New Pandemic Strategy Needed: Dr. Zeke Emanuel & Former Biden COVID Team Members Calling For New Approach

Dr. Zeke Emanuel

[Music]
Marianne O’Hare: Welcome to Conversations on Health Care . This week we welcome Dr.
Zeke Emanuel, Co Author of a New Piece in the Journal of the
American Medical Association , written along with other former
members of the Biden Administration's COVI D team on call for a new
strategy to combat COVID. Now here's Mark Masselli and Margaret
Flinter.

Mark Masselli: Our guest is a respected physician, health advisor and author. It's his
latest writing that's making news. He was a member of the Biden
COVID - 1 9 Advisory Team . But now he is and his co authors have gone
public with a call for a new national strategy to deal with the
pandemic.

Margaret Flinter: Dr. Zeke Emanuel and his colleagues just published their thoughts in
the Journal of the American Medical Association , and it's been called
The Striking Critique . But we want to focus on his opinions as they
rela te to the public health sector.

Mark Masselli: Dr. Emanuel, good to see you again . We'll get to the specifics very
quickly. But first, what has been the reaction to your perspective ? It's
been reported that the Biden Administration has ignored the advice.

Dr. Zeke Emanuel: Well, first of all, I would correct the idea that this is a critique . We did
not write this as a critique . We wrote this trying to be helpful. You
know, the Biden Administration came in , in 2021, January 2021, with
a good strategic plan, which they executed that. But as the virus
evolves and mutates, you know, our strategic plan has to be updated ,
and what we were suggesting is an upd ated strategic plan with an
updated goal. The second thing I would say is, whoever's been letting
out the rumor that they're – the Biden Administration is hostile to this
doesn't know what they're talking about , simply false.

Margaret Flinter: Well, thank you for that , and I think it's always important to
reconsider it. Let me – let me say that, from the perspective of a
reader, really appreciated the comments that you made and the
recognition that time moves on and things change in a pandemic, and
they cha nge pretty quickly, sometimes, tell us a little bit about some
of the key recommendations then that you've moved forward with.
There's a lot of them we'd love to talk about. But I'd like to
particularly hear from you about this idea, which doesn't sound
en tirely new, that our data infrastructure for dealing with a pandemic
like this needs a serious upgrade and reboot , who's going to take that
on? And where do you think we are with making that happen?

Dr. Zeke Emanuel: Well, first of all, let me say that I t hink one of the most important
things that we do in the set of articles is to emphasize that the idea
that we're going to eradicate the Coronavirus here is just false. And
we're not going to eradicate with our vaccines, and we're not going to

Dr. Zeke Emanuel

get rid of it . Like many other viruses and respiratory viruses, whether
it's Rhino Virus or RSV or Influenza , we're going to live with
Coronavirus. And the real challenge is then to get us to a low state,
we're not ready for the endemic state yet, get us to a low state of
cases, hospitalizations and deaths, and then live w ith it in a new kind
of normal.

Second, that means we need to change our frame . Our frame can't be
just to measure the number of cases from COVID or the number of
deaths from COVID. We need a new meas ure which the CDC hasn't
used yet, but which needs to be developed going forward, which is
total viral illness burden. How many people get viral illnesses ? How
many are hospitalized every week for ? How many people die because
of this cumulative respiratory viral illnesses that represent all the
viruses that we confront ? And that we say there's got to be a new
threshold, we need to think of that like a bad year of influenza, or
maybe a littl e higher, something like 70,000 or maybe a little more
deaths per ye ar. So that's the frame. That's what normal would look
like. That's, you know, there's still plenty of things we can do to
decrease the mortality and morbidity of those illnesses. But it's not an
emergency. It's not a pandemic, and it's certainly not 1 , 500 people
dying a day, which is what we have from COVID today. So that's
where we should be going and I thin k that's an important reframing,
and when we get to the endemic state, there aren't big surges. We're
not getting a million new cases a day or 1 , 500 d eaths. We can go
about normal life , dine in doors, not have to wear a mask. But to get
there , it's going to require a lot of things. One thing is we need better
information on which to act , and that was the whole point of the idea
of the proposal r egarding a data infrastructure.

Right now a lot of what the CDC relies on, frankly, or more projections
and modeling based upon limited data acquisition and not just for
COVID but for lots of illnesses. I mean, they don't even measure RSV.
We need a whole new fram ework , and the system, I just got off the
call with a senator's aide who was interested in that data
infrastructure, what would it take? Should it be at the CDC? Should it
not ? We need a new whole new government arrangement so that
automatically health sys tem , physician offices, labs, download data
every day, and we get a public display , right , non identifiable data
about where we're having outbreaks, what kind of viral illnesses are
happening, how many people are ending up in the hospital, how
many people are dying, we really need that data infrastructure. Israel
can have it, Britain can have it, we can too. I don't think it should be
housed at the CDC for a whole series of reasons. But, you know, in the
modern age, with Microsoft and Google and Amazon and Facebook
having these data capacities, and many, many other small startups,
we really need to be able to do that .

Dr. Zeke Emanuel

Mark Masselli: You know, to be able to do that, it seems to be the one keyword is
that we need leadership. And I go back to our conversation w e had
back in July of 2020, where you were really focused in on what we're
lacking is leadership, and that the new – next administration was
probably needed a year to sort of unravel all the things that didn't get
done. So I want to get back to this issue of leadership , and it's not –
it's not personal about the Biden Administration or not, but you said
maybe CDC is, is not the best carrier of the torch? Who really will do
that? And do – you just mentioned some of the corporate institutions,
do you think yo u're going to see some of this leadership evolve out of
our corporate citizens, the larger companies and tech companies as
well?

Dr. Zeke Emanuel: First, I don't think that this kind of data infrastructure is not in the
wheelhouse of CDC. Their tradition, their culture has not been collect
real time data, make sure that data is accurate . Their culture has been
quite different, which is get a little representative data, and let's then
extrapolate and model , and I think that's the wrong place to go.
There's n o substitute for real data , and I don't think their culture is
going to be the right culture. The point of identifying these
corporations that have done, you know, have real time great data
collection , I mean, their 's real time, it's not like every evening , they
get a download, it's like every second or millisecond they know where
you are, which store you're walking into , etc. and they can
automatically track it. There's not a person tracking it, it's done by
their computers.

I don't think they're going to step up and do this, I don't think they
should step up and do this. People don't trust them, but a public
private partnership that uses their tech capacity and their operations
capacity, combined with a public health approach, including things
like non - id entifiable information, two - factor authentication, so people
don't use – my data doesn't go out without me approving it. I think
those things are important , and maybe we do need a public private
partnership where the public sector guarantees certain things . We're
not selling these data, we're not exploiting them for commercial
benefit, etc. And the private sector, as it does, in many cases, helps
st
build the infrastructure and make sure that it's first u p to 21 century
standards and second, easily updatable as technology progresses.

Margaret Flinter: Well, there are clearly a lot of domains that we need to live in, as this
pandemic continues , and hopefully, as we begin to suppress it. Part of
it's up in the Cloud with data, data infrastructure, and part of i t is
boots on the ground , and I want to pick up a little bit on some of your
comments about the boots on the ground piece. You've talked about
the need for much more of a public health workforce, probably at all
levels of that public – public health workfo rce. You've talked about
community health workers, which we're so glad to hear you call that

Dr. Zeke Emanuel

out. You've also talked about very specific groups like our school
nurses, in schools , and we would add to that the school - based health
centers which is also a nat ional system with nurse practitioners and
other healthcare staff on the ground in the schools. How are we going
to move that forward? What can your audience or our audience do to
please support this call and how do we move from this as a good idea
to somet hing that really moves us forward for whatever the next
challenges are to come in public health?

Dr. Zeke Emanuel: So one of the things that I've been calling for , for a long time is data is
really important , data alone doesn't [ Audio Cut 00:10:07], and on e of
the reasons I think that many of the tech companies have failed when
they come in the healthcare is that they don't realize you need what,
you know, we in the medical, in effect [inaudible 00:10:17] right, to
get the information, and then you got to d o something with it and
then do something , is not, you know, about the healthcare systems,
you know, they can send you an , I mean, the tech companies can send
you an app, but that's not doing something. But doing something in
healthcare requires peopl e int eracting with other people. They can
interact virtually or personally, but they have to interact , and the best
way to interact , the first level of interaction should be community
healthcare workers who are responsible for a defined area, know the
people in the area and can help . They can help on infectious disease
outbreaks like COVID, but they can need to be able to help on other
things. When we have severe heat waves or severe cold snap s ,
checking in on people who are homebound, making sure meals are
deli vered to them, making sure when new babies are born that things
are going well with the mother. There are lots of things that a public
health workforce like community healthcare can do, and it's
extremely – would be extremely beneficial in oh so many healt hcare
ways.

I think that's a kind of effect around, a public health effect around
that . We need to begin developing , I emphasize , school nurses, for a
whole series of reasons. Firstly, I think we've paid enough attention to
our kids and in particular, our lessons, their health and mental health.
And school nurses can be very --- we gather these students together,
they can be very efficacious in terms of getting out intervention.
Finally, if you got viral respiratory illnesses, one of the complications is
it tends to exacerbate things like asthma, and other things that can
compromise children's learning if they have to leave school to get
treatment, and then stay out. Now, if they went to a nurse, the nurse
could handle either him or herself or through teleme dicine with a
physician or nurse practitioner, treating these kids think about
probably be easily handled in a short period of time and go back to
the classroom and not lose those very, very important learning
opportunities.

Dr. Zeke Emanuel

Mark Masselli: Well, I'm very e xcited , both the idea of a community health worker
workforce, I'm not sure if you're thinking modeling that up on an
AmeriCorps Program where we train people because we have a sort
of a disparate community health worker network across the country.
And cert ainly, you're focusing on schools were so insightful and right
to the point, but you also write about the need for an electronic
vaccine certificate platform and you support vaccine mandates. Is it
best to have students in school even if they're not vaccin ated?

Dr. Zeke Emanuel: Look, I mean, I think this is a no brainer . We require all sorts of
vaccines to get into school, and COVID is just another one of them.
I've also written a long time ago, I can't even remember, you know,
probably four or five years ago, calling for the fact that we should
require flu vaccines for kids. We have a lo t of kids who unfortunately
die of flu , and we should, you know, flu vaccine is far from perfect, it's
definitely going to get better over the years to come. I think
mandat ing those kind of vaccines is really, really helpful for the
country.

Margaret Flinter: I was very happy to see your call out of the numbers of people who
died from flu every year . It's always made me a little crazy that we
don't emphasize that on a daily basis throughout flu season the way
we've been emphasizing COVID and having knows those are pretty,
pretty impressive figures. But I want to turn to this issue of treatment ,
you kno w, I characterize the pandemic a s the shock and awe of the
first wave and g etting up testing and then the gratitude and relief that
we had a vaccine. But we also now have some treatments , and I know
your colleague on the Biden COVID Transition Board, Dr. Kessler is
going to have to decide soon if the government should still provi de
the three monoclonal antibody treatments that are authorized for
early stage COVID. I know there's some research that shows t w o of
them may be ineffective against Omicron , which we think is the
dominant variant, what do you advi s e them to do? What would your
best advice be?

Dr. Zeke Emanuel: Well, I don't have all the latest data and I don't want to second guess,
Dr. Kessler . But it seems to me you got two ineffective monoclonal
antibodies. I don't think there's any doubt that Omicron is the
dominant str ain of COVID going around, and there are two -- two of
the antibodies are ineffective , and by the way, that was totally
predictable . It was heavy investment that the NIH made in developing
monoclonal so encouraging monoclonal, we knew what’s going to be
a problem . Way back in January 2021 wh ile we were on the transition
team, several of us met with some of these monoclonal makers, and
they were guaranteeing, oh, whatever the variant is, ours is going to
work, it's – we knew, you know, viruses evade the trea tments that are
directed at them, and they mutate, and it was predictable, these
monoclonal s will stop working . I think it's quite clear that providing

Dr. Zeke Emanuel

one that works, Vir, I thi nk is what we ought to be doing. You
shouldn't provide ineffective treatments, that is called waste, and
they're very expensive.

Well, by the way, one of the things I worry about, and I think we say
this in the pieces, you've got oral antivirals, that's great. It's a huge
breakthrough. But our experience with HIV and many, many oth er
viruses is you use monotherapy, you're going to get resistance quite
quickly, you need multi - drug therapy , and so we're going to need
many of these oral antivirals and we should be turbocharging our
r esearch and development on this. There are a lot of g ood promising
ones in the wings. And then we need to combine them and test the
combination to ensure that -- reduce the risk that we will have
resistance to a combination of drugs. That seems to me clearly the
strategic approach that we need to take. Unfor tunate, I mean, I have
to say, I'm somewhat more than somewhat disappointed in the NIH
being slow to get to that point .

Mark Masselli: You know, just trying to think about the force multiplier of money
that will be needed to execute on this strategic plan. I'm wondering if
you have a sense, do we have enough reso urces right now to
undertake it, if we don't, what will be needed? And then do you think
there's going to be support in Congress, which is having so much
difficulty getting things back past like, bu ild back better, and coming
to any consensus? What's your sense of the size of the resources that
might be needed, and whether or not Congress is going to be able to
push that through?

Dr. Zeke Emanuel: Mark , first , I haven't done a cost estimate of these things , and what
we have suggested is not a final strategic plan, it is part of a strategic
plan. Second, let's keep our eye on the ball of how much COVID has
cost the country, trillions of dollars, trillions of dollars, okay . If we're
spending a few 100 b illion to avoid trillions of losses , last I look ed ,
that's called a good investment. And we got to stop thinking, have to
stop thinking of this as spending money instead of investing money.
This is an investment, you have a data infrastructure, data is val uable.
We all know data is gold, right? It's valuable, even if the government's
not monetizing it, other people are going to get insights that are going
to save money , and that's cri tical. So, you know, you ask me about,
you know, various things that will cost money. Yeah, they're going to
cost money. But, you know, an investment costs money to o as long as
it produces return, and if we can avoid serious lockdowns, right, if we
can get to endemic COVID faster , that's going to save us, you know,
economic, it' s going to reduce the economic losses, and that's like
saving money. And so we have to see a different framework than oh
this is just the government spending money, some spending is just
spending, a lot of spending is investment , and we need to
differentia te those two. One of the key things about this spending on

Dr. Zeke Emanuel

the data infrastructure , community healthcare workers is they return
money by preventing outbreaks, preventing problem s that cost more
down the line.

Of course, we need a rigorous analysis of how much this is going to
cost and give a good estimate. But, you know, if you improve the
indoor air filtration systems and air handling systems in buildings,
right, we're going to have fewer viral infections, that actually is
valuable from an absenteeis m and presenteeism perspective.

Mark Masselli: One quick one because you wrote a book about great healthcare
systems around the globe , and we've had David Gergen on who's
always telling reminded us, Americans have to find American
solutions. Tell me what you th ink the best country is in the globe in
terms of dealing with a COVID pandemic and where we might stand
against them.

Dr. Zeke Emanuel: Taiwan.

Mark Masselli: Hands down.

Dr. Zeke Emanuel: I don't think there's a discussion about it.

Mark Masselli: Yeah.

M argaret Flinter: Yeah. Certainly.

Mark Masselli: It's their fear of SARS.

Dr. Zeke Emanuel: I mean, they had – they had , look, they're not, not 100 miles off the
coast of China. They have a million citizens working in China, right ? By
all rights, they shou ld have been overrun with COVID, almost nothing,
right? Why did they do so well ? Well, they had a data infrastructure,
they know when people go to the doctor, the day they go to the
doctor, they know wha t they're going for. They cross that information
with their – the information of people coming back from China and
Wuhan, and they immediately identified them , tested them began to
isolate them. Second, you had a – you have a country that trust its
healthcare and government, and therefore what the Minister o f
Hea lth said, p eople trusted, they follow ed , right . You don't have to
have half the people say we're not getting vaccinated and many
people not wearing masks, etc, etc. All of that makes a big difference.
Very, very good response. I don't know if they're the best in the
world, to be honest .

Mark Masselli: But they’re good.

Dr. Zeke Emanuel: It's a really good model , and if we were Taiwan, i t would have been a
lot better.

Mark Masselli: Yeah.

Dr. Zeke Emanuel

Margaret Flinter: And a really good healthcare system too.

Dr. Ze ke Emanuel: Yes, it's very cheap, very cheap. Now, there are many problems, and
we probably wouldn't change ours for theirs , but , you know, people
who intersect with the Taiwanese healthcare system, they sing its
praises. It's true. Hospitals are kind of l ike graduate dorms, they're
very bare bones. But on the other hand, and doctors ’ work, you know,
you don't get 15 minutes with a doctor. They're like a factory. There
are lots of problems. But quality is very good and people are very
satisfied , and the cos ts are a third of our costs.

Mark Masselli: Say one last thing , what do you think about this Pan - COVID vaccine,
any sense, they were going to the Walter Reed Hospital .

Dr. Zeke Emanuel: We’re looking at it and I look, I'm not the expert on that. I've talke d to
people who are holding meetings and trying to get the latest on
where we are in that development. It's certainly something lots of
people are looking at , and if we can do it, we will do it. I'm sure. I
think that's an area we, the U . S . obviously excel s at , and I think, you
know, pushing it forward is goin g to be critical going forward.

Margaret Flinter: Dr. Emanuel, we really appreciate you joining us for this discussion.
Dr. Emanuel is the Vice Provost for Global Initiatives at the Perelman
School of Medicine at the University of Pennsylvania, his website
www.ezekielemanuel.com and you can find him on Twitter at Zeke
Emanuel. Dr. Emanuel, thank you so much for joining us on
Conversations on Health Care toda y , for your insights and for your
many decades of service to the country and health care.

Dr. Zeke Emanuel: Take care.

Mark Masselli: Alrighty, ciao .

Margaret Flinter: Nice to talk to you.

Dr. Zeke Emanuel: Bye, bye.