Intro/Outro Speaker:
From the library of the New York Stock Exchange at the corner of Wall and Broad Streets in New York City, you're Inside the ICE House. Our podcast from Intercontinental Exchange on markets, leadership, and vision in global business, the dream drivers that have made the NYSE an indispensable institution of global growth for over 225 years. Each week, we feature stories of those who hatch plans, create jobs, and harness the engine of capitalism. Right here, right now at the NYSE and at ICE's exchanges and clearing houses around the world. And now, welcome Inside the ICE House, here's your host, Josh King, of Intercontinental Exchange.
Josh King:
At the beginning of the pandemic, we all had a lot of questions. How do I keep my friends, families, colleagues, and even myself safe? Should I wear a mask? Should I wear latex gloves while pumping gas? I did that for a while. We all wanted to know how long this was going to last. I remember sitting in a ski lodge on February 26th, 2020 surrounded on all sides by panting breathless skiers packed liked sardines watching President Trump, Secretary Azar, and Dr. Fauci in their first coronavirus task force briefing as they announce that Vice President Pence would coordinate the nation's response. The weeks and months that followed constituted, for all of us, a crash course in epidemiology, virology, and pharmacology. As we read and watched the news, our eyes gravitating from mainstream outlets to niche medical journals that few of us ever knew existed. When everyone started talking about the Lancet, I thought of all those yellowing copies in the old home office of my dad, the town pediatrician of Newton, Massachusetts.
Josh King:
It was easy to get overwhelmed, but few voices were more direct, steady, and sanguine than Scott Gottlieb's. He gave us the facts, was patient with our dumb questions, and helped us understand what was happening and what was yet to come. Throughout the pandemic, he laid out what the science was telling us and how we could use that to live and adjust our lives. During this historic crisis, the New York Stock Exchange, like the rest of the world, turned to the experts to help us understand how we would get through COVID-19 and keep those who work in our building safe. Dr. Gottlieb walked us through the steps as we temporarily closed the trading floor, sent most of our employees home, kept calm, and carried on. Scott's been a singular voice in public health, particularly for the business community. His deep understanding of science, economics, and finance make him a uniquely qualified ambassador for the medical community, who can parlay complex messages into intelligible content with direct action. Our conversation with Dr. Scott Gottlieb is coming up right after this.
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Josh King:
Welcome back. Just describing Scott Gottlieb's career would take as long as we have for this episode. In brief, he served as the 23rd Commissioner of the FDA and was also the FDA's Commissioner for Medical and Scientific Affairs during the Bush administration. He helped implement the Medicare drug benefit as a senior advisor to the administrator for Medicare and Medicaid services and was appointed by the Senate to serve on the Federal Health Information Technology Policy Committee. Scott currently serves as resident fellow at the American Enterprise Institute, special partner at New Enterprise Associates, and is on the board at various companies, including Pfizer, creator of one of the vaccines that went into 60-some-odd percent of our arms. That ticker symbol, listed PFE, listed right here on the New York Stock Exchange. Welcome Scott, Inside the ICE House.
Scott Gottlieb:
Thanks for having me.
Josh King:
As of today, on the Mayo Clinic's website, 46.9% of the nation is fully vaccinated. 54.6% have at least one dose. As we head into the fourth of July weekend, that's well short of President Biden and Jeff Zients' goal of 70%. In the next 48 hours can we jab another 20% or resign ourselves to what this flattening plateau means for the nation?
Scott Gottlieb:
Well, the goal was 70% of adults over the age of 18 and we're going to fall short, but we're not going to fall short by a lot. They'll probably get to 65, 66% on a look back. The bottom line though is that we do need to get vaccinations rates up if we want to really create a substantial backstop against this new more contagious variant, Delta. If you look at some of the modeling looking out to the fall, September, which is when we think we're going to have another surge of infection, as result of this new variant. If can get vaccination rates up to about 80% of eligible adults over the age of 18, you're starting to get into territory where the virus just won't be able to spread. We'll probably be more at about the 70, 75% range. I think we could get to 75%, we'll probably get to 70%, because we'll continue to pick up people over the course of the summer, but we'll be short of where we need to be if we want to see chains of transmission really get broken off.
Josh King:
What's your advice today to companies like the NYSE where people congregate every day, pretty close quarters, in terms of social distancing, masking, and maintaining public health?
Scott Gottlieb:
Well, look, I think right now prevalence is low, so the risk is low, and in parts of the country where you have high vaccination rates, high levels of immunity also from previous infection, you're not going to see even the Delta variant really get a strong foothold. If you look at the modeling going into the fall, the consensus models predicts that we're going to have a surge of infection somewhere around back to school. That's going to be about 20% of the peak of the previous epidemics. Now, I think those models are a little bit overly ambitious, because they don't bake in the impact of immunity acquired through prior infection enough. Some of the models do, some of the models don't, but if you look beneath those models, what you see is wide variation between the states. So whereas before we had pretty much a confluent epidemic across the entire country, some regions were harder hit than others and regions were hit at different times.
Scott Gottlieb:
What you're going to see now, I think, is a hyper-regionalized epidemic where there are certain parts of the country that really are engulfed in infection, have widespread transmission and other parts of the country that are largely impervious. And I think when you look at the Northeast, the Northeast is going to be one of those regions where you're not going to see the same velocity of spread. You have a lot of people who've been infected in the Northeast, we've had successive waves of infection, including the first wave. We were the hardest hit region here in the Northeast, and we also have higher vaccination rates. And the combination of immunity from prior infection and the immunity acquired through vaccination, I think is going to make this region less susceptible to really high levels of transmission, so you're just not going to see the prevalence.
Scott Gottlieb:
So it's a long way of saying if you're a business operating in the Northeast, I think the kinds of measures that you're going to be contemplating going into the fall is going to be different than if you're a business operating in Missouri or Ohio or Arkansas, states where vaccinations are low and where you're likely to see more spread of this Delta variant. So heading into the fall, I think businesses need to understand what the overall level of vaccination is in their population. If it's low, I think they need to contemplate certain measures to try to keep the virus out of a workplace setting, especially if they operate a workplace setting where people are close together and it's conducive to spread, so you need to assess what is the risk of spread in your work site? Are people interacting close together? Do you have large groups of people interacting? Do you have poor air handling in a confined space where you have the risk of a sort of super spreading event?
Scott Gottlieb:
Then you need to assess what is the immunity in your population? Are most of your workers vaccinated or do you have an undervaccinated population? And then, from there, I think you need to contemplate what measures you're going to implement, it could be things that try to keep the infection out, so you have symptom checks, you screen people. It could be things that you impose on individuals, people who aren't vaccinated have to wear masks. It could be requiring people who are unvaccinated either to work from home or to undergo some periodic testing, but there's layers of things you can contemplate depending on what the risk is in your particular setting.
Josh King:
On your CNBC appearances, Dr. Gottlieb, your scrupulous about disclosing your business engagements, including your directorship of Pfizer. Curious what the last year and a half has been like working with Albert Bourla and his team in the life-saving effort to roll out the vaccine.
Scott Gottlieb:
Albert's been all in on bringing this vaccine to the market, and also advancing other therapeutics. There's a small molecule drug, an oral drug, in development at Pfizer, as well, in advanced development that could be a potential treatment for coronavirus. I think what was striking from the perspective of being on the board was how front and center this program was. Typically, on a board, and especially Pfizer, but any company, I've been on other boards, as well, and I serve on other boards, You don't get briefed at every board meeting about development program. There's hundreds of development programs going on. The management team was exceedingly engaged in this program. Albert was very hands on in directing it personally. And at every meeting, the board was getting briefed on updates around COVID-19 and spent a substantial portion of our time being updated and weighing in on the COVID-19 related activities.
Scott Gottlieb:
The company was really focused on this and I think that that helped bring this product to market more quickly, the fact that Albert was so engaged, the fact that he was directing this. From my experience at FDA, that kind of senior involvement makes a difference. When things were important to me at FDA and I got personally involved in them, it helped drive them forward. And so, I think the same thing here. Albert's direct engagement in this development program, I think, helped accelerate the timeline.
Josh King:
I mentioned in the introduction that we've all got into science and medicine through this, but it also turned the names of important, perhaps behind-the-scenes doctors, like Dr. Fauci and yourself, into these household names. I think Dr. Fauci has spoken most recently to Kara Swisher about how he got through the increased attention, both good and bad. How's your life changed?
Scott Gottlieb:
From the perspective of just the public scrutiny, I think Tony faced far more scrutiny than me. I got some mail, got more inbound in my inbox, was the subject of some attacks online in social media from people who disagreed with the positions that I was taking. But I think just the biggest change was all the changes that were a result of COVID and having to adjust our lifestyles, how we worked, who we cared for families, so I don't think my experience was that unique from a lot of other people who faced challenges. And in many cases, you could argue it was easier, because I was able to adjust, insofar as being able to move a lot of my professional activities to home. A lot of people still had to go out, still had to do jobs where they interact with the public, where they put themselves at substantially more risk.
Scott Gottlieb:
The biggest change in terms of the content of my work was just much more of it was directed publicly, right? I was doing TV every morning for a long stretch of time on CNBC. I'd wake up and do a 6:10 a.m. hit. I was doing the show at the end of the day, and that when on for months. And then, obviously, doing Face the Nation on weekends and writing for the Wall Street Journal every week, so there was a lot more involvement in communicating and with the media.
Josh King:
So if we think about where you first got into absorbing all that information, if I got my history right, you studied economics in the town where I used to live, in Hartford, at Wesleyan. Worked in investment banking before deciding to go into medicine at Mount Sinai. What did you see in supply and demand curves that convinced you that medicine was right for you?
Scott Gottlieb:
That's an interesting way to phrase the question. I had been accepted to medical school before I went and worked in investment banking. I had deferred it and I was a little uncertain about a career in medicine at that time. And I think my work in investment banking sort of reinforced that I really did want to be a doctor, both on a positive and a negative. It sort of reinforced that I wanted to do something different than just be engaged in business. And maybe my aversion to being an investment banking analyst helped me decide that I'm better off, probably, practicing medicine.
Scott Gottlieb:
But I saw medicine as a profession where you would be engaged in lifelong learning, where I liked the science, I liked the material and I liked the idea that you were going to be doing things that were rewarding in a very personal way. And I don't practice right now, I practiced up until my youngest child was born, so I stopped practicing about maybe seven years ago, and I miss it. I really do miss both the idea of being a doctor and caring for patients and delivering medicine in a hospital. I miss the pace of it and I miss the intellectual exercise of trying to solve disease, trying to put things together, trying to figure out what was wrong with patients, helping them through it, counseling them. I miss that interaction.
Josh King:
I mean, you may miss it, but apparently there are a lot of people that are getting ready to follow in your footsteps. Schools across the country have reported increased interest for public health degrees, specifically epidemiology. Here's a clip from Fox News underscoring that point.
Reporter:
Plenty of people agree, applications for all epidemiology degrees at the University of Arizona had increased by 26% compared to this time last year, and their online degree, in particular, has nearly tripled in interest.
News Speaker:
And I think it would be right to say that COVID-19 has really brought public health to the forefront of our lives. Individuals really feel empowered to use their training to help themselves and their families, as well as their communities.
Josh King:
Scott, in your role as a physician, you practiced medicine, but at the FDA, there was a lot of public health work. How did you switch between those two hats and what attracts you to medicine versus public health and vice versa?
Scott Gottlieb:
Well, they're integrated, right? I mean, the work of a public health official or an epidemiologist and the work of a physician, I think, are tightly coordinated, if you're delivering care in the right way and they're tightly coordinated in the policy realm, as well. The medical background and the work with patients, I think was very important to my work in Washington. And I think, too often, and I was sort of emblematic of this later on, too often you have a lot of doctors doing policy work in Washington who haven't practiced in a very long time. And so, after a while, your perspective is no longer informed by the patient experience. And early on, when I was senior advisor to Mark McClellan at FDA, when I was a younger physician, I was practicing while I was working in government, so I would go and do two 12-hour shifts on weekends. So I'd work all week at the FDA, and then on a weekend, Saturday and Sunday, I would do shifts each day, 12 hours, that was really important, continuing to see patients, I felt, was really important to informing my perspective.
Scott Gottlieb:
And a lot of the physicians who end up in government roles, over time, you stop seeing patients and you become a little bit atrophied and that was my experience when I was FDA Commissioner. I had stopped practicing, I hadn't practiced in a number of years. I think you lose that perspective. And it's little things, when you're a physician, you see a lot of people live very difficult lives in this country on very little and you see that as a physician, how hard it is for something as simple as coming to a doctor's visit could be, for some people, an exorbitantly expensive difficult affair. They work all day, they take care of a family all night, they can't afford help, so they have to somehow figure out how to get off from work without losing their job, find a way to get coverage for their children, and they come into a busy clinic where there's a one-hour wait in the waiting room or a two-hour wait. And then, as a physician, you send them to another clinic or you send them to a pharmacy, but there might be only one pharmacy that takes their insurance that they can go to.
Scott Gottlieb:
And this because a full day endeavor, just going to an office visit. When you're a physician, you see that, you start to see that and you realize how difficult it is, the sort of obstacles people face. When you're in a policy realm, you sometimes lose sight of that, so just thinking about COVID, for example, we set up mass vaccination sites, how could people not be able to come to vaccination site and get a free vaccine? Well, for a lot of people, getting to a vaccination site where they have to get transportation to the site, have to wait a period of time at a specific time of the day, so they can't set their own hours, that's an exceedingly difficult thing. And I think when you're a physician you see that and it informs how you think about the policy.
Scott Gottlieb:
When you're a policy maker, sometimes you lose site of that. You're sympathetic to it, I'm not saying that policy in the realm are sort of cavalier and don't want to be cognizant of the hardships. You don't understand it unless you see it, and many of us who do policy, we come from diverse backgrounds, but by the time you get into these jobs, you're in a different sort of realm. You're not the one struggling with some of the hardships of people who work in more difficult jobs, don't have health insurance. But when you're a physician, you see it, because you have that more direct interaction.
Josh King:
I mean, talking about struggling with those hardships, Dr. Gottlieb, a pivotal moment in your tenure at the FDA was focusing the agency's attention on the opioid crisis. In January 2018, the number one priority of the FDA was reducing the burden of addiction threatening American families. It was one of the first times the agency recognized the misuses and abuses of opioids and that it had a role to play in reducing exposure to these drugs. How do you see the situation now that you're out of the driver seat and where do you think resources need to be directed?
Scott Gottlieb:
Look, I think a lot of the opioid addiction crisis in this country is driven by things that aren't just related to problems with the delivery of care and how we were prescribing opioids. I think a lot of them relate to broader societal issues. A lot of these opioid deaths are deaths of despair, if anything, that problem is not only far from being solved, but I think it's exacerbated by COVID, and what I think you're going to see is a real resurgence, once we start focusing on this, you're going to see that there's going to be a real resurgence in opioid abuse, methamphetamine use, other forms of addiction. I think the addiction crisis has been magnified as a result of COVID and the year that we've been through and we're going to face a real challenge with his going forward.
Scott Gottlieb:
I saw, as my role at FDA, FDA has a purview over this, but its purview is a narrow purview. It's not engaging all the aspects of law enforcement. Obviously, we have limited capacity to try to reach in and help people, reconstitute their lives in ways that help them avoid addiction crises to begin with. But where FDA played a role, I thought, or should've been playing a more prominent role was in trying to rationalize prescribing. We knew, and we know, that a certain percentage of people who are exposed to opioids for an extended period of time, and that period of time isn't necessarily a month, it could be a couple of weeks, are going to develop an addiction to the drugs. There's sort of a fixed percentage of people who will become habituated and eventually addicted to the drug, and it's just a sort of function of math. If you expose 100 people, one person out of those 100 will develop an addiction problem. And it's not quite that stark, but there is a sort of fixed percentage of people.
Scott Gottlieb:
And so, the goal, from a public health standpoint, my perspective, was to reduce exposure, that we should rationalize prescribing to make sure opioids are only prescribed when it's absolutely necessary and are prescribed for the shortest period of time and that the FDA had an affirmative role to play in trying to do that, in trying to reach into medical practice and take affirmative steps to try to rationalize prescribing. So that was a big focus of our policy activity. The other big focus of our policy activity was a view that I had that FDA had a role to play in the illicit use of the drugs. Historically, the agency said, "FDA regulates drugs used for their labeled purpose." If someone's going to intentionally misuse a drug in an illicit way, in an illegal way, that's a law enforcement problem, that's not a public health issue, that's not an FDA regulatory issue. And my view was, no, we also bear some responsibility for the entirely illicit use of the products that we regulate.
Scott Gottlieb:
And, in fact, early on in my tenure, probably two months into my tenure, we withdrew Opana ER, an opioid that was on the market, based on a side effect that emerged only when the drug was used in an illicit fashion. So if you crushed that drug up and injected it, which clearly is an illicit use of the product, a certain side effect was unmasked that was killing people. And we withdrew the product because of that side effect, because of a side effect associated with the entirely illicit use of a drug. And that was a Rubicon, that was a watershed moment, a lot of people said we didn't have the authority to do it. We were challenged. Congress eventually stepped in and legislated to give us explicit authority. Now, I felt we had the authority to do it. We prevailed on that, but just to affirm that we had the authority to do it, Congress stepped in and passed legislation explicitly saying, "FDA has the ability to withdraw a drug based on a side effect that emerges with its illicit use."
Josh King:
In your recent commencement address at Wesleyan, where you were presented with your honorary doctorate, you gave a speech, Dr. Gottlieb, about the work that a public health official needs to now focus on. Let's take a quick listen to that.
Scott Gottlieb:
The most profound, and perhaps disturbing, challenge laid bare by the events of the past year are our protracted social ills that have hurt too many of us for too long and were made more glaring by the consequences of the pandemic. COVID hurt some among us a lot more than it hurt others. Another challenge was our lack of cohesion as a nation and the social and political rifts that were able to divide us, even on seemingly obvious things like wearing a mask or getting a vaccine.
Josh King:
So this broader community protracted social ills that you talked about, the lack of cohesion, these fundamental issues that public health officials need to tackle, how do we begin to address the issues from a public health perspective and what's the role of the private sector in this fight?
Scott Gottlieb:
Well, these are broader societal issues, I don't think that they're just public health issues, but we've long known that infectious disease, disease generally, but particularly infectious diseases oftentimes don't impact the population in a uniform way. Certain segments of the population oftentimes bear a disproportionate burden from infectious diseases and a lot of infectious diseases become diseases of poverty. Social factors associated with poverty are oftentimes conducive to the spread of infectious diseases. People who have to live in crowded circumstances, interact a lot, oftentimes lack access to basic care that can head off the sequelae of an infection or get it treated early. You can go through a litany of infectious diseases that ultimately cluster in pockets of poverty and seep through cracks of inequity in society.
Scott Gottlieb:
COVID, because it was such a dramatic event spread so rapidly over the population, I think became a very glaring personification of that basic problem and you saw groups in this country substantially, disproportionately burdened from COVID, where death rates were exceedingly high in certain segments of society, and particularly among Black Americans, Hispanic Americans, Indigenous Americans, you saw overwhelmingly higher burdens of disease and significant serious outcomes from disease. And New York City was sort of a microcosm of this. I think when you look at the data in New York City, you saw this in a very stark fashion. Scott Stringer put out data early on looking at some of the social factors that underpin this and show, for example, that a lot of people from minority groups are working in essential jobs where they're continuing to work. If you look at the breakdown or who is working from home and who had to go into work and continue work in essential jobs, you saw a disproportionate number of Black Americans, Hispanic Americans.
Scott Gottlieb:
You had issues with multi-generational homes, where if someone got infected at work and they were asymptotic or mildly symptomatic and didn't know they were infected, they would bring the infection back into a home where there was a crowded housing situation, where you had a multi-generational family, and so the infection would spread through the entire family. You had challenges people faced in just marshaling the social capital at work to demand better conditions. A lot of people didn't have that social capital work. They couldn't ask for PPE or didn't feel they could ask for PPE. They couldn't demand work conditions that were safer, so I think COVID brought all those things to the forefront and the question is, has it changed the landscape for addressing them?
Scott Gottlieb:
I think it has in some ways, in some positive ways. I think that it's brought a greater recognition about the burdens and some of the ways we can address it, but we will see whether or not we have sort of a sustained response. In terms of just the consensus in this country, I think that we have political divisions around a lot of aspects of life, right now, in this country, and we saw those same political divisions start to encircle some of the things we needed to do to keep ourselves safe from COVID. And some of it was a result of people's ideological orientation, and I get that. And some of it was people who feel mandates shouldn't be imposed on you that's in an infringement of people's exercise of personal liberty. Some of it was born of the fact that the mitigation and things we had to do disproportionately hurt certain segments of society. Who is hurt the worst economically from businesses being closed? It was the people who worked in those businesses or who owned those businesses. It was the restaurant owner, it was the waitress and the waiter.
Scott Gottlieb:
And so, certain segments of society bore disproportionate burden from the mitigation, but some of it was also just politics. I mean, some of it was people lining up along ideological lines, and I think starting to adopt positions based on a preconceived political perspective, rather than just an informed view about what it was that we were asking society to do. There was sort of this enterprise that manufactured opposition to anything that we were trying to do, and early on it started with an enterprise saying COVID's no worse than the flu, well that wasn't true. Then it became, well there's this vast number of people who have pre-existing immunity to coronaviruses, as so we're overestimating the vulnerable population, well that turned out to be untrue. Then it became masks don't work, that was not true, masks worked if you wore a high-quality mask in a proper way, now we see that industry of manufactured skepticism migrating to vaccines.
Josh King:
You serve, also, as a special partner at New Enterprise Associates, that's a venture capital firm that is invested in some of the world's most visionary entrepreneurs and business leaders, many of which have ended up being publicly listed here at the New York Stock Exchange. That includes Box, which is ticker symbol BOX, Coursera, which is COUR, and Snap which is SNAP. So NEA has this deep pipeline of health care companies all across the stages of the capital cycle. How did you get involved with the firm and how do you look at new opportunities in the healthcare space?
Scott Gottlieb:
Yeah, I had been involved with NEA going back to 2007, and so when I left the FDA, when I was in the agency as a deputy commissioner, I left the agency, I joined NEA as a venture partner and was there for 10 years. And I was introduced to NEA through people who worked there who had worked at Alex Brown, so at the time, a lot of the people who had previously worked at Alex Brown in the healthcare group, after they left Alex Brown and did other things, they ended up at NEA, so there was a very strong DNA from Alex Brown already inside NEA, and so they pulled me in. I was there for 10 years. When I went in to be FDA Commissioner, I left NEA, obviously, and then when I left FDA, I went back to NEA, this time in a different role as a special partner and as an investing partner. My mandate's broad. NEA, as you mentioned, invests across the healthcare space, but we have a life sciences team, medical device team, medtech team that does investing also in some services, like tech enabled services. And then, we have a healthcare services team, that just took public, for example, Bright Health, I believe on the NYSE.
Josh King:
Yes.
Scott Gottlieb:
I work across the different segments. I would say, if there was one place where more of my time was spent, it's actually on healthcare services, most people think I'm investing in biotech companies. Actually, more of my time, and the one investment that I've made since I've been there in the last year has been in a healthcare services company and that was true also during my last stint at FDA, more of the work that I did was in the healthcare services space, but I do have the ability to invest across the different groups and look for opportunities across all the different groups.
Josh King:
You still get excited looking in the wide eyes of a founder who's got a big idea and see all of this potential, Scott, that in the early 2000s or even the '90s was just a figment of our imagination?
Scott Gottlieb:
I do. And, for me, the opportunities I like the most, and they're hard to find, because you need to manufacture them, are a person with an innovative idea who wants to start a company. A lot what I see is series A investments, series C investments, where you have a company that's been founded and people are bringing it to you, they're doing the round, they're raising capital. What I really like is to find someone who has an idea and wants to start the company from the beginning and we've done that. I mean Bright Health is an example of that. I remember the meeting five years ago, I was in the meeting at NEA when we met with those founders and we had the discussion about founding that company five years ago. Just went public. Radiology Partners, another big healthcare services company, same thing, we founded that company with an entrepreneur who we had a close relationship with, who was also a venture partner at NEA. Those are the really exciting opportunities, when you can sort of put it together from the beginning. And so, anyone who has an idea who wants to tap a pool of capital, please give me a call, because those are the kinds of opportunities we're looking for.
Scott Gottlieb:
And the virtue of NEA, two things I would say, one is that it's a large pool of capital, and so we put money into our companies along the way. We can help them [inaudible 00:31:06] it's not a firm way that we do the series A and then we have to find other investors to do the series B or series C. NEA invests all the way through and Bright Health is a perfect example of that. We can write small checks and help start companies, we're not just looking for crossover rounds where we have to put a lot of capital work. And the other thing is, NEA is very patient. I was on the board of a company that we had invested in before I got on the board, it was like 15 years ago or 10 years ago and we were still in it. We were still continuing to put capital into supporting the company, so some of these investments turn over very quickly, you grow it very fast, you take it public, others have a very long time horizon and NEA's able to do both.
Josh King:
I mean, it takes a long time for that Bright Health banner to get on the façade of the New York Stock Exchange, but when it does, it's such a journey fulfilled and I don't usually do this Scott, but if people are listening to this and they're in any of the healthcare spaces that you've mentioned, what is the best way to knock on the door of NEA and you?
Scott Gottlieb:
Probably to send me an email. I mean, it's not that complex, honestly. I admittedly have not been as good on email this past year as I had been previously, but I don't think it's that hard to catch someone's interest, if something is compelling.
Josh King:
After the break, Dr. Scott Gottlieb, former FDA Commissioner, resident fellow at the American Enterprise Institute, and special partner at New Enterprise Associates, and I dive deeper into Scott's outlook on COVID-19, his new book, and where we are headed in the future. That's coming up right after this.
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Josh King:
Welcome back to the show. Before the break, Dr. Scott Gottlieb and I were talking about his background. A little over a month ago we had the opportunity to host you at the big board to ring the opening bell in celebration of New York's reopening and to thank our frontline heroes everywhere for stepping up and making this moment possible. What really caught your eye about how the medical community, the first responder community, everyone who worked in the grocery stores and put on the masks and helped us from day one, how they really stepped up?
Scott Gottlieb:
Well, I think in the medical community, I'll take that first, I think one of the things that was profound and moving was the response to the crisis in New York. I mean, New York really bore the brunt of this in many ways, because it was the first part of the country to be hit, it was hit exceedingly hard, we didn't know what we were doing, we didn't know how to adequately treat COVID, the death rate was excessively high. We got much better at it when the second wave emerged in the summer. But in the beginning. We didn't know how to care for patients and you saw the case fatality rate disproportionately high relative to where it ended up during the later waves of infection, and I think one of the things that was really striking was seeing not just the dedication of the doctors in New York, and I had been talking to them over the time period. I had trained there, as you know, I worked at Elmhurst Hospital for years, so I knew a lot of the hard hit parts of the city.
Scott Gottlieb:
But seeing doctors from other parts of the country stream into New York to help, I mean, that was, I think, very poignant and kind of emblematic of the country. I think the other thing that we need to take recognition of is how many people continued in jobs where they were putting themselves at risk, knowing they were putting themselves at risk in the face of an uncertain threat, and that was certainly the case in the beginning. I mean, anyone who continued to work in a delivery job, anyone who continued to work in a front-facing job where they were interacting with the public, grocery stores, things like that, was putting themselves at risk in the face of a very uncertain threat. And I don't think people were cavalier about the threat, I think they were cognizant of it. I just think that they felt an obligation to continue doing what they were doing, and those were acts of patriotism, people engaging in shared sacrifice and taking risk to continue to do their job and serve the public and you sometimes don't take measure of all those ordinary heroes who, every day, kept the country going.
Josh King:
At about the same that people were going into those environment, the medical community was coming to the aid of New York's call, April 2020, you made this bold pronouncement that the only way out of this pandemic is going to be with technology and many of us in those early days, they couldn't believe that this is going to go on as long as it did, but you were looking into the future and saw that more effective testing, a focus on vaccines, investment in therapeutics really going to be the only way that we're going to beat the virus. What data, really, were you looking at, the primary data, that convinced you that there wouldn't be any silver bullet and the world would have to look very different for quite a long while?
Scott Gottlieb:
Well, look, it was a highly contagious virus and it was going to end up infecting a certain percentage of the population before stopped circulating, and the more that you have contagious variants emerge with this new Delta variant, the more that you're going to have to ultimately get immunity into a larger portion of the population to break off chains of transmission. Right now, if you look at Delta, probably 85% of the American population's going to end up with immunity one way or another, before this stops really circulating. People have a choice now how they acquire that immunity. They can acquire it through natural infection and some people will and some people have or they can acquire it through vaccination, and obviously, you urge people to acquire it through vaccination. I think people who acquire it through natural infection may have to end up acquiring it more than once before they become more impervious to infection, but that's the data I was looking at.
Scott Gottlieb:
We lacked the resiliency early one and we lacked the infrastructure that we thought we had and that we always knew we would need to deal with a pandemic risk of this magnitude. And, in part, it was because we had prepared for flu, and my book talks a lot about this, about all the preparations we had put in place, but they were really a technocratic illusion. A lot of them were geared to flu, a lot of them had atrophied, and so we didn't have the preparations and the resiliency that we thought we had and that we kind of knew we would need to deal with this, and so we need to think differently about how we prepare for these kinds of risks in the future. I think we need to look at public health preparedness through the lens of national security, that's going to require certain investments in infrastructure. It's also going to require looking at how we monitor for these threats differently. We've always relied on international conventions and agreements between nations to guard against risks and inform us when these things emerge.
Scott Gottlieb:
We've seen those break down time and again, and so fool me once, we've been fooled multiple times now, where we've sort of relied on the international health regulations and conventions forged through the WHO, and countries haven't fulfilled their obligations under those, particularly China, they didn't do it under SARS-1, they haven't done it with respect to certain avian flus that have emerged, where they refuse to share the source strains or information. They didn't do it again with SARS-2, so I think that's going to mean we can't just rely on people to voluntarily make information available and share information that's going to alert us to these threats. We need to get our tools of national security more engaged in this mission. Historically, it hasn't been. That means getting our clandestine operators engaged in the public health mission. Historically, they have not been, it has been something that's been seen as sort of the domain of the CDC and not the CIA. That's going to have to change.
Josh King:
On Twitter a couple of days ago, following your feed, you posted the proofs that had arrived for the new book. I think it's your first book, Uncontrolled Spread: Why COVID-19 Crushed Us and How We Can Defeat the Next Pandemic. I mean, you've given us a preview of what's inside and the thesis, but just on the process of writing a book and how much effort it takes, how did you find time to sit down behind a screen and craft this argument? Was it a bit of a different world that you allowed yourself to go in instead of focusing on the here and now every day on your heads?
Scott Gottlieb:
I started the book probably a year ago this month, I started it probably July of last year, maybe July, August. I started the book after being encouraged to do it by a literary agent that I had had contact with. So when I left FDA and talked to a literary agent about doing a book about my FDA experience, never took it forward. And he called me back over the summer, last summer and said, "Hey, remember the book we talked about, I think this is a good time for you to do a different book focused on these issues that you've been writing and talking about." And so, it seemed like a good idea. I was encouraged to do it and he convinced me, and I started it probably July or August, like I said, it's about 550 pages. It's a big book, about 1,500 references. I did it in whatever free time I had, it's been a busy year, as you sort of said at the outset, but whatever free time I had, I would stay up late every night writing the book. Weekends I spent writing the book, it's consumed me over the last year, because I was doing a lot during the day and then all the free time that I could pull together, I was working on the book.
Scott Gottlieb:
Now what said, the are things I was doing on TV, my op-eds for the Wall Street Journal, obviously, I was immersed in this story, interacting with people, constantly collecting and sifting through information, so all that went into the book. It was a hard lift. And in the book, what I try to do also is I sort of draw on some of my experiences and lessons learned in public health. I talk about things that happened at FDA while I was there that I think informed a perspective on how I think we could have or should have responded to certain aspects of COVID, so a lot of that's woven in. A lot of the lessons learned from FDA and from working in public health are woven into the fabric of the book in various places, so people get a little bit of a perspective on my thinking about just how to approach public health challenges.
Josh King:
As we wrap up, Dr. Gottlieb, one of the most remarkable things about our research into you and your career is how you really reinvented yourself throughout that career. It's obvious that medicine and health are common threads for all the work that you've been a part of, but you've found so many ways to intersect these disciplines in other fields, whether it's finance, policy, clinical work, and now writing. What advice do you have to people looking at their career, maybe where you might've been 25, 30 years ago and trying to figure out what the next step is for them?
Scott Gottlieb:
Yeah, well, I would frame it a little differently than reinventing myself. I think that, to your point, I had worked in business, I had worked in policy, I obviously have a background in medicine, I think that the ability to sort of reach across different disciplines and integrate it into some perspectives helped inform what I was doing, but also helped me elevate my work and gained more attention for it. The fact that I was able to look at healthcare through a lens of business, the fact that I was able to look at medicine through a lens of policy, and then be able to write about that, and articulate a point of view and do it in a way that I could get it into the public discourse on op-ed pages and on TV. I think it helped what I was doing, I think it helped inform what I was doing and made me better at my job, particularly when I was in the government.
Josh King:
No one's going to blame you if you plan to take a long vacation now that the proofs of the book are in your hand. You've given it that one last read and sent it back to the publisher, but that doesn't really seem your speed. In addition to promoting the book and your work continuing with AEI and NEA, what do you think's next for you?
Scott Gottlieb:
That's a good question. I'm looking forward to hopefully getting back to what I was doing and having a much more normal end of 2021, 2022. Getting back to the work at NEA and getting back to a broader [inaudible 00:43:41] policy issues. I think, from a policy standpoint, I expect a lot of my focus over the coming year is going to be on some of the themes that come out of the book. How do we now translate some of the what we've been through into a new security posture and particularly looking at trying to view some of the public health challenges that we face through a lens of national security and making different kinds of investments, building out different kinds of capacities. I hope that I have the opportunity to continue to talk about that and start working with Congress on some more enduring changes.
Josh King:
A lot of changes to come, a lot of work to come, and we'll let you get back to it. Thanks so much, Scott, for taking an hour out with us and joining us Inside the ICE House.
Scott Gottlieb:
Thanks a lot.
Josh King:
And that's our conversation for this week. Our guest was doctor Scott Gottlieb, former FDA Commissioner, resident fellow at the American Enterprise Institute and special partner at New Enterprise Associates. If you like what you heard, please rate us on iTunes, so other folks know where to find us, and if you've got a comment or a question you'd like one of our experts to tackle on a future show, email us at [email protected] or tweet at us @ICEhousepodcast. Our show was produced by [Stefan Caprile 00:44:53] with production assistance from Pete Asch, Ian Wolf, and Ken Abel. I'm Josh King, your host, signing off from the library of the New York Stock Exchange. Thanks for listening, we'll talk to you next week.
Intro/Outro Speaker:
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