What We Now Know About COVID Prevention and Treatment: A Podcast with Monica Gandhi

06/02/22 • 51 min

GeriPal - A Geriatrics and Palliative Care Podcast

We are two and a half years into the COVID pandemic. We’ve lived through lockdowns, toilet paper shortages, mask mandates, hospital surges where ICU’s overflowed, a million COVID deaths, prolonged school closures, development and roll out of novel vaccines, an explosion of social isolation and loneliness, and the invention of the “zoom meeting.”

But what have we really learned over this seemingly endless pandemic other than how to make a quarantini? Well, on today’s podcast we invite Monica Gandhi to sum up the evidence to date about how best to prevent getting COVID (or at least the severe outcomes of the disease) and how to treat it, including the role of Paxlovid in symptomatic disease.

Monica Gandhi is a professor of medicine and associate division chief of HIV, Infectious Diseases, and Global Medicine at UCSF & San Francisco General Hospital. In addition to her research publications, she is a prolific writer both on social media and on media outlets like the Atlantic and the Washington Post. Some call her an optimist or maybe a pragmatist, but I’d call her someone who inherently understands the value in harm reduction when it’s clear harm elimination just ain’t gonna happen.

So take a listen and if you want a deeper dive into some of the references we discuss on the podcast, here is a list:

So take a listen and if you want a deeper dive into some of the references we discuss on the podcast, here is a list:

Previous Episode

Should we prioritize the unvaccincated for treatment? Govind Persad and Emily Largent

It’s been a while since we’ve done a Covid/bioethics podcast (see prior ethics podcasts here, here, here, and here). But Covid is not over and this pandemic keeps raising challenging issues that force us to consider competing ethical considerations.

This week, we discuss an article by bioethicists Govind Persad and Emily Largent arguing that the NIH guidance for allocation of Paxlovid during conditions of scarcity. They argue that the current guidelines, which prioritize immunocompromised people and unvaccinated older people on the same level, should be re-done to prioritize the immunocompromised first, and additionally move up older vaccinated individuals or vaccinated persons with comorbidities. The basis of their argument is the ethical notion of “reciprocity” - people who are vaccinated have done something to protect the public health, and we owe them something for taking that action. Eric and I attempt to poke holes in their arguments, resulting in a spirited discussion.

To be sure, Paxlovid is no longer as scarce as it was a few months back. But the argument is important because, as we’ve seen, new treatments are almost always scarce at the start. Evusheld is the latest case in point.

Sometimes, you can’t always get what you want...

-@AlexSmithMD

Next Episode

Who should get Palliative Care? Kate Courtright

In the US, geriatrics “grew up” as an academic profession with a heavy research base. This was in part due to the tremendous support of the National Institute on Aging. Clinical growth of geriatrics programs has lagged academic research, despite the rapid aging of the population.

Palliative care, in contrast, saw explosive growth in US hospitals. In contrast to geriatrics, the evidence base for palliative care lagged clinical growth, in part because palliative care has no centralized “home” at the National Institutes of Health. The National Palliative Care Research Center (NPCRC)and Palliative Care Research Cooperative (PCRC)were founded in part to meet this need.

Today we interview Kate Courtright, a critical care and palliative care physician-researcher who conducts trials of palliative care. Kate’s journey is in a way emblematic of the lack of centralized funding for palliative care: she’s received funding from three separate NIH institutes, the NPCRC, and been involved in the PCRC.

We talk with Kate about how despite how far we’ve come in palliative care research, we still don’t have answers to some fundamental questions, such as:

Who should get specialized palliative care? Should eligibility and access be determined by clinician referral? By diagnosis? By prognosis? By need?
If we move away from clinician referrals as the means by which people get access, how do we keep the clinicians engaged, and not enraged? Can nudges help? (see our prior podcast on Nudges with Jenny Blumenthal-Barby and Scott Halpern)
When should people get palliative care? What does “early” really mean? We can’t possibly meet the needs of all people with newly diagnosed serious illness
How do we move from efficacy (works in highly controlled settings) from effectiveness (works in real world settings? What’s the role of implementation science? What is a pragmatic trial?
What outcomes should we measure?

We cover a lot of ground! Working on a mystery. Going wherever it leads. Runnin down a dream...

-@AlexSmithMD