Dr. Henry Wu ’89 is one of the country’s leading experts on infectious diseases. He regularly studies outbreaks around the world, and even though scientists have anticipated a pandemic for years, COVID-19 has characteristics that make it particularly loathsome – including a high degree of transmissibility in asymptomatic carriers.
Podcast Editor Allen Murabayashi ’90 spoke to Wu about the pandemic. Listen above:
AM: Thanks for joining our Team Up Podcast, produced by Punahou School. I’m Allen Murabayashi, an alumnus from the class of 1990. As part of our #PunsUnited Coverage of the COVID-19 outbreak, we’re interviewing alumni working on the front lines of this global health crisis. They’re out in force, playing instrumental roles in helping their communities across the world during this unprecedented time. After graduating from the University of Pennsylvania, epidemiologist, Henry Wu matriculated to Harvard Medical School, and then received the Postgraduate Award from the London School of Hygiene and Tropical Medicine.
He’s published dozens of academic papers and been cited in numerous books with titles like, “How Can Emergency Departments Better Prepare for Emerging Infectious Disease Threats?” and “A Returned Traveler with a Fever Walks into a Triage.” In other words, he’s exactly the person you want to listen to when the largest pandemic of our lifetime spreads like wildfire across the planet. Henry’s classmate, Janet Masamitsu told me he’s such a soft-spoken, super nice guy. To back that up, Henry told me he’s historically shied away from talking to media outlets, but with the amount of misinformation, he feels it’s important to get facts and science out to the general public. Henry’s often brought in as an expert for outlets like The Wall Street Journal, CNN, ABC, and Fox Business News.
HW: My name is Henry Wu. I’m from Punahou Class of 1989, and I’m in Atlanta, Georgia, where I’m an Assistant Professor of Medicine at Emory University. I’m a specialist in infectious diseases, and I also am the Director of the Emory TravelWell Center.
AM: You’ve been working in infectious diseases for about 20 years. Can you describe what a normal year looks like in your profession when there isn’t a massive pandemic?
HW: Particularly, in travel medicine, infectious diseases, even without a pandemic, it’s always interesting. Somewhere in the world, there’s always an outbreak or something new going on, so part of my job is to monitor what’s going on in the world, and when I see travelers or sick persons who have traveled to those areas, to consider these things, so even in a normal year, I’m dealing with a lot of new infections and things I’ve never, either never seen before or sometimes never heard of, but certainly typically, we do not deal with a pandemic like this.
AM: You had a four-year stint at the CDC. Can you explain what the role of the CDC is in government?
HW: Well, the CDC is the government’s public health agency, and so they’re involved with anything related to public health, research, surveillance, policy, and I would contrast that with the NIH, which is the government’s more straight research body. Now, they work side by side in many ways, but their missions are slightly different. CDC’s role is to monitor diseases, not only infections, but even non-infectious conditions, and develop policies to help prevent illness and deaths from these various conditions.
AM: We’ve seen a parade of faces representing a myriad of different governmental departments from the CDC to the FDA, to the Department of Health and Human Services. Does the U.S. government have a standard response playbook to an epidemic or a pandemic, or does each administration tailor its own response?
HW: To the large degree, responses to epidemics and pandemics are led by the CDC, and for the most part, the playbook is very much the same through, based on previous experience, based on science, and led by CDC in terms of strategy and approach. Each administration can certainly, can have their own influence in how the response is managed, and so obviously, in major responses, there’s often a White House-appointed head of the outbreak response, so certainly, that can affect the response. Generally speaking though, historically, the actual activities of the response, the planning, or at least the more immediate activities are handled and dictated by the CDC.
AM: Epidemiologists had been warning for years about a flu-like pandemic that was a likely scenario that would wreak havoc around the globe, but COVID-19 seemed to have caught many countries flat-footed. Why do you think this is the case?
HW: I think it’s a mix of issues. First of all, it spread extremely rapidly, and we know epidemics can spread quickly, but one of this size is pretty unprecedented. I think some aspects of the illness also were a little deceptive, I think, or at least misleading in some ways. I think the large number of mild cases, even asymptomatic cases led many, both persons and authorities to be a little less concerned, but certainly, those of us who study these diseases recognize fairly early on that this was potentially a very dangerous epidemic.
AM: I think we’ve all been reading various scenarios of how this plays out. I think in the most dire predictions, we’re sheltered in place until a vaccine is developed in 18 months. In the most optimistic case, the President the other day called for parts of the country to reopen by Easter. How do you see this playing out?
HW: This outbreak has been extremely unpredictable in some ways, and so it’s hard to make predictions, except I do think preparing for the worst is important, and that this may be fairly prolonged more than a few weeks. We’re talking potentially months, and even if things do die down during the summer, which we hope it will, both because of seasons, seasonal changes, as well as control efforts, most of us expect it to return in the fall or winter the way most seasonal respiratory viruses return, so I do think it’s a long-term battle. On the other hand, I don’t necessarily means it means shelter-in-place the entire time, but I do think it is very much a week-to-week situation, and I do think normal activities, the way we used to are going to be a little, significantly curtailed and potentially to some degree, for some months, and if not, a year or more ahead.
AM: Do you see any scenario where localized regions are able to have more activity than some of the hardest-hit regions, and then we sort of play whack-a-mole in those areas?
HW: I do see that. It’s clear that some areas are affected more than others, and not just because some localities are diagnosing or have ability to test and diagnose more cases than others. I do think certain parts of the world, probably certain states or cities in the U.S. may do better, either because of aggressive prevention or maybe they’re just relatively insulated than with less interaction with more active epidemics, so I do think it is quite possible there will be always certain areas that are more active than others that warrant more attention.
AM: One of the more curious things about this spread of the disease is this real geographic discrepancy in the attack rate, the affected age ranges and the mortality rates. Do you have any hypotheses about why this is the case?
HW: I can’t say that in almost any outbreak early on, it’s very difficult to really come to an exact measurement of the case fatality rate, and that’s due to many reasons and primarily because usually, the cases that are identified early on are the sickest, the ones that present to the hospital, while the milder cases are the ones who just don’t make it into your surveillance system or are missed. The COVID-19 outbreak is a great example. I think you’ll see a wide range of case fatality rates being reported, and some of it is very much likely due to just various amounts of ascertainment of mild cases. I think a good example would be the case fatality rate described in Hubei province compared to the rest of China is wildly different. It’s much higher.
The presumption most of us have is that in Hubei, where the outbreak started and got bad very quickly, the cases they were primarily seeing were the ones in the hospital, and their hospitals were very quickly overwhelmed to the point that mild cases probably were rarely seen and diagnosed in the hospital. On the other hand, the remainder of China, having seen what was going on in Hubei province was much better prepared to identify and diagnose cases, even the mild ones because they did not deal with the numbers that Hubei was dealing with. In the U.S., a somewhat similar situation but for different reasons, our testing capacity has been a bit slow to ramp up, and for that reason, we are testing primarily the sickest persons in hospitals. In fact, we are even telling folks, at least here in Georgia, who might have COVID, but have mild illness, to really just stay at home and assume you have it. We don’t necessarily have the capacity to test everybody right now.
The case fatality rate numbers are going to range wildly. I personally don’t pay attention, too much attention to the exact numbers on the various dashboards, because I do think they are very much going to be affected by numerous factors. I do think that the overall case fatality rate is probably higher than what, historically what we see for Influenza. It certainly is less than SARS and MERS, the Coronavirus cousins. I won’t hazard too much of a guess, but it’s probably somewhere in that 1 percent range.
Again, the 3 percent, 2 to 3 percent that’s being reported is again, probably biased by the testing. The other reasons it could vary enormously is it really also just depends on the population getting sick. Obviously, when a nursing home has an outbreak, the case fatality rate will be very high given the age and the various comorbid conditions the residents have. These are all variables that really can make the case fatality rate range wildly, and not until we get more good data and potentially even blood tests to determine if somebody had a mild illness and maybe didn’t even know it, an exact, more accurate number for the case fatality rate really, we really cannot get, but I do think we have a rough estimate on the ballpark.
AM: Do you think that the R0, the communicability rate is higher than Influenza or is it still kind of in question as well?
HW: It certainly is in question, but I think most of us would think it is higher, and that’s a number that’s very much an observed number, and again, only as good as the data you have, so if we’re not very good at identifying cases, which we are, certainly are not good at in the U.S. at the moment, I think an accurate R0 calculation’s going to be difficult. I think it’s clear it’s high with the amount this disease has been spreading, and there’s various disease-specific factors that affect R0, I mean, not only its intrinsic ability to spread, if it’s airborne, but also how susceptible the population is. One thing about COVID-19 is presumably, this disease has never been encountered before, certainly not in modern times, and therefore, I would assume virtually none of the population is immune. Whereas for seasonal Influenza, we certainly have vaccination. We certainly have had circulating Influenza for all of our lives, so certainly, we may have immunity from previous infections, so there are many reasons why the R0 for flu is probably going to be a bit less than for COVID-19.
AM: A lot of epidemiologists have been advocating this shutdown everything, cancel everything position, and some critics have suggested that epidemiologists don’t consider economic costs. Is that a fair criticism?
HW: It’s fair in the sense that in public health, epidemiology, our main goal is to stop an outbreak. Now, it does not mean cost is not a consideration. Certainly in public health, cost benefit analyses are a part of the decision-making process, so I do think it’s a fair issue to raise. I would say though that most of us believe that this outbreak is serious enough in terms of potential loss of life and disruption. In many ways, that aid make drastic measures, even causing economic disruption are probably warranted. I do think, certainly of course these decisions need to be made in, with discussion with politicians and economists, however, I think most of us believe that the potential risk for both loss of life, not only immediately, but in future years is high enough that these drastic measures are warranted, but I’d also agree that again, we’re in uncharted territory.
I mean, I don’t think it would be easy to come up with the estimate of the cost or the economic damage. Certainly, it will be high, but again, yeah, it would be hard to predict how high and maybe it will be left to historians to decide if, what was worth it, but I do think though that we’ve seen a number of pandemics over the last couple of decades and how much this COVID-19 has permeated across the world. This rapidly is alarming, and certainly, I do consider this a much bigger threat to the world in general than previous epidemics.
AM: I’ve spoken to a few high school groups in the past and explained to them that there are actuarial tables that assign a monetary value to human life. When they hear this for the first time, a lot of them are blown away by this notion because I think we’re generally raised to believe that the value of human life is incalculable. Do epidemiologists think about the monetary value of human life or in a situation like this, do you think the worst case scenario is two million people dead, so if we can cut that to 250,000, we’ve done a good job?
HW: I think both are considerations. I think thousands or millions of deaths that in theory were preventable is something to put a lot of effort into, but it is … You’re completely correct, in public health, to do a cost benefit analysis, there is in some ways a monetary value on life. Again, and it’s not meant to say what a life is necessarily worth, but it’s more to be able to compare different interventions in public health and decide what makes most sense, and so the reality is if we had infinite resources, sure, we could vaccinate everybody with every vaccine we could. We could make sure everyone drives a very safe car, we could do all kinds of things that in theory, could save lives, but the reality is we cannot afford it. In public health, when you are comparing various interventions, some idea of it’s, this interventions cost and how many lives will be saved is very much a factor that is considered.
AM: If you were in charge of the pandemic response, what would you be doing differently than you’re seeing now?
HW: Oh, wow. That’s a dangerous question.
AM: Yeah, I know.
HW: It’s dangerous because even if I have things that I would have done differently, I can’t be sure things would be any different or necessarily better, but certainly, I do think that many aspects of COVID-19 were a little unexpected, the high percentage of minimally symptomatic persons and possibly asymptomatic, although I think the distinction between minimally symptomatic and asymptomatic is not a clear one at best. I mean, I think if you think about it, how often do you feel a little run-down, a little stuffy-nosed, a little fatigued, but for the most part, you feel fine? Again, we’re dealing with an infection that in many folks, presents with those mild symptoms, so if in somebody’s head they are feeling fine, are they really asymptomatic or just minimally symptomatic? The reality is, a high proportion of the cases are this, which would make our traditional tools in finding and isolating and containing an epidemic very difficult, because those tools are primarily based on symptoms. I think that’s where we clearly could have done better.
I’m not sure the more drastic interventions that would have been required to stop it would have been palatable. It would have been fairly drastic travel restrictions much earlier. Now certainly, we’re in that point now, but the challenge in these responses are that many of the tools we have can seem extreme or heavy-handed, and certainly, on one hand, we want to implement them to prevent a serious outbreak. On the other hand, the time to do that is before the outbreak becomes obviously serious, and that’s where the challenge comes when it comes to convincing the public or politicians that these are necessary. That’s the difficulty in public health.
Sometimes our tools or what we want to do may not be feasible. I think historically, this’ll be an interesting outbreak to study in how each country handled it. China, by most reports, if you trust their numbers, and I generally think there’s some truth, has had some success in really curbing domestic transmission. Obviously, that was achieved with very draconian measures that would be nearly impossible in most societies with more individual freedoms, so I do think there will be a lot learned here in terms of the right way to approach it. It may be that the right approach may not be the same for each country.
It may be that some, in some places, more draconian measures are feasible and effective, whereas in others, a different approach might have to be adapted. I don’t have an easy answer. I do feel like early on, when some of us were reading the early case reports and realizing many of these cases were very mild, we had an early concern that initial screening criteria, both for travel, as well as who to test would not be stringent enough to catch many of the cases.
AM: The response to the outbreak has become weirdly political, even at a local level, all the way up to the federal level. Who should we be listening to at this point in your estimation?
HW: Yeah. I do think that the politics have been a very unusual twist in all this. I would also caution not only some of the politicians and things that have been said at various levels, but also social media, which as you know, is often driven by misinformation and sometimes even deliberate campaigns to misinform. I would strongly encourage folks, I think for public health related advice, us, certainly start with the CDC and the state health departments. While certainly there may be mistakes and needs to change, policies and messagings, I can assure you that my colleagues in the state and federal public health departments are doing their best to make policies and recommendations based on the best scientific evidence possible.
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