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Andy Slavitt on How Politics Became a Public Health Crisis

In the second of two exclusive video interviews, MedPage Today Editor-in-Chief Marty Makary, MD, MPH, of Johns Hopkins in Baltimore, discusses the strategy and public health messaging of the COVID-19 pandemic during the Trump and Biden administrations with Andy Slavitt, former White House Senior Advisor for COVID Response, past head of Medicare/Medicaid, and the author of the recent book Preventable.

Watch the first video: The U.S. Fumbled the Early COVID Response in Two Major Ways

Following is a transcript of their remarks; note that errors are possible.

Makary: Hi, I’m Marty Makary with MedPage Today. I’m here with Andy Slavitt who used to run CMS and has been a senior advisor to the Biden administration on COVID. He’s also the author of the new book Preventable: The Inside Story of How Leadership Failures, Politics, and Selfishness Doomed the U.S. Coronavirus Response. He’s also, by the way, an editor of MedPage Today [editor’s note: Slavitt is a member of MedPage Today‘s editorial board]. Thanks so much, Andy, for all you have been doing.

Slavitt: Great to be with you. I’m an admirer of your book, so it’s good to get to finally chat.

Makary: What were the top things that needed to be fixed that you would say were the biggest successes when there was a new administration that came in?

Slavitt: Well, look, we had a very different specific job to do than the Trump administration did, and for us, I think, to keep it very simple, it was more, better, faster. And by that, I mean get more people vaccinated as quickly as possible and as equitably as possible.

We took a different approach than the Trump administration did to the vaccination process. I think their strategy was more of a vaccine production process. Let’s produce a lot of vaccines and send them to states and then give states the accountability for how they decided to vaccinate people. And as a result, when we got there, only 46% of the vaccines that had even been produced had gotten into people’s arms. There wasn’t any consistency with how much volume was being sent.

So guess what happens when you have a shortage — people hoard. And so there was all kinds of hoarding going on throughout the system. It wasn’t transparent. And there was no management of the process. There was no direct pharmacy distribution. There were no federal FEMA sites. There was, really just basically, we’ll ship it off and we’ll let the states decide what to do. Which, by the way, was the same strategy they had with regard to testing and everything else, which is we are not going to be accountable for getting this right. We’re going to put this on the states, which we thought was the wrong strategy.

We had to alter that strategy as much as we could while the wheels were in motion. So we had no standing inventory. We only had 40% of the public who said they even wanted the vaccine, if they could get an appointment. Most people couldn’t get an appointment because they had allowed a system in place that was very complex. And no one knew where the vaccines even were. They didn’t have a good inventory tracing system to even track the vaccines. There was no RFID [radio-frequency identification] on any of the vaccines, only on the large batches. So, we basically had to put in place kind of an entirely new strategy and take a different approach.

Makary: What would you say has been the greatest mistake and the greatest success this calendar year in the entire COVID strategy?

Slavitt: Well, look, let me start with the big picture. The transformation that we’ve undergone as a nation from early January to the Fourth of July is probably the most significant transformation in the health and well-being of a nation in as quick a period of time. There’s all this hindsight bias, which is, “oh of course things were going to turn out the way they’ve turned out.” But the truth is, in early January it was really frightening. And the country was at a low point in terms of morale, patients’ tolerance, trust. They didn’t believe anything that was coming out of the government, 3,500 people a day were dying, the vast majority of people said they wouldn’t take the vaccine even if offered.

To a point where today I would say — and this is my characterization, you may or may not agree with it — COVID-19 is a manageable challenge. It’s not gone. But I put it in a category of a lot of things in our lives. We have a lot of manageable challenges. Not to belittle it, but the traffic here in Southern California is a challenge. You know, it doesn’t keep me from driving my car, but it’s a challenge, but I manage it.

COVID-19 — if you are vaccinated now — is, largely speaking, a manageable challenge. So what happened between then and now was, largely speaking, the president taking accountability and saying, “we’re going to do this, and I’m going to own the results. And I’m not going to get sidetracked by fights with governors or pointing fingers or blame or anything else. And I’m going to bring in an experienced team of people who are going to focus on execution, execution, execution, execution, execution.”

And, in my case, in addition to that, to talk directly to the public and make sure that they were getting the truth as best we knew it, and as clear language as possible. Not talking over people’s heads, not putting out misinformation, not denying the problem. And that was very important to do because the public had just been through a year of being told that this wasn’t a problem, [or] maybe it was, but it had a quick solution and it had a silver bullet and it was about to end, and it wasn’t really that bad. And nobody believed that any longer, or I shouldn’t say nobody, but very few people believed that any longer.

So, that’s the work we got done. I’m sure that there were things we could have done better. I was buoyed to see the analysis out of Yale this week, I don’t know if you saw it, which showed that the acceleration of the vaccination program over the last 6 months has saved about a million hospitalizations and about between 75,000 and 150,000 lives. The study said 300,000, but I think that was a high, unrealistic number. When you look at the study it’s 75,000 to 100,000.

So, look, we should all as a country feel great about that. I don’t want to give the president full credit. I want to give everybody in the country credit. Every vaccinator, every doctor who had a conversation with people, every pharmacist, every employer who gave people time off, everybody who went and stood in line and got vaccinated. It’s a monumental achievement for the country, not withstanding the fact that there’s always things you can do better.

Makary: The president outlined that target of 70% vaccination rate among adults by July 4. I think some people think that we failed in that target, but actually 21 states met the target and a lot of states came close. Do you think that target was too aggressive, or appropriate?

Slavitt: Oh, we knew it was aggressive. And quite honestly, not worried about the difference between 67% and 70%. That’s not going to make a difference. What is gonna make a difference is what you just said, which is that 70% is 90% in Vermont and 50% in Arkansas, or something close to it. And that’s the real threat. If you want to be worried about something, nobody should be worried about 67% to 70%. And, by the way, the delta in that 67% to 70% is almost entirely people [ages] 18 to 25, which is not that surprising. And it was a challenge we knew we had. But I think the president wisely put out a rallying cry.

I think the idea behind putting out a goal like that was twofold. One is his real goal from Fourth of July, which if you may recall, was that Americans should be able to gather together in small numbers, outdoors without a mask, to barbecue for Fourth of July. That was his original goal, and when he set that goal, I think people thought, “huh, that’s a little ambitious.” We obviously well exceeded that. We were barbecuing Memorial Day. We were indoors without masks, as we all know. So I think the president wanted to make sure that he had some numbers behind something that would make sure to get there, and we more than achieved that.

But the other reason is because I think he believes that the nature of a goal itself forces everybody to work harder and try to achieve something. If he’d have just said, “hey, we’re fine where we are on Memorial Day, no need to put another goal on this,” we wouldn’t even be at 67%. We’d be at 64, 65%. So he, you know, he was pushing the country to rally to get to as high a point as possible, as quickly as possible.

Makary: I think people have lost sight of the fact that of the 67% or so of adults now vaccinated, but that encompasses almost all or the vast majority of high-risk people. I think it’s about 88% of seniors in the United States now. Do you think there’s the misperception out there that the risk is evenly distributed in the population?

Slavitt: I think the important question is the link between cases and hospitalizations and deaths. If we’ve broken that link then that, by definition, will mean that we’re in much better shape, even if we see cases start to come again as it was like late summer and late fall. And I think you’re exactly right. We have largely, largely influenced that link.

Now, sadly, all you have to do is listen to Chris Christie, and I encourage everybody to listen to Chris Christie’s conversation that he had with Frank Luntz. Sadly, this is an unpredictable disease. So, he talked about his two cousins, one of whom was a smoker and overweight and one of whom was her spouse who was a longshoreman and incredibly healthy, who both got COVID. And sadly they both passed away. And his longshoreman cousin’s buddy was immune because he was young and healthy. He was under 50 and healthy. My 19-year-old is in bed today. He got COVID 6 months ago and he is still experiencing symptoms from COVID.

So you never know, you just don’t know. So on the one hand, I’m incredibly encouraged that we’ve taken so many likely deaths off the table through the vaccination program. At the same time, I think there’s this misperception that if you’re younger and your mortality risk is lower, then maybe you don’t need to get vaccinated. And I would strongly encourage people to think through that decision. It’s obviously an individual decision, but think it through, talk to doctors, talk to people you trust, talk to people who’ve been vaccinated, because as you said, the risk of taking the vaccine is almost nonexistent. The risk of getting COVID, unfortunately, is still real.

Makary: So on that last point, Andy, about your 19-year-old child still experiencing symptoms from COVID, how do we address this notion out there that the only risk of COVID is risk of mortality, when there’s other risks, like the one that your family is experiencing, without over-blowing those risks? How do we hit that balance?

Slavitt: I think the question is also like, what do you change because of those risks? Like, I don’t think it would be acceptable to say we shouldn’t send kids to school because of the risk of long COVID. I think it would make sense to say that we should take precautions. But I think the reason people are pushing back against long COVID is if they hear it in a way where they think someone’s implying that therefore we should, I don’t know, shut down the economy or something. And we would never shut down the economy for a largely preventable illness.

Now, my son got COVID because it was before the vaccines were available. So vaccines are available today. Vaccines are highly, highly protective against illness of any kind, and very protective against serious illness. Now they’re not perfect. There’s going to be breakthrough cases. But for the small amount of breakthrough cases and for people who choose not to get vaccinated, ask yourself what actions should we be willing to take because of a very low risk and because of the fact that people have the option to get vaccinated and are choosing not to.

And the reality is that that’s not a situation where it makes sense to create a lot of restrictions. It makes a lot of sense to continue to educate people, to counsel people on why getting vaccinated makes sense. It makes sense to do a lot of research into long COVID, and to educate people about it. It makes a lot of sense to make sure young people are educated and are aware about long COVID and where the risk is highest, because I don’t think they’re spread evenly among young people. I think there are certain attributes to young people where it seems to, for some reason, afflict them more greatly. And there needs to be education about that. And a lot of colleges are choosing to require vaccinations before people return in the fall. And that’s a reasonable choice given the fact that kids are going to socialize. And they’re not always going to look out for the one in five, or one in 10 potential that there’s some long-term affliction that hits them.

Makary: You did a tremendous amount of research for your book Preventable. What were some of the sort of revelations that you had come up with in that book that may not be well known to your general physicians out there in the United States today?

Slavitt: Well, look, I think we get probably close to an “A” for the hard sciences here. I mean, you can’t look at this vaccine track record, the speed at which it was developed, the quality of the vaccines, and not say, “yay for us” for basic research, for science, for the development of the vaccines, for the clinical efficacy, the vaccine profile, the safety monitoring — all that stuff is great. And, look, if we have an oral antiviral in the near future, a Tamiflu type thing, then I’ll give us another “A.”

Where I give us low grades, maybe a “D,” maybe an “F,” is on the soft sciences, the social sciences. Psychology, sociology, kind of political science, all the things that doctors probably didn’t take those classes, or they were gut classes and you guys were all pre-med — I’m joking of course. My roommate was pre-med and he laughed at the classes like sociology and stuff like that. But the truth is, we all did, we all thought like, “oh, they’re soft sciences.”

But the truth is that’s what tripped us up. Our ability to communicate with one another about why a common goal could save lives. Our very unequal society where half the people get paid by the hour and were forced to be exposed to people, and another half of the people get paid salary and were able to be relatively safe and indoors. And much more exposure to Black and brown communities, rural communities, farm labor camps.

And there’s a point in the book, Marty, where someone said to me, “Andy, I don’t know anybody who’s died from COVID.” And he said it kind of in a way that was a little bit accusatory, like, is this really real? How real is it? It’s not really affecting me and people I know. And I said, look, you do know people who died from COVID. It’s the people that grow your food. It’s the people that drive the trucks and deliver the food to the warehouse. It’s the people that work in the meatpacking plants. It’s people that work in the grocery stores and who deliver your GrubHub to your house. You don’t know their names necessarily, but you know them because they work for you. And there’s this whole other world.

And there’s a chapter in my book called, “The Room Service Pandemic,” about this phenomenon, where you’ve got half the people who are working in the hotel, and you don’t ever see them, you know, you don’t walk in the back door of the hotel. You don’t see what their life is like, but these are people that go home from their hourly jobs and sleep on the couch because they don’t want to get their husband or wife sick. They don’t hold their children’s hands because they’re worried they’re going to spread COVID to them, or get COVID from them. And for a lot of people, including myself, my life was much easier than that. I had enough savings to be indoors.

So, anyway, I’m going on and on about this, but my point is just that all of these elements of our society that are not the hard sciences are things I hope we pay attention to, because they’re really the things that showed up in a big way and were big challenges for us.

Makary: And were some of these problems also global problems? By January of this year, a lot of countries had also gotten hit very hard, not just the United States. Countries that didn’t have incredible borders and testing systems set up from prior pandemics. Were some of these problems also global?

Slavitt: Well, I mean the whole thing is global. But I will say one thing related to this. There’s this whole group of people who were thinking and proposing, I think quite cynically, that we just get to herd immunity by letting everybody get infected and letting COVID run rampant, and it will then run through society. And that was stupid, harmful, and I think self-serving. And they have to answer for a lot, including why do we have variants today more prevalent in our society?

You know, it’s not easy to manage a pandemic. There’s no perfect answers. And we ought to be very generous about people who were making honest mistakes. We ought to be very generous about people who had the right amount of empathy and made very tough decisions, even if they didn’t all turn out to be right.

I’m a lot less forgiving of President Trump’s miscommunication, organized miscommunication effort, to tell the public not to worry when they had a lot to worry about and could have protected themselves. I’m a lot less forgiving of his silencing of scientists who disagreed with him, including forbidding even his own health secretary from talking to the press for 45 days, because he wanted to use the phrase, “Things could change at any time.” It was pulled from the press, that was in the book. I’m not forgiving of a president who was unwilling to take accountability here.

So, look, politics became a public health crisis for us, Marty. And I know people feel uneasy talking about it sometimes because it feels like we’re being political and we’re causing people to choose sides. But the truth of the matter is, this is not a Republican or Democrat thing. Mitt Romney would have run a highly competent COVID response. Mike DeWine did. Charlie Baker did. This is not about Republicans or about Democrats. This is about very specific leadership at a time that failed us. And we can’t pretend that didn’t happen.

Makary: The book is called Preventable: The Inside Story of How Leadership Failures, Politics, and Selfishness Doomed the U.S. Coronavirus Response. Andy Slavitt, you’ve really committed a tremendous amount of your own time working on the vaccine rollout. Thank you for your public service. It’s nothing new for you at your second tour of duty or maybe third. And I really personally appreciate your willingness to join the effort to fight denialism of the pandemic and the coming pandemic early last year. There were not a lot of people that were willing to speak out, to tell folks that this is going to be bad and to take it seriously. So deeply appreciative of you and also for your being a part of the editorial board at MedPage Today. So thanks for being with us.

Slavitt: Do you mind if I make a final comment, which I probably should have said at the beginning?

The country owes just a tremendous debt of gratitude to the clinicians that are watching this today, and your colleagues and nurses, other frontline workers, phlebotomists, people picking up the trash. We put you on the front line of a crisis that we didn’t give you full preparation for. And your resilience saved a lot of lives and comforted a lot of people. But it was unforgivable what we did as a country. And you bore the brunt, and your colleagues bore the brunt. So I’m saying this to say thank you, but I’m also saying this to say that we need to listen to you in your experiences as we look at and think about how we go forward, and make sure we don’t make some of these same mistakes again. And we need to honor the sacrifice that many of your colleagues made. Some of them the ultimate sacrifice.

Makary: Well thanks, Andy, for saying that, and I’ll just take a tiny piece of that credit since I’m 90% research, but I agree with you. My colleagues that showed up to work in the emergency room and in the ICU, in the middle of this pandemic with really no vaccine available to them, that was really risking their lives for the sake of others and in doing so in the true spirit of medicine. So thank you, Andy.

Slavitt: Sure. And, by the way, the profits from the book are all donated to people who are on the front lines of COVID relief, feeding people, caring for people, etc. So that’s my small thank you.

Makary: Great. The book is called Preventable. Andy, great to have you with us. Thanks so much.

  • Greg Laub joined MedPage Today in 2005 as Production Manager and led the launch of the video department in 2007. He is currently responsible for the website’s video production. Follow