Scott Gottlieb on how, and when, to end social distancing
World History permanently altered by this episode. I don't think you can have an episode of this magnitude and not have implications that are going to be potentially quite profound that. We don't fully understand yet. Hello welcome to the show on the box media podcast network. The big question right now is what comes. After social distance there is no national plan. We are in appeared of enormous sacrifice economically socially personally. And there's no national for using that time. Well people are doing things. States are doing things. Cities are doing things. But there's not actually been articulated strategy for what comes next so. I think it's really important to look at the people who are trying to articulate those strategies and tried to get a realistic understanding of. What is the path here? Like what even if we do all this right. What is right? Look like one of the people trying to figure that out is Scott Gottlieb. He is the former. Fda Commissioner is Donald Trump's first FDA commissioner and he was a very rare trump appointee and then he won quite a lot of plaudits from people on both the left and the right after working in the trump administration went back to the American Enterprise Institute a Conservative leaning. Think tank where. He's really been one of the key voices on. Cronin bars particularly on the right part of the people on the right. But some real expertise here trying to get this taken seriously trying to think about it and systematic way and he's one of the lead author on a plan now for reopening the economy. So we talked about that plan here talk about sort of the coin of ours response in general and one thing that I think is worth keeping in mind and go to. Vox and we'll put this in the show notes. You can see a big piece. I've written on the various plans to reopen the economy. And the way they're actually kind of scary beal here that here too. There's not a snapback to normalcy here. We're not imagining. Even if everything goes well that in two months or three months or four months or back to something. We will recognize economically socially as normal. That's particularly true for more vulnerable populations which is part of. I think it's so important that we're actually talking about these plans interrogating them and trying to understand what they mean for us and are they the path we want to take as always email is as reclined show at Fox. Dot Com as clan show at. Vox Dot Com. Here's Scott Gottlieb Scott Gottlieb. Welcome to the PODCAST. Thanks for having me. I wanted to start here in. Twenty nineteen the Global Health Security Index gave the US the world's highest score high score in the world on pandemic readiness so in terms of our capabilities. We were ahead of countries like Germany and South Korea Singapore Taiwan and when the pandemic head. It doesn't seem like we were able to fully maximize at. What do you think is responsible for that gap between our capabilities and our response meal for years we we were preparing for pandemic And we were focused mostly on flu and so there was some things that were different about a corona virus. Where some of the planning that we had undertaken I think wasn't as applicable for example we envisioned the ability to scale of vaccines against the pandemic flu strain in ways that we couldn't do in the setting of a corona virus but I think in many respects the kind of planning that we didn't name preparations that we thought we had warrant as robust as what we believed near the most visible example of that stockpile. We had been stockpiling equipment in anticipation of a potential pandemic for years. But clearly we didn't have enough ventilators. We didn't have enough personal protective equipment for frontline. Healthcare workers in Masks. And the other thing is we never thought to stockpile things like testing equipment or reagents that would be used to try to roll out very broad diagnostic testing capabilities. And so there were certain things that despite all the planning that we had done over a very long period of time and I was there back in two thousand and five when a lot of this began when there is real focus on pandemic planning in anticipation of the risk of bird. Flu a lot of that planning either eroded over the years or more lightly wasn't robust enough to deal with something that was this novel on this scale. This really is a once in a generation pathogen and in many ways I think it evades some of the planning that. We didn't some of the anticipation that we had. What is the ways evades out? Because we call the once in a generation pathogen. I think it's worth talking about how that's true We've been reporting on this advice for for some months and when I go back and look at those early stories even epidemiologists we were talking too often. Didn't see how this is going to get that men often. We didn't see how this get. Even Dr Farsi. was downplaying some of the threat desolate as early. February so in the public health community among people who understand infectious diseases. What got missed originally. And what do we need to learn from those misses for next time? I think in some ways this pathogen occupies that sort of sweet spot between being virulent enough being deadly enough that it can cause of death and disease being severe enough and also being contagious enough that it can reach around the world a lot of pathogens that we've seen in recent years SARS and mirrors were very deadly but they weren't very transmissible laden they didn't transmit human-to-human inefficient ways and also they were so deadly that they incapacitated their hosts and they made themselves self evident. If you had SARS outbreak in your city you knew how to SARS outbreak this pathogen because of the asymmetric spread because of the large number of people that become only mildly. Symptomatic has the potential to spread very efficiently. And in fact is very contagious. And so we know. A lot of people get infected from any one individual but is still stolis cohort of people that sizable enough that developed severe disease and could succumb to it that it can cause an extreme amount of morbidity and mortality and really incapacitate a healthcare system and cause mass casualties and so in many respects. I think it was that pathogen that we long feared that occupied that that perfect middle ground between transmissibility ease of transmission and violence The ability to cause a lot of death and disease so before we get into your report about how to begin reopening the country. I want to set some expectations here. Many of us are living under lockdown. Right now we remember what normalcy is like. And I think the expectation from any of us is at when lockdown ends normalcy is. What returns. Are we going back to normal anytime soon? Does the status quo snap back into place? I don't think there's going to be a binary point in time when we just returned to what we were doing. I think world history permanently altered by this episode. I don't think you can have an episode of this magnitude and not have implications that are going to be potentially quite profound that we don't fully understand yet including public health implications. There's going to be public health implications for these these severe lockdowns as going to be people who didn't get prenatal care didn't didn't seek healthcare and ended up having a medical sequentially for that. But I think also as long as this pathogen circulating in the background and we don't have a vaccine for it we don't have very effective therapeutics and I don't think we're going to have those things by the fall and we may not have them this year. This is going to alter the way we live and do business You know some of it's going to be subtle you'll see businesses advertising deep cleanings In between you know Uber Rides airplanes. People aren't gonNA shake hands as much anymore. I think wearing masks in public is gonNA come more fashionable in western societies. He might see airports using alter violet light and shared. Walkways things like that so some of it will be subtle and some of it will get dividends for in the form of maybe less than flu. Seasons are just you know reduce transmission of of illnesses. Generally some of. It's going to be more profound. I think the marginal customer for a stadium or a concert or a cruise ship. I don't think they're coming back Soon I think people are going to be more circumspect about travel particularly international travel businesses are going to be more circumspect about bringing together large groups of people. So you're GONNA see a change in a way. We live in the way we do. Business in the question is can we get back to our normal economic activity or are normal level of economic activity with with that kind of sort of profound pervasive change? In a way we we operate and it may be hard. I talked about an eighty percents economy if this continues to circulate in a fallen you have outbreaks because in the US the consumer you know really drives the economy in China if you look what happened in China. The manufacturing sector bounced back but the Chinese consumers still hasn't returned. If you see what people doing in China they're going to work and then going home if we have a situation where business bounces back but consumers sit. Sit Out or they're reluctant to re-engage in the same way that they were engaging economy before where a very consumer led economy and I think that's GonNa be a pervasive drag. Your plan divides the coming months into four phases. And then it establishes triggers for states to move from one phase into the next to just start into it. Can you give me a high level overview of those four face? Well let me tell you what Phase one is the phase. We're in right now. The population base mitigation We WanNA WE WANNA move into phase. Two which is starting to reopen America. What we tried to do with the report was create really identifiable milestones and in Thai policy. Decisions around those milestones. And we did that because we want to give people something to shoot at. We wanted to give very sort of clear identifiable objectives. So people can debate whether those right or wrong. I think you know we had laid out sort of broad broad objectives that it was hard to put granular details around and metrics around. I don't think it would have been as useful so one of the one of the very clear milestones that we identify as we say fourteen days after you have a sustained reduction in new cases you can start to reopen. The economy can start to lift. Stay at home. Orders and allow certain businesses to go back to work and sort of a staggered fashion while still implementing certain Certain restrictions and commensurate with that. You also need to have the capacity to treat. Everyone's you need to make healthcare systems rebounded and has sufficient capacity and you also need the capacity to test everyone so you need to have the ability to do point of care testing in the community and really test everyone who may present with symptoms of Corona virus which we don't have the capacity right now so those were the three milestones that we identified it when you would make a decision to reopen the economy. So I want to go into a part of phase one here because I think people understand the part of phase one they have to do social distancing staying at home but something you talk about in phase one is that we need to increase testing capacity. And we need to enter. The health system has the capacity to save. We treat a cove in nineteen patients and others. Who Need Care? I mean this is when when you talk about that flattening the curve. This is what people raising the line or raising the bar right. Raising the amount of testing and healthcare. We can actually offer. Are we doing enough on that right now? In states like California and New York and Washington and others that are in. Intense lockdown is the huge sacrifice being made by the people locking down sacrificing income and wages and social life. Is that being matched by a true mobilization on the health. Care supply side. We're doing a lot to increase testing capacity. But we're GONNA hit an upper limit back up getting from one hundred thousand tests to a million tests is going to be easier A lot easier than getting from a million tests who one point five million tests and the reason I say that is because what we did up until this date is we took platforms that existed. Labs that were out there. Labcorp inquest academic labs and we got them in the game. We stood them up so now they're vast platforms are available for Corona virus testing. And that's why we've been able to increase testing. We're probably by the end of this week at a million tests the week in terms of capacity. Next week we'll build on that but getting to the point where you have to three million tests capacity per week which is probably where you need to be initially as you do this transition. That's going to be very hard because we've tapped out the available platforms and now would depend upon creating new platforms and new supply chains to fuel those platforms. And that's GonNa be very hard. We're GONNA hit an upper limit and we're probably approaching that right now in terms of what the spare capacity is in the country. And now it's going to be a question of how fast can Abbott and be and other companies build new testing platforms. And how fast CAN LABCORP QUEST? Scale up new labs that didn't exist before and that's a harder. That's a harder exercise. And so where do we need to be as we do this transition you know one benchmark would be to say basically everyone who presents to a primary care doctor for whatever reason should get swabbed for Corona virus? That wouldn't be an absurd objective if you want to really widespread screens that you can capture not just symptomatic people but a symptomatic people at least initially for a period of time just swab. Everyone just like a child goes into a pediatrician's office if their ear hurts they get strep test. If their nose is running they get a strep test of their throat hurts if they disrupt testing of their lethargic in school they get a strep test. You can think of Corona virus at least initially same way. You WanNa swab very liberal and report the results so that you can detect small outbreaks. Do those case based interventions isolate individual people who were infectious rather than? Try to do what? We're doing now isolate entire populations. So will we get there? I don't think we're going to get there by May. I think that we're still going to be under testing relative to what is the optimal public health standpoint. I think we have the ability to get there by September but we need to be doing a lot of things right now really investing in that Congress is going to need to ultimately act. I I WANNA get very wonky in technical in the testing question here because I've been looking at every one of the plans people released for how to get the economy back up and running your plan. The Center for American Progress Plan the Harvard Safra Center plan. Paul rumors plan for mass testing the economist. And what I see and there are two things I wanna come back later to. It based contact tracing but but but here on testing is massive scaled up testing. You talk about a couple of million a week. Some of those plans talk about a couple of million a day. Roamers plan talks about twenty two million a day and so a huge question in all this seems to me to be. What are the constraints on? How rapidly we can build up testing. What what what. Don't we have that we need to have? Is there a resource material? Constrain is just getting bodies out there like what keeps us from going to five million tests a day in two months. Why why is that? A is that an unrealistic goal. And if so what makes it unrealistic while the resource constraint that we're going to bump up against right now so what? We did up until now as I mentioned was sort of get labs that were there into the game. We stood him up. We got them working on krona virus tests. Now we're going to be at a constraint in terms of not having available platforms. We're GONNA have to build more machines to actually run to test if we want to get to the levels. You're talking about in some cases we'd have to build more of those little toaster size boxes at. Abbott makes that. They put in doctor's offices of these for flu. Swabbing strep testing and now using corona virus testing so building. That hardware takes time. Deploying hardware takes time especially into places where it's not currently deployed and in the other limiting factor is the testing supply chain. It's not the the machines that we might not be able to build. We're not gonNA have enough reagents. We're not gonNA have enough plastic tips to pipette samples from one. Well to another. We're not gonNA have enough plastic cartridges to put the samples and we're actually running short of swabs to To Swab People's noses it's all the low margin commodity products in the testing supply. Chain that we're now having problems obtaining and it it's lesson learned that if you look at any complicated supply chain. I learned this from when I was at FDA. If you think about where the vulnerable vulnerability as in your supply chain where the weak points are where things go shortage. It's never the high margin product because a high margin product has a good manufacturer WHO's invested manufacturing. Who has invested in continuity of business decisions to make sure they never go down because they're selling an expensive machine. They're selling a high margin product. It's always the commodity prog the low margin products because that's always a manufacturer that's probably offshore. It's probably one or two manufacturers. It's been consolidated manufacturing because it's low margin the business and They can't scale up because they've underinvested in manufacturing for many years and so if you're making pipette tips you know you don't have a lot of residual manufacturing capacity you don't have a state of the art plant necessarily and so hard to scale it up. That's the weak link in the supply chain. That's why I said at the outset thinking about stockpiling these things. We never envisioned being in shortage of of swabs for nasal swabs or reagents in fact. That's what's happening now. And this is something where if we invoked and aggressively mobilized against the Defense Production Act. We could do more. I mean I'm obviously not a manufacturing expert but the folks who make cue tips potentially could be mobilized into making swabs apple. Could help make the little toaster things? I don't know what you need to do to get region. I recognize what I'm saying is going to sound very crude. But is this a situation where resources exist and they need to be directed and mobilized through some kind of central planning or? Is this something where even if you put into play that level of aggressive direction you still couldn't invent the agent that you need to make this work. Yeah I don't know how much you can Just create new manufacturing some of these commodity products because sometimes there's materials that go into them as starting materials knows in fact are the weak link in a supply chain so even if you had extra manufacturing so for example within ninety five masks you can build a plan to make masks but the actual ingredient that the product that goes into making those masks manufactured outside the US would be hard to scale new manufacturing for that. And that's what's in shortage right now. So some of the starting green is now in a way that comes into play with the with the testing supply chain with respect to the the point of care tests. I think we're GONNA need that made by companies like Abbott and be back Dickinson. Those are a little bit different that those companies control their entire supply chain end to end so they they don't just make the high margin product. They make everything that's used in the performance that test. They make their own Swabs their own pipette tips their own cartridges. And they make the toaster sized box. So that's a supply chain that could be scaled a little more easily because they control it so I think that we're going to build a scale capacity and that's why I think some of the swing capacity now and some of the necessary capacity is going to be those poincare tests right now. The only one that's approved is actually to cepheids gene expert which isn't a true poincare test. Net is not really in doctor's offices as usually in community hospitals and maybe large medical practices but the Abbot is a truly point of care tests. Eighteen thousand doctors offices beady makes a similar machine that they use for flu testing as well. Anything STREP throat testing also. They're not approved yet but I would suspect that they're going to be on the market within the next month or so That's GonNa make a big difference too and in trying to scale those systems having those companies make more whether or not you took over facility and tried to convert it to making those boxes. I'm not sure that's going to be more efficient than just Having those companies ramp up their own manufacturing which is in fact what they're doing so I want to talk about the other side of what? He called the comprehensive covered. Nineteen surveillance system so on the one hand. You have the widespread and rapid testing. We've talked a bit about what we need there. And what the difficulties are there. But then there's what you call the National Sentinel surveillance system and this is a way you can track the background rate of infection. It's a way you can do contact tracing. There's a lot of discussion about whether or not you not based contact tracing where people download an APP which seems to be happening at least to some degree in Taiwan. This seems to mean to be another one of these things. Get it scale. It really helps but on the other hand the idea that every American is going to download an APP that lets the government or some company or someone trace who they've been near and who touched to end You know they have to scan a qr code when they walk into a building. That's a very big cultural shift to end. It goes quiet again. Some of Where we were where we tend to be in this country and we're not operating in a moment of high political trust or high trusted corporations. So can you talk a bit about what that might look like? And what you think the obstacles to getting there might be Lon- think we're GONNA get to that that kind of An APP I don't think that we would accept that in an in the United States. I think there'd be a lot of privacy concerns. I don't think we should be doing that. And so the idea of having some kind of APP that word Geo Track people and tell you when you've been in contact with someone or or report when you've been in contact with someone who had grown virus as a way to do contact tracing I don't think we should be doing that. They're they're they're experimenting with things like that. In some countries it South Korea had something similar to that I think technology could be very helpful though and where we have to have a very robust debate is when it comes to case based interventions and self-isolation. So if we if we have the system we need and we have very robust screening in the community and we end up identifying people when they have mild disease into matic disease for the period of time that they're infectious. What do we do? What do we ask them to do? We can ask them to voluntarily selfies late or we can enforce that self-isolation And the question is are we gonna go towards enforcing the self-isolation now? In fact we've already done that with corona virus with the early cases we quarantine people and we enforce self-isolation when he actually quarantine some individuals on military bases with a multi drug resistant to Berkeley closys or measles. We oftentimes require self-isolation. And we enforced we enforce with public health officials. Sometimes we enforce it with police and so in this setting. Are we going to do that? I think we should. I think we should be asking people to self isolate enforcing it. But are we going to be using tools to enforce that self-isolation as opposed to public health workers to make it more efficient so basically text messaging people every day saying are you home that would be at least invasive or requiring them to download nap in tracking their phone to make sure? They haven't physically separated from their phone. Obviously it could go out and leave their phone home but these layers of layers of protection. You can do it with video chat things like that to make sure people are adhering to a self isolation. We have to have that debate because even that level of case based interventions seems to Make some people concerned and I think of. We're not GONNA be at a point where we can ask people to self isolate and do something to help. Supervise that to make sure that they actually had here. We're going to have to then accept that we're going to have larger outbreaks than we might otherwise having is going to be hard to control this infection because simply asking for voluntary compliance with self-isolation may not be enough. Now the flip side of this though is that you don't want to impose restrictions that alienate individuals or Make people concerned about their privacy. Because if you do then what's going to happen? Is You're going to discourage people from going out and getting tested and self identifying when they have grown a virus and that's the last thing you want you want people to be encouraged to get tested and identified and diagnosed with Corona virus. We need to balance whatever we impose against not discouraging people from actually getting tested and where that line is. That's a debate we need to have. We haven't had it yet when people are identified as being positive with krona virus. What do we ask them to do? Ultimately this decision's GonNa be up to mayors and governors but I think that the way this has been debated in in sort of the public discourse people go right to the sort of South Korea style apps where they tracked every movement. And you don't recognize that technology that fulfills a purpose. That's far away from that level of surveillance and intrusiveness which I don't think we should ever get to but that does implement some kind of requirement individuals to take responsibility when they're infectious to not go into contact with strangers other people the public at large. We'll talk a bit then about when you say we need to massively scale contact tracing. What does that look like? It's it's a lot of things but but at a basic level it's what states like Massachusetts doing right now with our hiring one thousand public health workers do contact tracing so that when they turn over positive cases when they identify people with infection they'll interview them they'll Talk about who they might have been in contact with. They'll trace down those individuals. They'll ask them if they have signs or symptoms of Corona virus. They may ask them to get tested. Some of them they may ask to self isolate for period of time depending on the level of exposure and a likely that could have could be infected or at least fight slate until they get back a negative test. That's the traditional sort of bread and butter boots underground work of public health. We don't have the capacity right now. We've underinvested in our public health infrastructure for years. We don't have the capacity to do that at scale so very quickly if there was a large outbreak in a city will overwhelm the capacity of any cities public health infrastructure. To do that at scale talking about if you have more than like thousands of cases. You're going to overwhelm the system for shore. So we need to build that out recognizing that we're probably going to need more capacity because this is a virus that we're we're going to have to contend with some reasonably size up outbreaks. Now you can use technology as I mentioned with respect to the case based interventions into self-isolation to augment. Some of that. But you can't use it you can't use technology to augment all of it ultimately you need people doing this work. This episode is brought to you by. Us Salar there's never been a better time to switch to US cellular. Because now when you do you'll get fifty percent off your choice of selects new smartphones. That's amazing phones. Lake the Samsung Galaxy S. ten ee or the Google Pixel for a great choice on a great phone. Now that's fair. Us Cellular Choose Fair. Terms apply check. Us Cellular Dot Com for details. Hey It's Cara Swisher you may know me as the only person who looks cool wearing sunglasses indoors but in my spare time. I host a podcast called Rico decode every week. We talked about power. Change THE PEOPLE. You need to know around tech. 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So if there's a sustained reduction in cases for at least four days in state the hospitals can save we treat all patients requiring hospitalization state is able to test people with covert nineteen symptoms and the State is able to conduct active monitoring of confirmed case in their contacts. You can go to reopening state by state and tell me what you think will reopen when we go state by state. Because I don't think you mean that you can have an NBA game Again so if you if you manage to get to phase two what kind of economy re looking at. What is what is opened. And what can we not still do? Yeah I think it's going to be we're going to be entering this in. May We're going to be starting to make these decisions in Maine through June. I think it's going to be a gradual reintroduction of activity. Oh probably lift the stay at home. Order is but you'll tell people if you go out you have to wear a mask for a period of time. You'll allow certain businesses to go back to work. I but you'll tell businesses that they have to put certain restrictions in place to try to reduce the number of people who congregate together so reduce the risk. That that you can spread infection in the workplace. Basically maintain some social distancing a workplace. They'll be increased local ordinances on food handler's temperature tax checks on food handler's tables have to be spaced apart. You can have more than seventy five percent you fire of your fire capacity and certain businesses limited number of people that can be endorsed things like that to just try to reduce human the human interaction as much as possible while having a functioning economy allowing people to re engage in normal activity and you'll slowly introduced that what's GonNa be introduced. It's going to be places where a lot of people crowd indoors for purely entertainment purposes so bars venues concerts Clubs things like that probably going to be the last to open up now against this backdrop. We're going to be entering summer when people preferentially WanNa be outside anyway so you try to do whatever you can to move as much of that activity into outside venues rather than indoor venues where. There's slightly less risk of transmission. It's really crowding people together inside. That creates the biggest risk for transmission. I think we're talking here about some of the population did not all of it in phase two even in a phase three. That doesn't have a vaccine. My mother is in her seventies and has the lung damage. My father is in his seventies. And he's immuno-compromised. Do they get to go out? What kind of normalcy returns for them if any or are they in a position of essentially self-isolation until there is a vaccine. Well there's a difference between what is the government require you to do. What are they asked you to do? And what are you choose to do? I think that there might be sort of guidance. That people who who have certain conditions are in a vulnerable position with respect to this virus for longer periods of time. Try to avoid going out and I. It might not be enforced. Not going to be pulling people's licenses industry and checking your age and where you going to make sure you out for legitimate purposes but there might be some strong recommendations as certain individuals delay their reintroduction. If you will but I think the bigger question is what are people choose to do? And I think that there's going to be large groups of people that choose to do things very differently so long as this virus is continuing to circulate even at low levels But certainly so long as we continuously outbreaks in American international cities. Which I think we're GONNA see through the fall in the winter if we don't have a really strong significant technological solution to this in the form of a drug. That is really a game changer. Which I suspect. We're not GONNA HAVE THIS SEASON. We're not GONNA have this fall in winters can take a little longer to get that and I think people who are older vulnerable are GonNa make decisions to limit their activity. And that's why I talk about the eighty percent economy. I think there are certain things that people don't do and certain things don't come back. I mean just talking to my own parents You know they're talking that way about trying to be a little bit more circumspect about what they do heading into the fall. I know a lot of people that are canceling vacations or making different decisions about the fall in anticipation that is probably GONNA be so. Still some furtive risk from this. We don't remember really. I mean very few of US alive. They lived through a time when they were polio outbreaks. In the summer. But when you talk to your parents or people who lived through that they talk about summer camps being closed pools being closed. Kids didn't go out. We know if you look back at the history of smallpox Diptheria when when infectious diseases were became epidemic cities at change city life. Things closed people in do things. We've never lived through period like that with a highly infectious disease doubt transmitted through you know. Normal interactions or could be transmitted on a surface on a subway a city. That was deadly enough to invoke realistic fear and this is deadly enough to invoke realistic fear. When you have a pathogen like this circling it's going to impact city life particularly in urban centers. That's been the history of pathogens like this. We just haven't had to deal with one and when those when they came along we were able to vanquish them with technology. Now we're going to be able to vanquish this with technology. I'm very confident that the questions the timeframe I wanna hold though on the what you just said here and try to face. It's emotional cost a little bit more frontally What you're saying that for people who are especially vulnerable and that is a lot of people. A lot of older people a lot of people with Some kind of pre existing compromised immune system. This is going to be a rough year. It's going to be a year where you don't get to have normal even other people. Maybe you're getting a lot closer to that or at least don't get to have it safely and I don't know that I don't know that any of us are totally prepared for that right. I mean it's only April if people are gonNA have to be following this through the fall even as even as the people they love starting to go out in a way that makes him more of a danger to them right. I think about this myself. That if social distancing is lifted because San Francisco I live for California where I live has managed to make face to in a way it becomes more dangerous for me to then go see my parents because I've been in contact with more people. Maybe I've been going back to work or I've been whatever it might be. And in a in a perverse way as the rest of the country becomes less isolated again. The people who bear the brunt of this in terms of their vulnerability might become yet more isolated because the folks were being so careful before and so posed lower risk to them pose a higher risk now particularly in these in these urban areas. Mesh is going to be a very tough way for people to live or am I missing some part of it no. I think that I think that there's going to be more trepidation about what we do that. The things that really tip that balances if again technology but also a very aggressive surveillance system if you have a surveillance system plays in surveillance is probably the wrong word if you have a health monitoring system in a testing regime. We you know that you're testing so many people on a daily basis for Um Corona virus that you're likely to surface now break when his only hundreds of cases and before becomes thousands and thousands of cases. I think if you can demonstrate that to people that's going to inspire a lot of confidence people feel fairly comfortable to go to go out again because you're living in a city like New York of nine million people and you're testing regime is going to is as sensitive enough to pick up outbreaks of five hundred people. Your absolute risk of actually contracting. It's fairly low. You know you're in a city of nine million people. What's the likelihood that you're gonNA come into contact with the four hundred who have corona virus and then come into contact with them in a way that you can actually get the virus pretty low but if you don't have that in place and you're walking around and you recognize that your risk be quite high and nobody knows it? That's an uncomfortable position so February twentieth in New York City and I can look at my calendar right now and see what I was doing in New York City. That does days. We were at a lot of risk of corona virus. We just didn't know it. And so if that's the situation in perpetuity that's GonNa that's GONNA create a lot of fear and uncertainty. Anything people are going to be more reluctant to go out now. That said we should be able to get to those sort of state that I described where we have very broad screening and place where people can go and get tested very easily. Where we're doing what you what you referred to sentinel surveillance which is basically testing a representative sample of people to try to capture a symptomatic mildly symptomatic spread before small outbreaks. Become big outbreaks. We can do all that but it takes a lot of planning. It's GonNa require the you know the administration working together with Congress and some of it has to be done legislation. Some of it can be done through regulatory changes but we really need to have sort of a comprehensive plan. That'S THE SECOND REPORT. We put out this week where we tried to outline in a very long report. What are the detailed steps that you need to implement to try to get to a very broad testing regime and a health monitoring regime And so we try to outline what what we think needs to happen there as well as same authors on both papers you mentioned a couple of minutes ago the questions vaccine's or therapeutics a phase. Three which is a much more. Normal phase of life works off of that. So I know you've talked a bit about the best. We need to make on on medications. Just let's start here. Why don't you give me your survey of where you think we are? And what you think is plausible in terms of therapeutics. Say by the end of the year so by the end of the year. We're not going to have a vaccine. I think base case we need to figure that a vaccine may be two years away and hopefully we can get it sooner than that but I think we need to work off of UH assumption that we're not GonNa get it sooner than that so we're going to have to live with corona virus for a couple years and we have need other technology if you look at what could be available by the fall. It's really a small subset of drugs. I would be focusing attention and resources on that small subset and really trying to work aggressively with those manufacturers to try to pull those products through the development process and turn over the data cards that you're GONNA need to turn over to determine whether or not they're safe and effective whether or not they're going to have an impact on this disease and so what others drugs. One is room desks here from Gilead. Which many people probably heard about? It's an antiviral drug. It inhibits viral replication. It's pretty far along. There's data available right now. That suggests that it's active Lot of doctors are using it. They believe that is active. Is probably going to be more effective. If used earlier in the course of the disease rather than late the other the other products are the therapeutic antibody so this four companies making these veer biotechnology regeneration Amgen lily. These are basically biotech manufactured. Antibodies the same kind of antibody. Your body would produce if it's exposed to the and that antibody your body would use that antibody to fight the virus if you're exposed again. There's two ways to get those antibodies. One is to take them off. Someone who's been infected in other ways to actually manufacture it at scale using the tools of biotechnology and that's in fact what these companies are trying to do. That's an attractive product for a number of reasons I welcome. It uses a treatment early in disease. It's probably less effective later and disease because they have to have a lot of virus on board. It's hard to give enough. Antibodies to mop it all up but it could also be used as a prophylaxis as a bridge to vaccine. Will you might be able to give a monthly injection or bi monthly injection and basically vaccinate people be able to give them something that would prevent them from getting infections. So you can use that in your frontline healthcare workers you can use it in. Tsa agents food handlers. Who are coming into contact with a lot of people in a more likely get infected and then spread the infection. You can use it in context close contact so when someone's sick identify who they're in contact with and you give them the injection right away to prevent them from getting sick so that could be a very attractive drug. The combination could be very effective if you can have both of those by the fall a treatment to help people who are infected and show up in the emergency room and in an antibody that can help prevent infection and those who are exposed. That's a pretty potent combination now. The the biggest obstacle in addition to doing the trials to figure out if they work if they're safe and effective is going to be manufacturing them as scale. That's something we can solve for right now. We should be working on how we're going to make investments to help these companies scale manufacturing and get to you know large commercial scale manufacturing in time for the fall so that of the one of them does work. We're able to turn on his big quickly and produce not hundreds of thousands of doses but millions of doses a month. That's the kind of position to be in. There was money set aside in a recent Senate bill that cares acted Senate and house bill. The president signed that actually set aside upwards of ten billion dollars to do just this but that needs to be implemented the companies need to be aware of it and pursue those opportunities. You need the agencies working to stand that up that all has to happen. It's not hasn't happened yet but you know we have time to do that. But that's the kind of thing I think. We should be focused on right now. You talk also in phase three about sir logical surveys determined population immunity. I've seen conflicting reports on whether people who've got encourage virus our immune and I recognize. There is some here that we simply don't know. But what is your best? Guess on that if we had that sir logical would it even matter because people are actually immune or would it not matter much because a substantial portion could get reinfected while I think both of those things? I think that there is immunity here. People who are infected most developed a robust antibody responses a highly immune genyk virus. Your Body sees it as foreign and develops a lot of antibodies. That's important is getting people. Sick as the revved up immune response the virus and so you develop. Antibodies that immunity probably last six months to a year. The antibodies decline. You might have some residual immunity might have some what we call you. Know Sell based immunity Where where if you're really challenged with the virus in two or three years you might get sick again But you the illness you'd get the second time. When be as severe there is a cohort people about a third based on some very early data that we're getting out of China now. A state came out this week. That suggests that a percentage of people maybe up to thirty percent don't really develop a robust antibody response. We don't know why it tends to be younger people as that can potentially partially explain is pure speculation but explain maybe why younger people also don't seem to get sick from this virus. Maybe they're not mounting a very vigorous immune responses so that they the inflammatory response from the immune system is in something that is happening in them. And that's why they're not having the same bad outcomes that Middle aged people and older people who do mount a very vigorous meeting response develop antibodies. Do pure speculation. We don't know it's one study and we need to figure it out but the bigger issue also is that once we do this serological. Testing logical testing is important. It's important understand where the virus has been. Who's been exposed? It could be important for decisions. About return to work in certain professions where there's going to be high exposure right like police officers or emt workers or or or doctors and nurses but by and large what we're going to find his at a very small percentage of the population has actually been exposed to this virus. If you talk to the models and the experts United States they say anywhere from one to five percent of people probably have been exposed virus already if you look at the data coming out of Europe. They're already using serology. It's again in sort of five percent range when you look across Europe. Some some countries higher like Italy but most of the countries are in a five percent range. So the idea that. There's thirty or forty percents. Population has had this virus. In that Colbert illness. You had in January or February in you know what it was probably was corona virus. I think that's GONNA turn out not to be the case it's going to be a small percentage of the population. Certainly in the single digits that have any level of antibodies from either being asymmetrical mildly symptomatic or having it knowing they had it. And it's not going to be enough to create Herd immunity enough people who have immunity that this can no longer spread. It's also not going to be enough to have this pool of people turn just returned to work one of the things that worries me going forward is it has been hard enough to get states into phase one and to try to do phase one well not every state is air even as we speak and then you move into phase two. I think there's going to be a lot of relief but something that is planned for in your proposal but there were also seeing in other places like Singapore which had a very effective response but now had to go back into lockdown. Where you can't have people over and they're they're going back into a very intense freeze is that you might have to bounce back and forth between phase one in phase two for a while and the political difficulty of getting people to accept that once they have lifted it the political difficulty of going backwards going all the way up to the president. Who really wants to out of phase one as quickly as possible and is not going to be excited in an election year. About reestablishing it. It seems that the obstacles to being able to dance back and forth are very high. But if we don't we could end up back in a very very difficult situation given what you just said about the absence of likely herd immunity. I'm curious given your proposal. Talks about this. Possibly go back how you think about the obstacles to doing so. I think there will be political obstacles. Not just at a national level but our local levels well but ultimately these decisions are going to be made by mayors and governors. And even that's going to be a hard decision because you wanna be the city that shuts down activity while the rest of the country's humming and it's going to be in the best interests of every other part of the country that you do that but it's not going to be in your best interest if you look at the history of this outbreak in this epidemic. Seattle should've taken more aggressive steps earlier. Now it ended up that the The epidemic in Seattle wasn't as large as we thought might be because Seattle was a single large cluster that was expanding as opposed to multiple introductions with multiple clusters. So in some way. We dodged the worst outcome there. But they were very slow to take aggressive steps. They kept activity humming along far longer than they should have. And that would have the first city to really start to shut down economic activity and you saw reluctant to do it. So I think it's going to be a challenge when you have outbreaks in cities at what point do cities you know. Pull the trigger and start to shut down economic activity and start to impose some of the population base mitigation not just to prevent spreading their cities but also prevents spread more. Broadly in the United States. It's going to be in the country's interest that when there are outbreaks local officials take aggressive actions. It's not gonNA always be that a parent to local officials that they should step aggressively forward if they think that there might be things that they can do that are more limited so this is going to be hard just not not just at a national level national decision-making where having the decisions aren't going to get made but I'm more worried about local decision making and people being reluctant to take steps that could serve the national interest well but may be served their local interests not quite as well Scott Gottlieb. Thank you for doing. Thank you very much for being on the PODCAST. Thanks for having me. Thank you to Scott Gottlieb for being here. If you want to learn more about the plans I have two quick recommendations for you. I mentioned at the top is peace over which is not just about the I plan but also center for American. Progress is plan. The Harvard Suffer Center ethics Plan or proposal and Paul Romer Nobel Prize winning economist. His plan You can find the show notes or box The headline is. I've read the plans reopen economy. They're scary. They are scary and Party. When you begin thinking about the mass surveillance or mass testing regimes. They are beginning to consider. Maybe we need them The future may be scary here and then also on the weeds this week. Matt Iglesias and I dive into plans. And try to think through some their assumptions More deeply you can download that. Replicate your podcasts. As always thank you to Karma for researching Jeffey gelded for producing. Vox Media Putz production.