Andy Slavitt on Vaccines, Biden, and How Life Will Get Back to Normal
Tags: Coronavirus, Science, Public Health, Covid 19, Society

This article is adapted from a new live-event series called Medium in Conversation. Andy Slavitt is a former administrator of the Centers for Medicare and Medicaid Services under President Barack Obama, host of the pandemic podcast In the Bubble, and author of the forthcoming book Preventable — a behind-the-scenes look at the U.S. coronavirus crisis and response. Sarah Collins is the editor-in-chief of Elemental. Slavitt and Collins spoke in front of a Zoom audience on December 8 about incoming Covid-19 vaccines and what people can expect in the coming weeks and beyond.

Elemental: Since day one of the pandemic, [you have] been reaching out to your vast network of health care experts, politicians, and scientists and broadcasting info through Twitter threads and Medium posts. What compelled you to start reaching out to experts and writing these posts, and what were you hoping to accomplish?

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Andy Slavitt: Remember this, back in March, which wasn’t that long ago, nobody knew anything. Now everybody’s an armchair epidemiologist and we all know curves, but the administration wasn’t saying a lot and it was hard to know what the reality was. I was just calling, talking to hospitals in New York, talking to scientists, talking to politicians, talking to labs about how long things were taking. I’d pick up the phone and call people who are manufacturing ventilators. So one day, I just basically put it all in a thread. I’m like, “This is what I did today,” and it had 10 million views. I was like, “Okay.” So I did it the next day. And then I did it the next day. I realized that people were lacking really transparent information in a way that was usable. Over time, I think as people have had more basic information available to them through reliable sources, I’ve gone away from providing facts and more towards what I’m learning and towards impressions, so I don’t drive everybody completely crazy.

Well, you’re not driving us crazy. You’re helping us a lot. Now you’re 10 months into this, and you’re still doing it. How have you not managed to spiral into just a pit of despair and rage at some of the things you’re learning?

I never despair. Maybe sometimes rage. There are things to be angry about, but even then, I think you [can] catch yourself and realize how much of it is just frustration at the situation. I’d love to be able to sit here and say, “Look, everybody’s doing the best they can, and therefore we have to be a little bit charitable.” I would love to feel that way. I actually don’t feel that way. I don’t think everybody involved has been of pure instinct and trying to save the most lives. Look, if we were out there doing our best and failing but I felt like everybody was out there prioritizing trying to save people’s lives, then I’d be very charitable to that.

But there are things you run across and people you run across who have other agendas that they’re laying over this. And then I think occasionally you get angry just the way things are in the country. That things are unfair for certain people, for farm laborers, for people in jails, for people in nursing homes. As you run across that stuff, it makes you want to call attention to it and want to make it better. Look, a lot of those things were true before the pandemic, they’re true and worse during the pandemic, and I think it’s up to us whether they’ll be true after the pandemic.

The theme of this talk is that it’s darkest before dawn. I want to start talking about the darkness. As of today, more than 283,000 Americans are dead. Cases are spiking in nearly every state. Health care workers and hospitals are overwhelmed. Public health experts are exasperated. And then you have the pandemic deniers and the anti-maskers and our current president. As you’ve said, we aren’t just dealing with a pandemic. We’re dealing with a society who doesn’t know how to deal with the pandemic. So, in a nutshell, just in a few sentences to start, how did we end up here?

I think there’s a couple of things about our society that have become real challenges in the pandemic. If you wanted to pick a country where you’d say, “Where’s the easiest place to make a billion dollars?” if that matters to you, you’d probably say the U.S. is at the top of the list. But if you wanted to pick a country with a collective commitment we had to one another to save lives, unfortunately, we wouldn’t be at the top of that list. We’re a country that’s not used to sacrificing. So, if I don’t have my Starbucks in the morning, I’m cranky, right? Whereas my grandparents and all of our great-grandparents went through the Depression. They went three years without coffee, right?

We’ve never dealt with a big global health crisis like this en masse. It’s the kind of thing we think happens to other people. It happens in Asia. It happens in Africa. One of the premises of my book is you have two lines of defense. One of them is your technology and your government and your CDC. If that works, as it always has for us, that’s great. But your second-line defense is each other, and that’s where I think we’ve really fallen down. Without even mentioning Trump, without even mentioning what I consider to be very bad leadership, we have some endemic flaws that we have to face up to.

A lot of those things were true before the pandemic, they’re true and worse during the pandemic, and I think it’s up to us whether they’ll be true after the pandemic.

In this time when everything is so serious and scary, what do the next six weeks look like for us, and what mindset should we have to get through both safely and sanely?

The best mindset is it’s only six goddamn weeks, right? Six weeks from now seems far, but six weeks ago doesn’t seem that far. We have to understand that what we’re asking of each other is not unlimited. If you want to be busy doing something, be supportive of the people that need it. If you need help, by all means, ask for help. Ask the people in your life for help. If you could provide people some help, do it because it’s been challenging over the holidays. It’s challenging during the winter. I don’t want to make light of it, but it is much more dangerous out there than it looks.

How is the Slavitt family navigating right now? What are you doing? How careful are you being?

We’re careful. I mean, all of us have had preexisting conditions of some sort. All of us are slightly at risk. Look, I’m not going to lie. We have the privilege to be careful. It would be very irresponsible if we weren’t because there are people that are forced to see us every day. If you work at the grocery store or whatever, you should not be forced to see us without a mask because you don’t have a choice. We have a choice. I mean, the people in this country that have a choice — the separation between those who do and those who don’t is enormous.

In my book, I interviewed a whole bunch of different people. One was this guy who works at an Amazon warehouse. Not only did he get Covid-19 at the Amazon warehouse when he was forced to work, but then he went, when he got sick, and he couldn’t get a test because there were no tests, they stopped paying him, and so he had to get back to work as soon as possible. So, for any of the rest of us that aren’t in situations like that, I would hope we would be realizing how privileged we are and then doing everything we can to just help out those others.

That brings me back to the analogy “it’s always darkest before dawn.” We’re in this terrible spot, but there is a guaranteed light at the end of the tunnel and soon. It’s just a very strange place to be. You tweeted about this, and you said, “What will I regret not doing once the dawn is here? Knowing with good certainty that soon enough will be out of this is a gift of sorts.” How do you intend to use the remaining time of the darkness in a meaningful way?

The thing about that expression — it’s always darkest before dawn — is that people usually say it when they’re trying to tell somebody, “Hey, I know it seems bleak, but keep going. It’ll get better.” But they don’t know when it’ll get better. We are in an amazing situation where we actually have really good confidence that over the course of 2021, because of the vaccines, things are going to get a lot better. What that should tell us is “Okay, we’re living through a historic period, but there’s a limited window. What do we want to do to take advantage of that window?” I just think, maybe it’s my own obsession, but I just think about all the people that are going to die every day.

It’s like every death you can prevent, any bit of despair you can prevent, and I don’t distinguish between people dying from Covid-19 or people who are upset and have addiction challenges or people who have any kind of challenge, those things are going to be better soon, I hope. But we’ve got to help people get there. I just view it as an amazing opportunity, whatever way any of us can in our community, to reach out and help people. Sometimes you’re not in a position to help people. You may need help, but you have to ask for it. I think there’s nothing more encouraging and empowering in the human condition than asking someone for help or hearing someone’s plea for help and knowing you can help and doing that. We started out that way, I think, in April, but we got a little bit away from this in the last few months, and we turned against each other.

People say, “Well what do you do about the people that don’t believe in this?” Don’t do anything about it. When does it make sense to worry about the things we can’t control? If there are people that are going to be doing stupid things, the chances of us changing their minds are pretty low. I guess I advise people that when the dawn comes, are you really going to want to break your relationships with your children, with your cousins, with your friends, over a temporary situation? And people don’t like to be judged, so it very rarely works anyway to glare at people who aren’t wearing a mask.

That’s great advice. I think as we move into the dawn in this conversation, we know that the two things that will get us there are vaccines and a new administration. And so I want to talk about both and start with vaccines. Despite the ineptitude in America’s Covid-19 response, there’s a lot to be proud of when it comes to vaccine development. What stands out to you about the development process?

There are the career civil servants, like Peter Marks at the FDA, like Rick Bright at BARDA, Anthony Fauci at NIH. Part of the reason why we have gotten where we are is Rick Bright made an investment in the messenger RNA platform in 2017. And Peter Marks came up with this idea that we would embed government people on each of the best pharmaceutical teams so that we wouldn’t have to do the back and forth of the submissions to the FDA, and he called that Warp Speed because he’s a Star Trek geek. And before it got big — before the White House started calling it that and before the White House was even aware of it — Marks said, “We should get money for Congress to do at-risk manufacturing.” The civil servants have been so maligned by the president and by this administration. These are real heroes here.

There’s lots of heroes, and I don’t begrudge credit for anybody for getting these things done successfully because all the vaccines, like every other good thing, are a massive team effort. But I think when the story emerges, that will be there. And it’s not a uniquely American thing, as you know. There’s BioNTech in Germany, Oxford in England, all around the world, and it’s not a story, sadly, of U.S. collaboration and cooperation, but it is a story of science absolutely kicking butt. They should be very proud.

We’re probably just about a week away from vaccines starting to roll out across the country, which is incredible. You did a great podcast recently about vaccines and about their dissemination. Do you feel optimistic or pessimistic about how the rollout will go and why?

It won’t go perfectly. But it depends what our expectations are. Sadly, I don’t think the public is willing to give the process any time. I think people will be barbecuing on Memorial Day whether we have a vaccine or not. So we have to run pretty fast at this. I think in terms of how we’re going to see where our readiness is in each of these processes, I think we’re actually quite good at having a vaccine that is going to do far better than we thought, which essentially means we don’t have to give it to quite as many people for us to reach herd immunity. I think manufacturing is going to be a challenge because we’re going to be a little bit behind, but I think we’re talking about weeks, not months. In other words, if you’re not in group one or group two or group three, it’s not a matter of like, “Okay, you’re not going to get it for months and months.” It will be probably a matter of weeks.

I think our distribution system, whether it’s FedEx for Pfizer or McKesson, they are good logistic partners. And then the last mile is you’re at the CVS, you get a call, you get a note, you got to come in, and you got to come in a second time, you got to be scheduled, and all of that. And then, of course, you can’t be at the CVS with 700 people; you’ve got to be in there one at a time. And I think they know what they’re doing. There will be bumps. We’ll be following it closely. But in the big picture, if we should get it done by May or June and instead we don’t get it done till July or August, that’s still an enormous success. In fact, getting it done in 2021 is an enormous success.

We have the privilege to be careful. It would be very irresponsible if we weren’t.

Each state’s handling of the pandemic so far has been really individual and all over the place. How does that play out in terms of vaccine dissemination and is that individuality a problem?

Yeah, it has been a problem. States are not set up to manage disasters on their own. They don’t have public health departments set up to do it, they don’t have the capital resources, they can’t do what they want to do, which is close businesses but keep them whole and keep them from closing. So the federal government had a much bigger role to play in all of those things, including procurement. And so we need a much more coordinated effort here.

Hopefully, most states will just follow the [American College of Physicians] guidelines, and there’ll be some interesting public debate. When should teachers be vaccinated? College students? We’ve thought through most of the big-chunk issues in most states. There will be states where we have really complex challenges in terms of rural populations. There will certainly be bigger challenges. But the thinking that went into this from the U.S. Army has been good, and the ability to get the vaccine from here to there, we know how to do it. We’ve got to hope that as many people as possible come back for their second booster, things of that nature.

We’ll all be in the squishy middle for a while. Some people will get vaccinated, some won’t be, some will be halfway. Do you see a system where there’s some sort of badge or passport you have for proof that you have been vaccinated and then, therefore, you can go back to college, you can go to work, go back to the office?

Sure. What we have today is low tech, where you can’t go to college unless you get your vaccinations, you can’t go back into certain schools. And I think with things like sporting events and music events, you see organizations like Clear getting involved. I think there are partnerships between companies like StubHub, Clear, and different sports and music leagues where you’ll be able to either confirm your vaccination or get a test as you’re buying tickets to something. And it will just become a part of the social compact that you don’t go into large events or large spaces or large crowds with other people if you’re at risk. So I do think that will become more of a norm.

And look, at the same time, massive reductions in community spread will start to make them less and less necessary over time. Not this year, not 2021, but over time, we’ll have very low levels of community spread.

The way I talk about it is presumed guilt versus presumed innocence. If I ran into you in the streets, Sarah, and you weren’t wearing a mask, I would have to presume that you might have Covid-19. At some point in time, the community prevalence goal gets so low that I’ll run into you in the street and I’ll assume you don’t have it, and that’ll be back to the way we used to think in 2019. And if you were seeing a friend, you’d give them a hug, and you wouldn’t think twice of it because the risk would be so low.

The vaccine will help us get to that point. With the vaccine, plus mask-wearing for a while, we’ll start to get the community prevalence so low that the chances of us running into each other and one of us having Covid-19 would be incredibly remote. Risks are never zero, but when we get back to that point, some habits will stick. We may still wear masks during the wintertime; we may never shake hands again because we wonder why we ever shook hands to begin with. It may be a whole new set of habits, particularly for certain times of year.

What is the threshold for when it flips, where the presumption of guilt becomes the presumption of innocence? Or the threshold for when you actually go in for a hug? What is that point?

Right. So I’m going to say it depends on one factor, which is your own risk prevalence. So if you’re 85 versus 25, it’s a different answer. If you have diabetes or something like that, it’s a different answer. So I think you’re going to be around a loop, but I think you just go back and look to the measures that were rolled out by Deborah Birx back in April that were never followed. And you have prevalence levels per 100,000 that are really, really low when you get to green. And there’s something called European green, which is a level that they get to in Europe.

I don’t know if people saw the videos in Australia — they just had these massive street parties because they got to a level of Covid-19 that was like zero new cases in a day for some period of time. They just had massive street parties because their chances of getting Covid-19 were literally approaching zero — if not zero. So it can get down to that. It doesn’t seem possible, but the way the math works, it’s actually interesting.

Just like we have exponential growth, there’s a parallel concept called exponential decay. And exponential decay is actually a good thing, even though it sounds kind of goofy and eerie, but it’s when exponential math works in your favor. It’s how 100,000 cases a month later becomes a dozen because if you get the R naught below like 0.5 — which means that every person spreading it to less than half a person — you start to take that number and multiply everything by 0.5, 0.5, 0.5, 0.5, you’re cutting stuff in half really rapidly. So, that can happen quite quickly, but we shouldn’t jump the gun either. I mean, we should just be checking out those tolerance levels. And I think the good news is that to your point about the election, we’ll have a CDC that my presumption is will be very clear and very specific about what those numbers need to be.

That’s great. I look forward to the day with specific and clear instructions. One more question about vaccines for you: There’s been a lot of rumbling about vaccine hesitancy and how some Americans may not get the vaccine because of distrust and misinformation. Other experts are saying that this is overblown and actually talking about it all the time normalizes it and makes it a thing. What do you think?

I guess I don’t know how worried to be about it, to be honest, Sarah. If you’re worried about political interference in the vaccine process, all you have to do is look to the fact that Europe already approved the vaccine. They were not involved in our political process. The data is incredibly strong.

There’s a set of people that will never take the vaccine. Fine. We can understand that. No one’s going to convince them. That’s not a huge part of the population. There are others that maybe they don’t like needles or maybe they don’t want to get a second dose or maybe they’ve got other types of concerns. We need to listen to what those issues are. I don’t think the answer is bullying people into taking it but rather to listen. I think we need probably 70% of people to take the vaccine, and I think that’s achievable.

I talked to people who are very different from me politically the other day, and they said they’re taking the vaccine. I asked if they would be public about it, and they said they will be. It would be great if President Trump publicly took the vaccine and told his supporters to take it. I don’t think he will. I suspect he will do the opposite. But if he did, that would be great.

Speaking of administrations, let’s talk about the Biden administration. You have said that you don’t just expect “not Trump” but that you expect repair. What do you mean?

I had this conversation with David Frum, and he said something that stuck with me. He said it’s really impossible to get an “A” managing a vaccine and managing a pandemic, but it’s a no-brainer to get a “B.” Because to get a “B,” you need to demonstrate some amount of compassion and empathy and a decent level of competence, and people will give you a lot of credit. So it’s almost remarkable that we have had a president that has been unwilling, in my opinion, to show any amount of compassion or competency or just level with the public, just to say, look, here’s the situation. So repairing those things is a no-brainer because that’s a low bar. So is demonstrating compassion. I mean, the president-elect himself, I think because of who he is and what he’s been through, will do that. He will talk to the public that way. The people around him, the people who’ve been brought in, they will be competent, and we will get the straight answers, and we will get the truth. Unfortunately, that’s not the job. The job is to build back, and it’s to fix the things that aren’t working.

The fact that he named someone to run, for example, the impact on health equity and health disparities, that’s like saying we don’t just have to be good at this, but we have to fix the things about our country that were shown to be broken. And it doesn’t happen automatically.

We may still wear masks during the wintertime; we may never shake hands again because we wonder why we ever shook hands to begin with.

So this is a wishful-thinking question, but I’m going to ask it. When Biden comes into office in late January, will there be any tangible differences that we notice immediately? Will it feel like a switch has flipped?

I think in some respects it might because I think we’ll start to feel like we’re getting clear, compassionate communication hearing from science. I think it will feel like we’re seeing the progress as it happens. We’re getting told the truth. That doesn’t mean it’ll be instantly better, and I think it would also mean we’re going to have things asked of us.

Biden announced key members of his health team recently, including the heads of CDC, HHS, the surgeon general, and an appointment for Dr. Fauci. Any surprises in these selections? What do you think of them?

I don’t know the woman who has been asked to run CDC. I’ve heard really good things about her. So in the sense that I don’t know if I call that a surprise, everything I’ve heard is she’s the exact right kind of person that we need right now.

Xavier Becerra to run the department of HHS is, I think, an excellent choice. I love the idea of finally combining health and justice as kind of a powerful concept for our country. We couldn’t ever have needed it more than we do now. And he’s a wonderful person. I think he’ll be great.

Jeff Zients will run the pandemic response. I don’t know anybody more competent and more execution-focused than Jeff. He and I worked together on the ACA turnaround, and I just think he’s amazing. I’m so grateful he was willing to do this.

Then Fauci’s role is great. I mean, that should bring a smile to everybody’s face. Vivek [Murthy] is one of the most empathetic and compassionate people that most people who’ve met him have ever known. And then all of them have another quality that we’ve been missing, which is they all are trusted by the president or the president-elect.

You have some relatively weak people [currently] at CDC and HHS and FDA who just kind of want to know what the president wants. They don’t want to tell him what’s right. You end up in a place where any dissent gets squashed, and you end up in a place where people just sort of crawl into a shell.

I think we’re going to have a place where people will all very much be on the same page, which the public needs. And I think they’ll keep adding more good people. I’ve been helping out where I can in the process of looking at people, vetting people, and they’re just incredibly thorough. And they’re looking for people who look like America. They’re looking for people who have actually experienced challenges personally. They’re looking at people who are the best at what they do, and they like people who are team players. And by team players, I don’t mean like loyal to a fault. I just mean people who aren’t looking to get a lot of credit for things. I think a lot of that is Ron Klain, to be honest. I think Ron — he’s got a lot of wisdom in terms of how these things can work best.

I want to talk about the war on truth and science. In this new administration, how can we change the minds of people who are Covid-19 denialists and also who are questioning science and scientists? Or are people just too far gone or do we not try?

I think this is a bigger question caught up in bigger waves than even the pandemic. It’s just sort of how tribal we’ve become. I try to explain it to people this way. It’s like, let’s say, I don’t know what your religion is, Sarah. Let’s say you’re Protestant, and you meet a priest who you love and a Protestant pastor who you don’t love. Then people ask, “Why didn’t you go to the priest on Sunday? Why didn’t you go to see the Protestant service?” You’ll say, “That’s who I am. I wasn’t evaluating what I liked better. That’s my identity.” In this country now, a lot of these things that shouldn’t be part of our identity are part of that package.

And you do what your tribe does. And if your tribe says they don’t like masks, your identity in the tribe is far more important to you than any specific individual decision like whether to wear a mask or not. And that’s where people have it wrong in terms of communication because I think that people can’t be persuaded or bullied or what have you. To some degree, some people can be persuaded with logic and emotion and experience. But we have a far deeper set of issues, which is, how do we identify?

Biden is making this [vaccine push] about patriotism. And maybe that’ll work for some people. I just had an episode that comes out tomorrow looking at how Biden should reach Trump country with his messaging and his communication. And simply saying, “Look, this is public health. This is not a political issue,” you would think would work.

But if they’re getting counter-messages, then it becomes very challenging. As you know, everybody’s not reading my Medium posts. People who agree with me are probably more than people who don’t. Not that people don’t disagree with me, but the people who don’t like what I have to say in general are not likely to read it. People want to get the information that appeals to them. And we live in a world where we want to satisfy our need for who we are and for what our tribe is and what our tribe wants. And that’s part of the whole In the Bubble podcast is making exactly that point, that we’re all in our own bubble we define.

We tolerate inequality much more than most countries do. We have very little collective will. We have very little recent experience sacrificing.

I wanted to end with some lessons learned. You just finished your book, congratulations. Originally you thought this book would be basically all of your posts with more color and context, but when you really got to thinking about it and writing about it, it was a much more introspective, intense process. If we went through this pandemic again and Trump was not president, what would it be like?

That’s the ultimate question that I try to get to in the book. I wanted to write a book that would read like The Big Short around 2008 issues and really still be a readable, on-the-ground book with occasional jumps up to 10,000 feet so you can see how some of these lessons work. And, of course, in the process of writing it, you make these discoveries around things that have been deeply wrong and deeply challenging. Trump didn’t come out of nowhere, so it’s impossible to say that this was driven by Trump because the causes that caused us to elect him are some of the same things. We have a lot of unexamined issues that we need to have dialogues about. We tolerate inequality much more than most countries do. We have very little collective will. We have very little recent experience sacrificing, certainly for one another. We’re very comfortable, and we’re hesitant to give up even the highest of those creature comforts.

And the real question is, are we introspective enough to come away and learn the lessons? I know we’ll learn the literal lessons. We’ll have enough PPE next time; that won’t be a problem. But will we learn the more fundamental lessons? Hong Kong, which has the most cross-border travel with Wuhan, has had fewer than 100 deaths because they’re just practiced at this. They get it. One of the things that happened here is that certain people who could isolate safely, who were white, who were more well off, and who were younger, as soon as they started to feel safe, they started to feel very impatient.

And so all you’ve got to ask yourself is, what if next time this doesn’t prey on older people — what if it preys on kids like the measles? What if it preys on people that golf? It could be you next time. So our attitudes change, and it’s not entirely because of racism, although that may be some of it with some people. It is because human nature is such that as soon as we start to feel safe, then we start to crave and recognize the things that we want. And I spend a lot of time with sociologists and risk managers and all of this. This is all stuff I’ve learned, not stuff that I knew going into the book, that helped me understand how we process things because we’re self-protective. We don’t want to live in fear. We don’t want that fight-or-flight brain on. So we start to go, “Oh, this isn’t happening to people like me as much. I’m not as afraid, and therefore my behavior changes.” That happens with everybody, not just people with bad intent.

What does next year look like for you, professionally? I know you have this incredible book that’s coming out, and I’m sure you’ll be doing lots of talks like this one. What does it look like for you?

I do several different things. As you mentioned, United States of Care is a nonprofit that I founded a couple of years ago that we’re dedicated to trying to get every American health care and to never have to worry about health care again. So I will spend a fair amount of time, hopefully, on that, working with the administration and states and others to do that because that’s a passion. I founded an investment fund called Town Hall Ventures, which invests in underserved communities in health care to try to bring health care to underserved communities. So I will spend time on that.

The podcast has been a delight to do. And as things get better, I’ll do it as long as people want to keep hearing it. So we’ll have to see what happens there, but I enjoy that. At some point, I’ll probably stop writing these daily threads because they fill up people’s timelines. So we’ll get back to normal. I think there’s a lot of repair work to do. My passion happens to run right into the kinds of things we needed this year. And if that’s the case next year, I’ll keep doing those things for as long as needed.