How We’re Doing It Wrong and How to Fix It, with Rajiv Shah

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Andy calls up Rajiv Shah, who is leading an initiative in the US to fix our pandemic response. Rajiv is president of The Rockefeller Foundation and former head of USAID, where he led the response to the Ebola crisis in West Africa.

Keep up with Andy on Twitter @ASlavitt and Instagram @andyslavitt.

Follow Rajiv Shah on Twitter @rajshah and Instagram @drrajivshah.

Check out these resources from today’s episode: 


Andy Slavitt: [00:00:47] Welcome to In the Bubble. This is Andy Slavitt. We have an exciting show today. Rajiv Shah, who is the man with the plan. Rajiv is the president of the Rockefeller Foundation. He formerly ran the USAID response to Ebola. And he has a gigantic plan where he is organizing dozens of states, manufacturers, the federal government and others to really change our response to the pandemic. Largely as you’ll here using one major tool that he’s ramping up aggressively with money, resources and people. It is a really interesting conversation about somebody who is leading our way out of this cycle. And I think you’ll find Rajiv very interesting. So I think that’s all there is to cover. Let’s bring up Rajiv Shah.

Rajiv Shah: [00:01:46] Hey, Andy. How are you?

Andy Slavitt: [00:01:56] Man, what a time. So has the CDC been compromised?

Rajiv Shah: [00:02:03] Well, I think the CDC is the most important public health agency in the world with the most expertise, the most experience and and the best scientists. But there have been times through this crisis where I have publicly disagreed with CDC guidance. I don’t know enough about what and how those guidances are produced and how that process has changed. The biggest challenge was the recent issuance of guidance to not test people that don’t have symptoms. That was extraordinary. It’s difficult to almost appreciate how extraordinary that was. And so I very much welcomed the recent correction to point out that, in fact, 40, 50, some people have estimated as high as 60 percent of spread in the United States is actually from people who are pre-symptomatic or asymptomatic. And we have to figure out ways to test that population and take those people out of the chain of transmission.

Andy Slavitt: [00:03:09] Right. I mean, just to say, if people who are asymptomatic or pre-symptomatic, actually did stop taking tests, our visibility into COVID-19, which is already not what it should be, would be even more dramatically reduced. My question is, people out there are wondering who they can listen to, and I think you and I are people who are normally used to saying, oh, take your cues from the CDC. What can we tell people now?

Rajiv Shah: [00:03:35] You know, if people do need to know who they can listen to, and frankly, they need specific guidance, not, you know, broad pronouncements that say, well, you know, based on six different factors, you do or do not need to get tested, or you do or do not need to see a clinician. ]What we’ve learned from every pandemic we’ve fought successfully at home and around the world is that clear and specific guidance that is easy to follow is critical. And it should be coming from the CDC. If you look across even the federal government — I mean, right now we’ve had groups of states have come together and said, look, let’s figure out ways to test everybody that needs a test, whether they’re symptomatic or not symptomatic. And the Rockefeller Foundation has partnered with 10 states, five Republican, five Democratic, to acquire the kinds of tests, these antigen tests, that enable that screening testing strategy to work.

[00:04:31] The Department of Health and Human Services has gone out and pre-purchased a 150 million of these rapid antigen tests, which are effectively screening tests for this purpose. So, you know, the CDC, when it issued the guidance that it issued around pulling back testing for asymptomatic people, was actually undermining, in my view, efforts that even other parts of federal government were trying to move forward. And now it appears to be better aligned. But I have three school age kids. I am helping this school figure out, you know, what to do. Schools across this country need specific guidance on whether to test, how often to test, what level of frequency is required. So the Rockefeller Foundation has supported the Duke Margolies Center, Mark McClellan, a former FDA commissioner, to produce guidelines. And we’re doing that in concert with and in consultation with the federal government, including those at the CDC, because, you know, we’re not really interested in pointing fingers. We just want to say, how do we get America through this crisis?

Andy Slavitt: [00:05:41] Yeah. I. I’m not trying to point fingers either. What I’m trying to do is help people manage the clutter because it’s confusing enough to be in a novel virus. It’s confusing enough to hear guidance that’s not clear. But then to hear these same agencies, or different agencies, contradict itself and to worry about political interference, that’s really challenging. And I think the reflection of that is I think some of the things we’ve studied show that people just stop listening. They don’t believe any of it. They believe even what they hear today, if it’s good information, it will get contradicted. And I think the presence of CDC meant to be assuring, meant to be the best information we know, not always meant to be perfectly right, but I think we’re past the point of a changing just when information changes.

Rajiv Shah: [00:06:32] That’s right. I think there’s a a line between learning and evolving as we gain data like early in this crisis it wasn’t clear that you needed to do testing in a certain timeframe. For example, I think it was, you know, maybe June-ish when we saw data that indicated that most of the spread in America is happening within 48 hours of people getting tested. So their tests coming back three days, four days, five days later, are basically ineffective, that taking people out of circulation pre their point of spread. So we’re always going to learn data points that tweak the scientific approach to tackling the virus. But it should be 100 percent clear — because it was clear and Ebola in 2014, it was clear an avian influenza, was clear in Zika and mosquito-borne illness in Latin America a few years ago, there are always some simple, clear things that are always true. And social distancing, wearing a mask, getting testing done as quickly as possible and taking people who are positive out of the chain of transmission, those types of things for a flu pandemic are known. They’ve been known for 100 years. They’re not things that you sort of discover along the way.

Rajiv Shah: [00:07:52] And that’s been true in West Africa. I was at U.S. aid and we led the West Africa Ebola response. And we, I think, struggled at first because we didn’t have real time data on who was positive. And it was a lot of guesswork. We deployed U.S. military labs, these DOD bioterror bioterror labs. We used helicopters to transport blood samples. We did everything we could, and I tracked daily, were we getting the kind of confirmation of a positive down from eight or nine days to under four hours. When we got it under four hours, we saw a quick and rapid turnaround in the effectiveness of the response. So much so that the hospital beds we built, that we called the Ebola treatment units, most of them went unutilized because they weren’t necessary, because we had a data-driven response. And so, you know you need a data driven response. And the most important point of data is who’s positive when, where and take them out of circulation.

Andy Slavitt: [00:08:53] Right. That was an incredibly proud moment, and a very scary moment for the world, but an incredibly problem for the country for you and others, going and really bringing the resources and the expertise to take what was already a very scary situation, prevent it from getting much, much worse. And of course, that ultimately also prevented it from coming to these shores. But that didn’t used to be our only measure. We used to care a great deal more about what goes on. Let me ask you about Africa. You’ve been involved there in suddenly public health initiatives over time. Africa’s continent of 1.3 billion people, as of today, they have fewer than 30,000 COVID deaths. We’re obviously a nation that’s about a quarter of the size, roughly. And we’re we’re just crossing 200,000 deaths. Is there something that Africa has learned to do well over the course of battling public health crises that, despite not being, you know, technologically as advanced as the U.S., and despite not being an extremely wealthy continent, we should we should understand.

Rajiv Shah: [00:09:58] So that is a great question. And the answer is a resounding yes. And the answer is what we have called in Africa and other emerging countries around the world, community health. It’s enlisting people who are not doctors, who are often not nurses, they’re often, you know, women and young people from communities that might be, you know, three hours outside of a capital city and very inaccessible. But we’ve identified who they are. We’ve connected them to the healthcare system and we’ve asked them to go door to door and collect basic information in the context of, for example, fighting hunger or fighting malnutrition or supporting pregnant women so they can give birth in assisted facilities. Those efforts over the course of two and a half decades have saved millions of children and maternal lives. It’s one of the proudest things I have gotten to be a part of. And it’s not any one institution. It’s the whole world came together, started investing with Republicans and Democrats.

Rajiv Shah: [00:11:02] I mean, Americans and the British, the Chinese and Indians and Africans themselves. And it has been an extraordinary success story for humanity. But it’s been grounded in the idea we that go out, go to people’s homes, knock on the door and find out if there’s a pregnant woman and make sure she’s got access to a skilled birth attendant and make sure she has enough nutrition to protect her and that child. And then all the other things that led her off of that. And that skill set of just going out, knocking on doors and connecting the people who are vulnerable, that’s something we don’t do in America.

Rajiv Shah: [00:11:36] I’ve found it amazing, the Rockefeller Foundation is supporting a community health approach in Baltimore. But if we weren’t supporting that, that doesn’t happen naturally, because in America we have a very privatized system effectively for healthcare. And you either have access or you don’t, have your access is either easy and trusted and financially compensated or not. And if you’re in that or not category, you know, no one’s knocking on your door to say, you know, do you have enough masks? Do you have enough gloves? Do you have a hand sanitizer? Are you cared for through this crisis? And the countries that have won here, South Korea, Australia, New Zealand, they’ve done that. They’ve had an all-in-it-together mindset. And I think Africa has had that mindset as well.

Andy Slavitt: [00:12:22] So you point to a couple of things: one is our separation of a private healthcare system from a from a public health care system. And you point to the use of what we talk about in healthcare as non-clinical labor, but culturally competent local labor. And for those who who don’t follow it, there are models here in the U.S., they’re nascent models, they are not the dominant way of doing things, that are trying to export some of those lessons. Do those lessons translate well to a crisis like COVID-19 in Africa? Because they’re more familiar with the public health crises, are they more likely to be compliant with the basics as you talked about them?

Rajiv Shah: [00:13:01] I think they are. I do. There’s more of a sense of trust, especially because if the person sharing information about the things you have to do, social distancing, hand washing, wearing masks, taking temperature checks more regularly to getting tested more frequently. If that person is from your community, speaks your language, you know them, you trust them, you know their family, you’d have a different level of your ability to listen and change your own behavior to align with what you’re hearing. I saw that in villages I visited rural Liberia during the Ebola crisis where we actually enlisted 11,000 through West Africa — the United States supported the financing and training of 11,000 community health workers, whether they were in northern Nigeria or Guinea, Sierra Leone or Liberia, that went out door to door to do this. And they were local people trained in part by the USAID and trained in part by the United States military, that’s very good at training people based on, you know, protocols that were developed, in this case, with Medecins Sans Frontier. And they did an excellent job of getting a handle on the pandemic. So, yes, I do think where it works, it’s translatable because there’s that sense of community trust. And by the way, think about what that would have looked like in America if you had every church leader, every pastor, every mom, every local community leader, college football coach, superstar basketball players, whoever it is we listen to in our American communities, all saying, hey, wear a mask, hey, stay six feet apart. Hey, we’re all in this together. This is not going to be something that divides us. This is something that brings us together. And it’s how we help protect each other and how we help protect each other’s parents and grandparents. And the people who are really vulnerable because of age and preexisting conditions. Could have been a great moment for our country.

Andy Slavitt: [00:17:58] You kind of left this just really critical question, which is how a first world, wealthy country that’s used to big technological rescues and solutions, that’s really, as a result of that, narrowly missed having a crisis like this before, and has probably not had the kind of serious sacrifice in generations — and certainly there are people who have immigrated to this country whose family has experienced those things more recently. But for people who have been in this country for 100 years, at that point time, the depression was 10 years of sacrifice, that World War II was six years of sacrifice. But remember, they didn’t know it was six years. I think we’re in the middle of it. It could’ve been could’ve been endless. And we’re running did certainly trust issues. So even if we got all the technology perfect, compare the sociological response here in the U.S. to what you’ve seen around the world in Asia, Oceana, Europe and in Africa.

Rajiv Shah: [00:19:03] Well, what I’ve seen is a much more ‘we’re all in this together’ mindset. You know, you look at South Korea, we worked very closely to both learn lessons and to support their successful effort. I mean, early on, they built a great partnership between private companies and their version of the public health agencies we were just describing. And if you flew into South Korea, you know, you got tested at the airport, you got sent home, you were checked on daily by someone who gave you a phone call. You probably got a care package mailed to you that included some food and some other safe items that would help you get through it. And your host family — because you were quarantining probably in a room in an apartment — also got a care package because they were supporting you. And in doing so, they were supporting their country. That is the kind of mindset, you know, that it would that we need in this country, that we are all in this together and whether, you know. And frankly, you look at the reality of COVID-19 black Americans, five times more likely to be hospitalized from COVID, you know, significantly higher mortality rates in the lower income and minority communities. Rockefeller supported efforts early in minority communities, also on on Native American lands throughout our country to help support it. Those are the folks who got hit first and hardest. And, you know, people who could decamp to the Hamptons were relatively safe compared to those that were in Queens. And that’s the reality. So, you know, we had this moment and I think we still have this moment to call on a sense of shared sacrifice and a sense of showing a real commitment to each other.

Rajiv Shah: [00:20:43] I think even people who are very fortunate and very safe and relatively protected, are willing in this moment to step up and do something that would be helpful. I mean, I get to be a part of the Rockefeller Foundation, I can’t tell you how many people have reached out to me across this country saying, what can I do to help? What can I do if I want to be helpful, if my people I know my community want to be helpful. And that’s the better angels of our nature that we need to summon in these moments. And you do that with kind of clear and consistent messaging and frankly, asking people.

Andy Slavitt: [00:21:16] You’ve had an extraordinary career. As I said in the introduction, your economist, your clinician. You’ve had global public health experience. You’ve had experience at two of the largest NGOs in the world. Do you feel like you’re made for this moment in some. I feel like you’re made for this moment in some respects.

Rajiv Shah: [00:21:36] Well, thank you. That’s very kind. I don’t know that anyone’s made for a moment. But one thing I have learned from my time at the Gates Foundation or even at USAID and now at Rockefeller, is that it’s just that people do — in times of crises, you can get people to come together and do things they wouldn’t otherwise do. So when this started in America, we brought together industry leaders, scientists, actually Republican and Democratic kind of former officials from various administrations and experts and said, OK, what do we need to do for America to survive this crisis? And the answer was a national testing and contact tracing strategy for our nation. We put it out there, we part of the 1-3-30 plan. But the important thing I want to mention about that is the people who made that happen, no one got compensated by the Rockefeller Foundation.

Rajiv Shah: [00:22:25] They were just good people, whether they were venture capital investors or well-known scientists or far less well-known ethicists and community health workers. But they came together because I feel like that is the nature of both this country and crisis, is that if you want to bring people together and craft solutions that everyone can get behind crises enables that kind of pace and speed and urgency that you frankly don’t have if you don’t have a crisis. So one thing I’ve learned from those past experiences is that, you know, during a crisis, you do need to step up and you do need to aim higher and you frankly need to reach out and bring people together who would be otherwise sort of strange bedfellows.

Andy Slavitt: [00:23:09] Yeah, tons of opportunity for that. What’s the role of the NGO, of a Gates Foundation, of a Rockefeller in a crisis like this?

Rajiv Shah: [00:23:20] Take risks. Lead. Support others. And that’s basically it. Take risks to create plan strategies, innovations that can help a country move forward. Put yourself out there. Put your money to work first so you can demonstrate that, oh, if you actually do testing and contact tracing in low income African-American communities in Baltimore, you have a bigger impact on on the transmission rate in Maryland than if you put those resources elsewhere. You know, it’s NGOs and civil society organizations can go do that while everybody else is still thinking about it. You do it very quickly. So that’s that’s sort of the I think the biggest value we bring in these types of moments.

Andy Slavitt: [00:24:06] What the mission of Rockefeller? 

Rajiv Shah: [00:24:09] John D. Rockefeller, when he created this institution 107 years ago, wrote that our mission will never change. It will always be to lift up and promote the well-being of humanity around the world.

Andy Slavitt: [00:24:23] Is it hard to make it institution like that go fast? 

Rajiv Shah: [00:24:27] Yes, absolutely. But our DNA from the beginning has been about applying science and data to solve problems, about building kind of strange bedfellow partnerships between government and industry, and about kind of putting our money to work to deliver results. So to that extent, we have a lot of experts in lots of different fields that all are committed to those key principles. And so we can’t do it on everything, but when we pick one thing and say, OK, COVID-19 is a huge setback for our mission of lifting up humanity and our nation that gave birth to this institution, you know, more than 100 years ago, now’s the time to step up and do it. We’re sometimes able to move very quickly.

Andy Slavitt: [00:25:14] I will say that, for people paying attention, Rockefeller Foundation is not a support player in what’s going on. But you’re actually, I think, a protagonist in that you’ve stepped up in a ways that they’re a funder. What’s been fascinating is the role that Rockefeller has carved out has included a pretty bold statement around what needs to happen around what you consider to be the most important area, which is testing. You talked about how you arrived there, what the importance is and the progress you’re seeing.

Rajiv Shah: [00:25:59] Well, we got there by focusing on the basic idea that you can only overcome a pandemic if you are hyper data driven. That is just a reality. And so the most important data point to know is who’s positive and and how do you reach them to make sure they don’t infect others? And that’s the driver of any pandemic response. And so that’s how we started. Then we looked around and frankly, it was, what, mid-March and or early March, and America still didn’t have at that point a national strategy for testing. We didn’t actually at that point have, you know, good validated testing products out in the market for people to acquire and use. And as you know, there were some early challenges with the with the actual CDC test kit itself that we learned later delayed the effectiveness of the American testing regime early on. So we kind of said, all right, let’s step into that challenge and just bring folks together and figure out what the solution is. And, you know, maybe 30, 40, but a core group, came together and just, you know, looked at all the data, kicked this thing up and down, talked to industry leaders, said, what’s your manufacturing capacity? How would you do it? And at the end of the day, issued a plan that had some clear quantitative targets. We said in seven to eight weeks from the plan issuance, we wanted to go from, I think, five, six hundred thousand tests a week to three million tests a week.

Andy Slavitt: [00:27:29] And where are we now?

Rajiv Shah: [00:27:30] Well, this was back in the spring and we actually hit that three million target. Right now, we’re about maybe 30 million tests a month, about five and a half million tests a week. And we said that by September we wanted to be at 30 million tests a week, of which we know we’ve got nowhere close. But we have done a lot of work through the course of the summer to create opportunities for more new tests to come online, together with some partners at HHS, as you know. And the result is, America will get to the targets we set, but get there, you know, seven or eight weeks late. And if that happens, you know, it brings into light your earlier point, which is we then desperately need the detailed protocols from CDC on how to use this now available screening test to get schools open safely, to get universities to work safely, to protect people in nursing homes, to protect Americans that are essential workers and vulnerable communities. And that’s the piece that we’re working on intensively right now.

Andy Slavitt: [00:32:15] So let’s let’s match up to kind of the need to get to the form function, if you would. We wouldn’t need, which is, you know, I don’t feel well, I got symptoms. I’m either in the hospital or I’m going to the hospital. I need a test. Presumably they need one that’s reliable. And obviously that has quick turnaround time. But that’s one test. Then you have tests for communities who just want to know where the virus is so they can take actions. And then there’s a third form, which is I have a desire to do something, go about my life, go to school, enter a church, whatever it is, get on an airplane. So I wouldn’t have tests available to me for that. If you think of the breakdown of what those needs are, and how close we are to having the kind of right type of functional test, which with the third type being kind of clearly more at-home, do it yourself, paper, antigen. The first time being more traditional PCR maybe being saliva tests or something. How do you how do you think we’re doing in each of those arenas?

Rajiv Shah: [00:33:22] OK. So those are the right three categories. Absolutely. Let’s call category one diagnostic testing. I mean, are these words get thrown around and they mean different things to different people. But you just described a clinical diagnostic test. You have a need for a test because you have some reason to think you might be positive, including, you know, you have some symptoms. And so you go get a clinical diagnostic test. I think we have about five million of those, four and a half million of those a week right now. The problem is, as I mentioned, there’s been good data to show that people are spreading early in their COVID-19 experience. And so the reality is the national average of three to four to five days, depending on where you are — and the reality that some high risk communities, you know, vulnerable Latino American community around Orlando, it’s twice that. That makes the tests useless from the perspective of taking actions that are protective to others and reducing contagion. So the issue there is get the test back results quickly, but we probably are pretty close to the right volume of testing for clinical diagnostic testing, specifically.

Rajiv Shah: [00:34:34] Screening tests are, I think what you described as I need a test because I want to go to school or I need a test because I’m working in a meat packing plant and there’s no social distancing available as an option, there we have estimated the need for about 25 million of those types of tests a week. And maybe America is at a million or so now. And we’re about to see the biggest step function increase in the tests that are available for that purpose. And I’m very excited about that, because too many people are going to get the kind of clinical PCR test when they should be getting this rapid, let’s say, a less sensitive but good enough antigen test that’s cheaper, faster and frankly takes burdens off the clinical system for those people who need a clinical diagnostic test. The barriers, I’d say, are twofold. One is the lack of detailed protocols which we talked about, for how to use these types of tests in different institutions, because you can’t ask, you know, a school administrator to kind of sample their population and figure out what makes teachers feel safe. You’ve got to have protocols that help define the answer. And then the second is, frankly, reimbursement. To me, America is spending — I mean, you’ve worked in big dollar agencies, but America spending 40, 45 billion dollars, as the Duke Margolies Center has recommended, to cover the cost of widespread screening, testing for vulnerable populations would solve that problem and probably would be the most efficient part of the two, three trillion dollars we’re spending dealing with the crisis. So in some sense, that’s a major, major hurdle we have to overcome, because otherwise, you know, NBA players who make $20 million a year, they get tests every day so they can go to work. But teachers who our kids depend on for a brighter future are being told you’re not important enough to justify a test.

Andy Slavitt: [00:36:30] What’s the cost of the test you’re assuming?

Rajiv Shah: [00:36:32] Well, there’s the real cost and what people are charging. And I think the real cost is probably should be down to 30 bucks a test on the high end in just a couple of months. People are paying in the market for rapid antigen tests right now, 100, 150. I mean, I can tell you anecdotes of north at 200 dollars to get a quick-result test. And this is the one area where we should be deploying these things in a way that generate public health outcomes not maximize profits in that context. 

Andy Slavitt: [00:37:06] My whole focus has been entirely on price because I believe whatever the right protocol is, it is a protocol with a lot of frequency. And so you can’t do that at $150, you can do it at five. You can do it at 10. You could do it at 15. And, you know, I kind of rage against some of the profiteering that I see and what makes this country great.

Rajiv Shah: [00:37:32] If you look at the HHS procurement of the BinaxNOW test, they bought $150 million or $37 million for public statements, that gives you a rough sense of potential price point. You know, if you’re doing things massively at scale. So I think in some sense you can target very low per unit price point. And I think as a lateral flow, as a technology becomes more broadly available, folks will be doing this in their homes. And I don’t know how you see the trajectory of this, but we certainly see it as a medium-term trajectory that if a 50, 60 percent efficacious vaccine applied in a selective manner, it’s not going to make our schools all that safer or make our nursing homes — well, maybe nursing homes, it’ll make a little bit more safer. But essential businesses will need ongoing screening, testing protocols and products in order to really make their employees and their partners feel safe.

Andy Slavitt: [00:38:31] I used to think that these were like the ticket to entry tests. And now I look at it differently. Now I look at it the same way I look at a vaccine. The more people test positive and pull themselves out of circulation, the more we’re going to drop R, and the more we’re going to be back to a situation where we’re finding occasional cases instead of community spread. And when we have occasional cases, you know, we’ll be able to use things like pooling and sewage testing and things like that. So,, it happens as fast as people like you guys and the states that are working with you. the 10 states you mentioned who are all agreeing to deploy these tests, can make them happen. Ultimately it’s about making people feel safer, but it’s going to be a weird thing to tell people, hey, you have a test that’s 60 percent successful. They’re individually not going to feel safer. But as a community, we will all feel safer.

Rajiv Shah: [00:39:29] Yeah. Although I would say I think, you know, we’re two months out from having most of the supply base for antigen test be much more sensitive than that. And you’ve probably seen the same thing. But 85 percent is a reasonable target. Explaining how to use an 85 percent-plus test sensitivity and why that’s better than a much higher sensitivity that takes longer to get your result is something that is part of the task of developing the protocols and rolling that out. But this is the only way I see America functioning in Q1 and Q2 of next year, by the way. And so there’s like we have the talent and we have the resources and then we should have the priority to make this work. And Paul Romer and I wrote an op ed back in the spring saying testing is the only way out, sort of defining this basic approach for economic viability. He estimated that every month we’re locked down in our economy, we’re losing $350 billion of economic output, and therefore made the point that, you know, a larger investment in testing to allow economic activity is well worth it from a economic management perspective.

Andy Slavitt: [00:40:44] From his lips to Mitch McConnell’s ears.Give us a feel for the next year. What bits of progress happen when, and when do folks start to take continued steps towards a life that they thought was normal before this happened.

Rajiv Shah: [00:41:06] Well, as you know, there’s a lot of variability across America in answering that question. I think the the I’d say three big realities are number one: this goes on longer than most people assumed. And even after we have things that feel like solutions: good therapeutics, some efficacious vaccines, and those are kind of publicized and written about and talked about for many, many months after that point, people are still going to feel like they’re living through a pandemic. And we’ll have to take precautions as such. Months, maybe years after that point. So this goes on longer than people realize. The second observation is this will continue to be deeply exacerbating inequalities and inequities in America. It’s just the reality that if you’re in a lower income, more dense community where you have to go to work using public transport and in crowded settings, you know, you’re gonna be more transmissive and you’re gonna be more likely to acquire COVID-19. And so this is an opportunity to start addressing inequality and inequity in this country in a way that’s far more profound than what I’d say most public health experts can muster on their own. It has to be a national commitment to say, let’s build an America that’s just a bit more fair and a bit more equitable so that the folks who are doing all the work and taking a lot of the risk are protected. And we start treating them a little bit like we’re willing to treat CEOs and basketball players.

Andy Slavitt: [00:42:42] The people putting food on their table.

Rajiv Shah: [00:42:43] Yeah, exactly. And then I’d say that the third thing is, you know, I’m optimistic that the testing strategy can work. I’m optimistic that, in fact, if we get to 200 million tests, of which the vast majority are screening tests, and that is what the U.S. market looks like in the month of January from a testing perspective, and we have clean specific protocols on how to deploy them, all of a sudden, you know, schools can be confident about protecting teachers and being active. And we can stop the learning loss that’s debilitating this nation right now. And all of a sudden, you know, grocery stores and healthcare settings and people who provide essential services and service work can both be safer and feel safer and get about their work. And the economic activity, therefore, can proceed, even as the public health crisis, even as we’re still living through a pandemic and well before people have gotten their first and second shot of a vaccine that’s likely to only be somewhat efficacious.

Andy Slavitt: [00:43:47] Well, thanks Raj. Thanks for all you do.

Rajiv Shah: [00:43:49] Hey, Andy, thank you. And thanks for all that you’ve done over over the many years now.

Andy Slavitt: [00:43:53] We’ll stay in touch.

Rajiv Shah: [00:44:04] Thanks to Rajiv. I hope you enjoyed that conversation. Having had a chance to work with him, I think he is part of a bright hope for our future responding to this pandemic. OK, let me tell you about our next three episodes. On Wednesday, Senator Chris Murphy from Connecticut will be on the program. And we are going to be talking about the Affordable Care Act, Supreme Court case, the pandemic. And you will find, if you don’t know Chris, that he is a very interesting guest. We’re excited to have him. The following Monday, we have a very rare opportunity, a rare sighting. It’s called a Schumer. We are going to have the Senate minority leader, Chuck Schumer. And we are going to talk about the response he’s leading with the Justice Barrett hearing, which will begin right after we speak with him. And, of course, the pandemic response, trying to get a bill to support the states and the rest of the country. It is a really great opportunity to hear from Chuck. And then on the following Wednesday, we’re back to the science. We are back to the policy. We are back to the pandemic with an amazing guest, fascinating guest, good friend of mine, Zeke Emanuel. So I think that will be a lot like our episodes of Larry Brilliant with Ed Yong, with Mike Osterholm, and I think you will really get a kick out of it. So as we kick into October, we’ve got some great shows for you. Thank you so much for tuning in. And we will talk on Wednesday. 

Andy Slavitt: Thanks for listening to In the Bubble. Hope you rate us highly. We’re a production of Lemonada Media. Kryssy Pease and Alex McOwen, produce the show. Our mix is by Ivan Kuraev. My son Zach Slavitt is emeritus co-host and onsite producer. Improved by the much better Lana Slavitt, my wife. Jessica Cordova Kramer and Stephanie Wittels Wachs still rule our lives and executive produce the show. And our theme was composed by Dan Molad and Oliver Hill, and additional music by Ivan Kuraev. You can find out more about our show on social media @LemonadaMedia. And you can find me @ASlavitt on Twitter or @AndySlavitt on Instagram. If you like what you heard today, most importantly, please tell your friends to come listen. But still tell them at a distance or with a mask. And please stay safe. Share some joy and we will get through this together. #StayHome.


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