This transcript has been edited for clarity.
Abraham Verghese, MD: Hi, everyone. Welcome to another episode of Medicine and the Machine with my co-host, Eric Topol. Today we’re honored to have Eric Goosby as our guest. Eric is a long-time native of San Francisco. He went to Princeton for his undergraduate education and then to the University of California San Francisco (UCSF) for medical school, residency, and an infectious disease fellowship. He is an internationally recognized expert on infectious diseases and worked at the center of the HIV epidemic as it blossomed in San Francisco in the 1980s. He was the founding director of the Ryan White CARE Act in 1991, and as global AIDS coordinator under President Barack Obama, he was responsible for implementing the President’s Emergency Plan for AIDS Relief (PEPFAR). He also served as the UN Secretary-General’s Special Envoy on Tuberculosis. He’s a member of the National Academy of Medicine, professor of medicine at UCSF, and most recently was appointed to President-Elect Biden’s COVID-19 Advisory Board. We are extremely pleased to have you here today, Eric.
Eric P. Goosby, MD: Thank you, Abraham. It’s my honor and pleasure to be with both of you today.
Verghese: I thought I’d ask you to begin by reflecting on the parallels between COVID and the HIV pandemic, which we both lived through and cut our teeth on, so to speak. How has this felt for you on a personal level and as an infectious disease specialist?
Goosby: You know, that’s something I thought about often as COVID broke. The immediate response at the local level, the delivery system, was awakened by individuals presenting themselves to emergency rooms and hospitals. This was the inciting moment for HIV as well as for COVID. With HIV, there were suspicions, but it wasn’t until people reached late-stage disease and started presenting with severe illness related to opportunistic infections that we realized that we were dealing with an outbreak epidemic.
The difference is that HIV had a 10-year incubation period. People often were without symptoms during that period, and as a result, infected individuals were healthy enough to move around and interact socially and infect others. It took medical delivery systems years to recognize HIV and develop a response. From recognition to developing a test took 4 years. The earliest antiretrovirals were available in 1989, but effective ones didn’t come out until 1994. With COVID, those timelines have been accordioned into a 10-month time frame. The same reactions and delivery system capacity expansions had to be developed for COVID as were developed for HIV, but over a much shorter time frame.
Verghese: This pandemic has disproportionately affected people of color, people of low income, and people disadvantaged by healthcare inequities. And now, as we roll out the vaccine, there’s a great distrust among those same groups. Can you talk about the pandemic and the population that has been most at risk?
Goosby: As with any disease, minority communities continue to bear the brunt of late awareness, late diagnosis, late entry into care, and late initiation of treatment. As a result, you see outcomes that are less than optimal in these populations, over and over again, for hypertension, diabetes, coronary artery disease, HIV, and COVID. This is an example of the same disconnect that our delivery systems have for populations that are at high risk because of barriers to accessing and being retained in care over time. The obstacles are complicated. They have been well described but we have not developed effective strategies to counter these barriers, and they continue to result in these disparities in outcomes.
In addition to that, COVID is disproportionately transmitted in populations that have to face the public, in jobs that are essential, that carry out a necessary, essential service, and are more populated by minority individuals — from postal services to transportation services to retail services. Members of Black and Hispanic communities are more likely than Whites to take those jobs, which also tend to be on the lower end of the pay scale. As a result, the ability to create a bubble through Zoom meetings and working from home was something that did not fall to everyone, especially essential workers. That added to the disproportionate impact on minority communities.
Oftentimes, members of minority African American and Hispanic communities have comorbidities from diseases that have not been diagnosed or adequately treated, and that positions them to be more susceptible to the ravages from COVID. So I believe that all of those factors have contributed to it.
Finally, there is the distrust that minority communities have developed over the years because of real and perceived transgressions that have been wrought on the population by public bureaucracies and institutions. A lot of this is true and based on facts. A lot of it is transmitted by word of mouth and has been amplified as people try to make their point. So we have a complex awareness of COVID, the threat it affords, the responses that have occurred, and the disproportionate impact on minority communities, but these have been interpreted in a variety of ways that may or may not be accurate.
Eric J. Topol, MD: I wonder, Eric, if you could lay out what you think would be the best way to titrate the hesitancy and mistrust with respect to vaccines. Because we need to vaccinate as many people as possible or we’re not going to get out of this pandemic.
Goosby: We need to acknowledge that this is the topography we’re in, that the mistrust is front and center, and that we as a medical delivery system have not embraced and established credibility deeply into minority communities. We must acknowledge that we’ve got to make up for that. To do that rapidly, we need to use — and I choose that word lovingly — community-based organizations that already are identified and trusted by the community we’re targeting.
With HIV, we did that by understanding and embracing the different roles that high-risk groups have in being identified and retained in delivery systems for chronic progressive diseases. It’s worth taking the time to understand barriers to access and retention strategies that apply to certain individuals because they have a chronic progressive disease.
COVID is a little different, but it highlights all of those biases and prejudices that the delivery systems present and the perceptions that patients have when they decide to engage the delivery system. The way to reintroduce credibility is to go back to community-based and faith-based organizations that begin from a position of credibility.
Unfortunately, as you’ve said, Eric, it has to happen yesterday. So doing this rapidly and moving forward with the deployment of the vaccine, in spite of these barriers, is still essential.
Biden’s First 100 Days
Verghese: Eric, I was pleased to see that you were appointed to the advisory board that is helping President-Elect Biden with this problem. If you look at the ways in which the current administration has handled this — other than the speed with which the vaccine was developed, a speed that I didn’t think was possible — there have been many, many missteps before and after that, including with the distribution. We’ve had Vivek Murthy on the show and we’re honored to have spoken to two of you who are on this advisory panel. Can you broadly share what President-Elect Biden’s and your strategies for this might be going forward?
Goosby: We are deeply focused on the first 100 days. President-Elect Biden has been very clear about vaccinating 100 million people as a target for that first 100-day period. We have unpacked that and looked at it state by state and large city by large city, and how that would play out. Our attempts to connect with states and local community processes that are rolling out vaccination have largely been at the state and local level. Our ability to get an understanding of the federal orchestration has been spotty. We haven’t yet been given the entire depth and breadth. We’ve been given what I’d call the vertical vision in some areas, and that has told us that we need to move the dialogue to the state and local level, which we have done.
I believe that the vaccination effort is first, second, and third on the list. Doing that in a strengthened and excellent way is essential, as is keeping the rollout going so that people don’t have periods of long waits and begin to develop narratives of being excluded from accessing the vaccine. We have already seen some narratives develop, even with minor waits.
The manufacturers tell us that they have confidence in their ability to keep the supply line robust, so we are now factoring that into how we distribute vaccination. In short, the dialogue has been about the modeling — whether taking an individual and giving them a shot, then waiting 2 or 3 weeks for the second shot, should include hoarding of that second dose for that person. We’ve looked at how many people we get under the vaccination curve for the first shot if we move to vaccinating everybody with available vaccine, knowing that the manufacturers will be able to, on the other end, within a 2- to 3-week period, supply the next dose. We’ve not decided how to handle that, but the preliminary modeling looks like we can potentiate the number of people who get vaccinated by the tens of thousands within that 100-day time period. We’re not making bad decisions to do it quickly. We’re just seeing if we can accommodate that unmet need more rapidly, more comprehensively. And again, it’s predicated on the manufacturers’ ability to continue to supply.
Another priority is to strengthen testing, focusing specifically on how schools are going to reopen. Determining the frequency of testing, the type of testing, how that relates to quarantine duration, and trying to free up some of those decisions and containment are the other part of the strengthening exercise. All of this is being discussed regionally and with the states. We’re looking at state-level discussions, which have largely occurred with the Trump administration. Now we’re trying to lay over that, a regional distribution of human resources, which are more often than not the rate-limiting factor for expanding services. So, for example, in California, understanding the human resource needs of the Bay Area, and within that geographic area, moving people around more freely, is what we’re trying to look at.
Topol: Even with the most aggressive vaccination implementation, which obviously hasn’t started out as well as we’d hoped, it’s going to take a while. And we now confront this B117 variant, which is more infectious. But there are so many other things we can do besides vaccination. You alluded to the testing, but as you’ll recall, back in April, the post office wanted to send out 650 million masks and that was thwarted by the Trump administration.
What about all of these things we could do, such as getting higher-quality N95 masks or better surgical masks to every household; rapid home tests to every household; better genomic surveillance; digital surveillance; wastewater surveillance? There are so many things we could do in these months while we wait to achieve a herd immunity level through vaccination.
Goosby: All of those measures are being looked at. They all have utility and should be part of the toolbox that municipalities, universities, and academic medical centers have access to that afford real monitoring of the larger population. Pooling of samples is another piece that has been looked at. All of those, to varying degrees, have been tried but not brought to scale anywhere.
What we’ve tried to do is understand the best practices, for lack of another word, and some of what you mentioned could be best practices. Very little has been shown definitively to play that role, but very few of those measures have been tested, to my surprise. So we are taking that step where appropriate. I think there will be an expansion of what we think are best practices, and then those will become more widely available with technical assistance associated with it. The ability to bring rapid assessment of a problem to a state or a city, and a remedy, is very much part of what the new Biden/Harris strengthening exercise will look like.
‘The Unspoken, Undealt-With Issue’
Verghese: I have a broader concern about race. When the Black Lives Matter movement exploded with sort of a national awakening of consciousness, I was hopeful. I was excited. I hoped it would remain front and center, but it seems like it’s very quickly slipped away from the dialogue. This is part of a broader question that we’ve wrestled with several times on this show with different speakers, about race in general, society and race, and how that colors everything we wind up doing.
Goosby: I’m not surprised that you bring this up. For those of us who’ve moved through life in a minority relationship with a dominant culture, it’s something that is the unspoken, undealt-with issue in the United States and globally. As a species, our propensity to identify “same” and “other” has played out in ways that continue to reverberate through every society on the planet. The experiment that has been the United States has taken the forefront in the sociologic evolution of a society, in the race sense, on many fronts, but it has not put a purse string around the dilemma and taken it to completion. It has not acknowledged what happened with enslavement or acknowledged the impact that it had on individuals, families, and communities, an impact that continues to reverberate in all of our large cities and rurally. We don’t connect the dots. It’s not for blame; it’s to understand the strengths and weaknesses of the social makeup of minority communities as they deal with dominant cultures and that minority-dominant cultural schism, so that minority input is included and is part of the solution, concretized and institutionalized.
The United States looked like it was going down that road at different points in its history. I would say the Black Lives Matter episode brought it to a frenzy with the George Floyd murder and the reaction to it in so many municipalities. I shared your hope and optimism that this was going to be different, but we have seen that every time there has been a rise in awareness, it spreads a little bit, but then it recedes. I’m fearful that we are seeing that pattern once again.
I am hopeful that the Biden/Harris administration could seize everything we’ve just talked about and see the receding opportunity for engaging in a dialogue around race. COVID has highlighted those disparities once again and is a wonderful opportunity to bring a discussion around race to the table, and to bring an expectation that there be an institutional response. I know Stanford has done a lot of this and I’m sure Scripps has as well. The discussions around race that have occurred have been different for me at UCSF than they ever had been before because of the awareness that’s come about recently. But we haven’t figured out a way to capitalize on it, so I share your concern.
Verghese: One of the things that strikes me in this pandemic is that the science has been so very good, and to watch it evolve in 10 months has been amazing. But it seems to me that we need to bring that kind of scientific approach to race. Just as we applied warp speed around the vaccine, we need to apply warp speed around race rather than sticking on another Band-Aid. I don’t quite know what shape that takes, but it seems to me that that’s the kind of effort that’s called for.
Goosby: I agree with you. Perhaps it takes all of us thinking about how to challenge the new administration to engage on this issue, thinking of a call to arms, so to speak, coming from an eclectic but credible group. There’s a willingness to do it, so it could help the Biden/Harris administration get the momentum to push it over the hill. Targeting some of the congressional leadership would be my thought on that as well. I’d love to join with you two to think about how we might leverage that, because I believe that this is an opportunity; the four big caucuses in Congress are all seeing this in the same way. They’re all talking about it.
Verghese: Having Kamala Harris as vice president is a wonderful start and we’re all excited about that.
Overcoming Vaccine Hesitancy in Healthcare
Verghese: Next, I want to ask both of you about a phenomenon that I find astonishing: In some places, up to 50% of physicians and nurses are turning down the vaccine. Clearly, science alone isn’t enough, even among people you would think are being scientific about this. What are your thoughts on that? We can’t get out of the gate if we can’t get our own people to take the vaccine.
Topol: I wonder whether the early percentages of the healthcare workforce that are reluctant will change over time as the high efficacy rate becomes obvious. But I’m very interested in what Eric thinks, as to why there still is a significant minority who are unwilling, at least at this point, to go ahead with the vaccine.
Goosby: I have wondered what someone with a scientific, on-point, infectious diseases background is looking at when they say they hesitate to take the vaccine. My gut says that the mass action of people getting vaccinated will win. It will take longer because of that delay, but I think the majority of people will eventually take advantage of the vaccination.
Plus, we should unpack the process and explain that phase 1 through phase 3 for approval were not cut short, that the numbers were larger than we usually use in vaccine studies, and that the criticism on how long we have followed individuals is less valid as the days and weeks are added in to learn how long the cell-mediated response lasts. There’s no way to shorten that.
It wasn’t a truncated approval process; it went through the same hoops that any vaccine goes through. We just did it in a way that assumed the product was going to work. They ramped up manufacturing when we started the phase 1 study so that the product could go right into phase 3 trials, once phase 1 was completed. This has changed the National Institute of Allergy and Infectious Diseases’ thinking about how they should conduct clinical trials in the future because it has startled everyone by how effective it is. The criticism of the process falls short of being anything worrisome. Tony Fauci’s working groups have noticed this and are taking a second look at everything they’re doing with clinical trials in other arenas.
Topol: These have been the largest vaccine trials in history and were conducted in an expeditious way but without any shortcuts, getting to complete efficacy. Now we’re seeing what has become a supply issue, and all of these newfangled recipes are being suggested: half-dose; one dose and then delay the second dose. Can you comment on that? Why conduct these trials if you’re going to come up with new concoctions that haven’t been validated?
Goosby: And that are not based in science. We’re making recommendations that ignore the science we have. I agree that we should follow the science with what we recommend. If it gets to the point where we can see that the supply on a manufacturing level is going to fall short of the demand — and we’re not there yet — if that happens, those alternative schedules could be considered in the face of the surge. With the emergence of the variant, the more contagious aspects of it are real, and it does appear anecdotally now to be younger people who are succumbing to this at higher rates than they did with the original COVID. In South Africa we’re seeing that even more so. They’re noticing that kids are being admitted to the hospital at two to three times the rate that they were earlier in the year.
I do think that education is important for vaccine acceptance. I’m old enough to think that people will decide that they’re going to use it or not, and we can only do so much to prepare that ground. We’re obligated to do everything we can — don’t misunderstand me — but I think it will ultimately come down to a personal decision. And that is something we simply have to watch and be available and ready for. My guess is it’s going to pendulum-swing into most people getting this vaccine.
A Global View
Verghese: Your perspective on the world and infectious disease is quite unique because of your work with PEPFAR and with tuberculosis as a UN special envoy. Let’s talk a bit about COVID and the world in terms of the gains that were made in the PEPFAR era. What is going on now in terms of countries that were in desperate straits without PEPFAR? Where are they now with COVID?
Goosby: We have been lucky that COVID has not had the same ability to spread in sub-Saharan Africa or Southeast Asia, aside from the new variant. That has presented a much calmer mood as the outbreak expands in sub-Saharan Africa — South Africa and Nigeria being the worst hit. As part of its global response, the World Bank has set up a fund — COVAX is what they’re calling it — that the Global Vaccine Alliance (Gavi) will administer and will contribute $12 billion for vaccines for low-income countries. That is being taken seriously. The African Union, the US Centers for Disease Control and Prevention (CDC), and Gavi are partnering with Ministries of Health in these countries to understand what the vaccine burden will be.
In a second effort, the Gates Foundation is looking to play a role in identifying stragglers, those who are slower to develop a capability, and provide funding for directed deployment of technical assistance. And the United States, with CDC; the Department for International Development in the United Kingdom; Japan; Australia; and, believe it or not, China, have started serious discussions convened by the World Health Organization on what kind of mobilization of human resources can be expected. Not solutions, but more of a start than I’ve ever seen for any other outbreak. So I’m optimistic that these are the seeds of what will indeed grow into a redwood tree.
Topol: The continent of Africa has done admirably well in the COVID pandemic. It makes the US performance look even more austere. Were there prior experiences that have led to this enhanced ability to respond? Countries such as Senegal and so many others have been extraordinary. Or is their time still to come, where we’ll see issues related to underreporting? What’s your sense about what’s happening in the continent?
Goosby: I think the initial slowness of spread reflected the lack of movement of people on the continent more than anything else. The spread that did occur was at transportation hubs — Nigeria, South Africa — huge hubs for coming in to Africa. But once people are in their homes, the average African does not travel much. Going somewhere “within driving distance” is unusual. Most people still depend on walking. And I think that saved them. The ability to spread that virus was severely limited. They did not have high-risk groups that stayed in the general population. They didn’t have rapidly accelerating transmission in some segments of the population as they did with HIV and as they do with tuberculosis. I think that saved them. We are not out of the woods yet, however. I believe the awareness that they dodged it initially is there, and that nonpharmacologic containment and mitigating interventions are still the tools of choice and will be effective. I would emphasize in country discussions about how they have kept their containment low enough, and that case-finding and contact tracing still are the tools that will keep the lid on it. The United States has been the example we’ve used to show that when that runs afoul, when the numbers get too high, as your percent positives go above 8%, 10%, 15%, you move into community spread that you can’t stop until you do something really drastic, as the United Kingdom has done.
The epidemiologic awareness in Ministries of Health because of PEPFAR, and the individuals, the surveillance, and the reporting that PEPFAR demands, have created a cadre of people who know how to implement those types of things, which are the core of a pandemic/epidemic outbreak response. In addition, we do have contact tracers who are active and experienced in most every Ministry of Health in Africa. This definitely made it easy to expand an already existing capability as opposed to creating a new one.
Strengthening the Pipeline
Verghese: You’ve had such a distinguished career, Eric, and we’ve also had the opportunity to interview another UCSF product, Mark Smith, on this program. We need to have so many more distinguished Black physicians like you. I want to talk a bit about the pipeline issue, because this is quite relevant to trust among the African American community. Without seeing more Black physicians out there, it is harder to get the kind of trust we need? How can we avoid the attrition we have?
Goosby: I think the lack of presence of minority faculty has a bigger impact than people think. When your better institutions do not have faculty that reflect the demographics of the populations they serve, this becomes problematic exactly for this reason. A meritocracy should rely on performance and talent only. Academic medical centers have made their reputations on keeping that pipeline robust. But their plate of duties also needs to include — in their faculties and how they move their curriculum to their students — sensitivities around race and bias that affect decisions for our patients, and also affect how that delivery system is used and perceived by these communities. This must be part of the consciousness of academic medical centers so that we create the right product with the appropriate sensitivities around all of this.
Many good people in our society are indifferent and insensitive to these issues. They don’t understand what you’re talking about and/or are too busy to give it the time to unpack it. Good people. I’ve seen it with my colleagues on the faculty, good people who don’t really see the disincentive when their comments to residents and fellows may be interpreted in every way, including racially, but they’re just thinking about an issue in a very concrete, matter-of-fact way — one, two, three, four: this is what you need to do — and often convey lack of trust.
The typical example is the resident having to present as if it’s an attending presentation every time they present a case because the attending isn’t sure that they looked at the potassium. So the attending wants to hear everything. After the fourth time they do that, you trust that the person has checked the potassium. But I think that threshold for giving that to a resident or a student who’s Black or Hispanic can be interpreted very differently. I’ve had residents and a couple of fellows distraught over the fact that they’re treated differently, and over work rounds and teaching rounds that they perceive as totally motivated, because “I’ve got to prove myself every time I open my mouth and my White counterpart doesn’t.” It may or may not be true, but that’s how it’s perceived. And academic medical centers need to get down into the weeds on that and heal themselves so that we can produce students who are aware of those nuances and sensitive to them.
Topol: That’s a great point. Really important.
Verghese: It’s been a privilege to have you on the show, Eric. We were tickled to hear that you, Vivek Murthy, and many other distinguished people we have been in dialogue with are going to be on this new COVID advisory panel. I hope you’ll come back and chat with us in a couple of months, maybe after your first 100 days.
Goosby: Anytime. Thanks to you both.
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.
Eric P. Goosby, MD, is an internationally recognized expert on infectious diseases. He has worked for multiple US presidential administrations and was the UN Secretary-General’s Special Envoy on Tuberculosis. He is a professor of medicine at UCSF and a member of the National Academy of Medicine.
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