The CommonHealth

In Episode 120, the first episode of our Department of Defense mini-series, Joint Staff Surgeon Major General Paul Friedrichs, discusses how the Department of Defense has overcome challenges from the pandemic, incorporating lessons applicable to any large organization struggling to function in today’s environment. Early in the disease the aircraft carrier USS Theodore Roosevelt was sidelined, recruit training and military exercises were interrupted as they searched for answers on how to safely operate. Currently, vaccination rates among active-duty military members are among the highest in the nation and operations continue relatively unimpeded. Domestically, tens of thousands of National Guard and active-duty troops have responded wherever needed to support communities throughout the United States in roles from intensive care delivery to administrative support. Worldwide DoD biosurveillance and research programs designed to protect U.S. forces against disease while deployed overseas play a major role in virus identification and vaccine development - including the mRNA platform which is the basis for the Pfizer and Moderna vaccines. The establishment of the Defense Health Agency presents an opportunity for much-needed organizational streamlining of the extremely wide breadth of military health capabilities, however, it is important that less visible, yet vitally important, assets such as overseas infectious disease laboratories, are able to continue their vital work. Likewise, the impact of active duty medical personnel cuts must be carefully considered regarding the ability to detect, prevent and treat infectious disease threats. As Covid-19 evolves, U.S. military medical personnel will continue to work collaboratively with colleagues at home and throughout the world for answers. Air Force Major General Paul Friedrichs is the Joint Staff Surgeon, the medical advisor to the Chairman of the Joint Chiefs of Staff and responsible for coordinating all issues related to health services including operational medicine, force health protection, and readiness among the combatant commands and the Office of the Secretary of Defense.Read the report here: https://www.csis.org/analysis/department-defense-contributions-us-covid-19-response-home-and-abroad

In episode #119, Dr. Peter Kilmarx, Fogarty International Center, discusses the struggle to advance contact tracing. Efforts early in 2020 to create a national Covid-19 Response Corps – at least 100,000 needed – were not successful. Instead a “hunger games scenario” ensued in which each jurisdiction scrambled to make its own solution. In our federalized system, each state, and in some instances county, has had to build its own public health workforce while balancing the budget. The lack of an integrated data system made it difficult to track progress. Contract tracing has made only marginal progress in curbing transmission. Experiments in the use of new technologies have not gotten off the ground in most places. New York City is one shining exception where 90% of cases are tracked, and 75% of their contacts. Success in places like New Zealand, Taiwan, and Viet Nam relies on robust, fast testing systems, consistent social support for those in quarantine, and a tradition of public health workers in the communities. Public health in America has entered a period of crisis, in the face of politicization, distrust, and abuse. In the Biden administration, executive orders and the American Rescue Plan have made major commitments towards contact tracing, testing, and strengthening the public health workforce. In the meantime, foundations, civil society alliances, and public health professional associations have played an expanded role. “Contact tracing does work” if the right pieces can be put in place.Dr. Peter Kilmarx is the Deputy Director of the Fogarty International Center, at the National Institutes of Health and is a Rear Admiral (retired) in the US Public Health Service.

Dr. Michael Osterholm, head of CIDRAP at the University of Minnesota, is among the most popular, respected, and trusted communicators on the pandemic. What is the recipe?  Simplicity rules. He learned from his rural Iowa background, “if something doesn’t play at the 10:00 o’clock coffee club at the S&T Café on the main street of my little town, then it’s not going to play.” Be frank and honest: “Always tell the truth.” If dark things such as variants lie in the future, do not shy away from spotlighting them. But be careful of forecasting too far into the future, which can at times be based on “pixie dust.” Appeal to both “hearts and minds.” “Kindness is one of the most important virtues.” In his lauded and highly successful podcast, ‘The Osterholm Report: Covid-19,’ he is able to “combine science, policy, and life all in one venue.” The anti-vaccine movement has gained substantial strength; witness the ‘Defeat the Mandates’ rally on January 23rd at the Lincoln Memorial, which featured Robert Malone, now a celebrity since embraced by Joe Rogan, who compares public health officials to Nazi Germany. “This is the biggest challenge to global health in my lifetime.” It threatens childhood immunizations, generates “death threats I have received.” Many colleagues are burning out and leaving. He and other colleagues from the Biden presidential transition Covid-19 Advisory Group recently laid out a road map for “the new normal” in three Viewpoints published in JAMA. “We can’t keep swinging from surge to surge.” We need a better plan for data, testing, ventilation, rebuilding our health workforce. But we still have to prepare for the unknown. Recall Lewis Carroll’s advice: “If you don’t know where you are going, any road will get you there.” And “Don’t be surprised when you are surprised.” China’s ‘Zero-Covid’ approach, based on draconian lockdowns and mass testing, has delivered far better outcomes than we have seen here in the United States. But it will not succeed in the face of Omicron. “It is like trying to control the wind.” Something beyond ‘Zero-Covid’ is needed.Dr. Michael Osterholm is Director of the Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota.

Dr. Chris Murray, head of IHME, joined us in episode 117 to discuss his recent provocative piece in The Lancet, ‘Covid-19 will continue but the end of the pandemic is near.’ “The Omicron wave is really different,” extraordinarily fast and much less severe. The current massive Omicron wave will infect 50%-60% of the world by March, creating dramatically enhanced population-level immunity. The unvaccinated and never-infected will become quite scarce, as transmission becomes very low. Aided by the advent of antivirals, “Omicron will become another recurrent infectious disease” that in magnitude is going to be like a bad flu season. Major emergency government interventions will become a thing of the past, even as future variants emerge. Americans will celebrate – almost like a post-war moment -- even as America passes the milestone of one million deaths. Complacency is a risk: some will see this shift as a license to do nothing. “We really have to stick to the truth,” strengthen data and surveillance, improve the health system, and better manage future outbreaks. Another risk: those opposed to vaccines, masks, mandates, social distancing may seize on this transition to advance their cause. “I have not yet received an invite from Tucker… or Joe Rogan.”  China, through its Zero-Covid approach, is hugely vulnerable to Omicron which will eventually break out and threaten to overwhelm China’s health system. In this new phase, attention will turn to other pressing global health concerns, including anti-microbial resistance, the subject of a newly released five-year study of its global burden, led by Dr. Murray.Dr. Chris Murray is Director of the Institute for Health Metrics and Evaluations, (IHME), at the University of Washington, where he is also the Chair of the Department of Health Metric Sciences.

Dr. Anthony Fauci joined J. Stephen Morrison for a CSIS live-streamed conversation on January 11. Today’s podcast is based on that conversation. Does Dr. Fauci believe the pandemic is in transition? Yes. “I have been talking about a transition since October 13.” What might that mean? “Ultimately we will need a new strategy. We cannot let this virus dominate our lives for much longer. We have to get to the point where all of us get our lives back.” The pandemic remains “a moving target.” Omicron is in effect the fifth wave, and we have to get the American people to pull together to end it. “We all really want the same goal.” It’s a mistake “if we landed on Normandy and begin to argue among ourselves over whether it was a mistake to land...  soon enough you get off the beach and win the war.” A reset on communications is needed but the “degree of divisiveness and polarization is profound, driven by disinformation and misinformation.” Internationally, it is in both the U.S. moral and national self-interest to assist low and middle-income countries to respond to the pandemic. The United States is doing “more than the rest of the world combined” and will do more. But other wealthy countries must also step up. Dr. Fauci remains worried that as the situation stabilizes the will to finance long-term capacities will fade. “We have been to that movie before.” The decision to restore US membership in WHO “was a big shot in the arm” for WHO, and WHO has done very well of late, particularly under the leadership of Dr. Tedros. It is “absolutely critical to develop a new détente with China” as well as with other countries in Asia where future viruses may also arise. The Department of Defense has a critically important role to play in our response, in logistics and science. Advancing the readiness of US forces overlaps with protection of the world.Dr. Anthony Fauci is the President’s Chief Medical Advisor and Director, the National Institute of Allergy and Infectious Diseases (NIAID).

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

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

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

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

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