Episode 07: Dr. Céline Gounder

Full Transcript

PA System [00:00:00] This is West 8th Street, New York University

 

Announcer [00:00:11] From New York University, you're listening to Conversations hosted by President Andy Hamilton. In each episode, Andy talks insight, inquiry, and imagination, with a leading mind from the NYU community.

 

President Hamilton [00:00:36] Hello, everyone. Today, we welcome Dr. Celine Gounder, a clinical assistant professor at NYU Grossman School of Medicine and a practicing HIV infectious diseases specialist, an internist, an epidemiologist and also a journalist and a filmmaker. Dr. Gounder, who has written for numerous publications, is a CNN medical analyst and also frequent expert guest on CNN, on the BBC and many other networks. She's also the host and producer of American Diagnosis, a podcast on health and social justice and also Epidemic, a podcast about the covid-19 pandemic. Dr. Gounder recently has served on President Biden and Vice President Harris's transition covid-19 advisory board. You'll remember that was a critical group advising the incoming administration from November the 9th, 2020 through January the 20th, 2021, very much setting in place the strategy for the new administration towards covid-19. It's a great pleasure and an honor to welcome her to today's podcast. Welcome, Dr. Gounder.

 

Dr. Gounder [00:01:58] It is great to be here.

 

President Hamilton [00:02:03] And of course, we're going to be focusing on the issue that is on all of our minds here at NYU in New York City, but also around the world, of course, the pandemic. And we now have a new government in Washington, D.C. It's a government who has explicitly stated that they will be following the science. And we also have public officials in place who are committed to seeing us through the end of the pandemic. But, of course, at the same time, we've also just recently passed that grim statistic of 500,000 Americans dying from Covid-19. So the talk naturally is turning to what is the timeline? Is there a realistic chance of finding our way back soon to some kind of normalcy? But of course, in order to achieve that return to normal, we require a set of responsibilities—personal, civic, economic responsibilities in a timely manner. I'd love to explore just in this first general question, what do you think will be critical over the next six to 12 months to get back to that degree of normalcy? And what will be our personal responsibilities as citizens and as communities?

 

Dr. Gounder [00:03:32] Yeah, I sort of break this down into a couple of different time periods. So we have the immediate month or two ahead and I think this is really a very critical moment because in a sense, this is the calm before the storm, before the UK B117 variant becomes the dominant strain here in the United States. It is already accounting for over 10 percent of covid cases across the U.S. and is rapidly growing and will be the dominant strain by the end of March. And this is critical because this strain is more infectious and more virulent, meaning that for every person who's infected, they will infect more people individually. And then for every person who is infected, they will have a more severe disease and so are more likely to end up in the hospital and more likely to die. This is also happening at the very moment where we're seeing vaccines getting rolled out and people have good reason to feel optimistic, to feel like there is light at the end of the tunnel. The danger in that is that we may be lulled into a false sense of security where we may be letting down our guard, not being as adherent to the mask wearing and the social distancing and so forth. At the very moment where this more infectious, more virulent strain is spreading, Many of us are concerned, if you look at the numbers right now in terms of numbers of cases, hospitalizations and deaths, they have plateaued. They have not continued to decrease. And so we're probably at that tipping point right now where we're about to see another surge related to the UK variant. So that's sort of the the near term. We are seeing rapid rollout now of the vaccine, we're over two million shots in arms per day. We now have three different vaccines that have received emergency use authorization from the FDA. So that's Pfizer, Moderna and now Johnson and Johnson. And with respect to Johnson and Johnson's vaccine, Merck has agreed to help manufacture doses of that to really scale up the supply. So this is really an astounding partnership across competitors, you know, and I think that speaks to the urgency of the moment. But I think the good news is that we have made some real progress in terms of getting people vaccinated. We're at over 50 percent of people over the age of 65 have received at least one dose of the vaccine now across the United States. And I think once we can get the vast majority of people over 65 and those with chronic medical conditions vaccinated, I don't think we necessarily have to wait for herd immunity. But once you can get those groups largely covered, then I think we may be looking at a return to some semblance of normalcy.

 

President Hamilton [00:06:28] Yeah, it's very encouraging. You touch upon the collaboration among pharmaceutical companies. It's also very heartening to see the role that universities have played in the development of the vaccine. Our own NYU Langone was one of the key sites for testing a number of the vaccine candidates before their emergency approval. And I have to add, my former home, the University of Oxford, of course, has been a key part of the development of the vaccine that's now being pushed further forward by AstraZeneca. We will look back in the rear view mirror in due course and I think see a very encouraging set of collaborations. Universities and companies.

 

Dr. Gounder [00:07:12] I agree with you, and I think this really speaks to the need for that kind of collaboration between academia, between government scientists, for example, at the NIH and for the private sector. They each have a role to play in all of this.

 

President Hamilton [00:07:25] Yeah, just coming back to the comment you made Saleen about mask wearing and continued social distancing and making sure no gathering's more than a very small number of people. You wrote recently very forcefully in The New York Times about the risk of letting down our guard. Of course, you've also played a key role on President Biden's transition advisory board. You've seen close to hand the diversity of responses across the United States to the pandemic, diversity of responses to the different regulations that you have talked so much about. Are you optimistic? Do you see that we will be able to pull together as a country to get beyond the threat being posed by the new variants? Or do you see the country breaking down into different regions with inevitably different consequences for the unfolding of the pandemic?

 

Dr. Gounder [00:08:25] Yeah, I do think we're going to see a fractured response here over the next month or two. With respect to how careful we are as the variants do take hold, the UK variant in particular, that said, I think you are seeing on both sides of the aisle governors loosening mitigation measures. I mean, here in New York is a great example, return to indoor dining and the like when this is really not the moment to be doing that. So I don't think it is a party line vote, so to speak. I think people across the political spectrum are really tired and exhausted. And with the arrival of the vaccines, there's this feeling of almost as if it's a silver bullet, like problem solved. We just need to get people vaccinated and then this will be over. And it's a little bit more complicated than that where we really do need to be careful, at least for a couple of months more at least another, you know, two, three months while there is a spread of the B117. But while many people are still not vaccinated, that is a really critical window that where we do have to double down on some of these mitigation measures.

 

President Hamilton [00:09:40] Yeah, there's been so much focus on on the vaccine and the different candidates and their rollout, and of course, one of the things that's been much discussed as well are the consequences for some people of infection not being a short term, but actually having long term consequences. And I wondered if you talk just for a few moments about treatment of the disease, obviously treatment of the disease for someone who has not yet been vaccinated or for a variant that might short circuit vaccination. What do you see as the potential for the treatment of the disease, particularly for those suffering from long term consequences?

 

Dr. Gounder [00:10:26] Well, there are a couple of different theories as to what's happening with long covid, so to speak. One theory is that you have a viral reservoir of ongoing low level replication. Another theory is that you have fragments of the virus may be lingering MRNA that is causing persistent immune activation. And then a third theory is that this is an auto immune response triggered by the acute viral infection. And what is interesting about all three of those theories is that it is possible that vaccination could really help treat all of them. And that would be if you have, for example, a viral reservoir remaining or fragments of the virus remaining, if you boost the immune response, you may be able to clear that. And if this is an auto immune response with the vaccination, you may be able to redirect, in a sense, the immune response away from this auto antibody response where you may be able to treat the long covid in that way. And so there's real promise in terms of studying the vaccines, not just for prevention, but for treatment of long covid.

 

President Hamilton [00:11:37] It's so important as we lived through the pandemic, I think all of us have been reminded, of course, we have of the the role that pandemics have played in human history. But it's also very important that we learn lessons as we work through what works, what doesn't work, policy changes that are effective and those that are ineffective. What would you see as as the key failures in the last 12 months of the public health response in this country to to covid? And I ask it less to to apportion blame, but more what can we learn as we also put in place the policy changes and infrastructure improvements for the next pandemic? There's a lot of fear of drug resistant bacteria, for example, being not too far on the horizon is a threat to public health. So what would you see as the key failures that we can then learn from in enhancement about public health responses?

 

Dr. Gounder [00:12:41] Well, certainly there have been failures in the past year, but there have been failures that go back to the beginning of the last administration. And even earlier, these are failures that, again, have been bipartisan failures. So what I'm alluding to is tremendous underinvestment in public health. This has really been the stepchild to the biomedical industrial complex, so to speak, the health care system, public health has really not been invested in on anywhere near the same level. And if you look at, for example, the NIH budget versus the CDC budget, there's an order of magnitude difference there. And this really speaks to our values as a society. Public health is very much about the public. That means also valuing health disparities, which is very different from the values of let's create research that create products based on that research. And those who can afford to pay can benefit from that. And those are very different philosophically. So I do think it speaks to a weakness in how we value and invest in public health. Even prior to the 2008-2009 recession, we under invested and then that recession hit. We lost about 50 to 60 thousand public health workers since then. Some of that was through layoffs. Some of that was people not being hired. Some of that was people leaving or retiring and not being replaced. But that's a huge number of people that we've lost and and researchers have looked at if we were to staff our public health departments, you know, semi appropriately for the actual need right now, we would have to hire about two hundred and fifty thousand public health workers across the country to meet sort of the basic baseline level needs. And that's not to mention the added need now during the pandemic. So I think I think that's one thing that really needs to be readressed. I think another is, and this is unfortunately something that goes back to the beginnings of this past administration, was really a dismantling of the pandemic preparedness infrastructure that was put into place after the Ebola epidemic. And unfortunately, we see this over and over again. You have a crisis. A lot of resources are put into addressing it and then people sort of forget what happened. And then that money gets stripped away, reallocated to other things or just, you know, there's just disinvestment. And there is now a move to resurrect some of those structures to to reinvest again. But I think we need to be thinking even bigger. We know that epidemics are arising at a faster and faster rate. If you look at the last couple of decades and people may not even realize there's another Ebola outbreak. In fact, more than one, one in Guinea, one in the DRC now. And we are now putting into place some travel restrictions here in the United States for people traveling through those areas. And so I think we need to realize these are going to happen more often. This is not a just in time approach where you're dealing with the emergency we need to be thinking about just in case, because there is going to be an in case. And so how do you deal with those things when they predictably come?

 

President Hamilton [00:16:02] Yeah. Is there a country, Celine, in your opinion, that got covid? Right. It wouldn't surprise you. I keep a very close eye on what happens in the U.K. The U.K., of course, has a very different health care system from the United States. But I think no one would point to the UK as a model of managing certainly the outbreak. They've they've done well with vaccine distribution, but the pandemic itself was problematic. And this, of course, was a lot of focus on Sweden and on Germany and other major industrial countries that reacted and responded in public health policy ways that were different from the US. But even they are now finding consequences of a pandemic that is hard to control. So what's your sense across the industrialized world of places that got it right and those that didn't?

 

Dr. Gounder [00:16:57] Yeah, I mean, I think what the U.K. got right is the NHS. So they have a system that is centralized that can push something out very efficiently. You know, I've heard from folks in the UK, oh, you know, I just got a text message from my GP's office saying, you're now eligible. Here are some dates and times. You just hit a button, you're scheduled to show up and that is it. There is none of this Hunger Games to get an appointment for a vaccination. So it's it's really efficient. I think the countries that have really done well with this are by and large countries that also experienced SARS, that experienced murres, you know, the avian flu and so on. So you're talking about East Asia, countries like Singapore, Vietnam--and Vietnam is not a highly developed country. And yet they got it right, which means that they understood the threat. And instead of, you know, having these debates about public health versus the economy, they understood, frankly, that it's not a choice, that you really have to address the public health threat, and that is what protects the economy. So, yes, you have the short term pain, but then it's sort of like ripping off a Band-Aid. You minimize the period of pain and then you have a return to something that's not normal but, you know, relatively more functional. And so I think countries like Singapore, Vietnam, but also Australia and New Zealand understood that and got it right

 

President Hamilton [00:18:25] As the vaccine rollout continues, and certainly at the current moment, as we're recording, this supply is still far outstripped by demand for that for the vaccine. So we haven't really yet faced the consequences of massive vaccine hesitancy. And I wondered if I could just touch on on your experience in Guinea and in the in your documentary Dying to Talk, there's a section where you talk about failed policies in Guinea, and you referred to them as, in addition, a parallel epidemic of mistrust, cynicism and conspiracy theories. Of course, in that case, in the face of an Ebola outbreak. How do we now learn from that in terms of dealing with the United States of America, with Americans who may resist the vaccine, a concern that it causes harm or following different conspiracy theories? I'm a scientist. You're a scientist. We know that that very often they are based on inaccurate, nonscientific information. How do we fight that misinformation that obviously has a wider impact in society and indeed puts us all in jeopardy.

 

Dr. Gounder [00:19:41] Well, it's been really fascinating to me to observe the parallels between the two outbreaks, the Ebola epidemic in West Africa and covid as a pandemic. One parallel is that they were having they were in the middle of their own presidential elections in Guinea when Ebola hit last time around in 2014. And there is no question that the response got politicized much as it did here when we were in our own election year and it hit. And I think that's really unfortunate. And in a sense, it was predictable what what what was going to happen. What is in common also is distrust of the government. And it's very logical, frankly, some of this distrust when you see what was happening on the ground in Guinea, is it a government that serves the people or is it what I would call self serve government where you go to serve in government to serve yourself, not public service? And I think, unfortunately, there are some patterns of that strains of that here as well. Also, if you look at what are the groups in the United States that have the greatest hesitancy about vaccination, the least trust, confidence in the vaccines, there are a couple of different groups, and this is played out in survey after survey after survey. So you have communities of color, in particular black and indigenous communities, less so Latino, honestly. But if you think about why black and indigenous communities, well, these are people who've been enslaved, who have had their lands taken away from them, their livelihoods taken away from them, who have borne the brunt of medical abuse and experimentation over centuries. And so it makes sense that those populations in particular would have greater distrust of not just the health system, but government writ large. And then also the other groups that are distrustful, hesitant about the vaccine are rural Americans and right wing partizan Americans who have great distrust of government. So I think this is really a reflection of that. And then it gets explained through sort of the cultural lens in different ways. But that is really what is the underlying problem here is, is a lack of trust in government. And so how do you build trust in government? I think that really requires engagement of civil society at the at the most grassroots levels and a government that actually delivers for the people so that they see there's a reason to trust. And this is one big difference between us and some of the European countries, like Germany, for example, where there are very real social and economic support safety nets that were offered to the people during the pandemic that gave people a reason to trust, that gave people a reason to believe. And I think unfortunately, we just don't have that here.

 

President Hamilton [00:22:40] I'd love to just develop a bit further. You touched upon that, the disproportionate impact of covid-19 on different parts of American society and particularly American citizens of color. And you've also spoken about how President Biden is committed to redressing those inequities. Could you just talk briefly, Celine? What would you see as the critical issues that the Biden administration should be facing right now to address those disparities in covid related care, but also in all forms of health care in the country?

 

Dr. Gounder [00:23:21] Yeah, I mean, I think in terms of covid right now, the big conversation is around equitable distribution of vaccines and to me that comes down to access and the hesitancy question, it's both. It's not one or the other. It is both. And with access, you know, is somebody able to get to the vaccination site? Are they able to take time off work without losing income? Are they able to make an appointment? You know, those are all the kinds of barriers people are facing right now. And so that means you really need to take the vaccine to the people, not, you know, build it and they will come. It's we need to take it to you. And so that means embedding the vaccine distribution in communities through organizations that people trust and already make use of. And so this is very much part of the Biden strategy. So if you look at the use of federally qualified health centers, the community health centers, which are by and large in communities of color and using them to distribute the vaccine, this is very much why that's being done. In addition, some of these FEMA mass vaccination sites are being placed in the most vulnerable, hard hit communities and then the use of the retail pharmacies. It's not every retail pharmacy, at least right now, that is providing vaccination. They've really been focusing on those that have been identified based on the CDC social vulnerability index, which are the retail pharmacies that that serve those communities. And again, that's by and large communities of color and trying to make sure that they have ample supply of vaccine through facilities that that people know and and trust.

 

President Hamilton [00:25:04] The issue of disparity, of course, we've talked about within the United States, but of course, the disparity also extends globally. And I wonder if you could talk a little about how you see we should be tackling the critical issue of logistical distribution, ensuring safe and fair distribution across the world. And of course, nowhere is that more necessary as we look at the impact of covid on the world's economy, travel, international tourism, they will all be important for a return to normal, normal life, as we discussed at the beginning. But how would you hope that the Biden administration and indeed to the World Health Organization address the issue of of fair and equal distribution of vaccines, as well as health care related to covid across the globe?

 

Dr. Gounder [00:26:07] Yeah, well, I'm very encouraged that, first of all, the Biden administration has rejoined the World Health Organization, that we're participating in Covax, which is very much focused on how do you get vaccine distributed equitably around the world. So I think those are important developments. I do think, you know, we have purchased enough vaccine for the entire U.S. population and then some. And so while not all of that has been manufactured yet, we will have a surplus come sometime later this summer. And so I think part of the strategy will be to donate that surplus around the world. I think stepping back, what we've seen with this pandemic should be a reminder that what happens halfway around the world can very much affect us. And so that means we need to be investing in surveillance systems and international collaboration in helping build up health systems that they can respond more quickly on the ground wherever an outbreak occurs. So I hope that people will have taken that message away from this outbreak and understand the importance here returning to covid vaccines and why that needs to be distributed equitably. One of the things that we've seen is where the virus is allowed to spread uncontained. That's where you see these new variant strains emerge. So it's not surprising that these variants have emerged out of the U.K., out of South Africa, out of Brazil, where the virus was allowed to spread like wildfire. Even if we vaccinate our entire population, if you have ongoing transmission elsewhere in the world, then you have the potential for the virus to continue to mutate, to get to the point where our current vaccines may no longer be effective in protecting. And so that remains a real vulnerability for all of us. So it really makes sense to be trying to control the virus, not just here, but around the world.

 

President Hamilton [00:28:04] I'd like to draw that conversation to a close Celine. But as I often do in these podcasts, I like to think about how you talk to students at the Grossman School of Medicine, particularly even students, before they get into medical education and are thinking about different career paths. By making reference to your own career path, you've clearly found your passion in life and in working in infectious diseases, but particularly infectious diseases as they affect people in the developing world. How would you encourage a younger student to find that passion, but also to find that pathway? Because as we all know, in order to have an impact on society, on the world, we need to get down into the details of a career, be it in the humanities or in medicine. How do you express that to students when you're advising them about career paths?

 

Dr. Gounder [00:29:11] Yeah, I guess what I would say is be creative, and I think that applies in a couple of different ways. One, I think it's really important to be multidisciplinary, especially in this day and age. I think you learn a lot by drawing from different disciplines, and it makes you much more adaptable based on what the new problem might be. And so I think that's important. I think, secondly, the job for you may not even exist and you may have to create that for yourself. So what I would say is identify, you know, what are your strengths, your skills, what are the problems you want to solve for and then see? Well, maybe there is a job that fulfills that. Maybe there's not. And if there's not, how do you create that? Because that's I think where there's the greatest opportunity, where there's a need, there's a skill set to address that need. And yet there is not a clear career path or or industry. And I think when you're entrepreneurial like that, that's where there's the most room for making an impact.

 

President Hamilton [00:30:18] Celine, thank you very much indeed. This has been a fascinating conversation we are living through very strange and indeed troubling times, but these are times when the roles we all play make a difference and really do affect the as yet uncharted waters that we are all navigating. And you, in your role as an infectious disease expert, your role in advising governments, your role in and helping in informed the general public, you are clearly having a very profound impact on our passage through this pandemic. And so let me thank you very much, Dr. Celine Gounder, for being our guest today. And let me thank all of you for listening and good luck to all as we see the end of the pandemic approaching. And we all hope that it will come as fast as possible. Thank you.

 

Dr. Gounder [00:31:20] It was my pleasure to be here.