Making Sense with Sam Harris - #191 — Early Thoughts on a Pandemic

Episode Date: March 11, 2020

Sam Harris speaks with Amesh Adalja about the spreading coronavirus pandemic. They discuss the contagiousness of the virus and the severity of the resultant illness, the mortality rate and risk factors, vectors of transmission, how long coronavirus can live on surfaces, the importance of social distancing, possible anti-viral treatments, the timeline for a vaccine, the importance of pandemic preparedness, and other topics. If the Making Sense podcast logo in your player is BLACK, you can SUBSCRIBE to gain access to all full-length episodes at samharris.org/subscribe.

Welcome to the Making Sense Podcast. This is Sam Harris. Okay, this is my second podcast on coronavirus, and it is very consciously a follow-up to the one I just dropped with Nicholas Christakis. I've done this with Dr. Amish Adalja, who is an infectious disease specialist affiliated with Johns Hopkins University. specialist affiliated with Johns Hopkins University. As many of you know, the Johns Hopkins website has become a resource for more or less everyone on the spread of coronavirus. And Amish has a background in infectious disease, and he's helped develop U.S. government guidelines for the treatment of plague and botulism and anthrax. He has edited the journal Health Security, a volume on global catastrophic biological risks. He's a contributing author to the Handbook of Bioterrorism and Disaster Medicine. So the spread of an emerging pandemic is very much in his wheelhouse. As you'll hear, he sounds less concerned than I do. And the reasons

for that become explicit at two points. So I just want to flag that here so that you have an emotional barometer to the conversation. The first is that his estimate for the case fatality rate for coronavirus, worst case, puts it at 0.6%, which is six times worse than influenza, but quite a bit better than the worst case scenarios being talked about elsewhere. He definitely thinks that this is going to be considerably lower than 1% fatality. So if true, that's obviously good news. Six times worse than the flu would still be quite terrible when you run the numbers, but it doesn't put this virus at 3% or 2% or even 1.5%, which is a very common figure one sees at the moment. So I don't know how accurate an estimate that will prove to be, but that is one reason why he sounds more hopeful

than I have been. But there are two other reasons that don't become explicit until the end of our conversation, and I want to preview them here so you have the appropriate frame coming in. The first is that Amish is a man who spends a lot of time thinking about the worst-case scenario. And the worst-case scenario is something like a bird flu that mutates and becomes highly infectious among people and has something like a 60% mortality rate. He is thinking about species-annihilating plagues that we know are possible, right, and that we need to prepare for. So in light of that possibility, what we're experiencing now, even the worst-case scenario, is very much a dress rehearsal for something much, much worse that could yet happen.

So that's worth understanding. But the other piece here, which again, we talk about only at the end, is that his primary concern now is not to sow panic, right? And my primary concern has been to spread not panic, but heightened concern. Because I'm encountering people who think that this is no big deal, right? I'm encountering them disproportionately on the right side of the aisle politically, but I've seen people with real reputations and considerable reach tell their fans that this is just like the flu and 6,000 people die every year of diabetes and we don't freak out about it. They're not even making contact with the dynamics of this thing that is unfolding in front of us. So where you come down on the need to mollify people's fears or amplify their concerns here, I guess, is a matter of judgment. And Amos and I are running in different circles

and have calibrated that rather differently. So please know that going in. I see a society that still doesn't want to close its schools. I know people who are still going to concerts. I have people who seem surprised that I expect that their spring break plans are going to change. I know people who don't seem to understand why conferences are getting canceled. And there's a pervasive sense, again, especially on the right side of the political spectrum, that the media is exaggerating the problem here, very likely for political and monetary gain. And my concern is to break through that bubble. And you'll hear in a few places where I attempt to do that without fully understanding Amish's concern not to so panic. But we come to a full understanding by the end. Anyway,

I hope you find this useful. Undoubtedly, this will not be the last conversation on this topic. I have. Amish has agreed to come back anytime there's new information that he thinks people should know. And I will do my best to make myself useful during what I am confident will be a challenging time for all of us. And now I bring you Amish Adalja. I am here with Dr. Amish Adalja. Amish, thanks for joining me. Thanks for having me. So this is the second podcast I have done on coronavirus in 48 hours, and I just, I really want to cover this topic completely insofar as we understand it at the moment, and

you really seem to be the right person to speak with here. Give us your background and why you have any expertise on this topic. Sure. So I'm an infectious disease, critical care, and emergency medicine physician that has focused, I focused my whole entire career basically on emerging infectious disease, pandemic preparedness, how infectious diseases and national security intersect. And that's basically where I've kind of niched myself. And when these types of outbreaks occur, it often is something that I've been thinking about long before the outbreak occurred. And that's sort of why the media sometimes turns to me during these incidents. And I try to understand them, dissect them,

predict what's going to happen, and even do this when there's not an outbreak. And you're affiliated with Johns Hopkins, correct? Right. So I'm part of a think tank at Johns Hopkins called the Johns Hopkins Center for Health Security, which is a think tank devoted to infectious disease emergencies and was founded back in 1997 by the man who eradicated smallpox from the earth, D.A. Henderson. And it was initially founded in response to bioterrorism, but has now really expanded to think about all infectious disease emergencies. And we have a multidisciplinary team of epidemiologists, physicians, people with MPHs, lots of different types of people, infectious disease modelers, and we try to really keep on

top of these issues and kind of be the leading voice on them. And you do seem to be the leading voice because the Johns Hopkins dashboard seems to be the dashboard that everyone is using to track the spread of this disease. Yeah, that was something that people put together rapidly. It's not in our specific center. That's actually, I think, from one of the engineering schools that put that together. But it's been really useful, and it's been refreshing to see the world using Johns Hopkins' talent to help understand what's going on. Okay, so it's March 10th, the day we're recording this. I think we'll probably release this on the 11th. And at the moment, there are around 118,000 confirmed cases

and a little over 4,000 deaths. And I know we have a denominator problem still, so we don't actually know how many people have been infected. So it still requires some guesswork to estimate the case fatality rate. But what is your best estimate at this point? So the best estimate, I think, is derived mostly from the South Korean data where there's been extensive testing, the most per capita testing that's been done in any country where they actually have drive-through testing centers. There, you're seeing the case fatality rate at 0.6. So that's now become my upper bound. I do still think that there is probably a severity bias there because it still takes some effort to want to go get tested. So we're still not fully getting capture of everybody that might have

very mild or minimal symptoms that people don't even barely notice. So I think 0.6 is the upper bound. And I think the lower bound is going to be somewhere, I would say, a little bit above seasonal flu, which is 0.1%. So it's somewhere in there, but it's still a lot of fluctuation and still a lot of uncertainty. Okay, so that is actually quite a bit more sanguine than anything I had heard up until now. I recorded my previous podcast 48 hours ago, and there you have, I think it was the Lancet reporting 1.2% to 1.6% or somewhere in

there. I mean, something like, you know, half the rate of the most dire predictions of around 3%. So you're reasonably confident that 0.6% is the upper bound, which now we're talking about six times more lethal than the seasonal flu. 0.6 seems to be the best way to look at this. When you think about the fact that we've had major testing constraints in many countries, and South Korea has been very aggressive at testing, and that's where they're seeing their number. So I think that that's the easiest parameter to try to put into this big world of unknown about this. And I definitely think the 1%, 3% numbers are way off because of the severity bias. It's important to remember that seasonal flu is 0.1%, so it's still a magnitude higher, and it will be more difficult than dealing with the seasonal flu to deal with this virus. I want to talk about the comparison

with flu with respect to both severity and contagiousness in a minute. But I'm wondering, have any of these ships that essentially have been rather unfortunate and accidental science experiments where you have people cooped up in a giant floating petri dish with this virus, and then you just have them quarantined, and so we can see what happens. Have any of the ships provided a clear picture of the case fatality rate here? I mean, I'm sure there's an age bias with respect to the cohorts who are on the ships, but why don't we have a clear picture based on what's happened in each of these cases? I think you just answered your own question, that there is a severe age bias when you're on a

cruise ship, because remember, those are going to be older people. Those are going to be people with medical conditions that like to go on these trips. It's not going to necessarily be the representative sample of the population that you need to actually calculate a proper case fatality ratio. What the ships do offer us is some idea of the attack rate, even though that's also limited because sometimes those ships were doing things in order to try and prevent spread, even though it wasn't very successful. But we saw about 20% attacked in the Japanese cruise ship. So I do think that they provide some information, but it wasn't quite the perfect experiment. And I think it ended up almost being torture for some of those humans that were left on board that ship. And I wouldn't draw too much from it,

other than the fact that we know that this is contagious in those types of settings and that elderly people are disproportionately going to be impacted with severe illness if they are infected. Okay, so let's deal with this, the comparison with flu, because many people have been drawing comfort from the idea that if you're a healthy non-smoker under 70, you basically have nothing to worry about. It's more or less just like the flu. And most of us are going to get this, right? In fact, I think I've even saw you say more or less this in a talk you gave. I watched a YouTube video of a lecture you were giving a couple weeks back. So most people are going to get this. And if you're healthy and not too old, it's not likely

to be a problem for you. Another statistic that I've heard a lot is that 80% of cases are mild. So what is a mild case, and what is actually rational to believe here? And I say this, knowing, personally knowing someone who is 50 and an extreme skier, i.e. quite healthy or was quite healthy until he caught coronavirus, a non-smoker, and he's now on a ventilator. Obviously, this is an anecdote. This is not science, but I don't have similar stories to tell about flu. So what's the picture in terms of comparing the severity of this generally to flu? While it is true that most cases are going to be mild and indistinguishable from the cold and the flu, this does seem to have a higher case fatality ratio. So you are more likely to see

people die from this than from influenza. It is true that the deaths cluster in those that are elderly, that have other medical conditions, but it's important to know that just because something clusters there doesn't mean that other diseases, other deaths can't occur in other age groups. So we are going to see healthy people that die from this. It's not going to be the norm. It's not going to be as common, but it is going to happen, and it's important to prepare for that. So even we see that with influenza right now. This year's flu season, to draw the comparison back to flu, has seen the most children die from influenza in recorded history, except for during the 2009 H1N1 pandemic. So we don't often hear so much

about the younger people that die from flu as well, but it is true that those deaths occur. And because this has a higher case fatality ratio likely than seasonal flu, we will see deaths in other age groups, although they will be clustered in the highest age groups. And in terms of the mildest cases, it's true to say that it would be possible for this to present as benignly as an ordinary cold. There are people walking around with the sniffles who may in fact have coronavirus. Right. That's definitely true. Because remember, coronaviruses are a family of viruses. There are four of them that cause seasonal colds every year. And this is now basically becoming the fifth seasonal coronavirus. And we are going to see the spectrum

of illness where many people will just have the sniffles or just have a cough or a sore throat, and nothing really becomes of it. It's just like a normal cold. But then there are that group that have risk factors or, by luck of the draw, have a more severe case. So that's kind of one of the things that this virus is used to transmit itself so well is the fact that you've got these mild cases walking around in the community that just look like a cold, but they can then yet transmit it to other people. So that's really advantageous from an evolutionary standpoint for a virus to have this spectrum of illness with these mild cases out there that are really serving as vectors for the virus. And what do you make of the fact that it seems to be systematically more benign in children? So that's a really important question that we're all trying to answer and try to come up with

hypotheses for. There's a couple of them. One is that children tend to have less robust immune responses, and maybe most of the symptoms that we're seeing, especially the severe ones, are triggered by an overabundant immune response that's more characteristic of adults than in children. And we know that that's the case for many infectious diseases. For example, chickenpox is much milder in a child than in an adult. So that's one hypothesis. The other is, going back to those four circulating coronaviruses that are around every year. Children get a lot more colds than adults, and there might be some cross-immunity because they have many more exposures to coronavirus in their daily life than an adult might. So that cross-immunity might be somewhat protective,

but this is one of the leading research questions we need to understand, especially as we're trying to figure out what the role of children are in transmission as you hear about school closures occurring around the country. Would that cross-immunity suggest that parents who have young children who also seem to get exposed to more of these viruses than people who don't have kids, would we likely be able to detect a lesser severity in their case? It's a logical conclusion. I don't think that we've actually tested any of that, but these are all important things we need to do when we get proper diagnostic testing available to do these types of studies. But these are all important research questions that are going to help us

kind of right-size this outbreak response. So let's talk about the contagiousness of this. In terms of the so-called R0 factor, how does this compare to flu? It looks like it's about in the same category as flu. And there's a lot of mysticism, what I call mysticism about the R-naught. People think it's like something intrinsic, it's an intrinsic feature, like horsepower on an engine in a car, when it's not. It's really an average number. And you can have varying R-naughts for the same infectious disease. It just depends on what that person does and the environment they interact in. So you can have someone like typhoid Mary, who has a very high R-naught for salmonella typhi, which caused typhoid fever. And you can have someone who

doesn't have a high R-naught. So it's not something that I spend much time trying to delineate if the R-naught is 2.3, meaning one person infects 2.3 other people, or if it's 2.8 or whatever it is. I kind of think of them in batches. I think if the R-naught is less than one, meaning that most people are not going to affect anybody, it's not something to worry about. Then I think of the other extreme. The R-naught is 15. So that's something like measles or whooping cough. That's going to be very hard to deal with because you're going to have lots of people infected and lots of exposures. And then I think of that middle ground of the R-naughts between two to four. And I put flu, and I put this virus in there. And I think that's a better way to think about it than trying to look at it

as some intrinsic feature that you're trying to compare between viruses. I think that gets a little bit too, trying to put too much of a statistical flavor to something that really is not completely exact that way. It's just, this is transmissible. It's not as transmissible as measles. It's more transmissible than tetanus, which is not transmissible between humans. In terms of the mechanism of spread, what do we know about that? This is a respiratory virus. So the main way that it spreads from person to person is through the coughs and sneezes that people experience and the particles that emanate from their body. These are large droplets that fall to the ground in about six feet because of the action of gravity. And it can also be transmitted from the surfaces that people touch that may have those droplets

on them. But the main mechanism is this respiratory droplets, the coughs and sneezes, because you got a lot of questions I get all the time about, if someone hands me a pen, can I get it from a pen? And I mean, of course, the answer is theoretically yes, but really, that's not how this virus is transmitting. It's mostly through coughs and sneezes from person to person. We don't know that there's quote unquote airborne spread. Airborne spread is a, some people mix that up with respiratory spread. Airborne spread refers to a virus or a pathogen that can stay in the air for a long period of time. So if I got on an elevator and had measles, for example, and then you got on the elevator an hour later, that air would still be infectious. That's not

really what we're seeing. There may be some component of airborne spread in hospitals when they're doing procedures on people and they're aerosolizing the virus. Suppose they're putting a breathing tube in someone or looking down in their lungs with a telescope or giving them a treatment that requires a drug aerosol. That can sometimes cause airborne transmission, but the primary means is really these respiratory droplets. So with respect to surfaces, how long do we think it can live on a surface? If you go look in medical journals, you will find stories of coronaviruses living nine days, being viable for nine days on a surface. But that's important. That's hard to extrapolate to everyday life because there's certain environmental characteristics that are

conducive to the virus and certain ones that are not. So for example, temperature, humidity, UV radiation, all of that affects the viability of a virus. And this is not a very hardy virus. It actually has this lipid envelope or this kind of fatty layer around it, which actually can dry out. So when you talk about viruses and how well they survive in the environment, if it's an enveloped virus, like the coronaviruses are, it doesn't usually last that long in the environment compared to something like the norovirus, which you might have heard of from cruise ship outbreaks. That can be very difficult to get out of a surface or in a structure that it might have been contaminated

with it. So what I would say to most people is this is probably hours to a day or so, and it's not something that you have to worry too much about because this is a virus that's easily deactivated by your standard household cleaners that you use during cold and flu season anyway. Okay, so unfortunately, I just watched a press conference given by the mayor of New York City, Bill de Blasio, where he said that this virus degrades in only a matter of minutes if it's on a surface. This is a direct quote. It's only a matter of minutes before the virus is rendered inactive in the open air. And he was referencing subway poles and plastic chairs and tabletops. And that seems to be misinformation. Would you be confident touching a tabletop that someone had just sneezed on a few minutes later and not washing your hands? sneezed on a few minutes later and not washing your hands? No, I think that minutes is, that's not scientifically accurate. If it was hours, I would agree with, but I don't think minutes, unless the surface is a special surface that's got special characteristics on it, like it's made of

copper or something that's bad for the virus. But no, I don't think that minutes is correct. Okay. So if you're among the nearly one million people who've watched that press conference on Facebook, please be advised. What about objects that you might have shipped to you in the mail? So someone has ordered a computer from Apple that was just freshly minted in Shanghai and made the trip, let's say it took 10 days to get to their house. Now they're opening it like it's a very large piece of medical waste. What do you say about that moment? I don't think there's a real risk there. I wouldn't hesitate about opening a package from China unless somebody told me that they packaged sneezes in there for me, just special. But no,

I don't think that these types of ordinary products are going to be a risk for individuals to touch or open. Okay. So let's talk about flattening the curve. This is a phrase that many of us have absorbed now. What does it mean and why is it what we should be thinking about at the moment? So what we're talking about is an epidemic curve, and that's the number of cases that occur over time.

And what flattening the curve refers to is trying to not have this big initial spike of cases. So you still have the same area under the curve, the same number of cases, but you spread them out over time, and that's somewhat easier for communities to cope with, especially when you're talking about bed space at a hospital or any kind of limited resource that might come into short supply during a pandemic. So that's why you see people talk about, for example, closing schools or limiting social gatherings or trying to do any kind of social distancing, just trying to decrease the intensity of spread, knowing that you're still going to have the same number of cases, but they're going to be spread out and they're more easy to

deal with. So after this last podcast I recorded with Nicholas Christakis, and after absorbing the growing concern around the spread of this virus, the punchline I've come away with is that if you can work from home, you absolutely should. And whatever non-essential social contact you have on the calendar should be canceled. If you have tickets to the concert that you've been looking forward to for a month and that's rolling around this weekend, you shouldn't be going to that concert. You should avoid eating in restaurants if you actually can avoid eating in restaurants. Anyone who can pull back at this point should pull back. Is that too alarmist or is that simply good advice at this point?

It's all going to depend on each individual's risk hierarchy and where it all fits. If you're an elderly person or have medical problems, or maybe you live with one, someone like that, and you want to decrease their exposure, it might be prudent when you have high- high intensity transmission in your community to take those types of actions. I don't think that the whole world needs to take those actions. I myself haven't done most of that. I think that you have to really look at each location that the virus is spreading in and make a distinction on whether or not you think that this social distancing is going to help or it's going to not have an impact. Because if you have widespread community involvement with this virus already, social distancing is maybe going to decrease your individual risk, but then you have to put that into your own value hierarchy and decide, yes, this is really important to me,

so I'm going to risk it and just be very meticulous with my hand hygiene and not touch my face, or this is something that I didn't really want to go to anyway and I'm not going to do it. Once we get to a point where if there's high-intensity transmission, then you might see more stricter recommendations coming out about that type of non-essential travel. But I do think that you're going to see variations across the country and variations with each person's risk preference. And we do know that social distancing can cause damage because it's going to cause economic disruption when that happens. So there are some things that are easier to do, like telecommuting, but some things that might be a little bit harder to do. And I think that it's going to be difficult. And we didn't do so much

of that during 2009 H1N1. We had some school closures and people did some things, but not as aggressive as we're seeing now. So it will be interesting to see how this actually plays in an American setting with people trying to adjust their daily life to this virus. And I think eventually you're going to see people start to be able to cope with it a little more as this doesn't go away without a vaccine. Just push back on two points there. So we know that we're not doing and have not been doing adequate testing. So we really can't be confident that we know how fully it has spread in our community. How can a person assess that it hasn't yet spread much in the community and they don't have to worry about going down to the local coffee shop? And two, given that the primary vector of contagion is having someone cough or sneeze too close to you, even more than anything that you can control by assiduous hand-washing, going to the rock concert puts you shoulder to shoulder with people who at any moment might turn and cough and sneeze on you. So I'm not quite sure

how to be confident going into those spaces, given those two facts. So you're not going to be able to completely avoid this virus in that type of a setting. If you're in a concert or if you're at something where you're going to have multiple interactions with people that are not in a controlled manner and rock concerts are going to be very different than certain other activities like going to a restaurant or going to a coffee shop where you have some, you can have some distance between people. And I do agree that we don't quite know how much this is transmitting in our communities. But one indicator that you can use is looking at what hospitals are doing. You're going to hear about, even if there is a small proportion that get critically ill and need ICUs, you're going to hear about that even if there is a small proportion that get critically ill and need ICUs, you're

going to hear about that in your community. So I think in most communities, we haven't heard about people in the ICUs. There are definitely cases in ICUs, but we don't have large numbers of them, which may be an indicator that there's been less community transmission, or maybe this is less severe than we thought because we're not seeing those ICU patients all across the United States. So it does become difficult because of the testing problem. And I do think that there is some level of community spread going on in every city in the United States. But then what lesson should we draw from the experience in Italy right now? I mean, it seems like there's no reason to think that we are different from Italy apart from the timing at which the virus first landed.

What's happening in Italy now that is basically forcing the whole country into lockdown and straining the health system to the breaking point? And why wouldn't you expect that to happen here if we just carry on business as usual? I do think that the experience in Italy and hearing about these ICU bed shortages is something that kind of hits home for America because the health systems are somewhat similar, not completely similar. And it's unclear to me exactly what's driving the force of infection in Italy and how that might be different in the United States. We do know they have an older population than the United States, so that may account for more severity than here, but it's not that much older. I think that the Italian

government is taking an approach where they want to try and flatten the curve in a very drastic manner, kind of following what China did. And I think that paradoxically may make things worse because you're going to panic the population and you're going to inundate the hospital with scared individuals and other parts of the healthcare system are going to suffer just like it did in China where people with heart attacks and strokes had difficulty getting their way to a hospital. I think that we have to really drill into the Italian numbers and understand how much testing they're doing, what is their real case fatality ratio there, and try and use that information the best we can to prepare our hospitals and our ICUs for what might be a very severe season. I do think that some of those drastic social

distancing measures may be necessary in certain situations, but I don't think that you can have a blanket lockdown and expect that to actually work or be effective and not have negative consequences that might outweigh any positive there. But this is all very fluid and very hard to quite... These aren't easy decisions to make, and there's a lot of uncertainty here. And that makes it hard to make any kind of specific recommendation on what to do without having full data and knowing what's exactly going on in the ground in Italy. To come back to my question, because I really do want to sharpen this up and have listeners come away with a clear plan of action. come away with a clear plan of action. Again, my heuristic here is that if you can work from home and if you can cut out social contacts, there are people who can't, obviously. There are jobs that

are synonymous with being in that particular store or restaurant or office. But if you can pull yourself out of society to whatever degree and thereby deny this virus a path through you and your life to others, that seems to me to be an intrinsically wise and ethical thing to do. Apart from, again, there are economic consequences to doing that, which people who own restaurants and own retail stores are understandably worried about. But if the goal were simply to stop this thing as fully as we can, which is to say flatten the curve as fully as we can, and keep the healthcare system running, is there any argument against taking that advice? No, I don't think there's any argument against taking that advice. I think sometimes it becomes impractical for certain people to do, but it is technically what you should be doing even during flu season if you can.

And there are some things that are easier to do and some things that are harder to do. I don't think we'll see full social distancing with every American, but I do think that there will be a large proportion that do do that, especially those with high-risk conditions that are worried for their own safety or if they have relatives or they live with people that have those types of conditions. I think it's going to be hard for that to happen for everybody, and there's going to be limited social distancing in certain locales, and I think there's going to be a hesitancy to go to complete social distancing as an ideal. Although theoretically, yes. I mean, if you look at the actual facts of it, yes, if everybody social distanced, you would be able to flatten the curve substantially.

And in terms of actually flattening the curve and even reducing mortality, as we're seeing in China now, I mean, that is being achieved in China by the most extreme and heavy-handed quarantining of the whole society that has ever occurred. I saw at some point recently, I forget where, it probably was on social media, that South Korea seems to also be driving this contagion downward. Is that true? Is there any place else that's having success the way China is? We have seen, I guess, variations of the Chinese model in other countries, with Singapore, with Hong Kong, as well as even Taiwan, where they have done some extreme social distancing. We're even seeing it now being implemented in New York State and Westchester County. China, I think, took a very authoritarian approach because they had that

tool available to them and really went to an extreme level that we really haven't seen probably since medieval age to medieval time with basically locking down 60 million people, suppressing free speech in terms of what doctors were allowed to say, and making it very difficult to even leave that area using armed guards. And that was something that we were very, from a public health standpoint, most people were very kind of appalled by that type of reaction. And now you're seeing people say, maybe that flattened the curve there, maybe that bought the world some time. And I don't know if that's the truth or not, because this spread very quickly.

And I wonder, when I saw this virus emerge in late December, and we realized quickly that this was something that was spreading between human to human very efficiently and had been spreading at least since November, unbeknownst to anybody, we knew that this wasn't going to be just a China problem, that it likely had left China. And a lot of us really argued that this probably should have moved from containment at a very early stage to mitigation with less of that type of lockdown mentality and more with fortifying hospitals, vaccine development, antivirals, diagnostic testing, and really taking a different approach, more like the one we took during 2009 H1N1. Right, but it's true that H1N1 is not as contagious, right? I don't know if it's not as contagious. We know that H1N1 infected a billion people over six months. So that's pretty contagious. And 61 million people were infected with H1N1. So

it wasn't something that was small. And I think that's the best model we have. We don't know where this one's going to end. And I would say this is around the same contagiousness level of H1N1, maybe a little bit more because we don't have, in H1N1, we had certain age groups that were less likely to be infected because of prior immunity that they had. I think that the approach of containment probably wasn't the best one to take for this type of virus, and it might have expended public health resources that could have been better spent fortifying hospitals. And of course, the Chinese built new hospitals and did things during this outbreak. And I think that some of that Chinese stuff is not replicable in other parts of the world because there are certain values in other countries that people do not want to transcend that China

did. And I think those are very good values. And I myself objected to what China did there, because I do think that there's another cost that's not necessarily this disease that you have to kind of figure into what happened in China. And especially the fact that this is now being held out as an example by certain individuals, I think really can put us in a domino effect of this kind of draconian response that may in the end, we might lose more than we gain from it. Yeah, I mean, I think there's nothing to emulate in the Chinese model apart from drawing the conclusion that insofar as you can avoid social contact, that is the way to mitigate the spread of this thing.

And if you really manage to avoid it, if you could wave a magic wand and impart a new norm of social distancing to everyone, you know, not at the point of a rifle, but at the point of a bright idea, we could change the level of contagion a lot. But it's just whether everyone can get the message all at once. And we have a kind of coordination problem, and we have massive economic incentives pointing the other direction, which worries me. Right. And you have to remember that people run businesses, people that if people can't work and then they eventually aren't going to be able to eat. So there's going to have to be some trade-off that you have there between social distancing and then being able to be productive and be able to flourish. So how much does smoking play a variable here? I don't know the relative rates of smoking in China and in Italy compared to the U.S., but is there any reason to believe that smoking is part of the epidemiological picture here in terms of the

severity of the disease? We definitely have seen smokers get severe illness in China, but the number, looking at some of the data, some of my colleagues smokers get severe illness in China, but the number, looking at some of the data, some of my colleagues are looking at that, and at least the data that's been published, we haven't been able to see a major signal there. But it is true from a physiological standpoint that smoking is something that is conducive to respiratory viruses being much worse in a smoker than in a non-smoker because it does damage all of these airway protective mechanisms that you have and makes you more at risk for diseases like emphysema and bronchitis, which make you more likely to have a severe case. So I do think

smoking plays a role. How much of a role it's playing currently is hard to tell, but I do think all things being equal, a smoker is going to have a harder time with this virus than a non-smoker, and it may be responsible for some of the severe illness that we're seeing in certain countries where there are higher smoking prevalences. So in addition to being old, the risk seems to go up with every decade here. So in addition to being over 50 and being a smoker, the points a person might have against them include heart disease, lung disease, cancer, compromised immune systems, diabetes. Is there anything to add to that list, or is that comprehensive? I think that's pretty comprehensive. I mean, obviously, you're going to

need to get a lot of data on the severe cases to see if there's any other disease processes, but they all kind of fit into that cluster that you're mentioning there. I think people who are on dialysis, I might add as well, kidney disease is also a high risk for people to have a severe infection. But it's really any of these chronic medical conditions that keep people going to the hospital, keep them having to take medications, especially ones that interfere with their immune system, as well as advancing age. It also seems like being a man is a chronic medical condition here, perhaps on other fronts as well. So do we still think that it's hitting men harder than women? It does appear to be a signal that we're seeing in the data that males are disproportionately getting more sick with this than females are. And I think we've seen that with other infectious

diseases. Even influenza is worse in males than females. And that may have to do with some idiosyncrasies and the differences between the immune system in a male and a female and the influence of certain sex hormones like testosterone and estrogen on the way the immune system functions. And maybe men have a more, actually, I think they have a more exuberant immune response, which is responsible for how sick you feel. And that's likely what might be behind this, but it's something that needs to be investigated. What about the idea that a higher exposure creates a more severe expression of the virus. So I think this was alleged with respect to medical workers in China getting it, some of them being quite young and

dying. Is it a story of you're exposed or not, or it really matters just how much dose you got of the virus initially? There definitely is a dose response because we do this in animal challenge models where when you're trying to look at a virus, you might give them a really, really high initially? There definitely is a dose response because we do this in animal challenge models where when you're trying to look at a virus, you might give them a really, really high dose of something to see what the lethal dose is. So there definitely is an inoculation effect. So the more you're exposed to, the intensity of the exposure could give you an overwhelming infection that might be hard to recover from versus someone who gets a smaller exposure. The kinetics of that haven't all been worked out, but we've seen that with many, many different pathogens, that the load that you're

exposed to does have an impact on the severity of symptoms and how quickly you become ill. And what does recovery look like? I've heard reports of lung damage in people who recover. There's a giant green number on the Johns Hopkins website. I think last I looked, it was 65,000 people had recovered. How cheerful a picture is it to recover from this? So I would look at that number that you've seen, the 65,000 number, with a little bit of, put a little context to it. When we use the word recovered in terms of this type of data, they're talking about officially recovered by those ministries of health in those countries. And what they're using there is fever-free for a certain number of days and

two negative diagnostic tests. That's not really what recovery means to an individual. For me, what recovery means to an individual is that they're able to do their activities of daily living. And so I think that many more people than that have actually recovered because that's more of an epidemiological distinction that they're trying to decide when can they discharge someone and not have them infect other people. When are they clear of the virus, basically, not clear of symptoms. Recovery is going to depend upon how severe in general your infection was. Obviously, if you just had a mild illness that was indistinguishable from the common cold, there really is no recovery period. You're going to have about a week of illness and you're

going to bounce back just fine. If you're in a hospital and suppose you have pneumonia or you end up on a mechanical ventilator or in respiratory failure, then that recovery is going to be months and months with lung damage, with taking you a while to get back your same exercise tolerance if you've actually had damage to your lungs from this. So it's going to really depend on how severe the initial insult was from this virus. And those that are in ICUs are going to have protracted recovery periods, just like with any other type of pneumonia. So let's talk about what might be on the horizon with respect to treatment and prevention. Let's talk about treatment first. What do you think the plausible timeline is for developing an antiviral treatment? So fortunately for us, we have this ability to

repurpose antivirals that may have been used for other causes, for other reasons, and then trying them out on this virus. And we've been doing that rapidly. So for example, there is a product called remdesivir, which was used in the Ebola trials in the Democratic Republic of the Congo and didn't do so well in those trials, but it had activity against coronaviruses and actually animal studies against the Middle East Respiratory Syndrome coronavirus that look good. So that's currently in phase two clinical trials right now. And we are hoping to see results from that in a couple of weeks. It's already been given to patients on compassionate use basis. So there is a lot of hope that that antiviral will appear maybe in several months after we get data

from the clinical trials. There are a whole host of other things. There's actually a malaria drug that they're repurposing that happens to have activity against this virus. And that's already FDA approved. So doctors can actually prescribe that in the United States off-label to their patients with that. And then there's a bunch that are kind of earlier in the development stage. So I do think we will see an antiviral much quicker than a vaccine, for example, but it's still going to be several weeks before we get data on how effective they are. What's the anti-malarial? Is that chloroquine or something else? It's chloroquine, yes. What's actually the belief now with respect to the efficacy of chloroquine as a treatment? We haven't done human trials on it, but there is a lot of

studies in vitro, even before the SARS and before all these other coronaviruses, trying to use it against the other common cold-causing coronaviruses. And it seems to exhibit an antiviral effect against the virus. And that's why what people are trying to count on is, does this have activity against this specific coronavirus? And what we're seeing is some anecdotal reports of people using it, but there has been some effort to try and study this in a randomized controlled trial and see if what they've seen in a test tube actually works in humans. Are any of these other countries who don't have the same requirements that the FDA imposes on us out ahead of us in testing remedies? Do you know what China is doing with respect to antivirals? I know China has multiple clinical trials going on, not just of these antivirals that we mentioned,

but also of traditional Chinese medicine. So there is basically, I think hundreds of clinical trials have been registered in China regarding different antiviral compounds. So that's where the most cases are too. So you have to remember that it's difficult to recruit patients for trials, especially in an emerging infectious disease outbreak when there may not be that many patients out there to actually recruit to put into your clinical trial. So you're going to see the vast majority of trials being done in China because that's where the bulk of patients are. Okay. So what's the soonest, let's say some drug was showing promise in China, what do you think the soonest it could be properly vetted and manufactured and made available in the U.S. or in any other Western country?

I would say it's going to be months. I think the FDA is poised to work very quickly if they have a compound that works. They have this mechanism called the Emergency Use Authorization, which they used, they exercised during the 2009 H1N1 pandemic to make an experimental intravenous antiviral against flu available. So they can work fast. You just have to have some amount of data to show them that this is safe and is likely going to be efficacious. And that's a little bit of a risk-benefit type of nuanced thing that they have to do with each different product. But I do think it would be months before we would see an antiviral. Some of them, like remdesivir, which is the one that's in the phase two clinical trial made by Gilead, that one we may see faster because they've got a lot of safety data already from the Ebola trial,

so they can leverage that safety data to just really look at the phase two trial results. And maybe you see a decrease in the virus count in people and you could rapidly get it available. And I know that I've been reading about the company being able to rapidly scale up production and that they're investing a lot to be able to do this. So that may be something that we see in the short term if it's effective in the phase two trial. And when do you think the bottleneck around testing will be unblocked? When will it be just straightforwardly easy to get a test? If you have a fever and you call your doctor, and I got to imagine at some point we're going to have a test that a person can take from home so that they're not going out there spreading this illness on the way to get tested.

When do we arrive at that happy time? So the roadblocks to testing are rapidly disappearing, but there's still a lot of them that need to be removed. Right now, we've moved from the CDC being the exclusive purveyor of tests to the state health labs. And now we've got big companies like Quest and LabCorp that can test. But these are all send-out tests that are not done in your hospital. There may be some academic medical centers that have made their own tests. But for most hospitals, they're having to send this out. And that's a burden because there's paperwork, there's regulatory stuff at the hospital level that the hospital administrators want you to do before you test somebody. That needs to disappear. And we need to be able to do this just like an HIV test or a flu test. And for that to happen, we have to have

onsite testing. So that means that the kits that people have for other respiratory viruses in their hospitals, they need to add this novel coronavirus to it, or there have to be standalone kits. And that's going to take probably several months. There are some companies going through the FDA to get these types of kits approved, but I do think it's going to be some time before we get to the ability to just test or even have home testing. And I know the Gates Foundation is investing in home testing, and home testing is something that people have been trying for flu for some time, and I've actually done a project on that. That's really the goal, is that you can test this at your home so that you know whether you have it or not,

because it's really going to take some time to get a lot of the difficulties with testing. And I've been frustrated with it myself, trying to figure out how you're going to get these tests ordered, because as soon as you order that test in the hospital, all the hospital administrators will swoop onto you saying, why are you doing this? What's going on with this patient? Is everybody protected? Are they isolated properly? All of that kind of stuff happens. So it becomes a headache for a lot of doctors to go through that when many of these cases are mild. But I do think this has been one of the biggest, I guess, learning points in this outbreak. And it's been the biggest mismanagement of this outbreak has been this lack of diagnostic

testing. So what about a vaccine? What's the most optimistic timeline? 12 to 18 months, probably closer to 18 months. Vaccine development is usually measured in years. This is something that takes a long time to do. We are moving as quickly as possible and already have candidates basically poised to enter phase one clinical trials because we've got some new technology that can get you to a vaccine candidate very fast. But you have to remember when you give a vaccine, you're giving that to a healthy person. So there is this high burden of safety testing that you need to do because the person is not sick and you're giving them some kind of medication. So you want to make sure that there's not any side effect. And because this vaccine is something that you're going to feasibly vaccinate

the world with, you really have to do clinical trials that are going to show you side effects that happen maybe in one in 10,000 or one in 100,000 people so that you have some idea. So you're going to have to do big clinical trials to be able to come up with that proper risk-benefit analysis because it may be that there are certain risk groups that you don't want to give this to and certain risk groups you do want to give it to, and that's going to take some time to figure out with big clinical trials. So I would not expect a vaccine in any time before 12 months. And I think if everything goes perfectly, hopefully by 18 months, we have it. And remember during H1N time, you know, before 12 months. And I think if everything goes perfectly, hopefully by 18 months, we have it. And remember during H1N1, that vaccine, even though we know

how to make flu vaccines, didn't appear until after the virus had actually peaked in the fall of 2009. And once we get a vaccine, would you expect it to be like the flu where you need a new version of this every year? No, I don't necessarily think that's the case. It might be more like measles, where you just need to get one and maybe a booster. The coronavirus is very different than flu in that sense. The flu is kind of the trickiest virus to make a vaccine against because of its genetics and its structure.

And that's why we have to update the flu vaccine every year because we don't have a universal flu vaccine. I do think it's feasible to have a universal coronavirus vaccine. Well, that's one happy point here. Okay, so give me your picture of the next 12 months. So for the next year, we almost certainly don't have a vaccine. We may or may not have effective antiviral treatment coming in some months, that the possibility that we might have something to give you if you get sick that radically diminishes the severity of the illness, that certainly argues beyond just the necessity of

not destroying our healthcare system. That argues, you know, for the personal wisdom of flattening the curve. I mean, if you're going to get sick with this, it sounds like it's much better to get sick some months from now when there's a chance that we can give you a medication that helps you. So what do you think, for instance, will happen during the summer months? Is there any reason to believe that the spread will be diminished or even halted during the summer or not? The best evidence we have is from the other four coronaviruses that circulate every year. And what they do is peak in the winter and spring, and then their transmission decreases during the summer in temperate climates. So that doesn't mean that they go completely away, that they are there at a much lower level because transmission characteristics aren't favored. We think this coronavirus may behave

like that. We don't know for sure. I think there's good reason to extrapolate because virus families tend to do very similar things when it comes to seasonality. But remember that there's also another half of the globe and the Southern Hemisphere will be entering its winter months when we're entering our summer months. So we may see increased intensity of spread in Australia and New Zealand, for example. And then what may happen is in the fall, it will come back. And that kind of follows the H1N1 flu pattern. And I think that's the most likely scenario that we'll see some decreased transmission in the summer and then increased transmission in the fall. Now, is the seasonality entirely due to just how human beings behave differently in warm

weather? Or is there some intrinsic property of the virus itself that is interacting there? I think it's both. There definitely are changes behaviorally that humans do in summer versus winter. But the virus also, viruses tend to have certain transmission characteristics that are favored or unfavored by certain environmental parameters. So for example, the ambient temperature, the temperature in your nose, the humidity, all of that does have an effect on how well the virus can transmit between people and remain viable on surfaces. So it's kind of a combination of both

that we see with respiratory viruses that have seasonality. So, and I see we're getting to the end of our hour here. What's your level of concern about this big picture? I mean, like, do you think that this was the plague we've been waiting for in infectious disease, and we're struggling to raise all the resources and make all the changes we need to respond to it? Or are you cautiously optimistic that this is a mere dress rehearsal for the plague that we will one day need to respond to better than we've been responding to this one? I think it's a dress rehearsal for a major play, because if you look, for example, at our avian flu viruses in China, the mortality rates of some of those are 60%. They don't transmit efficiently from human to human, but they are flu viruses.

And what if one of those reshuffled and was able to transmit efficiently from human to human? That would be cataclysmic. We're dealing with a mortality rate of less than 1%. This is something that's going to be very difficult for hospitals and healthcare systems to cope with, but it really shows you just what a virus that kills less than 1% can do to a world. And I do think that this is a lesson, that we're not doing this perfectly. And if we were to have an avian flu virus, have human-to-human transmissibility, all bets would be off because if we're having this much trouble dealing with a 0.6% mortality, imagine what would happen if there was a 60% mortality flu virus circulating around. So I think it's a dress rehearsal. This is going to be bad though. And I think that there are going to be a lot of

disruptions that we're going to have to deal with, and it's going to be probably somewhat worse than H1N1. H1N1 was the closest that we came to this type of thing in the modern era. And even though most people are going to have a mild case and recover just fine, it is going to be a burden to work in hospitals, and it's going to really hopefully get people to think about how important infectious disease preparation is, even when there's not a pandemic, because some of this stuff could have been predicted back from 2003. We had a SARS outbreak.

We saw what a coronavirus could do, and people wanted to make a vaccine for that. But really now, 17 years later, we have no coronavirus vaccines for humans. We have no coronavirus antiviral. So this shows you what happens when there's complacency with these threats, even though everyone in my community had been sounding the alarm about coronaviruses since at least 2003 and some people even before that. So what specifically would you say that we, at the level of individuals and institutions and cultures, what should we change emphatically? Just take the emergence of novel viruses and other pathogens out of wild species

into the human population. I mean, is it safe to say that we should not have wild animal markets where you put a bat on top of a pangolin, on top of a pig, on top of a monkey, and have people work in those kinds of environments. What are the things you would just check off your list of things for people to never do again to prevent the emergence of a truly killer plague? So emerging infectious diseases all emanate from animals. So we do need to get smarter about how we deal with animals and those live markets where multiple different animals are housed together and their body fluids are mixed together when they're slaughtered and people are doing all of that without appropriate personal protective equipment, I mean, that's basically a powder keg for viruses to jump into

humans. And many of those viruses won't do anything. They'll just be dead ends. But there is the chance that you have a SARS or you have this novel coronavirus or you have avian influenza that can actually take off. So we do have to really be meticulous about how we deal with those animal markets. And that might not mean necessarily banning them, but there are safety procedures that you can put in place the same way that you do at a slaughterhouse to protect the workers and protect individuals from being exposed. I do think that that's one thing that really needs to happen. I think we kind of have an idea of what viruses are likely to do this. And we have to get better at surveillance

for them all the time. How many times have you been to an urgent care clinic and the doctor says you've got some virus? Sometimes that virus might be important because many of these infections, just like this novel virus, might present with just mild symptoms, and that's in you,

but it could be the first sign of a pandemic. And that's what happened during H1N1 when two little girls got sick with a flu virus that nobody had seen before. They figured it out. Those girls were fine, but that was the sign of a pandemic. We don't do any of that surveillance regularly. We don't diagnose things down to a specific level. We don't have antivirals that are broad spectrum, or we're not really looking at that kind of thing all the time. Only when there's an emergency do we start pushing for antivirals that are broad spectrum, or we're not really looking at that kind of thing all the time. Only when there's an emergency do we start pushing for antivirals. I think a lot of that is what's missing and why pandemic preparedness is something that we're perpetually trying to emphasize in the media or to politicians, that this is something you need to do and think of as a national security issue, because look at how many billions of dollars are being lost,

how many lives are going to be lost. And I think it's because we don't really take these steps that are very obvious steps to take if you've studied infectious disease emergence. You seem a little more sanguine about this than I was expecting, although I guess I could have expected it based on your YouTube lecture. I'm wondering if that is by reference to how bad it could be. Obviously, if an avian flu ever became fully human transmissible and 60% lethal, that's quite a comparison case. But do you really not think that we could be in the territory of something like the 1918 influenza, given the current dynamics of coronavirus? No, I don't think so. 1918 killed 50 to 100 million people. We didn't have antibiotics.

We didn't have antivirals. We didn't have any kind of vaccine development. We didn't have intensive care units. I don't think that we're at a 1918 level with this. I think this is, if you want to gauge it, it's going to be like a double, like something like 1957 or 1968, where we had influenza pandemics. It's going to be more on that scale, which were more severe pandemics, but not quite at the 1918 level, but more severe than 2009. So I think that that's where I would place it in that level. So if you were going to bet on the proportion of people in America who are going to get this over the course of the next 18 months, what would you think that number is? Probably 30 to 50%.

So if we say 50% of 340 million people and a mortality rate of 1%, that would put us at 1.7 million dead. So if it was half of that, it's still an enormous number of people dead from this virus. The highest flu death rate we have, I think, outside of a pandemic is 80,000 in 2017 to 2018. So this is a magnitude higher than that. And I do think it's going to be disruptive and bad. But I think that what I'm worried about is that people's actions and reactions and panic will actually make things worse and really lead to this kind of cascading effect where hospitals can't operate, where there is widespread social chaos going on. And that's what really worries me more than the virus itself. Right. So that's interesting. So I'd like to include this part of the conversation, if that's okay, because it just seems like we're unpacking some of the subtext here. So you could well imagine that 800,000 people could die from this over the course of the next year based on what we currently know about the severity and contagiousness of the virus. That does not seem far-fetched. No, I don't think it seems far-fetched. And I think that that's kind of one of my scenarios that I've envisioned.

What I want to see is, you know, I have a hard time reading into the healthcare system in China or even the healthcare system in Italy. I'm much more familiar, I'm much more comfortable talking about the British or the Canadian or the American healthcare system. And I contend to know what goes on in intensive care units of those types of hospitals. So that helps me. When we get data from there, I think I may refine what I think. Because I think it's much easier when you know what happens in an ICU, when you're one of those types of doctors that deals with that, that you have some idea of how sick these patients are. And I really want, if I had a colleague that would call me and tell me what this is like, that's a very different story than me reading these raw statistics from China and not knowing what's going on. And I think I might get a better picture and

have a more refined idea of what I think the case fatality ratio might be and how many deaths there would be once we start seeing more cases in the United States and we can see what this virus looks like faced with kind of the most advanced healthcare system in terms of critical care interventions in the world. That might sound like I'm trying to cheer for American exceptionalism, but I think it is true when it comes to critical care and severe illness that there is American exceptionalism. And you can look at the H1N1 death numbers and compare the United States to other places, and you do see disparities there. We're very good at this. And so I want to see what happens when we have severe cases in the United States. We've had some deaths here in the United States,

but those are not really representative because they're largely drawn from nursing home populations or elderly populations. And we know that these respiratory viruses are very different in that group than they are in other age demographics. Right. Although this is all assuming that we've sufficiently flattened the curve and that you're not on a gurney in a parking lot when you have this thing. I hear you about not wanting to spread panic. I'm a little worried that apart from seeing videos of people fighting over toilet paper in markets around the world, I'm worried that people aren't concerned enough. And when I see the way this is interacting with politics, you know, strangely, ironically, this is a virus that seems engineered in the current information environment to kill Trump supporters, because the stuff I'm seeing on Fox News and the right side of the aisle politically in the U.S. is just a denial of the severity of the problem at every level. And so it seems like they could use a little more panic, at least on that side of things. I won't take offense that I've been on Fox a lot, but I've been trying to... It's a fine line

between invoking panic and getting people proactively prepared. And I've been trying, at least in my media appearances on Fox or wherever it might be, I've been trying to walk that line as best I can because I do really worry about public panic making it very hard for public health professionals and healthcare professionals to do their job and actually prompting a politician to make some kind of drastic decision that will make things worse for everybody. So it is very difficult to do that. And you are seeing this be politicized on both sides. And it's almost the opposite of the politicization that we saw during the Ebola outbreak, which is interesting. So just to sharpen that up, your concern is that people with ordinary flus, people who just get a

cold, people who have a fever for some other reason, panic and go rushing to the hospital. And that makes whatever curve flattening we've achieved less and less achievable. So what do you recommend people do if they're concerned that they might be sick with something? The same things that you would do for something like influenza. If you are somebody that's a high risk group, that you're older, you've got medical conditions, you really have to have a lower threshold to seek medical care. But the vast majority of people who get this infection are not going to need hospitalization and can be managed at home with over-the-counter types of remedies. So we don't want all of those people showing up

in emergency departments, urgent care centers, at the doctor's offices, spreading the virus and making crowding even worse. That's what we don't want to happen. There are going to be certain people that are going to do that anyway, but we want to keep that to a minimum. So we need to get clear on who needs to go to the hospital and who doesn't need to go to the hospital. And that's what I'm really worried about is that hospitals will not be able to cope with this. And hospitals in the US kind of run at almost capacity all the time. And even a severe flu season can put a hospital into dire straits. We saw that during the 2017-2018 flu season. That's what I'm worried about happening is that type of panic running to the hospitals, just like the panic buying of

surgical masks all over the country has led to possible shortages of those surgical masks that people may need in hospital settings. That's what I'm kind of worried about, these kind of disruptive events that are on top of this big disruptive event, which is the virus, and that cascading, and then politicians nationalizing something to make masks or doing something like that, that may end up having negative consequences that we're stuck with for some time, or closing borders or doing things that may not necessarily be effective, but are perceived by the general population as this person's doing something, even if it's not effective. And we

see that all the time with outbreaks. Okay. So is there anything that we haven't covered that you think we should hit? Is there any advice you have or any resources you want to direct people toward? Because again, we're having this conversation on March 10th. I've learned that a week is a very long time in this business. The world a month from now could look very different. Where would you direct people to get the best information on a daily basis? I do think the Centers for Disease Control does have a lot of good information there. They do put out new fact sheets. They do have press conferences. I think those are really accessible and have most of the up-to-date American-centric information. So what's going on in your country? I think that the local health departments that you, the municipalities that you may live in, those are also good resources. And I would advise people to look at those now,

because if there are going to be measures taken, it's going to appear there. And you want to know what local health departments are thinking about now so that you have some outlet and some way to give them feedback and understand what's happening in your local community. I do think that the Center for Health Security website where I work, just to plug that, does have an extensive section devoted to coronavirus. And we're working basically around the clock to keep up to date and having multiple conference calls a day to try and understand what's going on. So I think I would recommend our website as well. The WHO has a good website as well that has some information there. And I would also recommend that. But it's going to be a media frenzy for some time, and it's going to be hard to sort out the disinformation. So I do think that people should start looking for

trusted sources of information. And that may be the CDC and your local health departments, as well as some of the academic websites that are out there. Also, you can sign up for the various newsletters that come out of Johns Hopkins on this topic. They have one just devoted to COVID-19. Right. And then there's also a journalistic outlet called Stat News, which is owned by the Boston Globe. That's probably the premier science reporting organization in the world, I would say. And then there's also the University of Minnesota has something called CIDRAP, C-I-D-R-A-P, the Center for Infectious

Disease Research and Policy. They're also a very good source as well. Amish, it's been an education. Thanks so much for your time. Thanks for having me.