Interview: Marc Lipsitch

0101 - Interview: Marc Lipsitch

Epidemiologist Marc Lipsitch fights COVID from deep inside the science.

Marc Lipsitch Interview


Interview conducted 11/9/2020


WAM was able to spend some time with epidemiologist Dr. Marc Lipsitch of Westminster Class of ‘87, in a generous and candid conversation about how he sees COVID-19 affecting us now and throughout 2021. Marc, the 2009 inductee of Westminster’s Thompson Science and Technology Hall of Fame, shared his observations across COVID’s presence in science, politics and culture. Marc is Professor in the Department of Epidemiology at the Harvard T.H. Chan School of Public Health. He is also the Director of the Center for Communicable Disease Dynamics. He is currently working on modeling the transmission of Coronavirus disease. Our interviewers for WAM were alumni Corliss Blount (producer), Michael Slade, and Malcolm Ryder.


Corliss: Thank you so much, Marc, for taking the time to talk with us. We're excited about it. So we're going to jump right in. I just wanted to start with what I'm going to call the icebreaker, and then Malcolm will kind of take over. So, Marc, tell us about your path from Westminster to being an epidemiologist.


Marc: Well, in some ways it taught me most of what I know. Westminster was where I took a lot of math and sciences as a high school student.


And then I kind of went in a different direction for awhile... in college I was a philosophy major. But I ended up getting a PhD to a large degree based on things I had learned at Westminster, with a few updates in college and then obviously graduate study. I kind of skipped the college stage to a large degree in science, but I did a little bit of it. That was very exciting to me, and then I came back to it.


Corliss: Let me just ask you, how long were you at Westminster? I was only there three years.


Marc: I got there in sixth grade, so I was there for seven years.


Malcolm: A nice long tenure…


Corliss: All right. because our audience is Westminster alumni, we want to make sure we have that Westminster connection. So thank you for that.


Marc: Yes, I was very excited to write letters to Mr. Brannen and Mr. Godbold when I got tenure, to tell them that they taught me a surprisingly high percentage of what I knew.


Corliss:I think for me, it would have been that I learned what they taught me! But that's okay.


Malcolm:Of course… they live to get those letters!


So, hi Marc. Just 20 seconds about why I'm here. Other than being an alumnus, I'm a management consultant in organizational change management. And, I do a lot of strategy work, and try to get paid for it! So, you know, the complex problems that come up, those are my playground. It's been just fabulous to live in the world of the web and be able to hear you and follow your thought process, without even having met you yet.


We wanted to be sure that we invited you to talk about what you want to talk about the most. But the whole herd immunity issue kept coming to the top of our wishlist.


It seems like it's not a three-dimensional problem. It's like a 6 dimensional problem! So, we have a few questions that we could just throw on the table and you could take over from there.


Michael: And just so you know, we all saw the event you had with JAMA the last week.


[YouTube live w/Marc - JAMA discussion of Herd Immunity with Marc & Dr. Jay Bhattacharya of Stanford: Herd Immunity as a Coronavirus Pandemic Strategy - November 6, 2020, 3:20P Central US ]


Malcolm: Everyone's heard the news from Pfizer this morning, about their trial success. So that's a good thing, of course. And then, you know, the weekend [election] was great news for half the country or maybe a little more than half…


Marc: Was good news for the whole country. It just, not everybody recognized it.


Malcolm: Joe Biden was starting to release names for pandemic advisory teams and so forth.


One thing that we're definitely interested in is, how do you feel about those appointments? Are you expecting or interested in being in that group? And whether you go there or not, what would be, you know, your most urgent piece of advice to them right now?




POLICY AND POLITICS


Marc: Yeah. Well, I know those people pretty well. Michael Osterholm, I know quite well. And, um, David Kessler, I know a little bit, and Celine Gounder, I know a little bit mostly from social media. And Atul Gawande, a little.


I think very highly of all of them. And, I think it's just encouraging to see a group that's as scientifically based and sensible, and knowledgeable from a number of different perspectives. And also not all a bunch of white guys, it's a nice change. Those are all positive signs and I'm really excited to see this administration starting to formulate its plans, which it's already been doing during the campaign. So, yeah, I think the composition of that group is set and I look forward to hearing their plans. If anybody wants advice, I'm happy to provide it, but that's the group and it's a really good one.


Malcolm:That's great.


I guess the other question that follows is, what you might think about how the public can really get a grip on this transition, and maybe start to embrace it –because, it's like one of those culture war issues. There's a bunch of people that just aren't going to accept it no matter what, even if it's good for them. And then of course, a lot of people who've been waiting for this. What are your thoughts about that?


Marc: Yeah, I mean, you know, this is not my professional expertise. This is just me as a citizen, but I think that what we've had, and I guess it borders on my professional expertise, what we've really had is a rejection of science and a rejection of expertise and a deliberate dividing of the populace, along party lines and along other lines, in terms of people's response and attitude toward the pandemic.


And I think if you look at any of the countries, almost any other country in the world, but in particular, those that have had better outcomes than we, which is very many of them, a common thread is that there's a degree of public unity, on the importance of controlling the virus, and not everybody, uh, agrees with all the policies anywhere.


And you know, in some countries you can express that dissent and people do, but I don't know of any place else where there's been so much deliberate undermining of a sense of common purpose. And this is not the only topic on which that's true, but it's one topic on which that's true. And, well, there are many topics on which common purpose really helps. But fighting a pandemic, where getting it, where each person who gets it, is then a risk to someone else, is really a paradigm case of a problem where unity matters.


So I think, I think just lowering the tension, lowering the temperature…


I'm starting to hear one message coming from the bully pulpit or the pre-bully pulpit, and in advance of inauguration day it can only be a positive thing. But it's a very daunting task because the situation's been allowed to deteriorate so badly that it's a lot to clean up.




THE SCIENCE


Malcolm: Hmm. I’m going to surprise my teammates and ask this question. ACA is at risk, a vaccine just came out, and who knows whether mask usage is going to keep up with the explosion in the number of cases being reported now. They all seem tangled together to me, but of course, 48 hours ago, we didn't know about the vaccine. Do you see any of these three factors taking more emphasis than the others?


Marc: I mean, I think all of them are months out, right?


The vaccine will not be widely available for some months… the change of administration and the consequences of that will not be out for several months. And we have a big hole in the middle, in the next two months where things are unlikely to get better because we continue to lack national leadership while cases are growing. It's getting colder and people will be indoors more. And the virus is probably more contagious under colder and drier conditions. There's still a lot of susceptible people. And all of that adds up to continued growth in cases, if not accelerating growth in cases.


So, I think the short-term outlook is not very encouraging. I think it's somewhat encouraging that for example, Utah announced yesterday that they were -- or this morning, I'm not sure that they were -- implementing some fairly serious control measures, because their hospitals are under threat.


Unfortunately there's going to be this pattern that we modeled in our Science paper in March, but were not endorsing and were not even predicting, but it turns out to have been kind of what's happening. Which is, things start to get out of control and controls are imposed, too late to totally preserve healthcare functioning and then things get more controlled.


And maybe it moves to another place… that's where spread is, uh, intense. And we repeat the cycle of sort of waiting too late.


There's this repeated problem that putting in control measures has a three to four week delay typically in terms of leading to a peak. We just aren't gonna, we aren't… it's a very challenging problem because nobody wants to crack down when everything looks good. And if you wait until it looks really bad, then you have to suffer for several more weeks before the changes take effect.


Malcolm: That's a very interesting point.


Michael: The head of the CDC a month or so ago, held up a mask at a Senate hearing and said, you know, this is better than a vaccine. I think that was his wording. Can you explain that? In terms of, it's one thing that the vaccine is something that's farther out there, but masks are something we can do today. Can you compare the efficacy of masks versus vaccines over time here?


Marc: I think we still don't know.


So the vaccine data… I'm reluctant to call something data when it's a press release, without backup. I'm not saying that they're making it up or something, I'm sure that there's real data behind it, but, I think it's discouraging to have announcements made with no real numbers. But that's how they did it. I'm sure we'll see more and that some of it will become clearer, but, the data so far suggests that the vaccine from Pfizer is very protective against illness from this virus. We don't know whether it's protective against infection or whether it protects you from infecting others. That's a further question that we may or may not learn about this vaccine.


Malcolm: That the vaccine is, or is not, an antivirus.


Marc: Well, what it means is that it may or may not contribute to herd immunity in the way that we typically use vaccines to build herd immunity, which is, we vaccinate people – that protects them against getting the disease, but also against getting the virus that causes the disease. And if you don't get it, you can't transmit it.


That's how vaccines against measles and chicken pox and rubella, and a lot of other infections work. And it's probably how this one will work, but, we just don't have the data yet and probably may not have that data from the Pfizer vaccine because of the way the trial was set up.


We know that masks provide some protection a little. We believe they provide some protection against getting infected if you're wearing a mask, and we have better evidence that they protect you from infecting others.


So in that sense, there are some things we know or have strong evidence about with masks that we don't have evidence about yet with the vaccine. But I think in the long run the vaccine, the vaccines, if they are as good as this initial peek hints at them being, then vaccines will be obviously both a more long-term solution and a more effective solution.


Michael: Is there a way to make an apples to apples comparison in terms of percentage of effectiveness between masks and the vaccine?


Marc: I don't think there's really strong data on the vaccine, on the masks, on the exact magnitude of order of protection from masks. And again, it's against a different thing. What the masks mostly do is protect you from me. If I'm wearing a mask …


Michael: I'm saying as a replacement, I think people understand the vaccines, the long-term solution. It's just that, meanwhile, there's going to be an awful lot of people not caring about masks…


PRIORITIES AND PUBLIC SAFETY


Malcolm: All right, well, here's another kind of opposition. Maybe this is a false opposition. But you know, we're looking at one possible scenario where schools are open and hospitals are closed. I mean, they're not closed in the sense that they shut down, but that they're maxed out. The combination of those two things feels to me like it's going to drive the problem into homes.


Marc: Well, I think the evidence so far is that schools are not major sites of transmission.


It's not that there's no transmission in schools. Obviously they are places like any other place. But especially in places where there's been reasonable efforts at mitigation and people wearing masks and, and trying to distance, which is easier with older kids and harder with younger kids, young children seem to be less susceptible to getting infected and maybe less likely to transmit it.


School is an organized environment. And we shouldn't forget that, that does have some effect on people. If you have them under the watch of a teacher or whatever, they do behave in a more orderly fashion typically than they behave if they're not in a school environment. So, the evidence so far is that schools are not driving transmission.


It is clear that bars, when they're open and restaurants, when they're indoors and crowded and other indoor crowded environments do drive transmission, and many schools are very crowded and many schools are very poorly ventilated. So it's not that they can't transmit -- it's that schools are to me the last thing we should close. And so I really admire the efforts to keep them open. We should be focusing the closings on many other things that are less important than the education of our kids.


Malcolm: What about the teachers? I mean, it seems like, well, out here in California, anyway, you know, we get our fair share of sensational, whether true or not, news images of teachers who are scared to death, or they don't feel like they have anything like the political influence necessary to garner support of themselves as first responders, so to speak.


Marc: I think in a country that's as dysfunctional as this one has been about COVID, people not knowing what to think is perfectly understandable. I mean, I think that's in fact part of the purpose of the disorganized responses – to keep people confused. Hopefully that will begin to change at the national level. And it's certainly already changing to some extent, or it has been different at the state level in many states. So I have no doubt that people are scared and they're scared in Massachusetts as well. Teachers are scared.


But I don't think that the data justify that fear. I think that, you know, the data are still evolving and you can't give anyone a guarantee of absolute safety, but, in comparing the risks in schools to the risks in other sorts of things that we in some places are still doing, they're smaller risks.


Malcolm: I guess, with the new task force coming up, we would hope that everyone could go there and at least get a very well accounted and consistent presentation of the latest information that might be useful.


Marc: The task force is not an agency, right? The task force is a collection of experts who are helping to shape policies.


But I mean, the CDC is the agency that in 2009 during H1 N1 flu provided information to the whole country and to a large degree to the world, and CDC has been kneecapped by this administration. Again, that seems to have been deliberate and it's meant that the information hasn't gotten out that we do know, and also that we haven't even generated as much information.


CDC has not been as active in doing research and studies that can help us understand transmission better. It's been a real problem. I think the task force is not the answer. It's a good thing. And it's a first step, but, what we need is to rebuild the thousands of people working at an agency like CDC, into the powerhouse that they have been and could be again. The task force can push them that direction, but they're only a dozen people or so.



JOURNALISM


Michael: In the vein of finding good sources of information, are there people who report on science that you think do a good job of explaining? I'm thinking of, for example, Laurie Garrett, or Bob Wachter, people that take these concepts and they're good at expressing them to the public. Are there any that you think people should be listening to?


Marc: Yeah, I think those are good examples. I find Helen Branswell really excellent at STAT News. She's been at it since SARS in 2003 when she was in Toronto and she really knows everybody and an awful lot about this field. Ed Yong at the Atlantic is really great. Roxanne Khamsi at Wired has done some really good reporting. I mean, I have to say, I think the journalists have done a phenomenal job overall.


Not everything is right and not everything is always clear, but the fact that what CDC should be doing has now been taken over by the New York Times and the Atlantic COVID Tracker, is a remarkable fact. And, the fact that these individual journalists are, continuing to explain what's going on, in quite effective ways, is also great. There are many other good ones, but those are some of my, a few of my favorites.


Malcolm: Great. I also want to bring up, uh, Sanjay Gupta.


Marc: Yeah. He's great as well.


Malcolm: And he's got three kids at Westminster. I’d love to get time to talk with him as well and find out how he feels about it as a parent, but yeah.



PRIORITIZING POLICIES


Malcolm: All right, so, Mark, a really open question for you, which came to me after watching you earlier this morning, on video. And, my question is this -- hypothetically, if children, however you want to think about them, were always given first priority in policymaking, on how to get from the lab to the public, do you think that prioritizing that way would change anything about how we're pursuing the problem right now?


Marc: Well I think that, with respect to schools, it would have a very clear implication. I wrote in the New England Journal of Medicine in July with my collaborator, and my other collaborator, the latter one being my wife, about the importance of schools as essential services and the importance of in-person schools.


You know, I think when we try to figure out how to decide what parts of society to keep open and which ones to close, there are many, many reasons to make those decisions, but I think, prioritizing schools over bars and even over restaurants is a, is a very child-friendly policy. I think what's unusual about this infection is that it's so mild in the best vast majority of children. It’s unlike the sort of classic vaccine preventable diseases like measles and mumps, where, where children can get severe disease, and, unlike flu where it's most severe in older people, but children are major transmitters. So it's a really weird infection in the sense that it doesn't naturally lend itself to prioritizing children.


But I think if we take a broader view and step away from the biology and the epidemiology and take a broader, more societal view then to me prioritizing children means doing our very best to make schools not only safe, but perceived as safe, so that we can get their lives back somewhat to normal.




STRATEGY


Michael: Here's a question that we kind of skipped over. Going back to your experience with H1 N1, what lessons did you learn from your work that you think are applicable to the current situation?


Marc: Well, I think I might not have been able to answer that very well at the time or, you know, before this one, because it's only by contrast that you really see, uh, certain things. But, I mean the importance of leadership at every level and the importance of transparent science driven actions at the national level is just critical.


And the comparison is really quite clear that, you know, that was a less severe disease in almost every dimension than this one. We didn't know that at the beginning, but in the end -- and it became clear, and the response was rational and relatively unified and apolitical and worked much better. Although, the problem, to be fair, was a lot less wicked than this one.


So I think, you know, had we had better leadership, this would have been incredibly hard too, but as it has been hard say in most of Europe -- the difference is just monumental… it didn't rip the society apart.


I think the other lesson is the importance of data. I had an op-ed in the Washington Post about a month ago now, with a colleague about the needs for rebuilding our data systems and public health. Public health has been disinvested for quite a long time at the local level, then more recently, been handicapped at the federal level by Trump's policies.


The result of that is that people are still sending too much data around on Excel spreadsheets. And, the technical capabilities to analyze the data are not there. To generate the data, we -- meaning, you know, every state -- had to go through this exercise of figuring out how we are going to count cases, because we don't have any way to access the population in a sort of reliable way.


Some people said, let's try grocery stores. Some people said, let's try, um, let's try parking lots, let's try door to door, all different ways of trying to test and assess the burden. The fact that we have so little infrastructure to do that, and then to process what we learned from it in a sophisticated and efficient way, is a clear lesson.


Not that it was so much better in 2009, but I think for the time it was better.


We've seen from both of those cases in 2009, it took us months before we really figured out how severe or not severe it was. That was due to limited data. And this time the problem has been a different set of problems, but the same broader problem of not understanding the situation that's around us very well.



IMMUNIZATION


Malcolm: I've gotta fast forward and think more about vaccines.


It sounds like there's not going to be just one vaccine. It also sounds like the production scale is a fairly daunting problem. And then, once there are vaccines in circulation, liberally, I'm going to guess that that's still just going to be a part of the package of things that people need to do, and start getting used to doing, to protect themselves and each other. So if we hear something like, well, vaccines will be available on Valentine's day, how are we supposed to assess that?


Marc: Well I think the first thing is to say there are seven and a half to 8 billion people in the world. And Pfizer said, I think I read, they think 1.3 billion doses. I don't know if that means doses or people's worth, because you need two doses for each person. So say it's half a billion people worth by the end of next year. That's not a global solution and this is a global problem.


And, we haven't talked about vaccine nationalism, but that is one of the issues that this is raising -- the equities and inequities between countries in their access to vaccines. But focusing on the USA, you know, we might have a good tranche of vaccines available by sometime early next year, middle, maybe spring, I would say more than Valentine's day, but maybe things will move faster.


We have to get them out to people. This vaccine in particular needs to be at minus 70 degrees Celsius, uh, for storage. And that's not something that most community health centers or doctor's offices have. It's in, you know, it's possible in hospitals, but those hospitals actually have those freezers for other purposes, and they're back ordered and that's going to be an issue. So distribution’s going to be an issue.



DEMAND AND SUPPLY


Marc: I think, you know, if you read the survey data, lots of people are very skeptical about vaccines. It'd be interesting to see what they say after this announcement. In particular, the skepticism has been high among certain groups of people of color. Not all. My understanding is that immigrants tend to be, this is more anecdotal -- from one mayor that I've been in conversations with on a committee that I'm on --, that certain immigrant communities tend to be quite enthusiastic about vaccines, but certain other communities of color seem to be skeptical of this vaccine, for various reasons and of course have also been the hardest hit. So that's gonna be an issue.


I'm actually somewhat optimistic that as the value of the vaccine becomes clear -- and as people realize, you know, if I don't get this vaccine, I'm just going to be living in this misery -- I think people's views might shift. I don't think answers to hypothetical questions are all that informative, but it is a hurdle that has to be overcome. So getting enough supply, and getting it out to enough people and managing the logistics where you have to, ideally the plan is to give people two doses of the same vaccine. But as there are more vaccines, the management of that is going to be confusing to everyone, and logistically hard.


I think it's, it's not all going to be solved the day the vaccines are produced, but on the other hand, I don't want to be, uh, … I can think of a million things to say about, we have to be careful and we shouldn't be sure and blah, blah, blah. But I do think the news is very, very exciting and that we should be hoping that other vaccines quickly follow with good results.


Michael: One other question I had was in terms of people thinking it's wonderful for everybody to get the disease… There seems to be this phenomenon of long haulers, or people who had maybe minor disease and then have follow on symptoms or other health issues that seem related. I mean, I guess it's still early days and we don't know that much about it. Can you comment about that? To me, that's a reason to not get it to begin with.


Marc: Yeah. I mean, I think the frequency of those long haul COVID symptoms is still uncertain. Howard Bauchner [editor of the Journal of the American Medical Association], I think it was in the discussion before our public debate last week, he said that there are a lot of cases where you only know about the ones who got it, but you don't know the denominator. [Experts speak in terms of numerators and denominators to track the number of people with exposure – the denominator – versus the number of confirmed cases – the numerator. For example, one confirmed case per every thousand people exposed is noted as the fraction 1/1000.] Right. So I think a critical question is just how common that is, but it clearly is not vanishingly rare because we hear a lot about it.


And that's clearly a reason to delay or try to avoid getting it.


The economist for one of the Republican house committees tweeted this morning, the expected utility of delaying your infection just jumped dramatically with this morning's news. Meaning, that if you can delay getting infected until there's a vaccine that you can receive, then you've prevented it, not just delayed it.


THE LONG GAME


Marc: To me, that's the more important issue. It's bad to get infected at any time, for some people worse than others, but, once there's a realistic prospect of having a vaccine that can prevent it then delay is prevention because you're pushing it into the future.


It's also true that the healthcare system is learning how to treat the infection. And presumably outcomes are improving. The data for that are less plentiful than I would have expected. But, it seems as though for infection, outcomes are improving. That's another reason for delay. Another is to try to smooth out the burden on the healthcare system. Back in March, when everybody was saying flatten the curve, flatten the curve, I tried to lay out all these different reasons why delay is a good thing. And those are still true.


Malcolm: Sounds like something we should put back up on the front burner for everybody again.


Michael: Malcolm, anything further? I think we're encroaching into Mark’s time here longer than we said we would.


Malcolm: Oh, no. I'm gonna be a gracious host here, Mark. I can't overstate how great it is for us to get to talk to you.




Corliss Denman (West ‘73) Contributor




Malcolm Ryder (West ‘72) Contributor




Michael Slade (West ‘73) Contributor