S1E1: Do We Need a Coronavirus Czar? / Céline Gounder & Ron Klain

“We cannot build a wall, a real wall, or a metaphorical wall to keep this disease out. We have to understand it’s coming. It’s here already. It’s going to come to a greater extent and we need to be preparing to deal with that.” -Ron Klain

In today’s episode, our co-hosts Dr. Celine Gounder and Ron Klain discuss whether the U.S. should be appointing a coronavirus czar to oversee and coordinate the national response to COVID-19. They share thoughts on the U.S. response so far, including travel restrictions, social distancing, and the decision to appoint Vice President Mike Pence to head the coronavirus response. They end by answering listener questions on traveling for spring break and address discrimination against Chinese Americans.

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Celine Gounder: I’m Dr. Celine Gounder.

Ron Klain: And I’m Ron Klain.

Celine Gounder: And this is “Epidemic.”

Ron Klain: On this show, we’ll bring you the latest news and analysis about what’s happening with the coronavirus epidemic. You’ll get to hear from some of the world’s leading infectious disease and public health experts, and you’ll get practical advice about what you can do to protect yourself, your family and your community.

Celine Gounder: We’ll also help you understand the bigger context. We’ll bring you diverse angles from history and anthropology to politics and economics, depth and texture you won’t get elsewhere.

Ron Klain: Before we start with our first episode, here’s a little bit about us. Celine and I met back in 2014.

Celine Gounder: I’m an infectious disease specialist and epidemiologist. I spent the earlier part of my career working on tuberculosis and HIV in sub-Saharan Africa. I later served as Assistant Commissioner for Tuberculosis in New York City. I started covering the Ebola epidemic in my writing and on TV in June of 2014 before I went over to Guinea as an Ebola aid worker myself.

Ron Klain: And I’m experienced in public service, a long time aide to presidents. In October of 2014, President Obama asked me to serve as the White House Ebola response coordinator and oversee his whole of government response to the West African Ebola epidemic.

Celine Gounder: It’s a pretty small world when it comes to people working on a Ebola. So inevitably, Ron and I crossed paths. Ron, you’re not a doctor, so why did President Obama tap you for this job? Why were you the right person for this?

Ron Klain:  Well, he made a deliberate decision not to bring in a doctor to coordinate the response. In fact, we had the world’s best medical experts already working in the federal government on this response, and he didn’t want someone else to interfere with their advice. What was going wrong in the fall of 2014 was that all the parts of the government weren’t working together. He needed someone with experience in government management and administration, running large government programs. I had spent the first two years of the Obama administration overseeing the economic recovery program, the stimulus plan, and the president thought this was the same kind of thing- a really complicated, nasty problem that needed attention at the white house to sort out how the agencies were working together to work with foreign governments, to work with state and local governments to make all the parts work.

Celine Gounder: So, what did you actually do as Ebola czar?

Ron Klain: So, President Obama had said we were going to put the whole federal government to work on fighting Ebola both in West Africa and preparing for cases we’d see in the United States. So my job was to make sure that strategy was implemented every day, to work with the federal agencies that had to implement this strategy to make sure they were working together effectively to solve problems, to bring decisions in front of the President quickly for his action to work with our partners, particularly then in the United Kingdom and France that played a large role in the Ebola response, and the nations in West Africa themselves, and also work with Capitol Hill. We needed money to fight the Ebola response. We went to the Capitol Hill and won a $5 billion aid package that was essential to what we were doing.

Celine Gounder: Why is it important in a situation like this, to have someone in charge who’s not the president? So, you know, not the Secretary of Health and Human Services, or Secretary of State or, Secretary of Defense.

Ron Klain: Coordinating a response like this is a full-time job and all those other people you mentioned, Celine, already have full-time jobs. It’s also important that it be done out of the White House where you have the full range of the federal government at your disposal. You have relations with foreign leaders at your disposal, and so I think it can’t be done out of one agency. That’s what the Trump administration was trying to do with the coronavirus response until recently having the Department of Health and Human Services run it. That’s not going to work, and it really needs to be someone who’s really on it full-time with a full-time team of people working together to try to make something this large really effective.

Celine Gounder: We’re in the midst of a crisis now. How do you govern in a crisis?

Ron Klain: Well, I think it’s really important for this kind of a problem to start with science. Start with medicine, make sure that the experts who have the scientific background, the medical background, their wisdom, their expertise is driving the policymaking. And then you have to have a process to, in a very quick order, make decisions that usually the government takes months and months to make. Are you going to have a policy about travel restrictions? Are you going to set up a special network of hospitals to deal with patients here that may need treatment? How are you going to work with state local governments, private providers? Get that done very, very quickly. So it’s, it’s you relying on expertise, speed, and decision making, and then removing the roadblocks, the turf battles between agencies that sometimes slow things up. So those are the things you really need to deal with something like this.

Celine Gounder: Ron, why are we hearing different things from U.S. government officials? Here’s Dr. Tony Fauci on MSNBC. Fauci has been the director of NIH’s National Institute for Allergy and Infectious Diseases since 1984. Dr. Fauci has served under Presidents Ronald Reagan, George Bush, Bill Clinton, George W. Bush, Barack Obama, and Donald Trump.

We’re seeing cases now in a considerable number outside of China and other countries like South Korea, Italy, Iran, Japan. And when you start to see sustained transmission from person to person in multiple different countries throughout the world, it’s inevitable that this will come to the United States.

Celine Gounder: Here’s President Trump.

Well, I don’t think it’s inevitable. It probably will. It possibly will. It could be at a very small level or it could be at a larger level.  Whatever happens, we’re totally prepared.

Celine Gounder: Why are we getting conflicting messages?

Ron Klain: What we saw Wednesday night at the President’s press conference was on topic after topic, the President contradicting his senior health experts and some of the nation’s leading experts. The President said that the vaccine would be here very soon. Dr. Tony Fauci, the nation’s leading infectious disease expert, a few minutes later at the same podium said that it would be a year to a year and a half before we had the vaccine. The President said that it’s not inevitable that the coronavirus will come here and spread here. Dr. Anne Schuchat, the number two person at the Center for Disease Control said that it was, of course, we were going to see cases here. So on issue after issue, the President, his health advisors went back and forth at the same press conference, standing there together, and I’m sure the American people must have been confused by that.

Celine Gounder: So why aren’t we calling this a pandemic? I’m calling this a pandemic. We’ve met all the criteria. This is a novel virus to which people haven’t previously been exposed and don’t have immunity. It’s spreading rapidly. We’re seeing communities spread on multiple continents now, and it’s deadly among certain high-risk groups like the elderly and people with chronic medical conditions. That’s a pandemic.

Ron Klain: You know, Celine it’s a great point. I think what this is flagging is one of the key weaknesses in our global health security system, and that’s with the World Health Organization. The World Health Organization is highly reliant on its relations with member states to be good, to give it access to those countries, to investigate epidemics, and to fund the WHO. And what we’re dealing with here is an epidemic that started in the world’s largest country and one of its most powerful- China. And so the WHO has tried to go very slowly and, not minimize necessarily, but also not be perhaps as clear as it should be about the extent of this problem. So it delayed declaring this a public health emergency of international concern not to inflame the Chinese. I think people need to understand that while we have great experts at the World Health Organization, I think very solid leadership and Dr. Tedros there, they’re under pressure from China to, to try to tamp things down and to try to not add to the disruption about what we’re seeing in China.

Celine Gounder: Public health experts like me calling something an epidemic or a pandemic matters because the measures to control the disease are different. With an epidemic, there may be a role for travel restrictions, contact tracing and quarantines like we saw with Ebola. The goal is containment.

Ron Klain: But here where you have it spreading so much already you have it on multiple continents, multiple countries. A containment strategy may succeed in delaying its arrival here. It’s not going to prevent it. We cannot build a wall, a real wall, or a metaphorical wall to keep this disease out. We have to understand it’s coming. It’s here already. It’s going to come to a greater extent and we need to be preparing to deal with that.

Celine Gounder: Some have said that travel restrictions and quarantines just seem like common-sense. Here’s Congressman Brian Mast at a hearing of the House Committee on Foreign Affairs in January.

I feel as though the sense that I’m getting from you all about quarantine not being the right path does not pass the test of common sense. So, if there are people that come to our country because there is no quarantine on them because of this academic approach instead of common sense approach, what do people do to protect themselves when they are exposed to others?

Celine Gounder: Are there any downsides to continuing with the containment strategy, like travel restrictions and quarantines.

Ron Klain: President Trump likes to say he’s implemented a travel ban. What he’s implemented is a travel bandaid, which is a series of restrictions that may sound appealing but aren’t really effective. So the President has banned certain people from coming to this country from China, not based on their risk level, but based on the color of their passport cover. So we have Americans traveling back and forth. Foreign nationals not allowed to come here from China. That still means thousands of people a day are coming from China. What’s more, the President’s order doesn’t restrict the flow of crews coming on planes and ships bringing goods. The truth here is that we could not ban travellers from China because the U.S. economy and the U.S. healthcare system would grind to a halt overnight without the supplies. Most of our hospitals have just a few day’s supply of medicines, antibiotics, equipment that come from China, and they’re going to come here on Chinese boats and Chinese planes with Chinese crews, and nothing that the President can say is going to change that.

Celine Gounder: Is there any reason we can’t keep working on containment even as we start to take additional measures to mitigate a pandemic. Is the horse out of the barn?

Ron Klain: Look, obviously trying to reduce the number of people traveling around to and from China is obviously a good thing. It’s going to slow the introduction of the disease here or the spread of the disease here, but we have to understand, as you said, Celine, the horse is out of the barn and, while the disease started in China, it’s now in Japan. It’s now in South Korea. It’s now in Italy. Are we going to restrict travel to and from all those countries? And frankly, it’s also here in the United States. Should countries restrict travel to or from the United States? So, I think we need to understand that while we can try to reduce the pace with which this disease is spreading a bit by these travel restrictions, we’re not going to stop it.

Ron Klain: And I think there’s another important point here. The whole reason to have a containment strategy is to buy time. And that that’s only purposeful if you use that time to actually take steps to get prepared. So instead of pretending like the disease won’t come here, our focus should be on, are we doing the right things now at this period of time to get ready for a larger coronavirus outbreak in the United States?

Celine Gounder: Scientists actually looked at how much airport screenings delayed the spread of H1N1 influenza during the 2009 pandemic, and those screenings only delayed transmission by a couple of weeks. A couple of weeks isn’t meaningful when it’s going to take another 18 months or so to develop and test a vaccine.

Ron Klain:  Well, I think time does matter here. As I said a minute ago, if you use it well. For example, in the fall of 2014 when we were fighting Ebola, when I took over, we had only three labs that could test for Ebola in the U.S. It took us ten weeks to get that up to a hundred. We had only four hospitals that could treat a patient. It took us about eleven weeks to get that up to seventy-five. So if you use a few weeks wisely, a few weeks can make a difference in our preparation here on the home front. We don’t really see any effort to spin up hospitals, to deal with patients, and so I think that should be our focus, is whatever kind of respite we have before there’s a widespread outbreak of coronavirus in the U.S. Are we using that time to good advantage?

Celine Gounder: Well, and this is why government and business leaders really need to get on board with this. Now, individuals aren’t empowered to take the necessary social distancing measures we’ve been talking about. Their employers need to make it possible for people to work from home as much as they can. We may need to close schools, and if schools are closed, what are parents supposed to do about childcare if they can’t work from home?

Ron Klain: You know, Celine, people talk about these kinds of extreme measures, closing businesses, closing schools, and ultimately it may come to that. But we have to remember when we close these gathering places, human beings don’t disappear. So we saw this in West Africa in 2014 in the Ebola epidemic where many communities close their schools, but then the children went out and played together. And so the students were still mixing. They were just mixing outside of the school place. Here in our own country, you can imagine, if we closed the schools, where are all the kids going to go. That’s, first of all, a childcare problem for people who still have to work, but it’s also just a reality of the fact that we aren’t going to lock every American child up in their home for weeks at a time, and so we have to balance between trying to separate people and the reality that we’re human beings. We’re going to gather whether we gather in the workplace or at school or out of those at movie theaters, or at shopping malls, or at the playground.

Celine Gounder: Here’s a tweet I got from Amelia who works at a community hospital. She says:

Why is there no pandemic preparedness in the U.S. for community ERs in advance of this disease? We have had one email, that’s all the prep we’ve had. No PPE [personal protective equipment], discussions regarding levels and risk assessment. No prep for green zone / red zone. One isolation room. No public ed campaign.

Celine Gounder: It’s not enough to have personal protective equipment. I think some hospitals like Bellevue in New York City where I work, are prepared. We have protocols. We’re training our staff on those protocols and conducting practice drills.

Ron Klain: Yeah. You know, Bellevue, where you work, Celine, is one of the crown jewels of our system. We set up in 2014, what we call it Ebola and Special Pathogen Units. The good news is that Bellevue is one of the best in the country, but there’s only ten hospitals in the entire country in that category, and beneath that fifty hospitals at a lower level of readiness. That means there are hundreds of hospitals in America that aren’t part of that program and really do not have staff equipment or training to deal with something like that. So what are the other gaps beyond that we should also be worried about?

Celine Gounder: In my mind, screening and testing. It is crazy that we are way behind South Korea on this. The CDC still hasn’t released lab tests for local public health use. Private labs haven’t released tests. The FDA hasn’t done anything to encourage private labs to develop tests. We also need to update our screening algorithms. It’s not enough to test people with known exposure and travellers from China anymore. Everyone with respiratory symptoms who has traveled outside the country recently should be tested for influenza and other common viruses, and if they test negative, they should be tested for coronavirus.

Ron Klain: You know, Celine, as you said, we’re way behind Korea. They’ve tested over 35,000 people there. We’ve tested fewer than five hundred in the United States. We may not know that coronavirus is in fact here, and we’re just not testing for it. On Wednesday night, we learned that there was a patient at a hospital in California who’d been admitted and there for, with an infectious disease for more than a week. The hospital officials asked if he should be tested for coronavirus. A government official said no need to cause he had not been to, or exposed to people who had traveled to China, or known people with the disease. It turns out that this person has coronavirus and it suggests it’s possible. We think the case count is still low here because we just haven’t looked hard enough to find the cases. We haven’t tested all the people who should be tested, who may be suspects for having the disease.

Celine Gounder: I really worry about the folks in the ER and urgent care who see everybody, you know, who have no idea what their patient has upfront and who may not be taking the right protections when they first see a patient. You know, I’m on the coronavirus call team for Bellevue, and if I’m called to see a patient who might have a coronavirus, I know that I need to mask and gown and glove up. But for somebody who’s seeing the patient for the first time, doesn’t know the story, doesn’t know the symptoms yet, they may not know to take those precautions.

Ron Klain: Celine, that’s exactly my fear that we have bought some time to prepare with the different measures that have been put in place, but we should be seeing every day efforts to push these diagnostic tools and how to make sure that we don’t wind up taking an infectious patient and having them spread this disease throughout a healthcare facility in the U.S. I mean, that’s the thing that scares me the most. Hospitals as wonderful as they are, are collections of the people who are most vulnerable to this disease.

Celine Gounder: Ron, do you think the federal government is doing what it needs to be doing to get us ready?

Ron Klain: No, Celine, I don’t think we’re moving nearly fast enough. On Tuesday, President Trump did finally ask Congress for 2.5 billion dollars in emergency funding for coronavirus. Now, I had testified before Congress three weeks earlier saying that the administration needed to get that request to Capitol Hill quickly so these programs could be funded. Finally, it has again, three weeks later, finally stepped up and done that. But we’re not sure how quickly it’s going to move that package to the Congress. And in fact, it’s kind of slowed it down by demanding that the Congress cut programs, social programs to pay for these urgent measures that are needed. And that’s going to lead to complexity and delay and dispute on Capitol Hill. So it’s important that the Congress and the White House agree immediately on what needs to get funded, how much money it needs, and get the money out there right away, and every day, while there’s delay and wrangling in Washington, is a delay, that we get further behind addressing this on the front lines.

Celine Gounder: Ron, you’ve acknowledged that you’re partisan. You served as chief of staff for Al Gore and Joe Biden. How do you put politics aside in a situation like this, especially in an election year, how do we ensure that our policies are grounded in science? Is appointing a coronavirus Czar the answer?

Ron Klain: This doens’t need to be a partisan issue at all. When we were handling the Ebola response, I worked most closely on Capitol Hill with a very conservative Congressman who wound up being the chair of the Trump campaign who helped us nonetheless fund the Ebola response. Global health security has traditionally been a bipartisan issue. President Bush, who I disagreed with on many things, launched a massive effort to fight AIDS in Africa, and also to fight malaria in Africa. This isn’t a Republican-Democratic issue. Now, the question, in this particular case is, will President Trump politicize the issue? Will he pursue his politics? Or will he let science and medicine govern the response?

Celine Gounder: So, why was the White House Office on Pandemic and Preparedness Response abolished. It seems like having that in place right now would be really important.

Ron Klain: It’s horrible that it was abolished. It was abolished in July of 2018. Here’s what happened: After the Ebola response, I said to President Obama, you shouldn’t have this one-off disease Czar situation. You should put someone in the White House who’s permanently getting ready for the inevitable next epidemic or pandemic that’s coming that has a team that’s ready to prepare us, and then when it comes, respond. President Obama accepted that recommendation and in late 2015 set up the White House Office on Pandemic Preparedness and Response as part of the National Security Council. That continued for the first year and a half of the Trump administration, but in July of 2018, when John Bolton took over as National Security Advisor, he decided that fighting diseases was not the kind of thing the National Security Council should worry about. And so he recommended to President Trump to abolish the Global Health Security Unit. And so since July of 2018 we have not had a White House office focused on this, and we’re seeing the consequences of that right now with this coronavirus problem.

Celine Gounder: On Wednesday evening, the president announced he was appointing a coronavirus Czar: Vice President Mike Pence. Here he is on CNN:

As a former governor from the state where the first MERS case emerged in 2014, I know full well the importance of presidential leadership, the importance of administration, leadership, and the vital role of partnerships of state and local governments and health authorities in responding to the potential threat of dangerous infectious diseases.

Celine Gounder: As governor of Indiana in 2015, Mike Pence’s delayed action allowed an alarming spread of HIV in Scott County. He had ideological objections to syringe exchange programs. This is a man who has a history of prioritizing politics over science. Ron, what do you think of the President’s choice.

Ron Klain: I think it’s not a great choice. As you said, when Mike Pence was governor of Indiana, he rejected the advice of public health professionals. Someone who puts politics over science is a big problem. Secondly, as I said earlier, coordinating this response is a full-time job, and that full-time job needs to be done by someone who’s working on it full-time. The vice president has many other responsibilities and Vice Presidents can do important, complicated things. They can play a huge role in moving initiatives for a President, but this kind of problem really needs a full-time focus.

Celine Gounder: And again, mixed messages. After that press conference, HHS Secretary Alex Azar told the press that, no, really, he was in charge. And then less than a day later, Mike Pence appointed Dr. Debbie Birx as White House Coronavirus Response Coordinator. I am still confused. Who’s in charge?

Ron Klain:  I really wonder if the Vice President’s priorities here are response and science, or politics. One of the first things that the White House did yesterday after they put Mike Pence in charge was, their first directive was, all press calls about coronavirus have to go to Mike Pence’s office, and that’s not the right place to start. The right place to start is focusing on the response, the moving of resources, not managing the PR on this.

Celine Gounder: Look, to be fair, it’s not just in the U.S. that the coronavirus response has been politicized. For example, a public health official working in Egypt told me that the first case in Africa wasn’t the first case. They’re covering up the index case who was missed a few weeks earlier. They have hundreds of contacts they’re tracking down, but they’re only reporting twenty or so, and this is all because their tourism industry is finally recovering and they don’t want to damage it.

Ron Klain: You can’t separate the question of epidemic and pandemic response from politics. Now, it doesn’t mean it’s a partisan issue, Democrats versus Republicans, but it does mean the kinds of things that drive politics — economics, questions of national status, questions of how we run our healthcare system — are intertwined in epidemic response. We have to understand as this proceeds, there’s going to be continuing intersections between political considerations, policy considerations, public relations considerations, and how effective we are in responding to this. The goal of policymakers should be to try to strip those barriers away, and try to let science and medicine be the driving force. But in our country and around the world, these political considerations bleed in, and that’s something we need to be really be on the watch for.

Celine Gounder: So some have said that our focus needs to be on the U.S.

Ron Klain: Clearly, the focus of the American government needs to be on keeping the American people safe. But the way we keep the American people safe is to improve global health security. It’s funny to me that some elected officials understand immediately that to fight threats like terrorism, you need to send American troops and American experts overseas to fight the terrorists overseas so we don’t have to fight them here in the U.S. But they don’t see that the same thing is true for global health security. If we don’t want to see viruses spread around the world, if we don’t want to see the American people at risk from diseases from around the world, we need to help other countries check those diseases in their own countries. We need to help, particularly poor countries, to improve their healthcare systems and to help bring these diseases under control so we don’t wind up with them here. We live on a very, very small planet. Someone can get on a train, to an airport, to a plane, to any major American city in twenty-four hours. The idea that we can protect our country just by thinking about our own country is a fallacy in the modern world, and we need to be engaged with the world to keep the American people safe.

Celine Gounder: Every week we’ll answer a couple of listener questions. Tweet us your questions @CelineGounder and @RonaldKlain, that’s @CelineGounder and @RonaldKlain. We answered a question from Amelia earlier. Here’s also a question from Tracie.

I am a little nervous to travel by plane later this week and over spring break in a few weeks with my family, fearing exposure to COVID-19. What are some things I should do, what are some things should I worry less about? I am traveling within the U.S.

Ron Klain: So far there are no travel advisories to parts of the United States from the Centers for Disease Control. And while we have now one case of community transmission in the U.S. that’s confirmed, there may be others. We don’t really know that there’s a particular place in the U.S. that’s any more or less safe than any other place. We saw travel advisories to the U.S. for the first time ever from the Centers for Disease Control in response to the Zika outbreak in the winter of 2015-2016. We may see that again this time. So my advice to you would be to check cdc.gov, stay on top of the information there, but right now there’s no reason not to travel to any part of our own country.

Celine Gounder: I’ve been getting a lot of questions lately about what individuals, families can be doing to protect themselves as, as coronavirus starts to spread here in the U.S. and you know, honestly, there’s some pretty basic things you can do, one of which is wash your hands. And if you have no choice about traveling, there are a couple of precautions you might take. Open the air vent above your seat. This will help dilute potentially infectious particles in the air and it helps blow them to the ground more quickly. Definitely bring alcohol sanitizer with you, and you might consider bringing disinfectant wipes to clean surfaces you touch like tray tables.

Ron Klain: Here’s one more thing everyone should do. They should tonight go down to Chinatown in their city and buy dinner or go shopping there. What we see, inevitably, what we’re seeing already, is discrimination against Chinese Americans and Chinese-owned businesses being savaged by people staying away out of needless fears about coronavirus. This virus infects humans, all of us, not people who are particular ethnicity or race. And when you have an epidemic like this, there’s inevitably discrimination, stigmatization, ostracization, and we’re starting to see that already. We all need to make a personal stand against that. We need to encourage our leaders to take a stand against that. And I think it’s very important that we all do what we can to try to fight that kind of needless discrimination.

Ron Klain: Next week we have a great guest lined up for you: Dr. Tom Frieden, the former Director of the Centers for Disease Control, and probably the world’s leading public health expert.

Celine Gounder: Dr. Frieden oversaw the CDC’s response to the Ebola epidemic in West Africa. He’ll be sharing what he learned from that experience.

Celine Gounder: “Epidemic” is brought to you by Just Human Productions. Today’s episode was produced by Zach Dyer and me. Our music is by the Blue Dot Sessions. If you enjoy the show, please tell a friend about it today, and if you haven’t already done so, leave us a review on Apple podcast. It helps more people find out about the show.

Celine Gounder: You can learn more about this podcast, how to engage with us on social media, and how to support the podcast at epidemic.fm. That’s epidemic.fm. Just Human Productions is a 501(c)(3) nonprofit organization, so donations to support our podcasts are tax-deductible. Also, check out our sister podcast, “American Diagnosis” at americandiagnosis.fm where we cover some of the biggest public health challenges affecting the nation today.

Celine Gounder: I’m Dr. Celine Gounder.

Ron Klain: And I’m Ron Klain.

Celine Gounder: This is “Epidemic.”