In the Bubble with Andy Slavitt: Our Shot

The Next COVID Crisis: Funding (with Jeff Zients and Zeke Emanuel)

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Andy tackles the pressing need for more COVID funding with two guests who are fighting to make it happen: outgoing White House Coronavirus Coordinator Jeff Zients and former COVID Transition Team member Dr. Zeke Emanuel. What will happen if the U.S. can’t afford to pay for a fourth round of vaccines? And what is holding Congress up? Zeke and Andy also discuss the plan Zeke is spearheading for the next phase of the pandemic, and Andy puts Zeke through a lightning round where he asks him about variant-specific vaccines, the potential return of mask mandates, how best to use oral antivirals like Paxlovid, and much more.

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Andy Slavitt, Jeff Zients, Zeke Emanuel

Andy Slavitt  00:52

Welcome to IN THE BUBBLE. This is your host, Andy Slavitt. That voice you heard was from our exclusive interview today with Jeff Zients, who leads the COVID response out of the White House. Jeff was kind enough to come on our show. I’ll talk about that in a minute. But he’s essentially laying out what’s at stake for you and for us, because the country has not properly funded our COVID response from the Congress. And we’re gonna get into that today. I’m talking to you on my iPhone. It’s amazing how much the thing can do. It better be because it’s $45,000 now, did you know that the iPhone 13 is $45,000? No, it’s not $45,000. But it was a lot of money. I broke my iPhone over the weekend. And it’s a good thing, I got a new one. Because then the contraption that looks like it was built in 1974 that I use to normally record these episodes, like stop working. And so I’m recording this on my iPhone. So if it sounds a bit different to you, but maybe you’re listening to on the iPhone, and maybe it’s all the same, you feel like we’re talking to each other. On my iPhone. It’s like a phone conversation. But these iPhones, I swear to God, this iPhone 13. It does things before I think about it, which is great. That’s great. It is what it is. So this show, we’re going to talk to Jeff science, and then we’re going to talk to Zeke Emanuel. And Jeff is going to talk to us about the congressional funding issue. And we’re thrilled to bring you that conversation. I will say this, you’ll notice that Jeff and I are friends. And there’s a little bit of a thing about this show. And you listen to interviews, and I think it’s probably a double-edged sword, which is on the one hand, I think it helps us get interviews that other people may not be able to get and maybe that’s a good thing. On the other hand, it’ll make you say, Hey, Andy, you’re not as tough on this person. I’ve got to do better and figure it out. I hope that I use our friendship appropriately to bring you the information you need and ask him questions and get people comfortable. But I also, you know, understand that I’ve got to make sure that I’m asking the tough questions, feedback, welcome. Particularly positive feedback. After that, is Zeke Emanuel, who’s been on the show before? Zeke is a really amazing person to talk to about what’s going on with his budget request and why we’re not funding the defense against this pandemic. Because he’s both a public health expert, and he was at the Office of Management and Budget under Obama. So we understand how the budget works. He understands the question of like, why after we’ve spent 93% of the money, and we need more still, because guess what, we’re still in the middle of the pandemic. And guess what? We are going to need money for boosters and for medications and for drugs and to vaccinate the world. Like why wouldn’t Congress just be like, oh, yeah, duh. So do ask the questions. Is there been an accounting have we ever given the Congress the information they need? Or what are the reasons that Congress isn’t doing this? We get into it; we get inside this topic and Zeke is great. He has also led an effort, as you’ll hear, to define the things that need to happen next, in our country, the United States, around COVID in the COVID response, he brought together the best experts really some of the best experts mainly the guests on the show, former guests on the show, and put together a really comprehensive plan and all things seem to happen and so you come for the newsy bit about coverage but the really fun part of the interview I found when I’m talking to Zeke, is we go at rapid fire every single topic related to the pandemic. Boom, boom, boom, boom, boom, and Zeke who is not shy will come at us with every answer we want to hear and his opinion about everything that happens next we need to think about in this tech stage, okay, first, before we get to Zeke, though, let me just bring up Jeff.

Andy Slavitt  04:57

Look we’re catching you in between Meeting. So I don’t want to take too much your time. I can picture you in the west wing with the work that you do, which, which has just been incredible, hundreds of millions vaccinated because of the work that you and the team have done. But you’ve relied on Congress to help get that done, I assume. So I think most of us understand that there’s been a proposal from the Congress that has not yet been funded. To continue the work of fighting this pandemic. Can you tell us a little bit about that, and what those funds are for?

Jeff Zients 

Sure, you’re right Andy, in that Congress providing funds and support has been critical to this effort since day one. You know, And I do think due to the whole of government effort partnership with governors and local officials, the private sector, you know, we are in a much better place than we were a year ago with over 215 million people fully vaccinated, you know, we have very effective treatments now, including the Pfizer pill, which is 90% effective at keeping people out of the hospital, if they do get COVID, we have more testing capacity, we have free mask available. So we have the tools to protect Americans, and also to be prepared for whatever the virus might bring, including the possibility of a future variant. And having these tools, the vaccines that test the treatments, that’s not nice to have that need to have. And we need funding to ensure that we have the tools and to ensure that we are prepared funding from Congress, the amount of funding is billions of dollars. But at the same time, the cost of being unprepared or not having the tools is many, many multiples of that. So right now, we don’t have enough money. For fourth doses, if they’re called for booster shots, additional booster shots for all Americans, we don’t have the funding, if we were to need a variant specific vaccine in the future. Immediately, we don’t have money to order more of a very effective monoclonal treatment. So in addition to the Pfizer pills, the monoclonal treatments have been very effective at keeping people out of the hospital. Already, we’ve had to cut back allocations to our state partners by 30%. So we preserve the inventory that we do have. And then you know, as you know, Andy, this virus knows no borders. So the president and the US has led the global efforts to vaccinate the world, we are donating 1.2 billion doses to the world, we’ve already shipped 500 million to 113 different countries. And this, you know, the variants to date have started outside of our borders, getting the globe vaccinated is really important. And we run out of money to help get shots in arms across the globe. So we need money to continue to lead the world in getting the world vaccinated. And it’s really Congress’s job now to provide those funds, to pass the $22.5 billion in emergency funds, so that we can continue to keep Americans protected, prepare for whatever the virus could bring in the future and continue our efforts to vaccinate the world.

Andy Slavitt  08:20

Okay, so I think what I heard from you is, we need to purchase more of the treatments that we could use to take care of immunocompromised, we need to purchase more COVID tests, which we’ll need to do over the summer, in the fall. If there’s a fourth dose authorized by the FDA, then you will need money to purchase that. And of course, we’ve got people around the globe, who are vaccinating people every day, it sounds like from USAID and funding these vaccines and we’ll need money for that. So I guess it’s a good thing, though, that there’s no BA2 or no wave coming out. So the Congress doesn’t have to worry because the pandemic is over. Right?

Jeff Zients 

Well, first of all, it was a very good summary. You captured it well, that’s exactly why we need Congress to act. But you’re right. And there’s, you know, the possibility of increased cases here. There’s also the possibility of a new variant as we talked about earlier in the future, and without funding, we will be unprepared for that possibility of increased cases and severity. And hospitalizations. We won’t have the monoclonal is, as we talked about before, we would not be able to purchase if authorized by the FDA, a fourth dose or a variant specific booster, if that’s authorized or called for. Our testing capacity, which we’ve worked to really expand there’s hundreds of millions of at home tests available each month. We have a good inventory at this point. But we risk that if we don’t continue to invest in testing capacity. So we could run short of tests treatments, vaccines if Congress fails to act, and I think BA2 is a reminder that this fact that this virus is proven to be unpredictable, and we have to be prepared for all scenarios. So it’s really important that we invest now, have the tools and be prepared for any possibility.

Andy Slavitt  10:18

See, I thought Congress was going to wait until the pandemic was over before pretending it never happened, rather than in the middle of it, not providing the funding, you don’t need to comment on that. That’s just my own. My own sense. I mean, it’s easy to understand how people could say, hey, when this has passed, we really need to make the case how we need to be prepared for the future. But in this case, you’re talking about a future that is months away, weeks away, in some cases. So it’s very, very important. So what are you hearing? You know, when you when you place calls, to talk to senators, in Congress people, do they get it? Do they understand? Are they sympathetic? Do you feel some sense of hope there’s a path?

Jeff Zients 

You know, I do, Andy, and that, you know, I talked to members of the House and the Senate Republicans, Democrats, I think people understand how much progress we’ve made. Yet, as you keep emphasizing correctly, that the pandemic is not over, that we have entered a new moment where we can move forward safely, if we have the tools, and we have the resources to make sure that we’re prepared. At the same time, I think it’s where Congress is struggling is how to how to pass this bill, and how to fund it. You know, we believe this should be passed on an emergency basis. That’s how COVID money has been done in the past. So without any offsets, where pay for is, if you will. And there’s as I said, precedent for that, you know, if there isn’t an insistence on finding offsets, they need to be found soon, in that this situation is urgent. 93% of the money that was allocated for COVID response, direct code response has been spent. So there’s very little left and remaining funds are for areas like, you know, medical care for veterans or FEMA disaster relief. So we don’t have good resources to draw on from the prior allocated funds. And we need to make sure that this gets funded. So it’s up to Congress to either pass it on an emergency basis, without or without offsets or find viable offsets. But the important thing, and I think it’s come, you know, it’s clear across the last 10 minutes of us talking because we need this money, we need urgently to make sure we’re prepared. And we continue to protect the American people.

Andy Slavitt  12:49

And so the house is out right now. But is there a sense that they can act urgently? Do they have the vehicle? And I think for the people who are listening to this show, who love getting involved, and making sure that people, really their elected representatives understand what’s at stake? Is there a sense that there’s an action that can be taken pretty quickly? Yeah, I

Jeff Zients 

Yeah, I think so Andy, you know, we’ve been talking to Congress, both the House and the Senate, and, again, Republicans and Democrats for months now, and made clear that the funding would be at the stage we’re at now in March that we’d be running out and that we need it for tests and treatments and vaccines. And we’ve shared all the backup data on how the money’s been spent. So I think Congress has what it needs. And we know that Congress can, can act quickly when it needs to when things are urgent, and this is clearly urgent, and we really want Congress to focus on this, we’re doing all we can to support them to do so. And the consequences are severe. And we’re already starting to see those consequences. As we’ve had to cut back on monoclonal treatments and an important fund that helps uninsured people get coverage for treatments and testing. So we’re already seeing consequences. And we really need Congress to act quickly.

Andy Slavitt  14:15

Well, Jeff, I know you’re in the middle of the day. So I really appreciate you coming on and joining one thing that I know about, I know a bunch of things about you, which I won’t say but one thing I know about you is how much you don’t like being the center of attention. You don’t like praise. And so I would ask you to suffer for 30 seconds. When I tell you a lot of nice things are being said about you and the work that you’ve done in the work that you’ve led. And all of it I read and I smile because it’s true, but I want to just say what incredibly dear and kind person you are and what a great team leader you are. And I had the privilege of working for you and with you a couple of different times. And I can just say there’s very few better people to be in a foxhole with than you Jeff.

Jeff Zients 

Well, Andy a couple of reactions. First of all, you’re way too kind and too generous. Second, sort of right back at you, I’ll be in a foxhole with you any day. But I think what has made this possible is the tremendous team, the cross government, whole of government effort, with outstanding individuals, working night and day and as a team across government, and I think, you know, with our state and local partners with the private sector, it’s made a huge difference. And that’s what’s led to us being in the position where we’re in where people can begin to return to their more normal routines. And we have a plan to move forward, safely. And I think, you know, one of the benefits here also is I hope that we’ve begun to restore some trust in government, that government can tackle the biggest problems and make a real difference. I think this has been a case study in doing just that. So thank you for the opportunity. And thank you, Andy, for being Andy.

Andy Slavitt  16:28

Hey, so we actually just got off the phone with Jeff told him to figure out, it seems odd that Congress has not funded our ability to continue to fight the pandemic, as far as I know, the pandemic still going on, is that your impression?

Zeke Emanuel 

Oh, absolutely, it looks, you know, while that’s sort of coming down, they’re still over 1000 a day, which is about seven to 10 times more than you would want for endemic COVID. And we have BA2 circulating, which has to make you very nervous that we’re gonna have another surge, how big? Who knows.

Andy Slavitt 

So you’re one of the very few people that’s both an expert on public health and Washington, I get to the extent that you can be an expert on Washington, at least you know, how the place works. So it seems like an obvious thing to be funding right now. I can understand if we were two years from now and saying, hey, let’s fund pandemic preparedness, then I expect a little amnesia from Congress. What’s going on?

Zeke Emanuel 

Well, I think, first of all, fatigue, people are tired, you can see this all across the country. Walking out people have taken their mask off, even in large crowds, they’ve taken their mask off indoors. They want to believe it’s past us. And I think politicians respond to that. You’ve seen all the states remove mask mandates for that reason. Second, I think it’s how Washington works. We’re now into midterm season in politics and campaigning and drawing lines in the sand. And I don’t think we’re into, you know, this is a bigger national interest. This is an emergency. You know, and truth be told, it doesn’t feel like an emergency, even if it remains an emergency 1000 deaths a day, let’s just put it in context is, you know, over 350,000 deaths a year, which certainly makes COVID, the number three or four killer after heart disease, cancer, and, you know, stroke plus or minus, depending on how you want to count that. And I just think, you know, we’ve lost perspective.

Andy Slavitt  18:59

So how do we gain perspective back? I mean, in your, in your normal, quiet ways, he, I say this, because Zeke and I are, are old friends and he’s about as quiet as I am actually less. So. You decided to write a letter to Congress and got a bunch of people on board to sign it, including me, which tell us a little about but the letter you authored, and what you’re trying to make.

Zeke Emanuel 

We were very chagrined. And by we I mean me and 200 of my closest friends, were very chagrined by the fact that here we are still fighting this pandemic, still more than 1000 deaths a day facing another potential surge. I mean, there’s almost no expert who doesn’t think we’re going to have a surge The only question we’re arguing about and no one has any basis on which to make a better or worse prediction is how big that surge is going to be. It can make arguments on both sides and Congress is being asked to fund $15 billion dollars or $50 per person and can’t seem to come up with the money and is stalling. And as you say lots of things are at stake. We have, you know, the fact that were don’t have enough money for monoclonal as we can see, we’re going to run out of them. And therefore were the federal government’s already rationing them in early April, the ability of doctors and healthcare systems to care for people who don’t have insurance for COVID, that money goes away by May, we won’t have enough […] for people who are immunocompromised, if in fact, we really do need a fourth dose, even for some of our population, we don’t have money to buy that. And I’m not even talking about, you know, pushing on long COVID, next Generation vaccines, the therapeutics to multi drug therapy, we need the surveillance systems we need going forward so that we can carefully monitor for new variants we can monitor for another outbreak. These are I mean, $15 billion, is chump change in most of our views. I mean, if you look at some, you know, I have a certain advantage in that, you know, I worked in the Office of Management and Budget so I know something about federal budgeting. And I have some sense for what we need for COVID. You know, $15 billion is nowhere near enough. And it’s a very, very wise expenditure. And so it’s extremely frustrating that we can’t seem to as a nation say, this is a top priority. It’s beyond politics. And, you know, we’ve already seen almost everything is gotten so heavily politicized, whether it’s Ukraine, or, you know, Supreme Court justices. That doesn’t seem to be anything which with which people are willing to put down political affiliation say they know, there’s a national interest. There’s a collectivity here that we have to invest in, if we want it to thrive and be a world power. And that’s what’s I think, super frustrating. And I think anyone in the Biden administration, or a leader in Congress, trying to get the country to do the right thing on this has to be like scratching their head and you know, where has common sense and rationality gone.

Andy Slavitt  22:23

And look, I mean, we got caught not being prepared for the pandemic, when it arrived the first time feels like, excusable, but understandable. But being caught by surprise, during the second, going into third year, the pandemic feels willful, right?

Zeke Emanuel 

It does feel like it’s would be tragedy. And I think that would be a disaster. But I take it that there’s a political calculation here, if, you know, we have not enough tests, and people are clamoring for tests. We have a lot of hospitals full. People will blame Biden and the Republicans won’t, who held up the funding won’t be blamed. I think that’s got to be the political calculation. And the only, I mean, I really do think the question, is there anything we can rise above politics on? And if it’s not this, it doesn’t seem to be Ukraine? You know, maybe the answer is, in 2022. It’s all politics. And it’s all hand-to-hand combat. And there’s no national interest that we can rally around.

Andy Slavitt 

So let’s try to figure out how to win the politics. I mean, you put this letter together, what are you hearing? Are you hearing anything from members of Congress from the Senate from Hill from staff? Is there either a cuz look, I would say that, like, I haven’t seen, even advocates being very outspoken about this on the Hill. I mean, even people who I would expect to vote for this being very outspoken about it. It feels like it’s almost been brushed aside to say, Well, look, we’re focusing on the Ukraine, or we’re focusing on inflation, too many problems.

Zeke Emanuel  24:15

I do think that there’s an element of too many problems. But one of the things that I certainly think is important for people, you know, who have decision making authority is to distinguish the urgent from the important. Lots of things seem urgent, but only a few things are really, really important. There’s no doubt Ukraine is super important. And I do think that much of the United States prestige is tied up with Ukraine and making sure Ukraine doesn’t lose. But the pandemic is also really, really important. And we should not think well, it’s just them. Because it’s not just them, and when hospitals get over full, it’s all of us who suffer, when parts of the country have large surges and outbreaks, you know, it could be that another variant is going to brew there and not overseas. And I think we have to understand what’s important. We have two exceedingly important items COVID. And Ukraine, and also, you know, Andy, both of those feed into the other problem with people worry about, which is the economy, inflation, etc. If we could get a handle on COVID, we would certainly have not completely solved the problem of the economy and inflation, but certainly get a strong handle on it, because a lot of the supply chain snack foods would be better, if not totally resolved.

Andy Slavitt 

Yeah. I mean, in listening to Jeff, and I know you’ve spoken with him, as well. And I’m glad the audience got to hear from him before we just started this conversation. It feels like they’ve got a pretty linear accounting of what they’ve been spending their money on. It’s like 93% of the dollars are already spent. It’s been very clear. And in case it wasn’t clear, you made it clear the letter you wrote exactly what won’t get funded. And when, you know, it’s not all that mysterious, in your mind the way these things play out. Assume nothing. But do you feel like this eventually finds a path? Whether it’s the emergency path, whether it’s, with pay force, without pay force? Do you feel like people will be forced to the table? Or will the only thing that force people to deal with this issue is just rapid surges and more trouble?

Zeke Emanuel  26:36

I do think eventually this happens. The only question is when. And I think for the reason you said, obviously your experience coming through here too, which is, look, if we have a surge, and people can’t get Evusheld, or we run out of monoclonal oils, or we run out of plaques of it, people will demand money, and the people who’ve been holding it up will cave and vote for it. The question is between now and then, are we going to be able to get education spend money wisely. One of the things that always frustrated me when I was in Washington and in the government was, you know, the stop, start, stop, start. You know, people always say, and you especially hear this from Republicans, we got to run the government like a business, well, no business would run, stop, start stop start, it is totally inefficient, and totally ridiculous way of operating. And yet, that’s what we’re being put through. And it wastes a lot of money, by the way. And it means that we’re not prepared in a smooth way. You know, right now, if you were running the government, like a business, you would want your supply chains as open as possible, you would want to have a stockpile of critical elements, you would want to be investing in the next generation, whatever it is for worries about supply chain disruption that are, you know, could come because of Ukraine, could come because of China. Who knows. I mean, China itself is facing a serious, serious potential threat from Omicron. And who knows, they may be have having to shut lots of factories and upsetting the supply chain once again.

Andy Slavitt  28:22

It’s like an own goal, right? I mean, there’s enough challenges that we creating our own. You’re actually the perfect person to be pushing this not just because you ran the health care portfolio at the Office of Management and Budget, not just because you’re a public health expert. But because a couple of months ago, you started pushing both behind the scenes and publicly for a broad plan around the next steps in the next action in the pandemic. And I wonder if we could just shift the conversation to talk about that and talk about some of the content behind that, some of the people involved in the process? Because I think, well, first of all, maybe start with what you were trying to say, because we were we were kind of the Omicron way was in the process of starting to come down in you came out and it said something which got a lot of attention.

Zeke Emanuel 

So a bunch of people who were on the Biden COVID transition Advisory Board, we’ve continued to meet because we learn a lot from each other. We don’t always agree, but we learned a lot from each other. You know, how do you interpret this data? What are you seeing in your neck of the woods? And we wrote a series of articles in JAMA about out how we, in this, as we’re entering the third year really need to begin thinking about living with COVID. Because we’re not getting rid of it, that’s become quite clear. It’s not clearly a seasonal event, we’re gonna have to live with it. Well, what does it mean to live with? What is the kind of responses you need to have available if you’re going to live with COVID, that was our thinking. And part of what we said is, you know, we need another strategic plan, we’ve been running a strategic plan for a year, which is focused on getting people vaccinated. And that’s, you know, we did a really good job, but we need the next plan at that has to look at the whole forefront of what we can do as a government. And so it occurred to me, you know, it was Christmas Day, and it occurred to me, like, you know, we need a strategic plan, where we’re relatively free, certainly compared to the White House, people who are dealing with every fire, and at that point, a huge fight around Omicron. And a huge problem with getting enough tests in the country that we could develop a strategic plan. And so a bunch of us got together, what’s the strategic plan for getting to the next normal? What are the things we need to do, whether it’s vaccines, or testing or surveillance, or schools, or indoor air quality or workforce issues that we need to do? And that’s what we put together. And we also wanted to say, what is the likelihood we’re going to have a serious surge, intermediate surge, or we’re going to have a best-case scenario where, you know, cases in Coronavirus are going to go down. And we’re actually going to get to a pretty normal state within the next 12 months. So we, you know, we game plan that out and look at all those things. And I think it was trying to help government. So everyone in government would sing from the same songbook, and everyone would know what everyone else was doing it. That was our basic idea. Not that we were going to get everything right, because one of the things we’ve learned in COVID is, you know, you can’t bat 1000 and even batting 750 is pretty hard. But you can sort of get a wide systematic look, that will be mostly right.

Andy Slavitt  32:15

So, this kind of puts you in an interesting position, Zeke, in some ways, at least at the current moment, at least for some time period, you were kind of the Uber knower of what to expect, and what the public canon might expect, and what we should be thinking about and planning for in this living with COVID faith. And I think when you say living with COVID, it means different things to different people, to some people. That’s a scary thought. To some people, it’s kind of a comforting thought, to some people, they just don’t know, because it’s very ambiguous. Given that you’re down in this sort of Uber position, were you seeing the whole playing field, tell the public kind of how to think about what’s ahead, based on the best analogy been able to see.

Zeke Emanuel

So I think what’s ahead is a sort of intermediate situation where we’re gonna have surges, how big? I think we don’t know; they could be very serious. And we put a probability of about 40%, on a very serious surge with a lot of deaths.

Andy Slavitt 

Compare very serious, like, would that be like a Delta and Omicron level surge.

Zeke Emanuel

It could be an Omicron level surge, with about 250,000 deaths a year. And again, I’m a little hesitant, and because there are things we can do actually do that will decrease that impact. One of them is get vaccines and boosters to people over 65, which would be really important. Only about 29%

Andy Slavitt 

But I kind of feel it, but I kind of feel like we sort of know the limitations and what’s practical to do at this point. I mean, I feel that’s less of a guess, given public attitudes and so forth. I mean, yes, there’s..

Zeke Emanuel  34:10

I would say some of its public attitudes, some of its trying a different rollout, if you will. I mean, so one of the things I’ll just say one of the things we strongly emphasize in this report is we should have a mini division of community health care workers to get to people who are vulnerable and not so easily contacted. I just got something that could change some of these around.

Andy Slavitt 

I’m going to give you we can change 10 percentage or so. But I think the broad buckets you’re creating are very helpful and I’ll stipulate that yes, we can improve to some degree incrementally, but can you give us the other 60% you got 40%. That was not pretty. It’s 250,000 deaths a year. What’s the other 60% look like?

Zeke Emanuel 

A 50% chance to sort of intermediate 10% have a really good, you know, it’s not going to be a problem, it’s going to be flu like, and actually, given the precautions we have, we’re actually going to do even better than a sort of severe flu year, the real, I think, unknown. And the thing which motivates I think a big portion of the population is long COVID. We don’t know enough about long COVID. We don’t know if you have two shots in a row or three shots. What are your chances of getting long COVID? How severe is it? And I think if we hadn’t the answer to those questions, and it turned out, you know, you get three shots, your chance of dying is 1 in 35,000. And your chance of long COVID is one in 10 12,000, then we know COVID would be kind of like flu, we would have to protect the vulnerable. But most of us could go around without real worry. The problem is we don’t know the long COVID thing. And when I go around it, I hear from a lot of people, that’s what they’re obsessed by, because it’s so frightening. Brain fog, fatigue, shortness of breath on a chronic basis, not being able to get out of bed. You know, no one wants to risk that that ruins your life. But if you knew that, that’s not going to really happen. I think people would say, All right, you know, given Omicron, given three shots, the low risks of serious illness and complication, I’m willing to, you know, live a normal life, take that mask off. And it I do think that would make a big, big difference. is that

Andy Slavitt  36:40

Is that embedded in your middle 40% scenario that the scenario where COVID, an acute basis is reasonably reduced in terms of hospitalizations. But that long COVID is a more material threat than the kind of odds you just gave.

Zeke Emanuel 

That would be, that would make a very serious problem. I think going forward, because I think people wouldn’t know how to live like that. If you said, Look, your chances are 1 in 20 of getting long, COVID Even with three shots, people would like I’m not taking those shots of brain fog that just like, that sounds that sounds too much like Russian roulette for I think a lot of people. And that I think is where we’re at. We simply don’t know the answer to that question. And, you know, from our groups that that is a top priority question. It’s an emergency to get the answer to that question. And the NIH has to put the pedal to the metal to get that answer. And it shouldn’t be hard, because we do have probably several million people at least doing long COVID.

Andy Slavitt 

Yeah, well, and Billy, and some number of people who’ve been infected. The math should be there. It feels like, yeah, it feels like people kind of wave away the lone COVID thing to some degree, at this stage, for a variety of reasons. You know, we just had Senator Tim Kaine on the program, who you may have heard him describe, oh, yeah, symptoms that he still has. And I’ve heard him talk about him before, but it got him to show it if you haven’t listened to this episode, folks, you should listen to it. The symptoms he is describing, I thought they were intermittent. They’re not, they’re 24 by 7, he is never in a state where he’s not feeling the symptoms. Now, he would tell you that these symptoms he’s able to get through his life. And, and he is he really is not asking for sympathy. He’s actually asking people to pay attention. People have it worse than he does. But I can’t imagine a 24 by 7, right. And by the way, his case of COVID. That was pre-vaccinations. But his case of COVID was one where he didn’t really experience symptoms during the acute phase.

Zeke Emanuel  38:58

Yeah, mild. So I think that’s 100%. Right. And even if he can get through the day, what is drained out is the joy of life, because you are basically keeping the symptoms at bay, and you’re never feeling vigorish 100% really in it. And I think that is the problem. And that’s the fear of many, many people. They don’t want to experience that. And they don’t even want to run the risk of a reasonable risk of it.

Andy Slavitt 

Let me voice the voice of the COVID, do my best to voice of the COVID skeptic, the COVID cynic, the Tucker Carlson, the COVID curious someone, Bill Hanage on the show called the COVID curious who would say you guys keep moving the goalposts. First you told us we had to push out the curve to prevent a lot of hospitalizations. Then you told us it was about deaths. Now you’re telling us about this that what there’s all those things. So once all those things stop being problems, and I’m not saying that there are no those things are longer, perhaps I’m saying that this is the voice of the cynic. Now you’re saying, Oh, no, no, no, no, we have to do everything we can to prevent COVID, because of some long-term effects that are very hard to measure, respond to that criticism.

Zeke Emanuel  40:21

So first of all, I don’t think that’s true. What I want to know is, what are the risks of long COVID. And the second thing is, you should remember, if it’s long COVID, if it’s very frequent, and we have 60-70 million people who’ve had COVID, and it’s very frequent, you will have a huge healthcare bill, a huge disability bill, lots of people not in your workforce, you will have a major economic shock to the United States. And so don’t dismiss this and say, you know, you’re just moving the goalposts. This is something that again, many of us have been worrying about for months and months and months. And what we really need is information on which to know how big a problem this is, or is not. We’re not saying you got to move the goalposts, we’re saying, Please tell us or get us the data on, is this a problem that we have to worry about? Or do we have a solution for the problem that’s called vaccination or therapeutics or what have you?

Andy Slavitt 

Okay, so just a close up, I think it might be fun and interesting to take, do the very top lines, kind of, I want to say, a lightning round of I, if I give you a key word, and you know, you guys have done a bunch of work and what could have should happen here, what people should expect. Some sense of,  maybe it’s a sentence or two, like if I say the word schools, like school closings, like do a general sense of, of how to keep schools open, and when school should be closed. And is that a risk again?

Zeke Emanuel 

It shouldn’t be a risk; they should be the last thing to close because kids learning is so important and in person is so critical to it. And the second thing we need to do to make sure that happens is to improve, dramatically improve the indoor air quality of every classroom in America.

Andy Slavitt  42:06

Masks recommended versus when masks should be required if they should ever be required again.

Zeke Emanuel 

Oh, they shouldn’t be required again, if the number of cases goes up, and you’re in the presence of someone who can’t be vaccinated because they’re immunocompromised, or they’re a child and it’s not approved for

Andy Slavitt 

Lockdowns, ever again?

Zeke Emanuel 

I could see that only in super extreme cases, and probably not from COVID.

Andy Slavitt 

Boosters, frequently to prevent infection or only for the most compromised populations.

Zeke Emanuel

My suspicion is we’re going to need forget the booster issue, we’re going to need a mix and match, we’re going to need different, not only mRNA, you’re going to need mRNA with protein vaccine, and that’s going to give you the best protection. And you might then need a booster every year every second year. But I don’t think the idea of every six-month booster which some people are trying to propagate is realistic.

Andy Slavitt 

Tested and treat and Paxlovid Should this be something that’s ubiquitous? Or do you worry about the effects of people developing immunity to things like Paxlovid and it should be reserved only for people at serious risk?

Zeke Emanuel 

Well, I am worried about resistance. And second, I do think for that reason, you have to develop a multi drug cocktail. And you can’t just rely on Paxlovid. On the other hand, we do need to use it for people who are at a reasonable risk of getting serious infection. That’s what it’s developed for, you don’t develop a very important intervention and not use it/

Andy Slavitt 

Variant specific vaccines.

Zeke Emanuel 

I don’t see at the moment that we are going to use them; we should develop them. And we should be able to develop rapidly the mRNA. But as I said, I think the solution out of this is going to be a mix and match, we’re going to have several different vaccines developed that are going to provide wider and longer lasting coverage. We just don’t know what they are because again, we haven’t done that research. But we need to do it urgently.

Andy Slavitt  44:08

Investments in the air quality, you touched on this related to school. What else should we be doing?

Zeke Emanuel 

Well, we should change our building code so that every building being built going forward, and we should measure the indoor air quality and grade buildings and put that grade out just like they do on restaurants. You know, this is an A restaurant totally clean. This is a B restaurant really needs some work so that people can begin using the power of public shaming to get buildings to upgrade their air quality.

Andy Slavitt 

How we should think about the extent and the limits to US funding global vaccinations.

Zeke Emanuel 

I think the issue now is distribution administration and we have to help countries with that because it’s going to be important to keep variants from developing and therefore keeping America safe.

Andy Slavitt 

Okay, here’s a curveball and I’m not sure if you even addressed it. But I know it’s one that’s passionate of yours and mind dealing with the mental health consequences of the last couple of years.

Zeke Emanuel 

A huge problem, and we don’t have the workforce for it. So we’re gonna have to develop novel ways of delivering mental health care. But again, this is a huge problem, which is just, you know, it’s like an iceberg, just below the surface. Lots and lots of people are suffering, and they don’t know what to do with it. But we’re gonna have to train more people to develop a group therapy and other therapies.

Andy Slavitt 

How about any reforms to the way we do public health, communication and coordination, including at the CDC, any changes you’d like to see there?

Zeke Emanuel 

Absolutely. We need better messages; we need much more response. And we also, we need a national response on misinformation. And it’s not just focused on public health, we’ve got to stop the media bubble that people live in and break down those algorithms and prevent them from allowing people to just hear the same message over and over again, that’s not good for having a national dialogue.

Andy Slavitt  46:08

And you’ve already talked about lung COVID. Is there anything else any other major pillar that I missed that you think is a fundamental component.

Zeke Emanuel 

I think the workforce, the healthcare workforce is something that really needs attention, they’ve been working for two years straight, a lot of people are burned out and fried. And I think bolstering them is going to be really important as we go forward. You can already see it in England that they’re having shortages in hospitals, it’s a major problem.

Andy Slavitt 

Well, all this stuff takes funding, which brings us back to where we started. And you know, it’s something that we are a wealthy country, we are a country that can and should debate our priorities. People like you and me are used to winning and losing battles all the time, based on what we think the right priorities are. But over time, winning this is a particularly weird situation. Because we have actual known events to respond to let alone I think, a smart strategic way of thinking about things that you put out of your plan, and that the White House when they put out their plan subsequently put out Jeff, who was on the beginning of the show, released a plan which we will lead to both your plan and the White House plan in our show notes. But very fundamentally important. I think it’s I love it about the way you work, Zeke, which is you know, you think both big and immediate at the same time. And I don’t know where you get the energy, man.

Zeke Emanuel 

Thanks, Andy. Really appreciate it. And I couldn’t agree with you more, we need to fund these priorities.

Andy Slavitt

Oh, by the way, one other thing I have to say, and I told you this before, but we need to include this in the show. Sometime in 2020. We had you on the show. And then following that. We had someone named Rahm Emanuel on the show, I’m not sure which order I’m not sure which order was I maybe we had […], I don’t remember which order. But if you look at it from a purely listenership standpoint, both those shows did very well. Your show did significantly better than this character around a manual

Zeke Emanuel  48:26

Sibling rivalry, always present.

Andy Slavitt 

Okay, I want to thank Jeff, I want to Zeke, I want to thank you for listening. Hopefully, this brought you up to speed on this topic, and correct to say, it’s just crazy that we have invented this yet. And I’m going to be continuing to work on it. So as our next episode coming up Monday, person that I’ve been dying to talk to, and I think it’s gonna be an amazing interview, Rachel Levine, who is the Assistant Secretary for Health for the US government. And she is the highest ranking trans woman in I think the history of US government, and the first four-star trans women, and she won’t be the last. And then ken burns the documentarian, who we know from his documentaries around the Civil War and baseball, and so many other things. Really, really interesting guy pleasure to have him on the show. We had a great conversation about a new documentary he’s releasing about Ben Franklin, who by the way, had a really interesting role to play in inoculations, vaccinations. So talk a little bit about that, but all kinds of other interesting stuff. And then we get into long COVID But we’re gonna go back to our interview with Senator Tim Kaine who has been suffering the consequences as apparently have a number of his colleagues in the Senate and House of long and COVID. And we’re going to get into that. I know that was a topic that you heard. Zeke talk quite a bit about today. We’ll go further on long COVID Hey, thanks, everybody, for listening. I hope you have a really wonderful rest of your week.


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 and Veronica Rodriguez. Jessica Cordova Kramer and Stephanie Wittels Wachs are the executive producers of the show, we love them dearly. 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, please tell your friends and please stay safe, share some joy and we will definitely get through this together.

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