S1E9: Did Anybody See This Coming? / Juliette Kayyem

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“It’s not an on/off switch. We are living with coronavirus until we get a vaccine, and that could be 18 months, if we’re lucky.” – Juliette Kayyem

In today’s episode, co-hosts Dr. Celine Gounder and Ron Klain discuss what we could have seen coming with this pandemic and speak with Juliette Kayyem, faculty chair of the Homeland Security Program at Harvard’s Kennedy School of Government and a security analyst at CNN, about the differences in approaches to the COVID-19 pandemic between public health and homeland security, the roles that both state and federal governments must play during this pandemic, and some of the failures that have happened thus far. They also talk about what we can expect to see in the coming months in the US. On March 21, 2020, Juliette Kayyem, published an article in The Atlantic, “The Crisis Could Last 18 Months. Be Prepared,” https://www.theatlantic.com/ideas/archive/2020/03/there-isnt-going-be-all-clear-signal/608512/

We also hear from a healthcare worker on the frontlines at a trauma center in New Jersey about the shortages of protective gear and other essential equipment that his hospital is facing.

Listener Q&A: How effective are convalescent serum and remdesivir in treating COVID-19?

This podcast was created by Just Human Productions. We’re powered and distributed by Simplecast. We’re supported, in part, by listeners like you.

Celine Gounder:  I’m Dr Celine Gounder

Ron Klain: and I’m Ron Klain.

Celine Gounder: And this is “Epidemic”

Today is Tuesday, April 7th

Ron Klain: In this episode, we’ll talk about what we did, or didn’t, see coming with the Coronavirus epidemic, and we’re gonna talk about the path forward from here. Our guest is Juliette Kayyem. She is one of the leading experts on homeland security. She was an assistant secretary at the Department of Homeland Security under President Obama.

She played a pivotal role in major operations with relate to the H1N1 pandemic. She’s also the faculty chair of the homeland security and global health project at the Harvard Kennedy School of Government.

Celine Gounder: In this episode, you’ll also hear from a frontline health provider.

Ron Klain: And as always, we’ll wrap up with some listener questions.

But first, let’s take stock of where we are in the country, right now. This week has been flagged by many officials as what will be one of the most grim weeks we’ve seen in a long time in this country. Here’s what the surgeon general, Dr Jerome Adams, said on Fox news this Sunday, “This is going to be the hardest and the saddest week of most American’s lives, quite frankly. This is going to be our Pearl Harbor moment, our 9/11 moment. Only It’s not going to be localized. It’s going to be happening all over the country, and I want America to understand that.” So Celine, do we think this is a Pearl Harbor, 9/11 moment in the week ahead?

Celine Gounder: Well, Ron, I think Pearl Harbor and 9/11 definitely left their imprint on the American psyche. There is no denying that. And sadly, this is on a completely different order of magnitude than either Pearl Harbor or 9/11. About 2,400 people died at Pearl Harbor, about 3000 on 9/11 and we’ve already had almost 10,000 people die from coronavirus in the US and that is still on the upswing. Many, many, many more will die before this is all over.

Ron Klain: Yeah. You know, it’s interesting. I think one thing all these events have in common is that the systems, the warning systems, were flashing alerts in each of these instances and our government didn’t take the actions that needed to prepare for these threats. There were alerts at the start of World War II, certainly that there would be a war in the Pacific. Very famously, President Bush got a warning that Al-Qaida was planning an attack on America the month before 9/11. And here, there have literally been decades of warnings about a dangerous pandemic coming to our shores, and those warnings have largely been ignored.

Celine Gounder: Right, so we had some early warnings here. We’d experienced influenza pandemics before: 1918, 1957, 1968, but it was really the early years of HIV /AIDS pandemic and then with the anthrax attacks concerns about bioterrorism that really put pandemic preparedness on our radar in the 1980s and 1990s, especially. And then came SARS. Here’s Dr Tony Fauci, the director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health, testifying about SARS at a congressional hearing in 2003 and aired by C-SPAN:

“SARS, unfortunately is not really a surprise because SARS is one of what we’ve experienced as shown on this map here, over the last decades, and in fact, through all of civilization, the emerging and reemerging of diseases, SARS is one of those that has significant public health impact. An emerging disease is a brand-new disease that we’ve not seen before. SARS has several characteristics. One, it is transmissible relatively easily with regard to a face to face contact, but luckily not beyond that. However, it is a very important disease that we need to take seriously. It is not impossible, but there would be little chance that it would spread like influenza could spread because its influenza is so much more easily spread than SARS.”

And then came the H5N1 bird flu. This is president George W. Bush speaking at the National Institutes of Health in 2005, courtesy of C-SPAN:

“Today I have come to talk about our nation’s efforts to address this vital issue to the health and the safety of all Americans. I’m here to discuss our strategy to prevent and protect the American people from a possible outbreak. If history is our guide, there’s reason to be concerned. In the last century, our country and the world had been hit by three influenza pandemics. First, what struck in 1918. Killed over a half a million Americans and more than 20 million people across the globe. One third of the US population was infected. The 1918 pandemic was followed by pandemics in 1957 and 1968 which killed tens of thousands of Americans and millions across the world. Three years ago, the world had a preview of the disruption an influenza  pandemic can cause when a previously unknown virus called SARS appeared in rural China.”

Celine Gounder:  And then after that came H1N1 swine flu. Here’s Congressman Henry Waxman in 2009 on CSPAN:

“There was much, we did not know about H1N1 virus. We didn’t know how dangerous the virus was. We didn’t know if there would be a vaccine available. We didn’t even know if the virus would return in the fall. Indeed, we are already seeing a large increase in cases. A pattern that is likely to continue. The epidemic will undoubtedly lead to hospitalizations. Schools may close, healthcare facilities may become overwhelmed and almost certainly there will be some who will die.

Celine Gounder: Experts have been predicting for decades that we were going to have a deadly pandemic of a respiratory disease. We thought it would be influenza. We didn’t think it would be coronavirus, but we had been anticipating this for decades, and that was under both democratic as well as republican administrations. Ron, you have the institutional memory here. What were we doing this whole time?

Ron Klain: Well, so the story of preparation is a story of steps forward and steps backward.

After the anthrax attacks in 2001 the country did a lot of things to get prepared right thereafter, but then kind of fell back on preparation. There were warnings in 2005. It’s that year both a Republican president, George. W Bush, spoke about the dangers of a pandemic and a young Senator from Illinois, Barack Obama wrote a piece in the New York Times warning about the dangers of a pandemic coming.

We obviously saw a lot of this play out with H1N1 in the Obama administration, and then the Ebola response, which I coordinated. We’ve put in place many measures to be prepared, but some of those measures were walked back by the Trump administration, and the warning signs here simply were not taken seriously enough.

When the president says nobody saw it coming, that’s just not true. Many people saw it coming. We just didn’t do what we needed to do to protect our country from this threat.

Celine Gounder: So Ron, my big concern right now is that people are waiting to see the cases and deaths in their own community. And what we know is that there is community transmission now in most of the country.

It’s just that we haven’t seen the deaths yet. There’s about a 14-day lag between when the infection occurs and when you might develop symptoms of the disease. And I’m just worried that we’re waiting too long to do something.

Ron Klain: You know, Celine, I think that’s true on a couple levels. First of all, uh, everyone in every community ought to expect this disease.

Not only is coming, but is there already. There are reports today that even in places that report very low counts of the disease, what they’re really seeing in the hospitals is a rapid increase in people being hospitalized and dying from undiagnosed respiratory and related illnesses. So I think what’s happening is the disease is outpacing our ability to test for it.

Every place in the country is seeing it, even where the counts don’t reflect that. What that really means is it’s present. It’s taking lives, it’s hitting our healthcare system. Every city, town, state ought to be taking the steps necessary to prepare their healthcare system for the onslaught of cases that is here, and that is coming.

Celine Gounder: Before we get to our interview with Juliette Kayyam there is something I wanted to share. If you like our show Epidemic, I think you might find this podcast interesting too. It’s produced by the people at Foreign Policy Magazine and its called Don’t Touch Your Face. On each episode host Amy McKinnon and James Palmer look at one place somewhere in the world and examine how its affected by the coronavirus. You can learn a lot about a country just from the way it copes with a pandemic. Listen to Don’t Touch Your Face on Apple Podcasts, Sportify or wherever you get your listening fix.

Ron Klain: Joining us today on the Epidemic podcast is Juliette Kayyem. Juliette ‘s an old friend, she’s the former assistant secretary for Homeland Security under president Obama, and she’s the faculty chair of the Homeland Security program at Harvard’s Kennedy School of Government.

Celine Gounder: Juliette is also a colleague of mine at CNN where she is a national security analyst and she’s the author of Security Mom, an unclassified guide to protecting our Homeland and your home.

Juliette recently published a piece in the Atlantic titled, “The Crisis Could Last 18 Months, Be prepared.” Juliette, I’d like to start by asking you, how do the public health and Homeland security approaches to the COVID- 19 pandemic differ?

Juliette Kayyem: Oh, it’s, it’s such a great question. And thank you both for having me.

I’m a huge fan of the podcast. So, every crisis has brain and muscle. So, the brain is what in fact needs to be done. What are the policies that are going to guide us? So, think about, you know, issues like flattening the curve. But you also need muscles. You can’t just have good ideas in the white house or at some agency, you need to be able to implement it.

What the Department of Homeland Decurity does is it actually works with state and local through the federal emergency management agency, FEMA, to get them ready to exert some muscles. So, you need both parts. That’s what you’d want to see here. Public health and Homeland security, working hand in hand. So that’s how I think about any crisis.

And I think the challenge you’re seeing here is. They’re still fighting over the plan, right? There’s still questioning of the experts by our political leadership end. We’re also challenged on execution as we’re seeing with the failure to plan ahead, the failure to surge resources, the failure to really meaningfully implement the defense production act.

Ron Klain: Yeah. And so Juliette, let’s talk a little bit about how this has played out. So, you’ve worked at the national level. You also had a lot of involvement with state governments.  What strikes me here is that we have a threat that came from overseas that is totally paralyzing our country from coast to coast, and yet largely the federal government has kind of said, “Hey States, you work it out yourselves.”

How do you see the federal and state roles here and how do you see the failure of the federal government to really step up in a more active and robust way.

Juliette Kayyem: Only the federal government would have had the capacity at the beginning to know what’s coming and to know that something was going to happen here and what would we want to do?

What would we wish we had done? Well, we wish we would have had better testing, more isolation, all the things that you’re hearing about now in terms of our missed opportunity in January and February. And with that information, the federal government should have been educating governors and mayors. Mardi Gras was allowed to go forward, right, in New Orleans. The mayor never got a briefing about what might happen, right? If you have a big event like that. So that’s what you would have wanted on the front end. But let’s just, let’s just, you know, let’s just move on, right? Okay. So now we’re in the middle of this. You’re still not getting what we need from the federal government.

Because we have the country’s first 50 state disaster. So, imagine hurricane Katrina across 50 States. Right? And so that just means that the mechanisms of mutual aid and assisting each other don’t exist now, essentially. Right. Because every state is facing the same thing at the same time. So ,this is exactly when you need a strong federal presence.

Ron Klain: So let’s talk about what, from your perspective, has or hasn’t happened and, and why hasn’t it happened. So, on testing, on taking control of the supply chain, on increasing manufacturing, on getting those goods to where they need to get. These are all things that there are people inside the federal government who could have been marshaled to do and do very effectively and yet on all of these things, we trail other major developed nations. Why is that?

Juliette Kayyem: I think there’s a couple things. I mean, I think there’s a, a huge management issue in the White House. They’re so bad at what they do. They don’t know how to execute policy. So one perfect example is the head of the Army Corps of Engineers.

He goes on Twitter to say, we are happy to help. We just need to be tasked because Ron is, you know, the agencies aren’t self-executing. They have to be tasked. Part of it I think is. Three and a half years of a border enforcement. Focus by the Department of Homeland Security that essentially undermined and failed to nurture all of the response capabilities that should have been nurtured with state and locals over the last couple of years.

And then I think in terms of what’s happening now, I don’t, once again, I mean, I love what I do, but I don’t think it’s like rocket science, right? It’s not like I have to find a vaccine. I mean, I’m. Logistics. Right? Essentially what Homeland security is, is logistics, like, you know, move something from point A to point B based on the threat environment and work with state and locals to do that.

And so I think what you’re seeing is the president failing to invoke the very tools he has. And the most obvious one is defense production act. I think it’s philosophical. I think it’s something about, he views it as socialism. I think the chamber of commerce and other lobbying that we heard went on convinced him that he could just urge the private sector to deliver.

And I think the chamber really does need to do a reckoning about its lobbying efforts throughout January and February.

Celine Gounder:  How do you weigh when to lift social distancing measures? You know, I think, um, you wrote in the Atlantic, you have to weigh the benefits of the mission against the losses. You know, what are acceptable losses here?

Juliette Kayyem: What I mean by that is when military planners think about a mission, say, you know, going into, you know, the invasion of Normandy, right? They know people will die. You’re just balancing whether those are quote-unquote acceptable losses. How do you talk about acceptable losses in the Homeland? I mean, I have three kids, right?

I mean, what is one of them? You know, I mean, if you, you know, there’s no acceptable losses, right? I mean, every parent would say no, there’s no acceptable losses. And I think that’s one of the challenges. But at some stage, we do have to balance potential loss to the virus, uh, with, you know, the necessity of keeping the Homeland running.

We’re not there. We’re not even close to being there. But that’s what I think about when people ask me. Uh, when are we reopening?

Ron Klain: How should us, all as citizens, think about what our state of mind should be at this moment in time?

Juliette Kayyem: I’ve thought about it a lot. I mean, I think part of it is language. I tend to use terms of common mission.

Like I talk about mobilizing for social distancing. In other words, get everyone engaged rather than defensive, right? We’re actually actively working together to fight this thing. I am using words like war, which I tend to avoid as a progressive Democrat. Right. You know, I like the war on terror. I hate that language.

Right? This, I think is actually helpful. It gets people to focus on purposefulness, right? That we are doing this because it’s super hard. And then as a mom, I sort of admit the strangeness of this all. Right. I, you know, I mean, it’s, there’s no reason to not admit this is totally bizarre and give yourself a break.

There’s no rules here. And I think, I think the more that we can admit that, um, that’s also helpful to people. But. The fear is real and justified.  The only way to own that fear is to actually give people something to do. And I think if we can portray staying at home as a doing thing rather than as a hiding thing, I think we’re better off.

Celine Gounder: Juliette, what do you think the coming months are going to look like.

Juliette Kayyem: If our social distancing felt like an on off switch, like all of a sudden we weren’t inside. The next part is really gonna be how do we manage and live with the virus knowing that a vaccine isn’t until next year. Um, and that’s going to feel a little bit more like whack-a-mole.

Some places go up, some places go down. There’ll be potentially new outbreaks. So certain communities or schools will have to close down again. It’s going to be slow. It’s going to be hard, and it’s not going to feel the same to everyone, but it’s going to, the good news is we’re going to have more tools by then.

Right now, we only have one tool, at least as, as citizens, which is social distancing. We’re going to have potentially more treatments. We’re going to have, um, uh, um, ways in which we can minimize the spread because we’ll be able to track people faster. Everything we lost in January and February, there will likely be a shaming aspect to this, which there should be.

Right? In the same way, you know, there’s a shaming of people who are sick, not, you know, isolating themselves and sort of making sure that they understand their community involvement. All of those tools will be available. As a planner, I don’t know what that date is. As I think about the Homeland security, I don’t know what you tell governors and mayors, what you tell them is.

Here’s the metrics that the scientists and health people are looking for, and when those metrics are met, that’s when we start to think about recovery. But it’s not an on off switch. We are living with coronavirus until we get a vaccine, and that could be 18 months if we’re lucky.

Ron Klain: Well. Thank you for joining us, Juliette.

We look forward to your insights here. For people who want to follow Juliette on Twitter,  she’s @JulietteKayyem, that’s at J U, L I, E T T E, K, A, Y, Y E, M. And her information on Homeland security and on this coronavirus crisis is excellent if you follow her on Twitter. Thanks again for joining us, Juliette.

Celine Gounder: This lack of preparedness has very real consequences for healthcare workers and patients in our hospitals right now. And this takes us to our story from the front lines today. We’ve got Rob Sigler who works at a level one trauma center in New Jersey. He’s also a volunteer EMT. He talks about the shortages they’re facing, shortages of personal protective equipment and ventilators.

Rob Sigler: Hi, Dr Gounder and, and Ron. My name is Rob. I’m actually in New Jersey and I can tell you that working on the front lines unit after unit after unit has to keep being converted to take care of these, these COVID patients. And even a reasonably well-stocked, um, level one trauma center, like mine is still facing massive shortages of surgical masks or procedure masks, however you want to call it, N95s, vents, at this point. We’re having to, to reach back and start using like trilogy transport vents and backup vents and older, um, ventilators. A lot of staff like myself, because I’m nonclinical, one surgical mask for the entire duration of our shift. Most of us are not fit tested, so we’re outright not to, to go anywhere near, um, these covid units.

And it is incredibly difficult. And it’s also very insulting to see our president accuse all of us, that are haggard, we’re short staffed. A lot of us are actually catching this, despite every precaution we take. And it is immensely frustrating. Um, and yet I’ve seen many of my peers rise to the occasion.

I’ve seen physicians take extraordinary measures to, to help a patient’s loved ones that are also in isolation and use their own equipment to like FaceTime or, or keep them in touch. And, and I have to say that I very, very much appreciate the fact that you guys are also speaking out on our behalf. You know, when you guys have been in similar or Dr Gounder and your case are, are actively in similar or the same situations.

And, um, you know, despite all of that, I know we all fight together, but I mean, thank you guys.

Celine Gounder: Rob the next couple of weeks are going to be really tough where you are in New Jersey. I hope you have what you need to take care of yourself and your patients.

Ron Klain: Every week we answer a couple of listener questions.

Our question today comes from Bob Soltis. “Bonjours, doctor and bonjours, Ron. Bob Soltis from Cleveland and Paris, thanking you for your informative podcast. Would you please update us about using serum from COVID- 19 survivors as a treatment? Is that viable? And please tell us about remdesivir. Is that a viable treatment yet? Thanks. And keep up the great work.”

Celine Gounder: So Bob, we’re still in very early stages in terms of assessing both convalescent serum as well as remdesivir in the treatment of coronavirus. Remdesivir is what we call an analog. It’s made to look like one of the letters of the genetic code adenosine, and so when the virus tries to incorporate it into its own genetic code as it’s replicating, it actually interrupts that process and prevents the replication from happening.

A number of hospitals, especially the academic medical centers, are making use of remdesivir, in particular, as part of five different COVID- 19 clinical trials, and it’s also being delivered through a compassionate use program to some patients. The issue with convalescent serum is that it’s difficult to produce in the large quantities that we would need to be able to treat people across the country.

So, in some ways it’s more about proof of concept as to whether that approach works and whether other similar approaches may also help us control the disease.

Ron Klain: To send us your question, you could record an audio file on your phone with your question and email that to us@helloatjusthumanproductions.org that’s hello@justhumanproductions.org

Celine Gounder: Epidemic is brought to you by just human productions. Today’s episode was produced by Zach Dire and me. Our intern is Sonia Bharadwaj. Our music is by the blue dot sessions. If you enjoy the show, please tell a friend about it today, and if you haven’t already done so, leave us a review on Apple podcasts. It helps more people find out about the show.

You can learn more about this podcast, how to engage with us on social media and how to support the podcast at epidemic.fm that’s epidemic.fm. Just Human Productions is a 501 C3 nonprofit organization. So your donations to support our podcasts are tax deductible. Go to epidemic.fm to make a donation.

We release epidemic twice a week on Tuesdays and Fridays, but producing a podcast costs money. We’ve got to pay Zack, so please make a donation to help us keep this going. Also, check out our sister podcast, American Diagnosis. You can find it wherever you listen to podcasts or an American diagnosis.fm. On American diagnosis, we cover some of the biggest public health challenges affecting the nation today. In season one, we covered youth and mental health, in season two, the opioid overdose crisis, and in season three, gun violence in America. I’m Dr Celine Gounder.

Ron Klain: and I’m Ron Klain.

Celine Gounder: Thanks for listening to “Epidemic.”

Juliette Kayyem Juliette Kayyem
Dr. Celine Gounder Dr. Celine Gounder