Dr. Bob Wachter of the University of California, San Francisco (UCSF) Medical Center is a leading voice in providing evidence-based, timely information about COVID-19 to his more than 165,000 followers on Twitter. We sat down with Dr. Wachter to discuss how the COVID-19 pandemic will progress over the coming months, with factors like holiday travel and the arrival of vaccines.
Putting on your predictor hat - take us through what you anticipate the winter, spring and summer will bring in the U.S.?
Clearly we are in the early stages of what’s going to be the biggest surge of all. We’ve far surpassed the numbers we were seeing over the summer, which is scary.
We got a little complacent. The case fatality rate (CFR) of COVID-19 - that is the ratio of people with a confirmed diagnosis of COVID-19 who die as a result of the disease - has gone down 60 or 70% from the early days, and that’s real. However, some of that improvement was due to hospitals not being overwhelmed, the way they were in New York in March. With the current surges we’re seeing in cities like Los Angeles and parts of the Midwest, all bets are off – mortality rates seem likely to rise as people are unable to receive the best possible care from overwhelmed hospital staff and systems.
When you look at the benefits from the pharmaceuticals, the only one that has shown a clear mortality benefit is dexamethasone, a corticosteroid given to hospitalized patients to tamp down the immune response. Other medications, including monoclonal antibodies and remdesivir, have shown improvements in important endpoints (hospitalizations in the case of the monoclonals, when given to outpatients; length of hospital stay in the case of remdesivir, when given to inpatients) but it’s hard to find a significant mortality benefit from any of the medications. Interestingly, while there was a lot of worry about the limited availability of monoclonals, the use of them has been underwhelming, mostly because it’s tricky to identify eligible patients and carry out the logistics of giving a long intravenous infusion in the outpatient setting.
The bottom line is that, while we hoped for a game-changing therapeutic, it is the vaccines that have come to the rescue. Now that we have two vaccines – one manufactured by Moderna and the other by Pfizer-BioNTech – that are proven to be 95% effective in preventing cases of Covid, including severe cases, the new challenge is to distribute them quickly and effectively, and to convince people to take them. There is new urgency to this effort, driven by the major winter surge that is straining hospital capacity all over the country, as well as the emergence of a new, more infectious mutant virus. Our experience with rolling out testing and PPE doesn’t create a lot of confidence that the vaccine roll-out will be free of glitches. It will be important for individuals to be vaccinated to protect their own health, but even more important that we reach a high enough level of societal immunity – probably about 70% – in order to tamp down the spread of the virus and give us some hope of returning to “normal.”
Given the challenges that we’re seeing this winter, what do you recommend regarding travel?
In late summer, I visited my 90 and 84-year-old parents in Florida. My father is in hospice and I thought it was unlikely that I’d see him alive again if I waited until I was vaccinated. Based on the numbers at the time, I estimated that the risk of getting Covid from a single flight was about one in about 5000. And if you then multiply that by a 1% mortality for people of my age, you go from one in 5000 chance of getting it to one in 500,000 chance of dying from it.
So I decided it was worth the risk. I wore an N-95 and a face shield and took the mask off for about three seconds to gobble down pretzels — probably my biggest risk would have been aspirating on the pretzels. I thought to myself, if I got sick because of this flight, how would I feel about it? I decided I’d feel good about it. It was the right call. Given the current state of the pandemic, I probably would not make that flight today, at least until I was vaccinated. Why? Because during a surge, it’s far more likely that people sitting around me would have Covid, even if they were asymptomatic. It means you have to be even more careful than you were when the prevalence was lower. Ditto with the new variant – the same level of caution and yet your risk is higher if the virus is more infectious. It gets exhausting. We’re all having to make about 100 decisions a day like this.
In your book The Digital Doctor, you speak to the importance of implementing tech in healthcare and the unintended consequences. How have they played a role, if any, in the current pandemic?
I’m a huge fan of AI and I think it will ultimately transform everything. I might’ve hoped this would be a tipping point for AI, but I can’t think of an area where it's made a significant impact on our response to COVID, at least not yet. To me, the big tech-related change coming out of COVID is telemedicine. It was on a path toward a tipping point, but it would have taken five years – and Covid accelerated it to two months! The accelerated adoption of telemedicine won’t just be meaningful as a visit replacement, but it also accelerates the path towards more digital home-based care, with implementation of home sensors and home patient surveys, for example.
What I don’t know is where all the data are going to go. Here’s the conundrum: if the patient is home, and checking their glucose four times a day and their blood pressure once a day, stepping on a digital scale and so forth, what happens with all those data? Does that data get streamed to the primary care doctor? I hear people talk about this sometimes, and they say “the doctor is going to be so grateful to be able to know all of the information about her patient.” That is not a universe I am familiar with, because every single one of the 300 primary care doctors who work for me — if I told them that data stream was going to come to them, they would all quit by 5 p.m. this afternoon. It’s impossible. You can’t take that data flow and try to have it attached to the chassis of the current healthcare system. There needs to be a new middleware – comprised of both people and technology – that filters it, deals with false positives, triages it, arranges for an appointment with a coach or a nurse practitioner or a physician. It simply can’t be a straight shot to the doctor, or the system will break.