Podcast: Success stories and challenges from the COVID-19 pandemic

Jim Dryden (host): Hello and welcome to “Show Me the Science,” conversations about science and health with the people of Washington University School of Medicine in St. Louis, Missouri…the Show-Me state. As we continue to detail Washington University’s response to the COVID-19 pandemic, in this episode, we take a slightly different approach than we normally do. The director of the U.S. Centers for Disease Control and Prevention, infectious diseases specialist Dr. Rochelle Walensky, participated in a conversation at the Washington University Department of Medicine’s Grand Rounds, where she called vaccine development and distribution one of the success stories of the pandemic.

Rochelle Walensky, MD: We delivered in a year 550 million vaccines. I mean, that’s extraordinary. And if you had asked a priori would we have been able to do that? I’m not sure we would have. Was it enough? Do we need to do better? Do we need to do more? Yes. But that’s extraordinary that we were being able to scale up — well, we were able to have a vaccine in a year and then scale up vaccine delivery.

Dryden: But she says more needs to be done to get more people vaccinated in the United States and around the world. As the U.S. approaches 1 million COVID-19 deaths, Walensky sat down with Dr. Bill Powderly. He’s co-director of the Division of Infectious Diseases at Washington University. In this episode, we’ll hear much of the conversation between the two of them with Powderly asking the questions. The two discuss the state of the pandemic, as well as the importance of lessons that were learned during the HIV epidemic decades ago, and how those lessons can be applied by doctors and scientists waging battle today against COVID-19.

Walensky: We learned so much early in HIV in terms of who is getting care and access to care. And we in infectious disease have long known that where infectious diseases go are not in places of wealth but in places of poverty and places of lack of access. They quickly go there. I became an infectious disease doc because of my training in inner-city Baltimore in 1995. I was an intern, and watching that happen in real-time was really instrumental. A third of my internship class went into infectious diseases, just to give you a sense of how motivating that time was for so many of us. Fast-forward to where we were with COVID, and I vividly remember being at the bedside and talking with a patient about quarantine. “You should go home and quarantine.” And then it became very obvious that this patient couldn’t go home and quarantine. And the word “quarantine” in and of itself was a privilege. It also was very obvious that the first people who brought SARS-CoV-2 to the United States were people who traveled on airplanes, people who traveled on cruise ships. People who had the resources to do those sorts of things. And then it became a disease of the more vulnerable. And so there were so many lessons that were learned in what we did in HIV and carried through what we were seeing in COVID. What was obvious for the rest of the world is what we knew in infectious disease all along. That equity played a big part of this. Lack of access. We’re going to see it again in long COVID, where those who have been more commonly afflicted with the disease, who had less access to care and more co-morbidities and therefore higher risk, are going to bear the burden of that disease as well. So there were so many parallels that we could see in both of those diseases.

William G. Powderly, MD: You’ve raised a critical importance issue: health equity. We’ve seen this in COVID, but it spans much more beyond COVID. As the CDC director, how do you think we need to go both in terms of health policy and as a country, in terms of addressing equity in health care and how do we do that in a way that truly gets to the root of the problem?

Walensky: We have a lot of work that we need to do. I’m proud to say that in April, just weeks after coming to the CDC, we at CDC declared racism a serious public health threat. And in doing so over 200 public health departments around the country have followed suit. So we’ve made a lot of progress in people knowing and focusing that this was an issue that we needed to work on. I have challenged our agency specifically. I have set targets and we have a new strategy for health equity and said, “We have spent a lot of time documenting a problem in health equity. You don’t need to look very far to say it’s true in maternal mortality. It’s true in chronic diseases. It’s true in access to care. It’s all true.” And I said to the agency, “I don’t want to document the problem anymore. I want to implement things that will fix the problem because we continue to look and we will find it wherever we look.” And so it was really inspiring for the agency, I have to say. People who are tired, who have had a hard couple of years to be able to move forward with something that that is really inspiring for them to work on. So those are the things that I really wanted to continue to do. I do think one of the challenges has been the public health workforce itself. I learned so much from our HIV clinics’ community health workers, and the power of those community health workers to do things that I was completely unempowered to do. I remember one vividly where a patient was lost to follow-up. We were very worried about her and we sent this community health worker to go find her. He did, and she said she wasn’t coming because she had alopecia from her HIV, and she was too embarrassed to come to clinic. And he said, “If I buy you a wig, will you come to clinic?” And she said yes, and he showed up with her wig and into clinic she came. That’s what community health workers can do. And if we had community health workers sprinkled across the nation, in our churches and in our community-based organizations, when it came to vaccinating this country, there would have been trusted people on the ground to have people come to and say, “Yeah, you should get that vaccine.” So I think there’s a lot of work that we need to do. We certainly need a public health that is as diverse as the communities we serve. We need to upskill that public health workforce. So there’s a lot of work that we need to do. We’re working out of the CDC and I think we have work to do across the country.

Powderly: You brought up the public health workforce and you and I were talking previously about one of the challenges that we have at the moment. And that is burnout, the mental strain of this illness, this two years of a pandemic. I wanted you to comment both from the workforce perspective, but also in the general public health issue, because a lot of times when we talk about public health, we don’t talk about mental health.

Walensky: Two-thirds of our public health workforce had a depressive diagnosis, anxiety. 10% had suicidal ideation. I mean, real challenges in our public health workforce. So when we look at how we’re going to scale up that workforce, we need to both bolster the value of the workforce. So if you look — there was a study that was done that looked at public health before the pandemic. In the last decade between H1N1, Ebola, Zika and now COVID, our public health workforce is somewhere between 60 and 80,000 jobs in deficit. It’s extraordinary, and we lost thousands of jobs in COVID. It’s not that we’ve lost the jobs it’s people have vacated them. And so when you think about what we need to do in public health, it is not just skill up our workforce. We need to make sure that that workforce feels valued. We need to make sure it’s a revered place to be. CDC —

Dryden: Walensky explained to Powderly that by requiring the CDC to do things it had never done before, this pandemic uncovered places where the organization needed to evolve and modernize.

Walensky: CDC never had the infrastructure to receive a reportable disease at a million cases a day. Reportable diseases are things like measles and gonorrhea and syphilis, we don’t get those at a million cases a day, fortunately. And increasingly through this pandemic, people have wanted our public health guidance to say to them, “Can I visit Grandma this weekend?” And so wearing my physician hat, I certainly know how to give individualized advice. But this balance between what the public is asking of us in this moment at CDC for public health information and what we generally think of as people going for their individualized information based on their individual circumstances, their individual risk tolerance, has been a really interesting line to walk.

Powderly: So two years into this, when you think about the pandemic, what did we get right and what do you think the opportunities will be if we face something like this again?

Walensky: We delivered in a year 550 million vaccines. I mean, that’s extraordinary. And if you had asked a priori would we have been able to do that? I’m not sure we would have. Was it enough? Do we need to do better? Do we need to do more? Yes. But that’s extraordinary that we were able to scale up — well, we were able to have a vaccine in a year and then scale up vaccine delivery in an extraordinary fashion across this country. So I think we can talk about the challenges of those who are vaccine-hesitant and the divisiveness there, but we were able — for people who wanted a vaccine, it was available to them and even for people who didn’t, we were able to move the needle on many people. So I think that that is one thing. Another thing I’m really proud of is our ability to quickly get data out. When we said, “We need vaccine effectiveness data as fast as we can have it because everybody wants to know how well this vaccine is working and is it waning?” We now have infrastructure in vaccine effectiveness, leveraged from our vaccine effectiveness work in flu. And we now have the capacity of linking in 29 jurisdictions — so two-thirds of the United States population — vaccine immunization data to testing data — those two did not speak — to death data. And because of that, we can now within four weeks, look at vaccine effectiveness for cases and deaths for two-thirds of America. Where could we have improved? I can tell you where I was when the CNN feed came that it was 95% effective on the vaccine. So many of us wanted to be hopeful. So many of us wanted to say, “Okay, this is our ticket out. Right? Now we’re done.” So I think we had perhaps too little caution and too much optimism for some good things that came our way. Nobody said ‘waning’: “This vaccine is going to work. Oh, well, maybe it’ll wear off.” Nobody said, “Well, what if the next variant doesn’t — it’s not as potent against the next variant?” And then maybe the other thing I’ll say is this area of gray. I have frequently said, “We’re going to lead with the science. Science is going to be the foundation of everything we do.” That is entirely true. I think the public heard that as, “Science is foolproof. Science is black and white. Science is immediate and we get the answer, and then we make the decision based on the answer.” And the truth is, science is gray. And science is not always immediate, and sometimes it takes months and years to actually find out the answer, but you have to make decisions in a pandemic before you have that answer.

Powderly: It’s interesting. One of the first things I said to our ID fellows when they start their fellowship is, “In your residency you learned black-and-white because you have to know what to do in a specific situation. In fellowship we teach you gray.” But I’m going to put you on the spot by saying okay, and recognizing that uncertainty, where do you think we’re going with COVID?

Walensky: Every piece of advice I’ve gotten is, “Don’t predict what’s going to happen.” So I have no idea what’s going to happen. But when I think about what the years ahead look like, and I don’t even mean the months ahead, I think that overall our immunity is going to hold us in good stead. I don’t know whether we’re going to need another boost and I don’t know when, and I don’t know what that’s going to look like. But I do think ultimately we will have good level population immunity for variants that come our way and that ultimately we will have a coronavirus that we will then tolerate in some way.

Powderly: I used to say that the thing that keeps infectious disease doctors awake at night — this is pretty common — was a new virus to which we had no immunity. The issue is that this will happen again. It may not be in our lifetime. I hope it’s not in my lifetime, but it will happen again. How do you think we can better prepare both nationally and globally for a potential new pandemic?

Walensky: So I think our data sources need to be key. We need to be able to have a full line of sight, almost like a 30,000-foot view of all of the respiratory viruses that could potentially lead to this. And we’re working on that. We started a new center for forecasting and analytics that will be able to model and forecast what could be coming. I think we need a public health infrastructure that’s ready to handle it because I think ours was really too frail to be able to handle it at this time. And I do think that if we had more health equity in this country, that we wouldn’t see these great disparities between — and in fact, I think we would all be healthier and we would all be able to tackle it better.

Powderly: So this is a question from one of our ID fellows. As an infectious disease physician, I find it reasonably straightforward to be able to estimate risk of infection with COVID. However, I find it very difficult to measure the non-ID aspects, and the CDC has had to make some tough choices. How do you approach making these decisions with competing risk/benefits? The risks to mental health, the economic risks, all of those things?

Walensky: That is such an important question. One of the things I think that’s really been a challenge here is on the right side of every news screen is the number of cases and the number of deaths from COVID. And that’s because we’re counting them and we’re looking under the lamppost of all the cases and all the deaths. And there have been so many other things that we’re counting that don’t make the headlines. Opioid deaths and mental health challenges, screening for cancers. So we’re not tallying that as much. I think we will be tallying that in the future, but we need to make decisions now. We’re tired, and I know what ID faculty do in a pandemic. We’re all tired. This is what we are called to do. This is what we train for. We would kind of never hope we’d be here, but this is what we were trained to do. And then at the individual level, I would just say, as providers, to listen. I had a social worker in our HIV clinic when I was a fellow who used to teach me how to give a new HIV diagnosis. And she said, “The first thing you do is you say, ‘Your HIV test came back positive, and then that means you have HIV infection.’ And then you don’t say anything else. You wait.” And it’s a forever wait. But the first thing that comes out of somebody’s mouth is usually the most important thing to them. And then the thing that you can address. It could be, am I going to lose my job? Where am I going to get meds? Is my baby infected? You don’t really know what that is unless they say it first. And so people have often said to me, “How do you get — how do you convince people to get vaccinated?” And the answer is, “Well, you listen to the reason they haven’t been.” Right? Because you can’t really address all of the reasons. You have to sort of say, “What is your reason?”

Powderly: How does the CDC balance its domestic role in the United States with its global role in global public health?

Walensky: Yes. We have collaborations in 60 countries. We have people around the world. When you speak with a country director in DRC and you want to talk COVID, that may or may not be the most important infectious threat that they have. Or Ethiopia or health threat that they have right now. And it’s actually pretty humbling to sort of anticipate that you’re going to have a conversation about one disease and realize that that is actually not the important challenge that they have. We have to vaccinate the world for COVID-19 and we have to do that in the context of vaccinating for measles in Ethiopia.

Powderly: Yeah. Your comment did remind me that war is very bad for public health.

Walensky: War is bad for public health. I know how challenging it is to train during this. This is what we were meant to be doing in this moment. It’s a gift. We’re tired. And one of the things that was very obvious to me as division chief and I’m sure to you, Bill, is we are trying to deliver incredible care to really sick people. And at the same time, the child care closed and mom is home with COVID. And so just because we’re health-care providers doesn’t mean that we are immune, so to speak, from all of the other challenges that COVID presents, milestones lost. And so I just want to acknowledge that and thank you all for what you have been doing over the last several years.

Dryden: Walensky, who earned her undergraduate degree at Washington University, participated in a conversation at medical Grand Rounds. During her visit she also participated in an event held by the Forum for Women in Medicine, where she discussed the trajectory of her career. We heard her in conversation with Dr. Bill Powderly, the co-director of the School of Medicine’s Division of Infectious Diseases. “Show Me the Science” is a production of the Office of Medical Public Affairs at Washington University School of Medicine in St. Louis. The goal of this project is to keep you informed and maybe teach you some things that will give you hope. If you’ve enjoyed what you’ve heard, please remember to subscribe and tell your friends. Thanks for tuning in. I’m Jim Dryden. Stay safe.