Harvey Fineberg Reviews the US Pandemic Response

; Harvey V. Fineberg, MD, PhD


June 17, 2020

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This transcript has been edited for clarity.

George D. Lundberg, MD: Hello and welcome. I'm Dr George Lundberg and this is At Large at Medscape.

Today we have the special honor of having Dr Harvey Fineberg with us by Zoom interview, with me in Los Gatos, California, and he in Palo Alto, California. Dr Fineberg is the president of the Gordon and Betty Moore Foundation in Palo Alto.

We're going to be talking about — what else — the COVID pandemic: where are we, what's going on, and where are we going? Dr Fineberg, thank you so much for being with us today.

Harvey V. Fineberg, MD, PhD: It's my pleasure, indeed, to see you and to have a chance to discuss this really important topic.

Lundberg: Harvey and I go way back. We met when he was the dean of the School of Public Health at Harvard in the 1980s, and I had the privilege of being on his faculty for part of that time. After 13 years in that position, he went to the provost position at Harvard University for 4 years. After that, he held two consecutive 6-year terms as president of the Institute of Medicine, bringing it into its current position as the National Academy of Medicine. Since 2014, he's been in Palo Alto. That's his background — a truly distinguished career.

Harvey, I have to tell you that the editorial that you put in The New England Journal of Medicine on April 1 of this year, "Ten Weeks to Crush the Curve," was one of the best editorials I ever read. It's really, really well done.

We're looking back at that today and we're 8 weeks in. You had six points in that editorial, and I'd like us to go through those ad seriatim. You tell us what we were thinking at the time, how it's worked out, and where we might go from there, point by point. Is that okay?

Fineberg: Sounds good to me, George.

Lundberg: We start with the first one, which said, "establish unified command." Sounds important to me. What happened?

Fineberg: The essence of any strategy, when you begin a war or any campaign, is to have a unified command structure. That means someone who's got the responsibility, scope of authority, the knowledge, and the skills to carry out oversight and management of the entire enterprise.

We did not get that. We do not have it. We recently had the appointment of a chief advisor on the so-called Warp Speed Vaccine Development Program. But you know, George, President Lincoln did not appoint Grant, his chief advisor on the Civil War. General Grant was the commander-in-chief of the Union Army.

We need the analogy. We needed it in April. We need it today. We need someone with the authority, responsibility, and ability to carry out the array of activities needed to successfully manage the COVID pandemic.

Lundberg: Well, I certainly couldn't agree more. Looking at the numbers, on that day, April 1, the United States had 5000 fatalities from COVID. Of course, everybody knows we're now over 100,000.

I would say that there was more than one place in the world where this central command happened. How about New Zealand?

Fineberg: Well, New Zealand had a very different approach to this, taking it seriously from the beginning, mobilizing from the beginning, perhaps also having a bit of luck as an isolated place that not as many people naturally congregate from all over the world. Nevertheless, New Zealand is a great example thus far of a success.

You could point to Taiwan as another case where the national organization was focused, organized, and implemented successfully. There are a number of such examples, George, that we could point to, learn from, and adapt to the needs in the US.

Lundberg: Coming a little closer to home, actually, there wasn't a central command, but in some ways there was. Dr Sara Cody, our health officer here in Santa Clara County, took control. She didn't have the kind of resources the federal government would have, but she took control. We're down in the teens in terms of daily new cases here. We didn't crush the curve, but it's pretty close at this point.

Fineberg: Our local health officers in the Bay Area and Dr Cody, chief among them, deserve all the credit for seizing the moment in March when they anticipated what was coming and acted to help hold down the spread of infection here in the Bay Area. There's no doubt in my mind that thousands of lives have been saved because of that early action in California.

Lundberg: I completely agree. That's Northern California. Southern California is a whole different game, but we'll talk about that one later, if at all.

Your number two was, "millions of diagnostic tests." Yeah, that's a great idea. How'd that go?

Fineberg: We were late to the game. We had some real missteps early on with the first tests that were introduced by the Centers for Disease Control and Prevention and subsequently withdrawn. We were operating under an outmoded and inapt model of testing, mainly at State Departments of Health—not looking at all the purposes of testing, having tests available for clinical discrimination of those with and without disease at a given moment of time, those who had already had the disease, understanding surveillance needs in the community.

Testing has been a sore point in the execution of our response to the pandemic in the United States. Even today, we really don't have the complete strategy in place that would provide adequate testing to meet every important purpose in the COVID-19 pandemic.

Lundberg: Well, we have to move on because there are many other points here. Number three, "protection of healthcare workers," which is a big deal.

Fineberg: It is, it was, and it will be a big deal. I do think this is an area where we are finally getting to be better positioned. I am confident that as we get into the later months of this summer and into the fall, that there will be built up sufficient reserves of personal protective equipment to provide the kind of protection every doctor, every nurse, and every worker in a hospital setting deserves.

But keep in mind, George, that protection also should be applying to our first responders. It should also be applying to those who have frequent interaction with the public. The adequate numbers of appropriate types of protective equipment, again, in the right place at the right time.

This is still something that we have to work on to achieve. But here, I would say that we're on a pretty good path.

Lundberg: We've made good progress there. Where we were out of control was in those places like New York City and the Bronx and Queens, where it was a flood of patients, and they just didn't have the equipment. Many healthcare workers, as we both know, got infected and a fair number have died, but they are heroic.

This is a new infection and we really didn't know anything at all about it. We have to cut ourselves a little slack on that one. We've done a lot of things well, considering how new it was, although we did have 6 weeks at the front where we didn't get much done.

You had five population groups, and we've been able to delineate those better in these 8 weeks and learn more about how maybe half the people who are shedding the virus are asymptomatic or have very few symptoms, which makes this a particularly difficult problem.

Fineberg: You're absolutely right. Dividing the population or at least ascertaining which of us is infected currently, exposed to someone who is infected, previously infected and getting over it or having gotten over it, for example.

These are still challenging requirements because they're not static. It's not as if you do it once and you're done. It's about a dynamic understanding of the movement of this virus in the population. The point you made, George, about the potential for transmission from the asymptomatic or presymptomatic infected person is one of the most insidious features of this particular virus and one of the things that makes it so hard to control.

Lundberg: One point that you made in point four is the immune part.

We've been assuming that immunity may be produced by infection. We're hoping that immunity can be produced by a vaccine if and when we get a good one. But frankly, we don't have any way to know either of those answers because the virus hasn't been around long enough to know if immunity would be present and for how long and how strong. That's unknowable. It's just been too short a time.

Fineberg: You're certainly right again, George, because if you think of it today, maybe 6 months have passed since the very first cases in China. If you want to know whether immunity will last for a year, there's no way to know at this point in time.

This remains one of the critical unknowns, and as you point out, it has real implications for the potential of vaccine to provide adequate protection against subsequent infection.

Lundberg: Back on April 1, your number five was "mobilize the public." Frankly, as a member of the public on April 1, I think we were ready to be mobilized. I really think we were. We're a very divided country politically, but we all want to be alive and we don't want everybody over here being so sick. I think it was possible, but we know that didn't happen either. What do you think?

Fineberg: It was and still is a missed opportunity. I believe, as you're suggesting, that the vast majority of the public want to do their part and to be part of the solution, not part of a problem. They want to know what is it at this time that I can do to protect myself, my family, my neighbors?

We've gotten mixed messages from the beginning. I think, George, because of the tension between treating this as a health problem and treating it as an economic catastrophe, it was the inability to look at those jointly and see that if we could really radically diminish this virus by aggressive public health action, all of these steps we're talking about, we could have been in a much stronger position for a more confident and enduring reopening of the economy.

Lundberg: Obviously, the economy is hugely important because there are all kinds of health effects of a bad economy.

Let's move on to number six, which is, I think, a good story: the ongoing, real-world, research learning. Our research establishment has done a lot of great work in a short time to learn a great deal.

Fineberg: One of the bright spots, as you're pointing out, is the array of science and effort of learning that is emerging from every corner of the scientific community and from, frankly, others who are now getting into the science of coronavirus, of virology, of epidemiology, of working toward practical solutions. I think learning as we're going is going to be one of the hallmarks, looking back on what was done reasonably well in the coronavirus pandemic.

Lundberg: Looking forward, you chair a standing committee on emerging infections at the National Academy of Medicine.

I'm afraid that after SARS and after MERS, things lapsed a little bit there in terms of studying these kind of things, including trying to pick up on a vaccine. Meanwhile, Dr Victor Dzau, your successor at NAM, has appointed this new standing committee on emerging infections. You have an outstanding group of people there. Please describe a little bit about the future through that committee's viewpoint.

Fineberg: Indeed. When you look at the coronavirus with a historic lens, you can see immediately that it stands in a long train of emerging infections. You could go back in our lifetimes to the HIV pandemic in the 1970s and '80s, and actually starting unknowingly even before that. You have, as you mentioned, SARS and MERS, the earlier coronaviruses. We have Ebola. We have Zika.

We have a whole array of infections that emerge or reemerge periodically. Most of them are zoonotic, meaning that they begin in a different species and they come into the human species. Many of them, when they enter the human species, do not transmit very well.

For example, you'll remember all of the concern that we had over avian influenza, especially starting in the late 1990s, which, when it entered the human population, would produce very severe illness. But that particular influenza virus did not succeed in being transmitted from one human to another very well.

The coronavirus now has these very dangerous combinations of transmissibility, infectivity, and severity that have created the pandemic. But it's not the last. It's only one in this series.

Preparing now, even as we face the current emergency, to be better equipped, to anticipate, to prevent, and to respond to future emerging infections is a vital requirement for our ability to remain healthy and resilient as a community.

Lundberg: How about a wrap-up? Where are we? Where are we going? What needs to be done right now? What are our chances of at least a little better success than we've had in our country?

Fineberg: You know, George, I am reminded of our esteemed colleague, Bernard Lown, a great cardiologist who founded the International Physicians for the Prevention of Nuclear War and received, on their behalf, the Nobel Peace Prize in 1985.

He was asked about the nuclear situation: "Dr Lown, are you an optimist or a pessimist?" And he said, "I am a pessimist about the past because there's nothing we can do to change it, but I am an optimist about the future because that is ours to shape."

I feel the same way about our response to the coronavirus.

Lundberg: Well, I think that's exactly the way we all have to feel. Bernie is a great old friend from the '80s, also. Thank you for giving us that as a final word.

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