In the Bubble with Andy Slavitt: Our Shot

The Latest Science of Fighting COVID-19 (with Dr. Scott Gottlieb)

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Description

In perhaps the most essential episode of the series, Andy gets a real sense of where we are now in the scientific response to COVID-19 with Dr. Scott Gottlieb, FDA Commissioner under President Trump. In this riveting conversation, they cover the science, the politics, and the policies that got us here and will lead us out. They also discuss the importance of their bipartisanship work together and Scott’s forthcoming book, Uncontrolled Spread.

 

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

 

Follow Dr. Scott Gottlieb on Twitter @ScottGottliebMD. Check out In the Bubble’s Twitter account @inthebubblepod.

 

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Transcript

SPEAKERS

Andy Slavitt, Dr. Scott Gottlieb

Dr. Scott Gottlieb  00:00

I think we’re going to have a surge of infection in the fall, it’s not going to be anywhere near, like the peak of last winter. If you look at the modeling, the modeling is predicting at the peak, there’ll be about 20% of the number of infections that were at the peak of January wave that we saw.

Andy Slavitt 

So 10s of 1000s, 50,000, something like that?

Dr. Scott Gottlieb

Well, you know, 50,000 40,000 infections a day. Yeah. You know, if you believe the modeling, but it’s going to be, as I said, hyper regionalized, there’s going to be parts of the country, whether it’s very low levels of infection in parts of the country, there’s more pervasive spread.

Dr. Scott Gottlieb

Welcome IN THE BUBBLE. I’m your host, Andy Slavitt. That was Scott Gottlieb, he’s the former head of the FDA, from this episode, you’re in for a real treat. This is probably the most essential of all the episodes of our season so far, it is one you absolutely cannot miss any word of Scott is that good. Scott is probably the person that brings together the best scientific mind, the best political mind, the best policy mind. And he’s someone who liked me get all of his information directly, by observing, by talking to people by being in the flow. And he’s actually in the board of Pfizer, which gives him a leg up on some of the scientific information. Unlike me, Scott is a real scientist, and a physician. So he brings you a lot of real firsthand perspective and opinion that I simply can’t.

Andy Slavitt

And so this is going to be a wonderful episode where we focus on the facts of where we are in fighting COVID-19, the science of fighting COVID-19 in a way that I think everybody can understand. It is a critical piece of the puzzle for all of us. And as we get to week three, you know, we should be leaving week three of this series, with a feeling of kind of where we are, as much as one can know it. Scott lays it out for us great from soup to nuts. After listening to this, I expect you’ll have the best possible baseline of information. And then allows go on to some other topics, I want to say of the best possible baseline. That will be until you read the quote, “new study with the jolting headline.” Undoubtedly, you’re seeing them every day or two.

Dr. Scott Gottlieb  02:45

It’s a headline that’s surprising, because it just sends us all back reeling a little bit to oh, no, are we headed back into the crisis we just left. And it is really disturbing. And it can get to us any day. Anytime we see a headline which, you know, may show something that implies that the vaccines don’t work or that a variant is gaining traction, or, you know, Lambda, or J&J or this or that and just shakes their confidence. Because, you know, we’re all quite a bit scarred from the last year, including me. So you know, we all see these headlines, and they have this potential to throw us off our course. So my sermon today is actually on what to do when you see this single new study, this headline, that potentially throws you off your course. And of course, it’s very tempting to react to it, we have three basic choices.

Andy Slavitt

The first is, you know, get on Twitter, and kind of relish in the panic, reading people, pushing it around, jumping to conclusions, telling us what it means. And just, you know, we have a really crappy day, if you do that, you know, that’s one of the temptations, there’s a second option, which is to just ignore it, you know, put your head in the sand and say doesn’t exist, I’m not going to let it get to me. You know, when the truth is, it’s not the worst strategy in the world to be honest at all times, in large part because you can’t carry around every burden, that’s not going to hit you. You can’t carry it all around as a potential worry. You just can’t. So sometimes it does make sense to just ignore it. There’s a third choice, which I think is obviously the best choice, which is actually wait and let it ripen.

Andy Slavitt  04:43

I mean, these studies are like, you know, they’re like green bananas. You don’t want to eat them right away. Just wait for the questions to get asked and answered, which allows whatever it is to be put into context, in which I assure you will be much more reasonable and easy to understand, of course, and IN THE BUBBLE, we will try to help you try to do that. But others will as well. And I think, you know, it takes a little bit of discipline to wait. But let me give you a current example that is fresh today. You know, there’s a new study out from Israel, it’s not even the study, it’s a headline, which says that the vaccination success rate from Pfizer’s dropped from like 90% to 65%. And that’s jaw dropping on its face. It’s something that would be upsetting to people if indeed it were true. And you know, indeed, people are reeling from it now.

Andy Slavitt

I saw this and I got a hold of Tony Fauci. I got ahold of Rochelle Walensky; I got a hold of several other people just together through some facts. And, you know, the truth is that you really don’t know much of anything from looking at this one green banana. First of all, it says, 60%, we don’t know whether that’s 10 people, whether it’s 5 people, whether it’s 100 people, and all that matters. The second thing is, it talks about largely that it is asymptomatic spread, that is gone from, you know, the sort of 90% range to the 65% range. So this means that we are finding that there’s more people who have been vaccinated, or and who haven’t been vaccinated who are testing positive for asymptomatic spread. Okay, interesting. But what Dr. Fauci told me was that they are now in Israel, testing virtually everybody that is in contact with someone who had positive for COVID-19.

Andy Slavitt  06:52

So it stands to reason that if you’re going to be testing more people that are in contact with people from COVID-19, you’re going to find more people with some sort of with dormant conditions. Okay. But what about this bit about how that the higher percentage of people that they’re finding are people that have been vaccinated, that clearly must be troubling, that can’t be good news. Although it turns out as Fauci explains to me, the very simple fact that in Israel, a larger percentage of people have been vaccinated means it absolutely has to be true, has to be true, that more people who they find are positive are going to be vaccinated. But it says nothing about the effectiveness of the vaccine. It’s a scary headline, maybe from a reporter or someone else who just noted the fact.

Dr. Scott Gottlieb

But it just absolutely doesn’t mean anything. It’s like saying that there were finding that if in the NBA, more tall people are getting COVID-19, than in the regular population, just are more tall people in the NBA, so that is not at all concerning. So there’s a couple of things that are possibilities that we’re going to find out about from this study. One is, if it indeed is true, and the numbers, the 60% number, that they’re talking about 65% number, differs pretty significantly, from what we’re seeing in almost every other country, which shows numbers that are an 80%, 90%, 90%, plus. The other thing we don’t know is whether or not this could mean that if it is true, that for certain populations, the length of the vaccine, the durability is beginning to wane a little bit. That’s a possibility.

Andy Slavitt  08:46

We would expect that when the vaccine begins to wane, its durability, we will first see it in Israel since Israel was the first place where people were been vaccinated. So the Israeli Health Ministry is meeting this week. And they’re going to discuss whether or not it is indeed time to begin, particularly with the elderly population, to provide a third booster. So that conversation will happen. And that’s a conversation that’s going to happen eventually, at some point anyway. And when it does, it’ll come out of danger from Israel. Is this that time? We don’t know. It could be. It could be not. But when you add all of this up, what it tells you is for what doesn’t definitively tell you anything about what’s going on with the effectiveness of the vaccine tells you something about the fact that more people in Israel are vaccinated doesn’t tell you how many, we don’t know how many people have this increase or because they’re just testing many more people that come in contact with people with COVID.

Andy Slavitt

So none of these things are part of the context. As of today. The teams of people in the CDC are talking to the people in Israel, all those questions are being answered. And so we will find out one way or the other, but there are lots of good explanations other than the panic inducing explanation that comes from this headline. So it’s a great example, on how we shouldn’t allow ourselves to get knocked off course so easily. It’s a great example of how it sometimes makes sense to just let this information ripen. It’s probably not nearly as significant, as the headline implies. And of course, if there is something wrong, then we will learn about what this change means. And we will learn whether or not it means we need to change course, with our vaccines. And of course, if it makes us feel better, we can always begin to take more precautions just in case, we can wear a mask. If it makes you feel better indoors, N95 mask.

Andy Slavitt  10:49

We can be careful and cautious around people that haven’t been vaccinated or have immune deficiency issues. We can do all those things as wise coping mechanisms, but doesn’t mean that we have to lose our cool, that we have to panic, that we have to put ourselves in a situation where we’re kind of replaying the tapes from last year, and feeling very much out of sorts. Like we’re gonna go through some of the same trauma again, it absolutely doesn’t mean you have to put yourself through that. Okay? So that’s, I think, what I want us to take away as much as everything else, try to take things in stride, don’t get knocked off course by a single study, you’ll get the facts. And so with that, I am really happy to talk about all of the things we know and the things he suspects with one of the smartest people around. Scott Gottlieb.

Dr. Scott Gottlieb 

Hi, let me close this door just in case the dog barks again, I’m sorry.

Andy Slavitt  12:08

I will appreciate that.

Dr. Scott Gottlieb 

I’m set.

Andy Slavitt 

I want to get to your book. I actually find doing interviews easy. I find doing book interviews really hard for some reason, like I play back the interviews I do unlike any normal topic on the pandemic or healthcare. And then my answers are reasonably tight. And I’m only talking about when I get asked about the book. My answers are terrible.

Dr. Scott Gottlieb 

Yeah, it’s an interesting thing you say that I feel the same way. When I talk about the book because there’s so much in there and so broad out and as you if you don’t want to end caps you don’t want to condense your book down to a single line, like my books bigger than that, how can I talk my book in a soundbite.

Andy Slavitt

Exactly, though, like people will say like, you know, your book really talks about what’s going on the Trump administration. I’m like, yes, but not just that. It talks a lot about, you know, society. And this, the people and it says it’s the worst interview known to man because, you know, you got it. You want to give it what you’re supposed to give a tight answer. And you know that you know, you’re supposed to give a tight answer, but I can’t seem to do it. So I listened to myself on being interviewed by […] and PBS. And it was the worst. I was like, I’ve never seen a more boring person talking about this book. Yeah, I describe myself in my book, probably bragging a little bit more than I should have as one of the only Democrats to talk to the Trump administration regularly. You’re one of the only Republicans I know, who talks to the Biden White House on a pretty regular basis.

Dr. Scott Gottlieb

You know, I’ve been in touch with Congress and the administration all through this. I mean, one of the more memorable days for me was early on in March, probably around maybe March 12. I talked about it in the book, but I forget the exact date. I spent the morning on Capitol Hill briefing, the Republican conference, Republican Congressional Conference. So all the Republican congressmen crowded into a room. Liz Cheney had invited me to speak to them it was right before the Cares Act was gonna come before Congress, and she’s trying to build support to get that passed. And I gave her a pretty downbeat assessment about where I think things were heading. This is before you know, New York shutdown, it was before there were a lot of cases turned over in New York. So we were right at the cost of being aware of how much spread was underway in the United States.

Dr. Scott Gottlieb  14:30

The only visible reminder that there was risk during that meeting was they were the breakfast was grab and go. So instead of a buffet line, which they usually had they had someone serving the coffee and you had to grab your breakfast sandwich because they didn’t want people touching, shared utensils. And then that afternoon, I went and briefed the House Progressive Caucus. […] others invited me to brief the Progressive Caucus. It was sort of an eye-opening day went from briefing some of the most conservative members of Congress to briefing some of the most liberal members of Congress. And the one sort of pervasive emotion through, you know, the morning and afternoon was fear. I mean, you know, there was sort of a palpable sense of fear and uncertainty, more uncertainty, a lot of the questions that, you know, will focus on what was going to happen, how much risk were we? And that was a very memorable day. I mean, that really sort of crystallized for me moving across both sides of the aisle.

Andy Slavitt 

Well, that was a day when we were all Americans. I remember very explicitly when we were scared, we were all Americans. Unfortunately, that didn’t last. So let’s get into some of the things that are most on people’s minds right now. We are entering the summer months. And on the one hand, if you look back to where we were in January, we’ve come an extraordinary distance. Still, you know, we’re at a place where only two thirds of adults have had their first shot. So on a scale of 1 to 10, if last March, you were 10 in terms of worry. Where are you now?

Dr. Scott Gottlieb  16:29

Yeah, look, I’m probably a 5. But I think that understates the level of concern, because in the near term, I don’t have a lot of concerns, I think that we’re going to have a comfortable summer, I think, you know, infection levels probably aren’t going to start to build within this new variant of delta variant until we get into maybe August, September, except for certain parts of the country where it’s becoming epidemic now, you know, certain parts of the rural south. But I do think we face risk heading into the fall. And the bottom line is this, 85% of the American population is going to develop immunity to SARS-CoV-2, we now have a choice of how we acquire that immunity we can do through vaccination, or we can do it through natural infection. But the reality is with this more contagious variant, when you look at Delta, at least 8-%-85% of the population is going to have to develop immunity before this stops spreading given how contagious it is. And while vaccination rates are high, they’re not evenly dispersed across the countries, there are still pockets of extreme vulnerability where we’re going to see dense outbreaks at some point probably heading into the fall.

Andy Slavitt 

So okay, you say 5, let me ask you to split that into regions. And for people who live in Vermont, what’s your level of concern for over the next few months?

Dr. Scott Gottlieb

It’s low. You know, it’s, you know, two, its low, Connecticut, same. I’m in Connecticut, high vaccination rate, a lot of immunity from prior infection we can’t discount. So far, these new variants don’t appear to pierce prior immunity. And so you know, we also have a lot of immunity in the population, people have been infected. But when you move to Missouri or even Ohio, Arkansas, Alabama, where vaccination rates are low, and we probably don’t have quite as much infection, especially in rural parts of those states. My concern is very high.

Dr. Scott Gottlieb  18:20

Okay, let’s take it to the individual level, we’ll get it regionally. If you’ve been double vaccinated, how worried should you be about life in general, let’s just say over the next few months, going, you know, through the summer, no matter where you live, how worried should you be on a scale of 1 to 10?

Dr. Scott Gottlieb

I think if you’ve been vaccinated, your chance of very bad outcome are extremely low. Your chance of developing severe disease, requiring hospitalizations, your chance of succumbing to COVID, dying from COVID are extremely low. Yeah, there’s still a risk that you could contract the infection become mildly infected or even become asymptomatic and transmit the infection. But that’s substantially reduced to as you know, that was the basis for CDC lifting the recommendation around vaccinated people wearing masks a recognition that people who are vaccinated, far less likely to transmit the infection. So I think if you’re fully vaccinated, your risks are low.

Dr. Scott Gottlieb 

I do believe that, you know, based on the data I’ve seen, and this is public data that, you know, the immunity acquired through vaccination is going to decline over time, particularly for older people, people who are more vulnerable, don’t have as robust of an immune response to begin with. So I do think that at some point, we’re probably going to want to provide boosters to a certain segment of the population who are at higher risk of COVID and for whom the vaccines may not have the same durability, but for most people who get vaccinated, I think they’re gonna have a durable response and the risks from COVID are substantially reduced.

Andy Slavitt 

I’d love to come back and talk a little bit about the fall and boosts and so forth. But as far as the summer is concerned, if you’ve been vaccinated, is your main message, you’ll enjoy your summer, you got low risks, there’s obviously exceptions if you’re immunocompromised, or for kids or if you have kids at home there’s some adjustments, perhaps that need to be made. But just holding those off for the time being, generally speaking, you’ve been vaccinated, you’ve gone through a year of hell, here you are in the summer, would you go so far as to say, even God forbid, enjoy yourself?

Dr. Scott Gottlieb  20:20

I think that’s right. I would tell people to enjoy themselves this summer. I mean, I made the comment on TV that it’s going to be like Woodstock across America this summer, I think people have a lot of, you know, pent up desire to go out vacation, spend time with family, I think people should do it, I think we have an opportunity to do it. Infection levels are going to be low in most parts of the country, I think they’re going to remain low. I mean, if you look at the modeling for the outbreak, so we’re anticipating in the fall, sort of right around back to school from 6.7, from this new Delta variant, some states show no up took at all and of infections, other states show raging epidemic. So it’s going to be hyper regionalized, in terms of which parts of the country are affected. And I don’t think it’s going to be like last year, where in the fall of 2020, you saw dense outbreaks in the Midwest, it really started in the Midwest, if you remember, Wisconsin was you know, lit up with infection, and it was mostly rural parts of Wisconsin, and then the infection became national, I don’t think that that’s going to be the case this time where you have a regionalized epidemic in certain states, and then it sort of grows into a national epidemic, I do think that there’s going to be parts of the country that are largely impervious, impervious might be an aggressive word, but are going to be largely impervious to epidemic spread of COVID, unless something unexpected happens.

Dr. Scott Gottlieb

And there’s one variant. So delta isn’t just one variant. Delta is really five variances, you know, there’s one version of it one strain, people call it sort of Delta plus, that when you look at the experimental evidence, the vaccines don’t appear to cover it as well, it seems to pierce the vaccines. And this is based on, you know, experiments done in test tubes, where you’re looking at the ability for antibodies produced by the vaccine to neutralize the virus in petri dishes. So we don’t have clinical evidence to sort of support that. But there is concerned vaccines may be less effective against that particular strain.

Dr. Scott Gottlieb  22:10

When I fly, I tried to get upgraded to Delta plus. No, no, this, this show has the best dad jokes that you’ve ever heard. And it’s well known. I mean, most people listen for the really high-quality humor like that. You kind of laugh that most roll their eyes, but you’re very kind to laugh. So let’s move to the fall, let’s talk about the fall and the winter. You give it a good outlook on the summer, if particularly you’re vaccinated and by region. So what do you anticipate, like if you’re watching the news, if you’re watching CNN, or NBC or CBS? And you know, we know the anchor, the anchor comes on at the beginning and says, well, COVID, we have an outbreak. Are you anticipating like, lots of outbreaks, lots of small outbreaks? Are you anticipating something that looks a little like 2020? What do you think the fall will look like?

Dr. Scott Gottlieb

I think we’re going to have a surge of infection in the fall, it’s not going to be anywhere near like the peak of last winter. If you look at the modeling, the modeling is predicting at the peak, there’ll be about 20% of the number of infections that they were at the January wave that we saw.

Andy Slavitt 

So 10s of 1000s, 50,000, something like that?

Dr. Scott Gottlieb 

You know, 50,000-40,000 infections a day. Yeah. You know, if you believe the modeling, but it’s going to be, as I said, hyper regionalized, it’s going to be parts of the country where there’s very low levels of infection and parts of the country that is more pervasive spread. I think those models are a little bit aggressive, quite frankly, I don’t know that it’s gonna be that bad. I wouldn’t be surprised to see 40,000-50,000 infections recorded on some days as we get into the fall and was sort of in the peak of a surge or infection. But I think it’s probably going to be a little bit lower than that. But very concentrated in certain parts of the country where there’s low levels of vaccination, not a lot of prior immunity from prior infection. This is if the Delta variant becomes prevalent, which it seems to be I don’t, I think with Delta plus the one that appears to pierce vaccination, if the current trend Delta becomes pervasive across the US, it should crowd that out the immunity that people acquire through the current from the current strain should be protective against other forms of the Delta variant.

Andy Slavitt  24:29

Do you see Delta plus could outcompete Delta?

Dr. Scott Gottlieb

It isn’t. So that’s a good suggestion that it won’t but always, you know, obviously, always hard to tell. I think, at some point, there’s going to be a recommendation from CDC around boosters for a certain segment of population, it’s probably going to be for people who are above a certain age and you know, out a certain length of time from completing their original vaccine series. So you know, I think my recommendation would look something like if you’re over the age of 65, and you’re more than 9-10 months out from completing your vaccine, your original vaccine, you should get a third dose, maybe it’s 60, maybe it’s 55, maybe it’s 12 months, maybe it’s 8 months, I’m not sure. But if you look at the data out of Denmark and other nations have done a good job tracking natural infection immunity acquired through natural infection, it does show in the older population a decline and its substantial decline. And it’s very age dependent, so the Danish study, Danish landmark study, which looked at people who had infection after a significant interval, and I think 7- or 8-months overall protection from people who are infected with still 80%.

Dr. Scott Gottlieb 

So still really good for the population as a whole lot of residual immunity. But if you looked at the cohort 65 and above, it was only 47%. So substantial decline in the older cohort. So if you want to maintain protection from infection above 50%, I think you’re going to want to get boosters. Now, that said, there’s probably the studies came out just in the last few days looking at this, there’s probably a compliment of residual immunity from T-cells, and memory B-cells, where the vaccines are inducing a longer-term immunity and protecting you against severe disease. So that means that you might be more likely to get infected after a year, let’s say you get vaccinated a year later, you might be more likely to get infected, your antibody levels have come down. So you might only have 50% of your original protection against infection. But you’re going to have other immune cells that protect you against severe disease from protecting against hospitalizations, protect you against death.

Andy Slavitt  26:36

Does that mean you’re contagious?

Dr. Scott Gottlieb 

It means it can be contagious, too. But if the goal is to protect people from infection, in part, so they never get infected in the first place, because you know, infection is obviously uncertain, some people will have bad outcomes, and you want to reduce the likelihood that they’re going to transmit the infection, you want to maintain their protection above 50%. That’s sort of a threshold that you want to maintain above. And to do that in an older population, you’re probably going to need to provide boosters.

Andy Slavitt 

So what I mean when you say big picture is COVID’s not gone, but we have the tools. Tools aren’t being used perfectly. But we have the tools to effectively make COVID a manageable challenge for the country now, which is an enormous difference than where we were, which was an emergency and kind of runaway train. So just to test that a little bit to make sure that I said that right. Do you anticipate overflowing hospitals in certain communities?

Dr. Scott Gottlieb 

No, I think that the death and disease, the morbidity and mortality from infection is going to be substantially reduced. And look what’s happening in the UK right now. 90,000 Delta infections, 93,000 based on their last for lease, they’ve had about 1000 hospitalizations, only 8% of the hospitalizations have been people who are fully vaccinated. You know, if you look at deaths of those under the age of 50, there’s been no deaths and people under the age of 50, who’ve been fully vaccinated. It’s a little hard to look at over the age of 50, because most of the people over the age of 50 have been vaccinated. So they’re going to be breakthrough infections. People who were over the age of 50 and get infected with Delta are breakthrough infections, are people who’ve been vaccinated infected when you look at under..

Andy Slavitt  28:18

Were they single or double vaccinated?

Dr. Scott Gottlieb

I’m talking about fully vaccinated. Okay, so the case fatality rate in the UK right now, if you looked at the data is anywhere from, you know, .2% to .3%. If you look at sort of a 28-day mortality, that’s substantially reduced from where we were, right? And it’s probably going to come down a little bit more. So we’re not quite at the level of mortality caused by flu, but you’re starting to approach flu. I mean, everyone said COVID, was flu a year and a half ago. COVID clearly wasn’t flu. But at some point, the level of risk that COVID poses societally in terms of hospitalizations and deaths is going to start to approach what we see from seasonal influenza. I think when you get to that point, this becomes a manageable threat. The healthcare system can manage it. And it’s, you know, quite frankly, a decision individuals start to make about how they want to acquire their immunity, because like I said, at the outset, 85%, maybe more percent of us will develop immunity to COVID one way or the other, we will develop immunity to COVID. Some of us will have to acquire that multiple times, people now have a choice.

Andy Slavitt 

Yeah, I think to remember the data that during a bad flu season like the number of daily deaths is like what is 100 or a couple of 100?

Dr. Scott Gottlieb 

It was about 100 at the peak of flu season.

Dr. Scott Gottlieb

About 100. And so, you know, just to compare COVID is, you know, between two and three times that right now come down from substantially more from 30 times more, or close to even 35 times more, but it’s not there yet. What are the interesting differences is the flu has a very kind of spotty vaccine. And COVID has a very well-functioning, highly functioning, effective vaccine. So one would think that as particularly the people that are most vulnerable, which are going to be, you know, start with seniors are vaccinated, that we could be down in that range at some point or lower.

Dr. Scott Gottlieb  30:26

We’ll probably, you know, we’re probably closer to that range right now, a lot deaths are a lagging indicator, not only because the deaths that are occurring today are infections that occurred, you know, a while ago, but we record deaths from death certificates, and it takes a long time for that information to actually be aggregated. So if you sort of project out deaths that will occur as a result of infections happening now. It’s substantially lower than what we’re recording on a daily basis.

Dr. Scott Gottlieb 

You’re smarter than me. I think this is consistent with my thesis, which I don’t know if you agree with or not, which is that COVID is becoming a manageable challenge. We have tools, it’s not going away. But it’s no longer in the bucket. I mean, I’m thinking about the average person sitting home saying the last year felt really out of control, we didn’t really have the tools to deal with this other than adjustments that are our own behavior, which run into limitations. And of course, we can all control our own behavior, we can’t control other people’s behavior. And we lost a lot of things. And the sort of focus I was like, of the question of most people have, which is when is it okay for me to be back to normal? And I think a lot of my answer depends on a lot of people’s definitions of normal are going to be different. But that with some exceptions, for people who have the vaccine doesn’t work well for and I want to talk about that a second. Yeah, we’re living in a place where this is one of many manageable challenges in life, not something that overwhelms us. Would you agree with that characterization?

Dr. Scott Gottlieb 

I would agree with the characterization that for most people COVID is an addressable threatened and manageable challenge, with the one caveat that there’s still pockets of extreme vulnerability that we need to recognize and address because it’s not manageable for everyone. You know, there’s still issues with people who the vaccine hasn’t been accessible, or face challenges getting vaccinated. There’s still people who, you know, are scared of getting vaccinated and need to better counseling, better information, and there’s still people for whom the vaccine is not going to work.

Andy Slavitt  32:30

That’s right. I agree with that. That caveat. I don’t know when you graduate school, there was always the person who made a smart comment, then the person raised their hand, and then made a smarter comment on top of your comment. And your like, that guy always does it to me.

Dr. Scott Gottlieb

That joke was better than your Delta plus.

Andy Slavitt 

I think the Delta plus is the winner.

Dr. Scott Gottlieb 

Is that gonna be the excerpt that you guys use on Twitter?

Andy Slavitt 

I doubt it. But let’s talk about the, because in Pfizer’s actually doing something there that I want to talk about the next potentially exciting breakthrough for just a minute. Because people are talking about thinking about vaccines nonstop, but an oral antiviral.

Dr. Scott Gottlieb 

Yeah, we don’t think about it. But you’re right.

Andy Slavitt

So can you talk about the potential, the likelihood and the impact of an oral antiviral?

Dr. Scott Gottlieb

Yeah, so there’s a number of products in advanced development right now Merck has one that looks very promising put out data about 11 days ago, there was a pre-print, about two weeks ago, and that’s an advanced development. That’s a drug that they licensed from a company called Ridgeback. Roche has a drug that works on the same mechanism as the Merck drug generally speaking, but earlier, there’s a drug by Fuji that was originally developed for flu, that’s being put in a very large trial looking at potential effects against COVID. And then there’s the drug by Pfizer, which is a […] inhibitor, obviously, I’m going to go to Pfizer, you know that I think a lot of listeners know that all the drugs work by basically inhibiting some aspect of viral replication.

Dr. Scott Gottlieb  34:04

You know, the Pfizer drug inhibits […], an enzyme that the virus uses to replicate. These drugs look promising, I think people are, you know, cautiously optimistic at Pfizer about the compound that the company is advancing the government’s, you know, reached in as you know, and you were part of this and has partnered with the companies on some of the development helping to run the clinical trials, they’ve agreed to some advanced purchase agreements. I think this could be a real game changer. I think if we can get a drug that inhibits viral replication that’s safe, that’s largely non-toxic, that can be used on an outpatient basis, both to treat people who are exposed to the virus and at risk of a bad outcome.

Dr. Scott Gottlieb

So as a prophylactic some people who might be at high risk of a bad COVID outcome and know that they’ve come in contact with COVID. So sick contact in a house, something like that, as well as to be administered early in the course of the infection. To prevent progression to severe disease that can be a real game changer we don’t even think about it and yet we could potentially have it by the late fall yeah sort of Tamiflu like drug for COVID.

Andy Slavitt

Yes. Do you anticipate a day when you will be able to you know, have a family member walk into a drugstore pick up something that is like Tamiflu if you’re feeling symptomatic and just take it and boom

Dr. Scott Gottlieb 

Yeah, we will have that. You know, the reason I feel optimistic and you know, it’s I can’t say for sure it’s gonna be one of these drugs right? We don’t know. But there’s nothing so highly intricate about the way Coronavirus replicates that we can’t drug it. All the machinery that this virus uses to replicate we’ve drugged in other contexts. This isn’t HIV this isn’t sort of a widely very difficult to drug virus. This is a fairly straightforward virus. The only reason we don’t have a drug for Coronavirus now is normally Coronavirus causes very mild illness. And so there was never really a sort of public health imperative to develop a drug to target a seasonal, you know, Coronavirus that causes a seasonal cold and most people but this is a druggable target, we should be able to find a way to inhibit viral replication.

Dr. Scott Gottlieb  36:13

Now, that said, you know, it’s not going to be a cure all. I mean, you know, even using a drug in early disease to prevent replication as a way to prevent progression. It’s not going to work for everyone, just like Tamiflu doesn’t reduce symptoms for everyone and doesn’t prevent sort of flu illness, even when used early. But it will work for a lot of people if you have a potent drug. And I think beyond that it’s going to really improve psychology around COVID. If people know that there’s a pill that can help rescue them or prevent them from getting seriously ill, I think it’s going to make people feel far more confident around living a normal life against the backdrop of COVID circulating at some level in society.

Dr. Scott Gottlieb 

Yeah, yeah, that’s a great point on the psychology does feel like in particularly thinking about immunocompromised, immunosuppressed people, people can’t take a vaccine for one reason or another, having another answer out there. And you’re talking about the fall, when we’ll see results from these trials. And we could be in very quickly, with a little bit of luck, these things could be into the market in your hands.

Dr. Scott Gottlieb

And keep in mind, I mean, just to pick up on your point. If you have a drug that has a good safety profile for some people, they might take it in perpetuity over a period of time to prevent infection. So you know, if you’re an immunocompromised person or someone for whom the vaccines don’t work, or you can’t take a vaccine, and you have a drug that’s largely safe, and can be used as a prophylaxis, you might take it over the two months of peak COVID season. I mean, there are people who do that with Tamiflu now. Tamiflu who’s obviously approved for prophylaxis, but not for a month. But I know there are people who will take it for, you know, a month or two through a bad flu season because they’re so vulnerable to flu and vaccines don’t work for them where they can’t take the vaccines so that at least that option is available if you have a safe and effective drug for certain people.

Andy Slavitt  38:15

That’s interesting. And do you see it being a potential global aid? I mean, while we’re trying to vaccinate the world, and we’ve got, we’re 10 billion doses short of vaccine at the world at this point, I mean, we have a lot of work to be done there. But do you anticipate that while we’re in the process of doing that, that this can be a tool that can it can get manufactured enough scale that it can help us around the globe?

Dr. Scott Gottlieb 

Yeah, because it can be manufactured easily, you know, small molecule drug, you can partner with a lot of different manufacturing sites globally and produce this in, you know, potentially massive quantities. I do think that we’re solving the, you know, slowly, obviously not at the speed that we need to but we’re starting to solve the global vaccine supply issue, including the work that you did. We’ve delivered 2.7 billion doses of vaccine globally. You know, we need to remember it’s not just us and Western vaccines, China’s also providing vaccine rushes, providing vaccines. So when you start to aggregate all the vaccine supply that’s going to be available over the next 12 months. It’s more than enough to vaccinate the world. And Pfizer alone is going to send it they’re gonna produce 4 billion doses, Moderna I think 3 billion. You have J&J, AstraZeneca in the game, Sanofi is going to enter the market I believe at some point, Novavax looks like it’s going to be a successful vaccine. And then you have the Russian and the Chinese vaccines and India also is going to be manufacturing at a significant scale.

Andy Slavitt

And it’s going to take the world because by every estimation I’ve seen, it’s 10s of billions of dollars, even with the manufacturers, not making a profit in the developing world and in the in the medium wealth countries, it’s still 10s of billions of dollars. So it’s going to take you know, this is where I think the G7 and as you said the G20 is going to lead. I want to finish up with a couple of other quick topics, bipartisanship. And I want to talk a little bit about your book, which I was lucky enough to have a chance to look at. You know, you mentioned earlier in the show that you’ve been called by both Democrats and Republicans to talk. You and I, and I’m guessing you and other Democrats have done things together. Do you think it’s important to do that, for some reason to show a Democratic and Republican kind of working together saying similar things?

Dr. Scott Gottlieb  40:47

In response to a public health crisis and a national security issue? Absolutely. I mean, I don’t think for us to be effective, our responses to these kinds of crises can be politicized, I don’t think we can go forward with sharp political divisions of how we approach something like this, because then you can’t get the consensus that you need in time to be able to have an effective response.

Dr. Scott Gottlieb 

You and I co-authored a letter together last year, and it was about contact tracing and some related topics and kind of containment. And then we have other people on the letter Democrats and Republicans both become professionals. Do you think the fact that it came from the two of us and others change the way it was received, as opposed to if it came from, say, you know, Democrats only, Republicans only?

Dr. Scott Gottlieb 

Look, absolutely changed the way it was received. And there’s no question about that. You know, this became a challenge really early, because you started to see sharp political divisions over how we should respond to this. And once those started to materialize, I think it eroded the ability to get the sort of public consensus, public consent that you needed to implement the kinds of steps that needed, we needed the kinds of precautions that were needed. So this was a moment, like, like a national security crisis, this was a moment where people needed to initially just come together and create a consensus on how we were going to respond. And we didn’t do that, that set us back.

Dr. Scott Gottlieb  42:13

That eroded. I mean, our politics proved to be more powerful than our interesting concern for public health or for one another, or for PETA pulling together, and it was an election year, maybe that had something to do with it. It’s a very divided country, maybe that had something to do with it.

Dr. Scott Gottlieb 

And maybe because it was a public health issue, and so wasn’t sort of perceived the same way. Or maybe it was the uncertainty about the risks that it posed. And so people didn’t sort of put it in that kind of bucket of stuff where they say, we just have to work together. Because you know, you think about after 9/11, the country came together. We did controversial things, but we agreed to do them. And then we debated it later. But initially, we came together, you think even about the 2000, the financial crisis in 2008. And country came together, Democrats and Republicans came together to solve that crisis. It was highly controversial, and there was a lot of debate after the fact. But there was an initial response where there was an effort to do something on a bipartisan basis.

Dr. Scott Gottlieb

We didn’t really have that here. I mean, we had it around the Cares Act, there was clearly a political consensus around that. But we didn’t, we never formulated a consensus around what our initial response was going to be, what measures were needed. I mean, there may have been like, a couple of weeks in there in the beginning, but it was very fleeting. And that might be because at a sort of political level and leadership level, a public health crisis isn’t perceived in the same way as a national security threat, although it very much is, it poses the same risk to the country. But it’s not kind of put in that bucket that could be part of the challenge.

Andy Slavitt 

If Mitt Romney had been president, instead of Donald Trump, do you think it would have been different?

Dr. Scott Gottlieb

Well, look, I think things certainly would have been different with different political leadership. There’s no question about that. But I think that we make the mistake of trying, and I talk about this a lot in the book, and the book very much focused on this, I think we make a mistake, by looking at this through a lens of Trump or not Trump or you know, this political leader or that political leader. There were systemic problems with our response that are pervasive throughout the bureaucracy that under any president would have stymied in an effective response. And we need to, at some point, get past looking at this just purely through the lens of the political leadership, and the political mistakes that were made, and start looking in my view at those more systemic shortcomings, because that’s what’s gonna make us vulnerable in perpetuity.

Andy Slavitt  44:34

You know, I agree with that, as my book lays out, as well, but I also think there’s, in an extraordinary moment, there is something that really requires leadership, empathy. Politicians who are willing to see this crisis is something bigger than themselves as opposed to just how it reflects on them and I look at Governor’s around the country of both parties who I’ve worked with and who you’ve worked with, and I watched them do that. None of them to your point. None of them had a perfect response. I mean, this was a theirs, you know, is I had a guest on David Frum who said something which I repeat all the time, which is, it’s impossible to get an A in responding to a pandemic. But it’s also really hard not to at least get a B. And to get a B, you need some matter of execution, empathy and an effort to try to save lives.

Andy Slavitt 

I don’t think that’ll Trump even got a B. So I think there’s something about kind of populism and pandemic response that doesn’t fit very well, about trying to avoid tough decisions, and leadership and so forth. And politicians want to be loved. I mean, they go into politics. And making tough decisions is not easy for politicians, of any stripe, you get when I talked to world leaders, other countries, they had all the same challenges. But it didn’t break down around political identity. And over and over world leaders would tell me, I don’t know how we would have even been able to respond if people broke down under political identity lines. In other words, people here don’t love masks. Some people debate their effectiveness. Some people, you know, don’t wear them, some do, but it has absolutely nothing to do with political affiliation. And in your country, it seemed like, for whatever reason, it became kind of a matter of political identity. If I vote a certain way, then I’ve got to believe a certain thing about the pandemic.

Dr. Scott Gottlieb  46:18

If you look across the world, I mean, at least you look at in sort of Western democracies, the measures were contentious. There was a lot of debate, there were protests around masks and other countries. There were protests around the mitigation for sure. I mean, we saw that in Europe, I think it’s probably a fair point that it didn’t break down as cleanly in other nations along sort of political identity. It was definitely a break along ideological lines and other nations, but you’re probably right, that had been becoming capsulated, in sort of political identity, Republican versus Democrat as it did here. But, you know, partly that probably also reflects the fact that our ideologies are very closely sort of aligned to our political identities in this country. Part of it may have been just sort of partisan leanings. But the debate occurred everywhere, I think, or at least in the West that occurred everywhere. Here you’re right. I think it broke down more along party political lines that did automations.

Dr. Scott Gottlieb 

No question in Europe. I look, I think the only other curveball I’d throw into that equation is the places that had experienced prior severe epidemics or pandemics, responded with less division, because they’d seen the horror of some of the prior pandemics or epidemics that had ravaged their country or that threaten their countries. And so they responded with more uniformity.

Dr. Scott Gottlieb

Look at the Pacific Rim, those are the countries of Thailand, Vietnam, Japan, Korea, Hong Kong, China, New Zealand, Australia, I think you can put the Philippines in there as well, I’m probably leaving out a few nations, when you look at the aggregate cases in the Pacific Rim, I looked at this in sort of the fall of 2020, they were registering in totality, fewer daily cases in the city of Los Angeles. So an entire region of the world had figured out how to keep this virus at bay and still are, largely keeping it at bay. So I think that there’s definitely things that we could have done, definitely things we did wrong, and definitely things that other countries are able to achieve because they have a different level. And you talk about this in your book about social cohesion being a critical factor, it’s that people say the reason why South Korea was able to keep the infection as because of the surveillance state. That was certainly one feature.

Dr. Scott Gottlieb  48:34

But it was the testing, it was the tracing, it was people being willing to get tested. It was, you know, a sense of civic virtue, that you wouldn’t want to introduce the infection to a workplace or into a job site or into your family. You know, we have a situation here where the vaccine can prevent you from being a carrier of the virus and introducing it into a […] setting. You know, why don’t more people say to themselves, I’m going to get vaccinate because I want to protect the people around me. I don’t want to be the person who goes to work. And there’s a vulnerable person working. I’m the one who introduces the infection to that workplace and someone gets sick because of me, that should be a stronger sentiment around why we’re promoting vaccine here. That’s the kind of messaging that you know, it was very effective in South Korea that it was sort of, you know, agreeing to these public health measures was an act of civic virtue, you were doing it to protect the people around you, not just to protect yourself, just like wearing masks, you’re going to wear a mask to protect the people around you. It’s not just about protecting you. It’s about protecting others. That was part of what made them successful. And you talk about that a lot in your book.

Dr. Scott Gottlieb  

Well, it’s something you and I need to figure out how to fix next time, Scott. I mean, it’s a challenge. I’m gonna lay your doorstep at my own. Because I do think you were an amazing example and others, Mark McClellan, others and I certainly tried at times, although I had my beef at the Trump administration. And as I told The Trump administration. Yeah, I’m not going to be silent. If I see you guys making big mistakes.

Dr. Scott Gottlieb  50:05

This is where the leadership matters. You talk about the political leadership, I think this is where political leadership could have and would have made a critical difference, which it’s not just about the execution. It’s about galvanizing the public without bringing people together around sort of a shared set of measures that we could have taken, that if we practice them consistently, we would have had a better outcome. Yeah.

Dr. Scott Gottlieb  50:29

Maybe you and I could work on how to figure out how to, for the next go round, figure out how to take the politics out, I’m not sure I know the answer, you got a book coming out, I just want to close on that. I think people should be enormously excited to read it. Because you get an informed point of view, you see all sides of it, you do what a lot of people don’t you express things to the appropriate amount of humility and caveats when required and with amount of confidence when you see the data that causes that. I think this book is one of the gifts that I think we will use to build on coming out of the pandemic. So I encourage people to pre-order it, but maybe you spend a second on how you thought about that book coming together and what you wanted to accomplish with it.

Dr. Scott Gottlieb

So the book is titled “Uncontrolled Spread”. I tried to do in a book, what we’ve talked about here, I tried to look beyond and I lay this out in the introduction tried to look beyond just sort of the political narrative and look at the shortcomings in our response related to systemic failures. And so you know, challenges with the way CDC responded to the crisis. I think CDC needs to be fundamentally reformed. We don’t really have an operationally minded agency capable of responding to a crisis of this magnitude, we should have learned that from past crises when we saw challenges with the response to H1N1, Zika, Ebola, I talk a lot about needing to look through look at public health preparedness through the lens of national security, and how do we build better resiliency in our system in the United States, so that we’re better prepared for threats like this. So things like having a hot base, capable of scaling, testing, and manufacturing of biologicals. So this is a book focused on identifying what went wrong. And with a focus on the more systemic features of our failings and in how do we prepare better for the future. And so it’s a heavy policy book with a lot of recommendations about policy steps I think we need to take to build out better preparedness for the future.

Andy Slavitt  52:30

I think you leave the book, if you read it, you leave the book smarter, better informed. And also, I think emotionally with a greater sense that there are solutions, and that there are smart people working on and thinking about it. So I recommend it.

Dr. Scott Gottlieb 

Yeah, I think what you know, some of the insights from this book, I hope, that are going to make it unique, are very detailed, blow by blow of what went wrong with things like the development of the diagnostic test, with the rollout of the vaccines and the antibody drugs. And so I get into a lot of detail with what was going on inside the government during those episodes and places where I think we fell short. So I hope that there’s some new insights that come out of this as well, that helps you identify the problems.

Andy Slavitt 

That will be a great read, and thank you for the contribution. And I would love to have you really come back with towards the end of this series. We’re going to do a wrap up of kind of where do we stand on the science and where do we stand as a country and would love to have you come back for that.

Dr. Scott Gottlieb 

I would be delighted to.

Andy Slavitt 

Thank you, Doctor.

Dr. Scott Gottlieb 

Good to see you.

Andy Slavitt 

Really appreciate.

Dr. Scott Gottlieb 

Take care, thanks!

Andy Slavitt

Terrific conversation with Scott. I’ve been playing that one back for myself several times. I always learned so much with Scott. And we have a great conversation. In fact, it was probably about twice as long. And that’s the edited version. But the common wisdom is that people don’t want to listen to an hour and a half conversation between me and Scott. So we might have that some other form. But we don’t have it here to save you having to listen to Scott and I talked for very long. But I do want to talk about what to expect next because on the show because now we’ve been through three weeks’ worth of IN THE BUBBLE – OUR SHOT, and we’ve gotten ourselves to a place where I think it’s safe to say we’ve opened some questions and we’ve essentially put ourselves in a situation where we know as best we can, especially can possibly know kind of what’s going on, and that there will be some uncertainty and some ambiguity, but things are headed in the right direction. The worst is behind us. And we know the State of the Science. And we know that occasionally things are gonna happen to try to knock us off our game.

Andy Slavitt  54:58

But we really try hard not to that happened or at least I am. So now we’re going to cover a series of topics in the next coming weeks, one by one that I think critical components to where we are and where we go next. The next week is going to be a focus on those unvaccinated people here in the US, how to understand them, what to do about it, what it means, what the implications are, how to talk to people in those situations, etc. And we’re gonna have the people that helped me at the White House to come on the show, and give us some really critical information. Molly Brody from the Kaiser Family Foundation, has done the best survey work to help us understand these this group. And Frank Luntz, the political pollster has conducted some amazing focus groups, that were a big help to us in the White House, to help us listen for the language and really understand what we’re hearing from and what the needs are of people who haven’t been vaccinated. And then Wednesday, a great conversation, where we’re gonna go really break it down in a really interesting way with David Axelrod, who’s one of the best kind of political commentators and social commentators around. So, that will be week four. In the meantime, have a great weekend. Thank you so much for letting me be with you. And we will talk to you then.

CREDITS  56:31

Thanks for listening to IN THE BUBBLE. Hope you rate us highly. We’re a production of Lemonada Media. Kryssy Pease and Alex McOwen produced the show. Our mix is by Ivan Kuraev. Jessica Cordova Kramer and Stephanie Wittels Wachs still rule our lives and executive produced 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 at @LemonadaMedia. And you can find me at @ASlavitt on Twitter or at @AndySlavitt on Instagram. If you like what you heard today, most importantly, please tell your friends to come listen and please stay safe, share some joy and we will get through this together.

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