Q&A With Goosby, Pt. 5: What the U.S. Gets Wrong

School of Pharmacy

Synapse: The COVID-19 pandemic has caused massive economic, social, and overall disruption. In your opinion, what is the biggest, most critical reason(s) that this pandemic is so hard to stop? Why has it gone on for so long, especially in the U.S.?

Dr. Goosby: I think that the decentralized medical delivery system puts us at a disadvantage in that we can’t identify and rally resources to respond to anything in a given geography, because our geography has healthcare that’s paid for by seven different large plots of money that don’t talk to each other, don’t transfer patients between each facility, and want it that way.

They want to preserve their part of the pie from which they make profit, not save lives as the main focus of their attention even though they talk about it in their communication strategies as their sole motivator — it’s their last motivator!

And I’m just so frustrated with it I could scream. This isn’t an area of research, or an interest of mine; it’s just something I fell into.

So I’m on the advisory — the kind of kitchen cabinet — for the city and for the state. And they’re budget-controlled; all the policies are signed off on by these two groups. So I’m seeing it up close, and it hasn’t gotten better.

The idea that the United States has decided to let a small number of people get a profit from healthcare, while the population is not adequately responsibly covered for disease threats — you know, including hypertension, diabetes, and coronary artery disease — the disincentive to identify disease in a client of Sutter Health and have them use the system is high.

They don’t want you to get a blood test or get admitted to the hospital, because they keep more money if you don’t.

And that crazy conflict of interest has not been fixed!

You know, it was talked about in the late 70s when they started thinking about managed care. But the profit-driven voices have won that hands-down and aren’t looking back.

The general person in the community, because of their unfamiliarity with healthcare and what they should or shouldn’t receive — especially as you move into minority communities; the self-expectation is so low, the system isn’t being challenged for not delivering.

And people are making more profits, people are signing into buying stock for healthcare systems that they’re looking to help supplement incomes and retirements and all that, and it goes into that economic thinking, and never comes out.

Healthcare’s different from investing in an airline or a trucking company. There’s a different ethics to the commitment that a healthcare delivery system makes to the patients who use those systems, and to the larger society.

They’re connected differently from somebody who makes profit. And we’ve not had that conversation. And we haven’t because the people who make the large profits from it are doing everything they can to not have us have that conversation.

It goes down political lines, Republicans are rabid over protecting this turf, and always have been — not as healthcare, but as just another motor of profit that they want out there — unregulated, kind of unyielding to changing needs as long as it doesn’t impinge on their profit.

Anyway, I’ve said enough about it.

Synapse: Some countries have managed to keep their COVID-19 case numbers and death rates very low, while in other countries, the cases and death rates continue to stay very high. What do you think defines an “effective” response to a pandemic? What’s the main difference(s) between the countries that are keeping their cases well-managed, and the countries that are not?

Dr. Goosby: It’s the concept of community viral load — in an individual with the virus via the flu, HIV, COVID, you get infected, and your blood level of virus goes up per dilution. And the higher the load, in general, it correlates with higher infectivity.

So with the same exposure of secretions or in an aerosolized virus, an exhalation, you expose the individual to more virus particles in a high-viral-load individual than in a low-viral-load individual. That isn’t necessarily true in a respiratory spread viral disease. But it is generally true, still. It’s very true in other diseases.

The countries where you didn’t see spread had a lower community viral load. In their communities, if at any given time, you went out and sampled blood, you would find a low level of virus in the patient, in the people who were asymptomatic, and in people who were symptomatic, or you wouldn’t.

You may find a high viral load. Countries with low viral loads don’t transmit. Countries that don’t move people around don’t transmit. And I think that with the combination of countries where a person stays within a ten-mile radius of where they live for their entire life — you don’t have wide community spread challenges, because the community has not been inoculated to the degree that a city with an airport and a train and bus systems, and a workforce that goes to work every day and comes home every night, will.

And the United States is set up, because of our ease of transportation to a large degree, to be one of the first places that it broke out.

Except for the outbreak in Wuhan, everywhere else that broke out was where there was an international airport. And that inoculation — if you want to think about it as that — the country inoculations were bigger where there was more airport travel, more airplanes, more people on them, going into your community when they got off the plane.

That was all happening for weeks before we knew COVID existed. We had Italian mutated viruses in Washington, Seattle, and in Los Angeles, California during the first outbreak of the Wuhan virus in the first week of January last year.

Going back to blood samples, we can recover the virus as early as that. So it just tells you that the viral movement through the population is still a big factor, but once you reach a certain prevalence in the population, that’s overwhelmed, and the risk becomes a regression to the mean — you see one risk emerge.

And you don’t see a change in that until you get your R0 — your reproductive number — below one. So that’s how I would kind of think of it in terms of viral kinetics.