You’re listening to a press conference from the Harvard School of Public Health with Atul Gawande, a professor in the Department of Health Policy and Management. This call was recorded at 11:00 a.m. Eastern Time on Tuesday, February 9th.
MODERATOR: Hi, Dr. Gawande, welcome.
ATUL GAWANDE: Thank you. I’m delighted to be here.
MODERATOR: We’re glad to have you.
ATUL GAWANDE: Is this Nicole?
MODERATOR: Yes, this is Nicole. Hi. Yes, we got started with the introduction stuff just so we can get to your questions that much faster. Do you have any opening remarks that you’d like to share with us before we get going?
ATUL GAWANDE: Just a thank you to everybody for your interest. Do you want to be the one to call on people or should I do that?
MODERATOR: I can take care of that. You just answer questions and I’ll take care of the rest of it. Are you all set? Any other comments you like to make before we go on?
ATUL GAWANDE: No. Delighted to dive in. I’ve put out a bunch of stuff this week, so it may or may not be relevant. Happy with wherever the conversation takes us.
MODERATOR: Excellent. Thank you, Dr. Gawande. All right. I think that’s everything to get going. So, first question.
Q: Thank you for taking the time. And I want to say that I read through your op-ed that you coauthored saying vaccines alone aren’t enough to end the pandemic. And there were two points you made that really stood out to me that I hadn’t heard before. The creation of vaccines that can target multiple strains as well as the need for more access to therapeutic drug trials. So could you please expand on those ideas?
ATUL GAWANDE: Yeah. First of all, you know, you’re in Florida where the latest reports that just came out in a preprint on Sunday are that the rate of the B.1.1.7. mutation has reached ten percent of cases in Florida. It was less than one percent that we’d recognized nationally just a few weeks ago. The doubling rate is every 10 days. And so that’s very concerning, extremely concerning. So on the one hand, we have a nicely falling rate of hospitalizations, cases and deaths. But then we’re seeing a rising number of cases. We know what happens that two to three weeks after that, we see a rising number of B.1.1.7 related. We will see B.1.1.7 related hospitalizations, and then we will see deaths to follow. Basically, hospitalizations follow cases by about two weeks and another couple of weeks after that, you see the deaths. And so we’re racing to get the vaccines out. The vaccines are against B.1.1.7. The evidence is that they are protective.
However, the South African variant and the Brazilian variant have the E484K mutation, which is an additional mutation to the spike protein genetic material. And that has still some diminished effectiveness of the vaccines that have been checked against it so far. And the vaccines can be reformulated to be multivalent, to add the additional encoding that would allow for success against the variants. The process often takes quite some time to create for traditional vaccines, some of which are under consideration now, like Novavax, or protein subunit vaccine. You have the others where they load the genetic material, in the case of Johnson & Johnson into the adenovector, adenovirus vector, or the mRNA vaccines. And those can be relatively rapidly updated to add the new encoded genetic variants and put into production if necessary. So just yesterday, there was already announced that Moderna and at least one other vaccine manufacturer is generating the booster’s needed to address the South African and Brazilian variants if they were to become a problem in the US. And I would expect those to be spreading and become significant. And so you know, our group of members, former members of the task force, did endorse that. We move ahead with multivalent vaccine preparation.
On your second point, this was about the therapeutics trials. Yeah, there was investment and a great deal of focus on the monoclonal antibodies, but we’ve not done what Britain did. Early on, Britain made a consortium of hospitals that agreed to do all of the kind of organization, paperwork and processing so they could rapidly deploy tests, for example, of dexamethasone, which was a cheap, readily available treatment that could be tried in a structured trial and rapidly determine its value. And that was absolutely crucial and lifesaving, we with all of our many hundreds of thousands of active cases that are out there, should be setting up a similar structure with clinics and health systems to be able to offer treatments across the entire course of infection, including from early on. And we point to some examples, such as colchicine, where there’s promising early evidence of the effect. It would not be effect that is specific to any one particular variant and offers the possibility of inexpensive treatment. But we need to gather more structured evidence and do it quickly.
MODERATOR: Are you all set, Dr. Gawande?
ATUL GAWANDE: Sure.
Q: Sure, this might be the opportunity. With the multi-strain vaccines, do you have any idea of what kind of timeline we’d be looking at for getting those out? For example, would that be months or years?
ATUL GAWANDE: Well, let me put it this way. When the Chinese released the genetic code of the vaccine of the virus that was originally spreading in China, within five days, Moderna and the NIH had produced their vaccine. There’s additional time after that to put it into production and do the testing. But you can move very quickly to create the variants. The FDA is in the middle of coming forward with a process, that I expect to see in the next week or two, for approving new boosters. The way we do that for the flu is that there’s a foundational vaccine that got a large-scale trial. And when the new flu variant arrives in a given year, then you mainly are looking at the antibody response, and you don’t have to wait until you see whether infections are reduced to approve a flu vaccine to go into production every year. And I think a very similar process is likely to be what the FDA will come out with. It certainly would make a lot of sense.
Q: All right, thank you very much.
MODERATOR: Next question.
Q: Thanks so much for doing this, first of all. I’ve been listening to you here and then also on the In the Bubble podcast, with Bob Wachter, which has been great. Obviously, the pandemic has underscored how complicated health care delivery is. And I’m curious what kind of lessons you’ve learned from your time at Haven that you’re bringing to your role on the Biden COVID advisory board.
ATUL GAWANDE: Well, so my role on the Biden Harris Transition COVID-19 advisory board came to an end with the inauguration. But the main thing you’re getting at is, in a pandemic where some of our biggest problems have been that we’ve can all breakthrough and follow through, understanding how you drive out operations and capabilities has been critical. There’s no way without my experience at Haven, working both around technology and standing up operations, there’s no way I would have been able to stand up what I subsequently did with creating, first a large-scale testing alliance and then founding a company called CIC Health to provide the logistics and operations for the Broad Institute and subsequently other labs to bring large scale mass testing to New England and then beyond nationally. Never would have known how to do that. And of note, I’ve co-founded it, but I’m donating any income that I should receive. I’m not receiving any income at present. But that was critical. And then being able to enable the pivot to also add mass vaccination. So we developed the protocols for achieving large stadium level vaccination and then deployed it at Gillette, Fenway Park and very shortly Reggie Lewis Track and Field in Roxbury, Massachusetts. And that ability to forge partnerships that require you to put technology, information technology, and user-friendly strategies, operations that just create a viable end to end experience for people who need to sign up and get through and not have all of the lines. I mean, we really prided ourselves on minimizing waits and then using every last drop of vaccine and now, also driving wider and wider access and addressing the equity issues. All of that I simply would not have known how to do that and assemble that kind of capability.
Q: Thank you, I appreciate that. Just as a quick follow up, because I want to conserve time. Why do you say all of that wouldn’t have been possible without your Haven experience?
ATUL GAWANDE: Well, I mean, I’ve run tech teams at Ariadne Labs, but never had to really manage and drive out production and make that work the way that I had to at Haven and could learn from people like Amazon and JPMorgan Chase about how they really do that. And then couple that with a public health care mission and what that takes. And then it’s not just the tech side. It’s also just seeing how you drive out and deploy to very large volumes and the pace with which you can do it and the volume of people and what how to manage that organizationally. Also, I would not have known how to do that.
Q: Thanks so much. Appreciate it.
MODERATOR: Next question.
Q: Hi, Dr. Gawande. Going forward, I know that the Biden administration is looking at the Defense Production Act and leveraging it to help with the production of vaccines, distribution of it. I just wonder from your vantage point, knowing as much as you do about vaccine development and just a general public health distribution, where do you see some efforts possible where they may not be looking and or have you advised them on such opportunities?
ATUL GAWANDE: Well, I mean, it’s not my particular area of expertise. What I loved about the Transition Advisory Board is I got to be alongside people who had a tremendous amount of expertise there. So when it comes to the production process now, the critical thing that I came to understand and I know that they are doing, but we weren’t doing before, was every manufacturer has every reason to be optimistic and to communicate optimism about their production process. You have to put people on the ground, on the production line, at the fill finish facilities where they fill the vials to understand and anticipate where the production problems are going to be. Even with having those people in place, when you’re producing a new vaccine type like an mRNA vaccine that has never had to be produced at a massive scale before, there are lots of unpredictable hitches along the way. I can tell you from running vaccine operations that it’s been a huge difference to go from a system where on Tuesday you’ll be told how much vaccine you’ll be receiving at the end of the week and only have one week heads up while trying to determine how many appointments to look for, people set expectations and that was an impossibility. And now having a three-week line of sight has made it dramatically easier. Just for example, we opened up more than 12,000 appointments over the next couple of weeks on Friday. And that’s just enabled everybody to plan. And, you know, we know that the vaccine will be there in two weeks based on the commitments the administration has made. So there is a fundamental unpredictability that I came to understand from the chance to talk to manufacturers and from my colleagues on the advisory board, but I don’t have any special insights there about further ways they could use the Defense Production Act or follow through on making more of those complicated mRNA liposomal constructs happen faster.
Q: Thanks. And then one quick other one on the public health and the health equity part, that seems to be a really big focus point for many people right now, some saying in a way never before. And obviously a little bit of this is a result of the protests last summer. So I just want to hear your take on that and sort of what you think is inspiring this focus and what is required to keep the momentum going.
ATUL GAWANDE: Well, a couple of things. Number one is, it was very clear that speed became the priority early on when there was so little planning for standing up vaccination sites and getting them up and going and opening them so that you could be moving vaccine enough and the vaccine doesn’t sit on shelves that led to speed over equity. We had my own vaccine sites, but, you know, across the country, we made online scheduling and enrollment available because you can get people through more speedily that way. You made mass vaccination centers that, you know, in many cases people needed to drive through, drive to and that allowed for you to start getting to mass scale. And you’ve seen this dramatic increase. I mean, it’s been amazing. The doubling time for delivering vaccine has been every two weeks, basically for the last month. It’s been a fourfold increase in the volume of vaccination. And I think that will continue so that we’re no longer limited by ability to deliver. We’re going to be living limited by the supply. Now, very appropriately, people are concerned that that system does not allow for equity. That’s along every dimension, age, education, income, race. There is a system. It’s too complicated. It requires a certain level of tech savvy and the ability to, you know keep poking and poking until you get through and that really, at a time when we’re trying to get to the over seventy-five population as a first step and beyond the health care workers and first responders, that has become an obvious set of barriers. I think at this point we’re still very early in the learning of how you drive equity. So I take the lessons from the last week include, boy, you got open call centers so that you can enroll people who don’t have easy access to the smart phone or the ability to navigate what are still complicated interfaces for people. There’s the need to be able to get people to have sites open that are closer to people’s communities. You then also have the problem that is of online scheduling.
Many people from outside of the more underserved communities are scheduling in and, you know, talk to colleagues in one state where they’d open black churches for access. And it was white people from out of the community who filled the appointments. If you have a complicated system, people know who know how to work the system and believe they deserve to work the system are the ones who get access first. And so there are interesting experiments underway. North Carolina as one example, where they are allocating blocks of appointments to community health workers, to care coordinators and others, and providing clear incentives that make it so meeting the proportion of your racial distribution and income distribution in your population are required as part of what you’re doing at the county level. Those are, I think, the first steps going forward. It’s no surprise because it’s just not acceptable to have the worst hit populations be the least likely to get the vaccinations. And the barriers are substantial. I think this is less about resistance and much more about the problem of not making these kinds of systems. Easy scheduling systems getting in the door, easily accessible, put right in front of people, especially for people who are have a lot on their plates trying to make ends meet.
Q: Thank you.
MODERATOR: Really quickly, Dr. Barry Bloom was on the call a week or two ago. He talked about the Defense Production Act a little bit and how that would not work so well with vaccine. So I’ll put a link to that in the chat in just a second. Next question.
Q: Hi, thanks so much for doing this. I was wondering how concerned you are about these new variants, and I was on the phone with someone this morning who said that he’s really worried that we’re going to be overrun by them in March and April and the vaccines aren’t going to arrive in time. Do you have that concern or where do you fall on that?
ATUL GAWANDE: I’m very concerned. The vaccines, however much we scale up distribution, it’s not going to be fast enough to address the problems of variants by itself. Israel is at 50 percent or more of the UK variant and 50 percent of their population being vaccinated. And their cases and hospitalizations continue to go up. And we’re going to experience that here if we don’t take added measures, the ones that, you know, we called for. Well, the ones I would call for include some of the ones we discussed. Such as, we have to develop a better portfolio of treatments as well as vaccines, and we have to have our prevention and mitigation strategies continue. Number one, I would recommend that we move to medical grade masks, cloth mastered, difficult to keep a roof over your nose because it’s just the way they’re designed and fit. Some of them are well designed so that they stay on your nose and fit you better. But the medical are inexpensive and to do that effectively, I would favor seeing those used more widely. And I think that if we the second thing is, I’m very worried we’re letting our foot off the brakes. You have Iowa, North Dakota and the Wisconsin legislature all enacting mask mandate removals, the governor in Wisconsin reinstated the mask mandate, but the mask mandate is the last thing you remove, not the first when your hospitalizations go down. And my worry is that if people start putting away their masks we had, according to Mike Osterholm, 10 million people had Super Bowl parties this weekend, there’s a lot of concern. I have a lot of concern that, you know, we are still with deaths over three thousand people. We have cases occurring at a level that still are not below where we were in early fall. And we’re in danger of taking the foot off the pedal just as the strains are arriving and moving quickly through the population.
MODERATOR: Dr. Gawande, you have about two minutes left. I believe you need to go at noon, correct?
ATUL GAWANDE: I do. I can try taking one more.
MODERATOR: Next question.
Q: Quick question about the situation here in Massachusetts where CIC is playing a huge role. Can you help us understand why Massachusetts continues to lag in how many people we get vaccinated and how efficiently we’re using the doses we have? And second, you were talking about the equity issue, the CIC plan to continue the policy of the city of Boston at the readiness center of setting aside certain doses, setting them aside so that they can be distributed through community groups such as the Black COVID coalition here in Boston, essentially reserving them for people of color.
ATUL GAWANDE: So as far as you know, why are we lagging? You know, I think we’ve moved up in our rankings in Massachusetts and I don’t have a great explanation. What I see is a dramatic increase in the ability to deliver vaccination. And so I expect us to be climbing those ranks. But, you know, I don’t feel like I have a real clarity on why we were further behind. It doesn’t seem to just boil down to the fact that we focused on the health care workers first. So, you know, I wish I had a better explanation there. As far as the approach, I did highlight that North Carolina has tried that approach. And if it’s working and enables people in the community to have much more ability to access appointments and not be squeezed out so that they’re getting their fair share of vaccinations, I’m not going to oppose that. But I don’t have a commitment one way or another on the exact strategies that we’ll use in ensuring the community around Reggie Lewis that has actually served. But we’re working very closely with community leaders there and including the coalition of Black doctors who’ve been so pivotal to reaching the community.
MODERATOR: Dr. Gawande, it is after noon. Thank you so much for your time and hopefully we can have you back sometime.
ATUL GAWANDE: Thank you.
This concludes the February 9th press conference.