Jennifer Miller: Scoring the Ethics of Pharma Companies

Harlan Krumholz: Welcome to Health & Veritas. I’m Harlan Krumholz.

Howard Forman: And I’m Howie Forman. We are physicians and professors at Yale University, we’re trying to get closer to the truth about health and healthcare. This week, we’ll be speaking with Professor Jennifer Miller. But first, we like to check in on current health news, and Harlan, you have a paper out that really is illuminating, to say the least, about some of the challenges we face in healthcare. Now, give me a little summary of that.

Harlan Krumholz: All right, thanks, Howie. We had a paper that came out this week in JAMA, one of our leading medical journals. Then this paper was really a collaboration between our group at Yale, the Center for Outcomes Research and Evaluation, and the Agency for Healthcare Research and Quality (AHRQ) and CMS, the Centers for Medicare & Medicaid Services. And it sought to answer the question, what’s the state of patient safety within U.S. hospitals? We know that many people get hospitalized and unfortunately suffer from unintended adverse consequences. They have events that are related to the way in which we deliver care and lapses in patient safety are a major cause, and we’ve known this for a long time. And in 1999, there was a big Institute of Medicine report that was called “To Err Is Human.” That got us thinking that we shouldn’t just be urging people to be more vigilant, healthcare providers, doctors, and nurses to be more vigilant, remember to do the right thing, be careful.

You know, we needed to move from an era where we were just urging at the sidelines for the system to get better, to putting in place systems that would protect patients and ensure their safety. So we looked to a place like aviation, where there were checklists and routinized processes and the aviation industry had driven toward becoming a much safer place to fly. There are far fewer accidents that were occurring, far fewer oversights as they move from depending more on the expert professionalism of the pilots and staff and teams to depending on that, plus having in place lots of systems that would ensure that they never left without a full fuel tank, for example. Because there was redundancy of effort and lots of people were checking in and every time they took off, they went through the same routine. So for tedious routinized tasks, they made sure that they were all being covered.

So the question on this study was, what’s the current state? And have we improved much over this time in the face of a lot of efforts to try to move us from a maverick period of medicine where people just tried to be as good as they could be, to one where the systems were also helping us? This is built on something called the Medicare Patient Safety Monitoring System. So the government has a system that’s run by AHRQ, a government agency with the Medicare group that actually goes out to hospitals and says, “We would take like to take a look at your charts. We want to audit your records to see what’s going on.” And this is important because if you just went to the hospitals and say, “We want you to report to us how many errors or adverse events you have,” you’re sort of depending on each hospital in the variation which they ascertain these problems, and in a way, the fox is guarding the henhouse too. I mean, they’re being judged and maybe not all hospitals are working as hard to try to determine these events, but instead in this case, they’re going out, they’re picking random charts. They’re being sent to professional abstracters, healthcare professionals who dig through these records and try to identify if anything went wrong. If people had adverse events and we looked at adverse events related to drug effects, we looked at adverse events related to surgical procedures. We looked at hospital-acquired infections, and then we looked at things like falls or pressure ulcers, which also should be largely preventable with good systems.

And this was an enormous effort, Howie, more than 250,000 records over 10 years from more than 3,000 U.S. hospitals. It was the largest effort to understand patient safety in American hospitals that’s ever been conducted. And we found some really interesting things. I mean, we looked at the years 2010 to 2019, and largely there was a lot of improvement. We looked at heart attacks, pneumonia, heart failure, surgical procedures. And in each one of these areas, there were marked declines in the number of adverse events. Patients were safer today in 2019, of course, just before the pandemic, just before the stress test of the pandemic. But patients were largely safer than they had been in 2010, up to 2019. There were some areas where there wasn’t as much evidence of gain, but in those four conditions, those four areas, there were marked gains.

And then what we kind of have accompanied this with, and I know this is a little bit long-winded, but I’ll just finish here is to say that rather than celebrate this, I think this really showed that many of these events are preventable if we strengthen systems, but the rates are still too high. They’re still way too high, there’s still too many people who are coming in the hospital to get help and actually end up being undermined by something that happens, that was an unintended adverse consequence that likely could have been prevented, whether infection, adverse drug event. Something that could have been prevented and that we should be able to prevent if our system gets safer and more reliable.

So we’ve kind of came to the conclusion that, hey, good news to celebrate. We’re making progress, but hey, we’re not done. We’re not done by any means. We’ve got to strengthen these systems and make sure that no one suffers in the hospital because of, as a result of missteps or lack of prevention within our walls, that for events that not only can be disabling but actually can be deadly. And so we need to do a better job about that. So this study’s been in the works for a long time. Sometimes people see papers and they think, “Hey, I wonder what went into that.” Well, a lot went into this. But we were proud to be able to give an accounting of what’s going on in U.S. hospitals.

Howard Forman: And look, first of all, I want to applaud you and your colleagues for being able to do this. This is a mammoth undertaking. And as you point out, there’s been very few studies that have had sort of the breadth of survey that you’ve had. I mean, the New York, I think New York State Hospital Study by Harvard was done like 40 years ago now. And that was an extensive chart review so, we don’t do this that often. What you’ve done is like a once-in-a-generation type effort, but one of the things is, you make it sound like the glass is half-full, the glass is half-empty. And I’ll just say, having been a patient in the hospital a lot of my life—and not a lot of my life, but a lot compared with most people, at least 60 days, 70 days over the years—it does strike me how hard it is to reduce some of these adverse events.

You have a patient with an IV that’s been in for three days and you know, you’re going to be able to take it out sooner. You don’t want to stick the person in extra time. You want to take a full catheter out as soon as possible to avoid infection, but you leave it in one extra day because the patient’s afraid of going through the night, not being able to urinate or something. There’s so many things that you start to fixate on when you’re a physician as a patient. And I just wonder, do you have a sense for how much of what we’re calling adverse events really are baked in? The fact that someone can fall in the hospital is not necessarily a dereliction on the part of the hospital, because if I were to fall while I was a patient, I’m a low risk for fall, but if I were to fall, it’s not their fault. It’s just baked in that, unless you’re going to tether me to the bed and prevent me from getting out of the bed, I may go to the bathroom.

Harlan Krumholz: I think we need to be audacious in our goals. And you and I have both been socialized into a system to have this expectation that one of the costs of being hospitalized is bad things happen. And sometimes those bad things can be catastrophic things that can happen. And we haven’t been socialized and taught from the very outset to think, what would it be like if these never happened? And what are the string of things are associated with you? You tell me about the falls, so it’s like, it’s not just that a nurse needs to be at your side to walk you, but like how many times have we woken you up? So that you’re sort of delirious because you haven’t gotten any sleep for three days and you’re malnourished. So you’re weak and you know, these are all, they’re complex systems.

The root causes often are not straightforward, but the question is, are we going to make a commitment to drive ourselves, not to spend so much with every patient surrounded by four nurses at all time, but to find cost-effective solutions that maybe technology can also help with this, where we can say that we want to be in a position where we’re never harming people. It’s not a cost of coming in the door that all of a sudden you’re incurring this risk. But in fact, we’ve been able to create safe and reliable systems where we are able to decrease the risk. And the truth is we may not be able to get to zero, but this is a probability issue. And if we can move that probability way down, because there’s so many triggers in our hospitals that kind of enhance the risk.

And if we can start thinking clearly, and even like how it’s been years for us to get people to wash hands going in and out of rooms. And we think that’s a highly effective way to stop transmission of infection and still it’s not happening routinely. And I think we’re still not taking it seriously enough. And then there’s one other issue, which is, there’s great variation across institutions. So, that’s why I think this is actually remediable because there are places that are able to achieve quite remarkable rates of low rates of harm compared with others. And so I think it’s a matter of us prioritizing. Look, everybody wants to look at the bright, shiny object in medicine: “What’s the new drug? What’s the new this? What’s the new that?” But a lot of this blocking and tackling on the basics can lead us to great returns in terms of benefit for patients and our patients expect it. They don’t come into the hospital expecting to be harmed, and we’ve got to be worthy of that trust as they come in. They’re very vulnerable, and we need to make sure that they’re not suffering as a result of preventable harm.

Howard Forman: Yeah. And look, what you’re doing is illuminating a problem. And you know, our next guest is basically an expert in trying to help us do better in that way. I’m really delighted to introduce Professor Jennifer Miller. Jennifer Miller is an assistant professor at Yale School of Medicine. Her research focuses on the ethics of the pharmaceutical industry and digital medicine. She is the director of the Good Pharma Scorecard (GPS), an index that ranks pharmaceutical companies based on ethical performance. She’s the founder of Bioethics International, a nonprofit that researches and releases GPS rankings for pharmaceutical companies on factors, such as clinical trial, transparency, and data sharing. Outside of Yale, she serves on the World Economic Forum on formularies and on ethics committees. I want to start off by asking about your journey to being a world leader and expert in biomedical ethics. When you and I last spoke, I found it fascinating. I wanted our listeners to understand this path. You graduated from Fordham with a degree in physics. So obviously the next step was to go to Rome to study biomedical ethics. Do I have that correct?

Jennifer Miller: Yes. Science magazine wrote an article, and it was called “The Mistake.” I was hoping to be a PhD tracked in physics. And somehow my senior year got an invitation to a conference in Italy, at the Vatican with politicians and scientists to discuss cloning and stem cell research and other advances in biotechnology. And the invitation was a mistake. But for whatever reason, I didn’t realize that, got on a plane and landed in Italy. So I got off the plane in Rome, was pouring rain, went to the conference site and it turns out, of course, unsurprisingly, I am not invited, ended up getting snuck in as a translator and listened to for the first time, I think, a real live bioethical debate and just sort of realized how much work there was that could be done in that space.

Howard Forman: And so, and from there, you went ahead and you got a degree. Tell us about what getting a degree in Rome from, I can’t even pronounce it. You’ll pronounce it for us and getting a PhD, and what that has done to sort of inform you compared with so many other ethicists who go through very different paths.

Jennifer Miller: Yeah. So the university I studied at is a pontifical university, meaning it’s affiliated with the Vatican. So they claim they started the first full faculty in bioethics, meaning bachelors through PhD program. I was not interested in studying there when I first received the invitation, but I forwarded it to everyone I knew, and then no one accepted. And there was just something nagging in the back of me that said, “Somebody should be studying ethics along with science.” And so I ended up deciding I would just go for one year, and then the one year turned into a lifetime and here we are.

Howard Forman: And then after that, and then I’ll let Harlan speak, but I just want to make sure I’ll listen to understand this—that’s not enough for you. I mean, you went on and you went and did post-op work. You got additional training. What are the components that have gotten you to this point right now?

Jennifer Miller: A lot can help from the village, right. I think you can’t do anything without help from a lot of mentors and supporters. But after graduating with the PhD in bioethics and having done my dissertation focused on ethical standards for the pharmaceutical industry, sort of cataloging the problems that we know about companies and then developing corresponding normative standards that we’d like to see companies implement in order to address the problems, I sat back and I realized ethics focuses a lot on what you shouldn’t do, to some extent what you should do. But it doesn’t focus enough, at least back then, on how to get the good implemented, right? How to create space for ethics to flourish within institutions and sectors.

So I ended up getting a postdoc. I took a lot of fellowships, one at Fordham studying business ethics. Then I went up to Harvard for three years to study institutional corruption, which just means studying the factors that influence an institution to deviate from its mission, whatever that mission is. And then, again, delayed my start as a faculty person to study down at Duke, regulatory governance theory. So how do you regulate in government industry all to get towards this space of how do we sort of move the pharmaceutical and the healthcare innovation space to be more ethical, more patient-centered?

Harlan Krumholz: How do you think about this moment in the field? Because what I see are like too few bioethicists around too few rigorous approaches to trying to construct our ways to think through these problems and then reach pragmatic solutions that can iterate over time. It’s almost external to the whole process. And I worry about them. I’m so glad when you joined our faculty. I’m so excited whenever I talk to you about the opportunity to think through problems. But it just seems like you’re an unusual, there are not enough people and we don’t have enough processes in place to manage the large number of challenges that are coming our way.

Jennifer Miller: Yeah. So you’re in good company. James Childress, one of the early founders of the field or pioneers in the field. He often would conceptualize bioethics as a work in progress that you’re applying theories and normative frameworks to situations that are changing. We’re learning more, we have more empirical data over time. The technology is evolving, so what you said is absolutely right. Taking a learning perspective or approach to bioethics is important, iterative, right. Constantly updating your analysis based on new information and new advances.

Harlan Krumholz: Yeah, it just seems like we need to bring this some in, I just want to give a shout out to Bernie Lo, who was an early mentor of mine, who within UCSF [University of California, San Francisco] was able to carve out a very successful career in the area of bioethics and to try to integrate, as you have, action into practice. And I remember talking a lot about the work that Al Jonsen did that sort of was formative for me anyway, in my training. But between the time that I worked with Bernie and the time I met you, my interactions with people, bioethics. I mean, Zeke Emanuel aside, and Zeke’s kind of got his own sort of path and lane, particularly the way he’s been able to manage policy, ran bioethics at NIH for many years.

And Art Caplan, give a hat tip to Art, about being in the public domain and really interacting with the public a lot around these issues. But I just don’t think it’s enough. You know, it’s not nearly enough. And part of me thinks that we need more examples of how this makes sense. So maybe this leads to getting you to talk a little bit about what you’ve done, pragmatically. I mean, with this scorecard, like how have you tried to match the theory with practice and actually make change within medicine and healthcare?

Jennifer Miller: Yeah. I mean, it’s actually a big question, what role bioethicists should play. I definitely have taken more of an activist role lately, but using, you know, founded on empirical research on qualitative studies and all that stuff. Yes, big project that I think everyone knows about is the Good Pharma Scorecard. And it’s an index that ranks pharmaceutical biotech and med device companies annually on their bioethics and social responsibility performance to do a couple of things. It helps set clear goals and targets for the sector to say, what good looks like, what we should be aiming for all together, and then help us track progress on those goals over time. Which also recognizes where there are best practices and catalyzes better behavior to performances where needed. So I agree with you, I think that we don’t want to just think about what the problems are and what we should be doing but create incentive design mechanisms and other these other tools to help.

Harlan Krumholz: So just to be clear about this, tell me what problem you were seeking to solve with this. What was the problem to solve?

Jennifer Miller: Yeah, so we use a lot of medicines and vaccines, but at the same time, very few people trust the pharmaceutical industry. Ninety-one percent think that the industry puts profits before people and only 9% think that they’re honest and ethical. And from the outside, it’s actually really hard to tell what’s going on within companies, whether these are, you know, the distrust is misperceptions, right, and based on old data, old issues, or outlier cases, or actually if there are genuine and widespread problems within the sector today that need to be changed. And the truth is probably somewhere in the middle. And so the scorecard started out as prevalent studies, right? Let’s just design prevalent studies to understand what’s going on within companies and bridge those asymmetries of information. The prevalence studies overwhelmingly showed problems. Like none of the prevalent studies said, “Hey, companies are doing great.”

Harlan Krumholz: Just tell us more about what you mean by “prevalent studies.”

Jennifer Miller: Yeah. So you take a concern about pharma companies. One that I know we all shared, at least way back when, was that companies were selectively reporting trial results or selectively reporting outcomes within trial results and papers, right? So there was a transparency problem within pharmaceutical companies. And then the theory was that the information that was getting disclosed tended to be the positive clinical trial results, not necessarily the unfavorable of the negative results. And so interestingly, your team, which is part of the reason I came to Yale, had been studying this, but the bioethics field wasn’t measuring things. They weren’t getting into depth. And so I found Joe Ross, and we started doing these prevalence studies to see how genuine, widespread, and current that problem was. And what we found is there’s a pervasive transparency problem. Very few companies were meeting even baseline legal requirements for transparency, results reporting for a very narrow set of legally required trials to have results in the public space and then let alone higher ethical standards that we might want companies to implement for a patient in public health.

Howard Forman: Can I ask you one of the challenges I think in doing the work you’re doing is that it’s not naturally funded by our system, the federal government doesn’t set aside money and say, “We need better oversight. We need biomedical ethics and illumination of some issues that would otherwise not be solved.” How do you go about raising funds to do the work that you do and how do you make decisions about who you take money from and who you don’t? And part of the reason why I’m asking this is we had an earlier podcast with Lauren Taylor from Harvard, and it got me thinking more about like where the money comes from, where it goes to can matter so much to people. I’m wondering, how do you figure that out? It’s another ethical issue. It’s a sort of a meta-issue, almost.

Jennifer Miller: Yeah. So let’s back up a second. When prevalence studies detect genuine widespread problems within the sector that are very harmful to patients, you have to step back and say, “What should we do about this?” Right? And how, and then once you decide what you’re going to do, which in my case was reform the problem, you have to think about how you’re going to go about doing that. And so for the Good Pharma Scorecard, we were very lucky to initially get funding from patient groups. Our first funder was Susan G. Komen foundation and different foundations, like the [Laura and John] Arnold Foundation. Foundations love to support new projects; they like to support the development of new measures.

So when we add new measures to the Good Pharma Scorecard, it’s been relatively straightforward, and I don’t want to jinx this, but relatively easy for us to fund the development of new measures. So we are now developing new measures around equity and clinical research and those are very attractive to funders. Funding, sustaining the Good Pharma Scorecard, so repeating the same measurements year after year—not so attractive to funders. And we have to ask a society, do we want to just measure once or do, if you want to reform a problem, we have to keep measuring. And how do you sort of fund those long-term efforts?

Howard Forman: Do you have ideas about sustainable funding and what do we do as a society to make sure that the type of work you do is maintained?

Jennifer Miller: Are you really asking the cutting-edge, hard-topic questions? Ideally, patient groups and NIH would fund these things, but they’re not. So there are a variety of things I’ve been looking into. Most of these accreditation, certification, and rating and ranking programs are funded by the entities that they’re ranking. So Kimberley certification for conflict-free diamonds are funded by industry, credit rating agencies, the institutions. Once, the credit rating funds wasn’t always the case like before 1970; the investors funded the credit rating agencies.

So you could take a fee-for-service model, which is not what we did because we rank every company, regardless of what they do. It’s not fee for review, but something I’ve been thinking about doing is launching a membership program where a variety of institutions who support advancing ethics and patient centricity and social responsibility in the pharmaceutical sector could pay a membership program, a membership due every year. And that would support the sustaining efforts, not the new pieces. And you would have a variety of different types of entities and members like asset managers, like the whole ESG, environmental, social, governance investment space. They might be members, patient groups, foundations, and possibly also the pharmaceutical industry.

Harlan Krumholz: What was the day that you thought, “Gosh, I’m really glad I went into this field. I really think that I’m in the right place and I’m doing the right thing.” Can you tell us a day like that?

Jennifer Miller: Okay. June 9th of this year, so last month we hosted a meeting at Deloitte with the 25–30 largest pharma companies with a lot of C-level executives there. Heads of environmental social governance, ESG, chief medical officers, heads of diversity, equity inclusion, high-up people. And I debuted the new Good Pharma Scorecard rankings, showing how companies ranked on including different demographic groups in clinical research and companies didn’t score well. And only one scored fairly well. And they didn’t score well. So I was expecting a lot of pushback on the measures like we usually do in a big fight. I don’t fight, but just like me listening to them fight at the measures. And in fact it was the first time that all the companies, generally speaking, were in favor of the measures and they wanted to do more. They recognized that it was a problem. They wanted to use the Good Pharma Scorecard to benchmark and track progress and hopefully evidence improvement over time. And to me, that was quite a stunning moment.

Harlan Krumholz: That’s incredible. That really is.

Jennifer Miller: And then the other one.

Harlan Krumholz: I mean, What?

Jennifer Miller: Sorry.

Harlan Krumholz: Go ahead, I want to hear. I want to hear another one.

Jennifer Miller: Fifty percent of low-scoring large companies will improve their procedures within 30 days of getting a low Good Pharma Scorecard measure.

Harlan Krumholz: So just on the angle, why I was asking it is like, so when a young person is contemplating following your lead as a career. Like, what do you tell them? What is it that you say to them that might encourage them along this path?

Jennifer Miller: Harlan, when I was doing a job talk at Yale, you asked me something about, what brings you joy? Like, do what brings you joy. That’s actually, I adopted that, and I ask students the same thing. What are the topics, and they’re bringing you great deep satisfaction in studying. What’s going to bring you a joyful life? And when that’s at the service of others is often helpful in their regard.

Howard Forman: Well, it’s been an honor to have you come join us on the podcast. We have to have you back and just know how much I appreciate you as a colleague and a friend and how much the students appreciate you.

Harlan Krumholz: Yeah.

Jennifer Miller: I appreciate that.

Harlan Krumholz: And I mean, you’ve taught me a lot and I hope that there’s ample opportunity for the kind of work you’re doing to spread and to be integrated into almost all the projects that are done around here, because they all have ethical dimensions. And the truth is, I don’t think we’re paying enough attention to those things. And then the way you connect them into actions is just so important. And anyway, it’s great to have you as a colleague too, and really appreciate you coming on.

Jennifer Miller: Can I put a plug for anyone who wants to work on equity and biomedical research? Quick one?

Harlan Krumholz: Absolutely.

Jennifer Miller: Okay. So the next big area that we’re working on is equity and biomedical research equity in the pharmaceutical sector and we’re focusing on three areas. One, who we’re enrolling in clinical trials, right. We tend to test drugs on patients who are younger, healthier, more likely to identify as White and often sometimes more likely to be male than real-world patients. So the next Good Pharma Scorecard’s developing fair inclusion and representation measures. So comparing enrolled trial participants to the patients with the conditions targeted by a study, looking at which drugs and medicines we’re bringing to market and which conditions and diseases we’re targeting with our research, right? So how do we set fair and equitable research agendas that are helping everyone, not just select populations.

And then this is a growing edge. We tend to test drugs in high-income countries, even though often, the rest of the world, non-high-income countries need the drugs. And there are concerns that clinical trial data may not extrapolate across geographic regions. But even when we include non-high-income countries in research, we call the clinical trial participants partners. We don’t even make the products commercially available in those countries, which raises exploitation concerns, let alone affordability. So the next Good Pharma Scorecard measures are also looking at whether we provide commercial access and then affordable products in the countries for their time.

Howard Forman: That is one of the issues that we’ve faced over the last two years with the clinical vaccine, the vaccine trials. And for those of us that don’t spend a lot of time in this space that was highlighted a lot. And I looked at, I think it was a pre-print to the work that you’re doing right now. And it really is shocking how poorly in general we do in terms of representation.

Jennifer Miller: Yeah. And then Joe and I did a study looking at which countries participated in the COVID-19 vaccine trials. And there we found that while companies did submit their products for the vaccines, for regulatory authorization in the countries, they didn’t give them equitable amounts of vaccine. So we call these patients or people partners and then we didn’t really treat them that way. So.

Howard Forman: Thank you.

Jennifer Miller: Thanks.

Howard Forman: Thanks so much.

Harlan Krumholz: So Howie, that was a great section with Jennifer, and now we’re pivoting to this last part where we get to hear what’s on your mind. What are you thinking about lately?

Howard Forman: Yeah, just briefly. I think you’ve covered this really well over the last several weeks. But I just want to echo some of the things you’ve said, that COVID is not behind us. BA.5 and variants that follow that aren’t even variants of concern or interest yet, but will be, are coming, continuing to wave by. And they’re not peaking at all. Yet New York has a 15% positive rate. Connecticut as well, above double digits, hospitalizations are going up in Connecticut and New York. And really broadly across the country, deaths are mounting. Even if they’re lower relative to cases, they’re still way too high. And it seems like more and more of these variants are able to evade the immunity that we’ve already acquired through vaccination and prior infection. So it’s a little sobering.

On the other hand, I talked yesterday to a reporter about what can we do? And there are things that we can do for ourselves and things we can do for our communities. And they are a reasonable list of things that everybody should continue to think about. Continue to think about wearing a mask, if you’re going to be within any distance of somebody indoors and talking to them. And certainly consider testing if you have symptoms. And if you have symptoms or you don’t want to test, stay home. We have medications now that allow people that are at high risk of adverse outcomes to be treated very early. But the only way you can do that is if you do test. So encouraging people to take advantage of those free tests and those cheap tests that are available to individuals right now.

And then on top of that, I think we all have to just be cognizant to the fact that our lives are different now. If there are things that you might have done in the past, that would be high risks for spread, reconsider them. I’ve heard too many times people talking about going to crowded indoor events and all of a sudden there’s a large outbreak. And I think in order to help our communities, help each other, we have to actually pay attention to what our impact is on others, not just what our impact is on ourselves individually. And certainly the last thing, obviously, vaccination.

Harlan Krumholz: I was just wondering, were you surprised? I mean, in some ways we started talking about the seasonality of this and maybe expected a quiet summer, but the cases seemed to be increasing. Did that surprise you at all?

Howard Forman: It certainly did, because we were all hoping that seasonality was a feature of this virus. And I think what we’re learning is it’s not so much seasonality. It’s just that for most of the variance, you get an outbreak that leads to a certain amount of acquired immunity in the community. And until that fades, you basically have a little bit of a lull, but now we’re having variants that are evading even recent immunity. People that had Omicron in February being reinfected in May. And that’s something we did not see in the first two years of the outbreak. Now we’re seeing a lot of cases of people who aren’t having an increased, a rebound effect after Paxlovid, which we’re also seeing, but who are legitimately having a second infection.

Harlan Krumholz: If you had to make a guess about what’s going to happen in the fall, what do you think is going to happen?

Howard Forman: I think that the waves are going to continue getting bigger and bigger. I just declined an event in Missouri that I would’ve loved to have gone to, quite frankly. I hate travel, but it was something I wanted to go to. And what I talked to people and the thing that kept coming through my head is even if New York is starting to look a little better, will Missouri be a little better? What does it look like to go through an airplane where people are mixing from all over the country? It’s hard to imagine that we’re going to have a quiescent period anytime in the near future, particularly when people are not taking any serious measures in a population sense.

Harlan Krumholz: Yeah. It just seems like the best thing is for us to be prepared at all times right now and know that this thing might last, I’ll just end with this. You know, when Zeke Emanuel said at the very beginning of the pandemic, I remember Zeke wrote this. He said, “Black death lasted for decades. This thing could last for decades.” And at first I thought like, gosh, that seems like pretty dark. But now I’m thinking, it may be that we just need to manage with this thing being ever-present in the globe for a while. And I don’t see how China’s going to be able to keep zero-COVID policy. I just don’t see how they’re going to be able to do it. Given the infectivity of this thing, it’s going to be very interesting to watch.

Howard Forman: Yep. I agree.

Harlan Krumholz: You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.

Howard Forman: So how did we do? To give us your feedback or to keep the conversation going, you can find us on Twitter.

Harlan Krumholz: I’m @hmkyale. That’s H-M-K Yale. I’m @hmkyale. That’s hmkyale

Howard Forman: And I’m @thehowie. That’s at T-H-E-H-O-W-I-E. You can also email us at health.veritas@yale.edu. That’s health.veritas@yale.edu. Aside from Twitter and our podcast, I’m fortunate to be the faculty director of the healthcare track and founder of the MBA for Executives program at the Yale School of Management. Feel free to reach out via email for more information on our innovative programs, or you can check out our website at som.yale.edu/emba.

Harlan Krumholz: Health & Veritas is produced with the Yale School of Management. Thanks to our researcher, Jenny Tan, and to our producer, Miranda Shafer. Talk to you soon, Howie.

Howard Forman: Thanks very much, Harlan. Talk to you soon.