Deploying President Biden’s ‘Wartime’ COVID-19 Plan

IRA FLATOW: This is Science Friday. I’m Ira Flatow. President Biden has released an ambitious national COVID-19 Response and Pandemic Preparedness plan. It includes a newly created position of a COVID-19 Response Coordinator. It includes using the Defense Production Act to ramp up vaccine production. This week, President Biden said the US would purchase 600 million doses, enough to vaccinate virtually every American.

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– I’ve said before, this is a wartime effort. When I say– when I say that, people ask, wartime? I say, yeah. More than 400,000 Americans have already died. I think it’s 411,000 or 412,000 have died in one year of this pandemic. More than all the people who died in all– Americans who died in World War II. This is a wartime undertaking. It’s not hyperbole.

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IRA FLATOW: If we’re going to fight COVID like a war, shouldn’t we fight it with the same intensity? We’ve spent a fortune on military planes, ships, hospitals, soldiers, and weaponry. So how do we plan and put all the resources we need towards this battle and future pandemics?

That’s what we’ll be talking about with my guests. Let me introduce them. Thomas Bollyky, Director of Global Health at the Council on Foreign Relations. He’s based in Washington DC. Welcome to Science Friday.

THOMAS BOLLYKY: Thanks so much for having me.

IRA FLATOW: And Dr. Amesh Adalja, an infectious disease doctor and senior scholar at Johns Hopkins University’s Center for Health Security based in Baltimore, Maryland. Welcome.

AMESH ADALJA: Thank you for having me.

IRA FLATOW: Thomas, let me begin. This is a sprawling plan. What stands out to you in this plan?

THOMAS BOLLYKY: Well, I think the war analogy is appropriate in some ways, although it has some limits. So what stands out in the plan from the president is that very much it understands that this will be a sustained effort to fight this pandemic and with vaccinations, something that really will last for the bulk of this year– the broader effort for longer. And it requires an active government response in the economy, both to prop up that economy, but to mobilize all the resources we need for this vaccination campaign.

I was also pleased to see that it’s a bit of a shift from what we saw in the past administration where there was heavy focus on the supply constraints on vaccination– how do we develop vaccines, and line up the manufacturing we need to produce them, and the logistics of that supply– but very little on the administration constraints. How do we actually get vaccine doses into the arms of the most vulnerable people who need them? And then also how do we address demand problems? How do we convince people who might be reluctant to take vaccines, to take them?

The one part where I think there’s a limit to this war analogy is war gets people thinking from a nationalist perspective. And one challenge we’ve seen around vaccines is that is very much what we’re seeing globally. And I’m not sure that’s the best way to end this pandemic.

IRA FLATOW: You wrote a piece in the New York Times where you said we should treat COVID-19 less like the flu and more like an act of bioterrorism.

THOMAS BOLLYKY: That’s right. So in the case of the flu– seasonal influenza– we’re largely talking about scheduled appointments for vaccinations that occur through your clinical health practices and at pharmacies. In order to reach the goal that the president has laid out– a minimum of 100 million people vaccinated in 100 days– we need to see a much more robust vaccination plan.

We actually have these plans. We developed them after 9/11. We developed them because there was a greater appreciation at that point that public health was a matter of national security. And part of that preparedness had to take into account the risk of bioterrorism– a released potential of smallpox or a repeat of the anthrax attacks on a much larger scale. What would we do in that case to try to vaccinate a potentially exposed population within 48 hours? That’s what those plans do.

Oddly, with all the effort that went into planning the R&D in the development of these vaccines and the supplies that we needed, very little has been done to tap those plans from the past about how we actually administer them on short notice. So together with colleagues, Jennifer Nuzzo at Johns Hopkins and Sid Baccam at IEM, we did this piece looking at what that actually would require in terms of sites, vaccinators, how many you would need, what kinds of shifts they would need to run based on these plans that we had developed in the past.

IRA FLATOW: Amesh, you work for the Center for Health Security. How is a pandemic and health a security risk? Do we need to change our perspective on public health?

AMESH ADALJA: You’re seeing it right now. I think this is what many of us in the field have been arguing that public health and Infectious disease emergencies are inextricably linked to national security. The most obvious case was mentioned earlier– biosecurity, bioterrorism, such as the anthrax attacks. But you can see what happens to a country that lets an infectious disease run rampant.

It basically disrupts the entire economy. It basically takes the government from focusing on traditional national security threats to spending a lot of resources and time trying to stop an infectious disease outbreak. In our own country, we had our president infected with this virus and hospitalized. We had the joint chiefs of staff under quarantine because of exposures. I mean, that really is very clear– has clear national security implications.

So I do think what we have to take from national security is that there are parts of our public health that need to be thought of that way. That we need to build an infrastructure that doesn’t go through these cycles of boom and bust or panic and neglect. Where when things are in the headlines, there’s funding, there is interest, and then when they recede from the headlines, like the anthrax attacks did, all of that dries up. Because we are going to be faced with more infectious disease emergencies, whether or not they’re pandemic scale or maybe more on the scale of Zika or Ebola. And we’re going– we want to be able to be resilient to them.

So I do think that we have to fix– there’s a window of opportunity right now to fix this. To get pandemic preparedness the attention it deserves so that it is sustainable, so that it is funded more the way the Department of Defense funds budgets. If you think about how much money we spend on pandemic preparedness compared to how much we spend on an F35 fighter plane, you can’t even compare the two. And look what’s happened with this pandemic. It’s been said that if you stop this pandemic a month earlier, we’ll save half a trillion dollars.

IRA FLATOW: Well, let’s talk about preparing for it, because there’s a lot of talk of using the Defense Production Act to help ramp up production of vaccines. Amesh, tell us what the act does. Can the government start directing companies to produce vaccines? How does this work?

AMESH ADALJA: So the Defense Production Act has lots of different sections to it and lots of different aspects to it. And I’m not a lawyer, so I’m going to give you my understanding of how it applies in an infectious disease emergency. What it does is it allows the president to have companies prioritize orders from the US government. Say, that might be a vaccine, it might be syringes, it might be some ingredient that’s needed in masks, for example.

And it allows things to happen much quicker. Those contracts get prioritized. Some of the red tape disappears. And it just gives a lot of power to the president to direct resources towards what is deemed a national security emergency. And it’s been invoked before by President Trump. And it’s been invoked for other things in the past as well. But what I don’t think– what I think we have to think about is that it’s not going to be a magic bullet.

And the fact that we’re actually getting to the DPA for masks, for example, this far into the pandemic, tells you that there’s been a lot of failures that the DPA needs to be put into place. Because remember, after 2009 H1N1, the strategic national stockpile was not repleted of N95 masks. We have no one to blame for the fact that we need the DPA now but ourselves.

IRA FLATOW: Thomas, we’re relying then on private companies to create these vaccines that don’t give up their trade secrets very easily. Is that an issue?

THOMAS BOLLYKY: Yeah. So I wanted to build on a couple of things Amesh said and then answer that question. So one thing to appreciate is not only did H1N1 shift people’s expectations of what a pandemic might look like at this country. We had done all this investment after 9/11, particularly between 2004-2007, and we were hit by the financial crisis.

And that’s really where you saw states and localities, and to some extent the federal government, start to cut funding to that preparedness programs. Because the easiest thing to do, of course, is always to cut for capacity that you hope you’ll never need to use. And H1N1 reinforced that impulse, but it was really the combination of those two things that hurt us in the past.

So in terms of the DPA, it certainly creates a potential vehicle for the president to provide economic incentives to try to mobilize domestic industrial capabilities to meet a national security crisis like this one. In terms of vaccines, so far we actually haven’t had as much of a challenge in terms of mobilizing that supply and having companies provide it. Certainly, not in comparison to some other nations. Even the European Union is having some struggles getting their vaccines on time. But it’s definitely something in the background that can be used, if needed to, to move forward those supplies.

The problem really has been in terms of mobilizing the capacity more so in some other areas, like Amesh mentioned around PPP. To be a year into this crisis and to not have solved that challenge is really disappointing, to say the least. And obviously has had a tremendous health cost, particularly at a time where we may need better masks, particularly given more contagious variants that are starting to circulate.

IRA FLATOW: Are you saying that the mobilization of the Defense Act will not put more people on the ground– as they like to say in the military, boots on the ground– to be able to distribute the vaccine, to get it into maybe planes that need to fly to certain places, to have soldiers who are qualified to be able to dispense it. I’ve already seen soldiers on the ground and in parking lots giving out the injections. Are you saying that won’t help that?

THOMAS BOLLYKY: DPA is more around production and supply of the actual vaccines. We are seeing mobilization of vaccinators. So through FEMA, you’re seeing a ramp up of the availability of vaccinators, and starting to reach out to broader populations and provide the training you would need to have them be vaccinators.

I think the big issue on vaccine capacity and manufacturing is are we going to be able to convince countries– or companies, rather– that have failed candidates to provide their manufacturing capacity to the successful candidates? And we’re starting to see that. Sanofi announced– I think it was last week– that they would be manufacturing the Pfizer vaccine. Merck recently announced that its candidate failed. That’s another source of potential manufacturing capacity that you could bring to bear.

But what people need to understand is as exciting as the stories were in the early days of this pandemic of machinists and companies that had never built a ventilator trying to build one on the fly, mobilizing new companies to make anything from toilet paper to PPE, that’s harder to do in the vaccine manufacturing context. Vaccine manufacturing is one of the most complex manufacturing challenges in the world. It’s part of the reason why so few countries can actually do it.

The fastest way to increase our supply is to get existing manufacturers, particularly those that don’t have a successful candidate, to manufacture the successful products. We’re starting to see that. And I have hope that we’ll see more of that moving forward.

IRA FLATOW: I’m Ira Flatow and this is Science Friday from WNYC Studios. The national plan talks about mass vaccination campaigns, turning stadiums into places where you can vaccinate hundreds in a day. Do you actually see that happening and is that the right way to go?

THOMAS BOLLYKY: It is one of– it’s a component of the right way to go and it’s certainly what we advocate for in that New York Times piece. If we’re going to hit the targets that we need to hit to sustain one million vaccinations per day for 100 days– and I should point out here we have seen a ramp up of vaccinations in the US over the last week and a half. But we’re still averaging– since December 14, when the rollout began, we’re still averaging just a little over 500,000 per day. So sustaining this for 100 days, even at one million a day, would be a feat.

The president has said he’d want to reach one and a half million a day. To hit these targets, you need a component that involves mass vaccination. Ideally, of a population where their eligibility for vaccination, because they’re a priority population, is easier to identify. So something like people over 65 where you’re really just looking at driver’s license or other documentation to show that they qualify.

You cannot just do that, though. And this is the important part I want to emphasize. You need to pair that with an effort to make sure you’re reaching vulnerable populations. So think essential workers in meatpacking facilities or vulnerable populations with high health risk at federally qualified health centers. And to do that, you also need to pair what you’re doing on a mass vaccination side with mobile clinics that can reach those more vulnerable populations.

IRA FLATOW: But how do you get the messaging to be single and national-led? I mean, we’re hearing the face-masking messaging, the keeping kids home from school or not messaging. Is there any way to nationalize that or is that not a good idea?

AMESH ADALJA: Well, at the end it’s going to be state and county health departments, and local physicians, and pharmacists, and others that are putting the vaccine into people’s arms. But what we need to do is have the federal government talk to states, think about where they’re faltering. How can you help each state? It might be different in different states. And then see where the government can help with the coordinating function.

And what we saw– and this is very similar to what happened with the testing problem– is that it was left to the states. And the federal government washed their hands from it. We’re seeing a turnaround in that rhetoric now in the Biden administration where they’re recognizing that they can’t allow the states to fail at this.

So I really think you’re going to have to have each of the 50 governors, each of the 50 health secretaries meet with the federal government and see what their needs are and what they can– and how the federal government can help them meet these challenges. And the same thing probably has to happen at the county level with states, because we’re already hearing about discord between county governments and state governments.

So this is really a cascading failure. And it is exactly reminiscent of what happened during 2009 H1N1 with the vaccine rollout, where there was a lot of opacity and what was coming to you when, where it was coming, how much of it was coming. The same type of thing was happening then. And this was all in all the after action reports from 2009 H1N1. But again, like many things in our field, it’s gathering dust in some drawer, and nobody actually ever read it or actually wanted to implement the recommendations for how to do a vaccination program at this scale.

IRA FLATOW: We’ve been talking about President Biden’s ambitious national COVID-19 plan. How that might roll out. How we can plan for future pandemics. My guests are Thomas Bollyky, Director of Global Health at the Council on Foreign Relations, and Dr. Amesh Adalja, an infectious disease doctor and senior scholar at Johns Hopkins University’s Center for Health Security.

There are two main issues here, as I see it. One, creating the vaccine and making enough. But the second is actually getting it into people’s arms. Is this an infrastructure issue or is it just a money and funding issue?

AMESH ADALJA: I think the two are inextricably tied together. Because you have to remember that who is doing this vaccination program are the state health departments. And these state health departments are chronically underfunded, undervalued. And they at the same time are setting up vaccine clinics, they’re also doing testing sites, they’re also doing case investigations and contact-tracing.

The same is true for the hospitals that are doing this. There’s nobody that was a COVID vaccinator in 2019. That wasn’t a job title. So these are people that are getting pulled from other parts of the hospital. And many of these hospitals are dealing with record numbers of admissions for COVID. So there’s just not a lot of manpower to do this.

And I think what you have to think about is if you’re going to do something on this scale– the biggest vaccination program or public health endeavor in the history of this country– you have to fund it appropriately. And Operation Warp Speed was a smashing success at developing vaccines quickly and getting them out the door. But this last mile of vaccination, of turning a vaccine into a vaccination, that’s where they abdicated. And when the funding came over Christmas weekend, that’s way too late. This needed to have been done months and months ago.

And you can see that states that did well– West Virginia, North Dakota– they were proactive. They didn’t wait for the federal government. They didn’t join the CVS-Walgreens compact. They did it on their own. That’s what has to happen is that in the absence of federal leadership, states had to do it on their own and they’re not very good at doing it.

So I do think what we have to do is really use all federal resources in order to get vaccine into people’s arms. And that includes mobilizing FEMA, using the National Guard, trying to get as many people who are trained to vaccinate to be able to do that. So for example, using dentists, even using veterinarians. That all has to be in the plan now, because the longer this continues, the slower this pace is, the faster this virus is going to spread, the longer this is going to take, the more variants we’re going to have. So we have a tool in hand. We just have to now implement it.

IRA FLATOW: Amesh and Thomas, I have one last question for both of you and it’s the same one. And let me ask Amesh first. How will we know– what metric is there to know if this new plan– if all these new plans are successful? How will we measure success that we have turned this giant ship around?

AMESH ADALJA: There are a couple of things. So it’s important to remember that the first indications that we’re going to see that this is successful is getting through this phase 1A priority group, including nursing home residents, because nursing home residents still really constitute a large proportion of those individuals who are getting hospitalized and those who are dying. So we will get a respite in our hospitals.

And remember that flattening the curve is largely about preserving hospital capacity, keeping cases to a level that’s manageable. And that’s the first thing I’m going to look at is our hospitals decanting? Is our death rate going down? That tells you that the vaccine is getting to the most vulnerable, that it’s working.

Over time, we’re going to start to see decreasing transmission. Case counts are going to go down. People’s risk perception will start to change because there will be not that fear of getting deadly disease. And you’ll see us approach herd immunity, probably in the summer. But the first thing I’m going to look at– and that’s what I’ve been concerned about from the very beginning– is hospital capacity and trying to give hospitals the ability to take care of other patients and to not be worrying about their capacity, their personal protective equipment, their staffing on a day to day basis.

IRA FLATOW: Tom, your reaction?

THOMAS BOLLYKY: So I really like what Amesh said in terms of focusing on outcomes. One challenge that we have at this goal of vaccinating 100 million people in 100 days is that it’s in on inputs. It’s good to have goals, but the goal here, of course, is reducing case counts and preventing unnecessary death. So I really like to focus on what we’re seeing around hospitalizations, what we’re seeing in terms of reported deaths from the virus.

I have to admit I am a little less optimistic about how soon we will be hitting herd immunity through this vaccine. To me, particularly for the next several months, I really view the primary goal with these vaccines is protecting vulnerable populations. We may, as we get more vaccine, hopefully maintain our adoption of the kinds of practices beyond vaccines– non-pharmaceutical interventions, social distancing, mask-wearing, and so forth– manage to drive down case counts and hopefully get this pandemic under control.

But given the challenges we’ve had in the past to vaccinating adults, I really think what we need to be focusing on is to make sure that we walk and chew gum at the same time. Get our numbers up. But also protect those vulnerable populations that are really driving hospitalization, and unfortunately, all the high number of deaths that we’ve seen in this country.

IRA FLATOW: Thomas, how do you view the future? Hopeful?

THOMAS BOLLYKY: I do view it hopefully. I mean, I watched this week– or just yesterday– the press conference with the new head of the CDC, the COVID-19 coordinator, and their team. And honestly, it was a breath of fresh air. Detailed, transparent, honest. You seem to see a much more robust effort to tackle these challenges and communicate clearly where we are. That’s a good start. I’m more optimistic than I’ve been in a while.

The area where I’m not as optimistic in the near term is internationally. Right now out of the 59 countries that are administering vaccines, just two are either in low income countries or lower middle income countries. Just two. So that gives you a sense of the disparity. I don’t think we’re that close to solving that problem. So domestically, I’m hopeful. Internationally, I’m concerned.

IRA FLATOW: Thank you both for taking time to be with us today. A lot to think about and I’m glad you’ve sent us down that road to talk about it. Let me thank my guests, Dr. Amesh Adalja, infectious disease doctor and senior scholar at Johns Hopkins University’s Center for Health Security, Thomas Bollyky, Director of Global Health at the Council on Foreign Relations. Once again, thank you both for taking time to be with us today.

THOMAS BOLLYKY: Thanks so much for having us.

AMESH ADALJA: Thank you for having me.

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