The Munk Debates Podcast - Scott Gottlieb on the future of pandemics and public health after COVID-19

Episode Date: May 26, 2020

On this episode of the Munk Debates Podcast, former FDA commissioner Scott Gottlieb on the future of pandemics, public health, and their effects on the economy.Become a Munk Donor ($50 annually) to get 72-hour advanced access to the full length editions of Friday Focus and Munk Dialogues. Go to www.munkdebates.com to sign up. Hosted on Acast. See acast.com/privacy for more information.

Welcome to the Monk Debates podcast. Every episode, we normally provide you with a civil and substantive debate on the big issues of the day. But our world as we know it has changed and so has our format for the next few weeks. We're bringing you a special series called The Monk Dialogues. We invite the sharpest minds and brightest thinkers for one-on-one conversations live on Facebook to reflect on what our world will look like after the COVID-Dilogs. pandemic. These dialogues provide you, the listener, with original insights into the pandemic's impact on everything from our shared values to the economy to international affairs. This week, we bring you former commissioner for the Food and Drug Administration, Dr. Scott Gottlieb, in conversation with Rudyard Griffiths. This is an edited version of the live event recorded Thursday, May 21st. Hi, I'm Rudyard Griffiths, the host of the Monk Dialogues, and welcome to our program this evening. On tonight's edition of the Monk Dialogues, we had the opportunity to speak with one of America's leading commentators and analysts on COVID-19. He is the former U.S. Commissioner of the Food and Drug Administration.

He's a board member of Pfizer, the drug maker. He's a member of the group known as the American Enterprise Institute. Institute where he's a resident fellow and he's a contributor at CNBC. Ladies and gentlemen, please welcome to the Monk Dialogues, Scott Gottlieb. Thanks for having me. Good to be here. Well, Scott, as we discussed, the purpose of these dialogues is really to get all of us thinking about the impact of COVID-19 on our society, on how we're going to work, how we're going to live, the future of just about everything.

And to do that by stretching our minds into the future, thinking about, what are the repercussions, what are the effects of this pandemic, not tomorrow or next week, but in the months and years to come. And again, thank you for being on the show. I think you're uniquely suited to help us in that intellectual journey. So let's begin by asking you, if there was one thing that you were going to kind of pull out of the last two or so months of our experience of this pandemic, one lesson that you would think that we need to really dial into and dig into when it comes to all the understanding the future of these pandemics going forward, what would that one thing or that one

lesson be? Thanks for having me here tonight. I think we felt we were much better prepared for this kind of a risk than we ended up being. We had spent years doing pandemic planning mostly for influenza. We were worried about a bird flu and that really started here in the United States back in 2003 and 2004 in earnest. We started significant planning exercises for the risk of a pandemic influenza. And we had built out an infrastructure for testing, for surveillance, for diagnostic capabilities, for stockpiling certain equipment that we felt we would need in the setting of a pandemic. And I think what we learned in this tragedy is we were far less well prepared than we thought we would be. Now, this was a coronavirus. It wasn't influenza. But a lot of the things that we did in anticipation

of the risk of pandemic flu should have been applicable here. And we should have been better prepared. And the one thing I think ended up being a challenge here and surprised a lot of us was the lack of diagnostic capability. The inability to get diagnostic testing in place quickly. The underfunding of public health labs and the public health lab infrastructure. And just generally being able to deploy a diagnostic quickly to do surveillance so that we would be able to detect spread before it got too late, before you had too much spread that you were at the point that you really had an epidemic underway, which is. in fact, what happened in the U.S. We were dependent upon syndromic surveillance data feeds of like how many people were visiting emergency rooms and that kind of information because we didn't have the ability

really to test people until we got into late February, early March. Scott, we had historian Neil Ferguson on when I asked him, how will historians write about this moment? His feeling was that the focus would be far more on the response than the virus itself and the initial outbreak, what do you kind of pull away again as the key insider lesson from our response, in particular these shutdowns? Hindsight is always 2020, and we never, you know, want a second guess people who have to make very difficult decisions in real time. But will we look back on this and kind of wonder, did we do the right thing? Did we react appropriately to the risk that we faced?

Well, I think we had no choice but to do what we did here in the United States, at least. The scope of the epidemic that was underway in cities like New York and New Orleans and Chicago and Detroit, without the kinds of population-based mitigations, the shutdowns, the stay-at-home orders that we implemented, the health care system would have been overrun. And we talk a lot about the public health implications of the shutdown, and there will be significant public health implications of the shutdown. We see vaccination rates way down. people are missing cancer screening. We see people skipping chemotherapy visits. And so there's

going to be a lot of implications, public health implications on the back end of this that we're going to be analyzing for a long time. But the reality was that there was no public health system so long as COVID was spreading epidemic in major cities. New York City effectively became a COVID-only health care system. You couldn't get health care in New York City hospitals for the most part, unless you had an emergency or COVID illness. There were literally hospitals that were made COVID only, including one that I used to practice that in Elmhurst, Queens. We simply had to break the epidemic. And I think what we didn't know at the time that this was becoming epidemic in those cities that I just mentioned, now, in hindsight, there were parts of the country that were

largely untouched by this, where the risk was much lower, where it wasn't spreading. But we didn't know that at the time. We didn't have good surveillance in place, so we couldn't really adjust our mitigation to just focus on those places that were hot spots where the greatest risk was and try to ring fence the infection in those regions. We didn't have the testing to do it. We didn't have the preparation to do it. And so I think one of the things that will be debated was there a strategy where you could have targeted the areas where the spread was the greatest and let other parts of the

country relax a little. We did that to some degree. Not every state and not every city implemented the same measures, and the federal government left it largely up to states and governors to make decisions about mitigation for that reason, because different regions experienced this very differently. But generally, there was effectively a national shutdown for a period of time, and not every part of the country faced the same risk. But I think in retrospect, we had to do what we did because on one hand, we didn't know who was at risk, and there were a lot of cities at significant risk. And we simply had to break the epidemic to get to a point where we can now focus on, you know, people who are infected with the disease and move towards what we call case-based interventions, trying to focus on continuing the infection by identifying individuals who are infected,

getting them diagnosed early, hopefully getting them isolated so that you can limit spread. With this pandemic, Scott, and once in the future, over the next couple of months into the next year, what is the public health objective? Is it to eradicate COVID-19? Is it to, manage simply the rate of transmission so that the healthcare system can continue to function and provide a breadth and depth of services that we expect? What is the goal that we're trying to manage towards? In the questions that came in tonight for you, I think there's a sense of confusion amongst the public right now about what they're hearing in terms of the messages coming out of different public health authorities at different levels. Is eradication realistic? Or is it

really about a policy of containment? Well, I don't think eradication's realistic. I think what our goal should be to try to limit spread as much as possible, taking reasonable steps that allow for economic activity and other public health functions to go on, but prevent the risk of another epidemic and prevent the risk of spread that's uncontrolled in a way that we lose control of the infection. Try to protect vulnerable populations, meaning getting testing and resources into at-risk, at-risk work sites. Not everyone's equally vulnerable to this, and there are groups that are uniquely

vulnerable to this because of the way they work, people who can't naturally social distance at work or people who live in more crowded housing circumstances or lack access to testing and health care in the first instance. So we need to make sure we get testing and resources into those communities, but we're not going to be able to eradicate this. I think this is going to become an endemic illness, meaning an illness that just continues to circulate. I think it will eventually settle into a more seasonal pattern and as other coronaviruses do. There are seven circulating coronaviruses. They're all seasonal infections.

Most of them cause a common cold. Sometimes people get more significant pneumonia from them, but mostly they circulate in the late winter. And this might end up being like the flu. It might end up being something that we get vaccinated for in an annual basis and it causes a certain amount of death and disease, but we're able to mitigate it with smart steps in the wintertime in terms of improved hygiene and making sure we get vaccinated

and eventually we'll hopefully have therapeutics for it. I think what we're trying to do now, now is by time to get to that point when technology can help us more fully vanquishes, when we have a vaccine, when we have effective therapeutics. And so we're going to need to be vigilant from here until that point. And hopefully that will come sooner than later. I know we're going to talk about that a little bit. But we're probably not going to have that at least available for mass use in the fall.

I don't think a vaccine for distribution to the general population is really a 2020 event. I think it's a 2021 event. And so we're going to need to get through one more cycle. with COVID. We're going to need to get through a fall and a winter season with COVID when this is going to be colliding with flu and when the risks of epidemic spread again are going to increase and we're going to need to be vigilant. So we're going to need to do a lot of things to try to contain the risk of respiratory illnesses more generally heading into the fall and winter. I don't want to put you on the spot, Scott, to make a prediction. You're a much more sophisticated

analysts than that. So let's just talk about risk. How concerned are you about the risk of a second wave this autumn. And the potential scale there of that wave, I mean, we're all looking back at the charts of the 1918, 1919 pandemic, where really it was the second wave that was the significant killer in that influenza outbreak. Is that inevitable with COVID that the second wave's going to be bigger? It seems like a lot of states are opening, a lot of provinces here in Canada, varying degrees of controls in place, limited testing in some areas, limited contact tracing. Does all of that look to you like a bit of a recipe for a heightened risk for a large second wave? Well, I think there will be spread in the fall and winter. I mean, what constitutes a second wave? Will the second instance

of this be bigger than the first? We'll become epidemic. I think we have better tools heading into the fall in terms of better screening technology. We'll have more therapeutics. Hopefully we'll have additional drugs coming online in the fall, better testing, better surveillance, better awareness. We're not going to be caught off guard this time. And so hopefully we can prevent that. But we're also going to be heading into a fall and winter season when this is going to be colliding with flu. And so the circumstances for wider transmission are greater. We're going to be heading into the months when this pathogen is going to be most efficient in terms of its spread. And it's going to collide with flu. And that's going to confound our ability

diagnose it quickly. So this is a real challenge. I mean, I think we face a lot of risk. And when you look at the data globally and you look at the exposure to COVID right now, you look at France, Spain and Sweden, seroprevolent studies, studies looking at antibodies and people, which identifies whether they've been exposed to it, runs about 5%. You look at cities like Milan, Barcelona, Paris. It's 7%. So 7% of those cities have been exposed to COVID, either asymptomatic infection or they develop COVID the disease. Paris and Wuhan, seroprevalent studies, were 10%. Here in the United States, you look at places that were largely unaffected like Boise, Idaho is 1.8 percent, but even in cities that were affected to a greater degree, Boston, 10 percent,

Los Angeles, maybe 10 percent. New York City is high at 20 percent. New York State around 12 percent, but the point being that around the world, countries and even cities where there were epidemics, only a small percentage of the population had this. We're a long way from herd immunity, and so there's a lot of people who are still vulnerable to this. think by the end of the epidemic here in the U.S., when you get into June, maybe a third of New York will have been exposed to this. That's getting to levels where you're going to have some reduction in the rate of future transmission because you have a large portion of the population that's now been exposed. But that's the outlier. Most cities, most countries, it's only a small

percentage of the population. So we have a very fertile ground for COVID heading into the fall and the winter in terms of a population that's been largely unexposed to this because our mitigation was successful and were able to contain the epidemic before it got out of control to even a greater degree and caused more death and disease. Okay, Scott, this is an important point for me just to underline with you, if I'm understanding you correctly, because there's been a lot of discussion about, again, trying to think about the months to come, the year to come, and people feeling some that herd immunity could be an effective strategy. In other words, that we allow the virus to spread, we shelter the people most at risk, but our best protection about the virus is to get to a level of

antibodies in the population, I don't know, 60, 70, 80%, whatever it is, to effectively neutralize the effects of COVID and its infectiousness. Am I hearing you correctly that you do not feel that that is a valid public health strategy? I don't think it's a valid public health strategy for a variety reasons. Number one, I don't think you can just tell people who are older or have comorbid conditions, have medical conditions that put them in high risk that they've got to stay in and everyone else can go out. And when you start adding up the number of people who have conditions that put them at a higher risk of a bad outcome here, diabetes, heart disease, lung disease, people who have autoimmune diseases or immunosuppressant drugs, it ends up being a very high percentage of your population,

people over the age of 65. You're getting into pretty big numbers. When you look at the data, you know, 45-year-olds didn't fare so well with this. When you look at hospitalizations in New York, half the hospitalizations were under the age of 55. So there were a lot of young people now. I realize there's more people under the age of 55 than over. But there were a lot of young people, younger people, middle-aged people, getting into trouble with this disease as well. And look at the level of death and disease that we sustained with a relatively small percentage of the population being affected. So even if you believe the data in New York, for example, and you believe 20% of New Yorkers

been infected. So about 1.7 million people have either had COVID or been infected with this. At the time that we did that study, there were about 17,000 diagnosed cases, a 17,000 deaths, excuse me. That's an infection fatality rate at 1%, which means the case fatality rate is much higher because people who are infected, at least 30 or 40 percent of them don't develop symptoms. The case fatality rate is how many people who develop the disease succumb to it. So it's always going to be higher for diseases where you have a lot of asymptomatic spread. That's a high rate of death for a disease. And that's in a setting where we were social distancing. People who were vulnerable were staying home, and we were still having infection rates at that level. So I think we're

going to have to be willing to sustain a lot of death if we want to just let this course of population. And you look at Sweden, and people talk about Sweden adopting some element of that strategy. And I don't think Sweden really adopted that strategy. I mean, people are social distancing there. They just left some of their restaurants and other things open, but people aren't really going out all that much in Sweden. They have the highest fatality rate per capita in Europe right now. They're a long way from herd immunity. And it's really just Stockholm. Other parts of Sweden, the exposure is very low. It's really just Stockholm where you see higher exposure levels. The seroprevolence study that was published recently showed about 7% in Stockholm. That's, again,

a long way from herd immunity. I know some people have said it might be as high as 20% based on some other studies, but even that isn't approaching herd immunity levels. So I think that that strategy, we do want to sort of go down that route, and I don't think we do, we're going to have to sustain even more death than we have. Scott, three quick questions. I've got on my mind before I take audience questions. Number one for you, as a parent of young kids, there's a lot of us out there, are schools coming back in the fall? Do you put a high chance of that, a high likelihood that children will be back in school? And will they be back in school in large numbers? Will it be staggered? Will it be limited availability? What's your take on the kindergarten to grade 12

educational system for this autumn? I think there'll be an attempt to open to schools this fall. I think we'll hopefully, if you sort of believe my optimistic scenario, will be coming off a summer when we'll see cases continue to go down, there'll be a seasonal effect here. I think that the schools are going to implement measures to de-densify classrooms, to try to have students only congregate in smaller groups so you won't let everyone go out for recess and mix together. You'll keep people within groups so you can do better contact tracing within the school in isolation if you do have cases. I think that a lot of schools are going to look to implement testing in the school. I think you might see attempts to de-densify classrooms by going to maybe four days a week in classroom and in one-day-a-week

telelearning or doing some teleclasses inside the school, keeping people separated and on computers. So I think there's things, schools, I know they're thinking about those things now, the districts that have resources to do that. Not every district does, but I think there'll be an attempt to open it. And it's going to become a question of what happens in the fall. I mean, hopefully this scenario in the fall is we have really good screening in place. We're able to detect cases early, get people diagnosed, get people isolated. There'll be communities that have outbreaks. There might even be cities where there's small epidemics or states will have to close things selectively. Some school districts will have to close down for a period of a couple of weeks as infections move through certain communities.

But you don't see a simultaneous national shutdown as you've seen now. I don't think we get through the fall and winter without having to grapple with this in some fashion and without seeing some schools close. And that's kind of like the H1N1 season as well, where you saw there wasn't a simultaneous shutdown of the entire school system nationally here in the U.S. in 2009, but you saw school districts shut down as local epidemics arose in local communities. This, mind you, is more contagious than H1N1. Yeah. Final question before are we bringing the audience here? And that's to talk a little bit about what's happening closer to this moment right now,

which is we are seeing states like Texas. We've had recently here in the province of Ontario an uptick in cases. You know the geographies. you know the regions, it, you know, some areas, maybe because they had very few infections, have bent the curve at a state level or at a province level, but there seem to be other larger jurisdictions like Texas, like Ontario, where we're having real challenges right now in bringing this virus under control in terms of bending the curve down. And yet right now, this last week and going forward, we're starting to open up. How do you think that's going to play out?

Scott. I mean, do you think, again, the seasonal effect will wash over or mask the result that just populations are going to be mixing more and people are going to be within the parameters of transmission of what is, as you said, a very infectious virus? I think we're going to see a slow burn. I don't think we're going to get rid of this virus. I think we're going to see continued spread, hopefully at a level that's manageable. Hopefully people continue to practice good things in their individual lives because that can greatly reduce risk if everyone just stood the collective action of everyone just going out a little less washing your hands a little more wearing masks cleaning shared services things like that once you distribute that kind of activity on a population-wide basis that has a

big impact on the epidemiology of spread and i think people are going to have that vigilance i worry more about the fall when people maybe come off a relatively quiet in summer and they kind of lose some of that and they let their guard down a little bit but we're going to see continued spread hopefully the summer does present the backstop and that kind of, you know, offset some of the increased spread. But you look in the United States, you've seen, if you look at over the last three weeks, you saw for the first two weeks hospitalizations coming down. Hospitalizations are really the most objective measure of the epidemic, because you're going to see cases go up because we're testing more, so we're going to be turning over more cases. But you saw hospitalizations come down for two straight weeks. In the last week,

at best, nationally, you've seen it sort of flattened out, but probably you're seeing a little bit of uptake when you look at the seven-day rolling average on hospitalizations. So we're seeing cases bounce up a little bit into hospitalization data here in the U.S. as we reopen. Now, that should surprise nobody. I mean, we expected that as we ended these mitigation steps, we were going to have some bounce in cases. And that's why most of the plans were for sort of a staged reopening, not to do it all at one. So a dimmer as opposed to an on-off switch. But we're going to have to watch that closely. You may have to slow down what you're doing or even pull back some of the things you've done. If you see the cases

bounced up too much. You look at states like Alabama right now where you're seeing a real uptick in cases and in the cities you're seeing the hospitals start to fill back up. There are some states and there's some cities here where there's some worrisome signs. It's not nationally, certainly, but there are certainly some states and cities. Georgia as well, you've seen an uptick in hospitalizations in the last about week. Okay, that's a really good point. It's hospitalizations that we need to be looking at to understand what's happening in terms of the future trajectory and course of this virus. Scott, I'm going to start bringing in some questions. And the first is from Nanda.

She's asking, during COVID-19 and future pandemics, how should governments, public health officials and citizens deal with anti-vaxxers and people who are against contact tracing of individuals? I guess people who have privacy concerns. So what's your feeling there, Scott, maybe just to elaborate on that question a bit, is this a kind of wake-up call for the anti-vaxxers? I mean, it was an increasingly powerful. powerful movement, unfortunately. I'll take a side on this. I'm in favor of vaccinations. What's your

feeling here? Are you concerned maybe that in terms of people actually using a vaccine, that they may not. And as a result, the burn, the spread goes on longer than necessary. Yeah, I'm very concerned about this. I mean, if you look at vaccination rates generally, people, there's vaccines that are highly effective and very safe. And we don't see vaccination rates at the levels that they should be. HPB vaccination is around 51%. The rate of people getting the second vaccination from Njikakal disease is about 56%. Only about half the population gets vaccinated for the flu each year. The shingles vaccine, which is effective, only about 30% of people, a third of eligible people get that. So we don't see people taking advantage of vaccines and we see far too much spread of infectious

disease and far too much disease and death from these diseases that could be managed much better if vaccination rates will higher. I worry about it in this context, for sure. You know, there are a group of people who are against vaccines who call their safety into question. They're as a minority, a small minority, but a vocal minority. And spread a lot of fear, I believe, that's misguided and misinformed about vaccines generally. And we saw that here in the U.S. with the measles mumps and rebella vaccine, where people pulled away from using that vaccine. We saw outbreaks of measles as a consequence of that. And so I think we need to do everything we can to try to inspire confidence in a new COVID vaccine. And that means making sure that they're put

through appropriate clinical trials, that we don't short-circuit that process at all in an effort to try to get vaccines to the market more quickly. We need to make sure we have robust data sets and can demonstrate with a high degree of certainty the safety and benefits of these vaccines, and so that when reasonable people look at the data sets, they can have confidence in them and we can get as many people vaccinated as possible. These are going to be novel vaccines, novel platforms that we're developing these vaccines on. And I think that that's going to lend itself to people being able to raise doubts and questions that could make people skeptical in a way that could have an adverse public health impact

if people don't get effective vaccines. Is that part of your thinking, Scott, about why it may be 2021 before we have a vaccine for mass adoption? Because simply, we need to do this right. And to rush a vaccine out in the fall could have, of unintended consequences, which is a lot of people suspicious about the vaccine and suspicious as to whether it's been as rigorously tested as other vaccines in the past. That's exactly right.

I think we need to put these through proper clinical trials, and those are going to be 10,000, 30,000 patient clinical trials, large-scale trials in settings where there are outbreaks and spread. I think we can use the vaccine experimentally in the fall in settings of outbreaks to try to ring-fence the outbreak. So you're using it therapeutically in a way if you think it works. but you're also using in the context of a rigorous clinical study where you're collecting data. So it's still an experimental vaccine, but you're just deploying it in settings where it could achieve a therapeutic purpose if, in fact, it's effective.

So you couldn't deploy the vaccine as a tool, but I don't think that we're going to be at a point where we're going to have those kinds of data sets available to license a vaccine for mass inoculation. To think that you're going to have those large data sets available in time for this fall to license it to approve the vaccine for general use, I think that that's very aggressive and probably not realistic. Even if we get trials enrolled in the summer, you're not going to know where the spread is. You're not going to know where to enroll those trials. You really almost have to wait until you have the outbreaks to enroll the trials. If we start enrolling trials in July and August in Dallas and the outbreak ends up being in Little Rock, Arkansas. Enrolling 10,000 people in Dallas might not have been the right decision.

You're listening to the Monk Dialogues, a special edition of the Monk Debates podcast. where we invite big thinkers to reflect on what our world will look like after COVID-19. This week, former FDA Commissioner Scott Gottlieb on the future of pandemics, public health, and their effects on the economy. Let's go to another audience question. I'll read it out for you, and we can go from there. President Trump has threatened to withdraw the United States from the WHO, the World Health Organization. What is your position? So, Scott, what's your view on the WHO?

has been a pretty strong debate about whether they were as neutral as they should have been vis-a-vis China and whether they were slow off the bat here to declare a global pandemic and to ring the five alarm bell that states and nations around the world needed to get a head start on preparations to try to reduce the effects of COVID-19. Well, look, I think the WHO here was far less effective than it could have been and should have been. I think it was less effective in the setting of the Ebola outbreak in Western Africa than it could have been and should have been. And that demonstrated the shortcomings of the WHO. I think that they were too late to really speak with a clear voice about what was going on in China, the scope of the risks to

press China to make more information available. So I think it's an organization where we have to do a lot of evaluation on how to make sure this doesn't happen again and make sure we have a more functional world health body. But I don't agree with you should be defunding it. I think this is a wrong time to weaken the organization still further, especially with the risk that COVID's going to become now epidemic in the southern hemisphere. A lot of those nations lack access to public health infrastructure and they rely more on the WHO. You think about parts of Africa, parts of South America. And so weakening the WHO in a setting when this could become epidemic in the southern hemisphere, this isn't the time to do it.

I think we need to re-examine the WHO after this public health emergency passes and do the best we can right now to press them to do a better job in the setting of the current epidemic. But I think a lot of this should be done after this epidemic's past to try to really reform that organization. Thanks, Scott. Great questions from the audience. So let's keep them going here on this monk dialogue with Scott Gottlie, the former commissioner of the

Food and Drug Administration. a board member of Pfizer, the drug maker, and someone who's really distinguished himself is one of the most astute and thoughtful commentators and analysts on the COVID-19 pandemic. So this question, Scott, is from Sheldon. This week, two companies announced results with respect to preliminary testing of a vaccine. Do these milestones mean the chances of developing a vaccine have gone up or just that testing can continue? And Scott, it's interesting.

Maybe we can talk a little bit about one of your other hats that you wear, which is an analyst on CNBC. We've seen some very big market reactions to the Gilead, therapeutic, and now the Moderna vaccine, a very preliminary study, I guess, or tests that they conducted. In both instances, kind of very small samples, you could say that these are just not even the first inning. It's maybe the first batter at bat in the first inning, yet this huge kind of reaction. in response to that. Do you think the two things are commensurate? Should we be as optimistic about, talk about the Moderna result this past week?

Well, look, I think it's encouraging. I wouldn't necessarily say that we should be tremendously optimistic about any one of these vaccines, but I think that what we've seen now is a number of early data sets released about different vaccines that demonstrates that it should be possible to develop a vaccine against coronavirus. I think that's the real takeaway here. We've now seen a number of different vaccines. vaccine constructs, some very novel constructs, in the case of Moderna, an MRNA construct, which we

haven't used before to develop a licensed vaccine, and Pfizer's taking the same approach. We've seen a number of these constructs be able to, in both animal models, as well as now people, induce the production of antibodies that should provide some level of protective immunity. And so that is a statement we couldn't make six weeks ago or two months ago. And so that's why I think we should be more encouraged. With respect to the Moderna data in particular, it's early. It was only 45 patients.

In all 45, the data showed that the different vaccines that they used, and they had three different doses, a 250 microgram dose, 100 microgram dose, and a 25 microgram dose. But in all three doses, they were able to generate the production of antibodies and people. They were what we call binding antibodies, meaning they bound the virus. What we don't know is, were they neutralizing antibodies? Did they bind the virus and destroy the virus? Testing for neutralizing antibodies takes longer because you actually have to expose the antibodies to the virus in a special lab, a B.S.

L3 lab, a secure lab, because this is now a special pathogen that needs to be dealt with carefully. They only looked for the first eight patients on whether or not the vaccine was generating neutralizing antibodies, and in fact, it was in those eight patients. And so I think a lot of people assumed, well, if it worked in the first eight patients, it's probably likely to work in some proportion of the next 37. We don't know, not all neutralizing antibodies is the same. We don't know what level of protection it's going to afford, but we infer that it will probably

afford some level of protection. These vaccines, any of them, probably aren't going to provide protection like we think of a smallpox vaccine or the measles vaccine where you're vaccinated and you can't get infected. This is probably going to be more like the flu vaccine where you can get infected, but it's going to reduce the severity of the infection and limit your ability to get COVID the disease. What about mutation, Scott? Are you concerned that the DNA sequences that we're using now for a lot of this vaccine research that's going on right now are primarily those that came out of the initial clusters at Wuhan in Europe and that viruses do mutate. Is there a risk here that we create a series of vaccines that are based on kind of COVID-1.0

and we move on to COVID 2.0 and 3.0 and 4.0. It's unlikely in a short period of time. So all viruses mutate, this virus is mutating. Just because it's mutating doesn't mean that, It's getting more dangerous or less dangerous or more contagious or less contagious, or that's going to obviate our technology. So we've looked at a lot of sequencing data now with this vaccine. A lot of this work comes out of the lab of Trevor Bedford in the Hutch in Washington State.

And what we see is the virus is undergoing drift, but the part of the virus is genetic material that codes for the proteins on its surface that is the target of our vaccines, particularly the spike protein, which is the protein that the virus uses to invade our cells, the genetic material that codes for that spike protein isn't undergoing as much change. And the changes that it's undergoing aren't changing that spike protein in a way that it should evade our antibodies to it. And so it's undergoing drift. And so if we have a vaccine, we might want to reformulate the vaccine every two or three years to get it more precise to what the current composition of that spike protein is.

But it's unlikely to be the case that we see such rapid mutations in the antigens, the things on the surface. of the code of the vaccine that we target with our antibodies that we do with the flu vaccine or with influenza where in a single season influenza sometimes we've seen undergoes so many significant mutations, so many significant changes that obviates the vaccine for that season. That vaccine is no longer effective. We're unlikely to see intra-seasonal mutations happen so rapidly that this would obviate a vaccine. But I think it's probably the case that when we do hopefully get a safe and effective vaccine, we're going to want to be formulated on some semi-regular basis to get it more precisely aligned with what the current predominant sequences for the parts that code for the region

that the vaccines is targeting. Fascinating stuff. Scott, do we know 100% that this virus was not genetically engineered in a lab? I think we feel pretty confident that this virus wasn't manipulated and certainly wasn't like a bioweapon that was deliberately released and engineered and released to cause an epidemic or cause an outbreak. I think where there's still some question is, we know there was a lab in Wuhan that was a high security lab. We know they were doing experiments with coronaviruses that had been isolated from bats and other species.

We also know that lab didn't have good procedures. And well before this, well before this episode, you can go back two years ago. There was articles in Science Magazine and some of the leading academic journals calling in the question the safety procedures in that lab, saying that they didn't have good controls in place for the special pathogens and calling into question whether they should have been allowed to handle the pathogens that they were handling.

So I think with some doubt in people's minds is could this have been an accident? Could it have been a lab accident where patient zero, if you will, wasn't someone who came into contact with an animal in sort of an inadvertent way, but with someone who was doing an experiment and accidentally infected themselves, maybe became asymptomatic, didn't know they had the infection, went out and then became patient zero and spread it. We might never have an answer to that question. We're going to have to look at the sore strains of some of the original infections to really get a sense of that and have much more information about what it was and wasn't going on in that lab and look at some of the strains that they were working with. And we might never get that

information. I mean, it doesn't seem like China's making a lot of that available. And so I think a lot of these theories and doubts are going to persist maybe in perpetuity. But when you sort of hear about people saying, well, could this have been a lab? but could this have been something deliberate? I think most reasonable people are saying it's not something that was deliberate and that someone released this deliberately, but could it have been a last accident? And I don't know that we can fully discharge that possibility. It's less likely.

I mean, I think we think it's the less likely scenario, maybe far less likely scenario, but I don't think we can fully discharge it. Wow. Then I guess part of this dialogue is thinking about the future. How do we get controls internationally in place to ensure, sure that countries that maybe are not at the standard of Canada or the United States in terms of lab infrastructure, lab technology, don't inadvertently or inadvertently release another virus. I mean, are you optimistic that we have the international consensus to do that? Yeah. Well, no, I'm not.

I mean, this isn't the only lab where there's been questions raised in the scientific community about procedures in certain labs. And there's been questions about labs in the United States where there were concerns that they didn't have proper procedures in place. So we need strong international bodies to be overseeing this. We have them, the World Health Organization. I think that they're not functioning as stringently or aggressively as they could be or should be. And we allow certain countries to hold certain special pathogens.

We probably need to re-examine that and make sure that there is a better set of universal procedures in place for ensuring lab safety for the labs that are going to handle the most dangerous pathogens. Now, there's going to be a lot of people who don't want to use this episode as the sort of rallying cry for that because there's a lot of people still pushing back on the notion that this could ever have been a lab mistake. And it's had to have just been sort of a natural occurrence that this virus jumped species went from a bat or another animal into humans. Probably that's the case. But, you know, I think we're never going to fully discharge that doubt, and I think we should re-examine lab safety more generally.

Well, that's an important call to be making. Okay, let's get some more questions. This has been a great discussion digging in a lot of issues that were certainly top of mind. For me and for you, the viewing audience, Mark Warren is asking, how important is a national testing strategy for the United States and why is it so hard for us to mobilize such a strategy? And Scott, we can ask the same thing here in Canada. The scaling up of testing has been a persistent challenge, and I would say maybe doubly so, the scaling up of any large-scale contact tracing system. Whereas, Scott, you know this better than most, you look at countries like Taiwan, South Korea, China. Frankly, they seem light years ahead on both fronts. Yeah, look, I think the

reality is that a lot of these tasks are going to be largely left to states. There's certain things the federal government can do to support these activities, but they're going to be largely left to States. Some states are doing a better job than others at getting in place its infrastructure. I think heading into the fall, at least in the United States, the challenge isn't necessarily going to be on the back end, the platforms for running tests, which was a challenge this go around. We just didn't have enough labs and PCR-based machines to run the tests. We scale that up. We've gotten it scaled up dramatically. We're now running about 400,000 tests a day. But initially, we're running about 10,000 tests a week. And so it's been scaled up dramatically in a very short period of time.

but we got our late start. I think that capacity is going to continue to grow. And when we get into the fall, we're going to have the capacity to do one of the federal officials said 10 million tests a week. That's probably right. It might even be more than that because we're going to have next generation sequencing. We're going to continue to scale up PCR-based platforms. We're going to be able to do massive screening with next generation sequencing. We're going to have many more point-of-care diagnostic tests approved, including antigen-based tests that are literally swabble sticks that you can use in a doctor's office.

And we'll have millions of those in the market. And so there'll be ubiquitous availability of testing in the marketplace. I think the challenge isn't going to be the back end running the test. It's going to be the front end. Who's collecting the test? And I think we're likely to have a situation where a lot of people don't want to do COVID testing. Because if you turn over a positive case, then you're going to have to shut down your office. If you're a provider or if you're doing testing at a certain site like a pharmacy, people won't want to go into that pharmacy if they think COVID patients might be coming in to get tested.

And so you're going to have a lot of places that say, no, we don't do COVID testing. If you think you have it, go to this special test site. And that's going to limit access. I suspect when you call your physician in the fall and you say, I think I have the flu, I feel like I have the flu. They're not going to say, come in and I'll test you for COVID and influenza. They're going to say, go to this special testing site. And if that's what ends up happening and we end up sort of relegating testing to special sites and it's not really ubiquitous in the community, that's going to greatly limit our ability to do mildly symptomatic and asymptomatic testing.

Really what you want to be doing is you kind of want to be swabbing everyone. Everyone who shows up at the doctor's office with anything suggestive should be getting tested in the fall. I worry that's not going to happen. That's what we need to be thinking about, how to get testing in a ubiquitous fashion into the community where everyone's conducting these tests. Scott, is anyone talking just simply about swabbing anyone that goes into a GP? I mean, regardless of whether you've got flu symptoms or not, you get tested. And you just do that for the benefit of your family, your coworkers, and others.

a stigma away from it and it just becomes part of our regular checkup through the autumn and into the new year. Look, I've been advocating that. I don't think it's an unreasonable idea. We want to basically get, we call it, sentinel surveillance system in place. We're doing sort of routine screening of the general population trying to catch asymptomatic spread. And so how do you do that? One way to do it is to do a random sample of the population and get them tested.

That's really hard because then you have to find that random sample, get the tests to them, convince them to get tested. to do it is just you screen such a large population that even if it's a selected population, it ends up effectively being a random sample because you're screening so many people. And one way to do that is exactly what you said. If you go into your GP's office, there's 3.8 million encounters with the primary care system every week in the United States. If you go in for a sore throat, you get coronavirus swab.

You go in for your annual physical, you get coronavirus swab. You go in for a sprained ankle, you get coronavirus swab. If we just sort of swab everyone for coronavirus, sure, it's a selected population that's coming to the doctor's office, but you're ending up doing so many tests on a routine basis that it ends up effectively being the statistical equivalent of a random sample or representative sample. And so I think what you're saying makes perfect sense, but what I worry about is if we don't get in place procedures now, we say if you're a physician's office and you do all this, you clean your office every night, you don't have a waiting room, you move patients directly into

examining rooms, you make sure your staff is washing their hands between patients and maybe they're wearing masks, whatever the procedures are. But if you do all this and you diagnose a COVID patient in your office, it's okay. You don't need to do anything special. Maybe you clean the room. We need to get in place universal precautions that allow doctors, pharmacists, others to diagnose COVID patients in routine settings without having to go through extraordinary hoops every time they do.

If we don't, they're not going to do the tests. They're going to refer patients away and we're never going to get to what you're talking about. Yeah, no, it's important not to build those deterrence into the system. Okay, lots of good questions here. Let's get some more in. This is from Terry Scott. She's asking, if a vaccine is developed, do you foresee a shortage? If so, will distribution be staggered? So those who are most vulnerable get it first? Or will some nation and groups benefit first at the expense of others? It's a big challenge, Scott. I'm sure it's one that you and your fellow board members at Pfizer think a lot about. There are the ethics. I think we all get that.

There's the aspiration. But what's the reality, Scott? Say China develops the first working vaccine. And China might develop the first working vaccine. China is using older technology to develop their vaccines. They're using, for the most part, of the four vaccines that are furthest along. Three are inactivated viral virus vaccines, which is an old approach. Probably is going to confer less immunity, but could be a much faster route to market and easier

to scale. And so they might develop the first vaccine, might not provide as robust immunity as some of the vaccines using the newer technologies that Western countries are trying to develop, but it could be quicker. I think ultimately the reality is we need more than one manufacturer, more than one large manufacturer that be successful here. Because if we only have one manufacturer being successful getting across finish line, we're going to be severely supply constraint, not just within the United States, but globally, not just globally, but even within a country. We're not going to have enough. And I think that the vaccines are likely to be licensed for higher risk populations first.

And I think you're likely to see some. It's not really rationing. You're likely to see the vaccine targeted to higher risk individuals who can derive more of the benefits of the vaccine. So you might not vaccinate people under the age of 30 or under the age of 20. Those are the kinds of, I think, decisions that are likely to be made. And as far as nations are concerned, if you look back in 2009 with H1N1, we had a situation where countries that were manufacturing their vaccine supply outside of their country,

including the United States, in other nations, those nations held on to the supply until they satisfied their local needs. And we did the same thing in one instance, where we held on to another country's supply of their H1N1 vaccine. And that was with a flu that while, you know, virulent, while dangerous, was far less virulent than coronavirus. And you saw that national behaviors. And those first vaccines that come off the lines,

it's not going to be a billion doses day one. It's going to have the supply is going to ramp. And so initially you're going to be supply constraint. You're going to have to make allocation decisions about it. And I think countries are going to behave the way they have historically, which is make sure I have enough for at least a portion of my population I'm most worried about before I, you know, try to make more equitable distribution of it. I'm not passing judgment.

I'm not advocating it. I think it's just the reality of what's going to happen. And I'm basing that on historical precedent, thinking back to 2009, which I'm I was involved in policy then, and I was watching that behavior very closely, and I think we were all surprised by it. Scott, just to build on that for a sec, you're painting a picture here. I think a lot of us listening to you would agree it makes sense. Countries will take care of their own populations first. But what does that mean for the virus globally?

I mean, we're seeing countries like Nigeria now having large-scale outbreaks in Lagos. Brazil is increasingly racked by this virus. If we have a vaccine in 2021, how much long? until we have a level of eradication globally that allows us to do something pretty essential, both for our domestic economies and the international economy, which is to restart the movement of people in planes across borders and press rewind back to January 2020 when we had international air travel. Is all of that like 2022, 2023 beyond? How do you see that playing out? I think we'll have enough for a global supply. So a lot of the companies that are working on

or working on manufacturing at scales that could provide for something akin to a global supply. Bigger challenge is going to be getting into a lot of markets. I think that initially what you would do, if you have a limited supply, is you're going to make it available to your population, but you're also going to try to get it into regions of the world where there's epidemic spread. Depending on what season you're in and where the virus is spreading, it could be spreading in different parts of the world. You're going to try to make sure that you get it into those regions first if you do have a limited supply. But how long did it take us to get global eradication of smallpox and polio? Those vaccines have been around a long time.

We still don't have global eradication of polio. So getting vaccine, it's not just a matter of the supply, getting vaccines into markets where you don't have good infrastructure, good public health infrastructure, is a very big challenge. Let's squeeze some more questions in. This comes from Gene Scott. She's asking, what is the best advice you can give the general population on how to live and deal with this in the coming months. Great question, Gene. At the beginning of this interview, Scott, you talked about some simple things, wearing a mask, washing your hands, keeping surfaces clean. I mean,

is some of this just practical in terms of reducing your risk? Or there are some other things that maybe people aren't doing, that you're seeing people not doing that you would recommend? Look, I think it just gets down to trying to decrease your personal risk. Limit your social network a little bit, go out a little less, go shopping a little less, be vigilant about trying to social distance where you can, wash your hands, use hand sanitizer. I recommend people using masks. We know that diminishes the risk of spread. So people are going to have to make personal decisions about how much they're willing to sacrifice, how much they're willing to inconvenience themselves to try to reduce their personal risk. But I think it's going to come down to that.

All of us taking collective action to individually reduce our personal risk. There was data coming out of a university here, but like if everyone makes one less trip to the grocery store every week, so instead of shopping twice, you shop once, that could reduce spread, ordering things more, instead of going out to the stores, all of that practiced on a mass scale, that's still social distancing, and that's going to help mitigate risk. And so everyone should think about in their lives how they can reduce your risk. It's never going to be risk-free once you start going out and about. So you're just sort of layering on things that reduce risk as much as possible. What about bars and restaurants?

Scott, how do people gauge that risk? Do you recommend that they try to look at the number of infections in their county or in their city and try to gauge risk that way? Or is it better, as you say, just to make a decision for the months to come that maybe those types of social activities are not going to be at the top of your list? Well, I think from a lot of people, those social activities won't be at the top of the list. That's something that's going to come back a little later. The thing I miss the most is going out to dinner. The thing I'm probably going to do the last is going out to dinner. When you do it in your local community, you have a better sense of what their risk is in your local community as opposed to traveling to a community you don't really know.

So I think people are going to stay local. I think things outside are safer than things inside. And so, you know, dining out is safer than dining in an enclosed space. And in fact, in my state, Connecticut, they're reopening restaurants, but you have to have table service outside. And so they're changing local ordinances to facilitate that. know, there's ways to do things that are higher risk, but do them at a lower risk. Smart. Okay. Coming to the top of the hour here, let's squeeze one last question in for Scott, from Joseph Scott. He's asking, can the COVID-19 virus be weaponized using something like CRISPR technology to target specific population? And if so, can this be prevented? I guess maybe to extrapolate

from that, Scott, just a bigger question here. We talked about the risk or the possibility that this may have been an engineered virus accidentally released from a lab. We don't know. We may never know. But are you concerned just generally about technologies like CRISPR that are really allowing people at low to play with mother nature in ways that could be extremely harmful for the rest of civilization? Is this a new threat on par with nuclear weapons or other big global threats like climate change that we understand well? And there's a lot of consensus towards doing something about them, but we don't maybe really understand the risk of man-made intervention into the world of viruses.

Well, just to back up a minute, I don't think that this was a virus that was engineered and then accidentally released from a lab. I think that there's a possibility that this was a virus that was in some labs or this lab in Wuhan's library and was accidentally released. If it was engineered in any way or changed, we would have probably been able to detect that in the sequence. But remember, a lot of these labs, what they do is they go out and they collect viruses from nature and then they just, you know, hold on to them. And so the same virus that was

in nature is just now in a test tube in a lab. That's the potential risk that you, if you don't have good controls in a lab, that you can slip up infect yourself if you're working with it. You know, to your point, yeah, absolutely. The technology for engineering, any pathogen and potentially weaponizing it is more ubiquitous. CRISPR is one technology. There's a lot of other technologies that are synthetic biology, a lot of other technologies that are more ubiquitous now, that doesn't take a tremendous degree of sophistication that anyone who has a PhD and access to an academic lab can probably mess around with. So yeah, it's going to be a growing risk going forward that it's easier to weaponize pathogens. And what you're going to worry about going forward,

what I worry most about isn't a rogue state. I worry about a rogue individual. I worry about someone just an individual, a sort of very good sophistication and diabolism. intonement that could become someone who ends up engineering something on their own and then ends up spreading it because this is more ubiquitous and that's much much harder to control. A really important message for all of us to reflect on. Scott, you've been very generous with your time and as usual, you've shared with us again, as I said, some hard-won insights from your time as commissioner of the FDA in the United States, a board member of Pfizer, educated medical doctor. Scott, just really appreciate all the analysis and sophistication that you've brought to our monk dialogue this evening.

Thanks a lot. Thanks for having me. Coming up next week, a conversation not to be missed with David Brooks of the New York Times. Former monk debater, we had him here on the main stage in Toronto last autumn for a monk debate on capitalism. He is our guest on Thursday, May 28th. At 8 p.m. Eastern, we're going to talk with David about the impact of COVID-19 on U.S. politics. There's, hey, a big election underway in the U.S. come this November, and also a topic that David is quite good on, which is the impact of COVID on our collective values. And let me conclude just by thanking all the partners that make this dialogue possible, the Peter and Melanie Monk Foundation and their sister foundation, the Oria Foundation, that underwrite, as with the Monk debates, all of the time, effort, energy, and cost. associated with producing these events.

Thank you for being part of this program. He lets all of us dialogue together to figure out the future of the world after COVID-19. Good night. I'm Rudyard Griffith. The Monk Debates are produced by Antica Productions and supported by the Monk Foundation. Rudyard Griffiths, Ricky Gurwitz, and Debbie Pacheco are the producers. The president of Antica Productions is Stuart Cox. Be sure to download and subscribe wherever you get your podcast.

And if you like us, feel free to give us a five-star rating. Thanks again for listening.