar. We’ll also include links to the URLs that Dr. Gupta mentioned. You can follow Carla on Twitter at @RobbinsCarla. And you can follow Dr. Vin Gupta at @VinGuptaMD. So go there for more information on what he’s thinking about. Also his commentary on the news outlets. We encourage you to come to CFR.org for the latest and greatest on COVID-19 and other situations around the world, because the world keeps moving even though we’re in this pandemic. And please feel free to send us your ideas and suggestions for other issues and people you want to hear from as we continue this series over the summer. You can email [email protected]. So thank you all.