Charting a Path Out of COVID Means Remembering Data and Humanity

; Abraham Verghese, MD; Caitlin M. Rivers, PhD


October 07, 2020

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This transcript has been edited for clarity.

Eric J. Topol, MD: Hello. This is Eric Topol, and with me is Abraham Verghese. In this episode of the Medicine and the Machine podcast, we have a very special guest, Dr Caitlin Rivers from Johns Hopkins. Caitlin is one of the leading lights for the pandemic. We're looking forward to talking with her about her views. She is known in the community for having some of the most clear-eyed, balanced views and really great optimism that keeps us going. Caitlin, welcome.

Caitlin M. Rivers, PhD: Thanks so much for having me.

Topol: A little bit of background, because you have really been so extraordinary to help keep us informed and also give us that critical balance in a time of crisis. I know you did your undergraduate degree at the University of New Hampshire, and you were at Virginia Tech — is that right?

Rivers: Yes.

Topol: You have both a master's in public health and a PhD. When did you get to Johns Hopkins?

Rivers: In 2017. I finished my PhD in 2015, and then I went to work for the military for a couple years as an epidemiologist, and then on to Hopkins in 2017.

Topol: It's really striking that in such a short time you've developed a background in MERS and Ebola, and you're testifying to Congress. You're putting together the reports, the blueprints, of how we should deal with the pandemic. You're a go-to on Twitter and social media. It's just fantastic how much you've been contributing. Before I start to get too deep into it, let me get Abraham to weigh in here.

Abraham Verghese, MD: I just want to echo what Eric said. It's such a pleasure to have you and watch what an influence you've had on the national scene, along with our previous guest on this show, Natalie Dean, who I think is a pal of yours.

I'm struck by the fact that we have more people going into medicine than ever before, more medical students. I think you have also made epidemiology sexy. I suspect that we're going to see a lot of budding epidemiologists because of your example.

Maybe, Eric, we can start by asking Caitlin, "Why epidemiology?"

Rivers: I have always wanted to be an epidemiologist. I don't think I have a great origin story. It's just always appealed to me. Our school motto at the Johns Hopkins Bloomberg School of Public Health is "saving lives millions at a time," and I think that's such a beautiful way to think about public health and the important work that we do.

But it's funny you mention the different epidemics that I've worked around. When I first started my PhD and decided to focus on emerging infectious diseases, I was a little worried that there wouldn't be enough events to earn a PhD. Unfortunately, that has not been the case, and it continues to be a pretty thriving field. Epidemics, pandemics — they keep us busy.

Moving Away From 'an Unhappy Middle'

Topol: No question about it. Right now, especially. You, in many ways, were early on providing guidance. One of the things that struck me — it seems like ages ago, but I think it was in March or April — you co-authored a report about reopening. It was so lucid, succinct, and it basically gave the steps. Can you review that and what happened next?

Rivers: This was a report that we published at the end of March. It actually came out the same week that many states were issuing stay-at-home orders. It was basically intended as a roadmap to say, how do we get out of this? How do we move from stay-at-home orders to being able to reincorporate community activities and regain control of the pandemic?

The major recommendation that we had is that you need to bring down community transmission through actions that we all have to take — stay-at-home orders, mask use. Once you get community transmission down to a place where you can manage, we move to what we call case-based interventions: diagnostic testing, contact tracing, and supported isolation and quarantine.

At some point, there would be a handoff where you could transition from everyone having to take these restrictive measures to something that's more flexible, where public health officials are really able to do much of the containment and really break chains of transmission. We laid out the steps and the indicators for how you would want to make that transition.

Topol: What happened? It seemed like none of the states took on the guideline. It seemed so logical, and that if we all did that, we wouldn't be in this mess that we're in right now.

Rivers: There were a couple of major obstacles, some technical and some political. I think there was an enormous amount of pressure on political leaders to reopen the economy and to reintroduce those activities more quickly than public health may have been ready for. I think that was largely an observation of the fact that there are many negative economic consequences to the stay-at-home orders that we were having to observe. Those pressures were very real.

But unfortunately, at the same time, public health, while trying as hard as they could to scale up those capacities — to hire contact tracers, to roll out more diagnostic testing — they were not able to get to the levels needed to meet the political leaders where they wanted to reopen. There was a bit of a missed handoff.

I worry sometimes that we landed in an unhappy middle where we weren't really able to recoup a lot of our economic activity, but we were also not really able to regain control of the pandemic. That, I think, is a missed opportunity.

As I always say on my Twitter feed, which you referenced, there's always time to change course. We can always chart a better course and end up where we need to be. That's where I keep trying to push us.

Topol: Your posts often help my optimism. Oftentimes, when I'm hitting a low, I'll read one of yours and say, "Okay, well, if Caitlin says we're going to get through this, I'm going to believe her."

Verghese: Caitlin, it's a hazardous thing to predict numbers, but many people have done that from the very outset. Where do you see us now? Where do you see things going in the next few months as winter approaches?

Rivers: I think the worst-case scenario is that we have a bad seasonal influenza year and we also have a tough few months for coronavirus. I personally don't have a strong sense of what the probability is of that worst-case scenario.

In public health, we're always thinking about what is that worst-case scenario and what can we do to mitigate it? How will we respond if that comes to pass? That's what I'm thinking about right now — how best would we tackle that?

One bit of good news is that the Southern Hemisphere basically skipped its flu season. The measures they were taking to control coronavirus transmission were very effective against influenza, so they did not see the twin pandemics. That doesn't mean that we will get off without that worst-case scenario, but it does give me hope that we will not face that particular situation.

It's clear that there is still a lot of virus circulating in our community. Right now, we are headed up a third wave, if you will, or a third resurgence. I think that we will continue to see these hot spots move around the country for the foreseeable future, probably until we get a vaccine or until we really buckle down on regaining control.

Topol: Do you think that the projections, that we may be around 15% of Americans having been infected, are about right at this point?

Rivers: It's tough to say because there's so much spatial heterogeneity. New York had a terrible outbreak, and seroprevalence studies show they're around 20% seroprevalence. But there are many places in the country in the low single digits — 1%, 2%, 3% — so it's hard for me to balance and get a good intuition of how that maps overall.

I think 10% is probably an estimate that I would give if pressed to do so, but the two take-home messages are, we are very far from herd immunity, and even for places that have had a lot of virus circulating and a lot of infections and maybe some degree of immunity, because of that spatial heterogeneity, there's still a lot of vulnerability in our communities. It's really not time to let up off our control measures. It's just as important now as it was in March.

Topol: What do you make of the resistance to wearing masks and the simple things of distancing? Many countries don't see that type of resistance. They stay with the program. They basically understand that it's a social contract and we're all in this together. Why do we have such a lack of adherence to simple measures?

Rivers: I actually feel pretty good about what the surveys and polls show about mask use. There is a great survey from Pew that shows that around 80% of Americans report wearing masks when they go out, either sometimes or all the time, which, for such a big change in guidance that happened really overnight and has only been around for a matter of months, I think is not bad. Nonetheless, I do think it's true that there is some resistance or some difficulty incorporating these recommendations into people's lives.

I would pin that down to a gap in communications — not exclusively, but I think that would be the area that I would press on if I had an opportunity to change the way that we think about it. It would be changing the way that we message these things. Hearing more consistent messaging about how to implement these measures, why they're important, and when you don't need them, to give people a little bit of flexibility, I think is good — teaching people how to think about it.

It would also be good to see more engagement with trusted local leaders, engaging people who already have trust and communications with their community, bringing them into the message and using them to help the community understand these important ideas.

Verghese: I really like that because that's always been a fundamental tenet of public health — to begin in the community.

Can I go back to the antibody story for a second? There are people out there who say that the figures of 10% or whatever percentage we pick are inaccurate because they don't reflect the capacity of people who don't have antibodies but may have been exposed to boost their T-cell response. Do you think there's some credence to that? Are we vastly underestimating how many people are truly resistant?

Rivers: I think the tricky part about these assessments or these hypotheses that float around is there's always a grain of truth in them and there is a way that they can be true. But my interpretation is that people are making too much of that. I think it is true that we may see the effects of herd immunity at lower than 60%, which is the rule-of-thumb estimate that epidemiologists give for a virus that is as transmissible as this one.

You hear people hypothesize that maybe the herd immunity threshold is lower than that. It could be. We also hear, as you said, that some people hypothesize that T-cell immunity might be weighing in, and maybe because of that, herd immunity threshold is not at 60%, as measured by serology.

But my take-home message is that we are still nowhere near herd immunity and our communities are still very vulnerable even with those maybes. What we're seeing in Spain is a good case study of the reason that we still need to be vigilant. Spain had a very severe outbreak in the spring, which they effectively controlled. They had a quiet summer. People hypothesized that maybe they had reached some sort of herd immunity.

When serosurveys showed that Spain was only in the 2% range for seropositivity, people said maybe it's T-cell immunity. They are now having a very severe resurgence, by some measures even worse than in the spring. If we are not cautious, that could be an outcome that we would see and want very much to avoid.

Topol: No question about that.

Verghese: I think it's safe to say that even though people may have very low antibody levels, theoretically perhaps they can then boost their T-cell response and generate a good antibody level. It must be kind of rare for people to have no detectable antibody and for us to speculate that they somehow have T-cell immunity. That's my take on the whole business.

Rivers: I think it's a bridge too far to say that we can rely on T-cell immunity to really change our epidemic dynamics. I don't think we have evidence of that.

Topol: I agree.

Now, Johns Hopkins has become a hub for the pandemic, not only in the US, but worldwide. The Center for Systems Science and Engineering is what everybody looks at for their website, and you're in the Center for Health Security.

How does your center work, and do you all work together? What is it like there? I did some of my training at Johns Hopkins, and I'm sure things are a lot different now than they were then.

Rivers: We have so many amazing researchers and experts at Hopkins that it's really a privilege to be part of such an incredible community. The Johns Hopkins map that everyone knows — and when I say everyone, I mean it gets billions of clicks a day — is run by Lauren Gardner, who is in the Department of Civil and Systems Engineering. She's been an absolute powerhouse.

We get the opportunity to collaborate, but we are part of different centers. I'm part of the Center for Health Security, as you mentioned. We are a multidisciplinary group of faculty. We have specialists in infectious disease medicine, anthropology, epidemiology — all sorts of people with different backgrounds.

We have been around for over 20 years, thinking about epidemics, pandemics, and deliberately occurring events. So we focus on these issues even during peacetime. It's been a real privilege to be able to use our expertise to try to help the country and the world face this difficult time.

One other little tidbit about us is that we were founded by D. A. Henderson, who led the World Health Organization's effort to eradicate smallpox. We're very proud of that legacy and of the amazing work that he did for humanity.

Topol: I think everybody should read the very succinct profile of you in Science from September 11, which is just terrific. I hope you were happy with it. It was so nice that your efforts have been highlighted. There are a couple of things I was going to ask you about that. Paul Farmer influenced you. Can you tell us about that?

Rivers: It's funny how that little anecdote has stuck around. I think it's in a couple of places on the internet. But basically, I read Mountains Beyond Mountains, which is a book I feel like every undergrad does and should read about the work of Paul Farmer and Partners in Health, which is an organization that he co-founded. They are champions for public health and underserved communities. Haiti is where it got its start.

When I read the book, I was really inspired by his clarity of vision and tenacity to create the conditions for good health for people who otherwise would not necessarily have access to those basic rights. Although I work on very different things than Dr Farmer, I think that's really where I got some of my enthusiasm and ambition about what public health can achieve, given the right energy, enthusiasm, and dedicated people.

Rapid Diagnostic Testing Could Be a New Chapter

Verghese: You've made testing a very important part of your strategy in some of your papers. Where are we with that? Will the availability of more rapid tests and home tests change some of the strategies that you've outlined?

Rivers: We had a late start with testing. I think that was a big factor in our difficulties in the spring, which to some degree carry over to this day. I do think we are entering a new chapter. There are now antigen tests that are fairly cheap, on the order of $1 to $5. They return results in around 15 minutes. Although there are not currently any antigen tests that can be run without healthcare providers, I think they're coming.

I think it will be the case that within a couple months, we will be able to access these quick, easy antigen tests with more ease and frequency, hopefully, than we have been able to do with PCR tests. My hope is that we will be able to use these antigen tests to reopen high-risk settings and communities — notably for me, K-12 schools, which I think is a big priority for the country, because schools are so important to our communities and our families.

The details of how those antigen tests will be used to that end are still being worked out because this is a very new approach to diagnostic testing for us — not the antigen piece, but the way that we are thinking about using diagnostic testing in the community setting to control a pandemic. That's not the way that we usually think about diagnostic testing. I'm very hopeful that this will be a new chapter for us.

Planning for a Disease-Forecasting Center

Topol: You've been thinking big. You're a young faculty, but even when you were training, you were working on this national disease-forecasting center, which I guess doesn't exist yet. It seems so logical. Can you tell us about that and whether there's a chance we could ever get this sort of thing?

Rivers: Yes, thanks for asking. This is an idea that's been around a while and predates me. I think it originated with my partner in crime, Dylan George, who I work with on this project and this idea. The idea is that we need a national center for infectious disease forecasting and analytics. It would look a lot like the National Weather Center in that it would be tasked with providing forecasts and doing the kinds of analyses and producing the insights that would allow us to make better decisions during these kinds of events. By events, I mean these public health threats that really impact the way that we live our lives.

Sometimes when I make that point, people will say, "This is the only pandemic we've had in 100 years; is it really worth setting up a whole new institution?" It absolutely is because although this is the biggest threat we've faced in 100 years, it's far from the only one. We had the anthrax attacks in 2001, SARS in 2003. We've also had H1N1, Ebola, Zika, and now coronavirus. Over and over again, we face these threats that impact our national security and our health security.

There are no other national capabilities that we rely on to make these huge decisions, trillion-dollar decisions for which we don't have solid funded national infrastructure. We don't rely on volunteers for the military. We don't rely on volunteers for weather forecasting. But that's exactly what we're doing for infectious disease forecasting. That's what we're proposing needs to change.

Topol: It sure seems like we need it. It also seems that with what's going on with the planet and the environment, we may be seeing more pandemics than ever in the times ahead.

Verghese: I'm always struck by the fact, Caitlin, when we have these conversations, that there's an exactness to the science of epidemiology. There's an exactness to our knowledge of immunology. Yet, we're up against societal obstacles: the obstacle to mask wearing, the obstacle to testing. It seems to me that we really need to bring science to bear on helping people come along so that we're all speaking the same way.

Do you know of any efforts that are looking at that? The best science can be undone if we don't manage to convince people. People are making the point that vaccines, even if we manage to produce them, if there's distrust and suspicion, they really won't change the picture as much as we would like them to.

Rivers: Absolutely. This is a lesson that we learn over and over again. I don't know that we have been as effective in the United States at incorporating it into our planning as some other places. Notably, in the 2014 Ebola outbreak, community engagement was an enormous part of getting control and really figuring out what people need to be able to make changes to their lives and behaviors, and how we can support them in doing that, and how we can communicate in a way that really speaks to their concerns and that resonates.

I'm not sure we've done that at the national level to the degree that we should have. There are certainly plenty of experts who specialize in doing exactly that kind of thinking, but I think the communication gaps that you've seen in this pandemic are evidence that we have a ways to go.

I also think the point that you raised speaks to a larger observation, which is that we have spent a lot of money and investment and energy on medical countermeasures — diagnostics, vaccines, and therapeutics — for the purpose of preparedness. That's good because we need those things and they're important.

But we are 7 months into this pandemic, and we don't have a vaccine and we only have a few therapeutics. Diagnostics did not go that well. I think we need to plan for nonpharmaceutical interventions: closing schools, stay-at-home orders, things that are more targeted and less restrictive. How can we really build up our capacities to use those interventions to the best effect? I think that's a big area of preparedness that we need to expand as well.

Topol: Especially since even with vaccines, we're going to need those nonpharmaceutical interventions all throughout next year, perhaps, and even longer, right?

Rivers: That's right. Unfortunately, I think we have a ways to go in this pandemic, and we will continue to draw on these nonpharmaceutical interventions for the duration, for sure.

'We Must Not Become Numb'

Topol: Of the things that you've had some unique experience with [was] the congressional testimonies. Your efforts there are so commendable. What was it like to do that? Do you think you were able to get across to these folks what's going on out there?

Rivers: I've been able to testify twice, which were both amazing opportunities. The first time, in May, was in person, and that was a really powerful experience because I got to visit the Capitol and see the members up on the dais. It was very cool. It was also nerve-wracking, but I'm very glad to have had the opportunity.

The second time, I was on Zoom, just like I'm speaking to you on Zoom. That was much more approachable because there was less intimidation from being in such a grand space. It was still an amazing opportunity and privilege to be able to weigh in on a conversation that's so important to our country.

Topol: Do you think that some of your messages got across or do you think it was not helpful to effect changes going forward?

Rivers: I hope that my messages were well received and that I informed thinking. I think it's always difficult when you work in academia, and particularly the intersection between academia and policy, to know where your ideas go or how they influence. I walked away satisfied that I had said what I wanted to say and that we discussed some really important topics. To that end, I was happy.

Topol: You convinced me. I just wondered what your reaction was in the room or especially when you were there. One of the things that is striking is that we tend to be very data focused, and we don't really cue into people and their lives. That's why, of all your tweets, the one that resonated with me the most was "We must not become numb. Those numbers represent people who were loved."

You see the reports every day about how many people have died and how many cases, and it doesn't really get into the fact that these are people connected with families and loved ones and friends. That's what I think separates some of your message because you have this humanist quality. It's a really important thing.

Verghese: I want to follow up on that. Thank you for those sentiments that you express. I'm sure there's a question that many of our listeners are curious about. You're a young rising faculty member in the center of the vortex, so to speak. You have young children, I believe. How exactly do you juggle all this? How are you doing with homeschooling and all the things that are on your plate?

Rivers: I don't know how I juggle it. It's day by day. I have three young children, including toddler twins. They keep us busy, but I'm making do just like everyone else. It's not easy, but on the other hand, we're home and we're safe. We're squeaking by here. It's true that it's a difficult time for everyone. Our family is in a good position of being able to stay at home, to provide online learning, and to really shepherd our kids through this experience. There are many other families that are experiencing a lot more complex challenges. I worry about that a lot.

Verghese: Do your projections take into account the fact that, as you just said, some of us can take the precautions while others cannot? They cannot afford to not work. They are living in packed situations. It's always an eye-opener to look in on clinic visits happening by Zoom and to realize that the person is in a very compact space with many people around, or they're in a car and driving to some place where there is Wi-Fi that they can access. Does epidemiology take into account the stratification of society that's come into such relief in these times?

Rivers: I think public health broadly does. I'm so inspired by the public health professionals who really try to create the conditions for health for people and think about the disparities and inequalities regarding access, and how we can provide wraparound services and supports to address not only the problem at hand — in this case, the pandemic — but also the conditions that make people more vulnerable to the pandemic.

I don't think that the pandemic-preparedness community has been as cued in to that observation as other subdisciplines in public health. That's a really important lesson we need to take going forward. In the back of my mind, I have always thought about viruses as equal-opportunity, but that's absolutely not the case. Other parts of public health have very clearly recognized that. I don't know that that has been as pervasive in my thinking. That's going to be a big, important change.

Verghese: You had a wonderful paper on opening society. But when it comes to schools, do you have any thoughts on how we might proceed forward?

Rivers: This is always changing because the science around children has lagged a bit relative to other areas of the coronavirus epidemiology. The reason for that is that schools were among the first institutions to close, so we haven't been able to observe all of the considerations around kids.

We know that schools are absolutely essential to our communities. They're essential for learning. They're essential for providing services, particularly to vulnerable families. And they're essential for parents being able to work and earn money. So reopening schools is absolutely a top priority for me.

My observation or recommendation right now, taking into consideration the latest science, is that the burden of virus in the community is the number-one consideration. In places that have a lot of virus circulating, it will be difficult to reopen safely without having tools like mass-testing or other major tools or interventions.

I also think that younger children should be prioritized, in recognition of the fact that they are at lower risk for severe illness. They may be less likely to transmit, although I'm not sure that we can really say that with much confidence. I'll also note that it's not just kids we're worried about; it's also teachers and staff. Don't think I have forgotten about that, because that's important to me too.

Young children are at low risk for severe illness, and they're also less likely to be able to engage productively in online learning. I would like to see younger children be able to return to school buildings first, and then incorporate the older children from there as community transmission comes down.

Topol: Another logical approach. That's kind of your imprimatur. I like that.

Toward the End of 2021

Topol: Going forward, the vaccines — what are your concerns? Because that's our main exit strategy. Are you thinking about some of the things that could get in the way, or are you pretty confident that this is going to go very smoothly?

Rivers: There's a lot to do around vaccines. And anytime you have a long road ahead of you, you have to worry about how to do that as smoothly and safely as possible. I learned from my vaccine-expert counterparts that we will likely have a product by the end of the year. I don't have the expertise to say whether that's true or not, but I'll take their word for it.

Many of the leading candidates have to be frozen, which requires a lot of infrastructure that we don't necessarily have. Two of the leading candidates also have to be given in two doses, which adds a whole other logistical obstacle to get people to vaccine sites, not once but twice, and on a particular schedule. I think it's going to be tough. I think it's going to take most of the next year to get everyone vaccinated.

It will, nonetheless, make a big difference. It will still be a really important tool in our arsenal and a really important chapter in this pandemic. But it will not be a light switch where we get a vaccine and then we can all resume our normal activities. It will be a step change in our pandemic, but not an on-or-off.

Topol: When do you think we'll see pre-COVID life restored?

Rivers: I wish I knew. I'm thinking toward the end of 2021. It's really hard to say with any certainty. We should all be mentally prepared to have quite a bit ahead of us.

Verghese: I know you have a background in computational biology. Are we able to bring those tools to predictions? If the vaccine is this effective, then this is what we'll see. If people wear masks to this degree, then this is what we'll see. Are we doing that sort of modeling, and is it worthwhile?

Rivers: There's a whole area of forecasting or analytics, if you will, that's more scenario modeling, which is exactly as you describe. What would happen if we were able to implement this set of interventions? What happens if compliance is 40% or 60%? You can explore the range of possible outcomes.

I think it's really useful for building intuition about how things may unfold and what the key lever points are. That's a really active area that I think this proposed center would be involved in — producing those kinds of analyses.

Topol: With the trillions of dollars that have been spent, as you were reviewing, it seems like getting prepared better would be a very smart idea and it would not cost so much.

This has been such a terrific discussion with you, Caitlin. I think we could go all day because you are giving us many really important insights. But we are really appreciative to you. You've been such a gem in a tough time for all of us. You've been, in so many ways, helping provide the information, the balance, the perspective, keeping us upbeat and not without basis.

Thank you for all of that. We're going to follow your career.

Rivers: Thank you.

Topol: I'm just thinking about where you're headed in the years ahead. Thanks for taking the time to chat with us today.

Rivers: Thanks for having me. It's been great. I appreciate it.

Verghese: Thank you.

Eric J. Topol, MD, is one of the top 10 most cited researchers in medicine and frequently writes about technology in healthcare, including in his latest book, Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again.

Abraham Verghese, MD, is a critically acclaimed best-selling author and a physician with an international reputation for his focus on healing in an era when technology often overwhelms the human side of medicine.

Caitlin M. Rivers, PhD, is an epidemiologist who specializes in the science of outbreaks and health security. She has helped draft several key reports on safe strategies for reopening, including one used by the state of Maryland and the District of Columbia. Follow her on Twitter @cmyeaton.

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