You’re listening to a press conference from the Harvard T.H. Chan School of Public Health with Howard Koh, the Harvey V. Fineberg Professor of the Practice of Public Health Leadership at the Harvard T.H. Chan School of Public Health and the Harvard Kennedy School and faculty co-chair of the Harvard Advanced Leadership Initiative. This call was recorded at 11:30 a.m. Eastern Time on Wednesday, May 20.
Previous press conferences are linked at the bottom of this transcript.
HOWARD KOH: So just some words of introduction. I know many of you, but I am a physician who’s trained in multiple fields and cared for patients for a number of decades. But as you heard, I’m a former Massachusetts Commissioner of Public Health through 9/11 and anthrax and also had the honor of serving as Assistant Secretary for Health in the last national pandemic challenge in 2009 for H1N1.
And so I’d like to start with a broad perspective of where we are as we approach tragically one hundred thousand deaths in this country from COVID and have more of a system approach to how we got here and what we need to do to recover and build a more resilient system going forward. So, if you look at the figures of one and a half million cases or more in the U.S. and nearing one hundred thousand deaths, that’s close to a third of the numbers worldwide, even though the U.S. makes up only about 4 percent of the global population. We have a fast-moving pandemic that we’ve all witnessed, but it’s come on top of a slower moving pandemic that’s engulfed the country for far too long, having to do with chronic disease, obesity, hypertension, diabetes, tobacco-related illness like chronic obstructive pulmonary disease.
And as we’ve seen COVID accelerate, we have seen also that people with risk factors such as obesity, diabetes, tobacco, hypertension are most at risk for getting ill and dying. I just saw a new study in Lancet that came out yesterday about a thousand patients being tracked in New York City hospitals. And it underscores all those themes if you want to take a look. So, when you look at the pandemic from that broad point of view, many of those underlying factors that are putting people at risk could have been prevented and should have been prevented. But unfortunately, the pandemic has exposed our underfunding of prevention and public health for far too long. I’m a physician who’s seen what happens when prevention is overlooked. Actually, that theme is what got me into broader policy and public health in the first place as a practicing physician. So, we need to keep that in mind as we move forward to address the pandemic and move into a more resilient system going forward.
I should also mention that since I was the city health commissioner through 9/11 and anthrax, just after that there was tremendous national attention to building a better emergency preparedness system for hospitals and public health in the community. I know I joined many health professionals at the time in planning and drills and exercises and tabletops. We always wanted to be prepared for the next challenge, including a pandemic, because the question for pandemics was never if, but when. If you track attention and funding over the last 20 years, the funding goes up and down and we haven’t had the sustained commitment to our preparedness going forward that we should. So, these are all the themes that come into play right now as we watch states move to reopen. So many of them have done tremendous work following the science and putting forward very careful policies and trying to protect their citizens as states reopen.
But what we have lacked, which is very evident now, is an explicit national plan of going forward, a federally coordinated plan for COVID response and recovery. In my view, we need that plan more than ever on a number of fronts. First, testing, we have all heard so much about the need for more testing. And the good news is that testing rates have gone up recently. The US is doing about three hundred and fifty thousand tests a day. And we all agree that that number should go up by orders of magnitude at least three to four times and maybe more as demand keeps rising. But we also need to test smarter as well as testing harder. We have so much evidence that this pandemic is particularly hitting high risk sites like nursing homes, prisons, homeless populations, meatpacking plants. It has an unfortunately tragic impact on communities of color and the racial ethnic disparities that this pandemic has exposed has been very striking and unacceptable. So we need much more attention to widening testing recommendations beyond mostly symptomatic people, especially since we understand that this virus can be transmitted in an asymptomatic fashion.
Another key area is as contact tracing is started around the country, we need to synchronize these efforts. It’s been estimated that the country needs somewhere between one hundred and three hundred thousand contact tracers. That’s very time intensive work. We need to harmonize training and evaluation and see how to build this public health workforce from the ground up. And I’m personally hoping that such contact tracers can be the foundation for a new revitalized public health workforce going forward. We’ve seen local public health being underfunded for way too long and community health workers can add so much right now with respect to diabetes prevention, to tobacco cessation, to opioid prevention and many other themes. All these themes also, by the way, are very important as the fall is coming, because everyone fears a second wave of COVID and seasonal flu will arrive as well, as you all know.
And then thirdly, we need to prepare and be more proactive in how we make available supplies and test kits and equipment and ventilators for the country. Again, if another wave hits us in the future, we’ve seen too often states competing against each other for such valuable supplies and equipment, and nobody wants to see that. All Americans want to see a unified system that’s working on their behalf. And in my view, that’s what a national plan could provide for the American people.
And so as I close and open up to questions, I’m hoping that some of these themes can help you as you continue to cover this very important pandemic. We need to address it. We need to be very careful as states reopen. We have to track trends in the cases and deaths and hospitalizations and supplies. We need to be ready if there is a resurgence in key places around the country. We don’t want to go one step forward and go two steps back. And we need a science-based way of unifying the country for a national effort going forward. What the United States needs is a united plan now more than ever.
MODERATOR: Great. Thank you, Dr. Koh. Looks like we have our first question already.
Q: Thanks for doing the call. Had a bit of a history question for you. Are you familiar at all with some of the history of social distancing? It’s obviously a new term for a lot of us. Is there any historic precedents for some of these lockdown measures? And also, I’m curious about the 6-foot rule. Where did that come from? Has it been used before to try to control the disease? Thank you.
HOWARD KOH: OK. Good questions. Yeah, the social distancing strategies have been fortunately well researched by looking at data from the 1918 pandemic that you all know through history. During that pandemic a century ago, some six hundred seventy five thousand Americans died. So, that was a devastating blow to the country at that time. There were cities like St. Louis that adapted and adopted social distancing early and aggressively. Whereas there are other cities like Philadelphia that adopted those practices a little later.
So a number of years ago, some key researchers studied those outcomes based on the timing of social distancing and showed that implementing those practices early save lives. St. Louis had a much lower mortality rate than Philadelphia back then. So that’s been a very important work. There was just a new study published in Health Affairs last week, because nowadays we can track this by cell phones, which is a pretty amazing tool to have at our disposal. And it again shows that places around the country that decreased their social mobility over last number of months have shown a decreasing burden of disease. So there is science to back that up.
The 6-foot rule comes from observations with respect to pulmonary transmission of this illness, it’s usually through what’s called droplets. And so when somebody is sneezing or coughing or now even speaking loudly, we have come to understand, droplets can be expelled that travel about six feet before falling to the ground. So, that’s where that rule began. Now, I must caution, though, that we are learning more about so-called airborne transmission where the droplets can perhaps last and linger in the air a bit. And some thoughts that maybe the 6-foot rule should be made, or should be revised with more data and examination. But this is where the studies and the research is very, very important. So those are some quick answers to your question.
Q: Thanks. Just real quick. You know, if the 6-foot rule is something kind of new for COVID, you know, this idea of veering off the sidewalk or, you know, kind of inching around people in the grocery stores or have you seen that kind of thing in past diseases?
HOWARD KOH: Well, I’ve seen, you know, we have seasonal flu and we have so many respiratory illnesses, so it’s always a caution to cover your cough and do frequent hand hygiene and have some distance between you and somebody who is clearly coughing and expelling droplets. To my knowledge, this is the first time it’s been so explicit as a 6-foot rule. But the general concept, of course, is used for anytime we have a new pulmonary illness.
Q: Thank you.
MODERATOR: Next question.
Q: Hi. You said that the issue of funding was very, very crucial as a shortcoming of the old system in the face of the epidemic. So, I was wondering what actually the government in the US or Europe or anywhere else could have done if they invested more money into actually enhancing the preparedness of the whole system. In the face of epidemics, they could have had more protection, better protection, equipment disposal, more tests, more tests, at least higher-level tests available. They could expand the network of local health care to provide both the viral and serological tests much faster than we are doing now. They could have invested more money into research on a vaccine against the SARS family of viruses. What exactly could have been done with the money?
HOWARD KOH: OK, great question. So, again, I saw the dramatic rise of emergency preparedness programs in this country through the fall of 2001, when 9/11 and anthrax was the major threat of the time. And so, for example, shortly after that, Congress established programs to fund hospitals, so-called hospital preparedness programs and also fund public health in the community to help with education and outreach and testing and other things. But as I mentioned, over the past 20 years, funding and interest and support of those programs go up and down.
The hospital preparedness program, for example, is now funded at about half of what it was back then. And we need such funding to be absolutely sustained for the future so that we don’t ever go through a pandemic like this again. And then from a broader point of view, you know, we see issues like obesity that are rising steadily in this country and indeed around the world. That’s a slow-moving pandemic. We need much more attention to prevention there. Tobacco, we have made some progress. That’s an area I spent a lot of time on in my career. But we still have over 30 million smokers in the US. And since the risk of chronic lung disease is so high with smoking, that is a risk factor for COVID right now.
And so, I’m really hoping that as we move into the next phase of this pandemic, we can start thinking about addressing these systemic issues. Again, they tend to put minority populations in our country at special risk. And that’s a theme I pay close attention to, if I can say, as a son of immigrants.
Q: To follow up. So basically, you’re saying that the best way to do face pandemics is actually to prevent systemic chronic diseases, which are which make people more vulnerable. That’s correct?
HOWARD KOH: That’s correct. Yeah. This is all – public health is all interconnected. And so, you know, we have a terrible pandemic right now, but it’s been exacerbated by these underlying risk factors that have represented a slower moving pandemic for far too long. And prevention is only several percent of the overall health care dollars spent every year. It’s natural for people to expect that if something happens, there’ll be a system to respond quickly to protect them. But I’m hoping that as we move into the future planning and strategies that we can invest more in a long-term strategy that promotes prevention, preparedness and public health in a much more substantial way.
Q: OK, thank you.
MODERATOR: Next question.
Q: Hi. Thanks so much for doing this. I apologize, I missed a little of your opening remarks, so I apologies if you mentioned this, but I wanted to pick up on what you were just talking about with public health infrastructure. As states, I think all 50 now reopened. How do you view the current state of public health infrastructure as it relates to the need or the need we have for it right now as we will reopen, especially testing, contact tracing, you know, all the things that we say are needed? Where are we nationally? Do we have what we need, in your opinion?
HOWARD KOH: Thank you so much for raising that question. That is absolutely critical. We have a public health infrastructure that is very vulnerable and it’s been cut back substantially over a number of years. I mean, traditionally, we don’t emphasize disease prevention in our country and then local and state health departments vary in terms of their size and funding.
But if I can say as state health commissioner here in Massachusetts, we have 351 cities and towns. I spent a good part of my time driving around, visiting local health departments which had only several employees for a community, and they would do anything from vaccination to restaurant inspections to substance use counseling, those sorts of things. They try to collect data, oftentimes using outdated systems in this era of electronic records and real time surveillance. We have to upgrade those systems right now in the best way possible. And so public health is always asked to do so much and address both expected and then unexpected threats. And I know that every public health professional in the country right now is working overtime to address this pandemic at the local, state, national and global level.
So, this is an area of tremendous passion for me as you can see. In fact, I moved into public health because I just saw as a clinician so much disease that could have been and should have been prevented. If we can now dedicate more of the funding coming from Congress for hospitals, yes, for doctors, yes, but also for a public health infrastructure in the community to build up the workforce, starting with the contact tracers, but going even further and making them permanent community health workers. That would be a great step forward. And then there’s so many other ways that we can make public health stronger so that we don’t ever have to withstand a pandemic like this again.
Q: Can I follow up with just one question about the messaging as it relates to contact tracing? It seems like it’s a very hard thing for people to understand at once that the economies are starting to reopen, albeit gingerly. And at the same time, they might get a call any minute now from somebody from the government who says you have to stay home for two weeks because someone, and we can’t tell you who necessarily, has been infected and was in contact with you. I know that’s how contact tracing works generally, but we’ve never done it on this scale. How do you see that playing out across the country?
HOWARD KOH: That’s a very important question. So, let me just stress that the concept of contact tracing is not new. It’s been used in infectious disease control for decades. There’s a long history, a lot of experience with it in areas like tuberculosis, for example. And then secondly, it’s been shown successful in many places around the world and most recently with COVID in collaboration with using technology in places like Singapore and South Korea. What you’re pointing out is that contact tracers in this day and age have to spend a lot of time and energy gain trust with the people that are trying to reach and then be knowledgeable about supporting them if they have to stay at home.
A lot of people being contacted may be at risk or may be elderly, for example. So, the trust issues are very important. It’s time intensive. It’s resource intensive. It’s not easy, but it’s just lifesaving work and prevention at its very best. So, we’re just starting with contact tracing around the country. And as I mentioned, it’s a patchwork of efforts. And this is where the federal efforts to have a national plan to coordinate this, evaluate this, train people, and then make it part of sustaining community health worker workforce going forward will be absolutely critical to revitalize public health.
Q: Thank you.
HOWARD KOH: Thank you.
MODERATOR: Next question.
Q: Good morning and thank you for taking my question. Given the risk profile that you highlighted in your opening remarks, are you at least somewhat heartened by the recent news that seems to indicate that states are getting to be more proactive with testing programs and expanding testing availability?
HOWARD KOH: Yeah, none of this is easy. And of course, this is a unique and unprecedented challenge for anybody in government. So, it is encouraging that the testing numbers are going up. The positivity rates nationally started around 20 percent. And that’s an indicator we track worldwide, because if that number is much lower, it means that we’re casting the net wide enough to reach enough people for tests.
In the US now, that that positivity rate has dropped under 10 percent in the last two weeks. We all look at places, though, like South Korea, where their positivity rate has been about 2 percent from the beginning almost, because they had very aggressive testing and very aggressive public health strategies from the outset. That’s an example of a society that has embraced testing issues, contact tracing, public health measures. And they’ve gone through a lot because they had MERS, another coronavirus, in 2015 and obviously have put a lot of time and energy into making those commitments last. So those are some of the themes we’re tracking here as the states reopen. We are making progress, but we still have a ways to go.
MODERATOR: Next question.
Q: Hi. Thanks for participating in this. As states are starting to re-open, there are obviously questions about what should happen with churches and in places of worship that have had to close. Can you talk about what considerations state and local leaders can should be making about whether to allow these to reopen? Is it just too dangerous for right now? What kind of precautions should be taken? And I know we’ve already seen some examples where some churches have reopened, but then had to closed down already because they’re seeing new cases. So, I mean, how can we prevent that from happening?
HOWARD KOH: Great question. So, we are looking to the CDC to advise with very detailed guidance on houses of worship, schools, restaurants, daycare, and you all probably know that over the last several weeks, those checklists and decision trees and more detailed guidance has finally started to come forward. I’ll have to double check and see if houses of worship have been directly addressed as of today. I know that preliminarily they were, but then they were held back.
So, ultimately, we need obviously to advise any part of society where people are gathering in groups. I’m sure that when that guidance comes forward, it will have some of the same themes that we’re getting familiar with. Perhaps they should have services in a staggered fashion during the day to decrease the numbers being in the building at any given time, that when they’re in the services they be at least six feet apart, that they’d be careful about touching common objects like songbooks and other objects in a service. Obviously, wearing masks is very important and there are there may be other themes as well. We know how important spirituality is to people and we know how important that is to get people through a very difficult time like this. So, we want houses of worship to open, but open carefully so that people can restore that part of their lives as a part of healing and recovery.
Q: Thank you.
MODERATOR: Dr. Koh, I’m going to follow up on that with a question that I got I think a day or so ago. And if you don’t know, that’s fine. The question that was presented to me was why are certain things being opened up and other things are not. So, for example, why are hair salons opening up but not retail stores? And why are restaurants opening up but not gyms? Do you have any insight into that?
HOWARD KOH: Well, the general principles are that places where you can have relatively few people in a gathering place at one time have been places where the risks are lower. But you’re absolutely right. There are no national standards or even suggestions about how to sequence this reopening. So, every state is doing it in their own way. So, we see one state opening one sector. We see another state opening another sector.
So, this is yet another area if there were some broad guidelines put forth in a federally coordinated way, it would make Americans think that the unified system is working on their behalf. So, we can drill down on this in any way you want. But right now, each state is doing it in their own way.
Now, you could also counter by saying the impact on the various states differ dramatically. Now, we all know that the Tri-State area of New York, New Jersey and even Connecticut have been the epicenter. But those are places where diseases and deaths are now going down, while collectively the rest of the country, we still have substantial burden that we’ve got to deal with. So, the reopening has to be dealt with very carefully and tracking numbers and metrics and indicators so that we can assure people that this is a safe and healthy process.
MODERATOR: Thank you. Next question.
Q: What’s the latest you’ve heard or seen regarding seasonality? My understanding there’s a hope that it will suppress transmission because of the physics of the droplets, but it’s certainly not something we can bank on. What of the experiences of Boston versus, say, Florida suggests about seasonality, if anything? And what should people know heading in the summer, especially as they get antsy to do social type things that we associate with summer? Thanks.
HOWARD KOH: Thank you. Everybody asks about that. We’re very fortunate at our school to have really outstanding researchers and modelers who have looked at that question, my colleague, Dr. Marc Lipsitch. We probably all know by now has studied that with his team and they study what’s called communicable disease dynamics. So, they have done the modeling that is the foundation for a lot of the scientific recommendations right now.
Their projections indicate some concern about a possible second wave coming this fall. And so, we all need to heed that very carefully. If a second wave of COVID comes this fall along with seasonal flu, it could really complicate the public health landscape even more. As I recall, they thought that perhaps the warm weather might have a minor contribution to lowering transmission over the next number of months, but not a major factor. I’ll double check that. But I think the major concern is a second wave for the fall. So that’s what we’re concentrating on now. And that’s why a national plan now to be much more proactive about all this is critically important.
Q: Thank you.
MODERATOR: Question about something you mentioned earlier with tobacco use. And I believe you may have been looking into vaping a little bit. Is there anything you can tell us about vaping and COVID and if there’s any increased relationship between vaping use and COVID?
HOWARD KOH: OK. The W.H.O. reviewed a lot of this literature recently on tobacco and vaping and recommended strongly that those practices needed to be minimized or avoided, especially in times like now as a COVID risk. I mean, just think about it. This is primarily a pulmonary illness, starts as a pulmonary illness. And we know that both cigarettes and vaping are agents that cause toxicity to the lung and then tobacco dependence alone is a condition that not only drives up chronic obstructive pulmonary disease, but is projected to cause a billion deaths in the 21st century. That’s a factoid that people don’t know, but this is the leading cause of preventable death in the world. So, we need to keep those themes in mind as COVID progresses. If we need more attention to prevention and public health going forward, we have to start with issues like tobacco, vaping, as well as obesity, diabetes and hypertension.
MODERATOR: Thank you. And I had another quick question. So, what is the more volume vulnerable populations that’s been affected by this pandemic has been the homeless population. And I understand there’s been some pretty large outbreaks within the eastern Massachusetts, Boston area homeless population. How has the public health concerns around the homeless population addressed these outbreaks? And do you see areas that for improvement in that area?
HOWARD KOH: Great questions. So actually, we have a new initiative at our school that started last October on health and homelessness. Actually, I chair that initiative at the Harvard Chan School of Public Health. And we need more research and public health attention to the health of the homeless, because in a world where we need health equity, these are people who have tremendous risk factors for disease and death. So, when COVID started, my colleagues on the front lines here in Massachusetts and around the world knew that homeless populations were at incredibly high risk.
If someone’s giving an order to or recommendation to stay at home and you don’t have a home, that is just an enormous challenge for you in terms of protecting yourself. People who are homeless may not have access to sanitation or use of a private bathroom, those sorts of themes. They are often living in very crowded conditions where they can’t stay six feet apart. So here in Boston and I know in a number of other sites, there have been tremendous efforts to protect them, to test them extensively. Here in Boston, actually, a site was set up for housing and caring for homeless people who tested positive, while our mayor, Boston Mayor Marty Walsh, actually has been a leader on that. And so, one of the outcomes of that is the initial results of pretty extensive testing of homeless populations here in Boston and elsewhere show very high positivity rates approaching about 40 percent.
And so, when that happens, we have a public health community here that isolated such patients and cared for them and tried to protect those who aren’t infected. So for right now, that has been quite an effort. But we need to continue to be very careful, not only for such populations, but also in prisons and for long-term care facilities and other places that I cited in my opening remarks.
MODERATOR: Thank you. I have another question while we’re waiting for anybody else to chime in. And this one may be way out of your area of expertise, but some of the areas of the world that have been dealing with pandemics the most have been African countries. And is there anything that we could learn from other governments in other parts of the world, such as African countries have been dealing with endemic pandemics, such as Ebola, and how they have been using very little resources to control these pandemics?
HOWARD KOH: What a great question. So, of course, Ebola came from West Africa and the public health practices that were employed there were really pretty astonishing. And we all witnessed that when that pandemic started in 2014. With COVID, there hasn’t been as much information coming out of Africa, although a number of those countries have been infected. We have watched carefully areas like South Korea that I’ve already mentioned, Germany, New Zealand, Iceland that has dramatically high per capita testing rates. And so, we have learned from them. I think I mentioned that in Singapore, the contact tracing experience, using technology and apps, is one that we are looking at carefully to see if we can apply those in the United States. We all witnessed that initial terrible chapter of COVID deaths in Italy, but that’s now starting to move in the right direction.
So, taking a global look at all times, learning from those who have had to go through this before us is key. You know, China has reopened up, although they’ve had a recent outbreak in Wuhan, where they’re testing all 11 million people again. So, we’re watching that closely. So, this is a time when global cooperation and teaching and learning is absolutely critical.
MODERATOR: Thank you and I have one last question for you. In your roles at both a federal and state levels, what were the major hurdles that you encountered to increasing support for public health?
HOWARD KOH: Oh, what a great question. So, every emergency is different and it has unique challenges. And by the way, I just respect anybody who serves in government during a time of crisis like this. It’s just all-consuming and very, very difficult. Through 9/11 and anthrax, you know, we had thousands of samples of white powder circulating around the state and country. Our state lab was flooded with these and our public health laboratory professionals were testing them for anthrax. We had to do tremendous communication every day to tell people how many samples we received, how many were tested, how many were positive. We were very fortunate that the end of all that in 2001, we had no positive anthrax in Massachusetts, although five people died around the country during that time.
So that experience taught me how important it was to have public daily communication from a top public health official, which in that case was me as the commissioner, and show people that a system was working on their behalf. In 2009 through H1N1, that was, again, very, very challenging and different. When I started, the day I started as assistant secretary, we all knew that that fall, several months later, H1N1 would come. We were fortunate then that a new vaccine was in the system and we got it up and out and distributed to millions of Americans in the fall of 2009. We had two simultaneous flu vaccination campaigns that ensued then – H1N1 flu vaccination and seasonal flu vaccination. So, you can imagine the coordination and communication that was needed.
What I look back on with great pride then, however, was that we had we had a one government approach where federal, state and local health officials were all working together, communicating together. There was a daily briefing led by scientists. And I think as difficult as that was, that’s what we need more of going forward in this pandemic. We have had not had the benefit of enough unified, high level scientific communication to just explain to the American people what we have now and what we could face going forward.
MODERATOR: OK. Thank you, Dr. Koh. Do you have other any final comments?
HOWARD KOH: No, I appreciate the breadth of these questions. I think taking a broader approach to all this, especially as we go into reopening and hopefully recovery, the more we commit to a systems approach to strengthening prevention and preparedness and public health going forward, the better off we’re going to be. We have to commit to never letting this happen again. And we can do it. We are starting to make some progress, but we have to be very careful, be very cautious, be science-based and have a coordinated national effort, a coordinated global effort going forward. That’s what I hope that we can all achieve together.
This concludes the May 20 press conference.
Michael Mina, assistant professor of epidemiology (May 18, 2020)
Michael Mina, assistant professor of epidemiology (May 15, 2020)