Dr. Robert Wachter, Chair, Department of Medicine, School of Medicine, University of California, San Francisco
Moderator: Michal Lev-Ram, FORTUNE 


Brainstorm Health 2023 - Assessing Covid For The Long Haul

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Dr. Robert Wachter, Chair, Department of Medicine, School of Medicine, University of California, San Francisco
Moderator: Michal Lev-Ram, FORTUNE

Assessing Covid For The Long Haul 

Dr. Robert Wachter, Chair, Department of Medicine, School of Medicine, University of California, San Francisco
Moderator: Michal Lev-Ram, FORTUNE 

All right. Well, I'm delighted to introduce our next guest. He is a bit of a celebrity to me as we were in the midst of the pandemic, he would be the person I turned to every time I needed to figure out what was actually safe to do or not. It is the one and only Dr Robert Walkter, chair of the Department of Medicine at the University of California, San Francisco Bob, as he is known, was quoted earlier this year saying COVID now is probably what COVID is going to be a year from now and two years from now. In other words, the new normal, he's an expert on clinical public health and policy issues related to the pandemic. He's also an author and as I said, a pretty popular guy on Twitter amass amassing a following of 275,000 people including yours truly, with his data driven detailed threads where he explained his own thinking, his own experiences, his family's experiences on COVID becoming a trusted resource and a real counterbalance to the plethora of misinformation that was out there. Dr Walker still believes the virus is a threat with long COVID, particularly troubling for so many. He joins Mihal Lev Ram for a conversation on what lies ahead and how we can all prepare ourselves for the future living with COVID. Please join me in welcoming them to the stage. So I'm guessing a lot of the audience here follows you on Twitter. But you were just saying how many Twitter followers you had pre COVID and today give us the number. I think I had 15,000 pre COVID and about 300,000 posts. So I think it's COVID and not me, I don't think I got that much more interesting in the last three years, the pandemic did something for you to do that. OK. So I'm going to start out with a question. Something that was just in the news earlier today, which is that the COVID crisis Commission came out with a report saying our government pandemic response exposed collective national incompetence. And I'm just wondering from what you've experienced lived through, from what you saw from the report. Are you surprised? No, that sounds right. I think we screwed it up pretty badly. Um Interestingly, one of the things the report said was operation warp speed was a real triumph. I mean, that was extraordinary, really involved, a public, private partnership with a lot of, you know, a lot of government resources but giving the private sector an opportunity to do its thing and the fact that they came out with vaccines that have been amazingly effective uh as quickly as it, it is remarkable. But testing uh non vaccine treatments, data, data gathering, data aggregation, you know, we just expose massive numbers of holes. And I guess I'm worried because next time I think will be harder. Uh you know, that this one part of the challenge of course, is the politics and the politics this time for the first six months after COVID hit, I think the Libertarian part of the country kind of gave it a pass. They said, all right, we'll go with mandates. We'll go with shutdowns next time. I think that's not going to happen next time. I think there'll be a push back on any, anything that the government tries to do starting on day one. So I'm quite worried about the next one and the next one could be worse than this. This was a very bad pandemic. Obviously, more than a million people died in the United States. But there's nothing in the, in the Book of Life that says you couldn't have a virus that's as infectious as this one, but far, far more lethal. So it's, uh that's kind of a bummer, but it's kind of, yeah, thanks for starting with the bank here. Um We'll get cheerier from there. I don't, I don't know about that. Um So sticking with the current pandemic that we've been living through or have lived through. Um, we've over and over. We've, we've kind of recalibrated our um our risk tolerance, right? And just how we speaking of ma mandates, you know, what, not just the mandates, but there were a lot of individual choices. We saw people make very different choices at this point in the game. What? There's been a lot of interest in what you do, you know, this is like the friend who you look to like, are you wearing your mask? Are you not? What should we be doing? Um How do you approach different scenarios in your life today? And what can you share with us? Well, I can't say I always wear a mask because here I am. But um first of all, I got my second by Val and booster uh two days ago, feel fine. Uh My judgment is that the rules that the FDA put out, which is if you're over 65 or you have comorbidities and or I suppressed, it's a reasonable thing to do. Uh I don't worry anymore that I'm going to die of COVID and that's very different than March 2020 when I was hiding it in my kitchen table. Um The main reason is that I got this booster is it's pretty clear that after six months, the effectiveness of your booster wanes pretty considerably in terms of preventing a severe case, you can bump that back up again to me at essentially no cost. I mean, the vaccine is incredibly safe. Uh You know, it's been over because for the anti vacc community has pushed very hard about its bad side effects. They're really nonexistent. It's one of the safer things that we prescribe in medicine. So I took the val and I think it's a reasonable thing to do. I wear a mask in crowded indoor spaces. And so I flew here this morning, I wore a mask on the airplane and maybe 20% of the people did. I think it's reasonable to wear a mask in a crowded indoor space that's not well ventilated and, and reasonable at this stage, if you're well vaccinated, not to wear a mask in less crowded spots. I now have indoor dining, do indoor dining, which I didn't do until about six months ago. So, talk to us a little bit about long COVID two and what we know today, not just about some of the very real symptoms people are experiencing and living with, but also some of the longer term risks that, that we're finding out about and, and is that not a deterrent or, you know, something that incentivizing people to still not want to get COVID? Yeah. No, I think that's exactly right. My feeling is the main reason to avoid getting COVID is to avoid getting long COVID today. Certainly there are still 150 people a day dying of it. So it's not nothing but the main reason I am still moderately careful, more careful than many. Um, and, and in part, the main reason I got the vaccine, uh probably the main reason I would take pack of it if I got COVID is the vaccine has been demonstrated lower the probability of long COVID. So has PAX of and the best way to decrease the probability of getting long COVID is not to get COVID. Um There are two things that what, what are the chances of getting long COVID if you get COVID? probably if you weigh all of the studies about 5%. So if you're thinking through the risks of everything and I, I, I use a risk of about one in 20 chance. If I get COVID, I'll get long COVID. It feels a little realer to me because my wife has Long COVID. Uh she's a very high functioning journalist. Uh She got COVID about a year ago. She will say to you, I don't have long COVID. If you were speaking to her now, she's a hell a lot smarter than I am, would not know, but she hits a wall most days at about one or two in the afternoon needs to take a nap. She'll forget appointments, which she never did before. So that and when you look at the spectrum of long COVA, there are people who are disabled by it, but I think more people look like her. It just has diminished her quality of life. I think it's worth thinking about that as you weigh risks and benefits the other thing that I think is very hard for people to factor in is it's not just symptomatic long COVID study after study. And these are really, these are bummers. I mean, there's no way for me to talk them away study after study shows that people who have had COVID compared to those who have not have a higher risk a year later of having heart attacks, strokes, diet study just came out yesterday on autoimmune diseases. There's a whole bunch of bad stuff that seems to be associated with getting COVID. You might say, well, I already had COVID so I don't have to worry about it. The problem is your risk of the second case is worse than if you only had one case. So I think we've sort of all decided collectively as a society not to even think about that. But I think as individuals weigh their decision making and whether to be a little bit careful to me, I think it's reasonable to be careful largely because of long COVID. I've still not gotten COVID as far as I know most of that at this point is luck. Uh, you know, I, I, because I, I'm certainly not being as careful as I was until about six months ago. But having seen my wife and, and really understanding the literature, I think if I can keep it that way, it's worth wearing a mask on an airplane to, to do that. Ok. Um, What about variants? Are there new scary ones on the horizon? Do we, do we just not care anymore? I feel like we don't care about it. Yeah, we, we should care a little but I don't think it's worth the average person obsessing about it. You know, we're basically still on the same Greek letter we were on 18 months ago, which is amazing because we, we all have to learn a new Greek letter every six months for the first two years. And uh so where we're seeing our variations on the theme and each one, if it takes over, it usually takes over because it's a little bit better at its job of infecting people or evading immunity than the prior one. But at least for the past really since January 2020 when Omicron first bait became a thing, there's been no variant that has been a game changer. There's been the yes, they have your immunity a little bit better than the old ones, but the vaccine still work fine. Pavid still works fine. Your home test still works fine. Monoclonal antibodies don't. So that's been thrown out as a, as an option. But the fundamental parts of controlling the epidemic, you know, does a mask work, does my home test work? Will packs of it work? Will the vaccines work? Does my prior infection protect me against getting infected? There's really no new variant that has changed that equation and none of the new variants which pop up every month or two have really seemed to be on the horizon. That will change that equation. That's no guarantee about tomorrow. A new variant could come out tomorrow. It could be a new Greek letter. It could make the vaccine not work at all. It could make, it could laugh at your prior immunity. But I think most of us feel like the chances of that is less than 20%. I think we probably throw out these things that scare the, let's talk about something happier. But yeah, I think that I think it's a reasonable way to approach the life now and say the state of COVID now is probably about the state of COVID three years from now. That's the best guess. And so whatever you're doing to live, your life is probably a reasonable way of thinking about what you're going to be doing going forward. Ok? I will take that. That's a little like it's like neutral of a bummer. Ok? Any questions for Bob, please raise your hand, we will bring a microphone over to you. You're welcome to raise your hand a little later. We've got one over here if we could get a mic over and if you wouldn't mind standing up and introducing yourself, you know, she wouldn't have to do that. I know. Hi, I'm Janice Whaley. I'm from Donor Network West. I'm in your neck. Neck of the woods. My question to you is Um, and I, I know you can't predict the future, but do you think that we're vulnerable again to a different type of pandemic that may come about? Um, and do you think that COVID ultimately is just gonna, like disappear? I don't, I can't see ac it's a good question. I can't see a circumstance where it just disappears. Uh You know, what has changed now is there's no one in this room of 100 and 50 people that has no immunity. You either have had a vaccine or you had infection or for most of you've had both. And so it's going to be around, but it's not going to kill people the way it killed people in the beginning when they had absolutely no immunity to it. I think that's the likeliest scenario for it probably forever. And at some point we'll just forget about it. It will just be something in the environment the way flu is and the way colds are, there's no way of predicting whether there will be something like it or worse than it. Uh, in the future. It's all maths. I mean, it's all viruses mutating and eventually coming up with some formula that turns out to be good at infecting people and good at hurting them and killing them. I think the chance is that, that will never happen again is zero. Uh, the last time it happened and it was as bad as this was 100 years ago. Will it be 100 years for the next one? That's possible. It could be 10 years. It could be 20 years. It seems unlikely it'll be a year or two from now. But it could be, I don't think there's any way of predicting. So I think we have to learn from this experience. So we're better at dealing with it the next time and report really made it clear that there's a lot of things we have to learn from. I mean, the CDC was just not built to do the things that we asked it to do. The fact that it basically had to beg for data from all of the states. You know, please give me your data so we can analyze it and tell people what's going on is ridiculous. That's a crazy way to run a railroad, but at least today it hasn't changed very much. And I I know you look at things very holistically, you look at systems, right? Um And you've talked about how during COVID, the health care sector as a whole, the entire ecosystem just became, despite all the issues became a lot more nimble and agile and innovative and collaborative is that all out the door? Just where, where is it now? Well, probably the, the two biggest things, the health care system. First of all, we built a tremendous amount of capacity. I mean, my hospital, every hospital, we had patients in the parking lot, patients in the cafeteria, you know, stuff we, you know, I've been a fan of telemedicine for 10 years and I had really been pushing it very hard at U CS F and managed to get our percentage of outpatient visits from 1% to 2% in about a decade. And it went from 2% to 70% in about two weeks. So just to show you the influence I have. Uh again, it's all the pandemic, it's all the pandemic. So I think we demonstrated how nimble we can be when provoked to, to it and when the payment and regulatory system lets us be. But I have to say it's somewhat disappointing. We're seeing new rule, we're seeing some of the old rules about telemedicine. For example, that for, you know, for example, I now would need to get a license in the state of Nevada to have a tele visit with a patient in Nevada that was all suspended for the pandemic. And all of those rules that make no sense whatsoever are being re erected. So we, yes, we became more nimble, but I'm a little worried that the system is sort of snapping back to the status quo. Are we better off or worse off than we were pre COVID as human beings in terms of uh no, it as as in terms of the industry, in terms of patient care. Well, I I think that COVID moved the I to me the most important issue is the digital transformation of medicine. I think me and that's a lot of the subject of the next day or so. A lot of medicine is going to be transformed by digitization by A I all that kind of good stuff. I think it moved us forward quite a bit. It probably leapfrogged us by five years uh where we can of our of data presenting data to people in forms that allows them to make better decisions. So I think we're better off in the big picture of how do we create a health care system that's better and safer and more equitable and less expensive in part because it accelerated the digital transformation of medicine. Ok. Well, I have to say, despite all of your bleak prognostications, you are such a comforting and calming and informative presence pretty fast trick today, those two things, right. So, thank you. Thank you.