A HASTINGS CENTER CONVERSATION WITH

EZEKIEL EMANUEL, DANIELLE ALLEN, AND MILDRED SOLOMON

The Hastings Center hosted “Re-Opening the Nation: What Values Should Guide Us?,” an online discussion of the ethical issues related to easing Covid-19 pandemic restrictions in the United States. As the nation weighs when and how to re-open the economy, we will need to build a new normal that leads with key values like public health, economic well-being, and respect for civil liberties. These values are often in tension with one another, or seen to be, but they can be successfully managed with forethought and sensitivity. 

This Hastings Center Conversation featured:

• Zeke Emanuel, Vice Provost for Global Initiatives and Chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania, and a Hastings Center Fellow
• Danielle Allen, James Bryant Conant University Professor at Harvard University and Director of Harvard’s Edmond J. Safra Center for Ethics
• Mildred Z. Solomon, President of The Hastings Center and Professor of Global Health & Social Medicine, Harvard Medical School. 

[Transcript follows]

[00:00:23] Good morning. I’m Mildred Solomon. I’m the president of the Hastings Center. And it’s my pleasure to welcome everyone this morning. We have nearly sixteen hundred people participating in this webinar from all around the world. I particularly want to welcome two of our Hasting Center fellows from China, one from Mohun. So welcome, everybody. For those of you who are new to the Hastings Center, we are an independent bioethics research institute. We’re not affiliated with any medical schools or universities. We have scholars who are on staff and also 200 affiliated Hastings Center fellows from around the world.

 

[00:01:07] The easiest way to sum up our mission is that we develop critical commentary. Analysis and policy recommendations to ensure the wise use of emerging technology, primarily from the life sciences, to promote just and care across the lifecycle. More and more, the Hastings Center is committed to doing public events like this one.

 

[00:01:32] We don’t think that the bioethical questions before us are ones that only experts should take a shot at. All of us need to be involved in these debates, and events like today are an example of our growing commitment to engage with the public. We called this webinar Reopening the Nation. What values should guide us? And that seems like a pretty straightforward question with pretty straightforward answers.

 

[00:02:00] We should be committed to values like the value of science. Committed to equal worth of all individuals.

 

[00:02:11] And gratitude to all of those frontline workers and health care providers who are putting themselves in harm every day to keep us going.

 

[00:02:21] We should be committed to the value of truth telling so that we can squarely describe the problem and therefore have a chance at fixing it. And we should be committed to the value of solidarity to provide economic relief to those who are suffering most like low wage hourly workers, like people of color, like people who are living in congregate.

 

[00:02:46] Residential settings like nursing homes. Well, it’s pretty easy and straightforward to name those values. It’s a whole nother thing to try to develop a path forward that can best honor those values and maximize them and aim not to do. Not to neglect any.

 

[00:03:06] That’s a pretty tall order. And that’s what we’re trying to do during this webinar, at least in a beginning kind of way to help us sort this all out.

 

[00:03:17] We have two of the nation’s most prominent and deep thinkers about these issues. Professor Danielle Allen and Dr. Emanuel, Dr. Ezekiel Emanuel. I’m going to introduce them and then I’ll start a discussion with them. I want everyone to know that we also will take a couple of breaks for you, too, to hear your questions in order to get your question to me. You have to write it in the question and answer function at the bottom of your screen. Professor Allen is a university professor, which is the highest kind of professorship that is that a university provides at Harvard and she’s at Harvard. She directs the Safra Center for Ethics. She is a political philosopher who has written, by my count, six books, I think Daniel all taking a different perspective on common themes of interest to her democracy, citizenship and justice. She’s also coalesced a very impressive group of thinkers who have recently issued a report on how we can reopen the nation.

 

[00:04:30] Dr. Emanuel is vise president for global initiatives and chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania. He too, is a university professor.

 

[00:04:42] During the Obama administration, he helped to he advised the Office of Business of Budget and Management and he was a major architect of the Affordable Care Act.

 

[00:04:54] Before that, he was head of the NIH, his Center for Bioethics. He’s an oncologist, and we’re proud to say a Hastings Center fellow.

 

[00:05:03] OK, I’m going to start with you, Danielle.

 

[00:05:09] Let’s start by describing the problem before we go to solutions. Let’s talk about what’s the kind of problem are we facing?

 

[00:05:18] What’s its magnitude and scope?

 

[00:05:21] Sure. Thank you, Emily. Thank you so much for having me. And kudos to the Hasting Center of Respondents conversation. And Zeke, it’s great to be in conversation with you again since you kind of are the person who got me into all this work in the first place. So at the end of the day, we have to recognize that we face two existential threats. The first was apparent sooner, and that was the immediate threat to life and health and the stability of our health infrastructure. So when the pandemic first hit its degree at infectiousness and case fatality rate meant that without controls, we were going to see overloaded hospitals and a collapse, potential collapse of public health infrastructure. That kind of collapse is very dangerous for a society. It undermines the legitimacy of public institutions generally and in that regard constituted the next central threat, not just to individuals who were at risk for life, but also to our society as a whole. The controls were necessary. We needed to have stay at home orders to get sort of mastery of the situation. But they have also clearly had significant profound economic impacts. We already face unemployment numbers and impacts to GDP on the order of the Great Depression. So not the Great Recession, but the Great Depression. And any kind of economic shock of that degree of severity is also an existential threat. So the key policy challenge is to figure out how to address two existential threats simultaneously, the health threat and a threat to health infrastructure and also the economic threat.

 

[00:06:51] Thanks, Danielle. Let’s stay on this topic of the problem, because I don’t think we have consensus on the problem. Zeke, you know.

 

[00:07:00] Flattening the curve. It was never about reducing the number of covered 19 infections.

 

[00:07:05] It was only about slowing the rate of the infections. And as a result, some very thoughtful people are saying that there’s no escaping the need to establish herd immunity, that we should just assume that most of us are going to get it and get on with the economy. And they acknowledge that people, older people, will have greater vulnerability, but that the claim is that we can do a better job of protecting them. But let’s get on with herd immunity and go back to work. What’s what’s the response to that?

 

[00:07:35] Well, first of all, like God, Daniel, I want to thank the Hastings Center for doing this broadcast. It is, I think, a tremendous contribution to a public discussion in this area, especially very rare in American society today to have an hour of very high level philosophical, economic and policy thought as opposed to a Twitter tirade.

 

[00:08:00] And I appreciate that, having never been on Twitter and never planning to do that.

 

[00:08:05] If I can come on, the water’s nice. You can do it.

 

[00:08:09] I would only get myself in trouble. So let me it’s a it’s a great question. And let me make several points.

 

[00:08:21] First of all, I do think that there is there’s clearly a trade off between public health and economics. But that doesn’t mean they’re in conflict. It does mean that if you do certain things, you are going to have an economic impact. If you do some economic things, you’re going to have a public health impact. And we need to understand a trade off and trade offs are just, you know, part of our life. How much risk are we willing to take for activities, whether they’re for employment or for pleasure? We make those kind of tradeoffs all the time. And as a nation, we individually, we rarely make existential tradeoffs, as Danielle has pointed out. But we often make serious tradeoffs. And this is the most serious one I think the nation has faced in a very long time. Even more serious than the Great Recession. In many ways, in part because it’s been so concentrated, so swift and therefore very difficult. And it also calls upon not just economic responses, but public health responses. Second point, when we think about this tradeoff and when we think about the economics of the trade off, I think we need to understand that there are two potential impacts on the economics. One is supply. So those people who say, listen, let’s open the economy now, like Governor Kemp of Georgia or the president or many other people. Open the economy now because we can’t tolerate 20 percent unemployment, 20 percent drops in GDP. They assume that the problem is that we have closed down nonessential businesses, done the physical distancing, and that when we open them up, everything’s going to return back to normal. This so-called V-shaped recovery that I think belies the fact that it could be a problem of the man. People might not be willing, even if the economy is open, to actually go out and risk their lives for, say, shopping at a small store or a restaurant meal. There’s evidence of that effect in two ways. One is polling data that says that people value, you know, aren’t going to participate in the economy until the health is secure. And the second is the data we have that reducing mobility, physically distancing, not going out to religious services, pre-dated actually most of the sheltering in place orders that people responded themselves, suggesting they’re hesitant. Now, maybe being cooped up for a while is going to change people’s responses and make them more daring and more a less risk averse. But I have a feeling that a lot more of this is on the demand side than the supply side. And that means that if you open up businesses, you’re probably not going to get the rush of economic activity that is anticipated. The third point I would emphasize is I think the people who are saying, look, we’re all going to get infected, let’s get herd immunity, overwith and reopen the economy and just have their numbers wrong. So even on the most optimistic are optimistic is the wrong word on the highest estimate of the prevalence of the virus in society. So about six million people. Now, those are the Stanford numbers. Herd immunity requires 65 to 80 percent of the population is infected. That’s about two hundred and twenty million people conservatively. We are far from that. It would take us a very long time to get that. And a lot of people would die if we got there.

 

[00:11:50] It is much more likely we’re gonna get some kind of immunity from a vaccine in 18 or 24 months than I think we’re gonna get herd immunity out in society and get two hundred and twenty million people infected. And by the way, if you have 220 million people infected and the case fatality rate is, you know, call it point seven point eight percent, we’re talking about a 1.9, 2 million deaths. In addition, now many of those may old people, but many of them won’t be old people. We’ve already seen that it is now the number one killer. And certainly in age groups, 30 to 60, it’s easily would be the number one killer under those circumstances. I’m not sure those are the risks American society is willing to take. And so that leads me to the last point, which is, look, everyone agrees. Danielle’s plan, the Center for American Progress plan, which I helped coauthor of the AEI plan, almost every plan coming out is going to have a face opening up. And that face opening up is going to allow us actually to keep touchdown. It’s not going to be that we’re going to have the same number of deaths just over a longer period, keep total number of deaths down, in part because we’re going to learn more about how to manage people. Maybe the ventilator is a bad idea, even low with low oxygenation, and we should manage people without it. And so I think that, in fact, this face opening is where we’re going to go. Everyone’s agreed to it. It does require some infrastructure, which we don’t have now. It’s a lot better than what Georgia, South Carolina and Tennessee seem to be wanting to do today.

 

[00:13:25] OK. Thank you, Zeke. So, Danielle, we mentioned the Saffer report a couple of times. It’s very impressive. You’ve pulled together people from many different disciplines and you’ve asked them to think really hard about what our next steps are. And you acknowledge in the beginning of the report that you’ve read and are influenced by things like the Center for American Progress report, the American Enterprise Institute. We have a left leaning think tank and a right leaning think tank. And you’ve been taking ideas from across the political spectrum. You identified three approaches.

 

[00:13:55] And I think you’re label for what I just ask Zeke, the one about. OK. Let’s let let’s just get herd immunity. You called it surrender, which I thought was a daring and interesting way to label it. And then you also identified two other approaches, freeze in place and then your preferred mobilize and transition. So could you describe those three approaches briefly and tell us what mobilize and transition is and why you like it?

 

[00:14:24] Sure. No, absolutely. So I think that the thing that the folks who argue for immediate and rapid herd immunity, miss, is that a disease that progresses with that severity and degree of rapidity does actually pose an existential threat, again, not just to lives lost, but actually to our institutions and their stability. That’s the key thing to recognize. And that’s why this was a category of surrender is relevant. That is, we have a job of social protection to do here, as well as a job of protecting individual lives. And insofar as we are the job of social protection that we have periodically drawn on, have war analogy, that you have to sort of bring a just war framework to thinking about this and that in certain sense, the key job is actually to secure the institutions that give you a stable universe in which you can make the kinds of tradeoff decisions that Zeke is talking about. So tradeoff decisions, cost benefit decisions are a hugely important part of policymaking. What we’ve tried to make visible is there’s another layer of policymaking, which is about how you secure the stability of institutions that permit that kind of routine tradeoff conversation in the first place. And it’s interesting that when you focus on that question of how you secure those core foundational institutions, the picture about tradeoffs is slightly different. Because really then what you’re sort of thinking about is how do you mobilize all your resources in order to secure these institutions so that they can deliver health, so that they can deliver a sound, a prosperous economy. So that’s where we ended up with our mobilize and transition paradigm, which is about how do you actually mobilize the economy to secure the resources that you need to deliver a stable health infrastructure. And of course, you can only mobilize your economy could do that if you’re also securing the economy. So securing the economy actually becomes a part of securing what you need for health. And so the projects of health and the economy become aligned with each other. There was that middle paradigm that we also spent some time talking about, which we called freeze in place, which was where people started in the beginning. I think when the sort of first shock and really set in and it was clear that we needed to halt the progression of the disease in order to secure our public health infrastructure. And I think there was a sort of code that you’d be able to help the disease reopen or halt again and so forth and do that. And that’s kind of ongoing way. And in some places, Denmark, for example, Germany, to some extent, governments invested in forms of public funding that could tide employers over so that employers wouldn’t have to lay off people, they could continue to pay wages and so forth, expecting that they would just reactivate economic activity at a certain point in the sort of folks you go merrily along their way. The problem with this approach, however, from an economics point of view, is that those repeated applications of collective stay at home orders make it impossible for businesses to plan. And they would mount up to a really gargantuan bill for a public investment if we were actually really trying to tide people over through repeated applications of social distancing. So that’s why that then if one’s really trying to achieve a full integration of economic picture and health, picture it and trying to achieve that precisely for the sake of knowing that you can actually deliver what you need on health front unless you have a sound economy. So those two things have to be aligned with each other. Then one has to ask the question really well, what does the economy need in order to deliver for the health system? Well, the economy needs in order to deliver for the health system is to be able to know that we’re gonna be able. Open up and stay open. And now that it’s a real sort of big question on the table for how can you possibly achieve that with the disease of the infectiousness and severity of this one currently? And that’s where the answer is. One really has to start to look at new approaches to control the disease. We can’t use National Collective stay at home orders to control over time because economic impact is too significant. You need an alternative that is aligned with what your economic goals are. That alternative is a massively ramped up testing, contact tracing and isolation program. So ultimately what we argue is to mobilize our industrial base, to mobilize our capacity to activate a supply chain and so forth in order to tracing is acquired isolation program. So instead of freezing the economy, leaving it just as it wasn’t her tiding people over that. The job is to actually drive really fast. Some significant recomposition of the economy to deliver the infrastructure that we need doing that. We then have the tools to control the disease, to support public health and to open up the economy. Keep it open so that we have the engines of prosperity needed to support the work we have to do for the sake of health.

 

[00:18:44] So thank you. Can I respond for a second? Yeah, absolutely. I think Danielle and I agree like 90 percent, which is I think it’s undoubtedly the case that we’re going to have to open in phases and that open and relaxed the physical distancing, reopen nonessential businesses. You need this testing infrastructure. And over the weekend, you know, we estimated Paul Romer and I put out something, you know, 2 million tests a day is kind of the minimum number you need because you need to test frontline health care workers, grocery workers, policemen and all sorts of people who are connecting with lots of other people because they’re at high risk of spreading it. Then you need to sort of ferret out the asymptomatic transmitters where we probably disagree. Danielle, I think is in the question of whether you can avoid the stop and start or what I once was six weeks ago. It seemed like a lifetime now. But the roller coaster.

 

[00:19:44] And then maybe you and I interpret the Singapore example in different ways. But just two and a half weeks ago, Singapore, which came out of the box, Korea, South Korea, Taiwan, Singapore, were the best examples of places that have really done a great job of responding, doing shelter-in-place and then reopening the without having to close the whole economy. And then Singapore had this tremendous resurgence in nut cases, had to re-impose school closures and non-essential business closures. And it seems to me that that does suggest that this open, close, open, close kind of rollercoaster situation is going to be in evitable. It doesn’t mean it’s going to be inevitable nationwide. It may be local, but I think it’s very hard to believe that no matter how good our testing and contact tracing infrastructure is, we are going to have some resurgence just in different places and we have to recognize that and be prepared for it. Is that make it hard for businesses? It is going to make it hard for businesses. Is it going to make it impossible for businesses? I don’t believe so, especially if we can tide them over in a better way than we have done hitherto. I mean, I don’t like the way we’ve done it because we keep doing we keep having these eight-week, you know, we’re going to give you eight weeks of payroll. Well, the problem with eight weeks of payroll, it takes you nowhere near the end of the situation where you’re going to be able to open up freely and get back to your previous revenue where 70 percent of your previous revenue. We need more long term planning. And one of the problems with this administration is they would prefer not to have this problem. They don’t want to admit it’s going to be an 18 or 24 month problem. And so every solution tends to be a short term solution rather than a more comprehensive structural solution.

 

[00:21:37] Thank you. Q Can I respond? I respond by. Yeah, go ahead, Daniel.

 

[00:21:45] I’ll do a quick response. I think we probably are in 95 percent agreement. Zeke I think we’re getting closer to each other. If a number has been 2 million a day for some time, actually, as I’m sure you know, for exactly the same reason that you start with health care workforce and so forth. So that’s so that regard rather the same minimal starting number than the question really is what the overall aspiration is. Our view is that the supply chain has two pathways for ramping up testing. One is maximizing the capacity of the existing supply chain. We think that can hit that 2 billion a day. But there’s also an innovation pathway. Excuse me. And we do think that innovation has we can get up a lot higher. And so I think the answer to your question about the stop and start piece truly just depends on the level of our ambition for testing, tracing and supported isolation. If our ambition is high enough, we absolutely decrease the need for that sort of closing. Repeatedly.

 

[00:22:35] I don’t like the temperature. I think it’s execution capacity.

 

[00:22:39] Well, there’s that, too. But we think that capacity is there. And for us, the questions so that obviously you need to keep that collective social distancing as an emergency tool is your absolute last up emergency tool for us this and sort of break the glass when needed kind of tool. But we think the goal should be to never have to break the glasses that we’re trying to figure out the right scale testing program to get to that point. So that’s the only place where we sort of disagree.

 

[00:23:00] I think at this point, which is very exciting and I think a big takeaway where you do agree is that we don’t have to conceptualize this as as the economy versus health. If the economy collapses, that has health and wellbeing implications that are profound. And what and what you’re saying, I think thing is if we take a robust enough response, we can rejigger the economy to do both things. We can actually decide to orient ourselves away from certain things that our economy was generating wealth on and towards the things that we need to mobilise at this war level that you’ve been advocating.

 

[00:23:35] It’s now at a level, I would say, just to clarify again, a war footing, not not an actual war, just something better.

 

[00:23:44] Yes, right. Right. Go for it. OK. Isabel has been observing the chat. I’m sorry. The question and answer function where we invited our listeners to pose questions. And Isabel, do you want to bring forward anything from the audience?

 

[00:24:03] Emily? So we’re getting a lot of great themes and questions in the Q&A. If you haven’t yet, please do submit any questions you may have in that box at the bottom of your screen. So one thing that audience members seem really interested in is the differential roles that federal and state governments might have to play. Could you comment on on where we might where states might have a strength, what roles that federal government must fill that the that the states cannot substitute for those types of differences?

 

[00:24:31] Sure. I’m having to jump in on that, actually, because I think it’s a super interesting question. And there’s been a lot of, I think, a public conversation about a sense that our federal structure in the sense of federalism and decentralization is a liability. And we think that’s not the case. We think our federalist structure is an asset for a few important reasons. We do need the national government, that is to say, the central government in Washington to fund what we are all trying to do here. And we also actually do need them to help stand up powers that permit governors in the states to execute on activating supply chain in the way that we’ve described. There is actually a provision in the Constitution that permits Congress to delegate authorities to compacts of states. The best example of that is the port authorities of New Jersey in New York, where they’re sort of delegated powers that permit those states to work together at a level of building infrastructure that we would normally associate with federal government. So we can do the same thing now with complex of states. In fact, serving to activate the supply chain of testing for the nation with powers delegated by Congress to that compact of states. In addition, we do new appropriations from Congress to public funding to support this. And of course, the White House needs to sign off on this. So we do need sort of whole of government agreements. And then what we also really need is for states to frame out the legal parameters of testing programs in their states so that they incorporate due process, civil liberties protections, privacy protections, nondiscrimination health ethics protections and so forth. And then lastly, for those of last mile deployment, this is the important question secrets. But as well. We really need strong organizational collaboratives among municipal leaders and county public health officials to mount a testing program. So county public health officials or district public health officials very often have the kind of expertise that you need here, but they tend not to have the person power, the sort of resources to support contact tracing, legal infrastructure, in-house, providing those kinds of things. Municipal leaders have those resources. So we’re really at a point where we need to see that come together in a really tight, strong collaboration.

 

[00:26:34] Q Isabelle, something else from the group, yeah.

 

[00:26:37] Another question that is coming up is people want to know why is testing the main priorities and particularly why is testing for coping 19 as opposed to a logical testing or other ways of testing kind of the focus of of your respective plans?

 

[00:26:53] Well, look, I mean, I think this is just pretty simple, if you want to open the economy, relax of the closure of nonessential businesses and such. You have to be able to control the spread of this virus and to control the spread to know how much it’s spreading and where to focus resources.

 

[00:27:17] You need testing and you need viral testing. Neurological testing is really important. It’s really important to know who’s gotten it. It will be really important for us to know how long people get the antibodies, how protective they are against re-infection and things like that. But that is not essential to the prevention of spread. And we need to reorient our testing regime away from diagnosing people who are symptomatic, confirming that they have kove it to trying to reduce the spread. And I think that’s a major, if I had to say, a major flaw in the CDC current approach. They last changed their testing guidelines. I think it was March 24, that is now a month ago. And it’s still oriented heavily towards people who have symptoms, fever, shortness of breath. And that’s a mistake. If you want to contain a spread, you need to focus on testing people who are asymptomatic. We have evidence that between 25 and 60 percent of the people who get this virus are age symptomatic and they may unwittingly be spreading this around and causing real havoc and death, frankly. And I think that’s why the focus is on testing. It’s not the only thing you need. You also need good contact tracing, as Danielle has said, that is technology enable the old gumshoe contact tracing, asking you to recall what you’ve done. And that is just not going to work in a fast spreading cobia 19 situation. We also need to step up our protections for vulnerable people. Part of that is souping up our protections for the elderly in nursing home and facilities. But those aren’t the only vulnerable people. One of the biggest, I think, deficits of the current data collection system is we don’t have good data collected on all the people, all the co-morbidities that are being associated with this problem and who has them. But, you know, if you just look at the number of Americans who have chronic diseases, you know, it’s well over one hundred and ten million. We need to know which ones are particularly problematic. Our young people with diabetes, you know, are they how much higher risk? We know that there are high risk. How much higher risk? What are the diseases that we really need to protect people from? So that when we do open up, we’d make sure that those people remain at home and are well supplied and protected so that we can reduce the demand, reduce the number of deaths and reduce the man on the health care system.

 

[00:29:50] What they. Just real quick footnote, Ziek said the most important thing that people really, really need to pick up on it. The CDC needs to change its guidance. As Ziek said, that guidance currently focuses on testing the symptomatic. As a part of therapeutic efforts and in fact, testing of asymptomatic is labeled as not a priority. That guidance has to change. It’s like a situation with masks. Originally, the guidance was really aimed at rationing to limited supply. It’s time to change the guidance and ramp up the supply. We really do need to test the asymptomatic as well, just as the says we can stop the spread of covered 19.

 

[00:30:30] That is a very important message, the Hastings Center can help reinforce that and using whatever assets and dissemination channels that we have as well. Thank you very much for that. Isabel, we have time for another question from the group.

 

[00:30:44] So there’s also been a lot of talk about wanting to hear from you guys about vulnerable population. So especially the audiences interested in undocumented immigrants, adults over 70. I mean, people who are living in rural communities, they want to get a sense of what do these tradeoffs and what would it look like for the economy to reopen specifically for these vulnerable groups? How do we ensure job stability? What does the next one year before a vaccine, two years before a vaccine, look like for those groups?

 

[00:31:14] So those are really important questions. And I think the first thing we all have to recognize is that we are all in this together without any question. And the health and well-being of all of us depends on our developing plans that incorporate everybody, including vulnerable groups and recognizing the distinctive needs and kinds of supports that are necessary to ensure that people in vulnerable populations are as much of a part of a health and protection plan as everybody else. So, for example, when you start thinking about the sort of phasing of the economies for a phased rollout of reopening, it’s important to recognize that 40 percent of the workforce is currently still participating in the workforce. So health care workers, public safety individuals and police, fire, so forth. But of course, also in various ways, vulnerable populations are very much also still fully participating in collective and kongregate forms of social life. Right. So incarcerated populations in the house are housing insecure contexts, people in nursing homes. And so those all are we need to do our part. The first phase of a fully ramped up testing regime so that people who are positive can be given support in isolation with job protections, material supports for that period of isolation, including the level of things like groceries, where that’s necessary or wage supports. And people are having to go without wages in order to be in support of isolation. And that is a process that has to include everybody, including undocumented workers. I think sometimes people use a metaphor of that to describe what we’re trying to do here, where if you have a hole in the net, if you have sort of places where you haven’t established safety and protections and support for isolation, for example, then you’re not able to stop the spread. The disease will continue to spread in those places where you’re not providing support. So actually, that’s our first phase work is it’s really about the people who are already still very much in context of interaction and they’re not able to participate in corporate social distancing. And that really does involve vulnerable populations in the first instance alongside health care workers. So that is a priority and that is again, why it’s just so important to set our ambitions high as we think about the scale up that we need for testing, tracing and supported isolation.

 

[00:33:26] Let me just add one point that, you know, one of the things we’ve learned from this learned is the wrong word that has been re-emphasized. The point we’ve known for a long time is the differential impact on low income and minority communities. This has wreaked havoc. You know, the disproportionate number of minorities that have been infected and died as a consequence, the impact on their health care services, the overstretched hospitals to begin with getting even more overstretched.

 

[00:33:59] Now, there are some immediate things we can do, it seems to me. We know that in African-American populations, hypertension, diabetes, obesity, the three things that put you at higher, much higher risk of complications from cobh it are much higher represented in those community. And we can take steps to protect those people, educate them, send people out to those communities with a lot more information and help it kind of change their their behavior so that they can reduce their exposure to COBA 19. But this is also going to take a much longer term investment and process. And I think or I hope we are shoveling hundreds of billions of dollars now out of the health care system, mainly to hospitals through the Carers Act and now what’s being termed beforethe bail out for that money, we should require certain changes in the health care system that really do address these disparities to low income rural populations and underserved populations and minority populations. You know, it’s something we’ve called for a long time, but given the fact that the federal government is now shoving this money out and assuring our hospitals and others, we should expect that there is a social contract there that we’re going to get structural change in. Again, part of my problem is that a lot of this money is going out without structural change. We need to lock in some structural changes that ensure that these communities are well served. One of the ones I’ve suggested is if we need to get back Dareton nurses and others to serve low income communities and rural communities. One of the ways of doing that, they should do a loan forgiveness plan where we’re going to pay for all medical school. You just have to work in primary care or an underrepresented medical or nursing services in those communities. Could be psychiatry, could be pediatric specialties. You work in those communities where the rural, underserved minority community, underserved Inner-City communities and we’ll forgive the loans. You can go to medical school and nursing school and other health professional schools. For free, but that comes. That’s a structural change that comes with a payback. And I think, again, one of the things that bothers me is, yes, we need to, you know, shore up the finances of hospitals and doctors and all sorts of areas, but we shouldn’t just give it for free and return to the preexisting system. That has been something we’ve all been complaining about, where all includes not just professionals, but the public about its unaffordability and all the other things and actually kind of put in some real changes that will continue after hope it fades from the stage of the nation.

 

[00:36:53] About we’ll come back to the audience in a few minutes. I’m going to ask. We’ll continue this discussion. And then Isabel will bring some more questions for both of you have talked about the twin responsibilities of testing and contact tracing, testing and asymptomatic people in order to do better contact tracing.

 

[00:37:15] And he gives me. You said we were gonna make it in that way, too, could you? Either one of you or both of you describe some of the apps fact in their function. And I have a follow up question about that. But let’s kind of just describe what’s on the horizon here for people.

 

[00:37:37] Sure. So let me start by saying so we do think that manual contact tracing, the gumshoe part of it is a really important piece of this and that has to be the kind of actually foundation layer.

 

[00:37:49] But then we think that technology and apps can support and extend extend that capacity. So in the first instance, it’s really important that contact tracing be done by people who are trusted within the communities where that contact tracing is occurring. So in that regard, it’s really important for local municipalities, county level public health folks to build out contact tracing programs, including by recruiting community organizations into the work. So New York City’s New York NYC knows that are HIV testing and contact tracing program is a great example where they do have a kind of recruitment process for community organizations and then a training, etc. so that they can build out the sort of army, so to speak, of contact tracers. Now contact tracing and that sort of human element is really important for helping people sort of work through the question of who are the contacts with whom they have closest proximity that they want to reach out to and share that that friend, that intimate acquaintance should also perhaps be tested for for positive Cauvin or just get tested for infection. But that kind of manual contact tracing doesn’t help a lot. If what you’re trying to do is figure out who was in the same sort of supermarket with you at the same time or who is in the same subway car with you at the same time, who to whom. You’ve also now sort of exposed you’ve been exposed to a virus and they need to be warned that they themselves could get tested. And so that’s where tech comes into some sort of extension and support. And there are really two different kinds of option. That is a Bluetooth based technology. And there’s sort of a g._p._s based technology with the Bluetooth based technology does is and this is sort of most likely to be viable in the kind of places where there’s a high, high penetration of relatively speaking, high end smartphones with good Bluetooth capacity, but it permits phones to register what other phones they’ve been here over the course of a day and then the of individual user’s phone. It doesn’t require centralization and then the phones can just ping each other when one of them has that one, whose owner has a kind of a positive test. And so that’s where the pings go out on the sort system. And that works for all the phones that you’re tracking with over a period of time. G._p._s is much rougher. What that does is really make it possible to say this sort of subway car or this sort of supermarket has had people in it who now are in that sort of database registry that may have a kind of positive for COBA test. And then again, you can sort of send out warnings to people who are also there. That’s a much, much sort of broader blunter approach. So in that regard, as of the Bluetooth is the most useful additional element. G._p._s could come in as well. You can also use g._p._s as a sort of memory. So, for example, if people sit down the contact trace or they can look back on an app and sort of look at their own movements to just jigga or trigger their own memory about where they were, when and where and so forth. So technology can come in and a lot of different ways. But I think it’s important to understand it as a support and an extension rather than a replacement for the traditional methods of manual contact tracing.

 

[00:40:48] Of course, these apps are going to raise privacy and surveillance concerns and it may be that many people will embrace them for the sake of safety. That’s for sure. As Reclined, who wrote in invokes inbox the other day that I love my privacy, but I love my mother more so we might be getting a lot of public support for it. But there are also legitimate, very real privacy and surveillance concerns. And I know that you’ve both done some thinking about how we could what we could do, both legislatively, technically in terms of technological design and a variety of different strategies to try to at least mitigate those privacy and surveillance concerns. Could you. Either one of you jump in and describe some of the things we might do?

 

[00:41:34] Well, look, I think, you know, we at the Center for American Progress have argued that, you know, you do have to I think Danielle used the phrase, we have to have a trusted intermediary with a lot of these data. You know, there’s a group in American society that, you know, very suspicious of the government don’t want them. They have data on us. There’s a group in American society very suspicious of attack.

 

[00:42:00] And often they overlap and they hate everyone. And I think neither of those groups are groups that people are going to trust with this kind of data. So we need some intermediate group that people can trust and we need to have these data utilized and the apps activated in a way that people can be can be assured of. Several things. One, that information about where we’ve been, who we’ve interacted with, how close we’ve gotten to them is not going to be merged with other data and that it’s going to be for alerting us to get tested. The second is that it is not going to be commercialized. You’re not going to keep that data, merge it in somehow. Big tech is going to make money like they do on all our other data. And the third point is that that information about who we’ve contacted is going to be destroyed in a regular manner when it’s no longer of any use to public health officials. And we’re not going to have some shadow retention of that data, which we’ve seen talked to in lots of other cases when we thought the data were the contacts or whatever other information was being destroyed when we opted out of Facebook. Facebook still kept all our information control what they claim. I think those are the kinds of safeguards we need to put in place for this to really have a role and for the public to trust it enough to have a role. I have to say I’ve actually found big tech totally unhelpful so far in this. It’s hard for me to see that they’ve done something really, really helpful in this regard when it comes to cobh at 90. They have lots of capacity. Believe me, Facebook already knows who you interact with on a regular basis, how close you’ve gotten to them when you leave your house, which stores you go into a Google does the same and they have not used this data.

 

[00:43:57] Maybe they’re afraid that people are going to be all upset, but they haven’t even been willing to give it to someone else to use in an effective manner. And I think either they’re going to become irrelevant in this process or they’re going to have to step up and actually be contributory to solving this problem.

 

[00:44:17] So, I mean, this is a huge and complicated issue and it does require a lot of and fast thought. So of course, Apple and Google have announced their effort to build an app into their phones. Of course, the next few months, that’s a piece of the conversation. But I think an important thing to recognize in terms of sort of what is it that we should want is that we should want a system where that relevant tech tools only store the data on the user’s phone so that people imagine a centralized server that’s collecting all the data that’s not actually necessary. What’s necessary is that data is stored on an individual’s phone. It can produce tokens that can be shared with other phones in the vicinity or that can be used to connect with us sort of broader G.P.S. system. So that’s a really important feature of the privacy protection element of this and the relevant data that needs to be central testing data when people test positive for covered. And that actually is on par with what we already do with flu tests and the sort of the way the CDC manages the data system like that’s which tracks all flu tests all over the country every year. And so that’s the tricky thing. And so the articulations between sort of centralized database of flu tests that is controlled and where tests are entered by medical personnel, not by individuals. And the communications between that and sort of through a server with apps that hold data on a person’s phone so that people can see whether there’s a match between the information that’s coming out of that sort of testing data and information that they have on their phone. So that’s sort of the key that the way things are. You had it in a privacy protective way. Zeek is completely right that in addition, you definitely need preemptive legislation that permit prohibits commercialization, because even if you design things in this price of privacy protective way, you have to presume a breach or a hack. Right. You have sort start by presuming that that you can never sort of design it to have 100 percent protections and your success. And so in that regard is the worry is that people can kind of reverse engineer even from the kind of token system that I just described, actually sort of we create the data that sort of underlying the kind of token system. And so in then protection against that, you want to legislate against commercial use of the data. You want to legislate in advance for penalties in the case of anybody. Reverse engineering from a privacy protective system and so forth. But so but there are things that we can do to build out a system so that can be functional in this privacy protective way.

 

[00:46:45] Thank you both, Isabel. Would you like to come back and bring in some more audience? This will be done the second and last break that we’ll take to to hear from the audience. And we have time for several questions.

 

[00:46:58] Our audience is really excited about these different strategies and medically sound ideas that are being floated right now. They also are interested in kind of the values that are driving these really a great introduction to some of the values that are at stake at the beginning. But people also want to know Daniel and seek kind of what primary values you think are guiding your decisions and how they’ve driven kind of the strategies you’ve developed.

 

[00:47:24] I think I’m a little struck by that. I mean, look, if you’re making public policy in this way, you know your want to maximize benefits to the population and maximize population well-being over time. It seems to me and I don’t think that’s all that controversial at this point.

 

[00:47:44] That’s not the only value. You know, we merely did outline some of the other values. You know, we have a certain kind of privacy, civil liberties, etc.. And we also need to recognize very much that I think Danielle put it, you know, we’re all in this together. This is an infectious disease.

 

[00:48:02] And one of the hallmarks of infectious diseases is that we’re all can affect our neighbors, our friends and people we don’t know in ways that we can’t necessarily control. And so there’s a kind of communitarian solidarity element to it. But it does seem to be that, you know, whether you’re talking about public health and reducing the number of deaths, reducing the number of hospitalizations, keeping those institutions whole, whether you’re talking about the economy, making sure people have jobs that they have that they know don’t go into poverty, etc.. You know, we really are talking about an overall well-being measure. And when we’re trading off against the two, we’re trying to get to some perfect point where we can save as many lives as possible while keeping as many people in a reasonable economic condition. So I don’t know. It doesn’t seem to me like there’s a big conflict over the values. We might weigh them slightly differently. But I do think those are the ones that are driving guns. I do think that there are some really complicated questions here that we haven’t discussed, where it’s not clear what the right framework is, in part because it tends to be more international in our understanding of the values that should guide international relations are, I think, much less well developed and our intuitions very much more widely.

 

[00:49:29] I think one of the things that is that we’re not seeing that it is a trade off between the economy and health, because what we’re identifying are ways to re not to modify the economy so that it addresses the health concerns. And we don’t have to think as much about trade offs as we do about design. Designing the economy to promote human flourishing. Zeke, you’re laughing. Probably think that’s a little too optimistic, but or I should or shouldn’t infer from your from your smile. But I do. I do think that is one of the things that Danielle was bringing up. And in relation to the question we just heard from the audience and Zeke’s comments on it. Danielle, can you say a little bit more? It’s not only the health that’s at stake, but you really talked about a deeper level that had to do with societal decay and threats to democracy and the values that undergird our commitment to democracy. Could you say a bit more about that?

 

[00:50:25] Absolutely. You read my mind, Millie. So this is this is good. Give me slightly subtle, but let me let me spell it out. So I agree with Zeke that well-being is the overarching goal. Zeke, use the phrase that our job is to maximize well-being. My vocabulary to about securing well-being or sometimes to talk about securing safety and happiness. And so what’s the difference between securing and maximizing? So there are a few things here. So when I’m sketching a picture of our social job, securing well-being, that well-being that we aspire to is about individual well-being, but also about societal well-being. And well-being is partly about the kind of society that we are. So a full picture of well-being includes individual health, that includes economic security for individuals. It also includes our collective work together to secure the foundations for a constitutional democracy that delivers liberty and equality and justice and fairness of opportunity, so forth, for everybody. So the package of things that we’re trying to secure is a package that includes some things that can be talked about in the kind of economic vocabulary of maximization, but other things that need to be talked about, rather, and a vocabulary coordination and the ways in which we can use social cohesion to deliver on the goods and some of those kinds of things that we do through coordination aren’t actually as susceptible to maximizing vocabulary as it is when we talk about individual well well-being and individual economic security. So hence my book, Securing Our Well-Being or securing safety and Happiness for all of us individually and all of us together. That’s a picture that requires sort of thinking about the design of institutions, the design of institutions. I think a piece of work that we need to put alongside sort of economic calculations of tradeoffs.

 

[00:52:08] Well, I guess I’m enough of a Hobbesian to recognize that it does require certain state institutions. Far be it for me to say for us to realize. Well, being being in a state of nature and being an authoritarian regime, neither of which are likely to maximize well-being. I agree with you. And one of the things I have to say that we haven’t had a large discussion of and not on this conversation, but not anywhere in American society yet, is to think through the political consequences, long term political consequences of the current situation. So let me just say, you know, one of the lessons of the depression we often celebrate in the United States, well, you know, we got the new deal.

 

[00:52:59] The New Deal gave us a whole series of new elements in the social contract, unemployment insurance, Social Security, not having kids work in factories, a new constitutional framework for thinking about individual rights, et cetera, et cetera. We got that because, you know, we had a political leader who recognized the importance of those things to preserving democracy. Many other countries did not get that. Germany got Hitler. Italy got Mussolini. Spain got Franco. It’s much more likely he’s happy out of these kind of tragedies and crises. Authoritarianism looks appealing. And what we’ve learned hopefully in the 20th century and one of the things we hope we won’t forget is that that does not maximize long term well-being. People do not like those regimes is as appealing as they may be in the short term.

 

[00:53:56] They’re horrible in the long term. And I do think we need to think about those elements. It’s a little ironic, of course, that I’m saying that on the day when new visas for immigrants have been suspended, it does seem to me that as all of us know, we have been flirting with a kind of a latent drift towards attacking judges, attacking the press, attacking the other party is the enemy, not simply the opposition.

 

[00:54:28] These are big threats, but they pre-date Kobe. They may be enhanced by Kobe, unfortunately. But I do think ensuring the institutional structures is very important. Let me just end this little comment by noting that if polling does suggest anything, it actually suggests Americans are beginning to value and reaffirm those democratic values. You know, the trust and faith in the federal government has gone up. And I do think that there are some, you know, use of the media, the mainstream media, not the fringe media, has gone up. I do think people understand it’s important to have a competent government. It’s important to have democratic rights. It’s important not simply to, you know, talk about control, but that we do have a system of checks and balances and federalism and to respect that.

 

[00:55:24] I actually you know, it it warms my heart to some degree. It it reaffirms certain faiths in the fundamental understanding of Americans of what it means to be American and what is unique about America. But sometimes it takes a crisis like this to reaffirm that. And I just hope we can sustain it.

 

[00:55:46] That’s a beautiful ending. Comments. Danielle, do you have the last word? We only have a couple of minutes left. And I wanted to say a few things at the end, but I love. I’d love to give you the chance to.

 

[00:55:57] More than any you’d like.

 

[00:55:59] Thanks so much, Molly. I think I would simply repeat what I said before that we really are all in this together. And as Zeke just said, we it’s important that we achieve resilience for our institutions because it’s through our institutions working through the entirety of our federal system that we’ll be able to deliver the health, infrastructure and protection against covered specifically that we need to all restore our sense of safety to have that psychological confidence that will permit us to go back about our business, to be open and stay open and to secure the underpinnings for a prosperous society and a healthy society.

 

[00:56:36] Well, I want to thank you both. This is exactly the kind of conversation that the Hastings Center exists to enable. It’s we discuss technical solutions, but we didn’t leave it at the surface of what the technical options are. We tried to talk about what values should shape our choices. And so I would just want to start by thanking you so much is exactly what what we exist to try to create. And what I think our country needs. As you began, Zeke, you talked about how, you know, this isn’t this is very rare to have an hour to talk through, a lot of complicated ideas. We began by the hour describing the problem and the terrible the terrible situation, the pandemic pandemic has put us in. We moved to generating some solutions. And I’d like to just end with, you know, basically talking about the opportunities in the way that you’ve just both of you just mentioned that would come if we could unite across all of our divisions.

 

[00:57:38] I think it’s a great fork in the road if we can lead to greater disarray and authoritarianism and anger, or we can see this as an opportunity to rebuild our structures in a way that are more promoting of human flourishing. We’ve mentioned a lot of them during this conversation. Structural changes that could address health care disparities. We haven’t mentioned telemedicine, but that’s certainly it being debuted in a very productive way, talking about seeing the economic benefits of using our powerful manufacturing and distribution channels that are so robust, but reorienting them to for the technical things that we need to fight this and many other many other good, stronger health, public health infrastructure that could be lasting.

 

[00:58:23] There’s a lot of good that could come from this. If we to use Daniel’s expression, if we mobilize and transition, though, maybe take that route and not the other. Thank you very much and thank you to the many people in the audience who participated. We will also have a video tape of this whole hour on the Hastings Center Web site later today. And we encourage people to distribute it and make it make it available as much as possible. A lot of special messages to CDC and others have come through this discussion. So I hope that the videotape makes it pretty far and wide. Thank you.

 

[00:59:04] Really? Thank you. Thank you. Good to see you.

 

[00:59:09] And if you’d like to continue the conversation, please check out Twitter using the hashtag ethics for reopening. Should a great discussion there. Thanks, everyone.

 

[00:59:21] Thank you, Millie. Thank you. HASTINGS Thank you, Danielle.

 

[00:59:24] Thank you, sir. Great to see you. Thank you, Isabel. Yes. Thanks for those questions. Very good ferreting them out.