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Teen SciCafe: When a Pandemic Strikes with Jay Varma – Transcript

Jay Varma (Physician and Public-Health Expert): Thank you all for taking some time, I appreciate your passion and interest in learning a little bit about what I’m really excited and interested about, and I’ve devoted my life to, which is all about how we fight infectious diseases kind of at the population level.

Slide: When a Pandemic Strikes: How to Detect and Stop Infectious Diseases

The title of the talk is “When a Pandemic Strikes: How to Detect and Stop Infectious Diseases.” But before we start, I wanted to just give you a little bit of background, because I know some of you may be interested in a career in public health. And I personally found it very useful over time to talk to people who had interesting careers and learn from them.

[Slide Title: Who I Am]

So I actually studied history in college and then went to medical school. After four years of medical school, I then had to do training in the hospital to become a practicing physician, what's called an adult medicine doctor or internal medicine physician.

And then I went to go work for the CDC, and the first two years I spent there, I was working and training as an epidemiologist in various infectious disease areas.

And during my CDC career, I spent 20 years living and working on infectious diseases all over the world. In Bangkok, and Beijing, in Addis Ababa, which is the capital of Ethiopia, and here in New York City.

I was with my family and actually in Ethiopia during the beginning stages of the pandemic and then returned in April of 2020 to guide the city's covert response.

[Image: Cover page of the sports section of the Wall Street Journal showing a photograph of Dr. Jay Varma, a photograph of basketball player Kyrie Irving, and the headline, “The Doctors Who Blocked Kyrie Irving.”]

And for those of you who are basketball fans, they just had this story in The Wall Street Journal, to show that you, too, when you become older, you can do interesting things like end up causing controversy in the NBA when star players are unable to play due to vaccine verification requirements.

So a couple of important definitions, just so we all understand each other. What is an epidemiologist? I know it's a really kind of weird term and I think before this pandemic very few people knew what that is.

But basically, it means somebody who studies diseases and health in large groups. So a regular medical doctor is concerned with, you know, you go to the doctor's office it's a one-on-one situation.

An epidemiologist is interested not in the health of one person, but in the health of thousands of people, or millions of people, and tries to understand what it is that makes them healthy, what it is that makes them sick, and how they can do better at that.

What we call public health is an extension of that. So public health is a much broader term and it basically refers to anybody who is responsible for the health of a large area like a city, or a state, or a country.

And when you work in public health, you need epidemiologists but you also need people with a lot of other skills and expertise. Everything from people who are good writers and artists to design health communications material, people who are good at laboratory science, people who are good at understanding economics and politics. So it's a much more diverse field than just epidemiology.

So public health people are responsible for monitoring the number of people and types of diseases in a population, and then doing things to help prevent in control diseases in that population.

So during COVID-19, it's public health people that are responsible for deciding who gets vaccines, how do we administer them, who gets tested, how do we deliver those services to people.

So what we're going to talk about today is, I just want to give you a kind of introduction to what it's like in the day or life of a person who works in public health. And throughout this I’m just using kind of a generic term “disease X,” it kind of applies to any infectious disease. So you could put COVID in there, or you could put the flu, or you could even put cancer in there, and you basically get the same results. So kind of everything I’m talking about, even though I’m kind of really focused on this infectious disease we're fighting right now, is really pretty applicable to almost everything that we do in public health.

So I want to walk you through some of these interesting questions. Well, how many people in New York City have disease X today? That is something that public health people are responsible for finding out. And I’ll teach you how we do that.

Is the number of people with that disease something we need to worry about? How do you make that decision? And then, if you do decide it’s something we worry about, what can we do to reduce the number of people with that disease? And again, we're talking about a big population.

And then, finally, I want to close by giving you some thoughts about the present and future of COVID-19, since that is really the most important disease that we're kind of all focused on day to day right now.

So let's talk about the first section, how many people have a disease, any disease? So, first of all, who's responsible for counting that, who is responsible for answering that question?

Well, it’s almost always dependent on whatever country you're in. It pretty much falls on a government agency, so let's talk about the United States.

In the United States, we have three major levels of government. We have the national or federal government–so that's the White House–and Congress, and the judicial branch of government.

We have the state, so if you're in New York, that would be New York state. And we have city or local agencies, and here in New York, it's the New York City Health Department.

So each level of government has a public health agency. So at the national level that is known as the Centers for Disease Control or CDC.

At the state level, we call it the New York State Department of Health. And at the city level, we call it the New York City Department of Health and Mental Hygiene.

And if any of you are tuning in from other parts of the country or other parts of the world, you can kind of insert your state. Let's say you're in California, there's a California State Department of Health, and there's a Los Angeles City and Los Angeles County Department of Health.

And each state has responsibility for answering that question: how many people have a disease, this disease X? And we actually have a term for what we call this counting.

We actually call it public health surveillance. Surveillance is a term that you might hear in a spy movie you know, we're watching somebody surveilling them.

We use this term in public health to talk about our process of counting, how do you count how many people have a disease.

So how do public entities actually do that? So the first thing we do is we use a term called a “case”. And so that basically means any person with a disease we call a case.

And for infectious diseases, there we have something we call “reportable diseases.” So of all the thousands of diseases that are out there, we identify about 80 of them that are infectious diseases that we think are really important for the government to know about because there's something we can do about them for a large population.

And so in New York City, for example, we have about 80 of these diseases, and any doctor or laboratory that diagnosis this type of disease, a case, has to report it.

And because laboratories are actually very carefully inspected and monitored here in the United States, they're really good at reporting. In other words, they never forget to report, or when they do, they can get caught and get penalized.

Doctors unfortunately are not very good at reporting. And so a lot of our disease counting really comes from the data that we get from laboratories. So when you go to the doctor and they say we're going to test you for COVID, that's a test result that we get reported 100% of the time to the New York City and the New York State Department of Health, so it's something we can be really good at counting. But we can't always rely on the doctor reporting that case to us, so we really depend a lot on these laboratories.

And the next thing we can also count is deaths. Any person that dies in the United States has a death certificate that's required to be signed by a doctor, and on the death certificate, it lists a cause of death.

So let's look at what this means when you're looking at numbers.

[Slide: Chart mapping the number of COVID-19 cases per day (confirmed and probable) in New York City from April 2020 to October 2021 The chart shows that cases spiked in April 2020 to about 5,500, decreased to less than 1,000 in the summer of 2020, reached a spike of over 6,000 in January 2021, hovered near 4,000 until April 2021, decreased to less than 1,000 in summer of 2021, then increased to hover near 2,000 in fall 2021.]

So what you have here is a chart that you can get from the New York City Health Department website. If you go to the website right now, you'll see this chart. And basically what you're looking at is, on what we call the vertical or the Y-axis, you're seeing the number of people who have the disease. And on the bottom line, what we call the X-axis, you're seeing the date.

And as you all know who are here in New York City, May and April of 2020 was a really devastating time. And that's when we had really the worst COVID epidemic in the world, actually at that time was here in New York City.

What you see is interesting on here is, you see that this big wave in January, it makes you think that life in December and January in New York was just as bad or actually worse than it was in March and April.

And this is just a perfect example of one of the challenges that we face with counting diseases.

As many of you may know, that New York City very early on in March and April, there were not many laboratories that could do COVID tests. So the number of people that we diagnosed with COVID and therefore counted was far, far fewer than actually should have been counted. At one point we were probably only counting one in every ten infections.

But when I got here in April, one of the first tasks I had was to build a huge laboratory system so that we could test anybody who needed to be tested and you could get tested for free.

So then, during the summer of 2020, we started having the ability to test thousands of people, a hundred thousand people a day. And so that's actually why you see this unusual phenomenon, that even though far fewer people were actually sick with COVID in December and January of last year because our laboratory ability was so much better we were actually able to diagnose more people.

So when you look at this data, you also have to ask questions and say, wait, did something actually happen in December, January different than April? Because it's not how I remembered it being. And so this is just an example of one of the limitations that we have with counting cases. You have to depend on, are people actually getting tested for that disease?

Here is another way to look at that same data.

[Slide: Chart mapping the number of COVID-19 deaths per day (confirmed and probable) in New York City from April 2020 to October 2021 The chart shows that deaths spiked in April 2020 to over 700, decreased to very few in summer of 2020, increased to about 100 in January 2021, decreased to very few in summer of 2021, then increased slightly in summer/fall 2021.]

And this is showing deaths. And here there wasn't a problem with counting deaths in March and April. And in fact, the system was really good at doing that, so now, you see actually a much more accurate picture of the different phases of the epidemic.

If you are here in New York, you remember March and April were really horrible and grim times. And certainly, people have been gotten sick, I don't want to minimize that people have gotten sick and died from this disease ever since then, but that was obviously the most extreme and horrible situation that we faced.

But what you see here is more of a reflection of what we all experienced if we were here, which is that really severe problem with deaths in the spring of 2020, and then the situation has been much better controlled since that time with a wave that we had, a second wave that we had in the winter of last year, and a much smaller bump in this past summer.

So, depending on the disease that you're working on, it's really important to understand what could maybe skew the results, what might give you kind of a false picture, depending on how many tests are available or not.

So we also have other ways of counting people with disease. We have a system that we call Syndromic Surveillance. And again that's a challenging word, I'll describe it a little bit. So basically what a syndrome means is somebody who comes to you, as a doctor, shows up in your emergency department and they're sick, and they have like a fever and a cough. And so we kind of grab those things together and we call it something. So if somebody presents with a fever and a sore throat and a runny nose, instead of calling it a cold we call it a flu-like illness.

If somebody shows up with a fever and a rash we call that fever-and-rash illness. So we call those syndromes. And so it doesn't mean we know for sure what you have because there are lots of different infections that can cause that type of flu-like symptoms. But we can track the number of people who present with that, and that kind of gives us a good way of guessing how many people might have the disease, even if you don't have the laboratory ability to test for everybody.

And the other way we do it is we get something, what we call a call from the astute clinician. Astute means smart or savvy, or really clever and aware. And it's basically, you know, if you've seen those posters on the subway that say, “if you see something say something.” You know they're talking about crime and terrorism. Well, we do the same thing with doctors. We say if you see something unusual say something. And it turns out that sometimes a doctor sees something unusual and calls us, and that ends up being the way we pick up an outbreak or count the disease as something unusual or different. So let's look at some pictures of that.

[Slide: Chart showing “Influenza-like Illness (ILI) overall emergency department visit count and ratio” between January 1, 2021, and October 10, 2021. Week-to-week numbers fluctuate somewhat, but have risen from an average near 100 in January 2021 to an average closer to 200 in fall 2021, with some weeks spiking near 300.]

So this is what we call flu-like illness, here we call it influenza, which is the longer term. So it says “ILI.” And this graph you see on the bottom there is a picture of what happened in January 2021 up until now, so this is all in this past year. And you see that in the past few months, the rates of what we call flu-like-illness have been rising.

And that probably is very similar to what you've experienced in your home. I’m sure many of you, I know it's been the case in my home, somebody’s gotten a runny nose and a cough or a cold. We've tested them for COVID, this happened to me, I had a runny nose, but I didn't actually have COVID. But that's happening.

So you're seeing an increase over time and that's very consistent, we expect in the winter months under normal circumstances, there are more people who get sick. And we can talk later about why that is, but this is one of the things that we count at the Health Department, to keep track of how many people have disease. So again, this is a clinical syndrome, this isn't people confirmed COVID, this is people who might have the flu, or they might have COVID but it's a kind of a useful way of tracking things.

[Slide: Two side-by-side front pages of New York newspapers from 2014. On the left, a New York Daily News cover reads “NY Doc Has Ebola: First confirmed city case of deadly virus,” with a photograph of Dr. Craig Spencer and microscopic image of the Ebola virus. On the right, a New York Post cover reads “Ebola Here! Local doc is NY’s first case, he treated victims in Africa,” with a photograph of police wearing medical masks and a smaller photograph of Dr. Spencer.]

And these are some newspaper reports, one from the Daily News and one from the New York Post. I’m not sure how many of you were still awake and following the news, or whether you were young children back in 2014 and 2015, but there was a real scare here about Ebola virus. There was a physician who had worked in Africa who returned back to New York City who ended up being diagnosed with Ebola. At that time I was in charge of the city's response to this and, as you can see from these newspaper headlines, we found out about it because smart people called us. This doctor knew when he got sick that it might be Ebola. He called the medical team that works for his organization, Doctors Without Borders, and they called us. So this is an example where just a phone call from the right people can make all the difference in the world.

So, as I described a little bit throughout this process, no matter what we do, no matter which approach we use, there is going to be some problem with accuracy. It turns out, there is no perfect approach to getting 100% of your count right.

So if we collect cases from labs, that's a really good thing because we know for sure that somebody has the disease. But we know this is an undercount, as I said, because not everyone who gets sick goes to the doctor and gets a lab test. As I showed you in those slides from March and April, even if you went to the doctor and wanted to get a lab test, there weren't any tests available in New York back in March and April of 2020 so it didn't really matter. So we always know that cases from labs are an undercount, but we also find them very useful because they tell us for sure that this person actually had the disease.

So you might say, well that's not as good, you showed me that data on deaths that looks pretty good why don't we just do that. Well, again, that is useful because it provides data that everyone cares about, deaths are a big deal, we don't want people to die of these diseases.

But there are some other limitations. When doctors fill out that death certificate they don't know for sure why a person died, especially if they died in their home. And so there's a real challenge with accuracy.

And, of course, deaths aren't the only measure that we worry about. We know that most people who get COVID don't die from this infection. Somewhere between you know one in 1,000 and 1 in 100 people die. So if we only counted deaths we wouldn't really have a good understanding of how many people are actually getting sick.

And some people will have symptoms that last for a very long time after COVID and are very debilitated because of that. So collecting cases from death is useful, but also has some limitations.

The syndromic data, where I showed you the flu data, you know, the person might have the flu. Well, that's really good, because you get the data quickly, you don't have to wait for a lab test to get done and for the lab to report it. But the challenge, of course, is it doesn't tell you what virus they have. There are lots of different viruses that can cause flu symptoms. And sometimes it's not even a virus, sometimes it's an allergy like the pollen in the air. Some of you probably have allergies, you get symptoms, it kind of feels like a cold. So, again it's useful but it isn't the full picture entirely.

So for all of those situations, I think the message that I’m trying to convey is that in public health, we know that our data isn't 100% accurate, but we take all of those different pieces–we take the laboratory data, we take the deaths data, we take the syndrome data, take the calls from people–and we put it all together and that's really where a lot of the job comes in. What is the best estimate that we have based on all these imperfect pieces of information?

And that's really what we do in public health, and that's why we're always honest about the limitations of our numbers. But what we try to be very strong about is saying we have expertise and putting all this imperfect information together and making a good assessment of it.

So now the next question is, okay, once we've counted the number of people with disease X, and we've accounted for all the reasons why it may be an under-counter or over-count, how do we decide if it's something that we should worry about, like is it something we need to do something about, or is it something we say, that's just a regular disease there's not a lot we can make a difference on.

So this gets really, really tricky trying to answer this question. How do you say how many cases is too many to act on? And so, a lot of times we use the term, and you've heard this term, an outbreak or an epidemic. And they basically mean the same thing. Really what they mean is something very simple: they mean there are more cases of this disease than you would expect to normally have during a certain time period or a specific place.

Let's say you're talking about your school, for example, or let's say your street or something like that. And let's say normally maybe you'd only expect to have two or three people sick in a week. But this week, there are 100 people who are reporting that they're sick. Well that's pretty different. So we define a time period and a place, and we say there's just way more people with this disease than we would expect. And that's when we use terms like an outbreak or an epidemic.

You've heard a lot about this term “pandemic,” and what pandemic means is really just an outbreak or epidemic that's impacting most or all of the world. So not just a few countries but everywhere has it.

You know, most of the time we talk about outbreaks we’re talking about one in a little city, or in a town, or maybe at a school or somewhere else. But a pandemic is one where everybody's affected by it in some way.

And really the complexity here is there has to be some type of judgment decision, there is no strict formula. Because even if the number of cases is greater than you'd expect, maybe that’s something that just happens from time to time and there's nothing you have a really good solution to fix it. And also, we have to think about, you know, even one case of Ebola–that's a very rare disease, so even that would be considered an outbreak, even though it's only one person who's actually sick.

And so, really, what you're talking about here is people in public health have to use the numbers, but they also have to make a judgment. How much illness and death in society should we accept? And there's no formula for how to do that, that's really just a judgment call.

And so we're facing this challenge right now with COVID. I mean this is one of the biggest challenges, if you read the news, or you listen to people talking online, people are saying that we need to learn to live with COVID-19. And that's something that that I agree with and we'll talk about at the end, but it also means we are willing to accept X number of people getting sick. Some number of people we’re willing to getting sick. A certain number of people going to the hospital, and a certain number of people dying every day, because the cost and effort to bring that number to zero is too much.

And this is a difficult question. And one of the reasons you don't hear elected officials–a governor, or mayor, or even the President–saying we're going to learn to live with COVID because we're okay with 50,000 people a year getting sick, 5,000 people going to the hospital and 1,000 people dying is because if they said that, what will be the reaction? People would be like, oh my god that person doesn't care about us at all.

But the reality is, at some level, this is what government and public health has to do. They have to make a decision about it–at what point is the cost and effort for all of society to bring the case numbers to zero, is that too much, and therefore we're willing to accept some number of illness and death?

And that is a really, really difficult problem, and I don't confess to know the answer to that. I would continue with this point, that we make these calculations all the time in public health even if we don't put a number on it.

So let's talk about some kind of very obvious examples. We can have zero traffic deaths a year. I can make it so that not a single person in New York City dies in a car. You know how we do that? We ban all cars. And we basically say you can never have a car in the streets of New York, and anybody who brings a car in gets thrown in jail. But do we want to live like that? Do we want a city where you can't get anywhere in a car ever, even in an emergency?

We could also have zero sexually transmitted infections in teens if we wanted to. If we locked everybody in their rooms and never let you leave. Now, of course nobody wants to live in that world either, so you accept a certain amount of infections in people because you want to have people live. So these are the types of things that we grapple with all the time, even if we don't actually think about them actively.

[On Screen Text: “What Can We Do To Reduce the Number of People with Disease X?”]

So the next question becomes, now that we've counted the number of people with the disease, and we've also decided that this is a problem–there are more people with disease than we think is acceptable, or the number is just way, way higher than it normally is–we need to do something about it. So what can we do? Let's think about the different ways in which we can control a disease.

[Slide title: Hierarchy of Public Health Interventions

A chart in the shape of a pyramid is divided into 5 horizontal rows with added text next to each.

The base of the pyramid is labeled “Socioeconomic Factors, i.e. racism, economic inequality, universal healthcare”

The row above that is labeled “Changing the Context to Make Individuals’ Default Decisions Healthy, i.e. taxing cigarettes, inspecting foods to make them safe, disinfecting water”

The row above that is labeled “Long-Lasting Protective Interventions, i.e. Vaccines”

The row above that is labeled “Clinical Interventions, i.e. medications to prevent or cure illness”

The top, and smallest, row is labeled “Counselling and Education, i.e. telling people to avoid high risk settings, wearing masks”

An arrow pointing from the top of the pyramid towards the bottom is labeled “Increasing Population Impact”; an arrow pointing from the bottom of the pyramid to the top is labelled “Increasing Individual Effort Needed.]

And this is a slide that comes from Tom Frieden who used to be the director of CDC, under President Obama's administration. And he's a really smart thinker on public health problems, and he came up with this pyramid that's really useful for me to talk through, even though it's a little complex. But I think you'll appreciate what it teaches us.

At the bottom of this pyramid, we're talking about things that have really big population impact. Things that, if you fix them and change them, millions and millions of people will benefit without any effort on their part, they will just do better and their health will be better.

And really what it comes down to, if I asked you this question beforehand, I think a lot of people would say oh, make sure more people go to the doctor, make sure more people care about the right thing, and then they'll make the right choices.

It turns out those things don't actually have a lot of huge population impact if you really want to improve the health of millions of people and their health. You don't actually have to do something that's really a health intervention, you have to improve social and economic factors. It turns out that if you can address things like racism, economic inequality, and provide universal health care and childcare, and other sorts of social supports and benefits. Even if people don't take advantage of it, even if people don't actually go to the doctor with that support, it turns out that has a huge impact on people's day-to-day health and the likelihood that they will live longer.

Because it turns out that there's a lot of improvements you can make in people's health simply by making their lives more comfortable and easy to live. And that should align with people, you know, we all talk about you're getting really stressed and you get sick. Well, think about that multiplied by 300 million-plus people living in the United States and that that really does have an impact.

The next level of intervention we can take is what we call changing the context to make your default decisions healthy. And this basically means doing things like taxing cigarettes. Cigarettes in New York City, they're really expensive. The reason they're expensive is we tax them.

Why do we tax them? Because of teenagers. And you know why? Because you don't have a lot of money in your pocket. And we know that if we make a packet of cigarettes cost fifteen dollars, you're going to think twice, three times or four times before you spend your money on that. Because that means instead of going to Chipotle with your friends, or going to see a movie, you're spending it all on one pack of cigarettes and you're going to make a smart decision to not smoke cigarettes.

So doing things like that, inspecting foods to make them safe, disinfecting the water. This is New York City tap water that I’m drinking. That means people are going to drink the water and they're not going to go out and buy plastic bottles and cause other things, or buy soda, they're more likely to drink water. So those things have a huge impact on health.

The next step is what we call Long-Lasting Protective Interventions, and this is where vaccines come in. And the reason vaccines are so beautiful is, if you compare them to something like masks–we put at the top of that pyramid we're talking about counseling and education–you know, masks are great, they're very effective. But you have to wear it all the time, and you can't stop wearing it. So you have to do it every single day, every time you're in an indoor setting that's not your home. So basically you have to always, always be doing that.

The beauty of vaccines is I give you an injection one or two times, or three times, you never have to do anything more. Your body is doing all the work. If somebody breathes COVID on you, your body is fighting it out off without you having to even think about it it's just doing it naturally. So things that are long-lasting protective interventions like that are so powerful because of that. Because your body does it and you don't have to make a decision about what to do.

The next step is what we call “clinical intervention.” This is what normally people would say, how do you improve health? Well, get people to the doctor more often. Well, that does help, but again, you’ve got to get people to the doctor, they’ve got to take the medications, not all medications really cure or prevent diseases, sometimes you have to take it every single day, and we know how hard that is.

And the last, it's kind of the least for population impact, is counseling and education. Now that is important, we always think it's important to educate and make people aware. But it turns out, it takes a lot of individual effort. And in terms of reaching millions and millions of people and getting them to all change, it's not that effective compared to some of these other factors that we talked about.

So how do we decide among all those things? So here's another way to think about this. We have to think through a number of different steps. It's not just, does it work or not. A lot of times in public health and science we look at research studies and we say, okay well there's a research study. We took this group of people, and gave them the medication, we took this group of people, and we gave him a sugar pill so it's not the medication, and we saw that the people who got the medication did better, therefore we're going to give everybody in the world this medication.

Well, that's only one step in the process is the evidence. So we need to know, scientifically does it work? Have we done research to compare different groups to say we give people this intervention and it works? That's the first step, the next things we need to do, then, to say at a public level is, is it feasible?

Let's talk about vaccines. We have the evidence that vaccines work, but is it feasible? Do we actually have the staff, the humans to go out and set up vaccine clinics everywhere, and actually get the vaccines to people? You know this is a challenge, there are lots of places that don't have those steps. Or even if you know vaccines work, how are you going to get them to people?

The next question is, is it acceptable? Do we know people are willing to get that vaccine? Even if we have the vaccine and we have people to give it, are people going to take it? The next is, do we know that the benefits are greater than the harms? Well for vaccines, we know that there's a lot of benefit and very low harm, so that's a reason to give it.

Can we afford it? Well you know, we as a country are willing to spend the money to buy vaccines, but there are a lot of countries around the world that don't have the money to be able to do it. So that will affect whether or not you're able to do this in your population. And does it align with our values? Is it something that we as a society think is really important to do.

This is an important consideration. So we value protecting people from a disease like COVID because it has sickened and killed a lot of people, and particularly in black and brown communities. And so it's really important for us to get these vaccines to people.

[On Screen Text: The Present and Future of COVID-19]

So let's talk about the present and future of COVID-19. And I’m just going to talk about this for a few minutes and then we'll open up to questions and discussion from the group.

You know I always start with this quote, which is you know, in the past been attributed to Yogi Berra, Yogi Berra is a famous Yankee coach from years ago.

And it's just an amusing thought, “It's difficult to make predictions…especially about the future.”

And that's kind of where we're at with this disease. You know the challenge with this disease is that we have learned that there are so many complicated factors that determine whether your city or your state is going to have a lot of COVID.

But there are some things that I feel reasonably confident talking about. The first is, unfortunately, we will never eliminate this virus from the earth. We're never going to get it out of here completely.

And the reason is because it doesn't just live in humans, it lives in animals. Wild animals, domestic animals like pets even. And when you have a disease like that, you can't actually get rid of it forever. You need to be able to what we call control it, but you can’t actually eliminate it or what we call eradicate it.

The other concern is what we call new variants. And we didn't talk about this, but I can certainly answer questions about this. All viruses mutate, that's just like what they do. Dogs bark, ducks quack, viruses mutate. Whenever they're copying themselves, and making new copies they make errors. And some of those errors result in the virus being able to transmit more effectively or make people sicker, and we know this virus already mutated very rapidly, both in humans and animals. So we have to be prepared for the virus to continue to evolve and potentially challenge us in the future.

When that will happen, when will get a new strain that's even more dangerous than this Delta strain, that none of us know the answer to. That’s really quite blunt, I mean the answer is nobody knows the answer to that, even though there are lots of brilliant people who are studying this problem.

The next key point is that our best protection will be vaccination of the entire globe. One of the reasons that we have vaccine mandates here in New York City–and they will eventually become more common throughout the world–is that we all breathe the same air and because we all share the same air. Everybody's life is connected to ours, so you know, we want to help the rest of the world, we should want to help the rest of the world, simply because it's the moral thing to do to help people.

But at the same time it's also in our self-interest. It is in our self-interest, so that when people visit us, or we visit them, that we are keeping everybody safe because we're all sharing the same air. And it's a real challenge because there has not nearly been the commitment from wealthy countries, including the United States, to making this a reality. And the reality is because the variants will emerge, we are going to continue to have to update the vaccines in the future.

When that will be, again, I don't know the answer. My hope is that it would be several years until it happens, but we have to be prepared for the possibility it could be as soon as a few months from now. And all that is certainly possible.

New medications will help but probably not that much. And this, again, is a much more complex question that we can discuss if people have questions about it. But it turns out viruses are really, really difficult to cure. Bacteria, things that will cause like, say a skin infection, those are pretty easy to cure. Or a urinary infection, those are pretty easy to cure with antibiotics that we have. Viruses are much, much trickier.

And so I think it's very unlikely that will have a complete cure for this virus and whatever cure we might get will probably be expensive and difficult to administer. Now, I would love to be wrong about this. But I suspect it will be quite some time until we're ever able to develop a cure, and may never be able to develop a really good one.

And you know when new variants emerge over time, there may be the need to wear masks for a short period until new vaccines are administered. I hope that this isn't the case, but we have to be prepared for it.

Because we do have this ability, with these new vaccine methods, to develop vaccines much, much faster than we have in the past. So I do think our vaccines will be able to keep up with changes in the virus, but it may mean that there may be times that we have to put on our masks and take off our masks. As many people in East Asia have been doing, ever since the first kind of bird flu outbreaks in the 90s, and eventually the first SARS epidemic in 2001.

And, unfortunately, and this is the part of the talk where I encourage you to start thinking about a career in public health, because it's also a very dangerous time, we know, for our world. Pandemics will occur more frequently than they have in the past, the single biggest driver is climate change. And climate change has many, many impacts on where insects and animals live, which is the major source of new diseases and humans. It has major impacts on the migration of humans–people move around because of things. It changes the way in which people have to interact and causes civil unrest and other issues.

And then, of course, we have the direct effects of climate change, the heat and water, and temperature patterns change the way viruses and humans interact with each other. So climate change is the single biggest driver. The second is what we call deforestation. It turns out, when you chop down jungles whether it's in Brazil, or in or in East Asia, or even in the United States,

you increase the opportunities for wild animals and things that live in the forest to interact with humans, or domestic animals like pets. And those interactions are what actually led to HIV. Turns out HIV originated in Africa, probably in the early 1900s from people chopping, colonialists coming in and chopping down trees and things, and driving humans into contact with primates in a way they hadn't before. And so, these new diseases emerge this way and they're just increasing now.

Urbanization. More people live in concentrated places where they're close to each other and infections will spread easier. And then, of course, travel. Which I think is a great part of life, and it's, as you can tell from my history, something I’ve enjoyed and done with my family. But it means a disease doesn't need a passport to cross the border, it can just get on a plane and be in another country, all the way around the world within 24 hours.

So all of this is to say, not to make you depressed or unhappy, but to say there's no better time than now to work in public health. So I hope I’ve given you some new information that was interesting to you, but it also inspires you to think about possibly doing something like this, for your own career. Thank you all very much.

Jaileen Jaquez: Thank you so much, Dr. Varma, for that incredible presentation you give us so much information. So we have one question from Lucia. This was in reference to that graphic that you showed with the number of cases. She asks why is there a pattern where the amount of cases seems to be lower in the summer.

Varma: Yeah, excellent question. And so, we think a couple of things are happening there. So one of them is that we know this virus, like a lot of other viruses, is transmitted by people indoors because the air that people are sharing is much more intense. If you're in a small room, you're sharing air with people very closely.

Whereas if you are physically outdoors, you have several ways in which the virus can’t survive. First of all, it flies into the air, and then it gets floated away because of the wind. Sunlight, it turns out, is really powerful at disinfecting viruses.

And then there are other factors. So one explanation is that during the summertime people spend more time outdoors than they do indoors, and so that's why you have lower rates of the flu and COVID and numbers. So that's one explanation.

And the second explanation is that the virus itself, you know, during summer months–depending on where you are and what part of the world you're in–but here in the United States there are different changes in what we call relative humidity, the amount of moisture that's in the air. And it turns out during periods of low relative humidity, like the winter where it's really dry outside, the virus is able to fly through the air a little bit more efficiently.

And so that's why you tend to see, even in tropical climates where the weather is relatively consistent, anytime there's a drop in what's called the humidity, the virus seems to be able to survive a little.

But I’ll close by saying that this question, what we call seasonality, why the flu exhibits the seasonal pattern, and why COVID does, is something that we don't actually understand really well. We think we know the answer in the explanations I gave, but there are probably other factors that we don't fully understand.

Abbey Novia: Thank you. We have a question wondering when do we think that COVID is predicted to clear up, given the fact that many people are refusing to get vaccinated or not wearing masks.

Varma: Yeah, to sort of challenge your question, of course, is the question of what does clearing up mean? And that's kind of one of the difficult questions I was giving to all of you.

Which is that we have to decide as a society what we think is an acceptable level of disease. Because the sad reality is that we will never get rid of this, simply because, as I said, this is a virus that has an animal reservoir, and we have to vaccinate the entire world and all the animals in it. So it's not ever going away.

I guess to rephrase your question is, when do we think we'll get to a phase where the number of people getting hospitalized and dying from this illness is pretty low–let's just say pretty low, really low, and we as a society think that that's okay because it's similar to what you see with the flu or with other viruses.

I don't know the answer to that. And my expectation is that it's going to be very, very different depending upon where you live. So let's talk about New York City, for example. So, you alluded to in your question, one of the biggest challenges we face is how do we convince people to get vaccinated? Right now we're fighting with adults, okay. We’ll talk about kids in a second. We're fighting with adults who, I’ll be very frank, are just being unreasonable.

The reality is when you share air with people you have a responsibility. Just like I’m not allowed to spit on the street, or pee on the street, or do any other things when we share spaces together a basic act of decency is to protect yourself and to do simple, reasonable measures.

And because this vaccine is so safe–I mean really, you're talking about a one-in-a-million chance of having some type of severe complication compared to a disease that kills, as I said, one in 100 or one in a 1,000 people–it is not a sacrifice to be vaccinated. It's the reason we have eliminated measles, have eliminated polio, and a number of other diseases in this country.

This is the reason I had been so involved in working with the city on getting vaccine mandates in place. So I do think that, over time, what we've seen with vaccine mandates with everything else–

And you're too young to know this, but people used to fight about not wearing seatbelts and it turned out you just put a seatbelt law and people screamed and shouted and said it was going to be the end of the world and it wasn't people got to earn seatbelts.

There used to be a time you could smoke cigarettes in bars and restaurants, on an airplane. And then those got all banned, people screamed and shouted, and said oh how dare you, you're infringing on my rights.

And guess what? Nobody does that anymore. So the reality is we're going to have to get through this time, over a few months, eventually, people will fall in line. Those are adults.

Children, now, is a much more challenging situation. Because we need to convince your parents that you should get vaccinated. And we need to make sure the vaccine is safe and effective at all ages. And so we're just seeing now that we're hopeful that by November 8, people between the ages of five and eleven–if any of you are on, or you have younger brothers and sisters–we’ll be able to vaccinate them as well, too.

So here is a plea. Please be a messenger to your parents, and your friends' parents, any of your relatives that have young kids to please encourage them to get vaccinated. If they want to quote, “do their own research,” that is fine. Just don't have it be on Facebook and Instagram and on Snapchat. Have their research be, go to the CDC website, read the actual research studies, go to the World Health Organization website, read the actual studies.

Or listen to trusted public health officials. Not, you know, their cousin’s friend who knows a nurse who said you shouldn't get vaccinated, but actual people who know what they're talking about. And so you as teenagers can be really strong messengers.

I just have to say that my heart lept with joy, I saw something online where a bunch of anti-vaccine protesters were protesting in front of a school, and a bunch of teenagers were giving them the finger. And all I could think was to clap and say thank you, at least this next generation understands in a way some other adults don't.

Jaquez: Thank you. In a follow-up to that, we have a question from Tiffany. What do you think of the vaccine mandates for those that have allergies or conditions that prevent them from getting the vaccine? So what would you say to people who are immunocompromised or are unable to get the vaccine?

Jay Varma: Yeah. So the answer is there are basically very few to almost no people who can't get the vaccine. Okay, this is very clear. In fact, the people who benefit most from this vaccine are people who have some other health condition that puts them at high risk for COVID. So the only people, there was really only one group–except for young children under the age of five who it hasn't been tested in yet, or the studies haven't been completed yet–the only people that can't get the vaccine are people who have a documented allergy to not just one vaccine, but all three of the vaccines here in the United States.

By allergy I don't mean your skin itches or your arm gets sore, I mean you get a full-blown body reaction to it that can't be treated with medicine. And the answer is that very, very few people, that is like, less than one in a million, fewer than one in a million. There are lots of people who claim they can't get the vaccine. And that is actually a personal opinion that they have, it is not based on medicine.

In fact, even people who have allergies–not respiratory, not like flu allergies, but have gotten like the Pfizer or the or the Madonna vaccine and had a reaction to it–there is a lot of studies showing that you can manage those people, you give them some other medication to help reduce their allergic reaction and they can be vaccinated safely.

Novia: Thank you, Dr. Varma. So this is a question from Eric, and this is a commentary on last winter and the summer, because of the precautions that people are taking for COVID, we've seen lower caseloads and other viruses like flu and RSV. And do we expect those numbers to rebound to normal levels if people continue using masks and social distancing, or do we expect them to still be low this winter?

Varma: Okay, first of all, that is an amazing question. Thank you for asking. That is like a super sophisticated question. And I’m going to give you an unfortunate answer, which is I don't really know. So it's one of these amazing experiments, where we haven't actually done this before. Where we kept people physically separated from each other, we had widespread use of masks and people being really diligent about washing hands.

Really diligent, I mean we never expect in public health to get 100% of people to do anything. And honestly, if you could get 50%, 60% of people to do something, that has a big impact. So you're exactly right, what we've seen by all of these interventions, has been a reduction in the number of people sick from a lot of other common illnesses.

I have to tell you, I had to work all over the world and travel all the time. I got sick all the time. I mean at least every month I had a cold or stomach illness because I was going to remote areas. In the 15, 16 months after COVID struck, I got one cold in that entire time and no stomach illness, it was amazing.

So it's a really difficult and interesting question about will people keep it up, will we continue to see low rates? And if we see low rates and then we take them off, have people lost some immunity and therefore the diseases will come back in more full force.

I don't think it's likely, but to be honest, none of us know the answer to that question. There was a lot of things that we don't understand about, you know, people's immunity over time to things like RSV. So it's going to be a really interesting question, challenge.

I mean the reality is, we as humans–and this is my own sort of personal bias, but I think it's shared by a lot of people–you know we crave connection. I mean you know the greatest thing that homo sapiens did to sort of conquer the world as a species was formed large groups, organizations, large states and cities and countries. You know animals can't do that in quite the same way.

And so we really do need to be closer together to each other, but that comes with the consequence. That comes with getting infections and transmitting them. So I do think over time people are going to want to remove the mask and to spend more time with each other. And it will be the downside of some of these infections being transmitted.

But it is interesting, I do think there might be a call for–and personally, just a personal level, I’m probably going to be a lot more careful about wanting to wear a mask when I go on a plane or travel on the train or do other things.

Even let's say six months from now, let's say we've gotten widespread vaccination and COVID rates are low, I'll probably do it from time to time during flu season and stuff like that. Because you can kind of do it, and it's pretty cheap to do, and it'll probably keep me personally safe. I don't know if we'll make it a public policy, though. That'll be a much more interesting debate.

Jaquez: Thank you, it kind of seems hard to imagine life without wearing masks. Now that we started, I don't know if I can ever not wear a mask. Another question from Jasmine, and that is how does morality play a role in public health, and who decides the moral standard?

Varma: Oh amazing question. And this is probably one of the most difficult non-science questions. You know some of those are science questions. This is a big deal, this is a really big problem. And I’ve had this debate with a lot of people, and I recently wrote an essay in a popular journal called The Atlantic about this topic.

So it depends so much on your–and this is a plea to all of you to be politically active. To just get involved in elections and decisions that are being made. And the reason is, it's not fundamentally a question for science, it's a question for democracy. The people that have to decide how many jobs is it worth losing to save one human life. So if I close a bunch of businesses, I know people are going to be out of work, but I’m going to save one life. Who makes that trade-off?

It's not people like me because I’m not elected. I’m a science and a technical person. I could make that decision, but I wasn't chosen by anybody to make that decision. So frankly, what it comes down to is it comes down to your elected officials.

And so you need to get involved. I’m assuming most of you aren’t old enough yet to vote, but you need to, as soon as you turn 18, register to vote and make sure you get involved. Start learning about these issues. Because that question and morality–it's a moral question, why are we not devoting more resources to vaccinate the rest of the world?

Why are we not doing it? Because the previous presidential administration had no interest in the rest of the world. And that wasn't, frankly, in my mind, an immoral decision. This current administration is doing more, but it's in that tension over how, you know–they've done a lot, they probably could do more, but they're also fighting it here domestically. And these are tensions that they face. So the current administration is doing the right thing, but a lot of us would argue it's not doing it as much as possible. And so is that moral question, or is it that they’re not enough?

Anyway, it's a long way of basically saying that the answer to that question ends up being whoever your mayor, or governor, or president is. And so the more you get involved in that, the more likely you're going to make sure that the people making those decisions reflect your values and not somebody else's.

Novia: Thank you, I have a question that's kind of a follow-up of the question we just had about the morality question. When you when you are working with New York Safe for pandemic response, and having looked at that pyramid of the different types of responses and seeing the socio-economic factors at the bottom, how much collaboration is there between public health and lawmakers to kind of put policy in place that's going to get at that bottom rung of the social-economic factors?

Jay Varma: Yeah, great question. This is a real challenge and debate that's going on in the public health world about how much should public health people, like government public health people, be involved in kind of pushing for things that aren't strictly under the control of the health department. The health department is like counting diseases and coming up with things to fix those diseases.

But we're not like the ones that decide housing policy for the city. We're not the ones that decide, you know, what the taxation rates should be on the rich, and should there be a universal basic income. All of those things, however, have a huge impact on health itself. So a lot of public health people have sort of defaulted to the position that it's their job to kind of document, to study these problems, and make people aware about them.

But we can't because when you're in government, you shouldn't be as noisy about how things happen or don't happen. And it's a real, real tension that I don't know if we have the right answer to. You know, I will give a plug actually for the previous mayor.

Mayor de Blasio, you know I work for him directly but, one of the things that was really interesting when I first came to New York and worked for Mayor Bloomberg.

For all of his challenges–and a lot of people have rightly criticized his policing policies and stuff like that–he was obsessed with public health. He actually wanted a report all the time about the latest death data, and who is dying, and why they're dying.

You know he has the whole school of Johns Hopkins, which is one of the best public-health schools in the country. He's funded all of that, that's why it's named after him.

So he was the first elected official that I know of, and really the only one that I know, who was so deeply committed to public health and understood the intersection of all these things.

There were a number of anti-progressive policies that he took for other reasons, but at the same time, he was really deeply concerned about that.

So it's a call to action to try to see if we can elect more government people, again getting back to this activism question, electing people who want to have public health people in the room when they're making decisions about taxation. And we can call this “health in all policies.”

Have a health person there when you're talking about building a new structure somewhere, or where you’re going to put your new sanitation facility, and maybe you shouldn't stick them all in the Bronx where people already have high rates of asthma and they need to be exposed to another incinerator. Make it a health question too. It's a challenge, you know, you need to find elected officials who really think like that because otherwise, you won't be in the room when those decisions are being made.

Jaquez: Thank you. And we have one more question: how do economic factors affect disease intervention?

Varma: Let me see if I can try to interpret that question correctly. One way to answer that question is, you're talking about cost and saying like, how do you get the money to do something? And that's just really about how well you can push and advocate in government. You know, public health people–doesn't matter whether you work, here or anywhere else around the world–we are often lower in the hierarchy of government officials than, say, the police or fire or treasury-type people, people working with money. But we need to push our voice, make sure there are more resources to it.

The other way to interpret the question is, I think you might be asking, why is it that things like economic equality make people live longer? And again, we don't actually know the biology of this. How is it that having more money in your bank account means your body fights off diseases better? We don't actually know the answer to that, but we actually know it's true.

And the reason we know it's true is you can look at studies where you control for every other type of factor, and you see things like perceived racial bias and other things like that. And stressors in life, whether from economics or other things, remain the only factor that would explain why somebody is getting one outcome for another. There are theories about environmental exposures, and how they can alter the way your body expresses certain factors from its genetics, but those are really all theories. But we know this.

And these studies have been done. You know in England, years ago when they had their civil service, there were interesting studies where they looked at different people's income levels, even if they have equal access to things. And you see even if they have equal access to healthcare, their health outcomes are worse. I mean we think that the mechanism is really that, basically, the more… And we all know this intuitively the more stress you have in your life, the harder it is to do things that keep you healthy, and the more susceptible you are. I can't give you a biological formula for that, but we just intuitively know it's true, and we have the evidence to support it.

Jaquez: Thank you, thank you, thank you so much, Dr. Varma, and everyone who joined us for this amazing event.

Varma: Thank you all very much.