Pandemic: Dr. Zeke Emanuel on the Timeline for America Returning to ‘Normal’

Dr. Zeke Emanuel

[ Music ]

Female : Welcome to Conversations on Health Care with Mark Masselli and
Margaret Flinter, a show where we speak to the top thought leaders
in health innovation, health policy, care delivery, and the great minds
who are shaping the hea lthcare of the future.

This week Mark and Margaret speak with Dr. Zeke Emanuel, Vice
Provost for Global Initiatives and Chair of the Department of the
Medical Ethics at the University of Pennsylvania. A former advisor to
the Office of Management Budget, he advised the Ob ama
A dministration on health reforms. He talks about his latest book ,
Which Country Has the World’s Best Health Care?, and how America
is failing at containing the pandemic.

Lori Robertson also checks in, the Managing Editor of F act C heck.org
looks at misst atements spoken about health policy in the public
domain, separating the fake from the facts . We end with a bright idea
that's improving health and well being in everyday lives. If you have
comments, please e - mail us at [email protected] or find us on
Facebook , Twitter , or wherever you listen to podcast s . You can also
hear us by asking Alexa to play the program Conversations on Health
Care . Now stay tuned for our interview with Dr. Zeke Emanuel here on
Conversations on Health Care.

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Mark Masselli: We're speaking today with Dr. Zeke Emanuel, Vice Provost for Global
Initiatives and Chair of the Department of Medical Ethics at the
University of Pennsylvania. An oncologist and bioethicist Dr. Emanuel
is the founde r of the Institute for Bioethics at the National Institutes
of Health. He served for two years as an advisor to the White House
Office of Management and Budg et in the Obama A dministration.

Margaret Flinter: A prolific writer, Dr. Emanuel has published over 300 peer reviewed
articles and 14 books, including his latest, Which Country Has the
World's Best Health Ca re ?, and previously with this great title,
Reinventing American Health Care, how the Affordable Care Act will
improve our terribly complex blatantly unjust outrageously expensive
grossly inefficient error prone system. Dr. Emanuel, welcome back to
Conversations on Health Care.

Dr. Zeke Emanuel: It's wonderful to be here , thank you for having me.

Mark Masselli: Well, it's great to see you. You joined u s last in 2013, which was a
time of hope and transformation. I kind of think anyti me prior to this
was a time of hope and transformation , but it was in the midst of the
health reform movement, which was fully underway. Now we are
seven years later and we'r e in the world pandemic and it's really
raging across a very divided America. Our death tolls are rising. We

Dr. Zeke Emanuel

have a national government that really seems unwilling to adequately
address the pandemic. I'm wondering if you could share with our
listeners, wha t your diagnosis of the problem we face is, and what's
your prescription to get our country back to a safer space till we get to
a vaccine.

Dr. Zeke Emanuel: It's really leadership. We have not had the leadership that we should
in Washington . We needed lea dership that would look at every
component along the way , a dequate PPE, adequate hospital beds ,
adequate ventilators, creating a vaccine, supply chains for testing,
cre ating a army of contact tracers . R ight now we need to be getting
ready for actually depl oying that is distributing and administering
vaccines, no preparation done. We have had a lack of firm leadership.
The President has been obsessed by the economy, the stock index,
the Dow Jones, but those are not going to respond well unless we
actually ha ve a response to COVID. I mean, people tell you in polling
over and over again and also by their behavior, yes they're cooped up ,
yes the monotony is killing them . B ut they also are not going to fully
engage in economic activity, sending their kids to scho ol, going back
to the office, unless they feel safe . Right now it ’s hard to feel safe in
almost every state in the country .

Margaret Flinter: Well Dr. Emanuel, we are concerned on so many fronts, and certainly
one of them has been the administration's seem ing attempts to
discredit the nation's most hig hly regarded infectious disease e xperts
like Dr. Fauci who I know you've had a long relationship with . But
more recently a really alarming thing is the White House shutting
down the CDC ’s COVID - 19 data collect ion infrastructure and funneling
this critically important public health data, kind of a way from how it
had been done into a new and somewhat on the side way of doing it.
Can you comment on that for us?

Dr. Zeke Emanuel: Yeah, I think they're trying to hi de data they don't like, and I think it's
terrible , you cannot respond to a crisis without information . They are
trying to prevent people from getting good looks at how the
pandemic is unfolding, who it's affecting, how many people are being
hospitalized b ecause of it , how much the hospitals are handling, how
many people are actually dying, their race, their socioeconomic
status, it is appalling. It is so brazen that it's just unbelievable. It's
certainly unethical and it's also bad for actually responding for the
country. What I really worry about is say, th at President Trump loses
and you have a new administration, reconstituting all this
infrastructure that's necessary to respond effectively is going to be
very hard. It will take lots and lots of focus.

M ark Masselli: Well, let me pull a thread on that a little because there's really no
shortage of good information and how best to m itigate the spread of
the virus. But the information seems to be undermined at every turn

Dr. Zeke Emanuel

of the corner. In Georgia, for insta nce, the governor is actually suing
municipalities that have issued universal mask orders for people
congregating in public . T he misinformation campaign has added really
a lot of confusion across much of the country on the best protocols to
follow. Thanks to you and your colleagues, you've created an easy to
read guide . I printed it out for my family this weekend showing the
risk factors for engaging in certain behaviors. I'm wondering if you
could tell me more about the COVID - 19 risk index that you and you r
team have produced, didn't see going to schools on that list, and your
thoughts on that as well.

Dr. Zeke Emanuel: Fi rst of all, on going to school we have another risk index that we're
going to bring out that's really school specific for exactly that re ason.
It was just too complicated , and there are too many variables about
what schools need to adopt, but we're very responsive . We want to
get kids back in school, but that has to be done safely so we delineate
the safety. L iterally, the graphic designer is putting it into an
infographic now . Partially , I just kept getting calls, should I fly on a
plane ? W hat if I drive ? C an we go to a restaurant ? G etting all these
questions, so we thought that it would be wise to create a risk index,
looking at various ri sk factors and put it on a scale from safe to very
high risk , and it’s a five point scale.

There's not data on each decision we make, but we've used a number
of criteria , four in particular . Does it occur in an enclosed space ? D oes
it involve crowds of peo ple that you can't really physically distance
from ? D oes it have prolonged time ? A re you there for an extended
period of time , b ecause we know that increases transmission ? D oes it
involve forced exhalations, that is , sneezing, coughing, yelling or
singing that is likely to put a lot of virus into the air and therefore
increase your risk of contracting it ? On the basis of those four things
we look at dining indoor restaurant, compared to playing golf
outdoors on an open course. Yes , golf is going to be much safer than
dining in an indoor restaurant . Working in an office is going to be less
safe than walking out on a trail or playing tennis. That's the kind of
metrics we use .

We ’re against singing in a choir, bad idea, because people are
constantly exhaling fr om deep inside, it's over a prolonged period of
time. It's already been translated into Hindi , into Spanish , into French ,
into Portuguese because I think the world literally , not just the United
States, the world is looking for this very clear information about how
risky different activities are.

Mark Masselli: I should know my wife's cho ir’s group is doing it by Zoom .

Dr. Zeke Emanuel: There you go. That’s very important. We recommend that.

Margaret Flinter: It ’s a strange world when singing is a risk fact or. Dr. Emanuel , you call

Dr. Zeke Emanuel

yourself an optimistic person but also a realist, and you recently
wrote that your best guess for when we return to normal allowing for
such things as i mproved treatments universal mask wearing and a
vaccine is November 2021 , I'm going to repeat that , not November
2020, but November 2021. We could reach a quarter of a million
Americans dead from COVID - 19 before the end of this year . How did
you get at that assessment and what's going to need to happen to get
us to what could even b e considered something approaching normal
life again?

Dr. Zeke Emanuel: Well, various parts of normal life are going to come back on line at
various points. If you say really getting to normal, it's going to require
a vaccine that, call it 70% of people ha ve and it's effective. If you just
say, all right, December/ January is the earliest we're going to get a
vaccin e that really people respond to . T hen as I mentioned , you have
to deploy it , y ou have to manufacture , y ou have to put it in vile vial,
so you hav e to get it out to where you can administer . You have to
put it in people's arms. A lot of people are suspecting we're going to
need two doses so you put it in their arms one day and then the next
day and then they're going to have to build up antibodies. Just play it
out.

The first people who get it are health care workers, grocery workers,
first responders like police, etc, then you're going to get high risk
people . Then you get out to us, average everyday people who aren't
necessarily first responders , t hat’s really going to -- you're talking
about the fall or the end of the year. That's how I came to November
21. Could it be January 2022 ? Okay, but it's in that range. It's not as
you say before the end of 2020 , and it's not even spring 2021 because
we're just not going to have the capacity. We're talking about
immunizing 250 million people twice. Just think of the logistics of that.
You’ve got to give it to people. You've got to track people. You've got
to figure out who's having an adverse reaction. That 's a massive
effort.

Mark Masselli: We're speaking today with Dr. Zeke Emanuel, Vice Provost for Global
Initiatives , and the Chair of the Department of the Medical Ethics at
the University of Pennsylvania. He served as an adviser to the Obama
A dministratio n on crafting the Affordable Care Act. He ’s also an
author of hundreds of papers and 14 books, including his latest,
Which Country Has the World's Best Health Care ? Dr. Emanuel , I really
want to talk a little bit about the pillars of this global pandemic s tory .
America is the only industrialized nation in the world lacking some
form of universal health care. COVID - 19 has clearly laid bare the
gaping holes in our health care system.

In y our latest book, you examine countries that have far more
efficient and effective and sometimes elegant health systems

Dr. Zeke Emanuel

compared to the US. I wonder if you could share with our listeners
what makes them work , how have those health systems contributed
to their own COVID - 19 outcomes, and what might we l earn from
them.

Dr. Zeke Em anuel: I have to say, the response in this phase, which is really the acute
phase still of COVID - 19 is mostly about public health. It's about getting
people to physically distance , to wear masks , to do hand hygiene. It's
really not about the health care sy stem. When they get sick , yes
they're in the health care system and that's different. But the
adequacy of our response has not been about the health care system
l argely, it's been mostly about public health. I think as you point out, it
show n some of the g reat disparities and inefficiencies in the way
we're organized, especially about collecting data and the coordination
that the CDC can do.

Having said that, I think the standout country probably is Taiwan , t hey
were close to China , t hey have a million peop le working in China , and
yet they've had fewer than 500 cases and seven deaths in the whole
country. How do they do it? Well, the first thing is they were
suspicious of China because of SARS back in 2003/ 2004. That led them
to really prepare and to stock p ile things like PPE. The second thing is
they have a mask wearing culture , so unlike us, they don't have to
push people to wear mask. People do wear masks because they think
it will protect them from illnesses like COVID. The third thing is they
have this health card. E verybody in the country has a health card
when they go to the doctor, the card is swiped. The Ministry of Health
knows why they're going to the doctor . T hen they pay the doctor.
They know what the doctor ha s done for them. It allowed them to
rapidly identify people who had been to China so that those people
could be tested for COVID and isolated. It also allowed them to
identify people who had respiratory symptoms, cough, shortness of
breath, other problems that would suggest if they might be a t high
risk for getting COVID , and they also could be tested for COVID . This
allowed them to very rapidly identify at risk people, and test them
and isolate them. That's been a big plus .

G ermany , if you look at Germany, Germany has a lot of beds and a lot
of ICU s compared to all others countries. They have got on a per
person basis 40% more beds than the United States. They were able
to cope with the very big de luge. In German, also unlike the United
States, they're more reluctant to intubate people than w e are. We did
a lot of intubation and it turns out for COVID intubation is not a good
idea . T hey probably had a lower mortality rate because th ey didn't
intubate people and they had ICU s that allowed them to give patients
more attention.

There are many oth er things in Germany that worked well. The

Dr. Zeke Emanuel

government jumped on it quickly, listen ed to the epidemiologist , so
you have a much more coordinated response right from the p rime
m inister, who was a no nonsense, really believes in expertise and
really believes in execution, unlike our president . A s you know, Angela
Merkel and Donald Trump don't get along and the different styles
speak volumes. They've done way better than we have.

Margaret Flinter: Dr. Emanuel, you're amongst so many things also a medical ethici st
and a teacher training th e next generation of clinicians, and w ow,
what a front row seat once in a lifetime seat that you would n’ t want
to have for our next generation to have. Looking at this pandemic,
they've seen people die in hallways while waiting to be seen in the
emergency room. They've seen ICU s that are overcrowded, while
other hospitals have capacity. They see professional athletes getting
daily COVID testing while some just regular Joe Schmo might not be
able to get a test at all . O f course th ere's the worry about when the
vaccine comes out w ill it be available to everybody easily and with
equity . A maelstrom of ethical challenges , I'm sure it's influencing
some of your views on ethics and equity in America right now , but
also how is it seeing it through the eyes of this young next generation
coming up? What are they seeing and how do you think they're being
shaped by this for the future?

Dr. Zeke Emanuel: Well, I actually, very, very early on in, I think , March I noted that this
was very differ ent than my experience growing up during the early
HIV days. In the early HIV days there was this huge debate, should we
treat HIV patients ? S hould we put ourselves at risk for treating the
HIV patients ? We had none of that debate with this generation . Thi s
generation it was quite clear we have an obligation to treat patient s ,
we're going to treat patients. Yes, we're taking on some risk , but that
is the price we pay for being doctors. I just applauded them and
thought how admirable . I do think this, first of all, this obligation, the
sense of duty, very prevalent, we often -- the generations behind us
get criticizes, they're so off they are not serious . Quite the contrary , I
think that their -- as you pointed out, their seriousness, their
commitment, their sense of duty, really admirable, and we should be
taking lessons from that.

Second, I would say that, you know, the disparities that they're seeing
are something I think that is going to shape them. I would not be
surprised if this was a generation very mu ch committed to issues of
justice and getting it right. I think that getting rid of the disparities,
that minorities or poor people get less good care that they can't come
into the hospital as frequently, that facilities aren't located near them .
I would t hink that they're going to be very committed to erasing those
disparities . It does seem to offend them very deeply.

I am worried about the gap between here and the fall when we're

Dr. Zeke Emanuel

going to have another uptick in the colder parts of the country. I
worry abo ut burnout , and I think that's something else that this
generation is going to have to deal with the sort of intensity of the
treatments and the issues. But, I think there's a lot to admire about
this generation. I would also say that I've written literall y just before
COVID came out in January, I wrote an article about moving a lot of
medical education online especially the preclinical years where you're
learning anatomy and pathology. I got a lot of pushback. Literally as if
COVID came to just validate my [ o verlap] because now Harvard
Medical School , the first semester at least is totally online for next
year. I do think we're going to learn that . W e've got to rearrange
medical school, the first pre - clinical stuff we can do that online . T he
clinical stuff we're going to have to fix how we're doing it. I think that
there’s in our near term future there's going to be a big shift in how
we do clinical education and w hat really a medical school is.

Mark Masselli: Well, there's a sliver of good news in this terr ible pandemic. I want to
g o back to those early days of the Affordable Care Act . I think we
heard from experts and they told us that any big legislation like this is
an iterative process. When we pass Medicaid and Medicare, we knew
it require legislative c hanges, and there were dozens and dozens of
changes made over the year in a bipartisan way. The same held true
for the ACA , but we could never get there because the ACA was
demonized.

It now seems like , and this may be too optimistic, there is some
support across party lines or at least in the public now, to see
continued reforms. As you've noted in your book, we have a uniquely
American challenge in fixing our health care system here. What do
you believe the next phase of health care reform will look like post -
election , post - pand emic , and I think it's fair to say the types of
reforms might be dram atically different than the pre - COVID
environment with the embrace of telehealth, as you said, online
learning a whole different way and other changes that have be en
done by, unfortunately right now only executive order.

Dr. Zeke Emanuel: Now I think you're 100% right . F irst of all we've now seen increase in
the number of uninsured 5.4 million in the last month, I think. We're
also seeing a lot of people lose their employer sponsored insurance
because they've been laid off. They're now going to be on Medicaid in
the exchanges , and then the anticipation is that literally tens of
millions of people who had employer sponsored insurance are going
to be on Medicaid. You'v e got a very different situation going forward.
I believe there is going to be big appetite to really reform the system. I
just hope that the next president meets that national appetite for
reformin g the system.

One of the things my brother and I put out t here is we do not see how

Dr. Zeke Emanuel

in the current system you can get a universal coverage given the
intransigence of 14 states like Texas , like Florida , like North Carolina ,
or like Georgia, so you're going to have to take Medicaid and make it
a national program. T hen I've suggested that we can simplify
everything by merging the exchanges Medicaid and Medicare
A dvantage into one program , b ecause I think Medicare Advantage has
been a hugely successful program bipartisan, the seniors who are
enrolled love it . I think we can, it's already a kind of exchange. I think
we can simplify the system. You have employer sponsored insurance,
you're over 65 you have Medicare, and if not you're in this Medicare
Advantage exchange program, whether you're poor or not . You can
get the universal coverage. You don't have insurance , re enroll you
directly in that. That simplification would also save a lot of money on
administrative costs. I think that there's things like that .

We also are just going to have to get our arms around the drug
spending. It's a huge portion of our bill . We're looking at Haemophilia
drug, g ene treatment that is about to be commercialized, it's in the
approval process , $3 million per patient we're talking about, and we
don't even know if it's lifetime. That just se ems to me unconscionable
and not something we can sustain for a long term. We ’re the only
country that gives drug companies a monopoly and then lets them set
their price. Every other country, I'm talking about Switzerland, I'm
talking about Taiwan, I'm tal king about lots of places committed to
the free market , they regulate drug prices, because you can't give
someone a monopoly and expect them to pri ce their commodity
responsibly. I think we're going t o have to look at that as well.

Margaret Flinter: We've been speaking today with Dr. Zeke Emanuel, Vice Provost for
Global Initiatives and Chair of the Department of Medical Ethics at the
University of Pennsylvania, and the author of the just published book,
Which Country Has the World's Best Health Care ? You c an learn more
about his important work by going to www.ezekielemanuel.com or
follow him on twitter @ Zeke Emanuel. Dr. Emanuel, we want to thank
you so much for your enormous contributions to advancing an d
impro ving health care for all, for your dedication t o public health and
the society, and for joining us again on Conversations on Health C are .

Dr. Zeke Emanuel: Thank you very much. It's been a pleasure and a great interview.

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Mark Masselli: At Conversat ions on Health Care we want our audience to be truly in
the know when it comes to the facts about health care reform and
policy. Lori Robertson is an award winning journalist and Managing
Editor of FactCheck.org, a nonpartisan, nonprofit consumer advocate
for voters that aim to reduce the level of deception in US politics. Lori,
what have you got for us this week?

Dr. Zeke Emanuel

Lori Robertson: During a July 14 press conference from the White House, President
Donald Trump made the outdated claim that US deaths from COVID -
19 are down tenfold . Data from th ree different sources show that, as
th
of July 14 the total number and seven day average of daily deaths
from the disease caused by the c oronavirus had declined between
threefold and fourfold from its peak more than two mont hs ago.
Trump made the claim as he argued that news organizations have
recently highlighted record increases in cases of the disease in several
states, rather than focusing on the fact that deaths from COVID - 19
have declined from their previous high.

At on e point Trump's claim about a tenfold decrease was correct. The
th
White House Press Secretary had used the same language in a July 6
press briefing saying that deaths at the height of the c oronavirus
th
outbreak were at 2500 per day, but on July 4 there wer e 254 deaths.
We found slightly different numbers . The data aggregation website
Worldometer reports that there were 2748 Coronavirus related
deaths on April 2 1 at the peak and 265 deaths on July 4 , t hat ’s also a
tenfold decrease. However, daily deaths have increased in the days
since, including in Arizona, Cali fornia, Florida, South Carolina, and
Texas, meaning Trump's tenfold talking point is stale.

On July 14, the day of Trump's press conference, there were 935
deaths a ccording to Worldometer. That's only a three fold decrease
from the peak in April . S lightly different totals from two other
sources , the COVID Tracking Project and the New York Times also
show less of decline in daily deaths than Trump claime d. There also
hasn't been a tenfold decline in the seven day average of deaths,
which accounts for a fluctuation in daily totals over a full week. All
three of those data sources show a decline of less than fourfold from
t he peak to July 14 in the seven - day average.

Trump does have a point that daily deat hs from COVID - 19 are “way
down” from their previous highs as Trump noted in a July 9 interview,
but on July 14, it also was no longer the case that deaths had been cut
tenfold as he said . He has simply ignored the increases in daily deaths
th
t hat have occurr ed since July 4 . T hat's my fat check for this week. I'm
Lori Robertson, Managing Editor of FactCheck.org.

Margaret Flinter: FactCheck.org is committed to factual accuracy from the country's
major political players and is a project of the Annenberg Public Policy
Center at the University of Pennsylvania. If you have a fact that you'd
like checked, e - mail us at www.chcradio.com . We'll have
FactCheck.org’s Lori Robertson check it out for you here on
Conversations on He alth Care.

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Margaret Flinter: Each week Conversations highlights a bright idea about how to make

Dr. Zeke Emanuel

wellness a part of our communities and everyday lives. While the
world grapple s with a global pandemic , public health experts have
been simultaneously b attling another ongoing health threat.
Mosquitoes are considered one of the deadliest animals on earth
leading to hundreds of millions of illnesses and some 2.7 million
deaths per year globally . Diseases such as malaria, dengue fever and
Zika are on the ri se.

Dr. Scott O’Neill: There is this one mosquito called Aedes Aegypti that transmits a
range of different viruses to people. They include viruses like yellow
fever, dengue fever, C hikungunya, Zika, and the consequences can be
very dire from a loss of life through to crippling social and economic
cost.

Margaret Flinter: Dr. Scott O'Neill is the D irector of the World Mosquito Program , which
has developed an innovative appr oach to eradicating the threat.

Dr. Scott O’Neill: I was particularly interested in thi s bacterium called Wolbachia. This
bacteria is present in up to 50% of insects naturally, but not this one
mosquito t hat transmits all these viruses. When we put the bacterium
into the mosquito the viruses couldn't grow any longer in the
mosquito. W e're se eding populations of mosquitoes with our own
mosquitoes that contain Wolbachia . We ’re able to spread the
mosquitoes across very large areas very quickly. Once the mosquitoes
have it they're protected from being able to transmit viruses. When
they're protec ted, th e humans are protected as well.

Margaret Flinter: Dr. O'Neill's team released the genetically modified mosquitoes into a
targeted area and the results showed a dramati c reduction in human
infections.

Dr. Scott O’Neill: In Northern Australia we deplo yed the Wolbachia over quite large
areas, entire cities, and we've seen essentially a complete elimination
96% reduction in dengue in those cities. We believe if we can scale
this intervention across entire cities, we can completely prevent the
transmissio n of diseases like dengue, C hikungunya, and Zika.

Margaret Flinter: The World Mosquito Program is one of six finalists in the MacArthur
Foundation's 100&Change competition, which awards are $100
million grant to innovative public health intervention s.

Dr. Scott O’Neill: We're hoping that over the next five years, we could bring this
technology to protect 75 to even 100 million people. We would hope
within 10 years we could bring this intervention to 500 million people .

Margaret Flinter: The World Mosquito P rogram an effective targeted genetic
engineering approach to eradicating the threat of deadly mosquito
borne pathogens, leading to a dramatic reduction in harm to public
health. Now, that's a bright idea.

Dr. Zeke Emanuel
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Mark Masselli: You've been listening to Con versations on Health Care. I'm Mark
Masselli.
Margaret Flinter: And I'm Margaret Flinter.
Mark Masselli: Peace and Health.
Female : Conversations on Health Care is recorded at WESU at Wesleyan
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