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Coronavirus Update With Ezekiel J. Emanuel, MD, PhD

Educational Objective
To understand the most recent developments in managing COVID-19
0.5 Credit CME

Ezekiel Emanuel, MD, PhD, of the University of Pennsylvania's Perelman School of Medicine, Department of Medical Ethics and Health Policy, discusses recent developments in the COVID-19 pandemic. Recorded August 19, 2020.

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Transcript

>> Howard Bauchner: Hello, and welcome to Conversations with Dr. Bauchner. I'm back after being away for a week. I'm here with probably my favorite guest, Zeke Emanuel. Zeke is the Diane S. Levy and Robert M. Levy University Professor, Professor of Healthcare Management, University of Pennsylvania, where he's Vice Provost for Global Initiatives and Chair of the Department of Medical Ethics and Health Policy. Welcome Zeke.

>> Ezekiel Emanuel: It's great to be here, and thanks for the flattering comment. I won't take it to heart, but I'll tell my mom to listen.

>> Howard Bauchner: You can take it heart. You have just a really fine mind, so I always appreciate it.

>> Ezekiel Emanuel: Well, thank you.

>> Howard Bauchner: So, I'll be wide ranging, Zeke, but let's start, you know, before we came on I mentioned, you know, have we become immune to the number of deaths? A hundred and seventy thousand deaths, a thousand a day until the end of the year gives us 300,000, and then the estimate is at about 50 percent more are COVID related but not COVID counted. That brings us almost to a half a million deaths. Have we just become immune to it?

>> Ezekiel Emanuel: Yes. I do think the fact that we're not shocked every day that we're losing a thousand people that somehow we can dismiss it as, oh, they're just the elderly or something, which is totally false, has made us somewhat immune. And we know [inaudible], as you say, we know that, you know, something happens over and over again. You sort of block it out. But to put it in context, half a million deaths is a little under an increase in 20 percent of all deaths every years. So, we have about 2.7, 2.8 million deaths in the United States, and again, even among those deaths, 75 percent of them are in people over 65. They're seniors. But, you know, 500,000 is a very whopping chunk of that from one illness that, you know, began killing Americans in late February. And I do think we've lost sight of how powerful it is. You know, as you said, a thousand people a day is, you know, a plane full of 300 people, three of them, dropping out of the air every day. That would shock us if we actually stepped back. Or, a thousand people dying from a hurricane, that's a shocking number. But we don't [inaudible] --

>> Howard Bauchner: Yeah, I see the number every morning, and I'm just amazed. As I said, I think we've become almost immune to it.

>> Ezekiel Emanuel: I also think early in this epidemic people had no idea. When I began talking, you know, months ago, about we're going to have a quarter of a million deaths by November, people were like, no, you know, you're exaggerating. And that's like, that's easily going to be the number by November 1st, election day.

>> Howard Bauchner: Right. So many different issues have come up. Schools have become a nightmare. I think, you know, we published an important article, schools close, mortality went down. Parents are divided. It's been difficult for teachers. I fully recognize it, but everyone keeps saying the same thing. For young children, first grade, second grade, third grade, fourth grade, not to be in school, kind of zooming education just may not work very well. What's your sense? Will we ever get back to school this year? Physically get back to school?

>> Ezekiel Emanuel: Well, first of all, Howard, I like to put this in context of, you know, it's not like the United States is the only country confronting the issue of school openings. Lots of other countries have done school openings, you know, whether it's Finland or Belgium or the Netherlands, New Zealand certainly. So, you have a lot of experience about opening schools, and it can be done safely. We've had one major other country that has opened, and it's not gone well. How much that was schools, how much that was other things happening in the environment, that's Israel. So, we can do it well, but before you can do it, you have to have a low rate of transmission in the community. And that's been the fundamental issue is we don't have enough people or enough the population, enough states, where we have a low rate of transmission in the community that would permit opening of in-person education. So, I think that's what is critical. We have to get the rate of transmission down, the number of new cases down, and then we can, you know, talk about it. There are places in the United States where you can discuss reasonably reopening in-person education. You've come from one of them, Maine, I think there are, you know, over a seven-day period there are like 11 cases of COVID in the state.

>> Howard Bauchner: Right.

>> Ezekiel Emanuel: All right. That means that you're having, you know, call it two new cases per 100,000 people per day. That's a number that you can open schools with. Especially if you have a testing capacity that has, you know, a positivity rate under three, certainly under five, yes, and I think those are the numbers we need to have to talk about reopening schools. So, New York City, it turns out --

>> Howard Bauchner: Yeah.

>> Ezekiel Emanuel: You know, it's problem, it could have reopened given the numbers of new cases and testing percentage positivity. The problem in New York is you don't have the infrastructure. You don't have outdoor spaces where you can hold classrooms and space people out. And that, I think, makes it hard in the city. Probably in the surrounding suburbs it's going to be doable, lots of Connecticut, Vermont, New Hampshire. As we said, Maine. You can open schools, if not all, every county or every school, a lot of those areas. On the other hand, clearly Texas, which leads the list, again, at nearly 200 cases per 100,000 over a seven-day period, it makes no sense to open up in-person education. So, I think that's a serious problem. So, the first question any parent ought to ask is what's the daily transmission rate per 100,000 in our community. Is it low enough that we can safely reopen the schools?

>> Howard Bauchner: The early experiences with colleges haven't gone very well. Many have retreated from in-person opening. Some delayed the decision, and some opened, and the early experience hasn't gone well.

>> Ezekiel Emanuel: Yeah.

>> Howard Bauchner: I think some college communities are saying a little nervous about bringing 19, 20, 21-year-olds, we both have children older than that, and how responsibly they'd behave. Any sense about colleges, Zeke.

>> Ezekiel Emanuel: Yeah. Well, I've spent a lot of time advising both my own and other colleges, and the problem is what students do, especially if they're off campus, but how much socializing they're doing, how adherent to the safety practices, wearing face masks, staying six feet apart they are, and it does app that they're not actually adhering to them whether it's at fraternity/sororities or other parties or bars that are near campus, it does seem that the necessary rules to keep any COVID transmission to an minimum, just aren't being adhered to, and that's the real problem. They're not being socially responsible. You know, I have talked to my alma mater, Amherst College, about reopening. They're going to reopen, the plan is, with about half the students on campus. They tested the faculty and staff and almost 1000 tests, all negative, but they're worried about a few students who are renting houses off campus to avoid the strictures of living on campus, and that is the worry, that they're going to throw parties there. And I think that's a very sad commentary on how we've not inculcated in people social responsibility, responsibility for others, actually adhering to rules, you know, that we expect those kind of behaviors. I don't know, it's a little sad that that's what, you know, our image of college life is and therefore what we've communicated to students about their responsibility.

>> Howard Bauchner: What's gone well?

>> Ezekiel Emanuel: What's gone well?

>> Howard Bauchner: Yeah.

>> Ezekiel Emanuel: Look, I think we have to be wildly impressed by the vaccine action, you know, the number of shots on goal, as you say, you know, number of potential candidate vaccines, vaccines that rapidly entered human trial that we now got, I think, it's seven in phase three trial.

>> Howard Bauchner: Yep.

>> Ezekiel Emanuel: That is pretty impressive. You have to be wowed by the scientific prowess that represents. Second is, you know, I think the British effort with creating large, simple randomized trials to test out therapeutics, I think that's been impressive. They got it up and running in March and quickly were able to generate thousands upon thousands of people randomized and get evidence right away of what was working, what's not working. And I do think in certain pockets of the country, where, you know, the governors, the mayors have spoken with one voice, a consistent voice, I think people wearing masks, adhering to social distancing, you have seen, and New York is a very good example, you've seen a dramatic decline and a persistent decline. You haven't seen a second bounce. We will see a second bounce. That's inevitable, but I do think that it shows that the public health measures work. You don't need magic pharmaceutical or a vaccine yet. You can get the numbers down low with the public health measures, and they can stay low. You need good leadership for that. You need consistent messaging, but the public is willing to listen. And I think that's been a positive sign. And I will say, we've learned a lot about the negative effects of opening indoor dining, indoor bars --

>> Howard Bauchner: Yeah. Bars, yeah.

>> Ezekiel Emanuel: Indoor gyms. Right away. And I think one of our problems is we got into this open/close. No. It's phased opening, and only some things are going to be open, not every nonessential business is going to be open. And I think in many places we lost sight of that. I saw statistics or heard a statistic from the public health person in Los Angeles saying that the day they opened indoor dining and bars, they have 10 million residents in LA, 500,000 of them went to restaurants, bars, and other locations. And it's like, you want to know why you had a resurgence? You know, it doesn't take a genius to figure it out there. And those should be among the last places open, and yet, for all sorts of reasons, quite understandable, but not good. They were among the first to be reopened, and that was a mistake.

>> Howard Bauchner: The other thing that I actually think we've done well, because the epidemiology was so clear by March or April, you really have to protect the elderly. It's unbelievable. I mean their mortality rate, once you're 65, 70, 75, or 80, is just enormous. And I do think we've done a really good job in protecting the elderly over the last couple months, and I think you see it in a ratio of numbers of cases to deaths, which is much lower than it had been. So, I do think that is the one thing that we've learned and we've done relatively good at.

>> Ezekiel Emanuel: But the number of cases in the young people has gone up, and that's the disappointing thing.

>> Howard Bauchner: It's skyrocketing, yeah.

>> Ezekiel Emanuel: Yeah, yeah. No, no. We had -- I do think that is true. We did learn who was vulnerable and I think moved relatively expeditiously in that direction.

>> Howard Bauchner: I want to go back to vaccines. I think, you know, there's been a, we've published a major study from China, phase three. There's been others in the other major journals, the more experimental vaccines. They're all early optimism by everyone. You and Paul Offit, who I've also interviewed, had a piece in the New York Times a few weeks ago about the so-called October surprise. I've interviewed Steve Hahn, who I was incredibly impressed with, about the mechanism for vaccine approval, whether or not EUA, emergency use authorization will be used, how transparent they will be with the data, will they allow the external advisory board to really drive the final decision by the FDA. How are you thinking about it?

>> Ezekiel Emanuel: Well, I have great respect for Steve Hahn. I think he is a man who wants to do the right thing. I think he's under tremendous pressure from everyone, as you might imagine, and I think until you've sat in the decision-making chair of a federal bureaucrat who has to make a critical decision, you can't understand all the political pressures. But, you know, there are literally lives at stake in whether you approve something or not. There's the trust in the vaccine process. There's all the political pressure that's going to be brought to bear on him. I don't envy him one iota, and I do think he has tried to make clear that his north star is going to be, you know, we need the data, and we need to have, you know, the scientific evaluation be proper and careful. And I think, you know, I'm feeling better about it. Knowing how much pressure there can be, I can't say that I'm 100 percent confident that there's going to be no shenanigans here. But, you know, with his hand on the pillar and being forewarned about what might happen if the science doesn't drive this, I'm very confident.

>> Howard Bauchner: I have instructed the scientific community, the medical community has spoken with a single voice about this.

>> Ezekiel Emanuel: Oh yeah.

>> Howard Bauchner: That everyone needs to see the data. There needs to be transparency. He has to bring in the consultants that generally advise the FDA. As I've said, he's written for us, and I did a livestream with him. I'm hoping he's able to resist. If there are political pressures, I'm hoping he can resist them and that a decision about a vaccine in October before the election will be based upon evidence and nothing else. You're an ethicist by training. I think sometimes people forget that because you live in a world of health policy. You've raised concerns about ethical distribution of vaccines both in the United States and around the world. It's been a remarkable phenomena of development. I think the U.S.'s commitment is up to five, ten, or fifteen billion dollars in procuring early delivery of vaccines, supporting the development of the ability to produce it before we even know if it's going to be successful. It's very different than any other time in my life around vaccine development, procurement, distribution. First let's talk about the U.S. What do you think will happen in the U.S. if there is a successful vaccine and then let's talk about the world.

>> Well look. I think inevitably, Howard, one of the problems is you're not going to have enough vaccine out of the box. So, even with the advanced purchases, even with some of the vaccines being relatively easy to produce, you're only going to have tens and maybe under at the most circumstances hundred million doses, you know, call it, before the end of the year. You know, a hundred million doses is really good, but it still represents a third of the population of the United States. It's not enough for herd immunity, even under the more recent revised calculations, which I have to say, I'm somewhat skeptical of.

>> Howard Bauchner: Right.

>> Ezekiel Emanuel: Where we only need 45 to 50 percent of the population vaccinated for herd immunity. So, you know, you're going to have to prioritize, and I think that's going to be a difficult ethical decision. One thing I would say is that in that prioritization, we have to keep our eye on the ball, and I think people are misinterpreting the ball here. So, the primary goal is, I think, to reduce premature mortality of people. Now, a lot of people assume, oh, well that means healthcare workers get it first and then the people who are at highest risk get it first. That may not be true. That may not be the best way to reduce premature mortality. It may be better to, for example, immunize people who are at high risk of transmitting the virus, both because of jobs, living situations, and other circumstances. And that, I think, you know, we have to leave an open mind and look at some detailed modelling about what the best way is to reduce the premature mortality. And that, you know, we should not rush to an assumption about, you know, it's high risk people that need to get the vaccine first. So, I do think that's going to be critically important in thinking about who gets the vaccine initially, and, you know, it may or may not be healthcare workers. Certainly, at Penn, we've seen the transmission among healthcare workers, now that everyone knows how to don and doff PPE --

>> Howard Bauchner: Masks.

>> Ezekiel Emanuel: It's basically gone to zero both acquisition from patients and colleagues. And, you know, I don't know that frontline healthcare workers are necessarily the first, ought to be necessarily, the highest priority given that they can don and doff PPE effectively.

>> Howard Bauchner: Payment going to be an issue in the U.S., Zeke?

>> Ezekiel Emanuel: Well, government incentive is going to pay for it.

>> Howard Bauchner: Okay.

>> Ezekiel Emanuel: So, it's acquiring all the doses and going to distribute them. That's like, what we did under H1N1. I might say that, you know, just having the vaccine and actually having it produced is not, that's necessary but not sufficient. You actually have to put it in vials. You have to fill, finish it in a sterile fashion. You actually have to have enough syringes and needles. We take all of this for granted, but I don't think we've had any case where we're planning to do, call it 250 or 300 million people, not once, because, actually vaccines that are going to get approved out of the box are almost all going to be two shotters. You're going to need two doses separated by three to four weeks, and I think that's, you know, not a good, you know, there could be a lot of bottlenecks there, and I don't think, as far as we can tell, and we did a report for the Center for American Progress on this, that the administration has well worked out each one of the potential steps. So, that worries me as well that we're going to find ourselves, yes, we can produce the vaccines, but guess what, you know, getting them into vials, shipped out, distributed, and into people's arms, each one of those steps are prone to a bottleneck.

>> Howard Bauchner: WHO was trying to raise 15 to 20 billion dollars for world purchase of vaccines and then sort through an ethical approach to distribution.

>> Ezekiel Emanuel: Right.

>> Howard Bauchner: Let's put the money aside. Let's say you could give the WHO a billion doses, 500 million doses, where do we go from there?

>> Ezekiel Emanuel: Well, you know, they seem, at the moment, to be under extreme pressure to distribute it based upon population, to make sure that every country gets it. And that does fulfill one important ethical principle, which is equal concern for countries. But it fails, the principle I mentioned before, that you really want to minimize premature deaths on the notion that, you know, death is total deprivation, and you can't compensate people for it. And it's very severe. So, if you want to minimize the harm of premature death, you don't actually distribute it evenly among countries. You concentrate on countries that at the moment when you have the vaccine have severe, the severe hot spots and where the vaccine is going to make the biggest difference in terms of reducing premature death. And, so, I think I see a tension in their current thinking from where what I think the ethical approach is.

>> Howard Bauchner: Will the U.S., Germany, Japan, the wealthy countries get vaccine first?

>> Ezekiel Emanuel: Almost inevitably they're going to get vaccine first. I think the real question is, is there going to be enough extra to make sure that it's fairly and equitably distributed, that there's enough for low and middle income countries. Now, you know, the negative thing is that there's a lot of pressure for vaccine nationalism. We saw this, you know, and the United States on this is not unique. You know, France, when Sanofi announced that it was going to send the first doses to the United States, France went berserk. The French population went berserk. You know, wait, this is a French company. We supported you all these years, and now the U.S. is going to get the fruits here? So, you know, we need to recognize this as a very common human instinct, and I think that there are actually good ethical reasons for it. On the other hand, you know, there is this effort by the WHO, Gavi, and CEPI to create this pool of money. They will be able to buy some vaccine. In addition, you know, some major vaccine manufacturers such as AstraZeneca have pledged to distribute the vaccine fairly and equitably. And so, I do think we have a reasonably good chance of having a fair number of doses that will be distributed among low and middle income countries that, you know, left to market forces, would not be available.

>> Howard Bauchner: China has played an interesting role. We published a phase two study about a week or ten days ago. It's more of a traditional vaccine. It appeared to have adverse events than the other vaccines. They're moved rapidly into phase three, given their population I suspect they may easily report out phase three data first. The Chinese always seem to have an interesting world policy. They've invested around the world in the different ways. Can you imagine them being a world provider of vaccine?

>> Ezekiel Emanuel: Well, again, part of the issue of traditional vaccines is the production process, a little more challenging than the R and A vaccines. And so, that may turn out to be a [inaudible] factor. But, I think, frankly they're more likely to use it in a political fashion, and I think we should, you know, see that for what it is. As you know, Howard, one of the things I like to do is read and think about history. You know, one of the great American achievements, maybe one of the greatest in the 20th Century, and we had a number of them, was landing a man on the moon. And what differentiated our program from the Russian program was our transparency and the notion that we weren't pounding our chest, we're doing it for America, but that this was a world, a human achievement. And I think we need to have that expansive view on this vaccine issue because it really has to be a world view. Remember, we can immunize the United States, but it ain't returning to normal if the rest of the world doesn't have a vaccine, right. I mean you can see what's happened in New Zealand, right. They were in some ways sterile. They had, I think, more than 100 days of no cases --

>> Howard Bauchner: Right, 107 days, right.

>> Ezekiel Emanuel: Then what do you get? You know, it comes in from outside because the rest of the world isn't that way. If we want to return to normalcy, where normalcy includes air travel, it includes communication with other countries, really open borders, you got to get this vaccine around the world and not just to the United States or not just to a handful of developed countries. And I think that's got to be our approach, and that's got to be our direction. It's going to be good for us and good for the world, and sort of having a very narrow-minded self-interest, I think, is not going to be good for the United States.

>> Howard Bauchner: Bob Redfield, Tony Fauci, many others, have really talked about the tremendous concerns about the fall. I mean we're still at 40, 50, 60 thousand cases nationwide. We really would like to be under 10 --

>> Ezekiel Emanuel: Per day.

>> Howard Bauchner: Per day, sorry, per day. I mean Bob couldn't have been clearer, and Tony, social distance, masks, we have to get under 10,000 cases per day throughout the U.S. I know there's pockets. Flu comes in the fall. We have to have a massive flu vaccination campaign. Any sense, any crystal ball of how it's going to play out in the fall, Zeke?

>> Ezekiel Emanuel: I agree with them. I've been worried about the fall from day one, and I think our early evidence that when you open up indoor bars, indoor restaurants, and etc., that you get these resurgences, has to make you worried about the fall, when things get cold. Forget flu for a second. When things get cold. Now, add on flu, another respiratory virus, and you have a serious problem. And add on the fact that we have a vaccine, in a typical year only 45 percent of adults get vaccinated, and our usual, many of our usual sites of vaccination. The workplace, schools are going to be absent. We're not going to be able to vaccinate people through those mechanisms. It is really worrisome. We could use, right, we have, flu vaccine is available today. I know because on Monday I got my shot, right. Two days ago I got my vaccine, my flu vaccine. We could have used, if we had thought about it, this moment, early in the late summer, early fall, to try out a new vaccine strategy at our expanded vaccine access, if, you know, the administration had planned, okay, in March we're going to have a vaccine sometimes, we're going to have to actually, because we're going to administer it to hundreds of millions of Americans, we're going to have to have new administration infrastructure, let's test it out and give it the dry run on flu. We haven't done that, but we should begin doing that, because it's going to be necessary. I have long been an advocate of mandatory vaccination. Certainly, for under 18, we can mandate flu vaccines, I think, relatively easily. I think, you know, even for adults, and presumably a lot of employers will require this. It'll enhance the number who get it, but given the unemployment rate and other things, it still won't be universal. We do need to have everyone get a flu vaccine if they can and expanded vaccination infrastructure, the sort of patchwork we've had, a few people at CVS and Walgreens and Walmart, some at the doctor's office, some at -- that's just going to make it hard, especially on COVID, where we need to give people two, and we know a lot of people will forget or a lot of people will, you know, ignore it, not have the time, whatever it is.

>> Howard Bauchner: Drug stores, grocery stores, drive-up vaccination. We have drive-up testing. I mean when you think about a different type of delivery system, and I like the idea, try if for flu. If it works, you can then duplicate it later on. What would you envision would be kind of an efficient way. Because like the AMA essentially is close. You can't do it at work. No one is coming to work, and then you have 30 million unemployed. So, unemployment and not, people not coming to work. Work places aren't going to do it. You can't get to the doc's office without PCR testing. So, that won't be an effective model. When you say a new system, what do you envision, Zeke?

>> Ezekiel Emanuel: So, one, if I were --

>> Howard Bauchner: Vaccine czar. I'll make you vaccine czar.

>> Ezekiel Emanuel: No, I don't want to be vaccine -- just think about the major of a city, right. You've got, you bring in the heads of your healthcare system. So, you bring in your pharmacies. You carve up the city, and you basically say, all right, guys, you're responsible for these blocks, right. You know, we don't really care whether they're your patients or not. You create an electronic platform so everyone can report, and then you get the city covered by the infrastructure you have. And I think that is the important, that would be the important approach. You know, lots of other countries actually have people go to people's houses to get vaccines, and I do remember my father as a pediatrician in the '60s doing that, going to kids who couldn't come in for whatever reason and give vaccines, go to their house and make a house call and give vaccines. I think we need to think about that model today, especially because it's the second shot that really worries me. Getting people in the first time, sure. But the second, you know, maybe they get a little pain, it's inconvenient, all sorts of things can make it hard to get that second shot, and so we need to, you know, marshal all the resources, have them in an organized fashion, and assign responsibilities and make sure that they get, the people, you know, vaccinated, who they're responsible for. But I think breaking it up by geography, assigning geographies to whether it's health systems or stores or whatever, pharmacies, is probably the way I would go at the local level.

>> Howard Bauchner: I've always said I thought [inaudible] --

>> Ezekiel Emanuel: Nationally, you know --

>> Howard Bauchner: Go ahead, nationally.

>> Ezekiel Emanuel: Nationally, they're not going to have responsibility. They're going to basically, yeah, we can supply you and we can make sure that the supplies get to you, but then they'll have, the federal government doesn't have the capacity to actually administer this.

>> Howard Bauchner: It's interesting. I always thought that the hardest medical job in the America was to be FDA director. I thought the last couple months it was probably Dr. Fauci's position. I think the hardest medical job in America for the last six months has been being a mayor of a big city. I feel for every one of the mayors who were thrust into these enormously complicated decisions with experts disagreeing. Not a lot of certainty about what to do, so I really feel like the mayors of the major cities, it's been a very, very difficult six months, and you're not going to have a lot of money come the fall, which will be --

>> Ezekiel Emanuel: Right, and Howard, they don't, they control some variables, but they don't control a lot of the big variables. So, you're responsible without all of the capacity to answer like getting PPE, getting ventilators, hospital surge capacity. So, I do think it's been a very challenging time.

>> Howard Bauchner: I want to return to one or two scientific questions. So, you know, the recovery trial really championed steroids. Now, there's a number of other steroid trials that will be reported out in the coming days, which is good. Remdesivir had some positive effects, not overwhelming. And I think there'll be some additional remdesivir trials. Many other trials ongoing. But the new kid on the block was this morning, yesterday, and the day before, convalescent plasma, 30, 35,000 patients treated with it. It went up on a preprint server. And then, according, at least to a report this morning, Drs. Collins and Fauci have expressed their concern that the observational data is not very clear. A sense of convalescent plasma, how this is just playing out, Zeke?

>> Ezekiel Emanuel: It shows you can get a lot of people but not have a well-designed study. I have to agree with Dr. Fauci, you know. I just don't understand the study. You have no placebo control group here. So, what are we supposed to make of this? They wanted to have a sort of difference indifference by how long it got delayed that people got it and then convinced themselves that, you know, if they got it later and it didn't make as good effect that, you know, that was sufficient proof. I don't think so. And so, the impact, you know, you don't know how to understand it. Because how you decide or how it was decided when people get it is very subjective, and one of the subjective factors may be who's likely to do better and who's likely to do worse, and you can't control for that. And so, I think the data are very hard to interpret, and it's certainly, I think, impossible to make a definitive judgment on whether to recommend the stuff, you know. If it were free, all right, but it isn't free. It's expensive, hospital based. I have to say, one of the things that does concern me, Howard, about a lot of the opening trials is that they're not easy things to administer or cheap. Right. We're going to now have monoclonal antibodies.

>> Howard Bauchner: Right.

>> Ezekiel Emanuel: Great. You're not going to, hard to produce, hard to produce in large quantities like remdesivir, and they're going to be pretty expensive and institutional-based therapies. We need things that are much cheaper. You know, if we, you know, get dexamethasone early on and it does have kind of the similar effects as it did on critically ill patients, that's a cheap, you know, oral medication. That's a very different scenario. But I think, you know, one of the disappointing factors to me is a lot of these early trials are going to report very expensive items, interventions, that have to be administered in hospitals, maybe financially lucrative, but it's not the kind of thing that can be scaled effectively or easily it seems to me. And certainly, it can't be used in the prophylactic or for mild cases.

>> Howard Bauchner: Right. The other issue is that many of them were struggling to enroll patients, and so many may end up reporting preliminary results that are underpowered, which will even make it more difficult to really understand the true impact for various reasons.

>> Ezekiel Emanuel: Knowing what recovery did in the UK and the fact that we're underpowered on these trials when we have, you know, thousands of cases a day --

>> Howard Bauchner: All these cases, right.

>> Ezekiel Emanuel: Throughout the country, that's disappointing.

>> Howard Bauchner: Zeke, last question. It's more of a political question. I don't think you'll be shy about it. This would have been difficult regardless of who was President. It really would have been. You know, we're a country that has free speech and we champion it, and people are allowed their opinions, but we haven't allowed good public health measures and science to win out, or it's been a struggle, let's put it that way. I mean, you know, for the first time about a month ago, you know, we finally saw a fair amount of the leadership both in democrat and republicans masking, finally saying it needed to change. Bob Redfield on my show couldn't have been clearer. We have to socially distance. We really have to mask for six weeks. We have to get the number of daily cases down or the fall will be a nightmare. You know, virtually all of the medical leadership has now spoken with a single voice, but we have struggled with the public. Is there a way to change that?

>> Ezekiel Emanuel: I think there is a way to change it, but, you know, the CDC has known about public health communication well before COVID. They knew what worked. They had proven what worked. They had a whole manual on it, and we violated almost every one of their requirements. You know, you have to be consistent, speak with one voice, and repeat the message over and over, and make sure that all the people who are looked up upon by society, whether they're, you know, political leaders, they're sports stars, they're movie celebrities, they're other people, who just, you know, business leaders, they have to speak with the same voice, and you have to get them together. The effort to create a common message and to get every leader to speak and reinforce that common message, whether it's by Instagram or tweeting, we didn't do that. Could we do that? Well, we certainly are going to have to do it around vaccination, and I think we're going to have to, you know, I hope that with the change in leadership we'll be able to get that done with the federal government leading and someone at the White House calling every celebrity, athlete, business leader, everyone they can think of to reinforce that message and reinforce it over and over. I mean one of the other things we know from communications studies is that, you know, one message isn't enough. I think it was Richard Nixon who said, you know, you say it once, you say it twice, you say it seven or eight times. You're sick of it, they're just beginning to hear it. And I think that's one of the things we know. You know, you have to repeat and reinforce what you're saying in many, many different venues, and in the United States these days, many, many different languages, to many different communities, with many different speakers. And I think that's just going to be critical. Yes, I do think we can retain it. Are there going to be people who constantly will criticize and chirp from the sidelines? Yes. We have to make them a minority and marginalize them by showing that actually doing these things is effective. And I think, you know, part of the problem is people put the mask on, you know, and they don't see an effect for six weeks.

>> Howard Bauchner: Yeah, right.

>> Ezekiel Emanuel: And that, we have to prime them for that. It's not immediate, you know. You don't put a mask on and suddenly it's gone from your, COVID is gone from your community. It doesn't happen that way. And so they have to know what to expect.

>> Howard Bauchner: Yeah, preventive medicine has always been difficult. Is normalcy, is normalcy going to be in 2021 or not until 2022?

>> Ezekiel Emanuel: Well, I've maintained November 2021, I think round about that time. So --

>> Howard Bauchner: You think a year --

>> Ezekiel Emanuel: You know, hopefully, we'll have enough normalcy so we can start the fall with in-person education and more in-person opening up of many, many more nonessential businesses. I think that's the key, and then, you know, when we have the 70 percent of the population or whatever the herd immunity number turns out to be immunized, then that'll be round about November 2021, January 1, 2022.

>> Howard Bauchner: This is Howard Bauchner. It's been Conversations with Dr. Bauchner. Really, my favorite guest, Zeke Emanuel. He's been a member of the JAMA editorial board. He's been so helpful in educating me about so many different issues. He's the Vice Provost for Global Initiatives and Chair of the Department of Medical Ethics Health Policy at University of Pennsylvania and the Diane S. Levy and Robert M. Levy University Professor. As always, thanks so much, Zeke.

>> Ezekiel Emanuel: Thanks for having me on, Howard, and again, thanks for that compliment. Really appreciate it.

>> Howard Bauchner: Really, stay healthy.

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