Robert Wachter

When Will Vaccines Eradicate the American Pandemic?

Air Date: January 4, 2021

University of California San Francisco Medicine chair Dr. Robert Wachter discusses the impact of emerging COVID-19 vaccines.


HEFFNER: I’m Alexander Heffner, The host of The Open Mind. I’m delighted to welcome to our broadcast today, Dr. Bob Wachter. He is chair of the UCSF Department of Medicine, University of California, San Francisco. Dr. Wachter, thanks so much for joining me today.


WACHTER: My pleasure, Alex.


HEFFNER: Can you tell our viewers what the difference is between efficacious vaccines in late-stage trials and what will amount to an effective vaccination deployment around the country?


WACHTER: Yeah, I mean, what we know so far is that in tens of thousands of patients the vaccines that we’ve heard about: Pfizer, Moderna and now AstraZeneca markedly decreased the rate of people getting symptomatic COVID and also the rate of getting severe cases of COVID. What we now have to do is deploy them in real life and real life is different than a clinical trial. Some people may not take it. The distribution can get screwed up. The freezer can go bad and the vaccine no longer is potent. There’s all sorts of things that have to happen right, in order to take what we now know from the science and deploy it into the real world. But it just can’t be understated how wonderful the science is, how extraordinarily fast this went and how astoundingly impressive the results are.


HEFFNER: These are novel mRNA vaccines compared to the attenuated or inactivated vaccinations that had been deployed primarily in the past. What is your sense of what that difference will entail?


WACHTER: Well today, so we’re doing this on Monday, today we heard about another vaccine, the AstraZeneca one that was developed with Oxford. That is a more traditional platform. It’s using a different virus assets vector rather than the mRNA and the fact that it too appears to be highly effective, maybe a smidgen less than the other two vaccines, is more proof of concept, that the target that all of the vaccines we’re going for is the right target. And if you can stimulate an immune response to that target, you’re good to go. The mRNA platform is just a new way of doing it, basically, using the machinery of your own cells to produce the spike protein that then your body decides to create defenses against. And that hasn’t been used before. The fact that it appears to work in incredibly well is great news, not only for COVID, but it’s a platform that seems like one that can be geared up really quickly for future infectious threats. Now, of course it’s a new technology and so everybody’s a little bit antsy about, is there something going to come out late in the game and in terms of a side effect or a safety problem, but you know, most of the vaccine experts I’ve spoken to don’t think so, they really think that now that we’ve watched for two months, have not seen any worrisome side effects emerging, yes, people have a little bit of fluish symptoms for a day when they get the vaccine, is really extraordinarily reassuring. So it just turned out, these ones were ready to go quickly. They’re out of the box first. But you know, now a week later we have reports of another one that works and we’ll probably have several more. So I think by early next year we’re going to have this embarrassment of riches where there are three or four or five effective vaccines ready to go.


HEFFNER: Doctor, what are your biggest concerns with respect to storage and delivery?


WACHTER: The history of the last 10 months would not give anybody a great amount of reassurance about the us government’s ability to manage a complex logistical program. We didn’t get it right on testing. We didn’t get it right on PPE and masks and things like that. And so there’s some concern there. Will we get it right? Is there a national plan? The concern is either heightened or decreased depending on your, the way you look at a glass of water, based on where we are in the political cycle. So, you know, I’m not giving away my politics too much to say that I have far more confidence in a Biden Administration’s ability to have competent people discharge this program in a way that’s apolitical, just focused on getting it right. I have a fair amount of concern about the Trump Administration’s ability to do that although I have to say to be fair, Operation Warp Speed has gone very well. This is the one part of their COVID response that they seemed to get right. And now we’re in this incredibly funky period where you have the Trump Administration, not saying that we lost and not being willing to sign out to their successor to be sure that the ball isn’t dropped during the handoff. So I’m pretty confident that things will be fine in January. I think the next six weeks are a little bit dicey until we sort it out. And it’s a really awesome logistical challenge. I mean, you’re talking about tens of millions of doses of vaccines that have to be tracked, shipped all over the country, some of them require deep freeze. Some of them require regular freeze. The new one requires not freezing at all. We’ve got to track in a database if you got the first vaccine with your first shot, we hope you get the second vaccine for your second shot. I saw your interview with Florian who said it may not matter, maybe that’s so, but I think ideally we’d sort of like it to be tracked well enough that you’ve got Pfizer on version one, you get Pfizer in version two, there’s a lot to do. It’s complicated. And the place we are at in our political transition makes it, adds a few extra degrees of freedom that will make, I’m very confident, what’s going to happen in the spring, a little bit less confident that over the next month,

HEFFNER: The best-case scenario that you’re describing of competent delivery and vaccinations in mass; even if that is occurring, right, the incoherence of the responses across all 50 states and the continual development of these micro clusters, sometimes macro clusters now, that, that still will be happening potentially even as the vaccines are being deployed, right?

WACHTER: Yeah. I mean, we have to count, the federal government can’t do all of this. There’s going to be a last mile issue where the federal government is responsible for getting vaccines to the state of California and, you know, to the state of Rhode Island, to the state of Alabama and then the state and the State Department of Public Health will take over and figure out the distribution of how much goes to this hospital, how much goes to this nursing home. So, there’s a whole lot of stuff there to do and to get right. And as you say, every state has demonstrated not only different levels of competency, but the politics have bled into the response in ways that I think have been largely unhelpful. And one of the nice things about the vaccine, the vaccine will get politicized to some extent, vaccines always do. There will be anti-vaxxers out there, but this might be a little different and better than masks and the rest of the response, in that the vaccines are a point of pride for the Trump Administration. I think they want it to succeed. I can’t think of anybody on the in the Biden Administration who also doesn’t want it to succeed. And so it feels like both sides of the political equation for once are rowing in the same direction. And I think that’s going to make it make it easier. You know, we were worried and we remain a little bit worried about how many people will take it or not. When you asked, Gallup did a survey about a month or so ago, and 50 percent of people said I wouldn’t, you know, I’m not sure I would take it. A more recent survey, that number was down to 42 percent. And that was before the news about Pfizer and Moderna. My guess is those numbers are not to be believed. Not that not to be believed in a way about the polls for the presidential election and not to be believed in a fake news way, but not to be believed as in a month ago, if you’d asked me, will I take a vaccine I would have said, I don’t know, I’ve got to see what the FDA process is like, has it been polluted by politics or are they using a rigorous, scientific, evidence-based process? I’ve got to see how effective are they, are they 52 percent effective, in which case do I want to wait a little bit and see, really be sure there are no side effects. The minute that the Pfizer and the Moderna vaccines came out and they’re 95 percent effective, and there’s no evidence of serious side effects after two months of use, I think what anybody said about what they take a vaccine a month ago is almost irrelevant. I think we’re going to see 70, 80, maybe higher, adherence to the vaccine. And so the limitation, the big limitation is probably just going to be manufacturing capacity rather than people’s willingness to take it and rather than the distribution. You know if the distribution screws up, it’ll take an extra week or two weeks to get it out there. The real limitation is how fast can they churn it out? And you know, what we’re looking at is every likelihood that the FDA is going to approve a vaccine in two weeks, the part, one of the things Operation Warp Speed did, was get them to manufacturing, manufacturer, a whole bunch of vaccine that will be ready to be distributed the next day. I’m a healthcare worker. I’m starting to see patients at the end of December. It’s possible I’m going to get my shot in about three weeks and I will get my shot. I’ll be first in line if I can be. But the number of doses of vaccine that will be available in the United States by the end of 2020 is probably 15 or 20 million people can be vaccinated. When you add up the number of people in the first group that’s up for vaccination, that’s healthcare workers, frontline healthcare workers, and people at super high risk, for example, older people in nursing homes. When you add up those two groups that gets you to about 50 million, five zero million people. So we’re not going to get to that whole group till the end of January, maybe February. And then the next group comes in, people at some increased risk. You don’t really get to the majority of the American population until late spring, early summer. And so people are going to have to be a little bit patient and one way of thinking about it and sort of an unpleasant way to think about it, is the amount of time between now and general vaccination of most people, to a point that we may reach herd immunity is about the same as the amount of time between now and the start of the pandemic. So depending on how long you feel this has felt, that’s about how long we have before the average person will get their vaccine and we may reach a stage that feels like normal.


HEFFNER: So, if the manufacturing capacity is sufficient and the willingness of the American people to take the vaccine, one, and then possibly a booster is sufficient for how long do you think realistically will we still live with hospitals being under the threat of paralysis, if not being paralyzed, just as a function of businesses not shutting down, mask wearing and social distancing not being in effect. It that, you know, in the best-case scenario of maximum efficiency with the vaccine, is there still a risk that COVID could be as bad as it is today, if not worse a year from now?


WACHTER: I don’t think there’s a risk that it could be this bad a year from now. Sort of no scenario, now that we know how effective the vaccines are and when you look at the ramp up plans for the companies, in terms of manufacturing, there’s no scenario that I can paint that says that we’re not going to be substantially better by the summer and substantially better, it’s, it’s a world in which not everybody has to have been vaccinated, but enough high-risk people have been vaccinated that the chances that somebody who’s going to get COVID and get really sick and need to go to the hospital, it goes down a lot. I mean, in the studies, one of the great things that we’re seeing is it’s 90, 95 percent effective, not only preventing cases, but also in preventing severe cases, the kind of cases that put you in the hospital, put you in the ICU and maybe kill you. And so that is spectacular news. And that means that when you reach a point of maybe half the people, maybe 60 percent of people have gotten vaccinated, it’s not that there’s no more COVID in the community. There is. You’re going to see some cases, but it means there are far fewer cases, and the cases are ones in which people are far less likely to get super sick. The other thing that’s important, and this will happen pretty soon, is I saw today that there are a thousand healthcare workers, clinicians at the Cleveland Clinic who are out of work because of COVID. There are 900 clinicians at the Mayo Clinic who are out of work because of COVID. The limit today in our ability to care for you if you get really sick is no longer hospital beds or ventilators, it’s nurses and doctors. And unlike the early days of the pandemic, where I am in San Francisco, we’ve been very light. We’ve done incredibly well. And so in March we were all scared. Nobody’s going anywhere. By April we said, wow, we’ve done pretty well. I had a hundred doctors and nurses come to me and said, can I go to New York? Can I go to the Navajo Nation? And we sent them, we sent pretty big contingence of clinicians to both New York and the Navajo Nation. And they, you know, it was incredibly impressive and courageous, but we could do it because San Francisco is light. Today, the surge is everywhere in the country, so nobody can send healthcare workers to another part of the country, because none of us know that we’re out of the woods. So that’s a long way of saying that by January or probably early February we’ll have inoculated enough healthcare workers so that assuming the vaccine works as well as it appears to work, at least that variable will be taken off the table. Healthcare workers will be safe. Believe me, we’re still going to wear masks. We’re still going to be careful, but you’re not going to see massive numbers of healthcare workers sidelined because of COVID. So that will help even before you reach the big part of the general population.


HEFFNER: Doctor, we believe that reinfection is not going to be a major problem, but there have been some incidents of reinfection that are documented and authenticated. So what does that tell you?


WACHTER: Well, I think the key thing is how unbelievably rare they are. We’re talking about tens of millions of cases of COVID and the number of truly documented, proven cases of reinfection, you can’t see my feet, but it’s the number of fingers and toes that I have up right now. It’s staggeringly rare. Now it means it can happen. And so the fact that you have been vaccinated is not a one hundred percent guarantee that you can’t get infected, but it means that it’s really rare. It also means that immunity must last at least 10 months, because if it lasted less time than that, we would start seeing a big spike in reinfection. So it’s almost the exception that proves the rule, in every, there’s no vaccine, there’s no immunity to anything that’s one hundred percent effective with no failures. It may be people’s genetic makeup or their own immune system that’s a little bit different, but the fact that reinfection is so rare and now we’re almost a year into it, tells us that immunity works really well and works for at least a year. Now, does it work for longer than a year? My guess is it probably does, but it wouldn’t be impossible that people get their vaccines in early ‘21 and they need another shot in ‘22. And if that’s the price that we have to pay, that’s okay. It’s not so bad.


HEFFNER: Would you say that the American healthcare system was under significant strain even prior to COVID?


WACHTER: Sure. I mean, our health care system is not designed that any rational person would design it. We’ve had a shortage.


HEFFNER: That’s what I want to ask you. We anticipate a new administration and the potential for reforms that can be longer lasting than just the recovery from this pandemic. You’re the right person to ask about those sustained improvements that can not only help us prepare for a possible future pandemic, but the everyday, deal with what was the unsustainability of the everyday strain of the American healthcare system.


WACHTER: Yeah, that’s a hard one, Alex, because in some way, these are trade-offs that we have been unwilling to make. So part of what is screwy about the American healthcare system is if you get really, really sick and you need a transplant, you need cancer treatment, you know, we’re spectacularly good. I think we’re probably the best in the world. The state of our research is unbelievable. The state of our training is fantastic. And yet, even with Obamacare, we have, you know, 15, 20 million people uninsured, far more people under-insured who see huge copays and huge deductibles, which gets in the way of them getting the care that they need. At the same time that that’s true we waste a huge amount of money. We overpay for a whole bunch of things, pharmaceuticals and hospitals, and you could argue some doctors. And so a rational system would sort of make all that better, but that’s hard cause you’re taking money out of one pot and using it to insure more people. Now you throw in a pandemic and you say, well, we need to make that better. We need to shore up the public health infrastructure. Where’s that money coming from? It probably is coming from hospitals, doctors, pharmaceutical companies, or people with really, really good insurance. It’s taking money out of that pot and putting it into another pot. We talk about how COVID has exposed the disparities in healthcare and how the outcomes among Latinx and black patients are far worse. That’s not a shock to anyone. We’ve known that for cancer. We’ve known that for pain control. But again, fixing them, it’s unlikely we’re going to get a whole bunch of new money coming into the healthcare system. The healthcare system is already a $4 trillion dollar economy. It’s already 20 percent of the GDP. So we’re talking about reallocating money from one part of the healthcare system to another part of the healthcare system and every part of the healthcare system that that is the recipient of that money believes that they need every cent of it and will fight like hell as you try to take it away. So as Biden and Obama learned, and as Clinton, both Clintons learned 20 years earlier, this is a hard system to muck around with, even though most of us who study it know that it’s not a perfect system, it can be made far better. The politics are pretty tough.


HEFFNER: In the best-case scenario, you’re able to incentivize differently those levers, you referred to reallocation, what are ways that that can be done in a way that is not going to offend the entire system or collapse the entire system, but where there may be windows of opportunity over the next 12 months to 24-month period?


WACHTER: Well, there’s nothing you can do that won’t offend at least some part of the system is, you know, one person’s waste is another person’s mortgage and that’s just the way it works. But it does seem to most of us who study health systems that the system that we currently have, which is known as fee for service, paying for things, an office visit, a hospital stay, an aspirin, a ventilator, is not the system that will get you the best outcomes at the lowest cost. It tends to drive over-utilization in part by the decisions that doctors make, hospitals make, healthcare systems make, and frankly, patients make. They, you know, patients, if it’s free, patients want more, it’s a natural thing. And so a better system would be one in which healthcare, the healthcare organization, you know, in our case, UCSF, University of California San Francisco was given a fixed amount of money to take care of a group of patients. And so if we could do it less expensively, then we would make a profit, if it was more expensive then that would come out of our bottom line. Now the challenge there is, if you don’t get that right, that’s an incentive to under spend rather than overspend, which is just as bad. So you have to build into that really strong measures of quality and safety and patient experience, patient satisfaction and equity so that the incentives are balanced. So the incentives overall for an individual doctor and the healthcare system and the patients are, if we can deliver the best care and get the best outcomes at the lowest cost, everybody wins. And you know, it’s the way most of the rest of capitalism works. You could argue that that is why Apple does well and Amazon does well. They figured that out and they do well in that environment. Although in the capitalist economy there, you know, there’s no, there’s no insurance. They sell to people that can afford it. That doesn’t work in healthcare. You have to be sure it’s accessible to everybody, even people who have no means. So figuring out in healthcare is just a, it’s a tough nut to crack. But I think most of us believe that the pure pay for doing stuff system is, will get the results this is designed to get, which is more stuff sometimes with relatively little value.


HEFFNER: And never before in your lifetime doctor, correct me if I’m wrong and probably in the lives of many of your colleagues around the country, have they experienced the full capacity of ICU beds? This is really the first time many in the medical system are grappling with that, right, you’re talking about…


WACHTER: You go through, our hospital is very full, tends to run full a lot. We sometimes have to make triage decisions about, you know, who goes in and who goes out that part’s not new. We’ve never seen anything though where the possibility of a tsunami is very real, that, you know, it, there are certainly are times where we’re full and we’ve got to deal with it and manage capacity. But not in a whole region, not in a whole state, certainly not in a whole country, not at a point where we’re also quite fearful appropriately that we’re going to get sick. And if we get sick, then all of a sudden, you know, we have enough beds, but we don’t have enough doctors and nurses. So we’ve not seen anything quite like that.


HEFFNER: And much of that has had to do with the particular way that this disease has paralyzed patients and the, not just the occurrence of the disease, but how patients experience it over days and weeks, and these COVID wards having to be sustained over, you know, many weeks and months.


WACHTER: Yeah. Well, I mean, there’s a lot of things about the timeline of this virus and just the way it works that, if this wasn’t so tragic are fascinating, I mean, the fact that, you know, 40 percent of people who are infectious and can spread it are asymptomatic. So you know, taking their temperature is almost for show. When they come in the hospital, they’ve already had the virus for a week or two. When they go to the ICU and if they die, that’s probably a reflection of what happened a month ago. So you’re always behind the curve. If they’re sick enough to be in the hospital, they’re almost certainly going to have to stay a week or two, if they end up in the ICU, they’re probably going to have to stay a month or so. And so, and you’re always like, it’s like looking at a star. What you’re seeing now happened, you know, a million years ago, you’re always seeing now the results of what happened already, which is why you’re always chasing your tail to some extent. And as we think about what’s happening around Thanksgiving, what’s going to happen on Thanksgiving is already baked in. It’s already from things that happened two or three weeks ago. What we need to do now will help us in December you know, that’s sort of an interesting superpower of the virus, those lag times.


HEFFNER: Right. And I’m sure too, as people are watching this, if Thanksgiving has passed for Christmas, New Year’s and the future, just, I want to thank you for your service to your hospital and to all the patients in need, doctor, and just give you a final word to those watching across PBS stations around the country to just encourage them to do what you think will help preserve the health of their neighborhoods.


WACHTER: Well, yeah, thanks Alex. It’s a remarkable time. You know, as I’ve said, it feels like we’re watching on a split-screen TV and on one screen you have this, this horror movie and then the other, you have sort of a feel good romcom. It really is the horror movie is real. What’s happening now, particularly in the Midwest is tragic. It’s happening everywhere, and we’ve become almost inured to 260,000 deaths. It’s, you know, we’re talking about the size of Pittsburgh, the size of Orlando, Florida of people who’ve died from this, it’s staggering. And yet we get, we have this unbelievably wonderful news about vaccines, you know, better than any of us could have dreamed of. And so the next several months are this weird time where we just have to get through and people have to continue to behave well with the masks and the distancing. And we’re no longer saying, and we don’t know when that’s going to end. We actually can say with a lot of confidence, it’s going to end by the summer, which is a long time off, but you know, if we can just hold our act to keep our act together, we can get through this.


HEFFNER: Dr. Bob Wachter, chair of the UCSF Department of Medicine, thank you so much for your time and your service.


WACHTER: My pleasure, Thank you.


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