In 1994, Laurie Garrett published The Coming Plague: Newly Emerging Diseases in a World Out of Balance. Two years later, she won a Pulitzer Prize for her reporting in Newsday on the Ebola outbreak in the Democratic Republic of Congo, then Zaire. Garrett, along with other journalists like STAT’s Helen Branswell and Science magazine’s Kai Kupferschmidt, has emerged as a leading voice of information and guidance on COVID-19. Though Garrett has been accused of erring on the side of alarmism during past outbreaks, COVID-19 is unlike any outbreak this country has faced in more than a century. In a piece last week for Foreign Policy, “Sorry, America, the Full Lockdown Is Coming,” Garrett urged Americans to quickly decide where they wanted to settle in for the next few months. Intelligencer talked with Garrett about that scale of lockdown, why testing for COVID-19 antibodies needs to be done, the chances of getting a vaccine, and exactly how much blame should be placed on the Trump administration.
What would a full lockdown in the United States look like?
It’s going to look different in every part of the country. What I wanted to say to people is, You don’t have a lot of time. The wise course of action for any household is to assume there’s going to be a lockdown of some kind. Get yourself to wherever it is you want to be with whomever you think you need to be with, so that you’re ready as soon as an announcement is made.
There’s a lot of news coming at us right now. What is the most important thread you’re following?
At the moment, the most critical information is whatever we can get from the lousy amount of testing that’s getting done. I am really excited that a team at the [Icahn School of Medicine] and collaborators around the world have come up with an antibody test. We’ve been desperately needing an antibody test. Do you know the difference between the current PCR [RT-PCR testing] tests and what we’ll know from an antibody test?
No, please explain.
Basically, there are a few kinds of testing information we wish we had. One is using real-time PCR — RT-PCR. You’re actually measuring the presence of the [ribonucleic acid, or RNA] of the virus in the host of the human sample. It’s telling you this person in front of you is infected at this moment. That’s useful for a diagnosis. But it’s not useful for very much more than that. On Tuesday the test might come up negative, but the person might be positive on Thursday.
The second kind of test would be an antibody test. What that’s measuring is: “Has your body ever seen the virus?” That’s useful in two ways. As a diagnostic, it gives the refined information: “Yes, you have this in you at the moment.” It also can guide the activities of the physician, who might say, “Gee, I’ve got a pneumonia patient, I wonder if they’ve ever had COVID?” But the most important thing is that that test can be a public-health tool. If we had this antibody test, we can go around randomly selecting people in New York City and find out how many New Yorkers, including right now, have had this virus in their bodies. Since we know the virus has never been in human beings before, anybody who has antibodies against it has been exposed since January.
If we can get this antibody test mass-produced — and I know they’re working on it right now — and put it into commercialization really quickly, this could be a game-changer for the whole pandemic. One of the things we would love to know right now is how many people who have had pneumonia since January were actually COVID cases? Having answers to that question would make a difference on a policy level. If we were suddenly seeing a surge in hidden pneumonia cases since mid-February, that would tell us we’re in deep, deep doo-doo; that this thing is like Italy; that we’re going to suddenly skyrocket and our hospitals are going to be overwhelmed. But if, by contrast, the same number of cases are found in the historic samples going back to the first of January, that would tell us, “Okay, it’s gradually unfolding, we don’t have to go down to lockdown every single person in New York, we may be able to flatten the curve.” And that makes a big difference in terms of how drastic our policies need to be. There’s a reason that the governor and the mayor and the mayor’s own department advisers are arguing. We just don’t have good, solid data to work with. We’re flying blind in New York City. They’re even blinder outside the city because the population’s more scattered.
How quickly could something like an antibody test get to market?
It is a multinational effort, so the good news is no one country or no one institution is likely to hold the patent and many different companies may come forward and bring it to market. Everything to do with patents and diagnostics is a mess in this country right now. The good news is part of the team that did this is in Finland, and they have much more progressive laws about patents and access. This was just published days ago; it’s fresh off the press.
Should we still be preparing for the worst-case scenario?
We’re already past the point! I’m hearing from doctors all over New York, frankly all over the country, that they and their nurses and the whole medical team are scared to death. They have no way of telling who is carrying COVID. Only a minority of COVID patients or carriers who walk in the ER have the full-blown list of symptoms: the dry cough, the high fever, the loss of appetite, muscle aches and weakness, brain fog. The vast majority of COVID people never show that constellation of symptoms. They may show one or two. And many never show symptoms that are diagnostic at all.
If you go to any hospital, but certainly anywhere in New York City, there’s an intake nurse or clerk who has direct contact with all of the emergency-room admissions or people who want to be admitted, and that person’s job is to take all of your insurance information and also to do some form of triage, to decide if this is an emergency case that has to get through the system fast. But now we’re asking those same people to decide if this is someone who needs to be separated from the rest of the herd. And that’s a whole lot of a burden to put on someone, especially if they don’t have protective gear to wear.
How did we end up so dangerously short on protective gear?
There are two issues here. One is an issue of readiness, and one is an issue of economics. Let me start with the second one. We’ve had ample warning that this was going to happen. And it’s not just affecting personal protective equipment — everything in the medical system, every single tool that is used to treat patients is infected by this. Medical-device and -equipment manufacturers discovered decades ago that they can make their products much more cheaply overseas than in the United States, whether it’s thermometers, masks, or some of the most sophisticated equipment (CAT scans, syringes). When you have a disruption in the supply chain that affects China, you have everything backed up for not just us but for the whole world. What if every place in the world increases demand at once? Can manufacturers meet that acceleration of demand? So it’s not just that some guy in Kansas needs PPEs, it’s Rio de Janeiro, Malaysia, Singapore, everyone needs an increase in production at once. If you work the supply chain backward, let’s say with latex gloves, and you get all the way to rubber tappers, what’s the rate of rubber extraction? We’ve built a house of cards, and I think this is one of the key reasons that the smart folks on Wall Street are freaking out. We’re seeing this whole house of cards tumble with the epidemic. It’s affecting every aspect of supply chain and distributed production in the entire global economy. That side of it is not unique to the Trump administration.
However, if you think there’s a likely pandemic coming down the road that’s going to hit America, couldn’t you have created national stockpiles, or anticipated the need for domestic production? We have become what’s called an adjusted-time-delivery economy. Whether it’s a quart of milk or a Mercedes-Benz, in the United States, we want to do everything we can to avoid the cost of inventory and warehousing. The whole retail model that evolved in our country was based on zero warehousing — no company had a pile of PPEs sitting in a warehouse someplace. So that left only one government intervention to speak of, and that was the national stockpiles that were created essentially to deal with bioterrorism. They were accelerated after 9/11; we stockpiled some essential supplies — masks, ventilators, massive numbers of drugs, supplies to deal with radiation sickness, and so on — scattered around the country in secret locations. But unfortunately, the scale of the national supply level is not pandemic level. It is an incident level.
All this takes me to the final point, which is, if you knew all this — the limitations on our stockpile, the production issues, the just-in-time delivery, and so on — shouldn’t some federal government office in January have said, “We need to start buying up PPEs?” And the answer is, of course, yes, they should have.
What do you make of the messenger-RNA vaccine, which is now going through clinical trials?
So far, we have one study that I know of, which was of only two rhesus macaque monkeys, that assures us it is possible to make effective antibodies against this virus. In humans, we have really mixed and confusing information from China and increasingly from Italy that indicates that some people may actually get reinfected. I’ll tell you why it’s confusing right now. Our tests are measuring whether you have viral RNA in your body at the moment, and there’s a limit to how sensitive they are. In the early days of HIV, when [AIDS researcher] David Ho was named Man of the Year by Time magazine, there was this declaration that we’ve conquered HIV because tests stopped finding the virus in the bodies of people who were on these antiviral drugs. But it turned out that the problem was the tests just weren’t sensitive enough. The virus could hide inside of cells. The minute you went off your treatment, you got AIDS and died. Now we know that none of the people put on HIV treatment can ever get off their drugs. The worst-case scenario is that it’s the same thing with the coronavirus, that it’s capable of lurking at incredibly low levels in the human body and then at some advantageous moment, long after you think you’ve become immunized, it can surge back.
How do you account for the coronavirus patients who have become infected a second time?
There’s two possible explanations. One is that the virus is actually lurking, never really gone, and you’ve had false claims of being cured. The other is that in fact the immune system is not making an effective neutralizing antibody response, so some percentage of these people are not truly immune and they can get reinfected. We don’t know which is true. This rhesus macaque study I mentioned gives us hope. It indicates that those monkeys make effective neutralizing antibodies and cannot get reinfected. But it’s just two monkeys, for God’s sake! Until we really know the answer, the whole idea of going the vaccine route makes me nervous. We just don’t know if it will work. While we’re trying to make vaccines, and while various companies around the world are frantically ploughing ahead, the virus itself is out there naturally mutating. If you go to www.gisaid.org, an open-source repository of all genetic strains of the COVID-19 virus, you’ll see that we already have 683 fully sequenced versions of the virus. That’s not HIV-level of mutation, but it’s a lot!
So that makes me worried that a year from now, when we finally have something that looks promising and we’re ready to go into large clinical trials, there may be enough strains that it has to be treated like the annual flu vaccine, where you actually get five or six viral vaccines at once because there’s so many different strains of flu out there. I’m not at all optimistic that we’re going to have a vaccine in a year or even a year and a half. I think it’s going to be far more complicated
What do you make of the media’s coverage over the past month and a half?
This epidemic is moving so fast that whatever you write is probably out of date by the time it’s published. Everybody’s just racing and trying to be as accurate as possible. But you know that much of what you write is going to turn out not to be true five days later. Maybe even five hours after publication. Given that, I think a lot of the reporting has been excellent.
But there’s a huge generation gap in terms of where people get their news. The whole idea of getting your daily New York Times to absorb what’s going on in the world is a marvelous, quaint notion of the past. So if you’re a younger adult, or frankly an older child, you’re likely to be osmotically absorbing this vast array of factoids off the internet, whether it’s Instagram, Twitter, Facebook, or you’re sitting in Reddit chatrooms, God help you, and somehow you personally are trying to filter the accuracy of that information. And that’s a pretty lousy way of having people decide what to do in a pandemic.
I wrote a piece that was published in The Lancet, arguing that it was insane that the primary voices of accurate information and up-to-date analysis of the pandemic had such poorly funded communications efforts. The World Health Organization has only five full-time communications officers — for every time zone on earth, for every language on the planet. Five people! One was for all social media on earth. This is true of every health-department agency. It’s true of CDC. Communications always ends up on the bottom of the pile. People who call themselves journalists with a capital J are counting on institutions like WHO to supply a steady stream of accurate assessment and reassessment. Those kinds of institutions have five sleep-deprived people working 24/7 to do that.
You have a whole other layer of difficulty created by governments trying to control information. China has been tearing down social media like crazy, and now they’re trying to shift the entire narrative into one that attacks the United States and says that the virus did not originate in China but in a military laboratory in the United States. But we have it here, too! Our CDC makes decisions about which kinds of reporters they choose to respond to. Certain people get blackballed, and you can’t get answers to your questions because you’ve written something that the director of the CDC found critical, found unreliable. Our top voice of reason, Dr. Tony Fauci at NIAID — he’s an amazing guy and has boundless energy, particularly for a man of his age, but you can only split hairs so far. Eventually, that human can’t answer every single journalist’s query and can’t deal with every single information outlet. I’ve been very heartened to see that Fox News is no longer claiming that the entire epidemic is a hoax created by liberals in order to smear the president. We are seeing a kind of deer caught in headlights. Tucker Carlson and Laura Ingraham and all these people are trying to act as genuine news anchors, anchoring accurate information about an epidemic, and that’s so new to them that you see them suddenly grasping, Oh, now what do I do? What does a real anchor say now?
This interview has been edited and condensed for clarity.
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