Candid on Covid

Westporter Dr. Scott Gottlieb has written the most important book of the year—or decade. In Uncontrolled Spread, the former FDA commissioner (2017–19) outlines in meticulous detail where our nation went wrong with this pandemic, why, and how we can avoid being caught off guard again. Gottlieb’s tome cuts out the political noise, providing a clear-headed insider’s perspective on a pandemic that left us stumbling around in the dark, grasping for a light switch. Uncontrolled Spread flips that switch. Even if some of what is illuminated is scary, it’s a relief, and readers will understand why Fortune magazine included Gottlieb in its “World’s Fifty Greatest Leaders.” Here’s our conversation with him.

Before Covid-19, what should the U.S. have been doing to prepare for a pandemic of this kind?
“We had sort of a monocular focus on preparing for a pandemic involving a novel strain of flu, particularly bird flu. Even for that, our preparations were inadequate, and only preparing for a flu left us even more vulnerable because this coronavirus behaved very differently than influenza. I had been a part of that planning in the Bush and Trump administrations. For example, we were not worried about diagnostic testing. In a flu pandemic, a diagnostic test isn’t a critical feature. One, flu has a very short incubation period so you’re not going to get people diagnosed before they go on to treat the infection. Two, most people aren’t contagious until they are symptomatic. Three, the diagnostic test for flu inside every doctor’s office would be sufficient. So we never thought about the need to scale deployment of a test. We also operated on an old notion of keeping a ‘warm base’ of preparedness. We should stockpile certain things and have manufacturing capacity we can scale up. But we found in this pandemic that if you merely keep a base warm, it’s not there when you need it. The best metaphor for this was the emergent facility charged with manufacturing the J&J vaccine. It was undercapitalized. It didn’t have the properly trained staff. It was kept warm but wasn’t hot and operational when we needed it.”

Once Covid-19 became a known virus, how was our government’s response lacking or misguided?
“The first critical mistake was not scaling deployment of a diagnostic test and relying on the CDC to develop and roll it out. Even if the CDC hadn’t contaminated its own lab and botched the rollout, we still wouldn’t have had enough testing capacity to keep up with a fast-moving epidemic. We needed to engage the private sector in developing tests on a mass scale. In retrospect, it seems hard to see how we didn’t realize this was going to move quickly. Once we got behind the curve, there was no way to catch up. The Chinese locking down the Hubei province and destroying their economy to get control of the virus should have been a good indication to us that this was not a garden-variety virus. The U.S. didn’t show real concern until March, and by then the virus was everywhere. My first phone call to the White House was the weekend of Martin Luther King Day in January. I had been tracking this since late December, but I became alarmed and made that call when the number of reported cases in Wuhan jumped from 50 to 200. Clearly, the Chinese government had been withholding data. All 200 cases were people critically ill with pneumonia. It’s very unusual for a respiratory disease to only present with severe pneumonia, so that suggested there were hundreds, maybe thousands, who had been infected.”

What should we be doing now to help snuff out this pandemic?
“If Delta remains the dominant variant, then in early 2022 we should be getting past the pandemic phase of this virus. It’s going to feel unsatisfying because we’ve gone through this tremendous ordeal and there’s not going to be a mission-accomplished moment. Prevalence will start to decline after this Delta wave runs its course. In spring/summer, this will largely dissipate, and we will have to deal with it next fall but in a much different way. With a largely immunized population, effective oral therapeutics, antibody-based drugs and widely accessible diagnostic tests, we have a much different toolbox and can turn this virus into a manageable risk. The big unknown is whether the new strain first identified by South African scientists, the Omicron variant, is going to become a global risk and displace Delta as the predominant strain. If it does, and if it’s able to pierce the immunity we’ve acquired through infection from the Delta strain, it could mean that prevalence remains high through the spring, and we are dealing with another wave of this virus, perhaps not as steep as the Delta wave, but persistent. The other unknown is how virulent the new Omicron strain is and whether it causes the same severity of symptoms.” 

What is your advice to parents who are hesitant about vaccinating their kids?
“Look, this is still a serious infection in kids. We’ve seen 8,300 five- to eleven-year-olds hospitalized with Covid. We’ve seen 150 kids in that age group die from Covid. Over 700 under eighteen have died. There are a lot of childhood diseases we immunize for that are less severe and we don’t even question them. Covid was the eighth-leading cause of death among children in 2020.” 

And for adults?
“We’ve done a good job vaccinating adults: 81 percent are vaccinated. That’s very high. We might get close to 90 percent but not much above that. I wish we would, but many who have chosen not to probably had Covid and have some immunity.”

Who should be getting boosters and any input on the brands?
“Depth of vaccination matters just as much as breadth. We need to be equally focused on getting people boosted. Clearly, vaccination effectiveness declines over time, particularly in older individuals. Data shows mixing and matching is safe and effective. People should take the vaccine that’s available to them.” 

Do you think the Covid vaccine will ultimately become routine for children?
“I think we are a long way from it being mandated as part of the childhood immunization schedule. The CDC will want to understand fully what the post-pandemic phase looks like and what the risk is to children when more of the population has immunity. They will want to see many vaccines on the market, including a protein-based vaccine. It will be a recommended vaccine, much like the flu vaccine.” 

Are we at a point where we can strike a happy balance between safety and sanity?
“We need to be willing to pull away some of these public health measures as conditions improve, even if it causes a slight uptick in cases. Policy makers and public health officials need to show we are adaptive. Westport’s decision to lift the mask mandate in November, given that prevalence was five cases per 100,000 people, was exactly what they should do. Conditions improve, people comply, you lift the requirement. If conditions worsen, you may need to reimplement. We need to accept this flexible approach and not see it as a failure if measures are lifted and infections pick up. Conditions change. This virus is going to come and go.” 

Are there other places where we should still be cautious?
“What makes a place unsafe: a lot of people in a confined space, with poor air circulation, who are exuding a lot respiratory droplets—talking loudly, singing—such as at restaurants or in social halls with older air-filtration systems and poor air circulation. There are ways to improve those environments, but those are more conducive to spread.” 

Do you think students in school should still be in masks?
“It’s not imprudent that schools are the last place to lift requirements. We want to keep kids in class and keep schools safe. We don’t want outbreaks disrupting school, so I can understand being more conservative than in a store or commercial setting.” 

Do you expect we will face worse strains than the Delta variant in the near future?
“One possibility is that future mutations will be within the Delta lineage. It will remain the dominant strain, so we may eventually reformulate the vaccines using a Delta backbone. But the Omicron strain represents divergent evolution. It’s a strain that has mutated along a completely separate evolutionary tree, and so the immunity we’ve acquired through past waves of infection may not be as protective. The hope is that, if it spreads globally, that properly boosted vaccines will still afford a meaningful level of protection.” 

How prevalent will masks be in our future?
“I think masks will become more culturally acceptable. Even if we get past this Delta wave and Omicron doesn’t become a persistent risk or a new wave of infection, Covid is going to remain a seasonal threat and I believe people will use masks more routinely, voluntarily, when prevalence levels are high, to reduce their risk in public settings. One of my favorite medical studies from years ago showed that if you wore a mask in public, on average people stayed a farther distance from you because they presumed you were sick. Now it’s the exact opposite; people presume you are healthy and want to stay that way. I can envision myself wearing a mask going through a public airport next winter. In Asia, wearing masks became normalized after SARS and MERS. It wasn’t always that way. It took a pandemic with a deadly respiratory pathogen to change culture in Asia. I think the same thing can happen here.” 

What should we be doing to prepare for the next pandemic?
“This pandemic represented an asymmetric risk for our nation. We were hurt a lot worse than many other nations. We need agencies with a logistical capacity to mount a response to a public health crisis of this magnitude. The CDC clearly didn’t have the capacity to scale testing. We are going to need domestic capacity to scale the production of antibody drugs and vaccines. We got lucky that we were able to manufacture these vaccines on relatively small platforms. If these had been vaccines requiring traditional biotechnology techniques, we wouldn’t have had the capacity to manufacture billions of doses. We need better tools for gathering information that can form our response. It took far too long to learn critical features of how this virus spread and what measures we could take to mitigate the spread. What was the appropriate distance for people to stand apart; what were the social and geographic compartments in which spread was occurring; how much asymptomatic spread was occurring? It took us months to get answers that we should have had in weeks. There were a lot of failures on the part of the CDC. We need to think about how we fundamentally reform that agency.” 

What inspired you to write your book, Uncontrolled Spread?
“I thought this book would come out when we were having a robust national debate about how to prevent the next pandemic, and that needs to be our goal. At some point Congress and policy makers will take up that question, and hopefully this book becomes part of that discussion.”  

How long did it take?
“I started in July of 2020 and turned in the first draft seven months later.” 

Do you sleep at all?
“It was a much bigger lift than I thought it would be!” 

 NOTE: Gottlieb’s book is available in bookstores and on Amazon. There is an audiobook and e-book as well. To keep up with him, follow him on Twitter @scottgottliebmd.

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