WEBVTT - Fighting Coronavirus with Data 0:00:15.356 --> 0:00:22.716 Pushkin from Pushkin Industries. This is Deep Background, the show 0:00:22.756 --> 0:00:26.076 where we explored the stories behind the stories in the news. 0:00:26.596 --> 0:00:30.596 I'm Noah Feldman. The past few weeks, we've seen the 0:00:30.636 --> 0:00:34.236 federal government taking measures to stop a coronavirus that would 0:00:34.276 --> 0:00:38.676 have been almost unimaginable not too long ago. The President 0:00:38.716 --> 0:00:41.756 declared a national emergency at the state and local level. 0:00:42.036 --> 0:00:45.116 More and more mayors and governors have declared stay at 0:00:45.116 --> 0:00:48.356 home orders. The US Mexico border is closed to non 0:00:48.436 --> 0:00:51.836 essential travel, same with the border to Canada. Most travel 0:00:51.876 --> 0:00:55.356 from the US to Europe has been suspended. Probably even 0:00:55.476 --> 0:00:58.596 more things have changed since I recorded this podcast on 0:00:58.676 --> 0:01:02.716 Monday evening. Does any of this federal response make sense? 0:01:03.276 --> 0:01:07.036 Does the state response make sense? Are we acting based 0:01:07.076 --> 0:01:10.756 on data, logic and reason? And what should we be doing? 0:01:11.756 --> 0:01:14.876 To get a really expert perspective on this, I spoke 0:01:14.916 --> 0:01:19.276 to doctor Farzad Moustashari during the Obama administration. Farzad was 0:01:19.316 --> 0:01:22.836 the National Coordinator for Health and Information Technology at the 0:01:22.836 --> 0:01:27.036 Department of Health and Human Services. Before that, he worked 0:01:27.076 --> 0:01:30.116 for the Centers for Disease Control in the New York Office, 0:01:30.436 --> 0:01:34.076 focusing on New York City public health. Now he's the 0:01:34.116 --> 0:01:39.116 founder and CEO of Allidate, a healthcare technology company. Farzad 0:01:39.196 --> 0:01:41.596 is one of the clearest and most rational people that 0:01:41.676 --> 0:01:44.036 I know, and I knew he would have a lot 0:01:44.116 --> 0:01:48.316 to say on this topic. Farzad, from very early in 0:01:48.356 --> 0:01:52.596 this crisis, and I mean very early, you were loudly 0:01:52.716 --> 0:01:55.876 saying on Twitter and I was following you closely, that 0:01:55.916 --> 0:01:58.916 we didn't have a coherent national response strategy, even at 0:01:58.916 --> 0:02:01.356 the conceptual level of knowing what we were trying to do. 0:02:02.076 --> 0:02:05.396 Have your worries on that front been at all alleviated 0:02:05.516 --> 0:02:07.916 or do you still think we have a lack of coherence? 0:02:08.036 --> 0:02:13.316 Oh my god, I wish No. We don't have a plan, 0:02:13.796 --> 0:02:18.276 and there's no clear criteria on when what are we 0:02:18.316 --> 0:02:21.956 trying to do in each community at what stage? And 0:02:22.036 --> 0:02:24.636 when are we in containment and we're trying to do 0:02:24.756 --> 0:02:27.436 contact tracing and stamp out the sparks as they're coming 0:02:27.476 --> 0:02:29.916 in and keep it out, And when are we trying 0:02:29.916 --> 0:02:33.356 to do social distancing and mitigation, And when are we 0:02:33.396 --> 0:02:38.916 going full bore on suppression and doing these extreme measures, 0:02:39.796 --> 0:02:42.436 and when are we going to get out right? So 0:02:42.676 --> 0:02:45.716 we have a plan that says a fifteen day plan 0:02:45.836 --> 0:02:50.236 to slow the growth. What happens on day sixteen. Noah, 0:02:50.596 --> 0:02:51.996 I was hoping you were going to tell me that. 0:02:52.356 --> 0:02:54.876 I mean, you know you're asking the wrong guy. One 0:02:54.876 --> 0:02:57.916 of us is actually a public health specialist. Well, I'm 0:02:57.956 --> 0:02:59.996 telling you, on day sixteen, you know what it's gonna 0:02:59.996 --> 0:03:02.396 look like. It's going to look bad. If we had 0:03:02.436 --> 0:03:07.236 done a miraculous job of slowing down transmission, we still 0:03:07.276 --> 0:03:11.676 would be seeing mounting case of hospitalizations, ICU cases and 0:03:11.836 --> 0:03:15.276 deaths on day fifteen, purely based on the people who 0:03:15.276 --> 0:03:19.756 are already infected. So I think we have to have 0:03:19.796 --> 0:03:23.116 a plan that says these are the measures, these are 0:03:23.116 --> 0:03:26.436 the data points that we look to to decide when 0:03:26.476 --> 0:03:30.916 we take these extreme economy crippling measures, and this is 0:03:30.916 --> 0:03:34.396 when we get out of them. And we don't have 0:03:34.476 --> 0:03:36.676 that right now. But not only do we not have 0:03:36.756 --> 0:03:39.916 the plan, we don't have the plan to get to 0:03:39.996 --> 0:03:42.996 the plan to get the data that we would need 0:03:43.036 --> 0:03:46.316 to be able to make that plan effective. Right because 0:03:46.396 --> 0:03:50.796 we're doing testing and the promise here has been testing 0:03:51.156 --> 0:03:53.476 more tests. Everyone who wants a test can get it. 0:03:53.676 --> 0:03:55.196 And let me tell you, my friends who are in 0:03:55.236 --> 0:03:58.796 the public health world are tearing their hair out saying 0:03:59.156 --> 0:04:03.716 we don't just need more tests. We need to get 0:04:03.796 --> 0:04:07.596 actual insights from those tests. We need, for example, to 0:04:07.716 --> 0:04:12.276 know among all the people, how many tests are positive, 0:04:12.316 --> 0:04:15.156 what percent of tests are positive. But right now we're 0:04:15.156 --> 0:04:18.436 only getting the positives. Secretary Esar said, I don't know 0:04:18.476 --> 0:04:20.956 how many tests are done. We don't know how many 0:04:20.956 --> 0:04:22.996 tests are being done. So when we see an increase 0:04:23.036 --> 0:04:26.076 in the number of positives, is that the infections getting 0:04:26.076 --> 0:04:29.676 worse or that we're testing more people. So you've described 0:04:29.796 --> 0:04:34.556 a very very grammar situation. Now you have seen public 0:04:34.556 --> 0:04:37.516 health issues from a broad range of perspectives. You've seen 0:04:37.556 --> 0:04:41.596 it as a New York City public health official, so 0:04:41.676 --> 0:04:44.756 that was the local. You've seen it from the federal 0:04:44.836 --> 0:04:49.156 level at HHS. Now you're seeing it from the private sector. 0:04:49.916 --> 0:04:53.156 You're almost uniquely qualified, it seems to me to say 0:04:53.196 --> 0:04:56.036 what we could realistically do now, So let's be as 0:04:56.076 --> 0:04:59.796 concrete as we positive can and productive. What would be 0:04:59.876 --> 0:05:04.036 your top, say, three recommendations to our national leadership of 0:05:04.076 --> 0:05:06.556 what to do. Yeah, let me focus on the testing 0:05:06.556 --> 0:05:10.076 issue for the three recommendations, because I do think that's 0:05:10.076 --> 0:05:12.476 the biggest priority is for us to get some value 0:05:12.756 --> 0:05:16.236 out of the testing. That's beginning to roll out Number one, 0:05:17.036 --> 0:05:21.756 we need to set up what's called a zero survey. 0:05:22.636 --> 0:05:26.156 And this is something that as an Epidemic Intelligence Service 0:05:26.196 --> 0:05:29.316 officer of the CDC station in New York City, we 0:05:29.396 --> 0:05:32.116 had this outbreak of West Nile virus that killed a 0:05:32.116 --> 0:05:35.156 bunch of people, and we said, but we don't know 0:05:35.516 --> 0:05:38.156 if it's really deadly to old people or if a 0:05:38.156 --> 0:05:41.636 lot of people get infected and only a small number die. 0:05:41.876 --> 0:05:44.796 So we need to go literally door to door to 0:05:44.956 --> 0:05:48.396 collect blood from people to test their blood to see 0:05:48.396 --> 0:05:52.276 if they've been exposed to this virus that was in 0:05:52.356 --> 0:05:55.316 nineteen ninety nine. We need to do that in New 0:05:55.396 --> 0:05:59.916 Rochelle now. So that's number one. So that's set up 0:05:59.916 --> 0:06:03.116 a zero study, which is literally a door to door, 0:06:03.156 --> 0:06:05.556 door to door. Will you gather data from each individual 0:06:05.556 --> 0:06:08.076 person who is infected and from those who were not 0:06:08.196 --> 0:06:11.356 visibly infective and evaluate that data. That's right, and the 0:06:11.396 --> 0:06:13.396 takeaway you'll get from that is what what will you 0:06:13.476 --> 0:06:16.036 learn from that study? Will learn of a hundred people 0:06:16.076 --> 0:06:18.996 infected with the virus, how many end up going to 0:06:19.036 --> 0:06:21.316 the emergency room, being hospitalized, being in an ICU, and 0:06:21.356 --> 0:06:24.916 being dead. Because let me tell you, that number is 0:06:24.996 --> 0:06:28.676 not two point three percent, and it's probably not one percent. 0:06:28.916 --> 0:06:32.836 It's probably smaller. The fatality rate, the infection fatality rate 0:06:33.636 --> 0:06:39.036 is probably much lower, and that's important why because what's 0:06:39.036 --> 0:06:42.916 gonna save us is herd immunity. At the end of 0:06:42.956 --> 0:06:46.436 the day, we have to use the fact that people 0:06:46.516 --> 0:06:51.036 are immune from this, whether through vaccination or through infection. 0:06:51.756 --> 0:06:54.676 And the good news would be if there are a 0:06:54.676 --> 0:06:58.756 lot of unnoticed infections of people who are now immune 0:06:59.316 --> 0:07:04.836 and can dampen the spread of this outbreak, walk me 0:07:04.876 --> 0:07:08.556 through this. So we do this close fine grand analysis. 0:07:08.636 --> 0:07:11.156 It tells us with much more accuracy than we presently 0:07:11.196 --> 0:07:13.636 know of the number of people who are exposed to 0:07:13.676 --> 0:07:16.116 the virus, how many will be hospitalized, and how many 0:07:16.156 --> 0:07:20.396 will die. Then with that information we can make a 0:07:20.436 --> 0:07:25.236 better prediction about at what point we can start relying 0:07:25.316 --> 0:07:28.676 on people who are immune to start getting back into 0:07:28.676 --> 0:07:30.436 the world. Is that right? And then we need an 0:07:30.476 --> 0:07:33.196 antibody test to test if people had been exposed, because 0:07:33.196 --> 0:07:34.956 there are lots of people out there on your hypothesis 0:07:35.156 --> 0:07:37.556 who've been exposed and haven't gotten sick and now aren't 0:07:37.556 --> 0:07:40.276 going to get the virus again. Assuming that it works 0:07:40.316 --> 0:07:42.916 like other viruses and not like the common cold where 0:07:42.916 --> 0:07:45.436 you can keep on getting it. That's right. So this 0:07:45.476 --> 0:07:47.476 would give us the data which would then move us 0:07:47.476 --> 0:07:49.996 in the direction of enabling what what's the picture of 0:07:49.996 --> 0:07:52.476 the world where we've got this data and where we 0:07:52.516 --> 0:07:55.076 have an antibody test and we can say, Okay, you know, 0:07:55.156 --> 0:07:57.716 Noah's been exposed, but he didn't get sick, so he 0:07:57.756 --> 0:07:59.316 can now go out there and do what. If I'm 0:07:59.316 --> 0:08:00.916 a doctor, I can go back to work as a doctor. 0:08:01.276 --> 0:08:03.556 If I'm running an ordinary shop, can I go back 0:08:03.556 --> 0:08:05.356 and work in my ordinary shop now? Because I'm not 0:08:05.396 --> 0:08:07.836 going to infect anybody exactly. The first use of this 0:08:08.036 --> 0:08:11.756 is honestly to inform our models of the world. If 0:08:12.036 --> 0:08:13.636 we're going to say that this thing is going to 0:08:13.716 --> 0:08:16.276 go on until thirty percent of the population or twenty 0:08:16.276 --> 0:08:19.516 percent of the population is infected, well, how many ICU 0:08:19.556 --> 0:08:23.116 beds is that it's a very different story if every 0:08:23.996 --> 0:08:26.836 ten people who get infected one of them needs an 0:08:26.916 --> 0:08:28.916 ICU bed versus if it's one hundred, versus if it's 0:08:28.916 --> 0:08:32.036 a thousand. So the first thing it informs is the 0:08:32.036 --> 0:08:34.596 state of the situation we're in right now where we 0:08:34.676 --> 0:08:37.796 desperately need to know and do not know what the 0:08:37.876 --> 0:08:39.836 impact of this is going to be on our healthcare 0:08:39.876 --> 0:08:42.956 resources and facilities in the search capacity because we don't 0:08:42.996 --> 0:08:47.716 know the ratio between infected and the cases. This is 0:08:47.756 --> 0:08:51.356 super helpful. So basically number one priority is you can't 0:08:51.396 --> 0:08:53.076 plan if you don't know what actually is going to 0:08:53.116 --> 0:08:56.036 happen in the world. And this information is so basic 0:08:56.396 --> 0:08:58.356 to figuring out what's going to happen that we can't 0:08:58.356 --> 0:09:01.236 do intelligent planning really without it. Correct And I was 0:09:01.276 --> 0:09:04.116 talking to a modeler from a university near you who 0:09:04.196 --> 0:09:07.716 was saying, I don't know that the future could go 0:09:08.476 --> 0:09:11.156 you know, many many different directions, And I said, what 0:09:11.316 --> 0:09:13.276 is the piece of data you need to make your 0:09:13.316 --> 0:09:17.116 models have smaller variants in terms of the outcomes. And 0:09:17.476 --> 0:09:20.196 she said, what I need more than anything else is 0:09:20.236 --> 0:09:23.556 I need to know the percent infected. So okay, let's 0:09:23.596 --> 0:09:25.756 do that. The other application of it is what you said, 0:09:25.836 --> 0:09:29.156 which is and some have posited this, well, maybe we 0:09:29.196 --> 0:09:33.236 could have, you know, green bracelets for people who are 0:09:33.516 --> 0:09:36.396 already immune and they could end up helping run the 0:09:36.436 --> 0:09:39.156 society while the rest of us are in lockdown. I 0:09:39.196 --> 0:09:42.436 don't know about that use of the antibody testing, but 0:09:42.836 --> 0:09:45.836 let's start with the epidemiologic uses. So that's number one. 0:09:46.116 --> 0:09:50.556 Number two is we need to know within a given 0:09:50.796 --> 0:09:57.396 city whether we're seeing widespread disease outbreak or not. And 0:09:57.956 --> 0:10:00.796 right now, in the absence of any guidance, in the 0:10:00.836 --> 0:10:05.916 absence of data, individual governors and mayors and others have 0:10:06.076 --> 0:10:10.396 made individual decisions, and I'm telling in some places it 0:10:10.436 --> 0:10:13.396 was too late, and I can also tell you in 0:10:13.436 --> 0:10:17.476 some places it's too early. And this is the problem 0:10:17.516 --> 0:10:21.956 with the germ of truth that the kind of cynics 0:10:22.036 --> 0:10:24.356 are having out there, of like, oh, this is much 0:10:24.396 --> 0:10:30.316 ado and we're overreacting. Well, in some cities, maybe we are, 0:10:31.076 --> 0:10:34.876 but we don't know which. And so we need to 0:10:34.916 --> 0:10:38.436 have a systematic way of using the tests that we 0:10:38.516 --> 0:10:42.036 have and using the information we've already collected to be 0:10:42.076 --> 0:10:45.196 able to know is this virus spreading. Is it at 0:10:45.236 --> 0:10:47.756 the point where there's sparks we can stamp out with 0:10:48.156 --> 0:10:51.676 contact tracing, or it's too late to start to stamp 0:10:51.756 --> 0:10:53.956 out sparks. The whole house is on fire and you 0:10:54.036 --> 0:10:56.356 need to just turn the hose on and slow it 0:10:56.396 --> 0:10:59.236 down and make it go a little less fast. And 0:10:59.316 --> 0:11:01.396 how would we find out this information and number two. 0:11:01.396 --> 0:11:04.356 If number one is door to door study, number two 0:11:04.476 --> 0:11:08.036 is just massive testing. I take it. Actually, it's not 0:11:08.116 --> 0:11:11.756 the number of tests, it's how you do the tests. Okay, 0:11:11.876 --> 0:11:13.836 tell me more about that. How do you do the tests? Yeah? 0:11:13.916 --> 0:11:17.276 The big problem is that we have two different public 0:11:17.276 --> 0:11:19.476 health reporting systems in this country. And if you just 0:11:19.476 --> 0:11:21.356 think about it, it kind of makes sense. Noah. Right, 0:11:21.836 --> 0:11:24.596 you go into the doctor's office and they draw your 0:11:24.596 --> 0:11:27.436 blood and they send it to the lab. The lab 0:11:27.476 --> 0:11:30.036 then gets a positive result and they report it to 0:11:30.116 --> 0:11:33.196 the public health authorities. Right, that is the laboratory arm 0:11:33.316 --> 0:11:37.596 of public health reporting. What information does the lab have 0:11:37.836 --> 0:11:40.476 about you? Almost none? I take it. I just know 0:11:40.716 --> 0:11:42.956 that's your blood sample. Yeah. They know your name, and 0:11:42.996 --> 0:11:45.796 they know your day of birth, and maybe you're addressed, 0:11:45.996 --> 0:11:50.276 maybe not, depending Right. They don't know your symptoms, they 0:11:50.276 --> 0:11:52.996 don't know your exposures. They don't know if you're hospitalized 0:11:53.196 --> 0:11:56.596 or going to be hospitalized, And which is why the CDC, 0:11:57.236 --> 0:12:01.596 in the Morbidity Immortality Weekly Report, the flagship publication of 0:12:01.596 --> 0:12:04.556 the CDC, had their first case report of forty two 0:12:04.636 --> 0:12:08.636 hundred plus cases positive cases in the United States. They said, 0:12:08.836 --> 0:12:11.916 we do not know the hospitalization status of half of them, 0:12:14.076 --> 0:12:17.596 So we didn't even know the age of ten percent 0:12:17.756 --> 0:12:22.876 of the positive cases. So giving more testing done in 0:12:22.996 --> 0:12:27.276 lab core and quest and hospital labs that end up 0:12:27.476 --> 0:12:31.956 flooding the public health system with cases that we know 0:12:32.076 --> 0:12:36.476 nothing about is not helpful. It's not getting more testing 0:12:36.516 --> 0:12:40.156 out there, it's we want to have tests done where 0:12:40.196 --> 0:12:44.916 the laboratory results are tied to the key clinical and 0:12:44.956 --> 0:12:47.556 epidemologic data for us to make sense of it. So 0:12:47.596 --> 0:12:51.436 that key data is is this person part of a 0:12:51.556 --> 0:12:54.156 known cluster? What is their exposure? Did they travel? Do 0:12:54.236 --> 0:12:56.676 they know someone? Do they who has it? That? We 0:12:56.676 --> 0:13:00.196 should ask people basically on a form at the same 0:13:00.236 --> 0:13:02.236 time as they're having their blood drawn, that forms should 0:13:02.236 --> 0:13:04.396 be filled out. That's the simplest form of this, right, 0:13:04.996 --> 0:13:07.116 And we should also ask them, oh, do you have 0:13:07.116 --> 0:13:10.836 any symptoms? When did those symptoms start. With those two 0:13:10.876 --> 0:13:14.916 pieces of data and the person's age in county, I 0:13:14.956 --> 0:13:17.836 can now construct an epicurve and I can tell you 0:13:17.916 --> 0:13:20.596 with those pieces of data, is the outbreak in this 0:13:20.636 --> 0:13:24.436 city getting better or worse? But I need both parts 0:13:24.476 --> 0:13:27.516 of that data. I need the clinical and epidemiologic risk 0:13:27.556 --> 0:13:31.636 factor data and I need the lab data so where 0:13:31.756 --> 0:13:35.396 can we get both of those pieces of data. We 0:13:35.476 --> 0:13:40.156 have to set up sentinel surveillance sites where at the 0:13:40.356 --> 0:13:43.956 cost of getting the lab test, you also will have 0:13:43.996 --> 0:13:46.876 to fill out the form. So this is where not 0:13:46.956 --> 0:13:50.036 just blasting the tests out there, but actually setting up 0:13:50.116 --> 0:13:55.436 some planful places where in an emergency room, every person 0:13:55.476 --> 0:13:58.156 who comes in with fever cough is going to get tested. 0:13:58.276 --> 0:14:01.316 Or in a doctor's office we set up doctors offices, 0:14:01.716 --> 0:14:05.516 we set up sentinel testing sites, or at a drive 0:14:05.556 --> 0:14:08.596 through clinic a drive through testing site, we make sure 0:14:08.676 --> 0:14:12.476 that we collect both pieces of information. That's how this 0:14:12.516 --> 0:14:15.516 is going to get done. And right now I have 0:14:15.956 --> 0:14:24.236 heard roughly nobody create an actual funded plan to resource 0:14:24.356 --> 0:14:29.516 the development of dedicated testing sites that collect the information 0:14:29.636 --> 0:14:34.356 at scale sufficient to answer these questions? Why far as odd? 0:14:34.436 --> 0:14:36.956 Why is it the case that if something is as 0:14:36.956 --> 0:14:40.036 straightforward as you're describing it as being the sentinel sites, 0:14:40.076 --> 0:14:42.556 and I take it it's called sentinel because it gives 0:14:42.596 --> 0:14:44.356 you an early warning of what's going on, or in 0:14:44.356 --> 0:14:46.756 this case and not so early warning. Why is it 0:14:46.796 --> 0:14:48.876 the case that no one is proposing that? And if 0:14:48.876 --> 0:14:51.716 I could make the question even a little meaner, you know, 0:14:51.796 --> 0:14:55.756 you were National Coordinator for Health IT for the Federal 0:14:55.796 --> 0:14:58.516 Department of Health and Human Services in the Obama administration. 0:14:59.356 --> 0:15:02.476 Why was this not part of what your team or 0:15:02.516 --> 0:15:05.876 the broader HHS community was trying to have in a 0:15:05.916 --> 0:15:08.796 contingency plan for the day that you knew perfectly well 0:15:08.836 --> 0:15:10.956 would some day come where a crisis like this would 0:15:10.956 --> 0:15:15.716 break out. Because we as humans lurch from panic to 0:15:15.876 --> 0:15:21.996 panic in periods of complacency. That's what we do. We 0:15:22.076 --> 0:15:26.196 all do that, and there are some more extreme examples 0:15:26.236 --> 0:15:31.276 of where we let complacency take root. But I don't 0:15:31.276 --> 0:15:36.356 think anyone is blameless in forgetting you just forget what 0:15:36.396 --> 0:15:39.076 it feels like to be in this moment, Like we 0:15:39.116 --> 0:15:40.836 should make a list of the shit we're going to 0:15:40.956 --> 0:15:43.756 fix during the period of complacency between panic and panic. 0:15:43.796 --> 0:15:46.316 Like we should make that list, and we should now, 0:15:47.556 --> 0:15:50.556 and we should just stick to it for God's sake 0:15:50.956 --> 0:15:55.116 and get it done. What's the barrier though, to simply 0:15:55.236 --> 0:15:59.196 a national edict from CDC that says, Hey, everybody in 0:15:59.196 --> 0:16:02.716 the country who's testing you must simultaneously fill out this 0:16:02.756 --> 0:16:05.476 form which we're posting online right now, and you must 0:16:05.516 --> 0:16:08.836 ask the patient about the progress of his or her symptoms. 0:16:08.876 --> 0:16:10.996 I mean, it sounds like of all the interventions we've 0:16:11.076 --> 0:16:13.036 you know, we can imagine that sounds like a pretty 0:16:13.036 --> 0:16:15.276 inexpensive one, except for the coordination of the data, which 0:16:15.276 --> 0:16:19.316 I recognize would take some work. So look, the US 0:16:19.316 --> 0:16:24.036 system really does delegate public health to stay local officials. 0:16:24.436 --> 0:16:30.876 The CDC is an incredibly powerful institution, but mostly through guidance, yes, funding, 0:16:31.596 --> 0:16:36.236 but expertise, and ultimately they need to be the ones 0:16:36.516 --> 0:16:40.156 who are front and center, who are speaking with the 0:16:40.236 --> 0:16:44.356 voice of evidence based public health to the American people 0:16:44.356 --> 0:16:46.796 about what the strategy should be. And let me ask you, 0:16:47.396 --> 0:16:49.516 when was the last time the CDC was at the 0:16:49.556 --> 0:16:54.556 podium at the Coronavirus Task Force. It's been some days. 0:16:54.756 --> 0:16:57.956 It's been many, many, many days, so we have not 0:16:58.156 --> 0:17:01.876 heard from and shook it. But to be fair, the 0:17:01.956 --> 0:17:04.196 CDC doesn't have to be at the I mean, that 0:17:04.276 --> 0:17:06.636 has some symbolic meeting, but the CDC doesn't have to 0:17:06.636 --> 0:17:09.276 be at the podium to issue a guidance on this, 0:17:09.636 --> 0:17:12.556 especially if it sees itself as, among other things, the 0:17:12.596 --> 0:17:16.316 coordinator of National Data. I mean, if we had the 0:17:16.316 --> 0:17:18.436 head of the CDC here and asked her, you know, 0:17:18.516 --> 0:17:20.476 why haven't you done this, what would she be saying, 0:17:21.116 --> 0:17:23.636 I don't know. I don't know, Noah. And to me, 0:17:24.396 --> 0:17:30.796 one of my proudest career experiences was being at this CDC. 0:17:31.916 --> 0:17:36.636 It's a fantastic institution with thousands of incredible experts, and 0:17:36.796 --> 0:17:40.716 I just do not understand why they have not been 0:17:40.796 --> 0:17:43.756 frem and center and leading in the way that they 0:17:43.876 --> 0:17:47.956 know how to in this experience. I just I'm baffled, 0:17:47.996 --> 0:17:50.476 and I don't have a good answer for you. We'll 0:17:50.516 --> 0:18:02.276 be back in just a moment. You've given us one 0:18:02.276 --> 0:18:05.716 in two suggestions, super clear, what's your third biggest recommendation? 0:18:05.916 --> 0:18:09.676 So the third piece of this is a system that 0:18:09.756 --> 0:18:15.556 I did play some part in really designing or creating 0:18:16.036 --> 0:18:19.956 some twenty years ago, which has now become commonplace practice 0:18:20.036 --> 0:18:23.996 in public health, which is called syndromic surveillance. And this 0:18:24.076 --> 0:18:27.236 is saying remember I talked about how long it takes 0:18:27.236 --> 0:18:30.836 and the data problems of getting a lap specimen confirmed 0:18:30.956 --> 0:18:35.276 with say coronavirus. The idea here was, well, people go 0:18:35.356 --> 0:18:39.356 to live their lives, and they register in the emergency room, 0:18:39.356 --> 0:18:41.516 and there's a piece of data collected for that, and 0:18:41.556 --> 0:18:45.356 they go buy medications and the phazinc at the pharmacy, 0:18:45.396 --> 0:18:48.036 and it goes deep at the counter, and you could 0:18:48.076 --> 0:18:51.796 gather up all those little bits and drabs of the 0:18:51.916 --> 0:18:56.276 exhaust of administrative data that governs our lives, and you 0:18:56.316 --> 0:18:58.796 can actually put it to purpose, putting your finger on 0:18:58.836 --> 0:19:01.996 the pulse of the city's health in real time and detect. 0:19:02.396 --> 0:19:05.276 At that time, we were thinking bioterrorism. Now we're thinking 0:19:05.316 --> 0:19:09.796 coronavirus pandemic. And it turns out we spend hundreds of 0:19:09.836 --> 0:19:13.876 millions of dollars. And as part of the health information 0:19:13.916 --> 0:19:18.916 technology transformation that I helped push, we required hospitals to 0:19:18.996 --> 0:19:23.836 report every emergency room visit to these state public health 0:19:23.996 --> 0:19:27.196 systems in syndromes where you could group them and say, 0:19:27.436 --> 0:19:30.316 does the person come in have a GI syndrome or 0:19:30.316 --> 0:19:33.476 a respiratory syndrome or a flu syndrome? And so we 0:19:33.556 --> 0:19:36.356 have the system. You don't have to build it. Now, 0:19:36.476 --> 0:19:39.076 you don't have to recreate it. We've spent a lot 0:19:39.076 --> 0:19:41.796 of money and resolved all the governance issues in state 0:19:41.836 --> 0:19:44.756 and local blah blah blah, and we're not using it. 0:19:45.116 --> 0:19:47.796 And again you're gonna asked me, why aren't we using it? 0:19:48.156 --> 0:19:51.876 I don't know, I don't know. I do not know. 0:19:52.036 --> 0:19:55.556 But the only place that has made that information publicly 0:19:55.596 --> 0:20:00.036 available is New York City. It's literally the website that 0:20:00.156 --> 0:20:03.276 we built fifteen years ago still works, and you can 0:20:03.316 --> 0:20:08.756 go on that website. You can google ep query Queer 0:20:08.916 --> 0:20:12.956 y Syndrome Surveillance, and you can go there and you 0:20:12.996 --> 0:20:16.356 can click on the box that says influenza like illness 0:20:16.436 --> 0:20:19.916 or respiratory and you can see the percent of all 0:20:19.956 --> 0:20:24.116 emergency room visits daily up until I think Friday. They 0:20:24.116 --> 0:20:26.756 have data in there now and you can look at 0:20:26.916 --> 0:20:30.276 daily rates of emergency room visits in every emergency room 0:20:30.316 --> 0:20:32.676 in New York City, what percent of them were for 0:20:32.756 --> 0:20:35.956 respiratory syndrome or flu like syndrome. And what you will 0:20:35.956 --> 0:20:38.196 see is that what has happened in the past two 0:20:38.196 --> 0:20:42.756 weeks has never happened in New York City before. I've 0:20:42.796 --> 0:20:46.436 been looking at this data for twenty years. Never ever 0:20:46.836 --> 0:20:52.276 have I seen a spike in illness that sharp, that steep, 0:20:52.516 --> 0:20:59.076 that fast. Four thousand, six hundred cases of respiratory illness 0:20:59.196 --> 0:21:03.716 or influenza like illness presented to emergency rooms in New 0:21:03.796 --> 0:21:07.516 York City last Thursday, a year ago. That day it 0:21:07.596 --> 0:21:12.596 was sixteen hundred, almost a threefold increase in those visits. 0:21:12.916 --> 0:21:17.556 It is an incredibly powerful tool for seeing what is 0:21:17.596 --> 0:21:20.116 going on in the community. And is it actually don't 0:21:20.116 --> 0:21:22.516 tell me that we have it? How many cases tell me? 0:21:22.636 --> 0:21:25.796 Is it causing enough illness in the community to make 0:21:25.796 --> 0:21:29.636 a difference to be seen in the data? And we 0:21:29.756 --> 0:21:32.556 have it in more than just New York City. We 0:21:32.636 --> 0:21:35.996 could look at it potentially in every state. And for 0:21:36.076 --> 0:21:40.236 reasons that I do not understand that data is not 0:21:40.796 --> 0:21:48.276 currently the centerpiece of our surveillance and response to this outbreak. 0:21:49.876 --> 0:21:52.356 What am I not asking you about that you see 0:21:52.556 --> 0:21:55.996 over the horizon going back to the national level as 0:21:56.556 --> 0:21:58.876 a potential problem that we haven't yet flagged. And I'm 0:21:58.876 --> 0:22:01.076 asking you that not because of your expertise only, but 0:22:01.156 --> 0:22:03.876 because you flagged a lot of the problems that we've 0:22:03.916 --> 0:22:06.836 been seeing earlier than other people did. So when you 0:22:06.876 --> 0:22:09.556 look now two weeks or three weeks or even a 0:22:09.636 --> 0:22:12.556 few months down the road, what do you see as 0:22:12.596 --> 0:22:15.996 the most serious problems that are also not being discussed. 0:22:17.196 --> 0:22:25.796 I'm really interested in this confluence of politics and policy 0:22:26.556 --> 0:22:33.116 and data around when we go to these extreme measures 0:22:33.116 --> 0:22:38.236 and when we come out, and particularly if we're not 0:22:38.356 --> 0:22:43.996 able to mobilize suppression effectively enough that we can go 0:22:44.116 --> 0:22:48.716 back to reclaim containment. That's what we have to be 0:22:48.796 --> 0:22:53.116 able to do to get out of this crisis without 0:22:53.116 --> 0:22:56.396 twenty thirty forty fifty percent of the population infected. Is 0:22:56.436 --> 0:22:59.956 we have to reclaim containment. We have to put out 0:22:59.956 --> 0:23:05.356 the fire and then really assemble crack teams of public 0:23:05.396 --> 0:23:07.636 health workers who can go around, stamp and out sparks 0:23:07.756 --> 0:23:11.956 much better than we've done before. And if we can't 0:23:12.036 --> 0:23:15.436 do that, then we will be continually faced over the 0:23:15.476 --> 0:23:21.036 next eighteen months until a vaccine hopefully hopefully is developed, 0:23:21.556 --> 0:23:25.436 where we're going to be facing economic ruination and trying 0:23:25.476 --> 0:23:29.956 to decide make those hard trade offs between how much 0:23:29.996 --> 0:23:33.196 can we ease up and then see more people dying 0:23:33.276 --> 0:23:39.076 and then push back down again, And every policymaker is 0:23:39.116 --> 0:23:41.236 going to be having to make that, Every elected official 0:23:41.356 --> 0:23:44.436 is going to be making that decision based on their 0:23:44.476 --> 0:23:49.756 own environment. So I hope that we can reclaim containment. 0:23:50.036 --> 0:23:52.836 I really really do. But if not, I think we're 0:23:52.836 --> 0:23:57.156 in for eighteen months of what I fear will be 0:23:57.316 --> 0:24:02.236 somewhat haphazard decision making around when to close, when to open, 0:24:02.276 --> 0:24:06.516 when to reclose, when to reopen back and forth. As 0:24:06.516 --> 0:24:08.836 far as said before I let you go, I do. 0:24:09.836 --> 0:24:13.036 A lot of people are wondering is there any hope here? 0:24:13.236 --> 0:24:15.236