Це відео не доступне.
Перепрошуємо.
Covid-19 Grand Rounds: A Conversation with Ashish Jha
Вставка
- Опубліковано 15 сер 2024
- In this UCSF Medical Grand Rounds, Bob Wachter will be in conversation with Ashish Jha, MD, MPH. Jha is currently Professor of Global Health at Harvard University and the Director of the Global Health Institute at the Harvard TH Chan School of Public Health. Next month, he will become Dean of the Brown University School of Public Health. Jha is the nation’s leading expert in evidence-based healthcare policy, particularly as it relates to the costs and quality of care, and is also a leading thinker on global health policy. During the Covid-19 pandemic, he has become one of the most visible experts in communicating with the public and profession about the policy response to Covid. In this Grand Rounds, Jha talks about communicating in the Covid era, what local and national policymakers have gotten right and wrong, Covid testing, the schools, how Covid will change the healthcare system… basically, all the issues that the country is grappling with as we try to get a handle on the pandemic.
Program
Bob Wachter: Introduction
00:02:01 -Discussion
01:07:04 - Closing
See previous Covid-19 Medical Grand Rounds:
• July 30: An Update on Covid-19 Testing, Treatments, and Vaccines
• An Update on Covid-19 ...
• July 23: Covid-19: Reports of New Surges from Miami, Atlanta, Houston, and UCSF
• Covid-19: Reports of N...
• July 16: How the Virus Gets in and How to Block It: Aerosols, Droplets, Masks, Face Shields, and More
• Covid-19: How the Viru...
• July 9: The State of the Pandemic, Opening the Schools, and the Outbreak at San Quentin State Prison
• The State of the Pande...
See all UCSF Covid-19 grand rounds, which have been viewed more than 675,000 times, here: medicine.ucsf....
Even though this video is 3 yrs old, thanks; non-academics don't normally get to hear grand rounds! What I appreciate/admire/find refreshing about Dr. Jha is that he begins by saying "let's talk abt what I got wrong" early in the pandemic." Contrast that with Trump's response in a press conference (abt 4-6 wks after the pandemic had really taken off) to the question of the Federal govt's. response, when he said "I'm not responsible at all" (that's a verbatim quote). It was literally jaw-dropping, at least for me. I greatly admire Drs. Jha and Fauci, our leading public health professionals, for their expertise and their stance that they follow the science, not politics.
Thank you for this wonderful interview. I especially appreciated that you gave Ashish room to expound on complicated subjects. That one time you didn't he was later given time to finish his thought. A wider audience should see Grand Rounds, if for no other reason than to learn how thoughtful people speak and interact.
Another excellent grand rounds. Thank you.
Thanks for the video
Wonderful interview, beautifully conducted. Thanks from an Indian Health Service child psychiatrist.
CDC screwed up the PPEs back during Ebola (anyone watching TV could see the difference in the dressing) and their handling of H1n1i virus is also questionable
You need fast low sensitivity paper test to say if people can go to school or work, not just for national statistics. Convince companies that it is their own interest and they will happily pay for the manufacturing of billions of paper tests.
Come on, get with it!
OK, stop being a follower, be a leader and show us how to do just that, with far less than a 40 - 50% false negative rate, resulting in more spread than were we to have a slower, more accurate positive detection rate.
After all, you obviously are hoarding a realistic solution, so share it!
Stephen Villano
Sure, will you stop with the sarcasm, then? This is just a summary, look for a graphical explanation at the same channel and maybe look up Dr. Mina:
ua-cam.com/video/AZWuyvBAWWQ/v-deo.html
If you agree it can be a game changer, please spread the word, we need to reach the decision makers and at this point that would be local leaders, since the federal government is useless.
@@Shelmerdine745 last week's Grand Rounds covered, in general, testing. The draw down from that is, a suggestion for an inexpensive (since it's going to be repeated often), 60 - 70 % positive detection rate test. That'd be essentially, one that'd take, assuming supply chain chokepoints are resolved, a day or two at most for results in a mass testing environment.
What wasn't shown to be exceptionally effective is a rapid test, like what is used at the White House, largely due to what information is available currently is limited by small sample size.
Studying what is the more effective, vs just seeing something being done, regardless of efficacy is what is needed, because getting that wrong at the front end results in yet another mask debacle (why should we trust you now, when you were wrong last time) and the resistance to adopt a superior method. Maddeningly, studies take time, both to conduct and to analyze, report on and peer review.
As an example, hydroxychloroquine, I was highly dubious, as I couldn't find any biochemical pathway in which it would be effective in the presence of two enzymes used to facilitate cellular entry. Later, it was shown in peer review, that Vero cells are essentially some of the worst medium to use to test therapeutics against this virus. That was basically, a competence error of someone using a known cell line, precisely in a way where it would fail to display clear results and would always fail, compared to human lung cell based culture medium and that, due to inexperience in a specific field, due to a lack of knowledge of fine details that would and were readily apparent to someone who specialized in the field.
Meanwhile, Vero cells are effective to amplify a viral culture for exposure testing of animal models or in vitro antibody testing.
Like everything, specialty fields have sub-specialties where those unfamiliar with the sub-fields would run down the rabbit hole. I've encountered it in military field medicine, I've encountered it in information security. One gathers the experts and one generalist becomes the mediator/traffic cop, suggesting continuing along a line or if unpromising, moving on toward something promising (hopefully). Complicated questions need complicated teams to address via complicated means.
After all, who would've considered supply chain problems, well, other than a medical logistician?
Simple solutions to complex problems invariably fail, due to unforeseen confounders, which would've been avoided had a more complicated and nuanced approach engaged in upon the onset of the emergency.
Stephen Villano
You did not follow the link and go further? The tests are already there, cost about $1 and it only takes about 10-15min to get a result. The sensitivity is enough to react if you are contagious. They just need to be produced in large numbers.
Here is the older video where the idea is illustrated graphically, hope you take a look at it. ua-cam.com/video/h7Sv_pS8MgQ/v-deo.html
I don’t get why you believe you need complicated teams to solve complicated problems with complicated means. It sounds funny, but doesn’t really make sense.
@@Shelmerdine745 I mentioned the relevant link, the previous Grand Rounds and we essentially agree, although I highly doubt scaling it up so massively will keep that alleged cost fixed.
Alleged, as regional supply issues typically increase costs in said regions, even when averaging. Adding volume massively, even more so.
There are some other notions, the federal government acquiring under contract, massive supplies of equipment, perhaps assembling as an interim center, perhaps not, depending upon need and how quickly supplies can be injected into the system, to either build reagents, precursors or even final products, then allow wholesale acquisition of said equipment and facilities as things ramp up, as the federal government has repeatedly proved capable of insane surge capabilities, even of constructing complex plants when needed, during World Wars, we can still use the same monster models.
Private industry is limited in sudden, massive scalar increases, due to cost barriers that aren't present to a government in a major emergency.
After all, we are indeed fighting an organism that has a phenomenally short lifespan, which increases potential mutation rates, which could potentially evolve past a few vaccines or therapies that are only now in the suggestion for study phases.
And more importantly, human lives were lost while we each typed our responses, which largely agree with one another.
It's simply a matter of how and who to scale up, within the better targeted areas and I'd need a hell of a lot of input, in the go big or go extinct game to then suggest precisely how to move forward.
Currently, I'd go big on rapid testing of therapeutics, given the volume of vaccine candidates being on short fuse, manufacture while testing vaccine programs and push on both precursor chemical manufacturing expansion to eliminate several choke points in the supply lines and if some look great, expanding testing the agent and manufacturing in house, then sell the whole kit and caboodle off when private industry wants to come in, with an appropriate contract that what the government develops, only their true costs are reflected in the cost per dose to the individual.
I know full well where many overprice potentially abused points are in the system. The anakit is a prime example, as the injector costs were paid for, fully, but the US DoD, but the costs captured unethically by industry.
I guess we should not forget the fraudulent studies (Lancet) quoted by medical leaders without peer review or the fact that bureaucrats not field people are running things. In asian countries often it is often experienced field people who lead the charge not desk jockies whose favorite line is "This is the way we have always done it" We should have paid attention to the expertise of those countries who have seen this happen many times before. Na we are special we know best.
Excellent summary on how we got to where we are and where we might be going from a public health point of view.
I am now trying to imagine how you keep a mask on K through 3rd grade kids, I want to see this for myself! Or keep them from touching each other and bringing the virus home to Dad and mom and Gram-pa and Grand-ma
I am treating children in this age group live, and there have been no difficulties. In a group setting, it will be extremely important that their families model correct mask use and make it the norm.
Allow me to correct Dr Ashish
Italy back in January did take the virus seriously, they just didn’t know that the virus had grown disproportionately fast in the region of Lombardy which is why the hospitals of the region were overwhelmed. Everywhere else in Italy the health system coped perfectly well and without any problem.
There were studies that showed that masks work and people died being told not to wear them. what happened to,
"do no harm1"
As hard as Dr. Jha was on the CDC, he wasn’t hard enough. Saying the people and scientists at the CDC are good people or have done good work in the past is irrelevant (but very typical of academics). This was their raison d’etre, this was their moment and they blew it in an embarrassing and public way and it cost at least tens of thousands of lives. Dr. Jha had every reason to believe the CDC would come through and they did not. Towards the end, he says to be honest and not go with the simple explanation or the party line. I had the sense he was holding back when discussing the abject failure of the CDC, probably because some of his friends and former colleagues still work there.
Bob, I would be curious to your response to the theory that the pattern of this virus is that it hits an area hard, strong and widespread with almost 70-80% exposure, but only having 10-20% developing moderate to severe symptoms and creating antibodies. Of the other 60% exposed, one group might have some innate ability to fight off the illness (t-cells from previous coronavirus exposure?, genetics?) and don't show any symptoms, while another group have an immunological response which only manifests as very mild symptoms and that doesn't involve a detectable antibody response.
According to this theory, the hard hit area would have actually achieved the proverbial herd immunity even though antibody screening will tell you that exposure is too low for this to be possible. If we use the forest fire analogy, this theory would be saying that we aren't seeing embers and small fires in areas where the fire can reignite and burn more, but rather that the area that is devastated is pretty much burnt out and there isn't enough fuel in that particular part of the forest to rage again.
In the US, this would mean that areas that have been through the worst of this with widespread infections and overrun hospitals won't see large outbreaks again, while cities and areas where the virus hasn't raged through are still vulnerable to an out-of-control period.
I'm not sure I buy into this theory yet, but it is true that the patterns seen across the world with this disease would fit nicely with this hypothesis. I cannot find any area in the world where the virus has hit hard that has yet to see another strong wave. Of course, it can be argued that this is due to better healthcare practices like mask wearing, social distancing, etc. All it will take is a second wave in one of these hard hit areas to disprove this theory.
What do you think? Is it possible that some of these hard hit areas have mostly achieved herd immunity?
Wishful thinking, dude. Nice try.
@@darwinismresearch-trolling7271 Nice non-response. If you are going to be arrogant at least back it up with a scientific data based response. A lot of us that pushed for mask wearing from the very beginning of this crisis were laughed at because the US health orgs were saying that masks caused more infections or were ineffective. In fact, many of the nations that dealt with the original SARS epidemic were saying that masks were essential in the fight.
Let's let the science guide us and be open minded to exploring all possibilities not just ones that might fit some current narrative.
Like I said, I'm not quite buying into this theory but I am at least open to considering it until it is disproven.
@@dontworrybehappy5139 You're just being a jerk. Look up "the straw man" fallacy. FYI, I too was "pushing for masks from the very beginning", In writing, despite popular support for local "experts" who were frantically paranoid about mask shortages. Flip off. Just.Flip.Off.
@@dontworrybehappy5139 [Reply out of sequence due to technical glitch.]You seem well intended but simply on a wild goose chase. That Todara character is one of those people who have training and he is using it to push fraudulent theories. Like that nut at Yale. He is extreme for saying herd immunity occurs way, way,way earier than VIncent & all of his guests. In other words, that guy you linked to is a quack and probaby interested in politics or fame more than healing. Yeah, I'm saying that. You can do better I don't thinkk you are a full time jerk but you are going down a gopher hole of wishful thinking and you are promulgating woo. Please don't
Yes, Dr. Michael Mina, how do we Advocate for these tests ?
Yes that is the million dollar question.
ua-cam.com/video/AZWuyvBAWWQ/v-deo.html
@@dontworrybehappy5139 That's a good link, too bad you had to start wargaming me because I don't buy your simping for the Swedish model & Trumpian false hopes of Herd Immunity where there is none.
In Covid seem that low temperature of body corelate with complication
Well, retrograde fever isn't exactly uncommon in the frail elderly, so that may well be a touch suggestive of a greater tendency toward complications.
Operatively, tendency, not universally. I suspect looking at clotting cascade markers for some of the more severe complication, as well as inflammatory markers suggestive of incipient cytokine storm.
@@spvillano Immune hemagglutination by cryoglobuline can theoretically occur in periferial capillaires
@@traiandanciu8139 no sign of clotting, only vascular spasm and loss of circulation. I've never come close, as near as I can ascertain, to ulceration, only leaves my hands feeling like some no good SOB ran my hands over with a truck when I pick up a frozen chicken.
And in winter, readily apparent to both a rheumatologist and my primary care physician. And that, due to exposure to well below freezing temperatures. Refrigerator temperatures typically would trigger cryoglobuline, as memory serves and even some temperatures above. Rapid rewarming removes the symptoms within 5 - 10 minutes, again, as memory serves, borderline.
There's enough that I suspect that's incorrect. That it began after mild frostbite, which is associated with some forms of Reynauld's is also supportive against that theory. Still, a tricky differential and frankly, it's not more than an annoyance and I have a lot of things to do that're better than incessant consultations to multiple conditions.
Including trying to figure out when to schedule in an ultrasound to rule out AAA, in the known presence of abdominal aortic dilation and unexplained anemia.
The latter more alarms me, as the known size of the dilation was far lower than aneurysm and such rapid expansion is unheard of outside of connective tissue dysfunction.
And worse, I have the skill to avoid Dunning-Kruger and more importantly, if I don't have a comprehensive understanding of something, I ask about it from my physician or another medical professional, for "homework" and a mile high view, then dig in on Google Scholar for a starting point and have a wonderful list of predatory journals to avoid (mental note, got a few more to add to their project, perhaps, join?).
In SARS-nCoV-2, I'm dubious, I lack a signal that could potentially activate it that early on. Frankly, I suspect immune overresponse by cytokines and NK cells, likely triggered by the late activation or lack of activation of innate response and a secondary program that's not currently understood. That'd match far better in that case, due to the strongly suggested innate suppression.
But then, I started out in electronics, where systems of systems approach was necessary, such as multiple phase locked loops, looking for different quadrature (and later, more complex) signaling. After, I went into military medicine for nearly three decades, to then land back into IT, all fields having a hand in, due to the oddities of all fields evolution.
And please excuse if I'm out of phase in a paragraph, I'm engaged in around 20 conversations currently, with several times as many more time delayed. I do have finite resources to granularize, until it's time to lock fully on. I do have autoimmune disease, hints of rheumatism and Grave's disease. My wife has autoimmune syndromes as well, that still need an immunologist to address, which is scheduled.
Starts at 5:10, sort of. What is it like dealing with the press in this work"?
Early March - we had wasted time since January.
Over time he was getting 100 media requests a day.
Does about 15. Focus: careful not to spread incorrect information. Had to read a lot. [HINT HINT trolls read,listen,study first before insulting people]
This has become political how do you draw the line so things don't become too political.
[Note to trolls: don't accuse them of "going political" they are discuss this exact issue, duh]
Mike Dewine, Republican did a good job but sadly diagnosed with coronavirus.
Hard to criticize Federal response because people channel that as criticism of Trump.
Q:What vulnerabilities/strengths of USA?
A: Read the piece he wrote. US squandered leadership role.
He believed CDC was greatest PH agency in the world.
Could not believe the debacles in February, did not believe it was as bad as it was.
Pro Publica [??] reporter called him, and then it sunk in...
13:30 -ish FAITH in CDC finally deflated by the end of February.
Who has done well/badly - depends how serious you take this - we don't want to be like Italy, with hospital overload. And we have largely avoided that. S Korea good job on Test/Trace but Germany has other measures. Australia did lockdown. Must do something, well. We did a mish mosh no one strategy well.
Q What did we do well
A vaccine deveopment executed pretty well
Q And?
A Remdesivir trial at NIAID. The Recovery Trial by other country good but that would be hard to do in USA.
Q Tension beween public health and economy...did that surprise you?
A 17:50Larry Sommers, etc...they say want a good econ policy then supress the virus.
Sad...virus has huge econ effects. Germany unemployment not nearly as bad as ours.
We have not done a good enough job. That point has not gone across in US (supress virus=economy)
He pleaded about bars...they said "tax receipts so we can open schools" but duh more disease occurred hence schools now problematized.
20:00 ish India Lockdown alone does not wipe out virus so when they were done with the lockdown the virus exploded.
Q Swedish strategy?
A Again, the politicization of all this....it's all complicated...there are no easy simple answers....
people want to use Sweden to say blah blah...America should do X... on the one hand, awful compared to its neighbors, but on the other hand ...it is nuanced...half the households there live alone...that is rare...it is built in social distancing...they had strong comm on avoiding large gatherings...it is a different country...they had a lot of deaths...a lot of damage to their country... how translatable is unknown
Q Domestic front- masks....what have we learned from all nthat
A Be more clear in messaging and do not express more certainty than you have [amen to that-I objected to the early no-mask gaslighting[ we were worried people would go out and buy N95 and healthcare workers would run out...as evidence shifted [bull - as masks became available]
Q Lessons when public health people say one thing and people see other advice on social media?
A Unhelppful to have a deeply polarizing person because whatever he says then supporters do what he nsays opponents the opposite...especially re school openings...the moment .... weigh in it becomes politicized....Governors trusted in this outbreak I wanted to see more civil society, religious leaders....because a Gov you may not like.
Q Does mandate work or not work?
A I want to say it doesn't work but don't know if that is true. As a civil libertarian I want to....look at China....it worked...it can work in an authoritarian state...we do not...I don't want to...super punitive not useful like arrests....for some people it is a matter of educating and some people de escalate...some punitive OK with fines jail seems draconian....most people OK to comply....Delta Airlines? O K off the plane OK but :DomNot FLy Delta wellgive them a chance to next time show nup with a mask [silly - it is a matter of making it not worth their while] I can't light a cigarette on the plane so in the same way...upright seat is a regulation so....stopping at 30:00 ish they talk about why couldn't we generate a fast test the technology has been around for a long time...but a huge hesitancy on the part of the White House [whoa!]
That got political awfully quick.
Yes, it started around the “one man from China” comment.
It did not become Political, it became Factual. We all Know that the problems
Originate in the White House. Facts.
Whole Spirit Sounds political to me.
because the whole crisis had been politicized long before this interview
One thing is for sure. Ashish Jha has a big ego and no any knowledge about this virus beyond typical political talk.
0 virus
millions see
class action has commenced
against our Moron-in-Chief Donny Jackass tRump
What UCSF has forgotten about is that Trump was trying to do a strong start to this COVID thing but all the state governors were complaining that he was trying to lead too much. So, Trump just gave them federal money and tried to let them do what was best for each of their states. Then, some governors like Cuomo said "The government isn't helping". The governors need to also start doing their jobs that are best for their state.
Boring