It's Okay to Overreact: Devi Sridhar Shares COVID's Humbling Lesson

; Abraham Verghese, MD; Devi Sridhar, MPhil, DPhil

Disclosures

March 18, 2021

This transcript has been edited for clarity.

Eric J. Topol, MD: Hello. This is Eric Topol on Medscape, and with me is my co-host Abraham Verghese. This is a really special edition of our podcast, Medicine and the Machine, because we have a phenom here, truly: Professor Devi Sridhar, the professor of Global Health at the University of Edinburgh, who has been a guiding light for the pandemic not only in Scotland or the UK, but for the world. It's actually kind of amazing given her background, her age, and everything else. Devi, welcome.

Devi Sridhar, MPhil, DPhil: Thank you, and your introduction is too kind. We're all just trying to do our best through this crisis.

Topol: Well, I want to just reinforce that my introduction is actually very modest relative to the things that you've been able to accomplish in your young career. There was a great October Lancet profile, which in a way was the beginning of how I got to know you. In it, Professor [Larry] Gostin at Georgetown said, "Devi is among the most inspirational and impactful global health leaders in the world...All of Devi's work is guided by the core values of achieving a healthier and safer world with equity and justice."

That's pretty nice, Devi, really.

Sridhar: You're going to make me blush; it's a bit overwhelming. Larry's always too kind in his praise and in his words.

Topol: Well, it's wonderful. It's richly deserved. Let's start with a little bit of your background: the youngest Rhodes scholar in history, starting at age 18, having already finished college — that seems kind of early.

Sridhar: Well, that's just how my life worked out. I think everyone has different experiences that shape their life. I never set out to be the youngest or to make life go faster; I just had good mentors and was always looking at what I wanted to do next. Yeah, it's been a journey, but now I'm finally getting a bit on the other side. Students now look at me and see me as old, so that's been a change.

Topol: Oh, hardly. What's amazing is, here you were, growing up in Miami, and you went to Oxford for the Rhodes Scholarship and you've never come back. We lost you.

Sridhar: I know this was the fear. I came to Oxford, and the plan was to go back, actually, to Harvard to do a joint JD/MPH program. I was interested in public health policy, and it seemed that was the way.

But I had a really good mentor in Oxford. I wanted to spend time doing fieldwork on the ground in a low-to middle-income context to actually understand global health, and it seemed like that was the right time to do it, and that if I went into a structured program it wouldn't really fit my interests.

Being an academic is an absolute fit for my interest, which is combining research and teaching, advisory work, flexibility, able to do independent work, develop projects. I feel quite lucky that I was able to do my degrees in Oxford and pursue an academic position, because it's given me a lot of freedom to do what I've always wanted to do from an academic base.

'Countries That Saw This Like Flu Have Paid Painfully'

Abraham Verghese, MD: You were really prescient at the Hay Festival, speaking out to say that we were not prepared for what was going to come. And sure enough, it came shortly after. I wonder, looking back, what we might have done better along the way. I think that's a question we keep asking ourselves. Also, what does it mean for our future responses to pandemics like this?

Sridhar: I think everyone who was working in global health knew that a pandemic was not an if; it was a when. It was most likely going to come from animals, because we know that most of our really serious infections spill over from animals into humans, and a respiratory pathogen would be the worst kind, because it spreads so easily.

I think SARS-CoV-2 had an added challenge in that it fell between two stools. If it had the fatality rate of MERS, which killed a third of people, every government would have run toward elimination. There was no way any government could have said, "We're going to accept some incidents." Or if it was much, much lower, let's say, similar to a normal seasonal flu, then we could have said, "Okay, we live with it."

Unfortunately it's too severe to live alongside, but it's not bad enough for governments to have a very clear vision of how to proceed — unless you were in East Asia or the Pacific, where they treated this like a SARS-like event from the start. One of the challenges has been in governments developing their strategies.

What you've seen very clearly is that parts of the world that saw this as SARS and treated it like SARS have been rewarded for having that strategy in terms of economic performance. Countries that saw this like flu have paid painfully, including through their economic performance, for underestimating this virus.

The lesson for the future is that you never underestimate and underreact to an infectious disease threat. You overreact. You can ease up when you get more information and understand how we live with it.

I think the other big lesson for me was about buying time.

There was this idea when it emerged that there was no choice but for everyone to eventually become infected with the virus. The idea was that this was unstoppable, and you just needed to build up your hospitals. We have to live with it and get on with life. But in the past year, how many vaccine candidates do we have now that are successful? Every day, there's a new one emerging, which shows that buying time bought lives.

Countries like New Zealand and Australia, that now can open up and vaccinate their entire populations, have managed to escape this pandemic with very few deaths and keep their domestic economy going. The countries that have lost — like the United States, Britain, Brazil, and others — tens of thousands of lives, over hundreds of thousands of lives, have paid for not buying time. Over those months, those people would have survived had they had access to a vaccine. We can see that now with the vaccine performance.

I think in the future, there'll be more of an emphasis on how do we buy time for science, and more faith that science will deliver. For example, if there's an influenza pandemic, how do we move from sequencing to a vaccine quickly and get that out? We know we can do it for coronavirus, so there's more ambition, but also not underestimating the threat of how much destruction and devastation outbreaks can bring.

Poor countries know that. West Africa knows this. They saw Ebola. South Korea knew this from MERS. Taiwan knew this from SARS. Unfortunately, we had to learn it the painful way in Europe, and the United States had to learn it the painful way this time as well.

Topol: The point you're bringing up is really worth emphasizing. This "flatten the curve" idea was mainly to try to spare medical resources from being overwhelmed. What you have brought to the fore here is that it saved lives. That is, people were spared — not only with vaccines but with better treatments, better approaches, such as learning to avoid mechanical ventilation if we could, or using anticoagulants or dexamethasone, and then even monoclonal antibodies.

This whole idea that if you died earlier in the pandemic, you might have survived later — I think that many people aren't in touch with that. In fact, there's even a Wall Street Journal op-ed recently saying that lockdowns were a waste. They don't seem to get it still.

Shifting Approaches, New Variants

Topol: You've been advising the government in Scotland, and it had a really very remarkable course along the way. Like many other places, perhaps it was the B.1.1.7 UK variant — I don't really know — what happened there?

Sridhar: Scotland was aligned with the rest of the UK nations in going into a late lockdown in March. At that point, it started to diverge slightly in terms of trying to get a local testing-and-tracing system up, so there was an outbreak response in place. Also, the country kept lockdown measures for longer so that we could get the numbers low enough for a test-and-trace to be able to function. We know it only functions if you can identify outbreaks, and if it's everywhere, then the system breaks down.

As we went into last summer, we basically eliminated the virus. Genetic sequencing has now shown that those strains were put out. If I think of June and July, we had a pretty normal summer in the sense that most things were open and people in shielded groups were sitting in cafes. There was a sense of relaxation, because every day they were testing thousands of people and finding two cases; hospitals were empty.

Then in August, tourism opened up, and tourism season. This was people going abroad on holidays, which is kind of a British institution that people go abroad to France, Spain, and Greece. It's like your annual holidays. When they returned, there was no testing, there was no quarantine, and there were no procedures put in place. What happened is that we just got reimportation and the system got overloaded because you had too many fires. You had too many chains of infection being set off.

At the same time, we had universities return, which in some instances were tens of thousands of students moving across the country — again, not being tested, not being quarantined, and going straight into communities. This really triggered our second wave in the autumn. We managed to then put in place restrictions early enough to keep it low enough.

Then B.1.1.7 hit in December. We know how infectious this virus is. It is much harder to suppress. There was that idea in December that it would be unstoppable because if it was really 70% more transmissible, many of our measures would not work anymore in terms of keeping schools open and keeping enough things running while having this variant.

But luckily, and this was through a pretty severe lockdown in January, we managed to bring it down again. Now the idea is, again, try to get to that level of elimination this summer where we were last summer, but this time we have a vaccine. The vaccine's now been rolled out to, I think, 40% of the adult population. The idea is for all adults to be done by mid-July, which is similar to the United States' ambition.

At that point, the idea is to look at immunizing children in the autumn if there are any approved vaccines. And to move to a point where now there are very, very strict travel restrictions. That lesson has been learned. It's managed quarantine for anyone coming in, but then to start to open up in a more safe way so that we don't repeat this winter next winter.

I think many countries suffered this. Greece as well, Iceland, where they managed to get on top of it, and then it was the travel and the tourism that kind of kicked off their second waves, which is a really hard thing because we want international mobility and countries to be open. It's just very difficult in a pandemic.

Topol: Well, there's another example of your impressions when you wrote the New York Times op-ed that we're going to pay for our summer vacations with a winter hit. You were sure right about that.

Sridhar: You could see it. I mean, I could see the whole situation falling apart. In some ways, it's common sense. If there's no virus and people are arriving from places where there is virus, then what is going to happen? We know how infectious this is. The anti-lockdowners often clamor, and the thing I say to them is, the two things that will continue to get us with this virus are the number of susceptible people — if it can keep jumping, you get exponential growth — and hospitalization rates. That means you can't just let it go, because your hospitals get deluged, as we're seeing in Brazil.

Until we solve one of those two problems, we're stuck. Vaccines solve the susceptibility issue, so we create barriers. There's a new study out from Scotland that shows it stops transmission. At the same time, we could have something that stops hospitalizations, which vaccines also seem to do, as well as therapeutics, and so on.

This is how I try to describe it to the anti-lockdowners, that, of course, we're all anti-lockdown. Nobody wants lockdown. It has massive harms. Which of the two problems are you going to solve for us? Are you going to go out there and develop a vaccine for us? Are you going to develop a therapeutic? Stop shouting you're anti-lockdown; go do something useful to get us out of this bind. That's my response to many of the people saying, "We're against restrictions." Who wants restrictions? No one wants restrictions.

'Caught Like a Child in the Middle of Divorced Parents'

Verghese: Like Eric, I'm just in awe of the breadth of your work. So much of the work you've done preceding this pandemic has turned out to be tremendously important. You've written a lot about governance and organizations like the WHO, Gavi, and so on. How do you think they've done in this pandemic? How do you think the WHO and other entities like that, without the kind of supervision or oversight that one has, say, in academia, how do you think they've done?

Sridhar: The WHO I feel bad for, because former President Trump gave it such a difficult time. It was blamed for so much of the spread, and I feel like it was caught like a child in the middle of divorced parents, between China and the United States, trying to please both sides and ending up pleasing neither of them. But when people ask what the WHO can do, it can really only do three things. I actually think it's done decently on each. Of course, we can grumble within that.

First, what can it do? Legally, it has the International Health Regulations (IHR). Countries notify it when an outbreak has occurred. China did that at the end of December. They alert the world that this has occurred. They did that in early January; a memo went out to governments about this new cluster.

They convened international experts at the point, to ask, "Is this a public health emergency?" When they first met on the 22nd of January, they said, "We don't know." They were ambiguous. They reconvened on the 30th of January and said, "Yes, it is."

That's where the IHR ends. That's the alarm bell. They've rung the alarm bell. Then it's time for countries to prepare or not to prepare. South Korea was already running, Taiwan was among the leaders. Countries started running at that point. Then you saw other countries just ignoring it, saying — and people fixate on this word — "Oh, they didn't say it was a pandemic." I say, a pandemic means nothing legally.

The word that matters was the public health emergency of international concern, which was January 30. I think they did a good job on that. How much faster could you move, because you have to be careful not to overreact. There are 300 outbreak events every month; how many are you going to declare an emergency? You have to use it very sparingly.

The second thing they can do is bring governments together, and they did that at the World Health assembly last May, where there was a resolution passed, including with the United States (even with President Trump), which said that they would approve to share any benefits of research of vaccines. You saw the COVAX facility to share vaccines, and governments said, "Yes, we're going to do this. We're going to share vaccines. We're going to share stuff." They got the agreement. Unfortunately, no one honors agreements of that kind, as we've seen, but WHO did arrange that.

Then the third thing they can do is provide briefings. From early January, they did do daily briefings. Of the governments that listened to those daily briefings — because I listened to them from early January — you knew a lot going into February, especially that China mission that came back in February.

By that point, we knew who's most at risk. You basically knew your risk groups. You knew the age gradient. You knew how it spread pretty well. You knew that you could use contact tracing and testing to bring it down alongside lockdown measures. Wuhan was only in lockdown, I think, for 70 or 75 days, which is remarkable given that we're going to be in lockdowns for over a year and a half in other parts of the world — on/off lockdowns. The countries that listened — New Zealand, Australia, East Asia countries, and even in Europe, including Finland, Norway, and Denmark — did better.

The countries that didn't even know what had happened, they didn't listen to WHO — they thought it was an agency for poor countries — ended up trying to reinvent the wheel and kind of find their own way through it. They came out with studies in March or April detailing the risk factors. I'm like, well we knew that. We knew that from February. Britain waited until Italy fell, Lombardy fell, in terms of their health system collapsing, before they said, "Oh, this is a problem." I thought, "Well, China built a hospital in a week in January. We knew it was a problem at that point."

In a way, I'm sympathetic to WHO. Were they slow? I think they were slow on, for example, human-to-human transmission in January. It was clear there was human-to-human transmission much earlier than they acknowledged. The second was on the airborne elements and the aerosol elements. I know this has been heavily criticized. But I think at some point they should have just moved quicker on that.

The asymptomatic spread has been really controversial. Is it presymptomatic? Asymptomatic? It's better, again, to overreact: Assume asymptomatic spread at this point and react in that way so we get people wearing masks and acting responsibly.

Have they been slow on certain things? Yes, but the truth is, all of us have been slow. I think all the experts criticizing them need to take a look in the mirror and say, "Where were we last January? What were we saying?" I think we may not like to hear what we were saying at that point either.

'This Was Really About Leadership'

Topol: Just to anchor that question that Abraham asked you, Devi, there have been two books you've written. The first one, The Battle Against Hunger, was in 2008. Then you wrote a book with Chelsea Clinton, Governing Global Health: Who Runs the World and Why?

How did you and Chelsea get together?

Sridhar: Chelsea did her PhD in Oxford on the Global Fund to Fight AIDS, Tuberculosis and Malaria. She was very interested in the global response to AIDS and the structures. Her father was very involved in setting up many of those structures. She did a PhD looking at how it was set up and how effective it has been. I was a post-doc at the time in Oxford, and we got to know each other.

When she finished that, we thought we should bring together our work. I had done a lot of work on WHO and the World Bank, the key multilaterals in health, and she had done a lot of work on the Global Fund, as well as Gavi, The Vaccine Alliance. We said that we should combine that and do a book that overviews how the global system operates and functions. In that book, we start with looking at infectious diseases and we end with looking at infectious diseases. We end on polio and start with Ebola.

But it was clear — we did an op-ed last February — where we could see, looking at the US infrastructure, that under a Trump presidency it was not ready for a pandemic. You could already see the writing on the wall by February that the US was going to struggle really badly. Absence of that federal response, I think, is what we paid for — painfully.

What this comes back to is, we can evaluate as much as we want countries' response. We can create indices, we can talk about core capacities, we can talk about surveillance; but in the end, a lot of how countries did had to do with their leadership and the political decisions made — bold decisions — by leaders who managed to carry their people.

This was really about leadership and getting populations to understand the scale of the challenge and what was required of them together to get through this as a community. We can see that leadership is just essential.

The countries that have suffered — I know in the US they are trying to turn it around now with the ambitious vaccine programs — have been the States with Trump, and Bolsonaro in Brazil. Brazil shouldn't be struggling the way it is. It has a pretty good health system. It's a better and more advanced country than many of its Latin American neighbors. As well as in the UK, in Britain, with Boris Johnson who, if I think a year back, was very consumed with Brexit and was still telling people he was going into hospitals and shaking hands with COVID patients, and that we shouldn't be scared of this virus.

I think there is something to say about leadership styles as well. Countries whose leaders took a more cautious [about the virus] approach, which tended to come, bizarrely, from female leaders, did better. If we think about New Zealand, Germany, even in Europe with Iceland, Finland, Norway, and Scotland (we have Nicola Sturgeon here). I think in the future, the interesting thing will be that we can make as many metrics as we want; we can evaluate countries' lab capacities, testing infrastructure, and hospitals. In the end, it's about the person who's in charge and how they actually lead a country through a crisis.

Sources of Misinformation

Verghese: Which leads me to a follow-up question, and it's one that I always bring up on this podcast. We know that there's a virus and that's a tremendous problem. We know there's poverty and that's a tremendous problem. But I think a big problem in this epidemic has been ignorance, or sort of willful ignoring, of science. Both by leadership — especially by leadership — but also by the general public.

I think there's really a need to treat this as a public health disorder just the way we treat poverty or malnutrition, because it really is at the heart of this pandemic. As a global health expert, what does one do about the kind of willful ignorance that got us into such trouble in the United States and all the other countries that you mentioned that have not done well?

Sridhar: To me, there have been at least three sources of this. I think one was leaders who deliberately misled. A great example is Donald Trump, who took a vaccine while not even admitting to the public that he had had a vaccine for him and his wife; who denied that this was serious for many months and treated this like the flu.

First are the bad leaders. There's Bolsonaro now, telling people to stop whining while there are mass graves being built. Why do we elect those kinds of leaders? I think there are many questions there.

The second thing is bots — accounts or people who spread misinformation. Eric knows this, being on Twitter. There is a vast amount of disinformation being spread and videos being created by people who just call themselves "professor." They're not even professors. They just call themselves "professor" on their Twitter handle, and they give themselves a PhD credential, and then they're putting up YouTube videos that are being seen in India. People aren't taking vaccines because they said, "I saw some professor." I'm like, at what university? They say, "We don't know; he calls himself 'professor.'" It's amazing to watch.

I've really struggled because you can't fight every single one of them; there are too many. You end up being consumed in the mud. How do you stay out of the mud of where anything you say, someone says something the opposite of it?

The third thing that's been really difficult is academics who are real academics, but who stuck their heels in very early to their position and refused to move.

Last January or February some academics came out and said things like, most of the population has already had it, or it was pre-existing immunity, or it's not as bad as we think it is. They have not moved. The world has moved. We have evidence. I really admire people who will say, "We thought the infection fatality rate was much less. It's higher than we thought. We reevaluated our position."

Or people who didn't agree on masks but now agree on masks because they can see that they're important. All of the things that we have discussed where people have kind of dug in their heels and stayed where they are...

Schools are a classic example. I get hit on both sides about schools: the people who say I'm killing children and teachers, and the people who say I'm damaging young children by keeping schools shut. But we also have academics who are sharing things and saying that kids are superspreaders and silent vectors, and yet are going out.

The evidence doesn't show that over the past year. Maybe the new variants change it. I'm open-minded. I will change my mind as the evidence changes. Then you have on the other side the people saying that, no matter what, we need to let schools run, regardless of what's happening. Well, that doesn't work either. We know the schools will just become full of infections from the community.

Nobody seems to want to ever move in academia. I think it's the egos and the need to be right. In the States there's a great example — I don't want to mention anyone by name, but from some of the classic institutions like Stanford, Harvard — professors coming out with things that actually are not evidence based. It's astonishing that they're not willing to say at some point, "I got that wrong, I'm willing to move."

Instead, they just keep digging themselves into a deeper and deeper pit. That's been astonishing. I think there are three sources: the academics who just refuse to move because of their egos; the bots and fake pseudocelebrity accounts pretending to be professors; and then, of course, the leaders who just are populist and not in tune with actual science.

Topol: I had an interesting experience of debating Martin of Harvard on the Great Barrington Declaration. I say, wow. Your point about the mis- and disinformation spreading much more widely than the real facts and truth is so essential.

Looking With a Children-First Lens

Topol: One of the things that I find so rich that you do, Devi, is that you get into the heads of the people through Twitter to try to be uplifting. Every day you have messages to get outside and see the bright side. Maybe that's the best way to summarize it. I think that's really invaluable.

Do you get any pushback about that? What's been the response? I think you do it in a way that's really extraordinary.

Sridhar: Oh, thank you for that. Well, that's kind of my personality; I'm kind of a glass-half-full person. I knew going into this winter that we were going to go through a really rough time. I wrote a piece back in October: "Covid: The next four months may be one of the hardest periods of your life," because you could already see that November, December, January, February were going to be horrible. We just knew it.

[It was about] telling people up front that it's going to be really bad but we're going to get through it together, and we're going to make it to the other side of this. That the spring will get better. It is better. We can see that the summer is going to be much, much better once we've vaccinated. I'm very optimistic in that sense right now. It was giving people the idea that we have to look to tomorrow and not to collapse under the burden of today.

Have I gotten flack? Of course. Yes. I call them the Mean Girls of Twitter. There were a few who were like, oh, you know, she's full of unicorn crap. Leave her to her unicorns and her rainbows. Well, if that's the worst you can say about me, then I'll take it. I bet you unicorn crap probably tastes like bubble gum. I mean, what's the worst?

You get this on Twitter, which can be silly. I think we have to give people realistic information but also hope. There are tough messages. Today, for example, I did say, "Happy Friday." I also said, "Children have gone backwards across the world, and we're in quite a difficult position with children."

There's a whole lost generation in terms of how much pain these young people have gone through, whether it's girls being forced into early marriages in poor countries because schools have been shut; the amount of abuse that's taken place across the world because children have been locked in their homes without access to supportive structures; kids who have missed out on meals; rising poverty, including in rich countries, which means increasing use of food banks; children going hungry. These are real issues.

I think we have to do it in a way that gives people hope that we can make it better. What does that mean? It means we need to put children at the heart of recovery. What does that mean? As we relax restrictions, we let schools go back first before anything else. It means, in Scotland for example, children can play outside and do sports before adults.

My next goal is that children can go into each other's houses and have play dates and interact before adults can mix. It's about saying, if we know children are bearing the brunt of this, how do we develop our policy responses and our scientific advice in a way that puts a children-first lens on it, and says, for ethical reasons, for moral reasons, we need to put children first for the future, and think ahead? I think our responses were appropriate for what we did, but children have suffered. Anyone who says otherwise isn't paying attention.

It's about the realism coupled with, well, what do we do about it? There's no point talking about problems if you don't have solutions alongside them.

Topol: No question about that.

Verghese: Just to follow up on that point. We have such a varied response about schools here in the States, because it's all state based or sometimes even district based. Do you have any guidelines or any thoughts on what are the parameters that allow us to return kids to school safely, and how we go about that?

Sridhar: I've worked on schools now for the past year or so. I'm very, very closely involved with the Scottish response to getting schools back. I'd say we looked at this in four ways, and I think this is how we have to look at it. The first is, what is the risk to children if they get the virus in a school environment? The second is, what is the risk to their families if they bring it home to parents or to grandparents? The third is, what is the risk to teachers in terms of occupational risk of being in a classroom with children? The final one is, what are the implications for R0, or community transmission?, which is what we want to keep under 1 so we don't have an accelerating epidemic. Through each of these, we try to collect the evidence at each point and answer them. We know even with the new variant that the risk to children is minimal.

It can happen, but if we keep our numbers low enough, you're okay. It's when your numbers explode that you have problems in children. We know older children can transmit more than younger children, but generally younger children are better.

Then we asked, what is the risk to parents and their communities? Yes, children can transmit. We know that they can transmit less than adults. So far, we've seen more adult-to-child transmission than child-to-adult.

Then we said, could children be largely asymptomatic carriers or silent spreaders? We looked in hospitals where, for surgeries, all children are being tested, and we found very few asymptomatics. Now we're finding something similar, because we've introduced lateral-flow testing twice a week into schools, and again, finding very few asymptomatic children, as many as you'd expect. It's not like half of kids are asymptomatic. We said that if we keep the numbers low enough, then we won't have introductions.

A third is risk to teachers. It does seem occupationally, from our surveys, from antibody tests and others, that so far teachers have not been more severely affected. Of course, our numbers have been low though in the context of low prevalence. I think that's what it comes back to, when we come back to the final one on community transmission — that if your numbers are low, you can run schools.

In Scotland, 76% of schools had no cases. No cases at all. They ran full-time, in person, all kids in the classroom. Distancing was not possible in the classroom because otherwise we couldn't fit enough kids in. We looked at the option, and you end up increasing inequalities because private schools can do it whereas public schools can't. We looked at masks. We said, masks make sense for older children, but they don't make sense for younger children who need to develop their speech and cognitive ability, to be able to interact and see facial expressions. So we said, masks depending on prevalence.

We kept in bubbles, so we had outbreak response. When there was a case, you could stamp on it quickly and get the bubble into isolation. There were things put in place, but in the end, the lesson for me is keep your prevalence low and keep schools open if you keep them low enough. We've had schools now open for 3 weeks in Scotland. Yes, there have been clusters in schools, but we have to keep our prevalence low, keep R0 under 1, expand the vaccination program, and try to get through this and try to keep schools open.

It's bumpy. There's no easy answer. Do I think schools should always be open? No. Do I think they should always be closed? No. I think it's actually how we work with the evidence and our current levels. Every week we get evidence in, now through tracing, through these lateral-flow devices. Teachers are being tested twice a week with these and taking the issue seriously.

The B.1.1.7 worries me, though, because I think when there's a variant you need to consider whether it's more transmissible, more transmissible in children, and could what we know change? That's why we've been going very, very slowly in terms of monitoring and opening up now. The public gets frustrated. They said, "Oh, our numbers look the same as they did in September when everything was open."

I said, "Yes, we have a new variant. We know that we need to act like there's a lot of uncertainty." So far, it seems to be going smoothly. But schools are a difficult one. We know kids need to get back, and the point I keep trying to make to people is, it's not about whether schools are safe or not safe; it's about how to make them safe enough to make it acceptable to open.

Also, we need to listen to all the stakeholders. What are teachers saying? What are scientists saying? We have a teacher representative in our group that we listen to regarding what it means on the front line for how she's operationalizing things. What I don't like is that it's become a very big shouting match between big egos over who wants to be right or wrong about schools. Kids are missing out and losing out; it should be about what's best for kids.

An American in Scotland

Topol: Right. Now, one thing I'm curious about, Devi, is you've been at the University of Edinburgh. You've been there 6 years as a professor and chair in global health. As an American, you're now at mix with all these Brits and Scottish folks; is there any xenophobia? Do you feel any less accepted as a person coming from outside the UK?

Sridhar: You know, it's been quite the opposite actually, especially in Scotland. I've been so overwhelmed by how warmly I've been received here. Scottish people, in general, really like Americans.

They especially like Florida, where I'm from. They like going there on holiday. I'm overwhelmed by how welcoming they are. I couldn't believe it — even things like being up for Scotswoman of the Year. Me of all people — a Floridian, a Miami girl who's ended up here, and just the warmth that I felt for this. It is tricky politically right now because Scotland has an SNP government, the Scottish National Party led by Nicola Sturgeon, who wants Scottish independence.

There are, of course, very strange political undertones. Americans won't fully get it. I didn't fully understand it when I arrived here, but when you say good things about Scotland, people automatically assume you're pro-independence. When I lived in Miami, I was proud of Miami and I spoke well of Miami. When I lived in DC, I was pro-DC. When I lived in Germany and South Korea — I love the places I live in and I want to represent them well.

That's been the only kind of catch sometimes. I get myself into trouble because people think— I've been called both the globalist, because of my ties to the World Economic Forum and my global health work, and WHO, and Gates, and this whole kind of globalist conspiracy of the deep state. I've gotten a lot of those conspiracy theories sent my way.

I've also gotten all the nationalist stuff, with being called xenophobic here. It's funny to my friends in the States, but it's not funny when you're actually living it. People say, "Oh, you are xenophobic," because last summer I was saying, "We need to not let people go on holidays." People said that's xenophobic. How is it xenophobic? Mali's closed all its borders, India closed its borders, Vietnam has done it, and New Zealand, so are they all xenophobic countries?

It's a public health policy we're putting in place for a pandemic. People then said, "Oh, well, it's for forever. You're trying to shut us off for forever." And I said, "Well, no; it's until we get vaccines." Now that vaccines stop transmission, we're going to head to the world of vaccine passports. We're going to have international mobility. I'm sure once we have confirmation from many sources that the vaccines stop transmission, Australia and New Zealand will open up. They're going to vaccinate their population, they're going to open up, and they're going to be back to international tourism and mobility.

It was a period of time during a pandemic where we had to survive those months to buy time without taking the hit of domestic restrictions and having the lives lost. That's the only hiccup I've gotten into, I think: the idea of you're either a globalist or a nationalist, which comes from weird sources on the web. Overall, it's been, to my astonishment, a really welcoming and really positive experience being here.

Topol: I had a similar experience, although it was more transient, when I did the NHS review invited by first Jeremy Hunt and then Matt Hancock. I was working with about 50 people from throughout the UK on that review. The respect for Americans, despite some of the problems that we have, was really pronounced.

A Return to the States?

Topol: One of the other things is, can we ever get you back in the US? You are a force of nature. We need your help here. Is there any chance we can figure out a way for you to come home?

Sridhar: Well, the great thing about COVID, if we think of silver linings, is that we work so much internationally now through Zoom. The past 3 days, I've been co-chairing a meeting for the National Academies of Science, Engineering, and Medicine on the next flu pandemic. That freaked me out, because they're like, well, what if we get something as contagious as measles and as deadly as Ebola? I'm like, let's just stick with COVID. Let's not go into that universe.

But that's exciting to be working virtually in DC on something that advises the US government. I'll see where life takes me. I think the great thing about the States is that you have so many excellent scientists, like you both and others. They've been hampered because we had an administration that didn't listen to the scientists. I think the CDC is a force of good and of science and has such a track record.

What was really painful to see was to have all of that resource completely silenced, muzzled. Now hopefully with Biden, we are looking toward really positive times. You have Tony Fauci in a very prominent role. You have so many brilliant academics who are there. I feel like the States is in good hands. I don't need to worry anymore about the States.

There are enough good people now, there are enough good people in the White House in the important positions where I don't need to pay attention anymore to what's happening. I'll just let them get on with it, and get back to thinking about low-income countries and also making sure in my roles in Britain that I keep an eye on things here alongside my colleagues.

'Goldfish Memory'

Topol: I'm in awe of the clarity of your thinking and the way you broke down the answers to these questions. I'm also in awe of your productivity. You're very busy, I gather, from your scientific work, your press work, and Twitter. How do you stay sane? I think our listeners, many of whom are also very busy clinically on the front line, would like to know. How do you keep it all together? How do you see the glass half full all the time? What's your secret?

Sridhar: Well, what choice do we have? We have to wake up every morning and think it's going to be a good day, and get on with life, and try to find our way of being happy and productive, and find joy.

I think humor helps a lot. If anyone follows me on Twitter, I try to respond to any abuse I get with humor. I find it quite funny sometimes, the kind of accusations I get. I have to restrain myself from not being too sarcastic to some of the stuff and try to just ignore it. Humor, laughter, positivity. I exercise a lot; that's probably my addiction. I exercise in the morning and at night usually, to process things.

The real thing is telling people to stay in the moment. Right now, it's so easy for your brain to become overwhelmed. There's so much happening, whether it's your personal life, your friends' lives, the news cycle. Even now, I feel like my brain has been deluged with the whole Meghan Markle thing. I don't know if it's made it over there, but that's been huge here. It's just kind of constant.

When I do something, I try to block everything and just be in the moment. If I'm writing a Guardian piece it doesn't matter what's happening in the world. I have to focus on this. If I'm with a friend and they're saying to me that they're going through a really hard time, I try to focus on them and listen to what they're saying in that moment. Having that burden of to-do things, and laundry lists, and the weight of the world in your mind is exhausting and it makes you paralyzed.

I call it goldfish memory: When I'm with someone, I'm just going to focus on you and I'm not going to focus on anything else. When I get to my work, I'm just going to focus on that and I'm not going to think about other stuff. When I go to bed at night, I just clear my head. I can't think about anything because then I won't sleep.

The schools have kept me up at night because there are so many conflicting data points, and there are so many stakeholders, and they're all not wrong. Sitting in meetings where unions are telling you how teachers are sobbing because they don't want to go into classrooms, because they're scared they're going to be infected. You are wondering as a teacher if you're going to get infected and die because we gave the wrong advice.

At the same time, we get every week a report from the child welfare officer. You hear about the rises in child abuse, and the children who are getting beaten up at home because they're not able to get out, and they have parents who have lost their jobs, and they're angry, stuck in tiny flats, and they have no money. You're thinking, well, kids need to get back to school. No one is wrong; everyone is right in what they're saying to you. How do you give the best scientific advice?

What keeps me up, the one thing that does stress me is, am I giving the best scientific advice? Where are the holes in my argument? I welcome rigorous debate, hard questions, and people telling me when I'm wrong — as long as it's not name calling (I think that's just a lot of Twitter). If someone says to me or sends me an email that says they think I'm getting it wrong, I really listen because I want to know if I'm getting it wrong. I really want to get it right.

Topol: Well, this has been an extraordinary conversation with you, Devi. In a way without knowing it, you kind of trained for the pandemic throughout your life — all the time you spent, whether it was in India or focusing on malnutrition and poverty, and then with Ebola. It's extraordinary. Of course, we're going to get through this pandemic. It's going to be really interesting to watch your next chapter, where you're going.

I have to say, ever since I got to know you from your writings and your work, whenever I see the term "global health," I think of you. You are just an extraordinary leader and you have such an incredible career in front of you. We're going to be following you because we know great things still lie ahead.

Thank you so much for sharing your views. These are complicated matters, perhaps epitomized by the schools, but it's been a real joy to have you join us today.

Sridhar: Thank you.

Topol: Thanks for what you're doing. You're amazing. You really are.

Sridhar: I'm just overwhelmed by how gracious you're being to me. Most of the time, I'm hearing how rubbish I am. If you're on Twitter, it's like 99% of people telling you why you're wrong. Today I posted my lunch, which was chocolate and a bread, and I'm like, I'm not going to look at the response to that. I sent out a cake tweet and I got so much hate for that. I don't know if you saw that.

After this is finished, I want to go to Bali. I've always wanted to go to Bali. I'm going to do it when I get my vaccine passport and things are sorted, and then see where this goes next. Hopefully, I can go back to the quiet academic life that has been missing for the past year, and back to things I love: teaching, research, and actually looking at interesting questions.

Thank you for having me. Hopefully at some point, we'll get together and be able to meet whenever we get back to meeting in person. I love California. I'm envious of your sunshine, your good vibes, and the nice weather.

Topol: You have a standing invitation at Scripps and Stanford for sure. We'll look forward to meeting up with you in person at the other end of this thing. Thanks a lot.

Sridhar: Cheers.

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.

Devi Sridhar, MPhil, DPhil, is an avid runner and left the podcast interview to get a run in between rain showers. She is one of six finalists for this year's Scotswoman of the Year award; the winner will be announced on April 29.

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