Physician Experts Address Top Questions About COVID-19
Leading Pandemic Voices Dr. Bob Wachter and Dr. Ashish Jha Share Views at Virtual Executive Advisory Board Meeting
Renowned physician experts Robert M. Wachter, MD, and Ashish K. Jha, MD, MPH, took stock of how the U.S. is faring in the COVID-19 pandemic during a virtual meeting hosted by the TDC Group of companies (TDC Group) on February 3. During the Executive Advisory Board gathering of the nation’s top healthcare providers and medical society leaders, Drs. Wachter and Jha compared ideas and answered questions regarding rapid testing, contact tracing, healthcare infrastructure, and other vital topics. At the heart of the discussion was how lessons learned so far will help the nation navigate the remaining months of the pandemic.
Both doctors have become public figures since the start of the pandemic, coauthoring editorials for major print news outlets, making frequent appearances for television news, and generating social media attention to keep facts in the spotlight.
During their conversation, Drs. Wachter and Jha not only asked questions of each other, but also took questions from fellow keynote speaker Richard E. Anderson, MD, FACP, chairman and chief executive officer of The Doctors Company and leader of TDC Group; from session moderator David L. Feldman, MD, MBA, FACS, chief medical officer for The Doctors Company and TDC Group; and from meeting attendees.
The following are the key questions asked and the responses given by these two experts:
Where do you think we are right now with COVID-19?
Dr. Jha: I think we’re in a precarious moment. Things in some ways look much better than they did just a few weeks ago. The number of infections in America is down about 40, 45 percent from literally three weeks ago, which was the high. Hospitalizations are down about 20 percent. And even the rate of death, which always lags, is starting to turn downwards. And all of this is good news, right? But this good news is also is giving a lot of policymakers a sense of relief, and we’re starting to see states try to open up.
And yet, there is this tsunami that I think a lot of us are seeing, and we’re saying, we’re really worried that tsunami’s pretty big. It’s sometimes hard to see when it’s way offshore, and it can drown you pretty quickly. And that tsunami is really these variants that are out there circulating in our communities. The one that I’m most worried about in the short run is the UK variant, where the experience of the UK, Ireland, Denmark, other places that were hit is that it can take off very quickly, and it can overwhelm healthcare and societies very, very quickly. And so that’s the thing that I think worries me. The fact that things are getting better, of course, is a relief. But I worry that we’re getting lulled into a little bit of a sense of complacency.
The only other couple of things I’d highlight at a high level are: One, vaccine delivery is moving along, slowly getting better, not fast enough in my mind for the problem at hand, which is this new variant, but getting better. And I think the Biden team has been very clear that they’re really going to ramp up as much as they can. Two, it’s always worth remembering that this is a global pandemic. However we may be doing in the United States, it will end up being shaped by what happens in Brazil, in South Africa, in India, and much of the world remains in the throes of this pandemic. So we always have to be keeping an eye on what’s happening outside our shores, because it doesn’t take much time for something that happens outside of us to end up affecting us.
How worried are you about individual people, institutions, and governments letting their guard down prematurely?
Dr. Jha: I’m very worried. I had a call with a governor and his team a couple of days ago, and they were saying, “Well, we’ve had bars closed for several months. When can we open up bars?” And I was saying not yet. Not anytime soon. And their argument back was, “You told us that when things were getting worse. But things got better. They’re way better now than when you talked to us last about this. What’s the metric?” And this sense that the goal post is always shifting is complicated, right? Because I can make the public health argument. But the other thing they’re hearing is these restaurant and bar and other business owners saying, “I’m out of money and we’re going to have to shut down forever, and that’s going to cause huge problems.” And that’s real. You can’t ignore that.
To be perfectly honest, if these variants didn’t exist, I’d actually start feeling like, given the numbers where we are, we could have a serious conversation about what to open up and how fast, especially with vaccines cooking along. But I don’t think, with the variant, that opening things up right now is at all a reasonable idea. But I understand the pressure that people feel.
What is the argument against opening up a little bit now and closing down later if needed?
Dr. Jha: The argument against that is a couple of things. I mean, one is that any action you take tends to have sort of a two- to three-week lag before you see its effects. We’ve seen that over and over again. So if you open up now, the impact of that really will be in a few weeks. But the flip side is, so let’s say we open up now and in three, four weeks you start seeing a big increase, maybe because of the variant, maybe because you opened up, first of all; then to shut down again, it’s going to take several weeks for that shutdown to affect things. It’s also incredibly disruptive for people to open and close. And when you know this thing is coming in six weeks, probably, at the most, then opening up now seems to me deeply unwise.
The last part is, you want to go into the rise of the variants with as low a number of cases as possible, because what we have seen in each of these countries is that the uptick happens, and then it just takes off super fast. I mean, the exponential growth you saw in the UK over literally a month or six weeks was among the most terrifying things I’ve seen, just from a graphical point of view. And it crushed the UK National Health Service. I mean, just the number of people who got sick and died in the last month or six weeks in the NHS was awful. Having seen that, it really is about not setting ourselves up for that scenario.
What kind of recommendations are you giving to people now about their individual behavior, and how have those recommendations changed in the last month?
Dr. Jha: I think the backdrop for all the advice that I’m trying to give people is that people are beaten down. They’re tired. Especially here in the Northeast, where it’s early February—February is always the hardest month, because we’ve had a couple of months of cold, dark weather, and then, of course, we still have another month or two to go. So I try to begin by giving people hope about where we will be in April, May if things go well. I really do think April, May is a time period where things will start getting meaningfully better. And I think a timeline helps people frame the question of what do they have to do.
One of the major problems in this entire pandemic has been the fact that we’ve never had a sense of timeline, because we’ve kept hearing from the federal officials, our former president, that it was about to be over. That was a huge problem, because then people couldn’t really plan and anticipate how much longer they had to go. There are lots of potential ways things could go wrong, but I’m pretty confident that life will really begin to look different by April, May if we do a good job of managing this variant that’s in front of us. That means really staying hunkered down, not for the next six months but really for the next couple.
What I personally do is, I go to the grocery store a lot less often. I have upgraded the quality of the mask that I wear. I have never cleaned my mail, or not since last March. So that stuff, the surface stuff, I don’t do any differently, but I have really been pushing people to be a bit more careful about any kind of gathering of people outside their bubble, if they can avoid it, just for the next month or two.
The vaccine adds a bit of a twist. I don’t think it’s reasonable to say to people who have been vaccinated, “Your behavior shouldn’t change at all.” I think vaccinated people getting together with other vaccinated people is a bit more reasonable. But what I have also been saying is that there is a third element to this, not only about you being vaccinated, and the other person being vaccinated, but how much spread there is in the community. We will be able to get back to doing a lot more of the things that we loved back in 2019 once we’re out of the bad surge that we’re in still right now.
Dr. Jha, as an expert in public health but not a virologist, vaccinologist, or sociologist, how do you decide what the boundaries are when speaking about things that are not in your field?
Dr. Jha: First and foremost, I try to do a lot of reading, because I feel like there’s nothing like reading the primary studies or literature to actually have my own opinion. Second, I find a few people who are bona fide virologists and sociologists and immunologists and try to look carefully at what they are saying. It has struck me that my role is really like that of a primary care physician, that kind of integrator, or like a general internist at a hospital. For instance, I don’t know as much cardiology as a cardiologist consult that I call, or as much infectious disease as the ID doc. But my job as a hospitalist physician—and you’ll appreciate this, Bob— is to integrate all of that and try to make decisions that won’t cause the cardiologist to say, “That’s crazy.” They may or may not quite see it that way, but the point is that you want to be playing kind of in that integrative space.
And that’s how I’ve seen my role. The country does need deep, deep experts every once in a while speaking to them. But I was describing to somebody that for a typical Good Morning America episode, the night before at 11 o’clock or often at 6:30 in the morning, they’ll text me with the questions of the session. And the three questions might be: What should we be doing about schools? How well is the vaccine working, first versus second dose? And what do you think of this new study that looks at remdesivir and the World Health Organization study versus the National Institutes of Health study? And there probably isn’t anybody who is the leading global expert on all three of those things, and what they’re not going to do in a two-and-a-half-minute segment is have three different people, each speaking to one of those questions. So ultimately, I’ve got to be able to figure out how to talk about each of them with enough integrity that people will see it and say, “Yeah, he’s got it right.” But also enough simplicity and clarity that most people can catch it in a two-and-a-half-minute news piece. I totally understand that for a lot of people, that’s uncomfortable, but I felt like it was important to do.
How do you answer the question about opening schools?
Dr. Jha: Yeah, it’s certainly the question I have spent more time talking about and thinking about. The number of phone calls, Zoom calls with both teachers’ unions and school superintendents, parents’ groups, etc. that I’ve done has been extraordinary. What I’ve come to believe is that schools are essential. You can run schools in a pandemic. You really can. But you have to do certain things to make it safe for both kids and teachers, and you can’t do it sort of willy-nilly. Just open up the schools and good luck, Godspeed—that’s not a strategy.
The problem is that we so polarized this conversation last summer with, “Schools must open.” And this has been a problem for the whole pandemic, because we took these complex issues where the answer always was, ”Yes, under certain circumstances,” or “No, under other circumstances”—which is kind of how life works—and made it into, ”Are you a yes or a no person?” And so a lot of school districts tried to open without the mitigation efforts, and teachers rebelled, and I was sympathetic to the teachers. And then the pushback happened, and I think sometimes the teachers’ unions went too far in getting to a point where under very reasonable circumstances, with good mitigation, they still weren’t comfortable.
The bottom line here is that we had complete lack of leadership to help guide the country. We never had good guidance from the Department of Education. The Centers for Disease Control and Prevention, under the last administration, was all over the place, literally, I remember one night they put out two pieces of guidance that directly contradicted each other. So no question that the country is going to be completely confused about what to do.
Moving forward, I like what President Biden has said: We’ve got to open up the schools. Look, we’ve got to get good mask-wearing and improved ventilation in a lot of places. I actually think regular testing in schools, once a week, testing of everybody or some version thereof, would help a lot. It would offer assurance and pick up some infections and give us more data. I think that would be useful.
I don’t think the variant should change this conversation. I think we can manage schools with the variant, at least the best I can see from the data. If it turns out I’m wrong about that, then we should be willing to stop and do things differently. But I think a data-driven approach here really can work, and I do think most kids can go back to school pretty safely for teachers and kids.
Some people have brought up the idea that no one’s going back to school until all the kids are vaccinated. At that point, it just feels like we may give up on yet one more year. And by the way, we should be very clear about the cost of keeping kids at home. This has especially massive effects on poor kids, and on kids of color from communities of color. The disparities that these things are going to generate over the next many, many years are going to be generational. We’re going to able to look back a decade from now and see a large widening of the gap between white students and black and Latino students because of this year.
Are there any cases of long COVID in people who did not have clinical illness?
Dr. Wachter: I don’t know if we know that yet. I mean, you would have to be asking people several months out what their symptoms were. These probably would have been asymptomatic people, so you’d have to look at the people who got cases at either low or no symptoms and how they were months out. And of course, you’d have to look at the control group, because a lot of people will tell you, two months out, “I have headaches” or ”I feel crummy.” And so it’s very important to look at the control group and see that it’s actually a signal that’s above the baseline signal. So it’s a tough study to do. I have not seen that study done or reported yet.
I think it’s a reasonable assumption that it doesn’t happen or it’s a very low probability. And you’re talking about then a low probability on top of a low probability of getting infected. But if people are insisting on a zero probability, like this can’t happen, I think we can’t say that today.
What is your definition of long COVID-19?
Dr. Wachter: There’s no standard definition in the U.S. yet; the UK says symptoms lasting more than 12 weeks
Would focusing on rapid, sensitive, inexpensive, and ubiquitous point-of-care testing mitigate the pandemic?
Dr. Jha: This is one of the things that makes me tear my hair out. We have had the technology to do rapid testing since last April. Early May was when we had our first antigen test authorized by the Food and Drug Administration. And the modeling data is very clear: These tests should be about a buck or two apiece. So if you could go to a Walgreens or a CVS and buy 20 of them for 40 bucks, and if you’re a grocery store worker or you’re a healthcare worker, you’re testing yourself twice a week. There’s very good evidence that that would have this profound downward pressure on the number of infections in the community, because basically, most people when they get a positive diagnosis, self-isolate. I mean, I think we all know about the occasional person who’s going to be a jerk and go out. But most people who have a positive diagnosis will self-isolate. And there’s very good data that much of the spread happens right before people develop symptoms into the first day of symptoms. That’s the time period where people are most contagious. And while these tests are not fabulous overall, they’re actually quite good in that very contagious time period. So you’re going to pick up people during the period of time when people are really, really at high risk, and depending on which test, sensitivities can be in the mid- to upper 90s even during the most contagious time period. And so, if these things were widely available—even if the sensitivity was at 70 or 80 percent—if these things were widely available and widely used, you’d see a very dramatic decrease in the number of infections in the community. And therefore, I’ve argued we should have it.
The FDA’s pushed back, and I’ve talked to the FDA, I’ve talked to Congress. The response has been, “Well, we don’t want to give people a false sense of security.” So you get a negative test and people are going to think that they’re fine when they may not be. But my take is, people have a false sense of security right now. I mean, there are plenty of people walking around thinking they’re not infected. We do need good messaging that says a negative test doesn’t mean that you’re not infected. Moreover, a really highly sensitive PCR test is no good if you can’t get it or if it’s going to take you three days to get your results back. So to me, this tradeoff has been a no-brainer, and I have really pushed for it. And you can see how successful I’ve been because we still don’t have enough rapid testing.
Dr. Wachter: Well, you’ve made some progress because they just announced some movement in this direction just in the last couple of days, right?
Dr. Jha: Yes, we’ve made some progress.
Dr. Wachter: The argument is perfect. The problem is logistics. How is this actually going to work? Who’s going to give out the tests? Are people going to buy them? Are people going to test themselves every morning when they’re brushing their teeth? It was difficult, always difficult for me to see how this would play out in our messy society.
There’s one organization that committed itself to testing as a way of plowing forward with its business. It’s called the NFL. The CDC had a paper on how they did this. People were watching. Take a guess how many PCR tests the NFL did over a six-month period: 623,000 PCR tests, testing basically everybody every day. So you see the volume of testing needed, if you really want to get tests out there and get people testing every couple of days, because the challenge, of course, is finding people who are asymptomatic. So in order to do it and have it be meaningful, it’s got to be in some regular cadence in largely asymptomatic people.
It’s just always hard for me to see how that would work, although clearly, it should be a part of the solution, and particularly in places like the schools, where you really are trying to create the safest possible environment. It is part of the solution, something that we have underemphasized.
Dr. Jha: The one experience I have very directly is that I helped put together Brown University’s testing program this past fall, and we tested everybody twice a week. It’s not that different from what many other universities did, but what was interesting was in November, Rhode Island was number one in the country in terms of the number of new infections per day—Rhode Island really had quite a bad situation in November and December. We saw a little uptick within the Brown student community, but overall, we did not see a spike, and the difference between what was happening at the community level and at the university level was more than tenfold. And I think it’s just because we were testing everybody so frequently. We had a strategy that if our numbers really started climbing and we wanted to finish classes, we’d go to three times a week.
It was really expensive. We were doing PCR testing with a 24-hour turnaround time. But the point is that I think that kind of aggressive testing clearly can work, and it has worked, but it’s not easy to do. It was really expensive, and most public universities couldn’t do it.
Dr. Wachter: I assume it was not just the cost of the tests but creating an infrastructure around contact tracing and so on.
Dr. Jha: Absolutely. That all was complex and expensive. I don’t mean to downplay the logistical challenges here, which are quite substantial.
What are your thoughts about the potential benefits of contact tracing, which has worked in other countries?
Dr. Wachter: Part of the challenge is that contact tracing depends on a public health infrastructure that we don’t have in this country. We’ve tried to build it on the fly, but we haven’t done super well. Contact tracing has its greatest benefit when the caseload is relatively low, and you can kind of deal with one case at a time. And what we’ve seen in the US is often, the cases explode and outstrip the ability of contact tracing to do its thing. I happen to live in the city in the United States that probably has done this best, and it’s circular in a good way, in that we were able to keep caseloads down low and deaths down low, which allowed the contact-tracing system to remain robust.
San Francisco’s contact-tracing system was well supported and well funded. We trained a whole bunch of librarians—who have the ideal skillset for contact tracing, and had nothing to do—to become contact tracers. And in San Francisco, we’ve had a grand total of a little bit more than 300 deaths. If the country had had San Francisco’s per capita death rate, we would have about 100,000 deaths in the U.S., rather than 440,000. But the reason it was able to work was, we never hit that point where the contact-tracing system was overwhelmed. We never hit the point that the hospitals were overwhelmed. There are a lot of systems that work OK when the cases are low, but when you really want them to work, they tend to fall apart, because they get overwhelmed, and contact tracing is one of them.
Anything new coming down the pike with treatment of patients who are particularly sick?
Dr. Wachter: The medication that has been the most impressive in terms of its results and impact on mortality is steroids, remarkably, which we’ve now known for six to eight months since the studies came out of the UK. Importantly, that is a lesson that’s come out of this pandemic. Much of the clinical research has come out of the UK, which had the infrastructure to do these large-scale clinical trials. It’s something we’re going to have to improve in the United States. Remdesivir has a mild effect, if any. It has no real impact on death, though it probably shortens the length of hospitalizations. There’s some evidence for these IL-6 blockers, but it’s also a relatively small effect. There’s now reasonably good evidence on the monoclonals, largely for people that are not that sick yet, and there the challenge is just the logistics of giving people an infusion—you can’t use your infusion center, because you can’t take a patient with COVID-19 and stick them next to a patient with cancer on chemo. And so the logistics of sorting out monoclonals has been tricky, and they’re expensive.
It’s interesting that the therapeutics have been somewhat disappointing. I remember a panel I held for our grand rounds, fairly early on, with experts from vaccinology and virology and clinical research. I asked them, what do you think is going to get us out of this predicament first, vaccines or therapeutics? And I think everybody said therapeutics. Everybody said we’re going to find medicines that lower the mortality and morbidity rate so much that it will eventually be like the flu. But luckily, vaccines won that race, surprisingly, because what we’ve seen in therapeutics is a lowering of the mortality rate by probably two-thirds. Your chance of dying of a case of COVID-19 is significantly lower than it was last March, but we’ve found nothing that has been the kind of game-changer that we had hoped for.
It feels like the energy has been taken out of therapeutics because of vaccines, which, of course, is wrong. We’re in this at least for another six months. People are going to get COVID-19 and get sick, and I hope we continue to do some work and try to find better therapeutics. We’ve not found them yet.
Dr. Jha: We spent a lot of time last year fighting over things that we really should have had no business fighting over, such as the distraction early on with hydroxychloroquine. Some of that is, I think, unfortunate. But I agree with Bob that we’re not out of this thing, and I have to say that we should still do a new push on therapeutics, because even in six months: Imagine we have 75, 80 percent of Americans vaccinated—we’re still going to have outbreaks. We’re still going to have cases pop up here and there. These vaccines, which are very good, are mostly going to prevent hospitalizations and deaths, but they’re not going to be 100 percent on hospitalizations. And wouldn’t we want to be able to have therapeutics? Wouldn’t it make a big difference in how comfortable we feel, knowing that if we’re unlucky and get infected, even with a vaccine, that there are treatments that are going to keep us from getting really sick and dying? I wish that was still a major priority, and I think it should be.
What do you think is going to be the long-term impact on the healthcare system of the pandemic?
Dr. Wachter: Biggest impact? Telemedicine, which I think is here to stay, and telemedicine not just as a visit replacement, but really opening the door to a level of digital transformation: hospital at home, more sensor-based care, more stuff that happens in people’s houses—because if you’re not coming in to see the doctor, then that’s not where you’re going to get your blood pressure checked and your weight checked and your glucose checked. We’ve got to figure out how we’re going to manage that data flow, which could easily overwhelm the system. That’s the big change.
The second change, digitally, is that we’ve all gotten used to these incredibly wonderful dashboards that at a glance tell us what’s going on. And I think that’s really important. We’ve not taken advantage of our digital data until now, and I think that we’ve learned something from that. I think that’s going to be important.
But I am skeptical: Here are the two other areas where we think about change: Massive investment in the public health system and infrastructure, massive attention to healthcare disparities and social determinants of health. I think we will give a lot of lip service to those things—I think we will do some level of pandemic preparedness, so we’re not caught completely unawares the next time—but the money to do either of those things will have to come out of the existing healthcare system. I think we’ll see a lot of discussion about public health, and a lot of discussion about social determinants. But I will be a little surprised if we put the resources into them that they actually deserve and that they need.
Dr. Jha: We’ve been moving toward more telemedicine, more home-based care. And what the pandemic did in my mind is bring into 2021 what would have happened by 2025 or 2030 anyway. Just accelerated it by a lot. It was interesting to watch the Centers for Medicare and Medicaid Services suspend a whole bunch of different rules about the kinds of quality measurements and all these other things for the short run, with the idea of: We’re going to let doctors be doctors. And I think people can say, ”Hey, I actually like the idea of letting doctors be doctors.“ Some of the stuff that we suspended is not going to go back to normal. There’s going to be a reevaluation of, I think, a lot of different policies. And not just those affecting telemedicine—though I agree with the basic thrust that we will end up with a lot more technology-based care.
Also, in the middle of the biggest health crisis in the century, we saw, for the first time, hospitals laying off people. And we saw primary care practices, specialty practices, and ambulatory-based practices shut down, go out of business. It’s very puzzling, and yet, if you look under the hood, no surprise that our payment models just did not work in this pandemic at all. Therefore, this movement we’ve had in our payment models away from fee-for-service and toward alternative payment models, whatever they may be, has been totally bipartisan. Obama, Trump. I think that gets accelerated under a Biden Administration.
Another thing that has been kind of simmering out there for a while is the whole issue around scope of practice and lots of fights about scope of practice. My sense is, coming out of this pandemic, that there’s going to be an effort to provide more flexibility around the questions of, what can nurses do, what can nurse practitioners do, and what do doctors have to do, especially with more widespread deployment of technology.
The last point is, if you think about where we were in 2019, with a lot of anti-pharma sentiment and even anti-doctor sentiment about surprise billing—then in 2020, doctors and nurses were heroes. So that has huge knock-on effects for the ability to do policy stuff with pharmaceuticals.
What is the impact of shutdowns (all or nothing) as an approach to population health? Why not promote rational partial reopening?
Dr. Wachter: The emerging data make clear that the impact on health has been negative, beyond the impact of COVID-19 itself. Deaths, when compared against prior years, are up more than pure COVID-19 deaths, which may be a mix of some deaths from patients not receiving needed care and some deaths that were from COVID-19 but were not characterized that way. The long-term impact on deferred or missed care will need to be determined over time. There may be some beneficial effects of missing unnecessary care as well, though these are likely smaller.
Is there a local source where we could find the prevalence rate?
Dr. Wachter: It depends on where you are. Most county health departments list case rates and test positivity rates on their websites.
What is the safety/risk of patients having elective surgery when not yet vaccinated, and does the thinking change if an overnight stay is needed?
Dr. Wachter: Hospitals are exceptionally safe, whether for an overnight stay or not. I wouldn’t necessarily wait until vaccination but would consider deferring if the hospital was in the midst of a significant surge—higher infection rates, more stressed system.
How do you feel about drive-through vaccinations and monitoring the patient in the car?
Dr. Wachter: Fine. The rate of severe anaphylaxis is less than one in 100,000. Someone in a car who can honk the horn or flash the lights is safe enough.
Dr. Wachter, an internist, is professor and chair of the Department of Medicine at the University of California, San Francisco, a member of The Doctors Company’s Board of Governors, and a thought leader in care quality, patient safety, and digital health. He has published more than 250 articles and six books and is the best-selling author of The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age.
Dr. Jha, a practicing physician, is dean of Brown University School of Public Health and professor of health services, policy, and practice. He is recognized globally as an expert on pandemic preparedness and response as well as on health policy research and practice, has published more than 200 pieces of original research, and is a frequent contributor to a range of public media platforms.
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.