Insiders Scoop: Lessons From the US Pandemic Response – Dr. Monica Gandhi



Name: Monica Gandhi, MD, MPH

Specialty/Interests: Infectious Disease | Public Health | Scientific Communication | Advocacy for Vulnerable Populations

Education: Harvard Medical School (MD) | UC Berkeley (MPH) | UCSF Internal Medicine Residency | UCSF Infectious Disease Fellowship

Current Positions:

Director | UCSF-Gladstone Center for AIDS Research (CFAR)

Professor of Medicine and Associate Chief | Division of HIV, Infectious Diseases, and Global Medicine

Medical Director | “Ward 86” HIV Clinic, San Francisco General Hospital

About Dr. Gandhi:

Monica Gandhi MD, MPH is Professor of Medicine and Associate Division Chief (Clinical Operations/ Education) of the Division of HIV, Infectious Diseases, and Global Medicine at UCSF/ San Francisco General Hospital. She also serves as the Director of the UCSF Center for AIDS Research (CFAR) and the Medical director of the HIV Clinic at SFGH (“Ward 86”). Dr. Gandhi completed her M.D. at Harvard Medical School and then came to UCSF in 1996 for residency training in Internal Medicine. After her residency, Dr. Gandhi completed a fellowship in Infectious Diseases and a postdoctoral fellowship at the Center for AIDS Prevention Studies, both at UCSF. She also obtained a Masters in Public Health from Berkeley in 2001 with a focus on Epidemiology and Biostatistics.

Dr. Gandhi’s current research program is on identifying low-cost solutions to measuring antiretroviral levels in resource-poor settings, such as determining drug levels in hair and urine samples. Dr. Gandhi also works on pre-exposure prophylaxis and treatment strategies for HIV infection in women. .

Dr. Gandhi also has an interest at UCSF in HIV education and mentorship. She also served as the principal investigator of an R24 mentoring grant from the NIH focused on nurturing early career investigators of diversity in HIV research, from which launched the annual “Mentoring the Mentors” workshop for HIV researchers held annually by the UCSF CFAR to train mentors in specialized tools and techniques of effective mentoring. She is also the co-director of the CFAR Network of Integrated Clinical Systems (CNICS) Mentoring Program. She co-directs the HIV/ID Consult Service at San Francisco General Hospital (SFGH), attends on the inpatient HIV/Infectious Diseases consult service, sees patients at Ward 86 as an HIV care provider, and serves as the Associate Director of the UCSF ID fellowship for Clinical Research.


1 | What led you to pursue infectious disease?

My upbringing greatly influenced my decision to pursue infectious disease. First and foremost, I’m an Indian-American but I was raised in Utah – there, the community was largely white and I perpetually felt like an outsider throughout my education. That said, Utah was an extremely formative place to grow up because I came to understand firsthand what it feels like to be stigmatized for factors that are out of our control.

For me, I felt different for my skin color, but I can sympathize with anyone who feels ostracized for their sexual orientation, their race or ethnicity, or perhaps their socioeconomic status that leaves them marginalized and excluded in different environments.

Complementing my life in Utah, I took trips to India frequently alongside my family where I saw firsthand the stark social disparities between the rich and the poor. Collectively, these experiences cultivated a desire to immerse myself in social justice work and serve those who were vulnerable, marginalized, and suffering.

I also knew that my parents were going to force me to become a doctor because I’m Indian-American! Jokes aside, there was some cultural pressure to become a physician – in fact, I have two siblings, both of whom also pursued medicine.

Fusing my political interest with the encouragement to become a doctor, I wanted to find the most political field in medicine where I could serve the marginalized and stigmatized. Eventually, I came to realize that infectious diseases like HIV affect the poor and vulnerable far more so than the rich and secure, and it was always of interest to me to think about the political aspects of infectious disease. Thus, I pursued infectious disease as it provided insights into the lives of the vulnerable and a tangible opportunity to support them.


2 | What types of students should pursue infectious disease?

Infectious disease is arguably the field in medicine most focused on social justice.

If you look back at the history of infectious diseases, there’s a recurring pattern where the poor are burdened with a far greater weight to shoulder through than the rich. Both the plague and cholera are clear examples that differentially affected the poor – those individuals who lacked safer housing and alternative sources of water were inevitably forced to navigate far greater challenges with far less means.

Today, I specialize in the care of patients with HIV and AIDS. This has been the perfect realm for me because HIV is fundamentally a political infection. The entire field of HIV was shaped through advocacy and activism, making this realm and the entire specialty of infectious disease the perfect place for those with a deep interest in social justice work and advocacy.


3 | Having emerged as a leading voice throughout this pandemic, what have you been uniquely advocating for?

Personally, I wasn’t looking to add to my workload when the pandemic struck. That said, I felt that as an infectious disease doctor, and specifically as an HIV doctor, I had a unique perspective on how we should respond to the pandemic at a systems-level.

At the beginning, countries were focused on minimizing transmission by shutting things down, closing schools, and locking down different parts of society. My work with HIV shaped my thoughts around this subject differently – I saw a parallel between how we responded to HIV and how we should have responded to the pandemic.

Instead of simply locking society down, we should have found a means of keeping people safe within the broader parameters of our human needs – this perspective is coined harm reduction, and this approach is centered around prioritizing our fundamental human needs instead of solely focusing on one infection. The safety of our communities and the utmost importance of minimizing transmission were indisputably major priorities, and continue to be – but this approach has been leveraged to serve those with HIV and substance use management- and I came to believe early on that we should have harnessed these same principles when responding to the pandemic.

The Harm Reduction approach prioritizes meeting people where they’re at. In the case of HIV, it is not reasonable to expect people to stay away from each other or refrain from sexual activity indefinitely. That wasn’t something we counseled. Sure, some individuals did counsel abstinence, but for the most part, the infectious diseases community disagreed with such individuals.

Throughout this pandemic, people could have been with each other (with mitigation procedures such as masks, ventilation, and testing), basking in the comfort of their social network through the various trials and tribulations. Schools also needed to be kept open – we’ve never before closed schools to the extent that we did during the pandemic, not even during the influenza pandemic of 1918. My work as an HIV doctor instilled within me this perspective and I started writing about harm reduction, advocating for means to keep people safe but still enable human needs to be met. A major focus of mine was the importance of schools for kids.


4 | How could we have applied Harm Reduction principles to our response to the pandemic?

There is a beautiful lesson in the context of our response to HIV that could have guided how we responded to COVID-19. When HIV first emerged, it was politicized because of the president at the time. Initially, the dialogue surrounding HIV was that there is a new pathogen out there, and that we needed to stay away from each other. Physician didn’t understand how it was transmitted, so there was PPE around the hospital and a great deal of precaution. Then, a major transformation took place: we came to understand how HIV was transmitted.

As soon as we understood the modality by which HIV spread, we changed our messaging, adjusting what we advocated for in a manner that was far more appropriate to the pathogen. We advocated that for those with sexually transmitted infections, oral sex was a safer alternative for intimacy and provided tools (e.g. condoms) and suggestions for different types of sex that carries a higher risk. We understood that humanity wanted, and needed, to be together, so we tried to find ways to keep people safe within the parameters of their needs and wishes, harnessing gradations of risk to guide our decision making.

The shift that took place in our response to HIV should have also been seen over the course of the COVID-19 pandemic. The minute we figured out that COVID-19 spread via respiratory transmission, we could have stopped mass cleaning. The minute we figured out that children were at much lower risk than adults, we should have ensured that they had access to what they needed: in-person learning. And once we acquired the vaccines, we should have let people decide how much they wanted to prevent the possibility of a more mild infection. At the end of the day, severe disease is what public health is meant to prevent.

Also, masks, distancing, and ventilation were really important before we had the vaccines. During the holidays last winter, we could have enabled people to see one another with testing, masking, and ventilation with our windows open, but we counseled abstinence.

People’s need to see one another is not something that should have been underplayed – it’s a fundamental part of humanity.


5 | If we could go back to March of 2020, what would you advise our public health experts about their messaging strategy and communication practices?

I believe that in March of 2020, when we were closing things down and figuring stuff out, our response to the pandemic was fine. However, by May of 2020, we knew a lot more about the nature of this virus, but our daily practices didn’t reflect that evolving understanding. Our failure to adapt our practices to our growing understanding of the virus played a toll on people, and partly fueled the distrust between the public and public health experts.

To name a few examples, for one, we knew fundamentally that fomites and surfaces don’t spread COVID-19. Thus, the mass cleaning protocols were not helpful, but we’re still doing them today. Secondly, we knew that COVID-19 could spread from people even when they felt well. Even when they were well, they could have the virus at high enough levels in their nose to spread, so temperature screenings, which are still being used in many settings, were never that helpful. You could spread the virus even without a high temperature. Thirdly, we failed to stratify risk accordingly.

To preface my point on risk stratification, it should be understood that COVID-19 was bizarre and slightly different from other infectious diseases. Both influenza and measles affected the young and the old, but with the unique pathophysiology of COVID-19, and the fact that children had lower ACE2 receptors in the nasal passages than adults, as well differences in innate immunity, children were largely spared from severe COVID-19 disease.

We deeply understood that the risk of disease was not uniform across all age groups, but we failed to stratify risk or message risk accordingly – our public health officials, for quite a long time, did not demonstrate in their messaging that adults were at greater risk and children at far less risk.

I think in an effort to keep people safe, experts wouldn’t make clear that children were at less risk, but this had two unfortunate consequences: tremendous fear, and school closures. Our failure to stratify risk accordingly brought those on the left to adopt a fear-based messaging approach, where they combatted those on the right and what they saw as the minimization of this virus. This widespread fear-based messaging really hurt our respond in the United States because it led to prolonged school closures in many states. In fact, we still have protocols in place today that have been influenced by this messaging and the failure to appropriately stratify risk.


6 | What key factors contributed to the politicization of the pandemic?

I believe that the politicization of the pandemic could be distilled down to four major issues, alongside many others.

Firstly, we failed to be clear about the methods of transmission – which are really respiratory from nose or mouth, not from surfaces or any other fomites.

Secondly, we failed to make clear that children were at far less at risk for severe disease than adults – this led to more prolonged school closures.

Thirdly, we failed to demonstrate that masks are a tool, but not the end all, and we faced the politicization of both masks and vaccines, the latter being far more powerful than masks in protecting us.

Fourthly, even though vaccines are absolutely doing their job, preventing severe disease, it somehow became messaged that they could prevent anything – any mild infection. That was a particularly bad message that became prevalent and fueled further politicization.


7 | What can we do now to generate greater trust between our public and public health experts?

We need to abandon all pandemic measures that don’t make sense: we need to abandon unnecessary restrictions, deep cleaning, and temperature screenings. We also need to message clearly that the reason we developed a vaccine for this illness is actually because it causes a severe disease and that vaccines are doing a beautiful job at preventing that. Even when we send these messages about everyone getting boosters, we need to emphasize that vaccines are keeping us safe.

The third thing we can do is make clear when masks can come off. While masks are a great tool before vaccines, they are not even remotely effective as vaccines. They’ve already become political, and they do have downsides: people like to see each other’s faces – it helps with socialization. So we need clean metrics and we need to stop wearing masks once vaccination rates are high enough or when hospitalization rates are low enough, and we need to allow masks to be optional for children in schools 8-12 weeks after they have access to the vaccine.

Fourthly, we need our messaging to be centered around our first principles – that our purpose in public health is to prevent illness. It isn’t necessarily to prevent some virus from getting into your nose. We need to focus our public health policies on hospitalization metrics and not case metrics after vaccination (although cases should and will be tracked by health departments).


8 | What lessons can we derive from the COVID-19 pandemic and carry forward when combatting future infectious diseases?

There are four lessons that immediately come to mind, each of which overlap in the context of our public health messaging.

The first major lesson is that we should never distort data to drive a political message to the public. The data was crystal clear: COVID-19 caused a great deal of disease, suffering, and death, and it was indisputably hard and scary for people. This was the most important message and its legitimacy should not have been debated. As more and more data was ascertained, we also should have been fully transparent with the public about newfound insights and willing to act on them appropriately.

Specifically, we should have been more open about risk stratification, making clear to the public what portions of society were less at risk and responding in a manner that aligns with that reality. Younger people were really restricted during this pandemic – this includes  K-12 students, college students, medical students, and so many more. We’ve overlooked the fact that our response to the pandemic, shutting down schools and restricting our students’ engagement with the world, may have implications for the next generations upbringing.

If we were more open about these underlying factors that came to be known with time,  there would’ve also been greater trust between the public and the officials. In the future, we need to be fully transparent, clear, and clean about what the data is demonstrating and project our messages with pure objectivity, ensuring that politics and biases aren’t weaved into the science, compromising what we hope to make clear to the public.

Secondly, we should have been clear about the effectiveness of natural immunity. This lesson is more specific and is an extension of the first lesson – that we need to be more transparent with the public, sharing exactly what the data is demonstrating. While we obviously want people to take the vaccines, the data indicated that only one dose was likely needed after recovery from infection; in fact, in some countries, even one dose is not required to show immunity. We should have embraced the fact that natural immunity is strong, and I strongly believe that if we were more open with the public about what the data was indicating about natural immunity, there would have been greater trust in our messaging.

Thirdly, when it comes to vaccines, the delivery of care at the patient level should have been free of judgement, anger, and frustration. I’ve seen healthcare providers say things like “how stupid are you for not taking the vaccine?” This didn’t happen in the context of HIV – people never said “don’t you know to use a condom, stupid?” Our healthcare providers have been through a lot, but we shouldn’t overlook the fact that far too many of us should have responded to vaccine hesitancy in a more encouraging manner. We should’ve been like “okay let me explain this to you, I know it will take a bit of time, but I want to make clear why vaccines are safe and give you all the information for your consideration.”

Fourthly, our engagement with social media needs to be different. Over the course of this pandemic each of us in our own ways were critical about different things, and social media ultimately amplified that. While this has its merits, we were not transparent about what we didn’t know and we were reluctant to embrace shifts in our understanding. If instead we could focus entirely on being super transparent and admitting the deficiencies in our understanding, our messaging would have been better.


9 | How did the root issues facing the US healthcare system manifest in our response to the pandemic?

We already knew before the pandemic that racial and ethnic minorities have had poorer health outcomes in so many different fields. However, this virus really disproportionately hurt racial and ethnic minorities.

There were so many reasons for that,  including the fact that our social structures failed to adequately support people in staying at home and taking time off from essential work.

The lack of economic and social support in our country, rooted in our capitalist and market-heavy culture, was largely why our response to the pandemic and our health outcomes were so greatly different from what was seen in less capitalist countries.

Secondly, the pandemic also laid clear the fault lines in education: private schools were open, public schools were not. This shows the disparity between our public and private education system.

Thirdly, fundamentally, we don’t have a healthcare system that is unified. We don’t have a single-payer system, we don’t have a means to easily capture and share data amongst people, we have different insurance plans, and this complexity prevents us from thoroughly and efficiently capturing data and informing our response.

The underlying infrastructure of our healthcare system slowed us down, unlike the National Health Service in the UK. There, they were able to mass vaccinate, everyone had links to people’s names and where to find them, and their vaccination program was implemented so much more smoothly than it was here.


10 | How can we improve the discourse between the scientific community on social media?

There surely wasn’t civil discourse between physicians. If someone was looking at the data from a mask study and came to realize that while masks were effective, they weren’t as effective as they hoped – or perhaps they recognized that surgical masks were effective while cloth masks were not – if this was said, there would surely be someone else in the medical field yelling at them. There was a massive failure to speak civilly to each other, especially on social media.

There was also a censoring of information and messaging. Even amongst people who held long standing positions for public health and worked tirelessly against illness their entire life, if they were advocating for something that deviated from what others were saying or felt was best, they were censored.

I personally can’t speak for society, but at least within the medical field along, we should recognize that our colleagues have all worked hard to acquire a professional degree and share a collective focus on trying to understand this illness – with that in mind, diversity in thought and belief should be embraced, and we should be more respectful towards each other.


11 | What separates your writing and communication practices (academically and non-academically) from the work of others?

Before the pandemic, I had been laser-focused on academic writing for years and my work has culminated in more than 200 publications. Ultimately, writing peer-reviewed scientific papers has been a great instrument for improving my writing capacity.

Moreover, I’ve been reading nonmedical literature my entire life and in medical school, I took a course called Narration in Medicine that instilled within me the fundamental concept of explaining things in a narrative fashion.  We should always write to tell a story, one that manifests in an arc and a flowing narrative – even within our scientific papers. We shouldn’t get bogged down in methodologies without moving the reader through a narrative.

I wrote more than 50 opinion pieces during this pandemic, ranging from ones on why masking was important to cellular immunity to how to shift our thinking on the pandemic after vaccines. When I write Op-Eds, I keep the narrative framework in mind and try to synthesize an overarching big-picture, but still include references to date to maintain scientific integrity.

My training in academia has instilled within me a habit to back up everything I am saying with references and data. My training as an educator has instilled within me a system to write as if I’m telling a story.

It was a fascinating experience to write about COVID-19 in a political environment, and I learned a lot about how to communicate with the public in this process – I think if I hadn’t become a physician, I could have written for the public. Tomorrow, I’m a publishing a piece in The Atlantic on COVID Antivirals, where I leveraged these same principles.


12 | What are you most excited to work on in the coming months?

I’m so excited to go back to HIV! It is my total passion! I did spend a lot of time on COVID-19. While synthesizing data and engaging with the public has been great, I want to go back to HIV because HIV outcomes have been hindered by the COVID-19 response, just as outcomes in other infectious diseases (such as measles, TB, malaria, etc.)

As expected, when hit with a pandemic, other priorities get pushed to the side. However, it would be good to refocus our efforts on other non-communicable diseases (such as cancer, cardiovascular disease, substance use disorders) and communicable diseases like HIV.

In a month or so, I’ll be less involved with the pandemic and will shift my focus to patients with HIV, serving them, messaging for them, and synthesizing the data and its implications for that community. That is my goal – to immerse myself full-time into HIV medicine again.


13 | Given what the pandemic has laid clear, how might the dynamic between the government, insurers, providers, and patients change here over the next 10-100 years?

I greatly hope the dynamic changes. I strongly think we need a universal healthcare system, which physicians have been calling for throughout the last few decades. I hope this is someday implemented so that insurance companies aren’t able to dictate whether or not you can receive treatments like monoclonal antibodies for COVID-19.

I know we’ll always have a society where we can provide better care for people who can pay out-of-pocket, but we greatly need a basic system of care such that no one is left out. There were undocumented immigrants who were truly and fully left out from receiving even basic care, especially when it came to outpatient monoclonal antibodies.

I hope that people at your level, yet to matriculate into medical school, tell it like it is and bring about these changes.


14 | What disciplines should physicians-in-training immerse themselves within to effectively impart change in the healthcare system?

There are two domains I strongly believe students should delve deeply into: narration and policy.

Firstly, I believe that anyone who goes into medicine should think thoroughly about how to communicate and refine their communication capacity, especially through writing. More tangibly, students can engage in narrative fiction and narrative-medicine courses in medical school.

Secondly, I believe that we as physicians need to have a deeper knowledge of policy – public policy, political science, how the different structures function and align, how to speak and communicate in these areas, and how to engage with them meaningfully to implement change.

I never studied these things in medical school but learned a lot during the pandemic. Even if you don’t pursue a degree in these areas, it is important to develop a foundation in this realm and learn how decisions are made.

This surely won’t be the last pandemic, but the importance of understanding policies goes beyond responding to infectious diseases.

Medicine has emerged as something far greater than servicing the ill, especially over this last year: I believe that medicine will play a larger and increasingly important role in redressing the systemic challenges facing this country, especially as people age and as we prepare to combat future infectious disease that will inevitably assess whether we’ve acted on the lessons that this pandemic has made so profoundly clear.

So yes, policy and narration are two areas to delve into.


15 | What new frontier in medicine most excites you?

I have done everything in my power to encourage physicians-in-training to pursue infectious disease – I love infectious disease.

I love the historical aspect of it, the advocacy aspect of it, the social-justice aspect of it, the stories – such as Camus’ The Plague, the measles, smallpox – I love it all.

I really don’t see another frontier in medicine more exciting than what infectious disease has to offer – there are so many rich areas to delve into, and the work is so fulfilling.


16 | What would you like to share with our premed readers?

I am the medical director of a very large HIV clinic, and we’ve had a lot of students come and shadow us here in the HIV clinic. I would encourage students to seek out similar experiences because there is something special about serving vulnerable safety-net populations.

I direct a clinic called Ward 86, and here, we are combatting so many challenges that the HIV population is forced to confront: the concomitant challenges, food insecurity, housing insecurity, racism, homophobia in the case of HIV, etc. Everything that comes with a safety-net clinic makes the experience of shadowing or serving within one a profound experience.

I’d advise premed students to seek out your publicly insured clinics, county hospitals, county clinics, or places where people go if they have public insurance or no insurance. Shadow the providers there.


17 | How do you like to spend your free time?

I like to read and spend time with my two beautiful children – my sons are 13 and 11, and I thoroughly love spending my time with them or immersing myself in a good read. That’s pretty much it – I’m not really a big sports person, so it’s really them and my books.


18 | What books have you thoroughly enjoyed reading over this pandemic?

During this year, I reread a couple of books that I thought were really important to me from the past – I reread *The Great Gatsby* because I remember this line where Daisy and Tom smashed up everything and retreated into their whispering wealth. It reminded me of what protects us during a pandemic – wealth – and how capitalism in the case of the US didn’t serve our patients and people who were more vulnerable to this illness.

I also reread all of Salinger. I was raised Hindu and there is a very Vedantic aspect in his work – specifically in *Franny and Zooey* – where the fundamental reality of things should include service. And that is what I also get from Hinduism and the concept of Karma – the fundamental importance of service.


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