We Can All Safely Experience Joy This Holiday Season

This transcript has been edited for clarity.

Eric J. Topol, MD: Hello. This is Eric Topol from Medscape and our podcast, Medicine and the Machine. I’m with my co-host, Abraham Verghese, and we’re thrilled to have Andy Slavitt with us. We’re reversing his podcast, In the Bubble With Andy Slavitt, and putting him in the bubble today to hear his views about the pandemic and his recent book Preventable, and asking him to try to forecast where we’re headed from here. I’m going to turn this over to Abraham because I know he’s just finished reading Preventable.

Abraham Verghese, MD: Thank you so much, Eric. Andy, it’s such a pleasure to have you on board. Both your tweets and your books are so informative. I have so many highlights in the book that I am embarrassed to bring up all of them, but my favorite must be the one where you caught someone saying that you can’t “undie” people. I think that was the most poignant of the highlights for me because, as of today, we’ve had about 800,000 people succumb to this epidemic and you can’t just undie them.

Andy Slavitt: I just saw a Kaiser Family Foundation study, which I’m sure you both saw, which talked about how many people since June we’ve lost who could have been saved if they had been vaccinated. That gave me chills. I forget the exact number, but it was over 100,000 — close to 200,000. When the numbers get that big, we all lose the scope. At this point, we all have to work hard at making those numbers feel real. Human tragedies like this are hard enough, but it’s different to feel like we have the tools to make it go better and we’re not using them.

Verghese: I hadn’t thought of people like Scott Atlas in a long while, so reading the book made me revisit some pain. Before we get into the nitty gritty of the many things we want to talk about, I’m curious about the mechanics of the book. Were you writing this along the way? Were you keeping notes? Were you conscious that you were living through a period in history?

Slavitt: It’s interesting. I had already signed an agreement to write a book on a different topic before the pandemic started. Then, when the pandemic started, I couldn’t write that other book because I was too busy, like Eric and many others, with things we were trying to do to be helpful in the pandemic. During the first part of 2020, I talked with a lot of scientists, but also a lot of corporate leaders who were trying to do things on the personal protective equipment front, and others who were getting in the way. Then I talked to a lot of governors. And then I ended up talking to the White House and Jared Kushner and others. Finally, my publisher said, well, there’s your book. You have a kind of a bird’s-eye view and also an on-the-ground view of some things that are going on. Can you make that into a book?

The process became almost a bit of a therapy session. I had these unbelievable conversations; Eric, you and I have talked about this. You have this feeling — I know you’ve had it many times — and you’re like, oh, I just learned something that people really need to know. Either it’s bad and people need to prepare themselves, or it’s bad in the sense that the government isn’t doing something it should, and you feel like that needs to get out. For me, it was therapeutic to a certain extent to feel like I was perhaps writing one version of a first draft of history.

Verghese: It’s a wonderful book and really helps us relive that time, with an insider’s view of what was really happening behind the scenes during those momentous days of, essentially, the past 2 years.

Topol: I think what’s amazing, Andy, is how you called out so much that was preventable. And we’re still marching along through a second surge of Delta in the United States and moving on to Omicron. We’re still not learning, and we’re still not implementing many of the lessons you called out. You are an insider; you spent many months on the White House response team. In fact, we miss you profoundly. Those daily briefings, where you were the moderator and the sharp communicator, were essential for the public and for the medical community. You know what it takes for us to get our arms around this, and we’re not doing it. What can be done given all the obstacles we face?

Slavitt: First of all, that’s very nice of you to say. I feel like in some ways, I have a bit of an advantage of not having your expertise or other people’s expertise to weigh me down. I viewed being part of that extraordinary team as, number one, what I’ve learned in a crisis is that you pick one thing that you want to optimize and then you just do the best you can on everything else. It was very clear that vaccinating as many people as quickly possible at that point, ahead of the Alpha variant, was the main thing. If we hadn’t vaccinated people ahead of Alpha, we would have been dealing with what we ended up facing with Delta, only earlier. We didn’t know about Delta at the point when we were doing that work.

Alpha was enough of a threat, and we had a lot of impatient and unhappy people who had been overpromised, I think, by the prior administration that they would get their vaccines quickly — and yet people found themselves on a website, not able to get through. And I knew another batch of people who weren’t sure they wanted to be vaccinated, and we had to deal with them. The one bit of guidance I got from President Biden was, Andy, don’t worry about making me look good, just give people the information they need.

So I pretended to be talking to my sister, as if she asked me, hey, when’s a vaccine coming? Or, should I take that? Will I be happier or not about the tests and the ability to get a home test? I felt like I would be in good shape if I kept it at her level. My sister is an extremely smart person whom I respect a lot, so I don’t doubt her intelligence. But she doesn’t know this stuff, and she’s got a desperate need to know. She can handle bad news; she doesn’t need it to be sugarcoated. If I give her good news when the news is bad, she’ll come back and yell at me later, so I might as well just tell her the bad news now. From the communication aspect of the job, I found that made it all much easier. Let Tony Fauci highlight his expertise. Let other people highlight their expertise, because I was not the person who had the expertise. Let the scientists answer the scientific questions.

I have to say, I felt like the government was at a low point, much lower than we are today, in terms of public trust. And I felt if that wasn’t repaired, we were going to have no chance. I believe government can do big, powerful things and has to be able to do big, powerful things. I believe in our institutions as flawed as they are. I believe in the CDC. I believe in the FDA. I believe in the career civil servants. It’s the best we’ve got. Where we’re falling down, we’ve got to improve things. We can’t just say, we can’t trust anybody now so we may as well be left to our own devices. The problem we were facing in the first place was, when you can’t trust anybody, you hunker down and protect yourself and what’s yours. If we continue to view this pandemic through the light of how it’s going to impact me and not how it’s going to impact us, we’re going to be repeating this over and over and over again, and we are.

Verghese: Every prediction is that we’re going to see the same phenomenon with Omicron that we saw with Delta, with certain states having many more hospitalizations and greater pressure on healthcare workers. But what can we do differently? If you’re advising Biden and his team, what are you telling them that they can actually execute and that would make a difference?

Slavitt: If we start with the facts — and these facts are still coming in, and the state of the science, we’re still learning — but from everything I’ve read from Eric and others, there’s very good news in that if you’re boosted, you’re adding about an 80% vaccine efficacy rate and you probably are doing a fair bit to slow the spread of COVID even with Omicron. Without being boosted, with two vaccine shots, you’re probably at 40% efficacy. And if you’ve had prior infection (but no vaccine), you’re probably a lot less than that. So, you start with one of those facts and make sure people see and understand those facts.

Then there’s a readjustment and rethinking we have to do, because only 14% of the public are boosted. Fourteen percent — 47 million people — and we’re only gaining a percentage point every 3 days. If you can picture an Omicron wave starting to tack on top of Delta 30 days from now, we’ll only be at 25% boosted. We’re used to thinking, are you vaccinated? And that’s only a portion of the story now. We have to help people readjust their thinking.

I believe that people hate it when we tell them that the science has changed, but they’d hate it worse if we didn’t tell them the science has changed. We can’t say that two doses lets you into that restaurant or lets you into that country. We can either say three doses or tell people they are taking a big chance — it’s not what it once was. Readjusting people to that mindset is the first important step; doing it consistently and clearly and then saying to people, look, this isn’t a year ago. A year ago, we told you the bad news and we had no tools, so your hospitals are going to fill up. You have to stay home, avoid Christmas, all that. In 12 months, we’ve made an extraordinary amount of progress. We now have half a dozen tools that work. We have boosters, and we have therapies coming. We have rapid at-home tests, which allow people to move about and see their loved ones. We have better portable air purifiers, we have better surveillance, and we’re actually doing contact tracing with Omicron. We actually are able to track these cases as they come in.

It’s a different world now. We don’t have to postpone schools, necessarily. We can safely do a lot of the things we do in life. If I were communicating this, whether from the president or from a governor or a mayor, I would say, here are the facts. They are neither good nor bad. They’re just a reality as we understand it. We have these tools. Let’s aggressively use these tools as much as we can, and with minor changes to our life, we can all experience joy and we can do it safely.

Topol: Andy, I couldn’t agree with you more about the progress and the illusion that we’re not making progress, that we’re somehow going backward in terms of the projections. As you’ve seen, there are potentially a million cases a day with Omicron, the way it’s doubling every 2 days in the United Kingdom and Denmark and other places. But what we have is fact-free fabrication. These are aggressive campaigns of myths and disinformation. You know that, because you were trying to deal with it when you were at the White House and it hasn’t gotten any better since you came home to Pasadena in May. I joked that when you left the response team, everything went down with the vaccination campaign. Unfortunately, the disinformation has proceeded intensely. Can’t something more be done to take that on? That’s holding us back so much, don’t you think?

Slavitt: Let’s have an honest conversation here. At root cause, probably 20% of the public — and this may be an oversimplification — is anti-science. They don’t believe in institutions. They don’t believe what they hear from scientists. They’re deeply suspicious. Maybe some portion have conspiracy beliefs that predated the pandemic. I don’t think we should just look at it as all of these folks were predisposed or were already there. This is a political wave that Trump rode. It’s an anti-institutionalist wave that is harder to deal with than transactionally dealing with misinformation. It really is the guts of how people feel about society, about their connection to it, about a bunch of deeper issues. And it’s very hard.

Beyond that, though, we have a lot of people asking a lot of incredibly reasonable questions, and they need good answers and should not be lied to. If someone says, Hey, you know this mRNA vaccine — I know a lot of people have taken it and I get that it was invented a while ago, but it feels new and a little scary. That person is not a moron for asking the question or having that point of view. That person just needs to talk to someone they trust, who can say, hey, that’s a legitimate question. Here’s how to think about it. What other legitimate questions do you have? And that trusted someone is usually a local person, like a physician or some other trusted person. Unfortunately, I’d love to tell you that can be done at scale. I’d love to tell you that we can educate those folks, like one and done, but it’s a fantasy that there is a Tony Fauci or someone who can educate all those people. The reality is that those folks who can be persuaded at scale are already persuaded.

Topol: But don’t you think they’re vulnerable to the to the 20% who are anti-science ? My concern is that the 20% are influencing another 30%.

Slavitt: This is where I think things like vaccine requirements are quite useful, because a lot of these folks who are on the fence don’t have strong feelings either way. But if they hear you can’t go to your favorite bar, or you can’t sign up for classes at school, or you can’t work in your office unless you can demonstrate you’re not contagious, most people — in fact, it’s more than the 30% — up to 90%-95% of the public don’t feel that strongly about being vaccinated or boosted that they would protest that. In most workplaces, including the US military (which has a lot of young people from rural environments, a lot of people of color, a lot of people with all kinds of reasons to be suspicious, and younger people who don’t really feel they need a vaccine) 90%-95% don’t feel that strongly about it. If you talk to a typical person who’s not vaccinated, who’s getting vaccinated now for the first time because their employer requires it, and you ask them their attitude toward it, they’re like, Who wants a shot? Who would voluntarily get a shot? My employer told me to, so I’m doing it.

We’ve got to use the techniques that we know work, that some would call coercive. I would say they’re the nudges that tell people, you’ve got a choice, you don’t have to go to that bar, you don’t have to go to that stadium, you don’t have to take that specific job, if you don’t want to get vaccinated. Or if you want to get tested frequently, maybe that’s an alternative. We don’t want you to be part of this broader contagion unknowingly, and this is why: because we have young people, we have older people, we have people who have HIV, we have people who’ve had transplants. We can’t in good conscience say, go be around those people and be unvaccinated. If you don’t want to be vaccinated for yourself, that’s a personal decision, but we can’t allow you to be part of the chain of transmission. That’s the fact. And we’ve got to be strong about that, in my opinion.

Verghese: Early on in the epidemic, as you describe in your book, you came up with a manifesto to send to all the governors. It was very interesting how that was a litmus test for how people would respond. Some picked up the phone and were engaged right away, and others, of course, did not. I’m wondering what you think would happen if you were to send these guidelines for today to the governors. Do you think we’ve made any progress? Will there be a different reaction?

Slavitt: At that point in time, I didn’t know, I didn’t realize people would go into different camps about how they would respond to this. I was very naive. The thing I felt stupidest about in 2020 was that I didn’t think we would have a civil war on top of the pandemic. I honestly thought there was a reasonable chance that we would actually come together and treat this as something that wasn’t political, and that was very foolish on my part. But I’ll tell you, if it happened again, I’d only be a little chastened because I’m a bit of an idealist and a bit of an optimist. I thought people would react to this the same way they would react if their state were attacked, because their state was being attacked. If their hospitals were being attacked and their nurses and doctors were being attacked, they would say, I want a very practical playbook.

So I sent this letter out after calling a bunch of former CDC people — a bunch of people who have run crises before. It said, look, here’s the first 10 things you need to do. Then I published it in a newspaper with a bunch of people who signed on to it saying, these are the practical steps you need to take. I didn’t think they were controversial. I think today, nobody I know on a national level calls Ron DeSantis or Greg Abbott, Republican or Democrat, scientist or not. They don’t feel it’s worthwhile to even call them. We have all decamped to our own points of view, I guess.

Topol: You’re getting at what I indicated earlier, which is the political divisiveness that wouldn’t have been anticipated. I share your perspective that we had the common enemy of a formidable virus and we basically collapsed in this country and we have remained in that state of not having unity. It’s held us back. We are 65th in the world for fully vaccinated people, we’re lagging way behind in boosters.

But in addition to the political divisiveness, I want to get your comment about the infighting in the leadership of the government. Back in August, President Biden made an announcement that boosters would be needed in adults and we’re going to come up with a plan. Then he had the CDC and a couple of rogue scientists at the FDA going after that, and he did a lot of backtracking. There were a lot of mixed messages — 8 months, 5 months. No, this. Maybe not. Yes. I mean, it’s unbelievable, Andy.

We have this really tough political fight. Who would ever have guessed? Then we have infighting within our own agencies that you know very well because you were communicating on their behalf and moderating these discussions. I’m just amazed by that because this idea was right in August — Tony called it right. But we don’t have a czar for the pandemic. This is a problem, and now we need the boosters as one line of defense against Omicron and we’re not moving again. What do you think about that?

Slavitt: Boy, it’s really interesting. Let’s say with the benefit of hindsight, you’ve got scientists who said things that turned out not to be right, who said we don’t need boosters. The scientific process normally allows for a little bit of debate, and the scientific process doesn’t work well when people’s voices are suppressed. I think back to the Trump administration, when people in the FDA or CDC would say something and get fired for it. I think about other countries where what you hear is only what the government wants you to hear. So then what do you do? You get a couple of scientists who say, I don’t know that we need boosters. And they’re wrong, but they publish it in a magazine. In some ways, the best thing you can do is, oddly enough, invite that and say, what we’re going through is real-time decision-making. You’re never going to get 100 out of 100 people to agree. We’re not going to suppress their right to say it, but we are going to make a call based on the preponderance of the science, and the preponderance of science is X.

There was a lot of real frustration with these guys. Understandably so. But in some respects, what you’d want to say is, look, are you sure you want to publish this? I would stop short of saying you can’t publish it, because then you’ve got a scandal where it looks as if you’re not comfortable with the truth coming out. It creates an obligation because instantly what they’ve done becomes fodder for the misinformation folks. It’s a by-product of having a free society. I would have been plowing those guys with information that they didn’t have. But once the genie is out of the bottle, you have to keep pushing on it.

So, we have 14% of people being boosted and we’re doing about a million boosters a day. If you said, boy, if we hadn’t had those confusing conversations in August, would we be at 20%? I don’t know that we would. I remember when Pfizer came out and said we’re all going to need to get boosted. Look what’s happening in Israel.

One of the many mistakes I think a bunch of people made (and I’m willing to say that I’m part of that) is that we wanted to be so clear about how good the vaccines were that many people felt oversold. Instead of saying, this is one of the best tools we have, we kind of said, 98% efficacy — you probably won’t need masks, no more transmission, et cetera. We didn’t account for waning immunity, and we certainly didn’t account for Delta. Then we came back later and said, hey, the vaccines are good but not perfect. They’re still important. It looked like backtracking to people. And people were able to poke holes in vaccines, and then rather than say, yes, those are legitimate questions (which, by the way, you did, Eric) and we’ve got to be honest about this, there are others who were saying, no, we have to go to the mat and keep the story simple and say that vaccines are perfect, returns are great. That was regrettable.

Verghese: The other factor that is happening right now is that we’re all so weary. I see that in my housestaff on the wards; they are just tired. Even though our COVID numbers are reasonable now, we don’t know what to expect and they are just tired. I would venture to say, you’re probably a little tired, too. You were the idealist who held the townhall forums about Obamacare. I sense that you’re probably not optimistic that townhalls can work as well now, engaging the public in forums and bringing them around.

Slavitt: You know, I probably have a pathological need to do stuff. It’s my saving grace. No one likes feeling helpless. I’m not saying I don’t ever get there, but when you surround yourself with doers, people like Eric and others, you’re inspired to know that you can always make a difference and do stuff, so I feel useful. Maybe I kid myself about feeling useful, but at least it keeps me feeling positive.

In all our own lives, I think everyone asks themselves the question, how bad does it have to be before I go back to doing things that are less safe? A lot of people have the rational response. They’re probably not going to die. The burden always falls disproportionately in certain communities, and in places where those burdens don’t fall disproportionately, people will more and more say they’re willing to live with much more risk because the risk doesn’t necessarily fall to them. And I say, okay, that’s reasonable, but the things we’re asking of you are not monumental — to wear a mask around other people, get vaccinated, get boosted if you’re going to be around other people, and take rapid at-home tests if you’re going to have people to your house. During World War II, people went months without coffee. I can’t go a morning without coffee, but no one is asking me to.

We live in Los Angeles. My wife went into a convenience store an hour outside Los Angeles wearing a mask. There were seven people in the convenience store, including three who worked there, and they laughed at her hysterically. An hour outside an urban city metro area in a convenience store, people thought it was insane that she went in to pay for something and was wearing a mask. We have gotten ourselves to a place where there’s a very thin ground of reasonable where we can just say, let’s all agree that this is reasonable.

Topol: As you well know, many countries have made rapid tests free or subsidized them greatly. And last week, when it was mentioned during a White House press conference with Jen Psaki, she said we just can’t afford to do this. What’s your sense about rapid tests? Because we only have a few that are cleared by the FDA, whereas the European Medicines Agency has cleared 70 or 80. We’re not distributing them and they’re hard to find, and there are even better tests than the ones that are out there. What do you think?

Slavitt: I’d go to Congress, which is a hard thing to do, and I’d ask for $50-$100 billion for a rapid at-home test, to make them ubiquitous. I think I’d eventually pair them with therapies because, by the middle of next year, we’re going to have some availability — not as much as we would hope for — but some availability of these oral therapeutics. If I have the ability to get an unlimited amount of at-home tests, then in some ways, I can feel a sense of optimism that I can lead my life during the pandemic.

Also, by the way, only jerks go out in public when they when they know they have the flu. Some people do it, but they’re jerks. So if people test positive with a rapid at-home test, one would like to think that the majority of them are not going to want to go infect other people. At-home testing could have a really positive impact on our lives. It’s going to have a positive impact on the pandemic. Is that worth $5-$100 billion? Yes, we need to spend it on that. In the meantime, if they say they can’t do it without that money, I would be on the phone with every insurance company CEO and I’d say, you are on the hook to pay for these things. Go buy them in bulk and send them to your members; send a certain amount every month. Start with your low- and middle-income folks, because people who have higher incomes can afford them.

We have eight tests approved, because the other question is volume. I think one of the things that we’re not doing is buying these made-in-China tests that other countries in Europe are buying. I don’t know enough to know whether we’re making a mistake or they’re making a mistake. There’s some difference of opinion. We put in $3 billion to scale up manufacturing. Of that $50-$100 billion, I’d take another $10 billion or $20 billion to develop new tests. Because I do believe that is one very no-regret decision, and it’s got to pay back in terms of packed stadiums and the economy and football and keeping hospitals open for other kinds of healthcare that people need. I imagine it’s a great investment.

Verghese: Circling back to your book, I was struck by the business mindset you brought to sorting out the Obamacare problem, sorting out the healthcare issues that you saw the widow of a friend of yours face. It just highlights the fact that many of us in medicine are simply not equipped to think about things strategically, and people in politics certainly are not. It doesn’t seem to me that we’ve found a way to formalize the appointment of people like you to really run the government or the healthcare system in a managerial sense. We keep appointing people whose expertise is slightly tangential or they got the most votes, and as a populace, this is not a good way to go. This could be a case study for all the different problems that we saw along the way that you describe that were preventable.

Slavitt: Someone said recently that the US healthcare system is bigger than the economy of Italy and about as well organized, and that only a fool would say that they can come in and reorient the government of Italy. It’s such a good comparison because systemically, it’s inherently the same type of corruption. By corruption, I mean there are moneyed interests that drive so much of what we do and supersede so much of what’s in the common good.

There are 50 different economies within healthcare. There’s a $30 billion health information technology economy and an electronic medical record economy. No one even likes their technology, so how did that get to be a $50 or $100 billion economy? We’ve got economies of pharmacy benefit managers who do nothing but say, keep your prices high and I’ll get it lowered and I’ll take a piece of the difference. That’s a several hundred-billion-dollar industry. We have all of these economies inside healthcare and you could take as many well-intentioned people doing well-intentioned things, and they will find eventually that they’re running up against forces that are too big.

Now, I think we need to both fight those things and overwhelm them with positive forces. Eric is involved in so many things around innovation where he says, okay, can we take that negative and twist it to a positive by doing the things we do really well? Let’s innovate, let’s solve these problems. And indeed, those things happen and they’re very encouraging and help us make progress. But if, at the end of the day, we’ve got a country where 1 out of 4 people can’t afford to fill a prescription because the whole thing is just a massive expense, then we’re in a tough spot. It takes a lot of people, a lot of types of thinking, to address these things.

Topol: Andy, you’re kind of a Mission Impossible guy. You’re like Mr Phelps. Call him in to run Obamacare. Oh, by the way, why don’t you run this vaccine campaign and help get this communicated? You know the American healthcare system as well as anyone I know, because you’re on the inside and you’ve seen it in different prepandemic and intrapandemic lights. You wrote a book in real time, essentially about the pandemic.

To wrap up, we’re going to write the history books. It’s now 2030, and we got through these messy, messy times. COVID is endemic. Hopefully, we haven’t had another pandemic by then. What’s history going to say about the United States and its ability to meet this virus and prevail over it?

Slavitt: I think we’ll look back and give ourselves and A or an A-minus in what I call the hard sciences. And I think we’ll get a D-minus or an F in the social sciences. I think the mRNA platform is a beautiful story, as is the work of scientists around the country and the world who, on a distributive basis, sequenced and shared information and created therapeutics. I think our agencies, when you look back at FDA, forget real time; they’ll get high marks for getting a lot of agents approved rapidly. I couldn’t agree with you more on having more tests. But in the main, I think we will feel like the state of our science really showed well, and that should be encouraging for our future. If we directly applied all of this to something like climate change or the biodiversity crisis or whatever, you have to say, I feel optimistic about that.

On the other side of things — on human understanding of other people’s cultures and empathy, common-good sociology, the willingness to sacrifice for one another — all of those things at a human level, and on a political science level, I feel like we all should go back to school and pay attention to the classes that we didn’t take seriously because we didn’t think it mattered or they were easy. But that’s the stuff that tripped us up. I don’t think we have a lot to be proud of societally, with who we showed up to be.

Individually, like the doctors and nurses in Abraham’s facility, there are so many heroic stories, and so many inspiring people out there, people listening to you guys and this podcast. I sometimes get teary-eyed thinking about the heroic work people have done, because everything we fail at as a society falls on the shoulders and the backs of people in the healthcare system who showed up. Nobody was trained to do it, nobody was prepared to do it, nobody expected to have to do it. Yet people showed up every day and did it. I think the report card will show individual heroism, societal disappointment, and at least a very, very encouraging mark from what science did.

Verghese: I believe history will speak very well of individuals like yourself and Eric, who put yourselves out there and kept hammering away with a message that brings you a lot of nasty pushback. That’s been an important part of drawing the line and not backing away. I think history will remember that. It’s been a great pleasure for me to read your book and get to talk to you. Thank you.

Topol: Thanks so much for what you’ve done for the country. Beating your head against the wall, I’m sure, for many days throughout this. We hope we can keep turning to you for wisdom and leadership and communication. You’re a model of that. Thanks for joining us today and helping illuminate the Medscape audience.

This podcast is intended for US healthcare professionals only.

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