- (female announcer)
Production funding for
Behind the Headlines
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thank you.
- Where Memphis stands in the
fight against coronavirus,
tonight on
Behind the Headlines.
[intense music]
- I'm Eric Barnes with
The Daily Memphian,
thanks for joining
us, as we continue
to do the show remotely.
Today we are joined
by Dr. Jon McCullers,
an Infectious Disease Expert
who is Dean of Clinical Affairs
at the UT Medical School
as well as Pediatrician-in-Chief
at Le Bonheur
Children's Hospital.
Dr. McCullers, thanks
for joining us again.
- Happy to be back
with you Eric.
- Also Bill Dries, reporter
with The Daily Memphian.
So Dr. McCullers, we've had
you on a number of times.
You've been really
gracious with your time.
I think we had you on one
of the last shows we did
in the studio, as things
were starting to get,
so that would'a been March.
I listed some of your titles,
you're also a part of the
City/County COVID Task Force,
you're part of the
subcommittee of that group
that is going through
and looking at the
reopening phases.
At this point, what
do you worry about?
What number do you look at,
or numbers do you look at?
And what do you worry
about as we continue
this phased reopening?
- In terms of worry, I've
been fairly comfortable
for the last six to eight
weeks about where we are
with our daily trends,
our weekly trends,
where we are with our
capacity to deal with
the potential to have a surge.
The things that worry
me are not so much
where we're going day
to day or week to week,
but things like
schools reopening,
and the winter coming.
And worrying about things
that aren't in our
control right now.
Right now I feel
like we have things
under reasonable control.
But once we have to start
sending kids back to school,
or once winter comes,
and flu season starts,
maybe we lose some
of that control.
- Some of the worst predictions,
again, March seems
like 100 years ago.
But some of the
worst predictions,
there was the
Imperial College Study
that I think you and I talked
about on a podcast one time
that talked about millions,
tens of millions plus dead
in a worst case scenario
in the United States.
There were worst
case scenarios here.
We really haven't
come even close
to those worst case scenarios.
So it's a strange dynamic.
You get a certain number
of people who are saying,
well, the models were wrong
and we've overreacted.
From your point of view,
were the models wrong?
And did we overreact?
- Yes I think there's two
things to think about here.
So what is it that
models really can do?
So the way these
models are constructed,
they're not very useful
for asking a question
like what's gonna happen
three months from now,
how many cases are we gonna
have three months from now?
What they're useful for is
these kinda if, then scenarios.
You can say, if we do this,
or if we do this other thing,
what's the relative
difference in this?
So if we do it this way,
we see a lot more cases.
If we do it this way, we
see only a few more cases.
So the models are really
good at helping with choices
and decision making,
but not in giving you
an exact number of what
we're gonna look like
three months from now.
So in terms of, we
had those models,
and we were looking at them
a couple of months ago,
I said, there's probably
three possibilities
that we're gonna have.
One is that we're not gonna
be able to control this
and it's gonna look
like the model says.
And the model was really
a worst case scenario
if we don't intervene.
The second one was what
everybody had been talking about
which was that
flattening the curve.
And that was the idea that
we can't really stop it,
but we can kinda push
it back for a while.
That's gonna allow us
more time to get ready.
And I think that was kinda
the popular idea at the time.
And the third one that I think,
I was pushing a little bit,
and wasn't very popular
was the idea that we would
just cut this off entirely
and not get rid of it, but
at least stop transmission
or suppress it to a low level.
And that's what really happened.
Instead of flattening the curve,
we've truncated the curve.
We have reduced transmission
to really negligible levels.
It's still there, but
it's not accelerating
like it was before.
And so unless we mess up, we're
never gonna have that surge
that we were all talking about.
- One more follow up,
and then I'll turn over to
Bill because that was a lot.
You think that whole idea of
that surge, of that rebound,
again, it's hard to look
into the crystal ball.
You just talked very eloquently
about the problems of models.
But I guess maybe the
media folks and others
want to know what's
gonna happen.
But you just said
you don't think
there'll be a surge, even
as we continue to reopen?
- Right now we really do
have an element of control
and it's dependent
on the public.
So the public has to
be able to continue
to do social distancing
and wear masks
and not get together
in big gatherings
that might accelerate it, right?
But if we do those things,
I'm very comfortable
that we're gonna be able
to keep transmission
at this low, almost negligible
level within the community.
Now, what threatens that, right?
And what threatens that
is, you do something
like send all the
kids back to school.
That's something we have to do.
But it presents risk that
you're gonna accelerate
and you're not gonna
be able to control,
it's gonna get
outside your capacity.
What else might threaten it?
Well, we get into the winter,
we have flu season here.
The hospitals are
full because of flu
and other wintertime illnesses,
and we can't manage COVID.
So those are the things that
could disrupt the scenario.
But as it is, we've attained
a measure of control
and as long as we don't do
anything to disrupt that
we're gonna be able to continue
to control it at some level.
- Bill.
- Doctor, for several
days, for more than a week,
we have had the phenonenon of
hundreds of people marching,
as of last night as
we taped this show,
marching in different
parts of the city.
And the marches
began in downtown.
When you look at that from
this pandemic perspective,
are there concerns about what
that could do to the curve?
- Yeah I think from the
public health standpoint
and the pandemic perspective,
anytime we have groups
getting together,
that's worrisome to me that
we're gonna see more cases occur
we're gonna see this
accelerate the pandemic,
just because there's more
points of social contact.
Now the other side of
that is, first of all,
this was really an important,
critical thing for
us to be doing.
I think the protests
were incredibly important
and the consequences
not withstanding,
that was something that
we had to do as a society.
And we may have to deal
with it, but again,
I think if we see a surge
of cases for a week or two
that are based on this,
but we're able to maintain
our control and our capacity,
is something that
we can weather.
And maybe it's a little
bit of a harbinger
of what might happen in the fall
when kids go back to school.
The other two things I
think about though are that,
for the most part, the
protestors and the marchers
were wearing masks.
I think certainly Memphis has
done a better job with this
than many other places.
And if you looked
at those crowds,
and I had a daughter marching,
so I was getting reports,
most people were trying
to be responsible
and were wearing masks.
And the second is,
this is predominantly,
not completely, but
predominantly younger people
who are at less risk for
having severe disease
or death from it.
So if you want to
have one demographic
that's out marching, younger
people would probably be it.
- The timing for this pandemic
has included several holidays,
several cherished dates,
Mother's Day, Memorial Day,
Easter, Passover have all
come within the timeframe
of this pandemic, has that
given you some more indicators
or has it really given us
more challenges than this?
- What we've generally
seen, is on the weekends
when the weather is nice,
and certainly on
the holiday weekends
where you have an extra day
where the weather is nice,
we do see our indicators
of social distancing
and our people clustering
tend to rise a little bit,
and then they come back
down during the week.
And we do see some
fluctuation in caseloads.
In that we tend to see
more cases, a week,
or a week and a half
after those long weekends
particularly when
the weather is good
and people are likely to be out.
But to this point, it's
been fairly cyclical
that it may go up a little bit,
but then it's gonna
come back down
because again we have
this measure of control.
So again, it's something
that we do worry about,
we talk about the same way
we worry about the protests
and the people getting together.
July 4th is coming up,
that's on a Saturday
so we know that's gonna
be another weekend
where we might have a
little surge in cases.
But overall, the pattern
has remained stable
in that we've come back
down after those weekends
and kinda reestablished
that baseline.
- And before we go back to Eric,
now that we have testing
up to a certain level,
certainly at a higher
number than we did
at the beginning
of the pandemic,
what is the effect that that
has on watching those bumps
in the numbers for
positive cases?
What does that tell you
that you didn't know before?
- It was very interesting,
early in April,
we clearly did not
have enough testing.
We were missing a lot
of cases, we knew it.
So it was very difficult
to interpret the numbers
because we knew there
was just a lot of people
out there who were
not being tested.
Once we reached a level
where we really thought
we had both sufficient
quantity of testing
and really a distribution
across the county
so that we had equal access
to testing across the county
then we began to
feel more comfortable
in what the numbers
really meant.
We are at a point now
where I feel like,
at least for the level of
cases we have right now,
and if we were even
to double or triple,
that we have sufficient
testing to do it.
We still have some challenges
in the geographic distribution.
As one example, we
opened a new testing site
this past weekend in an
underserved area of the county
where we really hadn't had
a lot of access to testing
and that spike that we saw
on Tuesday with 190 cases,
many of those were from
this one neighborhood
that we had just not had
access to testing before
and we found a large
number of cases there.
I think some of
the spikes we see
are when we do
penetrate into areas
we haven't had testing before.
Some of them are clearly related
to some of our surge
testing in prisons
or in nursing homes where we
know there are positive cases.
It's kinda difficult to
subtract some of those peaks
and try to figure out
what the baseline is
when you have this noise in it
from these campaigns we're doing
to investigate where we're
seeing a number of cases.
- How much testing
should be happening
of people who don't
have symptoms?
Because a lot of the testing,
like you're talking
about in nursing homes,
those are hotspots, but almost
randomized testing of people,
given that we're
really under-utilizing
our capacity right now,
if I understand correctly.
How much more randomized,
almost asymptomatic
testing should be going on?
- So it's a difficult question,
and it's one we've
struggled with
for probably the last
four to six weeks,
and that's who should be tested?
Under what circumstances
should we be doing testing
of asymptomatic persons?
There's a couple of
issues with that.
The first is that this is
really an imperfect test.
The way this test works,
is if you have a very high
prevalence of disease,
so most of the
people have disease.
So for instance, if you're
testing in a hospital,
sick people who look
like they have COVID,
the test really works pretty
well and you can rely on it.
If it says it's positive,
it's probably positive.
If it says it's negative,
it's probably negative.
When you start testing
the general population
where the prevalence
is very low,
so maybe one in 200 people
or less are infected
the test doesn't work as well.
We start to see a lot more,
what we call false positives
where it may be positive,
and they're not infected
because the test does tend to
have a false positive rate,
and if many, many
people don't have it
then the false positives
tend to stand out there.
So that's one issue that we see
that you get into
some trouble using it
in a population where
the prevalence is low.
So we've tended to
point towards strategies
where you're going to
have a better chance
of detecting infections.
So frontline healthcare workers.
We've been testing
a lot of them,
even if they're asymptomatic
just because we know
they're more exposed.
As we've started to
have excess capacity,
we've invited other
frontline service workers.
So we've opened up our testing,
and tried to encourage it
in grocery store workers
and restaurant workers.
Those who are interfacing
with the public to some extent
and might be exposed.
And maybe they're more
likely to be infected,
the test is probably more likely
to be accurate in that group.
And then the third area we're
really concentrated a lot
in the last couple of weeks
has been in businesses.
Businesses are
trying to construct,
how do they deal with reopening,
and how do they access testing?
And that's one of
those questions is,
who are they gonna
target for testing?
And is it those who
are public facing
or those in critical areas
who they can't afford
to have positives?
Or is it everybody?
There's a lot of
expense with doing it,
so the everybody hasn't
tended to make a lot of sense.
- And let's go to Bill.
- Dr., what we hear
in the daily briefing
from the COVID Task
force continually
is capacity for testing, and
that people are not using
all of the testing
that's out there.
Why not?
What are you hearing from people
about why they
don't go get tested
when they might have symptoms?
- I think one issue
is that we really do
want to have excess capacity.
So it's not a bad
thing that we have
all this capacity out there.
We want to have that
so if there is a surge
we're able to combat it.
But at the same
time, we also worry
that we're missing people,
that they're not coming out
and getting tested
when they should.
And the capacity allows
us to really reach out
and say hey come, we
can get you in easily,
it's simple to get tested.
There's a couple
of things out there
that I think are
preventing some people,
or discouraging some
people from getting tested.
The first is, when we
first started this thing
everybody was very
anxious, was very worried,
this was new,
there was a lot of,
I need to go get
tested immediately.
It's been weeks since
some of that has died down
and people aren't quite
as worried about it,
I think, as they
have been before,
and don't feel that
urgency to get tested.
Which, again, is not
the message we want.
We want everybody to get
tested because it's important
and because this is a
really deadly disease.
And the second is the
word's gotten out there
that it's an uncomfortable test.
You have to put a
swab into your nose,
there's a little bit of
pain with it sometimes,
and some people, that's
enough of a barrier to say,
well maybe I don't really
need to get tested today
because I'm worried about
the pain from the swab.
And again, trying to get
out there and combat that
and say hey, there is a
little bit of discomfort
but it's not as bad
as COVID, obviously,
so we need to get you tested
and know what's going on.
- Are there different
kinds of tests
that we could see
come into play here?
- Yeah so there's two
different ways I look at that,
is we have some different
testing modalities.
So right now we're using a test
that you have to
send to a laboratory.
It takes about 24 hours,
sometimes longer to
get a result from it.
There are some rapid tests
that are out there right now.
They're being used
in some settings,
both in physician offices,
and in some of our
community testing.
They get a result
in about 15 minutes,
although, if there's a line,
then it may take a few hours.
Now the problem is they're
not as accurate as the test.
So you trade off the
convenience and how quick it is
for the accuracy, which is a
problem, but it is a trade off.
The second is, we're
typically using
what's called a
nasopharyngeal swab
where you have to push a swab
all the way through the nose
and into the back of the
pharynx or back of the throat.
That's why it's a
little bit uncomfortable
is you have to get all the
way back there with it.
We can do now, what's
called a mid-nasal swab
which only goes about
an inch into the nose
instead of all the way through.
You could use saliva for this.
As you go away
from nasopharyngeal to mid-nasal
to saliva, you lose a lot
of the accuracy of the test.
So again, we could make
it more comfortable
but you really trade off
your ability to get
an accurate answer.
Mostly we'd rather
have the right answer
and have a little
bit of discomfort.
- And before I send
it back to Eric,
there has been talk
here of setting a goal
of maybe 30,000 tests a day.
Is that the phase at which
maybe people get tested
several times, once we
ramp up to phase three,
is that what we're
talking about,
a number that's that high?
- So I'd say we're still
at the discussion phase
about that right now.
And that is really
thinking about,
if we had to do mass
testing, say in schools,
if we had to do mass
testing within businesses
using the public
health apparatus,
well obviously
3,000 tests a day,
which is where we are
right now, roughly
probably isn't
sufficient to do that.
So we're exploring,
how can we ramp up
our current infrastructure
to do 30,000 a day
which would allow a lot of that?
Now the other way to do that
would be to create other
avenues for testing,
maybe testing within certain
large businesses in town
to really distribute testing
across many different
medical offices.
This is something
I'm working on.
I'd love to have testing
in every minor med
and urgent care, and many of
the typical medical offices,
like we get any other test.
If we're able to achieve that,
then this won't become
such an urgency for the UT
and the city and commercial
labs to carry that burden.
- I will say, I got tested.
My daughter and I both got
tested a week or two ago.
For people who are hesitant
'cause they heard it's
painful, it was not painful,
it was just wildly
uncomfortable and strange.
But it really wasn't painful.
For my daughter, she had
basically the same experience.
I want to talk a
little bit about,
and we talked about
this early on.
I remember you saying to
me, either on the podcast
or on the show, that...
yeah we should shut everything
down, but maybe we wouldn't,
that people just wouldn't
be willing to do it
as long as they did.
There's clearly
evidence of some degree,
and I'm curious what you think,
the emotional toll
of this shutdown,
of the isolation for people.
One of the obvious ones
you see is this huge spike
in the overdose deaths.
What's your measurement
of that toll,
the emotional, psychological
kind of toll on people?
- I've been very concerned,
since we started this
of two things, one is
civil disobedience,
and people really
reacting against this.
And we have seen some of
that around the country,
but not as much as
I was worried about.
And I think Memphis
has been a lot better
than many other places.
We've seen it in
the protest as well.
The protests have generally
gone well here and been peaceful
have been robust, but
have been peaceful here.
And I think our response
to COVID similarly
has been more community oriented
and hasn't been as
anti-authoritarian
as some might have worried,
as I might've worried
about that particular issue.
- One of those points,
on a national level
that has gotten
politicized is masks.
I'm not gonna ask you to comment
on the political side of it.
But early on, I think
a lot of people said,
well, we think
masks are effective,
there's no downside,
please do it.
Have we had more research
in this really short period
of time that feels so long
that masks truly are effective?
Or is it really just a best
practice at this point?
- I think there has been a
lot more research to come out.
I do say, we knew that masks
were gonna be helpful in this,
and we were done a great
disservice early on
by federal officials,
by the attorney general,
by the CDC saying,
don't use masks,
they don't have any utility.
They're not gonna
prevent infection.
That was clearly incorrect.
It was done for
political reasons
and because we wanted
to preserve masks
for healthcare workers, and
that was the wrong message.
Many people, to this day,
say I'm not using a mask
because you lied to
me about this before.
So that's a big problem for us,
the reversal of the messaging.
But it's also true that
we're coming to see
a lot more data come
out, a lot more studies,
scientific studies about
the utility of masks.
So the second inaccuracy
I'd like to point out
is for a long time
after we went back to,
Okay, there is some
use for a mask,
it's been, you're wearing
a mask to protect others
because it's gonna
trap the particles
that you're breathing
out, or coughing out
or sneezing out, and prevent
you from infecting others.
But the mask still isn't
useful to protect you.
And again, that's an
inaccurate message
and one that goes against
the psychology of the thing.
Most of us, we may say
we're gonna be altruistic
and wear a mask
to protect others,
but at the root cause,
when you do the studies,
the altruism doesn't
change behavior very much.
What changes behavior is, I
don't want to get infected
so I'm gonna wear a mask.
And what we know
now is that there is
plenty of protection
from these masks.
The major impact may be
on others, certainly,
if there's a high
prevalence of disease,
but there is significant
protection for you from others,
particularly if it's in
a short-term environment.
If I walk into a restaurant,
I'm picking up takeout,
and I'm paying my bill, I'm
in there for five minutes,
that mask provides
really solid protection.
If I'm siting around at
a nail salon for an hour,
maybe that mask doesn't
help me very much
just because of the
time of exposure.
But for that short-term
low-risk exposures,
it really is very helpful.
And we need to
have that messaging
that yes, you're
protecting yourself,
you're also protecting others.
- Another tool that you
all have talked about
is contact tracing.
Again, as we move
towards this reopening
and things like you
said, opening schools up
and more places opening
up, what is the status
of contact tracing
in the Memphis area?
- The contact tracing is done
by the Shelby County
Health Department.
Early on, we clearly
weren't able to keep up
with all the cases.
They have really
increased their workforce
and right now, at
our current level,
we're getting to 100%
of 'em within 24 hours
which is our metric.
- Wow!
- So it's great right now.
The health department does
have a plan right now,
they're hiring
another 141 people
to do contact tracing
over the next month.
That's to provide
that extra capacity
when we do get into the
school year and winter.
I feel very comfortable
about it right now
although it was a
problem very early on.
- Bill, with just a
couple minutes left.
- Are we ready to live
with COVID-19 long-term?
Do we have, I guess
what you would call
the infrastructure or
the practices in place
to live with this virus longer
than just this outbreak
or this pandemic?
- I think we're at a point
where we can manage the disease.
And I think long-term,
we could continue doing
what we're doing and
be at this new pattern,
this new normal, and
control the disease.
There's two concerns in that.
The first is that
we're clearly killing
a number of small businesses.
So restaurants can't
survive in this new normal,
and a number of other things.
So that's gonna
cause a major shift
and a lotta problems
down the road.
The second piece of that
is some of what Eric
brought up earlier
which was the mental health
and the addiction side of that.
The longer we're put back
into this isolation
type of protocol
the harder it is gonna be to
deal with all of those issues.
And right now we have
a really major problem
in that people are avoiding
going to the physician.
Particularly when we
talk about mental health
and addiction, if
you're out of contact
with the medical professionals
that are helping keep you
straight that's a major problem.
And I'm very worried that
one of the long-term issues
we're gonna see outta this
is a spike in addiction
and alcoholism
and in mental health
issues like depression.
Both because of the isolation
and because of this limitation
of getting into medical care.
- Well there's more to that,
but we are out of time.
Dr. McCullers, thank
you for joining us.
And remember that you
can get past episodes
of "Behind the Headlines"
on the wkno.org website
or download them as a podcast
from The Daily Memphian
site, iTunes, Spotify
or wherever you
get your podcasts.
Thanks, and we'll
see you next week.
[intense music]
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