COVID-19: Where Are We Now And Where Do We Go From Here?

When we talk about why some places are affected others, that really depends on when was the virus introduced in the population, what's your population density, how many of your population have underlying conditions that are going to make them present with severe disease, and when did you put your mitigation strategies in?

Welcome to the Doctor's Pharmacy. I'm Dr. Mark Hyman and that's Pharmacy with an F, F-A-R, MACY, a place for conversations that matter. If you're concerned about COVID-19 and want to cut through the confusion, this conversation is going to matter because it's with my friend and colleague from Cleveland Clinic, Dr. Steven Gordon, who's the chairman of the Department of Infectious Diseases at Cleveland Clinic Foundation. He's also professor of medicine at Lerner College Case Western, and he has been studying infections his whole life. He's the ID guy, and he is just a good human being and a great doctor. I think at Cleveland Clinic, we're seeing incredible leadership around COVID-19 and how to prepare for it, how to think about it, how to study it. And our CEO, Tom Mihaljevic, went to the White House and was actually speaking to the president about how we address these things in a more coherent, intelligent way. And I've been hearing from some of the doctors who are from Cleveland Clinic who've gone to New York or other places. and they're just shocked at how chaotic things are in other parts of the country where Cleveland Clinic is just so on top of it. And I think they're a model for how we should be thinking about it. I know you're heading that up and a lot of other people obviously are working on this too, but I'm just so proud to be part of Cleveland Clinic and to know you and to just be under your leadership as we try to deal with this really horrible, crazy time of COVID-19. So welcome. to the doctor's pharmacy, Dr. Gordon.

Well, Mark, it's a pleasure to be here in an honor. And, you know, to level set, I am not the leader. I'm following and just a small part of the keg kind of in the process here. But this has been a, as you know, and we all know, you know, this is something different and it's gonna affect us not just this time, but obviously there's gonna be changes that are gonna be post COVID. as we say, we're not going to go back to Kansas after this in many domains, not just healthcare, education, and in certain ways on how we live.

Yeah, you know, it's just having a conversation with former Senator and Senate Majority Leader Bill Frist, who gave a lecture at Harvard in 2005 on how we were so ill-equipped to deal with a pandemic that would come because of some type of viral infection that could cripple us. and he talked about the need for a Manhattan Project, like an effort to actually prepare ourselves. You've been infectious disease your whole life. Did you see something like this coming? Were you kind of shocked? Or you've been following SARS and MERS and SARS-CoV-1 and Ebola and H1N1. Did this occur to you that this could happen in our lifetime?

Yeah, so that's a great question. So I think I'm old enough, enough gray hair to have looked through a couple.

I see a few black ones.

But you know, you talk about HIV. I mean, HIV had a cadence that was a little bit different, but in many ways, obviously, was not. There was a, I would say, a slow recognition, not just of all the cases, but the recognition that the transmission was going to be more than just, let's say, men having sex with men. And once that was kind of socialized, that obviously was a big deal. So lessons there, I think the other is if we look back, I would say SARS is what we would, so that's, you know, coronavirus one as opposed to now coronavirus two. You know, some people would characterize that as our first supersonic disease, meaning you had cases obviously centered in Asia, China, then the diaspora to places like Singapore and China, I mean, in Toronto. Now, fortunately, that could have gone this way, but it did peter out after 8,000 cases. Still don't know why, but obviously that had the warning shot. We had H1N1 in 2000, obviously eight and nine. So that was a pandemic, but that influenza strain was not particularly virulent. And then as you mentioned, MERS in 2012, also relatively small in terms of geographically what it affected. And so yes, I think in retrospect there's gonna be a lot of people that say I told you so, you know, that this was inevitable. But I think we want to kind of look forward. We're not out of this yet, but as you mentioned, Mark, I think there's gonna be a lot of hopefully lessons learned. Also, I think the other is, you know, this is one world. I mean, and so we do need to care about what goes on, no matter what your political or where you are, if there's something going on in North Korea, we actually do need to care about that.

Yeah.

And this, as you know, started out as some cases of pneumonia in a place called Wuhan, which is, you know, is as big as New York City.

But- I've been there, actually.

And then within, you know, less than four months, the epicenter moves from Wuhan come on to Italy and now New York City in the United States. So I think there'll be an interesting post-mortem on this. But I do think now is not the time for, you know, for blame or per se. It is a time, I think, for resilience and moving forward.

Yeah, you know, it seems like we've sort of, for the most part in the last 100 years, you know, this is this last bunch of years that most of us remember, have been a period of viral calm. Like we really haven't seen these horrible diseases like polio and measles and rubella and these things all got under control. And now this is sort of something that humanities had to deal with for thousands of years and we sort of had this nice window of just like, you know, everything's cool. And now it's kind of waking us up to realize that, you know, we have to think differently about how we approach preparedness and what we need to think about. Now the characteristics of this virus are sort of making it uniquely spreadable, right? It doesn't kill everybody. It can be asymptomatically spread. It's easily transmissible. SARS-CoV-1 seemed to kill everybody, and so they all died off before they could run around infecting everybody, right?

So.

How is this sort of unique characteristics of this different and how is this going to affect our ability to sort of get back to normal over the next couple of years because I just think we're in the thick of it right now, but I'm thinking, okay, what is the trajectory of this? Because it's not just like, okay, June 1st, we're back to normal.

It's like, what's happening? So great questions. I think, as you said, as you're rolling this out, it's like if you wanted to write a Michael Crichton novel of a bio agent, and it does, as you mentioned. So respiratory viruses similar to influenza spread very quickly. very small incubation period. So from exposure to onset of illness. As you said, it doesn't kill everybody, which then allows it to propagate. The other thing is we have no pre-existing immunity, right? This is a novel virus. So there isn't like influenza or other things where there might be pre-existing immunity. And then the other thing that you mentioned, I think is important. And it's a difficult nuanced concept, this asymptomatic spread. so I think a lot of people think there's like zombies out there that are not symptomatic, that are spreading all over. And I do think truly asymptomatic spread is less usual. What we have here is a period, what we call pre-symptomatic phase that probably lasts two days. Influenza may be a day where you don't have any symptoms or you're pre-apparent and the viral loads in this illness are highest at the onset and then fall. SARS-CoV-1 was different. It was high and then it got higher with illness. But this actually at the onset, and so you're most contagious when you have the highest viral loads. And as you mentioned, there is a period where before you might have onset of symptoms, you could be potentially contagious to others. Enhance the rationale for the universal masking. Now in terms of mortality, I mean, you mentioned we're seeing mortality rates all over the board a little bit. US, if you look overall, it's about 3 to 4%. It is not across the board equally though. This is a disease that is not treating our elderly and elderly with comorbid conditions, it's different, right? So, almost, I think in the states, 80% of the deaths are in people over 65. Most of those have comorbid conditions. Obviously we've seen young people, as you mentioned, in ICUs, most of those also will have a comorbid condition. Things that have come out, right, have been obesity has been one, which is an epidemic that you know very much about, and that's not just in the United States, Western Europe, but heart disease, obviously pre-existing lung disease. The other thing is to mention, as you know, is that as we get some more sero surveys, there's probably more infections that have occurred than quote-unquote are reported. Yeah. And therefore, the numbers of true death from infections might drop from the percentage we have here. Now, every death matters, we understand that. But in terms of, as we're looking, for instance, I know you're close to New York, some of the serial surveys that you mentioned estimate maybe 20 to 30% of the population in certain areas may have been exposed to SARS-CoV-2.

Yeah, I mean, I do believe the data coming out of Southern California where It was up to 50 to 85 times the infection rate when they looked at antibody testing. Does that make sense to you?

So I think, you know, antibody testing we view with a little bit of a jaundiced eye. It's not for individuals, it's for more seroprevalence to see. There is some cross-reactivity, but again, there is some bias in who gets tested. So for instance, in New York, they were testing that survey where people walking around, so it's somewhat selected in terms of people outside. But I do believe, obviously, it's gonna track with the reported cases. And it makes sense because testing, which we can talk about too, has not been available to the common man outside of hospitals. And so there is a lot of what we would say cases that probably could have been, if there was testing available, could have been diagnosed, but were not.

Yeah, I mean, if there's a million documented cases now, and there's 60,000 deaths, but maybe there's actually 20 to 50 million cases out there, then the death rate is much lower, right?

Correct. It would reflect more of what we'd say seasonal influenza, which is usually 0.1%, as opposed to the 3 to 4% that we're looking at in the States in terms of COVID Although the truth.

Is, you know, in an average year, 40,000 people die from the flu, but we already had in a couple of months 60,000 people die from COVID-19, right? So it's got to be a little bit more nasty.

Dr. Right. Now, it's interesting when you look at deaths because as you know, some people may have died from COVID without it being apparent. Dr. Dean:Yeah. Dr. Dean:But on the other hand, as you also know, there's reports now of people affected without being infected. So for instance, that chest discomfort that some people had last month, they might have been too afraid to go get evaluated. and the American, as you know, it was recently published that the heart attacks or all the procedures were down 30% in March. Did they go away or were people kind of suffering at home? Yeah. So there is obviously other effects of the pandemic not directly related to infection.

So let's talk about the testing because I think it's confusing for people. I think, I'm reading the New England Journal, today and they're like, well, we shouldn't test people who are asymptomatic. And then you're hearing other experts say massive testing is needed. We need 30, 50 million tests going out. We need to make sure we do aggressive contact tracing, isolation and quarantine of those who are contacted or affected and, you know, away from their homes like they did in China. I mean, it seems draconian and, and Harry Feinberg, who used to be the head of the Institute of Medicine, wrote an article in the New York Times about how to squash the curve, talking about some of these draconian measures. Does this make sense? And given what we know about what we're doing, can we even do this? Because what I've been hearing is that supply chain is such an issue that you want to test everybody, but the reagents are a problem. Medium is a problem. The swabs are a problem. Where do we get this stuff from China? It's not being shipped over here. Even if we wanted to, could we?

So great question. So I think the story of testing is going to be an interesting one in the postmortem. And I think everyone knows the story is that the Chinese released a sequencing of the virus. The Aussies actually, and the Germans got their own samples of live virus. And the Germans weren't able to make the tests that WHO used. The US decided to go after their own test, CDC as you know, and there were some issues there.

That's polite.

I think. But again, there was also this still this kind of concept that this was a traveler's disease, right? That, okay, we were only tracking people that, you know, in China and of course it was already here. And there's no surprise when we talk about why some places are affected others. That really depends on when was the virus introduced in the population, what's your population density, how many of your population have underlying conditions that are going to make them present with severe disease, and when did you put your mitigation strategies in, which to date have been closing schools, closing the bars. If you look at, there's no surprise, New York City, dense population, flights if you track, from Europe and it looks like by sequencing, you probably got the Italian strain, although you got more strains there. On the West Coast, it looks like it was more Asian strains. But the point being is that's a lot of potential propagation and not everyone who gets infected is gonna seek or needs medical attention, but they certainly could spread. And of course, there's no surprises why we're seeing what we're seeing. In Cleveland, as you know, Mark, not a lot of direct flights anywhere.

That's a problem.

But it probably also is has protected us. And we were able, fortunately, because we didn't have big introductions, I think, we followed the wave, we were able to prepare. And then our governor and Dr. Acton put in pretty aggressively some social distancing, just like Governor Cuomo.

Yeah, they were the first among the first in the country, right?

Yeah, I mean, to shut the bars down before St. Patrick's Day, that's a big, you know, for any politician, I mean, I've trained in Chicago, that's a big deal. in school closures. But now where are we? So we're never going to underestimate American ingenuity. I mean, if anything, we might not always do the right thing at first, but once we're challenged, you know, I wouldn't, as you know, as an innovator, you know, we will get there. The testing though, and if you look at there's good white papers by the Rockefeller Institute, there's also a plan going forward, testing is not is necessary but not sufficient. And so, yes, we need testing. We also need a test management system. The other thing I would say is I'm very humbled because I don't know all the presentations of COVID-19. Yes, there is a stereotypic acute lung injury that people focused on cough, fever, shortness of breath with malaise. But as you know now, if you look at the definitions, right? Anesthesia, maybe seizures, diarrhea, stroke. I mean, so without widespread testing, I don't know all the clinical presentations. And what is coming to our help? And you know, Mayor Cuomo, I think, just authorized all the Duane Reade's CVSs. So you're beginning to see testing occurring in outside of healthcare centers, which I think is a good thing. And again, it's not the test itself, it's test management. Now, if we're going back to work, if I'm an employer, The one thing they were all asking for, of course, is they all know how to measure three meters, hand hygiene, clean surfaces, but what they want is if I see, hey, I saw Mark look like he was coughing, we'll send him home, but people are going to want to know, is it COVID or something else? Yeah. Because they don't want to stay home for 14 days. And it's important if I was working with you to know or your household. And to date, as you know, the testing, we're going to get there, but yes, I'm agreement that we probably need it projected 30 million tests to move forward into recovery. Right now, we're at about a million a week.

That's a 30-fold increase and it involves so many logistical steps to make it work, not just getting the test kits and the reagents, but the logistics of getting people to actually do the testing, collect the specimens, the locations, yeah, that's why the drugstore is a great idea.

Well, here's a better one that might be coming, and that's self-administered. so this might become more like a, how could I say that? A pregnancy test. So there is one that's already FDA approved. You stick it, you don't have to stick it all the way back, but it's self-administered put it in, mail it back. We're looking at that for drop off as well. And they're also looking at saliva testing. So you really want to take this out of the physician's hand to order. I think you would call it frictionless testing and test management, like ordering an Uber. Yeah. And as I said, I'm fine with people getting tested because we don't know all the presentations. But then we need a test management system. So if it's positive, then how is someone going to come in and help in terms of the household, as you said, contact trace, treatment for most people is not going to be needed in terms of anything but supportive care.

So you basically have been in the hospital dealing with this. And people who are at home sick, get better, that's okay. But the challenge of this disease is that there's no real approved treatment yet. And we are trying a lot of things. And it's kind of scary when you look at the reports, like the hydroxychloroquine looked great, and then maybe not so much when you start to do randomized trials, or remdesivir seemed to be okay, but the impact wasn't that great, even though Anthony Fauci was touting it. This was sort of a modest improvement in reduction in hospital days and no mortality benefit. And there's other trials going on about cytokine blockers and other immunomodulators. From the perspective of infectious disease doctor who's been doing this for decades, do you see any of these things working? Are there things on the horizon that we don't know about? What is your lay of the land on on the treatment that could help to give people a sense of security to get the country to feel safe to go back out into the world and back to work. Because, you know, the pandemic of the disease is one thing, but the pandemic of fear and the pandemic of the crippling of our economy is a whole nother, which is really, you know, terrifying to me as just a humanitarian to see the kind of economic and social devastation that this is causing.

So great questions. You know, I'll start with, yes, there's been a lot of things thrown at this. I think some of this came out of China first. And, and I think the importance which is emphasized is a pandemic is not, is not an excuse for not good clinical trials. And it's the clinical trials, as you know, that is comparing one treatment versus a control group is where you really are going to get the good Good concepts is, is this good? Is this doing harm? You mentioned the chloroquine azithromycin, and again, there's probably a lot of adverse effects that can affect your rhythm, and there were probably some obviously unintentional mortality without a lot of benefit. But it was good that trials are going on. The remdesivir you mentioned, so there's been a couple trials, one the compassionate use, which means no control arm. The was a buzz this week, I still have not seen the study. I mean, in a peer review, Right. As you mentioned, it looks like it may not have a mortality effect, but we'll see. But again, remdesivir was not designed for corona specifically. As you know, it was more of a Ebola. And again, it's parenteral, meaning it's not a pill. Moving forward, you might have also heard about plasma therapy. So we've been using IVIG for many things. Will this work in a respiratory virus? Not clear. Trial.

Dr. That's where you take them. blood of someone who's been sick, get the antibodies out of it, and then give it to someone who is sick.

To see if it'll help fight the infection. Correct, so it's that passive immunity, right? Like breast milk. Yes, I mean to a degree. So trials are ongoing there, but I do think there's been, I've never seen so much crowdsourcing in terms of research efforts globally, and so a lot on the pipeline. Of course, what we're waiting for is to move out of this, what we'd say pre-protective era, meaning where there is no protection. We don't have herd immunity, we don't have an antiviral, we don't have a vaccine yet until we get one. And that's what you're talking about right now is moving from sheltering in place to putting the toe back in the water for quote unquote a little bit of normalcy. And that's what you're hearing all the governments now rolling out their plans on moving from phase two and how do we go to recovery in a way that is relatively safe and again moving, moving, moving to build that confidence. And that's where the testing becomes important because testing can build confidence. You know, do I have corona or do I have something else? That's what people are going to be thinking. And in three months, four months, we're back in flu season. Yeah. So the test are going to have to distinguish RSV from flu from COVID-19. Yeah. You know, so we're and from that.

Point of view, Well, let's talk about the vaccines because I'm definitely nowhere near any like an expert on this. But I'm sort of paying attention and it seems as though there's a lot of companies out there trying to innovate some fast, some slow, and there's new technologies for developing vaccines that we didn't have before that allow it to be accelerated, which is great. But there's also challenges because vaccines in some cases that we've tried, haven't worked for these kinds of diseases. They sometimes actually make people worse. And then we have this underlying problem, which I think nobody's really talking about, which is that as you get older, vaccines tend to work less well. And if you're obese and overweight, which is 75% of the population, they also don't work as well. So we're holding out this promise of vaccines As if it would be the magic bullet that lets everything go back to normal. But I wonder about that and I'd love to hear your perspective because you're not so convinced that it's like the end of the story.

No, and I think that's very prescient. So let's talk about first of all vaccine development. You're right. So in the old days you would take maybe a heat killed, a capsule and we've got some good products for that. Viruses are a little bit different, but the technologies are very interesting. And some of the more promising, I think there's 100 candidates that are being looked at. Some of the ones that are moving up that you might have heard about are what we call the DNA vaccines. These are the adenovirus vectors. So Oxford, so the Jenner, that's in the UK. Jensen, another big pharma, also has the same platform. Essentially, you're taking adenovirus which can infect us in the upper respiratory tract. This one can't multiply, but it is a live vaccine and you put a little snippet in of coding that codes for hopefully the protective antigen, that little crown on top of the coronavirus. And if it looks good, and again, some of these are moved out of primates into humans arms already, and it does look good, that hopefully, as you said, you'll get not just a response, but a protective response. And most importantly, it's got to be, as you said, scalable. You're talking billions of doses.

Yeah.

And as you said, it's usually a vaccine is not one for all. I mean, there's different populations. And in this case, as you point out, the elderly or some of these people with the biggest conditions, it may not be as immunogenic. in that population. But I do think it is a way then for people to gain confidence. There's equity, there's going to be equitable issues, as you know, in terms of distribution, who gets it, nationalization in terms of who develops it. But I think most of these companies are going in with not trying to make profit on this, but really using it to get us into a protective phase. But your skepticism on, you know, is it really going to change the calculus for those that are actually most at risk for this, I think is a good one.

Yeah, wow. Okay, well I want to shift gears a little bit because there was this age-old debate between Louis Pasteur who discovered the bacterium, the pathogen, and spent his whole life dedicated to showing that these pathogens cause disease. He had a colleague at the same time, Claude Bernard, who talked about the biological terrain, the host in which the pathogen lands, and that that was more important. And rumor has it, I don't know if it's true or not, folklore, that on his deathbed that Louis Pasteur reneged and said, no, no, the host isn't bored. And I noticed that looking at some of the Cleveland Clinic studies that were going on and some of the questions are being asked, You guys were talking about things like zinc and vitamin C and N-acetyl cysteine as therapeutic agents. I was just struck yesterday by a study that came out of China that you might have seen that looked at different regions that had selenium contents that were different in the soil. So selenium we get from the food we eat and if it's not in the soil we don't get it. So in certain parts of China there's almost no selenium. In other parts there's plenty of selenium. And in this one study, they found that those places where there was no selenium, the death rates were five-fold higher, meaning 500% higher, and in those counties where there was adequate selenium, there was a three-fold benefit of cure in those patients. And that's just one nutrient. So I'm wondering how you're thinking about this as an infectious disease doc. in Cleveland Clinic looking at some of these adjunctive therapies that could help to mitigate the effect of the coronavirus and interfere with its replication or its ability to actually cause more serious disease?

Now, another great question. So that is not a matter of expertise, but I do think-- I know a little bit about it, but I'll let you go. No, but I think-- but there are, is, you know, there's social determinants of health. And so one of the things that is very clear is, like many other things, if you have someone zip code, age and race, you know nothing else about that person. There are certain buckets. And so how much of this, I think it gets back to how much of this is biological versus how much of this is other issues that are not. And I think that's going to be interesting situation. I think the other group that's very fascinating to me are the children or the kids. So it's clear that they must be getting infected. Yes, there have been some situations where they probably have even been hospitalized. And I know that there's been some recent reports about maybe an association with Kawasaki's. But by and large, I think- It's.

Like an autoimmune kind of reaction to infection.

Exactly, exactly. So I think, well, we're going to have to, I have not seen transmission studies from kids to adults, but I think we're going to learn a lot more about that. And the other thing that you probably also is, the whole issue about inflammatory. So we talk about inflammatory diseases like coronary artery disease, HIV as an inflammatory, generating, how could I say that, disease. And again, with the obesity, is that also a inflammatory state where something like coronavirus might accelerate that? So I'm not smart enough to actually give you good answers on that. I'm just a guy in the trenches upstairs.

There's a lot, you know, I had a great conversation that's going to be on the podcast with Dr. Dariush Mozaffarian, who's the dean of Tufts School of Nutrition Science and Policy. He was very dubious about supplements. He said he began to look at this with the head of the, there's an immunological nutrition focus there at Tufts. He said they began to discover a lot of the data that existed on how these things could interfere with viral replication. For example, the zinc ionophore goes and binds to the ACE2 receptor that is required for the SARS-CoV-2 to bind to and so sort of can interrupt its replication and things like quercetin or other nutrients, the selenium story we just talked about. And they're talking about how do we sort of begin to actually help our population get healthier so they can become more resilient in the face of the disease and not maybe get as sick. 'Cause the real reason, seems to me that we're in this shutdown, the real reason our economy is tanking is not because of coronavirus, it's because the host, us, our general health as a population is so poor, where only 12% of us are metabolically healthy and the rest to some degree are not. And that's maybe why this is ravaging our society because six out of 10 of us have chronic disease because we have up to 90% of us have some level of nutrient deficiencies even at the RDA level. I just wonder in my mind of strategies around helping support the dietary changes that we need and the nutritional support. How are you guys thinking about this at Cleveland Clinic? Has this come up in any of the conversations?

I think that's all great. But as you know, Mark, it's hard to change behavior at any age. and we don't want to waste the crisis. So the way I'm beginning to think about this in terms of a prevention strategy is, you know, out of H1N1 came cough etiquette. And so I think out of this, we want to move toward what I call enhanced respiratory viral protection. So this might mean that things like masking during flu season is going to become de rigueur, the hand hygiene, the social distancing. If you look at other countries, for instance, Japan, and I know you've traveled all over the world, Wearing cloth masks is actually- It's normal.

I do it all the time.

And they've been good studies there with that in hand hygiene. Of course, shoes are taken off before getting in the house. That actually decreases all respiratory pathogens with the vaccine. So I think as we move forward into the fall, we're talking about school openings, it's certainly possible that maybe we can adopt, as I say, become more Japanese in that regard. and looking to change behaviors. I think the other thing is it becomes important is, okay, we obviously need to get back to work into the workspace, but what's going to change and what has this unmasked about healthcare delivery, education, actually working at home? And if you think about it, you know, we've had a huge uptake like others with Virtual medicine. Yeah. Even how we're communicating now. And do we need medical meetings anymore, you know, where people are flying around? If you look at education, you know, how much of education really needs to be face to face? And this is going to, I think, change a lot of the things that we were doing and hopefully make it more better for the learner or for the patient. In terms of patient-centered delivery of care, I am still going to obviously see patients face-to-face, but why would someone, if I can do things virtually, why go to the parking, wait for me? True. I mean, this is going to change.

How we move forward.

Yeah, it's interesting. It is interesting.

There's, I mean, we at the Center for Functional Medicine at Cleveland Clinic, we're trying to do a lot of virtual visits. We're doing a lot of them. And I remember at the beginning of the year, our CEO got up and said, we want to move to 50% virtual visits within X amount of years or X amount of time. And there are so many legislative and regulatory obstacles to doing this and cross-state practice. And it's all gone out the window. So all of a sudden, you can practice online, you can get reimbursed online, you can practice out of state without the state licensing. It's all the, sort of anachronistic systems that we had in healthcare, which really is one of the most anachronistic industries on the planet. When you look at how we do things, right, compared to other tech things, it's so different. And now all of a sudden, it's like changed overnight, right?

No, I think that's very, I mean, and so this could be threatening, too. I mean, But if you think about it, as you said, people want value, right? I mean, in how they get it, it's kind of like Netflix streaming. And I'm not saying healthcare can all be translated that way, but much of what we do is kind of centered around the physician. And I think on the other side, it's good too, because a lot of docs are okay with flexibility in their schedules, right? As long as I put on a tie and I'm not walking around in my underwear, I can have face-to-face. As long as I can make decisions, wrap my hands around my patients virtually, that's okay. I can still order. And I think there's going to be some very, very interesting things that will occur because of this or potentially could occur. And even our healthcare system now, as you mentioned, I think our platform now, we're going to be able to zoom patients. It's going to be embedded by next week.

Yeah, it's pretty amazing. In my practice in Lenox, we're doing all virtual now. all Zoom. It's just incredible how quickly we just, you know, the world changes. So I want you to take your infectious disease expert, crystal ball, and I want you to look two years ahead and what is the trajectory for us over the next years? What do you expect is going to happen in terms of waxing and waning of the disease, getting back to normal? I know we can't be sure. I know we're guessing, but, and nobody really knows, but given what you understand, because you're really in the belly of the beast right now, what is your intuition about how this is going to unfold and when society is going to be able to get back to some level of normalcy?

So again, these are just indicators. I would submit, so this is a zoonosis, meaning that it came from an animal, a bat most likely the original source, and then some intermediate mammal whether it's a pangolin or something else we don't know. But one thing we know for sure is that the only diseases, infectious diseases we've been able to eradicate in humans are those that only infect humans. So smallpox is the example there. And so it's unlikely, as you said, that coronavirus is going to disappear. Now, the good news is it is a pathogen that also wants to continue going on. It's not killing off all humans in terms of this nature. and as you know, we tend to modify as things go on. There is mutations, it is an RNA virus. The mutations are not as frequent as other RNA viruses such as HIV. So it's also possible that that may happen either more virulent or not. But I would predict, Mark, that we are going to learn to live with this. Our lives will change a little bit in terms of, as we mentioned, in terms of the social distancing, in terms of of how we kind of congregate together or not. I also believe that immunity will, we're going to either get it one of two ways over the next 18 months. Herd immunity, meaning.

Can you explain what that is?

So herd immunity is one of the things, I guess the way I think about it is, it's kind of like playing touch or something. So, you know, you get one person chasing people around, as each person gets touched, they freeze, and over time, you're going to get spread of the touches throughout the whole population. and once you reach a certain level of protection, then the virus has got very little way to go. And so when we think about traditional infectious diseases like chickenpox, polio, we talk about measles, mumps, once the population has developed a lot of immunity, and fortunately for us these days, it's been more through vaccination.

Yeah.

But there's still pockets. I mean, we all saw the measles outbreaks that occurred in unvaccinated populations. in Williamsburg so they can still pop up, but they're not going to globally spread. And I think that will happen here. We will achieve an era of protection. Now, what we will learn from this--.

Before I just want to stay on that herd immunity thing for a minute because before you answer the rest of the question, what I've been hearing is that we don't know if once you get it, that you can't get it again. Are you actually immune once you've had it once? And that is a terrifying question. What is your opinion on that?

It is. So I think with Corona, remember we've been infected. There's four seasonal coronaviruses that occur that cause a common cold, usually in kids in terms of this nature, usually don't cause a lot of severe illness. And this might morph into that over time. And so I think that that's important. Now there have been reports people have heard about people negative and then becoming positive. I think what you're seeing there is that's an artifact of the test. So we do know, and we know this in our own healthcare population that we've studied and will publish, is that you can detect the virus even when you're feeling better through the RT-PCR that the sensitive test we use. But what we saw and what others will see is the level of detection at, say, 10 days after or 14 days after is thousands of times less in terms of quantity, and we associate that again with lack of symptoms with transmissibility. So it's not to say that it's dead virus, although most studies have not cultured coronavirus, which is hard to do after eight days. But there is this level where you can still quote unquote test positive, but you are probably no longer contagious or transmission.

But what I mean is if you have the antibodies and it looks you've already had the infection and like, three months later you get exposed to it again, can you get it again?

I would say that most likely it will probably be attenuated or you'll be protected if we view this like most other respiratory viruses that we talk about, assuming that there's no big mutation.

So, won't hit as hard.

I don't believe so. I believe that, as we talked about, no one has immunity and some of the people getting, everyone obviously can get, the first time you get an infection may be the worst, but I do believe the second time would not be is worse in most patients.

And haven't they done monkey studies like that where they've infected them and then they follow them, let them get better, then try to reinfect them and they're resisting the infection, right?

That's a great question. So at least we have a rhesus model, we have a macaque model for corona, and there's a ferret model. So the ferret also is very susceptible.

Oh, they're so cute.

Yeah, to influenza. So these are good, yeah, whether the protective antibodies or not, the antibodies in the vaccine trials, when they get the vaccine, it looks very protective in terms of these adenovirus vectors that are being developed. But as you said, animals are not humans.

That's sort of good news, I guess. So then getting back to normal, you're saying this is sort of going to be with us for a long time. It may just become more indolent. It may not, you know, cause level of disruption. But I heard that you need like eight hugs a day to be healthy. So, I'm a big hugger. I don't know what's going to happen to society from a sort of emotional point of view.

I think, Mark, that's a great comment.

Is everybody going to become gerbaphobes?

Well, I mean, there might be some that will, but I think what you said is very interesting because in the hospital now, what we're seeing is obviously it's a very lonely literally isolate and experience, whether you have COVID or not, visitors are restricted. And again, I think when you're hearing these testimonies and what we see is, even among people that survive, is that is a very different approach. I too like to, you know, even if I'm not helping a patient, if somebody happens, you want to be able to obviously, condolences to give your, how could I say that, you know, at least to be there, and that's being prevented or at least not being done face to face. And most patients now, they're afraid they're going to die alone. And unfortunately, that has happened, right? And it's very isolating in that regard. There's also stigma. So healthcare workers, they get it. It's, okay, did I do something wrong? Was I not washing my hands? And now I can't help my team. Did I infect someone in my household? And then of course, they still fear, am I going to, end up on a ventilator or things of this nature. So there's a lot of stigma still. And then you go back to work. And if you've had COVID, you know, someone might look at you still a little bit differently. You know, there is stigma. And we have to try to, I'd say eliminate that. My own feeling is, is that probably after 28 days, and we've got data from our own health care providers, but after 28 days of a positive test, your issue about needing to be that Scarlet Letter for infection prevention purposes is probably no longer needed. And obviously we're going to do studies to support that, but that's my gut feeling on that.

So what's happening on the inside of Cleveland Clinic? How is Cleveland Clinic approaching this? And what are you seeing in terms of what's happening in the ICUs? And you've got the best healthcare system in the world. We have a Cleveland Clinic and yet there's still high mortality. I looked at the numbers the other day, it seemed to mirror New York about 14% once you get in the ICU. That's a lot. So how is Cleveland Clinic approaching this as an organization that we can learn from?

Well, I think everyone's got the playbook. I think, as I said, we activated the command center early in January, and that's a good way that kind of command and control to get stakeholders at the table and kind of to be able to activate, to think about We've obviously learned and communicate with people in Italy and other places to see what's going on. We do have obviously tentacles in China as well. And once it became clear that it's coming, then it's preparing. And the first mission was we didn't want to be faced with that moral dilemma of deciding who goes on a ventilator and who doesn't. And so once that became clear, it became making sure we have excess capacity for ventilators. And some of the things I think the system of the ICUs did was amazing. I mean, in terms of that type of preparation and big things, right? Staff, stuff, and space. And I think that's how we attack all these problems. And that was done amazingly. And also the innovation. So you see this, right? Where the ventilators, the IVs are out of the room to prevent touches. When I rounded with the ICU team, I could round from my desk with the, you know, in terms of watching the patient rounding. So that actually was very innovative in terms of how we approach the patients and testing, you know, all these tests that we do all of a sudden became very parsimonious and outcomes were very good. So if we look at acute, what we say acute respiratory distress syndrome, ARDS, a very bad outcome no matter what the cause is. Our mortality overall, and again, the state is being looked at was no worse for any other ARDS. And I think that that's important. When you see high mortality rates, it's not because there's not smart people. It's usually that the ICU is being overwhelmed with clinical cases. You just overwhelm your system to deliver the care.

Yeah, and thank God that, you know, Cleveland Clinic is so well organized. It has such a collaborative structure. and thank God the governor of Ohio shut things down early. So I think, you know, they turned the entire new health care education campus into a hospital, but I imagine it's empty because... Yeah, no, hopefully it will.

Never be used, but I guess better to be prepared, yes.

Yeah, and I think there's a lot of foresight and I think, you know, Cleveland Clinic is such a leader in thinking about all this. I wonder, How do you think that medicine is going to be different after this?

I mean, as I said, I think there's going to be a lot of changes. And if I was King or something, where I'd be investing in is I think that 5G and internet should be a free utility for all Americans. And I say that because why should there be any more snow days? why should patients who, you know, whose transportation couldn't get here, why should that result in a missed appointment? Yeah. In terms of information and sharing, right? I mean, for the person that needs delivery of medicines or food or things of this nature. And again, this did not affect all Americans equally, as you know, Mark. I mean, people like you and I are fairly, I think, blessed in terms of not just in health but also resources. a paycheck for us to work at home, you know, is a minor inconvenience. There are many people that don't have that luxury that have to be out there and don't have a space where they could isolate or quarantine. So I think this also has unmasked a lot of opportunities for improvement, as we talked about, and that's your big important in terms of wellness and secondary wellness. and I think it also has made us more reflective in terms of hopefully spending some reflective time alone and what's important in so many ways. It matters. You know, you're a hugger. I mean, yes, I learned to make sure you tell the people you love, you love them. My parents are, my dad's close to 90, my mom 88. They're in well health in Michigan, but again, it makes you realize what's important. Yeah.

So how have things changed for you personally in the middle of all this?

So I still say, I'm kind of, you know, it's been kind of an interesting cadence in terms of, for me personally, I've seen amazing things in terms of watching the leadership, in terms of decision making. I think, as you know as a leader, I think we try to do the things about, right, you want to be consistent, you want to have hope, stability, but most important, trust. and the ability to take new information and change your mind. And we're very blessed, I think also, Dr. Mihaljevich has made everyone whole. That is to say, everyone's still getting a paycheck, there's been no cuts, no furloughs. And I think that has gone a long way also in terms of activation and having people ready to kind of not ask what the clinic can do for them, but what can we do for our organization, for our patients?

That's amazing because Mayo Clinic, I heard, cut their salaries by 20% and the neighboring, I think, University Hospital did the same thing. So I think it's a testament to the clinic and to how much it cares for the people who work there. In our Cleveland Clinic, we don't call the people who work there employees, we call them caregivers. Whether you're, you know, someone who's doing sanitation or whether you're a doctor, you're a caregiver. and I think that is a really important thing in terms of how we value the people who work there.

Dr. I know, I mean, as you have my administrator, but I think— I still.

Feel guilty about that. Dr. Gordon is talking about is he let us take his top administrator to help run our Center for Functional Medicine, and he did it with grace and humor, and it has been the best thing for us because she's probably one of the most valuable employees at Cleveland Clinic.

I'll give a shout out to Tani. But I think, we know that our best assets walk on two legs and that's always true. It's not the bricks and mortar. But I do think, yes, there's going to be, even if you come to the clinic now, it doesn't feel the same as a patient point of view or a provider. I mean, in terms of the face mask, the thermal scanning, the kind of no visitors, preoperative COVID testing, but so we'll see what happens. But I think there's a lot of opportunity here to reassess how we deliver our services in a way that's better not just for the patients, but also the providers.

Yeah, it's really an unusual time and I think however hard it is right now, I think it's time for us to stop, reflect and look at how we have been living and how we have been doing things and see if there's a different way that actually works better for us that is good. And I've been in some inspired by the sort of collective action of humanity in this moment to face a common threat, which, you know, in an era of divisiveness and conflict and, you know, racial and ethnic and political and even nutritional conflict, I just see humanity coming together to face a common threat together and do things that I never thought would be possible. that people would voluntarily, you know, stay at home to protect not only themselves, but to protect their communities, take care of the healthcare system, you know, seeing the people in New York on the balconies, you know, cheering and singing to all the healthcare workers as they walk to work. I mean, I just, it's just been a moment where humanity has come back. And I feel like that is a good thing. And I think if we can carry that forward in both our own lives and in how we think about health and healthcare, it's going to be a good thing.

Well, thank you for that, yes.

Yeah, so Steve, any final words on what we should be thinking about, expecting, and knowing about this pandemic?

No, I do think that hopefully the worst, quote unquote, that initial clinical burden now I think is we've taken, there's been obviously, as you know, Mark, a lot of mortality, I mean 50,000 lives at least, that's, you know, I mean that can't be understated in terms of this. And as we also talked about, a lot of the loneliness that might have been associated with that and some morbidity. But I do think, I think we're gonna learn from this. I think globally, yes, this is gonna strengthen even more of the global healthcare system in terms of early warning, collaboration, cooperation. This is another reminder that most of the new and emerging infectious diseases are zoonoses. that is to say diseases of animals that kind of come to man. And a lot of that is about a lot of the things that we do. Obviously, it's a global world. So I think that's another aspect. But I also think, like you, I think that it's time for self-reflection and hopefully there'll be a lot of good out of this as we kind of move forward. And as Americans, I think for the homeland, I would never underestimate America. I think our grit and our innovation, I think we'll pull through this stronger than before.

I thank you for that. I thank you for being here out there in the hospital, on the front lines, doing the hard work of trying to figure out how to take care of these patients, how to take care of each other, and get through this in one piece. So I really appreciate you and what you're doing.

Well, thank you so much, Mark. It's been a pleasure.

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