Howard Bauchner, MD, shares his medical and scientific wish list

Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.

In today’s COVID-19 update, JAMA's Editor-in-chief Howard Bauchner, MD, shares his "Medical and Scientific New Year's Wish List," and also takes a look at the state of vaccines and key COVID-19 questions scientists are looking to answer in the coming months.

Learn more at the AMA COVID-19 resource center.

Speakers

• Howard Bauchner, MD, editor-in-chief, JAMA scientific publications

Unger: Hello, this is the American Medical Association's COVID-19 update. Today, we're discussing the latest trends in research on COVID-19 with Dr. Howard Bauchner from his vantage point as editor-in-chief of JAMA and the JAMA Network in Chicago. Dr. Bauchner prefers that I address him as Howard. I'm Todd Unger, AMA's chief experience officer in Chicago.

Unger: Howard, I want to begin with an editorial that you published in JAMA right before the holidays called “A Medical and Scientific New Year's Wish List.” In it, you lay out the key goals you'd like to see accomplished in the new year and some of them related to COVID. Others are broader. Can you talk about why you were compelled to write this and what do you hope that the profession takes away from it?

Dr. Bauchner: Well, firstly Todd, once again, thank you for having me and for people who celebrate, I wish everyone a happy and more importantly a healthy New Year. I've never written one of these before. And I think I did it for two reasons. I've now been at JAMA for 10 years, and people have asked me to be more vocal in the platform than I have.

I still will take great care in how I use the platform. I think it's one that is substantial and I hope influential, so I will take great care with it. But people have asked me to be more active on the platform in different ways. And this has been a remarkable and difficult year for the United States and the world. Probably close to 500,000 people have died, excess deaths, 350,000 attributable to COVID-19. And then probably another 150,000 excess deaths, so 500,000 more than World War II.

And I'm not sure how much better certainly the first half of 2021 are going to be, so I thought it seemed like an appropriate time to articulate at least one person's wish with respect to medicine, just specifically in science. It wasn't a broad ranging wish list. It was, as I indicated, one individual's, and so those were the two principle reasons I did it.

Unger: I really liked what you said, which was respect for science and scientists and public health officials, healthy and civil debate, and a fundamental commitment that no individual in the U.S. should go without health insurance. That is amazing. I was surprised or interested to see one of the other things on the list, which was around hypertension.

Unger: And you called for a national campaign to treat every individual with hypertension in the U.S. Can you talk more about that?

Dr. Bauchner: Sure. We received an opinion piece or viewpoint about six or seven years ago that said hospitals have to report 400 quality indicators and some are to different groups, and some will be less than 32-week gestational age births, others will be less than 34 weeks gestational age. And it's just overwhelming the amount of additional administrative work.

And I think one thing we've learned is that when we try to do many things, we often end up not doing anything particularly well. And we published a remarkably disturbing piece in JAMA about four or five months ago by Paul Skolnik that said the quality of our recognition and treatment of hypertension in the United States had declined over the last decade with substantial racial and ethnic differences. And I found that disturbing because over that same period of time, we've learned that hypertension is related to many different adverse health outcomes. Kidney disease, earlier development of dementia, and obviously cardiovascular disease. And many other groups, the American Heart Association, the Centers for Disease Control, the NIH, the AMA have really begun to talk in earnest about the need to focus on the diagnosis and treatment of hypertension.

It resides firmly within medicine. Some of the goals for a healthier life is better housing, improve climate, better foods. Those are difficult. Those are societal issues. Hypertension is a medical issue and diagnosis and treatment are possible and treatment isn't that expensive. And so that's why I focused on hypertension. As I said, I worry that when there's 400 quality indicators, we may not do any very well. And I'm pleased that before I wrote this, the AMA, the CDC were very focused on hypertension.

Unger: Yeah. I know my own internist had said to me, "If there's one thing that he knows, basically to get the biggest improvement is to control hypertension. It's moved me, as has the work with the AMA.“

Howard, another wish that you mentioned, I talked about it up front is this issue about respect for science, scientists and public health officials. There's also recently published in JAMA about how physicians can deal with patients' misinformation. Can you talk about this? It's been a recurring theme. How are you looking at this as we head into 2021?

Dr. Bauchner: Raina Merchant, who's on our editorial board and is director of the Digital Health Center at Penn has written about this extensively. It's clear that the way in which we now communicate goes beyond traditional media. So it definitely goes beyond the traditional media outlets, even our podcasts.

So much information is now in social media and there's been a lot of advocacy for certain treatments, that there was very little data to support. Obviously, the great concern more recently has been around misinformation about vaccines. Now interestingly enough, people's acceptance of vaccines seems to be increasing, the COVID-19-related vaccines seem to be increasing for a number of different reasons.

And so, it's something that organized medicine needs to be become more effective at. The traditional CDC playbook about communicating public health messages was verbally and in print. And I think we need to really try to understand how to be more effective in social media. And traditionally, we want to maintain a recognition of different views, but there are statements in social media that are just wrong and not evidence-based. And we probably need to be more direct in refuting those, then simply saying, "That's someone else's opinion."

And I don't think that's what we're trained to doing, and we likely need to become more effective at understanding what approaches will work in social media.

Unger: Yeah, it seems like the forces of misinformation are very well-organized on social media and we really need the same capacity on the positive side of information, in making sure that people understand what is real and what is true.

Let's talk a little bit more about vaccines. This week, it was revealed that scientists are studying if the Moderna vaccine supply can be doubled by cutting doses in half or delaying the second dose, for instance. Supply is not necessarily right now the biggest challenge, but rather than the distribution of that supply and getting it into people's arms. So how do you look at what science is telling us here, and is it something that we should be pursuing?

Dr. Bauchner: So Todd, you did a great job in distinguishing the two different issues. So the issue that faces us this week, next week, and the following week is that apparently there's 10 or 15 million doses of vaccine that have not been given. That is, they've been distributed to different groups but they have not been given to individual patients. That's the first task at hand.

Once we've accomplished that, then we'll understand what the extent of the vaccine shortage is. It's very unclear because it's very hard to get very definitive projections from Moderna and Pfizer. Both companies want to produce as much vaccine as possible, but whether or not they can make enough to meet the so-called demand in the United States is unclear.

So the first goal is to make sure that the 15 or 20 million doses that have yet to be given are administered. That's likely to take a few weeks based upon the projections I saw over the weekend. So let's say somewhere around February 1, we'll know what the next month of supply will look like.

And if that month of supply is 10 million doses, and you'd really like to administer it to 20 million, 10 million new individuals, assuming that the initial 15 or 20 million people get their second dose, then come February 1st, you have 10 million additional doses to provide. Then you have to make a decision at the population level. Is that sufficient? And there's different approaches that people have talked about. At the moment, we know what happens with respect to immunity if a vaccine... if both of these vaccines are given three or four weeks apart. That the early data suggests that 95, 90 plus percent of individuals have a good immunologic response.

Dr. Bauchner: The question is, if you instead of giving it at three or four weeks, you give it at six weeks or eight weeks or 10 weeks, is that going to reduce the ultimate immunologic response? One could assume it would still be very high, but it may not be. You simply don't know. And if people only get 50 or 60% protection after a single dose, and they're now exposed for two or three more additional months, because they haven't gotten the second dose, is that worthwhile? These become an enormously complicated, scientific, epidemiologic and mathematical problems to solve.

The only other point I would make, is say we get to February 1 with 10 million more doses available. We know that somewhere around 15% of the U.S. population has probably been infected. That's about 50 million people. Rather than delaying the second dose, what we could do is not give that first dose to people who've previously been infected. That would save us potentially in the short run 50 million doses. That may be a better approach. I do know that both Moderna and Pfizer are going to need to provide additional information to the FDA so that they can make a final recommendation about either having the dose, splitting the dose, or delaying the second injection.

I know that at least over the weekend, Dr. Fauci and I spoke to Dr. [inaudible 00:11:34]. Neither of them, based upon the current data they've seen, are supportive of that approach.

Unger: Well I, for one, cannot wait to get my vaccine. And I know that JAMA has looked at several issues surrounding vaccines, including people's willingness. You mentioned that before. Can you talk about that and other issues, including not limited to mandating vaccines?

Dr. Bauchner: I was wrong about something. I assumed this phase 1A would go well, and I think like many people, I'm surprised. I thought it was to go largely to health care workers and those in nursing homes. And I think everyone has been surprised about the struggles in different areas of the country.

So that's both been disappointing and surprising to me. Where I'm optimistic and the early data suggests it, is that as more and more people have been vaccinated, and people have gotten more comfortable with the notion of vaccination, I think the acceptance is gradually increasing. There's some early polling data. In addition, when I've spoken to people around the country, very few health care workers are turning it down.

And many of those individuals are Black or Latinx. And there had been very substantial concerns that people in those communities may be more vaccine-hesitant for various reasons. So I think the early data are suggesting that people will accept the vaccine. Sadly, and as most of the listeners know, the numbers in this country in terms of daily deaths, as well as the number of individuals being hospitalized is also much higher than it had been. And so I suspect people are seeing more COVID-infected individuals in their lives and that may also be moving people to accept the vaccine.

The other issue you raised is whether or not we should pay people to be vaccinated. We just put up a viewpoint today about that. And I think there's broad, ethical concerns about paying people to be vaccinated.

Unger: Well, as we get closer to the one-year mark of this pandemic, we still learn a lot about how it affects people differently. Can you talk about some of the key findings that are emerging about what physicians need to know as we navigate the next couple of months?

Dr. Bauchner: Yeah. Well, I think we're still trying to understand what the best treatment beyond corticosteroids are. So for seriously ill individuals, it's quite clear that corticosteroids represent standard of care. There's been some data about some other additional drugs and how effective they are remains a little unclear. JAMA IM published some papers on Toci, saying it wasn't effective. There may be some data coming shortly that suggests it is effective. There's been some other IL6 inhibitors that have shown some effectiveness. And the question is how much do they add for the seriously ill patient in addition to corticosteroids?

Then there's the prevention, which we've talked about before, which is monoclonal antibodies. There's two products. They seem effective. Interestingly enough, they've not been very substantially used. Apparently, there was concern that there'd be a shortage and in fact, there appears not to be a shortage. In part because of under-use. Administration is complicated, hospitals are overwhelmed, and so that may be one of the issues.

Dr. Bauchner: And then of course, there's a great unknown about the long-haulers. We've seen numerous papers, but they've been very small case studies and case reports. And so we still don't have a great understanding about how many individuals may in fact qualify as long-haulers, what would the definition of long-haulers be, what's the constellation of signs and symptoms that those patients may have? Are there any preventive strategies? That's the great unknown, and I think increasingly, people are concerned about that. I don't think we'll see high-quality data about those issues for many months.

Unger: Well, that's a good segue into our final question as you look ahead into 2021. What do you think are the key areas of research or the key questions around COVID-19 you anticipate in upcoming research?

Dr. Bauchner: So I would put them in two different camps. The public health camp involves vaccinations, so what will be the strategies that President-elect Biden introduces shortly after becoming President to increase vaccine uptake and vaccine administration? Will there be a change around the recommendation about spacing out the current two approved vaccines? Will additional vaccines become available?

So I think those are the public health questions. And as a reminder to the listeners, for the near future, social distancing, masking, hand washing remain critically important. Also, I think because of the Christmas travel, either by airplane or by seeing individuals, I think January and February are going to be very, very difficult months in the United States for patients, clinicians, health care workers and hospitals. Clinical questions, new treatments for those who are seriously ill. Again, we have not resolved the issue about convalescent plasma. There's some other trials ongoing about different therapies. Prevention therapy, we know about the monoclonal antibodies. We had published a study about SSRIs being effective in reducing conversion from mild disease to serious disease, but we thought that was a preliminary report.

So that needs some additional data. And then of course, the question that we had already discussed, which is what will emerge around so-called long-haulers, or the long-term effects of COVID-19 on individuals?

Unger: Well, thank you so much as usual, Howard. It's incredible to get your perspective. Thanks for being with us here today. And folks, if you want more information on COVID-19, visit the AMA COVID-19 Resource Center at ama-assn.org/covid-19. Thanks for joining us. Please take care.

Dr. Bauchner: Thanks, Todd. Always a pleasure to be with you.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.