Pandemics, Preparedness, and Markets

DENTZER: Hello and welcome. I’m Susan Dentzer, senior policy fellow for the Duke Margolis Center for Health Policy in Washington, D.C., serving in the role of presider over today’s discussion on “Pandemics, Preparedness, and Markets.”

As we know, we’re truly in the midst of this epochal pandemic and response to COVID-19, and so we’re pleased to be joined today by three distinguished discussants who, given their backgrounds, I think to varying degrees are experiencing a sense of maybe déjà vu all over again as Yogi Berra once said.

Tom Frieden is with us. He’s senior fellow for global health at the Council on Foreign Relations, and also president and CEO of Resolve to Save Lives, an initiative of Vital Strategies. And of course, Tom previously served as director of the Centers for Disease Control and Prevention from 2009 to 2017 dealing with the most recent large Ebola outbreak. Before that, he was commissioner of the New York City Health Department.

We’re also happy to be joined by Jennifer Rosen, M.D., who’s director of epidemiology and surveillance in the New York City Department of Health and Human Health. She oversees and guides surveillance and epidemiologic—excuse me—analyses there, and leads investigations of outbreaks. She’s also an internal medicine physician.

Willem Buiter, who is a visiting professor at the Columbia University School of International and Public Affairs, also an adjunct senior fellow at the Council on Foreign Relations. He previously served as either a chief economist or as an economic adviser to both Citigroup and Goldman Sachs, including through the financial meltdown of 2009.

I want to remind everybody that this conversation today is on the record. We’re going to have a discussion among the panelists first and then we’ll move to open the line for questions from all of you. When we get to that point, I would ask you to make those questions as succinct as possible.

Tom, we’re going to go to you first. We know that the virus now called SARS-CoV-2 and the disease it causes, COVID-19, has spread into 145 countries around the world, killed in the thousands of people. We have more than 8,500 cases in the U.S. across fifty states and D.C., almost two thousand cases in New York City alone, and a case rate in New York that appears to be doubling almost overnight. Would you give us your best update at this point on where the U.S. and the world are with respect to the size and severity of the pandemic?

FRIEDEN: Thank you very much, and thanks to everyone for joining us.

This is an unprecedented pandemic. Just to give you a sense of how unusual it is, it is the first time a new pathogen has been tracked to emerge, infect people in the lungs—a respiratory pathogen—and spread all around the world. It is also the most societally-disruptive infectious-disease event in more than one hundred years, since the great influenza pandemic of 1918-1919. We are all in this together to help flatten the curve and reduce the likelihood that the need for care will exceed the ability of care in our health-care system. As you note, we’re seeing a rapid increase in cases. Already, close to 160 countries and territories are reporting, all U.S. cases.

There are some things that we know about this virus and we’re learning more every day. And one thing I want everyone to understand is there’s still an enormous amount we don’t know. We wish we had less uncertainty about this, and we understand how important that is for individuals in their homes, for businesses, and for the economy. But the fact is this is a new virus. As far as we know, it never spread among people before November of last year. And we’re learning more about it each day. The more we learn, the better we can do to protect people, tamp down the pandemic.

We do know that it spreads person to person. If we compare it to the SARS virus which caused an outbreak in 2003-2004, SARS was more deadly but less infectious than this particular virus. We’re now honing in on how much more infectious this is and how much less deadly this is. This does spread from person to person. We’ve seen examples of about a 10 to 15 percent what’s called household attack rate, which means that not everyone in the same household as one patient who has the disease gets it. On the other hand, in a small series from one of the cruise ships, crew who were sharing a double room, most of them got infected if they were in close quarters—quite literally close quarters—with another.

So when we think about how bad a pathogen is going to be, we look at how infectious it is and how deadly it is. In terms of infectiousness, we know this spreads person to person. There’s also new data out just a couple days ago showing that it survives on contaminated surfaces quite similarly to how the SARS virus survives. That’s important information because it means that the risk that this could spread from a contaminated doorknob or elevator button is there, the risk that this is one of the ways it’s spreading in hospitals is there, and we need to do more to clean carefully. In terms of the deadliness of this, it is important to understand that eight or nine out of ten people who get the infection will have no symptoms, mild symptoms, or moderate symptoms, and that ninety-nine out of a hundred who get it will survive.

We still don’t know some very important things. We don’t know how common spread from people without symptoms or before they get symptoms is. We don’t know whether children who have a somewhat less severe course with this disease, whether they spread the diseases to others and therefore how effective school closures will be. We don’t understand fully how this is spreading in hospitals. We have examples of hospitals that have seen large numbers of patients and not gotten anyone infected, from Singapore for example. However, we’ve seen terrible examples from Italy and Wuhan of thousands of health-care workers getting infected, and we know that in the U.S. now many health-care workers have become infected.

And we don’t have enough information about who is most vulnerable to severe disease. So, for example, we know that the case fatality rate increases with age, but there are also young people who become ill. And we know that people with underlying conditions are more likely to die, but we don’t know the details of which underlying conditions are most deadly.

Flattening the curve is an essential concept here. You’ve probably all seen the graph by now of having a lower peak that’s stretched out over time. What that allows is a reduced risk that intensive-care capacity will be outstripped and there will be the terrible problem of not having enough care for the people who need it most. We recently looked at all of the estimates and have a new insight that we’ve posted today indicating that in a bad scenario there could be a tenfold greater need for intensive-care beds and ventilators than is available.

We’re all in this together, and there are things that everyone can do to make a difference. The trajectory of what happens depends on the actions that we take now. We cannot rely on warmer weather to make this go away. We have no idea whether that will have an impact. There are some coronavirus strains that have a summer peak. In warmer climates the influenza virus continues all year round. But it’s likely that this virus will be around for a long time and we’ll need to develop a new normal.

There are four different areas where we can act. Each of us as individuals can wash our hands, stay home if we’re sick, cover our mouth when we cough or sneeze, and stop shaking hands.

For medically-vulnerable people, self-isolation is very important. As one infectious-disease expert put it, people who are medically vulnerable need to become semi-hermits, staying six feet away from just about everyone.

For the health-care system, the concept of (safer ?) surge is essential to be ready to improve infection prevention and control, to treat large numbers of patients, and to surge up the need for intensive care.

And for society and government, it’s critical to make decisions based on real information, adjust as we have more information to weigh the benefits and the costs carefully.

I will just end with two last thoughts. First, that public health—whether local, state, or federal, or global—needs to be at the table making decisions and at the podium sharing updates. In the U.S. I’m deeply concerned about the absence of the U.S. Centers for Disease Control in some of the essential decisions and communication. This is like fighting with one hand tied behind your back. At the CDC there’s a Center for Immunization and Respiratory Diseases. There are more than seven hundred health professionals who have spent their lives working on this issue. They’re the ones who are most likely to be able to help us figure out what we can do to meet our three core goals of reducing the number of infections, improving health outcomes of those who are infected, and minimizing the societal cost.

Thank you very much.

DENTZER: Great. Thank you very much, Tom. And just a very quick follow up. The uncertainty that you mentioned around so many aspects of the virus, is it precisely why the social-distancing strategies are so important? We’ve heard some experts say everybody should have as the default expectation that they may have the virus and they may be transmitting it as we speak. Would you agree with that assessment?

FRIEDEN: One of the things that we’re continuing to—one of the things that we’re continuing to learn about is how this virus is spreading, and we still don’t have a clear sense of what the greatest risks are and where there may be the greatest challenge and the greatest opportunity to drive down infections. There are societies that have controlled this without the extensive social-distancing measures. However, when it’s spreading rapidly as appears to be happening, for example, in New York City and Seattle now, this kind of social distancing is essential to rapidly drive down the number of infections and reduce the possibility of overwhelming the supply.

But Jennifer may want to comment further on that.

DENTZER: Yes. And Jennifer, let’s go to you. Please sketch for us the situation in New York City as it stands now.

ROSEN: Sure. And thank you for having me here.

In New York City there’s widespread community transmission with over two thousand laboratory-confirmed cases, but we know that reported case counts significantly underestimate the true burden of disease, in large part because outpatient testing has been discouraged and many people have mild illness. There have been over five hundred hospitalizations, of whom over 30 percent have been in the intensive-care unit, and there have been nineteen deaths. But these numbers are rapidly changing.

In terms of New York City Department of Health Guidance, given widespread community transmission, to address your question earlier, we feel that everyone should act as if they’ve been exposed regardless of whether or not they have had contact with a confirmed case. Everyone, even people who are well and have no symptoms, should practice social distancing and stay home, avoiding all unnecessary events. People who are sick with symptoms of COVID should stay home if symptoms are mild and not due to another chronic health condition like asthma or emphysema. But people should call their doctor if symptoms don’t improve after three to four days.

In New York City there is no indication for testing in—for COVID-19 in an outpatient setting, and testing should be reserved for hospitalized people who have severe illness. This is for several reasons. Most importantly, the results won’t change management. There’s no treatment at this time for COVID-19 and the recommendation will still be to stay home. And also, because outpatient testing results in more exposures. In addition, testing reduces supplies that are needed for testing of more severe hospitalized cases, for whom knowing a diagnosis is important because if it’s not COVID-19 there may be a treatment for another etiology.

In New York City, similar to many other parts of the United States, we’ve implemented community-level social distancing. We’ve encouraged teleworking and staggered work hours. We have the country’s largest school system and schools have closed citywide. All unnecessary services have stopped and there’s been a ban of gatherings over fifty people.

Thank you.

DENTZER: Great. Thanks so much.

And, Willem, we’ll go to you now. We, obviously, have seen almost unprecedented turbulence and declines in global financial markets, really unprecedented behavior in the relationships even between stocks and bonds, and obviously an almost-unprecedented effort if not a truly unprecedented effort by the largest industrialized countries to weigh in with really large fiscal stimulus packages and monetary easing as well. Since no one at this point can foresee the future, what—where are we, from your assessment? And what do you think may lie ahead?

BUITER: Well, this is a quite unique shock, right, a severe economic shock that has depressed both demand and supply, and which has financial consequences which, if unattended, will feed back onto the real economy and make things even worse.

Not enough by a long distance has been done to offset, even minimize the damage caused by the coronavirus and by our collective response to it. Most of the economic damage is a result of the social distancing rather than of the virus itself. We’re just beginning to see data in the U.S. now hinting at a contraction in GDP in Q1, same in China, and this is only the tip of the iceberg.

Because this is such a unique sort of demand-and-supply-driven crisis, fiscal and credit policies rather than monetary policy is where the action will have to be. Households lost access to income, corporates lost access to revenues, and we’re either going to watch them go broke or we will support them through credit or grants—grants that will have to be funded by the federal government, the only entity with sufficiently deep pockets.

I mean, seeing some hopeful signs. I mean, the U.S. passed a $8.3 billion bill mainly aimed at providing sort of for the medical infrastructure to deal with the coronavirus. But you know, we need the trillion that is on offer. We need it now to counteract the otherwise inexorable drag-down of the economy not just into recession; into what I would call likely depression. The recovery, when it comes, may be also quite swift, but if the—as seems to be the case—the slowdown is not globally synchronized, even areas that are—well, China now is, sort of having provisionally resolved domestic coronavirus, will be suffering from export demand because their markets have gone seriously on the blink.

So we are looking at the most serious economic slowdown not just since the great financial crisis, but since the Great Depression. This could well be more serious than the great financial crisis. And unless you do more in providing credit and fiscal support, this will certainly be the case.

DENTZER: So a question to both you, Willem, and Tom. Obviously, the U.S. response to the—to COVID-19 was delayed in very important ways, including by obtaining adequate test kits and distributing them appropriately. Obviously, Willem, you’re suggesting that our actions on the economic front have been delayed and potentially causing greater damage as a consequence. How bad is this going to be specifically because of these delayed responses on both the public-health front and the economic front? Tom, let’s go to you first.

FRIEDEN: There’s no doubt that the slow rollout of testing worsened things in places like Seattle and elsewhere because it didn’t allow communities to recognize that the disease was spreading. It’s important to understand that the whole point of social distancing, and in fact the potential benefit of the travel ban, was to get ready as a society. And what we saw in the countries around China and the areas around China that responded very aggressively, they had experience with SARS. They worried it was coming and they were able to scale up rapidly. Right now the major concern that I have and that other public-health experts have is the risk of outstripping health-care capacity. This would be catastrophic. It’s what we’re seeing in Italy now and it’s what we could see in communities around the U.S. soon.

The key is to be situational in the response. It very much depends upon what the situation is locally. That’s why state and local public-health leadership and political leadership is so important to a response. What’s right in New York City today is not what’s right in many other parts of the United States today. For example, as we’ve mentioned, in New York City, where we have widespread transmission we’re afraid, the focus has to be to tamp it down; social distance; stop, identify, and control outbreaks in congregate settings; protect health-care workers in the health-care system. In a community that doesn’t have the availability—doesn’t have the current spread of coronavirus, it’s a question of quickly identifying when it comes in and trying to contain it before it spreads widely.

There’s no question that the United States as a whole didn’t use the time that the travel bans have gotten us as effectively as we could have to be as ready as we need to be. But our focus has to be to move forward—to scale up testing, to be ready to scale up health care, and to effectively implement social distancing. At the same time, we recognize that at some point we’re going to need to come out again, we’re going to need to protect the vulnerable, and we’re going to need that—to do that in a way that allows us to work, to learn, and to live with a new normal unless this virus, which is very unlikely, can be completely eliminated.

DENTZER: And, Willem, to the question about delayed response on the economic front, your view?

BUITER: It’s extremely serious. Many small- and medium-sized businesses have lost all sorts of revenue or most of it, and unless they can get credit—which they cannot get now any longer on commercial terms from banks in many cases—they will go against the wall. And so a public credit guarantee or a publicly-sponsored and -funded program of selective debt forgiveness is an essential part of being able to resuscitate economic activity once the medical conditions permit it. And we are still moving very slowly there on the credit side especially, and even on the—on the tax side. We haven’t seen the bulk of the trillion-dollar tax cut legislated.

So I’m quite dismayed that the only entity that really has done all it can, the Fed, is the entity that can’t do very much because you don’t have a monetary policy problem. It’s not a question that rates were too high at 1 ½ percent. But of course, the problem was that credit was not available and will not be available at any rate, and that’s not an issue that the Fed can address. That is a fiscal issue.

So it is extremely serious because we continue to move too slowly.

DENTZER: And we will make the point that on the health-care side many in the health-care sector have made the same point, that emergency assistance to hospitals to obtain sufficient supplies of various goods and services, personal protective equipment for health-care workers and others, that that response, at least at the federal level, has been sharply delayed as well.

All right. We’re going to go now to open up to questions from all of you. We do have about eight hundred people on this call, so for very important and obvious reasons I would ask all of our questioners to keep their questions as brief as possible. No speeches, please; this is a time for questions.

So, Operator, would you please instruct the audience on how we’ll proceed with a question?

OPERATOR: Yes, ma’am. At this time we will open the floor for questions.

(Gives queuing instructions.)

We’ll take our first question in the queue. Caller, please identify yourself and proceed with your question.

Q: This is Susan Esserman.

My question is, what practical steps are being taken now to mobilize production and distribution of N95 masks, eye protection, and ventilators to hospitals in need, especially in New York City where emergency doctors and nurses are already exposed to great risk, are being infected, and are seriously ill as they have had insufficient personal protective equipment?

DENTZER: Tom, why don’t you start with that? And, Jennifer, if you have something to add, please do. Tom?

FRIEDEN: I don’t have direct involvement in what’s being done on the manufacture or distribution side of this. There is a high likelihood that there will be insufficient respiratory protection and protective equipment. That’s one of the reasons why there’s a strong recommendation that if you have mild illness do not seek care in New York City now; you’ll be using things up that other people need more.

There are some things that can be done in the short term. One of them is to increase the use of reusable respiratory protection, things that are called elastomeric respirators and tappers. These are respirators that can be safely cleaned and reused by the same health-care worker for weeks or months at a time. We hope those will be more widely available. All sorts of prioritized—the best available evidence suggests that a regular surgical mask is sufficient for providing care in most but not all circumstances. Anytime there is any aerosolization—things like intubation of a patient or bronchoscopy or sputum induction, then an N95 or higher level of control is needed.

I don’t know, Jennifer, if you have other things you’d like to say about this.

ROSEN: I don’t have anything to add. Thank you.

DENTZER: OK, great. Let’s go to the next question, Operator.

OPERATOR: Yes, ma’am. We’ll take our next question in queue. Caller, please identify yourself and please proceed with your question.

Q: Hi. This is Patrick Brennan with Booz Allen Hamilton.

This question is directed to Willem. We know that the economy—the workforce is going to change going forward. We are expecting more automation and more of a gig economy. Is this slowdown for service-type jobs going to hasten that change, or are larger companies going to shift to more automated and/or work-at-home workforces?

BUITER: Well, first of all, gig-economy workers are among the most vulnerable ones because they have no right to payment when they’re not working. They aren’t technically even employees; they’re self-employed. So they are among the most vulnerable, and so I would hope would benefit from the cash handouts which are under consideration at the moment in Washington—everything from $750 to a thousand (dollars) to four-and-a-half thousand for the optimists.

I don’t think that this particular crisis biases choice of technique against or in favor of the gig economy in any—in any significant way. I expect that we will continue to see the gradual substitution of automation for labor in a number of cases. Where? You can’t actually substitute capital completely for labor, automate. We might see some gig workers replaced. But until we go to the self-driven car, I think the gig worker, from that perspective, will be safe once the demand comes back. But they are in the frontlines of income loss, earnings loss, and economic vulnerability as long as the weakened economy lasts.

DENTZER: Operator, let’s go to the next question, please.

OPERATOR: We’ll take our next question from Sonya Stokes, School of Medicine at Mount Sinai. Please go ahead.

(Pause.)

And your line is open.

Q: Thank you.

There has been mixed messaging across health systems in New York City with regards to testing for COVID-19. For example, some hospitals are now moving towards opening screening centers throughout the boroughs, and the expectation among patients is that they can and should be tested there. What are the explicit recommendations to hospitals, given these settings? Should they be testing any of these patients in the screening centers? And if not, can there be consistent messaging with regards to this? Thank you.

DENTZER: Jennifer, would you repeat your testing recommendations of earlier just to be clear?

ROSEN: Sure. Thank you.

In New York City we have a clear recommendation that testing should be reserved for people who have severe illness and are hospitalized. Testing should not be done in an outpatient setting.

DENTZER: So the hospitals then that are doing testing of merely the worried well, if you will, or those even with other symptoms should not be doing it at this point, would be the clear recommendation, correct?

ROSEN: Correct.

DENTZER: OK.

FRIEDEN: Let me just add that across the U.S., there are places that are setting up screenings in parking lots and elsewhere. And if they have their own means of getting the tests done—i.e., the commercial laboratories or private laboratories, not the public health laboratories—then that can reduce the burden on the health care system. But it very much depends on where you are and what the capacity is locally, and what the epidemiologic situation is locally. And one thing to clarify is the different means of testing. Fundamentally there are three windows for testing. There’s public health testing, of tests that are now available in every state from the CDC. There is hospital-based testing by some advanced laboratories and some hospitals. And there’s commercial testing by the large commercial laboratories like Quest and LabCorp.

They all have a different role, but all of them are only now in the situation of phasing up to do the testing. And it’s important anytime we do a test in health care to think about what the test is being done for. And where there is not coronavirus spreading in the community yet, testing is done to try to identify it and stop it before it spreads. Where it’s spreading widely, it’s a question of best managing the patients who are affected and trying to tamp down spread. Thank you.

DENTZER: So, Tom, just quickly, for your best advice then for individuals who are not in New York City at this point but elsewhere in the country or the world is, what, with respect to testing?

FRIEDEN: Follow the advice of your local health department, because it will be different in different places.

DENTZER: Great. Thank you.

Operator, let’s go to the next question.

OPERATOR: We’ll take our next question in queue. Caller, please identify yourself, proceed with your question.

Q: Hi. This is Mike Callesen with Senate Foreign Relations Committee.

So in light of some countries offering aid to other countries to deal with this crisis, and other countries that manufacture personal protective equipment restricting the export of that PPE, how would you grade the international response to this? Are we cooperating and working together to the extent that we should? And if not, where are we falling short?

DENTZER: Tom, would you start with that one?

FRIEDEN: I think this is clearly a demonstration that we all have to work together, but it’s also a demonstration that in an emergency countries are likely to be first focused on their domestic constituencies. I think there are a series of lessons here from very technical—for example, it’s not enough to share the genetic sequence. The actual viral culture is also needed for very important studies that need to be done. To very broad, that going forward we have to have a much more knit-together system of countries working together to learn about health threats as they emerge, and how to confront them, and to respond effectively together. There are many different aspects of the challenge here, from supply chain, to epidemiologic information, to the cross-border spread of disease.

From a public health standpoint, we know that there is, for the first time, really good information on preparedness globally from something called the joint external evaluation. A hundred and twelve countries have gone through it. There are close to ten thousand very severe gaps around the world. We know how to close them. We know where they need to be filled. We know what it takes to fill them. We know how much money it will cost. And it’s crucially important that we invest globally, because that will make all of us safer. That’s on the public health standpoint.

On the—from the standpoint of supply chains, that’s a much bigger challenge. And that’s going to shift as we’re dealing with things like test kits, reagents, personal protective equipment now. If there is treatment and if there is an effective vaccine, that will then be needed to be addressed. And this is an area where transnational cooperation is going to be in everyone’s best interests. If we don’t cooperate, there will be a tragedy of the commons here. And Will may want to comment further on this.

DENTZER: And, Will, before we go to you, Tom just quickly, lots of concerns have been raised about the large volume of ingredients in pharmaceutical that come from China and India as well. And do we have a handle on disruptions in supplies of just even commonplace medications that will result at this point?

FRIEDEN: This is definitely a vulnerability. What are called APIs, or active pharmaceutical ingredients, are largely sourced from China. They’re not that complicated to make. However they have been centralized to China really because of the economic benefit of doing so. They’re cheaper. Interestingly, for many products, including most common medications, they’re quite inexpensive. So their variable cost is relatively small. But this is an area where we need to be thinking about redundancy globally because it is a potential vulnerability. As individuals what this means is that if you’re on a medication for a chronic disease, whether that’s hypertension, diabetes, a seizure disorder, or something else, it’s a good idea to have three months’ supply, if you can get it.

DENTZER: Great. Willem, just quickly, do you want to make a comment about sufficient or inadequate cooperation among countries around shoring up the supply chain, particularly around important health care related products?

BUITER: Well, I think it’s been quite shockingly inefficient. China is, in fact, the country that, despite a miserable start to the coronavirus crisis, is now getting all of kudos for, you know, sending medical equipment to places like Italy and other places in Europe. The U.S. has been in absolute America first mode, exhibiting the kind of protectionist behavior in terms of medical supplies it exhibits generally in economic policy. And I’m afraid that if we look at Europe as well, other parts of the world. There is very little active cooperation. This is the time where the whole really is more than the sum of the parts. And we can reduce vulnerabilities greatly inf you cooperate. But there is, unfortunately, little sign of it. It’s been very disappointing. Not surprising, but disappointing.

DENTZER: All right. Operator, let’s go to the next question, please.

OPERATOR: We’ll take our next question in queue. Caller, please identify yourself and proceed with your question.

Q: Hi. Chris Hensman from Arnold Ventures.

I was wondering about post-infection immunity and whether we have any clarity on whether there is a period of immunity post-infection. And then, also, how we might be able to capitalize on that, if we can verify that.

DENTZER: Tom, would you take that one, please?

FRIEDEN: We really don’t know yet. This is an important question. Serological or blood-test studies are just being developed. Even if there are antibodies, we won’t know how protective they are. One of the areas that’s encouraging for evaluation as a treatment is using antibodies. China tried using what’s called convalescent serum of patients who got better. We don’t have information on how that worked out. This is crucially important for vaccine development, but the bottom line, as with so much with this pandemic, is we simply don’t know. And because of that, it’s crucially important that we rapidly get information about what worked, how it’s spreading, and what more we can do.

DENTZER: OK. Let’s go to the next question, please.

OPERATOR: We’ll take our next question in queue. Caller, please identify yourself and proceed with your question.

Q: Hello. This is Mike Meese from AAFMAA.

What indicators should we be looking for to see what’s happening on the curve? Is that the rate of new infections or the rate of old infections where people have recovered? Or what are you looking for as we track the progress of this disease?

DENTZER: Let’s take that in two parts. Tom broadly, and then Jennifer if you want to make comments specific to New York, please do. Tom.

FRIEDEN: The primary thing we would look at is new infections. These are obviously difficult to track in a situation like New York City where we’re not trying to test everybody now. But ultimately what you want to see is fewer and fewer new cases, so that you can then begin going, ideally, back into containment mode, where you’re trying to identify and trace each case. There are certain things that we do throughout the entire response. And an adaptive response means that no matter what—no matter what phase of the outbreak we’re on, everyone who’s ill needs to self-isolate. Everyone who is potentially vulnerable needs to reduce their exposure to others. That we need to make health care safer through infection prevention and control. And that we need to, all of us, no matter what, wash our hands, cover our coughs, stay home if we’re sick, and stop shaking hands for the indefinite future.

We’re still learning about this, but the concept is that the broader social distancing measures, the stay-home advice, may be able to be relaxed if we know that the disease is not spreading widely. So that’ll be reflected by the number of new infections and the number of tests that are being done to give us confidence that we’re finding them. What that means is that as of today every person in the United States who has pneumonia should get tested for this virus. That will help us track where it is. And going forward, we need systems in place to determine where it is in the community. There are systems that can be repurposed from influenza, what’s called ILI surveillance, or influenza like illness surveillance, which tracks hundreds of thousands of patients with illnesses and get them tested for the flu. So those systems need to be repurposed to look at COVID, so we can see whether and where it’s spreading in the community.

DENTZER: Great. Tom, and you’re making the extremely important point that we have to understand both infections that are identified, but against the backdrop of who has been tested. Because, at the moment, we don’t have that very important effective denominator to decide how widespread this is. Let’s go to the next question, please.

OPERATOR: We’ll take our next question in queue. Caller, please identify yourself and proceed with your question.

Q: This is Nick Turse.

The situation in Italy looks increasingly dire. And given the current U.S. response, how likely is it that we can see something similar here? And when would we see it?

DENTZER: Tom?

FRIEDEN: That really depends on how vigorously and promptly we do social distancing. The models suggest that you have about a week from where there is unlinked community transmission to have everyone hunker down and stay home. Stop working, stop interacting socially. And that if you don’t do that, that you get into an explosive transmission phase. There also is likely—a likely component of what are called super-spreading events, where you might have a contaminated elevator button or doorknob. Unpredictable when and where, but there’s also a large number of secondary transmissions. What we’re hoping is that kind of peak that outstrips the health-care system does not come here. If it did, it could come in a question of days to weeks. And the risk would go on for months, until we have a better sense of how to control this, and a better capacity to rapidly identify cases as they arise, and shut down clusters before they become outbreaks, tamp down outbreaks before they become epidemics.

I don’t know if Jennifer wants to say more.

ROSEN: No, I don’t have anything to add. Thank you.

DENTZER: Tom, let me ask you a question. We have obviously some jurisdictions now in the U.S., most particularly San Francisco, having moved beyond social distancing to essentially sheltering in place. And obviously other urban centers around the country are watching the same—or, debating the same approach at this point. What do you think is the likelihood that other large urban centers are going to have to move to shelter in place?

FRIEDEN: We need to learn the minimally effective interventions that will tamp down the increase. In New York City, we’re now basically all staying home. And we see restaurants and bars closed. We see virtually all websites telecommuting. So the difference between that and San Francisco isn’t so very great. The bottom line is that all of us need to stay six feet away from as many people as we can. We need to wash our hands regularly. And for people who are in areas where there is widespread transmission, anyone who’s ill needs to self-isolate immediately, and mildly ill people don’t need to seek care, again, in areas where it’s spreading widely. We need to make sure our health care system is hardened or more flexible and resilient so the health care workers can be protected. And this is something which we will just have to take one day at a time to see what’s the most effective way to protect as many people as possible and reduce the risk that we end up in an Italy, or a Wuhan-type situation.

DENTZER: Great. Thank you.

Operator, let’s go to the next question, please.

OPERATOR: All right. We’ll take our next question in queue. Caller, please identify yourself and proceed with your question.

Q: Hi. My name is Emerita Torres. I’m with the Soufan Center.

You actually answered my question on the shelter in place in New York City, and the pros and cons of that. But I did want to ask another question regarding the economy. And I’ve been hearing a ton of job losses, layoffs, et cetera. I know New York City just passed a sick leave bill that I think will be incredibly important. But I’m just wondering, with college students graduating, what does the job market look like with this—with the failing economy over the next six months to a year, given the fact that we’re already suffering? Thank you.

DENTZER: Willem, would you take that, please?

BUITER: Yes. We are already beginning to see in the U.S. an uptick in unemployment. U.S. jobless claims number was up by seventy thousand. Before we were averaging between two and three thousand five hundred. But that’s simply the tip of the iceberg. I think there will be very few, if any, new hirings until we are beyond the social distancing phase. So the vintage of students that is graduating this spring is going to be faced with a very hard time. And it’s unlikely, I think, to change before the end of the summer.

DENTZER: A grim forecast, but probably the best we can do at this point.

Let’s go to the next question, Operator, please.

OPERATOR: We’ll take our next question in queue. Caller please identify yourself, please, and proceed with your question.

Q: Hello. This is Allen Abel from Maclean’s Magazine.

Asking about the politics of the current situation. What you think are the possibilities and practicalities of holding a presidential and congressional election this year?

DENTZER: I don’t know that any of our callers is an expert on that subject. So I think in the interests of time, we will just stipulate that everything is highly uncertainty.

Let’s move on, Operator, if we could, to the next question.

BUITER: We’ll all vote on Zoom.

OPERATOR: We’ll take our next question in queue. Caller, please identify yourself. Proceed with your question.

Q: Oh, this is Marie—this is Marie Brenner from Vanity Fair.

My first question is to Dr. Frieden. There’s a report this morning that is circulating about the malarial drug, hydrochlorique (sic; hydroxychlorioquine), being effective and being tested in France. What are your thoughts on that?

FRIEDEN: There are many drugs that work—there are many drugs that work in a test tube, but whether they’ll be effective in people remains to be seen. There’s, I think, reason to study medications that may work, but I wouldn’t run out and use them unless we have some evidence. Yesterday we had a discouraging report in the New England Journal of Medicine that two antiviral drugs, which are much more specific than chloroquine, which is malaria drug, didn’t work. They didn’t reduce the death rate in people with severe COVID disease in Wuhan, China. It’s very important that potential therapeutics get rigorously evaluated so that we can know how best to care for patients who have this disease. But outside of clinical trials, we’re seeing some compassionate use of one antiviral medication, remdesivir, that has promise. But we really need answers. We don’t know if they’ll work or not.

Q: And as a follow up, there have been additional reports that babies are now being—they’ve shown that there is a vulnerability in very young—in infants. Do you have any evidence of that?

FRIEDEN: We’re still learning. And what yesterday’s report from the CDC showed is that young people do get some severe illness. We still are seeing less severe illness than there are numbers of patients among children. But we usually see more vulnerability to severe illness in infants under the age of one, for a wide variety of infections. We’re learning more about this each day. And we do know that the risk increases with age. And the number of fatal infections among children has been quite small, even in Wuhan when there were many, many infections. So older is more susceptible, but that doesn’t mean that younger people are immune or can’t get quite ill.

DENTZER: Thank you. Operator, let’s go to the next question, please.

OPERATOR: OK. We’ll go with our next question. Caller, your line is open. Please identify yourself and proceed with your question. Again, your line is open.

FASKIANOS: Let’s move on.

OPERATOR: OK. We’ll take our next question. Caller, please identify yourself and proceed with your question.

Q: Hi. This is Esther Dyson from Wellville.

Like a lot of people, I’m getting all kinds of emails about this thing or that amazing solution. One is the drug Niclosamide. But my question is about oxygen. And if we have enough respirators, do we also have a sufficient supply of oxygen? Or do we need to go back up the supply chain and worry about that as well?

DENTZER: Tom, can you shed any light on that one?

FRIEDEN: Yeah. It’s not just a question of ventilators. It’s not just a question of oxygen. There’s tubing. There are connections that are needed to operate ventilators. Some of this has been looked at carefully in the planning for a response to pandemic influenza. But every aspect of the supply chain to support patients with pneumonia from this virus is needed. We know that that’s the major problem. We know that this virus causes something called acute respiratory distress syndrome, or ARDS. This makes it hard for people to breathe. Supplemental oxygen can be lifesaving. Intubation and placement on a ventilator can be lifesaving.

However, what we know from China is that the duration of stay in intensive care units can be one, two or even three weeks for people who have this severe illness. And that means the number of people who can be helped may be lower than the need. That’s why social distancing is so important. And every aspect of the supply chain needs to be looked at, as does the ability to operate ventilators. We may need additional people to be trained as respiratory therapists, to have nurses and other staff learn to do what respiratory therapists do in managing patients who are being supported with ventilators. So this is a major effort to scale up health services safely.

DENTZER: Let’s go to the next question please, Operator.

OPERATOR: We’ll proceed with our next question. Caller, please identify yourself and go ahead with your question.

Q: I wanted to ask Jennifer. I was interested in her—this is Ethan Bronner from Bloomberg, sorry.

That one shouldn’t do outpatient testing in New York now. My question is: Is that because we don’t have enough tests? Or is it because it’s really not a good idea anyway? My understanding all along had been that we’re lacking tests. That compared to South Korea and other places, tests are actually our biggest failing. But it didn’t sound like that in her answer. Thank you.

DENTZER: Jennifer, will your clarify the basis for that New York City recommendation at this point?

ROSEN: Sure. Currently the recommendation not to test as an outpatient does not have to do with supply. It’s because encouraging people to get tested results in increased exposures. And we want—for that reason, we want people to stay home. And the other big thing is that knowing the results doesn’t change management. We’re telling everybody to stay home. Whether you’re healthy or sick you should be staying home.

DENTZER: And the point at which people become sick enough that they should go to a hospital instead, give people some advice on that score, Jennifer.

ROSEN: Sure. If people who have mild illness—if their symptoms don’t improve after three to four days, they should contact their provider. If their symptoms worsen or people develop shortness of breath and require medical care, before seeking care you should—you know, if you’re—if you’re seeking care by calling 9-1-1, obviously you would notify EMS in advance that you have symptoms of COVID. But EMS knows what precautions to take. If there’s some reason that someone does need outpatient care for some reason during this period of time, it’s important to notify your provider in advance, call them, so that they can practice safe isolation and avoid exposures when you enter the medical facility.

DENTZER: And just to round that out, the primary symptoms that people should be alert to are fever and dry cough, correct?

ROSEN: Sure. Symptoms include fever, cough, shortness of breath, sore throat. These can all be symptoms of COVID-19.

DENTZER: OK. And it’s those that, as you say, if they do not improve after several days, contact your provider as a first step.

ROSEN: Correct.

DENTZER: OK, Operator, let’s go to—I think we’ll probably have time for one more question.

OPERATOR: We’ll take our next question in queue. Caller, please identify yourself and proceed with your question.

Q: This is Tom Smith from Congressman Andy Kim’s office.

Tom already briefly talked about it, but everyone’s talking about supplies, lessons learned from Italy so far is the people and medical professionals are also a limiting factor. So could you go—you talked about cross training. Is there any big things that we need to focus, if this goes on for a couple months, about people and medical professionals that are going to be a limiting factor in addressing this? Thank you.

FRIEDEN: Health care workers are—health care workers are our most precious resource. And we really have to prioritize getting protective equipment so that they can care for patients safely. We also have to prioritize figuring out how this is spreading in hospitals, so that we can cut off those means of spread and protect health care workers and patients better. That’s probably the single most important, most urgent knowledge gap we have right now. If we know how to care safely, then the health care workers can be protected.

We also have a challenge with frequent exposures of health care workers. So if a health-care worker is exposed, if they become sick they immediately have to stop giving care. But there are some circumstances where they may need to give care after exposure, but they’ll have to use at least a surgical mask, and they’ll have to wear gloves, and change those gloves between patients, and be very, very careful in case they’re developing the illness.

I think also understanding how to change patient flow in our health care facilities. What some places do in flu season I to set up a screening clinic in the parking lot, so that you can have more space to safely see people who aren’t severely ill. This is very important. We’re going to have to adjust our health-care system. But to end on a positive note, one thing that I think will come out of this is safer health care facilities, because even before coronavirus tens of thousands of Americans got fatal infections in our health care facilities each year. And I hope that we’ll have safer care going forward. Thank you all very much.

DENTZER: Well, I want to say a very important and sincere word of thanks to our three discussants today—Willem, Tom, and Jennifer—for walking us through an extremely rapidly changing situation, giving us a lot of food for thought, and a lot of concern about the response going forward, but some aspects of hope. So thank you for everybody who joined us on the call today. Obviously, the Council will be doing additional follow up conference calls soon. We’ll look forward to engaging all of you at that point. Thank you very much and have a good day.

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