3 coronavirus facts Americans must know before returning to work and school [PODCAST]

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“We can’t un-bungle our nation’s COVID-19 response. Political leaders acted too slowly; health agencies committed unforced errors with testing kits and, amid the confusion, an information fog settled over the land.

Americans remain afraid, perplexed, and chronically misinformed (despite wall-to-wall coronavirus coverage across the leading cable news programs and print publications).

To counter the uncertainty, any plan to get us out of the coronavirus crisis must first acknowledge and broadly communicate three immutable, scientific facts.”

Robert Pearl is a plastic surgeon and author of Mistreated: Why We Think We’re Getting Good Health Care–And Why We’re Usually Wrong. He can be reached on Twitter @RobertPearlMD.

He shares his story and discusses his KevinMD article, “3 coronavirus facts Americans must know before returning to work and school.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Robert Pearl. He is the former CEO of Kaiser Permanente, and he’s the author of Mistreated: Why We Think We’re Getting Good Health Care and Why We’re Usually Wrong. Robert, welcome to the show.

Robert Pearl: Thank you so much, Kevin. Thanks for having me on this show. I look forward to our conversation today.

Kevin Pho: So you wrote the KevinMD article “3 coronavirus facts Americans must know before returning to work and school,” and we’re going to get into the article in a little bit, but first off, can you just quickly share your story and your journey to where you are today?

Robert Pearl: My story began after I finished medical school at Yale and came to Stanford for my residency. At the end of my residency in plastic reconstructive surgery, I was planning to go to South America to fix children with cleft lip and cleft palate. And the plastic surgeon in Kaiser Permanente at the Santa Clara facility, a private pilot, crashed a plane. And they called me up and asked, would I be willing to come for a few months, until they could hire a full-time replacement? And I think the story to me is, you never know where life will take you.

The second turn in the road happened in 1998, when Kaiser Permanente got into major trouble. It was down to two days of cash in a state that required three days of cash to meet insurance regulatory requirements, and they had to borrow their cash. And I got asked to take the job. It wasn’t one that I really wanted to do. I loved being a practicing surgeon. But given the difficulties of the time, there were not a whole lot of people who wanted it, and those who wanted it, I didn’t think wanted it for the right reason. And so the second learning, I would say, is that windows open and windows close, and I decided to leap through at that particular time.

And then the last happened in 2017, when Mistreated: Why We Think We’re Getting Good Health Care and Why We’re Usually Wrong was published. It was a Washington Post bestseller. It got to number seven, one space ahead of Condoleezza Rice but six behind former President Obama. And at that time, I had to make a decision about what I would do next. I certainly couldn’t stay in my CEO role and go around the country trying to change American health care. And I would say to listeners that in our lives, particularly our professional lives, change is inevitable.

Kevin Pho: Fantastic. So this KevinMD article you wrote back in April got close to 4 million views, “3 coronavirus facts Americans must know before returning to work and school.” We’re talking in the middle of October, and this topic is still very, very relevant. Now, for those who haven’t read that article, can you walk my audience through it and share the story of why you decided to write it?

Robert Pearl: I wrote this story because I was surprised at that time, but I’m even more surprised now, because it’s continuing: the gap between the science that we know and our set of expectations. We somehow believe that this virus is going to disappear, that there’ll be a solution in a very short amount of time. And the data says the opposite. So every time we see that there are 500 to 1,000 deaths per day, or 30,000 to 50,000 new cases, we become surprised, when it would be shocking if it was anything different than those numbers.

So I pulled out three facts. I think the first fact is that we conflate ways we can diminish spread of the virus, meaning slowing down the transmission, with elimination of this virus. Staying home and wearing masks are very good things to do to slow down transmission, but they don’t eliminate the virus. As soon as the masks come off, as soon as social distancing is diminished, the virus comes roaring back exponentially.

The second one is that we are in this for the long haul. I don’t see any way that we’re going to get control of this virus without either a safe and highly effective vaccine or what’s called herd immunity, enough people having had the disease, and I don’t see that happening in the near future. Remember, the FDA is going to approve a vaccine that’s 50 percent effective. Let’s say it’s 60 or 70 percent effective. It still means that the virus will circulate, and the data says that fewer than half of people are willing to take a vaccine at this point. In an Axios survey, it was actually one-third of people, and in a survey out of my Monthly Musings, barely half of doctors were willing to take a vaccine, given what we know right now.

So the likelihood is that this pandemic will exist in the United States probably at least until the end of 2021. That’s almost twice as long as we’ve experienced it so far. And we should understand what the consequences are going to be, which is going to be tens of millions more cases, as well as probably 200,000 more deaths.

And then finally, I talk about the R naught. This is the number of people who catch the virus from an infected individual under normal social distancing, and that number is three. It’s exponential growth, Kevin, which means that one goes to three to nine to 27 and so on, up very rapidly, far more than we can imagine. It’s why, at events like Memorial Day weekend, we saw this tremendous surge. It’s why we saw what happened at the White House, when you had people unmasked sitting together in the Rose Garden. And again, we become surprised. This virus is here for a long time. It’s not going to disappear from the measures we were willing to do so far. And every time we pull back on our social distancing, what we will see is an expansion of the number of cases and an increase in the number of deaths.

And as you pointed out, this article was read by 4 million people, which tells me that people, subconsciously at least, understand that what’s happening right now isn’t going to solve the issue, and they are trying to get their arms around it in order to diminish their anxiety and their concern. And I’m hoping that by providing the facts, through the Coronavirus: The Truth podcast and through my writing, hopefully a certain calm can overcome our nation, and we can take the strategic steps necessary to do the best things on behalf of the American populace.

Kevin Pho: So you’re saying that we’re not going to have any sense of normalcy until the end of 2021. Now, that is a pretty sobering picture. What are some of the things that people can do to help stem that tide until the end of next year?

Robert Pearl: What people can do is they can wear masks. We know that that diminishes the transmission and will reduce the likelihood of spread, and they can certainly stay in outdoor environments as long as the weather stays comfortable, as well as keeping social distancing, sheltering in place. But I think more significantly than those specific steps, people have to understand that this virus isn’t going to disappear, and we’re going to have to find the ways to live with it, since we’re not going to see it go away, and I don’t see us having a vaccine. I don’t know whether that is as grim as you would say. It is just the reality of a virus that we have never had before.

If you want to look at the countries that have been able to fully control it, you can look at places like New Zealand, where the government imposed staying at home with a major amount of, I’ll say, force to make people do that. Or you can look at the other end, at South Korea, where when someone tests positive, they go inside that individual’s social media. They look at their Instagram, they look at the cameras in the environment they may have been in, and they can do electronic tracing of all contacts and notification. These extremes, and I’ll call them extremes, of invasion of privacy and limitations on freedom, I don’t see our nation being willing to do.

And that to me is the reality that I want people to be able to see, because if we keep pretending it’s going to go away, Kevin, I’m worried about the psychological health of people when, again and again, they’re disappointed. I truly wish that this virus had never gone from the bat into the human species, but if it’s here, I think we have to figure out how to live with it. I’ve written in my Forbes pieces about the Pareto principle, the 80/20 rule. What are the things that we can do? Like wearing masks, like staying outside, like maintaining some social distancing, like self-quarantining whenever we have symptoms, certainly getting tested if we have concern, and notifying those around us. These are, I’ll call them, moderately straightforward, simple approaches that achieve 80 percent of the outcome.

And when we start seeing that, I think psychologically, we can adjust to it, and we can take a strategic approach that will maximize health safety while minimizing the other negative sides: to businesses, where small businesses are going out of existence; to schoolchildren, who are falling behind academically; and to social interactions, which are having significant mental health consequences. In terms of depression, in terms of use of illegal substances, alcohol, domestic partner violence, all of these negative areas are coming out. And what are the 20 percent of the things that we can do, with minimum impact on our lives, that will get us 80 percent of the value? That’s the mindset I’d offer to the American populace.

Kevin Pho: The two countries that you mentioned, New Zealand and South Korea, have vastly different cultural values than we do in the United States. Added to that is the fact that here in the States, we have politicized coronavirus. Now, short of those extreme measures, is there anything else that we can do? In other words, are extreme measures the only way that we can successfully combat COVID-19?

Robert Pearl: The challenge with this virus that makes it different from other coronaviruses like SARS and MERS is that nearly half of the cases are transmitted through asymptomatic individuals. People may remember that in the SARS and MERS world, you used to have your fever checked wherever you went, because you were first symptomatic before you could give the disease to others. This virus is different. So time is a crucial factor. If today, Kevin, you test positive, I need to get to every one of your contacts today and make sure that they don’t give the virus to others that they come in contact with, others that they live with, others that they work with.

The idea of hiring thousands and millions, 5 million contact tracers, and making phone calls, when data has shown that the majority of people are not going to want to tell these people calling who they interacted with, in a context of 30,000 to 50,000 new cases, and with the data showing that the average person has 45 contacts in the previous 48 hours, the idea that we can have that speed of identification, notification, and quarantine is just absurd. And yet that’s what we keep talking about. You watch the Sunday shows, and everyone says, “More testing, more testing.” More testing doesn’t do any good unless you’re willing to take the next set of steps.

And I concur with you, Kevin. I don’t believe Americans will tolerate that degree of invasion of their privacy. They’re not going to tolerate the heavy-handedness that’s happened in other countries like New Zealand. And so that’s why I believe it’s not a negative view. It’s just a realistic view. This virus is here for the next 12, 15, 18, 24 months. And as Americans, we should figure out how we want to live with it. The idea that we will make it disappear until we have a vaccine that is 95 to 98 percent effective, I don’t believe it will happen in the United States, and that’s a reality our country, whether it’s political, whether it’s individual, whether it’s cultural, has been unwilling to accept.

Kevin Pho: Robert, we’ve seen President Trump receive the proverbial kitchen sink when it comes to therapeutics, including remdesivir, monoclonal antibodies, and dexamethasone. Now, what is your opinion in terms of how therapeutics can help stem the tide of COVID-19?

Robert Pearl: We have learned, as physicians, ways that we can diminish the lethality for people who become infected with this virus. Most of that change has not been through medication. It’s been through better understanding of ways really to avoid intubation and ventilators, and ways to be able to keep people in a critical care environment, but in less invasive types of ways. The data on remdesivir says that it possibly shortens hospitalization by a few days; it has not been shown to change the mortality. As you know, the antibody medications have yet to receive any type of FDA approval, and they have not been shown to change mortality.

The one drug, the only drug that has been shown to have a significant impact, as viewed through the lens of mortality, is dexamethasone, a steroid, and as a physician, you’re well aware of the fact that it’s a two-edged sword. One aspect is that this virus is made worse in people who have poor immunity. And as you well know as a physician, steroids diminish your immune response. And at the same time, what we see in some other individuals, particularly those who are most severely affected by this virus, is that we have an overreaction of our own body’s immune response, and that’s where the steroids come in. And in that narrow section of patients, it reduces mortality by a third. When I put it all together, these are supportive measures. But the idea that they will provide the solution to this pandemic, I do not see that happening, based upon what we have so far, anytime in the near future.

Kevin Pho: Anthony Fauci predicts a vaccine in early 2021 that could be either 50, 60, or 70 percent effective. Now, assuming a vaccine comes out and is distributed widely, is that going to move the needle?

Robert Pearl: It will move the needle slightly, because the more people who are vaccinated, assuming that it really prevents the disease, as you say, in 50, 60, or 70 percent of people, assuming that people are willing to take it, assuming there are enough doses available, it will slow down the spread, but it’s not going to get rid of the problem. And even Dr. Fauci talks about it being at least the end of 2021 before a vaccine will have the necessary impact on the population to be able to, I’ll say, allow us to return toward a previous normalcy.

I personally, Kevin, do not believe we will ever go back to what we used to call normal. I think this virus will be with us, in the same way that flu has been, for years and years to come, and we will continue to need to figure out how we can best manage it across time. Hopefully there’ll be future generations of vaccines that’ll be more effective, but as you well know, when it comes to the flu, we don’t have a vaccine each year that is more than 50 to 70 percent effective.

Kevin Pho: We’re talking to Robert Pearl. He’s the former CEO of Kaiser Permanente, and he’s the author of Mistreated: Why We Think We’re Getting Good Health Care and Why We’re Usually Wrong. He also wrote the KevinMD article “3 coronavirus facts Americans must know before returning to work and school.” Robert, we as a society are desperate to get back to some semblance of normalcy. Some schools are trying to reopen. Sports are being played, albeit in a limited context. In order to successfully combat COVID-19, do we need to go back into lockdown?

Robert Pearl: As we talked about, the Pareto principle, the 80/20 rule, is one that I believe in greatly. The idea of putting in everything we can possibly do to avoid transmission of this virus, I think, would be a mistake. It would harm children who won’t be at school. It’ll harm individuals at psychological risk.

Fundamental flaws in the American health care system: the ways that we have not effectively addressed chronic disease, the undervaluation of primary care, the way that we have been attracted to things that glitter and paid a lot of money for high-end opportunities, and missed the ways that we could preserve health. As you said, in my book, Mistreated: Why We Think We’re Getting Good Health Care and Why We’re Usually Wrong, I look at the systemic issues affecting our country. In the book that will be coming out next May, which will be called Uncaring: How the Culture of Medicine Kills Doctors and Patients, I look at the cultural aspects. Why is it, culturally, that doctors undervalue prevention and overvalue an operative procedure? Why do we overvalue unblocking a coronary artery and undervalue keeping it open in the first place?

Through your social media communications, you’ve looked a lot at the question of moral injury. And I ask physicians to ask themselves not about the moral injury that is inflicted on them, but about ways they might be inflicting it upon patients on their own: out-of-network billing, putting the patient in the middle; failure to control hypertension, which is controlled only 55 percent of the time, leading to more strokes and heart attacks; failure to wash their hands, transmitting bacteria from one patient to another; and the hierarchy of medicine, with specialists often looking down on primary care. These are the kinds of things that we can control. And I do believe that what’s happening with the coronavirus and what happens overall in medicine are very related, very analogous: that it’s easy to look at the systemic pieces and to overlook the cultural ones.

I believe that in the post-coronavirus era, coming out of the federal government having borrowed $80 billion, having come out of states that can’t balance their budgets, businesses where the owners have had to go into their savings, these small businesses, family-owned businesses, and individuals facing high risk of unemployment, we’re going to be in a world where change is going to be necessary. And I would say that within that world, the model of health care in the past, the fee-for-service world, the fragmented model, the view that what matters the most are the most complex interventions, as opposed to prevention and chronic disease management, all of that is going to change. We’ve said for a long time it should change. We’ve said it must change. Now it will change, not because anyone will say we will do it, but because no one will be able to pay for the systems of the past.

And as I think about where we will be as a country, I do believe that we will be moving to a capitated, integrated, technologically enabled world. We’ve seen some of that in the coronavirus, with telemedicine becoming a very common way of providing care. I think we’ve lived in a world where a year-over-year 5 percent increase in cost has simply been accepted as the normal trend. I think listeners had better be prepared for what’s going to happen when people simply say, “Maybe you think that’s something we should be doing, but we can’t afford it.”

And I’ll offer a final thought, Kevin. And that is that the only alternative to physicians and nurses and other health care professionals leading the transition is that we will face no choice but to simply cut back, and the moral injury imposed upon us from now having to recognize a two-tier system. And we saw it last week, with the president getting one level of care, which was very different than what most Americans can get. I think in a world in which we do not evolve change to raise quality while lowering costs, that will become the new normal. And the impact upon us as clinicians will be negative, and I encourage all your listeners: This is the time to make the change. Let the coronavirus have been the catalyst to force it to happen. For if we don’t do it, someone else will do it to us.

Kevin Pho: Wise words. Robert, thank you so much for sharing your expertise and insight, and thanks again for being on the show.

Robert Pearl: Thank you, Kevin, and I look forward to following the rest of your shows. They’re terrific, and I appreciate all of your efforts through social media. Thank you so much, Kevin.

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