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MIT Technology Review

The US’s war against covid-19

We talked to a former CDC director about how the government's response has been thus far.

April 1, 2020

Note: This episode has ended.

In this episode of Radio Corona, Gideon Lichfield, editor in chief of Technology Review, spoke with epidemiologist Dr. Cyrus Shahpar about the “war” against covid-19, and how his organization, Resolve to Save Lives, is working with governments to help them implement evidence-based strategies to defeat the pandemic. Shahpar will also be taking your questions.  

Shahpar is a director at Resolve to Save Lives, an initiative of Vital Strategies. He was the Deputy Team Lead for CDC's Global Rapid Response Team and an Epidemic Intelligence Service officer there. He has worked with humanitarian organizations including UNHCR, UNICEF, WHO, and WFP in large emergencies in Haiti, Pakistan, the Philippines, Jordan, Kenya, and Ethiopia.

Dr. Tom Frieden, CEO of Resolve to Save Lives, recently penned this op-ed, “We'll lose 'World War C' against the coronavirus if we don't fight the right way.” We encourage you to read it before watching the show. 

This episode was recorded on April 1, 2020. You can watch it below.

Gideon Lichfield: He was deputy lead of the CDCs global rapid response team and he worked on the Ebola outbreak in West Africa. Cyrus, thank you so much for coming to join us.

Cyrus Shahpar: Thanks for having me.

Gideon Lichfield: I didn't hear all that well, can you try and maybe come a little closer to your microphone or adjust it?

Cyrus Shahpar: Sorry, one second. Can you hear me now?

Gideon Lichfield: Yeah, that's better. Thank you very much. Okay. Great. So you're the director of Resolve to Save Lives, Tom Frieden to use to be director of the CDC, wrote an op-ed in the Hill recently that we shared with our audience about how the CDC is being sidelined. Can you talk a little bit, what do you think are the major flaws in the way that the US has been handling this pandemic that you think might have been avoided if the CDC were playing a more prominent role?

Cyrus Shahpar: Sure. So coronavirus, you know, is a respiratory disease and many of the world's experts in respiratory diseases are at the CDC, which is the US government's public health protection agency, essentially. So this is the group that has expertise in things like coronavirus and should be providing ongoing daily updates to inform the response. I think in any kind of emergency we have things like incident command and incident management and there's clear structures and clear overall leadership and an organization that we've used in countless emergencies, you know, all around the world. So I think that structure perhaps hasn't been in place throughout, you know, since the beginning. I think it was unclear based on you know, things like the task force who was involved at the CDC, the experts, were having continuous input into the US government's response. So I think, you know, it's kind of like saying, you know, I'm an expert in, but I'm going to be managing something, but I'm not going to talk to the people who know the most about it.

Gideon Lichfield: What sorts of mistakes do you think might have been avoided if the experts were more looped in?

Cyrus Shahpar: Well, I think you can go back and look at say quotes from the lead of the National Center for Respiratory Diseases, Nancy Messonnier, who said in January, this is something we really have to be concerned about. We have to get ready for in February. Similar remarks and at the time, you know, that was over two months ago. So in the past two months, what did we do to get ready for something that we know is a huge problem right now that is a pandemicwere we getting the health care system ready like we should have been or were we saying we're okay with, you know, a hundred cases, our case counts are good. Those were the kinds of messages that were coming out of the, you know, national leadership, not necessarily based on science and knowing that, you know, it might be good now, but based on what we're seeing in China and other countries in Asia, it's going to get a lot worse. I think you're on mute.

Gideon Lichfield: Oh, I am. Thank you. Thank you for that. Let's talk a little bit about the epidemiology of this outbreak. I mean, it seems like we still don't know some really basic things about this virus. We still don't know what's called the reproduction number (R nought), which is how fast it spreads or you know, how many people get infected by each person who has it. We still don't know the fatality rate. These are some, you know, basic numbers about the tell us just how deadly the epidemic is and how quickly it spreads and how many people it's likely to kill it. Why is it so hard for us to still have these data?

Cyrus Shahpar: Yeah, I mean, I think that we do have some kind of estimate of R nought and somewhere, you know, sitting around 2 to 2.5 right now without intervention. On the case fatality rate side, certainly we're seeing globally somewhere on the order of four to 5%, but huge variation across countries in North of 10% in Italy, you know, under 2% in Germany. And you know, why are we seeing this variation? Certainly there's reasons that could be driving it, like the age distribution of populations and the testing. But you know, there's been some good modeling done on what the actual case fatality rate is. Somewhere between a half percent to one and a half percent essentially if you were able to find all the cases. But the things that we don't know about that we need to know about things like the proportion of people who have it, that don't display any symptoms that could be transmitting disease. That kind of information has huge implications on how we control it who we test. So I think that information is especially important to find and we need to find out more about that in the coming days.

Gideon Lichfield: Yeah. Sorry. The CDC I think came out with a number recently where it said that about 25% of people now that have it are asymptomatic, but it's not entirely clear to me where that number came from. Do you have a sense?

Cyrus Shahpar: There's some studies from the Diamond Princess cruise ship. They did a lot of testing. From Korea as well, from Singapore. It's the places that do robust testing. I know Iceland is doing it as well. There was also a town called Vo in Northern Italy that tested everybody in the town, 3000 people, even though people told them not to. So they're picking up people that didn't have symptoms at the time of test. Now some of those people were what we call pre-symptomatic. So they went on to develop symptoms later. We just caught them in a period where they tested positive, but they hadn't, their body hadn't developed symptoms yet. And then some of those people were truly asymptomatic in the sense that throughout the course of their infection, they're not developing noticeable symptoms. So there are some, some sources for that information. But we, we also need serologic testing to do a better job of this.

Gideon Lichfield: Yeah. So let's talk a little bit about that. This I think the US the FDA approved a tests I think yesterday or the day before for testing for antibodies, serologic testing so that people can find out if they've had the virus, if they've had it in the past and unrecovered. So what would it, what sort of scale of testing would it take for us to get a really good sense of how widespread it is? How many people would we need to test?

Cyrus Shahpar: Yeah, we should have massive testing in place. You know, throughout the country in the United States you see successes in places like South Korea that have had massive testing because it informs things like you know, what the burden is in a community. Being able to know who's safe to go outside. We still don't, I'd say have 100% answer on whether or not you can get re-infected, which is a huge problem. We need to learn more about that too. If you can. Then that has implications for vaccine development. We don't have a reason to believe. I would say that that you can get re-infected we know SARS did confer, you know, a year to two of immunity and MERS more than that two other Corona viruses. But we have heard reports that, you know, people who tested positive, then were fine and then now negative and then positive again. So we need to dig a little bit deeper in that. But we really need massive testing before we, we're saying we let we turn the faucet on again and let people go out into society and kind of relax some of the physical distancing measures. We really need to have massive testing available.

Gideon Lichfield: Right. But to get an idea of how many people are really infected you probably could, am I right? You could just test a few thousand people? It'd be like taking an opinion poll, to get just enough.

Cyrus Shahpar: Yea you could if you wanted to estimate, say the proportion of people that you know have had an infection. You could do that. But if you want to inform people you know who work in a school or work in a nursing home and let them know, Hey, you shouldn't go to work, you might be younger, you might feel fine, but you're going to go interact with people that are highly vulnerable to make those decisions. We need to have testing available.

Gideon Lichfield: Right. So I'm just going to remind the listeners that you can ask, if you're on the Zoom meeting, you can ask a question and there are also other ways. If you're listening on Facebook or YouTube, I'm sorry, on YouTube, if you're listening on YouTube, you can also ask questions in there and we will see them on channel two. Dr. Shahpar, so I'm picking up on that testing question a bit further. What do you think happens? What do you think starts to happen when, I mean, some countries are already doing the serologic testing. Yes. The US is behind again, but what do you think starts to happen when some people are being let out because they've shown that they're immune and some people are still being cooped up. How do we handle that? You know, how do we handle that socially? How do we handle that politically? And are there any experiences that you had maybe with Ebola for instance, on how this, how that was?

Cyrus Shahpar: Yeah. And Ebola, I mean, it was useful to know who had antibodies because they could be put back into the workforce safely. So knowing who's, you know, more protected essentially to be able to do critical functions is important. So that's one of the benefits of having that kind of testing available. I think this is still, you know, coronavirus science is at an unprecedented pace. The number of articles and a lot of them are in preprints, they're not through peer reviews. So we, you know, we see the articles. It doesn't necessarily mean they're all, to the quality of what we would normally consider scientific review, but they're providing lightning speed information. So we need to process all of this to get a better sense of how things might change. So something I might say, I've said been on interviews for the past two months, something I might say today, tomorrow we get a new study that says something else. So it's important to just have that caveat in general for you know, for the interview that, our understanding of Corona virus is evolving every day.

Gideon Lichfield: Yeah. This is one of the things that's really striking is it feels like every day we learn a completely different perspective and the things we knew a week ago are no longer true. Some, a couple of questions from the audience. Someone is asking, can anyone get the virus or some people naturally immune? Do we know of any natural immunity?

Cyrus Shahpar: I haven't seen any natural immunity. I mean, in pandemic modeling, we look at this as a completely novel virus, never been seen before in humans. So there's no natural immunity. I'm not aware of any studies that show that.

Gideon Lichfield: Right. Going back to that sort of uncertainty about numbers. So there is the White House released some projections a day or two ago. Well, they talked about 100,000 to the 240,000 Americans potentially dying. Yeah. And I think one of the things that maybe was lost a little without announcement, was that those projections, as I understand it, assume that the entire country basically goes into lockdown, like China's dialogue now. I don't know if that's, maybe I've misunderstood exactly what the requirements were, but that it was assuming that things are happening that are not happening today.

Cyrus Shahpar: It does assume that within a week those places that haven't implemented measures will do so. But that's not a given. Certainly. And the thing is we say China's style lockdown. There's implementing the measures that we have been doing, especially like in Washington and in California, places like that early on. But then there's things that no matter what we do, we're never going to get to the China's style lockdown. You know, the China situation, Hubei province, more of a one area, and shutting down train, travel. Whereas here, you know, train travel is not a big part of how we move from state to state. The geography is different. We drive a lot. So in terms of having people go out of an area, it's going to be much harder to do that here in the United States even if everything else is in place.

Gideon Lichfield: But also in Hubei or in Wuhan they were not letting people leave their, basically their buildings, the residential compounds, unless, you know, unless they could show that they were like they had to or you know. So there were, those were very tight restrictions even within the city. North is a big issue and so how important is that like how much of a difference do you think it would make New York for instance, would it make a big difference if it shut down the public transport system and didn't let people move around?

Cyrus Shahpar: I think I we need to see, you know, the thing is critical workers are going on the public transport system. Hopefully those systems are being cleaned. I think that that would cripple potentially some of the response efforts. So from what I've seen, this is anecdotal from my physician friends in New York showing me pictures of the subway with them on it and nobody else on it. At the same time, people who can't afford not to work are riding the subways and you know, in certain rush hours and being together and that's a risk. And unfortunately they have to for their livelihood. There's no other solution.

Gideon Lichfield: But we don't, I guess- do we have enough data to know that if you could shut down the public transport, it would make a lot of difference?

Cyrus Shahpar: We don't have enough data to know if it would make a lot of difference.

Gideon Lichfield: Right.

Cyrus Shahpar: We know that, you know, it's one of those things they can't hurt. Obviously it's going to improve a bit, but then you have to weigh a lot of the non-health costs as well of taking that action.

Gideon Lichfield: Right. And in the US what would be the impact of, I mean the fact that it's reaching different States in the US at different times and every state is going to peak at a different time. What would be the consequences if some States clamped down while others have looser restrictions and then the States that clamped down earlier loosen their restrictions while other States are now clamping down. If you have this kind of patchwork approach, does that make it harder to contain or to bring the to flatten the curve?

Cyrus Shahpar: Certainly it means the whole situation for the United States is going to last longer and more people will die that don't have to because you know these, they're very connected, the States, it's not, you can't isolate States. We're not at the point where we're going to stand at the borders of the States and say, you can't come in here. I don't know if we'll ever get there. But the US has kind of a reflection of the world. You have the New York cities, which are kind of like Lombardy, Italy or Wuhan, China. And then you have California, Washington, which potentially hopefully Washington more-so right now look more like the Singapores and South Koreas. But the thing is we need even application of all the interventions in the United States. Otherwise, you know, we're all at risk. It's kind of like health security in general. If one country is risky, then everybody's risky.

Gideon Lichfield: Yeah. So that actually leads me to well a couple of other questions which are about what are - what are the implications for the US and for Europe when this pandemic starts to really take hold in Sub-Saharan Africa for instance or in India because one of the things, I mean there is, so there's a couple of things going on that, one is in a lot of those countries or a lot of the cities, especially in those countries, social distancing isn't really an option. There isn't even sometimes running water for people to wash their hands. The idea of shutting down the economy just is unthinkable and there aren't enough testing kits and there aren't enough medical facilities. Talk to us a little bit about, first of all, how you see it playing out in those countries? And then what does it mean for, for Europe in the US if whilst they are shutting down the pandemic is raging elsewhere?

Cyrus Shahpar: Yeah. Globally. Again, it's like the US situation where there's variability. It means that globally we're not going to be able to say we're free from the virus, you know, if it's, if it's smoldering in other places. And unfortunately it could be that some of the countries that have successfully implemented measures shut off the other countries and unfortunately leave them to, you know, deal with their own situations. We have a program to support Africa specifically. And we know there's going to be a lot of infections in Africa. We know their limitations to take care of sick patients. We know that in some capitals they have 50 ICU beds. That's it. So they're not going to be able to treat the sickest patients. We also know that they have a lot of severe potentially severe reactions to trying to implement the, not what we call non-pharmaceutical interventions to say you can't go to work, you can't go to school.

Cyrus Shahpar: There was violent reactions to that that have happened already. And so what we're doing is trying to inform governments on, no, what is it, what does the public think? We're doing rapid polling and things like that. If you were to do this, what are the repercussions just so they can plan better. But no matter what we do in those areas, we know that there's going to be limits and unfortunately they're going to have a lot of infections. Perhaps one of the only two things that Africa has going forward are one, they deal with infectious disease events all the time. So there are some systems on controlling outbreaks there. And two the age distribution of their populations is much different. Italy has 22% of people over 65 which is the most vulnerable group over 60 sorry. And Africa is around the order of 3-4%. So, potentially they'll have less deaths potentially

Gideon Lichfield: If you have a big outbreak. I mean, if we have very widespread infections in some countries in Africa, let's say, could it be that there virus mutates more because it's spreading further and therefore then new strains are introduced that then can come back to Europe and the US.

Cyrus Shahpar: Potentially, yes. We haven't seen a lot of mutation from what I've seen in this virus, but so far, but certainly everything's on the table, you know, with this virus. We try not to make projections at our organization that are three months out because there's so many things within three months that could go wrong, like a big mutation or it could go right, like we have a therapeutic option that seems to work well. But we know that April in particular is going to be a time of a lot of infections and unfortunately, deaths. And we started, you know, most countries were early in their curve at the end of March. And so, you know, the infection's going to spread. And hopefully the interventions will start to show some effect, flattening or bending the curve however you want to put it.

Gideon Lichfield: Right. Caught a couple of little factual questions here in the chat. Do people with different blood types react differently to the virus? Have we seen any evidence of that?

Cyrus Shahpar: There was a small paper and preprints around people with blood type A versus O and one being more susceptible. I think we're going to look at, we have a weekly science review at our organization. If anybody's interested, you can go to our website and we kind of summarize the science and take, tackle some questions that everybody's asking. This is one of them this week, so we'll have a science review on Monday that looks at this. But there was a small evidence of that. And ultimately, to be honest, it doesn't mean that if you know your blood type, you're going to do something different. So practically it's not, useful necessarily, but there was a small paper that did show some evidence of that.

Gideon Lichfield: Right. That's leads me onto another question, which is you like us, like everybody is deluged with information. How, what do you do to manage your information diet and not get swamped?

Cyrus Shahpar: Yeah, I mean it's, it is getting more and more swamped. Aside from hiring more scientists, which we're doing and have done to build out our team. I think it's also, you know, finding the information on COVID that's reliable is challenging. We, you know, when you're in medical school or already, you know, scientists, you learn to go to pub med, for example, you know, a library resource to look for articles. This is not the way you're going to find out information on COVID. You will find things from things even journals can answer these kinds of things. But a lot of it is in preprints there's over 650 articles I think today on. So how do you sift through and try to, you have to have a good eye for judging, you know, the quality of kind of a hypothesis and how they answered the question. And then going honestly to Twitter and following people to follow this and what studies are they highlighting? And just being more and following media articles and interviews with people. It's more of a broad effort to keep on track of the latest science related to covid.

Gideon Lichfield: Right. Another audience question. I know this is something that gets discussed a lot. Do we have any evidence that cases will decline when the weather gets warmer?

Cyrus Shahpar: I'd say there is evidence that you know, that flu viruses prefers certain climates. And that, has happened, you know, in the summer, we don't know this is a Corona virus. We don't know. I think most experts will say that it could decline but it won't be significant enough to change the course of what we're dealing with. So nobody is planning around that. I think in the response people are basically, you know, if it happens, that's great, but we have no strong evidence to suggest that will happen. So honestly it's not a part of the ongoing discussions you know, on a daily basis.

Gideon Lichfield: Right. I've got another question from someone who I'm guessing works in public health. Who is asking in Africa there’s clearly a massive implications for other global health programs. In other words, when COBID is taking over everything it disrupts the work that other public health organizations are doing on other diseases. So the question they're asking is what do you think, what do you think organizations in that sector should be doing now? What are your, what do you think is the most pressing role for them?

Cyrus Shahpar: Yeah, I mean it's a huge problem. I mean in Ebola, in West Africa, more people died from the consequences of Ebola, then actually from Ebola. Missing routine health appointments, missing vaccinations, all of this stuff was more from a health standpoint and also I think when asked those 18 billion of $53 billion in costs was non-Ebola cases. So it's a huge problem. And you know, I think a lot of the people running these programs in countries and also people who support these programs are looking at how they can pivot their programs to supporting COVID, which is the topic of right now. And the urgency right now and has the attention of all the ministries of health, but also perhaps, you know, make sure they don't, they don't completely, you know, look toward COVID without remembering that they have significant burden from other types of diseases, you know, TB, malaria, HIV, these things. How can we kind of find the synergies so that we strengthen COVID response but also make sure we're not ignoring the things that kill people today. That's a challenge. And it really depends on what the disease is, what the program looks like. You know, can we use lab capacity? We built a BSL 3 lab for TB. Can we use it to test COVID? These kinds of synergies to help support both, I think are important.

Gideon Lichfield: Right. Couple of other questions I'm getting, I think are, I mean I'll ask them, I'll ask you them, but they're also, I think suggestive of the level of just uncertainty that people have about this, despite the fact that there is lots and lots of information out there. Fairly reliable information. So here's one question. An MIT study, I haven't actually seen the study an MIT study apparently suggested that two meters isn't, or six feet isn't a sufficient distance for social distancing. Other, have you seen anything around that, around suggesting the virus can travel further? Or is this about, you know, identifying a reasonable limit that reduces the risk by a reasonable amount?

Cyrus Shahpar: Yeah, I mean, I think it's a reasonable limit with the assumption that the majority of transmission is respiratory droplet. And that's the breeding zone we typically have. Now if it's windy outside or if you're projectile coughing or these kinds of things, then you don't want to be within, you know, farther than two meters close to somebody. There was a study looking at a choir that recently showed an outbreak in a choir where it's suggested that there was airborne transmission because they were meticulous about the way they interacted, even though they met. And there are studies that show, for instance, loud singing causes airborne particles to be developed or loud voice. So that's study actually suggested that there was airborne transmission in that setting. But overall, so it's possible, you know, there's a spectrum of droplets that's up to smaller droplets to aerosolize particles. It's not just on or off. And medical procedures also create aerosolized particles as well as you saw, there was a new England journal article showing the aerosolized particles can last I think for four hours they suggested. So it really depends on the setting, but the majority, the typical you know, distance, you know, in a normal setting, absence of them shouting very loudly, two meters seems reasonable.

Gideon Lichfield: Right, okay. But no going there, people who sing loudly. So how do you think about, well, how do you advise people to think about the level of risk? Because it's, you know, you could, you could take an infinity of precautions to eliminate the last possible risk. And you know, I, and my friends we discuss, are you washing all of the boxes that you bring home from the store? Do you take your clothes off when you come in and leave them by the door? Or do you, you know, and so there are so many precautions that you could decide, well not decide to take. How do, how do you advise that people think about the way to manage that?

Cyrus Shahpar: Okay. Yeah. I mean, it kind of depends on what they're doing. If they're healthcare workers, if they're not, what their risk exposure is, you know, are they going outside every day for some reason other than going for a walk? Are they trying, you know, do they have some, are they essential for some reason and have to interact with society. The more you're exposing yourself to potential, you know, transmission, the more you should take precautions. Like, yeah, taking, I know healthcare workers who take off their clothes before they go in their house, you know, and make sure everything's clean, wipe down their car, wipe down their stethoscope, wipe down everything because they have a higher risk. I think, you know, with the boxes that's come up a lot in terms of, you know, Amazon boxes and things. I mean, the new England journal article showed that it's 24 hours on cardboard, but if the guy who delivered it isn't gloved or maybe it was wearing gloves but touching everything anyway you know, the, the risk is there.

Cyrus Shahpar: But is it, is that a reasonable risk to be concerned about? I would say most people would say no, not right now. I mean, you could just have a good practice where, you know, you pick up the box, you open it, then you wash your hands after, before you touch everything else and you know, after you've disposed of the box, that kind of thing is just a good practice. But the risk is very low compared to say going out in society, touching the elevator button, you're going to a crowded market, these kinds of things. So yeah, it's a spectrum.

Gideon Lichfield: A couple more audience questions. This is you know, I guess this is the question how, when do you think the pandemic will end? Are we talking about months, a year, a year and a half?

Cyrus Shahpar: It will end when we have a vaccine if it works. So most people will say 12 to 18 months for a vaccine. But that doesn't mean we can't have somewhat of a normal return to kind of the way we were was maybe with some modifications, essentially it new normal earlier than that. And a lot of that timeline depends on, you know, how we are about shutting down right now, how we are about getting ready during the shutdown. And this is on the, this is on the government. This is on healthcare systems to prepare public health to get ready to test aggressively and trace contacts aggressively. Do we do that over the next month or two while everybody's hiding inside? So that when we open things, it doesn't, there's not a big resurgence. That's a big thing. And then certain things, therapeutics in terms of medicines, are they effective? Are they not? We'll have some information on that. Hopefully, you know, this month, as soon as this month in terms of more robust evidence right now, unfortunately there's being decisions being made or magic bullets being described that aren't based on robust evidence for therapeutics and we shouldn't be rushing to hydroxy chloroquine when, you know, it's based on 150 patients.

Gideon Lichfield: Right, right. A lot of people are talking about the kinds of measures that they were taking early on in China and South Korea and Singapore, whether they're using both very thorough case tracking. So monitoring, you know, finding people who've been exposed and then tracking all of their contacts and also they just, you know, surveillance, monitoring people's movements through the cell phones or through an app requiring them to give up the location, history, in order to be allowed into certain places. So obviously there are lots of civil liberties questions, but do you think that that is something that would help, that we should be adopting in the US and how do you think we would handle the civil liberties problems of giving up that data?

Cyrus Shahpar: Yeah, I think there's certainly there's things that are being done in other countries we will never probably do here because they're just too invasive in terms of privacy and people not wanting to opt into that kind of thing. And I don't think we are in a position to mandate that. I don't know. Things change all the time with this response. It could happen, but I think there's things that we can do with the la, you know, with the apps and other devices to improve the contact tracing we have, we don't even have the basics in the United States to be able to contact trace like we need to. China contact traced over 700,000 people, and in Wuhan they had a team of 9,000 people ready to contact trace. If you go to your local state and health department now contact tracing is maybe a five page form and I go to the house because, you know, I'm only usually tracking 10 10 cases, right? But when we, when we open society again and people, when we open the faucet and people go out there, we're going to need to track thousands of cases. So that needs to be an electronic solution. So this is one of the most critical things we need to be doing over the next couple of weeks. How are we going to empower in the United States state and local health departments to be able to contact trace at scale? Otherwise we can't reopen things because we're not going to be able to drive down the cases. And when they come back we're going to get overwhelmed again.

Gideon Lichfield: So why was China set up to do this? Did they have thousands of people just sitting around and health departments ready to do contact tracing or was it?

Cyrus Shahpar: I mean, I used to work with them on global response and you know we traded a U S global rapid response team after Ebola, which I led at the end. And when we're coordinating with our China Chinese colleagues, I'd say, how many, how many rapid response teams do you have? And they'd say 10,000. And it was just a totally different scale of being able to mobilize the workforce. It's like kind of like the hospital as a tangible example, build a hospital in a week. You know we don't do that here, but they're able to do that.

Gideon Lichfield: Because those people are already healthcare workers or they simply mobilize people from wherever and train them to do it?

Cyrus Shahpar: I mean, part of it is that they have more control over, you know, the workers, the government you know, there's, they have a bigger public sector I would say, to be able to mobilize from.

Gideon Lichfield: Okay. So what would it, yeah, I mean, do you see any evidence that the US is starting to think about how to do this electronically?

Cyrus Shahpar: We've been a part of those discussions I think, and we've been advocating for it. I think the problem is, you know, everywhere you go, whether it's counties or States or the US government, they're all it's, we call it the fog of war. There's so much information. They're focused on now they're focused on the 200,000 deaths. They're focused on, you know, right now and they're not thinking about when we turn things off, what we need to have in place. So that's what we're focusing on and trying to focus the discussion there because these tools exist in other places. We need to come up with a solution. We need to come up with a workforce to implement that solution. That means expanding the workforce. It doesn't take, you don't have to have to be a PhD epidemiologist to contact trace, you just need to have a workforce, that knows how to use the app and follow up with things. So where is this coming from? How are we going to build it rapidly over in April essentially? These are all questions that I think needs to be answered.

Gideon Lichfield: Who in the US government is currently responsible for them?

Cyrus Shahpar: The what government is, sorry?

Gideon Lichfield: Who in the US government is currently responsible for those questions?

Cyrus Shahpar: No it's a mix of things. US CDC is usually the technical agency that puts out guidance. So they could put out guidance that says, you know, when you contact trace, this is the information you collect, how often who you collected from. And then you know, state and local health departments are usually the implementers. They figure out how to do it. The problem is state local health departments don't have the resources to develop an app. And there is some benefit to having say, you know, one single platform that can share data rather than having different platforms. So I think this is a challenge that this is the kind of thing, the detail that needs to be sorted out. And then in the app itself, I think we start with the basics of whatever we used to do on the paper. We just make electronic that'll help a lot. And then we can think about things like, do we want to use Bluetooth proximity to figure out, well who was I near that day? Who does my phone know? The other phone that I was near, can we anonymize that? So if I test positive that the people that were near me get a message or even going beyond that would be location-based kind of contact tracing so that if I was near an elevator button and I got infected later and then somehow five other people came later in the day and they all got infected, then maybe we could have an idea that that that place is not, there's something going on there. We could investigate that. So there's, that's an advanced kind of approach.

Gideon Lichfield: How do you, and so this fog of war that you described, you know, everybody overwhelmed with information. Do you think that that is because the US is such a decentralized system, such a federal system or would it be solved if there were just like stronger, a stronger agency, you know, more resources in the CDC to have created the groundwork for this.

Cyrus Shahpar: I think everybody's in the fog of war, like, you know, in the world, essentially most national governments, because this is on premise unprecedented and it hasn't happened in over a hundred years to this scale. Nobody was thinking that when we heard about 24 and they probably didn't hear about it. 24 is serious pneumonia cases and Wuhan on December 31st. Okay, here we are, April 1st you know, three months later and the world is shut down. It's not on the, it's not on the realm of possibility for most people. So it's overwhelming and people are more reactive than proactive I think because it's, we don't know. And there's a lot we don't know and we've practiced for things, but we've never seen it. So now it's about applying all the things we've practiced. And soI think the fog of war is an understandable situation that almost everybody is in.

Gideon Lichfield: Right. And then another question that's come in are once you've had it once, if you've had coronavirus and if you know that you've had it, because obviously part of the problem is a lot of people suspect they've had it cause they had the symptoms that they got. They never got tested because they didn't have to go to hospital, so they can't be sure. But let's say that you were tested and you are sure.

Cyrus Shahpar: Yeah.

Gideon Lichfield: People asking, okay, can I go out into the community now? Can I go and like work in a hospital helping people am I safe to circulate? Am I putting other people at risk?

Cyrus Shahpar: Yeah. So we hope so. We don't have evidence, but some places are giving certificates out, some countries that if you've had it and then you test negative, but you have, you know, and you've had the sufficient time to develop immunity and antibodies that you can go out safely. You know, and as I said, other coronaviruses in the past we've seen this immunity, we just don't know how long it lasts here. We don't know. We have to sort out this, these reports we're hearing about people getting re-infected. But the assumption is that there is immunity and you would be safer in that setting if you've already had it and you know, recovered and then going out into the community.

Gideon Lichfield: Right. I have a question from somebody in Sweden. Saying here our leaders are generally quarantining people over 65 and people who have other diseases whilst keeping society going. And there's a strong emphasis on personal responsibility for social distancing. Could the world learn from Sweden?

Cyrus Shahpar: I think Sweden is a great case study and natural one because of the decision to take the approach that they did and you know, we can look to Sweden, maybe if we want to control for weather and different things. We could look to Sweden in comparison to Finland and Norway and see what their growth curves look like. The last time I looked at this a couple of days ago, it looked like Sweden was relative, It wasn't performing as well as some of those other places, I think ultimately because there's so much we don't know about how it's transmitted, we have less control over. Even if I'm a good citizen, it doesn't mean that I can control whether or not I get infected if I don't know how it's transmitted or people aren't even symptomatic and they transmit it. So ultimately if that's the case, if there's asymptomatic transmission and, but the type of approach that Sweden has may not be enough to be honest. Right. That eventually they'll migrate toward the, there's a lot we don't know so we all just need to stay inside right now kind of approach.

Gideon Lichfield: I mean, there was this famous study for Imperial College a couple of weeks ago where they model different ways of dealing with the epidemic and they said you, even if you socially distance older people than people with weak immune systems and so forth, that still doesn't take care of the pandemic. It will still flat. Yeah.

Cyrus Shahpar: Yeah.

Gideon Lichfield: I don't know. Maybe that might have been possible in the, if it was in the really, really early stages, I don't know. But, but the point is we don't know how, since we don't know how widespread it is in the population, we can't actually tell if those measures work.

Cyrus Shahpar: Yeah. I mean, and right now, you know, the world, I think in general, Europe, United States, other places is saying stay inside. And as I said, we all, this is the time when we learn more about it. We get ready to, when we release things, we build up the healthcare system. We have massive testing. We do the contact tracing at scale so that it's a different place when we release the virus again. You know what I mean? Like when people are out- not release the virus, but when people are out and there's more mixing, more potential for spread of infection, we'll be more ready And know more about it.

Gideon Lichfield: Right. Do you think that in principle, if we did all of those things right, it would be possible after this initial phase of lock down, the first three months, or so to return to some kind of semblance of normality without having to go into lockdown again in say the fall?

Cyrus Shahpar: It's a good question. I think what we're preparing for is, yeah, multiple phase of lockdown again, and these need to be data-driven. They can't just be you know, we need to have indicators for each of those things and we've actually come up with the indicators and release them today in terms of the epi information that needs to happen, that you need to monitor, the indicators for when to lock down when they're not locked down, what you lock down. Because when you release things, you release them in phases, meaning you know, that you might say let daycares open first schools, maybe to let people go back to work before you allow people to visit nursing homes. You know, that's later on, much later because there's vulnerable people there. So it's more of a phased approach. Whereas the tightening or reinstitution of the lockdown, it's more of a let's shut it down. You know, again, because we're seeing cases rise, we're seeing contacts that we don't have any link for, you know, these kinds of indicators we need to control it and reduce the pig. So we're just going to implement everything.

Gideon Lichfield: Right. And what sorts of indicators are those? What sorts of things are you, will you be watching to what needs to be shut down and what can be opened?

Cyrus Shahpar: Yeah, so he's talking about when we lose said, well they're in three categories. One is the epidemiologic information, you know, the case, the trends in cases and deaths, what we know about the cases in terms of source of transmission. Do we know? And this all assumes we have robust testing so it's not an artifact of testing. Right? And then in healthcare, does the healthcare system have capacity? If we had double the cases are more people leaving, then are coming into the system. All of these things are different indicators we could use, we could use to determine whether or not the healthcare system is prepared. And then in public health, this is about, can we follow up on cases? All of them? Interview them for the context. Can we test 100% of symptomatic contacts or close to it? To be able to rapidly isolate them so they, so they're not in the population because we know that unlike SARS this Corona virus, there seems to be more, the infectious period seems to be earlier in the course of illness and even up to a few days before you're symptomatic. So the early identification of cases is extremely important. In this case, SARS was more of a, the longer you had it, the more infectious you were kind of situation. So, it's about the epi, the healthcare preparedness and then a public health capacity to find and isolate cases. Those, those are kind of the big buckets of information.

Gideon Lichfield: Right. The first of those, you really do need the massive testing that you were talking about.

Cyrus Shahpar: Yeah.

Cyrus Shahpar: And you can see South Korea has massive testing and they're probably, you know, with Singapore, one of the best performing places because they know who has it. Right now, we don't know in the United States who has it. Right. You might have had a cough. I might've had a cough a few weeks ago. Do I have it? I have no idea. Right.

Gideon Lichfield: But even in South Korea, I think they've only tested a pretty small proportion of the total population, right?

Cyrus Shahpar: Yeah, I mean, but they've tested around the, you know, there was a church incident. They've tested even asymptomatic people that were in contact with them and found some of them to be positive even though they didn't even know it. But yeah, it's on the order of a few hundred thousand tests I think.

Gideon Lichfield: Right. So here you're saying we need to be testing millions of people.

Cyrus Shahpar: Yes. We need to be testing millions of people.

Gideon Lichfield: All right. We are running sort of time. So one last question. I think about Bolivia, which is in full quarantine, but I think it's a question about poorer countries in general. So for a country like Bolivia that probably doesn't have the capacity to build this kind of contact tracing and all this infrastructure how would, how would a country like that return to some sort of normalcy after the quarantine if it doesn't have the testing capability and it doesn't have the contact tracing and all of that stuff?

Cyrus Shahpar: Yeah, it's a difficult question. I don't have a great answer. I mean, this is a humanity versus virus issue. It's not Bolivia, United States, you know, China alone. If you mentioned earlier, well, what if the other countries are having it and we've done a, you know, the United States or Europe has done a good job. This is all of humanity needs to come together. So this is where Bolivia needs to get support fro, maybe those who have learned some lessons and those who have more resources to be able to help control it in the country. So that's one of the things that I think needs to happen because without proper testing, again, then we're in the situation we're in now. You just don't know. And unfortunately that means you're going to let some of your population have preventable illness and death, which is just not acceptable, you know, so.

Gideon Lichfield: Yup. And I actually have one more question and then we'll wrap up, which is we've seen the FDAI think, well let's, sorry, there's a lot of discussion about relaxing regulations and approval processes so that treatments or the vaccine can get fast tracked or can get tested quickly. You know, the FDA did approvethe distribution of these drugs, hydroxychloroquine, which on ..., But it's, it's, it's approved that use, on patients with severe cases. So what do you think of rule of this idea that there's too much regulation standing in the way of approvals of things that might become treatments?

Cyrus Shahpar: I mean, I think we're, as I said, unprecedented situation, so the removal of some of those regulations could be helpful to get things to be able to test them, to get them to market, that kind of thing. I think chloroquine is different in the sense that, you know, it's not a novel drug, we've used it in malaria for a long time. So we know the safety profile, so to say, it's okay to use that now for this. Okay, that's fine. But if it's a novel drug, we might have to, you know, we don't want to necessarily rush to market and say, everybody can use this because we don't know the safety profile. So it's a balance. But I do think because this is unprecedented and everybody wants to find a therapeutic as soon as possible, we will you know, essentially fast track things as much as possible.

Gideon Lichfield: All right, well thank you Dr. Cyrus Shahpar from Resolve to Save Lives. Thank you so much for taking the time to join us.

Cyrus Shahpar: Sure thanks for having me.

Gideon Lichfield: Thank you all for listening.