Faust Files: Zeke Emanuel on ‘Living With COVID’

In this video, Jeremy Faust, MD, of Brigham and Women’s Hospital in Boston and MedPage Today‘s editor-in-chief, and Ezekiel Emanuel, MD, PhD, of the University of Pennsylvania in Philadelphia, discuss a new roadmap for living with COVID-19, and give an inside look at the COVID Advisory Board during the Biden-Harris transition.

The following is a transcript of their remarks:

Faust: Hello, I’m Jeremy Faust, editor-in-chief of MedPage Today. Thanks for joining us. Today, we are joined by Dr. Ezekiel Emanuel.

Dr. Emanuel was a former COVID-19 Advisory Board member during the Biden-Harris transition. He is also the lead author of a new plan for the future entitled “Getting to and Sustaining the Next Normal: A Roadmap for Living with COVID.”

Dr. Emanuel, thank you so much for joining us.

Emanuel: It’s my pleasure.

Faust: So when they had policies rolling out in the fall, I didn’t feel as if people, like maybe the Biden task force — the advisory transition task force — were really parts of those conversations. I certainly wasn’t, but I didn’t get a sense that others were either, and that there was kind of an increasing sense of insular “go-it-alone” kind of approach.

My sense though is that after December, when you and a few others from that task force and transition team published these editorials in the Journal of the American Medical Association — and we had a couple of those authors on with us at MedPage Today in this format — that after that there was a little more of an opening; more of a…robust conversation with those trusted people like yourself, and people who are also lead authors on this roadmap that we’re discussing. Have the last couple of months been a little bit more…has there been more time for those conversations? Is that a good way to ask it?

Emanuel: Yes. The answer is yes. And I do think that when we published the JAMA articles — and basically said ‘We need a new strategic plan; the old one is a year old — things are different; we’ve had Delta, we’ve had Omicron; and the perspective is very different. We’re not getting rid of COVID, we’re not going to have a vaccine that prevents transmission,’ I do think that probably changed the attitude, well, to ‘We need to rethink this.’ And we began a process of more systematic consultation.

Faust: And let’s talk about the rubber meeting the road. Has any aspect of the new roadmap already sort of begun to take shape even in just the last few weeks? And if so, what aspects have the administration indicated that they’re most interested in getting off the ground, and are there some areas that they say, ‘Yes, but we need funding?’ Where are we with a few of the key provisions?

Emanuel: Well, first of all, I think there’s a huge amount of interest; there was a huge amount of interest; we spent a lot of time when we developed the roadmap talking to the White House, as well as HHS [Department of Health and Human Services]. But, you know, just take the ‘Test to Treat‘ proposal. It may not be exactly the proposal I had in mind or you might prefer, but I do think that’s an example of something that we advised them on, and they took to heart, and have worked out what they think is the best kind of program they can actually stand up. So I do think that’s a good example.

I’ve had some discussions with people at the CDC about a data infrastructure and getting data inputs and making that, not an emergency measure, but actually more permanent and getting the standardization around the data platforms permanent. So I do think those things are happening.

Faust: I think the ‘Test to Treat’ is an important framework, but as always, there’s always surprises and twists. There’s already been some pushback from the American Medical Association, which said “Well, wait a sec, this could be a scope-creep problem where people other than physicians are involved in these decisions.” Where do you come down on that?

Emanuel: So first of all, I think the American Medical Association raised some issues, which is that these are serious drugs. They have a lot of drug-drug interactions. We need to be careful. And then they said everyone should consult their primary care doctor.

Let’s wake up…tens of millions of Americans don’t have primary care doctors. And they don’t have a doctor to consult. We have a healthcare system that leaves a lot of people falling through the cracks — we need to get to those people. They tend to be the most vulnerable people and often the people who actually need these medications.

So, I think, unless the American Medical Association has a solution to the problem of not everyone having a doctor, we’re going to have to go with something that doesn’t require a primary care or a specialist doctor for every patient to get this.

Otherwise, if we do require a doctor, it is gonna look very inequitable and the rich are gonna win yet again, which is not something we want to have happen.

Faust: I have a question about guidelines in the year 2022. Things are so politicized. I talked with my friend Carter Mecher, who developed the influenza plan back in the Bush years, and I said, ‘Carter, do you think we need four plans? Like one when the Democrats are in the White House but Republicans are in Congress and all the four, you know, do that grid. Because some states will not do certain things depending on who’s in charge.’ And he said ‘Yeah, probably. In a way we didn’t before.’

Are there parts of this plan that you think will have better uptake in certain parts of the country? And if that’s true, what can we do to reach the places that are actually hard to reach?

Emanuel: I think it’s inevitable. When you call for vaccinations and when the vaccine for kids is approved for 5- to 17-year-olds, mandating it as part of the school vaccination series, those kinds of things are definitely gonna be controversial.

But we also — one of the things we have tried to do is to recommend things that are going to be in the background and don’t require individual public attention, like the surveillance system, like improving indoor air quality. I think we spent a lot of time trying to think about those kinds of programs that would be best done, as it were, in the background. And people would not necessarily notice it.

Also, having a dashboard so you can communicate to people ‘Here’s what we’re looking at. Here’s why we impose these restrictions. Here’s when we can relieve those restrictions.’ I think it’s fundamentally important. And I think the fact that it’s taken us 2 years to get even a crude dashboard, of which your circuit breaker idea is integral to, I think that’s actually a mistake. I think that’s something that should have been done earlier.

I hope if there’s a legacy here for the next crisis and emergency, having a dashboard that the public can see, and can see what experts are looking at and why they’re looking at that is, I think, a very, very important learning from this pandemic.

Faust: Okay, last question. Other than money, what are the barriers to having everything that’s recommended in this roadmap become a reality?

Emanuel: Well, I think it’s the same thing over and over again. It’s the country forgetting, and the country wanting to move on, and the country not devoting the kind of leadership and skill to actually implementing these things. It wouldn’t take that long to actually do most, I don’t know all, but most of the things that get them going…it sounds huge: a hundred billion in the first year, 30 billion for the next couple of years, but that’s not huge given the magnitude of the economic insult of this pandemic — 7.5 trillion in economic loss; 6 trillion dollars having to be put out by the federal government to bail out various parts of the economy and American families. You know, 200, 300 billion dollars in additional investment is small change, and the return on investment is huge.

We can’t stop and can’t get into complacency. We have to continue this and really systematically improve our public health system in oh-so many ways. And let me say that the countries that did that after the 2003 SARS scare — Taiwan, South Korea, Japan — they actually did much better in this pandemic because they took those lessons very seriously, and they decided that they were going to hire more experts on infectious disease; that they were gonna put in better monitoring systems, and on and on, and that’s really something we need to do in the United States. We gotta stop being reliant on data from Israel or data from Britain or data from Denmark, and have our own infrastructure that really works extremely well, and become data producers and not data users.

Faust: If I hear you correctly, I think you’re saying that we are a billion wise and a trillion foolish, so that’s kinda the old, you know, a billion here, a billion there, pretty soon, it’s real money. Thank you for joining us here with MedPage Today.

Emanuel: Thank you, Jeremy. It’s been a fantastic interview, and I really appreciate your help in devising the dashboard for the roadmap; really, really helpful.