Earlier this week, Bloomberg columnist Michael R. Strain spoke with Dr. Scott Gottlieb, his colleague at the American Enterprise Institute and a former head of the Food and Drug Administration, about Covid’s variants, vaccination rates and coming risks. In this installment, Gottlieb, who is author of “Uncontrolled Spread: Why Covid-19 Crushed Us and How We Can Defeat the Next Pandemic,” discusses how governments should handle outbreaks this coming winter.
Michael R. Strain: First let’s set the stage. Looking back, how do you assess efforts to slow the spread of the virus?
Scott Gottlieb: I think a lot of the focus has been on the political shortcomings of our response. We have not focused enough on shortcomings in the public health system itself.
The pandemic consisted of two periods. First, the initial outbreak in New York. We were in the fog of war. We didn’t know how to treat Covid-19 and didn't understand its virulence. We overestimated the role of contaminated surfaces, and were cleaning our groceries. We underestimated the role of aerosols and super-spreading events. We didn’t understand how the virus was spreading because we didn’t have diagnostic tests and contact tracing. So we were forced to use population-wide mitigation.
We eventually got some testing in place and began to understand — much more slowly than we should have — how the virus was spreading. This allowed us to target mitigation efforts. States that did this right started to focus on closing large gatherings, bars and large confined spaces. They didn't shut everything. They started to focus on certain activities.
Strain: Should we have closed schools?
Gottlieb: I think we overemphasized the role of children as vectors for community spread and closed schools far too widely for far too long, not recognizing that schools really weren't major sources of community transmission.
Strain: Covid-19 cases are likely to pick up again this winter. Regionalized outbreaks are a real possibility. Given widespread vaccine availability, adults who are vulnerable to infection are in some sense choosing that vulnerability. Should that factor into governments’ responses?
Gottlieb: The fact that people do have the opportunity to protect themselves through vaccination is going to factor into the decisions we make around employing mitigation. This winter, we're not going to adopt measures in anticipation of outbreaks that might occur. We're going to adopt measures in response to outbreaks that do occur.
I think the measures that we adopt are going to be far less intrusive and less costly. I don't think you're likely to see broad business closures. I think if we have school closures, they will happen after there's an outbreak within a local district, just like we do in a bad flu season. We won’t close schools proactively, in anticipation of the virus spreading.
We could see a situation where mask ordinances get put back in place for public transport or public buildings in a city with an unusually dense outbreak.
Strain: Earlier you mentioned that the overall risk of Covid-19 outbreaks will be much lower because the most vulnerable people have been vaccinated. Will that affect the intrusiveness of mitigation efforts?
Gottlieb: Yes. The vaccination rate for nursing home patients or people over the age of 65 is very high. The people who are most at risk from the virus are going to be protected through vaccination with the exception of very young children. There is probably not going to be a vaccine available for them at least until later in the winter, so they're going to still be vulnerable through no fault of any decision their parents have made.
Strain: Other than masks and lighter-touch measures, are there other tools available?
Gottlieb: I think we've seen the full complement of the tools for population-based mitigation and social distancing. I do think that there's going to be more of an opportunity to use testing, tracing and tracking. There was just so much infection that we never had the opportunity to employ those tools.
Asian nations used them with a lot of success. That wasn't necessarily because they had intrusive surveillance states, though that's what many people say. Instead, they never had such high levels of virus that it exhausted their ability to use testing and tracing as a way to try to contain spread.
Strain: We have a lot of testing now. Have states ramped up their ability to do contact tracing?
Gottlieb: States have ramped up their ability to do contact tracing, but success isn’t just a function of state governments having contact tracers. A lot of this is happening in workplaces and schools, and not by state governments. Schools are doing contact tracing. If there's an infection in a class, the class will be quarantined or isolated for a week. If there is an infection that's turned over in a workplace, the workplace will test other people in the environment to make sure no one became asymptomatically infected. A lot of this is just happening organically as a result of very pervasive testing.
Strain: We’ve talked a lot about states and localities. Is there any role for the federal government to respond to the types of outbreaks you think might happen this winter?
Gottlieb: I think any federal policy is likely to be focused on things like masks on public transport. If we have a lot of spread this winter, you could see masks still being required for travel on trains and airplanes.
But, again, I'm not sure that you're going to have the situation where the epidemic is confluent and pervasive enough across the whole country that you're going to see a uniform national policy being sought. It's likely to be much more regionalized.
Strain: How do we prevent the next pandemic?
Gottlieb: Covid-19 revealed systemwide failures that point to the need to develop certain capabilities that we don’t have. We need to have a base of manufacturing capability in the United States for things like biologicals, such as vaccines and antibody-based drugs. We need to have the capability to scale diagnostic manufacturing much more quickly.
Typically, it's been the job of the Centers for Disease Control to develop the test for novel pathogens, but the CDC has failed to do that. And not just with Covid-19. It failed to do it with the Zika infection in a timely fashion.
We now have a history where the systems that we relied on don't work. So we need to rely on entities other than the CDC. We need to lean more heavily on the private sector to develop diagnostics in the setting of an outbreak with a new pathogen.
Public health authorities always anticipated that an epidemic would be regionalized. For example, a city would be attacked with anthrax or smallpox. So we would be able to focus resources on a very defined geographic area. We didn't anticipate a national epidemic that would require us to do this on a national scale.
We need to have a capability to be able to distribute vaccines more effectively.
We need to start looking at public health through the lens of national security and involving our tools of national security in this mission.
Strain: How would national security agencies play a role in stopping the next pandemic?
Gottlieb: Historically, the national security agencies wanted to avoid public health issues. And the public health community didn’t want the clandestine services anywhere near its mission out of concern that everyone with a white coat would be perceived to be a spy.
Covid-19 showed us that the intelligence agencies need to be involved in gathering information about emerging infections around the world. This information is held by soft targets.
If anything, Covid-19 has conditioned nations to be less likely to share information in the future. Most nations have learned is that if you're a host to an outbreak of a novel or dangerous pathogen, the first thing that's going to happen is other countries are going to erect trade and travel restrictions on you. The economic implications of being host to an outbreak have now grown more significant than they were in the past. This is going to make even friendly nations less likely to be forthcoming.
Look what happened when the UK announced that it had the new, more contagious variant of Covid-19 circulating. The first thing the French did was closed the Channel. If even friendly nations are going to behave like that with each other, imagine if we have a nation that isn't so friendly.
Are they going to be so willing to share this information in the future? Probably not. We're going to need to have more ability to gather this, and that's going to require us to lean on intelligence agencies.
Bloomberg
