Take As Directed

In Episode 120, the first episode of our Department of Defense mini-series, Joint Staff Surgeon Major General Paul Friedrichs, discusses how the Department of Defense has overcome challenges from the pandemic, incorporating lessons applicable to any large organization struggling to function in today’s environment. Early in the disease the aircraft carrier USS Theodore Roosevelt was sidelined, recruit training and military exercises were interrupted as they searched for answers on how to safely operate. Currently, vaccination rates among active-duty military members are among the highest in the nation and operations continue relatively unimpeded. Domestically, tens of thousands of National Guard and active-duty troops have responded wherever needed to support communities throughout the United States in roles from intensive care delivery to administrative support. Worldwide DoD biosurveillance and research programs designed to protect U.S. forces against disease while deployed overseas play a major role in viru

In episode #119, Dr. Peter Kilmarx, Fogarty International Center, discusses the struggle to advance contact tracing. Efforts early in 2020 to create a national Covid-19 Response Corps – at least 100,000 needed – were not successful. Instead a “hunger games scenario” ensued in which each jurisdiction scrambled to make its own solution. In our federalized system, each state, and in some instances county, has had to build its own public health workforce while balancing the budget. The lack of an integrated data system made it difficult to track progress. Contract tracing has made only marginal progress in curbing transmission. Experiments in the use of new technologies have not gotten off the ground in most places. New York City is one shining exception where 90% of cases are tracked, and 75% of their contacts. Success in places like New Zealand, Taiwan, and Viet Nam relies on robust, fast testing systems, consistent social support for those in quarantine, and a tradition of public health workers in the communit

Dr. Michael Osterholm, head of CIDRAP at the University of Minnesota, is among the most popular, respected, and trusted communicators on the pandemic. What is the recipe?  Simplicity rules. He learned from his rural Iowa background, “if something doesn’t play at the 10:00 o’clock coffee club at the S&T Café on the main street of my little town, then it’s not going to play.” Be frank and honest: “Always tell the truth.” If dark things such as variants lie in the future, do not shy away from spotlighting them. But be careful of forecasting too far into the future, which can at times be based on “pixie dust.” Appeal to both “hearts and minds.” “Kindness is one of the most important virtues.” In his lauded and highly successful podcast, ‘The Osterholm Report: Covid-19,’ he is able to “combine science, policy, and life all in one venue.” The anti-vaccine movement has gained substantial strength; witness the ‘Defeat the Mandates’ rally on January 23rd at the Lincoln Memorial, which featured Robert Malone, now a cel

Dr. Chris Murray, head of IHME, joined us in episode 117 to discuss his recent provocative piece in The Lancet, ‘Covid-19 will continue but the end of the pandemic is near.’ “The Omicron wave is really different,” extraordinarily fast and much less severe. The current massive Omicron wave will infect 50%-60% of the world by March, creating dramatically enhanced population-level immunity. The unvaccinated and never-infected will become quite scarce, as transmission becomes very low. Aided by the advent of antivirals, “Omicron will become another recurrent infectious disease” that in magnitude is going to be like a bad flu season. Major emergency government interventions will become a thing of the past, even as future variants emerge. Americans will celebrate – almost like a post-war moment -- even as America passes the milestone of one million deaths. Complacency is a risk: some will see this shift as a license to do nothing. “We really have to stick to the truth,” strengthen data and surveillance, improve the

Dr. Anthony Fauci joined J. Stephen Morrison for a CSIS live-streamed conversation on January 11. Today’s podcast is based on that conversation. Does Dr. Fauci believe the pandemic is in transition? Yes. “I have been talking about a transition since October 13.” What might that mean? “Ultimately we will need a new strategy. We cannot let this virus dominate our lives for much longer. We have to get to the point where all of us get our lives back.” The pandemic remains “a moving target.” Omicron is in effect the fifth wave, and we have to get the American people to pull together to end it. “We all really want the same goal.” It’s a mistake “if we landed on Normandy and begin to argue among ourselves over whether it was a mistake to land...  soon enough you get off the beach and win the war.” A reset on communications is needed but the “degree of divisiveness and polarization is profound, driven by disinformation and misinformation.” Internationally, it is in both the U.S. moral and national self-interest to as

Dr. Gigi Gronvall, a leading international expert on tests, kindly joined us for a spirited tour d’horizon. People need tests for multiple purposes on a continuous basis: You “can’t just get one test and forget it” since a test is just one moment in time. Sometimes however there are unrealistic, outsized expectations that tests will peer into the future. Why is the United States so prone to stumbling on tests? In 2020, responsibilities were thrown to the states, and antibody tests in the early days, approved by the FDA, were “the wild west” where often you could get a more accurate result “from flipping a coin.” In 2021, “a supply and demand market model” for antigen tests predominated, and when demand collapsed, Abbott destroyed millions of doses. More recently, since September of 2021, and accelerating under the pressure of Omicron, things are improving -- but “turning the ocean liner” is slow. The $3 billion investment in affordable antigen supply and accelerated development of new tests is showing results

Ashish Jha reflected as the year closes. Communications are now fundamental to public health. Most critical is to speak as though you are engaging friends or family who are outside medicine. Put the decisions in terms of your own family. Don’t tie masks and vaccines to political identity. The lessons of 2021? We were surprised by 20-30% of Americans unwilling to be vaccinated, by Delta’s power, and by limits to the federal government’s power. FDA and CDC remain weak and muddled. “Process and nonsense” delayed a booster decision for three months. What’s in store for 2022? Coping with omicron will be tumultuous. Americans are exhausted, frustrated, and angry, which will narrow the tools at our disposal. We may see 50-80 million infected with omicron. Over the long term, if we settle into 30,000-50,0000 Covid-19 deaths per year, on top of flu, that will overwhelm our health system. We need now to institute fundamental changes in ventilation, test and trace, and other capacities. The international environment? Fr

Philip Zelikow, former Executive Director of the 9/11 national commission, has for the past year directed the Covid-19 Commission Planning Group. He visited with us to explore where that effort stands, should a national commission move forward? How and why? It is “absolutely essential to take account of this sprawling crisis.” Our performance to date, despite our “magnificent edifice” of science and modern health tools, has been far worse than during the 1918 Spanish flu. A national commission can counter polarization, offer an alternative that unites citizens. It can avoid the “gotcha blame game” and construct choices made – the values, tools, and information that shaped critical decisions. Most of the story of what happened is in fact not yet well known or understood. A commission is “a bridge to rethink the American health system.” “Does anyone think the American health system is fine?” There is an urgency to act in 2022, while pain and memory are fresh before we turn our attention elsewhere. We cannot wai

Dr. Richard Lessells is among the exceptional South African experts on the front lines of discovering and investigating Omicron in South Africa. Alarm bells went off within the scientific community, as it became clear after just a few days that “an extraordinary number of mutations” are clustered in the key regions in the genome for immune protection and transmissibility. It was a “gut feeling. ” Omicron is highly transmissible, spreading very efficiently in a population with high levels of immunity gained from previous infection and in some cases from vaccination. How long to know just how dangerous Omicron is? It’s “too early to tell.” Lab work is underway to understand whether the virus affects T cells which are central to immune protection against severe disease. Why do we see such an unusual variant in South Africa? One theory, which Omicron may shed light on, is that the SARS-CoV-2 virus finds hosts who are very immune-compromised, persons living with HIV but not on anti-viral therapy. These individuals

Dr. Taison Bell, MD, an acclaimed African-American doctor, educator, and emergency medicine director in Charlottesville, Virginia, shares his personal story of how medicine – back home in Virginia – became the center of his life. “Success was not assumed in my neighborhood.” As a child with asthma, he connected with his physician, as he did also with his Black dentist and several teachers. Such “affirmative experiences” made the dream “seem like it was achievable.” In retrospect, “so many things had to align at the right place and right time.” The pandemic now puts a premium on doctors becoming communicators. “Things will not be the same from this moment forward.” “People arrive in my ICU because they are unvaccinated… People are generally willing to trust their local provider in their community regardless of what side of the aisle they are on.” But “everyone has an opinion, some spread by misinformation.”A recent conspiracy alleges doctors put patients on ventilators to intentionally make them sicker. “That

We asked Cary Funk, Pew Research Center, to make sense of how the pandemic has impacted our society and American opinion as we approach the pandemic’s two years. “It can be confusing.” Polarization now increasingly aligns between the vaccinated versus the unvaccinated, versus simple partisan identity. At the fundamental level, Americans are split over whether Covid-19 is a common problem. Does the “Big Lie” bleed over into the field of public health? “It’s all complicated.” “The political lens” increasingly encompasses so much of public health, accelerating the erosion of public trust and confidence in science, a trend that had already been underway for years. False statements can travel the globe in 48 hours, but knowing the impact is much more difficult. Are we at a turning point, a softening of polarization? “We need to wait and see.” Heightened US international engagement enjoys majority support and has not become politicized. What is the impact of the loss of 757,000 lives on opinion? We have to continue

From September 17-October 1, Suzanne Brennan Firstenberg created the largest participatory art installation on the Washington National Mall since the AIDS quilt of 1996, entitled ‘In America: Remember,’ composed of 700,000 white flags, in the shadow of the Washington Monument. A stunning achievement. Listen to her reflections on listening to those among the 16,000 who personalized a flag to memorialize their loss. “So many of these deaths happened in isolation.” The project unfolded amid our bitter divisions: “ We are tearing ourselves apart as a society.” 35,000 died unnecessarily over the two-week course of the installation. Remarkably, though, she succeeded in creating a solemn, quiet, respectful space where it was “safe to bring one’s grief” and escape our politics. Does this memorial create a lasting constituency that will press for a national commission? Any memorialization has to include an in-depth examination of what happened. Suzanne Brennan Firstenberg is an artist based in Bethesda Maryland.

Dr. Richard Brennan, WHO Emergency Operations, sat down this week with Steve and Professor Leonard Rubenstein, Johns Hopkins Bloomberg School of Public Health. Rick has been at the very center of urgent efforts, following the Taliban’s coming to power in mid-August, to avoid the collapse of Afghanistan’s health system, through fast-moving negotiations to bring emergency funding, opening air links, resuming Covid-19, polio, and measles immunization programs, and delivering emergency medical supplies. The political and security complexities to achieving these short-term, emergency stop-gap measures remain formidable, and the space for striking deals exceedingly narrow. How has the Taliban leadership seen things, and how did they agree to these initial measures which have to operate outside their control, a precondition of donors? What is the space in which he and others can find financing solutions that will sustain the health system long-term? Pressures upon WHO Emergency Operations in Afghanistan, combined wi

Dr. Jennifer Nuzzo has emerged as a forceful expert voice making sense of the complex and times confusing, shifting shoals of the pandemic. ”All of us have had to step into this sphere,” filling “a power vacuum.” It has however been chaotic. Public communication is essential “to move the needle” but the experience can be “tough.” Vocal experts are the subject of attacks, the worst during the Black Lives Matter protests. The field of public health needs to invest more in how to message on vaccines. People are "swimming in disinformation.” Though she is “cautiously optimistic” for the United States, “no one is going to run out the clock on this virus.” For poor countries, which increasingly are in desperation abandoning a response, the future is “bleak.” Are we numb to the more than 700,000 dead Americans? Perhaps. It’s impossible to wrap our minds around this scale of death in America. There is a need for a “national reckoning” through a commission, “a true opening of the books that goes deep.” Have we entered

On October 7, Andrew and Steve sat down with a close friend, Georgetown’s Prof. Larry Gostin, for a lively live-cast conversation about his new book, ‘Global Health Security: A Blueprint for the Future.” The podcast captures that rich, vivid exchange. The big messages: We underestimate the power of the SAR-CoV-2 virus: it is wily and pernicious and will continue to surge. We cannot forget anti-microbial resistance. A fundamental shift is needed in the US international approach – away from charity and towards advancing technology transfer to manufacture vaccines in low and middle-income countries to create resilience. That requires far greater pressure upon Moderna and Pfizer to cooperate in meeting urgent global needs. The USG has the legal authorities to make that happen but has not yet followed through. USG health communications have been “pitiful” and left the public “utterly confused.” That too can be corrected.   Professor Lawrence O. Gostin is University Professor at Georgetown University where he direc

Dr. Leana Wen joined us this week to explore her personal history and its revelations, laid out in remarkably candid detail in her newly released memoir, Lifelines: A Doctor’s Journey in the Fight for Public Health.  And to speak to the most pressing current challenges posed by the Covid-19 pandemic. Her childhood struggles, as a young immigrant Chinese girl living amid insecurity, taught powerful lessons about poverty, race, and health. Her tenure as Health Commissioner in Baltimore, operating in close partnership with the late Congressman Elijah Cummings, opened the way to confront opioid addiction, stigma, maternal and infant mortality, and the acute vulnerabilities of youth. In her new life in the print and cable mediascape, she follows the advice of former Senator Barbara Mikulski: “do what you are best at – and needed for.” The Biden administration needs to up its game with the public: “It’s not enough just to get the science right.” It is about values, communication, and public trust. America’s hardene

Carmen Paun, a dynamic, fresh media voice on global health in Washington, shares her personal and career journey from Romania to Brussels, and on to her arrival in Washington D.C. one year ago, amid the pandemic, to launch POLITICO Global Pulse. This past summer, while visiting family in a small village in the Romanian countryside, she was “shocked” to discover only 10% vaccinated at that time, the pandemic seen as “all just a conspiracy.” The pandemic was the trigger in creating POLITICO Global Pulse. In its first year, it did find its audience and voice quickly. What to make of the U.S. Global Covid Summit? It re-established that “the U.S. was in charge,” now the challenge lies in execution. Faith in American leadership has diminished, while African officials remain frustrated by slow delivery and the West’s export restrictions. Will the EU-US Task Force bring great transparency and accountability? “Hard to say… How fast is this going to happen?” The turn to boosters likely creates “a vicious cycle” that co

In a recent New Yorker ‘Letter from Biden’s Washington,’ Susan Glasser delivers a stark indictment: Trumpists and Republican leadership are consciously keeping enough people resisting the Biden administration’s efforts to control the virus “to keep the disease wreaking havoc.” Why that conclusion now? “It is no accident” that 1 in 500 Americans have died, now totaling over 687,000. It’s becoming obvious that President Biden cannot inoculate Americans against Fox News. In the meantime, the Biden administration, “on both foreign and domestic fronts, remains a jumble of aspirations and retains a haze of uncertainty about how to achieve them.” That directly shapes its international approach to Covid-19, including the recent Global Covid-19 Summit organized by President Biden on the margins of the UN General Assembly. It is “a statement of the obvious” that nearly half of the country is dedicated to the failure of the Biden administration. When a “flaming dumpster fire” pandemic continues in the United States -- t

Dr. Monica Gandhi toured the landscape with us. The recent recall of California Governor Gavin Newsom has bipartisan roots, in dissatisfaction with the “lockdown mentality” that closed playgrounds and parks, and kept San Francisco’s schools shuttered for 18 months. It was to a significant degree a “referendum on the illiberal liberals.” Once “the power of vaccines” came into force, however, California pioneered mandates, passports, and expanded testing; achieved over 80% vaccine coverage; and drove cases and deaths to exceptional lows. The future? “Immunity is the path out” to achieve control over Covid-19. Big concerns? Confused messaging around boosters terrifies the vaccinated and makes the unvaccinated believe less in vaccines. We are also witnessing rising intolerance: in our politically polarized debates over schools, vaccines, masks, and boosters, scientific discourse has lost balance and nuance.   Dr.Monica Gandhi is Professor of Medicine and Associate Chief of the Division of HIV, Infectious Diseases

Dr. LaQuandra S. Nesbitt, Director of the DC Department of Health, returned as our guest to share her reflections. Her view of President Biden’s six-point plan? Tying vaccination to sustained employment is the next phase: mandates will bring about an uptake in vaccines. The rising emphasis on monoclonal antibodies is a “huge initiative” that brings about a reduction in hospitalizations. The President negotiating access at-cost to over-the-counter test kits is a similarly big step. DC has avoided the worst outcomes seen elsewhere in the United States by “planning for the worst.” Plus there has been relative unity: “residents have done what we have asked them to do.” “At times of adversity, this city rises to the occasion.” Top challenges? Vaccine disinformation regarding infertility creates “myths” that remain “inexplicably” powerful. Managing confusion over boosters is “tricky” in the absence of a “single voice, single message.” Dr. LaQuandra S. Nesbitt has served since January 2015 as Director of the Distric