COVID-19 Tomorrow

Dean Minor’s position gives him insights into problems that confront both higher education and the medical community. He talks about the decision to reopen Stanford’s campuses this fall, the ongoing development of therapeutics and vaccines for COVID-19, and the differences between the US East Coast and West Coast in the handling of the pandemic.

Lanhee, meanwhile, brings a clear-eyed view of public policy to those issues, drawing on his many years of experience. He is the David and Diane Steffy Fellow in American Public Policy Studies at the Hoover Institution and Director of Domestic Policy Studies and Lecturer in the Public Policy Program at Stanford University. Lanhee previously served as a senior advisor to the presidential campaigns of Senator Marco Rubio in 2016 and Mitt Romney in 2012. During the George W. Bush Administration, Lanhee was a senior official at the US Department of Health and Human Services.

Nik kept the conversation focused on the road ahead: medical challenges, reopening, coming changes in public policy and social behavior. What follows is an edited version of their exchange.

We’ve spent a lot of time looking backwards on this crisis. I'd like to spend the bulk of this conversation really looking ahead and looking to see what we’ve learned and how we’ll apply it moving forward. Lloyd, you have a very unique position, given Stanford's prominence in grappling with this crisis.
L.M.: In northern California, we are very much into the recovery phase. In health care delivery, we last week had one of the largest weeks we’ve ever had in terms of elective surgical procedures. That was after bringing our elective surgeries almost to a stop when we thought we were going to have a massive surge in the number of patients. We’re also reopening our research labs, following a protocol approved by our county health officials. And this is a pattern across the country, as we look at moving into the next phase.

This virus is going to be with us until we get a vaccine or vaccines. We are much better now at taking care of people who require hospitalization, but we need to focus on identifying better therapeutics that can hopefully be used in the outpatient setting. As we return to more social situations, we need to continue social distancing and masks, to continue to focus on safety and on limiting the transmission of the virus.

This is now a marathon. It’s not a sprint. I hope we could have a vaccine that's being widely distributed within a year; maybe a little shorter than that. But then we have to have this massive distribution system and mass production of the vaccine—that’s not going to occur overnight.

Lanhee, can you share a bit from the health policy perspective?
L.C.: We have to accept the possibility that different states are going to walk very different paths. California has taken a relatively measured approach the entire time. Other states, like Texas and Florida, were more aggressive in reopening initially and now are dealing with some case growth. Different states have taken different approaches, but those decisions are being seen through a political lens because of how polarized and fractured we are.

Our federalist system means that different states will take different approaches. That is a feature, not a bug, of policymaking in the United States. I think the one challenge, Nik, will be this: We’re a very mobile society. More policymakers, certainly many of the governors I’ve consulted with here in the last couple weeks, are keenly aware of the fact that as the summer months roll on, people are going to want to get out and travel. That’s something that you’re going to see more and more states trying to wrap their arms around: How do they deal with this pandemic and come up with a policy within the boundaries of their state, knowing that there are deep interconnections and relationships between all of these different places

Regional compacts have been formed throughout the course of this pandemic response. Some have been more effective than others. In the Pacific Northwest, Oregon and Washington state have worked together very well, collaboratively. In the Southwest, we’re experiencing some case growth that’s concerning in Arizona. So, states like Arizona, California and Nevada should be thinking together about these things as well.

Contact tracing is going to be an important component of this, going forward. The larger problem is we’ve only got so many resources and we’ve got a lot of important policy priorities. How do we continue to ensure that there’s enough testing? How do we ensure there’s enough critical medical capacity? Personal protective equipment? All of this requires attention and resources. It’s going to be very difficult for states to prioritize, and they may have to make some tough choices moving ahead.

Lloyd, can you tell us a little about what Stanford is doing in terms of reopening the school?
L.M.: Assuming we go through the summer without seeing a major change in conditions, we do plan to bring some undergraduates back in the fall. We’re now looking at how can we do this and do it safely. One thing is that we’re going to need a lot of testing. We were early in developing and then receiving FDA approval for our diagnostic test, the so-called RT-PCR. It performs well. We developed a lot of experience with it, having tested over 60,000 people. We’ve scaled our capacity to test.

College is a time of growth in so many respects, but students are going to have to be more careful with social interactions. It’s not going to be the type of big party environment. We’re not going to be having football games in Stanford Stadium in the fall—or if we do, there won’t be a crowd in the stands. And we’ll be looking at contact tracing. Particularly in the communal living environment—even with single rooms, if we move to that in the fall—the virus can spread quickly.

Lanhee, can you discuss the economic impact? Is the federal government doing enough?
L.C.: I don’t think there’s any question that the federal government’s going to have to look at another round of relief. The first couple rounds came through without any controversy at all because people recognized we were in the midst of a huge economic calamity, and there had to be a policy response. The third round got bogged down a little bit in politics. This next round will get bogged down, I predict, a little bit more.

We’re going to have to figure out direct assistance to those who continue to remain displaced from the labor market, who are unemployed. Then, how do we promote work among those who have returned or who may be marginally attached to the workforce? I would expect something like a bolstering of something called the Earned Income Tax credit, which is designed to essentially promote work through the tax code.

And then, how do you support businesses? The Paycheck Protection Program, for instance, was designed to go to small- and medium-sized enterprises to help them continue to hire and invest in the midst of economic difficulty in many parts of the country. That funding will run out. There’s something called the Main Street Lending Program that the Federal Reserve has started. Those are both avenues that Congress will consider additional funding for.

The health care system has undergone a fundamental transformation in all of this. Congress and the president are going to have to get together on support for elements of the health care industry. With elective procedures just beginning to come back, and months of lost volume, that support will need to be pretty robust. And then the last piece of this is going to be funding for states and localities.

So, there’s a lot Congress needs to do. I think we thought several trillions were a lot to spend in an election year, but they’re probably going to have to spend more.

What are some of your concerns with regard to reopening?
L.C.: There are a couple of dangers here. One is, what’s the speed of reopening and how do you calibrate that? But another is that some of the public health establishment's credibility has been called into question because some reopening dictates appear somewhat arbitrary. So, it is incumbent upon policymakers to be transparent about why they make the decisions they make. That hasn’t been the case in some situations, and this opacity has led to frustration amongst some in the citizenry.

LM: What this pandemic has done, among many other things, is to underscore the need for a lot more research into emerging infectious diseases, into vaccines, antiviral therapies. That had been put on the back burner for a long time. Vaccinology has been challenged from a funding point of view, going back years and years. Hopefully that’ll change, moving forward. This isn’t going to be the last pandemic. Because of globalization, because of the way in which the world is connected, because of growing populations and a number of other factors, it's much easier for viruses to jump from animals into humans than it was even two decades ago. Preparation now will be really important.

Lloyd, you mentioned the possibility of multiple vaccines. Can you talk about that?
L.M.: There are over 160 approaches now being pursued in vaccine development with several that are very far along. We’ve all read about the Oxford University AstraZeneca vaccine that was being developed for a related virus. The Oxford team was very rapidly able to pivot that to the COVID virus. That's now in a Phase Two/Three clinical trial. Moderna has an RNA-based vaccine that all of us are very hopeful for. It would be the first genetic material vaccine to be deployed. That could open the door for many future vaccines and a whole new approach to vaccine development. There are a variety of other vaccines in production.

Ideally, we would like to have multiple vaccines. That will help in terms of distribution. Almost certainly, some people will respond better to one vaccine than another. As we get older, our response to vaccines declines. So it’s going to be important to have multiple, different candidates for each age cohort, to determine the best vaccine match to each individual.

In the meantime, we and others are focusing a lot on developing better therapeutics. The idea is a person is diagnosed, and then they have the option of receiving a therapeutic in the outpatient setting that we hope would reduce the severity of the disease and reduce the probability that they need to be admitted to the hospital. So, a two-pronged approach here: Having therapeutics now, hopefully very soon, and then a vaccine coming online as quickly as possible. But realistically, I think it’s still a year from now before we can expect the broad type of distribution of a vaccine, broad enough to create a herd immunity, which is what you need. There simply is not going to be any other way to quell this virus, at least in a timely fashion.

I hope that this experience will persuade more people that vaccines are necessary, that they’re the reason that we've been able to rid ourselves (by and large) of measles and other diseases that cause tremendously harmful effects when they're left unchecked.

In addition to COVID, we’re at a moment of enormous social unrest and a lot of focus on inequality. Health care inequality is a significant issue that has repeatedly been referenced, especially as we’ve seen higher rates within some disadvantaged communities. How can we address this issue?
L.C.: There are challenges we still see in our health care system which are systemic. Clearly parts of the population do not have access to the same health care as other parts of the population. I think there will be a debate about fundamental health care reform as we look ahead to 2021. We tried to remake the health care system in 2010 with the passage of the Affordable Care Act. A lot changed, but a lot didn’t change as well. This has led to frustration on the left, but also on the right. Regardless of who is in office come next January, there will be a pretty robust discussion about what the future of the health care system looks like.

L.M.: I agree with everything Lanhee has said. This pandemic has made graphically apparent that the social, behavioral and environmental determinants of health—which we know even prior to the pandemic accounted for 70 percent of all the determinants of health—really drive adverse outcomes in a pandemic such as COVID-19. Communities that are economically disadvantaged, underserved, are a setup for having the most adverse consequences of the pandemic.

We have to view our role as health care leaders as much broader than we have in the past. We need to be looking at preventative measures and that involves looking at those social, behavioral and environmental determinants of disease. That’s what’s ultimately going to be important at improving the health and health care of Americans. It’s a sad fact in America today that the zip code in which a person lives is a more accurate predictor of that person’s life expectancy than their genetic code. We can do better than that in this country.

One significant development we’ve seen during the pandemic has been the use of telehealth. Are there other innovations that will make the health care system better equipped with regard to access or cost or any other area?
L.M.: I do think that telehealth is a radical transformation and, if we do it correctly, a very welcome and value-improving transformation in health care delivery. Through the entire month of February, in our adult delivery system here at Stanford, we did roughly 1,000 virtual visits. In the latter part of March and April, we were doing upwards of 3,500 virtual visits a day.

We’re discovering that things we never thought we could do virtually, we actually can do very, very well. Let’s say a person is being referred by a primary care physician to a cardiologist. For the cardiologist, the more important part of that initial evaluation is the history. That can be done through an interaction like this, virtually, just as well as it can be done in person. The value proposition is this: By doing the first visit with the cardiologist virtually, the cardiologist has a pretty good picture of, well, this person needs a stress echocardiogram or this patient needs a number of other tests. Or maybe they don’t. And then the patient makes one visit to have the tests and see the cardiologist. In the past, it would've been two or more visits. That improves the efficiency of care delivery. It ultimately will improve the outcome, and it makes for a much better patient experience.

We also have the opportunity now really to create the digital home; to leverage digital health in ways that have been a challenge in the past. Every other aspect of the economy has been radically transformed by technology; the way we order goods and services, the way we perform financial transactions. But, prior to COVID-19, I have to say there was quite little in the way of fundamental changes to health care delivery. I think COVID-19 is now showing us the type of changes we can obtain.

What social behavior changes will persist beyond this pandemic? Lanhee, will there be public policy decisions stemming from these changes?
L.C.: With respect to telehealth, it’s been a rapid transformation and I think it’s been a good change. We’re leveraging technology to reduce the number of visits, but still ensure that people are getting access to good health care. Now, some of that development has been premised on some temporary policy changes that have allowed for telehealth to be reimbursed at levels comparable to in-person visits. Those policies will come to an end unless Congress and the administration move to make them permanent. So, there will be some effort under way to try and do that, to ensure that some of the gains we’ve captured do not get lost.

Also, telehealth is wonderful, but it does not necessarily address some of the equity concerns that were raised earlier. It could make them worse if, for instance, you don’t have access to a high-speed internet connection.

In education, the idea that distance learning is a solution that works for everyone is simply not true. My kid’s school district includes families that are quite well off and families that are not as well off and there have been tremendous differences between how students have experienced distance learning. And so, I would be hesitant to say that those shifts we’ve seen in the educational system are either long-lasting or desirable, quite frankly. There are huge inequities that have developed and huge challenges in the educational system that I hope do not continue past this pandemic.

Telework is going to continue in some industries but not others, in some geographies and not others. I don’t think we can expect those changes to be universal in our country. Regional and state-by-state differences are just part of the American design and are going to dictate differences in behavior by employers too.

L.M.: I agree. The challenge will be to look at where we need to have a better national infrastructure to respond to crises such as COVID-19. Early on, we weren't prepared in testing. We weren’t prepared in terms of what we thought would be a dramatic and sustained need for increased ventilators. So we’ll need to balance.

The very fabric of our country is based upon this balance between a national, and state and regional governments, and we’ll need to address how that is represented in responses to public health crises. We really will want and need to see more national leadership. A virus doesn't know the difference between a county line or a state line. In most cases, our ability to limit its spread internationally requires some new thought with regard to policy in the public health arena.

What would you say is the biggest misperception of COVID and how as a society can we address it?
L.C.: In the short run, the biggest misconception is that we can pretend like this thing doesn’t exist anymore. We may not need to completely reorient our lives, but we do need to make some changes and to adapt. The thing that worries me is the notion that somehow we can go back to business as usual, today. I just don’t think that that’s reality. In fact, it’s going to hinder our ability to eventually to go back to life as normal when that does happen.

L.M.: I think Lanhee stated it really, really well. This virus is going to be with us. Our lives are not going to return to the way they were in January for a long, long time. We are, every day, defining what the new normal is. I hope that our values, our principles, as a society, as a nation, continue to drive us in the direction that will, one day, make our children, our grandchildren, look back and say we did a good job managing through this crisis, that we got through it as a country and as a people and, ultimately, as a world group of citizens.

--

As CEO of the Americas and U.S. Senior Partner, Nik Deogun advises clients on business critical communications issues including mergers and acquisitions, shareholder activism, IPOs, crisis and litigation, and corporate reputation matters. Nik joined Brunswick from CNBC where for nearly 9 years he held several senior management and leadership roles, including Editor in Chief and Senior Vice President, Business News.

In addition to being a Senior Counselor at Brunswick Group, Lanhee Chen Ph.D., is currently the David and Diane Steffy Fellow in American Public Policy Studies at the Hoover Institution and Director of Domestic Policy Studies and Lecturer in the Public Policy Program at Stanford University. Chen is also an Operating Partner at New Road Capital Partners and serves as a Senior Adviser to and member of the Aspen Economic Strategy Group at the Aspen Institute.