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Challenges From the Pandemic

A conversation with Hal Andrews, President, and Chief Executive Officer, Trilliant Health and Vinay Prasad, M.D., MPH, Professor of Epidemiology and Biostatistics, University of California San Francisco

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Hal Andrews: Good morning, I'm pleased to welcome Dr. Vinay Prasad from the University of California, San Francisco. Dr. Prasad, welcome to Nashville and welcome to THE Summit.

Vinay Prasad, M.D., MPH: It's good to be here. Thanks for having me.

Hal Andrews: Thanks for coming. You and I were talking earlier about your role over the past couple of years in the context of the pandemic, starting to question some of the advice that was coming from the government and from medical leadership. The first thing I think about is as a leader, it's hard to be lonely.

There are a lot of times where it's lonely to be the person who is taking a stand. I've watched you, from probably two years ago, be the one of the first voices to question what was happening. Tell me what it's been like to be in that position of being lonely and taking a lot of pushback from people who didn't like what you were saying.

Vinay Prasad, M.D., MPH: Well, thanks for that. To your first point, I think it is naturally the case that when you're dealing with something unprecedented, and the response is also unprecedented, that smart, thoughtful, reasonable, scientists will just disagree. There's going to be a range of opinions. I think one of the challenges we've had throughout the pandemic was that many people would have you believe that there’s very little disagreement or that everyone thinks one way.

That kind of feeds into the second part of your question, which is, what is it like to be lonely? The truth is, I don't find myself that lonely, because I know many experts behind the scenes, people who work at FDA or CDC, people who are professors at different universities that call me, email me, talk to me and tell me that they largely agree with my worldview. What's my worldview? My worldview is you have to be very careful with unprecedented disruptions. You have to find a way, if you do something, to test it in the short term. You need to know that you're not making mistakes in domains you might not even imagine, unintended consequences, which we have always had to deal with in healthcare but have been amplified by this. The truth is that most scientists are pretty close to where I find myself and Marty Makary, and many others, in that we got to do something, but it should be proportionate, and it should be sensible, and it should also take into account that health is more than COVID-19, it's all of these other things we’re going to talk about from cancer to heart disease to going to see your doctor for a routine checkup.

Many of those things have been neglected over the last couple of years.

Hal Andrews: Let's talk about the unprecedented part, because Dr. Henderson, who's credited with eradicating smallpox from the globe, co-authored a paper in 2006 about how to respond to a pandemic. It seemed that, until the first or second day of March in 2020, it was accepted wisdom that there were certain ways to deal with a pandemic - and other things that you just didn't do. Over the past two years, we've done almost everything that he said not to do. How do you think we got to a place where we just go back on decades of wisdom, and throw it out the window?

Vinay Prasad, M.D., MPH: That's a great question. This is a pandemic guidance document that the late great D.A. Henderson, one of the men who eradicated smallpox, put forth. One of the things that document says is you need to only close schools as a last resort, you need to be very cautious with lock downs, because you don't know what the spillover effects will be on a society. Very quickly by the third week of March, we walked away from that wisdom, as you put it, and moved towards the strategy that we embraced for most of 2020. Why did we do it?

That's a good question. I think it was a confluence of factors. One, there was a report from Imperial College London, that had a forecast of deaths that, thankfully, never materialized. It was a worst-case forecast, and it scared people. I think that model was inaccurate. That fueled this sort of panic in the moment.

The next thing that happened was that some of the people who made these decisions were very comfortable making broad sweeping societal decisions without having a discussion, without even fostering a dialogue. It would later be revealed that many of them tried to quelch debate in the moment. The last piece of it is that technology enabled this response. I think had the exact same thing happened in 1998 or 2008, we wouldn't have had this response because we didn't have these technology tools, like Uber Eats and Amazon Prime and Netflix, that allow people to stay at home and allow a company to profit greatly from you staying at home. If you did this in 1997, we would have to work or we would lay off many, many upper-middle-class people. That would be unthinkable, and so there would be some balance struck between maybe we go to work: you go Monday, Tuesday; I go Wednesday, Thursday. We stagger our days. Maybe we keep some distance, and we take some precautions, but we wouldn't have had our particular response, which  I think was enabled by technology companies, and it is an ignorance of history.

Hal Andrews: About fear and trust - you mentioned the Imperial College report. There was another one out of the University of Washington, that was a similar model. For me, I remember the images of the hospital in Queens on CNN on what seemed to be an endless loop. I know a little bit about the hospital business and about those hospitals in particular and the population they serve. I remember that we gave battlefield promotions to a lot of medical students and put them on the wards. I remember one afternoon on the President's daily briefing, Dr. Birx came out and said, “Hey, and oh, by the way to my clinicians,” I'm paraphrasing a bit, but “we need you to do the respirators while the patients are prone." It hit me that we're not treating these patients the right way. For me, those images are stuck in my mind. How do we get the American people to overcome those images that were played endlessly for months, to return, get over their fear, to come back to the health system and take care of themselves the way that they should and the way that we need to as a society?

Vinay Prasad, M.D., MPH: That's a great question. What is the lingering impact of living in a constant state of panic for a year or two years or for some people going on into the third year? I think you're right. There have been many instances where the virus did lead to something like a healthcare system collapse, because it infected a lot of people all at once. They were often very, very elderly, and they came into places that had a scarcity of ventilators. You're also right, that some of the tactics we use to treat people in those moments were unconventional tactics. People gave a lot of drugs we don't normally give, and they tried a lot of ventilatory strategies that we wouldn't have normally done even three or four months prior to that.

How do we get people back? One thing that reassures me is, when you travel around this country, you go to airports, bars, restaurants, cafes, even hospitals, I think 97% of people are back to where we were in 2019.

Your audience, the hospital executive class, people who work in hospitals, and maybe some of the academic medical centers... a few cities, they tend to be coastal cities, I think they're the ones that are the hardest to bring back. Now, why is that? Maybe because a lot of these people have seen it with their own eyes on the frontline. Some of these people are stuck in that sort of defensive medicine mode of trying to protect liability.

One example we've been writing about recently, do I think it's still necessary for people to wear a mask in the hospital gift shop? I think it's a small example, but it's an example where that doesn’t make much sense to me. You can walk out here and go to this restaurant and this bar. What sense does it make to have this policy in hospital gift shops? I think that we're almost there to getting that last 3%, but it's going to be tough. Some people have been shaken by this pandemic. There have always been some people who are particularly fearful, especially of germs.

To some degree, this feels like a grand vindication of their view, so I think you have to bring them back slowly, gently. Some of the hospital policies should nudge them in this way. We want hospitals to be able to function as superbly as they did pre-pandemic. We want people to feel comfortable that if they have health concerns, they can go to the hospital. I think that's what we want.

Hal Andrews: Masks are another good example. We talked about Dr. Henderson. Raina MacIntyre had written about masks. It seems she devoted most of her life to studying masks when no one was paying attention. You talk a lot in your podcasts and in your writings about the importance of a randomized clinical trial. Dr. MacIntyre was really the only person who had done any randomized clinical trials on masks. Talk about what we need going forward, whether it's the vaccine or new therapeutics or diagnostics or screening. Talk a little bit about the importance of a randomized clinical trial as compared to a lot of the papers that have just been published over the past couple of years.

Vinay Prasad, M.D., MPH: The mask question and the reason it became so fiercely debated is we all remember within a short period of time, eight weeks, the recommendation did a total one-eighty. We can't deny the fact that all the experts went out there and said, “Don't do it, don't put it on your face, we know it doesn't work.” All the pre-existing literature said it doesn’t work. Eight weeks later, they come back and say, “Do it, you got to do it. You're crazy for not doing it.” The moment you do something like that, a huge reversal in a short period of time, it's natural that people are going to question; it's going to become a divisive issue.

Now, why did it happen? When they initially made the recommendation, that was the recommendation based on the best science - not to do it. That was what MacIntyre and many others had done. She had done some, at least one, randomized control trial and people have done meta-analyses. When they came back later, they were under a lot of pressure. They're under the pressure of people were now in their house, people wanted to do something and they felt like this was perhaps something they could offer. Honestly, they didn't have very good evidence.

Now, I wasn't against that, because I think it's okay sometimes to do things without evidence, but only as long as they are time-limited and as long as you try to collect evidence. What does good evidence mean? The moment you have something like masking, it's going to be - and it quickly became – politicized, and it varied based on so many other factors. It's very difficult to go back and look and say, places that mask versus places that don't, how do they fare? There are other differences between places that masked and places that didn't. The way to sort out the other differences from the thing you care about, is to randomly assign people to a therapy. You take 100 people, 1,000 people, 10,000 people, and you say: half of you, we're going to ask you to do whatever drug, pill, device,or comply with the behavioral intervention, wear a mask. The other half, you say, we're going to ask you not to do it, or we're not going to tell you about it. Then, you follow them to see how they fare.

The beauty of randomization is it balances all the things you know about that might be a variable, but it also balances all the things you don't know about. You're not even thinking about - or what we call known and unknown confounders. Randomization is probably the greatest tool in medicine in the 20th century, it's led to so many excellent studies that sort out the signal from the noise. We didn't do those studies here. That, to me the combination of absolute certainty, making a huge reversal in your policy, and not doing any studies to sort it out, that combination is naturally going to sow distrust and make people a little bit wary. I think it was a mistake to have that combination. Now, randomization I think is useful for many things: it's useful for a behavioral intervention, it's useful for the drugs and devices that we deal with in medicine, and we probably need much more of it rather than less of it.

Hal Andrews: Great. Thank you for joining us today.