Today, Explained - Zeke Emanuel’s exit strategy

Episode Date: April 16, 2020

President Trump wants to reopen the country yesterday. Bioethicist Zeke Emanuel, who served as a health policy advisor to former President Obama, offers a safe path. (Transcript here.) Learn more about your ad choices. Visit podcastchoices.com/adchoices

it's thursday april 16 2020 happy birthday dad i'm sean ramas firm and this is your coronavirus update from today explained let's uh spin the globe we'll start with the biggest planet on earth facebook the company today said it has removed hundreds of thousands of posts featuring conspiracy theories and medical misinformation about COVID-19. People who interacted with the bad stuff are going to get notifications and links to good stuff from the World Health Organization. Check your sources, people. Japan's Prime Minister Shinzo Abe declared a nationwide state of emergency today, extending one that was already in place in the country's major cities. COVID-19 is spreading there, but the country has not imposed lockdowns like we've seen elsewhere.

Despite sharing a border with China, Vietnam has fewer than 300 COVID-19 cases and zero reported deaths. According to NPR, that's because of early quarantining, aggressive contact tracing, and some serious consequences from a one-party communist state. Russia is postponing a big military parade, even though Vladimir Putin really, really didn't want to. He's now saying the risks are just too high. Infections continue to rise there. The United Kingdom is extending its lockdown by at least three weeks. The British government thinks the country is nearing its COVID-19 peak.

And back in the United States, we got new jobs numbers today. 5.2 million people filed for unemployment last week, bringing the total over the last month to about 22 million. The Washington Post is reporting that millions of Americans who were expecting stimulus checks via direct deposit on Wednesday didn't get them due to a glitch in the IRS payment matrix. The Post says a number of parents didn't get their $500 checks for dependents as well. The IRS and Treasury departments say they are working on it. The president is scheduled to speak about reopening the country later today. That's all while the governors of several states on the East Coast are extending lockdowns until mid-May. Much more on what it will take to properly and safely reopen the country in today's show. And before we get to

the show, you've probably heard that New Yorkers applaud their essential workers from their windows and doorsteps and stoops every night at 7. Tonight, a group called Peace of Heart Choir wants to dial it up a notch. Here's the idea. After a clap and a cheer, everyone does their best Sinatra and belts out New York, New York at the top of their lungs. You can sing along to the song tonight at 7 via WKCR 88.9, WBAI 99.5, or join in from just about anywhere on the planet at the New York Sings Along event page on, where else?

Facebook! The greatest city in the whole world. Thoughts spread in the news I'm leaving today. I want to be a part of it. New York, New York. These vagabond shoes. They are longing to stray.

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The deadline keeps getting punted. What's clear is he doesn't really have a plan to fight this coronavirus. But Zeke Emanuel does. He's an oncologist, a bioethicist, and was a health policy advisor in the Obama administration. The first thing I asked him was, is the country even ready to open back up? No, it's not ready on two accounts. First of all, we have too many new cases still of COVID-19. While we've probably bent the curve, we're still high up. And you can't even think about reopening the country until you've come down the back end

of that curve. That'll take another four to six weeks. It's a bell-shaped curve for your audience. So what goes up has to come down in exactly the same arc. So that's part one. And part two is we need a kind of infrastructure that allows us to move from mitigation, that is reduce the number of new cases and deal with the cases we have to containment when a new case pops up, isolate them, find the other people they've been involved with, and try to limit the spread of the virus. So that's a really important infrastructure, and we're far from that infrastructure too. So what we really need to do is to take the time we have now and get that infrastructure ready,

and there's no evidence we're doing that. What we know is that testing is something like 150,000 people per day, which is a slight improvement from a few weeks ago when it was 100,000 or so a day. So we've gone from doing not remotely enough to slightly more than that. We need to change substantially the who we test, not just the numbers. When I tell you how we change the who, you'll see that the numbers have to go up substantially. So right now, we're testing people. The top categories are all people who we suspect have COVID-19 because of symptoms. Healthcare workers, frontline healthcare workers because of symptoms, new patients because of symptoms, people over 65

because of symptoms, people with comorbidities like hypertension or heart disease or diabetes because of symptoms. That is, we're using the test to treat people. Really important, but bad if what you want to do is open the economy and limit the spread of the virus. If you want to limit the spread, you have to do a different form of testing and testing different people. You have to focus in on testing frontline workers who are actually interacting with a lot of people, everyone in the hospital, grocery workers, frontline responders, policemen, firemen, people who are going to go back into the office, people who are going to work in restaurants. Those are the people who

need to be tested because you got to clamp down if any one of them is positive because they're interacting with, if not hundreds of other people, certainly scores of other people. Then when you say, all right, if I got to do all these frontline workers and grocery workers and restaurant workers, how many of them are there? And let's say I want to test them every week to be, you know, reasonable. Three to four million frontline health care workers who have contact with patients every day. Three million grocery workers. You know, you're already at seven million people.

That's a million tests a day per week. And you haven't even talked about the policemen, the firemen, the people going back into their office. Is it your sense that we're never going to get there, that the president doesn't see that as a priority? I don't quite, you know, people have been asking me this question, and I just can't figure out what the dilemma is. Is it an FDA dilemma? Is it now that LabCorp and Quest just have run out of reagents? They haven't done it. I just don't know what the limit is, but there's clearly a big limit out there. I also think that the federal government, you know, there is some way in which it's abdicated its lead and responsibility in coordinating the national effort.

And I do think that we need more careful. Where are all the resources? Are we putting them in the right places? Let's bring on more testing capacity. And that needs to happen. What's your sense of the supply of personal protective equipment at this point? I mean, you're talking about a massive ramping up of testing that we still haven't reached. But obviously, all of the medical professionals, healthcare workers, frontline workers, grocery store workers, EMT workers are going to need a ton of PPE

if they're going to be helping us facilitate all of this. Do they have it yet? It depends what you mean by have it. One of the habits is, are you changing your N95 mask between patients? The answer to that is clearly no. People have been given an N95 mask and, you know, this is your mask for the year kind of thing. Well, that is not a good practice. I watched a CBS reporter in a news segment go into a New York hospital and he was interviewing a nurse. And she was telling the reporter, I'd like a mask like yours. I'd like all of us to have masks like yours and these white suits like you have.

Look at your hazmat suit. Look at what I'm wearing. And the reporter says, What is that? What is it? It looks like a garbage bag. Yeah. It is a garbage bag. I'm wearing a trash bag. We have on garbage bags and you have on very fancy stuff.

Yeah. Yeah. And I think that's part of the problem. We just don't have enough or the right amount in the right places. I mean, clearly the underserved hospitals, the public hospitals, they just have not had sufficient amount. And we also need it in places that haven't blown up yet but are very much likely to blow up that have sort of taken a laissez-faire attitude. You know, we saw this in South Dakota with the Smithfield pork packing plant. We're not doing shelter in place. The governor's been resistant to it. And then boom, you have hundreds of cases all from one plant. And other cities are going to have that too. Yeah. Are you talking about just the states like South Dakota, North Dakota, Nebraska that haven't made formal shelter-in-place policies? Are you talking about cities and states that have them in place too? Cities and states that were late to put them in place.

You're still on the exponential growth curve, maybe delayed a few days than what you would have done with no shelter-in-place, but you didn't do shelter-in-place in time. You know, that was clearly the case in New Orleans where they let Mardi Gras happen. They, you know, then got on the exponential curve. Parts of Florida, you're going to see a lot more. So, you know, Italy was late to implement social distancing, but once they did, they really clamped down. Obviously, we're not doing that. Will that affect the entire country's ability to proceed? People travel. And if you don't clamp down everywhere and have a national shelter in place policy and have a president who's trying to persuade every governor and giving governors cover to do it, that's how you get a national policy. And if you don't have a national policy and someone from, you know, South Dakota who happens to be positive but asymptomatic goes to some place that doesn't have a high level, interacts with a lot of people, you could have another explosion in those places.

And that's how it's happened. I mean, that's how we got it in the United States in the first place. People who were in China came back or people who were in Europe and got it in Europe came back. And, you know, just a few people spread it around. And all public health people think, all right, we relax the physical distancing. We allow non-essential businesses to open. People go back to work. We even allow some large crowds like religious services. And you will definitely have a recrudescence of the disease. If we can't get our testing ramped up, we're never going to get to contact tracing. And contact

tracing is the next step. That's after the break on Today Explained. Support for Today Explained comes from Ramp. Ramp is the corporate card and spend management software designed to help you save time and put money back in your pocket. Ramp says they give finance teams unprecedented control and insight into company spend. With Ramp, you're able to issue cards to every employee with limits and restrictions Thank you. ramp.com slash explained, ramp.com slash explained, r-a-m-p.com slash explained, cards issued by Sutton Bank, member FDIC, terms and conditions apply. All right, so my understanding is that if we can't really get the social distancing piece figured out and the testing piece figured out, we're never going to get to the place where we can properly implement contact tracing, figuring out who's come into contact with people who have COVID-19.

Do I have that wrong? No, no. Contact tracing depends upon being able to identify COVID-positive people and then look at their contacts rapidly. That's where technology really needs to come in and then get those people tested. That is the nature of the game. And in this situation, because the virus travels so fast, you really need to have technology augment basically old-style gumshoe contact tracing. Okay, so if we get the extended nationwide shutdown we need and testing on the massive scale we need and the PPE our essential workers need, none of which we have yet, how do you then trace contact? You need technology to help us identify people who are connectors, who interact with a lot of people and have come close to a lot of people. That technology is, you know, Facebook and Google already have it, and they can probably give you a list of everyone you've come in close contact with. And this is the thing that Google and Apple say they're going

to collaborate on, too? Yes, because you'll have it on the Android, you have it on the iPhone, but you don't need an app. They already know. And then you need to have a list for everyone who's positive, be able to detect that list and probably send out a message that says, you've come in contact with someone who's COVID positive. That doesn't mean you're COVID positive, but you need a test. You know, that's not rocket science. That's something the Google and Facebook engineers could probably do over a weekend if they really wanted to. And that is very, very important. But of course, none of us trust Google

and Facebook with our data, and we'd be very suspicious. So we need some independent, public trusted organization to do it, to guarantee us it's not going to be commercialized. They're not going to keep the data on us. They're going to erase it so that our individual privacy is protected. So a whole nother host of problems here. Even if we get to the point where we have the infrastructure, we have the third party, there's a good chance that Americans still won't want to volunteer their information to the government, to Google, to Facebook voluntarily, right? Right. Trust is a big issue here. And, you know, there's probably half the population doesn't trust the government and half the population doesn't trust the tech companies.

And so, you know, you have to find some other group that, you know, a three-way collaboration where one group that controls the data is some group that the public will trust. And rumor has it the president's going to seriously speak about contact tracing for the first time later today. I'm guessing it's because he's, what, just been preoccupied with trying to reopen the country? And maybe it's just that the attention has been on the testing issue, both the viral testing and now the serology testing that everyone seems to be focused on, the antibody testing.

Both are important, but they're not the only thing. They enable the contact tracing. They enable isolation. But remember, the real threat here, the real threat to opening are the asymptomatic infected people because they're the people unwittingly just go and spread it around. And any one of us could be that person.

And we need to basically focus in on that person and make sure that they isolate themselves for at least 14 days. Which we can't do without dramatically ramping up testing. Correct. Which we show no signs of doing right now. Correct. And by the way, the third leg of the stool is to protect the particularly susceptible, those who are older, those with serious comorbidities that we know give you a predilection towards getting the disease, vascular problems, diabetes, obesity, heart disease,

asthma. Does this keep you up at night? Well, you know, you got me on a day when I'm not particularly depressed. Last week, I was particularly depressed the whole week because of this, because I couldn't see a way out. I do think we have the capacity to ramp up testing. I think the pressure will grow to ramp, change the guidelines under which we're operating, have the CDC change those guidelines. I think there are ways or solutions to the testing problem. Is someone going to have to drag the president kicking and screaming? And if so, who is that someone? Is it Fauci? Is it Birx? Is it Newsom, Cuomo? Who is it? Inslee? If I were a betting man, it's probably going to be the business community.

Here's what you have to do if we're going to open up. He's got all these business guys he's talking to. I think they're mostly guys. So I think if they say, listen, I'd be happy to get my people back, but I need you to do something to make that a more viable and safe, by the way, process for me. Here's what I need. That may be the dance that we end up having. And if that doesn't happen, can you just remind us in your estimation what this looks like? Is it a second wave? Do we even get out of the first wave? Yes, we'll get out of the first wave because we're sort of sheltering in place. And it looks like the president's backed away from the May 1st opening. It'll be sometime in May or June for something like that. The numbers will have come

down substantially. Then we're going to, you know, we're not going to be prepared. We're going to relax the physical distancing guidelines and rules. People are going to go out and you're going to have a second resurgence, probably sometime mid-July, end of July, early August kind of thing. That will depend heavily on how much risk people are taking. I think in the last couple of weeks, I've heard more hesitation. Like, you know, 41 people who were grocery store clerks died. Maybe there's something to this, and I don't want to rush out and be the first person out there going to a restaurant, sitting at a table. You know, if the American public is hesitant and not assured that the

safety precautions, and they might actually be very slow to restart the economy. And so I think we don't know how fast that resurgence might take place. But if we don't have the proper regime to actually test, contact trace, I can see Americans being hesitant. I've seen enough 27-year-olds who aren't supposed to get sick from this thing die, maybe I'll be a little more cautious. We'll see. Have you had an opportunity to speak with the president since this pandemic became, you know, a crisis? I'd prefer not to answer that question. The answer is I have spoken to him,

but not in the last four weeks. Huh. What did you guys talk about? COVID-19. Various proposals to intervene. Did you feel like you convinced him in any particular regard? I don't want to go into the details. If you could talk to him today, considering everything you just told me about how far behind we are on testing still, how far behind we are on PPE still, how far behind we are on PPE still,

what would you say? Well, I completely agree with him that we need to reopen the economy. It's really important for all the Americans who lost their job. It's important to everyone. And try to explain why I think the testing has to go up and contact tracing and how you might do that.

And make a big impassioned plea that, you know, the only way you're going to convince Americans to do these things is if they have the assurity that they can be tested and that the health care system will be there for them. Did you ever think you'd see a pandemic like this in your lifetime in this country? I was of two minds. So I began teaching at the University of Pennsylvania, and I used to teach a course called Rationing and Resource Allocation, where the rationing part was all about pandemic planning and how you would distribute all these goods like a vaccine, an ICU bed, and ventilators. And so I've been thinking about this, and my students have been learning about this. And there's a line in that course in my slides that I show all the influenza pandemics in the 20th century, 1918, 1957, 1968. And I had a line that I would say, you know, we're overdue for a

pandemic in this country. We've gone 50 years without one of these. We're going to have one. And, you know, we had a near miss in 2009 with H1N1. I'm worried. So I'd always been thinking about it and always knew that there is a remote possibility. But if we have this remote possibility, the consequences are huge. But I also was like, hmm, you know, like everyone else, it's a low probability event, huge consequences, but low probability. And I think as human beings, we're kind of crappy at planning for low probability, high impact events. And I think we need to be better at that. It's like insurance. I don't buy insurance for a high probability event. I buy my insurance for a low probability event. I buy my insurance

for a low probability event, but high impact. We need to think about these kinds of planning things like insurance. So I've been thinking about this for 15 years. Did I actually think I'd live through this and have a role in it? No. But I mean, this pandemic has made so painfully obvious, so many dysfunctions in the United States from our social safety net to government preparedness to, you know, gross inequities. It feels like an opportunity to maybe hit reset on so many things we're doing poorly or just not doing at all. Do you think we will?

There are three or four things that this pandemic has really made clear. I think, first, it's made all of us insecure. The uncertainty, the insecurity is just palpable to everyone constantly. Second, it's made clear that we're social beings and social life is critical to all of us. Not being able to be in the same studio with you, doing this over the phone. It's like, I want to be of us. Not being able to be in the same studio with you, doing this over the phone. It's like, I want to be with people. Having a Zoom, you know, happy hour is not a happy hour, right? And I think people are really feeling hungry for that. And the third thing is, we're all limited in our experience. Yes, I can be in my house and I can go out for the same

effing walk over and over again. Yeah. And not being able to have new experiences is degrading substantially people's happiness. So I think the first part of your question is critical. It's security people want. So I do think we're going to have a reset and I think we're going to have a reset around security. Our government, our country has to give us some security. What does that security look

like? Clearly health insurance, clearly family leave, clearly unemployment insurance, whether you're in the gig economy or not. Similarly on social life, when this thing is over, you can forget virtual reality. What we want is reality. We want people. We want to rub shoulders with real other people. Thanks so much rub shoulders with real other people. Thanks so much. Take care, man. I just want you to know that I miss you and I love you. Can't wait for this shit show to be over so that I can touch people, drink with people, and have the best life ever. Zeke Emanuel is vice provost of global initiatives at University of Pennsylvania.

He's also got a new podcast, Making the Call. It's Zeke and another bioethicist answering big questions about COVID-19. Go subscribe for more Zeke wherever you're listening to this. Again, it's making the call. I'm Sean Ramos for him. This one's Today Explained. Thank you.