Raise the Line Podcast Featuring Dr. Anne Schuchat
Published on Apr 21, 2020. Updated on Sep 15, 2020.
Only a handful of people have as much responsibility for overseeing U.S. response to COVID-19 as Dr. Anne Schuchat, second-in-command at the CDC, and few can match her three decades at the CDC fighting infectious diseases, from AIDS, to Swine Flu, to Ebola. In this insightful interview with Dr. Rishi Desai for the Raise the Line Podcast, Dr. Schuchat cautions about the accuracy of antibody tests, supports a regional approach to easing social distancing, previews the use of census takers as contact tracers, and encourages young people to join the fight against the coronavirus and pursue a career in public health.
Listen to the podcast and read along with the transcript below:
DR. ANNE SCHUCHAT: CDC has thousands of people involved in our pandemic response. Of course, preparing and responding to emerging infectious disease threats is really core to our business. But we have staff in health departments all around the country and we have people in 60 countries around the world as well as hundreds deployed from our Atlanta headquarters to assist the state and local health departments.
We're tracking epidemiology, working in the laboratory on assets like a new antibody test to measure zero prevalence of the amount of people who've already been infected. We're doing investigations to understand how it's spread in households and trying to provide support about investigations around nursing home outbreaks, outbreaks in shelters for the homeless, in meat packing plants, and in a number of complex settings right now. We’re also providing guidance for clinicians and guidance for public health about how to really accelerate controlling the outbreak right now. We’re really focused on flattening the curve, slowing the spread, trying to understand how the community interventions are working, and doing models to predict what's going to happen in the future.
DR. RISHI DESAI: You know, speaking of models… Just yesterday (as you're well aware), the guidelines just dropped in terms of what we can look forward to in the weeks ahead. One of the things that struck me is that the guidelines mentioned two-week phases, three phases. You look at a state like Washington that started this outbreak for us here in the US: they presumably would be meeting criteria for phase one around April 20, just a few days from now. Do you feel like the public health capacity is built to a place where they could potentially enter phase one?
DR. ANNE SCHUCHAT: The Washington state example's a good one. The leadership in Washington state announced that they were going to work together with Oregon and California on a regional strategy, and I personally think that's a great idea. We know that the New York area is doing the same thing and the Upper Midwest as well. Today in America, people can live in one place, work in another, go to school in a third. And so having jurisdictions really work together, whether it's that macro level of the whole west coast or it's several counties around the DC metropolitan area, it's very important to coordinate and collaborate because if you're not in sync, the spread may just ping-pong across.
I think that it's really going to be important to have public health capacity, hospital capacity or healthcare capacity, good availability of testing, and rapid assessment of the indicators in order to open different parts of the community. But some things may open sooner than others, and they may open partially, open with physical distancing—perhaps having childcare centers where the parents are in healthcare or essential work or something opened before broader childcare centers. But I think CDC has been working on a variety of tools and a variety of metrics and connecting with the local and state health departments to see, "Do these make sense? Are these practical? Could you work with them?"
Contact tracing is a big deal. And, of course, we're now at this rapid transmission, high levels of disease in a lot of places where you just can't possibly keep up with individual case identification, contact tracing, rapid quarantining, or isolation of the individuals. But when we do have things open up, we want to be able to detect cases and their context really quickly. And so we're working on something called a COVID response core: both CDC, CDC Foundation, state, and local jurisdictions who've gotten about $600 million for their pandemic response to try to really staff up the public health capacity. It may be local or state employees. It may be census takers, Peace Corps volunteers—they're already government employees and they're not doing their regular job right now. Can we connect them with the local health departments?
I've heard of schools of public health students being assigned to local health departments to help with contact tracing. We know in West Africa during the Ebola response, we rapidly got all centers adapted from being usual call centers to being contact tracers by phone—where in societies, even in West Africa, where everybody had a cell phone. So we really need to use the tools of modern America and strengthen that public health capacity locally so that we can keep up with transmission. I think that contact tracing will be really important in the low incidence areas that haven't yet been hit. And then as we see control improve in other jurisdictions to prevent resurgences by early detection of the clusters.
DR. RISHI DESAI: One of the things you're getting at is this idea of increasing healthcare capacity. We've heard the phrase flatten the curve. The other phrase—I'm not sure if you're familiar with it—is "raising the line" of healthcare capacity. Raising the line includes all the things you just mentioned, as well as testing. With testing, going back to that point, I'm just curious to get your thoughts: we saw roughly 1 million tests done in January, February, and March cumulatively. And then we saw about a million in the first week of April. Again, another million in the second week of April. What is your sense in terms of where we need to be to start seeing parts of America reopen up? What weekly testing capacity—is a million enough? Or do we need 5 million or 10 million a week? What do you think?
DR. ANNE SCHUCHAT: No, I don't have a number. I would say there's several different opinions—you've probably been reading many of them about a target for testing. I think the traditional public health person in me who's used to studying respiratory viruses feels like you can't really test your way out of a pandemic of a respiratory virus. There are other indicators that are going to be timely, like the syndromic surveillance we're using. But I think that there's a huge demand for testing, and we know that a lot of people who can transmit don't have symptoms when they can spread. So the testing has a key role in this. We obviously need more.
There's so many people who do need to be tested who aren't getting tested yet, and we need to shorten the time between when a person needs to be tested and when they can be tested, and when the result from the test is available. So the surge in available tests and approaches to testing is good–the point-of-care tests, the high throughput tests—but we have this supply/demand mismatch right now, so it's not really just the number; it's getting them where they need to be, when they need to be there, with all the supplies.
It's not just having a machine that can test. It's not just having a point of care test. It's also the cartridges, the swabs. I think there's something called Swab Force, which has been created at the National Response Coordination Center, to figure out how to get enough swaps everywhere they need to be: the right kind of swab for the right kind of test. Can we ship swabs, or is that not okay? Well, the FDA has to say it's okay to ship a swab for that type of test kit. There's a lot of mismatch right now. We've got to get beyond it, so I don't have a number. I know the number is higher than where we are.
DR. RISHI DESAI: Speaking of FDA… The FDA this morning issued (I think for emergency use) authorizations for serology, and we know that in the coming weeks that serology is going to be increasingly important. There is a bit of a log jam in terms of getting these EUAs. Do you expect more EUAs to come through, and what do you sense is the reason for that log jam?
DR. ANNE SCHUCHAT: Yes, I expect many more to come through, but I think that it's going to be very important to understand the performance of these tests. An antibody test can lead to a lot of confusion. We don't know all that we want about the immunology of this disease. Is an antibody specific? Does an antibody-positive mean you had this infection and you're not going to get it again? Or is it just a nonspecific finding?
You may remember (you're probably younger than me!) but the beginning of the day of the HIV antibody test. Well, it turned out when a condition is very rare, the performance of the test needs to be really, really good for it to work well in the context of rare exposure. In those early days, if you tested a general population with the antibody test for HIV, more times than not, you'd be wrong. The person who got the antibody positive didn't really have HIV. Some states were going to require HIV testing as part of marriage certificates, and then it was like, well, we're giving up more wrong answers than right answers and we're ruining a lot of relationships. Let's get this figured out. And so it became a two-step process: screening test, follow-up tests.
So we're developing these antibody assays here at and elsewhere. We're using a second step on neutralization test to figure out: is that antibody-specific, or just an error? And I think the FDA may be double-checking before these tests go into widespread use. I think the UK ran into an, "Open the flood gates, and use all these tests," and then said, "Wait a minute. We don't even know what they're measuring." So we recognized early on with the PCR, the commercialization was way too slow—and speed is essential when you're dealing with a new virus.
Here, as we try to understand how we're going to use antibody tests—is it on the individual basis for a healthcare worker getting back to work, or for population studies where being wrong isn't that cosmic?—because you're not taking action on the individual result. So, I feel for the FDA. They have a tough job.
DR. RISHI DESAI: One thing you've talked about a little bit is the need for more public health workers to go out there and do contact tracing and things like that. It kind of goes hand-in-hand with public education to understand what these tests mean, and so on. As an education company, Osmosis tries to do our part around the education piece. I'm just curious: what do you see as the short-term advantages of public education campaigns, and then do you see that as a long-term strategy for CDC as well?
DR. ANNE SCHUCHAT: I have so many answers to that question! I'm really excited about the question. I am amazed and really heartened by what the American people have done recently. In response to this pandemic, there have been all these neighbors helping neighbors virtually. There's been so much "correcting the record" that people are doing online or in social media.
We had recent polling data I saw about the face coverings. It's amazing to me that in the United States, which was not a place where people wore masks or wore face coverings—we're not like a lot of places in Asia—we pretty rapidly went from "don't use them" to “we actually recommend a cloth face covering to people understanding that this is about me protecting.” I like to say, "I've got you covered by the face covering that I wear protects you.
I think that people are hungry for information. They're stuck at home, for the most part. A lot of them are connected, and connected with each other, and they're talking about important issues and solutions, and they're finding solutions and sharing them with the decision makers. And we're trying to listen. So I think public education has a huge role and the public voice is really important. It's important for us to know what those questions are, and to see if we can address them.
The other thing I was going to say about public education is kind of about students. I am really heartened that this need for a huge surge in public health capacity comes at a time of so much interest in public health. In the last several years, public health has emerged as a very popular major and a huge interest for young people around the country, yet there was, "Well, I'm really interested in public health, but there are no jobs," because public health had been so underinvested in. I think we're seeing right now that the consequences of not investing in public health are slow responses and not having the innovation that we need or the modernization that we need. And now we have an opportunity to really rebuild, even if it's just short term, getting more staff connected with their local or state public health and helping solve this pandemic. What a meaningful thing to have early in your career to get to be part of ending an epidemic.
I got to work in Sierra Leone during the Ebola epidemic and I got to speak at a graduation for medical students and public health students and pharmacy students who—essentially two years—graduated together because their schools had been closed. At the time I thought, “That'll never happen here.” It's happening here. But those students were so proud of the role they took in stopping Ebola. Before they went on to become a physician or a nurse or pharmacist or lab tech, they stopped an epidemic. They were contact tracers. They were helping with our vaccine trial. I think young people today have a chance to help stop this epidemic and help life get back to normal in their communities.
DR. RISHI DESAI: You touch on so many things in your comments, it's hard to know which one to go after. You mentioned the international aspect of this, and I'm curious to get your thoughts in terms of what role the CDC plays, and the WHO, and all these other groups in terms of making sure that we have vaccination available worldwide, and not just for the U.S. population, because, obviously, protecting people everywhere protects everyone everywhere.
DR. ANNE SCHUCHAT: Now when you have a pandemic, it means the human population has not been exposed to this thing and it's totally new and everyone's at risk. And I am really concerned about what this virus is going to do in resource-poor settings where people live in very crowded conditions and we're supposed to be socially distancing—it's pretty much impossible. You can restrict the bus passes and you can… But just to eat, you really are in very crowded circumstances and your home may be a home with many families really packed in together. So it's really scary to think of the challenges there.
CDC is working in 60 countries with people on the ground and many of our people assigned for something else are helping with COVID. We've had people in the Democratic Republic of Congo helping with Ebola—they're helping with COVID now. Of course, there's no more Ebola in DRC, and they're helping with both. But we really need each country to be able to find stuff and prevent epidemics.
We need the global community to come together to help. We need the research community, the R&D that makes vaccines, to work really fast. And whether it's Gavi—who's buying up stockpiles of vaccines for Ebola— or investing in future vaccines against threats, or it's something like CEPI or BARDA here in the US, really investing in those new technologies to get us vaccines. It's not just for Americans that those vaccines are going to be important. We're going to need the whole world protected. Whether we'll get a vaccine before this epidemic runs its course, whether COVID-19 is going to be with us forever, and we're going to have to vaccinate regularly or get vaccines that work long-term. We just don't know now, but we really need to gas up that vaccine development architecture to do its job as quickly as possible.
DR. RISHI DESAI: There have been some creative solutions that we've seen along the way: recycling N-95 masks, NIH just came out with a paper about that, Stanford has a protocol batch testing so that you do multiple swabs for one RT-PCR test... What are some creative solutions that the CDC has come across that you feel have reached the level of accuracy and reliability to a point where the CDC can really put their force behind and say, "Hey, we should all be doing this creative thing."
DR. ANNE SCHUCHAT: Yeah, the batch testing has been absolutely something that we've all been looking at, whether it's for PCR or for the antibody testing. That issue of doing a batch of five or 10 and then honing in on the positive batches—you can save time, you can speed the throughput, so that's for sure being looked at.
Our labs have also been looking—so many supplies have been in short supply—–they've been looking at alternatives. There's not that viral transport media: can saline work? Can you boil, instead of using extraction kits? They're trying a lot of these home brew things to figure out what could bridge that gap.
In other parts of government, they're really incentivizing industry to get their products out there early with the EUAs so that they're of use. It's such a complex supply chain right now, where to do a lab test, you need a swab, you might need PPE if you can't just do a nasal swab, and PPE is in short supply. You need the transport media, or you need the FDA to say it's okay to just mail the swab in. You need the equipment then you need the supplies for the equipment and you need to train people to run the equipment. Or you can have a point of care test that may be very simple to use. There's a lot of things there. We talked about vaccination, you need the needles, the syringes, as well as whatever the magic potion is that's going to go in them.
So, we're faced right now with the US not in control of our supply chain. Most of this stuff's not made here. We're very interdependent. No state can supply itself with everything they need. Our nation can't supply itself with our homegrown or home-manufactured products. So innovation is crucial. I love the face covering because you can make it yourself with socks, or a tee shirt, or a bandana. But I think innovation is going to be very important, not just in the diagnostic testing or the masks, but in our strategies to stop the epidemic.
I feel like the way people are handling the mental health aspects of this, the hardships, being at home or having to go to work because your job is one of those ones that you have to go to work. Finding ways to help each other: I think that's a really crucial area for innovation where we find ways to overcome the physical distance and stay socially connected with people who are really suffering from the economic impact or the physical impacts of their circumstances, that we find ways to bridge those gaps that work, that keeps them safe, and that keeps them protected.
DR. RISHI DESAI: The thing that keeps me up at night these days—I have a young son, and in my community, things seem to be quite flat, as is the case in many communities. And the thing that I worry about is that, of course, going back to the earlier point, is that we'll de-isolate too early and see a resurgence. I'm just curious to get your thoughts in terms of what keeps you up at night? What are you most worried about these days as we're at this kind of juncture in the pandemic?
DR. ANNE SCHUCHAT: I think it bears saying, because some of us have been saying, "Well, this is like the nightmare virus." Could they have made a worse virus in terms of thinking of something that would be transmitted before you have symptoms and can be so severe, and so forth? But there's one good thing about this virus so far: that it doesn't seem to affect children adversely, that it's very rare for young people under 18 to be hospitalized, with just a handful of fatalities so far.
That's the only silver lining that we have right now. Perhaps a nightmare is that it'll mutate and suddenly become much worse for children. But usually, the thing that keeps me up at night is an influenza pandemic, and we're basically having the equivalent right now with a new viral strain that spreads so easily through respiratory means that is just very difficult to control. The CDC is working 24/7 to do all we can. And I know that the American public, the countries around the world—there’s solidarity. We're all battling this really tough virus.
DR. RISHI DESAI: We have a lot of audience members who are going to be on the front lines or future clinicians, nurses, doctors, et cetera. And I'm just curious what advice you'd have for them.
DR. ANNE SCHUCHAT: Don't be dissuaded from that career in health or public health. It's just such a meaningful thing to get to do, to be able to help solve the problem when there's a crisis. I know that I'm just grateful to have work that is meaningful. It may be hard—it may be really hard—but that's meaningful and that I know contributes.
I did my clinical training back in the early ‘80s. I was in med school in the early ‘80s and did my medical residency in New York City in the mid-80s when the AIDS epidemic was just emerging. And I look at the numbers now: 20% of the patients in the hospital or 30% of the patients in the hospital have COVID-19. That was kind of what we had with AIDS when I was an intern. And, we'll get through it and you're going to find meaning, and you're going to help now hopefully on those front lines and then you're going to have that experience for the rest of your life—to really be able to contribute. It's so meaningful to me to have started my career in the middle of a pandemic (essentially) and see that we can treat people who are HIV-infected and they can live long and healthy lives. We can prevent the spread of HIV from one person to another person, that we can end that epidemic. I think, for you: take heart, keep up with those plans, have an open mind because maybe you want to do public health and not clinical, but it's a wonderful profession.
DR. RISHI DESAI: That's fantastic. Listen, Dr. Schuchat, I know you're extremely busy, so we tremendously appreciate your time. Is there anything else that we should talk about that we haven't talked about yet?
DR. ANNE SCHUCHAT: CDC.gov—check that out. It's got the best information updated regularly. We're getting our interactive web stuff going pretty soon. We're going to have a model dashboard that's going to post information about the variety of modelers that we're collaborating with to try to see what's going on. Not just one at a time, but all the different modelers, so keep an eye on that site.
DR. RISHI DESAI: Will do. Again, CDC.gov. Thank you so much, Dr. Schuchat for your time. I appreciate it.
DR. ANNE SCHUCHAT: Great, a pleasure talking with you.
DR. RISHI DESAI: I'm Dr. Rishi Desai. Thanks for checking out today's show. Remember to do your part to flatten the curve and raise the line. We're all in this together. Be well.