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(Recap of Rich’s last comment from Episode 209 in order to put this into context)
Richard Helppie
I know your question was a bit rhetorical but I think this was one of the issues that we have. You mentioned the Coronavirus and the pandemic, look, there's no mincing words here that the scientific community took a hit, the CDC took a hit, in things that are coming to the fore now; that the six foot rule was, frankly, just made up, that the lock-down policies were really ill-advised, the closing of schools was ill-advised, we couldn't be candid about the effectiveness of the vaccine and things like natural immunity, and other treatments being swept under the rug. And then more so when people see that the people imposing the policies - Governors Whitmer and Gavin Newsom from California, and the mayor of Denver, among others - people are going to look at this with a jaundiced eye. I just have to think that some of your pursuit of getting this renewal is going to run into a heavy wave of skepticism because of COVID. Speculation on my part, but I tried to put myself in a position of a representative, I'm going to be asking a lot of data questions and I'm going to be saying, show me your work given what we've seen happen over the last several years.
Dr. Deborah Birx
You encapsulated my enormous frustration, which ended me up in the White House. What was very frustrating to me is you can't say you're following the science and the data, you actually have to do the science and you have to get the data. You can't do it on your assumptions and your perceptions. People had a lot of assumptions and perceptions about HIV and there was a lot of misinformation about HIV related to cures, related to treatment, related to vaccines or not vaccines, all of that existed in the HIV field. The way you combat that is you put out all the information and you show your work. I can't emphasize that enough. So if you go to pepfar.gov, you can see all 60,000 sites that we are seeing clients in, you can see their viral load suppression, you can see their test positivity. You can see all of that in real time. Can you do that in the US with our infectious diseases? No. So what I say to America is learn from what we did in PEPFAR; the way you bring communities along and governments along is you use data and you show your work. The six foot rule; that's only one part of the problem. Remember when they were only screening in airports by symptoms? We had a CDC that had planned for a flu pandemic, and dag-gone, they were going to make this COVID fit into that square peg. They just hammered that COVID square peg into that round hole all of January and February and failed the country. The reason we didn't have tests is they believed you could follow this virus through symptoms. But you could see from what was happening around the globe, from the Diamond Princess and others, that this was being spread through people under 50, with mild to asymptomatic infection, spreading to those vulnerable because of medical conditions under 50, and those over 65. Those were the people who were getting hospitalized and dying, but everybody was getting infected. So you could see that and you could see why it was so rapidly transmissible. But today, we traced all of the data back to where we were in 2019.
Richard Helppie
To that point, there were populations that were basically fine. There was never a case to put a mask on a kid, there's never been a case to vaccinate a child, yet these things took on a life of their own. It struck to the credibility...and I don't know if you're in a position or if you have an interest in comedy, I know you were doing some of the briefings. That had to be a very difficult time and that we seemed to have created this environment where we can't say we only know what we know, or we've discovered new data and now we need to update people. I remember having discussions with folks about the effectiveness of the new vaccines and saying, look, we don't know what the long term effects are because we haven't had a long term. We've got to say that because those are the facts, and we need to continue to study it. How did we get it so wrong?
Dr. Deborah Birx
Well, first, we weren't collecting any data so that's the number one piece. I will say that on March of 2020 I created a graph that went all over the White House and got presented on national news that showed here's where the people are, they're going to have asymptomatic and mild disease and here's where the people are by age that are going to have more symptomatic disease and the having deaths, because we were getting data from South Korea and Italy in the midst of their crisis. They were sending me their data so I could see who was hospitalized. I was up against - and I think many of us were up against - institutions that said, oh, but wait, maybe children can be infected. I mean, really, people were saying stuff like that. And I'm like, no, no, they're asymptomatic. I think what you then saw is our actions didn't always match the science and data and that's very clear with the vaccines. The vaccines were created and tested solely to prevent disease and hospitalization and death. If you created a vaccine and studied it to do those things, then the roll out of that vaccine should be based on who is the greatest risk. We should have started with nursing homes, followed by people over 85, followed by people over 80, followed by people over 75, followed by people over 65, followed by people with medical conditions under that age, and then it would have said to the public, this is who is at risk for severe disease. South Korea did that; they rolled out vaccines in that way but secondly, they told their population this vaccine doesn't protect you against infection, so for those who can't mount an immune response they may still be susceptible to severe disease so if you have young children or you are young, test before you go and see your vulnerable grandparents.
Richard Helppie
Look, Sweden did that, Florida did that and Florida's governor was called DeathSantis for that very common sense approach of protecting the vulnerable. The incidence of death in children is basically zero worldwide; it's that rare, and that there was never a case to vaccinate children. All we did was thwart the herd immunity, while this whole thing got politicized and we crushed our economy and caused untold mental health issues.
Dr. Deborah Birx
I mean, let me be very clear about herd immunity. There are some viruses where natural infection does not create herd immunity and this is one of those viruses. Herd immunity is when you get infected and you don't get re-infected. That's what happens with measles, mumps and rubella. If you got them as a child, you didn't get them again; you were protected from that initial infection. You can see from the data that natural infection protection wanes, as well as vaccine protection against infection.
Richard Helppie
But isn't that a function of because of the lock-downs and not dealing with the first wave this just provided time for more variants to be produced? Isn't it true that if you had an infection in a first wave of COVID, you might get one of the variants later on? But there's the theory, by the way - and supported by some fairly esteemed people - that the variant never would have had a chance to create itself absent the fact that our response for this prolonged the pandemic?
Dr. Deborah Birx
No, actually, we have a huge amount of COVID infection today, you're just not seeing it because you're not seeing the data and the hospitalizations; there are waves that move through the population. The natural immunity from this virus is never 100%. So with all viruses, particularly RNA viruses, mutation is predictable. The only way you prevent mutation is by creating herd immunity, and we can't create herd immunity. So this virus will continue to mutate; it will continue to mutate both in countries that did well and are doing well and countries that didn't do well because there will always be that group of individuals. This gets to your question about why don't you just protect the vulnerable? The vulnerable in the United States are within our communities, very few vulnerable family members live in long term care facilities; the majority of the individuals over 85 is about 9 million, only about 10% live in long term care facilities. Most of those individuals live in multi-generational households that often include toddlers, young adults, 40 and 50 somethings and the elderly. So you're absolutely right. If those vulnerable population families now were given adequate testing and the ability to protect the elderly; if we continued...which Ron DeSantis used very critically, monoclonal antibodies - it's not that he didn't decrease the risk to infection in the state - he made monoclonal antibodies available. Now we have no viral specific monoclonal antibodies available, they are all ineffective; we've known that for more than a year, we haven't made any new ones. So if you want to continue to protect the vulnerable, again, you have to stay up with the science and the data. You have to work and have more drugs beyond Paxlovid because there's a lot of vulnerable individuals who can't take Paxlovid. Now there are no monoclonal antibodies and they can't take Paxlovid and we continue to have COVID throughout the population. So in my mind, when you have this - just like we had with HIV - you constantly have to be asking yourself, who am I missing now? Who's unprotected now and what new science am I going to do to protect them? What new data and am I going to collect to protect them? We stopped all of those things. It's like we froze in time in early 2021, and didn't work on a better-than-nature vaccine. I know it's hard. I worked on it for decades with HIV. Making a vaccine that's better-than-nature that protects against infection is going to be difficult. But in this day and age with the technical capacity in the United States it's possible; same way with new monoclonal antibodies and additional antivirals. But if you ask me, what's going to happen within the next four weeks, cases are going to go up across the south, there is a reconstitution of additional vulnerability; when you've lost 1.2 million vulnerable Americans it takes you a while to rebuild that vulnerable population, but it's being rebuilt, they are still vulnerable, because we're not getting testing out to those families. We're not telling families what they can do when there's COVID in their environment; and it's not just COVID, there are families that are vulnerable to flu and RSV.
Richard Helppie
To stay on the COVID and again, the credibility issue that I think is so important to anything we try to do for public health. The vulnerable populations are getting created because as people age their immune systems don't operate as well. So maybe there were elderly people lost in the first wave, as well as we're creating new elderly people; particularly in this country, we are we clearly have a graying of America, there's no question at all about that. I know that obese people, people that had a history of smoking, they were exceptionally impacted. Again, with a background in health data, I know how the records are coded and the way they were coded and compiled. If a person had COVID, I mean, you could have come in from a car wreck or a broken leg - okay, that's a COVID patient. That was a terrible way to capture the data; it should have been on admitting diagnosis, okay, are they presenting at the ER or from their physician because of the symptoms of COVID. But statistically, apparently, people didn't want to have that fact. But try to get information out to people about what are effective measures, we've now got this political divide where we have people in my town that are out in the parks by themselves with a mask on, nobody within 100 yards of them. And we have people that I know that have said they'll never take a vaccine. They're both trying to risk manage, but they're not operating off the same set of data and they don't have a trusted source to go to. That, to me is a tragedy of our time, about how this has become politicized. It's just a horrible thing.
Dr. Deborah Birx
Well, let's talk about access to trusted sources, because obviously, this is something we had to deal with within PEPFAR. In some cases, we actually had to physically build clinics, bring in physicians, community health workers, nurses, and really build a system for that community. In other cases, we were able to strengthen those clinics and outreach, but it all required outreach workers. So let's talk about what's happened in the United States. What I found - remember I was gone with global health for almost 20 years - I came back and traveled to 44 states, rural and urban, it was really important to me to see what was happening in the rural areas. When you say there's no trusted sources, people have been dying at 20% greater rates in the rural areas since 2008 from all conditions, and then people said, oh, they died from COVID because they weren't vaccinated. They died from COVID because they've been dying from heart disease, diabetes, cancer, at 20% higher rates than urban age matched individuals for more than a decade. Why is this true? Because healthcare delivery has silently been marginalized in our rural areas with no one saying or doing anything, anything - outside of Appalachia - nothing. So when I would hear people in Washington in mid 2021, say go to your primary care physician, CVS or Walgreens; I've been in those towns. I wrote the task force in the White House even though I'm not there anymore, and said, excuse me, there's nothing but a gas station, a church and a Dollar store - the Walgreens and CVS is 85, 95 [miles away] their primary physician doesn't exist there, ER is 350 miles away. Have you been to Elko, Nevada, have you seen the fact that they have to drive to either Idaho or Salt Lake City to get care? And that's state of play in the United States.
Richard Helppie
Well, look, we've had critical access hospitals become a political football. We need these facilities. We need federally qualified health centers not just in urban areas, we need to have enabling legislation for more telehealth, that a person that is privately insured can get a telehealth visit and their insurance will cover it. But if they get old enough and go on Medicare, then they can't - in the true form of telehealth visit. So there's a lot of things we can do in terms of reforming our health system. I've spoken a lot and published a lot about what needs to be done to change the finance system and talked with people from all points on the philosophical and political spectrum. We all come down to the same basic conclusion about what we need to do to reform that. Let me ask you this since we're on this topic, if you don't mind - and by the way, any topic you don't want to stray into just throw up the stop flag - but one of the things people don't understand much is that during the COVID crisis, had we kept the financing system in place without special legislation, most of the hospitals in America would have gone bankrupt. Does that tell you how bad the payment system is out of sync with what the public needs?
Dr. Deborah Birx
I just want to pick up with your great question, because these are the kinds of questions that people were asking about the global HIV pandemic. To many, they would talk, and they would see the problem and come to the conclusion that they just weren't going to act. Maybe it was too complicated, maybe it took too much guts. That's why I always come back to when all the leaders around the world were talking about the devastation of HIV around the globe, there was only one country that acted in a comprehensive and funded way, and said, we're going to do something and we're going to hold ourselves accountable - and that was the United States. That was President Bush and our Congress in a bipartisan way. Now, imagine if we said to ourselves, what is happening in the rural areas cannot happen anymore, someone needs to act. It's pretty simple. It's actually why I wrote the book, because there are some policy changes that CMS needs to do, because you're absolutely right; data should drive decision making, we shouldn't allow any physician to code for an infectious disease that hasn't been diagnosed, you can't pretend that - not in the 21st century. So CMS should right now say we're not going to pay for a flu code, an RSV code, an adenovirus, a viral disease code without you defining what it is and putting that information up in an available way so that the all communities in real time know what's circulating in their communities. Because I'm with you, people are smart, they know how to protect their friends and family, and they will if they know what's there; but they don't know what's there because people are making up what's there. You cannot tell the difference between adenovirus, parainfluenza, COVID, flu, or RSV, and I could add more, but that's enough for now. So CMS has to change that aspect overnight. Secondly, HHS has to say 1% of our funding and 15% of our funding needs to go to tribal nations and rural health because they have unique issues. We need to do research around the specific issues in rural health because how you combat diabetes, hypertension, stroke, and cancer is probably different. We didn't know what it was, we can't pretend that we know, so you've got to do the science. You have to invest in that; I'm not talking about more money, I'm talking about allocating the money you have in a way that's going to have a better outcome and a bigger impact. Then you get down to the policies; what you're really talking about is healthcare delivery policies. I can tell you, if we try to utilize the human resource allocation of skills in Africa in the way the United States had done it, we wouldn't be successful. What we had to do is work with governments and now we have to work with states to allow for task shifting; to allow nurses to do what physicians have done in some places, to allow for community health workers to do what nurses have done in some cases, and really provide care in a way where we're tracking outcomes and impact. But we're task shifting to available human resources that can be brought to bear to both prevent and treat disease. I think we have models that we know work in a cost effective way. Now we have to find a state - I think Texas may be one of them - that's willing to say we're willing to try a new model: data driven, measuring outcomes and impact, holding ourselves accountable, utilizing task shifting, creating more efficiency, forcing the federal government to legislate changes. Then finally, the biggest legislative change is take CDC [and] put them in the states because that's where the policy [is] and that's where the people are; they're not in Atlanta - not that Atlanta did miraculously better. I can tell you Georgia as a state didn't do miraculously better, even though they had CDC there because they were at home, they were working from their computers. They weren't out in the states understanding what was going on. Public health requires being in the public, not on a computer. Until we change our institutions to be understanding and aware of what's happening in this country, they're going to continue to put out guidelines that can't be implemented. I think what a lot of your frustration and the states' frustration was [that] an institution put out guidance that was not implementable. It starts with the six weeks, it starts with the closures of schools; there were a lot of us that were on that task force that said to CDC, the schools should not be closed - and we could not change it. So I went out on the road to keep them open. Across the south, every university that opened - except for North Carolina's system - stayed open. But that takes again, doing what you said, testing, providing information, talking with the students; students were willing to isolate if they were infected, they were not willing to quarantine because they had been exposed. That was easy to deal with, you got more tests out there and you said to them, we're not going to quarantine you, we're only going to isolate you. It's a totally different approach, science based. Once students see that you have a science data driven approach they're willing to follow guidelines, but not guidelines that can't be implemented.
Richard Helppie
This is very practical. I can't imagine you're a real popular person in Washington when you say take the CDC, which you served for many years, and disperse it to the states. It would make more sense because a lot of health care and health care outcomes and health care risks are very specific to the locale. I apologize to our listeners, our readers and our viewers; we got a little wonky. So HHS is Health and Human Services and CMS, is the Centers for Medicare and Medicaid - I don't remember what the "S" stands for, I'm so used to using it - but these are all important public policy. Dr. Birx, as we near the conclusion, a brief summation in what's coming up for PEPFAR, what actions need to be taken, and to my ear, it sounded like it really has to come from the president or at least the secretary of state to bring all these agencies together on a really ground level. If a person was concerned about contracting the HIV virus what action should they take or what action should they avoid?
Dr. Deborah Birx
So the great news is, I think Congress will reauthorize PEPFAR, because the structure is important for its success and [if] there isn't that structure; there isn't money without the structure, money without structure doesn't work. Money without data and managing does not work. So PEPFAR has got a structure that manages the program well and it's been highly successful so I think Congress will re-authorize. People today... viruses...HIV is an RNA virus. COVID is an RNA virus; all RNA viruses mutate because they're made out of RNA rather than DNA and they make mistakes, they make mistakes when they replicate. That's why - thank goodness - we are DNA based. But RNA viruses are like that so what's been really good in the HIV field is they've continued to do the science and the data. There are new drugs today that are effective against even a highly resistant HIV because again, it mutates. Also, there are more drugs today that are available to prevent HIV infection so if you are at high risk for HIV infection - which is mostly still within those key populations - availing yourself of the prevention interventions is absolutely key and PREP - Pre-Exposure Prophylaxis - is one of those. There is a long acting injectable that can be utilized, that means you only have to go to the doctor every two months. That's a big difference than taking a pill every day. Same thing for treatment in the US, there are long acting injections so that you don't have to take pills every day. So people continue to innovate in HIV and that's why we are making progress with HIV. That's why the country - just do what you describe - HHS through HERSA and through FDA and CDC and through NIH, continue to innovate, and listen to what was needed and get the science and data and look what we've done. We haven't done that with COVID. We learned that in 40 years from HIV. So I'm just devastated that not only are we not using science and data, but we're not learning from a prior epidemic that we responded to as a country, that we worked together in a bipartisan way, that we brought the agencies together. It's not just about the money but how that money is spent and holding yourself accountable. That's what should be happening with all these other in infectious diseases and what should be happening for pandemic preparedness; it should not be theoretic, it should be based on science and data.
Richard Helppie
Very nice, Dr. Birx, that might be a great summation there. But before we close today, is there anything that we didn't talk about today that we should have spoken about or any closing remarks you've got for our audience?
Dr. Deborah Birx
To everybody out there that's living in a multi-generational household trying to protect their elderly, trying to protect their aunts and uncles that are on chemotherapy, remember, COVID is not going away, it is still deadly to people who can't develop an effective immune response. It's our job to protect them. If the Federal government is not going to give us better vaccines, more monoclonal and more antivirals, then it has to be on us to protect them. These waves come through in limited time periods, you're going to have to educate yourself about whether it's out there. You know how to protect your parents, your grandparents, your aunts and uncles during that short time period. You can do it; we did it in our household. My mother and father - 94 and 96 - have never gotten COVID. My mother is still alive today, has never gotten COVID. There's a way to do it - and my grandchildren are in school.
Richard Helppie
Great. On that note, I want to express a lot of appreciation for your coming on our show today. This has been really thick with great information and insight. I feel like we've only really skimmed the surface. So please, the readers and the viewers and the listeners of The Common Bridge, I know you're at home, hopefully applauding for this recent episode of The Common Bridge. This is your host Rich Helppie, signing off on The Common Bridge.
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