Rochelle P. Walensky, MD, MPH, of Harvard Medical School and Massachusetts General Hospital returns to JAMA's COVID-19 Q&A to provide an update on developments in the pandemic. She is a signatory of the recent John Snow Memorandum emphasizing the importance of public health interventions to manage the spread of COVID-19. Recorded October 22, 2020.
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>> Howard Bauchner: Hello, and welcome to Conversations with Dr. Bauchner. It's Howard Bauchner, Editor-in-Chief of JAMA, and I'm here with one of my favorite, and one of my most engaging guests, Rochelle Walensky. Rochelle is Chief of the Division of Infectious Diseases at Mass General and professor of medicine at Harvard Medical School. Rochelle, thanks for joining me today.
>> Rochelle Walensky: Thank you so much. Always a pleasure to be with you.
>> Howard Bauchner: So, let's start. This is IDSA week.
>> Rochelle Walensky: It is. It is.
>> Howard Bauchner: And I know you pay homage, the ID community pays homage to one of my favorite people, Tony Fauci. Could you just say what that was like? I know that tribute kicked off IDSA week.
>> Rochelle Walensky: So, IDSA this year has a program called Chasing the Sun, and it's 24 hours of programming from all over the globe that happened between yesterday morning and this morning, and Tony Fauci kicked it off. Who better, of course? And what was so beautiful about it, as it was streaming, of course, it was streamed, was the chat box, and the chat box was just in constant flow of gratitude and tribute and enthusiasm for Dr. Fauci and what he stood for and how he's been a voice, a very public voice, a beaten-down voice, for our community, and I will just echo those thoughts here and say we are so very grateful to have him as our leader and to have him doing what he's doing in the face of a lot of adversity.
>> Howard Bauchner: A national gem. So, so many topics. Let's take them one at a time. See what questions come in. So, over the last couple weeks, this concept of herd immunity, which has been around, and we just published a paper for Omar Assad on it, and Ed Livingston did a podcast with him. But this notion of herd immunity has, once again, blossomed in the United States for a host of different reasons. You know, there were early reports whether Sweden was kind of, in part, pursuing herd immunity, whereas the rest of the country hasn't. And then, there was this declaration called The Great Barrington Declaration, signed from some very prominent individuals, not just from people who are advising the White House, and then I think it's called the Snowden Response which you signed, which I found. I'm not sure everyone knows who Snowden is. Can you just talk about the issue, in general, and one of the things I would like to avoid, there's been some angry back and forth between these groups, and I'd like to avoid the anger, because I worry that that follows the same rancor that we've seen through public health. I think this is worthy of discussion, and that's where I'd like to go with it. So, could you just talk about this, in general, Rochelle, because it's really on the front page of the newspapers.
>> Rochelle Walensky: Right, so, first thing is that herd immunity has never really been used as an infection plan. Like we don't try and give people herd immunity so that we can sort of end a disease. Herd immunity has always been a vaccination plan. So, it's interesting to sort of see this twist of how people are talking, well, maybe we can use a massive amount of infection and give it to people who might very well do fine with this disease, and that would sort of get is somehow out of this. You know, Sweden started thinking about this in March and that maybe generally healthy young people would do okay. I think they showed it failed. I don't think they were able to take the vulnerable people and somehow protect them and then take to help the people who were going to do well and somehow give them the disease. I think there were lots of cases in nursing homes. I think the, you know, the that's per million in Sweden were high. They rivaled that of the United States until they realized that that plan wasn't working. So, I will wholeheartedly agree with you, and one of the things that I think that's so interesting about this is that the people who put forward the Great Barrington Plan, this plan first herd immunity in the United States through a pathway of infection, are really extraordinarily smart, respected infectious disease epidemiologists. So, I want to just sort of set the table with that, but I fundamentally agree with their concept. And so, what I believe is, you know, the CDC has said about 47% of adults in the United States probably have some comorbidity that will put them at increased risk. It's not like all the people with increased risk are living in isolated nursing homes. They're just not. The other thing is that I think there's kind of two different flavors of vulnerability. There's vulnerability because of your comorbidity, and there's vulnerability because of your socioeconomic status, because you work as an essential worker, because you live in a multigenerational household, because you live in crowded conditions, and all those things make you vulnerable, as well. So, I don't really understand how we could simultaneously protect the vulnerable in our current society and somehow get to herd immunity through a pathway of infection, and I think that pathway is just going to lead to a lot of death.
>> Howard Bauchner: Just two quick comments, and then, you can reflect on them, and then we can go on. Firstly, I've read the Great Barrington Declaration, and it lacked detail, which is always a problem. How do you get from here to there? And we can talk about that around vaccine distribution, but how do you get from here to there? But part of the struggle has been, and I think, we know that taking out asymptomatic and rare events, children and young adults generally do well, but they don't live in a box. It's not like the NFL or the NBA. I mean, teachers are older, but the parents and grandparents of young people and children, their social network includes people at risk. I think, so that to me, is one of the central struggles, and we've seen the tension in schools already with teachers both in schools, as well as colleges saying, "I'm at risk." And in addition, in college, those college students are in communities with high-risk individuals, but the other is that I think people have ended up equating this pursuit of herd immunity with keeping the economy open. And I think the one thing that Tony's tried to do is to say it's not either or, and I think we've gotten trapped in the six-month discussion of either reducing exposure and death or opening up the economy, and I think that has been a real struggle, and I think that's what people have pushed on with respect to herd immunity.
>> Rochelle Walensky: Right, you know, to your first point, I think that we have sort of gotten -- we've gotten a mixed message here, because I think one of the things we keep hearing is young people do well, and it is true that young people do well compared 85-year-olds. What's not true is that young people do well with COVID, in general, compared to how young people do in a community without COVID. So, there was a piece in MMWR this past week that showed that the deaths among young people have increased by 50%. I mean, young people are not supposed to die. So, I think it's fine to say young people do well compared to old people. That is true, but I think we really do need to understand that young people are also dying, and they're dying at a higher rate than they normally die, and that's because more of them are getting COVID. So, I think we need to sort of reshift our framework as we think about young people's deaths, because yes, they're much rarer, but they're much more common than they should be. Your second point was about the economy. You know, I do think that we know the best prevention measure for this disease, and I think we know how to appropriately tackle it. I think the grocery stores are probably doing fine, right? People are getting the groceries. They're going to the grocery stores with their masks on, and there's not a lot of transmission that we're hearing about the grocery stores. There are pieces of this economy that I think if we do well, if we wear our masks, we can maintain, and I think we do well and where are masks all over the place, we could get to opening the economy quicker. I do, personally, really struggle with having bars open and schools closed. I just don't think that reflects the values of what I think our country should have right now. I recognize that keeping bars open keeps an economy open, keeps people employed. I recognize all the downstream impact of not having the bars open, but I do fundamentally think we have to get in a place where we can safely get our schools open and then think about how we open the rest.
>> Howard Bauchner: Let's go onto another topic. So, a few days ago, we published the second of Steve Woolf's research letters about excess deaths, and then interestingly, the CDC published something. It's virtually identical to Steve's. I called Steve. I go, Steve, was this your report? I got a little confused. I mean, both reports through October warned 300,000 excess deaths, about 200,000-220,000 attributed directly to COVID 19, and then, the rest could be for other reasons. I once again estimated this morning, based upon the last week's data, we will be above 400,000 by the end of this year. We will be above the deaths from World War II, and from my standpoint, it's the excess deaths that I think is the number that people should really try to understand. So, it will be somewhere above 400,000. The number of cases the last two weeks are not surprising, but enormously concerning. The report this morning is over 1,000 deaths yesterday. We know that as cases increase, the number of deaths increase. A number of people have said the next two months may be the darkest since the pandemic began. Rochelle, any sense of the coming months?
>> Rochelle Walensky: So, I have a whole slew of concerns there. One is for us to understand the excess death, I think we also need to understand that they're not all COVID, and that there's, you know, secondary bad outcomes that are happening just because of COVID, and this, actually, it's back a little bit to the Great Barrington Declaration that he, you know, for months everybody heard the term "flattened the curve." That everybody knew that if our hospital systems couldn't handle these volume of patients, that it wasn't just COVID patients that were going to suffer. People were not going to come when they had hospital needs, and I think some of that excess death is what we're seeing. So, I really want to make sure people understand that only 2/3, I mean, that's a lot, but only 2/3 of those were COVID related. And so, 1/3 of people of those excess deaths were not coming to the hospital, were not manifesting, or had delayed cancer diagnosis, all of these things, and if we get to a place where we, you know, have these surges that you're seeing, and we outstrip hospital capacity, I think we're really going to be in trouble. The other thing that really concerns me is I think these cases that we're seeing mid-October, now we're late October, reflect, you know, probably transmissions that happened two weeks ago, right? So, in most of the country, our weather was still pretty good. And so, you know, I have been saying stay outside for as long as we can stay outside, but, you know, October 7th wasn't a bad week of weather in the Northeast. I know that, you know, Wisconsin and other places that are really having a hard time. It was way colder there. But, you know, that does speak to what is going to happen a couple of months from now when we really can't go outside?
>> Howard Bauchner: Yeah, you know, on this conversation with other people, we've talked about the need for everyone to get vaccinated by flu. So, will coaches put that aside. Please, please, if you're listening are your friends or your relatives, please get flu vaccine. There's a few questions that came in that I mentioned we were going to talk about. So, let's move on to treatment. Now I'd like to look at treatment in two or three different ways. I think everyone knows we're done with hydroxychloroquine, both JAMA IM published a really high-quality, randomized trial about prevention and healthcare workers from Penn. There's been hydroxychloroquine papers in JAMA and New England Journal about treatment of seriously ill individuals. I think there's a couple more to report out, finalize, RCT. So, we're done with hydroxychloroquine. We obviously published the meta-analysis of seven clinical trials for steroids, and then, three of the trials. I think, without doubt, corticosteroids are the standard of care for people with serious illness. Sticking with serious illness, where are we with remdesivir and toci?
>> Rochelle Walensky: Wow, I wish I had better news sort of in general. We're like nine to 10 months into this, or 11 months, if you take the Chinese experience, and the only thing we see with a mortality benefit is the dexamethasone right now. So, and I suppose that's good news, because it's readily available. It's cheap. It's not going to create disparities of care. We can give it. We know its side effects. So, there's some sort of sparkle there. Remdesivir is hard. So, there are underpowered studies in China that demonstrated no mortality benefit. There's the ACT-I that demonstrated a decreased hospitalization duration but not a mortality benefit. We have, you know, the preprint of the Solidarity trial, which was not blinded but did not show a mortality benefit. And so, you know, I think, the asked one people it wasn't blinded. You know, we don't have duration of disease. There are a lot of things that we don't have that ACT-I was able to get, but it was a bigger study. And I am -- I think we need more data. I think we need more data. We don't know the long-term outcomes. I just think we need more data.
>> Howard Bauchner: Yeah, the other issue that happens, and I've spoken to other ID and critical care physicians is that the question changes. Now the question really is what does remdesivir add to corticosteroids? Because corticosteroids is the standard of care. So, the real question is, so, you have to do a new trial that is really remdesivir plus steroids in the critically ill? So, in some regards, as we get some information, the questions change, and that makes it difficult, admittedly, for physicians caring for patients as well as investigators.
>> Rochelle Walensky: And that's only going to get more difficult when we think about vaccines.
>> Howard Bauchner: Right, and in addition, we no mortality rate is generally gone down. So, your sample size calculations for the hard outcome of mortality is going to become even more problematic. Let's back up -- go-ahead. Go-ahead.
>> Rochelle Walensky: The value of those hospital days is really interesting. If all things were entirely equal and all remdesivir did was decrease those hospital days, and actually doesn't have a huge value to the individual. That has some, of course. We don't like being in the hospital. But the value is actually to public health, because we need those beds.
>> Howard Bauchner: Right.
>> Rochelle Walensky: So, then, how much are we willing to pay for that?
>> Howard Bauchner: All right, let's back up, because there's been -- we all know, you know, the focus early on was on critically ill individuals, and as a society, we know that there's more cases, less stats. We've done a better job protecting the elderly. We've done a better job with general care, as mortality has come down. Even age-adjusted, it's come down, but we really are trying to prevent people from going to the ED, the emergency department, and then getting hospitalized. And there, there's different therapies that are coming online or are here. So, remdesivir early in course, I guess that would still be inpatient, but remdesivir early in the course of someone hospitalized, and then, of course, people are waiting to really understand the potential impact of monoclonal antibodies, and both remdesivir and monoclonal antibodies are going to be expensive.
>> Rochelle Walensky: Right, so, you know, the EUA actually says anybody in the hospital should get remdesivir. Anybody who's in the hospital with documented or presumed COVID should get remdesivir. The NIH guidelines actually don't say that. The NIH guidelines say if you have moderate disease and, you know, low O2 sat. So, you know, I think the indications are different. I haven't seen a lot of data that says -- I haven't seen any data that says that that early is when we should be giving remdesivir. One could imagine if it's going to work against the virus and not against the inflammatory response that sooner is better. And then, of course, we get to the monoclonals. You know, this very much mimics what happened with HIV where the hospitals were full of HIV people dying. So, we focused on the dying people in the hospital, but now we want to talk about what's happening before the hospital, because wouldn't it be great if we didn't have to have this severe disease? You know, well, remdesivir is an IV infusion. So, how we do that logistically, I know there are other studies using it with aerosol nasal sprays, and whatnot, but the monoclonal antibodies are also an IV infusion. And so, how we are going to deliver those in/among outpatients in a wide scale of people. We know now that, you know, somewhere between 5-30% of people get hospitalized with COVID. What about the 70-95% of those who would now be eligible for monoclonal's if it, in fact, does decrease your disease progression, right? It's a massive, a massive endeavor to try and think about who would get it? How would we deliver it? How we would roll it out? And how we really, importantly, wouldn't exacerbate disparities in care, in terms of how we give it.
>> Howard Bauchner: Yeah, costs will be high. I mean, remdesivir, when it's given in the hospitals, usually ends up becoming part of the hospital charge. Not true?
>> Rochelle Walensky: Well, it does, but I mean, if you think about who's been impacted by this disease, it is people who are older, might be on Medicare, and people who might not have insurance. So, people on Medicaid. So, yeah, it's lumped into the hospital bill, but I think it's the taxpayer paying for it.
>> Howard Bauchner: Oh, that's absolutely the case. Sorry, I think once you get into the hospital, I think most hospitals, if they feel like there's an indication, they will give it. I haven't seen data about remdesivir, in terms of disparities, Medicaid people not getting it versus people with private insurance getting it. It just may be an issue of supply. Monoclonals are entirely different, even if they can be given in the outpatient as an IV prep, when you're mildly ill when you go to the wing of the hospital that allows you to get it and go home, access costs and equity will be a huge issue.
>> Rochelle Walensky: A massive issue. Not to mention I mean like that wing of the hospital that gives IV infusions is usually giving IV infusions for chemotherapy and, you know, rheumatologic agents that immunosuppress you. So, the physical plant is actually not trivial. Where those physical plants will be located, whether they will be in, you know, underserved communities. You know, that, I think, is a huge issue. You know, we see this with outpatient antibiotics. In the old days, when people went home with linezolid and they came, you know, as soon as they went to the pharmacy, they called you and said, "There's no way I can afford this drug." So, you know, the same thing is going to happen. This is an outpatient drug. Somebody is going to have to pay that bill. There's been a lot of discussion about what the government will pay for vaccines. No discussion about how the government will pay for monoclonals. I think it's going to fall to the patient.
>> Howard Bauchner: Let's now talk to the true primary prevention, herd immunity approach, which is vaccines. You know I'm a pediatrician. So, I've lived vaccines for most of my career, and I've spoken to so many people. I've seen the announcement the last week or two. I think people are encouraged that Steve Hahn and others at the FDA have been clear. The decision about vaccines, from their perspective, whatever the executive branch decides to do, they have no control over, but that the FDA is going to go through their normal process of considering an EUA. Different companies have made different announcements, and then, they will include the FDA Advisory Panel in that process. I think whether they include ASIP, or give that information to ASIP, the Advisory Committee on Infectious Disease Practices is uncertain. I was a bit disappointed when one of the companies, I think it was the companies, I think it was Moderna, announced, "Well, we'll get our EUA in December." I think that's the wrong messaging. I hope they would learn to say, we're applying for the EUA. Because I sort of feel like it gives a really uncomfortable message to the public, like who's making the decision? Moderna's not making the decision about whether or not the drug should be licensed. The FDA is. Whereas I think a different company, Pfizer, said we will apply for an EUA, and I think the report yesterday in one of the outlets was acceptance of vaccines is under 50% now. Not reassuring. General comments about vaccines. I'll have more specific comments, general thoughts/comments.
>> Rochelle Walensky: Yeah, I think, you know, first of all with regard to that single message that you said. You know, people come to me in my research world and they say we want you to show that our intervention is cost effective. And I said, if you want to engage in a cost-effectiveness analysis, you have to [audio cuts out] like let's not lead with the conclusion, right? If the data are truly blinded, we have to say they are truly blinded, and we are hopeful that we'll have some results by some given period of time. But to end with we're going to have an EUA, I think it's just entirely inappropriate. I think we need to make sure that the public understands. I think the scientific community does understand, but I think we need to make sure that the public understands. First of all, everybody wants to know, "When can I go out to eat again and when can I take off my mask?" And I don't see a path to that through at least '21, maybe '22. Maybe we'll be going out to eat, but you know, I think we're going to be with masks for a long time.
>> Howard Bauchner: I don't mean to interrupt, but this point has been made over and over, and I think it's worth making over again. Can you say why that's true, even if vaccine gets to 70% of the population?
>> Rochelle Walensky: Okay, so, let's actually just do a few pieces of easy math. If we presume it works and 50% of the people and 50% of the people get it, when you get it, you don't know if you're going to be the one who it worked in, and that's only 25%. Now let's actually think through how long it's going to take to distribute. So, if you sort of think about the distribution 660 million doses, because you have to give it twice, at least the two leading front runners, right? That's probably -- that's an extraordinary number of people to do in and extraordinary short period of time. Plus everybody needs it twice. So, you know, and if you presume that it actually doesn't work until, you know, you've got both doses and two weeks later that it's not actually kicking in for another six weeks after you've potentially gotten it. So, I think once you think about all of those competing issues in terms of the rollout and the coverage and the efficacy and the delay for it to actually work, we're going to be at a year if not two.
>> Howard Bauchner: Okay, now the National Academy of Medicine's already come out with their recommendation. We've interviewed a number of people about it, Michelle Williams from Harvard School in Public Health and Larry Gostin has written a piece about it, because there is quite a bit of priority for at-risk communities, and they want to make sure that at risk communities is not simply based upon race alone. They're concerned that that will be challenged in court quite quickly. So, there's social scales that have been developed. It's going to be rolled out in phases, which I think was a better term than tiers or priority. I think that choice of words is very important. ASIP is meeting, I think, Friday. They're likely to have similar recommendations as the National Academy of Medicine. Phase 1a is healthcare workers, estimated 20 million, hospital based, maybe nursing home, skilled nursing homes. I think that rollout, if the vaccine can make it to the hospitals, will be okay. Hospitals know what they're doing. They can store it. They can give it. They can enter it into the medical record. They can track individuals who've gotten it. So, for postvaccination surveillance. If you can't track, you're finished. The next 100 million is a huge problem. Can you, in your mind, imagine if you have high-risk communities. You're at Mass General. I was at Boston Medical Center. We're surrounded by high-risk communities. How do you get vaccines to community health centers, to practices, that storing these complicated vaccines is difficult. How do you imagine that working?
>> Rochelle Walensky: Yeah, I mean, I could see a pathway for how you get a vaccine. How you get these vaccines, I think, is a whole another story, right? I mean, these vaccines that need a cold chain to minus 70, that can't be thawed for longer than six hours, that need to have some documentation of you've got vaccine A, and therefore, the next time you come, you need vaccine A. I think it's going to be an extraordinary effort. It's not going to be your standard CVS's, or least your CVS's the way we know about them right now, because they're going to need to have minus-70 freezers, and a lot of them. I do think, you know, I want to be very careful to talk about healthcare workers, because I think when people think healthcare workers, they think frontline doctors and nurses. When we think about our highest-risk healthcare workers that may be, you know, our cafeteria workers, our environmental service workers, who, in fact, may come from higher-risk communities, and if we're all wearing masks in the hospital, they may be at higher risk. So, I want to make sure that we're encompassing, when we talk about healthcare workers, the techs, the, you know, all of the healthcare workers, not just the ones who we envision or is the typical vision of a healthcare worker. I think the communities are really going to be interesting. You know, one of the things, I think, that's really challenging here, every poll we hear it's the people willing to take this vaccine keeps going down. That's not optimistic, right? Of vulnerable communities, I think, is really a challenge, and what often happens, this happens a lot for women in medicine, is it becomes the more vulnerable community. They have to solve the problem. Like we're going to have the vulnerable communities solve the problem about why they don't want this vaccine, and that's not okay. It's all of our responsibility to solve that problem. You know, the folks in, you know, at the same time that we're trying to encourage vulnerable communities to want to -- to trust science and be involved in the vaccine rollout effort and be involved in these clinical trials is the same time that health insurance, their health insurance, might be threatened in the Supreme Court. So, like, those are conflicting messages for them to receive and for them to think about in terms of rollout of something that we need them to trust.
>> Howard Bauchner: You know, a vaccine goes from a manufacturing plant, and apparently, they're already manufacturing some of these vaccines, awaiting potential approval by the FDA. And then it goes to a shipper. I know McKesson is one of them. Do you have any idea? You know, McKesson gets 10 million doses. How is McKesson going to decide how to distribute it around the country?
>> Rochelle Walensky: I think November 3rd will have a lot to do with that answer. I really, you know, if I were to say how did remdesivir go, in terms of distribution, it didn't go very well.
>> Howard Bauchner: Correct.
>> Rochelle Walensky: And so, I do think that we won't have -- we'll know in a couple of weeks as to who's going to be leading the distribution effort, and I think that that's actually going to be very telling. I do think that if we have a central, national, coordinated response for distribution, one which I have not yet seen, and one that hasn't gone well for PPE, necessarily for ventilators, necessarily for remdesivir, I think we need that effort for this. It's critical. I do wonder whether -- let's say in, you know, early '21, we have two potential vaccines that we could use, let's just say that. Would be the case that, you know, Massachusetts or Illinois would get just vaccine A? So, that when we re-vaccinate, we know it's just with vaccine A. Of course, you have people crossing state borders. That makes it a little bit more complicated, but is the plan to give all states both vaccines? Good luck on your medical record keeping. Or will they distribute them in some sort of geographic way, so that we have a little bit better idea of who's gotten what?
>> Howard Bauchner: Right, the complexity of the decision-making is enormous. So, the highest-risk individuals, we know, are the old and the frail, and they don't exist in equal percentages around the country.
>> Rochelle Walensky: Exactly, 17% of Florida is over 65.
>> Howard Bauchner: Right, so Colorado and Minnesota look very different than Florida and Mississippi and Alabama. And so, I hope there's really wise people who've begun to think about this. One other question, and then, well, actually, two other questions. So many career scientists at the Centers for Disease Control have been pained by what's happened over the last six or eight months, just extraordinary individuals who committed their career to serve the population of the US and the world at the preeminent public health agency in the world. How do you think about beginning to restore its reputation?
>> Rochelle Walensky: Again, I think a lot depends on what happens on November 3rd, whether there's a motivation to restore the reputation. I think, you know, if we are in for another four years like the last four years, they may not be there very much longer. I think you can tolerate this for four years. I'm not sure those incredible public health servants who can't do their job, they literally can't do their job. They can't serve the public and the role that they're currently in, may not last there. That pains me to say. I do think that if there is an administration change that we need some like really trusted people coming back into light. There are people around this country, you've seen them all over the news. You've seen them. They've seen many of the past leaders of the CDC have had joint voices. Other HHS secretaries have had joint voices. I think we need those voices to come back. I bet some of them would be willing to serve again, people who we know have done an exceptional job and have led this country through Ebola pandemics -- or Ebola outbreaks and H1N1 and, you know, Zika and things that really have been challenging, to lead their voice again and to know that for the public health servants in those institutions to know that their leader is behind them and that their leader would do what's right.
>> Howard Bauchner: Only once since I've been at JAMA have I used our social media distribution channels for a personal note. Our scientists need to be left alone, from Tony Fauci to people at the FDA and the CDC, and the executive branch, it's been very difficult over the last six or eight months, to see [inaudible] relentless attacks by the president on individuals, as well as institutions, and if President Trump is reelected, somehow I hope he learns that in the long run, that just adds to society chaos. I want to finish with one question. When you look back over eight months now, nine months, what have been the biggest surprises for you, Rochelle? I mean, you're an infectious disease individual, incredibly well-trained, very articulate. I mean, people have always been worried about this kind of, I call it the Great Pandemic of 2020. People have always been concerned about it, but now it came. What's been the biggest surprise for you?
>> Rochelle Walensky: Well, I guess, I mean, some of these are not surprises but more like lessons learned. Mine is, of course, humility, right? Like we didn't know about this thing. We thought we knew coronaviruses. I don't think anybody expected this to have the amount of asymptomatic transmission that this had. I think it's the Achilles' heel of our response is that we don't know. You know, it's actually true of HIV, as well, and if we just knew who to test, then we would be testing them, right? I think that asymptomatic transmission, the pre-symptomatic and asymptomatic transmission has been one of the surprises. We aerosols, I think, was another surprise. We thought we knew how respiratory viruses generally work. We thought it was going to be droplet, and it turns out, you know, a lot of aerosol, and we've learned how much aerosol is emitted when people sing, and when people play trumpet and all sorts of things. You know, things that we didn't have our finger on the pulse of, in terms of respiratory viruses. If anything comes out of the, anything good comes out of this, and there have been some silver linings, I do think it's the protection of our vulnerable populations, and I mean that sort of based on comorbidities, but really, more importantly, this intersection of Black Lives Matter, attention to the racial injustice, and this pandemic. I sure hope we learn that lesson, and that he has just been so sobering for me, as we see the kinds of patients who are coming in our doors, the demographic distribution of them. And then, I think one of them has to be communication. I generally say that when everybody is well-intentioned and things don't go well, it's only because of communication. And so, I do think that communication has been an extraordinarily important part of how we have done good and how we have failed, and I just think that's key.
>> Howard Bauchner: I did a course for my friend, Larry Gostin, yesterday, and there were quite a few public health individuals and me, and I was thinking about communication, because we talked about it. You know, CDC has a kind of public health communication book. You know, where they train a lot of people how to communicate messages appropriately, and I was reflecting on some people's comments yesterday, and I realized, I'm not sure the playbook now with social media, podcasts, conversations, the playbook is the same as it was even three, four, five years ago. And I think one of the things we really need to think about is how do we communicate public health messages where there's an appropriate social media world out there? That's not going away, and everyone's not going to agree, and I don't think we've sorted out when there's a basic disagreement about facts, when there is a fact. How do you just say that's wrong? That's not true. I just don't think we have figured that out, and in general, most public health decisions and physicians and other clinicians don't want to be confrontative. And that may not be the appropriate approach going forward. We may have to figure out a different way to tackle public health messaging, vis-a-vis print news and social media.
>> Rochelle Walensky: And I think it's true both for, you know, for our spoken word. I think it's true for how we model our behaviors. I also think it's true for how we disagree, as you have said. You know, the college campuses are a really important story here to say, who's to blame when these kids are not -- and why we calling it blame, when there's an outbreak on a college campus? Is it because the administration didn't do their job, or is it because the kids did what kids do?
>> Howard Bauchner: This is Howard Bauchner, Editor-in-Chief of JAMA. One of my favorite guests, Rochelle Walensky. Rochelle's a professor of medicine at Harvard Medical School and Chief of the Division of Infectious Diseases at Mass General. Rochelle, thanks so much for joining me. I know it's IDSA week, and you had to carve out some time, but it's so much appreciated.
>> Rochelle Walensky: It is my pleasure to be here. Thanks so much for all you're doing.
>> Howard Bauchner: Stay healthy. Buh-bye, Rochelle.
>> Rochelle Walensky: You too, bye.
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