3 Takeaways - How We Can Defeat The Next Pandemic and The Future of Medicine: Dr. Eric Topol (#97)

Episode Date: June 14, 2022

Dr. Eric Topol explains how we can prepare for the next pandemic, including having stockpiles of variant proof vaccines for the families that are most likely to cause pandemics besides coronavirus and influenza. He also shares recent breakthroughs in medicine which will improve accuracy and diagnosis.Dr. Topol is the founder of Scripps Research. 

Welcome to the Three Takeaways podcast, which features short, memorable conversations with the world's best thinkers, business leaders, writers, politicians, scientists, and other newsmakers. Each episode ends with the three key takeaways that person has learned over their lives and their careers. And now your host and board member of schools at Harvard, Princeton, and Columbia, Lynn Thoman. Hi, everyone. It's Lynn Thoman. Welcome to another episode. Today, I'm excited to be with Dr. Eric Topol. He's a cardiologist, founder and director of Scripps Research, and the author of three books, the most recent of which is Deep Medicine, How Artificial Intelligence Will Make Medicine Human Again. Dr. Topol is one of my go-to sources on COVID and medicine,

along with former FDA Commissioner Scott Gottlieb. Scott's also been a guest on Three Takeaways. I think it was episode 59. I'm excited to find out what we can expect from COVID next, whether Dr. Topol foresees other pandemics, and also how medicine will be transformed both by artificial intelligence and new discoveries and tools. Dr. Topol's unusual. He's not only a doctor who had

his own disease misdiagnosed and as a result suffered excruciating pain, he's also at the forefront of the movement to use artificial intelligence and precision medicine to transform medical care. Welcome, Dr. Topol, and thanks so much for our conversation today. Thank you, Lynn, and great to be with you. Great to be with you as well. Let's start with COVID. Where are we in this pandemic? The virus variants so far seem to be milder, although progressively more transmissible in infection. What's the likelihood of a more noxious new variants in the months or years ahead of us? Well, it's pretty likely. First, I would start off by saying there's an illusion that

things are more mild, but most of that's because we have a lot of vaccinations. We have a lot of people with natural immunity from infections. So it may appear mild, but if you just look at countries that had very little COVID infections, places like Taiwan and Hong Kong and China, it's not at all these variants that we're seeing in the Omicron family sub-variants, they are not necessarily mild. They can be very severe and lethal. But the chance, Lynn, of getting an even worse variant is high because we have a number of forces working against us. One is that we have millions of immunocompromised people,

any one of whom could have this virus accelerate evolution within them and then transmit it to others, which is the leading theory of how Omicron got started. And we have proof that that has occurred in other people. But also we have a massive number of animal reservoirs and we have spillover from animal reservoirs, whether it's white-tailed deer or pet hamsters or mink into people. And then we see these recombinants or hybrid people that have co-infections with Omicron and Delta or two different Omicron variants. And so we're getting all these different things, no less the fact that we have the world not containing the virus, particularly in the United States.

So that's basically a nurturing ground for more variants. So the idea that the variant will just kind of get more and more mild over time and go away, that couldn't be further from the truth. It could get worse because we keep seeing more immune escape of these variants. And the more immune escape, the more transmissible it is, and the more problems that our vaccines and our immune system have to try to defend them. What is the state of U.S. data on COVID? Pathetic. It's pathetic because the CDC is so far behind and so incomplete. We have data from the CDC in March, and it's now June. That's the latest data as far as how well our vaccines are holding up and various key metrics. cases anymore because a vast majority are being done at home or not doing tests at all. So we only are seeing right now, whatever case numbers there are, it's unreliable compared to earlier times in the pandemic. So we're relying mostly on hospitalizations, but we don't even know

regarding those hospitalizations. Are they in people who've had three shots, four shots, no shots? I mean, prior COVID, we have nothing. So we're in the dark. We're flying blind two and several months, years into the pandemic, which is incredible that we go all this time and we still can't get our data systems improved. We are seeing some improved genomic surveillance. And so we're tracking that better than we did earlier in the pandemic. But as far as clinical medical data on the people who get COVID and have adverse outcomes, the data is very shoddy. What should we be doing now for COVID? Oh, so much. I think the interesting thing, Lynn, is there's so many layers of data which would be useful to everyone at the individual level. So can you imagine where you could look at your

smartphone and you would see your individualized risk at that real time? So for example, not just the test positivity cases, but also things like wastewater surveillance, the digital surveillance, which is what is the resting heart rate in your region? Because as that goes up, we know things are changing. Mobility, where you are, all the different metrics that we know are important, but we don't have any of that. We're telling people that it's up to you, but we're not giving people the data, which we could. And, you know, we actually started at Scripps Research. We started the first digital app here in the U.S. called Detect.

And that was mimicked by Germany. And they have several hundred thousand people that monitor COVID through their phone every day. But we could do that. But there's no will. And it's actually quite inexpensive. It's passive. All you have to do is have a wristband, whether it's a Fitbit or a smartwatch or any brand, and you start having resting heart rate. And you can see where there's a cluster of elevated resting heart many that we don't capture and provide to everyone. It's really unfortunate that we're not aggressive to do that. What else should we be doing to prepare for the next COVID variant or assuming that it is more deadly? Well, it may not be more deadly, but that's the worst case scenario is that it fully escapes our vaccines. That's unlikely since it's still the virus, it's still evolving, but it was only so much it can evolve.

So I don't want to think that it's going to be going back to square one here with no immunity. It's probably always be some, but we're already seeing some reduction in protection from severe outcomes. It used to be in Delta with a booster was 95% against hospitalizations and deaths, and now it's dropped down at least 10, even 15% points. So we are seeing with these Omicron subvariants, some issues with respect to the level of highest protection that we enjoyed, that we're lucky. We're not seeing that. So it could drop down further. What could we do? Well, we saw today, as far as the CDC report about ventilation and how we are not doing the things that we could do

to get indoor places like schools and everywhere, much better ventilation filtration. Of course, we can use the masks that are KN95s or N95s, which we don't. I mean, when I go to a grocery store now, I see nobody essentially wearing a mask, which is incredible, where we have increased circulating levels of virus. We also need to respect the virus, which we don't right now, in terms of indoor gatherings and distance and testing, rapid testing to be sure that people are not infectious. So for example, a lot of people are taking Paxlovid right now because they got a breakthrough infection or they never got vaccinated. But we think that

if you take five days of Paxlovid, you're good to go. Well, if you test yourself after five days, you may well be still infectious, even out to day 10 or longer. So testing is also important and everyone should rely as much as they can to help guide things with rapid tests. The COVID vaccines were developed remarkably rapidly. The next time around, if we need different vaccines or different therapeutics for new COVID variants, how rapidly do you think we can create, manufacture and distribute these? How much faster than last time? That's actually been a big disappointment because one of the great aspects of these mRNA vaccines with Moderna and Pfizer was that they were very suitable for fast tweaking. So an Omicron-specific vaccine, we could have it in no time. Obviously, we knew about Omicron in November, and that was trouble because it was so different than the prior versions of the virus.

And here it is, June, July, we have no Omicron-specific vaccine. And by the time we have that, that was a BA1 form of Omicron, and now we're already on to BA4 and 5, and who knows how well that's going to help. So it isn't moving fast as we'd like. On the one hand, as you say, in 10 months to go from sequencing the virus to having 75,000 people in trials to prove 95% efficacy. This is truly unprecedented. It's probably the most momentous advance in the history of biomedicine, really. And think of millions of people who would have died without such vaccines. But in addition to that, we also saw Paxlovid start from scratch, essentially, as a new molecule. And within two years, which typically takes at least 10 to 12 to 15 years, within two years, we had that also with very high, near 90% efficacy in high-risk people against hospitalizations

and deaths. So we've hit it big with vaccines and at least one treatment, a pill. But the next act, we haven't seen the next act. We haven't seen vaccines come fast. Particularly what I'm interested in is a pan-savicovirus vaccine that would knock out all the future variants. Nasal vaccines, we haven't aggressively pursued that. We have other medications, particularly pills that can be easily taken rapidly. We don't have others that are potent and safe. So we aren't, it's basically, we kind of made this big bet

and put all our eggs in one basket and we haven't yet done an Operation Warp Speed or anything aggressive to do things like that again. And that's unfortunate because the longer time it takes us to do aggressive things, put in resources, the longer this pandemic will haunt us. How likely are future pandemics besides or in addition to COVID?

And if they're likely, how do you think we should be preparing? Well, I think they're likely. And we wrote in January 2021, Dennis Bird and I wrote about how we could prepare for all these pandemics and have stockpiles of variant-approved vaccines for the families that are most likely to cause pandemics besides coronavirus and influenza and others. they can be sequenced and we can put forth vaccines that would knock out the whole family, all the variants of these viruses. And we'd have a big stockpile so that we wouldn't have to wait 10 months that we have it ready to go. We can do this, but it takes allocation of the resources to do it. We haven't even done it for coronavirus, no less these other likely. We know which viruses, which pathogens are the ones that are most likely to cause pandemics. And we know because of what's happening with climate change and what we've done to our environment, that we're going to see more pandemics.

That's really unfortunate. That's one of the things that we're not really prepared for right now. But we know there's great innovations that lie ahead, that we could be truly ready and prepared, anticipate the pathogens, and unfortunately, we're not doing it. Is it primarily a government funding issue that we need an equivalent of Operation Warp Speed with its portfolio approach of funding different approaches? Is that what we need primarily? For this pandemic, yes, because right now we can't even get a dollar more funding, not just to do a pan-sorbicovirus vaccine or new treatments or nasal vaccines in particular, because that's perhaps the most imminent thing that would help us. So these are things we need here and now, in addition to being able to buy more of the things, vaccines and drugs and Omicron specific

vaccines, we can't even do any of this stuff because there's a block in Congress to not allocate any more funding against COVID. This fantasy that it's done when it couldn't be further from the truth. We've got a long ways to go to get this contained. And just when you think it is, as has happened twice now in the pandemic, once in July of 2021, where Independence Day was going to be declared from the virus, that didn't happen very well. And then another time, it looked really good in May this year, 2022, or April, and then we got the sub-variants of all kinds. So that feature that you're touching on about the unpredictability is what you plan for. You plan for the worst and hope for the best, but we're relying on hope. That's not the way to go here. mRNA vaccines were a huge advance, and we're on the cusp of other enormous advances.

What does the future of medicine look like? Well, I've never been more excited about where that can go. And that's because we are seeing, I think, a series of breakthroughs like never before because of the combination of information like genomics and artificial intelligence. So for example, to be able to get cures of a specific type of cancer, like we just recently saw with colorectal cancer for a specific mutation, we've never seen anything quite like that. What we're seeing is taking accuracy to a very high level in diagnosis and in treatment and ultimately individualized medicine. So I couldn't be more excited about where medicine is headed. And unfortunately, some of that sense of the public is lost because we're in such despair

currently. But in the background, a lot of great advances are happening almost on a daily basis. Eric, I'm so sorry about your experiences as a patient. Can you tell us about that and how it's informed your work? It's also important as physicians that we experience things as patients, because even though we may have better knowledge and better contacts, the same sense of being roughed up can happen. And that's what happened with me. I had a knee replacement, total knee over five years ago. And when I had that, almost six years now, I developed a complication that I never heard of, the orthopedist never mentioned, called arthrofibrosis. And that was devastating for me, still is now six years later, a major handicap for me, because as you alluded to, when you introduced the session is

that the unmitigated pain and difficulty in managing it, but it wasn't even described as a possible complication, nor when it occurred was it diagnosed. The orthopedist told me, as I wrote about in Deep Medicine, that I needed to see an internist to get antidepressant medicine, which is extraordinary. I know patients all around the world experience this every day, but it was enlightening to say the least to have to go through this myself with an orthopedist, of course, who I referred many patients to for the same operation that I had. So I live in a fear that I have to go through the other knee someday because it's such a devastating complication for me to endure.

But at least I can do most things now that I want to, not all, but most, and things could be worse. I guess things can always be worse. At any rate, it gives me enhanced respect for accuracy in diagnoses, communication, time with patients. This is where AI likely will have its biggest impact, which is the gift of time. And of course, I had no time. I got the usual few minutes to see my doctor when I was in need. And we need to restore that patient-doctor relationship. I think it's completely eroded overall. There are some special bonds out there. But when I started in medicine back in 1980, it was a precious relationship that was typical, whereby there was trust and presence and time and all the things you'd want for empathy and communication.

Now that's the rare exception rather than the norm. We've got to get that back. And an average doctor's appointment, as you mentioned, is very short now. And doctors don't always have the time to listen or think about the rare diagnoses. And he just assumed that yours was a more common diagnosis and misdiagnosed you with depression. You were actually saved by your wife. Yeah, she did the research and found this condition. And ultimately, I was able to find a physical therapist who really knew how to handle this condition, which was the opposite of what the physical therapist that I was ordered to see by the orthopedist. So, yeah, I mean, it was just an extraordinary experience to have that.

And it motivated the book of deep medicine just because personal experience, which I know is common, a variation of what I've experienced, of course, not the same thing. And we have to do better. Medicine has undergone a lot of attrition that it can get back to where it was, which it's about humanity. It's about people bonding to people and looking after. And the greatest privilege I've had throughout my career is being able to look after patients and help provide their care. And that's what it's all about. But we kind of lost our way at some point. Before I ask for the three takeaways you'd like to leave the audience with today, what should I have asked you that I didn't? I think you did a pretty good job in our short time together to

cover the bases. And I think the ability for us to get out of this pandemic is there. And it's frustrating, of course, that we aren't taking it seriously enough and providing the resources. So you did ask about that. I've made a plea. I wrote about COVID capitulation, and it's just so vexing that we can't innovate out of this mess that we're in, because I know it's possible. Eric, what are the three takeaways you'd like to leave the audience with? I'm a very optimistic person. You may not have gotten that from our discussion, but the first thing is that I do believe we have the path to a much higher level of both accuracy in medicine for diagnosis, for individualized medicine, that is understanding what's unique about

each human being, and to get the gift of time and restore the patient-doctor relationship to where it should be and where it was, even in my career. So those three takeaways are kind of embedded in my excitement that we can get medicine back. We have to, and I think we know what is needed. Now we just have to take the actions and pursue this. It's more than a worthy goal. It's an essential one. And I know eventually we'll get there. Thank you for all your work as a doctor. Thank you for founding the Scri a doctor. Thank you for founding the Scripps Research. And thank you also for our conversation today. This has been great.

All right. Really appreciate it, Lynn. Thanks for having me. If you enjoyed today's episode and would like to receive the show notes or get new fresh weekly episodes, be sure to sign up for our newsletter at 3takeaways.com or follow us on Instagram, Twitter, and Facebook. Note that 3takeaways.com is with the number three. Three is not spelled out. See you soon at 3takeaways.com.