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Incoming Centers for Disease Control and Prevention (CDC) Director Rochelle P. Walensky, MD, MPH, returns to JAMA's Q&A series to discuss her vision and priorities for the agency and changes in its pandemic response strategies, when she takes the reins on January 20. Recorded January 19, 2021.
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>> Howard Bauchner: Hello and welcome to, Conversations with Dr. Bauchner. It is Howard Bauchner, editor-in-chief of JAMA. What a privilege today to be introducing Rochelle Walensky. Rochelle, I'm not quite sure how to introduce you because I -- I -- you could be in Never Never Land. You -- you were or are a professor of medicine at Harvard Medical School and you were Chief of the Division of Infectious Diseases at Mass General. But sometime tomorrow, I think you told me 12:02, you will become director of the Centers for Disease Control and Prevention, so welcome. Are you in Never Never Land, what -- when -- when does your formal position start?
>> Rochelle Walensky: Thank you so much. It's such a gift to be back and so thank you for having me. Yeah, I think you're -- you're sort of talking about the snowman's land the way I'm feeling it. Certainly, I will say tomorrow, I will -- I have every plan to be the director of the Centers for Disease Control and Prevention and what a privilege and honor that will be for me. Right now, I'm -- I'm just working really hard so I'm not exactly sure who gets to claim me, but what I will say is I've been doing a lot of the work of the trying to get up to speed, and making sure that we're hitting the ground running starting tomorrow.
>> Howard Bauchner: So, on behalf of JAMA, and I think much of American medicine, one congratulations. And I -- I don't think we could have been blessed with a -- a more effective -- what I hope will be effective and true leader of the CDC, so congratulations.
>> Rochelle Walensky: Thank you very much. Thank you very, very much.
>> Howard Bauchner: So, let's take it in a series of challenges -- challenges for the CDC.
>> Rochelle Walensky: Wow. So, there's -- there are -- you know, how -- how do I start? So, the -- there are challenges that I think we can sort of look internal facing and say, like, how is it that I make sure that the people who are there -- these incredible scientists, these incredible civil servants for their entire career, understand and feel the value that we should be giving them? They have been diminished; I think they've been muzzled that science hasn't been heard. This top tier agency world renowned hasn't really been appreciated over the last four years, and really markedly, over the last year, so I have to fix that. The good news in my mind is there hasn't been a mass exodus of the talent, the talent is still there. And so, really, what I need to do is -- is make sure that those voices get heard again, that I'm leading with trust, that this science is actually conveyed that people understand that their science is appreciated, that it's not just the good news you're going to hear because sometimes the science is going to deliver bad news. So, I -- that, I -- I have to fix immediately. I have to make sure that we're communicating to the American people so there's ex -- there's internal communication that I think we need to fix, there's external communication. I've done numerous -- you know, media appearances where I've heard people say -- you know, this is the first time we've heard from the CDC director in a year on this show, so I want to be able to -- to convey, in layman's terms, what the science shows, when guidelines change, when MMWRs are released and what that science shows, and not just me, but subject matter experts who can convey that. We need to do something about equity in this country and I think in the -- the CDC is very much devoted to that, I am, personally, devoted to that. I know the president-elect is devoted to that so we need to convey that. We obviously need to get this country out of COVID and the current pandemic crisis that we are in. Tomorrow will be the one year anniversary from the first case in the United States. Likely today, we will have hit 400,000 deaths, so like -- it was pretty stark. I -- I remember what I did last MLK weekend and it was -- it's interesting to think about where I was a year ago. I went out to dinner, I went to symphony hall in Boston. I heard the Boston Children's Chorus sing in a -- in a concert on -- on social justice. And so, when I think about what that -- what the past year has been like, it's just strikingly different. So, we need to -- we need to fix COVID, for sure. We need to -- you know, part of the challenge with COVID was that we had a frail public health infrastructure to start, it just wasn't in good -- it wasn't ready to tackle what it was given and then it was given more than it -- you know, otherwise could have -- could have perceived -- could have -- you know, done. So -- so we need to fix that public health interest structure and we need resources to do it. So, one of my challenges is just going to make sure -- make sure that congress knows and understands that -- that -- you know, we are in this because we had warnings for many, many other public health scares in the last 20 years and we didn't fix our public health infrastructure and our data infrastructure. I have a lot of work ahead, there's no question. And then, of course, that is all on the backdrop of the fact that the CDC does a lot of work for our public health in times without crisis, without pandemics, and that -- you know, we're going to see a lot of collateral damage from the last year in terms of hard-won gains that have been lost, child vaccinations, and -- and hypertension control, HIV control, mental health challenges, climate change impact on health, so we've just had a lot of collateral damage in the last four years in the last year.
>> Howard Bauchner: It -- it's interesting because I always thought two of the great gifts -- quiet gifts that the United States gives to the world is the Centers for Disease Control and Prevention, it's -- it's -- it's striking. And the other is PubMed and the National Library of Medicine, I thought those were these two quiet gifts that that we -- we give to the world. What do you think your own challenges will be? You're -- you're going from a -- a division of 75 or 100 people to a federal agency of just over 10,000 people. What -- how -- how do you think about that?
>> Rochelle Walensky: Yeah, I mean I think one of the reasons that I was chosen is probably because I'm new to the space, I'm new to the agency, right? So, that cuts both ways. Every -- when people write about me as this election for this position, they will say, but she has no public health ex -- have on the ground public health experience. True, I mean all of these things are true. So -- so I will have all of the benefit of coming in from the outside and being able to look in and say, this feels really broken, or on the end user of that guidance, which I was for a year during a pandemic, we couldn't make that work. So, I -- I do have that, which I think will be extraordinarily helpful. The flip side is, I don't have this robust institutional knowledge of the place. I don't have -- I -- you know, how do you get something done? And so, I'm going to rely on the people who've been there for their careers who've done a really remarkable job and to help me navigate that. So, much of what I think is so valuable in medicine and in public health is connections and communication. One of the things that's been so hard for me during this transition period is my lack of ability to actually just talk to the people at the CDC because you go through this agency review and you -- and you can't speak to the current people there, and so I'm really looking forward to just bolstering communication. So, I need to make a lot of connections with a lot of people, I need to make connections within the agency, the center directors, the people of the CDC. I need to make connections across the country with public health officials, with state labs, with epidemiologists, with the cities, and the localities, and the tribes, and the territories, I need to make those connections. And then I need to make connections in congress to make sure that we can get the resources that we need and so I'm going to be doing a lot of networking. Certainly, I need to understand the science and move the strategies and -- and COVID -- you know, forward, but I need to make those connections in order to make it happen.
>> Howard Bauchner: Rochelle, I've -- I always thought that the CDC has done a wonderful job communic -- communicating in traditional media, okay, that you have MMWR, and we've talked about this. You have newspapers, you have print, but that's not modern communication. JAMA has well over a million followers in social media and they have access to all of our content through social medias through -- through links. Do you -- do you think the type of communication that the CDC has done in the past needs to change, or to be upgraded, or to be broader, and wider? I'm just curious about what your concept is about communication in a very different space.
>> Rochelle Walensky: Absolutely, and I've already had conversations about this. MMWR I don't think is going away, I don't think JAMA or New England Journal are going away, right? I -- like the -- the print is -- the -- the -- is not going away and the signs conveyed in that way is not going away. I can do television appearances, I can do interviews, we can do media briefings, but -- but science is now conveyed through Twitter. Science is conveyed on social media, on podcasts, and in many different ways, and I think that's critical. I've already talked to the Communications Team, asking them who's the social media person at the CDC. And I think the reason that that is so very important is because, as we talk about vaccine hesitancy, or as we talk about anti-vaxxers, what's the CDC saying on Twitter about that? Because if you look up -- you know, if you search vaccine hesitancy on Twitter and you don't see mostly the people who are hesitant and not the scientific community and the response to that hesitancy, there's just this massive void and the right information I think is not getting out there. So, yes, that is -- I've already -- my -- my first conversation about communications at the CDC was, I want you all to be able to speak. I want to make sure that the science is conveyed. We have to say it to one another, we have to say it to the public, and then we have to say it in other forums. We have to have a social media plan for the agency.
>> Howard Bauchner: I know for the last two weeks, you've really been working on preparing moving from Boston to Atlanta and -- and taking -- being responsible for this remarkable. There are some vaccine questions but if you feel like you want to pass on them, you should pass on them. But I -- I feel -- I feel like that you're the head of -- you -- you're the head of the CDC to-be in -- in 24, 25 hours, so I -- I feel like I should ask. When will we know how strong a foothold South African variant has in the U.S. and will current vaccines address the specific variant? I don't think it's just the variant in South Africa but also obviously what's become known as the UK variant. Any comments about these variants and vaccines?
>> Rochelle Walensky: The first comment I'm going to say is I'm going to call them by their numbers and not by their country because I think [inaudible] the country that they're coming from. The second thing I will say is part of the challenge of recognizing these variants is a lack of public health laboratory infrastructure in order to do the surveillance. Part of the president-elect's budget is to bolster that dramatically and so I'm really -- and -- and the work is already being done to create those connections with industry, and academia, and public health labs to make sure we have a really good influx and we can follow these variants across the country, those that may be coming initially from countries abroad, and those that -- you know, might be emanating from our own country. I think with regard to the variants, we worry about four things in my mind. We worry about increased transmissibility, and we've seen that with some of them. We worry about increased morbidity and mortality. We haven't yet seen that, although I think we should worry about it because with more disease and more cases, we're going to have -- our transmissive more morbidity and mortality. And then how well and how robust these -- these variants that our vaccines and our therapies are in tackling them when they arise. And I know -- you know, it's not -- we will probably be doing most of the detection and the surveillance at the CDC level. And then I think a lot of the science, although some will happen at the CDC too, as to the impact on vaccines and -- and treatments will happen in other spaces. We are -- data are already starting to emerge. I -- I think the good news with regard to the variants or -- is that we had the efficacy of the vaccine is so good and -- and so high that we have a little bit of a cushion, so that even if the lat -- in the lab, some of these variants don't have as -- they don't appear as robust as the -- as the initial strain that we'll probably still end up with quite a good vaccine. And -- and I just want to remind people, like almost no vaccine we have is 95% accurate. So, before we panic, I -- you know, and say well, should I really get the vaccine if the variant doesn't get -- if it's not going to work against the variant? It's going to work against a variant and -- you know, will it be 95%? Maybe. Will it be 70%? Maybe. But -- you know, our flu vaccines aren't 75% effective every year and we still get them. So -- so I'm really optimistic about how these variants are going to go. I could be wrong, it could be that we'll -- we'll find variants and variants may emerge that have left -- you know, or -- or where the vaccine is less potent, but I'm still currently pretty optimistic.
>> Howard Bauchner: There's -- there's more questions. Obviously -- you know, part of the struggle, clearly the last two or three months is -- is knowing how many people have been vaccinated, how -- how many vaccines, immunizations have actually been delivered to the states, how many are in the warehouse, getting them from the warehouses people say into people's arms has been a real struggle. President-elect Biden, soon to be President Biden has talked about three or four very specific ideas about trying to increase the number of individuals who are vaccinated. I hope he's right about 100 million doses vaccinated individuals in 100 days, some of that will depend on supply, which I think people really need to understand. We don't know if there'll be 100 million doses delivered from either Pfizer or Moderna. What do you think the keys are for just the next month?
>> Rochelle Walensky: So, I don't think the president-elect would have suggested 100 million doses or 100 -- for the next 100 days if he, and his team, and we didn't have a vision that we'd have that supply. So, I think, certainly we have to worry about supply as one of the many constraints, I think of this as a multiple constraint problem, right? What are going to be all the constraints? So, we have to worry about the eligibility. In some places, it's been too tight and people can't get vaccine when they seem to be eligible. In some cases, it's been way too loose, and that you have all these people who are eligible, and then massive queues. So, we have to titrate our supply and our -- on our eligibility so that we somehow hit the sweet spot, wherever it is we are, with how much supply we have and how many people are eligible. And there's been a lot of work to make sure that we're following the CDC guidance but not in the ASIP guidance, but not too strictly that we're -- where too many people are being held back, and there's doses on the shelf. So, there's the people, there's also the vaccinators. We need to make sure that there are enough people out there who can vaccinate, especially when our public health system and our medical system is running pretty -- you know, 24/7 these days. So, can we look to retirees? Can we look to the public -- public health commission corps, medical military? Can we look at retired folks? Can we look at -- at medical students, nursing students -- you know, upper level students who could vaccinate? We're looking at dentists and vex -- veterinarians -- you know, a huge workforce of people to be able to vaccinate. And then the question is place. Where is it that people are going to go to get their vaccine? And I think there are four prongs to this that the president-elect and the team is working on, one is community vaccination centers, be it stadiums, gymnasiums, things like that. Another is mobile units, making sure we can do the outreach to get to those communities who otherwise wouldn't be reached. Another is for federally qualified health centers. Some of that is happening but not as much as could be happening across the states. And then finally, a pharmacy program, working closely with the states and the pharmacies to make sure we can do outreach at the pharmacy level. And the vision of that sort of four pronged approach to places is really founded in equity. We want to make sure that we can deliver volume but also volume to the people in places that -- that might be harder to reach. And then this collaboration at the federal level to make sure that with the entire support and resources available at the federal level to work with states to say, what do they need for help in order to do that distribution?
>> Howard Bauchner: I think that comments about delivery are so critical. As -- as you know, I -- I did most of my medical career in Boston that has community health centers that are very linked to the community. And many of those community health centers in Boston and around the country of which there's thousands are really in areas in -- in -- in -- that have been the hardest hit by COVID-19 in terms of black communities, Latinx communities, so it really makes sense to prioritize -- prioritize delivery through those community health centers. You know, I've jokingly talked about the ice cream truck going around to reach hard to reach communities, it's striking to me that the rural areas -- the rural states have actually done better than the -- than the urban states or the more urbanized states. There's got to be a lesson there somehow that they have figured out more creative ways to reach individuals.
>> Rochelle Walensky: Yeah, right, especially since density doesn't help. I mean definitely helps them on a -- on a transmission standpoint, it doesn't have them on a vaccine distribution standpoint. Yeah, you're absolutely right, West Virginia doing remarkably well. And what I want to say -- you know, you look at Arnold Stadium, Dodger Stadium, you -- you see that like what is possible. So, the federal government is not going to need to go into Phoenix and say, do you need help with your Cardinal Stadium, right? They've done a great job. So, the question is then, what does Arizona need? Do they need mobile clinics? Do they need more collaboration with the pharmacies? And so, I think the real vision is that the federal government will step in at a state-by-state level and say, what is it -- the help that you need? You've done a remarkable job in rolling out X but we need help in rolling out Y, so -- so how can we be helpful?
>> Howard Bauchner: One other question and then I'll have a final question, I know your time is limited. There's been some discussion about monoclonal antibodies particularly, the data on convalescent plasma is still really quite confusing, some positive trials, some less positive trials. I think convalescent plasma because you don't know if you're giving it for prevention of serious disease or to people with serious disease has become increasingly complicated but con -- but monoclonal antibodies have worked in the past and -- and appear there's some good data about it, but it doesn't seem readily available. Do you have any idea -- I mean when -- when you were working at the General before you were in this transition, how available was monoclonal antibodies to -- you know, the frail elderly who -- you know, has mild or moderate disease and you're trying to prevent progress to serious disease?
>> Rochelle Walensky: You know, I think if you're well-resourced, and networked, and you needed to get a monoclonal -- I was just able to get some for a colleague in LA today, but I know how to do that, right? And -- and so is this the answer to this pandemic? I worry that it's not. Is it the only thing we have as an outpatient? Yeah, that's what we have. I think there are doses available, but part of that has been it's so -- it's been so hard and clumsy to be able to implement. There are some places that have been able to do it well, that have been able to give thousands of doses. That, I -- in my mind, it feels like the exception and not the rule, or it feels like places that have resources, and -- and equity just really worries me there. You know, at the same time that we're trying to have a an informed decision making conversation with somebody who had a delayed diagnosis or a delay to -- you know, harder to -- to get a test back, you need to act quickly. Maybe they don't have transportation. You need to bring an infected person -- a highly infected person into a medical center to do the infusion, all of those things are just hard. And then we have this sort of over -- this sort of concern in the back of our heads that -- you know, are they going to work on the variants if they are truly monoclonal? You know, if you have a cocktail, maybe that's a little bit better. But this doesn't feel like the -- it may be -- you know, a step in the -- in the path to get us to a better place but I don't think that anybody envisions that this is going to be the panacea for -- for outpatient treatment, it's just too hard.
>> Howard Bauchner: So, the last question, and it's more personal. What's this meant to your family? You have children, a mother and father, you have a husband, we've talked about -- about this. It's an extraordinary appointment, you -- you probably didn't think this was going to happen six months or a year ago. But what's it mean to -- to you and your family?
>> Rochelle Walensky: That is so much. I'm the daughter of an Army general who fought in World War -- as the granddaughter of an Army general fought in World War II. So, I -- I do have service in my -- of course -- you know, through my veins, coursing through my veins. It's been a gift that my parents have been alive to see this and to see the reaction, it has just been extraordinary. You know, my family recognizes the sacrifice that this is going to be and they've felt it for the last -- what has it been, six weeks? They really understand and I sort of call it my mid-career residency. You know, I figure I'm going to go for several years, maybe a surgical residency, we'll see how long it lasts. But -- but I'm going to just dive in and -- you know, I -- I set it at my -- my nomination. I got called during a code and when you get called during a code, your -- your job is to be there to help. And so, I think my kids are really proud, I think they know that they're -- you know, may not see as much of me. And I think they know that and they understand that this is what I have to do, and I hope they take that with them, and they know that I'm not leaving them or caring any much -- any less about them, and I will be there for them, but this is what I have to do.
>> Howard Bauchner: I can't imagine the CDC and the country being luckier to have you been appointed to head the CDC, most -- mostly just because you can communicate, which is such an important task for the head of the CDC. And I -- I think -- you know, things that need to get better and I just imagine you'll be remarkably effective.
>> Rochelle Walensky: Thank you.
>> Howard Bauchner: And so, on behalf of JAMA and the JAMA Network, I want to congratulate you and wish you God speed.
>> Rochelle Walensky: Thank you so much.
>> Howard Bauchner: This is Howard Bauchner, editor-in-chief of JAMA. I've been chatting with the newly appointed director of the Centers for Disease and Control, Rochelle Walensky. Thanks, Rochelle, and stay healthy, and good luck.
>> Howard Bauchner: Bye-bye.
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