S1E2 / The Test Kit Debacle / Tom Frieden

I'm Dr. Celine Gounder.

And I'm Ron Klain.

And this is Epidemic.

In this episode, we've got a roundup of the latest news from the coronavirus outbreak in the United States and around the world. We're going to talk about Congress finally stepping forward and funding the response. We'll hear about Vice President Pence's press conference yesterday, and we have an interview with the man who used to run the Centers for Disease Control, Tom Frieden. We're going to ask him about the testing fiasco the CDC is at the center of and its impact on the coronavirus situation. And finally, we're going to be taking your questions on travel.

So first, our news roundup for the week. In the U.S., we're now seeing local community spread in California and Washington states. There's a nursing home in Kirkland, Washington, that's at the center of the Seattle area outbreak. This nursing home has had a recent history of disease outbreaks and violations with respect to infection control practices. Now, it's important to note that nursing homes are a very difficult place in which to control infectious diseases and are often susceptible to having flu outbreaks as well. Also in the Seattle area, North Shore School District, which is north of Seattle, is canceling class for the next 2 weeks. After a parent volunteer was diagnosed with the disease. Many are questioning what the impact may be for low-income students who may not have access to computers and the internet to continue their studies. In addition, many are reliant on the free and reduced lunches schools offer, and parents count on schools for childcare. Amazon and Facebook have both had tech workers test positive, and many tech companies are now encouraging employees to work from home if at all possible. Also in the Seattle area, researchers are recruiting healthy volunteers to participate in the first clinical trial of Moderna's experimental coronavirus vaccine. Outside of New York City, we now have a cluster of cases in Westchester County, but there's still no evidence so far of broader community transmission.

And in news here in Washington, where I am, the Congress is finally stepping up. The House of Representatives has passed an $8 billion package We expect the Senate to pass it and for President Trump to sign it. Now, the good news is this package is going to help fund the medical elements of the response, but there's still some major gaps. Nothing in this package that Congress is passing deals with all the people who are going to lose their jobs or have to stay home from work and not be able to work. People who are hourly wage workers who will lose income, this doesn't do anything to help that. It doesn't do anything to help parents who are going to need childcare when their schools close, or as Celine just mentioned, the problem of young people who are in schools who get fed there losing their source of nutrition. Doesn't deal with that, but it is a step in the direction of dialing up the response. And it is a step of trying to do more to fix this testing fiasco that has really bedeviled our reaction to coronavirus to date.

Meanwhile, Vice President Mike Pence and other top US health officials held a press conference yesterday in Washington, DC. Here are some of the highlights. The CDC is now advising that any American can be tested without restriction if a doctor orders that test. But I'm really concerned that this could lead to a rush by worried well who want the test, and we may not have enough tests for the people who really need them.

Well, and Celine, I'm actually worried about in some ways just the opposite, which is if our plan is to wait for people to raise their hands and say they want tests, we're not going to get this job done. We should be on an aggressive strategy of testing people with unexplained cases of pneumonia, people in nursing homes, at-risk populations, really focusing it there. The administration says they're going to step up testing by changing FDA rules to have private labs step up and test. They hope that at some point in time, commercial labs that people are familiar with in their communities like Quest will be able to administer tests there. But all of that is still weeks away.

You know, and I think one approach that we could be taking to better target the testing is if somebody has symptoms or concerns, there's a sort of step-by-step process you can take. You can first test them for the flu, then you can do an expanded, what we call multiplex PCR, for a broader array of common respiratory viruses, and then follow that up with a coronavirus test. So it's a good way of One, doing surveillance, two, reassuring people, but also making sure that the tests are reserved for those who really need it most.

Right. And so let's listen to Debbie Birx, who now works for Vice President Pence, helping to coordinate this response. Here's what she said on C-SPAN the other day.

This will be an essential lab test, so fully reimbursable. What we talked about with the commercial laboratories is exactly your question. And we asked them, and they're in validation this week.

Week. They—

some of them thought they would have tests available on Friday and the rest on Monday. I've asked them to prioritize the areas where we've had these clusters so that people can be reassured in those areas where there is— where we have identified virus has been circulating. In those cases, they will have it available at doctor's office and all of our pediatric offices that would need it. And they will transport it through a logistics network to make sure that they can be run.

Follow-up on testing. So look, I think we're seeing progress here from the administration. And Ambassador Birx is laying out some of the things we need to do to get testing to be more widespread and to remove the financial burden of testing. We're hearing stories of people say, I went in to get tested. It cost me $3,000, $4,000. My insurance didn't cover it. And that's also going to deter testing. I think there's some positive movement there, but it is late. More promises of acceleration isn't going to do it. This is going to be measured by what really happens on the ground, what people are seeing in their communities about the affordability and the accessibility of testing.

I think it's also important to remember that it's not just the cost of the test. The doctor bills you a fee, the facility bills you a fee, so just because the test is free, doesn't mean the entire visit is free. And so I, I really think we need to start thinking about other approaches, kind of like STD clinics use, where everything is completely free. Some countries have had innovative approaches to this, like the UK and South Korea, where they've set up specific testing through drive-through facilities where people can get everything done actually from the convenience of their own car.

Drive-through testing, that would be the American way, Celine.

Yeah.

You know, one other thing that happened at the White House this week was a meeting with President Trump and the CEOs of the major airlines. We're seeing already significant flight cancellations as a result of fears of the coronavirus, and the president met with the CEOs to discuss what other kinds of travel restrictions or measures might be taken. And one thing we did during the Ebola response is we routed all the flights that were coming from that area in that case, the 3 countries of West Africa, to just 5 US airports where we had screening in intensive levels, where we had health officials on standby to deal with people who might be sick. And I think you might see more of that. Now look, one difference here that Celine talked about in our last episode is that this is a pandemic, not just an epidemic. And the number of countries where this disease is spreading grows by 5 or 6 every day. So trying to manage this by managing the travel may be quite difficult, but I think it's a good thing to focus on. The government has amazing resources through the Department of Homeland Security to monitor where travelers are coming from, to route their travel, to screen those travelers. We haven't really utilized that yet in this epidemic, but that may be where this goes next.

Yeah, it's funny, I actually went through one of those screening processes at Newark when I came back from Guinea myself. So there's also been recognition, as we were talking about earlier, that nursing homes are really vulnerable to these kinds of outbreaks. Here's Seema Verma, the head of the Centers for Medicare and Medicaid, on C-SPAN yesterday.

As you heard, because of the, the risk for our nation's seniors, we are doubling down on our efforts. Today we put out 3 memos. One was to hospitals about triaging and placement for patients with suspected who have suspected or confirmed coronavirus. We also put out some information to nursing homes about limiting visitors to nursing homes, monitoring staff. And then finally, we put out some information to our state surveyors that are going to be surveying our nation's nursing homes and hospitals around infection control. So all of that information went out this morning.

So, look, this again goes back to the testing issue in two respects. First of all, we're going to need to test people in nursing homes pretty extensively. The data coming in from overseas shows that this disease, almost all the fatalities are in people over 60. This is going to be a concern in nursing homes all over the country. And secondly, we're probably going to have to test people who regularly visit people in nursing homes. We don't want to cut the elderly off from the outside world. That's bad for their health. It's bad for their mental health., but we're going to have to make sure that people coming in and out aren't bringing coronavirus into those nursing homes.

So now turning to the international front, WHO is reporting shortages of personal protective equipment. So that's the gowns, gloves, masks that we use in the hospital and clinics to protect ourselves. And this is really going to create problems for healthcare workers to do their jobs safely. WHO Director-General Dr. Tedros Ghebreyesus has said that we can't stop COVID-19 without protecting our healthcare workers first.

This is going to be a consistent theme in this podcast. I look at healthcare workers as the people who are going to save us when this virus really spreads in this country, but we also have to save them. They're the ones who are most at risk. They're the ones who are most vulnerable to getting the infection. They're the ones who are most vulnerable to being people who spread it, and so protecting our healthcare workers is just a critical strategic goal of any coronavirus response. Now, as for the path of the epidemic itself, we're seeing signs that the epidemic may be slowing in China. And as a result, the epicenter of this challenge is in the next wave of countries that have been hit by it: South Korea, Italy, Iran, and Japan. And the goal there, and the goal in the rest of the global community, is to try to slow the spread of the virus and push it back in the calendar, particularly towards the summer months. Not because coronavirus will disappear in the summer, we don't know that, we're not really sure about that, but more because seasonal flu diminishes in the summer. And that means that our hospitals and healthcare facilities won't be having to deal with flu patients in the summer and we'll have more capacity to deal with coronavirus. Delay is a win for this fight and that's what everyone is working on. Now, even as things get somewhat back to normal in China, and we're certainly nowhere near there yet, but as Chinese factories, Chinese production resumes, there's still going to be lingering effects on supply chains, particularly for drugs.

So antibiotics and acetaminophen are things that we use very often in patients who've had viral illnesses. Very often after the flu, for example, you might get a bacterial pneumonia. And acetaminophen is something we use to treat pain and fevers. So these are drugs that it's very concerning may be in short supply in the not too distant future. Meanwhile, in Iran, about 3 dozen government officials and members of Congress have been infected with the coronavirus. The militia has been sent door to door to homes to help sanitize the homes. And there's even been a leading prosecutor who has threatened face mask hoarders with the death penalty. Healthcare workers are being told to keep quiet about what they're seeing, and some have even been asked to falsify death certificates and report other causes of death than the coronavirus. Unfortunately, in Iran, there seems to be an overemphasis on controlling information rather than controlling the virus.

Yeah, I think this is something, Celine, as we see this disease around the world, we're going to see a big difference between more open societies that are more transparent about what's happening and authoritarian societies where information is suppressed. I mean, obviously case number one for that is China, where a lack of honest and candid transparent communication about the virus definitely made things much worse than it would have been otherwise. Now speaking of around the world, we still have the second worst Ebola epidemic in world history going on right now in Congo, and looks like it's nearing the end. Now why is that relevant to our discussion of coronavirus? It's relevant because the systems, the skills, the trained personnel, the talents that are built in fighting one epidemic often get flipped over to another epidemic. For example, when we were fighting Ebola in West Africa in 2014-2015, work that had been done in fighting HIV and malaria in Africa, particularly in adjacent Nigeria, were critical keeping Ebola from spreading to other countries. And that's really critical to us with regard to the Coronavirus epidemic, the scariest thing about coronavirus is what happens if it starts to spread widely in Africa. Of course, we're focused right now about our own country and the countries where it exists, and that's understandable and that's human nature. But where this virus could be a simply devastating, life-destroying event could be in Africa if it spreads there. So building up capacity on that continent to respond to and to react to epidemics is a critical, global priority.

Finally, in international coronavirus news, the Pope, I'm sure you'll be relieved to hear, tested negative for coronavirus. He just had a bad cold.

Hmm. Don't want to see the Pope get sick. Yeah. Celine, we're very lucky to have as our first interview on the Epidemic Podcast, Dr. Tom Frieden. To talk about this testing fiasco, his experience in leading the fight against Ebola, both overseas and here at home, and his perspective as the former head of public health in New York City, where we're starting to see the coronavirus really become a major consideration this week. Tom is currently president and CEO of Resolve to Save Lives, a global nonprofit initiative of Vital Strategies, working with countries to prevent 100 million deaths and to make the world safer from epidemics. You can find him on Twitter @DrTomFrieden. Tom, welcome to the Epidemic Podcast, and thanks so much for joining us.

Great to be with you.

Dr. Frieden, if you were New York City Health Commissioner today, what would you be doing to prepare the city?

I would think about it in 3 broad categories: the general public, healthcare, including nursing homes, and policymakers in government. For people, we really want to encourage wash your hands, don't shake hands, cover your mouth and nose when you cough or sneeze, and if you're sick, stay home. For healthcare facilities, we have to learn to surge safer, figure out how to do several things. One, make sure that we keep healthcare safe for healthcare workers and for patients. We've seen more than 3,000 healthcare workers infected in Wuhan, China. That means changing the way patients move around a facility. It means making sure that people who do triage don't get infected. And it really means thinking hard about nursing homes, because in nursing homes, we see explosive outbreaks of influenza. And for the public policy at the city, state, and federal level, we need to invest. We need to invest in communications, in addressing societal needs, keeping schools and work going, minimizing the societal harm as well as the health harms.

A follow-up question to that— how do you enable people to stay home from work if they're paid by the hour? There might be social pressure— let's say you work at Google— not to stay home. How do we enable that?

As a physician, the ethos is if you're not comatose, you should come to work. And we just have to get away from that because it's not safe. It's not safe for others. For people who are on daily wage, we have to try to figure out how to make sure that they don't have to choose between losing money and risking other people's health. We want it to be in everyone's best interest to do what's best for everyone.

So Tom, back when you were teaching me everything that I learned in the Ebola response, one of the first lessons you taught me is that in a crisis, you start with what you have and you scale up from that, as opposed to trying to invent something from scratch. We talked a minute ago about what you would do if you were New York City Health Commissioner, but what about smaller cities, smaller towns? They start with less. How do they scale up from a lower starting point?

Each community has strengths and weaknesses. Communities need to build on the strengths and address the weaknesses. In rural areas, for example, there are some populations that are particularly at risk. It might be a nursing home, it might be a community with a high rate of chronic disease such as diabetes, and we have to think of what we can do to best protect those areas.

So one major area of concern that's been reported quite extensively in the media is around testing. What do you think, Dr. Frieden, about how the CDC has handled coronavirus with respect to diagnostics so far? You know, why are we so behind South Korea, and how much of the blame actually rests on CDC?

I think we'll have to look back and understand blame. This is unusual. In all of the past responses, the CDC lab provided the laboratory tests, not just for the United States, but for the world. That was the case with H1N1 influenza, with Ebola, and with Zika. So the CDC has a facility that produces large-volume, high-quality laboratory tests. What went wrong this time needs to be looked at so it never happens again. What we need to do now is focus on getting tests out as widely as possible so that we can identify how much this is spreading. We also need to develop better tests, tests that are rapid tests that might be able to tell in 20 or 30 minutes if someone has the infection, and blood tests that will tell if someone's been exposed in the past.

Are there any point-of-care tests in development that we may have soon?

I don't know how readily available they will be or how possible they will be to develop. Some of these upper respiratory infections, the other coronavirus infections, have relatively low amounts of virus. So it requires a nasopharyngeal sample, which is not a pleasant thing to take. And then whether it has enough virus on it, only time will tell. I can't emphasize strongly enough that we are still learning more about this virus every day and virtually every hour.. And the more we learn, the better we can respond to it.

Where do you think we go from here on testing? If the goal is to rapidly ramp up our ability to test, to conduct surveillance even, what's the path forward from here?

We're going to need to recognize that this is a global pandemic. The countries that are affected are increasing by 5 or 10 a day. So essentially, it's going to be everyone with a dry cough or fever who might have this infection. There are systematic ways that we test everyone with those symptoms at sentinel clinics, so we can get a sense of how much of this is spreading in the community, if at all, or if it starts, when it starts to go down. The best scenario I've seen around the world is Singapore, which began testing everyone with severe pneumonia, and they picked up a few cases that way.

So, Tom, let's take the lens back a little bit. Your work at Resolve to Save Lives, part of your work at least, is on the general question of assessing the world's preparations for pandemics. So as we face this pandemic, give us a readout. How prepared is the world? Where is it more prepared? Where is it less prepared?

Ron, as you may remember, in 2012 we began pilot projects of the Global Health Security Project, and then we launched it formally in 2014. And in the past 6 years, 115 countries have gone through a rigorous assessment of how prepared they are. And the bottom line is we're not very prepared. The good news is we know where the gaps are. We know what the gaps are. We know how to fill the gaps. We know that there are close to 10,000 life-threatening gaps all around the world. And we know what it costs. It costs about $1 per person per year in lower-income countries. That means it'll cost us $10 to $20 billion over the next 10 years to make the world substantially safer from epidemics and pandemics. We've got everything except the money. And maybe with this crisis, where hundreds of billions of dollars or trillions of dollars may be lost, we'll have the money to close those gaps and make us all safer.

Dr. Frieden, what did you learn from your experience responding to the Ebola epidemic that you could share with us that, you know, worked and didn't work?

Good public health programs base their decisions on data, and great public health programs base their decisions on real-time data. The hallmark of an effective response is that it adapts to new information as that information becomes available, and it therefore works really hard to get that information. We won't have that information unless we have a laboratory network around the world, unless we have trained disease detectives, unless we have rapid response teams and rigorous epidemiology. So The better information we have, the better we can protect people.

Well, speaking of that, we have seen in this current coronavirus epidemic, just to be honest from my perspective, erratic and untrue communications from the president contradicting some of your former colleagues at CDC in their presence, contradicting Tony Fauci in his presence. Tony having to correct the president repeatedly. I mean, how do we deal with the public health communications challenge in this environment, and how do you assess it so far?

Going forward, what'll be key to watch is are the decisions being made based on science? The leadership of CDC and NIH speaking from the podium, that's very important. That's something to watch. There's always a little bit of jostling between different parts of the federal government, but CDC is the expert in this, and Nancy Messonnier told it like it is.

It's not so much a question of if this will happen anymore, but rather more a question of exactly when this will happen and how many people in this country will have severe illness.

We will maintain followed the principles of risk communication that are drilled into us at CDC. Be first, be right, be credible. She told people this was going to spread. She told people what to expect. And I think there was a lot of negative reaction to that, but she did the right thing.

Well, let me push on that a little bit, Tom, and see how far you're willing to go. So there's always jostling, but the spectacle of people attacking her because her brother's Rod Rosenstein, of political attacks on people at CDC because they're allegedly part of the deep state. I mean, that's not an environment that encourages candid and reliable communications from public health officials, right?

CDC remains one of the most trusted institutions in the US. They've clearly had a problem with test kits, but CDC is where the world goes to for this expertise, and it's where all of us continue to go to for excellent guidance on how to protect health workers, how to protect nursing homes, how to protect communities. So the CDC website becomes really the nerve center for the US response and, to an extent, the global response as well. And as long as the CDC experts, who are the same people who were there when I was running the agency, are allowed to do their jobs, I have more confidence in our ability to respond.

Dr. Frieden, why do you think some of these technical public health decisions are being politicized, and how can we prevent that from happening?

Public health decisions always have a political component. What we want to make sure is that the decisions are being made based on saving the most lives, and we're leveling with the American people about what the risks are.

And finally, Dr. Frieden, before we close, if there's anything you would like to say about Resolve and how how it might apply to the current coronavirus outbreak?

At Resolve to Save Lives, we've been working for the past 3 years to strengthen preparedness, primarily in Africa. There are huge gaps in preparedness, but there's a lot that can be done about them. Uganda and Nigeria, for example, have made major strides and are now able to find and stop outbreaks much faster than they were just a couple of years ago. And that helps them, that helps their neighboring countries, that helps the U.S., and that helps the global economy because it reduces the risk of the kind of economic shock that we're seeing. COVID-19 is a huge challenge. It's also our unique opportunity to both invest in strengthening early warning and rapid response systems around the world to tamp down this pandemic and to drive down the risk of a future pandemic.

Dr. Frieden, thank you for joining us today, and thank you for your service.

Thank you. It's a pleasure speaking with you both.

Each week, a feature on this podcast is going to be answering your questions. So you can get us your questions two ways. You can tweet @Celine or myself. @CelineGounder or @RonaldKlein, or you can record an audio file on your phone with your question and email that question to us at hello@justhumanproductions.org. That's hello@justhumanproductions.org. Please keep your question under a minute. Tell us your name and where you're calling from.

Here's a question from Toby Kuman from Newton, Massachusetts. Hi, Celine.

I'm about to host my son's bar mitzvah in about 4 weeks, and we have several relatives flying coming in from all over the country, at least 20 people or so, and about 10 or 12 of them are over the age of 70. I'm wondering what you recommend if we're considering, should we be thinking to postpone the event due to the threat of the coronavirus, and is it unsafe to have all these people be flying?

So I don't think there's a blanket recommendation I can give to everyone. I think you really need to look at the specifics of each case. So here's how I break it down. I think about, is this domestic travel? Is this foreign travel? And then what's your risk of, of being infected in the particular place you're traveling to? So is this a place that has community transmission or not? Have there been sporadic cases or no cases at all? So for example, traveling to the Kirkland or Seattle area in Washington State is very different from traveling to Omaha, Nebraska right now. So that's another factor I look at. Then I think about, Well, what is the risk to the person who's traveling of being infected? So are you somebody who's elderly, especially 70s and 80s, but we do start to see an increase in risk after the age of 50. Do you have a chronic medical condition, you know, and that could be anything from heart or lung disease to diabetes, kidney disease, liver disease, maybe you have an autoimmune disease, maybe you're in recovery from cancer. So there's a whole host of medical conditions that could put you at higher risk for complications. Then what about your employer? Does your employer have restrictions? So I know a lot of hospitals, anything from Mass General in Boston to NYU and Columbia in New York and others, are instituting travel restrictions for their employees. And then, you know, personally, I also think about could I be helping to spread the infection to other parts of the country? And while that will happen eventually, I don't want to rush that process along any more than it's going to be happening on its own. And then finally, if you're traveling internationally, there are a couple other things I would think about. If you got sick, how would you feel about the healthcare you would get there? It's very different to get sick someplace like Singapore than it is to get sick in a less developed country. And personally, what I actually worry about the most is getting trapped by travel restrictions that aren't based in science. You know, from one day to the next, could the administration decide, oh, well, you went to France and Paris has seen a lot of cases, you have to stay in France for the next couple weeks until we sort this out.

Yeah, I mean, first of all, it should certainly be a bright line that no one should travel to countries that are subject to a Level 3 CDC travel advisory. Right now, that's Italy, that's Iran, that's China, that's South Korea. You should check cdc.gov for the updates on those advisories before you travel. Likewise, Japan is subject to a Level 2 advisory right now, Doesn't mean you can't travel there, but it does mean that certainly if you have contact with elderly people or vulnerable people, if you're a healthcare worker, you shouldn't travel to a level 2 country. Again, those warnings are going to change. Stay on top of them before you travel overseas. The simplest and best advice for any travel planning right now is make sure that you get refundable tickets or travel insurance so that if your plans have to change, You can change them. And the last thing I'd add for our question from Toby, you know, I had to have my bar mitzvah canceled because my mom got sick just before it, had to learn my Torah portion a second time. So if you have to postpone or cancel, life will go on.

Epidemic is brought to you by Just Human Productions. Today's episode was produced by Zach Dyer and me. Our music is by the Blue Dot Sessions. If you enjoy the show, please tell a friend about it today. And if you haven't already done so, leave us a review on Apple Podcasts. It helps more people find out about the show. You can learn more about this podcast, how to engage with us on social media, and how to support the podcast at epidemic.fm. That's epidemic.fm. Just Human Productions is a 501(c)(3) a 501(c)(3) nonprofit organization, so donations to support our podcast are tax deductible. Also check out our sister podcast, American Diagnosis. You can find it wherever you listen to podcasts or at americandiagnosis.fm, where we cover some of the biggest public health challenges affecting the nation today. In season 1, we covered youth and mental health. In season 2, the opioid overdose crisis. And in Season 3, Gun Violence in America. I'm Dr. Celine Gounder.

And I'm Ron Klain.

Thanks for listening to Epidemic.