Take as Directed

Dr. Gigi Gronvall, a leading international expert on tests, kindly joined us for a spirited tour d’horizon. People need tests for multiple purposes on a continuous basis: You “can’t just get one test and forget it” since a test is just one moment in time. Sometimes however there are unrealistic, outsized expectations that tests will peer into the future. Why is the United States so prone to stumbling on tests? In 2020, responsibilities were thrown to the states, and antibody tests in the early days, approved by the FDA, were “the wild west” where often you could get a more accurate result “from flipping a coin.” In 2021, “a supply and demand market model” for antigen tests predominated, and when demand collapsed, Abbott destroyed millions of doses. More recently, since September of 2021, and accelerating under the pressure of Omicron, things are improving -- but “turning the ocean liner” is slow. The $3 billion investment in affordable antigen supply and accelerated development of new tests is showing results. The more recent commitment by President Biden to provide 500 million antigen tests through the mail to Americans has promise. “People want health information about their own bodies … people want access to tests. They know it is possible.” "Perhaps that progress can be extended in the future to home flu tests.” Dr. Gronvall also shared her thoughts on the Covid-19 controversy: put a focus on animal health and cleaning up live animal markets. And yes, we should cooperate with the Chinese: “You could get people together to exchange baseball cards and it would be productive.” So why not focus on vaccinating the world? On widespread, pernicious misinformation: “cut off the poison” immediately at its source and invest in long-term education.

Dr. Gigi Gronvall is a Senior Scholar at the Johns Hopkins Center for Health Security and an Associate Professor in the Department of Environmental Health and Engineering at the Johns Hopkins Bloomberg School of Public Health.

Ashish Jha reflected as the year closes. Communications are now fundamental to public health. Most critical is to speak as though you are engaging friends or family who are outside medicine. Put the decisions in terms of your own family. Don’t tie masks and vaccines to political identity. The lessons of 2021? We were surprised by 20-30% of Americans unwilling to be vaccinated, by Delta’s power, and by limits to the federal government’s power. FDA and CDC remain weak and muddled. “Process and nonsense” delayed a booster decision for three months. What’s in store for 2022? Coping with omicron will be tumultuous. Americans are exhausted, frustrated, and angry, which will narrow the tools at our disposal. We may see 50-80 million infected with omicron. Over the long term, if we settle into 30,000-50,0000 Covid-19 deaths per year, on top of flu, that will overwhelm our health system. We need now to institute fundamental changes in ventilation, test and trace, and other capacities. The international environment? Friends in South Africa emphasize that “the problem in South Africa is what you export to us – Tucker Carlson.” Biden has not done a good job internationally, has lacked bold leadership or any strategy. US global engagement “feels like an afterthought.” A national commission on the pandemic “is undoubtedly urgently needed.” Simplistic narratives do not serve our nation. Build on the emerging consensus: this is not the last pandemic; our agencies are ill-prepared; states need stronger public health capacities. Republicans and Democrats are more united than divided over these issues. Public health education is in need of an overhaul to work effectively in both red and blue states, engage the public, and broaden to enlist social scientists and security experts.

Dr. Ashish Jha is Dean of the Brown University School of Public Health.

Philip Zelikow, former Executive Director of the 9/11 national commission, has for the past year directed the Covid-19 Commission Planning Group. He visited with us to explore where that effort stands, should a national commission move forward? How and why? It is “absolutely essential to take account of this sprawling crisis.” Our performance to date, despite our “magnificent edifice” of science and modern health tools, has been far worse than during the 1918 Spanish flu. A national commission can counter polarization, offer an alternative that unites citizens. It can avoid the “gotcha blame game” and construct choices made – the values, tools, and information that shaped critical decisions. Most of the story of what happened is in fact not yet well known or understood. A commission is “a bridge to rethink the American health system.” “Does anyone think the American health system is fine?” There is an urgency to act in 2022, while pain and memory are fresh before we turn our attention elsewhere. We cannot wait until a pause: “the disease is going to run for a while.” The political momentum behind a commission is rising: we see a bipartisan Senate effort behind new legislation, and a recent strong endorsement from Dr. Anthony Fauci.

Philip Zelikow, White Burkett Professor of History at the University of Virginia, directs the Covid-19 Commission Planning Group. He previously was executive director of the 9/11 commission

Dr. Richard Lessells is among the exceptional South African experts on the front lines of discovering and investigating Omicron in South Africa. Alarm bells went off within the scientific community, as it became clear after just a few days that “an extraordinary number of mutations” are clustered in the key regions in the genome for immune protection and transmissibility. It was a “gut feeling. ” Omicron is highly transmissible, spreading very efficiently in a population with high levels of immunity gained from previous infection and in some cases from vaccination. How long to know just how dangerous Omicron is? It’s “too early to tell.” Lab work is underway to understand whether the virus affects T cells which are central to immune protection against severe disease. Why do we see such an unusual variant in South Africa? One theory, which Omicron may shed light on, is that the SARS-CoV-2 virus finds hosts who are very immune-compromised, persons living with HIV but not on anti-viral therapy. These individuals have difficulty clearing the virus, which permits it to replicate constantly over a very long period. Is this moment a pivot in the pandemic? That depends on whether Omicron significantly sets back vaccine protection, which would be a “step change.” Will this moment shock the world into more concerted global action, superseding the pattern of “vaccine apartheid”?  “I remain skeptical.” In the meantime, we have to fight against Omicron being fitted to a politicized narrative: by anti-vaccine groups, to tell the story that vaccines do not work. By others, to argue that there is nothing to worry about, that the virus is becoming less pathogenic, based on anecdotal evidence. 

Dr. Richard Lessells is an infectious disease physician at the University of KwaZulu-Natal, in Durban, South Africa. He is a member of the Network for Genomic Surveillance in South Africa, and a researcher at CAPRISA, the Centre for the AIDS Programme of Research in South Africa.

Dr. Taison Bell, MD, an acclaimed African-American doctor, educator, and emergency medicine director in Charlottesville, Virginia, shares his personal story of how medicine – back home in Virginia – became the center of his life. “Success was not assumed in my neighborhood.” As a child with asthma, he connected with his physician, as he did also with his Black dentist and several teachers. Such “affirmative experiences” made the dream “seem like it was achievable.” In retrospect, “so many things had to align at the right place and right time.” The pandemic now puts a premium on doctors becoming communicators. “Things will not be the same from this moment forward.” “People arrive in my ICU because they are unvaccinated… People are generally willing to trust their local provider in their community regardless of what side of the aisle they are on.” But “everyone has an opinion, some spread by misinformation.”A recent conspiracy alleges doctors put patients on ventilators to intentionally make them sicker. “That has become one of the toughest parts of care.” You have to have a “therapeutic alliance” and trust with the patient and family. When those do not exist, it almost always does not end well. Boosters a good thing? Yes, though “everyone has good points.” Talking openly about how he makes decisions with his family during the pandemic makes him “relatable.” It opens a window into how he is processing things. 

Dr. Taison Bell, MD, is an assistant professor of medicine in the divisions of Infectious Diseases and International Health and Pulmonary and Critical Care Medicine at the University of Virginia. He is also the Director of the medical intensive care unit (ICU) and director of the UVA Summer Medical Leadership Program.

We asked Cary Funk, Pew Research Center, to make sense of how the pandemic has impacted our society and American opinion as we approach the pandemic’s two years. “It can be confusing.” Polarization now increasingly aligns between the vaccinated versus the unvaccinated, versus simple partisan identity. At the fundamental level, Americans are split over whether Covid-19 is a common problem. Does the “Big Lie” bleed over into the field of public health? “It’s all complicated.” “The political lens” increasingly encompasses so much of public health, accelerating the erosion of public trust and confidence in science, a trend that had already been underway for years. False statements can travel the globe in 48 hours, but knowing the impact is much more difficult. Are we at a turning point, a softening of polarization? “We need to wait and see.” Heightened US international engagement enjoys majority support and has not become politicized. What is the impact of the loss of 757,000 lives on opinion? We have to continue looking at that. 

Cary Funk is director of science and society research at the Pew Research Center.

From September 17-October 1, Suzanne Brennan Firstenberg created the largest participatory art installation on the Washington National Mall since the AIDS quilt of 1996, entitled ‘In America: Remember,’ composed of 700,000 white flags, in the shadow of the Washington Monument. A stunning achievement. Listen to her reflections on listening to those among the 16,000 who personalized a flag to memorialize their loss. “So many of these deaths happened in isolation.” The project unfolded amid our bitter divisions: “ We are tearing ourselves apart as a society.” 35,000 died unnecessarily over the two-week course of the installation. Remarkably, though, she succeeded in creating a solemn, quiet, respectful space where it was “safe to bring one’s grief” and escape our politics. Does this memorial create a lasting constituency that will press for a national commission? Any memorialization has to include an in-depth examination of what happened.

Suzanne Brennan Firstenberg is an artist based in Bethesda Maryland.

Dr. Richard Brennan, WHO Emergency Operations, sat down this week with Steve and Professor Leonard Rubenstein, Johns Hopkins Bloomberg School of Public Health. Rick has been at the very center of urgent efforts, following the Taliban’s coming to power in mid-August, to avoid the collapse of Afghanistan’s health system, through fast-moving negotiations to bring emergency funding, opening air links, resuming Covid-19, polio, and measles immunization programs, and delivering emergency medical supplies. The political and security complexities to achieving these short-term, emergency stop-gap measures remain formidable, and the space for striking deals exceedingly narrow. How has the Taliban leadership seen things, and how did they agree to these initial measures which have to operate outside their control, a precondition of donors? What is the space in which he and others can find financing solutions that will sustain the health system long-term? Pressures upon WHO Emergency Operations in Afghanistan, combined with demands in Lebanon, Yemen, and Syria, have escalated to levels that greatly exceed capacities. What is to be done now?  

Dr. Richard Brennan is Regional Emergency Director, Eastern Mediterranean Region, World Health Organization.

Dr. Jennifer Nuzzo has emerged as a forceful expert voice making sense of the complex and times confusing, shifting shoals of the pandemic. ”All of us have had to step into this sphere,” filling “a power vacuum.” It has however been chaotic. Public communication is essential “to move the needle” but the experience can be “tough.” Vocal experts are the subject of attacks, the worst during the Black Lives Matter protests. The field of public health needs to invest more in how to message on vaccines. People are "swimming in disinformation.” Though she is “cautiously optimistic” for the United States, “no one is going to run out the clock on this virus.” For poor countries, which increasingly are in desperation abandoning a response, the future is “bleak.” Are we numb to the more than 700,000 dead Americans? Perhaps. It’s impossible to wrap our minds around this scale of death in America. There is a need for a “national reckoning” through a commission, “a true opening of the books that goes deep.” Have we entered a new era of high-level diplomacy? “No.” “We don’t have a Covid control strategy” at home or abroad. The lack of strategy is causing people to disengage. Can we be optimistic? “It can feel like there’s an unraveling” but that in fact is not happening.  A “civic spirit” among citizens is buoying America.

Dr. Jennifer Nuzzo is a Senior Scholar at the Johns Hopkins Center for Health Security and an Associate Professor in the Department of Environmental Health and Engineering at the Johns Hopkins Bloomberg School of Public Health. She is also a Senior Fellow for Global Health at the Council on Foreign Relations.

On October 7, Andrew and Steve sat down with a close friend, Georgetown’s Prof. Larry Gostin, for a lively live-cast conversation about his new book, ‘Global Health Security: A Blueprint for the Future.” The podcast captures that rich, vivid exchange. The big messages: We underestimate the power of the SAR-CoV-2 virus: it is wily and pernicious and will continue to surge. We cannot forget anti-microbial resistance. A fundamental shift is needed in the US international approach – away from charity and towards advancing technology transfer to manufacture vaccines in low and middle-income countries to create resilience. That requires far greater pressure upon Moderna and Pfizer to cooperate in meeting urgent global needs. The USG has the legal authorities to make that happen but has not yet followed through. USG health communications have been “pitiful” and left the public “utterly confused.” That too can be corrected.  

Professor Lawrence O. Gostin is University Professor at Georgetown University where he directs the O’Neill Institute for National and Global Health Law.