“Hammer and Dance”: Prof. Kent Kirshenbaum on the Pandemic (Part 2)

Hammer and Dance pt 2 (v3)

Dr. Kent Kirshenbaum is a Professor of Chemistry at New York University and a co-founder of NYU’s Biomedical Chemistry Institute. His research focuses on molecular pharmacology and bio-organic chemistry, including new technology for detecting specific virus particles. His studies are supported by the National Science Foundation.

In the first part of our interview, Prof. Kirshenbaum discussed the abdication of leadership at the national level regarding the pandemic, why states can’t take up the slack, cooking the numbers, the path to a vaccine, and how the US is screwing itself, among other topics.

For the second part of our conversation, we spoke after he arrived in his hometown of San Francisco following a solo cross-country drive from New York.

WHO’S GOT THE PAIN WHEN THEY DO THE MAMBO?

KENT KIRSHENBAUM: I’ve got some super good news for you, Bob. I’ll get to that in a second. First, there are a couple of things that I just wanted to fill in from your previous questions.

You asked me at the very outset how I would characterize the federal response. So that’s been going through my head, and now that I’ve had the chance to mull it over, the words that came to me were: incoherent, inconsistent, inexplicable, and infuriating.

THE KING’S NECKTIE: But other than that, Mrs. Lincoln….

KK: I also described this hammer and dance thing, which I think is a really powerful visual and it’s gone viral, so to speak. As I told you before, those are the two steps that are really essential to a public health response to pandemic or an infectious disease: the hammer—the initial suppression—and then the dance of trying to keep this R-number, infectivity, below one.

In this country, both aspects have been partial failures. Successful in some places, unsuccessful in others, but as a result, we don’t have control. We didn’t lay down the hammer evenly across the country, and then we just started to dance way too soon and way too vigorously. We should have been doing a waltz instead of the mambo.

TKN: Along those lines, let me ask you a selfish question, New Yorker to New Yorker. New York, I gather, did a pretty good job of containing the virus, of flattening the curve, and the caseload is declining. But what are the chances it’s going to blow back on us from other parts of the country regardless?

KK: Almost certainly it will. There will be re-establishment of infection and it will be a severe problem if our Rt number— the fundamental reproductive number—is above one. If New York can keep that value under that, then we may be able to maintain a reasonable situation even with incoming people from other parts of the country. By the way, New York state’s Rt value has been slightly above 1 since June 9, so I think it’s too soon to celebrate here. New Jersey and Connecticut have been nice examples.

It would be most effective if we could really clamp down on it. Vietnam, for example, has had zero deaths. They have people coming into the country who are infectious, but they identify them immediately, they isolate them, they let it run its course, and two weeks later they’re able to re-join society. We won’t be able to do that, but we need to keep this R-value below one.

And we can. I referred to it before, NPIs: nonpharmaceutical interventions. They work. Tremendously effective. And you can see that in the numbers in New York City, and in every other country around the world that’s kept a lid on this thing. I look at these numbers every day and I think it’s nothing short of miraculous what is going on in New York right now. I don’t actually understand why it’s so effective, but it’s super good news because it tells you everything you need to know. There is no vaccine that’s been widely distributed, there is no really effective therapeutic drug that’s yet widely available, and yet it is possible to contain this thing. It can be done and it’s being done in New York.

It requires leadership, and that’s something we talked about in our previous conversation. You cannot really do this effectively in the absence of strong leadership. It is absolutely essential. And that’s something that all of these governments have in common that have done a good job at the national level: they have effective leadership based on science, and a population that trusts the guidance, which is consistent, and is provided by the government.

TKN: Well, first of all, I think we should consider invading Vietnam again, because I think this time we’d know how to do it right. Meanwhile, it’s very clear that our federal government is absolutely incapable of providing the kind of leadership you describe. Or unwilling, which is even worse.

LIVE WITH IT

TKN: But to the notion of NPIs: a few weeks ago, there was a piece somewhere—in the Washington Post or something—about how a vaccine is not necessarily a magic bullet and we’re going to have to learn to live with this virus and future viruses. Not in a Trumpian way of, “Oh, 140,000 deaths is fine,” but in the sense of managing it and containing it without a vaccine.

And it was a super depressing article in some ways, but I have to tell you, after I read it, I felt so much better. Because up to that point, all my hopes were pinned on this magical vaccine, and after that, I began to think, “Oh, we have to learn to cope, and it’s possible to do that.”

KK: Absolutely. I’m glad that people are out there saying we need to be prepared to cope with this in the absence of a vaccine.

There’s modest expectation that a vaccine will prove to be widely available and effective. I mentioned last time that we probably will be able to begin creating doses maybe early next year. But at this point, I think it’s unlikely that the vaccine will make much of an impact until next fall, which means we have to get through this next fall/winter season relying mostly on NPIs.

TKN: That’s what worries me. 

KK: You should be worried. Everybody should be worried top to bottom. It’s just so depressing that we screwed up the hammer, and we screwed up the dance, and we’re going to screw this up too.

I was horrified by listening to Fauci’s testimony before the Senate, and Rand Paul was trying to shame him, saying, “Why can’t you provide the country with some good news? Why are you such a Debbie Downer?”

My question is: Where’s the good news, Rand? Hundreds of thousands of people are going to die because of irresponsible behavior like his, where he suspected he might be infected and went swimming in the Senate pool anyway. Hundreds of thousands! When I said that to my friend Harold around mid-March, when there were just a few thousand deaths, that number at that point seemed preposterous. Like, how could you possibly think things could get that bad? Now, it’s like, oh okay, if things continue at this pace, and maybe get a little worse with the kind of exponential growth that we’re seeing across the South, then we’re there.

TKN: Listen, I have just a basic grade school level of math skills and I can look at the daily ticker counting. I can see that we’re headed for 200,000 some time in the fall, if not sooner. And that’s just the beginning.

KK: Then you begin hearing people saying, “Well, we’re going to develop immunity and we need to learn to live with this virus.” I hear that a lot and it drives me crazy. It just drives me crazy. This is not a virus that we learn to live with! This is a virus that we learn to die with! Herpes simplex virus: that’s something that you learn to live with. Athlete’s foot: that’s a communicable disease you learn to live with.

TKN: But to be devil’s advocate for a minute, I think they’re using the term not to mean that an individual can live with this illness, but that as a society we can’t eradicate it, and therefore we have to “learn to live with it.”

KK: The reason I object to it so much, Bob, is because I think a lot of people do not use it in that sense. Yes, we do need to adapt, we need to mitigate, we need to contain, we need to control. But I really think a lot of people are using that phrase to mean that the virus is going to do what it’s going to do and we ought to just go about our lives. And that shrugs off the moral responsibility we have to look after the health and welfare of our citizens.

BUCKET BRIGADE

TKN: Well, that gets back to your point about leadership. The reason they feel that way is because it’s been fed to them by the same people who have abdicated leadership. Because our leaders first pretended the virus wasn’t there, tried to wish it away, et cetera, then realized they had failed and could not control it, and then switched to a strategy of saying, “So what? Big deal.” It’s a deliberate spreading of lack of empathy and it’s rife in MAGA Nation.

KK: Yes, it’s an infectious meme, that lack of empathy, coming from the very top.

Along with that is a denigration of expertise, which is another aspect of failure of leadership. When somebody stands up and says, “I’ve devoted my life to this, I’ve fought this kind of thing before, and here’s what we need to do.” Somebody like Fauci, for example. And then the lieutenant governor of Texas says, “I’ve stopped listening to Fauci, I don’t need his advice anymore, because it doesn’t correspond to the kind of life I want to have.” That’s the kind of expression of “We just need to learn to live with this” that I find so objectionable.

If the lieutenant governor of Texas was saying we’re not going to do anything about an outbreak of athlete’s foot that’s running rampant over university gymnasiums across Texas, I’d say fine. Let’s live with it. But with COVID-19? No. Hundreds of thousands of people are dying. How could you have an extended conversation about this and not remind yourself of the toll—the unnecessary toll—this virus has taken on the American population?

TKN: Well, I couldn’t agree more, of course. And you don’t hear a word of sympathy from the top, or condolences, or even just the most basic perfunctory expressions of sympathy, empathy, even if it’s fake. Nothing!

KK: Right. So we need that sympathy, empathy, we need a feeling of trust between the population and our leadership, and we need a coherent strategy from the very top. Trump called himself a wartime president, and you need to provide coherent guidance to all of the armed forces when you’re fighting a war. You don’t tell the Navy, “Do your own thing,” the Air Force, “Do your own thing.” You know, “Everybody go your own way.”

The analogy can be made to an apartment building being on fire, and instead of the mayor allowing the fire department to come and put out the fire, they show up with a whole bunch of buckets of water, some fire extinguishers, and they put them on sale in the lobby and they tell the residents of the apartments, “These are going out to the highest bidder. Imported from China, Ivanka designed them, they’re gold plated, come down and get them if you want, or maybe not. We’re going to allow you to use your sense of personal responsibility to decide what you want to go about doing in each of your apartments, and good luck to all of you.”

TKN: Well, all those things speak to broader ills in our country and in the body politic. This idiotic idea that all government is bad, this frontier rugged individualist myth, all that bullshit—it’s all been exposed for the con that it is, and we’re paying the price.

KK: I love rugged individualism. I’m so proud to be an American. But you can be as rugged as you want with this virus—it does not care. And unfortunately, competent leadership, on its own, is not always effective either. We’ve got a reasonably good governor here in California and it’s getting away from us. This notion of I’m going to tough it out, masks are for sissies—it’s not going to work. This virus doesn’t have a brain, it doesn’t have any kind of nervous system, it’s not a lifeform. It cannot be intimidated! Rugged individualism is not a solution.

And unfortunately, some of these things cannot be delegated to the free market either. It just doesn’t work. It would great if it did, and we can talk about the boundary where private entities are going to be more effective than a governmental capability, but public health is something our government needs to do and it needs to do well.

TKN: Remember that Rose Garden ceremony early on, when they trotted out all the CEOs of Target and Walmart and they were all going to do all this shit? That was the the blind faith in the free market. And none of it came to pass.

KK: How did those people not get called on it? They showed this big placard of how Google was gonna help set up contact tracing and how there was going to be drive-thru testing in Walmart parking lots or something like that. None of that happened. And it goes back to what we were saying before: this is what you do on a reality TV show. You get Central Casting to come out with a bunch of rich white men, which was the cast of characters in that episode, and do a bunch of happy talk. And they didn’t come through, except…..

You know what? I take it back, because I’m betting that they all came through—for their shareholders.

UNDER NEW MANAGEMENT

TKN: So that’s one of the big questions I wanted to ask you, which is: what the hell is wrong with us? Why, unique among industrialized countries, have we been unable to do the most basic intervention to get this under control?

KK: Because part of our spirit is, “I have my vision and I am going to enact it.” And that is what has been our source of strength. The Wright brothers. You can’t fly? Screw that. We’re going to fly. We’re going to figure it out, just going to do it. Just creativity, this radical sense of living your dream despite what others might tell you, despite conventional wisdom—that’s our strength. And that’s our weakness, because we like to go our own way.

TKN: You talked a little bit about distribution problems before. Let’s say we have a vaccine and it’s fully tested and successful and so forth. What sort of distribution problems do you foresee?

KK: (long pause)

Oh my gosh.

(Another long pause.)

It’s that’s same rugged individualist, mistrust of government thing again, and that’s going to be a problem with distribution of a vaccine as well.

A lot of people have this notion, like, “Do not vaccinate me. I have my vision about how to maintain my health, and you’re not going to jab me with that stuff ‘cause I don’t trust what it’s going to do to me.” There are huge segments of the population just over the bridge from me in Marin and Sonoma Counties that are hotbeds of anti-vaccination. So that’s going to be a huge impediment to the distribution of vaccine. Just this morning I was talking with some people about early stage drug development for anti-virals to treat COVID-19 and one of them said, “Well, Moderna and Pfizer are coming out with vaccines. Are you going to be fast enough with your treatments? Will they be unnecessary?” And I was like, “They can come out with a wonderful vaccine, but we’re still gonna need pharmaceuticals to treat infected people, because there’s going to be a lot of people who won’t get vaccinated.”

TKN: You’re anticipating all my questions. What is the broader public health impact of a significant number of people being anti-vax?

KK: It’s pretty easy to see because analogies can be made to measles, where people die who shouldn’t because they’re part of communities where there’s a significant number of people who don’t get vaccines. So I do anticipate it.

This is a weakness in our national character that can be exploited, and I believe it has been exploited by foreign actors who are encouraging the anti-vax movement and sowing doubt. And it’s not just about vaccination or public health. Creating doubt in general, even about issues that are demonstrably true or false, is a strategy used by authoritarian regimes. “Nobody really knows. You’re telling me something, but I’m going to believe something else.”

TKN: Well, that is part of Trumpian disinformation, which comes from Russian disinformation. Garry Kasparov talks about it. “The point of modern propaganda isn’t only to misinform or push an agenda. It is to exhaust your critical thinking, to annihilate truth.”

KK: Unfortunately, that’s really at the heart of this failure of leadership, because our leader does not have the interests of his fellow citizens foremost in mind.

TKN: (laughs) That might be the simplest and easiest concept to grasp: when you’re led by somebody who doesn’t care about you, it shouldn’t be a surprise that they’re not taking care of you.

ADVENTURES IN BABYSITTING

KK: That’s why in our original conversation I made the analogy to the failure to protect our military in Afghanistan. This is a basic thing that we ask our leaders to do: protect us. That is a central function of government, or at least should be.

TKN: I don’t think there’s any hope that we’ll get that kind of leadership from the current administration. But let’s suppose that we have an “under new management” situation sometime soon. What do you think life in America will look like in the next year or two, under a competent administration, while we try to get this under control?

KK: So 2020 is halfway done, right? Horrible year. We’ve just made it through the easy part. But I think by this time, a year from now, I think we’ll be able to start relaxing a bit.

I’m envious of my colleagues in Europe. I saw this amazing photograph today: in Prague they set up a huge table, a thousand people came for a joint meal, everybody shared food, wine, beer as the sun was going down over one of these famous bridges in the center of the city. I thought, why can’t we be doing that? We’re not going to be doing that for another year.

TKN: I can appreciate the difficult situation of a public health expert or a scientist who’s working with the US government. On the one hand, it’s obvious: we need their expertise. On the other hand, they’re working with an organization that’s not just completely dysfunctional or incompetent but actively malevolent…which is one of the reasons their skillset is needed so desperately. So what is your advice to the Faucis of the world? How does a public health official navigate that dilemma?

KK: I have no idea. I think it’s extremely difficult. I think they’re heroes, and I think it’s disappointing that so many public health officials across the country have been attacked, and even forced to leave their jobs. I don’t know how Fauci can do it. I really don’t. I think it’s an extraordinary thing that he’s being asked to do right now.

TKN: I know it’s an unfair question. It’s the same dilemma that Mattis and McMaster and the rest faced on the foreign policy front—and other experts in every field have face—as they try to babysit our mad king.

KK: Fauci is walking…..I was about to say, he’s walking a tightrope, but he’s walking like a four-dimensional set of tightropes going in all kinds of different directions. Because he’s got to tell the truth, but he’s got to work within an administration that consistently lies and fabricates. He’s got to warn the public, but he cannot create panic. He’s got to accelerate discovery of vaccines and drugs, but he can’t push it too fast because he’s got to make sure that people don’t get harmed. He is walking all these tightropes simultaneously. It’s pretty amazing.

TKN: As a layman, if I were to see Anthony Fauci fired, or resign in protest, that would be like a five-alarm fire bell going off. I think that’s true for many people.

KK: Well, we’ve had lots of alarms. Sometimes you just stop hearing them. You’re numb.

TKN: But that one would really freak me out. And I would hope it would cause a massive public outcry that might actually force a reckoning.

THE OL’ GOOD NEWS BAD NEWS ROUTINE

KK: Can I tell you some good news?

TKN: Yeah, give me the good news.

KK: You know it comes with a hook, right?

So I told you that there’s been such incredibly rapid development of vaccine candidates that we can really be quite confident that something will happen in the near future. Probably won’t be able to depend upon it for the upcoming season, but it’s going to start happening.

In fact, I cannot believe how quickly this is going. Since the last time we talked, I found out that large number of doses of vaccine have been created and people are receiving those vaccines. Isn’t that fantastic? Who could have imagined! The fastest we’ve been able to introduce new vaccines previously has been years. We just found out the sequence of this thing within the past few months and now a huge population is already getting vaccinated? That’s UNBELIEVABLY rapid progress.

TKN: Sounds too good to be true. So what’s the hook?

KK: Well, guess what population is getting vaccinated?

The Chinese military.

The vaccine candidate is from CanSino Biologics, a Chinese-Canadian collaboration. And they’re skipping Phase Three evaluation and just going right ahead and vaccinating their soldiers.

TKN: And what is Phase Three? Human testing?

KK: All three phases are human testing. First is for safety, with a very small number of individuals. Phase Two is initial efficacy and safety testing, where you get just an indication and look to see whether or not it’s safe in a slightly larger population. And then Phase Three is where you determine whether or not it really works.

Apparently they did a Phase Two and they saw some antibody response, which was looking favorable, and they’re just inoculating their military. From what I read, they’re refusing to disclose whether immunizations are voluntary or mandatory.

TKN: (laughs) I know the answer to that.

KK: You’ve been in the military—

TKN: Yeah, the American military. I can imagine what the Chinese military is like!

KK: There’s another kind of interesting wrinkle—it’s kind of like a minor detail, so I don’t know, maybe it’s not so interesting, but I also read that Beijing may ask Chinese businessmen who work for companies with significant overseas activities to also get vaccinated, and that will allow them to find out whether or not it’s effective. So they’re going to send Chinese business people abroad to the hot zone. “We’ve immunized you. Please let us know whether or not you get sick.”

TKN: I’m loath to side with the anti-vaxxers, but that all makes me nervous. If there was a Chinese vaccine to come out that had skipped Phase Three and was rushed to the market, I would be nervous.

KK: You should be. Trust in our public health system, trust in our scientific establishment, is crucial. Once it is lost, it is really hard to rebuild. You can ask the Black community in this country about how they feel about the Tuskegee experiments, and even though that was a long, long time ago, it still resonates. It’s an issue we need to deal with, and we need to be honest about it. We have to really walk a tightrope between speeding this thing along as quickly as we can—and as I said, it’s been totally impressive—and at the same time making sure we don’t screw it up and hurt people, which is something we cannot do. Which means we really need to pay attention to what people like Fauci and the guidance that they’re going to be providing.

TKN: That issue of loss of credibility takes us back to the early days of this and the confusion about masks. In the beginning, you’ll recall, we were told, ‘Ah, masks probably actually don’t do any good, or might even make it worse.” And then all of a sudden the authorities did a 180 and said, “No, you should absolutely wear a mask.” And now we have a problem getting people to wear masks—no surprise. Partially that problem is the bullshit we talked about before—the “precious bodily fluids” paranoid style that’s always been with us in America—but part of it also is that there was a mixed message put out at the get-go.

KK: Yeah, well, I didn’t believe it. I went out to a hardware store and got construction N95 masks.

TKN: And that is why you’re a PhD and I am a guy who stands on the street corner wearing a sandwich board.

KK: No, it’s because I’m an American, goddammit. And if somebody tells me “You don’t need a mask,” you know what I’m going to say? I’m going to say, “Fuck you. I’m going to get a mask!” (laughter)

THE FUTURE IS MURDER

TKN: What are the chances that we’re going to continue to see viruses and pandemics like this, and worse, going forward?

KK: It’s certain. As bad as this is, this virus could have been worse. I mean, it’s so much worse than the flu, but a fatality rate of 1%? There are worse infectious diseases out there. MERS, for example; we kind of dodged a bullet with that one, if I recall correctly, because early intervention stopping its spread was crucial. So I really do believe it could have been worse.

When I was in my twenties I read The Coming Plague by Laurie Garrett, and that had a big effect on my appreciation for public health. But maybe that was not the right title. It should have been called The Coming Plagues because it’s not going to be just one. This is going to happen again. And boy, it would be nice if we were learning our lesson.

TKN:. I’ve heard many people say the same thing: imagine something with a 5% mortality rate, or something that is hitting children, as opposed to seniors—a lot of nightmare scenarios that could be worse. How do we prepare for that eventuality?

KK: Just fund public health. Bill Gates talked about it a few years back, about how this needs to be a topmost priority, both at the national and international levels. There are many imponderables about how to do it best, but there’s a simple answer: Fund public health. And that requires faith in government.

I want to leave you with one last thought. As an American, I’m okay with occasionally being regarded with disdain by some of my foreign colleagues. Sometimes it’s mutual. But I prefer it when that disdain derives because our country is too powerful, and not because I’m being pitied. I’m not going to get used to that anytime soon.

TKN: There’s nothing to say after that.

*********

Dr. Kent Kirshenbaum is a Professor of Chemistry at New York University and a co-founder of NYU’s Biomedical Chemistry Institute, where he conducts research in Molecular Pharmacology and Bio-Organic Chemistry. Current projects include developing synthetic mimics of proteins in order to discover a new family of drug molecules, and establishing a new technology for detecting specific virus particles. His studies are supported by the National Science Foundation. A recipient of a NSF CAREER Award, Kirshenbaum received his PhD in Pharmaceutical Chemistry from the University of California at San Francisco and conducted his post-doctoral training in protein chemistry at Caltech. He is an inveterate bicycle enthusiast, and enjoys studying the interface between chemistry and cuisine. He serves on the Scientific Advisory Board for the Good Food Institute.

 

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