COVID-19

David Scheffer: Thank you very much. Hello, everyone. I'm David Scheffer, visiting senior fellow on international law at the Council on Foreign Relations. And I've been a longtime student of Scottish devolution and aspirations for independence from the United Kingdom. We have the privilege today of being joined by Michael Russell, who is cabinet secretary for the Constitution, Europe and External Affairs of the Scottish Government, and he is a constituency member of the Scottish Parliament, representing Argyll and Bute. He was raised in Troon in Ayrshire and educated at Edinburgh University and has lived in Argyll for over 20 years. Mr. Russell was previously Minister for Environment from 2007 until 2009 and then served as Minister for Culture, External Affairs and the Constitution before moving to the role of Cabinet Secretary for Education, which he held until 2014. He was appointed Minister for UK negotiations on Scotland's place in Europe in September 2016. I can attest confidently that Mr. Russell is a close confidante of Scottish First Minister Nicola Sturgeon. And, after her, he is the most informed and articulate spokesman on issues of devolution and independence in the Scottish Government. He has spoken often of the hazards of Brexit, of Scotland's determination to remain in the European Union, and of the inevitability of Scottish independence if Westminster continues down a destructive path of its own separation from Europe. A significant majority of Scots have repeatedly expressed their desire to remain in the European Union. While the independence referendum of September 2014 failed to achieve a majority vote, in part because of the UK government's position at the time to remain in the European Union, there is a majority of Scots for independence in all of the polls reporting in recent months. Thus, the aspirations for independence remain very much alive, while the Scottish Government prioritizes management of the COVID-19 pandemic. So it's a bit complicated. Mr. Russell and I will engage in discussion for 30 minutes, and then I will open up the floor for questions. Please feel free at any time to raise your hand, and I’ll see those hands stack up, and I'll begin calling on individuals at the 30-minute mark. So let's begin. Mr. Russell, it's a tremendous pleasure to have you today at the Council on Foreign Relations. I want to start with this sort of cosmic question. The Scots have a long history of division and union with the rest of the United Kingdom, which includes England, Wales, and Northern Ireland. For those in our audience who may not be familiar in detail with Scottish history and politics, can you briefly tell us what it means to be Scottish, particularly being a Scot living and working in Scotland, or the European Union during the turbulent politics of the United Kingdom and of the world today? How committed is Scotland to remaining in the European Union? And why? Michael Russell: I think I could probably speak for the next hour on that topic and not complete it. But let me just quote somebody who may be surprising to quote, Cecil Rhodes, who said that to be English was to win the first prize in the lottery of life. Scots don't feel that way. I think that the Scottish view of the world is much more modest, much more inclusive. And the reason we regard membership of the EU as absolutely central is because we share European values and those values of cooperation. We share the view of the world as held throughout Europe. And we find it increasingly difficult to reconcile that with not the plain people of England, as Chesterton called them, but the English government and the way in which it operates. In order to be a normal nation, and in that simple normality, in order to be a normal nation, it will be necessary for Scotland to be independent within the EU. It is not normal to be in the type of constitutional setting where we are presently where a substantial number of the powers that we need to exercise are not available to us. And it is, I think, we have to see all this through two prisms now. The world has changed enormously in the last three or four months. And those two prisms are Brexit and the vote of the UK, but not Scotland, to leave the EU. Scotland did not vote to leave the EU and yet is being forced to do so. And the COVID pandemic, particularly, as I think it continues to change views. Every individual death is a tragedy, and I offer my condolences to those people in the United States who have gone through such terrible times, as we've all gone through those times. But we have to come to some conclusions about those and where we want to go next, what the future will look like. There's a tremendous book that actually originates in America, John Barry's 2005 book on The Great Influenza, which celebrates the success of American medicine and the coming of age of American science. But Barry writes about pandemics in general in that book, and he comes to a conclusion, though, what makes the difference in terms of coping with a pandemic in governmental and governance terms is quality of leadership. It is governance itself. The conclusion he comes to and let me quote it because it's really important, “The biggest problem in coping with a pandemic lies in the relationship between governments and truth. Part of that relationship requires political leaders to understand the truth and to be able to handle the truth. Those in authority must retain the public's trust. The way to do that is to distort nothing, to put the best face on nothing, to try to manipulate no one.” And I think what you may have seen in the handling of the pandemic is that in Scotland, the pandemic and the difficulties of the pandemic have added to the views that have certainly grown after Brexit, that we need to have a more honest, a more truthful, and a more values-driven politics that we are able to have, and a governance that is better for people. So we have to do a lot together, and we're not able to do that. There is a barrier between us and the world. And it is removing that barrier that is really important. And I have argued repeatedly, that devolution, the devolution settlement, the settlement under which Scotland, Wales, and Northern Ireland presently live, which is only 20 years old, has not been able to bear the weight of either Brexit or COVID, because of the demands upon the governments to serve their people. We've not been able to answer them as fully as we should, because we do not have the full powers to do so. So it's a question of where power lies, how power is exercised, and where it would better lie and be better exercised in the future. And it is not in any sense ethnic, or racial, or to do with disliking people. I was born in England. My mother was English. Her father's proudest boast was that he had bowled out the great W. G. Grace, the cricketer. If you look at the chronology, W. G. Grace must have been a bit arthritic by then, but even so, you know, this is not about being against people. It is about a modern reaction to the world in which we live. And the better way we could run things in Scotland, if we were not at arm's length from it and removed from it. So that is a long way of saying it's normal to do it. We need to become normal because it will lead to a better governance, a better equality, a better deal for our citizens, and a better relationship north and south of the border. There's a very old saying that says independence for Scotland will get rid of the surly lodger and gain a good neighbor. And we need to go to being good neighbors with the others on this island, but not to be controlled by them. Scheffer: Michael if, as the US or the UK government claims, COVID has proven that the idea of independence is not viable for Scotland, why hasn't the United Kingdom provided resources for Scotland to weather the pandemic? I just don't see much news of stuff flowing from the south to the north during the COVID pandemic. Russell: None of us are capable of making the cost of the pandemic without an extraordinary loosening of borrowing and the loosening of the public finances. I mean that's clearly true. I mean, the UK has borrowed an enormous amount, going north of £300 billion at the present moment. We do not have full borrowing powers in the Scottish Parliament. It is one of the areas of restriction upon our powers. So we have not been able to borrow the amount we feel we need to deal with it. If you look at the scale of the German response, we're not able to match that in terms of the way in which we should to spend in Scotland. Now, the way in which Scotland is financed, as you well know, is very complex, but it relies upon essentially a thing called the Barnett formula. And for every pound that is spent in London, for certain parts of government expenditure, a proportion of that comes to Scotland, but it did, according to the proportion of the population, which is about 8.6-8.7 percent at the present moment. There is a complicated balancing formula to do with public finances and taxation, because we do not have full taxation powers. Now we have spent more than we have received in that formula on Brexit. There's no doubt upon that. Equally, Brexit has cost us far more than any compensatory payments. But remember, part of the issue of the union is sleight of hand. If you keep reassuring people that everything is fine, and that you are looking after people, then they tend to believe it for a long period of time. And they tend to avoid the confrontation that inevitably will come. We have spent more than has been provided for. We are not able to borrow the money we need to tackle the job properly or the way in which we want to do so. And therefore we believe that the financing of this is far from proving that we rely on and would continue to rely on the UK. It actually proves the opposite. This gives a justification for saying we could do this better ourselves. Scheffer: Why don't you just go ahead and hold the referendum for independence if you think the people of Scotland want independence? What is the obstacle right now? Russell: Oh, this is where this is where it becomes very strange for people to believe. We can't do that. In 1997, when the Labour government was elected in London and was committed to devolution, devolution had been attempted twenty years earlier. It had failed on a referendum not because the people of Scotland voted against it, but because a stipulation was put in that referendum that 40 percent of those who were on the electoral roll would have to vote in favor of it, and it just failed. So there was a majority for Devolution 79, but it was not carried through. When the Labour government was elected 1997 with a commitment to devolution, then the sticking point for support for that from my own party, the Scottish National Party, which was very much a smaller party at that stage, was there to be no glass ceiling on the arrangement. In other words, if the people of Scotland at some future date from that, decided that they wanted to move on to independence, they couldn't be forbidden to do so. And the compromise position that was reached with the Labour government, I was there when it was reached. I was with Alex Salmond in negotiations with Donald Dewar, who was then the Secretary of State of Scotland. The agreement that was reached was if the Scottish Parliament sought a referendum, then both Parliaments would have to vote for that. But there was no question that if the Scottish Parliament asked for that it would get it. And that is the mechanism that operated in 2014, that the Scottish Parliament asked to hold a referendum. It was granted. The UK Parliament voted with it. We have asked to hold another referendum, and we have been refused on two occasions. The first time contemptuously by Prime Minister Theresa May. The second time in a complicated but equally peremptory way by Boris Johnson. So we are not presently empowered to hold that referendum. Now that is in itself a subject of debate in Scotland. Some people say that the constitution would permit you to do so. I have never believed that that is the case, because I negotiated the agreement that said something different, but we believe that if the Scottish Parliament asked for it, then it should be granted. That is not the present situation. Were that the situation, then we would be holding that referendum. The argument against it from Boris Johnson is we had one in 2014, which, you know, is equivalent to saying you had an election six years ago, you're not getting another one. Johnson has indeed said it should be a matter for a lifetime. So in other words, you had an election when you were 21. You're not getting another one until you were 60. This is democratic nonsense. But it is impossible presently for us to do so without a concomitant vote by the Westminster Parliament, which when you think about it is very strange, because the UK was able to hold a vote to leave the EU. And the EU never said, “No, you can't do this.” And if that had been done, I suspect that would have been a matter of outrage. Scheffer: Well, so far, we've talked about both the pandemic and independence and I want to bring the two issues together. What is the highest priority of the Scottish Government during this year of the pandemic? Is it to deal with the pandemic, ensure the health of the Scottish people, try to get more funding for the National Health Service, restore the economy, or is it to pursue the political agenda of independence in the event Brexit and how London handles the economic withdrawal from the European Union this year, compels Scotland to break perhaps as early as next year? Are these coterminous priorities? Russell: No, no, the priority has been an absolute priority has been COVID from the very first day. We went into lockdown on the 23rd of March. And we said the week before, as I wrote to my counterpart in the UK government that we were suspending the work we were doing on the independence referendum and that there would not be a referendum this coming year, because clearly we wouldn’t be able to prepare for one. There was no reciprocal gesture from the UK. There was an election in the UK last December. We recognize the mandate that the Johnson government had to leave the EU. We, however, won the election out the park in Scotland, 48 to 59 seats. We believe that they should recognize our mandate to hold that referendum. They have not done so. Even so, COVID was a priority and remains a priority. We've taken out a very cautious approach. There has been a four-country approach, and I think it's fair to say it did work to start with. The lockdown was a four-country approach—Wales, Scotland, Northern Ireland and the UK—the rest of UK, England, follow the same approach. That has diverged somewhat in the last two months. And certainly, we have taken a very much more cautious position particularly on easing the lockdown. Our first minister has been much criticized for it outside Scotland. Inside Scotland, she enjoys very substantial support for what she has done. And that means, for example, today is the day where pubs and restaurants can open, and that's for the first time since the 23rd of March. Hairdressers are able to operate today. I probably look as if I need one, but hairdressers allowed to operate from today. Most of these things have happened earlier in England. Health is a fully devolved matter. So we are able to operate that policy ourselves. And we have done so we have even made slightly different decisions on the closing of the borders. The UK’s list of border closures we did not accept in its entirety. We looked at it again. And there was one country that we took a different view, which regrettably was Spain. And we've not allowed visitors from Spain to come to Scotland without quarantine, although England has. And we base that on the science. We've been very driven by the science. We've set up our own scientific advisory structure, and we would continue to be that way, so we'd be very cautious, very careful, and it's not over. I would really stress this very, very strongly. The pandemic has not come to an end. You know, we've just had seven days with no deaths. That's the first seven-day period with no deaths since I think the end of February, beginning of March. But we know this can come back very quickly. If you look at the figures today in Israel, for example, where you see that at one stage they were down to 10 new infections a day. Yesterday, I think there were 1400, you have to be very cautious. So we will continue to go on being quite cautious. And the First Minister has said it is not her priority presently to move on the issue of independence. But I do think that there are things happening which will force our hand, and I've said this, to react to them. For example, tomorrow the UK Government will issue a white paper on a number of topics, which is taking powers away from the Scottish Parliament. That will produce a reaction without a doubt. Scheffer: Next year you will have elections for the Scottish Parliament. The Scottish National Party has the majority of the seats in the Scottish Parliament. Is the First Minister waiting to see what the results could be from those elections with a stronger majority, perhaps in the Scottish Parliament, before she would take a rather definitive step towards trying to seek an independence move after those elections? Russell: No, I don't think so. I mean, we have a very strong mandate. In any case, I mean, you know, we have one the last I can't remember how many elections in Scotland. But you know, we won the December election. We've won every election, I think, since 2014. You know, I don't think that is the case. I think the case is that COVID is the number one priority both to suppress and eliminate the virus and to rebuild the economy. I took part in a webinar in Brussels office this morning with a banker called Benny Higgins, who is chairing our recovery group. And you know, we are very focused on the issues of economic recovery and a green recovery. I mean, Scotland, you know, has world-leading climate change legislation. We are very focused on the green recovery. So all those things are priorities, and we need to do those. But the election is very significant next year. Because if the UK government continues in a way it's going, then the anti-devolution, the anti-constitutional change agenda will be very, very visible. And you know, that will be a place in which a decision has to be reached. The other thing we need to do is conclude this debate. I mean, I think the problem with constitutional debates is that they cause uncertainty, and it is very important that we conclude this debate. So I would want to see next year's election taking steps to say we have to conclude this, and the issue is to give the people Scotland a choice. The people of Scotland voted for a choice. We've said, for example, in the election last December, this is about choosing not to have Brexit and choosing to be independent in the EU. We won 48 of the 59 seats. It can't be really more definitive than that. Scheffer: Does the rise of the Alliance for Independence Party recently, which is more focused on trying to achieve independence, rather than the Scottish National party's current priority in governing on the pandemic and then ultimately, the independence issue. Is the Alliance for Independence a realistic threat to the SNP? Russell: I'm scratching my head to think I've ever met anybody from the Alliance for Independence. So to that extent, I have to say, probably not. I understand the frustration that people have. I have that frustration. I would like to conclude this matter. I think there's work for us to do. But you know, if you're in government, you've got other obligations as well, and you've got to fulfill those obligations. There is a sense in which the, the debate has been about whether you can game the Scottish electoral system. If you can, because we have a two-vote system, where you vote for a constituency representative and you vote for a list representative. They think if you could, if you only stood on the list in a separate party, you would get more members. Wherever that type of gaming of electoral systems has been tried, it hasn't worked. If you look at Germany, you know that they have a very similar electoral system to ours. It hasn't worked there. So I'm not convinced that this is something that we should entertain too much. Equally, I welcome everybody in the cause of independence. It’s a very broad church. You know, the SNP may be the cornerstone of it. But it's a very, very wide “yes” movement, which embraces people in all parts of the legal spectrum, so I'm not going to lose sleep over it. But equally, you know, I've been a member of the SNP for forty years. I think I'm getting too old to change. So I’ll stick with what I've got. Scheffer: Michael, is there any way for you to describe for our audience two legal strategies: one is, is there a general description of what your legal strategy would be for independence if Boris Johnson continues to balk on a Section 30 opportunity for you to have a referendum? And then secondly, is there an emerging legal strategy, under I suppose almost any scenario, for Scotland to try to maintain its ties with the European Union, single market or otherwise? Russell: It shouldn't be thought that we have been unwilling to compromise or to be imaginative in this. In December 2016, we published the first of a series of papers called Scotland's Place in Europe, which we put forward in compromise, which would have seen a closer relationship with a single market and the customs union. And of course, one has to be aware in politics, as in history, not to have false memories. At that stage, there was no declaration from Theresa May or the UK government that they wanted out of the single market. That was only really ruled out in the Lancaster House speech in January of 2017. So we thought it was a suitable compromise. And one of the great tragedies of Brexit is if Theresa May, having become Prime Minister, had sat down and brought the leader of the Labour Party, Nicola Sturgeon, and you know, Karen Jones, who was a leader of Wales, and at that stage, Martin McGuinness and Eileen Paisley from Northern Ireland and said, “Look, how do we all get something out of this? How do we all get a compromise here? That the UK can leave the EU, if that's the will of the people in England, but that we don't suffer greatly, and those who didn't want this get something too?” That never happened. Theresa May’s style was not to listen, but to talk. So you would just go to have a discussion with her in Downing Street, and she would talk at you for an hour about how you really just weren't able to understand how good the deal was that she was talking about. And that just didn't happen. So as a result of which we're left in a situation where there is no compromise for the UK. They want to leave, and that is quite clear where they are now, on the poorest possible terms, because the word sovereignty has become this enormously important word, and you can only exercise sovereignty, according to the Brexit extremists who are now in charge, by cutting all the links, by not having any substantial links at all, and similarly, by not accepting any of the rules that that organization has. Now, you know, our position is we are willingly members of the EU. We agree with the pooling of sovereignty. We think the pooling of sovereignty is how people should go forward. It does not make you any the less sovereign. That is quite clear. I've asked the French, are the French any less sovereign for being in the EU? Are the Germans? The answer is no. So the question is, we want to join that. The EU will never say to any candidate member, “You're in. Fine.” But you know, we do observe the acquis. For over 40 years, we’ve observed all the rules. Members who come to join come very often from a long way back, and they have to change a lot of their systems to meet what are the 35 chapters of accession. We don't. We qualify. We've been doing it for 40 years. So the legal strategy there is we need to understand the chapters of accession very clearly and to be able to prove to the EU that we meet them all. The issue of accession has also been a live issue with the French in recent months. The issue of membership. Montenegro was part of this. But there is no intention to exclude. We are essentially functioning as an EU member. So of course, the legal strategy there is simply to go into that position, but connected with that is the EU’s quite proper position that they would not accept a candidate member unless they were independent, because it's an organization of independent states. So you have to get yourself past first base. And that first base is independence. How do you get to independence? Well, the barrier is holding a referendum at the present moment. I don't believe the barrier is getting the majority in that referendum. I think that would happen. Now, I think things have changed substantially from 2014. The barrier is holding a referendum. And I think there are only two ways you can go about that. The first way is to challenge that in court. And I think that is the most likely outcome. COVID has interfered with that. I think if you look at the way in which the Scotland Act was passed in 1999, there was no intention that the power to hold a referendum would be withheld for political reasons. And there are also mechanisms by which you can take a bill to the Supreme Court and have it judged there. So you will have to follow a legal route, I think, to get to a referendum, or a purely political route, you know, and you might want to, you know, think of Parnell, no one has the right hold the march of a nation. If the people of Scotland say they want a referendum, if the people of Scotland say we wish to vote for this, you’re democratic, I'm democratic, anybody who is democratic has to accept that that is a right that they have to do so. And the longer you refuse to allow that to happen, the less democratic that person is. Scheffer: Let me ask one more question and then we'll open it up. What is Scotland's place in the world today and under a prospective independent status? I asked that in the context, as well, of your relationship with NATO, which would be of interest to our American audience. Russell: We plan to have membership with NATO. Who wouldn't? That has been an issue in the party over the years. I have always been strongly on the wing that says this would be utter madness, given both where we are geographically, and also where our politics are. So that would be our intention to be part of that Alliance. I suppose you could describe us as a small, moderate, moderately left of center, European nation. [INAUDIBLE]. In Scotland, we're a fairly ordinary, small, quite talented, European nation. Resource rich. We have a very, very rich set of natural resources, very well educated. We are, according to the OECD, the best-educated country in Europe. We have assets to bring to the table, but we are a small European nation. That's what we are. And that's how we would operate in the world. More than half the members, actually just under half the members, eleven of the members of the EU 27, are the same size or smaller than we are. And in a rather neat thing, we're almost exactly halfway in the table of independent nations in terms of size. So there's nothing exceptional about Scotland in that regard. You know, we don't claim to be exceptional. But we do want to be normal, to go back to that point. Scheffer: Well, thanks so much, Michael. That has been so helpful. I want to open it up to questions now. And I see some hands popping up and I'd like to start. I think the first one that popped up was Ambassador Peter Galbraith. Peter. Moderator: Ladies and gentlemen, as a reminder to ask question, please click on the raise hand icon on your zoom window. When you are called on please accept the unmute now prompt then proceed with your name and affiliation followed by your question. Ambassador Peter Galbraith Hello, can you hear me? Can you hear me? Scheffer: Yes. Russell Yes. Ambassador Peter Galbraith: First, I want to express my appreciation for this program since my ancestors left Crinan in the Highland clearances, and my grandfather, who was in Canada, was all things Scotch as the Scottish community were called there, and he would be amazed and thrilled at the thought that Scotland might be independent. As David knows, I've spent much of my career in countries, in fact, that were breaking up or aspiring for independence. In Croatia, I was the first Ambassador there, but also East Timor, as it separated. And more recently, I've spent a lot of time in Kurdistan. And one thing that strikes me is that the power for independence is where you have a separate identity, often ethnic, where they feel unfairly treated by the majority, by the dominant group. I wonder, in the case of Scotland, whether this sense of unfairness at this stage overpowers the economic argument that Scotland really needs to be part of the United Kingdom, that it receives large amounts of funds. And the second question I have, very briefly, is that when you look at how other countries have become independent, when the Croatians or the Slovenes held their referendum, they didn't ask Belgrade for permission, they went ahead and did it. Would you consider holding a referendum if, in fact, Westminster turns you down? Or you lose the court case? Russell: Interesting questions. First of all, Crinan is in my constituencies, so I am the representative for Crinan. So you can you can come and see me at the constituency office, and I'd be bound to give you an explanation then. Thank you for your question. They are very good questions. Can I just challenge you in your view that in some way we are dependent upon money coming from south of the border? That is not the case. This is an area of some contention, I have to say, between economists, and when economists contend, and you will know what I mean, I tend to stand to one side until the dust is settled. But the reality of the situation is that you can certainly take an analysis of Scottish fiscal flows and see that there is substantial resource that goes the other way. And indeed, one can ask oneself, an interesting question, “Cui Bono,” who benefits? And if it was no fiscal benefit to the UK to have Scotland as part of it, why are they trying so hard to avoid independence? So I just I think that the premise needs to be examined, as all these premises do in terms of the history of, I won't say one's economy because it's not, but if you look at the history, for example, of the British Raj, and you look at the work that's been done on that in recent years, about the position of India prior to the Empire, then you begin to see some very interesting things. So I wouldn't accept that. And therefore I don't accept that, you know, in a sense, a feeling of grievances is overcoming the finance. I don't feel a substantial feeling of grievance. I think the system doesn't work. But, in that sense, I certainly blame the politicians who are operating it, but I don't feel oppressed in that way. I'm the biographer of Winnie Ewing, who was a great SNP figure in Parliament, one of the first MPs and a long standing MEP, and she tells a story of when she was on the lobby convention in the EU. And she tells the story of meeting Robert Mugabe, who said to her that the problem with Scotland and independence is that you are not oppressed enough. I don't think that is the case. I think we have a modern case for independence. And one in which, as Alex Salmond has often said, none of us have suffered so much as a nosebleed in the course of independence. It's a peaceful and democratic movement. In terms of permission, the big issue here is not permission, but recognition. I've talked about the way in which the EU would find an application for membership, I think, to be final. It would take some time as these things do, but it would be there. But recognition requires a constitutional route to independence. And you can see with the issue of Catalonia, that the lack of a constitutional route is a barrier to recognition. So I am cautious about taking any route that does not have constitutionality at its heart. And this is a longer process, but it is one I think it has to be gone through. And, therefore, I do not envisage circumstances in which we would say, you know, we are now going to break what is the Constitution. What we need to do is to make sure the Constitution does not attempt to break the people and to make sure that it is not a barrier to the normal process of a nation saying “we want to follow a different path.” Scheffer: And Michael, can I just follow up on that and ask is one of the strongest legal points that you might contemplate the one that you made earlier, namely that where the Scottish Parliament itself is requesting the referendum, that somehow has a significant weight with respect to the UK Parliament agreeing to that? Russell: Well, it should have. I mean, if you have a structure in which you'd have four Parliament's operating, and one of those Parliament's regards itself as sovereign, that is the UK Parliament regards itself as sovereign, which is a very medieval concept, but it still does. That system isn't one that we believe is stable, and neither actually do the Welsh, and Wales is an interesting example. Wales has a Labour government, not a Nationalist government, and yet their present First Minister, Mark Drakeford, who was my counterpart in dealing with Brexit and the UK before he became First Minister, has argued that the concept of sovereignty needs to be revisited. And in the UK, the concept of sovereignty should be shared sovereignty, and it should be willingly shared sovereignty. And therefore it can be withdrawn. Just as in the EU, you can choose not to share sovereignty. In those circumstances, Scotland would say we wish to withdraw that and take our sovereignty to put in somebody else's bank. And that's the modernization of the Constitution, which the UK needs to have. Wales, Scotland and Northern Ireland, for example, all voted against the withdrawal agreement, but it didn't matter because it can be overruled. And that is a difficulty. Scheffer: Let me ask now, Paul Sheard of the Kennedy School at Harvard. Paul Sheard: Thanks very much. I'd like to ask about the currency that Scotland would have or aspire to have, if it gained independence from the UK and tried to rejoin the EU, and what kind of monetary arrangements Scotland would aspire to have with the UK in the interim? And of course, in asking this question, I'm mindful that the euro is the currency of the EU. And the UK had a derogation from ever adopting the euro. But a rejoining Scotland presumably would not have that derogation, automatically at least. Russell: There is no obligation. I mean, this is an interesting issue, as you clearly know, because it's been a controversial issue in the first referendum and will be in a subsequent referendum. There is no obligation upon a member state joining to take on the euro. There's an expectation, but there is a process to go through, and for example, Sweden did not go through it and did not take the euro and is not a member of the euro area. I'm not going to give you a definitive answer on this. Because the moment I do, somebody will jump on it somewhere else and say this is why you can't do it. Rather strangely, the issue of whether or not Scotland could have its own currency, could continue to use a sterling in a sort of sterling area, or should go to the euro, is a matter of huge debate within Scotland by the anti-independence forces. All of which seem to end up with the view that Scotland cannot make any choices about its own currency uniquely in the world, that Scotland would have to end up with cowry shells or something, because it just couldn't have a currency. And what we've said very cautiously, and we are cautious about this, is as we approach a second referendum, we'll lay out the options that we have. We have talked about whether those options should include the continuation temporarily of a sterling area, with a number of tests that were applied before we move to our own currency. Some people have argued that the euro would be a suitable currency. I think, you know, there's been such a tabloid press attack upon the euro for years. I mean, one of the problems with Brexit, there’s been something got up substantially by this tabloid press. There's been such an attack on the euro for years, it's very difficult to have a rational conversation about whether the euro would be the right option as well. So, Paul, I'm going to disappoint you by not giving you a definitive answer. I am going to say there is, and will have to be, a definitive answer. But it's one which I think is as an aspirant country, we should only go to when we are ready with the Scottish people to have that debate. And at the present moment, that debate would be nightmarish, because it would be seen as a lightning conductor for everything else. Scheffer: Thanks. I think the next person on my list is Hani Findakly. Hani Findakly: Thank you very much. This is quite an interesting discussion. I'm not familiar with the politics of Scotland and the UK, but I have looked at the economics of countries that have broken up, starting with the India-Pakistan breakup and looked at about 30 countries. And while there have been a few exceptions, maybe about 10-20 percent, the majority of countries that break up tend to do worse than they would have done under a union and some of that, I think, is for obvious reasons. But another part is because of what economists call externalities. Things that we don't account for, and they interact with other things. So, you know, this is history. What's more important is looking forward, and it's fully understandable the emotional and other forces that drive that. But with COVID-19 and the expectations of some kind of a new normal with changes in the world economy, trade, the value of natural resources, and other things that countries depend on for their economic performance, I wonder if you have been through that kind of analysis and whether or not you have expectation that changes in the new world after COVID-19 will continue to be a benefit a breakup of Scotland from the union? Russell: Well, I'd refer you to a paper we published last month on the expectations we have of both a COVID recession and a Brexit recession. Whereas the rest of Europe will be suffering severely from a Brexit recession, they will have the advantage of what appears to be, and this week's EU summit will confirm it, you know, a pretty exceptional response from the EU 27 in terms of the MFF agreements that they're going to reach, and they're likely to reach with the leadership of Germany actually making sure that they do. They will not have a Brexit recession. So the UK will be double dipping in its approach. And that's one of the reasons why we believe Brexit should at the very least have been postponed. There was an opportunity to postpone the negotiations by up to two years, which the UK refused to do. And that would have been helpful. So our view is, as part of the UK, the economic prospects are very poor and will continue to be poor for longer and will be worse than we would otherwise have it from the COVID recession. I think it was the Financial Times that estimated that the recession would be the worst for the UK since 1709. I have no personal experience most of that period. But if that is the case, then I think we've got problems there. The second issue to consider here is the nature of Scotland, and as it is just now, Scotland is actually a rich country. I mean, you have to step back a little, and look at it. It has a small population, which is well educated. It has a very substantial amount of natural resources both of the 20th century and of the 21st century. It has a pretty considerable reputation and ability in exports. The number one food export of the UK, which is whiskey, of course, is a Scottish export, but actually, Scotland's export offering is very wide-ranging. So there is no reason why Scotland should not flourish. The fact that it isn't flourishing now might say something about how its economy is managed, and its economy is managed by the UK. And you know, when you look at that in the light of other experiences of economies being managed at a distance, and say that actually also may be a considerable issue to factor in. So my expectation is that choosing independence now, I don't think any of us can avoid the COVID recession. But I think it will mean that we would avoid the Brexit recession. It would also mean that the potential of the Scottish economy and the Scottish people were fulfilled. Our recovery plan leans heavily on the issue of natural capital. And I think if you look at the issue of natural capital, and the work we're doing as a well-being economy, I think you can see considerable advantages. So I'm not pessimistic about this. And I think there are occasions in which countries that go their own way suffer from it. As in personal relationships, if these things change, then people can flourish, and I would expect us to flourish. Scheffer: Thank you. The next individual is Julia Moore. We can't hear you quite yet. Julia Moore: Okay. I apologize if this question has already been asked or was the issue was addressed earlier. Because as you can see, I'm technologically challenged by this zoom technology. But let's assume that your Scottish exit happens constitutionally as you hope, and as you describe, what makes you believe that Scotland could overcome the tremendous obstacles to getting, forget the euro, getting membership into the EU and into NATO? Russell: Well, my personal conversations have convinced me that that is a case, to be honest. I spend a lot of time talking to people. It seems to me that the enthusiasm for having a small, new, highly educated, wealthy, and sharing European values country as a member of the European Union is likely, to be blunt, to be virtually irresistible. You know, there is no work to be done. There’s no queue. Nobody stands before or after anybody else. You have to qualify. But you know, I think it would require quite a lot of imagination to say that Scotland, being as it is, does not qualify. And certainly, the people I talk to regularly and all of the countries believe that Scotland will be a suitable candidate member for the EU, and will be accepted as such. And indeed, it would be very strange if it wasn't. This was, of course, an argument that the UK put during the 2014 referendum as David referred to earlier. And that argument was that an independent Scotland would not be a member of the EU. Now, David Cameron as the UK Prime Minister called in a lot of favors to get a few people in the EU to say that, and Scotland was affected by it. Because for many Scots, being in the EU is extremely important. But I have absolutely no doubt from my experience, from who I talk to, and from what they are saying because, you know, many European figures are saying this entirely clearly, Scotland would be a good fit for the EU. In NATO, I think that's also the case. I can't imagine that NATO would want to say no, that's not suitable to have. If you look at NATO membership, and if you look at our geographic position, I think that would be a strange decision to reach and a quixotic decision to reach. Whatever else you might call NATO, I don't think I’d call it quixotic. So I think in all those circumstances it is fairly obvious that will take place. It will take the procedure of admission. It will take, before that, the procedure of application. But what is different about Scotland? I would fail to understand that. Scheffer: You know, I might add, Michael, an answer to Ms. Moore’s question. I certainly recognized when I was in the quarters in 2014 in Brussels, skepticism because of exactly that point that you raised, that they wanted to simply maintain the United Kingdom as a full coherent nation, a powerful one, within the European Union. However, of course, because of Brexit, I had to witness with great interest that last summer, when the First Minister Nicola Sturgeon visited Brussels and gave some speeches there, she was feted almost by the European Commission and the European Union officials. It was a very, very different reception for Scotland. One that was very supportive and understanding that Scotland has a tremendous amount to contribute to the European Union. So, the tide, as far as I could see, had completely turned by last summer. Russell: I attest to that. I mean, I was around in 2014, of course, and you know, in recent years I have been talking to lots of people. But, Van Rompuy, the former president of the Commission and a former Belgian Prime Minister, so not a man fond of separatism in any description, has been on the record saying if Scotland applies and Scotland qualifies, which it does, Scotland will be a member. And I'm not asking people to be wildly enthusiastic about it. But that's the fact. You know, if we qualify, and we do qualify, and if we observe the acquis, which we have done, then we will be a member, and that's what we would want to do. Scheffer: Let me turn now to Frank Klotz, who is retired from the US Air Force. Frank Klotz: Thank you very much for an excellent presentation. I'd like to follow up with one of David's questions and your answers related to NATO. For many years now, NATO leaders have endorsed the importance of the UK’s independent nuclear deterrent force to NATO defense strategy. The UK independent nuclear deterrent depends, of course, on its space in Faslane. The SMP’s position in 2014, prior to the referendum, as I recall, was that continued presence of nuclear weapons in Scotland was not to happen. Has that position changed since? And if not, how would you see the UK’s concern, and ultimately NATO’s concern, about the future of UK nuclear forces being resolved? Russell: Let's start with the obvious, which is, you know, a small country of five million people is not going to possess nuclear weapons and shouldn’t. Scotland has no interest in so doing and would, therefore, not be a nuclear nation. Our position has not changed on Faslane. I think there's a substantial majority in Scotland who do not wish to see nuclear weapons on Scottish soil, and you know, I am one of those people. We may take a different view on these matters, but I am sitting as the crow flies about fifteen miles from Faslane across this lovely lock outside, and I therefore think I would feel perhaps a bit better if that was not happening. We said during the 2014 referendum that we recognize that doesn't happen overnight. And that therefore there would have to be a period in which that was negotiated and took place. But we would expect to negotiate having those nuclear weapons not in Scotland. Now, that is a matter, of course, which would have to be discussed with the UK and with NATO. But that would be our position. Now, it could be a different government in Scotland than the one that I would favor, but I think, broadly in Scotland's there is a pretty wide agreement upon that. In the UK, the Labour Party has always espoused the continuance of a nuclear deterrent. That is not true of the Labour Party in Scotland, by and large. So I think that would be likely almost under any dispensation. We believe in strong conventional forces. We talked about how those might be arranged in an independent Scotland and you know, we would follow that and we would wish to be part of NATO, but on that one, we do not wish to see nuclear weapons in Scotland. Scheffer: Michael, is there any particular opposition in Scotland to out-of-theatre operations by NATO? In other words, if you become an independent nation and join NATO, would we see Scottish soldiers in a future type of Afghanistan situation with other NATO soldiers? Is there any point of view on that? Russell: Yeah, I think the two areas in which we've expressed our interest and concern. One is we regard NATO sanctions as being extremely important and the NATO umbrella being extremely important. So as a member, we would meet members’ obligations. If we felt those obligations fit with our own view of the world, and we also believe in the European defense model, then we'd go along with that. We're also very interested in the way in which Ireland, for example, has carved out a place for it in terms of UN peacekeeping. And we do think there's a role for Scotland in that. We have a day efficient and effective contribution from our armed forces, Scottish regiments and Scottish soldiers. We would have thought we would want to see that within that context. But you know, we are committed to NATO membership. We're committed to working with Europe on defense issues, and we're committed in terms of UN action too. So we wouldn't be standing back, but equally, we'd be doing it from our standpoint. Scheffer: I want to entertain more questions. So I'll keep my eye on the roster here. But I actually have two I can pitch at to you in the meantime. One is, did you just have a special session of the Scottish Parliament? If so, why? Was it all virtual, and what was the big deal? Why did everyone have to get called back in July? Russell: Well, you know, we have a work ethic. Unfortunately, and necessarily, during the COVID epidemic, nobody believes that we should be away for a substantial period of time. We are technically on recess, but we're meeting in three weekly cycles. Because the First Minister, and the review of our regulations under COVID takes place every three weeks, so she addresses the Parliament, and we deal with that. And we do virtual questions sessions because we believe that that we should still be answerable to the country through its representatives. We are able to do quite a lot virtually. Where I'm sitting in my outdoor study in Argyll looking over Loch Riddon, I've done a parliamentary statement from here. I've answered parliamentary questions from here. I've appeared in front of parliamentary committees from here. Edinburgh is about three hours by car, so I've driven through on four or five occasions to do things there. But it is not a normal year. So our normal pattern would be we would end in the end of June. We would start again at the beginning of September. We finished at the end of June. We will start again on the 11th of August when schools go back. Schools have been off since the 20th of March. Schools go back on the 11th of August, and we will go back then. But I will be in parliament on the 29th and 30th of this month, and I will be doing a statement of some sort before then. So, we keep ourselves busy. We believe in serving the people. Scheffer: But there's no particular crisis this month regarding London's negotiations on Brexit or anything? Russell: Well, I think the reason I may have to give a statement before the 30th will be, you know, we're certain there will be a white paper from the UK Government tomorrow, as I said, on issues which we believe, substantially undermine the devolution settlement. So that will be part of it. But you know, the main issue is COVID. And the main issue is making sure that we keep the Parliament and the people informed of that. The first minister undertakes daily press conferences on COVID. Up until now, they've been five days a week. I think that will change shortly. But we still do them. They are televised. She is open to press questions for a lengthy period of time. And the quote I gave you earlier about truth and being honest with people is what we try to follow. So we've tried to make sure that people have all the information they need. Scheffer: I believe Peter Galbraith has another question, Peter. Ambassador Peter Galbraith: Thank you. And I wanted to just say I was not being critical of Scottish independence when I was asking about the economic issue. It was the sense that often in these circumstances, where people feel they're, in the case of Scotland, dragged out by what England did, that can overcome economic issues. And I also think I've pointed out that countries often do very well after independence. Obviously, the Baltic countries case in point. In fact, Croatia and Slovenia, clearly better without Yugoslavia. My question is how do events in Northern Ireland affect the Scottish situation? I think the polls show that there is a majority now for a united Ireland or at least very close. There's a process perhaps you might explain for having a referendum there. Do you see that process going forward with Boris Johnson's government? And I guess it would raise the question of if they are willing to do it in Ireland, how could they say no to doing it in Scotland? Russell: We've always accepted the special situation in Ireland. Ireland is recovering from, you know, a generation of civil war essentially. It is not like Scotland, and therefore, we've always accepted special arrangements for Northern Ireland have to be made and for Ireland. And we've never drawn equivalences with that and wouldn't do so. And it's quite dangerous to try equivalences, as you well know, between national movements in various places. You know, everything is different. But there are some interesting issues in Northern Ireland, and a special settlement within Brexit is a particularly important one. There is a special protocol in the withdrawal agreement that means that Northern Ireland will sit somewhere between the EU and the UK. It will have regulatory alignment with the EU and the border will therefore not be a border, per se, in terms of goods, and it will be treated in a special way. Now our view is if that is possible for Northern Ireland, it should have been possible for Scotland, and there should have been some special arrangements with Scotland, and that was not reached. The question of Irish reunification is a very, very different one. You know, there are a number of players in there. I think the new Taoiseach in Ireland, Micheál Martin, has made it clear that he doesn't think the time is right for a border poll. And the border pool can be called with the consent of both sides, but I don't think that's likely to happen immediately. I think it's likely to happen at some stage. But a lot of this is the same issue. And the issue is, Brexit has precipitated change that was underway, In any case. Northern Ireland voted against Brexit too. The only part of the of the island, so to speak, that didn't get anything it voted for was Scotland. Wales voted for Brexit narrowly, but voted for Brexit. England voted for Brexit, Northern Ireland voted against it and is getting special status. Scotland voted against it, and it's getting nothing. And the tensions created by Brexit have exacerbated what was an ongoing process. You've got to look at the issue of Scottish independence not as some modern phenomenon. This has been going on for well over 100 years. The establishment of the committee for the Vindication of Scottish Rights in the 1850s and 1860s, they campaigned for restoration of the position of Lord Advocate. The growing administrative devolution that took place in the late 19th, early 20th century, and there's a school that would argue that what has held us back were a number of events, which renewed UK solidarity or British solidarity: the two World Wars, the creation of the of the National Health Service, and so on. But the process has been going on. I mean, you know, I mentioned earlier my grandfather. My grandfather was a publisher. He was an Englishman, but he was a publisher in Edinburgh. I think he would be astonished that there was a Scottish Parliament, because he died in the 1960s, and it was a long, long way then. I mean, there was certainly no majority for it. I think he’d be astonished that his grandson was in a Scottish Parliament, a minister in the Scottish Parliament, perhaps even more so, discussing this with a distinguished American audience on a night like this. There has been a process underway, and that process continues to be underway. And that is true in Ireland as it is true in Wales and elsewhere. It is a question of how those that process comes to a conclusion that I think we're now talking about. Scheffer: Thank you so much, Michael. This has been a tremendous conversation about the past, present, and future of Scotland. And I deeply appreciate it and the Council on Foreign Relations and all of our participants do as well. You take good care of yourself, stay healthy next to the Loch there. And we'll see you. Russell: Thank you very much.  

Vin Gupta, public health physician, professor, and health policy expert, discusses the recent surge of COVID-19 cases in many parts of the United States. Carla Anne Robbins, CFR adjunct senior fellow and former deputy editorial page editor at the New York Times, hosts the webinar. FASKIANOS: Good afternoon to all of you. Welcome to the Council on Foreign Relations Local Journalist Webinar. I am Irina Faskianos, vice president for the National Program and Outreach here at CFR. As you know, CFR is an independent and nonpartisan organization and think tank focusing on U.S. foreign policy. This webinar is part of CFR’s local journalist initiative created to help you connect the local issues you cover in your communities to global dynamics. And our programming connects you with CFR resources and expertise on international issues and provides a forum for sharing best practices. It’s great to see you all. We’re shaking up the format a little by showing video, so we’ll look forward to your feedback. I want to remind everybody this webinar is on the record. And the video and transcript will be posted on our website after the fact at CFR.org/localjournalists. I’m delighted to have returning with us today Vin Gupta. He was with us several weeks ago, or months, I’ve lost track as we’re all in lockdown. Vin Gupta is an affiliate assistant professor of Health Metrics Sciences at the Institute for Health Metrics and Evaluation at the University of Washington. His research interests include pulmonary and critical care medicine. Dr. Gupta holds an active commission as major in the United States Air Force Reserve Medical Corps, as you can see. And he recently served as the primary public health consultant on pandemic emergency financing for the World Bank. He’s an NBC News and MSNBC medical contributor and is also a term member of the Council on Foreign Relations. Carla Anne Robbins is an adjunct senior fellow at CFR. She is faculty director of the Master of International Affairs Program and clinical professor of national security studies at Baruch College’s Marxe School of Public and International Affairs. Previously she was deputy editorial page editor at the New York Times, and chief diplomatic correspondent at the Wall Street Journal. So, Vin and Carla, thank you very much for being with us today to talk about the resurgence of COVID-19, and if we’re still in the first wave or second wave. We’ll discuss that. I’m going to turn it now to Carla to have a discussion with Vin, and then we’ll open up to all of you for your questions and comments. So, Carla, take it away. ROBBINS: Thank you so much, Irina. And thank you to all the journalists who have joined us. I know it’s an incredibly challenging time to be a journalist, and we really appreciate all the work that you’re doing on the ground. And, Dr. Gupta, welcome back. Thank you so much for what you’re doing. I said I wasn’t going to say thank you for your service, but I’m going to say it. It’s great to have you back with us. So this week, and this is the only arcane moment I’m going to have today, but this week as I was listening to Vice President Pence’s brief on the pandemic and talking about early indications of positive tests flattening in Arizona, Florida, and Texas, I remembered one of my favorite quotes from graduate school. And Thucydides wrote that during the Peloponnesian War words had to change their ordinary meaning and to take that which was now given them. And so I suspect that for many Americans coronavirus numbers are losing their meaning. We’re bombarded with data, we’re constantly being spun—being told this one matters, the other one matters, don’t pay attention to this, pay attention to that. So can we start with a quick overview on where we stand today nationally, regionally, and what numbers we really need to be watching the most closely and why? Is it new infections? Is it emergency room visits? Is it hospitalizations? Is it deaths? Is the age of those infected? Is it the percentage of people with antigens? I mean, I have a PhD and I’m utterly and completely confused.  GUPTA: You’re not alone, Carla. And I want to say thank you, again, for everyone coming to this event, for Irina for inviting me back, and Carla for moderating. It’s a privilege. I did have to just do a disclaimer. I’m in uniform. We’re actually—I’m an ICU doc with the Air Force Reserves. And we’re getting alerted occasionally that we may get sent out, just given everything that’s happening. So I’m not speaking on behalf of the Air Force even though I’m in my fatigues. And so I apologize for being in the car in fatigues. So with that all aside, my opinion is the following. You know, there are so many metrics out there. And the metrics themselves have gotten politicized. And it’s sad, frankly. And I’m going to speak candidly here. I think what I saw yesterday at the White House press briefing was diminishing urgency, flattening of curves, that if you go to COVIDActNow.org, for all the journalists in the room—I’m going to try to give you as many directed pieces of advice from my own biases as I can. They’re all going to be evidence-based in my opinion. COVIDActNow.org is a great repository of information on metrics that matter. One of which is the positive testing rate. If you go to—if you’re in front of a computer I’d urge you to go there right now. Go to Florida. And you’re not going to see anything that’s flattening, at least the way I think about flattening. I don’t think of a sharp curve up as flattening. The vice president was messaging as such. And I think that’s dangerous. And I’m going to get into Carla’s question in just a bit. But saying things that are not true in real time is dangerous because it puts our guard down. It makes the vice president, and the president, and the secretary of defense potentially say, well, we don’t need to active the critical care transport team in the U.S. Air Force—I happen to be in that team—where we could rapidly deploy portable ICU capability in Houston, in Tucson, in Florida, places that need it. You can’t just flip a switch tomorrow and say, hey, we need dialysis nurses. We’ll get them tomorrow. I can’t do that if I’m here in Seattle in an ICU. If I need dialysis on a patient with COVID, which is a frequent need, I can’t sometimes get that in my own hospital when there’s open beds, because there’s staffing issues. There’s all types of things. So we need a proactive approach and how we talk about data really matters, because it keeps your guard up or puts your guard down, which is concerning. Positive infection rates. What’s the test positivity rate? You hear a lot about that. That is critical. And that’s really—I’m going to give you a few metrics that I think matter. That’s an important one because no matter how much we’re testing, if the outbreak is not getting out of control it’s not like that number should be dramatically spiking, and you shouldn’t be seeing such dramatic growth rates in that specific test positivity number, the percent of tests that are positive. You know, they should remain—if the outbreak is not out of control that should not be an exponential curve, as you’re seeing on COVIDActNow.org. And it is. It is an exponential curve. It was flat and then it just immediately peaked up. That is concerning. So I would pay attention to that. And the threshold that you really want to focus in on is 3 percent or less. With below 3 percent, and then we think—and the WHO has sanctioned this, the CDC to some degree has sanctioned this although I don’t know—the CDC has become so politicized that it’s hard to honestly trust what comes out of the CDC anymore. Yesterday was a prime example. I don’t want to rabbit hole there. But anyhow, WHO has said 3 percent or less on that positive testing rate is key. And why is that important? It’s important because then if you are below that level you can feel reasonably confident to move from a mitigation, we’re going to—everybody needs to shelter in place, we need to minimize what we’re doing in public, there’s such disruption to normal life—to containment and contact tracing. One thing that has gotten lost in all the hullabaloo and all the mixed messaging is contact tracing right now is utterly useless because, one, the positive testing rates—or, the test positivity rate in Florida is 18 percent. It’s way too high for contact tracing to be effective. Because at that point we think the outbreak is out of control. You’d be contact tracing everybody. And we think you need five tracers for every confirmed case to do it well. How can you do it if an outbreak’s out of control? So you want that test positivity rate, the number of tests that turn out positive out of all tests done, to be less than 3 percent, because then you feel like maybe you can manage the number of positive cases that are being detected by isolating those individuals and then tracing their contacts. Anything higher than that, and tracing becomes impractical and cost ineffective. So that’s one. Hospitalization rates, to me, is self-evident. What’s your ICU bed capacity? Those are key. And I think for self-evident reasons. Because who cares what’s happening with cases and how we’re debating whether cases are rising because we’re just testing more, which is just a nonsensical argument, it doesn’t really—all those things are very proximal indicators—how many tests are happening, what’s the test positivity rate. Those things matter but they’re proximal indicators of the outbreak, meaning those are early—that gives you an early sense of what’s actually happening. The later indicators of, oh my gosh, Americans may die, are hospitalization rates and ICU bed availability—also available, to some degree, on COVIDActNow.org. You want to look on websites that aggregate data like that. You also want to look at the state health department’s website, especially in places like Florida, Arizona, that are in the midst of the worst of it, to see they sometimes will break down at the county level how many ICU beds are available. I should note that in Florida they’ve done some pretty astonishing things. They are now not even reporting accurately, supposedly, the number of ICU beds that are now available. They’re just defining—they’re listing beds by acuity, either it’s high acuity or low acuity. They’re not even talking about intensive care beds anymore in certain counties, which is problematic because it’s an effort to, in my opinion, manipulate the data so we don’t actually know what’s happening, which is extremely dangerous to planners and hospital administrators when they need it figure out workflow. When the governor needs to figure out if he needs to call the National Guard or beg the president to deploy somebody like me and our team members to come out and help. Data manipulation and trying to massage the data to make it seem like there’s not an emergency is a problem. And just I wanted to flag that for all of you. Some states, namely Florida, are trying to fudge definitions and trying to mask reporting availability of ICU beds. And it’s bad. But that matters. That’s a late-stage indicator. So just like hospitalizations, hospitalization rate, ICU bed availability, and then of course death rates, which I can get into in a bit. So one’s positive testing rate, which matters. We talked about the threshold. The other thing that matters on the proximal end, to get a sense of where are we headed, is the number of tests per confirmed case. So I’m not going to throw twenty different metrics at you. I’m just going to try to give you a few. The number of—so, test positivity rate, and the second one I would urge you to pay attention to is not how many tests are we doing in the country every day. That’s meaningless. But it’s the number of tests done per confirmed case. And why does that matter? We do about twelve tests per confirmed case. That’s pretty bad. Countries that have gotten it right, Australia does about eighty tests per confirmed case. New Zealand does 370 tests per confirmed case. Taiwan, South Korea, about ninety to a hundred tests per confirmed case. We do twelve. That means we don’t have to look too hard. We don’t have to test too broadly to get a confirmed hit. Said another way, we have a ton of cases and we’re still limiting who we test. I’ve been in the ICU to some degree since March. Because I’ve never had symptoms I don’t qualify for a test. My Air Force colleagues, some of them are anesthesiologists on the outside, none of them have gotten a test. And we’re actively caring for these patients. It’s absurd. Other countries don’t do that. You have to have symptoms. Really and you’re seeing in Houston and in other geos and even in Los Angeles, we’re back to where we were in March. Very narrow criteria on who can get tested. You have to be high risk, over sixty-five, living in a communal facility. You have to have symptoms, et cetera. We’re not testing broad enough. So that’s why look past the headlines on aggregate number of tests being done. It’s meaningless. We’re not testing broadly enough. And confirm—the number of tests per confirmed case. Our World in Data, if you Google that, I don’t believe that’s the actual URL. But Our World in Data, if you Google that, that will actually get you to a website that shows you the number of tests done by confirmed case. It’s a bar graph. It’s beautiful. And will compare it against other countries. That number needs to be quadruple what it is now for us to feel like we have adequate testing. So in summary, I would say on the proximal end the number of positive tests, and using 3 percent as a threshold, the number of positive tests done over all tests, number of tests per confirmed case. And then on the later end, so called non-lagging indicators—so gives you a sense of what’s actually—you know, how are people being affected. Look at hospitalization rates, ICU bed capabilities, and then of course death rates. And one last thing on death rates. We still think we’re underestimating the number of deaths nationwide. One, because COVID—you know, sometimes—first of all, there’s a huge epidemic of people just dying at home because of deferred care in places like New York City that were hard hit. And it wasn’t clear what they died from, but in many cases COVID-19 was either suspected or confirmed. But that was not lodged as the primary cause of death in an autopsy report in all cases. So there was a sense that there was some misreporting, not intentional necessarily, of deaths, especially amongst those that died at home in hard-hit areas back in March and April, and to some extent even now—especially in hard-hit areas down in Texas and Florida—because either a diagnosis was never rendered or was highly suspected but never confirmed. So there’s a sense that we’re still underestimating the number of deaths that are occurring because of COVID-19 in the United States. I’ll stop there. ROBBINS: Thank you so much. I have many more questions to ask you, but it’s not all about me. So let’s—why don’t we turn it over to the group, and I will follow up with my own questions. Irina, do you want to? FASKIANOS: OK, so Ray Stern, you go first. Q: Hi, there. Thanks for your time today. I appreciate it. It’s very helpful. I’m from Arizona. And as you know, there’s been a lot of attention given to my state because of what’s happening with the surge. I have a couple of questions for Dr. Gupta. Basically, I’m wondering how much blame, you know, should we fairly put on our leaders for this? You know, there seems to be mistakes just made all over the place. And the right decision, you know, often has consequences for the economy. At the same time, you know, our governor has seemed to follow the Trump plan. And there’s been already some accusations of covering up the data, just like you talked about in Florida. So I’m wondering if you look at Arizona, just how serious do you think the leadership problem is here? And then of course, the surge is the other extreme problem. I just looked at the COVIDActNow site. They’re putting us at 99 percent for ICU beds. You know, I guess I’m wonder how worried should I be about that? You know, is there a surge capacity that will come in, hopefully? And also we’ve got a governor who isn’t placing a mask enforcement requirement on the state. Should that be done? And what else can Arizona do to try to flatten this new curve? Sorry for the long question, but we’ve got a lot going on here.  GUPTA: No, no. That’s a really important question. Thank you for that. And first of all, I hope you and your family are safe. In Arizona, I know from colleagues, that’s a really difficult situation. I won’t mince words here. We’ve had failed leadership. And it’s been, in some cases, catastrophic. And I think if I did—if I willingly—here’s the analogy I like to think about. There’s a lot that’s not being done that we know could save lives. And if I withheld lifesaving treatment intentionally as a physician in the ICU, my license would get pulled. I probably would get sued. Other bad things would probably happen to me. So where’s the accountability? So let me start there with Governor Ducey in Arizona, not to pick on him but since you asked the question. Basic things are not being done. And you can only reason to think that maybe it’s political, that he doesn’t want to fear upsetting the president. The mask issue to me is mystifying at this point. Why are we even debating this? There’s plenty of data at this point that suggests masks cannot be recommended because, unfortunately, a citizenry like ours—which is diverse, which is opinionated, is not used to wearing masks—we can’t reliably expect us to comply with that at scale. We need 90 percent mask adoption, otherwise it’s not going to work. That’s what we know is effective. That’s what we’ve learned from our peer countries in the Asia-Pacific, where this is not a problem, cooperation with masks. They readily do it. But how can we encourage that? There’s no—we can’t just encourage it. The time for encouragement is done. That’s why mandating—a national mandate on masks is important. But when I even hear leaders that I think have gotten this largely right talk about it they say, well, we need to mandate masks. Well, where’s the enforcement mechanism? To your point, there needs to be an enforcement mechanism. What I’ve seen here in Seattle and elsewhere—I’m from Ohio originally—is essentially there’s a sign at the door: You must wear a mask. But what happens if you don’t wear a mask? And I’ve seen a lot of people just skirt the rules and not wear the mask. It falls to either me, with my toddler son, saying something to somebody, which I may or may not do and risk who knows what could happen afterwards. So I think it relies on our fellow Americans to enforce it, which is dangerous, or security guards to enforce it. That’s just not right. It makes no sense. So mandating masks at the state level, since the president’s not going to do it, makes a lot of sense. Governor Ducey should do it. But he should fine—there should be a fine. Just like we do with indoor smoking. And that, the threat of a fine, compels people to do the right thing largely. We need that. It’s very basic. And we should make it happen. Yes, people are going to be upset, but tough luck. That’s just how it needs to be. We’ve had success with indoor smoking. We should do it there. That’s one. Indoor dining needs to stop. I don’t know how much more evidence now we need out of Wuhan or other places that have studied indoor dining or other indoor gatherings in poorly ventilated air-conditioned facilities, but the transmission rates are twenty times higher, in some cases, than outdoor dining, outdoor gatherings where there’s distancing, at the very lease. If I was the governor I would stop indoor dining now. And Governor Murphy and Mayor DeBlasio have done it. To some degree you’re seeing some counties adopt that approach. But again, this county-by-county, municipality-by-municipality approach is not going to do anything for us as a country. It’s why we have a surge and Spain, and all these other countries, have continued flattening. We have fifty different approaches, multiple different approaches even within a state. It’s not going to work. So that’s number two. And to your other—to your last question about surge capacity, I’m deeply worried about all of you in Arizona, because 99 percent capacity in an ICU in the setting of COVID is a really terrible signal because it’s not like you have throughput of these patients through an ICU. These patients can take up to upwards of forty-five to fifty days to come off a ventilator. I just got off the ICU last week. I was caring individuals from Yakima who were in their early thirties who were there for forty days, intensive care. I mean, the definition of intensive care. I was in there for hours. My nurses were in there literally nonstop. Turning patients over from their back to their belly, continuous dialysis, twenty different drips, changing IVs out, big IVs in your neck almost—you know, every few days. This is serious stuff. And so it’s not like that number’s going to change anytime soon. Unless you deploy the military, unless you get the National Guard to do its job. I mean, one thing I think the military does do a good job of—again, I’m saying this—I know I’m saying this in uniform and so I want to be clear this is my opinion this is not the opinion of the Department of Defense—we know what we’re doing when it comes to portable ICU capabilities. That’s what we get trained to do. That’s what the taxpayer expects us to do. There’s a lot of money that goes to the training and keeping this mobile capability ready. Why aren’t we deploying it? It doesn’t make any sense. We deployed it readily for Ebola. Why are we not deploying it now to Florida, and Texas, and Arizona, and California? It does not make any sense. And yet, we continue to sustain the capability. Again, I think deploying active duty and reservist branches of the military—Air Force, Army, Navy—would give us some relief. Oh, sorry about that. It would give us some relief. But it would also mean that it would be some degree of admission of failure on the part of the president, that now we have to bring in the calvary, which, you know, if this—if the right thing was being done, again, to answer your question, that would be the right thing. And if I was Governor Ducey I would beg the president to do that. ROBBINS: Thanks. FASKIANOS: Thank you. Let’s go to Rosemary Westwood. Q: Thank you so much for doing this. I have two quick questions, I hope. The first, on ICU bed capacity, what is your understanding of, you know, the percentage of beds that are being used after that point at which it’s a big problem. Like, we’re seeing some regions in Louisiana have, say, eighteen beds, one of the most worrying regions right now. And as a percentage, I think that’s at about maybe 60-70 percent of the ICU capacity. So how can I measure, as a journalist, when I’m looking at this data, what threshold should cause us to think that we might overwhelm that system? And then the other question I have for you is can you just delineate between percent positive and what you call the number of tests to get a positive test? I think I’m sure not the difference between those two. GUPTA: Sure. No, no, I’m happy to elaborate on that. So on the first, anecdotally this is what I’ve seen, and working now in a few different ICUs in the COVID era and then before COVID. What I’ve seen is we never fill up—we never fill up every single bed because the rate limiting step often—is never the bed. It’s the number of beds you can staff. And staffing, especially nurse staffing, is always a bottleneck, especially now. So what I would urge you to do, and it’s probably different in your zip code than it is in my zip code. But what I’ve seen, to your point, about two-third to maybe 75 percent of so-called surge capacity is the most I’ve seen us actually operate in. It’s the rare time when you can call in reinforcements and everybody on a second call, third call, to come into the hospital. Its happens, but it’s in the rare circumstance when it’s all hands on deck. In my—what you really want to key in on, and the question you would want to ask your administrators at major health systems in your zip code, is what’s staffing look like? What’s ICU nurse, and respiratory therapist, and dialysis staffing look like? Double click on it, because it’s so easy to just talk about ICU beds. But I can say as a practitioner, it’s never the bed that’s the rate limiting step. We can always find a bed. We can—we can find a bed. What we can’t find necessarily is—can you find the twenty-four-hour nursing coverage, the highly skilled nursing coverage to take care of that individuals? And maybe—and in most cases a dialysis machine? Those are the rate limiters up front. So I would say typically speaking 75 percent bed capacity usually—if you’re going on the bed side, once you hit about 75 percent bed capacity from what I’ve seen, again, anecdotally, that usually correlates to 100 percent max capacity when it comes to your human health care workforce. And so that’s where I would really key in on when you ask probing questions to the CMO or the leader of the hospital administrators in the major health systems in your geo, because that’s the critical piece. To your second question, let me know if I didn’t answer your question, to the second question, so percentage positive tests. So just at a basic level, if you do 100 tests how many of those are positive? That—so the percentage of tests done in the prior twenty-four hours that are positive, and trend that out. That’s basically what COVID Act Now is reporting in Florida I think on a daily basis, if not a forty-eight-hour basis. So the number of tests done in a state or in a specific geo, and of those tests how many turned out positive. That positive infection—that positive test rate is key. And again, above 3 percent, you know, basically you worry that the outbreak is on an exponential growth pattern and it’s potentially going to get out of control. And it also means that contact tracing is effectively useless because there’s just too many positive tests that are out there. And in the absence of a technological innovation or broad adoption of technology to inform tracing—which we as a country are just not willing to engage in for a variety of reasons, unlike the U.K. and Germany—there’s no way we can do a manual contact tracing effort right now in the United States at scale. It just doesn’t make sense. The number of confirmed—the number of tests per confirmed case, so basically it’s—the way you would want to think about it is take the number of total tests done in you name the state and divide it by—or in the country—and divide it by the number of confirmed cases identified in that way. So it’s almost the inverse of what the positive infection testing rate—positive infection rate is. That inverse ratio, so number of cases per confirmed test, almost—again, it’s almost the opposite. It’s the reciprocal—is one way to think about how broadly or how narrowly we are testing, because if that number is small you basically means you don’t have to search too far and wide before you get a positive hit. So in our case, it’s twelve tests before you get a positive hit. In Australia, you have to test 370 individuals before you get a positive hit. There’s two applications for that. Again, just to make sure we’re—just to make sure I’m being clear. Maybe this point’s already come across, but if it takes 370 tests before you get a confirmed case, that basically means either you are testing everybody—symptomatic, asymptomatic, and people you don’t think likely have the disease. And that means anybody who wants a test can get a test, in other words. Or it just means you don’t have an outbreak. In our case, we’re only—twelve tests done before you get a confirmed hit, that either means we’re narrowly defining who can get a test, which is the case. You really can only be symptomatic. Don’t believe what they’re saying. You can—only if you’re symptomatic are you a high priority for tests still, all these many months later. There’s some exceptions, but that’s generally the case. Or it means your outbreak’s out of control. We have a combination of both. We have narrow testing and our outbreak’s out of control. In Australia they have broad-based testing. If you want a test you can get it. And they just don’t have that many cases. So that’s why that rate—you have to test many more people before you get a positive hit. I don’t know, is that clear? Was that—on either part of that question? Q: Yes. Yeah, they’re connected though, so that’s I think why I was confused. But that makes sense. Thank you. GUPTA: No problem. ROBBINS: Thank you. OK, so— Q: Can I get that website again, where that information shows up, Dr. Gupta? GUPTA: So COVID Act Now will do the positive test rate, I believe. And then Our World in Data I believe is the name of the website. Or if you just Google “confirmed COVID”—or, “tests per confirmed COVID cases” it should pop right up. And then you’ll see actually a really nice histogram that compares this against other countries. FASKIANOS: Thank you. Let’s go to Marie Albiges. I hope I’m pronouncing that correct. If not, please. (Laughs.) Q: It’s Albiges. I’m a reporter in Virginia at a daily paper. And so every day, you know, we put together the story of all the data, the confirmed cases, confirmed, you know, number of tests, et cetera. But I’m wondering just how much we really should be writing about the data on a regular basis when, A, the state has made mistakes in reporting in the past when it comes to coronavirus data and sometimes they’re unreliable. And, B, like you said, people have become kind of desensitized to what the numbers mean. So I’m wondering, you know, how much we should really be reporting on that data every day, or if there’s a better approach to how we’re writing about the data. GUPTA: So thank you for the question. And I think you’re appropriately concerned about the data, and how to best report on it. I would love—you know, I still think it’s important to present some of the data that we talked about, for the reasons mentioned . You know, there’s still value, even though there’s some concerns about how Florida is reporting ICU bed capability, if you—if that’s part of the story, it’s still a critical part of the story to tell because trends matter here. A snapshot in time is less useful, but trends do matter. So I would—I guess I would push you to, say, report on trends. And that’s key. And report on them—don’t report on absolute anything. Report on relative data metrics. So everything I’ve just mentioned here what you want to report on is trends in the positive infection rate, trends—by definition the number of tests per confirmed case is a relative metric. ICU bed availability, all these things. Trends over time, longitudinal data is what we really care about. I think that’s what you want to really focus in on. So whether it’s week over week or every three-day averages, that is very helpful.  What I think is really useful, and I think this gets back to a prior question here, is just double clicking on what are the major health systems in your—you know, in—wherever, in your region of Florida. And then speaking to the hospital administrators there directly, and not relying on the data the government’s reported out on the state of Florida’s Department of Health website, because I think you’re going to—it’s important to hear directly from the COs, the CMOs about their pain points. And it’s usually going to be, again, as I mentioned, on staffing, on the need for PPE, or what have you. To me, that’s the type of data, especially at the local and the municipal level, is really key to surface, because then national attention gets brought to it, and then potentially enough pressure gets made on state officials that they’re forced to act. But if you can balance—I think the best reporting at the local level is a combination of trends, quantitative—you know, looking at trends on these aggregate numbers, but then also seeing to the extent that you can get real data, actionable data from hospital officials and other leaders of major health systems. I think that’s going to be the most useful. So I don’t know if that’s helpful, but that would be my—what I’m—what I found to be really helpful when I try to message on some of these issues, you know, for certain elements. Q: Thank you. FASKIANOS: John D’Anna. And you need to—yes, thank you. Q: Sorry about that. I wonder, Dr. Gupta, if you could comment on the importance of timeliness in receiving test results. We’re talking to people here in Arizona who are waiting a week to ten days to receive their results. And as a follow up to that, are there any tracking systems that you’re aware of, or resources that you could point us to, that give us an average length of time to receive test results? GUPTA: Such an important question, especially as we think about this broader debate on returning to school. And so right now the delay—the most commonly available test is from Quest and LabCorp, and major lab-based companies that do lab-based tests. And these are the classic nasal swabs that you stick into your nose, and then somebody—some technician will then send it back to a Quest or LabCorp type facility to get run. On average, the best-case scenario is a seventy-two-hour turnaround on that test. What I’ve seen typically is five to seven days on average, just in the health systems I’ve work in, anecdotal reports. I’ve seen as bad as almost a month, just because things got messed up in transit. And it’s totally unacceptable and it makes testing virtually useless if we’re thinking that testing is a bridge to something. It’s all fine and well to know that you’re positive or negative, right, but we think it’s a bridge to then determine who needs to be quarantined, but then importantly who needs to get their contacts traced. And if we’re saying there’s a seven-day potential lag between finalization of the positive result and then notifying your exposures, then that doesn’t make any sense. We need point of care testing. And so I think this is where this synchs in with the larger debate on the CDC guidelines on school re-openings nationwide, and then the president’s pushback on that. One thing you’ll notice, a common thread, is that neither the CDC nor the president stipulated testing for children or adolescents going back to school as a requirement. And it’s—myself and colleagues were sitting here wondering, haven’t we been messaging on testing every single day since early March? And now suddenly it doesn’t matter, and we’re going to have fifty-six million school-age children go back to school, and they don’t need to get tested? This is the type of inconsistent messaging that ruins the trust—that trust compact between the American people and then I think people like myself, that have been trying to—and my colleagues—who are trying to message on the importance of masking, testing, et cetera. If we’re now saying we’re going to just restart a huge part of our economy and we’re not going to do anything with testing, if I was—if I was listening to that not living and breathing this reality every day I would say: What is happening here? Why are we doing that? And so the reason why they’re not messaging on it, it cuts to the heart of your question. Oh, sorry about that. Which is, we don’t have the right testing. They don’t want to message on it because you can’t have a seventy-two-hour lag between—or, a week lag—between testing and then saying you can go to school. We will, though. Importantly, we will have that testing capability, we think, by late fall/early winter. Becton Dickinson, Quidel, these are two companies that have a direct—a certain type of test that’s point of care, that’s going commercial in the next few months, and to the tune of multiple millions of units of supply in circulation, you know, we think September/October, and then tens of millions thereafter. These are the types of tests that you stick something in your nose, with a clinician watching over you, and then within fifteen minutes you get a result. Within fifteen minutes. And there’s other innovations that are in the pipeline, we think by late fall/early winter, will allow for not just same day but same hour, or even within the same half-hour finalization of the result. That’s the type of innovation that the government should subsidize for every school district in the country. That’s the responsibility. They should make sure they—every school has the proper clinician to administer the test or supervise it. And that’s the infrastructure unfortunately we need until we get a vaccine or there’s herd immunity. That’s what we need. And it’s going to cost money. That’s what the taxpayer dollars—federal taxpayer dollars should be funding, or at least partly subsidizing so it’s not on schools. But that’s what we need to reopen schools. And until we get that, this notion that we’re going to just stagger schedules, we’re going to thermal scan folks, we’re going to make sure there’s adequate ventilation, it’s all just nonsense. And it’s—us not messaging consistently is going to ruin—further erode trust between public health officials, people who are on the front lines, and the American people. They’re not going to trust us. So sorry I rabbit holed there and went a little bit in a bit of distraction, but I don’t know if that was helpful. FASKIANOS: Vin, what about saliva testing? Are those—is that an effective means? Are those tests being developed? GUPTA: They are, Irina. Right now what we understand internally is that saliva testing captures the right—the cases you want—i.e., the cases that are—there’s enough of a concordance between saliva and sticking something up your nose that—it depends on the organization, but Major League Baseball, other major organizations are adopting it. There is a chance that saliva—what we’re seeing is there’s about one in ten cases where saliva misses a positive hit that you would otherwise detect on a nasal test. But those tests we—that one case usually is a case of an individual that had the infection but is no longer infectious. So in other words, saliva captures the cases that matter. And you know, I’ve gotten some push back. Well, you know, how can you expect a six-year-old to assent to a nasal test, because they’re not going to like that. It’s going to be super traumatic. And I agree. Some of these point of care tests will allow you to spit into a tube instead of sticking something up your nose, but they’re not going to go online, Irina, until we think November/December, at scale in Q1 2021. But it makes this notion of a fall reopening of schools broadly I think terribly unsafe. And it’s creating an expectation that’s wrong for parents. I think parents need to be prepared, unfortunately, to hunker down yet again through the fall semester, with relief starting hopefully in the spring semester. But that’s the messaging that we need, not oh we’re going to start things up to September. Because now it’s going to create all types of disagreements, it’s going to create false expectations, and then people are going to get upset. FASKIANOS: Thank you. Let’s go to John Wotowicz next. Q: Yes. Thank you so much. And this is a terrific conversation. And, Dr. Gupta, thanks for all of your observations and answers here. I’m going to take it just—down a different path here, which is it would be great to get your thoughts on the extent to which this whole global pandemic is revealing some real structural flaws in the United States kind of devolved system of state-level health policy, health regulation, health reporting of data. Because when you look at, you know, larger places—you know, such as Germany—where, you know, it’s a substantial population, but where obviously all of these issues are being ultimately decided and directed at the center and at a national level. It’s hard not to at least raise that question. And just to identify, I’m with The City, New York’s local nonprofit—local news platform. GUPTA: Thank you for that question, which is a really important one. You’re right, the lack of a unified—all fifty states are sort of—you go at it alone approach to our health care system and financing of our health care system has been a huge problem for decades. And I think COVID-19 has really unearthed inequities in access to care. Until May, to give you an example, if you wanted to get a test—until May you had to—and all you could do was access a physician or an ARNP through a tele-environment, you had to—you actually had to own a smartphone, because they did not allow—CMMS did not allow you just to call your doc and say: Doc, I need a test. Or if you were working with a nurse practitioner, same thing. They didn’t allow that. They didn’t allow someone to get reimbursed on the provider end to communicate over phone with somebody to then, you know, prescribe a test. So basic things like that, where the essentially the common motif here is you have to be affluent, and you have to access to broadband technology. Otherwise, you’re going to get a prescription. It was a huge problem in the initial months where this epidemic, now this pandemic, took root. So I think there’s been progress. So what I will say is, and I hope there’s continued permanence of some of the changes I’ve seen, at least in a temporary fashion, when it comes to, for example, telehealth. There has been ninety pieces of legislation in the last three months to telehealth to broaden access to make cross-border licensing—to strengthen cross-border licensing arrangements, so I can be a doc here in Seattle and care for you in New York, who needed it. I didn’t have to be licensed in New York. I can how physically go to New York City, if needed, and practice medicine and get a license within twenty-four hours. Previously it would take months. Those changes—let’s hope they become permanent because that’s going to rapidly increase the ability to deliver access to health care in a tele-environment, regardless of if you’re sitting in an urban, densely-populated area or if you’re in a rural/exurban area. So that’s one. And I think that’s important. What I fundamentally think is a problem in our health care system that has not been addressed is we just have the wrong types of health care workers at scale. We have a—yes, we don’t have enough doctors. Yes, we don’t have enough nurses. But we don’t actually have enough medical assistants. And those are the types of individuals that do the type of work that allow me to practice at my top of license. So I’m not doing care coordination. I’m not calling in meds. I can focus in on the patient in my fifteen minutes I may have with him or her in clinic, try to deliver the best quality care so they can come in less often to see me, and it’s less of a charge to the system, but then they can interact more with the medical assistant, who can focus in on coordinating the care with social services, getting your medications refilled on a timely basis, making up those phone calls. Do you know what happened in the months right after COVID-19? Most MAs got furloughed, and then fired. So now we don’t have the connective tissue in our health care system that we need. We have nurses. We have docs. But they’re all being overstretched. There is a lot of unhappiness in our health care workforce right now—either because a lot of them have been laid off, and they have untenable bills, student debt, et cetera. Or, because we’re doing work that’s quote/unquote, “beneath” our license, that’s stressing—we’re expected to do top of license work, because we’re in charge of a patient’s care, ultimately, we’re guiding their overall care trajectory. But then we also have to make sure we’re care coordination. We also have to make sure that they have a safe discharge. All these things where we need more people that can strengthen the connective tissue of the health care system. I don’t know if that directly answers your question, but to me that is the dire lack—the key need for American health care moving forward. We need greater access to care. And broadening telehealth is going to be a key piece of that, making permanent some of these legislative changes. But then we also need a rethink on how we can incentivize roles like medical assistants, and more broadly. How do we make that a career that’s worth saving, and worth investing in, and that people feel like they want to actually continue in on? Without that, we’re just going to have a bunch of expensive clinicians, whether they’re nurses, ARNPs, or MDs, who are going to be doing nurse that they shouldn’t be doing. It’s going to create a bunch of waste with the health-care system. And it’s going to have these trickle-down effects, where you’re going to have Republican administrations come in every four to eight years and want to block grant Medicaid and create haves and have nots among states. And it’s just not right. But the proximal causes of that are waste, inefficiency. And part of—and a big drive of that, I don’t think we talk enough about, is who are—who are the people delivering our health care in and what proportion? We just don’t have that right. Q: Thank you so much. FASKIANOS: So we’re waiting for more questions, so Carla I know you’ve got questions. ROBBINS: I have a question. So if you look around the country, are any leaders getting it right? Are there any models for how to do a measured reopening? Or are we all just going to have to hunker down and wait for a vaccine or herd immunity to set in? GUPTA: So I—it’s a great question. I love what Governor Murphy has done. I think what Governor Cuomo and Mayor DeBlasio are doing now in terms of messaging in the setting of a very complicated situation is laudable. They’re taking action on indoor dining. They’ve been as strong as I think I’ve seen on masks. And they went through the worst of it and had the humility to call in reinforcements. And so they had humility. They’re operating with evidence. And so I think they should be praised accordingly. Truth is, I don’t think this is a state-level approach. So you know, this notion—and this is where I worry about their false sense of creating these regional approaches here. It’s not going to matter what Connecticut, New Jersey, or New York do if Arizona and Governor DeSantis in Florida decide, hey, we’re going to go our own way, because we’re all one country with one set of contiguous borders. The state-level approach has limitations. Just like if you’re a mayor, or if you’re the mayor of Miami, and I understand the president’s about to go to south Florida tomorrow. And the Mayor has said: You have to wear a mask. Turns out, the mayor doesn’t have any discretion or jurisdiction if the governor says, well, you know, what? You don’t have to wear a mask. We’re not going to mandate—especially if—and if the president comes in and says there’s not going to be a federal penalty even if state law says—if there’s one way or the other on masks. If there’s not a federal penalty for not wearing a mask, then it’s even further weakening messaging on the city level. And so I think it just goes to say there’s only so much that can be done at the city, municipal, or state level. We need federal leadership. We certainly need governors to be aligned with that federal leadership. But I feel for governors like Governor Murphy, Governor Cuomo, I thought Governor Whitmer withstood a lot of angst, a lot of conflict, but stood firm with a very strong shelter in place order, which I thought was right. I thought Governor DeWine actually initially—my native Ohio—was great, with Dr. Amy Acton, in terms of messaging, shutting everything down early. But unfortunately I think Governor DeWine’s a cautionary tale of somebody who has let that initial strength essentially completely dissolve, and you’re noticing a very clear uneven response now to the second wave or this extended surge, where now he’s saying, hey, we’re going to do masks in a few counties, but not statewide. Again, it does not make any sense. So I think governors— ROBBINS: But I understand what you’re saying about it can’t be piecemeal and all of that, and you know shutting down borders obviously is not possible. We’re not East Germany during the Cold War. (Laughs.) I suppose the question that I’m asking is: What do you think is a reasonable series of steps for reopening that when the numbers become—like, New York, in which the numbers are flattened after the horrors that we went through earlier. I mean, Cuomo’s talking about reopening malls, you know, there’s all of these things that are going on. What are reasonable re-openings that can take place once the numbers are, and at what level? I mean, what’s the pacing that you’re comfortable with that the government—that the government—a government that has good public policy should be doing? GUPTA: So, no, I appreciate that. What I would say at a high level is that to enter any phase of reopening moving forward a jurisdiction, however you define it—but I think we have to do this at the city level or at the county level—has to have an infection—a positive infection rate—that’s the most important metric in my opinion. That’s an early indicator of where things are at with the outbreak—has to be less than 3 percent, for re-opening. And the only reason I say that is because that’s when, it hit on the theme mentioned earlier, that’s when we can actually do something about it prospectively. If you have new cases, you have some hope of maybe containment because you can scale contact tracing. So I think, number one—one criteria here—and this is, again, my opinion. The infection rate, positive infection rate, has to be less than 3 percent. You have to have—you have to speak with local health system leaders about what’s the true ICU bed capability, not just what’s—not absolute number of beds, but how many can you staff? If that’s 100 percent of all beds, great. In most cases, it’s not. But assuming that you feel like there’s enough elasticity in your health system capability to handle a surge, and that—in my opinion that means only a third of beds are filled at any period of time—if ICU beds—3 percent less—or, percent or less on your infection positivity rate, one-third of less ICU beds filled. Then you can enter a phase where you’re opening up outdoor dining, where you can reengage in public in groups of less than ten, if there’s social distancing and, you know, universal masking precautions in public areas. That’s where that makes sense. And then I think the critical piece here that we just need to—if we really want to normalize life and get back to normal, until before a vaccine hits, we have to accept that we need app-based technology to guide contact tracing. That’s what the U.K. has done or is about to do. That’s what Germany’s about to do. There’s ways to do it that can protect data privacy issues. There’s ways to do it that could be, I think, sensitive to communities of color and other underserved areas, where there’s going to be even greater sensitivities to the adoption of technology to facilitate tracing. But let’s be real, we’re not going to be able to do a manual contact tracing effort at scale quickly. But we can do it with the assist of technology. So I think if we have a community that hits those metrics, less than 3 percent on the infection rate, we have adequate ICU capabilities—as defined by what administrators are telling you not what numbers are saying just in some database—and if there’s an appetite and an acceptance of broad downloading of an app, or what have you, or another non-app based technologies that could facilitate tracing, then I think we can think about outdoor dining and outdoor activities upfront. Of course, you’re assuming that you have mandatory mask enforcement as a part of that legislative approach. But that would be how I would think about a reopening process that may actually have some hope of curtailing any new infections from becoming niduses for new outbreaks. ROBBINS: And of course, those things are—many of the things you’re talking about are already happening in New York City, without contact tracing and without mandatory masks. I mean, certainly not with enforcement of masks. GUPTA: Well, I think those are two—those are two critical gaps that need to be rectified because—but New York is, again, far ahead of the curve. I think you had—and New York is—that’s why I highlighted it, because I think if you’re thinking about indoor dining and stopping that, the messaging on masks has been excellent, at least from elected leaders in New York state and City. So those are two things that most of the country doesn’t have. MR. RUBENSTEIN: Let’s try to sneak in Ray Stern before we close. Q: Thanks so much. Just wondering if you can talk about death rates just a little bit more. On one of the conservative sites that I was looking at they talk about how the CDC says this this is barely an epidemic at this point, according to the CDC. And I looked that up and it’s true, basically, though, they say that that could change. How do we explain this in full context to people? And the last question is, New York, of course, had this big first wave surge. A lot of doctors and nurses got sick. Are these people getting sick again or have they achieved immunity as far as we know, at this point? GUPTA: I think the death rate debate is—it’s so easy to mis-message on death rates as it’s 0.6 percent, why—or, the true death rate we think is 0.6 percent, even though we think the case fatality rate—how many people are actually dying right now in the United States out of those confirmed cases is about 5-6 percent. The question, and you’re seeing that sort of death rate curve level off and it’s decreasing consistently. So it’s causing people to wonder, what’s all the fuss about? And there’s a few reason why we’re all fussing. Number one is, this outbreak—if we continue to open up the way we’re opening up, if it continues that, you know, young people continue to be vectors for transmission, the median age of—that the majority of newly infected individuals in Florida is thirty-five, versus sixty-five in March. Similar findings in Arizona, in your home state, where younger people are now the predominant focus of the infections. You know, these are individuals that are—as long as COVID-19 is still circulating in an environment, it poses a threat to us as we enter the fall with flu. That’s the concern, because you can still end up in the ICU if you’re young, number one. But then you can still transmit it to older individuals, number two. As older individuals resurface and are now, you know, potentially going out, because we can’t have them shelter in place forever. So there’s going to be a tendency to want to normalize life. And as long as we have this circulating, it’s going to still pose a threat to those that are the most vulnerable. So that death rate, one, is a lagging indicator, deaths now probably are largely occurring from infections that occurred four weeks ago. And so there’s nothing to say that we’re not going to see an uptick in deaths as we continue to let our guard down. And I worry that our guard is being let down, based on scenes from July 4, based on core messaging from the White House. And if schools do reopen because the president’s blackmailing school districts nationwide with funding, which is, I mean, just completely dangerous to do, you’re going to see—there’re all the ingredients for a repeat surge and more potential risk to those that are the most vulnerable. That’s one reason. Number two, and I know I’m going over time. I’ll say this quickly. My colleagues and I have gotten better at saving lives at ICUs. We know things that we didn’t know in March. It doesn’t mean then that we should be playing Russian Roulette with ICU bed capacity. Yes, we can save more lives now because we know steroids work. We know that you should put everybody on blood thinners. We know that you should probably put somebody on their belly instead of keeping them on their back on a ventilator. These things we didn’t know in March. And so is that helping with the death rate and we’re saving more lives? Yes, potentially. But is that a pop-off valve we can rely on at scale? No, because as we’ve talked about ICU bed capacity staffing is such a limited—it’s still in such a limited supply there isn’t a lot of room there. And I wouldn’t bank on it. So that’s a key piece here. And then, number three, we’re testing more. And so we’re seeing that most of these new cases are happening among young people. Again, not a cause for celebration. Young people are transmitters of the disease. They can still end up in the ICU. There’s still a lot of risks. So that’s how I would—I guess I’ll close there, just in the interest of time. FASKIANOS: So, Vin, I just—one question came over chat. Natalie Megas. She can’t ask her question out loud, so I’m just going to read it. But going back to the school systems reopening safely: Is testing, in your opinion, the only indicator to reopen safely? Many states are leaving it up to parents to decide between virtual and in-person instruction. How can I report on this to help parents make an informed decision? And she’s a freelance reporter in Virginia. And that will have to be the last question. GUPTA: And sorry, just to paraphrase, it cut out a bit, the question is safety of going back to schools and balancing needs in terms of virtual versus brick and mortar. FASKIANOS: Yes. If testing’s the only indicator—if schools are not doing testing, are there any other indicators that would help parents make the decision of whether it’s safe to send their kids back to school or do virtual. So is testing—if we’re not doing testing, would you say then don’t send you kids? GUPTA: My opinion is: don’t send your kids. Because it just doesn’t make—I don’t understand the argument for why we’re saying testing doesn’t matter. It just doesn’t make sense. I know the American Academy of Pediatrics, the CDC, and the president are all aligned that we need to restart schools. We all want schools to restart, but it’s just what are we then basing a return to school strategy on? That’s where I would really ask your school district. Here in Seattle they’re talking about thermal scanning, which makes no sense. And I love our elected officials here in Seattle. They’ve been leaders on this issue. But looking for something, fever, amongst individuals that we know that if they were positive adolescents they would not have a fever—we’re looking for something we know is not going to be there. It doesn’t make any sense. So we have to—testing has to be the backbone. If it’s not, I would encourage parents to wait and not take the risk. Because even if your child may not be at risk, you would be at risk, or your grandparent—or, your parents might be at risk, if you’re a parent. So I would be very cautious. FASKIANOS: Well, with that, Carla, any final words? ROBBINS: Just actually one quick list here. The Times did this extraordinary things, they asked 511 epidemiologists what they would and wouldn’t do, what normal activities they would return to, and in what timeframe. What are they—are you doing any normal activities, or are you going to wait for the vaccine? Getting your hair cut? Going out to dinner outside?  GUPTA: Outdoor dining, absolutely. And I think that is something that we call still can enjoy. And I’ve seen a lot of restaurants innovate with community spaces, and I think there’s going to be more of that. So outdoor dining, I’d highly encourage it. And I think that’s fine. And that’s the only thing I would say that I’ve done that’s been true normalization. ROBBINS: It looks like you got your hair cut too. FASKIANOS: It does look like you got your hair cut. Or was that a home cut?  GUPTA: It’s my wife’s incredible cut. But, no, so I guess yeah. Sort of semi-normal. ROBBINS: Thank you so much. GUPTA: Thank you for having me. FASKIANOS: Thank you, Carla Anne Robbins and Dr. Vin Gupta. This is fantastic. We really appreciate it. We will be sharing out the recording and transcript of the webinar. We’ll also include links to the URLs that Dr. Gupta mentioned. You can follow Carla on Twitter at @RobbinsCarla. And you can follow Dr. Vin Gupta at @VinGuptaMD. So go there for more information on what he’s thinking about. Also his commentary on the news outlets. We encourage you to come to CFR.org for the latest and greatest on COVID-19 and other situations around the world, because the world keeps moving even though we’re in this pandemic. And please feel free to send us your ideas and suggestions for other issues and people you want to hear from as we continue this series over the summer. You can email [email protected]. So thank you all.

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