 All right, well both to those live participants tuning in right now whether here or on YouTube and to posterity to whom we address ourselves presuming there is a posterity. We thought we would gather and talk about the state of the coven 19 pandemic and more specifically in what remains of this hour. And the state of testing in the United States, where it's at where it might be going and how to make it better. My name is Jonathan Citrin. I'm a co founder of the Berkman Klein Center for Internet and Society at Harvard University. And I'm so pleased to be joined by Margaret Bordeaux Beth Cameron and KJ Song. We should introduce each of them and then dive right in so Dr Bordeaux please tell us how you found yourself. Thinking so hard and working so hard on the state of the pandemic. Great to be here. Right, so long story short, but I'm a physician by training I work at Brigham and women's hospital. And I am the research director for the program and global public policy at Harvard Medical School. And in my role there, I started working with all sorts of amazing people outside of health on policy issues around health security. And, lo and behold, I started that job about a year ago and lo and behold, the greatest health security emergency of our lifetimes and of many generations is upon us. So, I, I'm thrilled to be here and talking a bit about it. And I also work with the other colleagues that we have with us today. All right, well that's a good way to pass it over to Beth Cameron. Beth tell us how you came to be working on the pandemic, especially because your top line affiliation at the moment is with the nuclear threat initiative. And I realized that at some point everything is made of atoms but how did you specifically get into COVID. Thanks Jonathan and thanks for this opportunity so I am the Vice President for global biological policy and programs at the nuclear threat initiative, but the nuclear threat initiative was stood up in 2001. As an organization that focuses on nuclear and biological catastrophic risks. So, you know, pre pandemic, my organization and my team, we're working on preventing a future catastrophic biological risk including a pandemic like this one but also potentially a worse pandemic that could emerge naturally or as the result of an accidental pandemic like this is not a lab release or deliberate biological event. The future is becoming now and so my work has blended into working in a, in a variety of ways looking at what we need to be prepared for the next pandemic but also inevitably to be more prepared for the one that we're facing right now. I was working at NTI I was the senior director for global health security and bio defense on the National Security Council staff, and I helped stand up the office. That office and transition it into the Trump administration from the Obama administration in 2017 and so at the moment I'm looking at, you know what what our country has done with this pandemic and I'm frustrated that would be the word I would use to describe where we sit right now. And is that, is that the very office that Ambassador Bolton dismantled. It is. I ran that office and then I handed it over to rear admiral Tim Zimmer a very very capable expert in disaster management and public health. And then it was decommissioned disbanded closed whatever word you want to use a year later in May of 2018. Got it. That seems singularly poor timing in retrospect. And KJ song, the chief of strategy and policy at partners in health. Somebody I know has been working on multi drug resistant TB across the world. How did you find your way to coven. I am a doctor and started working at partners in health which is a nonprofit global health organization based in Boston. That was 20 years ago and have been working mostly on the implementation side of things. So, with a lot of infectious diseases like TB HIV. You know, I tend to be more, I still have that that viewpoint. So more somebody who actually is working within the program and maybe not so much seeing what the policy debates are about. Right now also within is a PI has has a project here in Massachusetts. It's focused mostly on contact tracing. So again, you know, I have that viewpoint. And involved in protocols workflows training of contact tracers and and seeing a lot of, you know, how the epidemic is unfolding here in our state. Got it. Okay, well to get us started, I would just love to canvas each of you and Beth sort of got to start it with a word frustrated I'd love if there's just three words you could use any combination and compound words count as a single word. That would describe your sense of the state either of testing specifically or our response to the pandemic as a country United States generally. What words would you choose. Dr son want to leave us off. About confusion confusion confusion. Three confusions I can guess what the fourth word would be. Dr Cameron. Well I said frustrated that describes me but I guess I'd say for the response frustrating fragmented. And maybe as someone who works on national issues and unified plans disenfranchised and it's not a surprise that all three of those things have an F in them. That's your grade so far as I'm inferring. Dr Bordeaux I don't know if you're going to continue with the alliteration but your three words. Okay, well I'll have a phrase and a word with respect to testing. We sometimes a medicine use a phrase about like how people say oh this is an acute on chronic problem that a patient is having this is a cute on acute problem. The testing crisis is hyper acute and the crisis overall is acute. Just medically speaking when you say acute, you mean have to deal with it now or quickly on set quick. Well, on set quickly and urgent urgent deterioration is usually what we rapid deterioration is what we mean in medicine. I'm sure I would describe for this kind of time in general is reckoning. You know what what we're seeing is really a reckoning on a number of fronts with issues that we haven't dealt with. In the past for a long time, including our public health system being really very feeble, poorly funded strafed of resources, and trying to cobble together some type of, you know, response with very underfunded resources and institutions, a reckoning because of the, this has really, you know, been a profound moment where we're realizing how unequal access to health and resources are in our country and start is being thrown into stark relief. Around our current governance and the fact that it is not going well and it is not capable of mounting a appropriate response to this threat. So, it would be great to describe as crisply as possible what you think an appropriate response would look like on earth prime where somehow the US is doing something differently. What is happening that isn't happening right now or what's not happening that shouldn't be happening. And what difference is it making. I mean that's a way of getting at how much is our current situation just sometimes, you know the cards fall a bad way and things are tough versus with the right planning this could be very different. And I don't know if he wants to start Margaret. Well actually I was going to have Beth start yeah because I think that Beth has spent a long time thinking about what this country's capabilities are should be with respect to a health crisis response. And then, you know, I think KJ also has got interesting perspectives around things we're seeing around the world going right that are not happening here. Got it. Alright well with that agenda, Beth. Well, I definitely don't want to take away from KJ's response but I was going to start by saying, on earth prime, we would be fully capable of doing what South Korea with Germany with New Zealand what other countries have done and it might not look exactly the same way we're a different country where we're a larger and more dispersed country but when you look at the EU the European Union taken in total, and you look at its current caseload and how it's dealing with the coronavirus crisis, the EU is drafting a recovery plan they've actually put it put out a recovery plan. I think that's a really important word because they're recovering they're viewing recovery from this crisis and we're still very much responding in the middle of it we're not even able to focus on recovery so on earth prime, we were are fully capable of doing what they have done and on earth prime I think you know way back in January, we would have been able to know that, you know, as soon as we knew there was an emerging pathogen with pandemic potential that it was already here, because we are so intensely connected to China to Europe to all the transit points that we should have known immediately that there were cases here, and we sort of we should have searched our public health response our community health workers are contact tracers, and ultimately our testing appropriately then, and prepared for a 12 to 24 month period of time where we need testing in a way that we still don't have it in this country so those are just the opening things I would say. So Beth was there always going to be a lockdown. Was there going to have to be given just the size of the country the porousness of the borders and the drama of a decision to shut everything down before you've got community spread how momentous a decision that would be where we pretty much headed for a lockdown period and it's just a question of getting out of it that we've messed up. I don't know the answer to that question I'm interested in hearing from Margaret and KG what they think and I've asked a few people this question and I haven't gotten one. I have I've heard a lot of different answers there. There are people who do believe it was inevitable to do a lockdown of at least a short period of time with the country is dispersed as ours to sort of level set get testing and tracing you know into place and then reopen slowly with those capabilities in place the way that many countries in Europe. But I'm not actually sure whether it was inevitable. I mean we fumbled this so badly in January, February and March that it's really hard to know whether we would have had to do a lockdown or a lockdown as dramatically as we ultimately had to do in March. So I'm interested in in Margaret and KJ's perspective on that from the clinical point of view and epidemiological point of view. So we should throw it over to KJ and get your impression on that question and also here. Is there something specific about testing as foundational to all of this that makes it at the moment, the room of the house that is burning most brightly and most requiring attention. I would just say that I don't know whether this is kind of an interesting first question, you know, it's kind of like a retrospective. I think this is maybe a difference between maybe, you know, a more policy aspect and then implement this aspect I mean, we had the lockdown so it doesn't really matter whether he was necessary. Your answer to that question is could a would a should I got a patient in an acute state right now, and I need to do something so it's fine to gently redirect us to that. I'll just say that I would just say that that there's a lot of, like I see a lot of in policy circles, I do see a lot of South Korea and deep. You know, like, wow, we could have been like, yes, we could have been like South Korea, but we're not. And the other thing though is that, you know, it's not really fair. I mean, they have they had experience right so I think a lot of the Asian countries around China, they had gone through SARS. South Korea had had completely bumbled mirrors and has rolled. They were chopped off. And this was years ago. So in some sense they had been, they've been preparing for COVID for over 10 years. And you cannot. You just can't. There's no way there's there's no without having that experience as a country. I just don't think that it's possible to plan this out and clearly, you know, in, in January and February, even in March here, we just thought that this was no big deal. That what South Korea do it was doing was what wasn't that complicated. So it's interesting to see if KJ and Beth are already disagreeing. It might just be a disagreement about historical empathy, and whether to disagree. We don't I don't disagree with you about the premise that we could have done what South Korea did. I absolutely believe that. But I, you know, we went through Ebola. It was not MERS. We had less cases. But we behaved in such a way and we were the American people were really worried about Ebola and we surged hospital capacity across the country. But even more to the point MERS was absolutely a crisis in South Korea, but we have so many deployed Americans and US forces Korea sitting with, you know, with soul working with soul on the Korean Peninsula, that that wasn't just a, you know, that wasn't only a South Korean crisis. That was a crisis for the United States and the United States government and potentially force readiness. So we should have learned a lesson from that too. And I think we did learn a few lessons from that that we just didn't act on. And so I'm really eager to get into the specifics, whether it's retrospectively in terms of preparation or prospectively with the acute patient in front of us right now. What are the specific things that would point the arrow in the right direction if I'm right am I right in assuming maybe I should take this baseline first from everybody is the arrow in a very bad direction right now or I mean if you're looking just for the record end of July 2020 about to hit August, otherwise known as March 115. And is your sense that things are sort of leveling off even in the hard hit states and if we just hold on everybody will be returning to New England New York status, or do we need some massive change to the way this country is doing things in order for this to attenuate. I don't know who wants to take that. Well, I'll just say a couple of things as somebody who had South Korea and envy, you know, and still do. You know, I think that the thing that I find remarkable and this is you know true anywhere I've worked in the world, you know, you're in a space where, where a public health system or health system just has a ton more assets, you know they're just more organized and yes they're. Maybe they try to deploy one asset it doesn't work you know okay fine you know they put it back on the shelf they get another strategy in place. And that's the thing that's been hard to communicate with people here is how few assets we have to work with. And I think I've you know I've learned a lot from working with kj and partners and health as they've tried to just roll out testing and you know to various communities in Massachusetts. And it's like okay so you know we have to design a testing system that you know people can access but they have to access it through their employer based health insurance to get them to pay for it and they have to schedule you know they have to medical home they have to go to their doctor and they have to go to the hospital. It's just like this tremendous amount of sort of administrative like maneuvering to try to do the simplest thing that other can just call on their community health workforce their public health workforce up deployed we don't have to think about where we're going to get them from there. You have another partnership with this other lab we can just get on that you know they just have a lot more assets that can deploy and we don't have that and we need to get smart really fast about building that. You're conveying so much frustration understandably that it's saturating your bandwidth it's actually sort of fading out a little bit, but I just I wanted to quickly ask to follow up. Is our trajectory one that is about to moderate whether regionally or nationally if we just sort of stay the course, it might be regrettable when you compare our curve to all those other curves of the other countries but basically this thing is going to attenuate of its own accord, or are we in need of some signal change in the way that we are handling this crisis do you have a sense of the answer to that question. This thing does not attenuate of its own accord. In fact, this is one of the most ridiculous errors that were made by the public health people at the beginning of this epidemic is that they saw the occurs attenuating in Wuhan or in South Korea, they say wow there's a natural peak in decline. There's nothing natural about that. That's that's a coordinated intense public health response that is suppressing the transmission of the virus. And you think there's a story in Texas there's a story in Arizona right now which are hot spots at the moment but appear to be leveling off that involves a local public health response there that's helping. So I think it's a confused public health response remember I said confusion confusion confusion. There is panic. There are people who are individually socially distancing and wearing masks and shutting down their their businesses. And this is all this is all part of the public health response. I don't think that you'll have a sharp decline, like you have had it that that is possible when you have a very coordinated public health response I think will be more like the Northeast, which was also very confused. And there are many many other states that are that is version in territory, where the virus is going to explode. So in fact, it's going to get worse. Yeah, I agree with our president is going to get worse before it gets better. And Jonathan you asked about an arrow and trajectory and I would just ask what what arrow like who's shooting the arrow what's the target. We don't have a national set of targets that have been communicated across states. We don't have a national plan or arrow going anywhere we have is a whole bunch of different targets and arrows and people are sort of shooting them around the country. And, and we're forgetting that we're a country where people are traveling in the middle of this and where, you know, not everybody is going to comply so we need to have you know a percentage of the population getting the message in a coordinated fashion so I would say it's chaotic and viruses thrive in chaotic environments and so we're feeding the virus right now with our chaotic response we're making it worse. There's a phrase a joke in medical school where you're learning how to do surgery and you're learning how to control bleeding. And they'll all the surgeons will tell you when you're learning how to control bleeding they'll say oh don't worry you know all bleeding stops eventually. So, right. That's the counterpart to the economists in the long run role that right. So yes, this this shoe shall pass it just sort of matters in terms of what we lose in the passing, whether it's lives with livelihoods. I mean really, the stakes are just tremendous here. I'm, you know, it's their economy the geopolitical stakes in my opinion are very very high. You know, I, there's, there's a lot to lose. And so we do need a major, major redirect, and it needs to happen. So, as absolutely seen as we as we can pull it off. And we, I think we see a lot of sort of yes KJ's mentioning oh well let's just muddle through there's a vaccine on the horizon you know something is coming to save us nothing is coming to save us. We already do have the tools to control this, we just need to implement. And I can kind of walk through, you know, what those tools are. Yeah, hit us up the most foundational tool. Yeah, I mean, you know, I would say there's sort of three, I describe it like a three leg of stool. So you have your population based interventions where you ask people to do things like wear masks and wash their hands and stay socially distant and not go to parties where they're, you know, close together so those are kind of what you ask the population to do. And you have the other leg of the stool is your environmental modifications so these are creating environments that where the virus is less likely to transmit so it's implementing ventilation standards and a lot of our buildings it's setting up our workplaces so that people are just automatically distance from each other. And the third leg of the stool is contact tracing and that's finding out who's been exposed to somebody who's been infected and helping them monitoring them to see if they do in fact become sick and keeping them separate from other people and supporting them in that process of remaining separate from others. And those are the three things. If we do those things, we will get control of this. We, and we can do it basically without locking down or any, you know, very draconian, you know, giving up a tremendous amount economically and socially. So if we do those things we can make it and we can certainly make it until we have better therapeutics and potentially a vaccine. And is that assuming a certain low prevalence in the environment where you want to deploy the three legs if it's running wild somewhere. Do you just need like a lockdown to cool it off before you start telling people they should eat outside instead of inside. I think that I think that if you don't have those three things in place, then you lose control of that you have to act with more and more severity and more, you know, and more, more quickly. So yes, I think there is a sense that you know lockdowns become inevitable when you don't have those three things in place and are unable to refine them. Yeah, I would say that I remember when we were above 2000 cases a day in Massachusetts and it was just a total. I mean, doing contact tracing is just crazy. You know, you're just calling people frantically people are are infected by different people. And now I'm thinking about, you know, 10,000 cases a day in Florida. So it's not, you know, there's nothing that's going on in terms of contact tracing, except for practice, you know, it's good practice, because you're going to get hopefully you're going to get to the point where practices in rehearsal. Well, practice is that you know, you're doing content tracing for the first time. So, you know, because you hired a lot of new people, you've got some some very, very experienced public health nurses, but then you had to hire a lot more people. They need to get trained up and they need to work. And the only way to really do this, learn how to do it correctly is to actually do it. So I think that's helpful. But, you know, yeah, when you've lost your lost control like that, then you just need to shut it down. Shut everything down. And, and then, and then once it's reset, then you can start over. I think there needs to be national agreement on when that reset happens, you know, there's been some discussion about what's the metric for that, you know, is it 25 cases per 100,000 that leads to, you know, the inability to control it even with the three legs of the stool in place. There's been an agreement across state lines that that's what's going to happen and so if New York does it that way but Florida doesn't. We end up in a situation where we just continually are perpetuating spread and so I do think there needs to be a reckoning to use Margaret's word on things like that on a, you know, a shared understanding of what it means to lose control of the virus and what needs to happen. And, and also a really fact based communication with the American people about what that means for how long it might be and what what the American what the government's going to do in the meantime to get back in control and we lost our chance to do that in March, April and May, but we still need to do it. And testing specifically again we just returned to that is the reason that testing is so important, because it's a predicate to contact tracing once I know I've been exposed a test will tell me whether I should stay quarantined, or not, or are there other reasons to be doing sort of sentinel testing or tell me, why is testing so important if we couldn't test would we how far up the creek would we be. I don't know who wants to know. Well, I'll just say, you know, testing is basically the one way we have to study where this virus who has it, and where and where it's spreading. I think it's more fundamental, a problem than losing your contact tracing capability you're losing your eyes on the epidemic. And, you know, whenever you are trained in disaster response the first thing like disaster planning the first thing the very first thing that you they'll say you need, and they're right is a map. You know, without a map, nothing else can happen. And that's the testing capabilities are map. That's what's giving us situational awareness. It's what's giving us what's leading planning. It's what's going to drive resource allocation hopefully. And so without that we're just dead in the water. That reminds me of the aviators creed of, I think it's aviate navigate communicate in times of trouble. Like, yeah, like, make sure the plane is not pointing down and then, unless you're trying to get out of stall anyway, and then figure out your map and where you're trying to go. Yeah. And there's many, and there's many other purposes for testing like you said, for example, they're going to open up. And all of the, the Massachusetts universities are talking about doing surveillance testing. So surveillance testing is, okay, let's just test everybody in a certain population, even if they have, whether that not they have symptoms or not. So, for universities, they're going to have bring back thousands and thousands of college students, they're going to be tested regularly. Plans are have been there. There's a huge amount of activity. People are just running like crazy trying to figure out how this is going to be done. But there's a real commitment there on the part of universities. That is very, very, you know, that tells you what people are infected. It shows you where there are outbreaks. You can roll that into contact tracing. I think that the availability of testing is great for community education. You know, there's something that's very visceral about getting tested and then waiting for that result. If you've ever had any sort of test for infectious disease, it's, I still remember when I, when I, when I, when I stab myself, and I had to get an HIV test. And I remember those days, just for the longest days, when I was just waiting for that. And it makes you think a lot about the disease and how it affects your family and community. It's a great teaching moment for, you know, when we're talking to people. So, you know, it changes also the understanding within the community of how COVID is transmitted. You know, we've had multiple large clusters of largely asymptomatic young people. And those communities now are actually really fine because they know that this has happened before. So, you know, you get, you get a better understanding of that understanding of how the disease is transmitted is, like Margaret says, it's of course is important to policy makers was actually very, very useful for community members to understand. Well, thank you for broaching the question of the colleges reopening, which in mid summer is on a lot of people's minds, including people asking questions in our own q amp a q. I'm curious on that front, you're phrasing it as a really good thing because it's an example of a community being able to create the kind of map that Margaret's talking about. On the other hand, to the extent that you see a lot of testing going on, which I think is in effect privately managed even by a public university it's for a particular community. They're driving the demand for tests, and it sounds like it's not just one and done they're going to be testing students. You know, three times a week or something everybody on campus three times a lot of testing to keep that community to some level of comfort, when that feeds into a national testing system. How, how does it get decided when there's only so many tests that can be turned around in three or four days. Whether it goes to state you or whether it goes to a fish processing plant and their employees or whether it goes to a community at large. How does that get figured out. How does that get figured out in in our in the typical American fashion, which is that an auction, you know, well, you know, the person who pays for it gets it right. That's an ocean. Yeah, I mean, this is kind of the NBA, the NBA style, right. So I think that the NBA bubble, you know, their universities are trying to create this on campus and, you know, some are going to, there are some are going to succeed some are going to fail. The strategy is definitely one that is very much suited to American culture we're going to try to make a bubble, and we're going to try to keep keep the virus out. So no, I don't think that there's, there's, there's a rational distribution of a scarce resource. I mean, this is people are, are, are working like crazy to try to protect their communities. And, you know, there is, there's confusion, you know, when you have, when you have a global pandemic. It's kind of crazy. And Beth, as somebody who was at the center of national policy making and planning apparatus. Is it basically like it's called the American way, like, let there be supply and demand and, you know, may the best college get the tests and hope that the basketball team doesn't get them first. Is there some command and control kind of thing you want to do. There, there should be a unified plan, there should be, you know, a public health response that is led by the federal government, obviously states have a lot of control and universities have capabilities that they can bring to bear and they're privately owned. So what we're missing is a consolidated plan and prioritization and communicate honest communication about where we are in this movie and the fact that we do have this incredibly scarce resource of testing right now that we know that the two largest commercial communities for testing in America lab corn quest are not able to turn around tests quickly so we're talking about unless you're in the hospital or an essential, you know, healthcare worker you're talking about a seven day a week or longer to get a test result back, which basically means the test itself is interesting from a research perspective but it's useless in identifying where the disease is and how to control spread. How would you prioritize it? Well, how would you start to order it? Yeah, well first I would say we need to know where all the barriers to testing are I mean we know that we have a national crisis but we don't actually know from each state individually where the capabilities and gaps are. We know how each state is currently prioritizing tests. And there should be, you know, a reckoning amongst governors, ideally led by the federal government and the CDC to have that conversation. And we should have had a long time ago but if we vector in using KJ, KJ is good point we are where we are. We're jumping in right now into this movie. And if we're using the best science, is it pretty clear how you would reconcile that resource or is it so values laden as to who should get the benefit of a test or you know, is it pretty clear? It's pretty, well there may be differences of opinion on this webinar but I mean it's absolutely clear that people with symptoms and essential workers, so essential workers, people that have to be at work, healthcare workers, essential employees, people with symptoms. Why shouldn't people with symptoms not get the test but just assume they've got it? So the second thing I would say in Margaret Ray's supported isolation is that we don't have a really sophisticated, not even sophisticated, we don't have a clear way of telling people if you are close contact of someone who has it, or if you think that you have it, you need to be quarantined and this is what you should do and we are going to support you to do that if you can't do it yourself. And sounding then like KJ's point about one of the reasons to do a test is to drive home the seriousness of the issue to a person who ideally would be self quarantining, even if they're not sure they have it and you're just saying like the test would really help persuade them they should do it. I think the ideal situation is that we would have enough testing and supported isolation and not so much circulating disease that we would be able to use those things together. Where we are now is that we do have a scarce commodity so I think it is an important strategy in places like Arizona and Texas and Florida that supported isolation within the absence of a quick test should absolutely be the norm, because even if they're tested they're not getting the results quickly enough. So, but this shouldn't be a Texas only strategy there should be a plan for how we're dealing with this when you get to a certain case load. There's a lot to say, I mean, you know, there, we are, like I said, we're at an acute on acute moment, right. So, where a lot of things are happening to create sort of a perfect storm in terms of driving needs for testing. And one of them is that we're having rising case loads and uncontrolled community spread and some of the most populous states in the country. And so they are trying to, you know, map out who has the disease and who does not. And testing is an important part of that. You raise a nice point that you can actually, you know, kind of maybe sort of do things without real confirmation of testing which is kind of what New England did. You know, New England is never tested extensively to really understand do we just lock down and we told people if you're sick will stay home. I just want to say by the way when you say oh you're sick stay home you're asking people to stay in a house, not go out ever for 14 days. So this is not like a little ask you know this is kind of a big ask you know for folks. So but anyway, you know you have these tests, the needs for testing these states are growing rapidly. And by on the other side of the seesaw, you have New England and places that want to open up and they want to be surveillance testing so they which is actually a pretty high demand I mean that's a pretty. You want to test large portions of your population twice a week that's like not a little deal that's a lot of testing. And so you have both of these, you know, situations demand growing, and it turns out that we aren't we don't live our lives. In one state it turns out that we are reliant on national and global supply chains and we're reliant on commercial laboratory companies that process. A lot of the states tests, even in New England, the same company quest or lab core processes test from Massachusetts, just like they do in Florida. So they are already prioritizing who is going to get their test and who's the test result going to go to. I think from the hope would be that we would be able to come up with a national consensus on who should get some access to that and to maximize our disease control efforts. And I think the first priority and I don't think it's that controversial to say is you want to be able to test so that you don't crash your health system and infect your health workforce. So that's usually the priority and it is the priority for quest and lab core. You know the second, you know, we can talk about who would be second in line my vote would be testing to break community be transmission lines of community transmission. That would be, you know, really your folks that you know have been exposed and folks that have. That's part of contact tracing. Somebody gets a note exposed. I mean you want test testing to try to break up community chains of community transmission would be the second in my book that would be where I would go. You know there is some debate or should you reserve the testing for folks that are living in congregate care situations and you are testing a long term care residents or people who are incarcerated. You know those those are some value judgments there. I think if we just had any you know sometimes any plan is better than no plan. And we need any plan, you know, because once we have a plan, however flawed it is, you know we can start throwing our weight towards solving for that part of the equation how do we make sure hospitals don't get overwhelmed. We can use PCR testing maybe we could get by with some other diagnostics in that setting. You know, how do we test, you know, folks that wanted to go to college campuses, could we use these antigen tests that have gotten a lot of play recently you know they're cheap and quick and maybe not as accurate as long as you just mentioned you got your PCR molecular testing which is usually when somebody says a test that's kind of what they've been meaning so far in the United States and that's the one that takes a bit of turnaround and where there's kind of bottlenecks on the reagents the chemicals you'd use. Then you mentioned antigen testing which is the strip of paper and in 10 minutes it gives you a kind of reliable answer. Testing why aren't those everywhere right now. Yeah, so I'm going to pivot a little bit to KJ and Beth you might have a better understanding but you know they just didn't have the kind of uptake in this country that that they should have. And I think that they are, you know, they're pretty cheap thing they were around back in January and February, I think people thought well we have a we have a better test which is the PCR test and our systems are kind of let's lean in on that. And so I think it it's sort of has become now like oh maybe this is a better better idea now that we are in such a crunch. Yeah, so should we ask KJ on the front lines and just to bracket it the third type is the serological testing to look for antibodies that somebody might have produced which maybe isn't as relevant and controlling things but KJ for the antigen testing where you're looking for like a little protein that the virus would be throwing off. And therefore could be detected but isn't always, even if somebody's got it. Why don't you have that in your arsenal right now. It exists, there are, there's a couple of FDA approved. I think there's two different ones now. There's actually I know a couple of facilities in in Massachusetts that are using them, but they've come out recently and they haven't been widely used yet, I think that they will be used more. I don't really, you know, just pivoting back to your original question. I don't really think that this is, you know, it's not really a capacity or a technology problem or issue. The problem is that we just have an explosion of COVID in this country. So, you know, you've got multiple states in the Sun Belt, they're just trying to diagnose people so they can put them in the right ward. They're not, they don't have any sort of testing capacity to do anything else, any sort of public health intervention. They just have, you know, they have to do, you know, hundreds of thousands of tests. So, you know, you can build up your testing capacity, but this is exponential growth. So you're going to have more, unless you actually do something about it. So I do think that until, you know, certainly we should build up our testing capacity because like you say there's other things down the road, like surveillance testing testing college students testing testing public school and K312 testing workplaces, all of these things require more testing. But I don't think that the current problem right now can be solved until people actually get a handle on the epidemic. There's another question you asked, which is how do you, you know, part of the way to, to try to work towards a more equitable distribution of resources is, you know, it's kind of interesting policy guys, really take a top down view but, you know, we're a democracy. So if, you know, why is it that Brockton public health? Sorry, the Brockton school district, you know, they got 16,000 students there K312. How come they're not getting tested every three days like the Harvard students are. And is that really issued that, you know, I guess it'd be nice that policymakers are thinking about that but maybe community members maybe parents need to start, you know, raising their voices and asking these questions and demanding the same type of resources that our Harvard students are going to get, our BU students are going to get that NBA athletes get. Totally. I mean, a national plan doesn't mean that you don't, I mean, it doesn't mean that you don't set out priorities for kids going back to school and that the kids going back to school that should be the priority shouldn't be K through 12. I mean, I definitely think we should be talking about these issues we should be talking to the massive disparity in our country and where COVID is circulating among people who people of color in our in our society. Those are things that can't that tone does get set at the national level as well as the state and I think rightly a lot of people have put some some comments into the chat. It's not just states it's also you know cities and counties but you know we are a federated society, but the tone gets set from the top and what the tone is right now is that the states get to decide the county level everybody decides for themselves and we're not going to set out specific priorities and when that happens. The people at the top, the wealthiest people in our country are the ones who are going to win, or the ones who are that that's what's going to happen or it's more likely to happen I mean certainly there are states and local communities that are doing a great job. But we're leaving it to them and not setting the tone at the top so kg I take your point but I think policymakers job is to pay attention to those issues. Well this sounds like a little bit the story of the water system in Flint writ large and with something communicable. I guess there's a political or policy question to say, how does Flint get the resources, it needs that if that were to have happened in a different zip code. It would never have happened, but if it did it would be remediated much more quickly and is that somehow a local community thing, or is it trust the White House to fix it. I would say that you know the history of course of multi drug resistant tuberculosis and activism is very much set by the fact that or is very much influenced by the fact that it is a communicable disease issue. And one of the things well we have in our court. In our favor, maybe if you want to look at it as a silver lining is the fact that communicable diseases transmit to other people and to rich people and to people with resources, which is to say a viral injustice anywhere truly is an injustice everywhere if you wait long enough. It's going to be hard to buy your way out is what unless you just pursue such isolationism that you talk yourself into thinking that a problem somewhere else can be. It's hard to find the island and turns out this is going to be one of those stunning exercises and equity because it's not just like oh we're all connected and kind of a spiritual way. I mean we share a microbiome that is going to connect us and so my my thinking is that how this in general will play out is yes there will be a mad rush where the strongest will be able to elbow their, their way to scarce resources. But at the, but, you know, they still can't go to Paris, even if they're behind a wall and have a deep moat and get tested every day. You know there's still Americans that have to answer to the via and are influenced by the status of the epidemic everywhere. And so, you know, I don't know if you take as a good thing or as a bad thing but I think that the cove it is not here to allow us, maybe to get away with this kind of this kind of lack of laws I fair or let's just see what happens approach. Now we've hit the top of the hour but of course we started a little late due to technical difficulties so if I can indulge a little bit past the hour. Maybe a kind of wrap up question for this installment at least of each of you. And it would be a reminder to those watching and listening about what the name of the game is here in very basic terms is it making sure the healthcare system isn't overtaxed as people inevitably get sick from this until we have some rabbit out of a hat like a vaccine that is then well distributed. Or is it something else like what's sort of the overall picture of where we're trying to go on that map we don't have yet. And this is maybe a different way of asking the question. What's the forward two years from now July of 2022. What's the picture and how much is it still different from July of 2019 I mean how much has the day to day of the life of various Americans been even two years from now will still be different can we if movie theaters are still around walking without a mask I'm curious even two years from now what your vision is on that front so either where are we going on the map or what's it going to look like in two years I'm curious what people think I don't know who wants to go first. I'll jump in. Look we're we're guesstimating here so nobody watching this for posterity can say any of us are well they will be able to say whether we're wrong or not in two years but they'll have historical empathy. They will. So I'll I'll say this I mean I think so first you asked you questions I think one was where do we want to go like what is that we know what is the optimal and endpoint or quasi endpoint here short of a vaccine and a safe effective equitably distributed vaccine and I think we want to be Germany we want to be South Korea I want to have controlled this disease such that it's not gone. There it's still transmitting there may still be hotspots we still have to be vigilant, but we don't have 1000 cases per day we don't have the massive community spread that we have in many states right now. And I think that's totally achievable but in order to achieve it we have to get the three legs of the stool that Margaret so well describes we have to use them and we have to use them in concert with other environment, testing and tracing those are the three legs. Yes, I think rough. Yes, contact tracing testing supported isolation. Yes, reverse testing tracing supported isolation. What am I missing Margaret sorry. Oh well I sort of envisioned those three, you know population environmental and then I just that's a very robust third leg of, you know, testing contact tracing supported isolation on that one leg. Sorry, we all have different legs of different styles analogies throughout this crisis. Thank you. Yes. But where are we going to be in two years. I mean, I hope that where we are in two years is that we have a safe and effective vaccine for this disease that's been distributed will covert 19 be gone in two years I don't think that it will be. I mean I think the history of vaccination programs around the world for other diseases tells us how hard it is to eradicate something so I think covert 19 is here to stay for the foreseeable future. I hope that it's a vaccination program that is not more rigorous than annually but we just don't know we don't know what what the vaccine is going to look like and that will drive whether we go into a movie theater, especially in the winter with or without a mask so I think that's on the table. I think it's on the table that movie theaters and shopping malls won't survive this crisis because of the economic downturn that we're all living in, but I think it's possible. And I think we should should prepare for the world where that that isn't what we what we end up with it if we want a different world, but right now we're not behaving like we do as a country. Okay, do you want to give your prediction. No, I mean I think that's, you know, I think when we have vaccines and therapeutics. By that time, it will make things a lot easier. And I think most people are confident that at that point, you know, you'll still have to do all of these things that we're doing. I don't think anybody in the public health sphere is predicting this is going to be around for years. But it's going to be a lot easier. We're going to have more tools. So we will, you know, I think at that point, we're pretty confident we'll be able to have much better control than we do now. I think the harder issue is in the next six to 12 months when we don't have these things or these things are not going probably more, you know, where we don't have access or enough of these, these tools. When we get to that point, like other countries have, can we have much better control? Can we have much stronger suppression? I think we can. You know, we're obviously failing right now. But, you know, the tool, the playbook is there, the public health tools. The countries are all very effective. And I think that once things get a little worse, then I think there was going to be more appetite to do things the right way. I like your flavor of optimism. I'll say that, like, just to say at the beginning of this crisis, I was really scared to say, like, make a prediction that was too dire. And now I'm a little scared to make a prediction that's too optimistic, but like, I don't want to, I don't know. I don't want to give up on eradication. I don't want to give up on elimination. And I think that if we can crack the governance nut right now, we can come together and have some leadership and a national plan and we execute on it. And with all of our resources and get behind it, I think we could do a really good job. And then I think we'll get a vaccine in here and we'll mop it up. I mean, often, vaccines fail because they have an animal reservoir. You know, that's, in general, that's why, and there's no evidence yet that that's the case here. An animal reservoir is a place where the virus is leading and then jumping over every so often. But we got, you know, I remember when, you know, Ebola was raging in West Africa and, you know, it was so crazy that Jim Kim and the head of the World Bank was like, we are driving it to zero. We're driving it to zero. Now they didn't eradicate Ebola, you know, absolutely. But like, that's where we're going to go. That's where we're driving the bus. Let's get to zero. And then you can tell me how naive I am in two years. Well, we can author a mask. Great way to end. We can check in perhaps in sooner than two years. Many other topics to cover, including complimenting centuries old public health techniques with ones that are months or mere years old or just around the corner like low energy Bluetooth and things like that. But thank you all so much for taking the time to share your thoughts and even to disagree a little with one another. And I look forward to the prospect of reconvening. Very good. And thanks all to those who tuned in. Alright, catch you soon. Thanks very much. Bye.