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Transcript: Future of Global Health with Caitlin Rivers

Thought Leader: Caitlin Rivers
November 17, 2022

MS. WINFIELD CUNNINGHAM: Good afternoon, and welcome to Washington Post Live. I’m Paige Winfield Cunningham, deputy newsletter editor here at The Post, and today we have two segments on how countries can be better prepared for global health challenges.

My first guest today is Dr. Caitlin Rivers. She is an epidemiologist at Johns Hopkins Center for Health Security. Dr. Rivers, welcome to Washington Post Live.

DR. RIVERS: It’s great to be with you. Thank you.

MS. WINFIELD CUNNINGHAM: And before we get started, I have a reminder to our audience. We would love to hear any questions you have. So please tweet at us using the handle @PostLive. Well, let’s dive right in. Dr. Rivers, we are nearing the three-year anniversary of the first reported covid case. It’s hard to believe it’s been that long. If you could go back in time, can you identify one thing you really wish that health experts in the U.S. would have known before cases exploded here?

DR. RIVERS: Well, one of the early revelations of this virus is that asymptomatic and pre-symptomatic transmission is possible, meaning people can spread it without necessarily knowing that they are infected. That is a different attribute than some other infectious diseases where you’re not really able to spread until you’re clearly infected. That discovery, for me, that asymptomatic and pre-symptomatic transmission is possible really changed my understanding of this virus and ratcheted up my concern about it. And so I think looking forward to preparing for the next outbreak, epidemic, pandemic, being able to quickly understand the epidemiology of the virus is going to be really important to informing our understanding of risk.

MS. WINFIELD CUNNINGHAM: And let me ask you that same question when we’re thinking back over the last three years and the many policy decisions that were made. Is there one thing that’s really clear to you that should have been done differently in terms of the response?

DR. RIVERS: I think there are many opportunities to learn. I can’t think of a single thing, but lessons that I will be taking from the pandemic into my career going forward–and of course, I specialize in outbreaks, epidemics, and pandemics–is the option to use face masks to reduce transmission. In the early days of the covid-19 pandemic, it was not widely recognized that that was going to be an important intervention. We now understand that it is. I think we have all redoubled a commitment to ensuring that schools are safe so that they can remain open for children for learning and so that children can access the services that schools provide.

And I think one lesson that has been true across outbreaks–this is not a revelation from covid-19–is that it’s very important that we act quickly and aggressively before things spiral out of control. And I think that underscores a real need to have the elements in place to do that aggressive response so that we can get ahead of the virus and prevent these kinds of widescale events.

MS. WINFIELD CUNNINGHAM: When I think about the different measures that were used to try to stop the virus, it seems like one that didn’t get a lot of attention was air filtering systems. I know that we’ve had some reporting here at The Post about how there’s sort of been an under investment there and oftentimes an underappreciation for the importance of clean air. Can you talk a little bit about that? Do you have a similar sense, or was there adequate attention paid there?

DR. RIVERS: I’m glad you raised that, because ventilation and filtration is another element of emphasis that has been added as we’ve gone along across the pandemic. It was not prominent early in our response, but I think we’ve all come to understand that it needs to play a bigger role. Focusing on ventilation and filtration has the benefit of helping against not just covid-19, but all sorts of infectious diseases. We’re in the middle of a large wave of RSV. We’re likely headed into a bad flu season. Ventilation and filtration can help to prevent those viruses from spreading as well.

MS. WINFIELD CUNNINGHAM: And I want to talk about RSV and flu, but first, a little bit more about covid. Of course, one of the biggest problems in the response was sort of the fractured response and different decisions from local leaders versus state leaders versus recommendations from federal agencies. Are there any–do you have any thoughts on how we could have a more unified front next time, assuming we’re still going to have the same system we have now of a pretty–you know, not a homogenous public health system? It’s very fractured.

DR. RIVERS: That’s right. And that is both a feature and a challenge of our public health system. Most of our public health authorities lie at the state level and in some states it’s even lower at the county level. And that means each jurisdiction has the option or really even the power to make their own decisions. And as you know, that can lead to a lot of differences in how jurisdictions can respond. That is a strength because public health and what each community needs varies from place to place. But when we have a nationwide event like this, where people look around and say, why am I under these restrictions or why am I benefiting from these decisions, whereas my neighboring jurisdiction is not, I think the federal government’s role here is really advisory to provide the kinds of guidance and assistance that can help state and local jurisdictions to make those decisions. But I think there will always be some discrepancies in how things are implemented, and that needs to be something we plan for and recognize going forward.

MS. WINFIELD CUNNINGHAM: Well, and one other thing we found was really fractured was the way that health information was collected, and we know it wasn’t collected the same way everywhere. A lot of times there was an inadequate collection of health data. How did that affect the effort to find solutions to the pandemic?

DR. RIVERS: That’s right. Many people don’t realize that data that is shared from state and local jurisdictions to CDC is done on a voluntary basis, and often a data use agreement, a legal agreement has to be negotiated before any data is shared. And this is true for every single public health issue. Covid-19, monkey pox, influenza: All of those require individual data use agreements from every single jurisdiction.

The problem is, it’s very slow. It can take weeks, if not months to negotiate these agreements. And often, even after the agreements are done, the data are not standard. Part of the reason that we were very late to recognize the disparate impacts by race and ethnicity of the covid-19 pandemic is because not all jurisdictions collected race data and not all jurisdictions reported race data. And so I think going forward, one thing I know that the CDC is interested in, is gaining the authority to be able to compel or direct that data reporting in certain public health emergencies so that we can turn the crank on really getting that data flowing faster, be able to analyze it and share it out with both the public and with the public health officials who need it to make decisions.

MS. WINFIELD CUNNINGHAM: Of course, one massive success we saw was the rapid development of the vaccines, and you know, the fact that virtually anybody could access a vaccine within months of them being rolled out. And yet, I know that we have still had a problem of people not getting vaccinated, and it seems as though that effort to get those folks vaccinated has really stalled. Can I get your thoughts on that effort? Are we going to see more progress, or at some point, do we just kind of realize that there’s going to be a certain population that isn’t going to get the vaccine no matter what they hear about it?

DR. RIVERS: I think in public health, we always try, and we always hope. I think that right now many people have–even people who are reluctant to get vaccinated have relationships with their primary care provider, with other medical professionals in the community, and I know that those people are committed to continuing to try to increase vaccination levels. But I think you are absolutely right, that vaccine levels are still not where we want them. Only about 10 percent of eligible people have received the bivalent booster that has been available since September. This is the formulation that protects against the variants that are currently circulating. It’s an updated vaccine. Only one in 10 eligible people have gotten it. And so I just want to encourage people to do that, especially as we head into the winter season.

MS. WINFIELD CUNNINGHAM: What about the low vaccination rates among kids? I think those numbers remain pretty low. Why do you think that is, and how much does that concern you?

DR. RIVERS: Children are at low risk of severe illness, and so parents have a low-risk perception. They don’t perceive their children to be at high risk of severe illness. And that is largely accurate. It’s one of the small mercies, if you will, of this pandemic, that children are largely spared. I am a parent. All three of my children are vaccinated, and so I do strongly encourage it as a means to prevent our kids from getting sick or getting severely sick. But I think that’s the reason why parents have been reluctant. They don’t see their children getting as sick as they might from a disease like influenza.

MS. WINFIELD CUNNINGHAM: And of course, much has been made of the political divisions over the pandemic and a lot of mistrust in public health officials. Any thoughts on how–what health experts can do to try to rebuild trust with the public after all of this?

DR. RIVERS: It’s going to be a long road to rebuild, because I think you’re right that a lot of trust has eroded. But I think that public health is up for the challenge, and I think it’s something that starts today and will continue on for a long time.

One of the primary ways that we think about risk communication comes from a CDC handbook on risk communication, “Be first, be right, be credible.” And I think we need to return to our roots in trying to achieve be first, be right, be credible. And I think by continuing to show up and do that well, that is the way that we will build back that trust. But I don’t expect it to happen overnight. I think that we really need to be in it for the long haul.

MS. WINFIELD CUNNINGHAM: And I know we briefly mentioned kids, but let’s return to that topic, because it’s one I know that I wrote a lot about during the pandemic, and that was the approach to schools and the closures. And I know recently, we have seen very troubling test scores. Now granted, it looks like test scores are kind of poor across the board, even in states that tended to keep schools open more than other states. But what’s your–what’s your overall take on where we’re at with kids and education, and did we learn any lessons?

DR. RIVERS: I’m concerned about this as well. Again, I am a parent, and my children were home for a long time during the pandemic. And I think that it does need to be a shared national commitment not only to keep kids in school, but to keep them safe in school. And that was always my policy stance, if you will, around education, that schools are not inherently safe against viral transmission, but they can be made safe. I think earlier in the pandemic, masking was an important strategy. Even now, ventilation and filtration are important strategies. And that is true not just of covid-19 but also the RSV and influenza that we are seeing right now.

But it’s not just about public health. Schools are for education. That is their purpose. And I never saw the energy around catching kids up that I saw early in the pandemic when school closures were prevalent. There were a lot of discussions about summer school and tutoring and what are the strategies that we can use to reach kids who have fallen behind, and I’m not sure we’ve really stayed in touch with that enthusiasm. And so that’s something that I would like to see us return to.

MS. WINFIELD CUNNINGHAM: So, the threat now of RSV and the flu, I’m remembering I think two weeks ago, my middle child, half of his class was actually gone, out sick. So, this is definitely going around. Can you talk to us about how serious those threats are this year?

DR. RIVERS: I’ve been seeing that in my area as well, and it is a very widespread problem. The virus that’s circulating the most right now from what I’ve seen is RSV, or respiratory syncytial virus. This is a virus that is very common and spreads very easily both through the air and through contaminated surfaces. For most older children, for working age adults, it causes a cold. But for young babies and for older adults, it can be very serious. In fact, hospitalizations for RSV right now are the highest we’ve seen in years for children under the age of one year old. And so if you have cold-like symptoms, even if they’re not a big deal to you, I really encourage you to stay home when you can and wear a mask if you have to go out, because it’s those young babies that we’re thinking about.

Looking ahead a little bit, we’re already off to quite a severe flu season. We’re about two months ahead of schedule. And the level of flu activity that we’re seeing right now is more on par with what we would normally see in January. So, if you haven’t gotten your flu shot, I encourage you to do that. And again, think of these strategies that we used during covid-19 to reduce transmission and bring those into this next flu season. As a working parent, I know how disruptive it is to be home with your kids all the time when they’re not feeling well, and I know that I’m going to do what I can to avoid that.

MS. WINFIELD CUNNINGHAM: Do we have a sense yet of who is most at risk from the flu this year, and also how effective this year’s flu shot is? I know that it does vary from year to year because it’s sort of a guessing game as to how to formulate it.

DR. RIVERS: That’s right. Young children and older adults–this is common across infections–are at the highest risk of severe illness. But really anyone can get severely ill with influenza, and that’s why it’s important to get vaccinated every year. We don’t yet have a sense of how good this year’s vaccine matches up with what’s circulating. But based on what I’m seeing so far in the data, I feel pretty good about it. Again, we won’t know really until January. But the two strains that are most common right now are H3N2 and H1N1, and both of those are in this year’s formulation. And so I am hopeful that it will be a good match.

DR. RIVERS: And before we leave the topic of covid entirely for this interview, I did want to ask you about an investigation that recently was released by Senate Republicans, and it concluded that the pandemic was, quote, “More likely than not the results of a research-related incident.” What do you make of that finding?

DR. RIVERS: Well, I think this is a really difficult area that from my perspective will never be settled to the highest evidentiary standard. I don’t think we will ever truly know from where the pandemic originated. I think it was most likely originating in animals because most new infectious diseases are. But again, I’m not sure that we’ll ever get that final say. But I think it’s enough to recognize that it is a possibility maybe that that labs can be sources of leaks, of accidents, of spillover events. And I think that–just that observation enough to know that it’s possible is reason to continue to focus on lab safety and lab biosecurity as important strategies for reducing our overall risk.

MS. WINFIELD CUNNINGHAM: Let’s talk about a little bit of good news for a minute. Over the summer, there were a lot of kind of scary headlines about monkey pox and the threat of that, but now it appears the spread has significantly slowed down. What happened there?

DR. RIVERS: This is a good news story for public health. Monkey pox is a very uncommon virus that spreads right now–during this epidemic–spreads primarily between men who have sex with men. Over the height of the summer in August, there were about 450 new cases every day, and there are now only about 25 new cases every day. And so there’s been dramatic improvement over the course of that epidemic.

I think we can attribute a handful of things. It’s an all of the above situation. But certainly, education and behavior change in the affected community, vaccination and outreach and contact tracing by public health officials I think have all contributed to what we’re seeing is a rapidly declining outbreak.

MS. WINFIELD CUNNINGHAM: I know that you were recently part of an initiative at the CDC that was trying to forecast how bad the next virus outbreak could be and offer some policy solutions to that. And you likened the effort to the National Weather Service. Can you explain a little bit how that worked?

DR. RIVERS: Yes, the Center for Forecasting and Outbreak Analytics is the newest Center at CDC. It was founded–we opened our doors, if you will, earlier this year, and its purpose is to bring forecasting and outbreak analytics to public health problems where decision makers are having to make decisions very quickly. And in the past, they haven’t always had the data or analyses that they need in order to make those decisions in an informed matter–manner rather. And so the purpose of CFA, the Center for Forecasting and Outbreak Analytics, is to bring together the best modelers, the best data scientists, epidemiologists, and really create an engine to produce those analyses to support decision making.

The center is just in the hiring stage right now, getting their feet under them. You can see a few of their early successes at But I think this effort will really grow into be–into one of the core capacities that we use to respond to outbreaks in the United States.

MS. WINFIELD CUNNINGHAM: So, what’s on your radar right now? What are you watching out for in the future, and what should Americans be watching out for?

DR. RIVERS: In addition to influenza and RSV, which are two viruses that are close to home and are causing quite a stir this year, I have my eyes on an outbreak of Ebola Virus Disease in Uganda. This outbreak of Ebola is caused by Sudan virus, and I note that because it’s a different virus than what had caused outbreaks in the DRC and in West Africa in previous years. That’s important because none of the vaccines or the treatments that were developed for those other strains work on this strain. And so Ugandan officials are really having to rely on traditional and core public health strategies of contact tracing, isolation, and quarantine to break chains of transmission. And it’s been a bit of a struggle. It’s been a difficult outbreak to really get their arms around, and so I have my eye on that closely.

MS. WINFIELD CUNNINGHAM: Well, unfortunately, we’re out of time, so we’ll have to leave it there. But, Dr. Rivers, thank you so much for joining us today. It was a fascinating conversation.

DR. RIVERS: Thank you.

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