Rudyard Griffiths: Welcome to tonight’s Munk Dialogue. The purpose of these Munk Dialogues is to get our minds thinking about not the effect of this pandemic on us today or tomorrow, but how it is going to change our society in the months and years to come. Over previous episodes with people like Fareed Zakaria, Mohamed El-Erian, Samantha Power, Malcolm Gladwell, we focused on topics ranging from global affairs to the economy.
Tonight we will dig into preparing for the next global pandemic.
Our conversation this evening is with Scott Gottlieb. We have the opportunity to have a far-reaching conversation with one of America’s most interesting voices on this pandemic. He has an impressive resident resume: He’s a doctor of internal medicine, professionally trained at Mount Sinai. He was the head of the U.S. Food and Drug Commission. He is a board member of the drug-maker Pfizer, a CNBC contributor, and a resident fellow at the American Enterprise Institute. Scott Gottlieb joins us tonight.
This interview has been condensed and edited for clarity.
Rudyard Griffiths: What is the objective of the public health objective? Is eradication realistic, or is it really about a policy of containment?
Scott: I don't think eradication is realistic. Our goal should be to try to limit spread as much as possible, taking reasonable steps that allow for economic activity and other public health functions but prevent the risk of another epidemic. Try to protect vulnerable populations, meaning getting testing and resources into at-risk communities and work sites.
I think this is going to become an endemic illness, meaning an illness that just continues to circulate. I think it will eventually settle into a more seasonal pattern as other coronaviruses do – there are seven circulating coronaviruses. They’re all seasonal infections but mostly they circulate in the late winter. Mostly they cause a common cold. Sometimes people get more significant pneumonia.
This might end up being like the flu: something that we get vaccinated for on an annual basis, and it causes a certain amount of death and disease, but we are able to mitigate it with smart steps in the winter.
I think what we’re trying to do now is get to the point where technology can help us more fully vanquish this, when we have a vaccine and effective therapeutics.
We’re going to need to be vigilant from here until that point. Hopefully that will come sooner than later. I don’t think a vaccine for distribution to the general population is really a 2020 event. I think it’s a 2021 event. We’re going to need to be vigilant and do a lot of things to try to contain the risk of respiratory illnesses more generally heading into the fall and winter.
Rudyard Griffiths: Let’s talk about risk: How concerned are you about the risk of the second wave this fall, and the potential scale of that wave?
Scott: I think there will be a spread in fall and winter, but what constitutes a second wave? Will the second instance of this be bigger than the first?
We have better tools heading into the fall, in terms of better screening technology. We’ll have more therapeutics. Hopefully, we’ll have additional drugs coming online in the fall. Better testing, better surveillance, better awareness. We’re not going to be caught off-guard this time.
But we’re also going to be heading into a fall and winter flu season. The circumstances for wider transmission are greater. Right now, at least if you think about Canada and the United States, this really became epidemic as we were heading into summer. There’s probably some seasonal aspect here, we caught a break in terms of when this happened. As we head into some reopening, it’s the summertime. That’s going to be some backstop against transmission.
But we’re not going to have that benefit heading into the fall and winter: the months when this pathogen is going to be most efficient in its spread. It’s going to collide with the flu, and that’s going to confound our ability to diagnose it quickly. This is a real challenge.
In countries and even cities where there were epidemics, only a small percentage of the population had this. We’re a long way from herd immunity. There are a lot of people who are still vulnerable to this.
We have a very, very fertile ground for COVID heading into the fall in the winter in terms of a population that’s been largely unexposed because our mitigation was successfully able to contain the epidemic before it got out of control.
What about anti-vaxxers
Rudyard Griffiths: During COVID-19 and in future pandemics, how should governments, public health officials and citizens deal with anti-vaxxers and anti-contact-tracing individuals? Is this a wake-up call for anti-vaxxers? Are you concerned that people will not use a vaccine, and that the spread goes on longer than necessary?
Scott: Yes, I’m very concerned about this. If you look at vaccination rates generally, there are vaccines that are highly effective and very safe, and we don’t see vaccination rates with levels that they should be. Only about half the population gets vaccinated for the flu each year.
We don’t see people taking advantage of vaccines, and we see far too much spread of infectious disease and far too much disease and death from these diseases that could be managed much better if vaccination rates were higher.
We need to do everything we can to try to inspire confidence in a new COVID vaccine. That means making sure that [the vaccines] are put through appropriate clinical trials, and that we don’t short-circuit that process at all in an effort to try to get vaccines to the market more quickly. We need to be sure we have robust datasets and can demonstrate with a high degree of certainty the safety and benefits of these vaccines.
That way when reasonable people look at the data sets, they could have confidence in them, and we could get as many people vaccinated as possible. These are going to be novel vaccines, novel platforms that we’re developing these vaccines on, which will lend itself to doubts and questions that could make people skeptical in a way that could have an adverse public health impact.
The World Health Organization
Griffiths: President Trump has threatened to withdraw the United States from the World Health Organization. What is your position?
Swisher: I think the WHO was far less effective than it could and should have been. I think they were too late to speak with a clear voice about what was going on in China, slow to press China to make more information available.
We have to do a lot of evaluation on how to make sure this doesn’t happen again, make sure we have a more functional world health body.
I don’t agree we should be defunding it. This is the wrong time to weaken the organization still further, especially with the risk that COVID is going to become epidemic in the southern hemisphere – a lot of those nations lack access to public health infrastructure, and they rely more on the WHO.
I think we need to re-examine the WHO after this public health emergency passes and do the best we can right now to press them to do a better job in the setting of the current epidemic.
Griffiths: How important is a national testing strategy for the United States? And why is it so hard for us to mobilize such a strategy?
Swisher: The reality is that there are certain things the federal government can do to support these activities, but they are going to be largely left to states. Some states are doing a better job than others at getting this infrastructure in place.
Heading into the fall, at least in the United States, the big challenge isn’t necessarily going to be on the back end – the platforms for running tests, which was a challenge this go around. We just didn’t have enough labs and PCR-bases machines to run the tests. We’ve gotten scaled up dramatically: we’re now running about 400,000 tests a day, but initially were running about 10,000 tests a week.
That capacity is going to continue to grow. A federal official suggested we would have capacity to do 10 million tests a week – that’s probably right. The challenge isn’t going to be the back end – running the test – it is going to be the front end: who is collecting the test?
Likely we have a situation where a lot of people don’t want to do COVID testing. If you turn over a positive case, then you’re going to have to shut down your office. Or if you’re doing testing at a certain site, like a pharmacy, people won’t want to go into that pharmacy because they think COVID patients might be coming in to get tested. You could have a lot of places to say, “No, we don’t do COVID testing. If you think you have it, go to this special test site.” That’s going to limit access.
If we end up relegating testing to special sites, and it’s not ubiquitous in the community, that will greatly limit our ability to do mildly symptomatic and asymptomatic testing. What you want to be doing is swabbing everyone. Everyone who shows up at the doctor’s office with anything suggestive should be getting tested in the fall. I worry that’s not going to happen. We need to be thinking about how to get testing in a ubiquitous fashion into the community.
Griffiths: If a vaccine is developed, do you foresee a shortage? If so, will distribution be staggered so those who are most vulnerable get it first? Or will some nations and groups benefit first at the expense of others? There are the ethics, but what’s the reality, if, say, China develops the first working vaccine?
Swisher: China might develop the first working vaccine. China is using older technology to develop their vaccines. For the most part, of the four vaccines that are furthest along, three are inactivated viral virus vaccines, which is an old approach, and is probably going to confer less immunity, but it could be much faster to market and easier to scale.
And so they might develop the first vaccine. It might not provide as robust immunity as some of the vaccines using the newer technologies that Western countries are trying to develop. But it could be quicker.
Ultimately the reality is we need more than one large manufacturer to be successful here. If we have one manufacturer being successful, we’re going to be severely supply constrained.
The vaccines are likely to be licensed for higher-risk populations first. You’re likely to see vaccines targeted to higher-risk individuals who can derive more of the benefits of the vaccine. You might not vaccinate people under the age of 30 or 20.
As far as nations are concerned: If you look back to 2009 with H1N1, we had a situation where countries that were manufacturing their vaccine supply outside of their country in other nations, those nations held onto the supply until they satisfied local needs.
That was with a flu that, while virulent, was far less virulent than coronavirus. Every country that gets the vaccine is likely to make sure they can satisfy their local public health needs before they make more equitable distribution of it.
This first vaccines that come off the lines are not going be a million doses on day one. The supplies are going to ramp up. Initially, you’re going to be supply-constrained. You’re going to have to make allocation decisions. Countries are going to behave the way they have historically, which is, “Make sure I have enough for at least a portion of my population I’m most worried about before trying to make more equitable distribution.”
That’s just the reality of what’s going to happen, based on historical precedent.
Watch the full Dialogue
Join us for the next Munk Dialogue
Next week, a conversation with New York Times columnist, political commentator and best-selling author, David Brooks on how our politics and society will be different after COVID-19.
- When: Thursday, May 28, at 8 p.m. ET
- Where: tgam.ca/live
Globe readers can submit questions by e-mailing firstname.lastname@example.org.
Previously in the Munk Dialogues
April 9: Malcolm Gladwell
April 15: Fareed Zakaria
April 23: Mohamed El-Erian
April 30: Samantha Power
Visit munkdebates.com for more information. The livestreams will also be embedded on The Globe and Mail website.