[Intro music] Skipper Chong Warson: Hi. My name is Skipper Chong Warson, I'm a design director in San Francisco. Welcome to "How This Works", a show where I invite people on to talk about subjects they know incredibly well. And today, Dr. Peter Chin-Hong is with me from The University of California at San Francisco. He and I are going to talk about being an infectious disease expert and professor at UCSF. Specifically, we're going to talk about the novel coronavirus and COVID-19, both topics about which he knows an incredible amount. We'll talk about the current state of the virus, the vaccine candidates, and how holiday travel might work as other get togethers. Dr. Peter Chin-Hong, thanks for making time. Dr. Peter Chin-Hong: My pleasure, Skipper. Thanks for having me on. Skipper: So let's start with the general opening of our show. First, I'd love to know how should I refer to you? You know, some of my best friends call me by all three of my names, even my wife. May I call you Dr. Chin-Hong? Or something else? Peter: You can call me Peter but my students call me PCH, like Pacific Coast Highway. Skipper: Nice. Peter: Because those are the initials of my name. Skipper: That’s great. I'll go ahead and go with Peter. So let's start with you. Would you tell me a little bit about yourself? Who are you? Peter: Sure. So I’ll start with where I'm at right now. I’m an infectious disease clinician and professor of medicine at the University of California, San Francisco. But it took me a while to get to this spot. Because I was born in the Caribbean. In Trinidad and Tobago, the most southern island in the Caribbean chain. And it's right off the coast of Venezuela. I looked at a brochure in high school from a friend and Brown University looked really cool. It had all these black and white pictures. So I took a leap of faith, went to Providence, Rhode Island, was there for undergraduate and medical school. Then, I visited that same friend who'd moved to San Francisco to work for Oracle, lived in the pre-hipster Mission (District) on Valencia Street, ate a burrito everyday, and fell in love with San Francisco. So I decided to come here. Skipper: That’s awesome. So, as part of our introduction, I usually ask guests, what's something about you that many people might not guess — something you feel comfortable sharing. Peter: I think when people see me, they see me as primarily Asian, but actually coming from the Caribbean which has such a clashing of cultures and mixing of races, ethnicities, and backgrounds. And I think people may not know, but I'm 12.5% Indian and 12.5% Scottish. And I love that, it makes me connected to so many different people, wherever I meet folks and encounter them. Skipper: Thanks for sharing that. I really appreciate that you brought that up. Indian, Scottish, Asian, we all have component parts, so much more than what might be signaled from our physical appearance. That’s a great reminder. Peter: Thanks. Skipper: So let's get into our main topic today. Peter, what are we talking about? What is the thing that we're talking about in which you are very well versed? Peter: Well, we're talking about COVID. And when I think about COVID, I don't just think about the biology of COVID and the medicine of COVID, I think about the social implications and the way it's upended all of our lives. We put our lives on pause, you know, for all these months, for a year, it’ll be more than year by the time we get back to some semblance of normal. Skipper: Yeah. Peter: And I think that is something that none of us in our wildest dreams, would have thought would take that long. Or that it would take so much out of us. Skipper: Yeah, I agree. When I look back to when this started, at least here in California when I became more aware of it in February and in March and now we're recording in December, I did not think that we would be this long into this situation. Peter: Back in spring and even in summer, we always were looking forward to something in the future when we thought things might have burnt out. I think in those days, we were saying at least for Thanksgiving or Christmas, we'll be able to see our family and loved ones. And now it's not looking like that's going to be possible. Skipper: Yeah. I'd like to ask you one more background question. How did you become first interested in medicine? You know, what was your inspiration? Peter: So I think growing up in the Caribbean, I was struck by the fact that was specifically infectious diseases — even as a small kid. I'd run around and see a lot of folks in the village that I grew up in with a lot of transmissible infections. It wasn't inherently an optimistic field because, sure, some people didn't have access to medicines, but the ones that did they got cured so being an optimistic person, that was something that drew me into the field. Originally, I was worried that I had hookworm or parasites, for example, some pretty unnatural fears for a seven year old. But then the story got deeper. During high school in Trinidad when one of my best friends, his dad, I later on found out he had HIV and died of AIDS. So I think that was really a part of my sort of pre-medical school development and motivation to join a force that can help not just people I encountered, but on a broader scale larger populations. And so that in maybe another era, another incarnation of that story, I would have been able to help my friends’ dad. Skipper: I see. Peter, I'm sorry for your friend’s loss. Their dad. Skipper (cont’d): Normally, we dig a bit more into how someone has come to know their subject matter but I think given what's happening in the country — and in the world for that matter — that we really should get into the nitty gritty of our topic. So, in the news, week over week, we see the number of cases and deaths increasing. What's happening? Peter, can you break it down from your point-of-view? Peter: Well, I'll break it down into two main issues — and maybe two areas in which I think we've not done such a great job in the United States. And that is, one voice alignment of the whole country to one purpose, which hasn't been the case in COVID-19. We’ve had 50 different countries with 50 different practices. Skipper: Yeah. Peter: Because what had happened is that the authority over the control of the pandemic was relegated to the states so that meant that, you know, the heart wasn't beating synchronously, we were like all these different muscles twitching. So that's one issue. Skipper: Sure. Peter: The second issue, I think, just broadly speaking, is we didn't really have much alignment of science with politics. It was very divisive. And whenever there is a division, people exploit those fractures or use those fractures as an excuse not to do one thing or the other. And, to me being in medicine, having science divorced from this pandemic was really heartbreaking. And I think those two things were probably the singular things that led to our demise. Skipper: I agree, those are excellent points. Skipper (cont’d): In the last few weeks in California, stay-at-home orders have been issued because hospitals are filling up and fewer intensive care unit (ICU) beds are available — in some counties preemptively. What's the current situation? Peter: So, the current situation is very bleak. And it's not just the absolute numbers Skipper, it's the rate of increase of cases and the rate of decrease of availability in hospitals. So the tempo and the speed is really what's breathtaking to me. Apart from this, the numbers that we focus on in the newspapers, on radio, on TV, let me give you an example. The Central Valley, which I know well, because we have a UCSF campus in Fresno. Skipper: Okay. Peter: And I speak to my colleagues there all the time. And a few weeks ago, there was 25% or more ICU beds capacity. Then, last week, they were around 10%. And now they're at 0% or close to that. So that rate of decrease of ICU bed availability is really unprecedented in a non pandemic year. So that speaks to where we are. In the Bay Area, we're not doing too bad. Currently, we're about 20% ICU bed capacity. But in SoCal, they're doing substantially worse, below 10%. So the fact that we have to think about ICU beds as a metric is itself frightening. When on a good day we should be thinking about cases or test positivity rate, some of the traditional metrics we use. But, you know, we don't have much more to think about beyond ICU bed capacity other than deaths. And that, to me is very frightening. Skipper: There's not much gray area to your point. Peter: Yes, there isn't. And, you know, when you think about ICU beds, that's a metric of last resort, you know? And that is very different. In the first two waves in California, we were mainly focused on reopening or metrics that states or counties use to then reopen, but we're thinking the opposite now, which is, ICU beds. Wow. Who’d ever think we'd come to that? Skipper: Yeah. You talked a little bit about what's happening at the UCSF campus in the Central Valley. What about the UCSF campus here? What's happening inside the medical center? You talked about how there was 20% capacity for ICU beds. So 80% have been filled and there's only 20% left? Peter: Yes. So at UCSF here in San Francisco, again, the numbers don't look too bad in terms of ICU, but that's a relative comparison. In an absolute number, I think 20% is not anything to celebrate. And in California, we've always taken the burden of our neighbors so when Imperial County was burning up with COVID, we took some of those patients here. When San Quentin was exploding with cases, we also took care of those patients here. So there's nothing to stop us from wanting to extend our help to the surrounding areas. And once that happens, that risk from that area also becomes our risk as well. Skipper: So much attention has been placed recently on the vaccines that are in development. Last week, the United Kingdom distributed the vaccine to at-risk people and frontline medical workers. And last Friday, the Food and Drug Administration authorized the vaccine made by Pfizer and BioNTech which uses synthetic mRNA to prime the immune system. It's currently approved in Canada and several other countries for emergency purposes. What's your assessment? Peter: I’m very excited about the Pfizer/BioNTech vaccine product because the efficacy exceeded our wildest dreams. So the bar was pretty low from the FDA perspective, they would look at vaccines favorably with a 50% efficacy. So 95% is actually breathtaking, particularly when you compare it to the influenza vaccine (flu vaccine) that is only 40-60% effective, depending on the year you look at. Skipper: How does that compare to the MMR vaccine or DtaP in terms of efficacy? Peter: So those vaccines also very good, they are in the 90% efficacy range. So it's comparable to the best vaccines that we have. Skipper: Great. So is this the vaccine, the Pfizer vaccine, the one that UCSF is receiving? Peter: Yeah, so UCSF will get about 1,000 vaccines in the first rollout. It's probably going to arrive here in the next few hours (on Monday). And by Wednesday or Thursday, we'll start immunizing the frontline of the frontline workers. Of course, we don't have enough to immunize all healthcare workers, even. But every week, there'll be vaccines pushed into California. If you think about the numbers of healthcare workers in this state, we have about 2.4 million healthcare workers in California. Skipper: Wow. Peter: And so that's a lot. And if you think that we only get a fraction of that to begin with, you're not going to see everyone so you have to think about who's most at risk of the healthcare workers. And then that's not even thinking about the nursing home residents next, which will be the group that we also worry about. Skipper: Are you going to be receiving it at some point? Peter: I hope to get it in the next week or two, and it could be my Christmas present, I hope. Skipper: That would be a great Christmas present. So there are challenges with the Pfizer/BioNTech vaccine — the cold chain temperature, raw material shortages, two-part dosages, etc. What worries you the most? Peter: What worries me the most, Skipper isn’t only the structural challenges like you mentioned — like super cold temperatures, like -70º C, your deep freeze is only about -8ºC, for example. We can talk about the two dose thing but what worries me most are the structural issues, we don't have a single payer in the U.S. And so the distribution is actually quite complex, if you think about it. The Department of Defense has its own distribution line, the company has its own line, which is going to be the first wave to California, and the state has its own line. So different sites, you hear about Walgreens and CVS doing nursing homes, you have different states and counties coming in at different levels, and the VA, vets, and the Department of Defense are going to get their own line. It's all a little bit confusing. Above all, you need to have an information system to really keep track of everyone. We move a lot in the U.S. even in pandemic times. And if you got a vaccine in San Francisco and you happen to be in L.A. for the holidays, then some mega information system has to keep track of you and to know whether or not you're there on time. And you have to figure out a place to get that vaccine when it’s so tightly linked to county at this moment. Skipper: Yeah. That all makes sense. Do you think that the initial vaccine orders that have been placed by our government will help our country to re-open as we are waiting for additional doses starting in Q2 as well as other players? Peter: I do believe it's the only way we can get the country to reopen but it wouldn't be immediate. It will be a gradual rollout as people have heard and there'll be a lot of in-between time or grey time when there'll be some people immunized and some people not. We probably won't be changing protections like mask wearing and social distance in the next few months. But hopefully, by summer, we can actually start enjoying or begin glimpsing the life that we aspire to pre-pandemic. Skipper: Yeah, the life of the past and the life of the future. Peter: Yes, for sure. Skipper: So other vaccines are also in a variety of stages of development — stage one through three, which is the furthest along. Are there other vaccines or other technologies that you're keeping your eye on? Peter: First, let’s finish up the vaccine part now. Skipper: Yes. Peter: So, Moderna is set to be FDA approved soon, on Dec 17th. They're meeting and we expect very similar results in terms of regulatory approval simply because they’re very similar vaccines. Probably the next vaccine will be AstraZeneca, although that's been plagued by puzzling clinical trials. And I think people are sorting through the data now, where it seemed that the half dose worked better than the full dose. And it's about 70% effective, but it is a cheaper vaccine, it's easier to store, just refrigeration, and would be great around the world. Again, when you think about a pandemic, you can't just concentrate on one area like the U.S. because people move back and forth. And if you want the economy to improve in the world — which also affects ultimately our own domestic economy — everyone needs to be protected. So, hopefully AstraZeneca will help in that regard. And then the next one closer would be Johnson & Johnson, which is great, because it's just one shot. Refrigerated also. And then a few others in Operation Warp Speed like Novavax, etc. Peter (cont’d): In terms of the rest of the world, China has a few that they're working on, they have very different technologies. And then you might have heard about Sputnik in Russia, which was a little bit controversial in its rollout but that's also in play as well. So a bunch of different players from the vaccine end. And then we can also talk about some of the developments in other therapeutics as well. Skipper: Yeah, I'd love to just get a glimpse into because I think a lot of the chatter right now is around the vaccines and, you know, potentially what the rollout is, and there's a lot of opaqueness about when it will be available. But are there other things that you're keeping your eye on, you're listening out for? Peter: Yeah, so I think the big move in terms of the next big thing is to move therapeutics from the hospital from intravenous to the outpatient world. And hopefully with an oral formulation of a medicine that we can all use in addition to the vaccine. So this is when already you get infected. Or even maybe to prevent high risk people from getting infected. So, there are a few compounds in oral formulation being developed. One is by Merck. Another that is not an oral drug, but it's a inhaled version. It's called Interferon or interferon product that's also kind of promising because you can get it like a nebulizer and inhaled version like you would treat asthma or reactive airways disease as an antiviral, so that's kind of cool. And then there's talk about using antibodies like Regeneron or you know, the (Eli) Lilly product of antibody cocktail or convalescent plasma in the outpatient setting, where you'd prevent people from actually getting sick if you have it, or even one step further, you prevent people from getting sick all together. So it can be seen as a bridge to vaccination as we wait the next few months in the country for full vaccination of the community. So these are all some things that are happening. And I think there's been a lot of acceleration of science. So we'll see how fast these things take to get to market. Skipper: Yeah. What is the name of the Merck product? I can't remember what that is and I don't have it in my notes. Peter: I'm pretty sure it's molnupiravir — m-o-l-n-u-p-i-r-a-v-i-r. Skipper: Okay, great. You already talked about this notion of people moving from place to place even within California, some people are traveling in and out of states, even though the vaccines will be available soon. We're not through this, right? I read estimates that 50 million people traveled over Thanksgiving — 2 million people by air and 48 million by car. How should people be thinking about the holidays in general at the end of the year and then beyond in 2021? Peter: It’s a great question, Skipper. I hate to be a Debbie Downer because I'm usually a super optimistic person, but I don't think we should be doing a lot of traveling for this winter holiday unless you really have to on an individual level, like visit a dying relative. Weigh the risks and benefits but probably don’t go to the beach in Cancun because of where we are right now in the pandemic and the vaccine, unfortunately, would not change this curve. It’s too early. Skipper: Yeah. What are your own holiday plans, if any? Peter: I’m just gonna stay home in the Bay Area, which I've been learning the joys of more and more. I mean, I’ve always loved living here, but I think I've really begun begun to appreciate it even more and more, maybe try out some new takeout options from Michelin starred restaurants. Skipper: Sure, support some local restaurants with some great food. Peter: Exactly. Yeah. I mean, that's what we did for Thanksgiving. Instead of making stuff, we supported one of our local restaurants by getting food from them. And we may do that for winter holidays as well. Skipper: Yeah. So I'd like to rewind to one other question that came up since we initially talked. I wonder if you have any insight on this notion of how long the novel coronavirus has been in the United States? I read evidence that it's been here since November 2019, sometime last year. Do you have any insight on when it showed up here in the States? Peter: I think November 2019 is completely plausible. And even before that. And we were hampered by several factors in terms of getting that exact date, the main obstacle we had was that we didn't have enough diagnostic tests. So we were focusing on people who went to Wuhan, China when in retrospect, that was really foolhardy. And it took this scientist from Seattle at University of Washington (read: Helen Chu) to really look at some old samples she had in a flu study to then go back and retrospectively test some for COVID-19. And lo and behold, a lot of those people who were attending up flu negative had COVID all along. But again, we have a lot of travel between, particularly the west coast in the Bay Area, and China. Skipper: Yeah. Peter: So it made no sense that in an infection when you can tell if somebody has it by looking at them, because you actually transmitted more before you get sick, that people didn't have it long before then. There were a lot of people who died, who no one really thought about, but they probably died of COVID-19. Skipper: I see. Peter, is there anything that we haven't talked about that you want to get into regarding COVID-19? Or the novel coronavirus? Peter: I would say that, you know, there's so many things to talk about, Skipper. I don’t even know where to begin but in broad brush strokes, I would say what a journey it's been it's really exposed so much of our fractured healthcare system, not only in how people access health care, how they interface with clinicians, and we've had to reinvent that with tele-health more and more. But it also exposes some of the vulnerabilities in certain segments of our populations, which we already knew were there. But when people are dying in such high numbers, it makes it even more dramatic. And for me, personally, that was really striking in the pandemic, not only to black and brown communities — Latinx, African American. But also within Asian populations, you know, Filipino Americans and other folks, other essential workers. And that, to me, was very heartbreaking. And for much of the pandemic, I've had to be an advocate and be an activist when I didn't really think I would have to assume this rule at any point in my career around tear gas, around San Quentin and prison health, around getting enough personal protective equipment (PPE) for healthcare workers and doing rallies in the community. So again, at the end of the day, it also illustrates to me the resilience of people and the kindness of people, and how people really get together. Particularly when we were all in the dark about what this was all about and how we even get it was like the early days of HIV, I wasn't around for that point, but certainly from what I learned from my colleagues, people were very frightened. Skipper: Yeah. Peter: And of course, as we learn more and more, we adjusted to suit. Which makes it very difficult in this period because I think we know enough science, people in the community know how to protect themselves. And it’s really just will. And can we have the willpower to do so? Do we have the resilience? Do we have the strength to do it after being so fatigued after all these months? And that is something that I'm hoping we can all do. Skipper: I hope so too. I saw a headline before we started recording that the death count in the United States has surpassed 300,000. And to your earlier point about acceleration, it was only a month ago that the count was estimated at 250,000. So the fact that we've gone so quickly from 250,000, which is a tragedy, to now 300,000, it's much much larger. Peter: Definitely. And one other chilling statistic I saw recently was that everyday now in the United States, more people are dying of COVID-19 than died it in the 911 event. So that's to tell you how much of a problem it is. And I guess that brings up another point, which is, you know, people get numb by numbers and statistics and your, when you walk around in the Bay Area, in California, it really belies what's going on behind the hospital walls. In my world, you know, seeing people on (ventilators) and having to worry about determining what to do if we get an onslaught and we don't have enough beds for the people in the ICU. It's really a dissonance or a contrast between the peace and the quietness that's outside. Because this, in essence, is invisible. When you go to Safeway, go to Whole Foods or whatever, you just see a bunch of people wearing masks. But behind the scenes, it's hard to really connect those two. And when public health officials, say, "We need to do this." It seems like overkill or being too cautious but then, on the other side, that's not the story. Skipper: I agree. Dr. Chin-Hong, we could talk more about our subject matter at hand but we're nearing the end of our time together, I'd like to get into a couple of closing questions that I ask all the guests that come on the show. What is one of the most important lessons you’ve learned so far in your work or in your life? Peter: The first lesson that I think about isn't some medical fact or some medical insight, it's actually all the hate speech and hate crimes that we've had towards certain populations, specifically, one that that's close to me, obviously, is in the Asian American population. When you have political leaders using words like China virus and kung flu, it’s not just sending a bad message but it actually has implications for health. So, that’s one of the striking things for me in the pandemic. And the way we dealt with that was really by going on Chinese and Asian American media and just blitzing the population with science so that they can really respond when people said certain things and to have folks be an upstander. So that's one lesson. The second lesson, which is really, again, highlighted by COVID-19, was the fact that racism is a public health threat. And when we had the George Floyd protests, one of the points that I was asked to comment on over and over again was whether or not it was safe to go out and protest. So when you think of the framework that racism and anti-black sentiments are public health issues because they result in deaths, illness, and morbidity, and then the response to that public health threat is to protest and to protest safely, then you understand why it's important to have your voices heard. So I think that was another lesson that got re-emphasized to me during COVID. So again, the lessons from COVID were not just the biology and the medicine and the healthcare -- Skipper: Yeah. Peter: The biggest lessons to me was the societal lessons. And then in the face of a lot of kindness, there was also darkness as well. Skipper: Yeah. Dr. Chin-Hong, where can people find out more about you if they want to follow your work or the things that you do? Peter: Well, I think the the best way to follow me is on Twitter. I'm at @PCH_SF. PCH like Pacific Coast Highway. Skipper: Sure. Peter: And, you know, send me a message and, depending on the surge, I may not have as much time to tweet but early in the pandemic, that’s another thing that was really striking too, is that, you know, we didn't have a lot of guidance, because the CDC was very sidelined. Skipper: Sure. Peter: So we had to like learn from ourselves. So a lot of healthcare professionals took to Twitter to share practice good practices and science and we we learned from ourselves and so Twitter was really important for all of us during the pandemic. Skipper: I agree. There’s a lot of, even in my own household, there was, I don't remember his name, but I'll drop it into the show notes, there was a registered nurse (read: not at all correct, it’s Dr. Jeffrey VanWingen from west Michigan) who talked about the notion of sanitizing groceries and the idea of making sure surfaces are clean, and talking about these practices through the lens of being a healthcare worker. And I found that remarkably helpful in terms of the framework that I set up in my own house, in terms of when groceries came in, when we did take-out, to make sure that the objects that came into our house were as clean (and healthy) as they could be. Peter: Yeah, that's great. And Twitter also gave me community as well, because, again, in the isolation and loneliness of COVID-19, where we had to socially distance or physically distance ourselves from each other, that was the way in which we reached out — apart from Zoom of course. Skipper: That’s great. It’s nice to hear a story about social media where it's not a distraction, but it's actually a help. So thank you for that. And Peter, PCH, thank you for making time and space to talk to me today. Peter: I love what you're doing getting the word out there to lots of folks, not only in COVID, but in all the other topics that you're exploring and I find it very admirable. Skipper: Thank you, Peter. Thank you for your work and your service generally. And thank you for listening to How This Works. Please subscribe and leave us a review in your favorite podcast app. Also, if you could, tell just one other person about the show and why they should listen to it. You can find How This Works online at howthisworks.show, that's three words, no dashes. Again, that’s howthisworks.show. We’re also active in the social media places. I hope that you got as much out of my chat with Dr. Chin-Hong as we have in making it. And we’ll talk again soon. [Outro music] Skipper: You know, so much of our day is always — I feel like these days so much of our days are — consumed with solving technology problems. That sometimes I wonder what we did before all of these different products in our life -- Ooh. That's actually, that clicked right in. That sounds much better. Peter: Oh, that's awesome. Skipper: Okay. And I see your voice printing. All right, super.