341: Julie Gerberding | Answering Your COVID-19 Questions

Transcript for Julie Gerberding | Answering Your COVID-19 Questions (Episode 341)

Jordan Harbinger: [00:00:04] Welcome to the show. I'm Jordan Harbinger. As always, I'm here with producer Jason DeFillippo. On The Jordan Harbinger Show, we decode the stories, secrets, and skills of the world's most brilliant people, and turn their wisdom into practical advice that you can use to impact your own life and those around you. We want to help you see the Matrix when it comes to how these amazing people think and behave, and we want you to become a better thinker. If you're new to the show, we've got episodes with spies and CEOs, athletes and authors, thinkers and performers, as well as toolboxes for skills like negotiation, body language, persuasion, and more. So if you're smart and you like to learn and improve, you'll be right at home here with us.

[00:00:39] We've got a special episode of the show here today -- right on the heels of me, promising not to talk about COVID-19 all the time. Today, I bring you the former director of US Centers for Disease Control and Prevention, or CDC, Julie Gerberding. Gerberding led the CDC's efforts to prepare for and counter-terrorism. She is an Associate Clinical Professor of Medicine, infectious diseases over at Emory University and an Associate Professor of Medicine, also infectious diseases, at the University of California in San Francisco. She later went on to head Merck pharmaceuticals vaccine program, so she knows what she's talking about when it comes to infectious disease, vaccine, research and development, the CDC, and of course, COVID-19. Rather than our usual conversation here on The Jordan Harbinger Show, I actually took questions from you on social media, Instagram, Twitter, and Facebook, and over the next hour and change, we're going to go through some of those questions to get the straight dope and bust some commonly held myths about COVID-19, treatment, vaccine, protective equipment, and prevention.

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[00:02:05] Now here's Julie Gerberding.

[00:02:09] Julie, thanks for coming on the show, first of all.

Julie Gerberding: [00:02:11] Thank you. Thanks for having me.

Jordan Harbinger: [00:02:12] I assume you're busy with COVID-19 and watching Tiger King.

Julie Gerberding: [00:02:16] Well, this is a big, big deal, as everyone knows. So yes, we are watching it, but we're also in a sense on the frontline because we have people all over the world working

Jordan Harbinger: [00:02:26] Now rather than a standard interview, I wanted to take questions from The Jordan Harbinger Show audience, and we literally got hundreds of them from social media. So I'm going to get through as many as we can as opposed to a standard natural conversation if that's okay with you.

Julie Gerberding: [00:02:40] Let's try it.

Jordan Harbinger: [00:02:41] Yeah. Yeah. Give it a shot. Based on the questions we've received, I'm sensing there's a lot of misinformation out there. Ideally, I'd like to clear up some of that is well, because that's always helpful. How glad are you that you're not the CDC director right now?

Julie Gerberding: [00:02:55] You know, the one thing I know about the CDC director is he has a really hard job and there's nothing that makes it harder than being in the limelight like this.

Jordan Harbinger: [00:03:03] I can imagine there's a lot of scrutiny where normally there might just be a lot of maybe routine monitoring or maybe the job's never routine, but now everyone's looking at you.

Julie Gerberding: [00:03:13] Yeah. The crisis really does bring the CDC to the forefront. Most of what they do is invisible, and that's a good thing because that means that there isn't an outbreak or something in crisis mode going on around the public health community. But when a crisis occurs, the CDC is front and center, and that really does put a lot of pressure on the agency.

Jordan Harbinger: [00:03:32] So can we please explain how this is worse than the regular flu that kills thousands each year? A lot of people have been sharing this old photo of a medical textbook that says, "Coronavirus, just like the common cold." And then, of course, dot, dot, dot people who I guess are uneducated or don't want to be saying, "Oh, it's just the common cold. Don't be worried about it. It's just coronavirus. We've had these for centuries."

Julie Gerberding: [00:03:53] Yeah, you know, I'm glad that, for a lot of people, it is a cold. It remains in the upper airways and it doesn't cause serious complications. But what's different about this coronavirus compared to the four that we know normally do just cause colds, is that it's first of all, much more readily transmitted in community settings. And second, the fatality rate is significantly higher. And what happens is people who can't contain the virus in their upper airway suffer when it gets down into their lower lungs as a very high degree of damage to the lung tissue. And it's very, very difficult to recover from that.

Jordan Harbinger: [00:04:31] That's what's been scary for a lot of folks is not knowing what this actually is. Because I think for pretty much everybody who's been alive, there haven't been new diseases other than perhaps HIV or AIDS. Everybody thought, "Well, I'm not going to get that because I don't have at-risk behavior," but now at-risk behavior is going to get gas for your car or go into the grocery store, whichever one does.

Julie Gerberding: [00:04:54] We live in this very complex world right now and climate change, urbanization, crowding together with people, all of these things are causing these spillovers from the animal kingdom to occur more often. So while we recognize AIDS as a pandemic, it happened fairly slowly. And you're right, it didn't seem to touch everyone until we figured out it was sexually transmitted. And that touched a lot more people than originally recognized their risk. But since that time, we've had a number of these spillovers, we had SARS, we have MERS, we have Zika. Influenza is a spillover, and we did have a small pandemic in 2009. Ebola is a spillover, and now here we are with the coronavirus. So in a sense, this is a product of the connected world that we live in and we're going to have to really think differently about our risk under those kinds of circumstances.

Jordan Harbinger: [00:05:45] It's funny, when I was naming diseases just now, I didn't even think about Ebola because it was a novelty, fluffy headline here in the United States for most people, unless you knew healthcare workers in Africa or something like that. But MERS and SARS, I guess we thought of those as things on other continents that didn't quite make it to the United States, even though they did. It was just not that severe. But we have had these, you said spillovers -- does that mean that it comes from animals? Is that what that means?

Julie Gerberding: [00:06:12] All of the diseases I just mentioned are originally found in animals and they spill over usually through some kind of intermediate animal. Most of these are infections in bats. The coronavirus that we're dealing with right now, MERS, Ebola -- these are bat-borne viruses. And there are several other viruses that cause bad diseases that spill over from bats. But in the case of SARS and this coronavirus, presumably, there is something between the bat and people. For SARS, it was probably a civet, which is a small mammal. In this case, they're not sure. There've been a number of hypotheses, but we really don't know what the intermediate animal was. We do believe, however, there's pretty good evidence that that spillover probably occurred in the live market.

[00:06:59] Live markets are something we don't understand very well in the Western world, but in many parts of Asia, people buy animals while they're still living. In part, because they don't have refrigeration in the markets, and many people don't have refrigeration at home, so they buy the animals while they're still alive, and then they butcher them or kill them in their homes. And that, of course, exposes them not only to the living animal that might be harboring a virus but to their tissues in their blood in ways that can definitely cause exposure.

Jordan Harbinger: [00:07:29] Well, that's certainly interesting. I had not thought about the fact that people are buying these live animals for that reason. I guess if you have live bats in your house or live civets in your house because you need to keep them fresh, and then you have other animals next to them or near them, or people are touching them. It gives me shivers, but I also realize that it's just a way of life for other people and it was the way of life for us until my parent's generation or my grandparent's generation first got an actual refrigerator unit.

Julie Gerberding: [00:07:59] You know, we suspect these spillovers actually happen more than we realize, but usually they're happening in rural areas and they get quenched very quickly, so we don't recognize them. The difference now is that if you have a live animal market in the middle of a city of 30 million people, then you are sitting on top of a disease that can spread very quickly.

Jordan Harbinger: [00:08:17] That's really scary because tradition would then hold, "Ah, we'd like having these live animal markets," and I think that's kind of what happened in China, right? Is that they don't want to get rid of it because it's part of the economy and the culture.

Julie Gerberding: [00:08:28] Yeah. You know, when we were dealing with avian influenza, the live markets were also a culprit in the transmission of that infectious disease from chickens to people or from poultry to people in these live markets. So for a period of time, they were shut down and that really did clench the avian influenza outbreak. But unfortunately, they're back open in many, many places.

Jordan Harbinger: [00:08:49] Now what other pandemics or human events in history is this most like? I mean, we've had the Spanish flu, measles, Ebola. What can we expect from this situation given what happened then?

Julie Gerberding: [00:09:02] I suppose that we would have to say the 1918 Spanish flu pandemic is the closest thing to what we're dealing with. I mean, right now today, this virus is in 185 countries around the world. That's a pretty staggering spread in relatively few weeks, and we're dealing with a lot of deaths. Fortunately, not as high as the death rate was in SARS where about 10 percent of infected people eventually succumb to the infection. But nevertheless, high, probably in the same order of magnitude as we saw with the 1918 influenza outbreak.

Jordan Harbinger: [00:09:37] Oh wow, wow. Why the six-foot distance? Because when I sneeze and I don't cover it, which never happens, but sometimes I see that, "Wow, that guy, there went pretty far like it's on my bathroom mirror and that's really far away." Is six feet really enough or is that just the maximum practical social distancing we can really do? And beyond that, we just can't really keep doing it.

Julie Gerberding: [00:09:58] You know, this is not a hard science to some extent. It's a little bit of a statistical challenge. In other words, we know that the closer you are, the worse it is.

Jordan Harbinger: [0010:09] Okay.

Julie Gerberding: [00:10:09] And you know, if I sneeze directly on you, my droplets go from my mouth to your mouth. And that's obviously the highest and most hazardous situation. Once you've sort of propelled your droplets into the air, they could potentially land in someone, but it's not as likely from just the volume of air that they get disseminated in. I think the relevant alternative mode of transmission is when those droplets land on a surface and then people touch the surface, and as we all do, even though we don't notice it, we're touch our mouth and our face and we inoculate ourselves basically with those viruses. So that's why the emphasis on handwashing, because the environment gets contaminated with people's secretions, and we don't realize that we're picking it up and transferring it from our hands into our mucus membranes.

Jordan Harbinger: [00:10:56] Oh my gosh.

Julie Gerberding: [00:10:57] You think about some of the things we touch regularly, and this always has bugged me being an infectious disease doctor. When you go to the airport, and you get your ticket.

Jordan Harbinger: [00:11:05] Oh, I know where this is going.

Julie Gerberding: [00:11:07] Or you're on the subway and you're hanging on to the subway pole. That's why you carried that a hand hygiene materials in your pocket so that you don't have to worry about that

Jordan Harbinger: [00:11:16] Germaphobe trigger warning by the way.

Julie Gerberding: [00:11:19] It's hard for me not to be there.

Jordan Harbinger: [00:11:22] Yeah. I mean, for me, I just think about it and I go like, the one time you're eating something in New York and you realize, "Wait, I just got off the subway and you're eating like a slice of pizza and just straight to the garbage can, like I can't do it anymore."

Julie Gerberding: [00:11:35] You know, the one thing we forget is that our bodies are kind of designed to be pummeled with bacteria and viruses all the time. So we actually have a pretty good innate immunity, saliva materials, and your nose and mouth are kind of designed to help keep those things away from you, but they do get overwhelmed as what we're seeing with this coronavirus, so common sense.

Jordan Harbinger: [00:11:55] Yeah, that part makes sense. Since it's a novel coronavirus that means that it's never made the rounds through humanity and so, therefore, we have no antibodies against this at all?

Julie Gerberding: [00:12:08] That's right.

Jordan Harbinger: [00:12:08] Okay.

Julie Gerberding: [00:12:08] That's the assumption. We don't have any evidence that anyone is immune prior to this outbreak.

Jordan Harbinger: [00:12:14] Okay. And do we need to maintain the social distancing until we have a vaccine because that seems almost impossible?

Julie Gerberding: [00:12:21] Yeah. Well, again, when you're talking about a population, you're really thinking about the population impact. If I as an individual want to remain perfectly safe, I would have to hermetically seal myself in my house and that's just not practical. So we're always balancing what is the value of the intervention we're proposing and what is the practical reality that we have to live in the world and we have to accomplish other activities of daily living.

[00:12:49] So I think when you step back and look at all this conversation about flattening the curve, which is exactly what we're doing, basically, that's designed to buy time so that our healthcare system can take care of patients. In countries that have good health systems, intensive care really does save lives of people, but you can't save those lives if you don't have the ventilators and the nurses and doctors protected and the other medicines, antibiotics, et cetera, that you need to help treat the complications. And so by flattening that curve, we are buying time so that our health systems can scale out their level of preparedness.

[00:13:27] What we have today is better than it was four weeks ago, and by the fall, we'll have a lot more capacity because we are building ventilators and procuring masks and learning how to use them in a more prudent fashion. New protocols through sterilizing masks, for example, so they can be reused. So a number of things are happening that will decrease that challenge to our health system. And when that occurs, even if we get a second wave of coronavirus later this year or next year, we'll be much better able to manage the impact on our health system, and that kind of reduces the burden on our society to implement these measures that right now primarily are focused on accomplishing that goal.

[00:14:09] Now, when I say flattening the curve -- as I said that's designed to protect our health system -- but it's also important to decrease the area under the curve because after all, that is really what is driving the impact on individuals and families. So naturally, it isn't just timing that we're driving for here. We'd like to see a lower overall number of cases and an overall number of deaths from this disease. And that means we have to catch up with the epidemic from the standpoint of our treatments, which I'm absolutely astonished by the number of antivirals and antibodies that are under investigation right now. And there are more than 70 vaccines in some stage of development, including five that are already in clinical trials. So I'm confident that science will catch up. I wish we had it ahead of time. We don't, but never in the history of the world have we ever seen any progress in science this fast.

Jordan Harbinger: [00:15:04] Yeah. It seems remarkably fast. A month ago we were reading about how vaccines take years and years and years, and we shouldn't expect one anytime soon, and I still believe we shouldn't expect one anytime soon. Of course, that's still sort of the message, but to know that things are already in clinical trials, it really is astonishing. You kind of think, "Wow, humanity can conquer a lot of stuff," and it gives me hope about other things like climate change, for example. And I don't want to dive into that because it's not what this interview is about, but my generation thinks this is just impossible, it's just an insurmountable problem. And then you see something like a massive global pandemic and the speed at which it's attacking and it's like, "Oh, wait. No, we can do this. We just don't really want to right now." With this virus, it's clear that everybody wants to have this. I would imagine even North Korea is like, "Yeah, we'll take that vaccine. I mean, we don't like playing along with anything else, but we'll sure as heck take a gander at this vaccine."

Julie Gerberding: [00:15:56] You know, I think the world is truly aligned around responding to this crisis in ways that we've probably never actually been fully aligned before. So that does give me a reason to be hopeful if we can sustain that alignment and not deteriorate into the name blame-shame game. We really need to keep our eye on the prize here, which is an effective vaccine, but also the lessons learned. We won't be the same after this. We're not going back to normal. We're going to go to someplace new and hopefully better.

Jordan Harbinger: [00:16:26] What did we learn from, say, SARS that could have been implemented sooner in your opinion? Is there something where it was like, "Ah, you know, we kind of saw this respiratory thing as a trend in viruses." I don't know if that's a real thing. "Maybe we should have had more masks available," or something along those lines.

Julie Gerberding: [00:16:42] And we learned a few things in SARS that we didn't pay attention long term. One is the live animal markets are probably a culprit in this original SARS outbreak. Second, we learned that if we don't get things across the finish line, they're not there when we need them the next time. And in SARS, of course, we did start studying antivirals. We studied post-infection serum as an antibody treatment for passive immunization, and a number of vaccines were started, but none of them crossed the finish line in the 16 years that had passed since SARS originally appeared. So we didn't learn the lesson of finishing the job. And I think if we had finished the job for SARS, we would be starting this coronavirus in a very different place. We'd understand what does it take to make a very effective vaccine for coronavirus. And that would be very critical information to have right now.

Jordan Harbinger: [00:17:36] Yeah, I think so. People have asked, "Would I have a milder case if I was just exposed to a few droplets rather than a Petri dish type of exposure such as in an ER?" I don't know anything about this, but it seems like the virus, it colonizes your body, right? So kind of where you start might not matter beyond a certain threshold.

Julie Gerberding: [00:17:54] You know, we don't know.

Jordan Harbinger: [00:17:56] Okay.

Julie Gerberding: [00:17:56] That's the straightforward answer. It stands to reason that if you are exposed to a larger amount, the statistical chance that that will result in infection is certainly what usually happens with infectious diseases. But that doesn't necessarily mean that the more you're exposed to, the worse your disease is. Because that's more of a function of your body's own immune system and how you uniquely respond and what other vulnerabilities you might have as an individual.

Jordan Harbinger: [00:18:22] Right. It's not like Tylenol where if I take four instead of two, my headaches are completely gone instead of just milder. It's more like if I'm susceptible to this virus and I get enough to get an infection, which might just be a certain cliff, then I either get it and it's severe, I get it and it's not. It just depends on me.

Julie Gerberding: [00:18:39] I think you're expressing exactly right. Do you have an MD?

Jordan Harbinger: [00:18:44] I have zero qualifications whatsoever, other than asking questions -- not even -- asking other people's questions in a video format apparently is where my talents lie and I'm fine with that for now.

[00:18:57] What do you think is driving so many health-related conspiracies? Because it almost seems like stupidity is kind of the epidemic that we started with, and now we have something that is combined with that. That's much more dangerous. How do we sort of flatten that curve?

Julie Gerberding: [00:19:11] You know, when people are confronted with something that's this frightening and it is frightening. it's a pandemic. I mean, if we weren't frightened, we would be abnormal. Often the response is initially sort of denial. We tried to pretend like it's a problem for those people over there or people who aren't like me or I'm somehow healthier and not at risk, and then over time, we find out that isn't the case. And that kind of stage of denial is often followed by the stage of uncertainty. You hear different things from different experts, different leaders are taking this on in different ways. It's confusing, and when people are confused and frightened at the same time, they will search for their own trusted resources for information. And sometimes that trusted resource is someone like me who may or may not have any expertise or knowledge whatsoever, but is someone that's trusted for other reasons. And I think that's really the genesis of these theories. They get started and then they become a reality, even though they're not founded in scientific information. So it's kind of a normal human reaction. It's one of the reasons why when I was directing the CDC, we put so much emphasis on public health communication and how do we build trust and the credibility of the messengers, not just the message.

Jordan Harbinger: [00:20:30] I think right now people don't necessarily know who to trust. It does amaze me that they would trust some person on YouTube -- who has said numerous false things kind of as a job. That's their niche, making things up -- rather than trusting authority. That I think is a little scary. Do you think the crisis is worse because we have Internet and rapid communication? Or is this better manageable because we can actually transmit the information quickly? Because of course there are two sides to that coin.

Julie Gerberding: [00:20:57] Well, you're absolutely right, and I think there are two sides. We can get information out incredibly quickly globally. So advice and recommendations and data and clinical guidelines, for example, as well as all the social distancing measures, they were disseminated literally overnight. But those same channels work for information that isn't true, and sometimes the more scandalous it is, or the more it feeds into people's worst fears, the more legs it gets because it's sort of mutually reinforcing. That is something that even in the biopharmaceutical industry, we have to really work hard to understand, to track and monitor, but also to try to build our own credibility so that we can counter that perspective with what we believe to be the scientifically solid information.

Jordan Harbinger: [00:21:43] So conspiracies aside, I know I just sort of decided that we weren't going to go there, but I do. So many people wanted to know, is there a possibility that this type of virus could be made in a lab? And scientific consensus says, "No, we can see when things have been messed with," but we don't really know how that works as the general public.

Julie Gerberding: [00:22:00] Yeah. So our genomics are so good that we can fingerprint these viruses and really almost immediately could tell that this virus had a bat origin. And as we're watching it move through people, we're tracking how it's evolving. It's in the family of viruses known as single-stranded RNA viruses. So viruses in this family, like influenza tend to evolve more quickly than some of the other viruses that we commonly deal with. The fingerprints become really very helpful in tracing who's moved the virus from one person to another. And I think that's what gives us confidence that this was not a genetically engineered virus because it has the patterns in the very subtle macromolecular signatures that tell us that the origin can be readily traced back to the bat origin.

Jordan Harbinger: [00:22:51] So when we have things that are genetically modified or engineered, is there a sort of an obvious kind of like a scar on that RNA or on that virus that shows, "Okay, somebody went in here and changed something."

Julie Gerberding: [00:23:03] That's really a very clever way of describing it. And that isn't always the case. But I know even going back to my experience with the anthrax attacks in the United States, the forensic microbiology that went into tracing the genomics of the anthrax spores was amazing what we could learn and how we could compare even the most subtle differences from anthrax that someone might have caught in a farm, anthrax that probably had been developed for use in bioweaponry and everything in between. So at the macromolecular level, it's pretty compelling evidence.

Jordan Harbinger: [00:23:39] That's good to know. Because I think it would be great to lay that one to rest cause that's one of the major hang-ups. People say, "Well, why should we work with China? They might have made this in their lab in Wuhan," and it's good to be able to sort of say, like definitively, "Hey look, that's garbage. Stop watching YouTube."

Julie Gerberding: [00:23:54] Yeah. One of the things that I believe, and it's certainly been my personal experience because of the outbreaks I manage, is that Mother Nature is a really good terrorist. She does know how to evolve these viruses. That doesn't mean that real terrorists couldn't do worse or come up with something that's threatening or dangerous to us. Of course, that is always the threat that we face. But in our experience so far, the majority of the things we're contending with have been naturally evolved.

Jordan Harbinger: [00:24:23] Mother Nature didn't really need any help with this one.

Julie Gerberding: [00:24:25] I'm afraid not, no.

Jordan Harbinger: [00:24:27] We kind of pulled the trigger on ourselves here. What do we know for certain about gaining immunity after having the disease? Because it seems like there's conflicting information and I have friends who've had it and they're like, "Great, I'm going to live my normal life." And I'm like, "Well, you could get this again maybe." We don't really know, do we?

Julie Gerberding: [00:24:42] Not yet. We do know that people develop antibodies, so that's the good news. And they start developing those antibodies pretty quickly after they're infected. At least the more seriously infected people that we have been monitored closely. But what we don't know is do those antibodies actually prevent the infection the next time you're exposed. And if they do, how long does that protection last? And the duration of protection is a key issue because if it's a long time, that's wonderful news and it really helps us also have confidence that our vaccine will protect for a long time. But if the duration of protection is short, then either we have to vaccinate more than once, or we would have to have an expectation that the second wave is going to come regardless of the level of population immunity, because that immunity would disappear or decrease over time. But the other possibility, of course, always is, is the virus evolving to the point where it could escape that acquired immunity to the original virus.

[00:25:42] Fortunately so far, and I say so far because we're only really a few weeks into this, if you think if it emerged in December and it's only April, we could see the virus evolve. It's already changing a little bit, but will it evolve enough so that it would escape the naturally acquired immunity or the vaccine-acquired immunity that we just don't know yet and we won't know until a lot of time has passed.

Jordan Harbinger: [00:26:05] That. I think it makes it even a little scarier because people say this could be seasonal, like the flu. But is this deadlier than the flu? People say, "Oh, it's just the flu. There's flu deaths that are higher." Why is this scarier than the flu? Are flu deaths higher? And we're used to it, so we ignore those. Why should we be more concerned about this than the flu?

Julie Gerberding: [00:26:25] There are two reasons that this is different than flu. Well, I should say three reasons. One is because we just simply don't know enough, and that creates a lot of uncertainty and anxiety. But second, it is really efficiently transmitted at the community level, seemingly to all age groups. There's no prior immunity. With flu, we at least have some prior immunity to most strains. For example, in 2009 when we had the global pandemic, people who were older didn't get sick and they didn't get sick because in their youth, they were likely exposed to a similar virus and their bodies still remembered that exposure. So they had some durable immunity and they were protected. We don't have any evidence of that with this coronavirus. So we have to assume that everybody's susceptible, and that really is a game-changer.

[00:27:14] The other thing is, of course, that for the unfortunate people who can't contain the infection in their upper airway, once it spills over and really starts taking off in the lower airways, the so-called cytokine storm, which is an expression that describes what is really like a cyclone inside of your lung tissue with all kinds of cells and chemicals all coming together to try to combat the virus, but in the process of doing it, they're damaging the tissues of the lungs through all of this inflammation and that sort of chemical milieu spills over into the rest of your body can cause cardiac compromise, arrhythmias, heart failure, heart attacks. There's now evidence of neurologic disease associated with this more severe form of the illness and probably a lot of other organ damage and tissue damage that we haven't even fully defined yet. So it is a really bad, bad disease when it gets to that level. And I think that's part of the reason why it is so concerning.

Jordan Harbinger: [00:28:19] Why is it so hard to control infectious diseases even with all of the medical advances that we have now? Is it just like, "Dammit, dad, wash your freaking hands." Or what else is going on here?

Julie Gerberding: [00:28:30] Because they're many different routes of getting many different infectious diseases. You know, one of the important things that I'm watching for because of my background is the complicating bacterial infections that sick people are coming down with. So if you're in a hospital, say on a ventilator, or you have IV catheters and other devices keeping you alive, that's the environment where people get infected as a consequence of their care and the superbugs that hang around in our hospitals because they've become highly resistant to our normal antibiotics. They take over. And then they come in and they cause a second pneumonia on top of the original coronavirus pneumonia, or they cause a bloodstream infection through the catheter. Many of these are prevented, if preventable, but not all. And sometimes our antibiotics just aren't good enough to treat them. So while we're worrying about coronavirus and coronavirus treatment, we have to pay attention to all of the other things that can go wrong for patients in the hospital and superbug infection without super antibiotics is one of those areas where I've seen that we are especially vulnerable.

Jordan Harbinger: [00:29:38] When you led the CDC, what was your biggest worry at that time from a public health standpoint? What did you see as one of the biggest threats? And it could even be administrative, it doesn't necessarily have to be health.

Julie Gerberding: [00:29:51] There were a lot in that category. I would say it's almost like two ends of the spectrum. On the one hand, we thought about the influenza pandemic as a sort of the prototype infectious disease global threat, because we knew from 1918 how devastating influenza could be. And our thinking was if we could prepare for that, we could probably handle almost any other kind of globally transmitted infectious disease. The other end of the spectrum is the paradox of obesity and all of the health consequences that are spinning across our metabolic disorders and our lifestyles and our choices about how we live in exercise and so forth. So kind of the acute global outbreak versus the chronic global outbreak of obesity and getting both of those in focus was what really challenged me. Both from the standpoint of what do we do, both are very difficult challenges from a public health perspective, but also personally is how do you divide your time between the urgent crisis kind of outbreak situation and the chronic slowly gathering steam catastrophe that are metabolic disorders are creating for us long term and for our children for that matter.

Jason DeFillippo: [00:31:11] You're listening to The Jordan Harbinger Show. We'll be right back.

Jordan Harbinger: [00:31:15] This episode is sponsored in part by Notion. Notion is an app that can be used for your business, for yourself. We use it to keep all of our thoughts in one place. It can replace a lot of other tools that only have one purpose like Evernote or Google Docs, et cetera, and it can kind of combine notes, tasks, to-do list, spreadsheets and projects all-in-one place. And that might sound messy, but Notion does a good job of keeping things split up and organized in a way that's going to work for you. It's also highly customizable so you can work the way that you want. It's fun to use. It looks good. It's a great place to organize all your work and share with others. It's very collaborative, which means you can invite other people on your team. You can invite your wife to that shopping list. You can invite your assistant to that to-do list and those tasks. Notion is a tool for people like us that are looking to create their own workspace in the cloud as it were and get things done. Jason, tell them how they can try Notion for free.

Jason DeFillippo: [00:32:07] Well, they can try the Notion for free. Just head over to notion.com/jordan to get started. That's N-O-T-I-O-N.com/jordan and try it out for free.

Jordan Harbinger: [00:32:15] This episode is also sponsored by Motley Fool. I've been listening to the Motley Fool podcast for a while with Jen. These guys are smart. They have good insights. They've got a stock advisor. A lot of you have asked me, "How do I learn how to do investing in stocks?" And I am not the guy for that. I learned a long time ago to throw money in index funds, pick stocks here and there, but I certainly cannot give financial advice. Motley Fool can help you out. You can learn to invest with confidence. There's a fun community to help you achieve financial goals. In each month, Tom and David over at Motley Fool choose a new stock recommendation that comes with a full analysis of risk profile. In other words, why they chose it, what you're looking for. They've got hundreds of official recommendations. They choose the 10 best buys right now every month, and they'll send those along to you. And updated yearly, they've got these starter stocks, which is a curated set of what they believe to be the 10 best stocks to lay a solid foundation for what they would call a foolish portfolio. I see what you guys did there. I mean, these guys did pick Netflix ages ago and it's up like literally 20,000 percent or something like that. So, you know, not a bad pick. I mean, they're probably leaning on that, you know, but I don't blame them. Look, if they bought Netflix, I hope they threw a bunch of money in there. They're stock advisors. This stock picking service for newbies and experienced investors alike. A lot of people love this. They've won a bunch of awards. So go ahead and check them out and let me know what you think. Jason, tell them where they can get a deal on the Motley Fool stock advisor.

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[00:33:53] Thanks for listening and supporting the show and to learn more and get links to all the great discounts you just heard from our amazing sponsors, visit jordanharbinger.com/deals. Don't forget we have a worksheet for today's episode so you can make sure you solidify your understanding of the key takeaways. That link is in the show notes at jordanharbinger.com/podcast. If you'd like some tips on how to subscribe to the show, just go to jordanharbinger.com/subscribe. Subscribing to the show is absolutely free. It just means that you get all of the latest episodes downloaded automatically to your podcast player so you don't miss a single thing. And now back to the show.

Jordan Harbinger: [00:34:28] What is the function of something like the pandemic response team, of course, to respond to pandemics, but people keep saying, "We don't have one of these." How could they have helped the US? I assume it's not like, oh, there was a guy sitting around in a room that can develop cures in five minutes and he just happened to get fired. I mean, there's got to be more to the story, right?

Julie Gerberding: [00:34:45] Yeah. I think what people are really focusing on is leadership. I co-chair a commission. That is supported by CSIS, the important Global Health Think Tank. The commission is focused on how we can improve our global health security. So members of Congress from both parties and both chambers participate in the development of what we think would have been important steps to improve our ability to respond to something like we're experiencing now.

[00:35:12] My recommendations came out before the pandemic started, but the first recommendation was leadership. That we need a government leader who's permanently there to oversee the broad whole of government preparation for something as serious as a pandemic would be. And that is something that kind of has waxed and waned from one administration to another. In crisis, almost every president has appointed someone to that role. In this case, the president appointed Vice President Pence and President Bush had an appointed person who led the Homeland Security Council through all of the infectious disease planning and crisis we were experiencing then. Secretary Leavitt of Health and Human Services followed that with a very, very deep effort in pandemic preparedness. We literally went to every cabinet secretary with John Barry's book on the 1918 pandemic and sat with them, highlighted in yellow the passages that we felt were the most important for them to pay attention to, so that -- for example, the Secretary of Transportation understood that transportation had a role in a pandemic. Commerce understood its role. State Department understood its role and really tried to get all of the government to come together and plan an exercise and prepare and invest. And for a while I think we were pretty successful.

[00:36:37] The truth is -- and it's not a product of any given president or administration or party or government for that matter. The truth is when the crisis passes, our attention relaxes and complacency sets in. And we do continuously go from this crisis to complacency. So during a crisis, we invest, we have emergency supplementals. We do everything we can think of to do to try to help. And then when the danger passes, we relax back into a situation where the money goes away, people go away, the focus shifts, and then we don't really make that long-term progress that we need.

Jordan Harbinger: [00:37:12] That's scary because I would imagine people of my generation or the generation below are going to say, "Hey, why don't we have, how do we not stay? I mean, I remember staying home for six months as a kid. Why aren't we paying attention to that?" Kind of like the 2008 recession, people go, "You know, all these bank controls and maybe we jumped the gun a little. They're a little stringent. Let's loosen these things up." It just sort of makes sense. I guess it's human nature to say this is constricting economics or taking up a lot of funds. That happened once a century. Let's just not worry about it.

Julie Gerberding: [00:37:43] But I think that's true. And from where I sit because I see the prospects of climate change, urbanization, and the social forces that are at play in the world, I just do not believe that we're going to be so lucky that this is a once-in-a-century phenomenon, but I also have a viewpoint of optimism in a couple of senses. When something really bad happens, and you could say the economic crash in 1929 or World War II, which had just devastating consequences. The world changes. The post-World War II world is very different than the pre-World War II world.

[00:38:25] And even if you go to AIDS, which you know, it doesn't stick in people's minds as a pandemic, but it clearly is and it's not over yet. Many things have changed because of AIDS. Think about going to the dentist. For older people who went to the dentist as children, you never saw a dentist with gloves. You never saw the dentist impose such important infection control in the dental practice. But AIDS foundationally changed the way that we operate in healthcare environments, in dental practices, and in many, many other ways in our society that we haven't really thought about.

[00:38:55] So when confronted with something new, sometimes there is stickiness and we do make lasting changes. And I truly expect that this crisis is so significant on a global basis that we will change. Things will be different going forward, and I hope some of them are operating in a good and hopeful way.

Jordan Harbinger: [00:39:16] Should we be returning the supply chain for generic and specific antibiotics and antivirals to the United States? Do you think?

Julie Gerberding: [00:39:23] You know, every country is asking that question. Everybody wants to do it all at home now because they recognize the vulnerability. So that is a solution. You could bring everything home. It's probably not a very realistic solution because at the end of the day, if you go back to the raw materials that some of our medicines and vaccines, for example, our devices or our electronic devices, some of the raw materials are not available in every country, and they're not available in our country. So we do, somewhere along the line, have to be codependent on other nations and other partners to accomplish what we need to accomplish. So I think it's kind of naive to think that we can do the whole thing without a global economy.

The question is what are the assets that are so important to the national interests that we have to be able to have those homegrown, so to speak, and then where can we participate in the global economy in ways that allow a more practical solution to those things that perhaps are not so critical to our domestic security. If we had better partnerships and we were all better aligned on a global basis, I think we would be having different discussions. But right now, as everyone knows, the world is in a mode of intense nationalism. That was the case before coronavirus and I suspect it will become more conspicuous after for a while, although the learning curve may ultimately be that we are connected. Guess what? No matter how hard you try to put up barriers or boundaries, these viruses that mother nature unleashes don't have passports.

Jordan Harbinger: [00:41:03] Do you think the estimate of 100,000 to 200,000 deaths is accurate?

Julie Gerberding: [00:41:08] That's really hard for me to say. You know, I've looked at the published models and really tried to understand the assumptions and we've seen those models change in the favorable direction recently, lowering the projected numbers, but we're not even halfway through this yet, so it's pretty early to really know how it's ultimately going to land. If we could get a vaccine fast, that would be a big help. If we can find a treatment, that really helps reduce the fatality, right? That would make a huge difference also. So we just can't say.

Jordan Harbinger: [00:41:41] Were there things that you gained out when you were directing the CDC? Do you simulate pandemics and think like, "Okay, here are death tolls, theoretical death tolls and things like that"? Does that happen?

Julie Gerberding: [00:41:53] Yes. Well, clearly for a global influenza pandemic, those models were pretty sophisticated and we had something to go on because we had data from 1918 and some data from the smaller pandemics that occurred twice after that. So there were better scientific foundations for modeling influenza than we currently have for this new and unknown virus. But the models were just the beginning of it. Then we had to practice, and I think the thing that was probably the most dramatic during my tenure at CDC was the amount of effort we put into exercising.

[00:42:30] We had hired a number of retired military personnel from the US Army because the army is really good at logistics and planning, and so we added a lot of colonels and a retired general who is a retired three-star general, General Taylor, who is just phenomenal. And we spent three years really building up our capacity to understand, lead, and then practice in full-scale exercises. Sometimes a three-day all-hands on deck with states and locals with health leaders in healthcare systems just rehearsing what we would do and going through all of the different steps that would be necessary. We even with the cooperation of American Airlines at the Miami International Airport put passengers on a plane and brought it in and figured out how we would quarantine a plane full of passengers if necessary. And what would have to happen to allow those people to stay for a period of time in an airport quarantine environment. So that kind of exercise in rehearsal changes everything. But it's expensive and again, you can't do it if you're in a mindset of complacency. It took just the commitment in the context of avian influenza spillovers, which were occurring periodically and scared us because they add a 50 percent mortality rate. That really motivated us to take that practice seriously.

Jordan Harbinger: [00:43:51] With today's technology advancing rapidly, everybody's got a GPS in their phone. There's location services that can kind of track our every move. Is anybody collecting data of COVID-19 positive diagnosed individuals? You probably don't know the answer to that, but couldn't we use this information to track exposure? I think other countries are doing this. Obviously, there are privacy concerns with that. But at CDC, do you model that type of technology and just balance it against privacy?

Julie Gerberding: [00:44:16] Well, I left the CDC in 2009 and so we were not really there. I was still using a BlackBerry, I have to say.

Jordan Harbinger: [00:44:25] Oh, my gosh.

Julie Gerberding: [00:44:26] So during my tenure, that was not part of our planning, although we did recognize the value of GPS. But since that time, those techniques have been used in some surprising ways. There is a very important effort in Africa to use GPS to help track Ebola and Ebola risks so that people who needed vaccination could be found. Likewise, in Korea, during one of the MERS outbreaks, GPS phone data was used to try to find who had potentially exposed whom and what could be done to find them and make sure that they were isolated and properly sequestered from further transmission. So that is being done. And I'm sure there are many examples. I've read the same news you have about some of our Silicon Valley partners, et cetera, who are interested in trying to see how this could be valuable. I do hope that it's a voluntary thing and not something that's imposed because I care about privacy and I think we have to be careful how we use these kinds of tools.

Jordan Harbinger: [00:45:22] Yeah. It seems like it would be really easy to say, "Look, cause I know it's not for the disease, but we're just going to do some sort of statistical modeling here," and now suddenly, you know, 20 years later, yeah, everybody knows what you bought at the grocery store. I think we're probably already there anyway, but still, and I don't want to sign up for that if I don't have to. For disease tracking, yes. But for everything else, I don't know. Slippery slope is the argument that you would hear in law school.

[00:45:48] If we all have the right protective gear, so masks, gloves, et cetera, can everyone get back to their quote-unquote normal life and be safe? If we're protected, why would we need to stay at home? People have asked.

Julie Gerberding: [00:45:57] Well, you know, I think that's what we're hoping for that -- what I call population pressure, meaning that the number of undiagnosed people wandering around the community can be decreased. And if that's the case, then it's the Swiss cheese analogy. A mask is not the be-all and end-all of protection, but if you have a mask, you're a good handwasher, you do try to avoid large crowds, maintain your social distance -- each measure adds a little bit. Just like if you stacked up slices of Swiss cheese pretty soon, you would not be able to see through the stack. And that's really what we're trying to accomplish here. But what will change -- I think as testing becomes widely available and hopefully our health systems catch up with themselves a little bit -- is that in a community when we have a new suspected case, we can have that person tested quickly. Ideally, at a point of care, so they don't even have to wait for the result and that if the test is positive, they can be isolated quickly at home. And the rest of the people can maintain some common-sense precautions while the virus is still circulating, but at the same time have more freedom to go about their work. And that's, I think, a realistic next phase of what we could hope for in the coming months.

Jordan Harbinger: [00:47:15] How did health care organizations flip flop between discouraging wearing masks for those who weren't showing symptoms to now it's, "Hey, I actually, saw a mask out of an old pair of underwear." You know, like what happened there?

Julie Gerberding: [00:47:26] So the science of masks is not as good as it should be, but you have to decide what is the purpose of the mask. So in a healthcare setting, there are two reasons to wear masks. You put a mask on the patient so that if they're able to wear a mask, they are containing at least some of their airway secretions in the mask instead of releasing them into the room where they're our health workers and other vulnerable people in very, very close proximity. You mask the healthcare worker, so that they don't pick up that splash or splatter but also because health care workers do a lot of procedures and manipulations that don't just put them in contact with large droplets that end up in their mouth or nose or eyes, but they actually do procedures that create aerosols very fine mist of body fluids and respiratory secretions that can float in the air in smaller diameters for long periods of time. So health care workers wear the special mask, so-called N95 respirators, which are designed to fit very tightly on the face and not allow air to leak in around the edges, but also filter out any incoming aerosols or some fine particles that could pose an infection risk in those specialized situations. Those are the two reasons for wearing masks in the hospital.

[00:48:49] Now in the public, we are not recommending mass in the general public because we're worried about aerosols floating around the community. What we're advising mask for is more comparable to the patient's situation. If someone is asymptomatically infected person and doesn't realize, and maybe they're not careful with their coughing and sneezing, et cetera or they're singing while they're walking down the street and aerosolizing their secretions that way, that by putting a mask or cloth in front of that person's nose and mouse, that you're just reducing the likelihood that their respiratory secretions are going out into the air or landing on surfaces that someone else could pick up. Those cloth masks are not fail-proof. There's no guarantee that if we all were a cloth mask in public, that no one would ever get coronavirus again. They're just an extra margin of safety. And I also think there's a hidden benefit that matters to me, and I think about that when you go to the grocery store and you see the clerks or the people who are standing there day in and day out, watching customers pile by. If customers in the grocery store are taking the time to cover their faces with cloth, I think it sends a message to the workers that, "Our customers care about us too. And that they are conscientious about trying to reduce any hazards that they could create by being in the store while I'm providing them this essential service of keeping our food supplies open." So I think there's a humanitarian dimension to it as well as an infection prevention dimension.

[00:50:26] And that's why I ordered some masks. The ones I wanted aren't going to arrive until like after May and so I canceled that order, but I got some really great ones. They're pink and they have little bunnies on them.

Jordan Harbinger: [00:50:34] Nice. Good. Well, at least we can all maintain our sense of style and self-expression for the rest of 2020. Why is there such a mask shortage? Is it not having enough or is it bureaucracy? What's going on here?

Julie Gerberding: [00:50:49] Well, I think the planning for the requirement for masks and other personal protective equipment as well as many other medical supplies, including ventilators, was not based on the scenario that we are currently experiencing. I think they were planned for localized problems and not national or global problems. The supply chain for masks is a global supply chain. Most of the equipment for personal protective gear comes from elsewhere in the world. And particularly from Asia where they are using them in their own countries for managing their own outbreaks. So the supply chain is not limitless, and our stockpiles were not adequate to manage this size of an outbreak for the length of time that this is going to have to be managed. As grateful as I am, everyone that manufacturers are going full scale now and working around-the-clock and scaling up and out to try to meet the increased demand. But I think it caught the whole system off guard. Whenever you're planning for something, there's always a break-the-glass scenario, which is you can plan up to a certain level, but if something happens worse than that, if you're not prepared, and I think in this case, if the mindset was preparing for an influenza pandemic, the stockpile was not really sized for the pandemic that we have right now.

Jordan Harbinger: [00:52:09] Why do we think that the World Health Organization took so long to warn everyone about COVID-19. There's people saying, "It's because of China. They're in the pocket of China." Is that accurate? What's going on there?

Julie Gerberding: [00:52:20] You know, I don't have any insight that I didn't get to participate in those conversations. The WHO with the collaboration of public health experts around the world did establish very specific criteria for what defines a global outbreak and a pandemic basically, and they were checking boxes of that list, but hadn't checked the final box of widespread community transmission in multiple locations as quickly as others believe they were seeing that in play.

[00:52:52] So the controversy was, did the state of the world meet the stated criteria for declaring a pandemic of international concern? Or were we not quite there yet? And different experts had different opinions about that. And I think WHO took a conservative view. It seemed fairly obvious to me when I was watching the situation with the cruise ship in Japan, that this was an incredibly transmissible virus, and that we better be leaning into preparedness. So in retrospect, I have to say personally, I wish that that declaration had been made earlier only because it would have motivated, perhaps, even more, planning and action in places that didn't get out of the starting gate very quickly.

Jordan Harbinger: [00:53:36] When you were director of the CDC, how often does political pressure from the administration potentially affect your job? I mean, of course, everything in administration does can affect your job but is there ever kind of like, "Hey, maybe let's not declare this because we don't want panic," and you're thinking, "Well, the right thing to do is this, and I'm getting pressured to do that." Are there conflicts like that?

Julie Gerberding: [00:53:56] Well, there are always political conflicts, whether they come from Congress or the administration or at a state and local level from governors and legislators or mayors and city councils. Those things are the reality. I think I started out in my life thinking that, "Well, I'm a scientist. If you have good science, you'll end up with good policy." And of course, policy is like making sausage. Science has to be a foundation and I hope it will always be a foundation and it disturbs me greatly when it isn't. But nevertheless, there's a lot more that goes into how those kinds of decisions are made.

[00:54:30] For me, personally, I would say I was extremely fortunate. I served under two secretaries, Governor Tommy Thompson and Governor Mike Leavitt, who as Secretaries of Health and Human Services have truly respected the scientists. Tony Fauci and I and Elias Zerhouni were in the Humphrey Building with the secretaries anytime something was happening. During the SARS outbreak, Secretary Thompson held a morning consult with all of the agency heads, all of us who are scientists, and we had a daily briefing and he followed our recommendations. So I really think I was lucky and felt like I didn't have to cross any lines in the sand on the topics of the outbreaks that I was dealing with. And actually, there's a lot of mythology about how things look from the outside in when you're in the middle of a crisis. But I had many opportunities to brief President Bush when I was in government. Those were the hardest briefings that I ever experienced because he asked really hard questions. He was the best prepared of anyone I've ever briefed for dealing with really hard things pertaining to the anthrax attacks and then the smallpox immunization program, and then SARS, and then avian influenza and so on and so forth.

[00:55:45] The environment has just had the conduit of science into the decision-makers. I didn't always agree with all of the decisions that were made. Don't get me wrong, but I felt like the scientific and public health voice was heard and we were confident that when we executed those decisions, we were doing what was right for the people we were serving. So I don't mean to sound Pollyannaish. I recognize that it's challenging, but I do have confidence that our government can work and the more we bring the scientists into the conversation, the better it will work.

Jordan Harbinger: [00:56:19] There's a perception that states like Taiwan, South Korea, Singapore, got this right so early in it, the West, we've just bungled this whole thing. To what degree do you, or might you agree with that or is that just kind of armchair quarterbacking?

Julie Gerberding: [00:56:32] But I think there is a little bit of armchair quarterbacking and the story's not over yet, so we'll see what happens when countries try to go back to work, so to speak. I use Korea as a great example because Korea had excellent and assertive leadership early on, but their outbreak was a little bit different because it was linked initially to people who attended a church. They were affiliated with a very large congregation of people, and so the initial spread was easier to track or relatively easy to track because the people all had that connection. And so the Koreans could go in there and test the congregation basically, and then test the context of those people and very quickly identify cases and quarantine the exposed people, isolate the infected people, and were able to engage aggressively. They had the highest per capita utilization of testing of any nation, I believe so far. And that certainly helped, but once they kind of quench that phase, it suddenly got a little bit harder because then there are small focus areas of transmission kind of spread all over the country. And that was a little bit harder to identify, a little bit harder to track and trace. So they learned a lot in the process and I learned a lot by listening and reading and trying to understand what went well for them and what didn't go well.

[00:57:56] Merck has a team in Korea, wonderful leaders and fantastic people who are working now, and we're trying to learn and understand as much as we can from them so that we can share that with our other partners around the world and hopefully to Korea story will remain successful.

Jason DeFillippo: [00:58:13] You're listening to The Jordan Harbinger Show. We'll be right back after this.

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Jordan Harbinger: [01:02:20] I've heard a lot of people claim that the CDC and other governing bodies are in the pocket of big pharma, right? And you're working at Merck right now. So people are going, "Oh, this is all just one big, I don't know, global cabal or conspiracy," or something like that. But I would imagine there are controls in place so decision-makers must declare conflicts of interest and can't, for example, own a bunch of stock in a pharmaceutical or a biotech company, which might profit from the decisions that they make when they're running the CDC. Are you able to speak to that at all? What controls and policies might be in place to address conflicts of interest? Because some people think that those just don't even exist.

Julie Gerberding: [01:02:57] Yeah, I think that people are very wrong about that. When I went to the CDC originally, of course, I came from an academic background. So holding stock was not a privilege that I had and I didn't have to worry about conflicts of interest because basically I had not. However, when I was there, we would want to set up scientific advisory committees and bring outside experts in and the amount of screening and scrutiny that these people who are volunteering at really essentially no significant monetary investment, just trying to help the government make good decisions about scientific issues relevant to public health or any other topics. The amount of screening and disclosure and verification that they have to go through is actually a deterrent to getting good people in because they really have to provide all kinds of information that they've never really thought about and may not feel like a conflict to them. But in the eyes of the government, we have those safeguards in place. So it's actually if anything erring on the side of excluding qualified people from contributing their expertise or their perspectives, not encouraging conflicts of interests or taking advantage of people's biases. I've experienced that for all the years I was in government, and I do not worry about anybody being in the pocket of anyone when it comes to those kinds of appointments at the government level.

Jordan Harbinger: [01:04:19] In a dire situation like this with there is sort of a race for the cure mentality to save people, potentially save the economy, how do organizations such as the CDC weigh the risks between rushing to find a treatment or a vaccine that might involve, I don't know making human trials faster or cutting some sort of corners without necessarily knowing the long-term risks associated with novel drugs? How do you reconcile that? What does that conversation look like?

Julie Gerberding: [01:04:43] Well, the CDC is not the main purveyor of the clinical development pathway system. That's really an FDA primary jurisdiction, but of course, CDC has a strong stake in it, and I think this coronavirus, as well as the other new infections that I dealt with, are characterized by kind of two arms. On the one hand, you have the urgent need for treatment of very sick people who may die if we do nothing. So the ability to test new treatments in that situation where life is literally on the line allows you to put in investigational drugs, of course, with consent and informed participation by the patient, or if the patient is too sick, their family. So that yes, we can move experimental therapies in that setting because to do nothing for many patients is simply a death sentence.

[01:05:41] On the other hand, vaccines in a situation are just the opposite. We're talking about healthy people who hopefully won't even get exposed, let alone sick or in intensive care units. So we have to be sure that the vaccines are absolutely as safe as we can make them, and that requires a lot more testing and a lot more time. So part of the reason why we say we won't have a vaccine for this for some time for the general public is because we have to go through those stages of testing. And some of that safety data has accumulated months out from the actual initial vaccination because some side effects from vaccines might take a longer-term period of time to actually show up or be detectable. So safety is the most important thing.

[01:06:27] If you think back to 2009 when the influenza vaccines, which we know how to make and make a lot of every year, but we hadn't made one for this particular virus. And so the companies that were involved in that, not Merck, but the companies that were making the flu vaccine really had to follow the same rules. They had to do something very, very quickly under extreme pressure. But at the same time, they had to monitor the safety and it was through that monitoring that an unexpected side effect did show up. But you could go back to, I think, 1978 when the original swine flu scare occurred in the United States, there was an expectation that there would be a bad influence of pandemic that year based on some very early signals. So there was a rush to get a vaccine. And in retrospect, that vaccine actually turned out to be associated with a slightly increased risk of something called Guillain-Barre disease, which is the temporary paralysis. So the safety signal from that vaccination program scared everyone. And I think it's in our minds when we think about how do we bring a safe vaccine forward for Ebola, and Merck had to really watch very carefully about the safety of the Ebola vaccine. We just got licensed for the use that is now ongoing, unfortunately in the DRC.

[01:07:45] So treatments are one thing for sick people. Vaccines for healthy people are another, and the timelines are very different.

Jordan Harbinger: [01:07:53] When they make decisions to shut things down, how do you weigh the costs? Like tanking the economy versus the benefits of saving lives, of course, when recommending public actions that might take the economy, for example.

Julie Gerberding: [01:08:06] You know, I take some accountability here because of all of the time that we were thinking about influenza pandemic preparedness, and we included all of these measures, closing schools early because we knew from 1918 that was something that did help flatten the curve, number of the social distancing measures. I don't think that we adequately understood or model the economic consequences. And so, you know, from that time in early 2000 to 2020, the global economy has become even more connected. In 2003, when SARS occurred, China was hardly even on the global economic map. And today, it's a superpower from an economic perspective.

[01:08:51] So we didn't really fully grasp and grapple with given that we need to save lives as our first priority. How do we prepare our governments to be able to offset or plan for or have contingencies in place to support people whose jobs will disappear or stop temporarily, or who are going to suffer all kinds of other hardships? So the kind of doctrine of trust that needed to be built into the preparedness to offset these social distancing measures was not a prominent part of the planning then, and it certainly hasn't been a prominent part of the planning in recent years, and that's a really important place for us to start going forward.

Jordan Harbinger: [01:09:32] How much are decisions, like how long to shut down for, for example, how much of that is scientific and how much of that is the leaders saying, "Okay, we've got to make this playbook as we go. We're not quite sure what's going to happen"? How much of this is, "Hey, just trust the experts here"? Or is that changing? Does that change with each administration?

Julie Gerberding: [01:09:50] Oh, well, that's a hard question. I would characterize this phase of the pandemic response as adaptive learning. Meaning we do something, we see what happens. We watched somebody else do something. We see what happens. We tried to take that experiential learning into consideration as we make our next move. We'll make some mistakes. It's inevitable. There have been mistakes. There will be more mistakes. It's the nature of the uncertainty and the complication of the situation that we're dealing with. But we do learn and we model and we rely on past experiences. You know, it seems ironic that we're spending -- I mean, I have John Barry's book sitting right next to me. I went back to read the 1918 influenza story because there's so much in there to learn from that has applicability today. I'm not a person that focuses on blame. I'm a focus that's looking for learning. And I'm watching her evidence that as we experiment with what's the right thing to do, and we bring the best, smartest people to gather, to advise us, and we observe what happens and we listen and pay attention to how it impacts people. And we tried to adapt and adjust as we go forward.

[01:11:07] I have enormous confidence in people's creativity and cleverness. Some of the innovations that have emerged in the context of the coronavirus are astonishing. Everything from how do you ventilate to patients on one ventilator? Kind of a shocking consideration in America, but nevertheless, one that really saves lives could save more lives if we end up in worse shape than we are right now. So people solve problems when they have to, and I think we'll find our way out of this economic debacle that we're in, but I just can't predict how and when that will occur.

Jordan Harbinger: [01:11:41] After years of speculation of something like this happening and many, what some would say are near misses, are pandemics like this going to be a somewhat regular occurrence going forward? You don't have a crystal ball. I realize this, but there's a cognitive bias that the way things are right now might be the new normal. "Hey, we might have to do shelter in place every couple of years." What do you think about that?

Julie Gerberding: [01:12:03] Well, I certainly hope that it is not the new normal. This has been absolutely devastating for people around the world. So now, I hope this is not the new normal, but I do think that emerging infectious diseases are going to be part of our future and from the standpoint of global health security, we need to be much more serious about how we plan for, prepare for, and protect people in this kind of environment. Are there truly ways to take some of these threats off the table? I would say yes. Closing live animal markets are one. Trying to reduce the juxtaposition of humans and animals under the force of urbanization is another in which you think that they're somewhere north of 60 million forcibly displaced people in the world who are living in camps or refugee environments. Those are hotbeds for the emergence and spread of resistant bacteria or other emerging infectious diseases. And so everything in the world right now is stacked against the status quo in terms of infectious disease transmission.

[01:13:11] So we have to think about how do we reduce the pressure on the emergence of these new infections and second, how can we be prepared to recognize them when they do occur. Because you know, the framework really is fairly simple. It is to prevent what you can. Make sure you can detect something as quickly as possible and transparently report it. The third thing is to really full-court press try to contain at source, and I believe China did try to contain this new coronavirus at its source in unprecedented and sometimes frightening ways, but if that fails, then you're in the phase that we're in now, which is the mitigation phase where you're trying to slow the movement of the virus through the population so that you don't overwhelm your health system and can provide the care that people need. And -- I think the "and" kind of gets lost in the small print -- and sustain essential services in society. And we have to put more emphasis on that latter point while we're still trying to protect our health care system. And then of course, finally we get to recovery, which is where we all hope we can get to sooner rather than later. But how that will unfold and when and where is the place we have the most uncertainty right now.

Jordan Harbinger: [01:14:23] In terms of testing, it seems like we've been unable to do that at scale while other countries can. Is that accurate? And if so, why is that the case?

Julie Gerberding: [01:14:31] You know, I am as confused as anyone about the availability of testing right now. There are so many different claims about which tests and who, what, when, where, and how many. I really don't know. I have seen the same anecdotes that everyone has seen people talking about the long line to sit in our car and not be able to get tested. So it's clearly not enough testing. The question really is, given that, at least for the time being there is still a relatively scarce resource, at least in some communities. How do you use the tests we have? And that I think is an area where we need to align around some general principles.

[01:15:13] In my view, because I'm a doctor and you know, it's my heart and my ethical framework, if someone is sick enough to need hospitalization, they need a coronavirus test to make sure that the diagnosis is correct before we go down that treatment pathway because they could have something else that's more treatable and should be managed differently. So we definitely need hospital-based testing for sick people. I think in communities where there is not widespread transmission at the moment, that testing people as symptoms is also essential because there's still a chance to really get out in front of the transmission curve and definitely slow down transmission if you can find the suspect cases and test the people that they've been exposing or exposed to and hopefully, in a focal way curtail further transmission.

[01:16:00] In communities that are already experiencing broad transmission, if someone comes in with coronavirus symptoms, they probably have coronavirus. That pretest probability is very high, so well, I'm sure as an individual, I would want to know. That might not be the highest priority use of the test until such time that we can take care of number one and number two that I already mentioned.

Jordan Harbinger: [01:16:23] I'm really curious about the potential for universal antibody testing. It seems like the sort of, I don't know if it's batch testing and containment, but does testing and containment and disarray, it might be some of our best hope for allowing people to reenter society. Can you explain what universal antibody testing is? I know friends of mine have managed to get their hands on some of these tests through just buying them from private clinics and things like that, but we're not sure how accurate they are. There's probably a lot of false negatives on COVID tests themselves. Can you describe what these are and what these might do or not do?

Julie Gerberding: [01:16:56] Yeah, I'm very cautious about recommending widespread antibody testing right now. And the reason for that is that the tests are, many are not approved. There are counterfeit tests. We don't know what they mean. As I said earlier in our conversation, we don't even know if an antibody test protects you from re-infection. There've been some reports in Asia that reinfection may have occurred, although a little bit sketchy. As an infectious disease doctor, I would like to assume that antibody correlates with protection, but until we know that this is not exactly a return to work ticket. I think they're useful from a public health perspective in really understanding the full iceberg that we're dealing with right now.

[01:17:37] We see the tip of the iceberg does sick people who are in hospitals or who have symptoms of coronavirus and are getting the virus tests, but we don't know the rest of the iceberg that's sitting below the water, and those are the people who've already been infected. In a kind of a sampling way, we can learn a lot more about: What is the risk to kids in school or college? What is the risk to people in prisons or in areas where we may be missing a much more serious problem than we understand and we need to target more focused interventions? So we need to have the antibody tests to tell us something about the movement of the virus as it goes from place to place. I'm not dismissing their value or their importance. But I don't think that we can expect them to be very helpful in turning our economy back on. Because even given the frightening number of people in the United States with infection, it's still a very small fraction of our population. The vast majority of Americans are not immune, and yet we want those people to be able to return to work too.

[01:18:42] So we've got to think a little bit differently about what we need to understand from the antibody test, both at a population level as well as an individual and what we need to be doing to get our communities back out at work.

Jordan Harbinger: [01:18:54] I have a couple of friends have bought these and they're like, I've never prayed so hard to have a disease or have a test come up positive in a medical setting in my life. But I guess even if you do, you don't necessarily know if you're going to be bulletproof from this thing or not.

Julie Gerberding: [01:19:08] Yeah. Yeah. And as you said, there are false negatives and there are probably also false positives to some of these tests, so they can be falsely reassuring or they can be uninformative in terms of who is vulnerable and who isn't.

Jordan Harbinger: [01:19:20] When might we know if convalescent plasma will work, CP or convalescent plasma. For those who don't know, it's taking antibodies from somebody who's already been infected, giving it to someone who has not been infected, thereby potentially conferring immunity. It sounds a little bit like a blood transfusion except for its antibody transfusion. Do we have any reason to believe that it worked well in the past or not really?

Julie Gerberding: [01:19:43] You know, using blood products from people who've survived a serious infectious disease is a very, very, very old strategy for protection is called passive immunity. And if the sick person develops antibodies that are protective, they are very often evidence that it can be helpful in preventing infection in someone who's at risk for exposure. Whether or not they're helpful in treatment really depends probably on the course of infection in their use. So right now, there are studies going on, clinical studies among sick patients. There are also comparable studies where the antibodies are not derived from recovering patients, but rather are artificially created to basically do the same thing. So those studies are in progress.

[01:20:31] The optimist view is that they really will help augment the body's own natural immune defenses and will contribute to a speedier recovery or survival. The pessimistic point of view is that either they won't help much because it's too late. Or the real fear is could they make matters worse because sometimes the cytokine storm that seems to occur in the lung tissue where there are just all kinds of immune excitement and a lot of damage to the tissues by adding an antibody into that mix are you actually adding to the problem instead of ameliorating or making the problem better. So those are the reasons why these things have to be studied in clinical trials.

Jordan Harbinger: [01:21:08] Does convalescent plasma have the same approval timeline as a traditional vaccine? Is it faster or slower? We don't know?

Julie Gerberding: [01:21:15] It will be faster, I presume, because again, they would be using this approach in patients who are very sick and you'll find out whether it's helpful or not very quickly. Whereas with the vaccine trial, the real test of a vaccine is: do people get infected or not? And you have to assume that a reasonable period of time for a vaccine to be effective as, let's just say arbitrarily a year, well, you have to do the studies for a long time to figure out whether or not that protection is long enough to really be helpful from a public health perspective.

Jordan Harbinger: [01:21:47] Okay. That makes sense. What is the timeline, the rough projected guesstimate on getting treatments versus getting an actual vaccine? I assume treatments come before vaccines.

Julie Gerberding: [01:21:57] I think we all think that we will have answers to the treatment questions faster because you know, sick people either get better or they don't, or they survive or they don't. And so the endpoints are quick and clear. For the most part for vaccines, you know, as I said, it's many, many months. The safety data first, and then the dosing data. We have used vaccines for deadly diseases like Ebola, for example, before they're fully approved. Merck's Ervebo, which is our Ebola vaccine, was initially offered and used in the Democratic Republic of the Congo as an investigational vaccine because we had evidence from a clinical trial that it was effective and we had evidence that it was safe, but not conclusive evidence, or at least not that had been formally approved by our Food and Drug Administration or other regulatory authorities. So it's possible with coronavirus that before we have an approved vaccine for coronavirus, that we have an investigational vaccine that appears to be safe and useful and certain categories of really high-risk people, like healthcare workers, for example, might choose to take a vaccine like that when, if it's available. So it doesn't mean because we want to have something for the whole population for at least a year that some people might be able to have access to the vaccine earlier. And I think that's really the goal, how can we get an effective safe vaccine into the hands of at least some people as quickly as possible.

Jordan Harbinger: [01:23:28] Julie, thank you so much. This is really informative, and I think we popped a lot of questions that a lot of people had and a few bubbles on -- both hope bubbles and also conspiracy and misinformation bubbles. So I really think it's been informative and I really appreciate you coming on the show today.

Julie Gerberding: [01:23:45] Well, I hope it helps. It's always more questions than answers but having a conversation is the first step to really kind of improving our collective wisdom. So thank you.

Jordan Harbinger: [01:23:54] Agree. Thank you.

[01:24:00] Big thank you to Julie Gerberding. Links to other resources and websites will be in the show notes on our website at jordanharbinger.com. There's a video of this interview on our YouTube channel, also at jordanharbinger.com/youtube. And also in the show notes, there are worksheets for each episode, so you can review what you've learned here today from Dr. Julie Gerberding. We also now have transcripts for each episode, and those can be found in the show notes as well. You know, I just realized, I forgot to ask, how much of this COVID-19 can we link back to Carol Baskin? Oh, well, missed opportunity.

[01:24:31] I'm teaching you how to connect with great people and manage relationships using systems and tiny habits over at our Six-Minute Networking course, which is free over at jordanharbinger.com/course. The problem with doing it later is you're not going to dig the well before you get thirsty. You need to build your network before you need it even if it means starting from scratch. These drills take just a few minutes a day. It's been crucial for my business and personal success. I highly recommend you dig in. It's free right now and always has been at jordanharbinger.com/course. By the way, most of the guests on the show actually subscribed to this course and the newsletter. Come join us and you'll be in smart company.

[01:25:06] Speaking of building relationships, you can always reach out to me on social media at @JordanHarbinger on both Twitter and Instagram, and you can get a front-row seat next time we ask questions of a guest live on social media.

[01:25:17] This show is created in association with PodcastOne. This episode was produced by Jen Harbinger and Jason DeFillippo,  engineered by Jase Sanderson, show notes and worksheets by Robert Fogarty, music by Evan Viola. I'm your host Jordan Harbinger. Our advice and opinions, and those of our guests are their own, and I'm a lawyer, but not your lawyer, and I'm sure as heck not a doctor. So do your own research before implementing anything you hear on the show. Remember, we rise by lifting others. The fee for the show is that you share it with friends when you find something useful or interesting. So if you know somebody who wants the straight dope on COVD-19 or believes a lot of the BS out there, it might be a good episode to share with them since we get some credible information for once here. Hopefully, you find something great in every episode, so please do share the show with those you love. In the meantime, do your best to apply what you hear on the show, so you can live what you listen, and we'll see you next time.

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