For many decades. Weve all known you in the Public Health field, and its a real privilege for me to be here with you to talk about your brilliant new book. I want to just start simply, you know, explain the title silent invasion and the reasons you wrote the book, what you talk about all of it at the beginning of the book. Guest great, professor. And im going to call you larry, so thank you. Its really an opportunity to be with you again. We have had a a long career together battling pandemics around the globe and making sure the most vulnerable are served, and hope we take that message here in this country. But i called it silent invasion to really raise the alerts that despite the capacity we hadnt in diagnosing truly diagnosing respiratory diseases ever in this country. I was confronted that in africa in 1998 where fever was treated first as malaria and then a Something Else and then a Something Else, and maybe it was tuberculosis and maybe it was hiv, and it was all presumptive and we didnt know what was specifically harming the people of Subsaharan Africa. And we worked with the private sector and now we can diagnose hi tv malaria no matter where you live in Subsaharan Africa, the matter if youre the farthest end of the road or in the metropolitan area. And to come back to the United States and find out that 90, 95, 99 of 9 of flu was diagnosed presumptively and that we are only surveying for symptoms of respiratory diseases and making assumptions about what people were infected with, i found that really shocking in this day and age. Something appropriate for the 20th century, not the 21st century. So i really wanted to alert americans to the fact that we still could suffer a silent invasion. This virus came to a silently because we were not testing what our common respiratory diseases are. If you dont know its flu and you dont know if its not flu. So actually a call to action for defendant Laboratory Diagnosis of all of our respiratory diseases so that we know whats here and we know whats coming. I think even today the virus is silently moving around our communities and we are not adequately making it visible to the American People. Host yeah. I want to talk, they get a little bit more as we go along about your remarkable career with hiv, tb, malaria and also ebola, h1n1 influenza, sars one, zika. I want to get into that, the rich history i know youve had and youve been really leading the Public Health response in america and globally for such a long time. But theres another, the idea of silent invasion, you make another point quite forcefully and i think in the book about the silence of asymptomatic spread and you talk a lot about the idea that if somebody has flu they have symptoms and, but you can have a lot of spread before their symptoms arising. Can you talk a little bit about that part of the silence . Guest thank you. This virus in many age groups is invisible, and then very visible and a group of age groups and people with comorbidities that end up having severe disease and dying. So if you dont see it and you dont see it coming, then you miss all of the tools that we have to utilize them so that americans that only can survive but thrive. I often use silent invasion because i come out of the family of a lot of scientists. Were big sciencefiction fans so i wanted to really give voice to those of you who love sciencefiction. This was not sciencefiction but i think in a way many of the sciencefiction books have been talking about pandemics and global spread for a very long time, and that as societies we are not ready. And i think, im hoping, at us when theres an appendix at the end with clear legislative fixes that need to occur. I feel like even today with all the tools we have we remain vulnerable to silent Invasion Community by community because we not picking up the asymptomatic spread. Host i love the sciencefiction. When i grew up it was kind of, my Favorite Book was the microbe hunters, the early story of people that are looking into anthrax and tb was just, you know, fascinated me at the time. One of the things you said you wrote the book for, when you said you were writing it not to condemn, not to command but to recommend. And i want to get at the very end of our interview, debbie, the idea of what your blueprint for the future. But let me take you back now, i think i want to go back to the beginning, both to the early days but also to something that you said early on that you are compelled to accept the job knowing a donald trump was. Talk a little bit about why, when you got the call, you were reluctant to answer that call. Guest well, for those global Public Health people who have known me for decades now that when i see an injustice, when i see an inequity, when they see that that results in peoples lives being altered it something i am compelled to address. And so in january i could see this virus come, and obviously i was responsible for Subsaharan Africa and asia, and i was very worried about everybody that we serve their immunity by community, and a look at the data myself and i was like this is going to be serious, so my first up was to go to the white house to the Africa Bureau of the nse, the National Security council, and say to them i need to have an emergency meeting with all of the african diplomats. And so before the end of january with could all the applicant, african diplomats in the indian treaty room at them going through why im concerned, dr. Fauci fox hunter found utah, dr. Redfield about what were doing domestically so that africa could no and cable back to the country to things. That we need to rapidly develop tools and that they can tell their ministries to utilize the capacity that we built over the last two decades with pepfar. I wanted them to know that our resources were available immediately. So im trying to get africa and asia ahead of the curve and were sending out cables for state Department Come to all the embassies about my concern and how to utilize pepfar dollars to expand testing and let the ministries of health know the depth of my concern. Im assuming that the same thing is happening in the united unitd states, but then i just watched over february, i was over in africa most of february, and im watching and im watching the nightly news and im watching the reports of the press conferences that the task force and the president are holding, and to keep talking about the risk of being low, that we only have this handful of cases, and then were going to close our, we are going to close to china but were going to let all of the expat come back and only going to screen i symptoms. And i was like, the virus is everywhere. So did have a friend in the white house who was the husband to and pottinger who i i knew quite well and it felt they werent acting sun city him all of these messages and data about how severe i think this is going to be and is taking it to the task force and is telling me theyre not listening and im like please tell them again. Im like pushing up these messages and is calling me and say need to come back and help but, of course, my commitment was to the people i was serving and, frankly, i knew about the white house. I knew how, i frankly knew how i would be perceived, even though i was a Civil Servant and had nothing to do with trump political machine, i knew if i went into the white house to help, that all of their perceptions about the president would also become their perceptions of me because most people in america didnt know me. Overseas people to meet but not in america. Host we all know you here, for sure, in the field stretches so i kept saying no, but i could just see the tsunami coming and i felt like the diamond princess with such a real example to me about how america was misjudging this pandemic by only testing symptomatic people and the people they were living with and that testing the crew on that diamond princess and only looking for symptoms. The crew was much younger. I knew the virus was spreading through the crew. I just felt like we were not utilizing all of what i had learned and doesnt learn by working globally on pandemic by pandemic to bring that Knowledge Base to the United States. So finally out of frustration i answer the call and i came back. Host do you regret it at all, debbie . I mean, looking back and seeing what President Trump did in downplaying, were going to get into that because you talk a lot about that in the book, about flulike illness, low risk and other kinds of issues like use bleach and so forth. What do you think when you think back to those days, those early days . Well, how do you reflect on it . Guest the reason i dont regret it is because i know what happened upon my arrival. You know, those people who know me know that doesnt matter whos president. Ive worked with president s across the world. I dont care whose president , i dont care his prime minister, i dont care whose minister of health. I believe that i can assemble the right date to convince them to do the right thing, and ive seen that happen throughout my career. I saw african president s finally let us address the Lgbt Community to people who inject drugs, to people who are in prisons, who let us do the right thing to prevent hiv and to prevent and to treat those who needed our treatment. So i believe having worked with so many that with the right data i could convince the president and the Vice President that this was serious. And so i arrived with my list. I was really happy that first week that immediately when i said to the Vice President , heres a list of people to immediately call to the white house, we have to have our commercial laboratory developers make tests, not just pcr test but antigen test an antibody tests and weve got to have it immediately and youve got to get them all here. By wednesday they were all there. And so it was a lot of action that first week both on pushing therapeutics, pushing vaccine, pushing testing, getting people to take this much more seriously, i just want to thank my european colleagues because obviously i knew a lot of them from working on the global fund for nearly a decade. And they helped me. They sent me their data. They were about two weeks ahead of us, and i used that data for the european travel ban, the 15 days to slow the spread and the 30 days to slow the spread your kind of people go back and think when history is written they will see that that first wave, compared to many other countries, was much more contain than any of the wave subsequently i think as a country we reacted seriously in those three to four weeks and then we didnt. That was very disconcerting to me, certainly i talked out and about how the president got very different analyses from his economic, his cea team, and really that unraveled the president s confidence that my data was correct. Host yeah, you show so, i mean, or me in reading the book the one thing that comes across as your love of data and your frustration when it is not there, when its not accurate, when its not comprehensive, when where having to borrow data from other countries to make decisions here when we should be the vanguard, that really came through. For i kind of go on and want to look more in depth at the u. S. Response and also a little bit about the early days in china i cant help but ask you, didnt really feature in the book but you talk a lot about africa. You probably, you know, the one american in this nation that knows africa and its intersection with disease more than anyone else. What do you make of how covid is as transpired in africa . We were thinking it was cataclysmic end engine warnt early on, and yet theres some evidence that theres been less severe disease. Maybe thats a reporting issue, maybe thats an issue of just simply having a younger population. Whats your take on africa and covid . Guest well, larry, thats a brilliant question and it intrigues me and it intrigues me to today. Certainly some of it is testing and reporting, but you cannot hide severe covid disease and you cant hide most of the covid deaths. Ive said that across this country to many governors and mayors. There will be a full accounting state by state, county by county by what actually happened. But in africa they were blessed by three things that were really critical. Across the main part of africa that most people know around the equator going north and south, from east to west africa, the median age is between 15 and 14. 50 of the population is younger than 14. And we know from data now that this virus was very selective in general for the elderly. And so if you look at the continent, and that includes north africa which is a very different situation, i can talk about that separately, but africa as a continent has less than 9 of the population over 65. 65. We have almost 20 . The other big piece of it though is obviously with a history of hiv and tb, a lot of the individuals in the 90s, in the early 2000s before pepfar and the global funds succumbed hiv, millions and millions of people, so it emptied out a lot of the people who could invent 30, 40 and 50 at this point. We exchanged as a community the ability to people in africa to thrive, despite hiv tb and malaria. I think the second point is much lower comorbidities compared to the United States, much less obesity and thats what if you look across south africa, botswana where they do have older individuals, where that you have more comorbidities use a higher fertility rate from covid. And so the younger generation, the less comorbidities certainly underreporting but but i cal you when you look at access of death you dont see the same level of excess deaths in 2020 and 2021 that you see in the developed world. And i think its really a wakeup call, because like you, larry, we all thought pandemics would be horrific in low and low middle income countries, and in the end this pandemic singled out upper and upper middle income countries. Host incredible. Guest and there was no Natural Alliance of those countries. Because we were all focused on low and low and middle income country. So again there were no formal channels to really share information between our european colleagues and the u. S. And our Central American colleagues and canada. I mean, because we thought it was going to be there, and it was here. And i think this really opens up a glaring mistake that we all made over the last two or three decades is really establishing clear data exchanges among the upper middle income and upper income countries. Host yeah, very important point. Just very briefly on the early days of, you know, china and wuhan, and what the president , you know, knew or should have known and when. And also just reflect elizabeth about, you know, there was a significant clash between the white house and china on a number of issues, but particularly the lack of early reporting and lack of early reporting in an honest way in terms of human to human transmission. And then that ultimately led to the president sending a letter to the secretary, u. N. Secretary general, not getting a 12 month notice of withdrawal from w. H. O. How did the all unfold in the white house and how did a plate into the early days of the u. S. Covid response and the global Covid Response . You know, larry, i wasnt here and i could never really understand. So when i arrived at the white house, no one gave me any cia or other cable to suggest that there was information coming in through secure channels about how severe this would be. So when i heard that bob woodward interview, i was as shocked as america was. Because when i arrived, when i say no one, i mean no one in the white house from the nsc to the cia to the Vice President to the president , no one shared with me that they had an understanding about the severity, you know. My feeling was they are not taking this as severely, i mean as significantly as i think its going to be and thats why we have to make these changes. But that was very disconcerting to me to find up, i think that woodward interview was june or july 2020. I was shocked, and still no one showed me that that actually existed. So to this day ive never seen that document that talks about the severity. The reason i knew it was going to be severe is you could see on social media that the hospitals were getting overwhelmed in january. And at the same time china saying we dont think theres human to human transmission. So if im seeing the social media posts, the w. H. O. Should evincing those social media posts and they should have gone to the world and said this virus is highly contagious, spreading rapidly and result in significant illness in those over 70. I am still surprised by that. The data was out there. It may not have been coming from china per se, but that was the whole point of putting w. H. O. Representatives in every country is so that you werent always reliant on just what the National Reporting was. And after what happened with sars, i thought we had learned that lesson collectively as a community, but i think, once again, that early misleading about human to human transmission i think resulted in a lot of countries making very poor decisions about not developing tests and not really taking this as seriously as a should of tricky at such an important point. I want to stress one of the points you made because you heard dr. Birx say that she got to the white house and none of our most sophisticated machinery of government, you know, cia, intelligence, National Security, white house staff seemed to be aware of the seriousness of it. I mean, thats a stunning statement. Guest i think nsc was because matt was trying to get me back there. I dont think the agencies really were acting host including cdc. Would you include cdc and that . Guest you know, i dont know what the cdc was thinking at that time, but i can tell you that they did not prepare the country for a countrywide pandemic that was evident already in china. And what do i mean by that . Getting up the data streams that you needed, bring in the commercial laboratory developers. Its great that he worked on tests for the Public Health labs are we on