Transcript: Dr. David Agus speaks with Michael Morell on "Intelligence Matters"
In this episode of Intelligence Matters, host Michael Morell interviews Dr. David Agus, Professor of Medicine and Engineering and Founding Director and CEO of the Lawrence J. Ellison Institute for Transformative Medicine at the University of Southern California. Dr. Agus, who is also a CBS News contributor, explains what scientists have learned about the origins, spread, transmissibility and lethality of COVID-19 -- as well as what remains a mystery. He discusses the policies and practices that have led to successful mitigation efforts and explains how data may be used to better control future global health crises. Intelligence Matters will dedicate several forthcoming episodes to understanding the fundamentals and national security implications of COVID-19.
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Highlights: On the knowns and unknowns of COVID-19
Social distancing: "It is an amazing thing to see how behavior in our country — when we are put up to the challenge, we come through in the United States, and I'm proud of that. What scares me is what we don't know about this virus. What scares me is that not everybody, not 100% are following the rules."
Areas of success: "So when you look at countries like Germany, that have had uniform practices across it-- South Korea, China, Singapore, Hong Kong — they clamped down as an entire country with uniform practices. And people listened, and they understood, and they were shamed, or there was actually penalties for people who violated-- then you had a quick silencing of the virus. I hope we're getting there in this country."
The virus vs. the economy: "If you release the stay-at-home orders and enable the economy to grow, the virus grows and the economy falls again, precipitously, even more than it did before. So they are one and in the same."
How things may change: "My hope and prayers is we start to use data for good. And the data will enable us to find virus outbreaks early, to monitor our behavior to make sure we're doing the right thing, to really make the health of our society better so we can all focus on the things we enjoy, which is personal interactions, our job, our family, our friends. And that we actually enable us to use data to make health better. I'm so excited by the technologies that we have. I hope they can be used for social good."
TRANSCRIPT - INTELLIGENCE MATTERS - DAVID AGUS
CORRESPONDENT: MICHAEL MORELL
PRODUCER: OLIVIA GAZIS, JAMIE BENSON
MICHAEL MORELL:
Dr. Agus, thank you for taking the time to join to talk about this very important issue.
DR. DAVID AGUS:
Oh, it's my privilege to be here.
MICHAEL MORELL:
So let's jump right in. And I'm hoping that we can walk through the issues related to coronavirus in a kind of step by step and hopefully logical way. That will depend a lot on my questions. But maybe the place to start is kind of at the tactical level, with the virus itself. So what is a coronavirus? Why is this one called "novel?" And what is our best understanding of how it originated?
DR. DAVID AGUS:
In the 1960s people would be getting colds, and a very clever scientist put it under the microscope and they visualized the virus. And this particular virus had little projections out of it, and it looked like a crown. So hence the name "coronavirus."
And so cor-- about a third of common colds are coronavirus. And viruses, when they come out-- a new virus, say, goes from an animal to a human, over time they get weaker. Because if they were really strong and they knocked people off they couldn't spread anymore.
So viruses, over time, get weaker. So the common colds that we have now were potent and actually killed people early, and then have gotten weaker. Sometime in, probably, we know now mid-2019, a new virus went from bat, which is-- about a quarter of the mammals on Earth are bats, and they have very large numbers of-- bats and rodents are the largest harbinger of viruses.
This virus changed, and went from a bat to be able to grow in a human. Realize, over five million years our human genome evolved 1%. This genome of a virus can evolve 1% in a day. So it changes all the time. So it jumped from bat to human and was able to spread.
And so we called it COVID-19 -- 19 means 2019. And so it was a coronavirus, "coronavirus disease," COVID-19, and that's why it was called this. So it was a new virus that we hadn't seen before in humans. An amazing paper came out in the-- one of the medical journals last week where they actually looked at all the DNA sequencers, and the top DNA people in the world looked at it.
Because there were all these rumors that it came from a lab in China and all of that. So the conclusion of the paper was, how this virus binds to a human cell is so remarkable and amazing that humans don't have the computing power to do it or the brains to do it. Only nature could do it. It is the wildest conclusion of a paper I've ever seen in my life.
MICHAEL MORELL:
So there's no reason to doubt that it originated, spread through a natural mechanism? There's these stories out there about bioweapons. So there's no doubt in your mind about that?
DR. DAVID AGUS:
After this paper came out in the medical journal Nature, it is definitive that this was not engineered by humans.
MICHAEL MORELL:
And is this virus related in any way to the SARS virus from the early 2000s?
DR. DAVID AGUS:
Yeah. All these viruses are similar in many respects, and they're a similar family. And they all just behave differently. And whenever we see a new virus, we can't tell you its natural course. When people say, "Well, will this go away in the summer or not?" We don't know.
If I say, "If you got the virus, can you get it again in a year?" The answer is I don't know, because we haven't studied it for a year. So this is new. So this is new. And that's what's kind of daunting to scientists, to doctors, to patients, to everybody, is when you don't know what to expect, we all just get very stressed. We want to understand more than we do.
MICHAEL MORELL:
So what is it about this virus that makes it so dangerous?
DR. DAVID AGUS:
What we know about this virus is the day you have symptoms, the first symptoms, your virus level is the highest. Normally when you get a virus, a cold, or a flu, you have a low level of virus, and the symptoms are there, and the virus slowly builds up.
But because it's the highest the day you get symptoms, that means three, four days before you had symptoms, when you were asymptomatic, you can spread the virus. And about 20% of people never get any symptoms at all, and they have a period where they can spread the virus.
So this stealth spread, if you will, is what makes this virus so hard to tackle. When Ebola came out, you knew you were sick, so we quarantined you, and it was very easy to block it off. And a certain number of people died, which is still tragic, but it's a small number.
Here, because people don't know they have it, and they end up going to a church service, or they get in a gondola in Aspen and they breathe, and everyone in the gondola is infected. Or they go to a beach in Florida and they don't know they have it, they're asymptomatic-- they don't mean to harm people, but they did, because it spreads and spreads.
MICHAEL MORELL:
And then what about the lethality of it?
DR. DAVID AGUS:
So this is the tricky part, and this is the part that keeps me up at night, is that 98% of people have mild symptoms, maybe a little bit moderate, but nothing more than that. Two percent of people get very severe symptoms and end up hospitalized, some of them on a ventilator, and some of them will die.
The problem is, I can't tell you which 2%. So everybody thinks they're in that 2%, they're worried about it. And if we had the clue of who was the 2%, I could treat them aggressively upfront. I could try to prevent, in those people. I would have some knowledge. Instead, we have to clamp down the whole country.
So I don't know who that 2% is. Just last week I saw a couple, 50 years old. She was jogging five miles a day. He was overweight and had medical issues. She ended up on a ventilator, he didn't. And he was fine. Why did that happen? By not knowing that, that's one of the biggest clues that we're missing.
MICHAEL MORELL:
So there's this idea out there, right, that the elderly are more at risk of dying, and people with preexisting conditions are more at risk of dying. Are you saying that we're still trying to understand that?
DR. DAVID AGUS:
Well, they are at much, much higher risk of dying. So what I was talking is the 2% will get severe disease, and be hospitalized or be sick. Many of those are 30, 40, 50, and 60-year-olds, but they're the ones who get better. The 70, 80, and 90-year-olds general don't get better, unfortunately. And so when they get hospitalized, there's a much higher mortality rate.
MICHAEL MORELL:
Oh, I see. So what actually happens to your body when this virus infects it? What physically happens to you?
DR. DAVID AGUS:
So this virus enters through a receptor in the lung, and it's called ACE2. And then your body starts to make an immune response against the virus. And so when people start to get difficulty breathing, it's not the virus causing any problem anymore, it's your immune response to the problem.
And the immune response says, "Hey, I see a virus there. Let me make the blood vessels leaky, so more immune cells can get in and attack it." When the blood vessels get leaky in the lungs-- you know how when you fall and you skin your elbow, it gets swollen? That's getting leaky, so immune cells can come in and clear away all the gunk and the bacteria and things.
But when it gets leaky in the lung, that fluid makes it so oxygen can't go into the arteries and you can't breathe. And then when there's fluid there and you can't breathe, we have to use pressure. And that's what a ventilator does, it puts pressure in to be able to still deliver oxygen to the blood vessels.
So it's the immune response causing the problem, not the virus, at the end stages. So that's why many of the treatments that we're doing now were meant for autoimmune arthritis, or lupus, or other diseases, where it's actually blocking immune responses to help patients.
MICHAEL MORELL:
So you mentioned this briefly earlier, Doctor, but latest estimates of time, from time of infection to symptoms?
DR. DAVID AGUS:
Two to nine days.
MICHAEL MORELL:
And during that entire time can you infect others? Or just a period of that time?
DR. DAVID AGUS:
The amazing thing-- in today's world, where we can send a man to the Moon 50 years ago, although we haven't done it in a while, I still can't tell you if you're infectious or not. The way we know if you're infectious is by anecdotes, by stories. "I was exposed to the virus, and then two days later I talked to Jane, and Jane got the virus. Therefore, I was infectious at day two."
And so what we think-- and again, I have to emphasize that word, "think," because there's no assay for, "Are you infectious?"-- is that you're infectious two to three days, maybe four, before you're symptomatic. So if you have a very big viral load-- what we think is, you were exposed to a lot of virus.
Someone coughed a big amount, you breathed in a lot of virus, you're going to be symptomatic pretty quickly. If you have a tiny bit, just a couple droplets, maybe it'll take you nine, ten days to become symptomatic, and you'll be infectious two or three days before that.
MICHAEL MORELL:
And you mentioned this earlier, too, but we hear about this big group of folks who are asymptomatic. What does that mean? Why don't they get sick? And are they still able to infect others?
DR. DAVID AGUS:
That's the million dollar question, is that-- there's no question they can infect others, that they are predominantly of the younger generations. What we don't know is if their immunity, they were able to fight off the virus, does that mean that they have good immunity and they won't get it again in a year, or two years, or three years?
Will that immunity last? Will it not last? We don't know any of those. And again, we don't even know how many of those people there are. Many of them didn't have any symptoms, so they were never tested. Many of them had mild symptoms and they go, "Oh, it's just cold. It's not worth going in, and standing in line, and getting a test."
And so until we have what we call the "post-exposure test," which was just announced yesterday, the first one, which is a blood test that can look if you have immunity or not, we're not going to know the true penetrance, we're not going to know the denominator-- how many people have it in the country, and have been exposed, and how many asymptomatics there are?
The figure of 21% asymptomatic came from China. And we're not sure how accurate that data is, if it underestimates dramatically the exposure, we don't know. Listen, we all had little periods over the last couple weeks where you can envision a couple symptoms. "I feel a little bit tired and achy. Maybe I have it, and it went away the next day. I just don't know."
So that test is going to be critical. Right now it's a blood test, where I have to stick a needle in, draw a tube of blood, and do that test. Pretty soon it'll be a finger prick. And the hope is it'll be a finger prick at home, where you put it on a piece of paper, you mail that paper in, and I can give you the result. Because I don't want people going to a doctor's office right now getting that test, because again, it could be a conduit for spread, if you will. But it's an easy test. It's called an ELISA, cheap and easy.
MICHAEL MORELL:
So what about folks who have gotten sick, perhaps very sick, and they've gotten better, can they get infected again? Do we know that?
DR. DAVID AGUS:
We don't know. We don't know. And so that's only going to tell by time. Because there are two ways, right, that you can get infected again. One is your immunity wears off. And the second is the virus changes, so your immunity was to one virus, but the virus is a little bit different, so that immunity won't carry over to the new virus.
And so there are certain proteins on the outside, in the luggage, if you will of the virus-- remember, this virus is not alive. It's basically a package with instructions inside, which is RNA. And so your immunity is against the package. Well if it's to part of the package that could change, that the virus doesn't really need, it may not hold over till a year from now when the virus changes. If it's to something that's integral to the virus, it'll carry on.
MICHAEL MORELL:
So let me ask maybe a stupid question, but: where do viruses come from? How do they get created?
DR. DAVID AGUS:
Ha-ha. Viruses are a part of nature that were meant to actually speed up and help with evolution. They transfer DNA from species to species. And they're actually part of us, and have enabled the evolution tree to happen. And so viruses are common. If we look at our genome there are gobs of viruses in there. Thousands and thousands of viruses are part of us. And it's part of our, what we call "microbiome," are bacteria and viruses.
You have more viral DNA and bacterial DNA in you as a human than you do human DNA. And they control, these bacteria and these viruses, how you metabolize food, many aspects around you. The problem is, some of them are what we call pathogenic, and they can cause problems. Particularly newer ones like this.
MICHAEL MORELL:
I see. And they're always changing, and so they can change into something that becomes pathogenic, when it didn't start that way?
DR. DAVID AGUS:
Josh Lederberg, a Nobel laureate, one of the greatest scientists in our history, said, "The only thing that will threaten humans' dominance on Earth is the virus. It is our wits versus their genome." And it was such a powerful two sentences. And he said this 30-plus years ago, that nobody really paid attention. But it really was prescient at the time.
MICHAEL MORELL:
Yeah. And I want to come back to something you said earlier, because I hear people say this all the time. People will look at a map of where the outbreaks are in the world, and they say they see seasonality, right? Because there's all these cases in the Northern Hemisphere, and fewer in the Southern Hemisphere. And they say, "Ah, seasonality." But your point earlier is, we don't know that. Is that correct?
DR. DAVID AGUS:
No question about it. There's kind of this misnomer out there. "Well, in heat, the virus goes away." When it becomes summer, kids are no longer in school, so they're not confined in one area. We're outside. We're not indoors where we can spread things. So our behavior changes in the summer.
So in areas of the country right now where it's hot, we still have the same behavior as winter behavior. We're still in schools and others, so the virus spread. So I think it's more our behavior changes. As I look outside, it's sunny in Los Angeles now. UV sunlight degrades the virus.
So you are a lot safer outdoors than obviously in the indoors. And the indoors where lots of people are, that's what happened. In the cold, the blood vessels constrict. You get a little bit of fluid coming out your nose. That's a conduit. You touch it. That's a conduit for spreading a virus. You don't have that in the summer. So it's not that the virus changes, as much as we change.
MICHAEL MORELL:
I see. And I heard somewhere that there's a vitamin D issue involved? So when we get more sunlight, we get higher levels of vitamin D, and that might--
DR. DAVID AGUS:
No.
MICHAEL MORELL:
--play a role here, is that right? No?
DR. DAVID AGUS:
No, it's not accurate.
MICHAEL MORELL:
Okay, okay.
DR. DAVID AGUS:
Unfortunately there are a lot of people who are trying to find simple, kind of reductionist answers to this. "Take this, or do this." But no, there's no correlation between immunity and vitamin D, which people get upset when I say. But there have been many large studies done with supplementing vitamin D from various means to try to help with immunity, and none of them have ever worked. There's no correlation.
MICHAEL MORELL:
Okay, excellent. I will stop taking my vitamin D pill.
DR. DAVID AGUS:
I'm saving you money.
MICHAEL MORELL:
So let's go to the bigger picture here. So what does coronavirus look like in context, right? How does it, at this stage, compare to the average seasonal flu? To the 1918 or 1957 flu pandemics, or the 2009 Swine Flu outbreak? Put this is in context for us.
DR. DAVID AGUS:
1918 was an interesting one, the Spanish Flu. Which, by the way, started in Kansas and not Spain. Right? It was World War I, and so the media weren't allowed to talk about anything that would show weakness in the country, so we weren't allowed to talk about it.
And that spread like wildfire. The way we stopped it is exactly how we're doing it now, is we said, "You cannot congregate in more than groups of three. Close all churches. Close all schools. Close all sporting events." And we really did stay at home for a year, and we were able to stop it.
And so that was before air travel. The problem now, right, is that things happen literally overnight because of airplanes. And so in 1918, it circled the globe three times as it killed, and decimated the number of people it did. And we all see the models out now, "40% of the globe, millions of people dying"-- all of those models said it will happen over three years.
It wasn't all at once. And all of the models meant with no social distancing, with no medications that work, with no chance of a vaccine, with no growth in medical infrastructure, all of which are going to prove counter.
So we're not going to hit what all the models say, because our medical infrastructure is responding. Every city is looking at what New York City did right and wrong, and we're changing and we're adapting there. The drugs are starting to show potential benefit, and it's very encouraging.
We have several vaccine candidates already into patients. We are social distancing. And it is working in the cities that are doing it well. So all of that is great. But then you look at just the modern world. There's an amazing video just last week of-- one county in Florida closed their beaches, another county didn't.
And what you see is just people up to one border, where the county stopped, and it was empty. Yet on the other side of that county line, lots of people on the beach. And the problem is, they actually followed the cell phone of people that were on a beach, and see where they went.
And they all got on a plane and went all across the country. So we can spread things easily through air transportation. So even if your state is perfect, all you need is somebody from the state next door where they're still allowed to go to religious services, and it could spread virus back to your state. And you're going to ruin all of the social distancing your state did.
So this is a new era, where we have to work as a community and think together as one. And that's difficult but critically important. We have a thing of state's rights, where health is dictated by the states in our country, not the federal government.
So it's still today, governors send an e-mail, they're asked to, every week, "How many tests did you do? What were the results?" The federal government doesn't have the right of taking that data. The states have to give it to the government in an Excel spreadsheet. That's crazy to me.
MICHAEL MORELL:
Yeah. So, Doctor, as of today-- and we're taping this on a Friday, before the Wednesday that we're going to release it-- today we have 240,000 confirmed cases. But as you said earlier, there's probably more people out there who are infected, because to have a confirmed case, you have to have a positive test, right? So do you have a sense of how many more people may be infected than the 240,000 that have been confirmed?
DR. DAVID AGUS:
It's a critical question, and because testing has been so limited in the affected areas of our country, it's been hard to answer. The government was right when they say there are plenty of tests, because there are. The problem is, we don't have the infrastructure to run those tests.
So it's not the number of tests now, where it was initially the limiting factor. It's the fact that we only have a certain number of PCR machines. What the test does, it looks at a hundred letters of the virus's 30,000-letter code. And you have to amplify that through a technology, and you need certain people to run it who are good at running it, who know how to run it.
And you need these machines that are rather expensive to do it. And so we don't have that infrastructure. And so even today in California there's still a five- to six-day delay until you get your test results back, because there's a backlog. And most people are disincentivized from getting a test.
If you have mild symptoms and I say, "Get a test," you're going to really go and stand in an emergency room, where if you weren't positive when you went in, you positive when you come out? This idea of the drive-through testing, I think these are great.
But there are only a few of them in the country. Some of them are operating well. Others have crazy long lines. Our infrastructure just hasn't been built-- so I can't answer that question. My gut is, the number is underestimated, the 240,000, by anywhere from four to tenfold underestimated.
MICHAEL MORELL:
And it's really important to know that number, right? Because--
DR. DAVID AGUS:
Oh, yeah.
MICHAEL MORELL:
--you need that number to understand the mortality, at the end of the day.
DR. DAVID AGUS:
So as we get the post-exposure test, we can go into a city and say, "Hey, let me just test a thousand people, and have that be representative, and say, 'What percent of them were exposed?'" And then I can extrapolate, and models can give you real numbers. So my gut is, over the next several weeks, we're going to start to have those numbers as those tests get more common.
MICHAEL MORELL:
Let me ask you a question about testing that I have not heard before. So I'm an economist by training, and so I spent a lot of time in college and graduate school taking statistics courses. Do we know the false positive and false negative rates on the testing that we're doing now?
DR. DAVID AGUS:
False positive with this test should be near zero. It's very hard to get a false positive when you're looking for an RNA. So, in PCR, the false negative results are anywhere up to, I would say, 20-30%, potentially. If you have less symptoms, your false negative rate is higher.
If you have more symptoms, your false negative rate is lower. But again, those are estimates. It's very hard to know what is true. In order to get false negative and false positive, you need-- what is the truth? And so the problem is, we don't have a denominator of truth yet to know, to go back. So it's all estimates.
In order to know, I need to know, "Yes, they really did have it, and you said no." Well, I have that in some cases, but most cases I don't have the follow-up to know what real ground truth was. So my gut is it'll be 20-30% false negative, but again, it's just a gut right now.
MICHAEL MORELL:
Yeah, yeah. Okay. So the public health protocols. Do we have, in your mind, any options beyond stay at home, social distancing. Is that our only option at the moment? Or are there others?
DR. DAVID AGUS:
No. You had the mayors of New York City and Los Angeles announce-- and I think the White House may announce today-- is that we want you to wear masks. This is a predominantly droplet-spread disease. You know, when you stand in front of a mirror and breathe, that fog is droplets.
So our breathing creates droplets. Whether you're symptomatic or not, you create droplets. When you wear a bandana-- so, we don't want you to wear N95 masks, because they're in limited supply-- but when you wear a homemade mask, you basically block those droplets.
You wear a bandana and breathe on a mirror, you're not going to see the fog. And so if we all wore bandanas when we go out, we would stop-- because we need to go out now, to go shopping and other things-- we would stop spread of the virus, period, also. And it wouldn't be 100%, but it would add more to it.
The more we can get, so that the number of people, the person infected-- whenever one person is infected, and infects more than one other person, the virus will continue to grow. If it's less than one, that number is low, then the virus won't grow, and will slowly peter away.
We have to stop it like that. So our behavior change has to do more than just staying inside. When we have to go out, and anybody's who's out, whether you're working at a cash register or an EMT, you need to wear something so you can't spread if you're asymptomatic.
MICHAEL MORELL:
And if we had massive testing would that give us more options? Or would the public health protocol be exactly the same?
DR. DAVID AGUS:
Oh, yeah. We have this thing that we're very proud of in the United States called "privacy rules." In Korea, if you're tested, all of your neighbors get a text, "Hey, David in apartment 3B has corona." So they know to avoid me. And they know who's infected.
And they actually trace where I went, and anybody I talked to-- on my phone, they went back a week before it, "Who did David just meet? Let me test them and see if they're positive or not." They actually say, "Screw privacy, let's look at all of that data."
Google announced today that they have the data from Google Maps of who's effectively doing social distancing, and can send out what city. And they're giving it to the cities. They're not releasing publicly, which I think they should. But wouldn't it be amazing to know who's following the rules and not?
And then the ones who aren't, we have to figure out different rules to enact, because we all have to do it. We all have to think as one to get rid of this. This is an amazing part of humanity, where we have to go back to being a community. It's a new change in our mentality and our behavior that we really haven't thought about for decades.
MICHAEL MORELL:
Well, I'm wondering if this gets severe enough, that if Americans would welcome the kind of things they're doing in South Korea and Singapore and elsewhere.
DR. DAVID AGUS:
I hope so. But what it's going to mean is we have to treat people differently. Which, again, we don't respond well to. If you have no immunity and you're 70, I'm going to say you have to stay home, and you can't go out. If you're a 20-year-old, and again, you have no immunity, I'm going to say you can't go out, but the other 20-year-old can.
And people are going to say, "No way, I have my rights. I want to do this. I don't want people to know I had the virus, or I could have spread it, or I spread it somebody else. It's my right to keep my healthcare information private. I don't want you to mine my healthcare data to figure out who gets sick and who doesn't."
"This is my data." If I asked you to get a mortgage, you'd give me every financial record you have, and you don't think twice. If I say, "Let me use your healthcare to better treating humanity, and the rest of the world," you say, "No way, it's my healthcare data."
MICHAEL MORELL:
Yeah. So how significant do you think the ancillary health effects of staying at home are? Of loneliness and depression, et cetera. Are you seeing that?
DR. DAVID AGUS:
Yeah. My hope is that we're all learning ways to overcome it, and we're working as a community. So we're FaceTiming, or video chatting with our parents, with our grandparents, with friends. We're developing a community. Listen, I've heard from people I haven't heard from in decades.
And they're all checking in, "How are you?" And texting me. And I love that part of it. But we all have to be cognizant of the people who don't have support systems. If I'm going to get food, and my neighbor's 80, I text her or call her and say, "Hey listen, I can order food for you, and get food for you also."
You know, it's a time to step up and help each other. We can all be part of the solution.
Technology will enable all of us to be part of the solution, not the problem. And I think we have to step up, right? One of the biggest tendencies to staying at home is just eating, right? Food is always available. We have this thing called a kitchen cabinet.
You want to just have three meals a day with nothing in between. If you graze during the day, your stress hormones actually stay up, and your immunity goes down. You have to walk. Your lymphatics that control your immune system have no muscle in their walls.
So it's the rhythmic contraction of the muscles in your legs when you walk that actually make your body work. So walk around. Whether it be your apartment or your house. If you can, find a time to get outside and just take a small walk, whether it be a backyard, or just around the block when there aren't a lot of people and you can social distance. It's critical that we think of our health also.
MICHAEL MORELL:
Okay. So the snacks go away with the vitamin D tablets. That's excellent.
DR. DAVID AGUS:
All right.
MICHAEL MORELL:
So walk us through--
DR. DAVID AGUS:
Any other issues of yourself you want to talk about?
MICHAEL MORELL:
So walk us through the testing issue, right? Can you kind of summarize, why were we in such a bad place at the beginning? And where are we now? And are we on the road to where we need to be, et cetera? Can you kind of put that in context?
DR. DAVID AGUS:
The World Health Organization developed a test and was giving it out to member countries. The United States, in partly its hubris, and partly it was justified-- we have pretty good science compared to most countries-- said, "We're going to develop our own test, and we're going to do it well."
The initial approaches at testing were successful, but the problem is the controls-- that is, knowing whether the test worked or not-- didn't work for a bunch of batches tested. So all of a sudden the initial batches of tests that went out in the country were faulty, and people weren't using them.
And so we didn't have enough tests to go around. There was a panic. A large amount of testing came out. The government started to say, "Hey, private industry, get involved." Private industry gets involved, they were pretty freaking good. In today's world-- and I know I'm going to offend people by saying this-- but if you're the best and the brightest, you go to work for a tech company.
You don't go to work for the federal government in a testing lab. And I wish it weren't so, because those are heroes in those testing labs. And so once you get private industry that can put a thousand people on a problem, basically turn on a dime and attack something, all of a sudden we had large numbers of tests and they were out there.
We still don't have the infrastructure to run those tests. And realize, what the test is, it-- the virus has instructions called RNA inside. And this amplifies a hundred letters of that RNA that are specific and unique to this COVID-19. And it amplifies it, and then you see, are those hundred letters-- that represent two of the genes of the virus, and there are 30,000 letters in that virus-- are those two genes there or not?
And if they're there, both of them, you have the virus. If they're not there it doesn't mean you don't have the virus. So a positive is a positive. But a negative means maybe we just missed how we tested, or where we tested it. So it doesn't mean you're totally negative. That's where the false negatives come in. But a positive is a positive.
MICHAEL MORELL:
So you mentioned the intrusiveness of South Korea's approach. When you look broadly at the countries that have handled the crisis well, and those who have not handled it so well, what are the main differences that you see?
DR. DAVID AGUS:
The wildest anecdote I see is that when they-- Northern Italy had a big outbreak, and we saw it right after Fashion Week. Big, big number of cases surged in Northern Italy. So what they did was, they closed all of Northern Italy, just like we did in many of our states, 40 of our states.
But they left Southern Italy open. So what happened is, everybody from Northern Italy got in their car or got on a train and went to Southern Italy, where you can go shopping and go to restaurants. And basically, policy caused spread of the virus. Amazing. Policy caused spread of the virus.
And so unless you have uniform policy across the country, what you see is that. So the countries that are saying, "We have to shut down our entire country and our borders," are having very good results, and are able to get rid of the virus with time.
The biggest problem is that there's about a nine to ten-day incubation period, on average. There is about a two-week period of having the virus. So when you make an intervention, you don't see the results till two, three weeks down the road. And that's difficult. And that's frustrating, right?
"I'm losing my business, I'm staying at home, yet the number of cases are still going up?" It's very hard with that delay. Countries that have leadership that is explaining that, and showing why that behavior change matters, and really every day giving out updates on that, they're having pretty impressive results.
Countries that are just all over the place-- one day has a scare tactic, one day doesn't-- they're not, and have disparate results by states, which is what we're doing. The results aren't as good. So when you look at countries like Germany, that have had uniform practices across it-- South Korean, China, Singapore, Hong Kong-- they clamped down as an entire country with uniform practices. And people listened, and they understood, and they were shamed, or there was actually penalties for people who violated-- then you had a quick silencing of the virus. I hope we're getting there in this country.
MICHAEL MORELL:
Do you think the general health of a country's population is playing a role here? When you look at Asia you don't see a lot of obese people, right? But then you look at some countries in the West, and it's a different picture. Does that matter?
DR. DAVID AGUS:
We think it does. Certainly the trends in the United States is we're seeing more people who are very symptomatic in their 30's, 40's, and 50's, and we think-- it's a hypothesis, purely-- is that it's because we are more obese, and we do have more elevated blood pressure, which may increase the receptor for this virus, called ACE2.
It's a hypothesis. Certainly we as a country, we are not as attuned as others about restrictions on eating, and exercise, and obviously it's a wakeup call for us. It matters. Over and over again, we're seeing policy changes in certain countries-- in certain countries, you're allowed to smoke.
But if you get lung cancer, you have to pay a $60,000 surcharge, because why should the nonsmokers subsidize the smokers? In our country we need to bring back responsibility for behavior, I think, and really educate people why behavior matters. Because obviously it can affect the entire country.
MICHAEL MORELL:
So we're heard Dr. Fauci say that the timing of the country's reopening is going to be dictated by the virus, not policy. How should we think about how quarantining and social distancing protocols can eventually be scaled back? What would make sense? What would you have to see for you to feel comfortable in doing that?
DR. DAVID AGUS:
It's very hard to look at incidence of the virus as the number of cases, because as we've alluded to before, the testing. But number of hospitalizations is a pretty good metric. Right? I mean, the hospitalizations themselves don't lie.
And so, looking at the number of patients who are being hospitalized in a city can be powerful. And it may be that we restrict it in certain areas of the country, and we restrict travel. If we're only seeing growth in California, well basically we'll say, "Listen, the rest of the country can leave their home, but California we're going to restrict, and nobody can go or leave in California until the numbers come down."
And people aren't going to be happy with that. But I think in a data-driven way, to release parts of the country, not others, is probably what's going to happen. And so my hope is, that's an incentive to leaders at the local and the state levels to really say, "We want our state to be one of the ones that can actually go back to our business as usual," and push in that regard.
But it has to be data-driven. And I think the question now is, what are the metrics that we have to follow on the local, on the regional, and the federal level to being able to do that? And there's lots of talk now about what they are, and we're developing these indices, if you will.
MICHAEL MORELL:
And I certainly don't want to put words in your mouth, but I'm sure you see a significant risk of relaxing those protocols too soon?
DR. DAVID AGUS:
No question about it. Right? That's the risk. And everybody says, "Well, are you going to think about the economy, or are you going to think about health? Or, the virus." Well, they're inexorably tied. Right? If you release the stay-at-home orders and enable the economy to grow, the virus grows and the economy falls again, precipitously, even more than it did before. So they are one and in the same. And anybody who tries to get reductionist-- say, "Well, it's got to be the virus versus the economy"-- has no idea what they're talking about.
MICHAEL MORELL:
And then final question, Doctor, on sort of the big picture here. The CDC numbers, their estimates on the number of deaths-- worst case, best case, most likely case-- those make sense to you?
DR. DAVID AGUS:
It's hard to me, what makes sense. Any model is done on behavior today, and what is if we extrapolate out from today till tomorrow, to a month from now, to three months from now, what could happen? The good is, is that we're seeing behavior change daily.
We're seeing more states with stay-at-home orders. We're seeing medications being used and showing efficacy. We're seeing changes in medical infrastructure. We're seeing states learning what the good and bad of New York City's response is, and changing.
So what that means is, every model will overestimate death rates, because we're getting better at doing what we do. So any model you can see, in a sense, is worst-case scenario, because they're not modeling in the changes that we're all doing.
And so my hope and prayers are those models are three, four times what is going to happen. And any death that was avoidable is obviously a travesty, or we're upset about. But when you see numbers, 100,000 to 240,000, I think those are way gross estimates to what's actually going to happen. Overestimates, sorry.
MICHAEL MORELL:
Maybe we can take a brief couple of minutes here to talk about treatment and prevention. So where are we on treating somebody who is sick? And where are we on a vaccine? And kind of walk us through those.
DR. DAVID AGUS:
So treating it falls into two buckets. One is what we call post-exposure prophylaxis. So say your spouse had influenza. I would give you ten days of Tamiflu, and you wouldn't get the flu. If you had sex with someone with HIV, I'd give you a couple of days of an anti-retroviral, and you wouldn't get HIV.
We call that post-exposure prophylaxis. So the protocols now for frontline workers, for spouses of people, or live with people who have the virus, are now we're starting to use drugs in that setting to try to prevent people from getting the disease.
And then in terms of treating the disease, what we know initially from the China data, and now in the U.S., is the earlier you treat the better. As we've talked about before is if we can block the virus before the immune system is crazily activated, we're going to do better.
And there are drugs now that appear to be working. And I say that word, "appear," with quotation marks around it, because there are randomized trials, for example, in China that shows that hydroxychloroquine, which is the drug that President Trump talked about, about a week ago-- although it may be longer than that, my time horizon is off in this world we live in today.
MICHAEL MORELL:
Yeah, yeah.
DR. DAVID AGUS:
You know, that he talked about, showed that it was significantly better in time to fever resolution. X-rays of people worsening of disease, it did better. This is a drug that's been around for 30 or 40 years. It costs about three, four dollars without health insurance.
So it's very inexpensive. And it was meant to treat lupus-- or, it's on the market for lupus, and to prevent malaria. And it actually works against this virus, it seems. There's a drug called Remdesivir, which is an experimental drug from a company called Gilead.
There's an HIV cocktail called Kaletra. There are some Japanese drugs that have been shown efficacy. And all of those are initially showing potential benefits. The problem is, randomized placebo-controlled trials-- first of all, nobody wants to be in the placebo arm. Second of all, these trials take a long time to get full outcome. And we don't have time for that.
So now doctors are starting to treat patients routinely with these drugs, and I'm into that. We're at war now. And so we call that off-label use, or compassionate use if it's drug that's not yet on the market. And we're doing that routinely.
And the hope is now we're keeping the data and we're learning from every experience and getting better at it. And that's what's encouraging and exciting, is that there's doctors talking now-- the federal government you'll see announced on Friday that they're going to start to build this database, so every patient experience makes the next patient experience better.
But I'm enthused about that. In terms of vaccines-- remember, for three decades we've been trying to make a vaccine for coronavirus, the common cold. We haven't succeeded. The hope now, this new emphasis, every major biotech and pharmaceutical company, all scientists are working on it, that we're putting the best and the brightest minds to develop a vaccine that something will work.
So the initial one, which was a vaccine where actually we didn't inject parts of the virus, which is what we normally do. We actually injected the codes for parts of the virus called RNA into cells. That vaccine has already accrued patients, and is ongoing now to see if it's starting to show immune responses.
Johnson & Johnson is about to go into the clinic with a new vaccine. And there are about a half a dozen behind that. The problem is you first have to show that it can induce an immune response. Then you have to show that it's safe, and what is the right dose. Then you have to actually show it works.
So it takes 12 to 18 months to develop a vaccine. It's not like a treatment, where you know in a week whether it works or not. This is a much longer timeframe. So the hope by next year we can do that. And still, it will have dramatic benefit across the globe and all efforts should be pushed to do it. But it's not going to help us in the short run, the vaccine part.
MICHAEL MORELL:
So, Doctor, you've been absolutely terrific with your time. I just want to ask you two more questions. The first is: what makes you most worried here? And what makes you most hopeful?
DR. DAVID AGUS:
Hopeful is, the drugs are starting to show benefit. Our medical infrastructure really is coming up. And I think the behavior of people in our country, it almost brings me to tears when I think about how radically all of us have changed our behavior to work together as one.
It is beautiful. It is an amazing thing to see how behavior in our country-- when we are put up to the challenge, we come through in the United States, and I'm proud of that. What scares me is what we don't know about this virus. What scares me is that not everybody, not 100% are following the rules.
And so a couple of people, a couple of instances-- just yesterday, a couple of churches said, "We are still going to have services and pull people together." And just some of those instances can really hurt everybody in a community, and hurt especially the elderly dramatically.
And I don't want to see that happen. And we all have to step up and work together. And I don't think people are doing it to be bad people, or bad intent. I think it's lack of knowledge. And so I think we have to be better at the education side. We have to be better at the leadership side, and step up.
And the leaders are not just going to come from government. They're going to come from science. They're going to come from religion. They're going to come from companies. And when I see CEOs coming out and saying to their employees and explaining it, and bringing in scientists to talk to employees, paying their employees when they're not working-- it's a beautiful thing when our country comes together like that. And so my hope is we actually have positive come out of this in the long run.
MICHAEL MORELL:
And that is the final question, right? Which is: from the perspective of a physician, how do you think this experience is going to change how we live our lives in the future? I know that's a tough question.
DR. DAVID AGUS:
I think it's just the one notion of real world evidence. Our scientific system was built on the foundation of prospective clinical trials that can take months to years to do. And in today's world, with all the technology we have, we can look at your movement by looking at your cell phone.
I can collect your data almost instantaneously. My hope and prayers is we start to use data for good. And the data will enable us to find virus outbreaks early, to monitor our behavior to make sure we're doing the right thing, to really make the health of our society better so we can all focus on the things we enjoy, which is personal interactions, our job, our family, our friends. And that we actually enable us to use data to make health better. I'm so excited by the technologies that we have. I hope they can be used for social good.
MICHAEL MORELL:
Dr. Agus, thank you so much for joining us. I know you're incredibly busy, but we really appreciate it. Thank you.
DR. DAVID AGUS:
Oh, it's my privilege. Talk to you soon.
MICHAEL MORELL:
Thanks.
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