In today’s COVID-19 Update, a discussion with Peter Hotez, MD, PhD, dean of the National School of Tropical Medicine at Baylor College of Medicine and co-director of the Texas Children’s Hospital Center for Vaccine Development about his new book "Preventing the Next Pandemic."
Learn more at the AMA COVID-19 resource center.
- Peter Hotez, MD, PhD, dean of the National School of Tropical Medicine, Baylor College of Medicine
Unger: Hello, this is the American Medical Association's COVID-19 Update. I'm excited today to talk to Dr. Peter Hotez, friend of the show and dean of the National School of Tropical Medicine at Baylor College of Medicine; and co-director of the Texas Children's Hospital Center for Vaccine Development in Houston, Texas, about his new book, "Preventing the Next Pandemic."
I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Hotez, thanks again for being here today. In our past discussions, we've talked about your work on vaccine development, the importance of global vaccination program and fighting vaccine information. Your new book kind of brings those themes and more together. Why don't you start by just giving our audience out there a little bit of an elevator pitch on what the book is about?
Dr. Hotez: Well, a lot of it begins with my time as U.S. Science Envoy for the State Department and the White House Office of Science and Technology Policy. I did that in 2015, 2016, serving as Obama's Science Envoy for the Middle East and North Africa and President Obama's Science Envoy, and I loved it. It was just very meaningful and fulfilling. And the idea behind it was, I had been promoting these ideas of what I called vaccine diplomacy, building vaccines between nations, not only to produce life saving technologies but also to promote international cooperation, countries putting aside their ideologies to work together for a common good. And I had that opportunity to finally explore it and very grateful to the Obama White House and State Department for giving me that opportunity.
And I served during that time in the Middle East and North Africa during a time of great turbulence. This was 2015, 2016. It was at a terrible time in the Syrian conflict. It was around the time when ISIS was just gaining a foothold and gaining ascendancy, doing scary things. And then, there was the rising tensions in Yemen, which turned out to be a full proxy war between Iran and Saudi Arabia. There was a lot going on as you can imagine.
And they had me focus on three countries, Saudi Arabia, Morocco and Tunisia, for various reasons around the conflict. And that's when the light bulb started going off about how the drivers of disease go beyond the biomedical things that we think about in terms of war and political instability, aggressive urbanization, climate change, anti-science activities and how they combine in unique and interesting ways. And not only on the Arabian peninsula, but I identified about six or seven other hotspots of the world, and this was all pre-COVID.
And so, a key point of the book was ... I almost finished quite a bit of it even before the COVID pandemic struck. And then, with COVID, I was able to make the observation that, "Hey, COVID is not the extraordinary event that everybody says it is. It's really a culminating event of an unraveling that's happened over the last five, six, seven years from things like war and political collapse and climate change and urbanization and anti-science." And so, that's really reports on all of those things, and I think there's a lot of other side messages in the book. And one is, as physicians, as residents, as medical students, as fellows or as attending physicians, guess what we don't get trained in? War and political collapse, urbanization, climate change and anti-science, and maybe we should, because this is what's driving back disease in a big way. It asks for a broader view around medical training and education as well.
Unger: Yeah. You may not get that training, but physicians are certainly going to be on the receiving end of these trends that you kind of spell out. And you talked about some of those forces, you even kind of refer to this sometimes as like a new era that we've entered where the combination of all these forces is really encouraging the return of vaccine preventable diseases we thought kind of had vanquished. The reemergence of some of these diseases you called neglected tropical diseases and then, unfortunately, emergence of new variations. Can you talk about the concept of NTDs and some of these vaccine preventable diseases that we're seeing making a comeback as a result of all these forces out there?
Dr. Hotez: Well, let me give you an example of a couple of places, and then I'll bring it back to the United States. On the Arabian peninsula, you saw the hostilities there collapse health systems. We stopped vaccinating kids against measles and polio, and guess what comes right back? Measles and polio. The vaccine ecosystem is quite fragile. And then, with a cessation of vector control across Syria and Iraq, you brought back a parasitic infection, this leishmaniasis, which causes cutaneous ulcers on the face, even though it's not a fatal disease, that causes permanent scarring and disfigurement, especially for girls and women. And they even call it, "Aleppo evil" because of its hyperendemicity now in Aleppo with the conflict there. And then when Yemen, you started to see now the world's largest cholera epidemic because of the collapse, and addition to leishmaniasis and addition to vaccine preventable diseases.
And if that's not complicated enough, you have the fact that you have unprecedented temperatures in the Middle East, up to 50 degrees Celsius in some places, which is drying up ancient agricultural lands along the Tigris and Euphrates. And that in itself is destabilizing, causing people to move into urban areas. And then some scholars would say, or political scientists would say, those climate changes and global warming itself was a precipitating factor in all of the hostilities. It really talks about how it's all kind of intertwined. And while a lot of people will now talk about climate change, my premise is it's not climate change acting in isolation. It needs those social forces to coalesce and create something that brings back disease.
Another example is in Venezuela where with the Maduro regime ... It started in the Chavez regime, but with the Maduro regime, we've seen the socio-economic collapse in Venezuela causing people to flee the country. Outbreaks of measles as people flee into the Brazilian rainforest, coming into contact with Yanomami Indigenous people, causing decimating measles epidemics, going across into Columbia with the Wayuu Indigenous people causing epidemics. And then, people desperate for employment, working in the illegal gold mining industry where they're sleeping outdoors, being infected by malaria infested mosquitoes. All of that building together with a 40 year drought going on in Venezuela.
And in the U.S., we've seen this to some extent for other reasons, and that is this rise of anti-science where whole segments of the country were deliberately defiant of masks and social distancing. And now, four or five news polls say the same thing that those same groups are also now going up against vaccines and refusing to get vaccinated. And across America, especially our resident physicians are on the front lines, dealing with the horrible, horrible aspects of a COVID-19 epidemic that took the lives of half a million Americans. And so, these are the new factors that are causing disease to come back in a huge way. And what kind of question the book asks towards the end is, "What kind of infrastructure should we start considering in order to mitigate against this?" As physicians and scientists, maybe not too much we can do about war and political collapse, but there are things we can do to buffer those forces from bringing back disease in such a devastating way as they did.
Unger: It's so interesting how you pointed out how these are intertwined and how, when you think about war and political instability that causes massive population movement, urbanization, crowding in these mega cities that you're talking about around development. I think you mentioned that 40% of the poverty-stricken population is going to be concentrated in a very small portion of the world in the near future and what that could mean to the future of pandemic ripe areas. Is that right?
Dr. Hotez: Yeah. Well, what we're going to see is the world will coalesce into groups of these mega cities, cities greater than 10 million people. And historically, the few mega cities we've had on planet Earth have been London and Tokyo and New York, but increasingly we're going to see these in low and middle income countries. We're seeing the explosion of people in Lagos and Kinshasa, and people coming in from the countryside and living in urban areas that outstripped the infrastructure. You're seeing it in Sao Paulo. You're seeing it ... And now playing out in Delhi with this horrible COVID pandemic. And now the epicenter is in Delhi, and we're seeing the humanitarian catastrophe unfold there as hospitals get overwhelmed. And the simple fact that how do you do social distancing in low income neighborhoods in places like Delhi?
And so, this is a new reality, and what are the things that we can do in terms of building vaccine infrastructure to have vaccines ready to go in a faster pace than we're seeing right now? I mean, India, what is India going to do? It doesn't have the vaccines it needs in order to halt this pandemic in the next few weeks. And what could we have done to help in that? What are some of the other things that we could have done to prevent this defiance of science that we're seeing across the country, across the United States, which is so deadly right now in contributing to the loss of so many lives in the country.
And so, the book really takes a 30,000-foot aerial view of this. And, for me, it was fascinating to do work on the book because I'm not really a geopolitical expert at the end of the day, I'm an MD-PhD vaccine scientist developing vaccines. But by making vaccines and being in a place where vaccines are needed for people who live in extreme poverty, it took me all over the world and this gave me a chance to see it through a very unique lens.
Unger: Again, it just points out making the vaccine is just one part of the equation here and getting it to the right places and anticipating that in a world where there are so many kind of global threats that prevent what we need to get done. I mean, I—
Dr. Hotez: Yeah. I mean, I spent ... I was an MD-PhD student starting in 1980, so I've been at this for 40 years and always aspired to make vaccines for parasitic infections. And now, they're in clinical trials for schistosomiasis and hookworm and Chagas disease. And now, I realize I've just done the easy part. The hard part now is getting them accelerated and implemented. And with our COVID-19 vaccine, we have a bit of a glide path because there's such global urgency. People are willing to move that along at a faster clip. And that may become our first vaccine that we've actually licensed, which would be very fulfilling also.
Unger: And then, there are so many instances in the book where I guess prescient would be the right word to describe it. And you mentioned before about the anti-science movement and you wrote this book on the cusp of COVID. And you say in your book, "This anti-science movement could be a real problem." Now that you, of course, have hindsight here, did it surprise you in terms of just what a problem that has become and the global level of it?
Dr. Hotez: Well, I think where I vary with a lot of my colleagues was I saw the anti-vaccine movement accelerating, particularly after around 2015. And that's the benchmark from the book, starting around 2015. I've been going up against it for years, because I have a daughter with autism and written a previous book, called "Vaccines Did Not Cause Rachel's Autism," to debunk that, but noticed how the anti-vaccine movement, to re-energize, took on a political dimension. And they linked themselves to political extremism on the far right under this banner of health freedom, medical freedom, and they started to form political action committees in Texas and Oklahoma. And I saw that as really worrisome and, indeed, starting in 2020, those anti-vaccine groups that had formed under this tea party banner of health freedom, medical freedom, now took on protest against masks and social distancing.
And then, I saw how it moved into Western Europe last year. If you look at the language used by the speeches at the anti-vaccine, anti-mask protest in London and Berlin and Paris, and Berlin one, they actually stormed the Reichstag. It was the same kind of health freedom rhetoric that came out of the U.S., out of Texas, and even reports from the BBC and New York Times that it was linked to QAnon. This has taken a very dark turn with this globalization. And, of course, that wasn't complicated enough, so now we have Putin weighing in on this and the Russian government has launched what's being called this program of weaponized health communication, where they're actually filling our airways and our social media with anti-vaccine messages, in some cases to discredit Western COVID-19 vaccines in favor of Sputnik V, their own vaccine. This has been extremely destructive.
And so, what happens is any time there is a real problem, even though it's rare, it gets blown up by Russia and the anti-vaccine forces coming out of the U.S., like what we've seen with the J&J vaccine or the AstraZeneca vaccine. There may be one in a 100,000, one in 200,000, cerebral thrombotic events, extremely rare. And yet, this is now being used to discredit those two vaccines, which we need. Because, unless our vaccine gets up soon, these are two of the important vaccines we need as our workhorses for preventing COVID in Africa and Latin America and low income countries in the Middle East. And so, this is how much damage it can do.
And so, now I'm writing a series of articles. Maybe this'll be the focus of my next book around this anti-science, I don't know what to call it, confederacy or empire that has become so lethal. And my premise now is that when we talk about big things that we build infrastructure to combat, like global terrorism or cyber attacks, cyber security, or nuclear proliferation, the world's leaders have put in place a lot of infrastructure to combat or prevent it, or at least wall it off if it starts to happen. We haven't done that with this globalized anti-science movement and I think we have to start going in that direction.
Unger: Yeah. And as you point out, it's, pardon the pun, being injected into a system that already has a number of forces that are complicating things, and who would have anticipated that level of kind of political machination attached to the anti-science movement to complicate that further. And I think, to me, that kind of feeds into the premise of your book around vaccine diplomacy. How do we have vaccine diplomacy when you might actually see countries working against each other?
Dr. Hotez: Right. Well, I think this is another dimension of the book that when we talk about as physicians or physician scientists when we're communicating, the message is always, "Hey, you're just the doc. You're the physician scientist. Don't go into that political realm. It dirties your image or your message." And now, I'm finding that's not necessarily the case because, in some times, as physicians or physician scientists to say, "If the focus really is on saving lives, you sometimes have to get your hands dirty." Sometimes more than your hands dealing with ... Not so much because you want to become political, but in order to yank the anti-science out of the politics and expose it and shine a light on it. And to save lives, you have to go into that dark place.
And this happened to me last year when I was among the first to call out the Trump administration for the anti-science disinformation campaign, saying that deaths were due to other causes and the masks don't work, and the hospital admissions are due to catch-up elective surgeries. And I was among the first to call it out, not because I'm so brilliant, but because I've been going up against the anti-vaccine groups for years. That became a second profession of mine and I was able to call it out. But it took me to a scary place to be on the cable news channels and talking about the politics of an anti-science now to correct it. And it's still something I'm not comfortable with, and calling out the anti-science empire now. It's not easy for a physician scientists to be throwing darts at Vladimir Putin and what's happening on Fox News at night with the anti-vaccine rants. It's not fun, but I think it becomes a new necessary if we want to be good people and good physicians.
Unger: I think I just read an article in the Atlantic, too, about the similar problem and the thing that strikes me, it's obviously not a responsibility that can sit on your shoulders or a very small group of people. We're up against a pretty coordinated effort and it does take physicians speaking out and perhaps on things that they hadn't thought they would have to do, and weren't trained originally to do. That's very important.
Dr. Hotez: Yeah. But also, it may force us to ... We now teach bioethics in medical school and residency training, and I think that's fantastic. But we may have to look at version 2.0 in this new reality. Because the thing that would have helped me was having some tools to know how to do this. For me, it was all seat of the pants. Basically, it was my wife telling me, "If you don't do this, you'll feel terrible when you see the body count from COVID-19," and that was the motivating factor. But I have to believe had it been part of my training, maybe I could have done it more artfully than I did. I mean, I showed a lot of authenticity because that's what it was. It was quite authentic, but maybe not as smooth and elegant as it could have been.
Unger: Well, I don't know that I could go on "The Daily Show" and get interviewed and be able to talk to different audiences in very different ways like you're doing right now, so it's pretty impressive.
Dr. Hotez: Oh, that was just fun. That was just fun. Jaboukie is a great man. I love that guy.
Unger: Well just, I was remembering our last conversation and you were talking about possible routes, because we were thinking about how do we accelerate vaccination? And I remember you had talked about the kind of warehouse of AstraZeneca vaccine, which is not approved here in the U.S., and how we might do that. Now, we're looking at India and the possibility of the Biden administration talking about, basically, releasing some of that overseas and then kind of lifting a ban against the export of some of the raw materials that go into making vaccines. Is this what you would hope to happen in terms of vaccine diplomacy?
Dr. Hotez: Yeah. It's definitely a part of it. Remember the scale of this, we're talking about over a billion people in India. And if we're going to vaccinate 75% of the country in order to halt transmission, we're talking 800 million people times two doses for most of the vaccines, that's 1.5, 1.6 billion doses of vaccine. How's that going to happen? And we're trying to help with our low-cost recombinant protein vaccine that's being scaled now to a billion doses by Biological E. [Limited] in Hyderabad, and even that's not going to be enough and we've got to do it quickly. India has got some real ... One of the great strengths of India is vaccine manufacturing and production.
Serum Institute of India provides a lot of the vaccines for the world, as well as Berat and Hyderabad and Biological E. in Hyderabad, and a couple of others. We need to give them all the tools they need to make that level of vaccine. The only issue is that the game plan for vaccinating the world against COVID also dependent on India providing vaccines for the world. And now, what happens in terms of for self-preservation, India needs to keep those doses, who's going to provide the vaccine for Africa and Latin America? This is a very scary situation that we're in.
Unger: Well, that is a huge challenge, and I just encourage everyone out there to take a look at your new book, "Preventing the Next Pandemic," and learn more about what challenges physicians are going to face in the future and the steps that we're going to need to address those. Dr. Hotez, thanks so much for joining us here. I know you're really busy. I appreciate your perspective as always. That's it for today's COVID-19 Update. We'll be back with another segment soon. In the meantime, visit ama-assn.org/COVID-19. Thanks for joining us. Please take care.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.