This week I am talking to Monica Gandhi, MD, MPH (@MonicaGandhi9), Professor of Medicine and Associate Chief Division of HIV, Infectious Diseases, and Global Medicine, and Director of the UCSF-Gladstone Center for AIDS Research (CFAR) and Medical Director of “Ward 86” HIV Clinic, San Francisco General Hospital. She has many articles published on the pandemic, details of our immunity to the disease and what the future might look like living with COVID19
Monica came to prominence during the course of the COVID19 pandemic speaking out on the policies she saw being imposed in her community that were causing more disease and problems than they were solving. As noted in our discussion, it was 40 years ago HIV was first described and despite all the progress we have made in treating the disease it remains a killer with over 36 Million people dead and millions more living in its shadow.
Despite years of experience and science we failed to learn from these lessons and apply the knowledge to the pandemic unfolding. We failed to learn form the experience from the 1918 pandemic which was as politicized as the SARS-CoV-2 pandemic has been. This time around we messed up our messaging creating more confusion and fear than was necessary, much the same as we saw when the original HIV pandemic unfolded.
It took some stand out characters like Lady Diana Spencer, the Princess of Wales to bravely stand up to the general thinking
and show with her personal actions that the risk of HIV was not linked to contact
The Princess Of Wales visiting a hostel for abandoned children, many infected with HIV/ AIDS, in Sao Paulo, Brazil Image: Tim Graham Getty Images
We talk in detail about the school closure and the lasting impact this has had on our children and will continue to have and how we broke the trust between the parents, teachers and the children with poor communications and lack of transparency in the messages.
You can read the article she co-published: Revisiting COVID-19 policies: 10 evidence-based recommendations for where to go from here, that reviews the latest evidence concerning 10 key COVID-19 policy and strategic areas for deeper insights.
Risk Stratification
We discuss the importance of risk stratification when considering groups and the responses – especially important relative to children, who by virtue of the lack of the receptors to the spike protein found in the noses of children, are much less susceptible to the disease and at much lower risk.
Listen in to hear Monica’s views on the inequity of vaccine distribution and how we should mitigate that and her clear and simple solution on how we need to deal with this pandemic, based on years of experience working with HIV patients. It starts with a focus on hospitalization numbers and using this as the guide to response levels and then stratifying population based on risk to get to a manageable status for endemicity.
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Raw Transcript
Nick van Terheyden
Today, I’m delighted to be joined by Dr. Monica Gandhi. She is the professor of medicine and Associate Chief division of HIV, infectious diseases and global medicine. Monica, thanks for joining me today.
Monica Gandhi
Thank you, I’m happy to be here.
Nick van Terheyden
So I think you’re very well known. In many circles, your primary area of interest and work that you’ve done over many, many years has been HIV, that’s come to the forefront with all of the things that are happening with COVID 19, the pandemic, this is now another pandemic, as we look back at HIV. Last time I looked, it was about 36 million people had died from HIV. It’s changed dramatically, as you think back over the course of the work that you’ve done, and the incredible progress that we’ve made to HIV. Tell us a little bit about what you think that teaches us around COVID-19. And what we can apply moving forward?
Monica Gandhi
Well, you know, you’re right, that tape is the 40th anniversary of the first description of AIDS this year, 2021 40 years ago, June 5 1981, was the first description of AIDS. And though there’s still 37 million people living with HIV, it is important to remember that actually 37 point 2 million people have died of HIV infection since the beginning of the pandemic. So this is very much still with us. Five, over 5 million people have died from COVID. But this is a longer standing epidemic, HIV, and we it is not over yet. Bye, bye. Bye, you know, any description. I think that what I learned from HIV, as being an H, a long standing HIV doctor and watching also the policies around HIV, and the politics was that a harm reduction approach, where you actually advise people on how to avoid a pathogen like HIV, but still live within the parameters of their needs of their sexual needs of whatever is happening in their life, and advise on how to stay safe, but still, you know, live was the was the most profound thing that we did an HIV we risk stratified particular activities, this is a low risk to high risk activity. And we advised people accordingly. And, and it really gained the trust of the community. What happened in COVID, is that there is this idea in many countries, and most countries actually not all, like, Japan didn’t do it this way. But some countries just said, There is no other way but to just stay away from other human beings to to stay safe from COVID, even when we knew so much more after three months about cleaning not being necessary, and fomites. And surface not being a thing and transmission. And the idea that was somewhat in generated that the only way to stay safe was to stay at home and be not be around other people as opposed to, okay, their essential services, it’s keep them open with COVID mitigation procedures in place like masks and ventilation, we just use the kind of abstinence based approach. And that doesn’t work for human beings. And it didn’t work in COVID. And anytime there were more restrictions, like closing the outside, which wasn’t reasonable in some places, then people would go inside because people needed to be together. And so I think what I learned is that I’m surprised that we didn’t take some of our lessons from HIV, which was also to think about risk stratification. Younger people with COVID are less at risk. These groups are less at risk for HIV, and, and work accordingly. Instead, we used kind of a blanket approach in many countries, and I think it backfired.
Nick van Terheyden
I, I guess I’m surprised but I’m not because I read the 1918 pandemic book that was published pre this pandemic. And I read it as if I was reading the same thing about this, we fail to learn from that one. And that was 100 years ago. We just seem to consistently ignore history, despite the fact that it teaches and informs everything moving forward.
Monica Gandhi
Well, that’s actually a really good point. And I looked myself at the 1918 pandemic playbook the other day, because I was doing a talk on school closures, and for the pediatrics community here at UCSF, and what I was very amazed by historically, is what happened in 1918. Was this absolute focus on children, even though influence unlike COVID, affects the young and the old. COVID is very good at it. it’s much more likely to get severe disease in much older ages. And the young are really relatively fair, especially children. And yet, at least not in again, not in Europe in the UK as much. But the US really did really close schools. They just did. And they did it politically. And they did it along political lines that Democrats closed schools and Republicans didn’t. And the amazing thing about what happened in 1918, is the very progressive societies. So New York City was good example. They were told for public health officials were told you better close schools, you’re going to cause the transmission of this highly infectious respiratory pathogen and the public health officials in New York City about whether there were 1 million children in the public school system said absolutely not. Children need school, they need it for their learning. They need it for their socialization, and they need it for their food. 750,000 children in the 1 million public school students really did not come from affluent families. And they said, No, we will not close schools in New York City, Chicago, New Haven, they did not close schools, and then anywhere else, they closed schools, but then they opened them as soon as they could. So that was what happened in 1918. And here we have COVID, affecting children so much less but again, politically. Often politically, schools were closed worldwide. And UNICEF kept on saying stop open schools. No, no, this is really hurting children. But there was this profound fear of COVID. And, and I don’t obviously blame it on politics, I blame it on our messaging. Our messaging was somehow you’re going to get COVID and die at any point like that is so a non subtle, like, No, you’re much less at risk, when you’re this age are much more risk. When you’re this age, these are the risk factors. These are the way to stay safe, just message it properly. But it was really fearful messaging.
Nick van Terheyden
I think, you know, it, in hindsight is always 2020. It’s clear, there was a failure in a lot of messaging from government organized organizations from specialist professionals. And we saw that with HIV, I remember that vividly. And you brought back a lot of those memories. I remember that touch was one of those areas. And Lady Diana was one of the people that really tried to stand up and change. And he brought it
Monica Gandhi
up with HIV. I remember that. Yeah. So
Nick van Terheyden
it was part of her yes. You know, just being was to say, No, this isn’t the case. But what I recall from that was it took a long time, even with the the impact of leaders like that, to change the opinion. I feel like the same thing because I’m I get on planes and I’m hearing that they’re cleaning everything down and we’ve got wipes yet we know that that’s not the case. How are we going to change opinion so that we move forward with science. But we’ve changed our view and understanding we need to change it? How do we get people to move quickly with this because that’s what we need to do to open things up.
Monica Gandhi
In fact, not only do we need to do this, but it’s imperative to do this for mental health and for the emotions that this pandemic has created, along with the terrible illness that has it’s led to, there’s been amazing After Effects, measles, vaccines down all over the world, HIV control and main places tuberculosis, for the first time mortality rates went up this last year. Malaria, I mean, it is important. It is not and then everyone’s mental health. So this is how I see it. And it’s really interesting. You just talked about Princess Diana at the time, who was a model figure who did this, she showed she was brave. And she she showed that you can embrace people living with HIV. That was not how was transmitted. I think we need leaders and I don’t mean political leaders, I think we need the leaders that are that will lead the response. Neil Ferguson, Anthony Fauci people in in countries that lead the pandemic response to come out and be extremely clear about risk stratification, how it’s not once you’re vaccinated. There’s there are so many these vaccines are working great to give a profound security in the vaccines, and, and, and to say things like, I’m gonna just list the things that we need stop doing. Stop cleaning this stop being scared of everyone stop. You don’t need to wear a mask in the settings. There’s like, I actually think that’s really important. And when I think about, for example, your country and mine, the same thing happened. A politician who was the leader of the country, looked like they were minimizing COVID At least Boris Johnson beginning and certainly Trump almost throughout. And because of that there was an overcompensation by science, science based leaders to say we’re not only going to minimize this, we’re actually going to like not even be subtle in how we speak about an ScienceBase. Every speaker, we’re going to go all the way over like this is just so scary that we’re going to inflate some of the fear based messaging. And that was purely politics. I mean, if we’re just purely based on the science, we could have opened schools, much earlier in the US, we would have known the mitigation procedures, we’d stop wiping everything down, we’d stop making people scared of each other. So that became political in the UK and the US mostly, I really saw those effects that was in Denmark, sort of calmly message risks and apologized when they kept the schools open or closed for six weeks when the Prime Minister opened up said, so sorry that they were even closed for six weeks and and got everyone to agree to take the vaccine because there was just trust generated this kind of back and forth where science based leaders think they need to overcompensate for politicians who don’t take it seriously enough, that led to distrust of both sides.
Nick van Terheyden
Yeah, I think that trust element is a critical part and you bring out Denmark, they’re interesting, a very high trusting society, unlike some of the others that you’ve talked about. They did a really good job right up until the mink farm issue that I think broke a little bit of that that’s true. And, you know, the question is whether they can recover. But I agree with you that transparency is essential, as you think about it moving forward. And I know, you know, you talk about the school closures, you obviously have young children. You think about this, not just from a professional standpoint, but from a personal standpoint. Tell us you’re thinking about schools, school closures, and that stratification of risk for parents who are now all struggling with vaccination is available getting vaccinated, am I safe? What What should I be telling my children?
Monica Gandhi
Well, that’s a very good question. Because if we broken trust, with parents who at least in in many places around the US, there’s been a breaking of trust with parents that when there was messaging done about COVID, by major public health organizations, we didn’t clearly say, Okay, this is the risk when you’re at this the risk under 76, when you’re 60. And actually, it’s very small when you’re young. Why is the risk of small when you’re young? Two reasons, actually, there’s something to do with the receptor that takes in the COVID virus, the the children have the CS two receptor and is higher density in their noses, so they’re less susceptible to it, which is really different than each with that influenza. And then the second reason is, and this was just in a Nature paper recently that there is there a need immunity actually is not dysregulated, like a like older people’s can be that led to so much of the inflammation and the illness of COVID. So they have very good innate immunity to control pathogens in the lower respiratory tract, this particular pathogen. So all of that mentioned, or much less at risk. And so because we didn’t message that, because we use fear based messaging, teachers were fighting to go back even adults and parents were frightened to send their children back to schools when they did open. And then this is just clear that this epidemiologic association is there that children are less at risk. And now we’re saying get the vaccine. And if that trust has been broken, where parents say, but you exaggerated the risks for my children, you exaggerated, that they were more disturbing in school than they were at home with the mental health effects and learning loss of not being on them, why would I get the vaccine and that trust has to be rebuilt. I mean, I do think that getting a vaccine, and I’ve written about this getting getting I’m planning on vaccine in my 11 year old, which we have the 511 year old vaccine here, getting the vaccine is important for children, not because they’re at high risk, but because even a little bit of risk if you could eliminate that risk, you know, because there were some definitely actually only had 25 children die in the UK for a Nature Medicine study. Under 17. This was just published on November 8. And, and much higher, of course, for adults 100,000 At the same time for it for adults. So 25 Children, it was point 8% of the deaths among children number that year, so much less risk, but that is 25 Children, there is 897 children here in the US, as of this data have died from COVID. If you could eliminate a risk of anything for a child and the vaccine is safe. That’s why we’re encouraging parents to get it. Second is to decrease transmission to others, which I still think is a very fair thing to ask of young people. And we’ve asked that of young people for many of our vaccines that are not specifically children are most at risk, but the older adults that they’re around are more at risk. So that’s a good enough reason for me and when you opened up in the UK, more vaccines to younger people. That was it. In a good thing for for reducing cases. And then the third is that they grow up. And also that they they will, you know, having this immunity now is that so I really do think children parents should get the vaccine but there is this process and we created that distrust and that’s what I’m worried about is we created the distrust by this idea of absence base stay away from each other. That’s the only way to stay safe keep schools close keepers, because that’s the only way that was so not correct and not harm reduction.
Nick van Terheyden
So for those of you just joining, I’m Dr. Nick the incrementalist today I’m talking to Dr. Monica Gandy, the professor of medicine at UCSF, we were just talking about children, vaccination principles. As we think about the future, where do we go from here? This is this is not going to disappear. We’re going to move to endemic, what are our best sort of approaches to this and what’s realistic, I think we’re struggling with this. And we look to folks who’ve had the experience to be able to say, this is a reasonable course, that gives us back our lives. That’s what we’re all looking for that human contact, as you importantly described and that mental contribution. But I it’s it’s unclear how we’re going to achieve that, how do we get there,
Monica Gandhi
I actually have a very strong and clear and simple solution to how to get there, in my opinion, which is that with an endemic virus, where the virus is not going to completely go away. And I don’t think any country in the world except China is pursuing any strategy that is thinking about elimination. It means endemic and means it’s going to be around, it’s going to go up during the winters because that’s when people gather more it’s going to go down when it’s better respiratory viruses. That’s how they work. However, we are doing something right now that is not going to allow the transition to endemicity and acceptance, which is we are counting cases. And if we exclusively focused on hospitalizations as our marker of what is happening with the infection and disease, we wouldn’t know when which populations to boost instead of saying boosting everyone, we would know what to do with immunocompromised and older individuals, we would say during the winter, I would recommend people who are older and immunocompromised mask in crowded indoor settings. But we would stop staring at cases which are actually was an important marker to follow before when we were in pandemic stage. Because they were almost not you know, not completely but they were tracking with hospitalizations. It was really your country actually, that showed with the Delta variant where you opened up full on in the middle of a Delta variant search and July 19, you showed that that delinking was occurring that that decoupling between cases and hospitalizations were occurring. And now the relationship between cases and hospitalizations is so complex, because there are vaccinated people who’ve been hospitalized, those are the ones that most risk and need a booster. There are patients who if there’s a lot of virus around, they’ll get us they’ll get a severe breakthrough. We have to focus on protecting them. And there’s still people who haven’t trusted the vaccine and gotten the vaccine. So all of that put together means if we focus on hospitalizations, instead of cases, I think it’s a very easy transition to endemicity. Because in a place like the UK where hospitalizations are when they’re under control, you don’t impose restrictions on society. And I mean masks or gatherings. If hospitalizations increased, because there’s a new variant because the vaccine needs everyone to be boosted. That’s when you start imposing restrictions. But it’s the focus on cases if we will never get away from it if we don’t make this transition.
Nick van Terheyden
So why do you think there’s a decoupling between the cases and the hospitalization? Is it because we’ve gotten better we’ve got the vaccinations that’s essentially improved the outcomes. So there’s now not the same linkage and you don’t see that tracking?
Monica Gandhi
Yes, I mean, it’s pure and simple, like the purest way to say it is vaccines generate T cell immunity, antibodies and B cells as well but T cell immunity to the virus T cell immunity protects us from severe disease. And that tracking no longer happened like that when you got mass vaccination programs into play. So Singapore, Portugal have a lot of cases right now. Hospitalization staying flat. It is very important to if you start tracking hospitalizations, you won’t frighten society with cases you actually frankly in the UK Test a great deal and have a lot of access to testing. But is that really the marker of what public health needs to protect people from the need to protect people from getting sick? and that somehow we decided, which I understand why, because there was asymptomatic spread, we decided to do mass testing. And that was very fair before vaccines, but after vaccines, if someone is perfectly well, and they really can’t pass it on, because they’re fully vaccinated, what is the point of putting a swab in their nose and seeing if they have the virus in their mouths? What the point of public health has always been to prevent illness?
Nick van Terheyden
Absolutely. So as you think about the future, one of the things that, you know, I’ve heard you talk about extensively bothers, you know, those of us that think about this is the equitable distribution of this. Okay, so perhaps we fix it in some of those countries. But how do we go about this? It seems like this, it’s a worldwide problem, as is HIV, there is no barriers, no borders for any of this. How do we fix that?
Monica Gandhi
You know, I think we will look back on this time and see this as a profound, moral and ethical failing of countries like yours and mine. We have all of the vaccine doses that are available right now, the 7.2 5 billion doses that have been given out, as of today, you know, November 17, at 4.7% of them have been given out in low income countries. So many of the cases and deaths in 2021 were preventable if, if not not for people who declined vaccination. Those were unfortunately, we couldn’t get people to take the vaccine in some of the rich countries, but but for those who desperately wanted the vaccine, and died, those were preventable deaths. And there is no way that I believe I read recently that each of our countries have six doses for every one of our citizens just sitting there sick. So you have six doses, a child has six doses rating, and of course, 241 million doses. According to MSF, Doctors Without Borders will be wasted by the end of 2021. Just put down the drain. So beyond the variant issue, and the public health implications, so we’re not safe until everyone’s safe because God forbid another variant comes out that is more transmissible than delta. It’s just morally and ethically, I think it’s one of the most profound failings I’ve ever seen in history. I can’t I almost every day, I mean, I, I have declined to take a booster shot. By the way, even though I’m a healthcare worker, because I can’t look in people’s eyes, I meet with Kenyan team, every few HIV work abroad, and I can look them in the eye and say, I’m gonna go get my third child. Oh, sorry, did you get your first? You know, it is it is it is impossible to imagine that’s happening now. So what can we do? So you know, the World Health Organization, and doctors without borders are large organizations, and they are everyday beating this drum. I think that we need to be citizens advocates, like in the way that we were in HIV in HIV, what changed the equation for anti retroviral access to Sub Saharan Africa, it was advocacy by HIV activists. That’s what it was, it was marching in Durban and saying, I’m not going to take my pills until you can get your pills. And it was it was advocacy by people like you and me, actually, clinicians and people who were anyone who’s susceptible to COVID would be every single human being doing advocacy. So I think I’m actually going to start something I’d like you to be involved. And I just talked to another UC school because I’m in the UC system, university, California, we’re going to start something trying to figure out like, not in my arm and tilting your arm something, something and we are going to start a very major advocacy organization, we need to rally
Nick van Terheyden
what a rousing thought to finish on and a concept that says instead of people gathering and saying I’m not taking my vaccine, people gathering and say, I’m not taking my vaccine because I want that vaccine to be widely available. I think that’s a really positive note to finish on. As usual. We’ve run out of time. It is such a pleasure. I know. Visually, you are
Monica Gandhi
grabbing me now and that was great to talk to you. So
Nick van Terheyden
thank you very much, Monica. It’s great to have you on the show.
