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July 26, 2022
America Dissected
Presidential COVID with Dr. Megan Ranney

In This Episode

The president of the United States has COVID. Again. Abdul reflects on what this signals in the pandemic–and our politics. Then he sits down with Dr. Megan Ranney, Emergency Medicine physician and Academic Dean of Public Health at Brown University.






[sponsor note]


Dr. Abdul El-Sayed, narrating: President Biden tested positive for COVID-19 on Thursday. He’s experiencing mild symptoms and is expected to make a full recovery, but BA.5 is rampaging across the United States, raising COVID rates higher than at any point except for the first Omicron week. Over the weekend, the WHO declared monkeypox a public health emergency of international concern. And public health officials in New York confirmed the first case of polio in the U.S. for over a decade. Finally, a new analysis by Stat News showed that the CEOs of the top 300 health care companies made a total of $4.5 billion in 2021. This is America Dissected. I’m your host, Dr. Abdul El-Sayed. The President of the United States has COVID, again. Last time it happened, it was Donald Trump in 2020. His case got so bad he had to be airlifted to Walter Reed Medical Center where he was almost intubated. But being treated at a state-of-the-art medical center with medications almost no one else in America had access to at the time didn’t stop him from cosplaying a dictator and defiantly ripping his mask off from the balcony of the White House, even as he was still struggling to breathe. This, of course, after failing to disclose that he knowingly exposed dozens of people, including his erstwhile opponent, at a televised debate. It’s been nearly two years since that point, and we’ve come a long, long way on the pandemic. We understand a lot more about the virus, about how it spreads and how to prevent it from doing that. We have multiple safe and effective vaccines that are authorized for people of all ages. We have Paxlovid, an effective oral antiviral therapy which has pulverized the hospitalization rate. And yet we still haven’t really gotten over the politics of that moment. Today, only 68% of Americans are fully vaccinated, just more than two thirds. Only 32%–less than a third–are boosted. And by far, the biggest single predictor of vaccination status, is political ideology. Rather than bring us together, COVID and the shameless, cynical politicization of it by people in power in 2020, seems to have torn the holes in our social fabric even deeper. On Thursday, for the second time, an American president was diagnosed with COVID. President Biden had experienced un-restful sleep the night before, and tested positive on a routine rapid test, which he takes every other day. So far, he’s experienced only mild symptoms, thankfully. This was President Biden in a message on Twitter from his isolation in the residence of the White House.


[clip of President Biden] Hey, folks, guess you heard. This morning I tested positive for COVID. I’ve been double vaccinated, double boosted, symptoms are mild, and I really appreciate your ince–your concerns. But I’m doing well, getting a lot of work done. I’m going to continue to get it done. And in the meantime, thanks for your concern, and keep the faith. It’s going to be okay.


Dr. Abdul El-Sayed, narrating: The president is 79, an age where COVID can be particularly dangerous, but he’s also been vaccinated four times, and is being treated on Paxlovid. I expect that he’s going to make a full, uneventful recovery. But it’s also worth noting how the White House is dealing with this diagnosis. They’ve been forthcoming and transparent the entire time. The President began isolating immediately upon testing positive, and they’ve kept the public abreast of his course. But a presidential diagnosis of COVID should force us to take pause. Right now, BA.5 is reigniting the U.S. in COVID cases. Cases are up nearly 20% over the past two weeks, and COVID deaths are up more than a third. And we’re flying blind. Most municipalities have decommissioned their PCR testing facilities, and most of the rapid tests people are taking, go unreported. Worse, we’re careening into the fall, when cases have historically increased rapidly. And while vaccine manufacturers are testing and rolling out updated versions of the vaccine to catch up with the variants currently spreading, it’s possible that our government won’t have the money to buy them. Well, it’s not that they won’t have the money, it’s that they won’t have the political will. Congress has yet to authorize the COVID funding we need to update our vaccine armament, and buy the tests and treatments will inevitably need for the fall. I hope Biden’s diagnosis will force a change of heart on this, but I worry that instead it’ll entrench congressional Republicans who’ve been sandbagging the deal, giving them a fresh political opportunity to turn Biden’s diagnosis into an opportunity to attack the president rather than unite the country. COVID is not, and has never been, over. Even if there weren’t this major BA.5 surge, millions of people living with immunocompromization are still at serious risk of deadly infection. Millions more are living with the consequences of long COVID. Today, I wanted to use this opportunity to check in on the pandemic, so I invited Dr. Megan Ranney, an emergency doctor and Academic Dean of Public Health at Brown University. She’s been one of the most steady, most thoughtful commentators on the pandemic, and she joined me for a conversation about the President’s diagnosis, the course of the pandemic, and where we go from here. Here’s my conversation with Dr. Megan Ranney.


Dr. Abdul El-Sayed: All right. Can you introduce yourself for the tape?


Dr. Megan Ranney: My name is Meghan Ranney. I am a practicing emergency physician and Academic Dean of the School of Public Health at Brown University, in Providence, Rhode Island.


Dr. Abdul El-Sayed: Well, Dr. Ranney, we really appreciate you making the time, considering where we are in this sort of odd moment in the pandemic. I want to just jump right in. Let’s talk first about the President’s COVID diagnosis. In some respects, it’s always surprising when the head of state of the most powerful country in the world has a disease that’s killed a million people in his own country, and on the other, there’s kind of a moment where you’re like, okay, well, we all kind of expected that this was going to happen. This pandemic has been raging for a long time, and this is by far the most transmissible, most immune-evasive variant that we’ve seen. What do you make first of the President’s diagnosis?


Dr. Megan Ranney: I concur completely with you, Abdul. This is not a huge surprise. The current surge in cases is both very real and, as you and I both know, very much an undercount. So those official numbers that we’re seeing are an order of magnitude lower than what’s probably really going on beneath the surface. So I think it’s amazing that President Biden has escaped being infected for this long. It’s a testimony to the strictness of the precautions that his team has placed around him with masking and testing. But when you’re out on the road, you’re exposed to folks, and so it’s it’s really not a surprise. The good thing is, is that they held it off for this long. We’ve got vaccines and boosters and treatments, all of which make it a much lower-risk diagnosis for him than it would have been even a few months ago.


Dr. Abdul El-Sayed: So I want you to put on your your physician hat for a moment. You’ve got a 79-year old man, generally quite fit, who’s got an extremely busy schedule–lots of exposure risk–has been quadruple vaccinated and is currently being treated on Paxlovid, seems to be fine. Where do you see this diagnosis going? And then from there, what are the caveats?


Dr. Megan Ranney: So this is the story of almost every emergency department shift that I work right now. I saw a number of patients like this just this very weekend. The fact that he’s quadruple vaccinated and on Paxlovid puts him at tremendously low risk of bad stuff happening. And of course, an important thing for folks to know who are listening is that before we prescribe Paxlovid, we check basic blood tests. We need to make sure that your kidney function is okay. We need to make sure that your liver function is okay. And we need to be sure that you’re not sick enough to need the hospital at the time when we prescribe it. So already by the fact that he’s been prescribed Paxlovid, that means that at the moment that he got it, he was doing well. So you add that quadruple vaccination, which takes down your risk of severe disease and hospitalization significantly, add on to that Paxlovid–which for people who are vaccinated and age 65-plus, lowers your risk of severe disease by another 60 to 80%, depending on the study. We’re now down to an infinitesimal risk of something bad happening to him. That said, you and I have probably both seen patients who are older, do have some underlying health problems– COVID can uncover things that were already there. And so I would keep a very close eye on him, make sure he’s getting rest, make sure he’s staying hydrated. And really, this next week or so is going to be that kind of big period of watching and watchful waiting, and trying to encourage him to take good care of himself.


Dr. Abdul El-Sayed: As you alluded to, you know, this is a unique moment in the pandemic, given that you see patients like President Biden all the time. On the one hand, there was a bit of early hope that vaccines were going to do away with the pandemic entirely. On the other, they’ve rendered the kind of infection that was killing or has killed–still killing–thousands of people into a very annoying and frustrating but altogether beatable illness if–and conditional, very much conditional on–if you have chosen to follow vaccination protocol. What does the President’s current diagnosis tell us about the state of the pandemic, where we are, and how should we be thinking about not just where we’ve come, but where we’re headed?


Dr. Megan Ranney: So I think there are two big takeaways. One is, again, that we are in the midst of a surge. And like you said, for folks who have followed vaccination recommendations–people that have gotten their double vax and their first booster if they’re under age 50, or their double vax and their second booster if they’re over age 50–for most of those folks, the vaccinations and the boosters have taken this down to being a much less serious illness. But there are some exceptions, even among people who have been vaccinated. If you are immunosuppressed, you are still higher risk. And we know that those folks, as well as those who have not followed vaccination recommendations, are the ones who are still largely getting hospitalized, intensive care unit admissions, and unfortunately still dying here in the United States. We have over 400 people per day across the US who continue to die of COVID. You know, I spend a lot of my non-COVID time working on firearm injury, and I think it’s worth pointing out that that’s four times the number of people that die of gunshot wounds every day across the U.S. Firearm injury is absolutely an epidemic. We have to remember that COVID, despite the fact that we all want to pretend it’s gone away, is still killing a lot of folks across the U.S. And it’s because of those two things, people that haven’t followed vaccination recommendations or whose bodies are just not able to fight this off. The sad part to me, Abdul, is how many Americans, despite the widespread availability of vaccines, continue to not be fully up to date with the vaccination regimen. You know, the most recent stats from the CDC say that only around a quarter of those age 65 plus have gotten their two shots and their two boosters, despite the fact that that second booster is so influential in helping to keep people out of the hospital with this newest wave. And so the big takeaway for me here is how important for us, it is for us in public health, but also as a society to continue to work to keep this disease under control, right? So we have it right now at this low level where quote unquote, “only 400 people” are dying a day, but there’s so much more that we have to do as the virus continues to mutate, as we head into towards the fall, where we know that respiratory viruses generally surge. There’s so much more that we have to do to help manage this virus and to keep it at a level where folks can be out and about without fear of catching a lethal illness. The second thing that I want to say, though, about kind of where we’re at with this pandemic is to talk about long COVID–and maybe we can get into this a little later. Vaccination lowers your risk of long COVID, but doesn’t make it zero. Long COVID in of itself is still very much under investigation. But I think it’s worth mentioning as we talk about kind of Biden’s diagnosis and where we’re at in this surge, is that it’s, there’s infection and severe disease from the infection itself. But then there are all sorts of after effects–which we’re still figuring out.


Dr. Abdul El-Sayed: I really appreciate the way that you broke that down because we are not out of the pandemic yet. And unfortunately, so much of the way that policy is being made and talked about and COVID is being messaged is almost having the effect of blinding us to where we still are. A, It is failing to talk about the stories of people who, because of immune status, are still at very high risk of very serious outcomes if they were to contract it. B, it’s the fact that somehow in this country we’ve gotten to the point where we normalize 400 people dying of a disease every single day. That’s, you know, a plane crash, every single day. And then, C, we’re in this place where we are ignoring the long-term implications of the vastness of the experience of having been infected and the degree to which that’s going to have long-lasting implications over the long term. And all of these issues are issues that should force us to contend with how we think about the ongoing pandemic. And yet, we are not collecting the data that we need, we are not talking about the data that we collect, and we’re normalizing everything that comes out of that very broken process. You talk to people out in the community, and–you know, I was just at a couple of events earlier today–and in some respects, this this shows a certain unwillingness of the broader population to actually continue to engage with COVID. And on the other, I think a lot of folks have realized that because of that, it’s an unpopular issue, and have kind of given up on the leadership aspect of being willing to talk about unpopular issues when you lead. If you were a COVID czar for a day–and I actually know your colleague is COVID czar–but if you were COVID czar for a day and you actually had, like the power to be able to actually get people to pay attention, how would you be talking about this, and why?


Dr. Megan Ranney: So I think there are two big things that we need to be talking about today. One is about these social and behavioral aspects of COVID. Of course, we all want to be out and about and doing things the same way that we were three years ago before COVID was our thing, right? I sent my kids to summer camp this year. I’m going on summer vacations. I’m going to restaurants and going to shows. Right? And I think that I, as a public health professional am probably a little bit more cautious than the average American, so if I’m willing to do those things, so is everybody else. We’re not made to stay home forever. We’re made to be social creatures. We have to think about that social and behavioral aspect of how to help keep people safe, knowing that we are social creatures and we want to be out and about, working, having fun, seeing our family, doing all the things that are part of normal life. So that would be the first thing in my messaging, is that I would be thinking about how to make it really easy for people to stay safe, for people to do the things that help protect them with vaccinations and boosters, and to think, start thinking about how to both improve ventilation–which we know is such a big part, passive, easy part of helping to protect folks from COVID as well as other airborne illnesses–and about how to make masking easier when we are in the midst of surges, in crowded indoor locations. That would be the first part of my messaging. The second big thing is what you said around folks just pretending it’s gone. One of the things that worries me most–and I know worries the White House as well–is that not just the general population, but also politicians, want to pretend that COVID has disappeared. And, you know, they’re being forced to make decisions now, like with the limited funds that they have left for COVID response, do they buy PPE to restock our strategic national stockpile so that we never again have to go through that horrible shortage that we had in the spring of 2020? Or do they use the money to buy vaccines and Paxlovid to treat people when we come to the fall surge? And they’re choosing to buy vaccines and treatments, which is probably the right choice for today, but oh, my gosh, that’s shortsighted. And that makes me awfully worried for the winter to come. If we see PPE prices shoot up again, if we see a new variant that causes another level of worldwide infection and death like we had in winter and spring of 2020, I, as an ER doc, could be once again using my N95 for weeks on end, because of that short sightedness of policymakers. And so those two messages, those two things, around working with communities and then around making sure we’ve got funding and have our eye on the ball so that we don’t repeat the same mistakes again, is where I think we most need to be.


[ad break]


Dr. Abdul El-Sayed: There’s also the nature of the virus itself. It has traveled an evolutionary distance as far in the last 3 to 5 months, we estimate, as it did in the first year and a half of its existence. And even with potential new vaccines, you got a Novavax vaccine that is BA.4, BA.5 specific that’s in trials, and then you’ve got the Omicron-specific vaccines that are likely to be what we roll out in the fall, we’re still playing catch up. And that’s assuming we have the money to to buy a whole new armament of vaccines. How should folks be thinking about the long-range evolutionary capacity of the virus?


Dr. Megan Ranney: So I will say two things. One is I am not a virologist. So everything I say about the evolution of the virus, I have learned from others. I’m an emergency physician and I work a lot on health systems and behavior change, but I am not a virologist. The second thing is, is that even for virologist, the crystal ball is broken, right? I think the one thing that we can all say with certainty is that we can’t say what COVID is going to do next. Will it continue to mutate along these same lineages and sub-lineages within Omicron, or is there something else out there brewing, the same way that Omicron was back when we thought the Delta was the most evolutionarily fit variant, right? Nobody thought Omicron was about to emerge, show its head. There’s just no way to know. And so that gets into that second part that I was talking about, that I know that the White House is trying to emphasize, which is the need for funding. What we need more than anything is to continue to fund vaccine development. Looking at more SARS-CoV universal. Vaccines, rather than being targeted at these specific variants and sub-variants. Otherwise, we’re facing a world like flu vaccine where we’re, like you say, we’re constantly playing catch up, we’re behind the 8 ball. Maybe we’ll be lucky. Maybe we won’t. That’s not acceptable for something like COVID with the level of illness, long-term disability and death that it causes. So I would love to see more federal funding for some of these really innovative new vaccines that are currently in Phase 1 and some in Phase 2 trials. It’s a lot, as you and I both know, to, as a scientist, to get this through to the finish line of being FDA-approved and ready to be used on a widespread basis across the population.


Dr. Abdul El-Sayed: Yeah. And to that point, there are two pieces there that I want to pick up on. One is that folks need to understand that the virus is constantly testing new mutations. Constantly. And the ones you hear about are the ones that kind of make it through the virus’s own Phase 1, right? Which is to say, Can I outcompete what’s out there, right? Can this new phase outcompete what’s out there? And then you get a variant that starts to take off. And so you’re getting mutations happening all the time, it’s a random process. And the ones that you hear about are the ones that start infecting a lot of people because they’re that much more fit evolutionarily than what’s out there. And so there’s constantly a competition between all of these different mutations to do exactly what it’s doing, which is become more transmissible and then evade our immune responses. And so the notion that somehow, like Omicron is the end outcome, even though it’s kind of gotten to the point where this is about as transmissible as we have seen in recorded in human history, it doesn’t actually mean that you don’t, it is not possible to be more transmissible. Yet, and as our own immune status as a population consistently changes as a function of being infected and re-infected, the evolutionary pressure against the virus will change too. And so it may be that, you know, these Omicron mutations wear out their usefulness because enough people get enough immune function to them that you then have a different, a whole different class of variants. And that is a really worrisome thing. The other question here, and to your point, Megan, is that we do need a sort of silver-bullet version of the vaccine. I worry quite a bit about whether or not there’s an economic incentive for any corporation to actually get there. If you’re a corporation, you want to sell units, and you sell more units when people need upgraded units. And so there’s almost a, there’s an implicit obsolescence issue here, where the obsolescence of a version of the vaccine implies that you’re always going to be needed to make more vaccine. And it is really concerning, actually, early on watching Pfizer’s CEO keep going on to Twitter to talk about how we’re going to need yet more of his product, which, you know, and again, I say this as someone who is fully-vaccinated, who believes deeply in the vaccine, but also someone who recognizes that the people from whom we are wedded to buying these vaccines sometimes have ulterior motives. And, you know, I’m wondering how you think about how we deal with that implicit tension around, you know, the need for a universal vaccine that is not in the best interest of the corporations who sell obsolescent versions of the vaccine.


Dr. Megan Ranney: Right. I mean, I think vaccine development in general is not a winning commercial proposition. Right? It’s one of the reasons why mRNA vaccines never got into consumers hands. It’s not because the technology didn’t work. It was because no one ever funded bringing an mRNA-based vaccine to market, because it was really expensive. We spent a lot of money in Operation Warp Speed to make that happen. And it was that off-the-shelf technology, it had already been developed to a pretty high level and just had never kind of gotten over that finish line. Same thing is true for work that’s being done on malaria vaccines on, you know–name the kind of disease that affects the global south–and so many of them could have effective vaccines, but there’s just no commercial incentive for investment. So I think it’s a really real question. And, you know, the other side part of it is, is that we only have to look at some of the myths and disinformation around vaccines right now to see that not just the lack of kind of commercial benefit to companies from developing these vaccines, but also the potential risk from things that may not actually be fact-based allegations against vaccine companies, but are still there. So there’s a disincentive as well. I am a big believer in the idea that public health should be something that is handled not through a profit motive. It is very difficult to prevent disease if you require making money off of it. So to me, this is something that NIH takes on, is creating these types of vaccines, and Medicare and Medicaid and insurance companies, as they currently do, pay for the vaccines, and it becomes something that is a public good rather than as a profitable enterprise. But I also know that here in the U.S., the profit motive can drive a lot of good sometimes. And we did see aspects of that during the COVID, during kind of the worst of the COVID pandemic. So, but long term, we got to grapple with that. I will highlight the work of like Peter Hotez down in Texas, right, who’s not maintaining a patent for his vaccines as a really interesting and benevolent way to handle this dilemma, but also an unusual way. It’s not common practice.


Dr. Abdul El-Sayed: Now, I really appreciate you bringing up Dr. Hotez as an example of, you know, what this ought to be. But, you know, and the challenge that you name, you know, particularly around something like malaria, where we’re not that far away technologically from being able to do this, it’s just that a corporation can’t identify a paying set of customers. It’s not that there aren’t customers, it’s that they don’t have much money to pay. And so it’s an important point. I want to move to the question of what is our responsibility to folks whose immune status keep them in a circumstance where the very existence of this level of spread precludes any of the kind of back to normal that you named that you’re partaking in and I’m partaking in, that we can take for granted our immune status and our ability to fight off even this variant with the combination of having been vaccinated, and in my case, having been infected–I don’t know about your.


Dr. Megan Ranney: Knock on wood, not yet.


Dr. Abdul El-Sayed: You’re like one of the, you one of the last people standing here.


Dr. Megan Ranney: I blame it on all of my ER–you know, there have been recent studies showing that people that got exposed to a lot of coronaviruses, pre SARS-CoV-2, may have some sort of innate immunity. I blame it on all of those in our pediatric emergency department, taking care of–


Dr. Abdul El-Sayed: You credit, you credit all of those shifts.


Dr. Megan Ranney: Yeah, exactly.


Dr. Abdul El-Sayed: So how do we as a society think about our responsibility to a group of people who have extreme risk that outstrips where most folks are headed?


Dr. Megan Ranney: I think this is one of the most difficult questions that we have to grapple with. You know, I frequently say when I’m talking about equity in health care, health systems, and just in the idea of whole-body health, that every one of us is going to have a disability at some, at some time in our life, right? That’s just, that is the reality. And yet we pay so little attention to making sure that we are taking care of those who are currently living with disabilities, despite the fact that we’re going to be one of them someday if we aren’t already! And immunosuppression is one of those, right? It’s not just people with unique disorders, it’s also people that are on medications that suppress their immune system because they’ve got rheumatoid arthritis or other diseases that require immune-suppressing drugs, or because they’re cancer patients and undergoing chemo. Right? There’s a gazillion reasons that folks are living with immunosuppression. I think there are some lovely things like EvuSheld, which is not adequately promoted or used among people living with immunosuppression, that can be quite helpful in preventing the worst of this disease. And I think there are treatments such as some of the newer monoclonal antibodies, right? We have the one remaining one that works, but there are other ones under investigation, which can be helpful for folks with immunosuppression to avoid the worst effects should they happen to catch it. But I think we have to be, I would love to see a society that cares more about taking care of those who are living with chronic illnesses and disabilities. I also think I need to be honest, which is that it’s not the society that we live in, so that the safest and most lovely thing for us to do would be to try to stop the spread of this disease, for us to mask when we’re in the midst of a surge, not just for our own sake, but for the sake of those around us. But you and I both know that’s not that’s, not the world that we can live in. So I can talk Pollyanna-ish about where I wish we were for the sake of, to allow folks to be out and about, and I think we should talk about that as an ideal state in the midst of surges. We can also work hard to try to–right, it’s the whole equality versus equity debate–to try to create systems that allow those who are immunosuppressed to get back towards normal, with CoviShield and monoclonal antibodies being part of that.


Dr. Abdul El-Sayed: Yeah, I appreciate you’re more pragmatic point, and then also the ideals that we have to continue to speak into existence. I mean, we live in a society where we don’t even guarantee everyone access to health care in a world where literally 70% of us are, more and more, are born in hospitals and most of us will also die in hospitals–the notion that that, you know, people think that somehow if this is not a right, not a not a requirement of living in a in the richest, most powerful country in the world, that we can’t even establish that as part of our baseline, you know, it speaks to the certain strain of individualism that I think has flummoxed our ability to handle this this pandemic before it ever happened. I want to talk about two other epidemics, one related and one new. Long COVID is going to emerge as I think the long tail and could, you know, in the long term actually account for more disability overall than acute COVID did. And, you know, this is not a new situation. Almost every infectious ailment has a chronic version, right. Whether you’re talking about, you know, chronic chickenpox that sits dormant until it comes out in the form of shingles. You think about polio and chronic polio, and the ways that it can take your abilities and then ultimately take your life. You think about, you know, chronic staph infection. You think about all of these sort of diseases that have this chronic outcome, and we sort of ignored that because the acute outcome of COVID was so profound. It’s the worst single pandemic we’ve dealt with as a globe. What are the things that we need to be doing right now to prepare for the broader consequences of long COVID?


Dr. Megan Ranney: So the first and biggest thing is to define it. Data on long COVID right now is really poor quality from a scientific standpoint. So, you know, the ranges of estimates of how many folks who have COVID or are going to develop long COVID, it ranges from like 2% to 70%. The truth is probably somewhere in between those, but we don’t know. We don’t yet know exactly what causes it. The examples that you gave are of latent virus that stay in your body and then kind of emerge in periods of stress or immunosuppression or other illnesses. There are other theories that it’s around kind of changes in some of the kind of function of your body, around kind of micro circulatory clots, or around autoimmune dysfunction that are caused by the virus, but the virus itself doesn’t stick around. That’s a really important thing for us to understand so that we can develop treatments. We need to know who is at most risk in order to be able to prevent it and to treat it. So there’s that first really basic thing. And then the second part is, is that we need to prepare as a society. You know, if you look at chronic fatigue syndrome from Mono, some of the post-flu syndromes that emerged after the Spanish flu, we’re going to have to start thinking now to your point about how we will handle stuff that emerges, either that sticks around or that emerges months to years after an infection. And, you know, here at Brown, at the School of Public Health, we do have our long COVID initiative that is not doing that basic science research as much as thinking about the societal implications. And I will tell you that employers and government agencies are thinking hard about how they are going to handle what they expect to see as a rising number of disability claims, how to make appropriate accommodations for folks that are living with long COVID, and how to kind of prepare our insurance systems appropriately to be able to deal with long-term consequences. There are no answers yet. It is very much an area of important inquiry, and it’s an area for us as public health professionals, as citizens, to be aware of and involved in. Because we can help to shape the course of what happens next.


Dr. Abdul El-Sayed: I want to pick up on that point because I think your point about what happens next is really quite critical. And we already see this coming, we already are dealing with the acute consequences. And my fear is that for the most heinous political reasons, you have a few policymakers who are blocking funding for acute COVID right now in the middle of the acute crisis. And I worry about whether or not there will be the political will to fund the long-term consequences. On the one hand, you could see the present circumstances continue. On the other, we did see this major about-face on funding for mental health among that same group of people, because mental illness started to literally take life expectancy away in the communities that they represent. And I hope that it won’t have to come to that, right, where you think about the long-range consequences of long COVID, coupled with all of the other diseases of despair, as we’ve termed them, that affect these communities, because it’s not like with COVID, everything else went away. They’re all still there. In fact, they’re all likely a lot worse. And speaking of things that got a lot worse, we are now dealing with a new public health emergency of monkeypox. And you would think, right, the sort of conventional wisdom would be that, we largely failed to contain COVID, but COVID was really a serious containment challenge for a lot of reasons. It was a new ailment that behaved differently than the cousin that we were trying to compare it to, that is extremely transmissible and really quite deadly. Monkeypox is actually 101 when it comes to public health. Right? Because you have this long incubation period. You have effective vaccines, effective treatments, and it was largely contained within a group that we could identify and really get services to. And the importance of that long incubation period is that monkeypox is one of those rare diseases where someone can be technically infected, you can vaccinate them within five, six, ten days, and you can actually prevent them from getting the full outcome, right? And and that gives you a long window. And we had the vaccines! Like, they exist. Unlike COVID, where it took us, I mean, we had we had a marshal the height of scientific capacity to figure out how to manufacture vaccines at scale. This is not that. And yet we are in the situation where a slow-moving epidemic is now a public health emergency. And it tells us a lot about what we have failed to learn. Conventionally you’d say, Well, we learned our lesson. We tightened, we batten down the hatches, and we weren’t going to get caught with our pants down next time. That’s not actually what happened. It’s like the pants are perpetually off. They’re gone. And our public health system fundamentally failed on this front. As you think about the challenge of monkeypox. I’d love to get your perspective both on what needs to be done right now, but also what this tells us about the long-range rebuilding we need to do?


Dr. Megan Ranney: Gosh, we could have a whole hour talking about that second question. Um, you know, so we’re today, as we’re talking, we’re a little more than two months out from when the first monkeypox case was identified in the United States, in Massachusetts, on May 18th, if I recall correctly. And we are just scaling up testing and getting vaccines out the door in a major way. I actually think the speed at which we’ve responded is thanks in part to the fact that we had some smallpox preparation already in place. But I attribute, you know, it’s like one of those “on the one hand, on the other hand.” On the one hand, our response could have been worse. We could have just ignored it altogether. On the other hand, it could have been so much better. And the reasons why I think it wasn’t better and faster are because of the lack of central coordination. We had multiple agencies, HHS, we had FDA, we had CDC, all, ASPR, all kind of part of the response system, without a single coordinator and a single driving force saying, This is an emergency, and we have to go all out. Right? So it moved at the speed of typical governmental work rather than necessarily at the speed that a potential new epidemic deserved. And I think that the lack of kind of, like you said, the lack of funding and kind of underlying public health workforce is also part of it. The fact that we were all burnt out and exhausted from the last two and a half years certainly played into the lack of response here. I have to wonder, had the monkeypox outbreak happened pre-COVID, would our response have been better or worse? Everyone is just done right. We’ve lost, just like we’ve lost health care professionals at unprecedented rates, we’ve also lost public health professionals at unprecedented rates over the last year and a half, two years. I think there’s some promising developments, right? We’re seeing some increased, we’re seeing increased leadership from the White House. We are seeing the FDA move faster than it has previously to clear vaccine doses that were sitting in Denmark that had already been approved by the European equivalent of the FDA, and to get those shipped to the US a little faster than they planned on doing. And we’re seeing collaborations between government testing and hospital testing faster than we had during COVID. So I’m seeing some promising signs. But to me, it is, like you say, just another marker of how much work we have to do. I know there have been announcements this week that, there were some leaks that ASPR, which is the Strategic Preparedness response arm of HHS, may get elevated in terms of pandemic response in coordination, which is, I think, what we so desperately need. It’s what Biden did by putting first Jeff Zients and now Ashish Jha in charge of COVID response at the White House. I think it highlights, right, we need to have a person who makes decisions and directs the response. And to me, that’s one of the takeaways. And then we need to do a better job of training and supporting public health professionals, and getting them out on the ground–which is, you know, that’s why I’m in this academic team job here at Brown is because I believe that so strongly. It’s not a problem we can fix overnight, though. It’s going to take us a bit of time, just as it’s going to take us time to rebuild the health care workforce, to get folks trained and in the field . . . and supported appropriately.


Dr. Abdul El-Sayed: I want to just pick up and appreciate your point about just how fried people are in public health. And look, nobody goes into public health because they want to make a lot of money or get famous.


Dr. Megan Ranney: Nope.


Dr. Abdul El-Sayed: They go into it because they care about taking care of people and they believe in systems. And this has been the single hardest moment to work in public health. I talk to all my colleagues and everyone is just fried. And so in some respects, it’s really hard to mount yet another response in the middle of a first response that’s still not adequately addressed. And on top of that, public health has been systematically defunded for decades now, in part because of the point that you made earlier, which is it’s very difficult to sell people a non thing in a, you know, hyper-capitalist society when there are a lot of people who are there to sell them the answer only after they discover their need for it. Right? And you know, if you want to, you sort of compare the plight of a public health professional to a surgeon. A public health professional wants you never to need a surgery, ever. And most of us would want to be in that situation, but it’s relatively thankless because we’re telling people all the bad things that could happen to them, and asking them to change their behavior to protect them from ever needing a surgery. Whereas if you’re the surgeon, right, and somebody needs a surgery, as soon as you give them the surgery, you get paid a ton and everyone, thanks you so much for having done that and saved their life. And so it is, the way our the combination between our psychology and our economic system come together, leave us systematically underfunding public health–so leaving even the professionals who are out there doing this job thanklessly, underfunded, and then largely putting more and more money into the parts of our health care system that are the easiest to sell. You know, and you know, you think about, you walk into the atrium of a hopital–always really nice, right? Because that’s the part that most of us sort of see, understand, and use to solve the implicit moral hazard of asking whether or not we’re getting good health care. And so, you know, we fund a lot of really, really nice gurneys and atria, and we don’t fund that much when it comes to disease surveillance and the capacity to intervene early on in an epidemic. Dr. Ranney, we really appreciate you taking the time to join us today. Folks can find your work usually just by turning on the television, but if you could tell us a little bit more about what’s on your mind and what you’re working on, we would love that.


Dr. Megan Ranney: Yeah, absolutely. So I am active on Twitter @Meghanranney, where I share my latest thoughts around whatever issue I’m seeing in the ER today. I’m also, you know, here at Brown and folks can come and find me there as well. In non-COVID times, do a lot of work around firearm injury, use of technology to identify and prevent violence, and related behavioral health problems like opioid use disorder, depression, post-traumatic stress. But as with all of us, both because of my frontline work in the ER, and because of the behavior change theories that I know work, I’ve gotten quite involved with informing emergency preparedness and response in different ways over the last two years through COVID work.


Dr. Abdul El-Sayed: We would love to have you on to talk a bit more on firearms and opioid use disorder as well. We appreciate you joining us to talk about COVID and a bit on monkeypox today. That was Dr. Megan Ranney. She is the Academic Dean of Public Health at Brown University and an emergency physician. Thank you so much for joining.


Dr. Megan Ranney: Thank you.


Dr. Abdul El-Sayed, narrating: As usual, here’s what I’m watching right now. The WHO has declared monkeypox a public health emergency of international concern. Though a committee of experts who met last Thursday to discuss the outbreak couldn’t reach a consensus, WHO Secretary-General Tedros Ghebreyesus unilaterally made the decision, considering what a PHEIC implies. Quote, “an extraordinary event” that constitutes a, quote, “public health risk to other states through the international spread of disease”, and that could, quote, “potentially require a coordinated international response.” Check, check and check. The Public Health Emergency of International Concern declaration comes at a time when there has been nearly uncontrolled spread in the US, with 2,800 cases across 44 states. In many ways, the fact that monkeypox has spread this fast indicates just how broken our public health infrastructure is, following two-plus years of COVID. Public health workforces are fried, and public health itself has been so politicized that high-level second guessing and hesitation, it’s hampered quick responses. That, and public health agencies have just been underfunded for decades. Monkeypox, by its nature, should have been far easier to contain than COVID. We know what we’re dealing with. There are available vaccines, and it has such a long incubation period that vaccines can be given after an exposure and prevent full-blown infection. That, and the fact that monkeypox has remained tightly- clustered. Meanwhile, public health officials in New York confirmed the first case of polio in the U.S. for over a decade. The patient in Rockland County was unvaccinated, but appears to have been infected with a vaccine-derived version of the virus, a weakened but still living version. That version is no longer used in the US, but it’s still common in many parts of the world. It’s likely that this person was infected by someone who’d recently been vaccinated abroad. I worry that anti-vaxxers are going to use this as an argument against vaccinations when it’s exactly the opposite. This person would never have been infected if they had been vaccinated. Their body would have easily swiped away this weakened version of the virus. It’s the fact that they were not vaccinated, that rendered them susceptible. In the past, when polio vaccinations were nearly universal, this wouldn’t even have been a worry. But today, given the growing strength of the anti-vax movement, more people are going unvaccinated, and they’re opening the door for infection. I assume that if you’re listening, you’ve probably been vaccinated for polio, but if you haven’t, please do. And please make sure that any folks who are hesitant, understand that the best way to protect yourself from polio of any kind, is to get vaccinated. In health care news, our colleagues over at Stat News recently published a look into the earnings of health care CEOs in America, and the top 300 CEOs made a cumulative–get this–4.5 billion–yes! With a B, billion dollars–in 2021. It’s not like we were paying for a job well done either. Don’t forget, this was a year where 415,000 Americans died of COVID, and where life expectancy fell. In fact, that $4.5 billion, it was seven times as much as the CDC’s entire budget to fight infectious diseases. Seven times as much! But it’s a reminder that in our health care system, we monetize illness. We pay after people are already sick, rather than investing in the means of keeping people healthy in the first place.


That’s it for today. On your way out, don’t forget to rate and review the show. It goes a really long way. Also, if you love the show and want to rep us, I hope you’ll drop by the Crooked store for some American Dissected merch. We’ve got our logo mugs and t-shirts, our Science Always Wins sweatshirts are 80% off, and Dad caps are available on sale. Our Safe and Effective tees are on sale for $20 off while supplies last. America Dissected as a product of Crooked Media. Our producer is Austin Fisher. Our associate producer is Tara Terpstra. Veronica Simonetti mixes and masters the show. Production support from Ari Schwartz, Inez Maza, and Ella Price. Our theme song is by Taka Yasuzawa and Alex Sugiura. Our executive producers are Sarah Geismer, Sandy Girard, Michael Martinez, and me, Dr. Abdul El-Sayed, your host. Thanks for listening.