Scott Gottlieb on the future of pandemics and public health after COVID-19


Welcome to the munk debates podcast every episode we normally provide you with a civil insubstantial debate on the big issues of the day but our world as we know it has changed and so has our format for the next few weeks. We're bringing you a special series. Called the monk dialogues we invite the sharpest minds and brightest thinkers for one on one conversations live on facebook to reflect on what our world will look like after the covid nineteen pandemic. These dialogues provide you the listener with original insights into the pandemics impact on everything from our shared values to the economy to international affairs. This week we bring you former commissioner for the Food and Drug Administration Dr Scott Gottlieb in conversation with rudyard griffiths. This isn't edited version of the live event. Recorded Thursday may twenty first tie. I'm Richard Griffiths. The host of the monk dialogues and welcome to our program this evening on. Tonight's edition of the Bunk Dialogues. Where the opportunity to speak with one of America's leading commentators and analysts on Covid Nineteen. He is the former. Us Commissioner of the Food and Drug Administration. He's a board member of Pfizer the drug maker. He's a member of the group known as the American Enterprise Institute where he's a resident fellow and he's a contributor at C. N. B. C. Ladies and Gentlemen please welcome to the monkey dialogues. Scott Gottlieb be here. We'll Scott as we discuss. The purpose of these dialogues is really to get all of us thinking about the impact of Covid nineteen on our society on how we're going to work how we're GonNa live the future of just about everything and to do that. By stretching our minds into the future thinking about what are the repercussions what are the effects of this pandemic? Not Tomorrow or next week but in the months and years to come and again thank you for being on the show. I think you're uniquely suited to help us in that intellectual journey so let's begin by asking you. There was one thing that you were Gonna. Kinda pull out of the last two or so months of our experienced this pandemic one lesson that you would think that we need to really dial into and dig into when it comes to understanding. The future of these pandemics going forward. What would that one thing that one lesson be for having me here tonight? I think we felt. We will much better prepared for this kind of risk and we ended up being. We had spent years doing pandemic planning mostly for influenza. We were worried about a bird. Flu Not really started here in the United States. Back in two thousand and three two thousand and four in earnest. We started significant. Planning exercises for the risk of a pandemic influenza and we built out an infrastructure for testing for surveillance for diagnostic capabilities for stockpiling certain equipment. That we felt we would need sending over pandemic and I think what we learned in. This tragedy is far less well prepared than we thought we would now. This was a corona virus. It wasn't influenza. But a lot of the things that we didn't anticipation of the risk of pandemic flu should have been applicable here and we should have been better prepared and the one thing I think ended up being a challenge here and surprise a lot of was the lack of diagnostic capability the inability to get diagnostic testing in place. Quickly the underfunding of public health labs and the public health infrastructure and just generally being able to deploy a diagnostic quickly to do surveillance that we would be able to detect spread before it got too late before you had too much spread that you're at the point that you really have an epidemic underway which is in fact what happened in the US. We were dependent upon syndrome. Rick surveillance data feeds of like how many people were visiting emergency rooms in that kind of information because we didn't have the ability really to test people until we got into late February early March Scott. We'd historian Neil Ferguson. On when I asked him Macau will historians write about this moment. His feeling was that the focus would be far more on the response than the the virus itself and the initial outbreak. What do you kind pull away again as the key insight or lesson from our response in particular these shutdowns hindsight is always twenty twenty and we never want to second guess people who have to make very difficult decisions in real time but will we look back on this and wonder did we do. The right thing did react appropriately to the risk that we faced. I think we had no choice but to do what we did here. In the United States at least the scope of the epidemic that was underway in cities like New York in New Orleans and Chicago in Detroit without the kinds of population base mitigations. This shutdowns the stay at home or is that we implemented the health system would have been overrun and we talk a lot about the public health implications of the shutdown and there will be significant public health implications of the shutdown we see vaccination rates way down. People missing cancer screening. We see people skipping. Chemotherapy visits and so there's GonNa be lots of implications public health implications on the back end of this that we're going to be analyzing for a long time. But the reality was that there was no public health system so long as cova was spreading epidemic in major cities in New York City. Affectively became a couvert only healthcare system. You couldn't get healthcare in New York City hospitals for the most part unless you had an emergency or cove illness network literally hospitals that were made cove only including one that I used to practice that in in elmhurst Queens. We simply had to break the epidemic. And I think what we didn't know at the time. This was becoming epidemic in no cities that I just mentioned now. In hindsight there were parts of the country that will largely untouched by this where the risk was much lower. Where wasn't spreading? We didn't know that at the time. We didn't have good surveillance in place so we couldn't really adjust mitigation to just focus on those places that will hot spots where the greatest risk was and try to ring fence the infection in those regions. We didn't have the testing to do it. We didn't have the preparation to do it. And so I think one of the things that will be debated was was there a strategy where you could have targeted the areas where the spread was the greatest and let other parts of the country. Relax a little We did that to some degree. Not every state and not. Every city implemented the same measures in the federal government left it largely up to states governors to make decisions about mitigation for that reason because different regions experiences very differently but generally there was effectively. A national shut down for a period of time and not every part of the country face the same risk but I think. In retrospect we had to do what we did because on one hand we didn't know who is at risk and there were a lot of cities at significant risk and we simply had to break the epidemic to get to a point where we can now focus on you know people who are infected with the disease and move towards what we call case based interventions trying to focus on containing the infection by identifying individuals. Who are infected gave diagnosed early. Hopefully getting them isolated so that you can limit spread with this pandemic Scott. An and once in the future over the next couple of months Into the next year. What is the public health? Objective visit to eradicate covert nineteen. Is it to manage. Simply the rate of transmission so that healthcare system can continue to function and provide a breadth and depth of services that we expect. What is the goal that were trying to manage towards the questions? That came in tonight for you. I I think there's a sense of confusion amongst the public right now about what they're hearing in terms of the messages coming out of different public health authorities at different levels is a radicalization realistic or is it. Really about a policy of containment well. I don't think eradication realistic. I think what 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 to go on but prevent the risk of another epidemic and prevent the risk of spread. That's uncontrolled in a way that we lose control of the infection tried to protect vulnerable populations meaning getting getting testing resources into address communities at risk worksites. Not everyone's equally vulnerable to this near groups that are uniquely vulnerable to this because of the way they work people who can't naturally social distance at work or people who live more crowded. Housing circumstances are lack access to testing in healthcare. In the first instance. So we need to make sure. We get testing resources into those three days. But we're not gonNA build a radically this. I think this is going to become an endemic illness. Meaning illness just continues to circulate. I think we'll eventually set into a more seasonal pattern as other grown viruses do their seven circulating corona viruses. They're all seasonal infection most of them. 'cause a common cold sometimes people get more significant pneumonia from them but mostly they circulate in in the late winter and this might end up being like the fluid might end up being something that we get vaccinated for in an annual basis and it causes a certain amount death and disease. But we're able to mitigate it with steps into wintertime in terms of improved hygiene and making sure we get vaccinated and eventually we'll hopefully up therapeutic sport and we're trying to do now is by time to get to that point win. Technology can help us more fully vanquishes when we have a vaccine when we have affected therapeutics. And so we're going to need to be vigilant from here until that point and hopefully that will come sooner than later. I know we're going to talk about that a little bit. But we're probably not going to have that at least available for mass use in the fall. I don't think vaccine. For distribution to general population is really a twenty twenty event. I think as a twenty twenty one event and so we're going to need to get one more cycle with covert. We're GONNA need to get through a fall to winter season with covert when this is GonNa be colliding with flu. And when the risks of epidemics spread again gunning increase. And we're going to need to be vigilant so we're going to need to do a lot of things to try to contain the risk of respiratory illnesses. More generally heading into the fall and winter. I don't WanNa put you on the spot. Scott to make a prediction you're much more sophisticated analysts than that. So let's talk about risk. How concerned are you about the risk of the second wave this autumn and the potential scale there of that way? But I mean we're all looking back at the charts of the one thousand nine hundred thousand nine hundred nineteen pandemic where really it was the second wave that was significant killer in that influenza outbreak. Is THAT INEVITABLE WITH COVA. That the the second wave going to be bigger. It seems like a lot of states are opening a lot of provinces here in Canada varying degrees of controls in place limited testing in some areas limited contact. Tracing does all of that look to you. Like a bit of a recipe for a heightened risk for a large second wave but I think that will be spread in the fall and winter. What what constitutes a second way will the second instance this be bigger than the I will become epidemic. I think we have better tools heading into the fall. In terms of better screening. Technology will have more therapeutics. Hopefully we'll have additional drugs coming online in fall. Better TESTING. Better surveillance better awareness. Not going to be caught off guard this time and so hopefully we can prevent that. But we're also going to be heading into a fall and winter season when this is GonNa be colliding with flew into the circumstances for wider transmission or greater. We'RE GONNA be heading into the months when this pathogens going to be most efficient in terms of spread and it's going to clog the flu that's going to confound our billion diagnosis quickly so this is a real challenge. I mean I think we face risk when you look at the data globally and you look at the exposure to cove right now. You Look at France. Spain and Sweden Zero prevalence studies studies looking antibodies. And people which identifies whether they've been exposed to it runs about five percent. You look at cities like Milan. Barcelona Paris percents seven percent of those cities have been exposed to covert either a symptomatic in or they developed covert the disease Paris. In Wuhan seroprevalence studies were ten percent here in the United States. You look at places that were largely unaffected like Boise Idaho. One point eight percent but even in cities that were affected to a greater degree Boston ten percent Los Angeles may be ten percent. New York City's high at twenty percent New York state around twelve percent but the point being that around the world countries and even cities with epidemics only a small percentage of the population habits. Where a long way from her immunity and so there's a lot of people who are still vulnerable to this. I think by the end of the epidemic here in the US when you get into June maybe a third of New York will have been exposed to this. That's getting to levels where you're going to have some reduction in the rate of future transmission because you have a large portion of the population that's now been exposed but that's the outlier most cities most countries. It's only a small percentage of the population so we have a very fertile ground for covert heading into the fall and winter in terms of population. That's been largely unexposed to this. Because mitigation was successful able to contain the epidemic before it got out of control to even a greater degree and cause more death and disease. Okay Scott this is an important point for me to underline with you if I'm understanding you correctly because there's been a lot of discussion about again trying to think about the months to come the year to come and and people feeling some that herd immunity could be an effective strategy in other words that we allow the virus to spread. We shelter the people most at risk but our best protection about the virus is to get to a level of antibodies in the population. I don't know sixty seventy eighty percent. Whatever it is to effectively neutralize the effects of cove. It and it's infectiousness. Am I hearing you correctly that you do not feel that that is a valid public health strategy? I don't think it's a valid public health strategy for a variety of reasons. The one I don't I don't think you can just help. People who are older or co Morbid conditions have medical conditions and put them in higher risks. That they've got stay at an everyone else can go out and when you start adding up the number of people who have conditions put them at a higher risk of a bad outcome here diabetes heart disease lung disease. People who have autoimmune diseases are immunosuppressant drugs it ends up being a very high percentage population people over the age of sixty five. You're getting into pretty big numbers when you look at the data you know forty five. Didn't fare so well with us. When you look at hospitalizations in your calf hospitalizations were under the age of fifty five so there are a lot of young people now realizes more people under the age of fifty five and over but there there were a lot of young people younger people middle aged people. Getting into trouble with this This disease as well and look at the level of death and disease that we sustained with a relatively small percentage of the population being affected. So even if you if you believe the date New York for example and you believe twenty percent of New Yorkers been infected so about one point seven million people have either had covert or been infected with us. At the time that we did that study there were about seventeen thousand diagnosed cases. Seventeen thousand deaths. Excuse me that's infection fatality rate one percent which means the case. Taliban rate is much higher because people who are infected at least thirty or forty percent of them don't develop symptoms. The the case fatality rate is how many people who developed the disease succumb to it. So it's always going to be higher for diseases where you have a lot of asymmetric spread. That's a high rate of death for a disease. And that's in a setting where we were social distancing people who were vulnerable were staying home and we were still having infection rates at that level. So I think we're going to have to be willing to sustain a lot of death If we want to just let this course of population you look at Sweden people talk about Sweden adopting some element of that strategy. And I don't think Sweden really adopted that strategy. I mean people are social distancing. There they just let some of their restaurants and other things open but people aren't really going out all that much in Sweden. They have the highest tally per capita in Europe. Right now there's a long way from her immunity and and it's really just Stockholm. Other parts of Sweden. The exposure is very low. It's really just stockham. We see higher exposure levels. The seroprevalence study that was published recently showed about seven percent in Stockholm. That's again a long way from her media. I know some people have said it might highest twenty percent based on some other studies but even bat is approaching heard immunity level so I think that that strategy we do want to sort of go down that route and I don't think we do. We're going to have to sustain even more depth than than we have Scott Three quick questions. I've got my mind before I take audience questions number one for you as a parent of young kids. There's a lot of us out. There are schools coming back in the fall. Do you put a high chance of that. A high likelihood that children will be back in school and will they be back in school in large numbers. Will it be staggered? Will it be limited availability? What's your take on the kindergarten to grade twelve educational system for this autumn? I think they'll be an attempt to open the school this fall. I think we'll we'll hopefully if you sort of believe. My optimistic scenario will becoming office summer whim. We'll see cases. Continue to go down. There will be a seasonal effect. Here I think that the schools good implement measures to identify classrooms to try to have students only congregating smaller groups. You won't let one go out for recess and and mixed together you'll keep people within groups so you can do better contact tracing within the school in isolation if you do have cases. I think a lot of schools are GONNA look to implement testing in the school. I think you might see attempts to densify classrooms by going to maybe four days a week in classroom in one day week Taylor learning or doing some tele classes inside the school keeping people separated on computers. So I think there's things schools I know they're thinking about those things now. The districts have resources to do that. Not Every district does but I think they'll be an attempt to open. It is going to become question of what happens in the fall. I mean hopefully this scenario in the fall is we have really good screening place where able to detect cases early get people diagnosed. Get people isolated. They'll be communities that have outbreaks there. There might even be cities where there's a small epidemics or states will have to close things selectively some school districts to close down for a period of a couple of weeks as infections move through certain communities. But you don't see a a simultaneous national shutdown as seen now but I don't think we get through the fall winter without having to grapple with us in some fashion without seeing some schools closed. That's kind of like the h one n one season as well where you saw. There wasn't a simultaneous shutdown. The entire school system nationally here in the US in two thousand nine but you saw a school district shutdown as local epidemics arose in local communities. This mind you is more contagious than h one. N One final question before we bring in the audience here and that's to talk a little bit about what's happening closer to this moment right now. Which is we are seeing states like Texas. We've had recently here in the province of Ontario. An uptick in cases. You know the geographies you know the region's it some some areas. Maybe because they had very few infections have been the curve at a state level province level but there seemed to be other larger jurisdictions like Texas like Ontario where we're having real challenges right now in bringing this virus under control in terms of bending the curve down and yet right now this last week and going forward we're starting to open up. How do you think that's going to play out? Scott I mean do you think again. The seasonal effect will wash over or mask the the result that just populations are GonNa be mixing more and people are going to be within the parameters of transmission of what is as you said a very infectious virus. I think we're GONNA see a slow burn. I don't think we'll getting rid of this virus. I think we're GONNA consume continued spread. Hopefully level that's manageable. Hopefully people continue to practice. Good things in your individual lives that can greatly reduce rescue beverages The collective action. Everyone just going out a little last washing hands. A little more wearing masks cleaning shared services things like that once you distribute that kind of activity on on a population wide basis that has a big impact on the epidemiology spread. And I think people are going to have that vigilance. I worry more about the fall when people may become off relatively quiet in summer. And they kind of lose some of that They let their guard down a little bit. But we're gonNA see continued spread. Hopefully this summer does present the backstop in that Kinda Offset some of the increased bradberry. Look in the United States. You've seen if you look over the last three weeks you saw for the first two weeks hospitalizations coming down hospitalizations really the most objective measure the epidemic. Because you'RE GONNA see cases go up because we're testing more. We're going to be turning over more cases but you still hospitalizations. Come down for two straight weeks in the last week at best nationally. Seen SORT OF FLAT. Now but probably. You're seeing a little bit of uptake when you look at the seven day rolling average on hospitalization. So we're seeing cases bounce off little bit in the hospitalization data here in the US as we reopen now. That should surprise nobody. I mean we expected that as we ended these mitigation steps. We were going to have some bounce in cases. And that's why most of the plans warfare staged reopening not to do it all at once a dimmer as opposed to off switch. But we're going to have to watch that closely. You may have the slow what you're doing or even pull back some of the things you've done if you see. The cases bounced up too much. Look at states like Alabama right now. We are seeing uptick in cases and in cities. You're seeing the hospital. Start to fill back up there some states. And there's some cities here where there's some worrisome signs it's not nationally certainly but there are certainly some states and cities. Georgia's well. You've seen an uptick in hospitalizations in the last about week okay. That's a really good points hospitalizations that we need to be looking at understand what's happening in terms of the future trajectory and course of this virus. Scott I'm going to start bringing in some questions. And the first is from Nando. She's asking during covid. Nineteen and future pandemics governments public health officials and citizens deal with anti vaxxers and people who are against contact tracing of individuals. I guess people have privacy concerns. So what's your feeling there? Scott maybe just to elaborate on that question a is this kind of wake up call for the Anti vaxxers. I mean it wasn't increasingly powerful movement. Unfortunately I'll take side on this. I'm in favor of vaccinations. What's your feeling? How are you concerned? Maybe that in terms of people actually using a vaccine that they may not and as a result the burn. The spread goes on longer than necessary. I'm very concerned about this move. You look a vaccination rates generally people. There's there's vaccines that are highly effective in very safe. And and we don't see vaccination rates at the levels that they should be HP vaccinations around fifty one percent array of people gain the second vaccination from jacuzzis about fifty six percent only about half. The population gets vaccinated for the flu each year. The shingles vaccine which is effective only about thirty percent of people third of eligible people. That so we don't see people taking advantage of vaccines and we see far too much. You know spread of infectious disease in far too much disease and deaths from from these diseases that could be managed much better if vaccination rates were higher. I worry about in this context for sure. You know there are a group of people who are against vaccines call their safety into question there as a minority small minority but a vocal minority and spread a lot of fear. I believe that's misguided and misinformed about vaccines generally we saw that here in the US with the measles mumps rubella vaccine where people pulled away from Using vaccine we saw outbreaks of measles as a consequence of that and so I think we need to do everything we can to try to inspire confidence in a new covert vaccine and that means making sure that they're put through appropriate clinical trials 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 make sure we have. Robust data says and can demonstrate with a high degree of certainty to safety and benefits of these vaccines. So that when people when reasonable people look at the data sets they can have confidence in them and we can get as many people vaccinated as possible is going to be novel Vaccines Novel Platform that. We're developing vaccines are and. I think that that's going to lend itself to People. Being able to raise doubts and questions that could make people skeptical in way that can have adverse public health impact if people don't get affected vaccines is that part of your thinking. Scott about why maybe twenty twenty one before we have a vaccine for mass adoption because simply we need to do this right and to Russia vaccine out in the fall could have some unintended consequences. Which is a lot of people suspicious about the vaccine suspicious as to whether it's been as rigorously tested other vaccines in the past. That's exactly right. I think we need to put these proper. Clinical trials knows going to be ten thousand thirty thousand patient. Clinical trials large scale trials in in settings where there are outbreaks spread. I think we can use the vaccine experimentally in the fall in settings of outbreaks and try to ring fence the outbreaks using it therapeutically in wave to work but you're also using the context of a rigorous clinical study collecting data. So it's stole experimental vaccine. But you just deploying it in settings where. It could achieve a therapeutic purpose. In fact it's effective so you couldn't deploy vaccine as a tool but. I don't think that we're going to be at a point where we're going to have those data sets available to licensed vaccine for mass inauguration to think that you're going to have those large data sets available in time for this fall to license it to approve the vaccine for general use. I think that that's very aggressive and probably not real realistic. Even if we get in trials enrolled into summer you're not going to know with the spread is do not going to know where to those trials. You really almost have to wait until you have the outbreaks to enroll the trials if we start enrolling trials in July and August in Dallas and the outbreak ends up being in Little Rock. Arkansas enrolling ten thousand people in Dallas might not have been the right decision. You'RE LISTENING TO THE MONK. Dialogues a special edition of the. Munk debates podcast where we invite big thinkers to reflect on what our world will look like after covid nineteen this week former. Fda Commissioner Scott Gottlieb on the future of pandemics public health and their effects on the economy. Let's go to another audience question. I'll read it out for you. And we can go from there. And president trump is threatened to withdraw the United States from the WHO the World Health Organization is your position so Scott. What's your view on the? Who there's been a pretty strong debate about whether they were as neutral as they should have been vis-a-vis China and whether they were a slow off the bat here to declare global pandemic and touring the five alarm bell. That states around the world needed to get a headstart on preparations to try to reduce the effects of covid nineteen. I think the WHO here was far less effective than it could have been and should have been. I think it was less effective in the setting of the Ebola outbreak in western Africa than it could have been should have been and demonstrated the shortcomings of the W. H. O. I think they were too late to really speak with a clear voice about what was going on. In China this the scope the risks to press China to make more information available. So I I think it's an organization where we have to do a lot of evaluation on how to make sure this doesn't happen again and make sure we have more functional World Health Body but I don't agree with you be defunding it and this is a wrong time to weaken you. Organization still further especially with the risk that covert is going to become now in the Southern Hemisphere. Allow those nations lack access to public health infrastructure? Neighbor rely more on the. Who you'd think about parts of Africa? Parts of South America and so weakening the WHO setting when this could become epidemic in southern hemisphere. This isn't the time to do it. I think we need to reexamine. Who after this public health emergency passes and do the best? We can right now to press them to do a better job in a setting of the current epidemic. But I think a lot of this should be done after this epidemics past try to really reform that organization. Thanks got a great questions from the audience. So let's let's keep going here on this monk dialogue with Scott Gottlieb the former commissioner of the Food and Drug Administration a board member of Pfizer the drug maker and someone who's really distinguished himself as one of the most astute and thoughtful commentators and analysts on the covid nineteen pandemic so this question. Scott is from Sheldon this week to companies announced results with respect to preliminary testing Vaccine do these milestones mean. The chances of developing a vaccine have gone up or just that testing can continue and Scott. It's interesting maybe we can talk a little bit about one of your other hats the aware which is an analyst on CNBC. We've seen some very big market reactions to the Gilead Therapeutic. And now the Madonna vaccine a very preliminary study. I guess or test that they conducted in both instances very small samples. You could say that these are not even the first inning. It's maybe the first batter at bat in the first inning yet. This huge reaction response that. Do you think the two things are commensurate? Should we be as optimistic about talk about Madonna result past week? Well look I think it's encouraging I. I wouldn't necessarily say that we should be tremendously optimistic about any one of these vaccines but I think that what we see now is a number of early sets released about different vaccines that demonstrates that it should be possible to develop a vaccine against coronavirus. I think that's the real takeaway here we've now seen a number of different vaccine constructs some very novel constructs in case in return in. Marta contract which we haven't used before develop a licensed vaccine visors taking the same approach. We've seen a number of these constructs be able to in both animal models as well as now people induce the production of antibodies that should provide some level of protective immunity. And so that is statement. We couldn't make six weeks ago or two months ago. And so that's why. I think we should be more encouraged with respect to the Madeira data in particular. It's early. It was only forty five patients in all forty five. The data shows that the different vaccines that they use have three different doses of two hundred and fifty gram doses hundred microgram dose and twenty five granddaughters but in all three doses they able to generate the production of antibodies and people were what we call binding antibodies me. They bound the virus. What we don't know is where they neutralizing antibodies. Did they bind the virus and destroy the virus testing for neutralizing? Antibodies takes longer. Because you have to expose the antibodies to the virus in a special lab. It'd be a cell three lab a secure lab because this is now a special pathogen needs to be dealt with carefully. They only looked for the first eight patients on whether or not the vaccine was generating neutralizing antibodies. In fact it was in those eight patients and so I think a lot of people assumed well if it worked in the first eight patients. It's probably likely to work. In some proportion of the next thirty seven we don't know all neutralizing antibodies same. We don't know what level of protection is going to afford but we infer that. Oh probably afford some level of protection these these vaccines any of them probably aren't going to provide protection like we think of smallpox vaccine or measles vaccine where you're vaccinated and you can't get infected. Would this is probably GonNa be more like the flu vaccine? You can get infected. But it's going to reduce the severity of the infection and limit your ability to get Cova the disease. What about Scott. Are you concerned that the DNA sequences that were using now for a lot of this vaccine research is going on right now or primarily those that came out of the initial clusters on in Europe and viruses do mutate? Is there a risk here that we create a a series of vaccines that are based on kind of Kovin? One point zero and we move onto Cova two point zero and three point zero and four point. It's unlikely in a short period of time. So all mutate this virus mutating just because it's mutating doesn't mean that it's getting more dangerous or less dangerous more contagious less than pages. Or that's going to obviate technology. So we've looked at a lot of sequencing data now with this vaccine eylau this work comes lavish Trevor Bedford in the Hutch in Washington State. And what we see is the viruses undergoing drift but the part of the viruses genetic material that codes for the protein on its surface. That is the target of our vaccines particularly this spike protein. Which is the protein. The virus uses to invade ourselves the genetic material that codes that spike protein isn't undergoing as much change and it changes at. Its undergoing aren't changing that spike protein in a way that it should evade our antibodies to it and so it's undergoing drift and so we have a vaccine we might want to reformulate the vaccine every two or three years to get it more precise to what the current composition of spike protein is. But it's unlikely to be the case that we see such rapid mutations in the engines the things on the surface of the coat of the vaccine we target without antibodies that we do with the flu vaccine or with influenza. Where in a single season influenza? Sometimes we've seen undergoes so so many significant mutation so many significant changes obviates the vaccine for that season that that vaccines no longer effective. We're unlikely to see interest seasonal mutations happened so rapidly that this would operate a vaccine. But I think it's probably the case that when we do hopefully get a safe and effective vaccine. We're GONNA WANNA reformulate it on some semi regular basis to get it more precisely aligned with what the current predominance sequences for the parts that code for the region. The vaccines is targeting fascinating stuff. Scott do we know one hundred percent that this virus was not genetically engineered in a lab. I think we feel pretty confident that this virus wasn't manipulated and certainly wasn't like a bio weapon that was deliberately released and engineered and released to Epidemic causing an outbreak. I think there are still some question is we know there was a lab will Han. That was a high security lab. We know they were doing. Experiments with Corona viruses have been isolated from bats other species. We also know that lab didn't have good procedures and well before this well before this episode. You can go back two years ago. There was articles in science magazine. Some of the leading academic journals calling into question the safety procedures in that lab saying that they didn't have good controls in place the special pathogens and calling into question whether they should have been allowed to handle the pathogens. They were handling so I think there's some doubt in people's minds is. Could this have been an accident? Could it have been a lab accident? Where patient zero if you will wasn't someone who came into contact with an animal in sort of inadvertent way but someone who was doing an experiment and accidentally infected themselves maybe became as symptomatic didn't know they had the infection went out and became patient zero and spread it. We might never have an answer to that question. We're going to have to look at the store strain to some of the original infections to really get a sense of that and have much more information about what was going on in that lab and look at some of the strange that they were working with and we might never get that information. I mean it doesn't seem like China's making a lot of that available so I think liveliest theories in doubts gonNA persist maybe perpetuity. But when you sort of hear about people saying well Clinton's have been elaborate could have been something deliver. I think most reasonable people are saying. It's not something that was deliberate net someone releases deliberately by could have been a lab accident and I don't know that we can fully discharge that possibility. It's less likely I mean I think we think it's the less likely scenario may be far less likely scenario. But I don't think we can fully discharge it. Then I guess. Part of this dialogue is thinking about the future. How do we get controls internationally? In place to ensure that countries that maybe are not at the standard of candidates the United States in terms of lab infrastructure lab technology. Don't advertently or inadvertently release another virus. I mean are you optimistic that we have the international consensus to do that? Well no I'm not. I mean this isn't the only lab where has been questions raised in the scientific community out procedures in certain labs. There's been questions about labs in the United States where there were concerns that they didn't have proper procedures in place so we need strong international bodies to overseeing this we have them the World Health Organization. I think that they're not functioning as stringently or aggressively. They could be or should be and we allow certain countries to hold certain special pathogens. Who probably need to reexamine that and make sure that there is a better set of universal procedures in place for ensuring lab safety for the labs that are going to handle. The most dangerous pathogens now is going to be a lot of people who don't want to use this episode as he sort of rallying cry for that. Because there's a lot of people still pushing back on the notion that this could ever have been lab mistake. Miss had to have just been sort of a natural occurrence that this virus jump species went from a bad or another animal into humans. Probably that's the case. But you know. I think we're never going to fully discharge that doubt and I think we should reexamine Lab Safety more generally. It's an important call to be making. Okay let's get some more questions. This has been a great discussion digging in a lot of issues. That were certainly top of mind for me and for you. The Viewing Audience Mark. Warren is asking. How important is a national testing strategy for the United States? And why is it so hard for us to mobilize strategy and Scott can ask the same thing here in Canada? The scaling up of testing has been a persistent challenge. And I would say baby doubly so the scaling up of any large scale contact tracing system whereas Scott you know this better than most you look at countries like Taiwan South Korea China. Frankly they seem light years ahead on on both fronts. I think the reality is that allow these tasks gut are going to be largely. Left to states is certain things. The federal government can do to support these activities. But they're going to be largely left to states. Some states are doing a better job than others at getting in places infrastructure. I think getting into the fall least in the United States. The challenge isn't necessarily going to be on the back end the platforms running tests. Which was a challenge. This go around. We just didn't have enough labs in PC are based machines to run the tests. Scale that up. We've gotten a scaled up dramatically now running about four hundred thousand tests a day but initially running about ten thousand test a week and so has been scaled up dramatically in a very short period of time. But we got our lead start. I think that capacity is gonNA continue to grow. And we're when we get into the fall we're going to have the capacity to do one of these. Federal officials said ten million tests a week. That's probably right. It might even be more than that. Because we're going to have next generation sequencing we're GONNA have continued to scale piece based platforms. We're going to build massive screening with next generation sequencing. We're GonNa have many more pointed care. Diagnostic tests approved including Antigen based tests or literally. Squabble sticks that you can use in a doctor's office we'll have millions of those in the market and so they'll be ubiquitous availability of testing in the marketplace. I think the challenge isn't going to be the back end running. The test is going to be the front end. Who's collecting the test? And I think we're likely situation where a lot of people don't want to do. Covert testing because if you turn over positive case then you're going have to shut down your office if your provider or if you're doing testing at a certain segment pharmacy. People won't WanNa go into that pharmacy baking. Kobe patients might be coming in to get tested. And so you're GONNA have a lot of places a Saito. We don't do covert testing if you think you have it. Go to this special test site. And that's GonNa Limit Access When you call your physician in the fall and you say I think I have the flu. I feel like I have the flu. They're not going to say come in test you Kobe Influenza. They'RE GONNA say go to this special testing site if that's what ends up happening. And we end up. Sorta getting testing to special sites in. It's not really ubiquitous MMA community. That's going to greatly limit our ability to do mildly symptomatic nascent testing Is Kinda WANNA be swabbing? Everyone everyone who shows up at the doctor's office anything? Suggestive should be getting tested. In the fall I worry that's not going to happen. That's what we need to be thinking about how to get testing in a ubiquitous fashion into the community where everyone's conducting these tests. Scott his anyone talking just simply about swabbing anyone that goes into a GP. I mean regardless of whether you got flu symptoms or not you get tested and you just do that for the benefit of your family. Your Co workers and others. It takes a stigma away from it and it just becomes part of our regular checkup for the autumn and into the New Year. Look I've been advocating that. I don't think it's unreasonable idea. We WanNA basically get we call it sentinel surveillance system place where we're doing sort of routine screening of the general population trying to catch a symptomatic spread. And so how do you do that one way to do? It is to do a random sample the population and get them. And that's really hard because you have to find at random sample get tested them convinced him to get tested the other way to do it is just you screen such a large population but even if it's a selected population at ends up affectively being a random sample because you're screening so many people and one way to do that is exactly said if you go into your. Gp'S OFFICE THREE POINT. Eight million encounters with the primary care system every week in the United States. If you go in for a sore throat you get grown of our swab going for your annual physical. You get coronavirus swab. Go in for a sprained ankle. You get coronavirus swab. If we just sorta swab everyone for coronavirus shirts a selected population that's coming into the doctor's office but ending up doing so many tests routine basis that it ends up effectively being the statistical equivalent of a random sample or representative sample. And so I think what you're saying makes perfect sense but what I worry about is we don't get in place procedures now. We say if you're a physician's office and you do all this you you clean your office every night. You don't have a waiting room. Move patients directly into examining rooms. You make sure your staff is washing has between patients and maybe they're wearing masks. Whatever the procedures are but if you do all this and you diagnosed a covert patient your office. It's okay you don't need to do anything special. Maybe you clean the room. We need to get. In place. Universal precautions that allow doctors pharmacists others to diagnose covert patients in routine settings without having to go through extraordinary hoops every time they do. If we don't they're not going to do the tests they refer patients away and we're never gonNA get to what you're talking about. Yeah no it's important not to build those deterrence into the system. Okay lots of good questions. Here let's get some more end when this from Terry Scotch. He's asking if a vaccine is developed for ceus shortage if so we'll distribution be staggered so those who are most vulnerable get at first or will some nation and groups benefit. I at the expense of others. It's a big challenge Scott. I'm sure it's one that you and your fellow board members at Pfizer. Think a lot about there are the ethics. I think we all get. That is the aspiration. But what's the reality? Scott say say China develops the first working vaccine and China might develop the first working vaccine Chinese using older technology to develop vaccines are using for the most part of the vaccines and furthest along three are inactivated viral virus vaccines which is an old approach probably is going to confer less immunity but could be much faster route to market an easier to scale and so they might developed. The first vaccine might not provide as as robust immunity of some of the vaccine using new technologies. That Western countries are trying to develop but it could be quicker. I think ultimately the reality is. We need more than one manufacturer more than one large manufactured be successful here because we only have one manufacturer being successful getting press finish line. We're going to be severely supply constrained not just within the United States but globally not just globally but even within a country. We're not gonNA have enough and I think that the backstage a likely to be licensed for high risk populations I. I think you're likely to see some as not really rationing. You're likely to see the vaccine targeted to high risk individuals who can drive more of the benefits of the vaccine so you might not vaccinate people under the age of thirty or under the age of twenty. Those kinds of decisions are likely to be made as far as nations are concerned if you look back in two thousand and nine with h one n one we had a situation where countries that were manufacturing their vaccine supply outside of their country including the United States in other nations. Those nations held onto the supply until they satisfied their local needs. And we did the same thing. In one instance where we held onto another country supply their h one n one vaccine and that was with a flu that while virulent while dangerous was far less virulent than corona virus. And you saw that National Behavior Sandoz first vaccines that. Come off the lines. It's not gonNA be a billion doses day one it's going to have this supplies gonNA ramp and initially. You're going to be supply constrained you're going to have to make allocation decisions about it and I think countries are gonNA 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 I try to make more equitable distribution of it. I'm not passing judgment. I'm not advocating it. I think it's just reality. What's going to happen? And I'm basing that on historical precedent thousand which I was involved in policy then and I was watching that behavior very closely and I think we were all surprised by Scott just to build on that I. You're painting a picture here. Lot of listening to you would agree. It makes it makes sense. Countries will take care of their own populations. I but what does that mean for the virus? Globally I mean we're seeing countries like Nigeria now. Having large scale outbreaks in Lagos Brazil is increasingly racked by this virus. If we have a vaccine in two thousand twenty one how much longer until we have a level of radicalization globally that allows us to do something pretty essential both for our domestic economies in the international economy? Which is to restart the movement of people in planes across borders and press rewind back to January twenty twenty when we had international air. Travel is all of that. Like Twenty Twenty. Two twenty twenty three beyond. How do you see that playing out? I think we'll have enough for a global supply. So of the companies that are working on a working on manufacturing at scales that could provide for something akin to global supply. Bigger challenge is going to be getting into a lot of markets. I think that initially what you would do. If you have a limited supplies you're GONNA make it available to your population but you also try to get it into regions of the world where there's epidemic spread and depending on what season you're in when where the virus is spreading could be spreading in different parts of the world. You're going to try to make sure that you get it into those regions. I if you do have a limited supply but how long did it take us to get global eradication of smallpox and polio? Vaccines have been around. Long Time. He's on global radicalization polio. So getting vaccine is not just a matter of the supply getting scenes into markets. Where you don't have good infrastructure good public health. Infrastructure is a very big challenge. Let's squeeze some more questions than comes from Jean Scotch. She's asking. What is the best advice? You can give the general population on how to live in deal with this in the coming months. Great Question Jean. At the beginning of this interview Scott you talked about you know some simple things wearing a mask washing your hands keeping surfaces clean. I mean some of this just practical in terms of reducing your risk or. There's some other things that maybe people aren't doing that. You're seeing people not doing that. That you would recommend look. I think he just gets down to try to decrease your personal risk. Limit your social network a little bit. Go out a little less go shopping. Let's be vigilant about trying to social distance where you can wash your hands. Use Hand sanitizer. I recommend people using masks. We know that diminishes the risk of spread so people can have to make personal decisions about how much they're willing to sacrifice how much willing to inconvenience themselves to try to reduce their personal risk. But I think it's GonNa come down to that all of us taking collective action to individually reducing a personal risk. There was data coming out of a university here but like everyone makes one less trip to the grocery store every week so instead of shopping twice you shop ones that could reduce spread ordering things more said a going out to stores all of that practice on a mass scale. That's still social distancing. And that's going to help mitigate risk and so everyone should think about their lives how they can reduce your never gonNa be free once you start going out and about so you're just sort of layering on things that reduce risk as much as possible. What about bars and restaurants Scott? How DO PEOPLE GAUGE THAT RISKED? Us recommend that they try to look at the number of infections in their county or their city and try to gauge that way or is it better as you say just to make a decision for the months to come that maybe those types of social activities are not going to be at the top of your list. I think for people social activities won't be at the top of the list is something that's GonNa come back near the later. The thing I miss the most is going out to dinner the thing. I'm probably going to do less going out to dinner when you do it. In your local community you have a better sense of what their risk is in your local communities posted traveling to a community. Don't really know so. I think people are gonNA stay. Local things outside are safer than things inside so you know. Dining out is safer than dining an enclosed space and in fact in my state Connecticut. They're reopening restaurants but you have to have table service outside so they're changing local ordinances to facilitate that. No there's ways to do things that are higher risk but do at a lower risk smark. Okay why come into the top. They our let's squeeze one last question in four Scott from Joseph Scott. He's asking can the covid. Nineteen virus be weaponized using something like crisper technology to target specific population. And if so can this be prevented I guess maybe to extrapolate from that Scott. Just a bigger question here. We talked about the risk possibility that this may have been an engineered virus accidentally released from a lab. We don't know we may never know but are you concerned. Just generally about technologies like crisper. That are really allowing people at low text play with. Mother Nature in ways that could be extremely harmful for the rest of civilization. Is this a new threat on par with nuclear weapons or other big global threats like climate change that we understand well and there's a lot of consensus towards doing something about them but we don't really understand the risk of man-made intervention into the world of viruses? But just a backup a minute. I don't think that this was a virus that was engineered in accidentally from lab. I think that there's a possibility that this was a virus. That was in some labs or his lab in Wuhan's library. I was accidentally released. If it was engineered. In any way or changed we would have probably been able to detect that in the in the sequence but remember these labs what they do. Is they go out and collect viruses from nature and then they just hold onto them and to the virus that was in nature just now and it's been a lab. That's the potential risk that you if you don't have good controls lab that you can slip up infect yourself if you're working with it you know to your point. Yeah absolutely the the technology for engineering any pathogen and weapon izing. It is more ubiquitous. Crisper one technology. There's a lot of other technologies that are synthetic biology a lot of other technologies. That are more ubiquitous. Now that doesn't take a tremendous degree of sophistication that anyone who has a PhD. In access to an academic lab can probably mess around with so. Yep It's going to be a growing risk going forward that it's easier to weaponize pathogens and what you're gonNA worry about going forward but I worry most about a rogue state. I worry about rogue individual I worry about someone just an individual sort of very good sophistication and diabolical intent. That could become someone who ends up engineering something on their own and then ends up spreading it because visit more ubiquitous and that's much much harder to control a really important message for all of us to reflect on Scott. You've been very generous with your time. And as usual you've shared with us again as I said some hard one insights from your time as Michener of the FDA in the United States a board member of Pfizer educated medical doctor. Scott really appreciate all the analysis and sophistication that you've brought to our dialogue this evening. Thanks mad me coming up next week. Conversation NOT TO BE MISSED WITH DAVID BROOKS OF THE NEW York Times former monk debater. We had him here on the main stage in Toronto. Last autumn for muck debate on capitalism he is our guest on Thursday may twenty eighth at eight PM Eastern. We're going to talk to David about the impact of Covid nineteen on US POLITICS. There's a big election underway in the US. Come this November and also a topic that David is quite good which is the impact of covid on our collective values and let me conclude by thanking all the partners that make this dialogue possible. The Peter Melanie Munk Foundation and their sister foundation the orientation that underwrite as with the munk debates all of the time effort energy and cost associated with producing these events. Thank you for being part of this program you. Let's all of US dialogue together to figure out the future of the world after covid nineteen. Good night I'm readier Griffis. The Munk debates are produced by antica productions and supported by the monk. Foundation rudyard Griffiths Ricky Girl wits and Debbie Pacheco are the producers the president of Antica productions is Stuart Cox. Be sure to download and subscribe wherever you get your podcast and if you like us feel free to give us a five star rating. Thanks again for listening.

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