Jeremy Faust

Has the Pandemic Changed American Health Care?

Air Date: December 20, 2021

ER physician Jeremy Faust discusses the state of the pandemic and disparities between vaccinations and testing.

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HEFFNER:  I’m Alexander Heffner, your host on The Open Mind. I’m honored to welcome our guest today, Dr. Jeremy Faust. He’s an ER physician and an instructor in emergency medicine at Brigham and Women’s Hospital. Thank you so much for your time today, Dr. Faust.

 

FAUST: Good to be here.

 

HEFFNER: Let me ask you where we stand right now in terms of the pandemic landscape. We’re recording this in the fall of 2021. We hope that by the fall of 2022, thanks to people being vaccinated and the interventions of therapies like the Merck drug, you know, we can live freely amongst ourselves, maybe even without masks or, you know, as persistent masks wearing by next fall. Based on what you’re seeing in the hospital and anticipating this coming winter, do you think that’s realistic that by next fall we could be truly out of the woods?

 

FAUST: Well, I think the first thing you have to do before your forecast is to nowcast, is to understand where you are now, and then try to figure out if you have any idea about what’s coming down the pike. And I think that really where we are now is very heterogeneous. It’s very different depending on where you are. And that tells me that where we’ll be in a few months, let alone in a year will also depend on where you are and what has been done at that level. So look at a place where I am like Massachusetts, where a vast, vast majority of the highest risk adults and even lower risk adults and many teenagers are vaccinated. We do have Delta surges in areas of the state with lower vaccination rates. But when you look at the state in its totality and you ask, are there more deaths than usual, just altogether, because sometimes testing can be a limiting factor.

 

And I always use the aliens from outer space problem. If aliens came in and looked at our numbers where they say, hmm, something really unusual is happening here in Massachusetts. And they would conclude, no that there’s not a major deviation in the number of deaths here in Massachusetts. However, in other parts of the country, and certainly in parts of the world that remains untrue. There is a major deviation in excess mortality, more deaths than usual. So the way I look at this problem is how are we doing now? And does that mean anything about the future? So the future really reflects what we do today. I think that the more people walking around with antibodies, preferably from vaccination, but natural infection can benefit that too. It’s the only good thing about getting infected, that in several months or a year, that things can look more normal. But how we deescalate and how we decide to move forward is a less of a biological question and more of a question of what we want to do.

 

HEFFNER: The scientific question though, you have some familiarity with, in terms of being in the ER and seeing cases up close and understanding the nature of breakthrough infections. And you’ve written about this in the context of boosters and considering, you know, what the American people should do, immunocompromised folks, older folks, all Americans, but, you know, just as a pure factual matter, what have you learned treating breakthrough infections, about the nature of breakthrough infections?

 

FAUST: Well, I can tell you what my personal experience has been, but then I also want to put that into context of what the data show us. And my personal experience treating breakthrough infections is that most of them are very, very mild and that the vaccines have succeeded in what I believe that they’re supposed to do, which is to turn this virus, SARS-Cov-2, the novel coronavirus, into just another virus. And the vaccine does that for most people at an exceptionally high rate. So when I see a patient who has a COVID-19 illness and it’s a breakthrough infection, and I’ve seen a few of these, they, for the most part, look totally different and so much better than the kinds of patients that I was routinely treating months, a year ago when nobody had a vaccine on board. So have I admitted a patient to the hospital with a breakthrough infection? I believe I have done so. I know I have, but it seemed like it was part of another story. So a patient who had a lot of things going on, happened to also have coronavirus maybe that was driving that, that hospitalization, maybe it’s a contributor. Hard to say. Certainly there have been cases where people have had breakthrough infections where the only reason that they’re sick is COVID. And so for those folks we have to ask, well, is the vaccine perfect? No, of course not. Number two, do those people need a booster? So I think that that’s where the data have been so interesting, out of Israel, is that people who are older, certainly the older you get, the more likely that the vaccine needs to needs to be augmented by a third dose. I think that for young people, most breakthrough infections that I have seen, and that I’ve heard about, sound somewhat uncomfortable, they certainly are in terms of a temporary disability. I can’t go to work. I can’t go to school. I feel crummy, but it’s not the same level of misery, suffering and danger. That’s the real key, the danger that we saw before.

 

HEFFNER: There has been reporting on the more prolonged immunity or antibodies, basically suggesting that Moderna may allow our bodies to remember the virus and therefore be able to stave it off more effectively for a longer period of time than Pfizer. We also know that the Moderna vaccine itself is more volume of vaccine. I think nearly double, but more vaccine is being injected to you with Moderna. Do you have any insight into that in terms of the longevity of immunity or antibody protection?

 

FAUST: Well, when we talk about the vaccines and the protection that they provide, we have to be very clear about what we are trying to measure and what we are measuring. So there are circulating antibodies, that’s antibodies that are around your airways and in your bloodstream. And these are designed to really, these would be our body’s attempt to stop it infection before it happens. That kind of immunity is very much expected to go down in the weeks and really months after any vaccination. If we didn’t down-regulate that if it didn’t deescalate the number of antibodies that were going around our bodies, that could actually become a problem because we can’t have too many antibodies at all times. There actually are pathologic medical conditions in which that happens. There is such a thing as too much of a good thing, but when it, when it comes to the protection against not just infection, but against severe disease, that is really something that’s a little bit more like storing a weapons cache.

 

So once you’ve been vaccinated, your body stores that information away and says, when we’re infected again, let’s mobilize our resources to make sure that the attack isn’t a very successful one. Yes, they’re going to have an attack. It’s going to cross our borders, so to speak. But once they’re in, on the battlefield, we will have big guns and it’ll just take a few days or a week or two to mobilize that, but it’ll happen in time that we will win. And so that’s what these vaccines are so wonderfully good at. So we know that breakthrough is happening, especially with Delta. Delta is very good at infecting and getting on that battlefield. But we also know that whether it’s Madonna or Pfizer and quite frankly, J and J has done well too. Although I think that probably that second dose is really going to be essential.

 

We see this incredibly good response. So yes, there are statistical differences between the vaccines and their ability to keep everybody safe. And I think that that’s something we’ve just learned. It might have something to do with the amount of vaccine that is administered. It also might have something to do with the spacing because our body will respond differently depending on the space and time. You can imagine if from an evolutionary standpoint, why our bodies might notice something where you got infected on day zero, and then you’ve got infected on day 30 and it’s, your body may be thinking, hmm, this thing is still around this pathogen, this virus I’d better really take notice and store more of my immunity, memory on this particular pathogen. Whereas if it was on day zero and day 14 or day 20, your body might be thinking, such that it thinks at all, oh, this is still a temporary problem.

 

So we don’t have to worry so much about the long-term implications. So this is why a lot of vaccinations sequences that we do as you remember from childhood or adulthood, they’re spaced out. We tell our body, we give our body a little that jab, that stab of the reminder to keep these antibodies and keep these memory cells on books. And so that spacing it out actually might be a good thing. So it could be that Madonna got lucky in that the slightly longer spacing is what’s leading to this response. This is a huge argument in favor of boosting, by the way, is that the, that the booster is several months later, it’s really going to be the thing that tells our bodies, okay, hang on to this information for a long time, for years, maybe for life. So in that way, I think boosters, there’s a really strong argument for boosters, if we have the dosing figured out, if we have the safety figured out. And also, really, if we have the resources figured out, I’m very concerned that boosting a bunch of Americans who basically, that already have a pretty good life preserver, instead of throwing a life preserver to someone overseas who has nothing is actually not a great policy.

 

HEFFNER: How much of that is ultimately going to be based on an analysis of, you know, how protected the vaccinated public is, six months into the vaccination, nine months in after they’ve been vaccinated, a year after that? And so, I mean, from that perspective, there’s so many variables contributing to that question as to whether or not this year, this time, next year, we are out of the woods, but being an emergency care provider, what is out of the woods mean to you? Because you’re dealing with it every day. I mean, and you were dealing with it prior to the pandemic every day, but just in a myriad of other forms that were not exclusive to, or specific to the pandemic.

FAUST: Well, there are certainly different lenses to answer that question. Certainly you don’t want to be in a situation in which your hospital capacity is overwhelmed. So we see that happening and we see that coming close to occurring in areas where there’s not enough vaccination, where not enough people have immunity. So from my perspective, as someone who’s trying to keep the public safe when I go to work, the top level of emergency that the maximum Def con condition, if you will, is a situation in which we can’t offer the care that we would we’d need to do, in order to keep everyone alive. The last thing we want to do is have someone, not, someone who has what we call a modifiable death, someone who comes in with a life-threatening condition, we can help them, but, but we can’t now because we’re just overwhelmed.

 

That’s the absolute worst-case scenario. I think that’s the thing. We, we certainly need to make sure we’re through that in every place. We aren’t having that here, but we do see that elsewhere. The second piece is as a, looking more through the public health lens, is this virus having what I would call it, outsized impact. So is it causing more hospitalizations, more deaths, more disability than basically a dozen or hundreds of other viruses that we frequently encounter? And that’s where it really becomes a question of public will.

 

HEFFNER: Doctor, there was the aspiration that the system would be transformed to deliver more equity as a result of acknowledging the disproportionate outcomes of the pandemic, whether we’re talking about emergency cares that are inundated with traffic of patients in one zip code and not another, whether that’s a racial question or a geographic question, in rural versus urban communities. But I mean, just assess for me what transformation you still hope will be achieved as a result of maturing our society and innovating our medical infrastructure so that you can be confident and have not just the skill but the mental and psychological confidence that that the American healthcare system is there, you know, is equipped to deal with something like this.

 

FAUST: Well, the equity question is an extremely important one, and I think that we all recognize that COVID-19 has exposed this problem to those who didn’t realize that it existed, or for those of us who realize that existed made it all the more clear what a pressing problem it truly is. The, the best way to prepare for the next crisis in my mind, is really twofold. One is pandemic planning or outbreak, outbreak, and epidemic planning unto itself. How do you do this again? How do you do it better? And I can talk about what that means the second way is, well, once we’ve done all that, that there’s still the question of who are we as a people, as a country and as a species, and what do we enter, as we enter that crisis, what do our bodies look like or feel like, or what, what, how are they equipped?

 

And so what we saw in this pandemic is that if you don’t have the right health care, if you don’t have the right resources, if the system is stacked against you and you enter the COVID-19 era with hypertension and high blood pressure, you enter the COVID era with diabetes, you enter the COVID era with kidney problems, that when that virus reaches you, you are just less likely to be able to fend it off. So the best way to prepare for the next pandemic is to say, how can we minimize the effect it’ll have on us? And the answer to that is to enter, to enter fully equipped. And what I mean by that is that our, that we are as ready as possible, and that we don’t give whatever virus it is or pathogen. It is so many targets to reap havoc.

 

So where the, where the systemic problems come from, the systemic inequities that are bound up in racism and in other areas of discrimination where those really play out is, you know, how you show up to the fight. And I think that is where we need to work very, very hard. It’s a major argument for expanding access to, to healthcare. And I think that we saw so many statistics where we said, oh, look, when the Affordable Care Act came out, you did, they saw, they saw studies where if we got everyone basic, basically close to universal access to healthcare, that a couple of lives were saved for every thousand people who were enrolled and these are small differences, but on a population level, they were big. But now you look at it through the COVID lens, and it’s likely that those kinds of resources have a much bigger impact. So on a day-to-day basis in a non-crisis situation, yes, having healthcare does help you on the margins. And it certainly has some longevity implications. But when you enter a crisis like this, all of a sudden, the magnitude is just an impressively larger than I think most, most of us really anticipated.

 

HEFFNER: I mean, there seems to be a pretty clear and devastating acknowledgement, Jeremy of the fact that there are, if you will, medical deserts in this country. I mean, I refer to geography and race earlier because those are the lines on which this corresponds, which is there are deserts, you know, there are rural communities that used to have hospitals. No more. There are rural communities, they would have clinics that would basically inform people and make them literate about COVID in this case or contraceptive reproductive health. Gone. I mean, those, those seem to be just the facts that we’re dealing with is in this country.

 

FAUST: Yes. Well, I think that that’s certainly one area where we really have to be very careful. Some of the government metrics that look at hospital quality, sometimes don’t do a great job of addressing that. They make it worse by dinging hospitals that have not done well on certain metrics. Then those hospitals aren’t as affordable, aren’t as profitable, and then they have to shut down. So it’s actually kind of a vicious cycle. The, but there’s a practicality to these deserts, as you mentioned. And some of it is just how you roll out a response. For example, the, for me, if you wanted to think about what I sometimes call COVID 25 or the next blue, the next big problem that we face, how can we do better? Well, one way is to acknowledge those deserts. And for example, using pharmacies for testing centers and for vaccination centers works in a lot of places, but in other places it does not because they basically don’t have enough, there’s not enough coverage, there’s these deserts, as you said. So one of the suggestions that I think has been has been put forward by myself and others is to use things that are much more likely; use locales that are much more likely to be evenly distributed. For example, every zip code has a post office. Every zip code, every jurisdiction has a fire house or a fire safety center. These are places that that can stage massive testing centers. They can stage mass vaccination sites. And so that’s how I would address that problem. But yes, we also see the problem of educating the public. And, you know, you didn’t ask this, but it’s, I think it’s baked in. There is a problem that we never really considered when, when we, I say we, the government, people who plan for pandemics, didn’t consider the idea that an event like this wouldn’t be galvanizing, that we wouldn’t all rally around public health and what’s best. Instead, there would be a political divide. I know for a fact that people who wrote the pandemic plan that we’re basically using now did not anticipate that because there was no social media such that it is today, back in, during the Bush administration and early Obama administration, when these plans were developed. And there certainly wasn’t the kind of political polarization where, getting, wearing a mask and getting vaccinated was actually some kind of expression of a political stance as opposed to a public health stance. So we need to update our plans to reflect those realities, I’m afraid.

 

HEFFNER: And I think that’s connected with preserving your own mental health doctor and, and that of your, of your colleagues. And, you know, I often wonder about that, those of you who are on the front lines because, you know, having a public that is literate is a morale boost and is again inspiring confidence in the system. That’s something that clearly is going to be an incremental process in terms of getting the country to a place that it is more informed and dealing with the damage of information deserts and social media, you know, occupying that with this information. But you know, when I asked you before about the transformation of the medical system when you understand the trials and tribulations and trauma of this whole period, this era about which we will chronicle for years and decades to come, what advances would you like to see? A literate vaccinated public is one of them clearly. But separate from the question of equity, we want medicines and care to be delivered more equitably like in your hospital or in hospitals of your peer, ER physicians, what tangibly should be improved in a way that’s going to help protect these great public servants like yourself, who’ve courageously been on the front lines for all these months and years now?

 

FAUST: Well, I appreciate the concern. I think that the mental health tax on frontline workers is hard to quantify. It’s unequal, depending on what you, what you dealt with. For me, the, the feelings that I have a very different than my colleagues in New York, which is what I trained. So it just depends on what you’ve lived through and how. For me, as you kind of alluded to the, the hardest part for me has not been the frontline work, because while we’ve had a lot of COVID here, we never felt overwhelmed. We have resources, we did things like we tripled our ICU capacity so that our ICU wouldn’t be overextended in that moment. So we, we had so we were able to respond in time. So the kind of PTSD that I think a lot of people are living with, you know, I didn’t have to deal with. For me, the harder part has been to, to watch and see how hundreds of thousands of Americans have died because of misunderstanding in public health.

 

So if we had done a better job rolling testing. If we had done a better job in answering people’s vaccination questions ahead of time. If we’d done a better job in making sure that the, the politicization of healthcare did not cause people’s lives because they have preventable illnesses, now that we can now prevent. Those are the things that would make my mental health better, but I’m a public health person and everyone sees things differently. I think that the best way I think that hospitals can can prepare for this in the future is to essentially realize that the next threat may look similar to this one. And there’s going to be a long period of time where we have nothing. All we have is the things that we don’t want to do, which are putting on masks and staying home for a little while.

 

Well, what can we really do differently? I think that, as I said, way back when, early in the pandemic, we can avoid a massive, massive changes in our lifestyle by having huge testing operations. This can shorten the amount of time people have to stay home. It can shorten the amount of time that they have to make major changes. And what that does is, it saves lives and it’s less disruptive. But it also buys you clout. I’m very, very worried that if people don’t stand down, if we don’t back off, when it’s truly safe, that that we have, what’s called alarm fatigue. And that when a new threat comes up, we say, well, we need you to put the mask on. We need you to stay home for a little while. And the response will be, well, you said that when things were kind of not that bad. So I think that we need to prepare for the downstream effects of the fact that we’ve asked a lot to a lot of people.

 

 

HEFFNER: You know, you and Michael Mina have been spot on, on this. You know, just from the very beginning we also know that our FDA and our CDC, you know, they, they needed to behave like they were operating in 2021. You know, at the speed of globalization, the speed of lightening, we know that so I asked you about hospitals, but I, you know, in the 30 seconds, 60 seconds we have left, just you’re totally right. It’s entirely plausible that there could be a pandemic that’s worse, even though now this is even worse than 1912, 1918 rather. This pandemic is the worst in American history. And yet, I mean, the most deaths, you know, more deaths now, have been caused by, by SARS-Cov-2, then the great influenza of 1918, and even so, you know, we still have to keep our guard up.

 

FAUST: Right. Do we recognize a threat when it’s among us? It’s not like you know, a textbook photograph where there are carts of dead bodies, because we’re, we’re a much more organized society. We have trucks outside of hospitals. So yes, we have more deaths than 1918. Of course we have a bigger population. But what I would say is that these two pathogens belong in the same conversation, and we have 21st century technology and we have, and we still have over close to three quarters of a million deaths. That’s an unbelievable realization. I think that the way that we can move forward to end on like a positive, positive note at all, is to say, what have we learned and how are we going to deal with resurgences or new threats? And I think that we’ve learned that for example, we should make the test, just make the tests and we can swap in at the last minute, whatever the molecule has to be to make that test work. So make the plastic doohickeys and the swabs, have those ready. Have the tents ready to go. Have your systems in place for scanning that information and getting it to a public health center. So we can have much targeted, much more surgical responses than the ones we had to have. When you don’t have that information, you just have to shut everything down. The other thing we can do is we can watch wastewater because these can help us understand when there’s something new happening. If we read about an outbreak of H5 N7 influenza in Texas, it would be very good to know if it’s in the wastewater, because then we know it’s maybe in people. So that kind of thing, I think that we can do a much better job at anticipating the problems with the technology. We have. I think the fact that we are still 18 months into this, and I cannot go and get a rapid test for a dollar. It should be free because it saves everyone money. That’s disappointing, but I still hold out hope that we will be there by the time the next crisis emergency.

 

HEFFNER: It’s so self-defeating to think that we have free vaccines, but not free testing and not quick and easy testing. We should. We need to correct that. We still need to correct that.

 

FAUST: It’s actionable. it’s actionable because again, it’s a lot of testing. It’s funny. I spent my whole career talking about over how over-testing patients can be a problem, because what does it do you. But when it’s an infectious disease, it does do a lot of good because it tells you, hey, look, you are asymptomatic, but you’re positive, you’re a danger. Or you’re symptomatic, and you’re not even contagious anymore. You can go out. So the, the implications on health and on society are massive.

 

HEFFNER: Dr. Faust, thank you so much for your insight today.

 

FAUST: Thanks. Good to be here.

 

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