Call Me Back - with Dan Senor - When IS Post Corona, anyway? Part 2 - Turning the Corner

Episode Date: January 29, 2021

As we post this podcast, the US has vaccinated about 7.6  percent of our population, The UK is at 11.7%. Canada and Germany are hovering around  2.5 percent, France is at 1.7 percent, and Israel is at Over 50%.Scott and I have been talking, and he has laid out a pretty interesting take on how we’ll quickly hit a tipping point on vaccinations, when we won’t have a vaccine supply problem, but a consumer demand problem, meaning not enough people lining up for the vaccine. Scott also has insights into the new variants, what a gradual post-corona return to normalcy could look like, and perhaps most concerning - what we have learned about future national security risks from viruses as bio-weapons?

There's no reason to believe that this was a deliberate pathogen, but I do think what this proved is that a respiratory pathogen poses an asymmetric risk to Western democracies. The old thinking was that a nation state would never use a biological weapon that could blow back on them. But if a nation state thinks that they're going to be more adept at thwarting the impact of that biological weapon, they may see it as a tool that could encumber us much more than it can encumber them. Welcome to Post-Corona, where we try to understand COVID-19's lasting impact

on the economy, culture, and geopolitics. I'm Dan Senor. How will we know when we actually arrive at the post-corona phase? This is the second part of a two-part conversation on this question, the first of which was two episodes ago when we looked at Israel, what I call Vaccination Nation. And today we'll talk about the U.S., trying to understand when we will arrive at post-corona, and what is standing in our way. As we post this podcast, the U.S. is vaccinated about 7.6%

of our population. The U.K. is at 11.7%. Canada and Germany are hovering around 2.5%. France is at 1.7%. And Israel, over 50%. My mother, sister, brother-in-law, and even one of my nieces in Israel have already gotten both jabs. To help us understand what is happening in the U.S., we welcome Scott Gottlieb, who served as the 23rd Commissioner of the Food and Drug Administration. Dr. Gottlieb is currently on the boards of Pfizer and Illumina and a special partner with the venture capital firm New Enterprise Associates. He's a resident fellow at the American Enterprise Institute, and previously Scott served in a number of other roles at the FDA, including

deputy commissioner. He was also a clinical assistant professor at NYU's School of Medicine. Scott and I have been talking, and he has laid out a pretty interesting take on how we'll quickly hit a tipping point on vaccinations sooner than we think. When we won't have a vaccine supply problem, we'll have a consumer demand problem, meaning not enough people lining up for the vaccine. He also has insights into the new variants, what a gradual post-corona return to normalcy could look like, and perhaps most concerning, what we have learned about future national security risks from viruses as bioweapons. This is Post-Corona.

And I'm pleased to welcome Scott Gottlieb, the former head of the FDA, to our conversation. Scott, thanks for joining us. Thanks for having me. So let's jump into this. the former head of the FDA, to our conversation. Scott, thanks for joining us. Thanks for having me. So let's jump into this. I want to start with where we are in the current state of the vaccination campaign in the U.S. Well, we're picking up traction here. It was slow going at the outset. I think what you're seeing is more sites coming online and a greater diversity of sites. And that's really the key. You want to have different kinds of sites because different patients are going to want to get vaccinated in different settings. Some people are going to be most comfortable

going to a pharmacy. Some people are going to be most comfortable going to a community health center that they're used to getting their medical care from. Some people are going to be willing to go to large vaccination sites. I think initially what you saw was most of the vaccines were being pushed out either in nursing homes, because that was the initial priority, which was to get nursing home residents vaccinated, hospitals, because we were vaccinating healthcare workers, or when we were vaccinating in the community, most of the sites were these large vaccination sites. You see states and cities setting up vaccination sites at fire stations and stadiums. That's good. You can drive

a lot of patients through there, but a lot of people aren't going to be comfortable going to those kinds of sites. And so what you want is you want to get the big box stores into the game. You want to get the pharmacies like CVS and Walgreens and Walmart vaccinating as well. And you want to try to get this into the hands of community physicians. It's obviously going to be hard to get down to the level of small community practices, especially with the way these vaccines need to be handled and stored under very cold temperatures. But for a large multi-specialty medical practice, there is the potential to go into some of those settings and have vaccinations offered through those settings as well. And that's what we're seeing right now. We're seeing a greater diversity of sites get

stood up. So I think that the supply that's available is going to be able to get worked off on a regular basis. I don't think that we're going to have stockpiles and backlogs of, you know, vaccines sitting on shelves in about two weeks. I think what you're going to see around the country is when vaccine comes off the manufacturing line, it gets used because we have enough sites to distribute it through. So the initial conversation around vaccines was, it's hard to distribute it. We had vaccines on shelves, we had vaccines in warehouses, not all of it was being taken up by the states. The states weren't ordering all the vaccine that was available to different states. Now you're seeing the discussion shift to supply. You're seeing states and cities say, we don't have enough supply. We have sites, we have nurses to do

vaccinations, and we don't have enough vaccine to satisfy demand. I actually think that the conversation in about a month, maybe six weeks is going to shift to demand. I think that the demand here for vaccines is very deep, meaning there is a good number of people who really want to get vaccinated very badly, especially people over the age of 65. But I'm not sure it's as wide as we think. I think once you're once you vaccinate 120 million Americans, maybe a little bit more than that, that's really the low hanging fruit in terms of where the intense demand is. And if it's difficult to get vaccinated, if you have to go online and sign up and spend half a day going to a site that might not be near your home, you're going to have a hard time recruiting

beyond that number. And so i think we need to think about demand and how we inspire more people to want to get vaccinated even now when it seems like you know we're rationing these things and we don't have enough vaccine i think we need to be thinking about demand because in a month or two that's going to be um that's going to be the issue so so let me stay on that for a moment because because everyone in my world, and I'm sure everyone in your immediate world, all they're talking about is a vaccine. When am I eligible for a vaccine? How quickly can I get a vaccine? Where can I go to get a vaccine?

It's just there's this understandable panic about how soon we can all get vaccines. But what you're saying is that's probably a narrow set of the population that is thinking like that. And for a lot of people, it's actually a hassle to get a vaccine. And I certainly know that's the case here in New York, the stories I've heard about what it takes to get an appointment and all the rest. And so it's not like the flu vaccine at all. The flu vaccine is, I mean, you've made this point to me when we spoke recently. You said, look, with the flu vaccine, it hits you every, you know, the pressure to get one is everywhere,

and the ease of getting one is everywhere, right? You go to a CVS or any kind of pharmacy, you go to your kid's school, your office, the flu vaccine is almost seamless, and we're nowhere near that for, even for the people who are eligible for the coronavirus vaccine. Right. I mean, look, if you look at the data on uptake in nursing homes among medical staff, in some states, I've talked to some governors and others about this, you're seeing 40 to 50%

of staff in the nursing homes agree to get vaccinated. And it was brought into the facility and offered to them and they work in a healthcare facility where there's an imperative to get vaccinated. So that shows you that not all facility where there's an imperative to get vaccinated. So that shows you that not all of the public is as anxious to get vaccinated right now as certain pockets of the public. And so I think that the demand is very deep. There's a lot of people who really want it and will go through the difficulty of getting it. But we've created a system that has friction in it. It's not simple to get a COVID vaccine.

To your point, it's not like the flu vaccine where you're going to be able to walk into CVS and the pharmacist is going to repeatedly ask you to get vaccinated, or you might get vaccinated at work or your doctor's office. You're going to have to make an effort to get a COVID vaccine. And so how big is that population? Well, this year we vaccinated 123 million adults for flu. That was an all-time record. Typically, it'd be about 90 to 100 billion adults. And so the reason why it was so high this year is because that's a lot of people who were worried about COVID getting a flu vaccine because it was all they can do. So I think that's your target population. I think once you get beyond that, there may be a universe of patients beyond the universe who got the flu vaccine who will be motivated to get a COVID vaccine, but I don't

think it's double that. I think maybe when we get to between 120 and 150 million Americans vaccinated for COVID, it might become difficult. So we can get 50% of the public vaccinated for COVID, maybe a little bit more with some efficiency. But the idea that we're going to get 70% of the population vaccinated for COVID, I think is unrealistic unless we do more to make it easier to get access and we do more to try to stimulate demand. And my concern right now is we're so focused on the fact that this is a scarce commodity that we have to ration right now, which is true. We kind of take that for granted that we're not going to be in that situation forever. So when is the tipping

point going to come? Well, right now, most states are focused on vaccinating the over 65 population. That's about 50 million Americans. Let's just say, for argument's sake, that uptake there is very brisk. It was in the 75 and above cohort. And my state, about 90% of people over the age of 75 when it was offered to them got vaccinated. You're in Connecticut, right? Yeah. So let's say that of the 50 million Americans over the age of 65, we vaccinate 40 million of them or 45 million of them, which would be a lot. OK, so we have right now we've produced about 40 million vaccines in December.

We'll produce about 50 million in January. We'll produce about another 40, 50 million in February. If J&J gets their vaccine approved by the end of February into March, that's going to add tens of millions a month. And we'll produce another, you know, 40, 50 million vaccines in March. So now you're talking about bringing online between now and the end of March, you know, over 200 million vaccines or 200 million doses. 200 million doses between now and the end of March. Probably, you know, if we hit all our targets, yeah, over 200 million doses. Pfizer has said that they can produce actually more than the 100 million that they originally promised.

They're now saying that they can produce 120 million doses in the first quarter. I'm on the board of Pfizer, as you know. Moderna has said they'll produce 100 million. J&J could enter the market and produce tens of millions in February and into March more. And they said by the end of April, they'll produce maybe upwards of 100 million. Some of that is backloaded. But let's just say you could produce 250 million vaccine doses in the first quarter. And if the demand is really intense among senior citizens, we manage to vaccinate them in the next, you know, four weeks, three, four weeks, you're getting to the point where this is going to have to become generally available, I think, sooner than we think to try to continue to have demand keep up with

supply. Because people always ask me, well, I'm healthy, I'm 40, when am I going to be able to get vaccinated? And you've heard some people in the government say, well, May or June. I think it's going to be, you know, maybe end of February or March that this is going to be generally available. And we're going to be in the mode of having to, you know, say to people, please come in and get vaccinated. You know, if you want to get vaccinated. People under 65, under 60, like people in their 50s, 40s. Exactly. It's not, it's going to be some, it's going to be the type of thing where there's an inflection point. I said this to a governor recently. I said, you know, you wake up right now and you think, how am I, how am I going to ration this?

Everyone wants it. And I've got to set up this scheme to ration it. And this is a very difficult task. One day you're going to wake up and you're going to say, how do I manage to get all this vaccine used? Because all of a sudden there's going to be a tipping point where you've worked through some of these priority populations and there's much more vaccine coming onto the market than these priority groups. And

you're going to have to make it generally available. I mean, it won't be binary where one day there's just a deluge of vaccine and they're giving it all away. But there'll be a point in time where these states have to say, we'll have to open up the registration system so anyone can go online and get an appointment because we now foresee that, you know, demand is not as brisk anymore. We vaccinated the really strong demand and the supply is continuing to come online. And remember, the supply builds. So it's not like this is sort of binary all the way through. As months go on, the manufacturing is going to increase. And so your supply is also going to build as you get into March and April and May. And especially if J&J comes on the market. I mean, that's a game changer.

We'll have, you know, virtually unlimited supply by the end of the first quarter if J&J gets their vaccine authorized and everything goes well. So Israel right now, speaking of going full steam ahead, Israel's probably two months away from vaccinating its entire population. Prime Minister Netanyahu has said that his goal is to have the entire population more or less vaccinated by Pesach, by Passover, so people can be with their extended family for Passover seders. He sort of painted that image recently.

What is it about the Israeli health system? We did an entire episode two episodes ago on the Israeli health system and the Israeli vaccination campaign. We're calling it Vaccination Nation. Can you, from your perspective, because you're on the, for one, you're on the board of Pfizer. Pfizer is a big part of this story, but also as a public health leader. What is it from your standpoint about the Israeli health system that allows it to move so much faster than that of the US? They operationalize sites very quickly and very well. I know that. They have a sort of consolidated healthcare system where most people get their healthcare through three large payers, as you know, and they secured a lot of

supply. They worked early on to pay to secure early supply. And so one of the first countries really to secure a sizable amount of vaccine from Pfizer was Israel. And they worked proactively to do that. So those are the three ingredients that I know about. You're already seeing in the data, and it's, you know, still early and hard to draw conclusions, but you're seeing a reduction in hospitalizations among the 60 and over age set, which is the age that they've now successfully vaccinated by and large. And so you might already be seeing the beginnings of a population-wide effect from the vaccination campaign that they've implemented. Part of, I think, the attractiveness of Israel launching a vaccination campaign so quickly is they have very rich healthcare data.

And they were able to take this data that went back a couple decades. Each Israeli has these electronic medical records. And you take the data from these electronic medical records, and you take the data from those electronic medical records, pair it with the results from the vaccination, and then you have a real potentially powerful control group to look at for other countries to look at, including our own. How important do you think that is? Very important. And we're already seeing some data come out of Israel, like I said, about the potential population level impact of vaccination. We saw that a week ago.

We started to see the first reports come out of Israel. That's going to be very important for answering certain questions about the vaccine. So the question I get the most often about the vaccine is, does it prevent me from getting infected? And does it prevent me from spreading the infection? Because everyone wants to know, if I get vaccinated or my parents get vaccinated, can I go see them? Or can my children go see them?

Do I still have to be worried that I could spread the infection to someone who wasn't vaccinated or maybe for whom the vaccine doesn't work well? And to the answer to that question, which is unsatisfying to people, is we don't know. Now, it's not that we don't know. We strongly believe, and there is some data in the Moderna filing, and there's going to be more data coming out from Pfizer exploring this question. We strongly believe that it reduces the likelihood that someone's going to get the infection and it reduces the likelihood that they're going to transmit the infection.

And that's based on both experimental data as well as data actually in non-human primate studies, which are a good proxy for trying to figure out how a vaccine is going to behave. But to really answer that question and to answer the magnitude of the effect. So if we feel comfortable saying, yeah, it's reducing infection in some people and it's reducing your likelihood of transmitting the infection. The other key question is how much, you know, is it making it 50% less likely I can get infected, 90% less likely, 10% less likely? And the way to answer that question is going to be using real world evidence. It's going to be studying the behavior of populations after they're vaccinated and looking at people who were vaccinated and people who weren't vaccinated or looking at how the virus transmits in a vaccinated population. And from that kind of data, you're going to be able to start to draw firmer conclusions about those really critical questions because they get to the heart of how effective is the vaccine as a public health tool. And having a data set like Israel has is going to be really important because they can look at those questions longitudinally over time and they can understand how different patient characteristics as well

correlate with how effective the vaccine is. Because we know for some people, the vaccine doesn't seem to deliver as much effectiveness. There's something about certain individuals that we don't understand that they don't have the same level of immune response from the vaccine. And so those data sets are going to be very rich. And I suspect some of the best data on this question is going to come out of Israel because of the way that they've been, first of all, the way they vaccinated the population sort of all at once. And second, the way that they've seemed to so far be trying to answer these questions in a longitudinal fashion. And the other factor that's interesting is you have such a diverse population. You have over

70 nationalities. You have people from North Africa. You have people from Eastern and Central Europe. You have people from the Far East, you have people from the United States. So all these different national backgrounds combined with all this data is, and as you said, in a concentrated period of time, should even make it more interesting. I want to ask you about these different strains. So obviously this is a big topic causing a lot of concern right now. So can you just give us a quick explainer on the strains? There's the Brazilian strain, the South African strain, and the UK strain. So what is the research so far telling us about these strains? In terms of how

much more virulent they are and what kind of impact they have on people who already had coronavirus, so older, previous victims? Is it able to infect people who've already had it or both? Well, the new variants seem to be more contagious. And now there's some data, at least with respect to B.1.1.7, that suggests that it might be more dangerous as well. It might be more pathogenic. And which one is that? That's the UK variant, so B.1.1.7. The South African variant and the variant that's in Brazil, B.13.51 is the variant that's in South Africa, are similar.

But it's unclear if they're sort of the same lineage or they're two viruses that arose spontaneously in two different regions of the world and they just happen to have similarities. The strain in Brazil, the variant in Brazil, has more mutations than the variant in South Africa. The reason why that one concerns us a little bit more is that all of these variants have mutated the spike protein, which is the protein on the surface of the coronavirus that the coronavirus uses to gain entry into our cells. It binds to what we call the ACE2 receptor, which is the receptor in our lungs that the coronavirus binds to. And there's literally like a spike on it. So that's why we call it the spike protein. That protein is the protein that is used in the vaccines. And it's

also the protein that's a target of our therapeutics. So if the virus manages to mutate the confirmation of that protein, it's possible that it could therapeutics. So if the virus manages to mutate the confirmation of that protein, it's possible that it could change the protein enough that the antibodies that we develop against the vaccine or the antibodies that we develop from prior infection, from being infected with an old strain of coronavirus, may not be as effective at clearing the virus anymore if that spike protein changes enough. Now with the UK variant, it doesn't appear that the variant has changed that protein in a significant enough way that our old antibodies or the antibodies we've developed from the vaccine won't work against it. And also our antibody drugs,

we have drugs that are basically manufactured versions of human antibodies by Regeneron and that are being used as therapeutics. And the problem with the South African variant and the one in Brazil is that it's mutated some very key regions on that spike protein. It's mutated the parts of that protein that we develop some of our most effective antibodies to, specifically a part of the protein called the receptor binding domain. And so it may be the case that some of the most effective antibodies that we develop, either by prior infection or by vaccination, now no longer work as well against this new variant or maybe don't work at all. That doesn't mean that the vaccine suddenly won't work.

And it doesn't mean that everyone who had coronavirus suddenly will get reinfected with this new strain. It could mean that it doesn't work as well. And it could mean that people who were previously infected are more likely to get reinfected. So that's to be determined. We don't know for sure. I think a lot of people are worried about it, that you could see the vaccines not being quite as effective against this new variant as they were against the, you know, the sort

of old variant of coronavirus. We're going to have studies that turn over the card on this question pretty soon. Now, you can always update the vaccines, but that's something that we're going to have to think about doing for the fall. It's not something we're going to be able to do in the near term. But what you're saying is, though, it's not, we tend to think of these risks in binary terms. What you're saying is it's not necessarily binary. It just could mean that the vaccines out there now are effective. They're just, the efficacy goes down, but it's not

it doesn't go from one to zero, right? It's not it's not going to be like the flu vaccine. The reason why all of a sudden the flu vaccine may not work anymore is because the immunity that we develop against the flu from vaccination is because we develop antibodies against a very specific part of the flu virus called H.A. It's a protein on the surface of the virus. And all the other antibodies that we develop against the virus as a result of vaccination aren't really that useful. It's just the antibodies that we develop against this very specific part of the virus. And it so happens that this is the part of the virus that the virus mutates really readily.

So you could have a situation where the virus mutates this one part of its protein surface and all the antibodies that we developed against it don't work. And the antibodies that we developed against other parts of the virus are sort of inconsequential. With the coronavirus, that's not going to be true. You develop with vaccination and you actually may develop a more robust immunity from vaccination than from prior infection. You develop what's called a polyclonal effect, where you're developing antibodies against many parts of this protein. And a lot of them are important. There's certain ones that are more important. But it's not like the flu, where it's kind of binary, where it's really only one part of the protein that you're developing your most,

your only robust antibodies against. So even if the antibodies against this receptive binding domain don't work at all, because it's mutated so much, and that might be the case with the South African and the Brazilian variant, you're going to have antibodies against other parts of this protein. So a vaccine that might have been 95% effective, and I'm completely speculating here, I have no experimental evidence, maybe it's 60 or 70% effective against this variant. That may be okay because, you know, this variant isn't the predominant variant yet. I don't think it's going to become epidemic in the United States. And if it does, it will happen probably next fall or winter. I think the risk

that we face from these new variants is that they create localized epidemics in the spring and the summer when otherwise we should have a very quiescent spring and summer. I mean, this virus now is clearly coming down, as you and I discussed. I mean, we predicted this would happen. Levels of new infections are coming down. Hospitalizations are coming down. Deaths tragically lag, but now they're coming down, thankfully, as well. It's going to be slower. We should have had a situation where in the spring and the summer, we didn't have a lot of coronavirus. Between prior infection and 30 or 40 percent of the population having had this virus, right now it's probably close to 30 percent, and then we're starting to vaccinate. When you get to 20, 30 percent of the population vaccinated and 30, 40

percent of the population having had the infection, even though there's some overlap between those two groups, you're getting to a point where 50 or 60% of the population has some immunity to coronavirus. It doesn't spread as much. And then you layer on top of that the warm weather where people are out and about and they're not crowded into closed spaces anymore, where it spreads easily. And you shouldn't have a spring and a summer epidemic of coronavirus. The risk should have been to the fall. Now, with these new variants, because these are much more fit, because some people aren't going to have prior immunity, because they're going to transmit more readily, even in warm weather, there's the risk that they can continue to spread. So in markets where they might be one or two

percent of infections now, that's a real risk. Where is that? That's San Diego, that's Miami. But in places where they're only 0.1% or 0.2% of the infections, Boston, New York, Philadelphia, based on what we think, we don't really have good data on how prevalent these new variants are in the United States. That might be too little too late in terms of, you know, if it's 0.1% in New York, and let's just say it doubles in prevalence every week, which is basically what it's been.1% in New York, and let's just say it doubles in prevalence every week, which is basically what it's been doing in Europe. These new variants have been doubling in prevalence every week.

That'll probably slow down a little bit because it'll start bumping up against more immunized people here in the U.S. and more people who had the infection already. But let's just say it doubles every week. So you're in New York. It's 0.1% now, goes to 0.2 in a week, then 0.4, then 0.8, then 1.6, then 2.2 because it starts to slow down a little bit, then 3, then 4.5, then 5. So in six to eight weeks, you're at 5% of the infections in New York of this new variant. That might be too little too late because in eight weeks, we're now vaccinating at a faster clip.

The weather is warming. So New York may have dodged the bullet. And maybe it's not until next fall or winter that this sort of comes back. But you might have more infection than you otherwise would have had because it's going to continue to bounce around. But now what is the what what is the are not on each of these strains? Roughly that it's probably point five more than the sort of typical coronavirus and so you know um which is a lot the right um so now you look at miami or san diego it might be one to two percent of infections there already i think it was one percent last week it might be two percent now so now you got let's let's just say 1% in San Diego. And I think it's a little higher than that.

So now it's 1%. Next week, it's 2%. Then it's 4%. Then it's 7%. So it doesn't quite double. Then it's 12%. Doesn't quite double. Then it's 25%. So in six weeks, you're at 25%, 30% of infections of this new variant in San Diego. That's a problem. So that's the situation that we're dealing with. I think what could potentially happen is what happened last July. And last July, for most of the country, I don't know about you, I was having barbecues again. I was being careful, but we were going out again. We were starting to, you know, we were eating outside. You could socialize outdoors comfortably. Exactly. I saw my parents. Most parts of the country, prevalence was really low.

We weren't that worried about catching coronavirus. But if you were in Houston or Phoenix or Miami, things looked very different. So we could have a situation where there's some regionalized outbreaks and hotspots in an otherwise quiescent summer. And the only way to change that calculus now, because this is here, the idea that B1351, the South African, the Brazilian variant isn't here because we haven't found it. We're not looking, we're barely looking for it now.

It's here. The only way to really change the equation on this risk is to get more people vaccinated more quickly. That is really our only tool right now. Right, so it's a race, right? These strains are racing to replicate and we're in a race to vaccinate. And it's, it really is like a race against time. And that's why the game has changed on vaccination. I mean, we were going through sort of this very methodical approach to vaccination, trying to prioritize certain groups and work through those groups before we expanded eligibility.

And we still need to do that. I mean, there's still groups clearly that are vulnerable, that are hard to reach, that lack access to care and have been disproportionately impacted by COVID. All of that is true. And we need to have systems in place to try to get vaccines available to people who need it, because there are certain people who need it more because of what they do, because of their comorbidities, their vulnerabilities. They're older. They have other diseases. But simultaneous to that effort, we need to just be getting shots in arms. And so we can't stop or slow down the effort because we aren't able to work quickly through the prioritized groups. We've got to be doing both at the same time. And what you saw in a lot of states was they were saying, well, we're on, you know, 1A.2, and then we're going to 1A.4, and then we're going to 1B. And they were going

through this sort of very methodical process and weren't opening it up widely. And so they had vaccines sitting on the shelf because it took a while to work through these prioritized groups. I think they need to be doing both at the same time, trying to target it to groups that are more vulnerable, that are harder to access and face more risk from COVID, or have disproportionately suffered from COVID because they're essential workers, they've been getting infected at a higher rate, and then at the same time, just recognize, but we also need to get vaccines in arms. And so when we, if we're not able to work through this quickly, we need to expand eligibility and just get vaccines out and view every vaccination that we can accomplish as a win from a public health standpoint, because at the end of the day,

what we're trying to do is get enough immunity in our population that the new variant is more likely to bump into an immunized person than not my understanding on the uk strain is that the uk strain is easy to identify or at least easier to identify on normal on normal pcr tests so right go ahead so when what you're doing is when when we're sequencing and i'm on a board of illumina as well they're my two public boards, Pfizer, which developed a vaccine, and Illumina, which happens to be the company that commercializes the machines that are primarily used for sequencing, and also is doing a lot of the sequencing work looking for these variants. What you're doing to find these variants is you're basically taking samples of the virus in people who are positive, and you're sequencing it to look at the RNA makeup, the genetic makeup of the RNA of the virus. When you're looking for the UK variant, you can look for something called S gene dropout. So when you do the traditional PCR tests, you get this very specific finding on the PCR test, which is an indication that it may be the

UK variant. And so you take those samples, and then you sequence them. And what we find is about a third of the samples that have this S gene dropout are in fact the UK variant. So you're sequencing an enriched sample. And so when we come out with data that says we found 200 cases of the UK variant, we didn't just randomly sequence 200 people. We sequenced people who had this estrogen dropout. It was a very enriched sample set. But with the Brazilian and the South African variant, there's no way to tell on the PCR test who might and who might not have it. So there we truly are sequencing a random sample. So when we say we sequenced 2,000 cases

this week looking for the South African variant? Well, this week, there were, you know, 2 million people diagnosed with COVID. So of those 2 million people diagnosed with COVID, we randomly pulled 2000 cases and sequenced them. And if you believe, which I do, that these new variants aren't everywhere, but they're in sort of localized hotspots. And let's just say you sequence 2000 cases, and so you sequence 40 or 50 a state. And but the localized hotspot is, you know, Orlando, and, you know, pick your city in Orange County, California, somewhere else. And so you sequence 40 cases in Florida, Maybe you sequence one in Orlando. Maybe you sequence two because you tried to, you know, mix it up around the state.

So what's the likelihood that if 5% of cases in Orlando right now are this new variant, that the one or two cases that you sequence from Orlando are in fact the new variant? Very low. So you could easily be missing it. Now, this is all conjecture. I don't know where it is. I'm not saying it's in Orlando, but I just want to show how I want to hear from all our listeners in Orlando.

But right now, given the amount of sequencing we're doing, we could be missing this. So people who say we haven't detected it here yet and we don't think it's here. I think it's here based on all the connections based on how epidemic this is in countries where we know that there is connectivity. I think we have to assume it's here. It's probably here in low numbers, but there probably are some hotspots that we're not detecting. And how would you evaluate the state of our surveillance, the state of our testing infrastructure across the board? Well, you know, the state of the surveillance with sequencing is not well developed.

The UK sequences about 10% of all their samples. They're one of the best in the world. They've built this over the last year. It was a very deliberate effort to build out this infrastructure. We have not built it. We had a year to do it. We have not. I have an op-ed in the Wall Street Journal this week about this very point. Just understand, when they sounded the alarm late last year, when the UK sounded the alarm late last year on the new strain, at that point, they were the only country on the planet with genomic sequencing capability to study.

Every country has a lot of genomic sequencing capability, and we probably have more than any other country, but most of our capability is focused on research. And so we may be sequenced. We're sequencing a lot of coronavirus strains, but we're doing it in the context of academic studies. Right. I'm just saying they were testing their actual samples. Yeah, they're doing it in real time.

They're using it as a public health tool to do real-time sequencing. We're not using our installed basis sequencers to do that. So it was almost unfair to say it's the UK variant because it probably originated in the UK. They just identified it. Exactly. They were the first to identify it. And they get the moniker. Exactly.

They got punished for having a really good... So they're sequencing 10% of all their cases. We're sequencing about 0.2% to 0.3% right now. So that gives you the basis of comparison in order to be able to detect a new variant when it's anywhere between about 1% of the cases in the US, which is a threshold where it's still actionable. You can still do something about it at 1%, you have to be sequencing about 5% of the cases. So we're at 0.3%, we should be at 5% in order to have a 50% chance of detecting something when it's at 1%. And that's rough math. Let's talk about what the post-corona world could look like for us. And the only comp I can think of is when I've traveled through various parts of Asia over the last couple of decades.

And it always seemed so bizarre to me, you know, even when we're not in a pandemic or an epidemic moment in any of those countries. People are wearing masks. People are kind of sensitive about density, population density in certain areas, not all the time, but there's just a heightened sense of awareness. And then of course, when the coronavirus hit, many of those countries were able to just flip into high gear and the whole population knew how to act with great discipline right away. So I think about that world that seemed so foreign to me. And is that basically going to become our world even once we get to a point in which we have vaccinations and, you know, widely available vaccinations, herd immunity, all the rest? Do we start to look like, you know, Asia's done, which has been, Asia did dealing with epidemics over the last, you know, couple of decades?

I think so to some degree. You know, and a lot of the behaviors that you see in Asian countries now are a consequence of SARS. Things really changed in Taiwan and Hong Kong and South Korea after SARS and after MERS as well. And I think that COVID is going to have an indelible impact on our culture as well. We have more heterogeneity here. We have a diversity of views about the implementation of respiratory precautions in the winter. And people are going to just be more conscious of it. You know, if you come to work sick, you're going to be frowned upon. If you're sitting and coughing in a crowded space, people are going to look upon you with scans. I think you're going to see more people wearing masks in public. It's not going to

be something that looks odd when we see someone wearing a mask. You know, I think I'll be wearing a mask when I travel in the fall and the winter. I just think you're going to see different behaviors. And it doesn't mean that they'll be mandatory, although there will be certain things that we do that are different. I don't I don't think we're going to be crowding people into tight spaces next fall and winter. Yeah. Well, run conferences differently. So I think about how many, how much of the American economy has been historically, in modern times, been dependent on people having sort of packed in dense cheek to jowl experiences on airplanes, in theaters, in restaurants and bars, I mean, in subways and public transportation, those are all big aspects of our economy. Does that change? I think some of it changes. I think that there's going to

be, you know, it depends on the demographic, the age demographic that experience is being marketed to. I think you're going to see businesses have to advertise about the quality of their indoor air. I think that's going to be more commonplace. We, you know, it's HEPA filters, MER filters, we turn over our air every three minutes. You're going to see things like that in indoor spaces. I think people are going to try to create different seating venues in certain settings for people who have different levels of risk tolerance. So I think to get back certain customers into certain kinds of settings, if you want them back, you're going to have to do things differently. Will 25 year olds still crowd into bars in New York next fall and winter? Yeah. Will will a 65 or 70 year old couple go on a cruise ship that isn't putting in place some testing or some other precautions or requiring vaccination?

I don't think so. I think that they're going to want a higher level of vigilance to be applied. And I think businesses with relatively modest expenditures are going to be able to accommodate that. I think we go back to doing what we did, but we do it a little differently. And you're going to have to think of the kinds of precautions you're putting in place relative to who your clientele is. Does that put less of a premium on life, whether living in or visiting places like New York City and London and Tokyo, which is a big part of the business of those cities is providing all these amenities for people who live in these cities or visiting these cities. Those are those amenities are experienced in crowded places outside of apartments and hotel rooms? I think that if, unless something really untoward happens with this virus, unless we get a mutation that really defeats our vaccine, which I don't think is going to happen, you usually see these things coming.

I mean, these things take time to build. The UK variant didn't emerge in two weeks. It emerged over a longer period of time. We just didn't detect it. So we're going to get in place better detection. We're going to have ways to update the vaccine and potentially provide boosters to cover new variants. This shouldn't slip past us or shouldn't have to slip past us. I think next winter, we're getting back to doing the things that we enjoy with some added precautions, with people

changing how they queue people up and how they crowd people into spaces. And the net result is it looks like a really bad flu season. You know, we're still going to have and that's assuming we get a good portion of our population vaccinated. And I don't expect us to get 80 percent of the population vaccinated, but I'm thinking we'll get 60 percent, maybe 65 percent. I think the first 40 to 50 percent should be, I don't want to say easy, but very doable. I think getting between that 50 to 65% is going to be hard.

But if we get there, I think next season looks like a really bad flu season, assuming the vaccine isn't obviated by the virus. And, you know, in a really bad flu season, in the 2017, 2018 flu season, when the vaccine didn't cover the flu well at all, we had 60,000 to 80,000 people die of flu. It wasn't trivial. Hospitals became overwhelmed in certain parts of the country where it was particularly epidemic, but we weren't all sheltered in place and we didn't have 500,000 deaths. So I think that's going to be because we're going out again. We're living again. But again, if you're a business that puts on a big

conference, I think what you end up doing is you have a conference, you still have a conference, but there's a bespoke aspect to the conference where you bring together a small group for a more high touch experience, and then you stream it for a larger audience. So you're thinking of doing things differently. I suspect most companies, the December board meeting is going to be a virtual meeting. They're going to go back to in-person board meetings, but now when they bring people together, it's going to be a higher quality experience. It's not going to be a fly-in, fly-out meeting. You're going to have a two-day off-site, and then that December board meeting that you

would have had in person, that one you may have virtually. So you're going to see people do things differently to reduce risk. But there are some businesses, some industries, particularly here in New York City, that I just think, anyways, I can't imagine. I mean, of course, we can always reimagine, but I just can't imagine they lend themselves to that kind of hybrid, like live theater, for instance. Strikes me as very hard to replicate in a version of what you're describing. No, Broadway, where you're trying to, you're targeting an older clientele and people are in, but you know, that might be a setting where maybe, maybe they were going to have some immunity passports and, or, you know, certain validation and travel companies are

now working on that. So maybe they'll, they'll have that, or maybe being able to represent that your air quality is, is sufficiently good that the risk of widespread within a confined setting is low. We know that if you have good, brisk air circulation, the air is refiltered very rapidly. That reduces the chance for aerosolized spread. So you might have to look at things like that,

where your business is dependent upon bringing together an older population into a confined space. But again, remember, that older population is going to be, by and large, vaccinated. That's where vaccine utilization is going to be really high. So if, in fact, the vaccines continue to be highly protective, even in the face of these new variants, I think that that's also going to be something that changes psychology. And the final point here is consumer psychology, consumer sort of reaction to this virus is going to evolve between now and fall because the intense fear around COVID is going to diminish over time. Because as more of the population gets vaccinated, less of the population is going to get hospitalized, less of the population is going to die of this. And so

if you're turning on the news every day and there's 120,000 people hospitalized for COVID and 4,000 died today and your local hospital is building a tent, you're staying home. But if you turn on your news and there you know, there were 10,000 cases diagnosed today and, you know, 150 people tragically died or 100. And, you know, there's 10,000 people hospitalized across the country for COVID. That's a very different picture. Your behavior is much different in that scenario. fear from this is going to be reduced, not eliminated, but reduced over time as a result of the vaccine, which reduces the morbidity, the death and disease associated with COVID. So by the time we get into next fall, for better or for worse, I mean, there's from

a public health standpoint, you can say to yourself, well, that's not good because now people won't wear masks and they won't be careful and they will go to work sick. But I do think it's going to be a fact that people are going to feel more confident about living when they see less death and disease from this illness. We call this a once in a century event. What are the chances that the next pandemic will hit us in 10 years rather than 100 years? Is it really a once in a century event? You and I were speaking recently and you said it really is a once-in-a-century event. But then when you factor in China, it should have been a once-in-a-century or once-in-a-couple-century event. But China's masking of the epidemic in their own country is what really caused problems in terms of escalation globally.

This is a once in a century event that's going to happen again, probably in the near future. The conventional wisdom always was that we were going to be hit with a pandemic with a novel strain of flu. And in fact, the 2005-2006 pandemic playbook that we drafted, that we largely worked off of with the coronavirus inappropriately because it wasn't as relevant to a coronavirus as we thought it would be, always envisioned flu, and it specifically envisioned a bird flu. We are still at very high risk of a pandemic with a novel strain of influenza. The next pandemic is going to be caused by an RNA respiratory virus, a respiratory virus that replicates through RNA. Why? Because an RNA virus mutates rapidly,

and a respiratory pathogen spreads easily, especially in a Western democracy that has an unusually difficult time implementing respiratory precautions. And so there's other RNA respiratory viruses, and top of the list is influenza. So we face a big risk that we could have another, you know, pandemic at any time from a flu. We shouldn't think that just because this happened now, it's not going to happen for 30 years. They're two completely separate events and there's no correlation. The only correlation between what's happening now and the risk of an influenza pandemic is that the precautions we're taking now to cut down on transmission of coronavirus are really effective at cutting down the risk of influenza. And so if

we do implement certain sustainable measures in society that reduces the risk of the spread of respiratory pathogens, particularly in the wintertime, that will have the benefit of reducing the likelihood that you get widespread transmission of a novel strain of flu. Two final questions. One dark, one upbeat. I'll start with the dark and get it over with. There has been speculation,

some informed speculation, some probably uninformed speculation, that this has changed the game what we've what what what enemies of the west have learned through the coronavirus is it's changed the game in terms of the potential tools in the toolkit of terrorism and that there's a buyer bioterror tool here that had really not been experimented with before potentially a bioterrorism tool that could be used if you can drop some kind of pathogen like has been dropped on us and literally just shut down an entire society, every aspect of it, socially, economically, cause enormous, catalyze enormous political dysfunction. How worried should we be about that potential? And

do you think we're going to live in a world in which, in terms of the infrastructure you spoke about earlier, there's going to be an infrastructure set up to protect against these kinds of bioterror attacks? So I've written about this in the journal. I think that this has changed the game. I think we have to look at public health as a matter of our national security preparedness. And I think what this proved is that a respiratory pathogen poses an asymmetric risk to Western democracies, that we are uniquely incapable, maybe incapable is a strong word, but we are uniquely challenged at implementing respiratory precautions relative to other nations. There are nations that were much more adept at implementing respiratory precautions and reducing the spread of this than we were. And, you know, you know, the nations that did it well in the nations that didn't do it well.

So the old thinking around bioterrorism is a nation state, a rogue actor will do anything. But the old thinking was that a nation state would never use a weapon, a biological weapon that could blow back on them. But if a nation state thinks that they're going to be more adept at thwarting the impact of that biological weapon, they may see it as a tool that could encumber us much more than it can encumber them. Now, there's no reason to believe that this was a deliberate pathogen, but I do think it changes the calculus of the list of pathogens that we have to consider for the future as the agents of would-be terrorists. And, you know, for people who are diabolical, who just want to, you know, cause harm and aren't looking at this in a strategic way, what this has proven to those individuals is that, you know, the way to

shut down the United States is unleash, uh, a dangerous respiratory pathogen on them. So I think that it changes the calculus. Yes. Two upbeat notes, I think, but you'll tell me in closing. One is we've learned a lot about the process for approving vaccine vaccines. I think we've, we've the speed with which Operation Warp Speed worked, I think you'll tell me, is one of the fastest vaccination R&D, clinical trial, and approval processes in history. And so is that going to be the new normal for a vaccine?

Should we be as impressed with the process as it seemed to be? And the second is in terms of consumer health care, the changes in digital health care. The fact is, Scott, like the vast majority, over 80% of people who have had coronavirus antibodies have never stepped into a hospital or a doctor's office. They've used their phones, the cameras on their phones, to meet with doctors, to talk to doctors. Obviously, the severe cases have had to get in-person medical treatment, but a lot of people have dealt with this crisis virtually, and rules and restrictions from insurance companies and regulations have been suspended, and that could also be a permanent change. So can you talk about both of those?

Well, in thinking about Operation Warp Speed, I think we need to understand what Operation Warp Speed was. I mean, the government effort here was and should have been trying to scale up manufacturing and trying to provide for the efficient distribution of these vaccines and assisting to some degree in the development. You can judge for yourself how good of a job the government did at providing for the large scale manufacturing of these vaccines, which are in tight shortage, and providing for the distribution of these vaccines. But the constructs, the vaccine constructs and the science that gave rise to them actually was underway almost immediately. And there were already vaccines in clinical trials before Operation Warp Speed was ever really formalized. The reason why we were able to come up with these vaccine constructs so fast is that

this really was the advent of fully synthetic vaccines. We had never made a fully synthetic vaccine before. The technology was available. It was being developed. In the case of Pfizer, they were developing it for a flu vaccine. They were trying to develop a novel flu vaccine. And we were able to take these platforms and quickly pivot them into the development of vaccines for coronaviruses and found that this technology worked and it worked really well. So this is a technological inflection point. I think in the future, we're going to be developing vaccines through these fully synthetic avenues. The old notion of developing a vaccine, the old way to do it was you take the virus, you figure out a cell culture that it could grow in. In the case

of flu, it's chicken eggs. You grow a whole bunch of virus in these large vats, which is a very dirty business. It's hard to do at scale. It's hard to get the viruses to grow in cells. Then you harvest the virus, you inactivate it, and you put it in a syringe. That's basically how we make flu vaccine. This is a completely different process. So we've now changed the paradigm for making vaccines. And so we were fortunate in a way that we were right at the moment where this technological inflection point was capable of happening. And that's really, to me, the story of how we did this so fast. As far as the technology, I think you're right. We've seen technology transform every other aspect of our lives in terms of using it as a substitute

for certain kinds of interactions. But healthcare was... It hadn't happened yet. You're right. Healthcare was last. And there was a certain level of discomfort you had to get over where patients didn't want to go online

and get a telehealth visit. And doctors, especially the older doctors, didn't want to do it. Everyone was forced to do it. And everyone found it worked really well especially the older doctors didn't want to do it. Everyone was forced to do it and everyone found it worked really well. And insurance companies didn't want to enable it. They didn't want to pay for it. CMS provided for broad reimbursement here. I don't think we're going back to the old way of doing things because I think what people have found is doctors now realize they could really improve their efficiency. Insurers realize that it actually could save

money. It doesn't just drive utilization. And patients realize, why would I go to a pediatrician when my pediatrician can evaluate my kid's rash over the computer just as good? So I think that we've now accelerated an adoption curve. And will telehealth remain at the levels where it is right now? No, but it's never going back to where it was. We've changed the paradigm for the delivery of healthcare. And when you think about just the amount of saved time for people in terms of not having to visit doctor's offices every time they have something that they think may be wrong with them or routine checkup or deal with the diabetes check or whatever it may be, just think about the amount

of time and people's days and weeks spent visiting doctor's offices. If you can streamline a lot of that out, it's a huge boost to our economy. The productivity gains could be enormous. I mean, and people will start to capture that. We'll start to see studies that actually quantify that. Right. Scott, thank you, as always, for helping me and our listeners. Hopefully, we'll feel the same way, feeling a lot smarter about

a very complex issue. Really appreciate you being with us and stay safe. Thanks a lot. That's our show for today. If you want to follow Scott Gottlieb on Twitter, he's at Scott Gottlieb, MD. You can also find his published work at the American Enterprise Institute by visiting AEI.org. And we talked about Israel's vaccination story in today's episode as well. If you want to learn more about Israel's digital health and life sciences sector, and especially startups working to get to a post-corona world, visit startupnationcentral.org and look for The Finder, which is a database and GPS for Israeli startups. If you have questions or ideas for future episodes,

tweet at me, at Dan Senor. Post-Corona is produced and edited by Ilan Benatar. Until next time, I'm your host, Dan Senor.