Tetragrammaton with Rick Rubin - Dr. Jay Bhattacharya

Episode Date: June 19, 2024

Dr. Jay Bhattacharya is a professor of medicine, economics, and health research policy at Stanford University, where he is also the director of Stanford's Center for Demography and Economics of Health and Aging. After dedicating much of his career to studying the economics of health care, when the COVID-19 crisis began, Dr. Bhattacharya shifted his research focus to the epidemiology of COVID-19, the lethality of COVID-19 infection, and the effectiveness and effects of lockdown policies. This led him to co-author an open letter, The Great Barrington Declaration, which advocated for a lift of restrictions on lower-risk groups to develop herd immunity. He is also the co-author of the widely acclaimed textbook Health Economics, a staple in undergraduate and graduate curricula worldwide. He holds four degrees from Stanford: a BA, an AM, an MD, and a PhD in economics. ------ Thank you to the sponsors that fuel our podcast and our team: Lucy https://lucy.co/tetra ------ LMNT Electrolytes https://drinklmnt.com/tetra ------ Squarespace https://squarespace.com/tetra ------ House of Macadamias https://www.houseofmacadamias.com/tetra

Tetragrammaton. Tetragrammaton. Tetragrammaton. Tetragrammaton. Tetragrammaton. Tetragrammaton. Tetragrammaton. When I was four, we moved,

and we'd go back every four or five years to go visit. I still have very fond memories. I think the first was just this, when I was eight, was this impression of poverty, like what that meant. Because I'm now an American kid, eight years old. My main memories are the United States. We go back, and there was this like this monsoon,

but the streets are flooded. There's homeless families, like families, like little kids, dogs, moms and dads in the street. And I was like, we're going down some rickshaw to get to the station. And I was like looking around and asking my parents, what is this? And that was one of my first impressions

of what life was like for poor people in poor countries. You know, like we had a small family in the United States, and you go to Calcutta, and all of a sudden I got aunts, I got uncles, I'm like rooted and connected to this vast network of people. And I just, they just instantly accepted, you know, this little kid that's coming back because of my mom and dad, of course. Yeah. Over the years of going back to Calcutta, how much change did you see?

Enormous. So first of all, I'll give you just a couple snippets. So one is, when I was 18, we went back, and my family, they had a house that my dad had built with money from the US, and they had a TV. The TV had one station that would play from like 8 p.m. to 11 p.m. The entire village would come to watch the one station. So it was one TV for the community?

Yes. Wow. And they play this like, you know, I'm like, I'm an 18-year-old American kid and I'm used to Bob Dylan or whatever, and they're playing like this. It just looked hokey to me. But like for the community, it was a way to create a community. There was music, there was plays. It was really incredible, actually. Now, everyone has a cell phone.

There's TVs everywhere. It's just a very different thing. When did it really shift, would you say? The 80s. And then I was a medical student. I worked in a hospital in rural West Bengal in the early 90s. So I was a Stanford student then I was a medical student. I worked in a hospital in rural West Bengal in the early 90s. So I was a Stanford student then, a Stanford medical student. The contrast couldn't have been greater. There were three doctors in this little tiny rural hospital.

People would come with like ox carts. The electricity was off 12 hours a day. Wow. And not like, you know, we know the 12 hours. It's just random on and off, on and off. And so like they couldn't store blood. So every time before any surgery, they would go get blood from all the neighbors. Collect blood. Yeah. Wow.

And then throw it away if they didn't need it. Yeah. Because they couldn't refrigerate it, they couldn't store it. And all the nurses' kids during the surgeries would come study at the hospital because they knew the generator would be on so the electricity wouldn't be out. It was for me, for an American, it was eye-opening. It was like, what is poverty really like?

Tell me about deciding to become a medical student. I mean, I always wanted to be a doctor. From childhood. Yeah, I mean, there's this Indian thing of like, you know, doctors, engineers, lawyers, whatever. But I mean, I don't know. For me, I was always good at math and sciences. And then in high school, I started to think, look, what's it for?

And I thought, OK, I can become a doctor. That's a really useful way to use that. But then I actually got to medical school, and I really didn't like it that much. The way that it's taught, it's just this fire hose. I'm the kind of person that likes to ask why. And so that's why I did the PhDs, was to try to slow down the education. Was it competitive at the time that you got into Stanford? Was it a challenge to get into?

Yeah. My parents told me that, we grew up in Southern California, so I was a high school student in Claremont. And my parents wanted me to stay in California. So I applied to six schools. You could be close to them. Yeah. Yeah.

And so I got into Stanford, it was the furthest away from the house. Got into it. It was probably the best school in California. I mean, it was a great experience. I got to do my pre-med, but then I discovered, I thought I was going to be a chemistry student, but I discovered economics, which doesn't sound like a very big difference. How did you even end up taking an economics class? They have a general ed requirement.

And I took it and my brain just lit up. It was like, okay, you can use the math and statistics methods that I thought would be useful for science to ask questions about how people live, how people make decisions when there's scarcity, which is all the time. And I knew I still wanted to be a doctor, but I could see how you could use that kind of thinking

to make better decisions in medicine, to make medicine work in medicine, to make medicine work for everybody, not just for a few people. You think that's because of your Indian background and your experience in Calcutta that that connection was clear to you? If you'd asked me then, I wouldn't have said yes. Yeah, but looking back? Yeah, I think so.

At the beginning of the lockdown, I have asked myself, why did I have this very different reaction to the lockdown? Because one of my very first thoughts when I heard about the lockdown was that experience when I was eight, seeing what life is like for poor people. And I just had this vision of this is going to happen at scale to every poor person on earth. We're essentially pulling the rug out from under the sort of the economic infrastructure that allows poor people to have some semblance of access to food, access to health care, all this stuff. We just basically said, no, the fear around this virus, the well-being of like relatively

well-off people is so much more important than that. What were you most well known for before the pandemic? I mean, I've written a textbook on health economics. I taught at UCLA originally, and then I taught at Stanford, this class in health economics. Probably best known for that textbook. I've done a lot of research on infectious disease epidemiology and on obesity, on poor chronic health in Western countries.

I mean, I never wrote an op-ed before the pandemic. I never saw it the limel before the pandemic. I never sought the limelight. The whole thing is still a wonder to me. I thought the way you change the world is by writing scientific papers and convincing people about scientific points. So you have a degree in medicine and a degree in economics? Yeah. I mean, it was a strange combination, but I met this man who is now the provost at Harvard. He was my honors thesis advisor as an undergrad, and he had an MD and a PhD in economics.

I actually idolized him. His name is Alan Garber. Before I met him, I didn't realize it was possible to do the two things together. And after I met him, I'm like, okay, I have to do that. Tell me, where is the crossover between economics and medicine? How do they work together? We don't want to think about it, but medicine is basically about scarcity.

We are all going to die. Health involves making decisions about health. There's not a morality play. You make one decision about what you eat, but sometimes you want to eat the thing that's supposedly unhealthy because it makes you happy, right? And there's nothing wrong with that. But all of medicine's like that.

Every medicine you take has some potential side effects. There's a side and a downside for everything. Every single thing. And that's true for all of medicine is filled with those kinds of tradeoffs, often completely unrecognized. And economics, to me, is the science of showing what those trade-offs are so we can make conscious decisions about them, sort of knowing what we're giving up,

knowing what we're, and to me, economics is not about judgment, right? It's just people- It's about trade-offs. Yeah, and people navigate those trade-offs differently, but you can't escape them. They're just the reality of life. That's why economics, I think,

is so important in medicine. You're making an argument for every doctor to be an economist. I think so. I mean, it's funny because we train our medical students with, you know, you got to study biochemistry, you got to study molecular biology, but they're very little. I mean, if they study economics, it's not like business, a little bit of like business of medicine, which is not nearly as interesting as like the deep philosophical roots of thinking about life from this view of trade-offs. Wearing your economist hat, explain to me how healthcare works as a business in the

United States and how it's possible. I read that we spend the most in healthcare in the world and have nowhere near the best results That's true a hundred percent true How can that be the main reason is because we're the richest country on earth More or less pretty close to the British country on earth and so life is important to us and so we invest in it But because we're also the richest country on earth We have all kinds of things that we do that make us much less healthy than many other places. Like what? I mean, our diets are worse than most of the developed world.

Our lived environments are such that we don't really get as much physical exercise as we probably ought to get. If you want to extend your life very long, I mean, I think our social connections, we have much more isolated society. And for instance, if I compare it to my family in Calcutta, it's not even close. They're deeply connected to the community,

they're deeply connected to the family, and we live much more isolated lives. In many places, you have multiple generations of people, of family members living under one roof. As soon as people get richer, they stop doing that. Their family members move out, and they gain something. You also lose something.

You lose this rootedness, this connectedness, and that has health consequences, actually. The business of healthcare in the US is gargantuan. It's $1.05, I think we spent something on that order of our income on healthcare. It's tremendously unequal. If you have a job, you're going to have pretty good insurance. If you're older, actually, you have pretty good insurance through the government. But if you're poor, you're going to have very, very marginal insurance. There's still, even after Obamacare, tens of millions of people who have basically no

access to insurance at all or healthcare at all. I mean, they can get healthcare if they have emergencies, but not routine healthcare. So we have this like, we spend $1. and five that we earn on health care in an attempt to like patch over the Unhealthy lifestyles that we have and a lot of the business of health care is about trying to make you know after-the-fact fixes to Problems that are that are deeply rooted in our society Our life expectancy is and that is among the worst among big countries in the Western world. That's amazing. It's hard to fathom.

Yeah. It wasn't true in 1960. And what do we think changed in the 60s for that to be the case? I mean, I think partly much of the Western world back then was in recovering from World War II, and they were much poorer. And poverty, poor countries have lower life expectancy than the United States, right? So they're poorer. The United States grew richer, but the investment-

Richer and less healthy. And less healthy, yeah. What do you think it is about being richer that fosters the less healthy lifestyle? If you're richer, there's more room for error, right? So you live some lifestyle, and then later I can make it up. From my own research, for instance, I've seen that the life expectancy of people with diabetes has gone up.

The life expectancy of people with hypertension is not… You can take drugs, and now your high blood pressure will go away, and so you won't get strokes. Again, a really good thing. So, but the point is, like, you're doing a patch later on something, and because we're richer, we can afford to do those patches. There's nothing wrong with them. I mean, that's part of what medicine is about, is healing the sick and making people with

these conditions live long, fulfilling lives. But there's a trade-off really deep inside of it. If you don't have that, then you might maybe make decisions before about living more healthy so you don't get into those chronically ill states. Do you know why people in the United States take more prescription drugs than anywhere else in the world? I think Japan might take this more, but it is, but we spend more on prescription drugs than any other country. The first part of it is like even the same prescription drugs, we spend like twice as much as a Canadian would for the same drug.

Our markets are set up so that pharmaceutical companies have much more free rein to charge high prices than you would get in many other parts of the world. The argument there is that, well, you do that so that they can invest in research and development, but often that's not what happens, right? In fact, you saw during the pandemic how much power pharmaceutical companies had to change narratives about basically everything, like what you should do with your life, the vaccines, of course, but also just general fear mongering around what risks you really should care about and which risks, whereas silence about other risks.

So there's that. I think the political power of pharmaceutical companies is tremendous in the US. I think one of the two countries in the world where direct to consumer advertising of drugs is still allowed. So we get those crazy advertisements I'm sure you've seen where they tell you this drug will cure X. Promoting a product that you cannot go to the store and buy. Yes. And the goal is to see pressure your doctor,

say, oh, I just saw this advertisement. You can either tell people, here's a drug that cure X, and there's a long list of bad things that can happen if you take the drug that have to say, or they can just tell you about a drug with happy images, and they can't even tell you what it's for. What happens is they expect you to go to a doctor and say, oh, I saw this ad for this drug.

People look happy with that drug. Yeah. But really, what ends up happening then is you get the places where they're placing these advertisements, these media companies, are dependent on advertising dollars from pharmaceutical companies sponsored by Pfizer or whatever. And that really distorts our national conversation in ways that doesn't happen in other Western countries. Again, there's trade-offs.

It's not all bad. There are some drugs, if you're very sick, if you have cancer, for instance, there are access to certain oncologic drugs that you might have more difficulty getting in some other Western countries. But at the same time, you have probably certainly an over-medicated population. If you found out that you had an issue and had the option to take a drug or change something in your lifestyle, what would you personally do? That's tough because it's very personal and it would depend on the specifics. I see. Right? So like...

Give me an example of one that you would change lifestyle and one where you would take the drug. Okay. So I have high cholesterol, right? And there are lots of ways to address that. One is- Do you know why you have high cholesterol? It runs in my family. Okay. Yeah, I've had it since I was young.

So first question is, if it runs in your family, is it necessarily unhealthy for you? My dad died when he was 56 from a heart attack. My uncle died when he was 36 from a heart attack. My uncle died when he was 36 from a heart attack. It's an unhealthy condition. So for me, with that family history, what I ought to do is I ought to be exercising every day. I should be eating very healthy foods.

And I try to do that. But if I can take a drug that helps me when I fail, then I'll take the drug, right? That's the reasoning. And you'll, based on the give and take between the benefits versus the side effects or downside. Yeah. And so, for instance, I have taken statins, and I've read this literature on side effects, but I haven't had those side effects for me.

Just that's the other thing about medications is you get a very wide distribution of things, and someone will get a really bad side effect, others will get nothing. Are there any long-term side effects that you couldn't feel? It's possible. Like every single drug we take, some of them have been around a long time, some of them have been around a short time. And people tell you it's safe forever. Well, we haven't had it around forever.

Yeah. So I think the availability of the drugs then, it makes it so that it relaxes some of the conditions, but at the same time, you're giving something up. Yes. You're accepting risks, that's just a fact. And I've seen abuses of the system even in my professional life. So I've seen, for instance, when I was a medical student,

the movement to treat pain as a basic vital sign grew up. There was these new drugs that were supposedly not addictive that would address pain. And the opioid crisis grew out of that ideology. Like they were essentially telling doctors there's no trade-off. You can treat the pain that people are going through. Of course you wanna treat pain.

That's what's, because it's a compassionate thing to do. It's not morphine, which is incredibly addictive. And then you'll have done the compassionate thing and they'll be fine. Now looking back, are opioids as addictive as morphine? Not as addictive as morphine, but quite addictive. Quite addictive and quite destructive of lives. It actually, I think, distorted entire healthcare systems.

You get two classes of doctors. You get some patient the patients that come in and say they need opioids, and then the doctor would just write it because they're doing the compassionate thing. And another class of doctors would say no, and you'd have a fight with, like, there's a line between the doctor and the patient

that shouldn't be there, because the doctor's trying to do the right thing by the patient, but the patient wants the drug because they're addicted. And so it's just, I think it was an incredibly destructive kind of ideology based on claims that should never have been made based on the evaluations of the drugs.

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because you're more likely to know side effects and long-term responses? I mean, it is true that you know the side effects more. Weirdly though, a lot of old drugs, they're not evaluated by the same level of rigor of some of the new drugs. So you have a drug that's been used forever, but you don't have a randomized trial you can point to

and say, oh yeah, this drug does this for that. Cough medicine would be a good example of this. Whereas you have new drugs that may be evaluated for in some more rigorous way, but you have absolutely no idea what the long-term safety is. You can't know if there hasn't been a long-term safety. In your experience, is the data trustworthy, consistently? No. Yeah.

That's an issue. It's a major issue. Well, stick with statins. Okay. Yeah. That's an issue. It's a major issue. We'll stick with statins. So statins, there was a demonstration in randomized trials that you can change your cholesterol levels, both the LDL and HDL, the good and bad cholesterol levels, right, with the statins. And the trials are run for a certain period of time, sometimes a little longer than others, but let's say six months a year,

could be longer for some of them. The end point is control of cholesterol. Well, I don't really care what my cholesterol level is, not really. I mean, look. You care about your health. Right, I care about not getting a heart attack, like my dad had, or like my uncle died from, right?

And they had very high cholesterol levels. It's a marker, but it's not the same thing. Like controlling cholesterol levels, it's not the same thing. Like controlling cholesterol levels is not the same thing as avoiding heart attacks. It's not the same thing as living a long life. Certainly not the same thing as living a long, fulfilling life. And it's not the only stat you could look at.

A hundred stats, right. That your family shares. But these, so a lot of these drug trials are based on intermediate endpoints, things we can measure, right? Cholesterol levels, easy to measure. If you wanted to measure what's the long-term effect on survival, well, you have to run a very different trial.

In fact, in the trials for the statins, the first trials would just look at cholesterol control. They eventually did do longer trials to look at heart attack avoidance. And it doesn't actually reduce heart attack rates in some of the major trials that they had, they came out. At least some of the major trials they had,

it showed a small benefit in terms of living longer. So what's going on? Like we have a theory about, I can tell you the biochemical idea of the statins, it blocks this enzyme in cholesterol synthesis in your body, explaining why it might change cholesterol levels. So of course the trials would show that it reduces cholesterol levels because that's

what it does. That's what it does, right? But how does that lead to slightly longer life? Why doesn't it prevent heart attacks? How does cholesterol relate to heart attacks anyways? I mean, again, there are- Does high cholesterol cause heart attacks? It is certainly part of the pathway, or at least one pathway, but do we have a complete understanding of that?

No, we do not have a complete understanding of that. How much in medicine do we have a complete understanding of? This is the shocking thing. When I got to medical school, I thought I was gonna give them the keys to the kingdom, like we're gonna be like the doctor in Star Trek. There's a ton that's not known.

We have like a scientific Christmas tree, but we haven't filled in all the gaps. And we don't even know if we have all the right branches. Like, there's just a lot we don't understand. I don't see how anyone can go to medical school and not come away humbled at the complexity of the human body. And of course, economics gives you that humility with respect to our social structures too. Have there been times when we've had a, I don't know, in the 70s where we had a clear vision

of how something in the body works and then we found out in the 90s that was all wrong? All the time. In fact, one of my favorite medical school professors would tell me, he said, look, half the things we're teaching you are wrong. Wow. And I'm like, wait, what are you talking about?

I'm like, which half? He's like, well, I don't know. Yeah, if we knew we would only teach you the other half. Exactly. I mean, in medical school, I was told, for instance, that stress causes ulcers, stomach ulcers. You see a patient with a stomach ulcer, you'd say, okay, what's the stress in your life?

And imagine a doctor telling you to reduce your stress in your life. Is there anything more stressful than that? Don't eat chocolate, don't drink coffee, those were the things that exacerbate stomach ulcers. But they didn't really have any idea what caused them. And it turns out that it's a bacteria. I learned that since medical school.

And the way that we learned that was some doctor in Western Australia, Robin Warren, I think, he had this idea that there was this bacteria that caused it, wrote a couple of papers in peer review journals. H. pylori, yes. Yes, you know Rick, okay, so yes. The thing is, nobody believed him.

For a long time, no one believed him. Then he got a student named Barry Marshall who drank a slurry of H. pylori and caused an ulcer in himself. Convinced the world that H. Pylori caused an ulcer because he himself caused one, and they won the Nobel Prize. Now everyone knows for certain

that it's a bacteria that causes it. But if you told me that in medical school, if you tried to say that in medical school, then you're a crazy person, like you're an anti-science crazy person. Why is there this, when a new idea comes along, that it's a crazy person and to be vilified, especially when we know we don't know everything?

It doesn't make sense. Okay, so let me try to make an argument. Let me try to make an argument for why that it might be justified in medicine. I'm not sure I'd buy that argument, but I'll just try to make it, okay? The argument is that when you go see a doctor, if the doctor tells you perhaps the question you ask him, I don't know, I don't know, I don't know, I'm not sure, you just trying to make it, okay? The argument is that when you go see a doctor, if the doctor tells you, perhaps the questions you ask him, I don't know, I don't know, I don't know, I'm not sure, we don't have good evidence, you're not gonna come away

with a lot of confidence in the doctor. But you shouldn't have a lot of confidence because they don't know. Yes, that's true. The doctor's being honest. But there's also a placebo. There's just something about being near a smart person who's thinking about you that produces some benefit

we don't even understand, really. And so maybe there's an argument to say, okay, I'm gonna try to be a little more confident than I should, but at the same time, this is deeply unethical. We're pretending to knowledge we don't actually have. I've now made the argument to try to steel man it, but I don't think it's enough.

So I do research. I don't recommend that. So you think you could be honest. Yeah, I think you can be an honest doctor and still have the confidence, because you know more, right? Presumably as a doctor, you've done the reading, you've done all kinds of stuff, you know more.

So you should be able to say to a patient, I just don't know the answer to that question. Let's look this up together. No one knows the answer to this question. Let's try to make this decision together, given this uncertainty, based on what your values are as a patient. I think that kind of medicine would be a much more honest, much more effective medicine. What was the window that you went to medical school in?

I started in 1990, and I graduated in 1997. OK. So H. pylori is an example of something that happened after. Yeah. For doctors who went to school then or earlier, how do they know all the things that changed since what they learned in medical school? There are things called continuing medical education credits. You're supposed to keep taking some,

you're supposed to be reading the journal. Do all doctors just require of all doctors? Do they all do it? If you want to maintain your license, a lot of the specialty societies will acquire that you have some of those. Sometimes the states will acquire it. But they're usually just in your specialty, right?

You're not reading broadly. And a lot of it is just, actually it's like pharma funded. Right, so like you go to some conference like where the pharma is sponsoring the conference. And- They tell you about the new drugs. Yeah, they tell you about the new drugs, right? I think a lot of doctors, unfortunately, I don't think they keep up, but I think the

ones that do, they're getting it from their colleagues who found something from maybe they read a journal article, but usually it's like they read about it in the New York Times. It's a really haphazard kind of continuing medical education. How much of the current health world is driven by the pharmaceutical industry versus the pharmaceutical industry being called upon to solve a problem for the medical community? A lot of the kind of direction of thinking in medicine revolves around the availability of drugs. Right? I'll just give you another example, a non-COVID example.

So the number of people diagnosed with depression has exploded in the United States and around the world, actually, since the 90s. Is the world just more depressed than it was? I don't think that's the answer. I think before the 90s, there wasn't these SSRIs, these serotonin reuptake inhibitors, these drugs that nominally treat depression,

right? Before it was a very complicated thing. You had terrible drugs that had awful side effects. You had psychoanalysis that didn't seem to do very much, was very expensive, and actually could cause quite a bit of harm, I think, in the hands of bad practitioners. And now you have this drug. Much easier. And people started diagnosing more because of the

availability of the drug. A lot of doctors don't really understand this, but a lot of the medicines they practice is related very closely to the availability of relatively easy treatments, and drugs being the main one. There could be surgeries also that weren't previously available. So a lot of medicine is practiced because of these technologies that are available. Now again, these trade-offs here, sometimes that's a good thing, right?

Yeah, sometimes it works. Yeah. And sometimes it leads to the abuses and sometimes it does both. From where you sit, looking at the healthcare care system in the United States, tell me what's working and what's broken. I think if you have a chronic illness and you're relatively well off or have a good job, if you have cancer, you're going to get among the very best treatment in the world. You'll get what people think of as the right thing to do.

Now, it may or may not be the right thing to do, but you're going to get what honest people think is as close to the right thing to do. Now, it may or may not be the right thing to do, but you're going to get what honest people think is as close to the right thing to do as you can. You might get over-treated, but I think that's working quite well. If you're poor, you may have a hard time getting the most basic things. I think that's tremendously broken in the United States. Our systems of providing care for the poor make it hard to get doctors that will see you even for relatively serious things. Emergency here is pretty good.

You can always go to an ER, they'll take care of you. But you end up with the ER flooded with things that flow out of our social dysfunction rather than just medical things. So it's a lot of stress on medical systems having to do with the opioid epidemic is a good example of this, I think. Putting on your economist hat, how can that change to be a better situation for poor people? What could the system do differently? I would think there should be a political consensus around this.

We're a rich country. Why don't we just provide better care for the poor? On the left, you have this desire to reorganize all of health care, even parts that are people like. That's why it's so politically challenging to get something like Obamacare through there. It's really easy to say, look, you're threatening, I'm a middle-class person, I have health insurance

with my employer, I like my doctor, why do I want to change that? And that's actually a legitimate point. And on the right, you probably have too little desire to provide the care for the poor. What if Obamacare, for instance, had been just a Medicaid expansion to mainstream care for the poor. Like, what if Obamacare, for instance, had been just a Medicaid expansion to mainstream care for the poor?

Medicare for all, that means the government's going to take over all the insurance, even for middle-class people. You could still always, a rich person could always spend their money on whatever they want. When you have a single payer, like in the UK, for instance, there's a tension there. Is there?

Tell me what it is in the UK. Because it's like the solidarity, right? So I give lectures in the UK. It's really there's a tension there. Is there? Tell me what it is in the UK. Because there's like the solidarity, right? So I give lectures in the UK. It's really interesting what the taboos are. In the US, the taboo is that people can't get care if they want it. That's the taboo of death panels. In the UK, you shouldn't have to pay for care at all. If you charge for care, then that's a great evil.

And the argument is that there's this social solidarity. We all have, we're all in it together in our life. We all should get the same care. But the political tension there then is like if someone is relatively well off, they don't want to wait six months to get some surgery, can they jump the queue by paying private? It seems as if you do it, but it's an illicit thing. To me, the most important thing, like the most important thing in health policy to me is like how do you make care for the poor

so that it's not like this second class thing? I think you could do that without disrupting the kinds. The part that's working. Yes, the part, well, I wouldn't say working necessarily, but a lot of people like it. There are trade-offs again, and there's stuff where you can go a little bit. You don't wanna take away what someone likes regardless of whether it's working or not.

Yeah, exactly. The idea that people get to choose. Yeah, well the thing is that then you get a political coalition together to try to protect the thing that people like and there's a lot of conflict rather than trying to build a consensus around things that everyone agrees doesn't work. Even on the right, people agree that care for the poor isn't working. So for instance, suppose President Obama in putting putting together Obamacare, had just said, we're gonna expand Medicaid,

because we have 50 million people with no insurance at all. That's not right for a rich country. We're gonna mainstream the care that they get, so that they have access to a lot of the care that middle class people have. It's gonna cost us something. Taxes might have to go up, but it's worth it.

I think he could have got that through. No one in the middle class or the rich would have felt threatened by it. And we all want that. Nobody wants to live in society. Who would have not wanted that? I think the only people would say, oh, well, the taxes are going to go up. But like you're saying, you're spending the taxes on something useful. Instead, they tried to reform, to change the structures of care even for the middle

class and then use some of those changes to try to finance the care for the poor to make it look like there's no change in the deficit. It just was this like hodgepodge thing. I mean, I think not one single Republican voted for it. Like if you're going to have an enduring change to our social infrastructure, you have to have basically a very large number of people from both parties in favor. There shouldn't be this, like, political coalition that spends a decade trying to undermine it. We did this with Medicare and Medicaid in 1965.

It's different now than 1965. Yeah, it is. But you know, 1965 was a funny time, right? Like, there was a tremendous amount of social strife going on then. To get in place. What do you think allowed it to happen then? I mean, I think the death of a president,

a new president, that was what he was going to spend his political capital on. And then the other thing was like health care starting to become much more useful in the 60s. And the specter of like a lot of older people that had no access to care, so our parents, our grandparents, they weren't a very large fraction of the population. We had a population pyramid that looked like a pyramid back then. So you could make the political case, well, look, why wouldn't we care for our old grandparents?

And health care wasn't quite so expensive then also. It was like $1.20 was spent on health care, not $1.05. And also everybody has grandparents, not everyone has poor people. That's true too. Yeah, I mean, it's harder to build like this compassionate idea around poor. Let me push back a little bit.

I do think that people do care about poor people. I'm sure they do. I know they do. I feel like there's something about the way the system is structured that doesn't allow the thing that everybody wants to happen to happen I don't know why I don't know anything about it. It just seems like the political system is dysfunctional like this obvious Middle ground where everyone can agree like let's you can keep the thing the structure you way you want it for for the stuff

That you think is working for you, but let's let's care for the poor Everyone wants that really and we're willing to pay for that I think we just have to pay for that, I think. We just have to say it that way, like just put the trade-off plainly in front of the American people and they would accept it. Instead, you have politicians in both parties promising free lunches, and everyone knows those free lunches are lies. L-M-N-T. Element Electrolytes. Have you ever felt dehydrated after an intense workout or a long day in the sun?

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I mean, it's just everywhere you look. Before the pandemic, one thing I worked on was on the incentives that doctors have to choose to make recommendations that will have long-term benefits versus more expensive things that might benefit the doctor in terms of the income they get. A lot of the way we pay for health care in this country

is this system called the fee-for-service system, system. So you go see a doctor, the doctor does something for you, and you pay the doctor for that thing. But then there's no long-term follow-up in terms of like, was that decision a good decision for you? It's like a one-time transaction. And so the time horizon then for many, many medical institutions is very short. That's the advice you're getting because the doctors have an incentive just to look about, okay, what's good in this interaction versus the long-term effects. Am I managing your care so that you could avoid having to take the statins at all?

Can I help you make decisions that will give you a long-term benefit? We don't pay enough to cure that. So are you saying it's in the doctor's best interest that you come back to see them again? Yeah, I mean, that's how we structure our system. Like, it's not, I mean, it's not unique. Like, a lot of fee-for-service is pretty common around the world. But I think that those structures are going to create

misalignment between patients' long-term interests and the decision-making of doctors at the point of service. How could that change? How else could it work? Well, you could change the way we of doctors at the point of service. How could that change? How else could it work? Well, you could change the way we pay doctors, right? So, in fact, there's a law passed in 2015 that is called MACRA. In the U.S., Medicare is this health care system that provides health care for all the people over 65,

has a major influence on how doctors are paid. So you could change how Medicare pays doctors. In fact, MACRA does that. It says, okay, we're going to give every doctor in the country a report card. And the report card is going to be based on the outcomes on the decisions you make for your patients, long-term outcomes, a year, and on the costs. And so doctors that have low costs and great outcomes for patients will get a bonus from Medicare.

Doctors who have high costs and bad outcomes for patients will get a bonus for Medicare. Doctors who have high cost and bad outcomes for patients get a penalty. So something like that where you've linked the payment to the things you want, that's good economics. That's how economics works. Right, so you could do that. Now, there's been tremendous, like I worked with the Medicare to try to design that report card.

It was an uphill slot for five years. It was, we tried to develop this work card. There's a lot of resistance in the medical community first to be, no one wants a report card put on them. How do you- So it's just people don't run accountability? Is that what it is? I mean, you have a system that works for some people.

So people think, certainly for people that are in the medical care system, it works really well for them. Doctors are among the highest paid in the world in the United States. And so you're going to get resistance when you try to change it. I think that's where we kind of are. But like the structure of it could work. You'd have to, there's a lot of detail. Like what do you mean by good outcomes?

That's a really complicated question. I don't think those are unanswerable, but you have to answer it. You don't want to spend a trillion dollars for one day of extra life. You also want to make sure that you spend $5 for 10 years of extra life. But at some point, you don't want to say these things because now you're all of a sudden talking about life as if we're a dollar of value to it, which if we acknowledge that trade-off, it should never be something so explicit. It's just inhumane to think of that way.

But at the same time, implicitly it's there. It's a very sensitive conversation that you have to have in order to have a system that's designed for long-term benefits. That's the only way you get there. Tell me about the relationship between the insurance companies and the medical system. So the insurance companies are funny things. So the only reason you need insurance is that you could have outcomes that are so expensive that you can't possibly afford it, yet it's tremendously valuable to get it, right? So if you didn't have technologies like that, you wouldn't need insurance. You

could just pay for it out of pocket. If you're poor, then you could have a mutual aid society or something to pay for it, right? Insurance exists because of those uncertainties. And yet we expect insurance to cover literally everything. The insurance companies in principle should be representing patients, right? It's patients that pay for the insurance. But often they get captured by the hospital systems and by provider systems.

Explain that, what does that mean? How does that work? Well, so for instance, I would think insurers would try to negotiate the best deals with the hospitals, with doctors' groups, and say, OK, we'll include you, but we can't pay you this much. Doctors in Denmark are earning a third that for what you're charging us. And then they would pass the savings on to the insured.

We spend $1.05. That's way out of line with Western economies. Our insurers in principle should be negotiating with the hospital systems, with doctors, groups to try to represent patients much more effectively. And yet they don't. They just sign the checks that the doctor groups want, they sign the checks that the hospitals charge. And our government does the hospitals charge.

And our government does the same thing. Like they basically, the government is a major insurer for the elderly. There are laws to try to like negotiate better, to try to like, but in fact what happens is the doctors groups, the hospitals and the pharmaceutical companies have essentially, they write what those decisions end up being. How did it get to be that way? That's a really complicated question. I think part of it is politics.

It's very easy for physicians and for hospitals, with some reason, to go to politicians and say, look, we're really essential in this community. They get a lot of political power that way. The payment structures are set up with tradition in mind. We've always had a fee for service system. And so reforming that to change it to give rewards for more longer term outcomes, some people are going to lose. And those people are going to fight really hard to make sure that that doesn't happen. It's a really difficult challenge to transform

or to reform healthcare systems because it's so personal to everybody. Even wars are like something that happens over there. For healthcare, it's like it happens to you now. It happens to your grandpa. It happens to your kids. You're gonna fight much more and there's trenched interests all over the place. I think that's probably the most important reason. I've heard of new cancer therapies

that are available in other parts of the world that some rich people here fly to Switzerland or other places to get. Why would something that's getting good results be possible somewhere else in the world but not be possible here? I think part of it is like there's controversy over whether the results are good enough, right? So like the job of the FDA is to evaluate the efficacy of certain drugs and it has to both be safe and efficacious.

This is a theory, not the practice necessarily, but that's the theory. And the efficacy standards are set by the FDA are often very stringent. Are they stringent on behalf of the citizens? So I just described as the theory of the FDA. The practice, what I've seen, is often not stringent. Like we talked about earlier about intermediate endpoints, cholesterol instead of long life. So you end up with an FDA that's very inconsistent in the standards they use to approve drugs.

Sometimes the drugs are approved before the rest of the world, based on probably inadequate evidence, and sometimes they're much too stringent, and other parts of the world have approved them. So that's why people might go. There are also sometimes, there's controversies, right? There may be a drug where the randomized trial was equivocal, and one regulator says yes to it, and one other regulator says no.

You can go to a poor country and get it because there's very little regulation at all, you know, like interferon for various things. When I was a medical student, that was a big deal. People would go to Mexico or something and get treatment that wasn't available in the United States because there was a lot of controversy over whether it actually worked.

And also, I know many athletes, professional athletes, go to Panama for some injections of some sort of a... Erythropoietin, probably. If the professional athletes think it's valuable enough to fly to Panama, why would we not make it available here? There was a political movement. In fact, there was a law passed right before the pandemic called this Right to Try. Yeah.

Right? And the philosophy there is, well, if you have an investigational drug, why not make it available to people that are really sick that might help? And I mean, I find a lot of power in that argument. The counter argument is that a lot of people will tell you things will work when there's no evidence that they work. People will get taken advantage of.

You said earlier that half of what's taught in medical school is not correct. So we're starting on a very faulty ground to begin with. So the idea of not being allowed to try something that might work when some of the things that are allowed might not work. I have no counter-argument to you, Rick. I think I agree with you. I mean, we're in a funny position, right?

On the one hand, we want to promise that we have a regulatory structure that's going to tell you that every drug you take is safe and every drug you take is effective. That's the theory. Everyone wants that promise. At the same time, when you're really sick and there isn't a good treatment, even if you're not sick, you just want to enhance your performance in some way, you want to try things even if the powers that be haven't approved them.

And should you have a right to do that? As a company, do I have a right to sell you this? Imagine a company tells you, we haven't really evaluated this. We think it might work, but we're not sure. Use it at your own risk. Use it at your own risk. And I think it would probably be okay

to allow that to happen. I mean, in fact, that's what the law is, this right to try law under certain conditions. But a lot of people would say, well, you're just allowing Charleston companies to take advantage of people that are in dire straits, very, very sick and don't know what to do and there's no real good treatment.

So I don't know the answer to that question. I can kind of see both sides of it. What is economic epidemiology? Let me just ask, first start with what is epidemiology? Epidemiology is the study of the spread of a disease. One of the basic ideas of epidemiology is that if you invest in or work toward prevention of a disease, you reduce the amount of the disease in the population. Completely reasonable kind of idea, right? That's in fact one of the central ideas of public health generally.

Economic epidemiology says that it's not quite so simple. In fact, a lot of the desire or willingness for people to invest in prevention has to do with the perceived or the actual threat of the disease itself. So there's a feedback loop. Prevention reduces the amount of disease in a population. The level of disease in a population determines how much prevention there is. There's a loop there, not just a simple one-way pathway. And it's not a morality tale, it's just a fact, right?

So like if you are very worried about a certain set of diseases, you are going to be willing to invest more in trying to avoid those diseases. I'm willing to invest a lot to try to avoid having heart attacks because my dad had a heart attack when he was 56. My uncle had a heart attack when he was 36. Both of them died from it. And so in my mind, the kinds of things I'm willing to do are much more because of that fact.

Other conditions, I don't know, dengue fever, I'm very unlikely to get in this country. I'm probably not willing to do very much to try to avoid getting it. Just because the risk of it is so low in the United States, right? So that's the heart of economic epidemiology, that there's in fact not just a single pathway from prevention to the disease,

but the other way around as well. And it changes how you look at epidemiology, I think, when you understand that both prevention and disease are social phenomena. Then you have to think about that. So in other words, you don't throw the kitchen sink at everything because that's not what's best for the situation.

Yeah, that's right. The more I spend on time and effort and energy and thought on one condition, the less I'm gonna have for other conditions. There may be fundamental trade-offs there, too. That's another important lesson of economics and applied epidemiology. What it means is that I could look and say, okay, what does it mean to live a healthy lifestyle? If the list is like 5,000 items long, that's too many items. I'm not going to do all of those things. I mean, it's just not possible to do all of those things. In

fact, it's like actually weirdly inhuman to do all those things. You end up focused on prevention of disease rather than living your life. So the economic epidemiology broadly is applying some of the ideas at the heart of economics, which is these trade-offs, to epidemiological situations to try to understand better how disease actually spread in society as opposed to some abstract thing where I prevent a disease and the disease doesn't happen. What I've seen is a lot of people in public health are frustrated because they have good ideas for how to prevent disease, but people don't take them up. The reason for the frustration is because they don't understand that the demand for

prevention relates very closely to the level of the disease and that there are trade-offs implicit. They shouldn't be treating it like morality play. They should be trying to help people manage those trade-offs. So much of today's life happens on the web. Squarespace is your home base for building your dream presence in an online world. Designing a website is easy, using one of Squarespace's best-in-class templates. With the built-in style kit, you can change fonts, imagery, margins, and menus, so your

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The Squarespace app helps you run your business from anywhere. Track inventory and connect with customers while you're on the go. Whether you're just starting out or already managing a successful brand, Squarespace makes it easy to create and customize a beautiful website. Visit squarespace.com slash tetra and get started today. Today. You, along with an esteemed professor from Harvard and an esteemed professor from Oxford, wrote a document that eventually was signed by 60,000 other doctors and scientists,

yet you were silenced. What does that feel like? It was very, very odd. I mean, you know, in science, you write papers and you send it to a journal. Sometimes it's years, you have something you're super excited about, you document it as well as you can and you send it to a journal. They'll send it to peer reviewers and the peer reviewers look at it and try to tell you what you did wrong and you have a back and forth.

But you still have a voice, right? Eventually, hopefully, you get to publish the paper, the process of talking with people about it, people criticizing you over the paper, improves the paper, and maybe, this is what I always thought before the pandemic, is that this is how you change the world, is you make those kinds of discoveries

through, again, that social process. I've never had a situation before the pandemic where someone told me, Jay, you're not allowed to say that. But during the pandemic, that's happened to me constantly. Okay, so I'm a professor at a fancy university. And you're talking about your area of expertise. Yeah. Yeah, it's my area of expertise.

I mean, I think what I've seen is that it didn't matter what your expertise was during the pandemic. Were the people telling you, you can't talk about this, people with expertise in your area? Not necessarily, no. Often not. Often not.

Yeah. So the document you're talking about is called the Great Barrington Declaration. I wrote this with Sinetra Gupta of Oxford University. She's an amazing professor of theoretical epidemiology at Oxford. And Martin Kuhldorf, professor of medicine at Harvard, an amazing statistician, amazing epidemiologist. All three of you well respected, well thought up until this document. I mean, that document is October 2020.

I had some run-ins in April 2020. But you wrote that document, and you had the head of the National Institute of Health, a man named Francis Collins, a very eminent scientist. He was the head of the Human Genome Project. But he doesn't have any epidemiological expertise. That's not his area. He wrote an email to Tony Fauci, the head

of the National Institute of Allergy and Infectious Disease, a man with a lot of background in immunology, a lot of background in HIV, but not an epidemiologist. He wrote an email to Tony Fauci calling the three of us fringe epidemiologists. A friend of mine made a card that has my name and says fringe epidemiology. Yeah. So you'd never been a fringe epidemiologist prior to this. No. It's not really a scientific term. The whole idea was to excommunicate the three of us from science.

That sounds like that's not how science works. I thought the whole idea of science is you have different ideas. The only way it moves forward is through discussion of a new theory. Yeah. That is the theory of it. And that was also, I thought, the practice of it before the pandemic. I mean, I've now met people who tell me that they were silenced before in unfair ways.

But I'll just say that that is what you described is what I had always thought science was about. It's not that I'm always right. Were you shocked? I mean, when the Great Branch of that question happened, I'm still shocked to see an email from the head of the National Institute of Health to the head of the National Institute of Allergy and Infectious Disease calling the three of us for in-depth email. Then calling for a devastating take down of the premise of the declaration, which led to like, you know, death threats.

But it's just a smear. It didn't explain where the declaration was not correct. No. It wasn't an argument. declaration was not correct. No. It wasn't an argument. It was just an ad hominem attack. A smear. It was an attempt to excommunicate us. Right.

From on high, you have the high pope of science saying, this person is the heretic. These three people are heretics. That was what it was. There were other emails that I think gave some psychological insight what was going on. Tell me a little bit though about the conversations you had with your fellow writers when it was happening. Were you expecting this reaction? I wasn't expecting it from the head of the NIH. So what had happened early in the pandemic is I had done a study of how widespread the disease was in the population. And that study in April of 2020 led to hit pieces

against my family and my wife against me, led to death threats. It was so I knew to expect a very weird environment for talking about this. So I kind of expected that kind of pushback. But what I didn't expect was that the very heads of the institutions that fund and structure scientific biomedical

work in the United States to be directing it, that's a huge abuse of power. I have this position at Stanford in part because I've been pretty successful at getting NIH grant money. I mean, it's just part of how you become a prominent biomedical scientist in this country is by winning NIH grants. So you're like a trusted source, essentially. become a prominent biomedical scientist in this country is by winning NIH grants. So you're like a trusted source, essentially. I've sat on NIH grant review committees for years.

And your motivation in doing that original study that got you in trouble, what was your motivation in doing that study? To understand what the death rate from this disease was. That was amazing. Pretty reasonable. And how widespread it already had been. I mean, that was... Why wasn't anyone else doing this?

Why were you the only one doing this? It seems like that's the first thing you would do. I have to say I was shocked. I wrote it for the first op-ed I ever wrote in my life was in March of 2020 in The Wall Street Journal. I said, we don't know what the death rate is from this disease and called for a study. I fully expected the CDC to do that study. Of course. And it- Why wouldn't you?

Because your whole experience in life up till then was, let's do a study. Yeah, it was like- Let's find out. Exactly. It was a very strange time. So, but by October, I'd become jaded. But the university had gone after me. My own university had gone after me.

What was the first conversation between you and the university? What was the call you got? What happened was we did this study. We put it out as a, normally you go, often you go through like this long, years long peer review process. But we figured we had a result that 4% of LA County and 3% of Santa Clara County, where I live, had already had COVID, had already had antibodies to COVID. And that meant that there were 50 people walking around LA

County or Santa Clara County that had COVID that the public health authorities knew nothing about. And as the death rate wasn't 3% or 4%, it was like 0.2%. And there was this massive age grading with really older people, really high risk. Those were really important findings. The lockdowns had not worked. It was early April 2020.

We'd been locking down for three weeks, and yet 3% of the population already had it, or 4% already had it. So those are all real important messages. So we thought, OK, this is so important in the middle of this pandemic that what we'll do is we'll put it out as something called a preprint. It hasn't gone through peer review,

so we're not saying that it's been through the whole process. Put it out as a pre-print. Because it was an emergency situation. Yeah. And I think the pre-print process is actually quite healthy for science. A lot of scientists will put out their papers as pre-prints in order to get feedback from scientists before they send it to peer review. There's no saying this is the exact right answer.

It's like, here's the scientific result, let's discuss it together. That's what the pre-print process is supposed to be. And it's not uncommon. No. In fact, there's been a big movement toward open science. And pre-prints are a real important part of that. Because I think a lot of before, the old science was it took place behind closed doors.

It was really easy to kill papers if politically you didn't like the person or whatever. This allows scientists to have access to the scientific community in the open. I think it's a really good movement. I'm still quite glad for it during the pandemic. So we put it out as a preprint. It led to, first, what we expected,

which is a lot of scientists helped us improve the paper, improve the result. Actually, the result was the same, ultimately. We were right. We put- Just clarification. Yeah. And you know, proof that this- More detail. Yeah, and so it was, I mean, in that sense, Just clarification. Yeah. More detail. Yeah.

In that sense, it was exactly what science should be. It's not that people didn't criticize us. People did legitimate criticisms, and that was a good- That's how it works. Yes, exactly. You're not above criticism, but you want criticism versus your bad smear. Right. It's brass knuckles on the ideas,

kindness to the scientists. That's how science works. Because the work, you're not the work. Yes. You're doing work, here's this work outside of myself, what do you think of the work? Right. And it's not your bad.

It's like singers, right? Singers sing some song or write some music and they get, especially if they're famous, they must get a lot of praise and criticism. They have to probably disassociate. They're not the song. They're just... Yeah, the healthiest version of it is,

we created this thing that's outside of us, we like it, what do you think? That's all. Well, that's what science is. It's the exact same thing with science. Like, here's this thing I did, and what do you guys think? That's the same exact thing. Yeah Like here's this thing I did and what do you guys think? Right? That's the same exact thing. Here's my theory. Is that in fact the only way science

will work? It's not a way, it's the only way. It's the only way. Because no one's smart enough to really understand how the material universe actually works. You need a lot of minds on it and you need correction. That's part of science. So we got that. We put this out and a lot of people helped us improve the paper. It actually did ultimately get peer reviewed and put in a journal. But then I also got the hit pieces against me that were written that were entirely unfair, lies essentially about like, so the study was funded by small dollar donations to Stanford, the university where I work, for lots of people, regular people, but also like the founder of JetBlue gave $5,000 for the operational

costs of the study to Stanford. A journalist at BuzzFeed News wrote a piece accusing me and another professor who was on the study, John Ioannidis, of being unduly influenced by the $5,000 donation to Stanford for the study. The implication donation to Stanford for the study. The implication was that we took the money. It's so bizarre. Why do you think this could be? I mean, I think part of it was like the result was so counterintuitive to some people.

They put this lockdown, this absolutely extraordinary lockdown place that damaged the lives of countless poor people, stopped the education of children in this country, around the world actually. Some places for years, in California, my kids didn't see the inside of the classroom for a year and a half. They'd done this absolutely extraordinary thing. Our results said that it probably wasn't needed or it certainly wasn't working. That's the implication of the result.

A lot of people reacted to that as if it were an attack on themselves. Like they'd done something that needed to get done. They thought they were doing the responsible thing. Our scientific results shows that it probably wasn't the responsible thing. And they reacted by this, just again, this ad hominem, we're trying to expel you. And the press was fully on board the panic narrative then.

And so we come up with the results that the panic narrative probably isn't needed. And now we've undermined the presses that are putting this narrative together. They're not scientists, they don't have language to attack us through science. They instead, they treat us like we're evil villains. What's it like?

What does that feel like? I mean, you're trying to do something good in the world and you're being personally attacked. That's odd. Rick, I'm a very relaxed person. I mean, my wife always says I'm too laid back, and which is odd for an academic actually, weirdly, but for me, it's just like my nature.

I've never felt anxiety in my entire life until that moment. In a month, I lost 30 pounds. Wow. Couldn't eat, I couldn't, I forgot to eat. I wouldn't sleep. Yeah. There were, and especially I felt like helpless. Like there were people writing stories about my family. A lot of people would like help with the study, including my wife. And one of the things she did is she wrote an email to our kids' middle school listserv telling

people about the study. And she's a physician. In the email she wrote that if you have antibodies, then that probably means you're immune or something close to that. At that time, that was seen as misinformation. It's true. It's actually correct, but you weren't allowed to say it. So it was true, but you weren't allowed to say it. Yeah.

So she didn't know the rule. And so there was a BuzzFeed News hit piece on her for writing that with a hint that somehow I put her up to this to recruit people for this. It was really crazy, because people wanted to join this. They wanted to know their antibody status. I was getting calls from Stanford professors wanting to join the study.

Tell me about the conversation, the first conversation with your other co-authors. What was that like? It was tremendously, so there were junior professors and students that were co-authors. I wasn't on Twitter then, but they were getting killed on Twitter. They were under tremendous stress. And they're looking to us for leadership as the senior authors of the study.

And I tried to calm them. I said, look, this is a stressful thing, but we've done something really important. We found a really important result. You should be proud of it. I still say that to them. And many of them have stood by us through the whole thing. But it was, yeah, for junior professors, without the protection of tenure, it was a very tough time.

People just stayed silent. And the NIH guy, the head of the NIH, calling us for in jeopardy immunologist, that sent a signal to every scientist, you better stay quiet or else this will happen to you. So we put the paper out. There's these hit pieces. Stanford then starts something they called a fact finding.

Really felt like an inquisition. For months, I had to hire lawyers. I'd never, I mean, I've been a professor for decades. Have they done this to any professors before this? Was this the first time this has ever happened? I don't know. I assume that they must have. They must have, they had some infrastructure for this.

Wow. It never happened to me before. Yeah. And so it was like, you know, I'm a faculty in good standing. So it was just a very strange thing. And they're like, it felt like an inquisition. They're asking me about a thousand questions about like my motivations and about, the funding was to Stanford, right?

From this Jeff Blue guy. They knew that. And yet the university put me through the ring around this. They ultimately concluded that I did nothing wrong. Then they announced the ring around this. They ultimately concluded that I did nothing wrong. Then they announced the beginning of this fact finding with supposedly with a whistleblower. We asked them what whistleblower, what did it say?

They said then they told us there's no whistleblower because the BuzzFeed news author had written that there was a whistleblower. But it was just a made up. Yeah, I mean, I don't know what she was talking about because the university didn't tell us and they told us there was no whistleblower. So they announced the beginning of this process.

Well, how could there be a whistleblower if it's made up? I mean, I think what happened is like, there were people at the university did not like the result. And so they're like attacking us. Why would they care? I mean, it sounds like it's... I mean, part of it, Rick, is just hubris, right?

So some of the people at a university like Stanford are helping the government make decisions at this time. They're partly responsible for the lockdowns happening. They were afraid that they were somehow part of a great mistake. A mistake. Yeah. They're covering their tracks. Yeah.

And maybe the story they would tell themselves is, well, these guys are just wrong, and they're dangerous because they're wrong. But they're not saying you're wrong. They're smearing you. It's different. If you're wrong, they would try to prove you wrong. That didn't happen. I mean, that did happen, but it was a public thing,

where then the paper improved as a result. But there was also this smearing. There was also this reputational destruction on top of that. And the university, instead of trying to address that by telling people we're faculty in good standing, instead they hold this process. And at the end of it, after they clear us, they don't say anything. They issue no press release. So they announce the investigation, but not the results.

Right. They didn't call it an investigation, but not the results. Right. They didn't call it an investigation. They called it a fact-finding. So they were very clear about that, but it felt like an inquisition. They announce the inquisition, but they don't announce the results of the inquisition at the end of it. Do you know if that happened at either Harvard or Oxford to your two fellow writers? At Oxford, I probably shouldn't say too much because it's for Synecdo's story to tell, but she went through a terrible time.

And it was tremendously stressful for her. And at Harvard, Martin O'Longer works at Harvard, also his story to tell, so I won't go into details, but yeah, it was tough. And a lot of the 60,000 people, many have signed that declaration, the Great Barrierty Declaration, they lost their jobs for signing it.

They lost the ability to work with colleagues on grants, they lost social position as a result of signing. Is it now mainstream understanding that you guys were not wrong? I think that in the public at large, people mostly understand that we were right. They won't necessarily know what the Great Grantee Declaration is, but they understand that there was something wrong with the public health response to the pandemic, that in fact, we didn't do a good job protecting vulnerable older people when we harmed children. That's the substance of the declaration.

And everyone, I think, understands that. There's still the academics and the bureaucrats who designed and implemented a pandemic response are still trying to maintain that it was still the right thing to do at the time, given the information they knew at the time. Just because they don't want to be wrong? Yeah.

Or they believe it? It's hubris. I don't see how they can look at what's happened in the last three and a half years and claim a success at all. So some of them are just, they're just pigheaded. They're gonna go to their grave saying that they were right. Some of them are looking for scapegoats. Well, it would have worked except for these terrible professors that undermined it.

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I roasted with Namibian sea salt, cracked black pepper, and chocolate dips. Snack bars come in chocolate. Coconut white chocolate and blueberry white chocolate. Visit houseofmacadamias.com slash tetra. Based on these people still being in power, what happens next time there's a pandemic, if there is one? We locked down again. Just to be concrete, there was an inquiry going on

in the UK, COVID inquiry. And it's been fascinating to watch. They've had a number of the key players in the pandemic decision-making in the UK. And the line of questioning from the people that are running the COVID inquiry, the official COVID inquiry in the UK is, why didn't we lock down earlier?

Why didn't we copy China more? Why wasn't our lockdown more draconian? One of my colleagues, one of my friends is Carl Hennegan at Oxford University. He testified at this UK COVID inquiry and he was essentially treated like a pariah because he wanted a more measured approach. He actually didn't sign the Great Barrier Declaration, but he was advocating for better protection of vulnerable older people, not harming the lives of young people. And he got absolutely grilled, whereas the people that decided on the lockdowns have

just gotten essentially a pass. We're going to lock down again, Rick, the next time this happens. How were the results of the US's reaction versus, let's say, Africa or, let's say, Sweden, I know, did something very different? It's funny. It's like Africa had among the lowest COVID death rates in the world. Really? Yeah. Why would that be?

They must be the most heavily vaccinated. No, they're not the most heavily vaccinated. They're probably the least heavily vaccinated in the world. How could that be? They're, about 3% of Africans are over the age of 65. And this is a disease that hits old people the hardest. I had an uncle and a cousin, both over 70, die in India from COVID. Right? This is a disease that really hurts older people.

The death rate is something, in 2020, it was something like four or 5%. So there's no place in the world that had a younger population that had high death numbers from COVID. The problem is that there are many places in the world that had high death rates because of the lockdowns. Those killed young people. I see. Actually also kill old people young people. I see. Actually, they also kill old people, both.

I see. And Sweden is a great example, a great counter example, right? Did Sweden lockdown? No. Tell me what happened in Sweden. So Sweden had a policy, they didn't close schools for kids under 16. Did Africa lockdown? Some parts of Africa locked down for years.

And was there a difference between the places that locked down versus not? No. No difference? In fact, some of the, so let me just tell you about Sweden, because Sweden's a great example, right? And was there a difference between the places that locked down versus not? No. No difference. In fact, some of the... So let me just tell you about Sweden, because Sweden's a great example, right? So they didn't close schools, they didn't shut businesses down. At the beginning of the pandemic, they made the same mistake that we made in New York

City. They sent COVID-infected patients back to nursing homes in Stockholm. So you have a big death rate early in the pandemic. But through the rest of the pandemic, they had a much better job giving older people resources so that they could be protected even when the disease is spreading. For instance, they had sick leave for workers that if they're sick, they could stay home without having to worry about feeding their family. So Sweden was more in line with what you were suggesting.

Absolutely. And as a result, if you look from the beginning of the pandemic to now, they have lower age-adjusted all-cause excess deaths. Let me just pull that apart. Age-adjusted means accounting for the age of the population. So we can compare Africa and Sweden if you do the age adjustment.

All-cause excess deaths means not just from COVID, but deaths from everything. And excess means, well, compared to what you had right before the pandemic, the last five years before the pandemic, how many deaths would you have expected? How many did you get, right? That number is lower in Sweden

than it is in all the rest of Europe, and it's much lower than it is in the United States. You can say, okay, well, Sweden has this different healthcare system, the different social system, so that's not a good example to compare with the U.S. But can say, okay, well, Sweden has this different healthcare system, the different social system, so that's not a good example to compare with the US. But you can compare Florida and California. So Florida has open schools.

In fact, I was involved with, there was a lawsuit against the government of Florida and the Department of Education of Florida because of the decision to open schools in 2020. I was an expert in that case. We won that case and they opened the schools in the fall of 2020. Disney World is open in the summer of 2020. Disneyland is closed.

California, my kids don't see the inside of a classroom for a year and a half, public schools. And the all-cause excess deaths, age-adjusted all-cause excess deaths, are lower through the whole pandemic in Florida than California. Florida did a better job pandemic in Florida than California. Florida did a better job protecting human life than California did.

And in a Lesterconian way. Right. Without the unemployment hitting the poor, without kids' lives being restricted so much, without all of the kinds of policies that we followed in California, they still got better results. And I'll tell you why. I think it's very unintuitive to people when I tell them this result. Surely a lockdown would work.

You keep people apart from each other, disease won't spread. The reason they have better results is because the lockdown is a very classist thing. It's only a certain class of people. People aren't going to lose their jobs when you lock down. They can replace the job with Zoom that really can afford to lock down. When you lock down, essentially, you put poor people in a major bind. And you make them make decisions that just are very hard decisions about like, if I go

out to work, I might get sick, but I still have to do it, otherwise, I can't feed my family. That's like the fundamental decision, right? And of course there are essential workers that have to work to keep things going. What makes a worker essential? That was such a violation of norms. Public health does not have the right to tell you-

You're essential or not. You're essential or not, right? We just don't have the right to do that. And yet we took that upon ourselves, let's say, because I've heard from musicians, I've heard from poets that are just, they can't believe that they're called inessential. Actually, weirdly, a lot of people wanted to be inessential.

Professors didn't wanna teach, right? So they're essentially saying we're not essential, right? So it's a very weird thing. Like the essential essentially meant that you are well off in rich, you're a laptop class. And that's high social status, right? That's non-essential. Whereas essential is low social status.

You go out. People who have an actual job. Yeah, that actually have to work. So you have these tremendously unequal societies. You lock down, and people in the upper class, the laptop class, think that it's a virtue to stay home and say, well, most of the world don't have the economic means to do that.

And of course, they're not going to starve their families. They'll go do what they have to do to keep going. And the disease then will spread anyways. How were suicide rates during the pandemic? So in 2020, suicidality went up. A lot of, like, thoughts of suicide went up. I think there was a CDC study in June 2020 that found that one in four young adults

seriously considered suicide during the pandemic, 18 to 24 hours, one in four, a huge increase. But there wasn't increase in incomplete suicides in 2020. But starting in 2021 and 2022, you're starting to see a big increase in ER visits with suicide attempts and increases in even incomplete suicides in the United States and country after country that did lock down. Depression, anxiety at levels that are just unprecedented. Tell me what herd immunity is. How does it work? So herd immunity is a mathematical concept. And it's a mathematical concept that has a

physical analog that's just undeniable. It's just a scientific fact, right? So imagine you have a society that's completely immune-naive. They've never seen a disease. Is it called herd immunity because we think of it as it related to cattle at one point in time? I don't know the history of the term. It's very unfortunate that they have that term, actually, because people can misrepresent what it is. Well, it's something that affects all animals.

It's not even just a human thing. Yeah. It's a biological fact. But let's apply it to humans. You have a country or society or a world that has never seen a disease before. And it's an infectious disease. One person gets the disease, and they go out and do their thing. And the question is, how many additional people do they infect?

Well, every interaction they have might result in a transmission of the disease when nobody in the population has immunity. But suppose now instead, a lot of people have immunity to this new disease and a new person gets it. Every interaction they have will be often with people that have already had the disease, and so there's no risk of transmitting it.

Let's just talk about immunity. Before we get to herd immunity, with many illnesses, once you have it, you get sick, you heal, and then your body has antibodies that now knows that disease. It remembers the disease. And it can prevent it or at least prevent it

from being as strong of a response next time. Is that what immunity is? That's exactly what immunity is. Now, it's not just antibodies, but other cells. Our bodies remember, in a sense, it's like our bodies are a history of all the disease that we've been exposed to. So we adapt to the environment.

That's a version of adaption. Absolutely. And in fact, if we didn't have immunity, we would have been dead as infants. We actually get antibodies through our mom's breast milk. And then our bodies, when we're little, when we're babies, are quite good at adapting to new things that they're exposed to.

Also, all babies would just die. Just like how kids are good at learning new languages, much better than adults, kids are also better at dealing with new biological exposures. It's like a clean slate. Yeah, there's just plasticity to their immune system that can just deal with new things. But once you've dealt with a new thing, your body remembers how to deal with it the next time. The vaccines work this way too, right?

We expose people to some little bit that doesn't make you sick, but that trains your immune system to remember how to deal with it. Just a version of immunity. And our bodies are built that way. Now that's the biological concept, immunity. The epidemiological concept is that if population has a lot of people that have this immunity, then every new additional person that gets the disease

is less of a threat than a society. Because it can't spread to all the people who've already had it. Exactly. There are less potential already had it. Exactly. There are less potential places to spread. Exactly. That's what herd immunity is. I see.

Herd immunity is just that basic biological fact. It's a mathematical fact, frankly. It's a very simple thing. Is there anything that happens, and I'm not saying go to zero, but is there something, is there some number that when 70% of a group gets something, the likelihood of the other 30% getting it go down not just based on the math, based on something else, is that possible? I mean, that's exactly what happens with most many, many, many diseases.

A lot of diseases are endemic in poor countries that aren't endemic in rich countries. So the physical separation of poor and rich countries reduces the spread, protects the 30%. So that's why, for instance, if you go to some country, you may look up the set of immunizations you need as someone who's immune naive going into this setting where the disease is endemic. I see.

So that happens. That physical separation can happen. And just the fact that our world is so unequal causes that to happen. But then also the other thing happens. There may be people who have some resistance to a disease just naturally, maybe because, for instance, they've been exposed to similar diseases.

And also there's just unknown biological reasons why some people are particularly threatened by some diseases while other people are. Understood. There's a lot of heterogeneity. So both of those things happen. When young children get a cold or a flu, does that then make them stronger for the next time they get a cold or a flu or will they more likely prevent getting a cold or flu

next time based on that? So both happen, right? So you can have some diseases. The other coronaviruses are a good example. There are four or five other coronaviruses circulating in populations causing colds. And have been for a long time? Forever.

Forever? Yeah. I mean, I think that there's a theory that in the late 1800s, there was a new coronaviruses that entered the population and caused a massive pandemic. But now it's just a common cold. I see. What happens is you get exposed to that virus as a kid.

Your body remembers how to deal with it. It doesn't protect you from getting infected against that coronavirus forever. There may be variants or whatever. But the next time you are infected with the virus, you remember, your body remembers how to deal with it. And since you got it first when you were a baby, your body was really good at dealing with this new threat.

And so you're gonna get it again when you're four, you might get it again when you're 10, you might get it again when you're 13, but it's just a cold over and over and over again for these other coronaviruses. The problem with this virus was most people had never seen it. In fact, no one had seen it before.

How does the virus appear out of space? How does that happen? That is a whole other story. I think this is disputed, but I'll just tell you what I think. What I think happened is that we have this pandemic preparedness industry funded by the United States government in part. The theory of it is that in order to prevent the next pandemic from happening,

we should go out to the wild places and find the viruses and pathogens that are in the wild places and bring them into labs and play with them to see how likely they are to infect humans. Play with it means sometimes to alter their functionality so they're they are to infect humans. Play with it means like sometimes to alter their functionality so they're more likely to infect human cells.

Why would you do that? Because by doing that you can say, okay, how many mutations are needed so that it can infect a human cell? If it takes a hundred or thousands of mutations that are unlikely to happen in the wild, then that's a virus we don't need to worry about. It's a pathogen we don't need to worry about. Just throw it off. But if there's only a couple of mutations, a few mutations that are unlikely to happen in the wild, then that's a virus we don't need to worry about. It's a pathogen we don't need to worry about.

Just throw it off. But if there's only a couple of mutations, a few mutations that are needed, and all of a sudden it can infect a human cell, well then we better prepare for this thing that might come from the wild place and infect humans around it. You used the word hubris earlier.

It's just the first thing that comes to mind when you tell me this story. It is an absolutely insane program, but that is what we've done actually for the last 20-some years, is we've had a program to try to prevent- Has it ever worked out well? I don't think of any single example that they can point to of having prevented any. Actually, you might even say COVID is an example of a success story.

How do you mean? Well, why do we have a vaccine for the COVID four days after we first discover the sequence of it? That's odd. Yeah, and that is because this virus was a virus that this pandemic preparedness industry had been studying before, including in Wuhan. It's the research that had been done around coronaviruses

and around, particularly viruses very similar to this one that lead to the vaccine being developed, the vaccine target being developed so rapidly after the discovery of the virus. All that, I think, is entirely uncontroversial. Everyone agrees with that. The part that is controversial is the virus itself was the pandemic preparedness industry itself, the

research that was being done in it, the cause of the pandemic. That's the lab leak hypothesis. The lab leak is not even a nefarious thing. It's just I'm working with this thing with pipettes and a mask and my mask slips because it's a boring job and I get sick. I go home, I get my wife sick and then then everyone gets the kids sick, and it spreads. That's a lab leak. That's one theory.

The other theory is that in some bat in some wet market in China or in Wuhan, and it spread from there. Those are the two theories. I suspect that it's the pandemic preparedness industry that's to blame. Based on the four-day response? There's a lot of data points. There's molecular biological evidence There are features of this virus that in my view are not possible that have happened through evolutionary processes

The group so if we know That it's not possible through evolutionary means What would be the benefit in creating that a thing that's not that can't happen through evolution? benefit in creating that, a thing that can't happen through evolution. We create it so we can protect ourselves from it, but it can't happen naturally. It leaves me befuddled. Rick, if you ever... You read the story Pandora's Box, right? You have this box, you want to understand it, so you open it, and all hell comes out of it, right?

I mean, I think a lot of science is just driven by pure curiosity. Well, what if we put a furin cleavage site into this place? What would happen? Maybe we know furin cleavage sites are important for entering human cells in this way. What would happen to this virus if we allowed it to do that? Maybe that's an evolutionary response. Maybe it's possible to get a furin cle few nuclear sites and do a virus that way. And so I mean, I think they're just asking why questions, but they're playing with fire. There are some scientific questions we don't allow ourselves to ask.

So we banned nuclear testing. The scientists would tell you that there are things we learn from nuclear testing that allow us to keep our nuclear arsenal fresh. But we say, no, this is scientific knowledge we don't really want to explore because it's bad for humans. Even the exploration itself is bad for humans. We have these conventions that prevent research on chemical weapons. We just say, this is a scientific area that's outside the bounds of human curiosity.

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Take a breath and see where you are drawn. You mentioned peer review earlier. Tell me about the peer review process, your experience with the peer review process. How does it work? Strengths, weaknesses? So peer review, there's nothing magical about it, right? So I write a paper. I have some idea. I go collect data.

I do the analysis. How many times have you done this? I think I've published 170 papers in my life, something like that. I write this paper and I say, okay, I want other people to believe this paper. I want people to change. You're presenting a case, you're making an argument. Right, and so I send the paper to a journal. A journal is just a place where people collect these papers

and so the editor looks at it and says, well, this isn't really right for the journal. Well, I don't think this is true, and then he rejects it out of hand. That's one possible, in fact, that's the modal possibility. Sometimes the editor says, well, this is interesting, or maybe other people will be also curious about this, but I don't know if it's true. So then they send it to people that they trust, other friends of theirs generally, or other people with some reputation in this field that presumably know something about the paper

I've written. Often they have to send it to like 20 people to get three to agree, but you know, that kind of thing. I know this because I've been an editor of a journal or associate of a journal. So I send it and then these experts who agree to review it will look at it and they'll just, my experience with peer review is they'll be very nitpicky. Well, this doesn't look right, this doesn't look right. And they'll also make a recommendation to the editor.

Take the piece or don't accept the piece. Often they'll say, well, if they can address all these questions I have, then take the piece. And then the editor has a choice to make. They send back the authors along with all of the questions the reviewers have, you change the paper, you answer the questions, and eventually, there may be more than one round, the editor says yes.

So you're all working together to advance science, essentially. Yeah, I round, the editor says yes. So you're all working together to advance science, essentially. Yeah, I mean, that's the idea. Like now we have multiple people who have some expertise in this looking at the paper. That's the ideal, right? A lot of times it's perverted, right?

So for instance, a paper comes into an editor, it's challenging something the editor wrote 15 years ago. And the editor doesn't like that because they don't want their paper to become obsolete. And so they just say, I don't want it. I'm not interested. This can't be right. There's pharma money, special issues funded by pharma. And so they send it to friendly reviewers. They're friends with the person that's sending the paper in, or they're students, or they're enemies with. And it's like the paper in, or their students, or their enemies with. I mean, it's like science is filled with humans, right?

So there's all these petty intrigues that can alter the process. But even at best, what it is is just a few people, five people, thinking about this paper together and saying, well, they've answered my questions. It doesn't mean it's true, it's just we've answered your questions. And then it's published, it's a great day for celebration

because you've gone through this years-long process to finally get this paper that you've been working on for a long time out. And the world at large looks at it like, oh, it's true. It's not necessarily true. But it's always a theory. It's a theory that has been pulled apart and tested by knowledgeable people and they're

on board with it. But nobody knows what's true. Yeah. And there are other things it's really bad at. So there are examples, for instance, of people making things up entirely, making up data. This happened during the pandemic, actually, with some of the top medical journals. There was a paper on hydroxychloroquine, with data, as best we can tell, was entirely made up, or very close to entirely made up.

Really? Yeah. They found that hydroxychloroquine didn't work. Now, I don't think hydroxychloroquine works based on other things, but there's this paper that was published in the New England Journal of Medicine and in The Lancet with this fraudulent data set that found that- Does that happen often? I don't know how often it happens. There was a major reproducibility crisis

in the psychology literature, for instance, finding that a lot of the papers there were not reproducible. How did they get this result if it's not reproducible? Was it made up? Was it because it's just some fluke? There are a lot of incentives to make stuff up, actually. What are the incentives?

You can get tenure. You can get a social position. People will look at you like you published in these journals. Didn't something just happen at Stanford? The president of Stanford had to step down for falsifying data? Yeah. I mean, very close to that. So he published papers in the early 2000s where there was some of the key pictures were photoshopped.

Photoshopped meaning what? Okay, so you have a picture of a neuron and you copy the picture of the key neuron, you put it in another place also in the same picture. To tell a different story than what you actually saw. The defense is, well, it's just to make the story clearer. But yeah, it's like it's Photoshopped. That was the allegation and it was true. But now the defense was, well, look, the result is still right.

And it was part of what we just did at the time. Like, this was accepted by the journals at the time. So that means the peer review process accepts certain things that if you tell regular people about it, you go, what the heck? Well, how can that be? That happens all the time. Like, there are norms in science that shouldn't be norms. And all the peer reviews agree that it's a norm, and then we just don't even think about it. We have blind spots.

You don't actually send the actual data to the peer reviewer. The peer reviewer is just reading the paper. They're not trying to replicate your result. They're taking your word for it. That the- So nobody tests the data. The data is just always accepted.

Yeah, so while the open science movement, which we talked about before, the norm is that if you have a published paper, you also make the data publicly available so anyone can go check. But that doesn't make it true. But at least there, now someone can go check. It's now someone else can test it. Yeah, someone can go check it. Although, how many people are going to test data in papers?

If it's a really controversial result, you'll get a lot of people. If it's the modal result, no one will look at it ever again. Tell me what it was like editing. It's hard to get people to agree to review a peer review of paper. It's completely thankless. Generally, it's anonymous, and you have to read carefully somebody else's work. That's not advancing your career. And so getting people to review a paper.

And then when the peer reviewers come back with lots of questions or criticisms that the author think is unfair, and you have to tell the author, I can't take the paper, they get very upset with you, the editor. So in a way, it's like a thankless job. But it is, on the other hand,

it's like you get to see new results, you get to see people discussing important topics about that you care about. It's actually, it's like, you get to see new results, you get to see people discussing important topics about that that you care about. It's actually, in that sense, great fun. Can you remember the most interesting story that you got to edit for a journal? I mean, there have been some results I was looking at around the way the disease spread in nursing homes

that was quite interesting, actually. They tracked people using their phones, nursing home workers, from one nursing home to another, because they work in multiple nursing homes. And they show that that actually spread the disease, the COVID, into multiple nursing homes because of the way we structure our nursing home labor. I thought it was a really interesting result.

Really interesting. Yeah, I mean, it also suggested a policy we could have done. We could have restructured nursing home labor. I thought it was a really interesting result. Really interesting. Yeah, I mean, it also suggested a policy we could have done. We could have restructured nursing home labor so that we reduce some of that. What would you say we've learned from the pandemic that's gonna make the response to the next pandemic if there is ever one much better than last time? I can tell you what I hope we've learned

and I can tell you what I fear we've learned and I can tell you what I fear that we haven't learned. Okay. So first of all, the pandemic policies that are best suited for the relatively well-off are not well suited for the poor. I call it trickle-down epidemiology. The theory is that we protect the laptop class and that automatically protects everybody else. That's a lie. And we've learned that doesn't work, I think. And we've learned that those social disruptions of the lockdowns harm the poor, the working class and children in ways that are not recoverable. So just one example that we haven't mentioned is what happened to the poorest people in

the world. The UN World Food Program in early April 2020 did an estimate suggesting that 130 million additional people would face starvation as a consequence of the economic dislocation caused by the lockdowns. We closed schools in all over the world. Let's just take Uganda. We closed schools for two years in Uganda. There's no Zoom school for many of those kids. They don't have electricity. Many of them never came back after two years in Uganda. There's no Zoom school for many of those kids. They don't have electricity.

Many of them never came back after two years out of school. We have accelerated inequality into the next generation. And if you look into why they didn't come back to school, a lot of the families were thrown into such dire poverty that they had made the decisions whether to send their kids into sexual slavery or child labor. Why would a family do that? Because an alternative was that the kids would starve, but the family would starve. We put a tremendous number of people into dire poverty with the lockdowns.

That is, I hope, a lesson that we've learned, that you can't just stop the world and think that it's going to be good for health when for the vast majority of the world, billions of people, it's tremendously bad for health to have the world stop in that way. I think we've learned, at least I hope we've learned, that when you have a situation like we had with COVID, that you can't just say some scientists with actually really narrow expertise, epidemiology, virology or immunology, should be able to make decisions for everybody else. The world and infectious diseases even

are much more complicated than that. And they need many, many, many minds with many different kinds of expertise. I remember the early days of the pandemic, because I have this economics PhD, people would tell me, why are you talking? Like my friends would write to me saying, it's not time for economics.

I was actually talking about epidemiology then, but that idea that we shouldn't have other people with different expertise, we should have had poets. We should have had philosophers. Well, you never know where you're gonna get information. Like the idea that the only people who have any information is the believed expert in that area, I think it's a small way of thinking. And you had this like scientific bureaucracy that was hubris was the watchword.

Like you had Tony Fauci going on CNNs complaining about Rand Paul's criticizing him saying, look, if you criticize me, you're not simply questioning a man, you're questioning science itself. I mean, you're questioning science itself. I mean, think about that, Rick. Why would you, who would think that about themselves? To put themselves in a position of like, just godlike position. We should not be trusting people into that. Where do these decisions come down, especially on a global basis?

I understand it when it happens in a country, but when the same things are happening all over the world, how does that happen? How does that work? The World Health Organization issued a report in February 2020 saying that what the Chinese did worked, that lockdowns in January 2020 had worked, and they recommended the world lockdown. And country after country followed that advice. They looked to the United States also.

A tremendous number of people, epidemiologists, the scientific community, a lot of science of the world runs through the United States. And you had top scientific bureaucrats in the United States fully endorsing a lockdown in March 2020. Advising governments everywhere, they also had the lockdown. Is a one size fits all solution globally? Ever a good idea for anything? No. I mean, well, you know, I just-

No, is there any case where the right thing to do in Africa is the same as the right thing to do in the Antarctic? I guess I could think of a few things, right? So like, you know, we wanna make sure that antibiotics are available if there's a bacterial infection, right? That like, you know, we want to make sure that antibiotics are available if there's a bacterial infection, right? That's the right thing to do everywhere.

You want to vaccinate kids for measles everywhere, right? Measles is a deadly disease for kids. That's why the vaccine is such a boon. But to answer your other question, I think for the vast, vast majority of decisions that we make, what's good for one country isn't necessarily good. And certainly what's good for one country isn't necessarily good.

And certainly, what's good for a rich country is not necessarily good for a poor country. In Africa, they stopped vaccinating children. They stopped malaria control efforts. They diverted those things to COVID control. Well, COVID is very far down the list of problems in Africa. Malaria is a much bigger problem in Africa. Measles, all the childhood diseases are a much bigger problem in Africa. We took public health resources and diverted it from things that really mattered to things

that were something that didn't because we were scared. Music you