Seventh weekly Sunday off-the-record chat with experts

3 May 2020

Each Sunday, a friend organises a two-hour call for friends (many of whom are senior figures from finance, industry, and academia) to hear 10-15 experts talk about the COVID-19 crisis. This has now grown to more than 1,000 attendees, with a consistently all-star cast of speakers drawn from many different fields.

Tonight’s installment, the seventh in seven weeks, covered wide ground, albeit largely focused on the US:

A former senior executive in Medicare/Medicaid talked through what it will take to do test/trace/track/quarantine in the US
A pandemic expert talked about detecting and reacting to pandemics
The president of a top 10 US university talked through expectations for reopening — how and when?
A former National Sercurity Council member talked about preparedness
And many other fascinating conversations.

As with past conversations, it was held under the Chatham House Rule, meaning I can share a summary of the content but not the names of the participants. I have removed obviously identifying details as well. As with each of these, the notes are as near-verbatim as I can make them, and almost real-time (apologies for typos).

In the summary below, note that questions listed at the start of each section were pre-submitted by organizer to the speakers; not all were answered. Questions inline were asked live. At the end is a Q&A; I was not able to identify the respondent in each case.

Topic: Testing and Tracing

Bio: Former senior executive in Medicare/Medicaid, involved in Affordable Care Act

What does testing and tracing mean?
Who and how will testing and tracing be implemented?
What is the role of the employer in the process?
How will businesses that interact with consumers be involved with testing and tracing?

Three principles to opening up
- Decline in case load to manageable level
- Testing
- Contact tracing
Status of NY ex-NY, 17% WoW case growth, so not meeting the first critera.
Death rates are crying in 9 out of top 10 cities, ex NY
Rural areas are the new hot spots.
We will need testing to move forward. WIll focus on diagnostic testing [CCN: PCR, not antibodies]. This was not designed to scale, does not have interchangeable parts, and is labor intensive.
Now producing 150-200K tests/day
- But we started late, so that’s not enough
Will need around 3M tests/day. Need abundant, accurate (more than today — high 70s / low 80s currently), and quick.
Not focusing on antibody test which is much less important, highly inaccurate, and with the national immunity level at a few %, will suffer from false positives
First priority is frontline workers, including nursing homes. Also other centers of the pandemic such as prisons, meat packing plants
But everyone will need testing on demand over time.
Without this, economic activity will stall — employment but also consumer activity.
We need this because this is a highly asymptomatic spread with a long dormant period.
Second piece is contact tracing. You find out that you’re infected, who did you come into contact with? Notify them and the people they came into contact with
Working with Scott Gottleib and other experts like Larry Brilliant, Osterholm, and others made proposals to Congress.
The purpose of contact tracing is not to eliminate COVD-19. The aim is to contain it. We have a forest fire right now; need to reduce it to campfires, find those fires, and surround them. Find infected people and isolate them so virus has nowhere to go.
Our plan has 3 components:
- 180K people hired to do contact tracing. Large workforce. Highly manual process. Technology will not be a silver bullet.
- Use hotels/motels for voluntary isolation if they can’t do so safely at home
- Income displacement payment because these people are fulfilling a civic duty to protect the rest of us. We want to pay them daily while secluded– like for jury duty.
I spoke to Google & Apple, had some success to use their technology.
Now I think this isn’t the answer. The public perception is that people are comfortable, in a slight majority, but a large minority are not comfortable.
This will have to be opt in (the apps0. Even with 40% opt-in, it’s not enough. The person infected and their contact both need to be opted in, that’s an effective rate of 16%. The tech can help but it can’t be a substitute for hte labor.
This gives us the time to get to a vaccine.

Topic: Innovative Solutions to Pandemics such as using community based disease monitoring using mobile phones

Bio: Expert in pandemics; former tech executive; formerly of CDC .

How is the technology for Covid19 monitoring?
How invasive of civil liberties is the monitoring?
Will those who have been exposed be willing to quarantine?
How has big data changed the game?
How can we monitor if the epidemic is rising locally and then what do we do other than close the economy locally?
Was the Google Flu trend based on sales of aspirin, cold medicine and relevant searches?

This virus is growing a rapidly growing list of zoonoses that jump from animals to humans
These require serious focus
This is only the latest set. Ebola, Mers, Sars-1, H1N1
I investigated Hantavirus with 75% mortality early on impacting 25-35 year olds in 1993. There were flu-like symptoms, death within 48-72 hours.
Someday, COVID-19 will be a distant memory.
And then we will lose the spirit of cooperation and drive that is happening now. That cannot happen.
Policy and procedure are not always based on the best possible science.
Non-pharmaceutical interventions like lockdown, masks, etc can be done in a systematic way, also to document the intervention so that we learn from the next outbreak.
Any outbreak from an unknown pathogen, speed is of the essence, Reporting and response as well as detection
Any delay in detecting leads to greater spread, illness, deaths, and disruption.
In some countries, farmers and workers in live animal markets are connected to community-led surveillance systems where they report illnesses in animals as well as humans.
Cambodia is an example. There is a free national hotline to get current information on what is circulating in the community. Collaboration of all four major telecoms. 400 calls per day, 20-30 need some intervention
Now they are getting 15-20K calls per day. The ministry of health hired lots more people. It is a way of communicating all things COVID to the public. Most cases identified come through the hotline
Same system gets real-time stats from all of its centres on a daily basis.
In the US: “Flu near you” system — existing users encouraged friends and families to join. We launched COVID Near You to allow “participatory surveillance”.
Brazil implemented this during World Cup, Olympics, and Paralympics.
Social media, ML, AI, etc all offer opportunities to find outbreaks faster.

Topic: Opening up Universities during a Pandemic

Bio: Head of a university

Do you think some universities will choose to be online and others open for business?
Does an urban vs. suburban vs. rural campus make a difference in the opening decision?
How do you protect the two vulnerable populations: faculty/staff and members of the community over a certain age or with certain morbidity?
In your NYT OP-ED you mention that student parties may need to be restricted. Would you consider disciplining students who go to a social gathering off campus?

Although we think of this about bringing students back to classrooms, universities like us are like small cities — lots of departments, staff, etc.
Same challenges that any city or business would face
Undergraduate education poses special challenges
Will some universities open and others be online?
- If it resurges over hte summer as states relax, we will all be online — there will be no option.
- In (one state) right now groups of 5+ can’t be together, and people from out of state have to self-quarantine for 14 days
- We need to be in a position to reopen when possible.
- Where universities are will matter.
- Optimization correlates with location
- One exception: some small colleges far from medical centers will struggle to bring everyone back.
I know of no university that isn’t developing improved online courses, even if they think they can bring students back.
- Many int’l students won’t be able to come back due to travel restrictions
- Students with pre-existing conditions too.
- Large lecture courses will need to be flipped
- So online will be more important going forward.
Young people aren’t at high risk so we’re thinking about how we protect everyone else
Thinking about social distancing, wearing masks, keep people far apart in class.
Faculty who don’t want to teach in person, we can’t force them.
The practices being developed for hotels and restaurants will apply to us.
Students will have more restricted options for community engagement
How do we control students’ social life? Common question
- I hope that students will respond to a good public health campaign
- Can’t be forced on them. They need to understand that they could risk the university returning to remote operation
(Q: What will living arrangements be?)
We’re developing a “medium case” scenario where a lot of distancing is required.
- We will have more semesters and give every student a single room. Can’t put students in doubles. Looking at adding space too.
(Q: Will you defer to the state when deciding whether to open?)
We are willing to set a higher bar than the state, but we are working collaboratively and that is unlikely.

Topic: Will small colleges survive the pandemic?

Bio: Professor of Education at a major university

In your most recent book College Stress Test, you say that 10% of colleges have substantial risk of going under. Do you think the current pandemic increases the risk considerably?
With little endowments and dependence on tuition and kids staying in college, these schools must open in the fall to survive. Will the states allow them and will the faculty be willing to teach?
Colleges are in a dog eat dog battle for the same students. Does the current circumstance force the top schools to take the students away from the less respected schools?
How do you expect the college market to shake-out?

Life neither began nor ended with pandemic
I published a major study around which institutions were likely to close back in February.
There were market flows that told us who was at risk.
The market for higher ed was consolidating anyway. Big were getting bigger, richer getting richer, smaller getting leaner, and underinvolved in trouble.
This was a highly predictable flow.
The pandemic: as a guess, we doubled what we had seen before.
So if 10% of small colleges were previously at risk, we said 20%. But that’s only 2% of total enrollment!
Most students go to big universities, largely public. They will have more pain in the beginning and less at the end.
The private universities will be more calm in the beginning but are in bigger trouble because they don’t have deep pockets.
That diesn’t seem to be the case but it is relative to private universities.
I speak to 5 university presidents every Sunday. All of them say that they will reopen.
- They will also say, “it’s not my decision”
- We have ceded a lot of authority outside of institutions.
- We say “we will be open if the governor lets us” — I have never heard this before.
For institutions at risk, there are high levels of uncertainty. They have not been here before.
I play a game with them. I ask them: will you have your faculty teach with masks? Even two weeks ago, the presidents had often not thought that through. Now they say, “whatever the governor says”
We talk about teaching online. The right way to talk about this is to say that we will teach remotely — like this phone call.
Zoom and other tools, allows a familiarity once you’re used to the tech
So there is a lot of room for innovation around remote teaching
The problem is, where will the revenue come from? At risk of students not on campus.
(Q: You think 2% of the students will have to move if 20% of the schools close. Is that a big deal in the scheme of things?)
1970s — issue of base closing. Took 20 years to work out which ones to close. Colleges are part of the economy — they are like military bases. They play that role (i.e. in anchoring the economy of a small town). The students will do fine.
African American students are more likely to attend an institution at risk than others. So the pandemic will have differential impact on different portions of the population.
So the 2% will cause disruption and consternation.

Topic: Pandemic preparedness

Bio: Formerly of National Security Council.

How should we evaluate US and global preparedness? What are the major gaps?
How should we prepare for bioterrorism? Does that look different from preparedness for naturally occurring pandemics?
What will it take to get prepared for future catastrophic biological events?

Major gaps in preparedness
- We studied preparedness broadly and scored it very low, gave it a low failing grade. That seems accurate now. The US did relatively well but we got a B-. Overall health care, public confidence in gov’t, some metrics around whether capacity is utilized and exercised — these were areas where we scored low. Plus you need to exercise the capability you have and we had trouble there in the US.
- Whether accidental or deliberate, we need to be concerned about biological risk.
- Low capabilitiy to protect lab samples around the world for theft or sabotage.
  - 81% of countries got a low score
- Ability to protect people from pathogens (biosafety)
  - 66% of countries got a low score
- Ability to Oversee dual-use research
  - 99% of countries got low score.
- Our int’l fabric for dealing with pandemics, we look to the WHO — that’s important. We also have one for dealing with deliberate events. But in between those two, there’s nothing to deal with biotech risks –e .g., ability to edit pathogens to make them more virulent; nothing focused on bioterrorism or biosafety. WHO plays a role as does the UN but it’s no one’s first priority. We need to strengthen this.
How should we prepare for catastrophic events in general, including bioterrorism?
What will it take to get prepared for the future.
- We now know where the gaps are. The WHO has done >100 external evaluations. They found similarly low scores.
- No incentive mechanism either to take own actions or leverage donor funding.
- Think we should have a challenge fund to use development loans for preparedness
- Second biosurveillance.
  - Our mechanism is dated.
  - We need an epidemic forecasting capability in the US and a greater global one. We can’t just rely on reports from individual countries.
- Third, we need a supply chain reboot for PPE, for tests, for reagents, for supplies. Everyone is running out of them. Even worse in Africa
We need to be able to pivot in a crisis to make them faster than we can now
Accountability — there is no one coordinator / facilitator. Can’t just rely on WHO. Needs to be someone’s full-time job to think about pandemic risk. That should be at UN. White House also needs a dedicated team.
Hope that when we do the next pandemic preparedness index, we will see increasing scores.
If there’s a silver lining it will be if we focus on these neglected areas.

Topic: Telemedicine

Bio: Primary care physician and healthcare innovator; serial entrepreneur

Why is the future telemedicine?
How has telemedicine worked so far in the pandemic?
To what extent does the insurance industry dictate policy and has their position changed?

Most health systems quickly shut down / minimized F2F visits.
Most doctors are doing 60-100% of visits online (phone, video,, messaging)
Many doctors are working from home. They can because of electronic records.
USually only patients coming into office are those with chronic conditions, need test or exam. They are being seen by skeleton crew. And those who don’t have any symptoms. >50% is being done by telehealth.
For outpatients:
- Those with COVID concerns, being told to stay home and sequester; or based on their symptoms, go to the ER. Not many options in between, triage.
- Quickly seeing a shift from doctors to chatbots or maybe nurses. Doing so to preserve doctor time.
- This will become more important over time.
Still have to take care of those with chronic conditions. Can be done in many cases with home machines (for testing).
Not doing much preventative care. Keeping the lights on
In hospitals, telehealth has become important — e.g,. For specialists.
Even virtual rounds without entering the room in the hospital
What’s happening to help support this?
3Rs:
- Improved reimbursement
- IMproved regulation
- REgularity — people getting used to it.
INsurance companies: being more flexible.
- Doctors can bill at parity for medicare, most followed this. Now that it’s being paid for doctors are more likely to do it.
- Still things to be resolved –video? Asynchronous visits like messaging?
- Signs are that this direction of travel will continue
Regulatory questions
- Waving HIPAA security measures to allow (eg) SKype
- Doctors can now practice across state lines.
We have now crossed the chasm. Nuress love it.
The idea of going to a doctor’s office may be seen as archaic.
But it’s not enough. Goal will be how we really take care of someone effectively, safely, and quickly.
Automation will kick in to support — e.g., data collection.
Automation may manage some patient care if FDA permits. Escalate to doctors for outliers.
Then we will not have a shortage of doctors.

Topic: Medical Restructuring Post-Pandemic

Bio: Board member of a number of companies including health care services; former health care CEO;teaches health care services to MBAs..

Why did hospitals cut back their supplies of masks and gowns?
Who should be responsible for keeping necessary supplies?
Were you surprised how quickly the private sector produced extra supplies?
Who should stockpile medications that are sourced from outside the USA?
How will this financial crisis impact the medical profession, and how would you expect the changes in the capital structure will impact the patient/consumer?

Our prior efforts to continually lower costs in health care led us to be badly prepare for volume.
We saw this in lack of beds. Number of beds per 1,000 has been reduced by 60% in last few decade
We try to lower length of stay for each procedures; move people out of hospitals quickly to ambulatory services (for example)
Like the airline industry where they reduced capacity by stuffing more people onto every plane until there is a large snowstorm.
Extreme measure like cancelling all elective procedures.
That will lead ot a whole new set of problems. 30% of people say they haven’t receive needed medical care either because cancelled or because afraid of infection.
We say we will only reopen cities or universities when we have excess capacity in hospitals — where will that come from once we allow elective surgeries?
Also in the supply chain we did not have the spare capacity. You see that in PPE.
I am experienced with supply chain. How did we not have enough PPE? We can produce it in the US but we don’t ; good at sourcing cheapest possible products. Also moved to just-in-time inventory so no spare capacity.
Supply chain adjusted very quickly, four weeks. In the meantime people worked without the right equipment. They should not have had to risk their lives.
We will need to create a stockpile of supplies to meet future surges of demand. Cannot expect players in the industry to do so.
Likely to be done at the state level.
Finally, we were not prepared with commercial labs and testing. Two players dominate this space. Only recently started finding creative solutions — e.g., deputizing drug stores to draw specimens.
Expect that we will be able to meet demand over the coming months. We will not be limited by lab testing capacity within a reasonable amount of time.
Once we have a vaccine everyone will want one quickly. Think of needles, vials, stoppers, etc. to be able to inject 330M people, maybe 2x. Don’t think we are preparing that now.

Topic: Pandemic and Sports

Bio: Senior executive in sports and entertainment, involved in a future Olympics.

Is it possible for Tokyo to host the Olympics in 2021?
How have your plans changed for the Olympics in 2028?
Will cities be more reticent to bid on the Olympics?
You are involved in almost all sports. Which sports will thrive and which will dive in the post Covid sports world?
How do you think that the public demand for sports will be impacted by the virus? Have we seen the peak of a live stadium audience for sports and maybe concerts, as public gatherings will be too risky/difficult?
Is there enormous pent up demand for sports or has the public moved on?
How do you think this virus will impact the long-term valuation of sports teams?

Tokyo decision based in part on (a) athletes not having access to training and (b) limits of lab capacity meant no ability to test for performance enhancing drugs.
Worst case scenario is domestic-only fans in 2021.
Looking to 2028 LA — adding planning for theoretical pandemic.
Cities will still be ready to bid on the olympics going forward but it will change how it happens and what is considered.
LA is unusual because has capacity for complete games
Most future games will have a single city as the hub, but sports spread all over the country — e.g., Milan won’t host every event. Financially and operationally untenable otherwise.
Big sports will thrive in the future. Marginal sports will be crushed.
BAseball, golf, auto racing will be the first sports to come back. SOccer in Europe.
What about football and college football? Big question marks.
Huge pent-up demand for sports. People miss it.
Huge ratings for anything that is live and real.
May 17th golf match with for players, without fans — there will be much more like this.
New normal: just like after 9/11, there will be a new version of this. E.g., temperature checks, masks and gloves.
Doubt there will be fans in stands in 2020, maybe 2021. Beaches in CA suggests that people would be willing to though.
There will be short-term blip in valuation of franchises but only a temporary blip, unique and valuable assets.
75% (95%?) of NFL fans will never see a live event. Sports are designed to be watched on TV.

Topic: Religious Adaptation to the Pandemic

Bio: Associate Professor of Sociology at major university

Can Orthodox Jews socially distance, or is it too embedded in the religiosity and cultural requirements?
Will Jews follow the models of the Protestant faith and/or transcendentalism?
How should we expect religious communal activities to adapt to social distancing and the rejection of large public gatherings for religious services, funerals and weddings?

In Israel, NY, NJ — male jews > 13 are supposed to be 10 men praying together — “Minyan”. This has been challenged. Many have been cancelled, but there are many cases of secret groups praying together — people go to a pre-set place to pray together. Not keeping social distancing.
Big outbreaks happening in Orthodox community.
Orthodox groups are not always socially distancing — eg, funerals.
We see related issues in some other strict religious groups.
There has been a wrangling over expertise over how we live — whether in science or in religion.
So this should not surprise us. E.g., look at measles vaccinations as a flashpoint for this tension about who has the power to prescribe how we live.
So far this isn’t surprising.
In the Orthodox community there is a lot of cooperation with the medical establishment, both with behavior and religious law.
Pandemic hit during Passover seder. While some large families have come together, rabbinical prescriptions said it was okay to use electricity to have Zoom gatherings. Many rabbis have allowed this. Very unusual.
The other interesting question: what are we seeing in relationship to God with the outbreak? In islam and Orthodox Judaism, based on communal practice — required. Stress is not on personal relationship to God, but on communal practice.
Both in Jewish and Catholic quarters, call to develop private personal relationships with God. very interesting and this is more like Protestantism. In the past this has been the province of the mystic.
Religious adaptations to the situation. Are they a blip or will there be lasting change in practice and expertise? We don’t know. Mahy depend on how quickly the pandemic passes. If it goes on a few years, these practices will become more established.
Q: Given the health risks, why are religious Jews getting too close to each other in minyans?
- Some are trying to do so, keep distance
- Many are very poor, meeting in small spaces — they are trying
- Theologically: they are saying God will protect us. (You hear this from evangelicals too)
Q: Jews believe that if you are put at risk there are exceptions to theological law?
- Yes, we see that with the Zoom exception in some cases (allowing electricity)
Q: Iran, funeral for senior leader, infected many people. In Jerusalem, same thing happening with death of a senior rabbi.

Topic: Municipal Finance and the Pandemic

Bio: Professor at major law school; expert in Puerto Rico

McConnell is proposing a bankruptcy code for states. Is this the time for real?
Can a state bankruptcy code be constitutional?
What have you learned from your Puerto Rican experience?
Do you think there is greater legal protections for American revenue bonds relative to PR/Cofina?

Three things to know about the topic of state bankruptcy
- States currently cannot file for bankruptcy. Cities can (chapter 9 municipal bankruptcy) if state permits.
- If it were permitted, it would have to be 100% voluntary. Illinois is the poster child — they could not be thrown into it against their wishes. If Congress tried to pass involuntary bankruptcy law, would violate 10th amendment. So this is an option
- There are constitutional questions. It would be questioned under the contracts clause of the constitution, and as a violation of state sovereignty. I think it would be constitutional if framed properly.
Quickest way to make the case is to show that the main arguments against it actually demonstrate the virtues.
Democrats criticize the idea, typically because they think it will be used to wipe out pensions and whack public employees.
It’s sometimes pitched that way but entirely a mistaken idea
In fact there would be a more equitable sharing of sacrifice.
What happens without bankruptcy when distress? It tends to get visited upon one or two constituencies, usually beneficiaries of services in that state. That’s what is happening in IL. With bankruptcy,everyone would have to share in sacrifice.
In big city bankruptcy cases so far — Detroit, Stockton -_ Pension holders did okay.
Republicans say it would destroy the state bond market
- Assumes that the bond market can’t tell the difference between responsible and irresponsible states. Market does a good job in fact,
- If there was an impact on bond prices, it would take away the assumption that there would be a bailout.
- If it were terrible, then the municipal bond market would have already been destroyed but it has not.
No one wants a state to go bust but the alternatives are a bailout, or a collapse or default, both of which are worse.
Puerto Rico: the restructuring case has been going on for 3 years. Closest thing to state bankruptcy that we have. I’ve come away thinking it’s messy but actually works pretty well.
Q: Did there have to be a crisis to get state bankruptcy?
- Yes. That’s what we’ve seen with cities.
- No one wants to face up to the reality of what it would be like if there were a massive default. Need a crisis to get a consensus.