The COVID-19 crisis is the greatest shock to world order since World War II. Millions have been infected and killed. The economic crash caused by the pandemic is the worst since the Great Depression, with the International Monetary Fund estimating that it will cost over $9 trillion of global wealth in the next few years. Many will be left impoverished and hungry. Fragile states will be further hollowed out, creating conditions ripe for conflict and mass displacement. Meanwhile, international institutions and alliances already under strain before the pandemic are teetering, while the United States and China, already at loggerheads before the crisis, are careening toward a new Cold War. China’s secrecy and assertiveness have shattered hopes that it will become a responsible stakeholder in the international order.

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This article originally appeared in Stanford Medicine News.

Last fall, Dean Winslow, MD, saw the numbers everyone else saw: COVID-19 was killing nearly 2,000 Americans and infecting as many as 180,000 more each day. But he responded like few people could.

Winslow worked with state, federal and military leaders to get himself to Washington, D.C., where he now directs the COVID-19 Testing and Diagnostics Working Group, an 82-person, $46-billion interagency effort to track the virus and help steer the U.S. — and the world — out of the pandemic.

“I feel very lucky at this relatively late point in my career to be part of this,” said Winslow, who joined Stanford as a professor of medicine and as a senior fellow at the Freeman Spogli Institute for International Studies in 2013. “I had a wonderful 35 years in the military, and [serving in this role] almost feels like that, with the sense of purpose and camaraderie. And nobody’s shooting rockets at me.”

In November, with infections surging before vaccines were available, he wrote to Anne Schuchat, MD, the principal deputy director of the Centers for Disease Control and Prevention, volunteering to serve. But creating an official job within the federal government would take months.

Winslow couldn’t wait.

Joining the State Guard

Winslow retired from the Air National Guard in 2015, but he came out of retirement in March 2020, joining the California State Guard to help with California’s COVID-19 response and train California Air National Guard members. After the CDC asked him to join the working group, the California State Guard put him on state active duty orders and sent him to the working group.

“When I joined the working group in April, I was probably the oldest officer on active duty in the United States,” the 68-year-old Winslow said.

“I got to wear camouflage pajamas to work again,” he added, using airmen’s vernacular for the uniforms they wear while deployed.

Winslow took a leave from Stanford to join the group and began leading the team July 1. By that point, he had an official civilian job, so he started dressing like the rest of the team that includes scientists from various specialties, data analysts, and acquisitions and logistics experts from the CDC, the Department of Health and Human Services, the National Institutes of Health,  the Food and Drug Administration, and the Department of Defense.

The working group distributes testing resources, facilitates testing nationally, and tracks data from testing sites to know where the virus is infecting new communities and where new cases are occurring. The work has taken on increasing urgency in the past few weeks because of the more transmissible delta variant: Cases are surging again in parts of the country, especially where fewer residents are vaccinated.

“As vaccination continues to slowly increase, the way we’re going to finally eliminate this pandemic, at least from the U.S., is by focusing on these hot spots, particularly among vulnerable populations,” Winslow said.

The group is also working with manufacturers to stockpile diagnostic testing equipment, which was in critically short supply during the height of the pandemic. Part of the longer-term goal is to provide incentives for U.S. manufacturers to keep their operations in the United States.

“We’re looking to make sure that we do a much, much better job in being prepared for the next pandemic,” Winslow said.

If tracking the current pandemic while also preparing for future events seems like an impossibly big job, it’s also a job that requires the rare combination of skills that Winslow has accumulated throughout his career. Even leading personnel with diverse skill sets — all on loan from other agencies — is in his wheelhouse.

“He’s got this ability to connect with everyone involved in this process,” said Julie Parsonnet, MD, professor of medicine and of health research and policy. (She’s also Winslow’s spouse.)

“He’s a welcoming collaborator, and he’s completely nonjudgmental,” she said.

A Different Virus

Winslow graduated from Pennsylvania State University and Jefferson Medical College before starting his internal medicine residency in Wilmington, Delaware. As a third-year resident, he was responsible for inviting speakers to give grand rounds, at which experts present medical cases and discuss treatment options. When a speaker backed out with only two days’ notice, Winslow called an immunologist at the National Institutes of Health who studied necrotizing vasculitis, a disorder that causes inflammation of the blood vessels.

The immunologist, Anthony Fauci, MD, agreed to give the talk if Winslow could pick him up at the Amtrak station and give him a lift back. Winslow accepted the deal, and the two men have been friends ever since. (Inviting Fauci to deliver the Thomas Merigan Lecture at Stanford in 2012, Winslow gave his old friend more notice.)

Winslow and Fauci, who is now chief medical adviser to President Joe Biden, are members of the last generation to train before the AIDS epidemic. The disease shaped both of their careers.

Winslow launched the first HIV clinic in Delaware. He had seen a patient with a compromised immune system and lesions on his brain during his first week in private practice in July 1981. There was no test for the virus at the time, but Winslow saved some of the patients’ blood serum and later learned that the man was, in fact, his first AIDS patient.

When AIDS testing became more readily available, Winslow started seeing more cases in socially vulnerable individuals and persuaded the administration of the Medical Center of Delaware to start the clinic. Later, while working in pharmaceutical-biotech industry, he also helped oversee trials of inhibitors to treat HIV and helped gain FDA clearance for a device that tests resistance to HIV drugs.

For his part, Fauci in 1984 became the director of the National Institute of Allergy and Infectious Diseases, a position he still holds, and oversaw much of the AIDS research for the country.

Winslow joined the Louisiana Air National Guard in 1980, became a flight surgeon, then served as the state air surgeon in the Delaware National Guard. In 2008 he served as the commander at a combat hospital in Baghdad. He deployed four times to Iraq and twice to Afghanistan after 9/11 as a flight surgeon supporting combat operations.

“From the bottom airman on the ladder to the airmen wearing stars on their collars, Dean showed no preferential treatment,” said retired Brig. Gen. Bruce Thompson, who was Winslow’s commanding officer and has known him for 30 years. “Dean oozes compassion.”

When Winslow saw Iraqi children who could not receive the medical care they needed in Iraq, he arranged for them to be flown to the U.S. where hospitals could provide treatment.

In 2015, Winslow and Parsonnet created the Eagle Fund, a charitable trust that helps victims of war around the world.

“His whole career is about stepping up to the plate when asked,” Parsonnet said. “And even when he’s not asked.”

An Honest Answer

Four years ago, Winslow was nominated to become assistant secretary of defense for health affairs. In his senate confirmation hearing, Winslow fielded a question about a mass shooting that had just occurred in Texas. He answered honestly.

“I’d also like to … just say how insane it is that in the United States of America a civilian can go out and buy a semiautomatic weapon like an AR-15,” he said.

The late Sen. John McCain, R-Arizona, interrupted him to say this was not Winslow’s area of expertise, and soon the confirmation was put on indefinite hold. Winslow withdrew his name for consideration and turned his attention to helping victims of gun violence.

He worked with medical students and faculty to launch SAFE, Scrubs Addressing the Firearms Epidemic, a nonprofit organization of health care professionals dedicated to reducing gun violence and protecting the victims. SAFE now has chapters at more than 50 U.S. medical schools.

Winslow expects to stay with the working group for a year, then return to Stanford. The experience is reminiscent of other adventures he’s had in the military, in the clinic and in academia, he said. He’s surrounded by smart and dedicated colleagues, working together for a cause greater than themselves.

“I’ve had so many wonderful experiences in my life,” Winslow said. “I almost feel guilty for it. It’s like I’ve had more fun than any five people should have.”

What’s the risk for vaccinated people, specifically when it comes to this new delta variant?

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Modeling Health Outcomes Among East Asian Populations

The chronic progression to diabetes-related complications is apt for computer simulation modeling due to the long-term nature of health outcomes and the time lag for interventions to impact patient outcomes. It is problematic, however, to estimate the impacts of health interventions on East Asian populations with diabetes using existing models, which were developed and validated in European and North American populations with different epidemiology and outcomes.

To fill in this gap, Eggleston and her colleagues set out to develop and validate an outcomes model for the progression of diabetes and related complications in Chinese populations. They compared this new model, called the Chinese Hong Kong Integrated Modeling and Evaluation (CHIME), to two widely used existing models developed and validated in the United Kingdom (known as the United Kingdom Prospective Diabetes Study Outcomes Model 2, or UKPDS-OM2) and in the United States/Canada (called Risk Equations for Complications of type 2 Diabetes, or RECODe). Despite the continuum of risk across the spectrum of risk factor values, these two existing models ignore the progression from prediabetes to diabetes.

The CHIME integrates prediabetes and diabetes into a comprehensive model comprising 13 outcomes. These include mortality, micro- and macrovascular complications, and the development of diabetes. The researchers developed the CHIME simulation model using data from a population-based cohort of 97,628 participants in Hong Kong with type 2 diabetes (43.5%) or prediabetes (56.5%) from 2006 to 2017. Known as the Hong Kong Clinical Management System (CMS), this cohort makes one of the largest Chinese electronic health informatics systems with detailed clinical records. 

The next step was to externally validate the CHIME model against individual-level data from the China Health and Retirement Longitudinal Study (CHARLS) cohort (2011-2018), a nationally representative longitudinal cohort of middle-aged and elderly Chinese residents age 45 and older. The researchers validated the CHIME model against six outcomes measures recorded in the CHARLS data and an additional 80 endpoints from nine published trials of diabetes patients using simulated cohorts of 100,000 individuals.

Towards Reducing the Disease Burden of Diabetes

The researchers found that the CHIME model outperformed the widely used UKPDS-OM2 and RECODe models on the data used, meaning that the validation of the CHIME model was more accurate for trials with mainly Asian participants than trials with mostly non-Asian participants. The results indicate that the CHIME model is a validated tool for predicting the progression of diabetes and its outcomes, particularly among Chinese and East Asian populations, for which the existing models have been unsuitable.

With the new model, clinicians and health economists can evaluate population health status for prediabetes and diabetes using routinely recorded data and therapies related to the long-term management of diabetes. In particular, the CHIME outcomes model enables them to assess patients' quality of life and measure cost per quality-adjusted life-years over the long-time horizon of chronic disease conditions. The new model thus supports the economic evaluation of policy guidelines and clinical treatment pathways to tackle diabetes and prediabetes, address micro- and macrovascular complications associated with these conditions, and improve life expectancy.

Stanley Perlman, who has been studying coronaviruses for 39 years, got a nasty email June 4: “Dr. Frankenstein just wants more public money and wants to research things he shouldn’t be messing with. THANKS A LOT FOR CORONA LOSER.”

Perlman, a mild-mannered, grandfatherly virologist at the University of Iowa, didn’t know the author of the dyspeptic email and had nothing to do with the emergence of the coronavirus. But he had co-signed a letter to the Lancet in February 2020 saying SARS-CoV-2 was not a bioengineered virus and condemning “conspiracy theories suggesting that COVID-19 does not have a natural origin.”

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