Dr. Irwin Redlener (IR)
Randy Larsen (RL)
June 17, 2020
Dr. Irwin Redlener is the founding director of the National Center for Disaster Preparedness, part of the Earth Institute at Columbia University where he holds professorships in public health and pediatrics. In a wide ranging interview, Dr. Redlener discusses key COVID-19 issues: underlying medical conditions, therapeutics, vaccines, the age issue, communicating with the public, alternative standards of care, lockdown and reopening, schools and daycare, and nursing homes.
Underlying Medical Conditions
RL: Dr. Redlener, I read a report yesterday that just came out from CDC. It stated that underlying medical conditions can increase the risk of death tenfold. One of the most frequent questions I hear is concerning hypertension and diabetes … “I control my high blood pressure and diabetes with oral medications, am I still at risk?” What’s the data say?
IR: The data is not complete, but I did speak with a couple clinicians who treat COVID-19 patients, about this very question. They said, if you control high blood pressure and diabetes with medications, you probably reduce the risk that might otherwise be associated with those diseases. But, one of the underlying factors for both conditions is obesity. So if you’re obese, you are still at significant risk.
RL: I have done a bit of research on this myself, and the one thing most seem to agree on, in the US and Europe, is that a body mass index above 30 is not good. That appears to be a significant risk. It is a serious issue. On the other hand, the big joke I hear is what people are calling the COVID-20. Not getting enough exercise and spending too much time on the couch … eating junk food … is a big problem. So the best advice is to eat more fruits and vegetables, fewer snack foods, get off your butt and start exercising.
RL: I suspect we will have one or more effective therapeutics long before we have a vaccine for COVID-19. True?
IR: Yes. It’s very possible we will have effective therapeutics in the next month or two. We have literally hundreds of laboratories, maybe more than hundreds … if you take the whole world … that are working furiously on developing appropriate therapeutics. Just yesterday a report came out showing that a very common steroid …. dexamethasone … had great promise in treating people who are really sick.
Many who are critically ill with COVID-19 need mechanical ventilation to help them breathe. At least 50% of those people die. But it seems that treatment with dexamethasone may dramatically reduce the fatality rate. It doesn’t seem to be effective on mild cases or preventively, of course, but that is possibly a breakthrough initial finding. A word of caution: it still hasn’t been peer-reviewed by other scientists to make sure that it’s all accurate, but it is promising. And there are other therapeutics in the pipeline that are that are promising as well.
RL: Are you as optimistic about vaccines?
IR: One of the big controversies I’m involved in with colleagues is the issue of vaccines and how soon we can expect to see an effective vaccine. And again, there are many, many laboratories around the world that are working on vaccines.
Some of them are using entirely new procedures to make the vaccine and some are using old procedures. In my view any suggestion that we can have a vaccine ready for mass distribution and delivery to people before somewhere close to the end of 2021 doesn’t make sense. And the reason is even if we pour a lot of money into the development of the
vaccine and doing the initial testing on animals, there are limitations on how quickly a new vaccine can actually be brought to a mass market. They have to do with how big the human trials should be and how long we should wait to see if there are complications.
In the 1970s, we developed a swine flu vaccine. And there’s a famous picture of President Ford getting his shot. But a few months later, it was revealed that the new vaccine was responsible for many cases of a neurological disease called Guillain-Barre syndrome that causes paralysis. That vaccine program, of course, had to be brought to an immediate halt.
The last thing we need now is to rush the human trial period for a Coronavirus vaccine and manufacture what’s going to be seven billion doses for the whole world, before we make sure that there are no unforeseen complications.
It just takes time getting a lot of people to volunteer to get this in the human trial phase … and then we need to wait many months to make sure the vaccine actually works and that it doesn’t cause unanticipated medical complications. So that’s why those of us who are in the camp that say don’t even think about it before the end of the end of 2021. We just need patience to make sure the vaccine works and is safe.
Developing a new vaccine is more difficult than people imagine. The fastest we have ever developed a vaccine was for mumps, and that took four years. So we must be patient about the vaccine. I always say there’s a light at the end of the tunnel, and the light is vaccine, but it’s a very, very long tunnel.
The Age Issue
RL: There was a recent editorial in the Wall Street Journal that said 80% of Americans who died of COVID-19 were older than 65. Does this sound right to you?
IR: I think the average age is dropping into the high 40s, but the people who get sickest are still the people who are older and especially if there are comorbidities.
For a long time, we thought that children were somehow not vulnerable to getting COVID-19. There were a few reports out of China in early March of several pediatric fatalities, but they all had comorbidities. And since we don’t test everybody, and we certainly don’t test all children, we have no idea of how many kids are carrying the disease. That said, there have been quite a few reports of something called multi-system inflammatory disease which has caused hospitalizations of several hundred children around the country. In fact, a number of children have severe consequences of this syndrome. It’s actually caused by the after-effects of the virus. So a child may be ill from the virus or simply carrying it, but many weeks later have an extreme overreaction of their immune system which causes horrible problems in children.
RL: I know those cases got a lot of press attention, and it’s a terrible thing … but percentage-wise, it is very rare. We have 330 million people in this country, but very, very few cases of this horrific immune response in children.
IR: Yes, but if you’re a parent, it’s a very scary thing.
Communicating with the Public
RL: We are seeing lots of press reports on studies that are classified as “pre-release” … meaning there has been no peer-review. I think this is causing lots of communication problems. What is the public to believe?
IR: This is a problem. The public and the media are so hungry for bits of good news that we get this kind of high enthusiasm that’s often over the top … not warranted in normal times.
Moderna, announced that they were producing a new kind of vaccine, releasing “ a study showing that the 9 people who received the vaccine developed antibodies.
Never would such a thing become a news story until now … and it was a big story characterized as a major breakthrough … way too early and too preliminary to call for celebration and give it so much media hype.
RL: When I first started looking at pandemic preparedness … a quarter of a century ago … it first occurred to me that during a deadly pandemic, public affairs could be nearly as important as public health. Maybe that was because I had just come from an assignment working in public affairs, but I think there is some element of truth to that statement.
Alternative Standards of Care
RL: Alternative standards of care is a topic well-known to military medical personnel trained for battlefield conditions, and those who have worked in the field of pandemic preparedness during the past couple decades, but not so familiar to most others. Did we experience any of this during the peak of COVID-19 cases in New York City?
IR: Yes. My son is an emergency room doctor who supervises two busy ERs in New York City, and pulls a lot of shifts himself. So during the height of the COVID-19 outbreak in New York City, he never had enough personal protective equipment … which was astounding to me. But anyway, they did not. So he told his staff when they came in for their shift, they should put on their gown, gloves, face shield and mask, but had to leave it on, not changing them between patients. There was an insufficient supply of PPE which required violating what we consider to be appropriate practice.
This was clearly a case of alternative standards … as were many other protocols developed as the crisis was unfolding. One of the most difficult situations could be caused by shortages of mechanical ventilators. When you have an older person who is not likely to do well on a ventilator, you take that ventilator off that person and give it to a younger person who has a far better chance for survival, that is a bioethical crisis.
Randy, you certainly know more about this than I do, but in a serious crisis we may need abandon the perspective that is typical practice and resort to “combat triage”. In combat, you’re going to take care of people who are more likely to survive, but in a civilian hospital, the sickest people and the most desperately injured people get the highest priority for emergency care. During a pandemic priorities get flipped.
In many states, when we first started talking about pandemics in the late 2000s we had ethics committees in hospitals and state ethics committees providing guidelines for altering standards of care.
RL: Did those hospitals in New York you were talking about … did they already have those procedures for alternate standards of care, or did they have to develop them on the run?
IR: Well, they existed on a state level, the typical “reports on shelves”. Still, I believe that every hospital must have an ethics committee.
Lockdown and Reopening
RL: You published an article in April expressing some concerns about reopening too soon. Have we?
IR: I actually was very concerned that we should not be rushing to reopen our businesses until we had effective point-of-care testing and robust contact tracing. We didn’t have enough of either of these tools when my program, The National Center for Disaster Preparedness at Columbia University published its report on reopening on April 27 … and we still remain unprepared.
There are now 3 reasons why testing has been and still is necessary.
Initially testing was needed to track the prevalence and trajectory of the SARS-CoV-2 virus.
The second reason was that we needed testing so that health care providers could make a clear diagnosis of COVID-19.
And now we have a third reason for testing which has to do with the reopening. Put simply, we want to know if it safe to get a haircut, or go to a nail salon without knowing if your service provider is carrying the infection or not.
This has nothing to do with how many tests are being done nationally. This has to do with whether people in the services industry … such as the person who cuts your hair … has been tested this morning and is negative.
We need something we call point-of-care testing, meaning that we don’t need a lab and we know reliably within minutes if a person is negative or not. We don’t have this type of testing and we don’t have enough contact tracing. So I am still concerned about that.
RL: I’m getting a lot of questions about testing including the quality control of tests that are out there now … particularly some of the serology tests that I’ve seen. There are scores of them on the market … few are FDA-approved, and some of them detect the COVID virus that causes the common cold. So when can we expect to have effective testing?
IR: Well, first of all, the FDA has been working to try to get them approved and certified … not just released under a superficial review that results in an “EUA” or Emergency Use Authorization. The majority of those tests under review are PCR tests where we’re actually looking to detect the presence of the virus. Other tests, check for the presence of antibodies to SARS-Cov-2, called “serology” tests. An effective and reliable serology test would tell us whether what you thought might have been a cold a few weeks ago, was actually a mild COVID-19 infection.
Let’s go back to the person who cuts your hair. If they said to me … six weeks ago I wasn’t really feeling well, but I did not get tested. If we were able to give that person a serology screen, and they tested positive for antibodies, I would feel comfortable being in proximity to that person. The same is true for taking your family to your favorite restaurant. If all the kitchen staff and servers were negative for PCR that day or they had high antibody levels, I would feel comfortable in that establishment.
These tests need to be point-of-care, not the type that requires samples to be sent to a lab. None of this latter type is currently available. So we’re going on minimal information when we are talking about reopening a lot of businesses.
RL: Yeah … kind of like we’re driving in the dark, and accelerating as we go. However, I worry about the guy who used to cut my hair. He is a good friend, and I’m worried about his business.
IR: Yes. It’s not a minor thing I’m talking about people who need their paycheck every week. This is a very critical problem for economically middle and lower middle class people who don’t have a significant nest egg that they can depend on. These are the folks who make up the vast majority of Americans. And, of course, financial fragility compounds the stress of being cooped up, of not knowing whether you’re able to take care of yourself and your family because your income has been eliminated. This is an overwhelmingly difficult problem.
So in some ways we have a confrontation between the public health agenda and the economic agenda on an individual and family basis and it is really very difficult to kind of sort all this out. Yes, there’s a public health concern. Obviously. We have to control the pandemic, but there are other concerns which are really very important, as well. It’s the latter pressure which I think helped motivate governors to start reopening. It’s a dilemma and unfortunately, we’re seeing a new surge in cases and hospitalizations in some of the states as a result of the rush to reopen.
Unfortunately, we’re kind of stuck with these challenges with respect to work, school and family until we get effective medications and vaccines. Until then we have to learn to manage our risks. We had a son who was an intense mountain biker … who loved racing down rocky trails at very high speed. We worried about him … he was taking serious, but personal risks.
But in a pandemic, it’s not just the personal risk. It’s a community risk, particularly when people stop wearing masks in public and not following social distancing guidelines. So that means that we have a risk of community spread. It’s not just the risk you are tolerating, but you are putting your community, your neighbors and your family at risk.
It’s a different way of looking at risk, and much more complicated and one of the things that happens with the reopening. Unfortunately, people hear the message we’re reopening and they’re interpreting that as back to normal – which were certainly not.
I have heard reports now of people wearing masks in public areas actually being threatened by people who are not wearing masks … and they’re saying, “You’re just fear mongering. You don’t need a mask. Take the mask off.”
RL: I would like to have a mask that says, “I am wearing this damn mask to protect you”.
Schools and Daycare
RL: Okay, you mentioned schools … that’s certainly a big topic for everyone … and daycare. What should we tell parents about schools and day care?
IR: Every community is wrestling with this challenge. The New York City public school system has 1.1 million children and a thousand schools. Will the schools be ready for reopening in September of this year? Everybody wants that to happen because so many people have to stay home to take care of the children. The CDC has guidelines, but they’re not really complete and they’re not specific enough for a lot of communities. New York City is considering a split schedule to help with social distancing, but what about the teachers? What about some of the teachers who are a little older and maybe at risk themselves. Children could be silent carriers.
How do you make a school environment safe? I have six grandchildren. I know we need to get kids back in school, but is it going to be safe to be there? This is the heart of the matter for many families. Can my child go back to school or go back to a daycare situation and do so safely?
And then there’s so many other factors. What if a grandparent is living in your house, say an 80-year old with pre-existing medical conditions? Would you send your child to school knowing there’s a possibility that she will come home infected with SARS-CoV-2?
We have a long way to go before September.
RL: Let’s talk about nursing homes. The percentages of COVID-19 deaths in nursing homes and assisted living facilities in various states is shocking. Of the total deaths in Minnesota, 81% have been in these types of facilities …70% in Ohio … 69% in Pennsylvania.
IR: Yes, Something came out yesterday said that 50,000 people died in nursing homes from COVID-19. It’s chilling. And there’s no visiting allowed. So the idea of a relative dying from COVID-19 without you having a last chance to visit them in-person is profoundly sad. It’s just such an unusual situation in America and the world.
RJ: Last August, I lost my mother, but for the last 7 days she was surrounded by family … and thanks to Hospice we were with her 24/7. I can’t begin to imagine what that must be like for families today.
IR: Yes. My mom died 2 years ago and I was holding her hand. My brother was holding her other hand when she actually passed. I can’t imagine if I hadn’t been allowed to have those moments with her … I just shudder to think about that.
There are so many aspects of a pandemic. As you peel away the layers of what it means to live through a pandemic, it’s one thing after another. How are we going to cope with this? And we are in a pandemic limbo until we get effective medications and vaccines. It’s going to be a long, tough haul.
RL: And perhaps that is one of the most difficult aspects of a pandemic … it’s like terrorism in slow motion. We are far more used to dealing with disasters that happen suddenly … and then we begin the recovery process … after hurricanes, tornadoes and earthquakes … even after 9/11 … we began the recovery process the next day. That is not the case with a pandemic.
Dr. Redlener, thank you so much for your time.
Dr.` Irwin Redlener is the founding director of the National Center for Disaster Preparedness, part of the Earth Institute at Columbia University where he holds professorships in public health and pediatrics. He has written and spoken widely on issues of readiness for, response to and recovery from megadisasters. He is the author of Americans at Risk: Why We Are Not Prepared for Megadisasters and What We Can Do
as well as The Future of Us: Why the Dreams of Children Matter to 21st Century America, recently updated to incorporate how we can respond to the COVID-19 pandemic, to be coming out in paperback next month.