The Joe Rogan Experience - #1566 - Nicholas Christakis

Episode Date: November 18, 2020

Nicholas A. Christakis is the Sterling Professor of Social and Natural Science at Yale University, where he also directs the Human Nature Lab, and serves as Co-Director of the Yale Institute for Network Science. His most recent book is Apollo's Arrow: The Profound and Enduring Impact of Coronavirus on the Way We Live. https://www.amazon.com/Apollos-Arrow-Profound-Enduring-Coronavirus/dp/0316628212

the joe rogan experience train by day joe rogan podcast by night all day yeah i got into cigars lately i did sober october and uh during the month of october uh no drinking at all i started smoking cigars how did the Sober October work for you? It's great. I do it every year. It's nice. A little reset. It's interesting. You know, I mean, I have another friend of mine

who stopped drinking altogether and he said that it was making him cranky when he was drinking and of course there were extra calories and I listened patiently to him and thought I would love to do that but at the same time it's hard to give up completely. I enjoy a glass of wine with a meal.

That I miss the most. That was the worst when I was having a steak and I'm just like, God, I'd like a nice glass of red wine right now. But other than that, I don't drink much. I'm not much of a boozer. Although when November kicks in and I know I can drink again, there's usually a few days of excess. Which is, speaking of the subject of COVID-19

and the current pandemic we're into, that's not a good thing. There's a lot of people out there destroying their immune systems drinking. There's a very funny video that I found online of this gentleman who runs around his neighborhood, and he noticed that during the lockdown this gentleman who runs around his neighborhood. And he noticed that during the lockdown, he would run around his neighborhood and he would see the recyclable bins. And they were just filled with empty alcohol containers. He's like, this is crazy.

This is for the week? Like how much are these people drinking? Just vodka and wine. And there's a lot of that going on. Yeah, people have actually looked a little bit at that, at alcohol consumption. And it's a little bit like the toilet paper shortage. I don't know if you followed the whole toilet paper shortage thing. Well, what's happening is there's a shift in consumption. A lot of the drinking that was taking place in restaurants and at bars is now taking place at home.

So I think it's like half and half, like half the consumption in the past was at home and half was out of the home. And now it's almost all at home, which is part of it. But I also think as you're suggesting, the actual amount is going up too. So yes, it's, you know, and it's contributing to weight gain

and other problems in our society. The toilet paper thing, there's an easy fix for this, folks, that's way better. And I hate to do this to plug a sponsor, but it's a good sponsor. There's a sponsor called Tushy. And Tushy makes a bidet attachment that just fits onto a regular toilet and it cleans your butt. They're only 79 bucks and it's fantastic.

It cleans your butt so much better than just toilet paper. And it cuts your toilet paper consumption down by like 85%, 90%, because you just need a little bit of toilet paper to pat your butt dry at the end. Do you ever use one of those, bidet attachments? Well, in Greece, they're not uncommon to have bidets. So, of course, I'm familiar with them, but we don't have one here. You should get one. You should get one. Say that again? You should get one. I'm telling you, it's with them, but we don't have one here. You should get one. You should get one.

Say that again? You should get one. I'm telling you, it's so much better. We may. We may, in fact. You should. So I can't believe we've covered alcohol and bidets already. Yeah.

So let's talk about this. What made you decide to write a book on the current pandemic and the disease? Well, I mean, mean for me it started i was reading news reports in january about what was happening in china but i wasn't paying a ton of attention and then i have these uh chinese colleagues with whom i've been doing research for a long time and they contacted me in the middle of january we had been using phone data in china to study how earthquakes, for example, change human social interactions. So after an earthquake, who do people call? And we could imagine that the first person you call is very important to you, for instance. And

so we could use the phone data to study social interactions. And so we decided to use the phone data to study the pandemic and to study the movement of people through China and how they might carry the virus with them, which started in Wuhan in November sometime. the Chinese were so concerned with the virus that they basically detonated a social nuclear weapon and they put 930 million people, almost a billion people under home confinement starting January 24th and I could see that in the data and that really got my because the emotions ceased. People stopped moving in the whole country. And that really got my attention. And I got worried. And it was clear to me that this was going to be a serious global pandemic. And so I began to redirect the activities of my laboratory at Yale to study more and more about what was happening with this virus. And we did a whole bunch of projects, some of which, if you're interested, we can talk about.

We released this app called Hunala, H-U-N-A-L-A, Hunala, which you can get thousands of people use it now. It's like Waze for coronavirus. It's not a contact tracing app that looks backwards. It crowdsources information about who you're connected to, which is one of the things I study is networks, and where you live and forecast your risk. So people down the road from you are

reporting a traffic jam or a cop, and you can exit the highway and avoid that. And people, your friends, friends, friends are reporting a fever. It can ripple back through the network and feed this information to you, all anonymous. It's anonymized. It doesn't report who is having what. Anyway, and the app, incidentally, temporarily accesses your contacts. We don't copy the contacts. It doesn't copy that, but it makes it easier for you to identify who your social connections are. Anyway, so we did that.

We did a whole bunch of other stuff, which maybe we'll talk about. And so in the month of February, as we were doing all this work, I was getting more and more worried and that our nation wasn't preparing. And so in March, I started sending out some Twitter threads like Epidemiology 101, like basic stuff. And a lot of those started to go viral

and people were so hungry for information about it. It became clear to me, you know, factual information about what was happening. And then in the middle of March, my editor, my long-term editor at Little Brown, a woman by the name of Tracy Behar, contacted me and said, would you like to write a book? And I thought, yes. And my motivation was that I wanted to help the American public understand what we were facing. And I was very worried that people weren't taking this seriously enough. And so that's why I wrote the book. I wrote the book because I thought this is something I know about. This is something I care about. I care about our country. I didn't see our leaders as

doing the things they needed to do. And I just wanted to help people understand what was happening and what was likely to happen. What do you think should have been done that wasn't initially? Like in the January, the month of January, it's when everyone was alerted to the fact that this was going on in China. The White House knew, everyone knew, but we didn't really lock anything down until March. What do you think should have been done? Well, first of all, people like me knew this was going to be a serious global pandemic for sure by the end of January. And the president, we now know, unsurprisingly, was briefed even earlier, right?

I mean, if the president didn't have more information than me, then there's something wrong in our country. But certainly by the end of January, when China locked down, as we discussed, we should have begun immediately preparing our testing capacity, manufacturing PPE. We should have, I think, begun the incredibly important challenge of preparing the nation for the challenge we would face, like gearing up for a kind of war. We were about to be invaded by the virus. So public messaging would have been really important to tell people, we're facing a common threat. We're going to have to endure some sacrifice. We're going to have to

work together to repel this threat. Here's some basic information about the nature of the threat. So all of these things are ventilators, for example, also another sort of material that we needed. Preparing our hospital systems, for example, we lost several months in which we didn't really prepare. And honestly, I don't understand why our leadership failed us in this way. Who's responsible for that? There's also an issue where the pandemic response team that was in place for the previous administration was disbanded and sort of reassigned, correct?

I don't know. Yes. I don't know all the details about that. I know it wasn't just the Obama administration. They inherited the pandemic response from the Bush administration. And the CIA has been identifying emergent pandemics as a serious national security threat for a number of decades now, as I actually discuss in the book. people like Bill Gates have been warning about this. Tony Fauci was writing about this stuff when you and I were in elementary school. So there's a lot of institutional knowledge about the existence and nature of these threats. And so I don't know why we weren't better prepared when we saw what was happening in China. What could have been done differently? I mean, obviously, manufacturing of PPE and all those things, that absolutely should have happened. And that would have actually avoided a very unfortunate thing that happened where Fauci actually was telling people they don't have to wear masks. And he later admitted the reason why he did that is because he didn't want people rushing to get masks. And that would take masks away from the first responders.

That's a very, very unfortunate thing that he did because that eroded people's confidence in what he's saying. It lets you know that there are people that are in positions of power like himself or positions of influence that will lie for the better good but still lie. Yeah, so let's not – so the details of the Fauci statement, I honestly don't know. I haven't dug deeply to know exactly what he said and when. I can retrace for you some basics, however, about mask wearing early on. I actually put it on my Instagram because it was so crazy when he was saying it. It was an interview that he did on television,

and he was saying for the general public, you know, you don't have to wear masks. It's not helping you. And he was actually saying it might be bad because you'd be messing around with it and touch your face. Yeah, you could. So initially, it was a little bit, initially, there was ostensibly some confusion about whether it was advantageous to wear masks or not. It's clearly advantageous. It's advantageous to the wearer and it's advantageous to others. It reduces the stress on the system if everyone were to wear masks. And just to be very, very clear, it's neighborly.

Wearing masks is like driving the speed limit or not driving on the opposite side of the road. And there's now abundant evidence on the benefits of mask wearing. And furthermore, and then I'll come back to your Fauci issue, if we were to all as a nation wear masks and adopt some other basic things, it would allow us to keep our economy running better and our schools open. In other words, we can't have everything. There's a deadly virus that's afoot.

And so we're going to have to grow up and be mature do some things that are uncomfortable and unpleasant and may even seem silly but if we do those things we can we can avoid doing other worse things like shutting down our economy but anyway can i can i stop you for a second there because this is something that's actually kind of important when people are wearing masks here's like this is the common argument against it is that the virus particles are so small if you're breathing in air and it's getting through gaps in your mask, the virus is going to get through. But the impact of having a mask, the positive impact, is that if there is some virus in the air or virus coming from you, it's going to be greatly reduced. Correct?

Especially an N95 mask. You know, there are two parts to what you're saying. First of all, water molecules are infinitesimally small, and they're much smaller than the pores on the fabric of your umbrella. But your umbrella stops the rain. Why is that? Well, it's that the water molecules aren't coming down as molecules, they're coming down in droplets. So even though the virus is very small, much's that the water molecules aren't coming down as molecules. They're coming down in droplets.

So even though the virus is very small, much bigger than a water molecule, but still very small, and you're right that the virus itself could go through the fabric of a mask, that's not what's happening. Droplets are coming out of your mouth or are coming from someone else towards you. And the mask is extremely effective at stopping droplets. But hasn't it been shown that the virus is also aerosol now? Yes. So there's also aerosol transmission. And we can talk about that too. Obviously, yes, let's talk about that. But before we move to that, let's just stay one more sentence on the droplets, which is that when you exhale,

think about how if you had a fire hose at your house and the water was spraying out of the fire hose, and you had two different strategies for stopping the water from landing on the floor of your house. One strategy would be to run around with buckets and try to catch the water as it was landing from this arc of the fire hose. And another would be to put a kink at the end of the fire hose and stop the water from coming out in the first place. One of the reasons that masks are so effective, even homemade, handmade masks, forget the N95s, which is what I wanted to come back to, is that they are like plugging a fire hose or a garden hose at the opening. It's much more effective than trying to have someone else wear a mask, for example. So you're wearing a mask

and furthermore in the case of coronavirus, one of the big problems is people don't know if they're sick. This particular germ is very nasty. You can transmit it before you have symptoms. So one of the reasons for people to wear masks is they don't know they're transmitting the disease. It's very efficient to stop the viral droplets before they leave their mouth and from spreading to others. And when you wear a mask, you also protect yourself from inhaling droplets of other people. The N95s are more medical grade masks. They're even better than the cloth masks that you can buy on the Internet. But those, if you're going to use those effectively, you have to seal them around your face and use them.

And you don't really need to use them, those. I mean, you can if you have them. There's nothing wrong with it. But you also don't want the ones with valves. Those don't really help you. Yeah, the valve ones are kind of silly, aren't they? Yes. That defeats the whole purpose.

It can do it. It still helps. But yes, these are all relative things. Now, on the aerosol thing, what you're talking about is some of the things that you exhale from your body are little dried particles of viruses that are suspended in the air. And these can go a further distance. And there is, in fact, evidence of aerosol transmission, which is different than droplets. Both go through the air, but droplets are big and fall to the ground, whereas it's like raindrops versus little particles of dust that can float in the air, for instance.

And so there is aerosol transmission, and the masks that we use don't necessarily stop that. You'd need like an N95 mask well-fitted to stop that. But the masks still help. So I don't think there's a really good argument. I mean, I wish we didn't have to wear masks. I mean, I, you know, it's unpleasant, but of all the unpleasant things, you know, we could choose from doing, you know, if the choice is, do I close the schools in my local community or do I have everyone wear masks? To me, that's, you know. Yes. It's pretty straightforward

and simple. There's a great video online that I saw this morning of a guy who held up a lighter and he used a bandana first and he blew through the bandana and put out the the the lighter and then he put on a cloth mask and it was hard to blow through, but he did it and put out the lighter. Then he put on an N95 and it didn't do a damn thing. Put on a surgical mask. It just wiggled the flame a little bit, couldn't put it out. So it just shows you the difference in the quality of the mask.

My doctor does not recommend bandanas. He was saying, don't wear that. He's like, please. It barely stops anything. And if you're going to wear something, please wear a mask, an actual mask. Yes. Although, again, I would say that something is better than nothing. And one of the things that – one of the things I think is going to come up in our conversation, and we might as well tackle it now.

I was trying to think of like – well, I was trying to think of sort of general principles that are relevant here. There's no – in a time of a deadly contagion, Joe, there's no life without risk. In a time of a deadly contagion, Joe, there's no life without risk. And many people are used to thinking about risk in their lives, but many are not. And I think what I would like people to understand is that the world has changed. There's a new virus that's entered our species. It's not going to go away. It's going to be with us forever.

And we have to, first of all, accept that. Second, take steps to address it. And third, recognize that no single step is perfect. Even a vaccine is not perfect. So everything is shades of gray and degrees of risk. So for example, even the 14-day quarantine rule, that's just a statistical distribution. 2.5% of people are still infectious after 14 days. We just cut it off at 14 days. We can say, well, almost everyone can't spread are still infectious after 14 days. We just cut it off at 14 days.

We can say, well, almost everyone can't spread the virus anymore after 14 days. But it's not true that no one can spread the virus. So there's still some risk. Or you can wear a mask and it reduces your risk, but it doesn't eliminate your risk. And so pretty much everything we do is not perfect. And so we have to begin as a society and as households or as individuals make decisions about what risks we're willing to tolerate. And, yeah? Jamie brought something up this morning that people that had SARS, it showed that they had immunity to COVID-19.

Jamie, what were you talking about earlier? It was saying that I might have misunderstood or miss said that to you, but they were comparing immunity to SARS. They said that they were still carrying important immune cells 17 years after recovery. And they're saying that might be the same sort of thing with coronavirus, that you might have immunity for a long time. But there have been people that have been reinfected in as early as three months. Isn't that correct? Yeah. So this is, again, another complicated topic. So, yes, we now have some evidence that some people can be reinfected, but it's probably extremely rare. We don't know 100 percent, but it is probably extremely rare. extremely rare. We don't know 100%, but it is probably extremely rare. And part of the reason is that if you get COVID and they test you, and then three months later you get COVID again and

they test you again, they found you. And they say, aha, this person had it before and isn't immune. But there could be hundreds of thousands of people who also had COVID who were re-exposed and didn't get infected, didn't get symptoms the second time. And so nobody tested them. So you see, we only ascertain, we only see the ones that in fact do get reinfected. So you are right. There have been now some cases proven with genetic testing that have been infected more than once, but we still think it's rare. The thing that Jamie was alluding to is there are two parts to it. One is how long does the immunity last? And honestly, we won't know the answer for sure until time passes. There's no way to be certain. But we do believe that immunity will be sustained, will be reasonably sustained. And furthermore, I don't want listeners to confuse the difference

between antibody levels declining and you're being immune. So when your body's infected, you mount a defense, a response, and you produce antibodies. And for almost all infections, those just decline over time. And in fact, with coronavirus, those circulating antibodies, those proteins that attack the virus, go down to very close to zero by about a year, let's say. And this was completely expected. There's nothing surprising about this. But your body has in the interim also begun

to develop something called memory immunity or T-cell immunity. And that's what protects you from reinfection. And we believe, we have evidence for that people have sustained such T-cell memory immunity. How long that lasts. So Jamie was saying with SARS-1, which struck us in 2003, people can find evidence that even 17 years later, you can mount an immune response because your body remembers that it fought off this thing

17 years ago. And one more thing, and that is all different than the question of cross immunity, which is also becoming now people are, I mean mean the whole country is getting an immunology lesson. Yeah. Which is that – Which is probably good. What did you say? I said which is probably good. I mean it's about time that people recognize that in terms of pandemics, this is – I don't want to diminish the death or the suffering or anything, but it could have been far worse.

I'm so glad you said that because on the one hand, this is a bad germ. So roughly speaking, it'll kill about 1% of the people that get it symptomatically. You get this disease, you have symptoms, you've got a 1% chance of death. It varies by age, and we can come back to that too if you're interested. But as you're saying, it could have been so much worse. I mean, there's no God-given reason this virus isn't killing 10% of us or 50%, like the bubonic plague. And if you remember the movie Contagion, I think in the movie Contagion, it killed about a third of the people that got it. And there's honestly no reason that this, I mean, we could have been facing that situation. There's

no necessary reason we're not facing that situation. So you're right. It could have been much worse. And in fact, the 2003 coronavirus killed about 10% of the people that got symptoms from it. So it was about 10 times as deadly as the one we're facing now. Why has there been so little discussion, especially from our governments and our leaders, about methods to strengthen your immune system. That has been particularly frustrating to me. There's been so little discussion about vitamin supplementation, about changing your diet, about exercise, keeping yourself healthy, making sure you get enough sleep, lowering alcohol consumption, all these things that have been absolutely proven to boost your immune system. Why has there been, not negating the use of masks or social distancing

or all the other things that we know are effective, but why has there been no discussion about boosting your immune system? I don't know, but it's a really good question you just asked. So you're right. There are all these sort of healthy living things you can do from exercising, getting better sleep, reducing stress, losing weight, reducing alcohol and tobacco consumption. All of these things that enhance the ability of your immune system to fight off infection. And that has not been part of the public health messaging campaign.

I don't know the reason for that. It should be, actually, now that you mentioned it, we should be encouraging people to do that. I have to say, however, that I don't want us to get into a situation in which as many very fit people can get this germ and die. And also people can be behaving well or poorly and get this germ and die. And as a doctor, you know, I'm very understanding of human beings frailties. You know, we all are human. We we're soft on the outside and we don't deserve to die of a germ or anything else as far as I'm concerned. And so I don't want us to say, oh, well, so-and-so was a beast or so-and-so, you know, was a smoker. And so, you know, they deserve their fate.

No, no, no. We're not saying that. I know. I know you're not. But I'm saying on the one hand, I want to encourage good behavior. On the other hand, I want us to be careful not to suggest that you weren't doing it. But I'm just sort of clarifying the point. That it's your fault if you catch it and die.

Yes. Right. Of course. Of course. Yeah. Yeah. No. die yes right of course of course yeah yeah and people who and i think you know and i think um i think people should be should prepare their bodies for the possibility of being infected

but realize that there's no guarantee you know it's like those poor marathon runners that drop dead you know having run marathons their whole lives you know it's jim fix yeah that was jim fix is a famous guy who wrote books on running and Bill Hicks had a hilarious joke about him running and dying. Yeah, that's unfortunate, but that's probably some sort of cardio disease that he had. There's ways that the government could have done it without shaming people that did get sick. I mean, it wouldn't have taken much time to tell people. I mean, I've had multiple health experts on this podcast that talk about different methods to strengthen the immune system, particularly supplementation with vitamin D.

It seems to be, and Fauci's talked about this as well, seems to be particularly effective with boosting your immune system and also it's a giant problem with people um who are uh who wind up in the icu um there's a recent study that showed that 84 of the people in the icu with covid uh were deficient in vitamin c and only four percent had sufficient levels um and i'm sure go ahead So no, I haven't followed that particular literature, but as someone who loves the sun, and I could strongly endorse getting adequate sun exposure for vitamin D alone. Yeah, but you know the sun is the best way

to get vitamin D, for sure. But the way to get it through the sun requires you to be in shorts and nothing else like a like a neanderthal running around all day that's how we're designed i mean that's like that's really what we're supposed to be doing that's it's very unfortunate that we figured out houses i mean it's kept us alive and kept us protected from predators and the elements and all sorts of other things that would have killed us, but it severely diminished our ability to absorb vitamin D from the sun,

and vitamin D being not just a vitamin but also maybe even possibly mislabeled as a vitamin. It's really a hormone, right? Well, it can be a precursor to hormones, yes. But I think that, boy, you've wandered into an area that's sort of, I'm trying to remember my medical school. The last time I thought about vitamin D synthesis. But my memory is it doesn't take much sun exposure per day for your body to produce adequate levels of vitamin D. I think an hour a day or something like that. But yes, in general, you're right. That is to say that a lot of the ways we live in the modern world compromise our immune systems and their functioning.

I think there's very few people that are actually getting their blood work done. So even when you say an hour a day give you sufficient levels, how many of these people are actually going an hour a day and then getting blood work done and finding out what the actual vitamin D levels in their blood are? Very few. It's highlighting a weakness in our understanding of our own bodies. See, this part I would certainly agree with, Joe, in the sense that as a nation, in a way, we've... How to put this exactly? I don't want to say we've become soft, because that's not exactly what I want to say. It's sort of like, you know, we want our cake and eat it too.

And in a way, that's sort of what I'm trying to talk a little bit about with respect to the pandemic as well, which is that we all wish that we didn't have to endure this unpleasant reality that this virus is now afflicting us. It's a little bit, and we're all tired, you know, we all have COVID fatigue, but it's a little bit like being in the dentist's chair and he's done two root canals and you don't want him to do any more. But you're not wanting any more root canals has nothing to do with whether you need them. You know, unfortunately, this is the reality that we're facing. And so what I really want, and what I wanted to do in the book in Apollo Zero was to sort of help people to see the world for how it really is now, which is that something big has happened. Something that doesn't happen, but every 50 or 100 years or so.

And more importantly, this way the virus has forced us to live, which feels so alien and unnatural to us. In fact, this way, it's not new to our species. It's just new to us. You and I think this is outrageous. How can we have to do all of this stuff? But, you know, our ancestors have been dealing with this for thousands of years. We're not the first generation to have to do this. This is our time in the crucible. And I would hope for thousands of years. We're not the first generation to have to do this. This is our

time in the crucible, and I would hope for better for us. And in terms of crucibles, it's so small. I mean, again, not to minimize the death and the suffering, but I'm in the middle of reading Harari's book, Homo Deus, and in it, the beginning of it, he talks about famine and plague for most of the first chapter. And just the sheer numbers of people that have died in past plagues throughout human history before antibiotics and before we even understood what viruses were. I mean, it's horrific. Horrific. I mean, the bubonic plague would sweep through cities in Italy and kill half the people. Like within a month, half are dead.

Or smallpox, when the Europeans landed in our continent and they brought with them old world diseases to the new world, smallpox would wipe out Native American populations. 95% of the people would die. Yeah, yeah. Insane. Yeah. Yeah. So we're very... populations you know 95 of the people would die yeah yeah insane yeah yeah and so as you're yeah so we're very fortunate in terms as we said before that this is the disease we're dealing with i think in many ways this is going to give us a much better understanding of what could happen and and give us a better better understanding of what we need to do if something new comes along. Yes. I mean, I think that's right. I mean, I think, I mean, you're kind of,

I'm actually glad that you're going there because one of the things I don't want, I don't want to be seen as this like nihilistic, doomsaying, you know, pessimistic guy. Too late. And so, too late, yes. I'm glad you are bringing up the fact that actually there could be another pandemic. Yes. And usually, usually if you look at the respiratory pandemics for the last 300 years, the inter-pandemic interval is about 10 to 20 years. That means we have a pandemic every 10 or 20 years, but they're not deadly, usually. So, for example, we had one in 2009, the H1N1 pandemic.

Most listeners might have a vague memory of hearing about it, but people didn't really pay much attention because it didn't kill many people. It was like a common cold. So, we had a pandemic, but it wasn't very deadly. Then we had the 2003 previous coronavirus, the SARS-1 pandemic. It spread to about 30 countries. But for various reasons, that pandemic extinguished, and we only had about 8,000 people worldwide who died of that. So we'd also sort of forgotten that. The last serious pandemic we had of influenza A virus, it's a different virus than the coronavirus, was in 1957. That was the second worst pandemic we've had in 100 years.

And the previous leading killer was, of course, the 1918, the so-called Spanish flu pandemic. And the current pandemic we're having will be almost as bad as that in the sense that, just to be clear to listeners, it's not going to kill tens of millions like that pandemic killed, we don't think. But the point is, the current pandemic we have is the second worst that we have had in 100 years, worse than the 57, which was the previous second worst. So pandemics come every 10 or 20 years. They're only really bad, let's say, every 50 or 100 years. But there's no reason that we couldn't have another one soon, you know? And in fact, right now, there's surveillance systems in place in China which monitor the

emergence of new influenza strains. And there was just a paper published a couple of months ago suggesting there's a serious strain of influenza blooming, brewing, I'm sorry. So, you know, we'll see. blooming, brewing. I'm sorry. So, you know, we'll see. This one is a weird one, right? Whereas a lot of people get it and they're asymptomatic. I've had several friends that got it and literally experienced no symptoms. They were around people that had it. They got it. They tested positive and got as little as a mild headache or a slight cough for a day Jamie had it and he thought he had a sinus infection he thought he has allergies and he thought it was just his allergies kicking in turns out he was positive but he was very fortunate it was a very mild case do we know why when some people get it,

it's devastating, including young people? I have a young friend, he's 28, he got it, and he was really ill for two weeks, whereas some people get it and it's nothing. Yes. So we have some sense of some of the reasons it varies, but not a huge understanding yet of the interpersonal variation. But I would like to go on a tangent based on that, that highlights the ways in which these kind of protean manifestations of this disease, the fact that with this condition, you can go from everything from having no symptoms to mild symptoms like Jamie, to more serious symptoms like your 28-year-old friend, to really severe symptoms, to being hospitalized, to dying, right? There's this incredible range of diseases that this particular virus can cause. And in a way, this is very unfortunate for us because it makes it so much harder as a society to take the virus seriously and to combat it. Let me give you an analogy.

So I want listeners to imagine that there are two worlds. I'm about to describe two different worlds. In world A, there are 1,000 people. And a virus infects 10 people in this world, makes them seriously ill, and one person dies. So we would say that in this world, 10% of the people that got sick died of the virus. That's world A. In world B, there are 1,000 people. The virus infects 100 people.

90 of them get mild illness. 10 of them once again get serious illness, like in world A, and one of them dies, again like in world A. So in this world, in world B, 100 people got sick and one died, so we might say 1% of them died. In world A, 10% of the people that got sick died. In world B, 1% of the people that got sick died. Now, many people hearing about this might think that it's better to be in world B because it seems like the virus is less deadly, but that's a delusion. Because if you stop and you think about it a little bit more clearly, world B is the same as world A, plus an extra 90 people got mild illness. In other words,

no right-thinking person should prefer to be in world B than to be in world A. In world A, 10 out of 1,000 people got seriously ill and one died. And in world B, that happened, plus another 90 people got mildly sick. it's clearly worse the overall situation is worse than world b and that is in fact the situation that we are facing we are in a like a world b situation with this virus and the reason it's hard is that it all these extra people those 90 people who got mild illness make people take the disease more you know casually whereas in world a people might say, well, not many people are getting sick, but when they get sick, 10% of them die. Wow,

we should take this disease seriously. Do you see what I'm saying? Yeah, I do see what you're saying. So this virus is very sneaky in that way. Yes. It's really like, if you wanted to engineer a virus that's going to spread the most, that's kind of how you would do it. Have it affect so many people where they're like, it was nothing. And then some people where, you know, they're dead within a few days. Yes. And also, as you pointed out earlier, it also has this property of being transmissible when it's asymptomatic. So just to remind people, HIV is like that. You can have HIV for years and

not know it. You're spreading it to your sexual partners, and then it kills you much later. Versus smallpox, which you can't really spread smallpox before you have symptoms. The pustules erupt on your body, and that's when you become infectious. So there's no asymptomatic transmission in smallpox, and there is in HIV. And SARS-1 from 2003 was more like smallpox. In other words, people didn't begin to transmit the virus until they actually had symptoms from it, which is one of the reasons it was easier to control, because when people got symptoms, we could isolate them. Whereas with the SARS that we're facing now, the SARS-CoV-2, COVID-19, people can transmit it when they're not symptomatic. And in fact, there's a lot of analyses that have been done that show about 75% of the

infections have been acquired from people who are asymptomatic. There's another issue as well that we can compare to smallpox in that you can develop a vaccine for smallpox that actually works for your whole life. You can't really do that with COVID, correct? We don't know for sure. We don't know that for sure. I don't know that for sure. I'm hopeful that we'll be able to have a vaccine that confers long-term immunity, but I don't think we know that either way for sure. Can you describe what's going on with these I don't think we know that either way for sure. Can you describe what's going on with these mRNA viruses and how they differ, excuse me, mRNA vaccines and how they differ from a regular vaccine and what's coming down the pipe from Pfizer? These are mRNA vaccines.

It's different in that it doesn't actually contain the virus, but it boosts your body's ability to fight off the virus. but it boosts your body's ability to fight off the virus. Yeah, so there are many different ways of developing vaccines. And the idea, the general idea behind a vaccine is that we want to give you kind of an ersatz infection. We want to expose you, make it as if you had been infected, but without the risk of getting the disease to trick your immune system into mounting an immune response so that your body is then prepared if it gets the real infection to fight it off. And one of the simplest ways you culture it hundreds of times and hope for mutations that weaken the virus's ability to make you sick, but nevertheless keep

the virus able to elicit an immune response. And then we give you that strain as a shot and you have, let's say, a mild illness, you develop antibodies and immunity and it's sustained. Or you can have inactivated virus, like one of the Chinese, the Sinovac vaccine that was one of the first to start, which was out of China, is a live attenuated virus. So that is, oh, I'm sorry, did I say live attenuated already? I can't remember. But anyway, the Sinovac vaccine is a virus in which they take the virus. I'm sorry, no, it's not like the previous example. In this case, we take the virus and we treat it, let's say, with heat or with chemicals to kill the virus, but still have it be immunogenic. And

that's another approach. And there are many other approaches, a dozen or so, or nine or 10 different approaches, one of which is this mRNA idea. And here what is done is, so I'm sorry, before I tell you about that, another approach might be to take the RNA from the coronavirus that codes for a very important protein, the spike protein on the surface of the coronavirus, and insert that into a really benign virus, let's say like a cold virus, for example. So we take this other species of virus, we genetically engineer it so that we insert some material, some RNA into it, let's say, that forces that virus when it infects your cells

to give you a common cold, but also to express this protein as if you had been infected with COVID or coronavirus. And then you mount an immune system to that immune response to that protein, and now you're immune. So we gave you like a mild illness and we protected you from a more serious one. The mRNA vaccines are sort of like that. We inject you literally with RNA. And the idea is that your cells take up the RNA and start making the protein, the alien protein that your body would have made.

Like if we had infected you with a real coronavirus, the real coronavirus, as many people remember from high school biology, the virus can't reproduce on its own. Immunology, the virus can't reproduce on its own. It inserts its genetic material into our cells, which then start producing the virus itself. But now, in a sense, instead of giving you the whole virus, we give you a little part of it, just some part of its genetic material, the mRNA, which in an ideal world does the same thing, gets inserted into your cells. You start expressing this protein, which then your body attacks and you develop an immune response to it. And we are amazingly lucky that our scientists have been able to develop not one, but two different vaccines. And we'll have many other vaccines using different modalities. I have no doubt that come out in the next year or two. But the Moderna and the Pfizer vaccines, we were very lucky that they exist and that they are apparently quite effective but the but the story is not over on those i don't know if you want to talk about that but but it's good news but i don't want

people to get over optimistic either because you know it's my job to be a bit of a downer well the this is the this is the unfortunate narrative that people keep saying uh the the virus is killing it's like the average immune system is 99 point whatever percent effective in protecting you from the virus meaning 99 point whatever percent of the people who get the virus survive. No, 99% of people overall survive. 1% will die of all people who are infected, approximately. And if you're older than 70 or 80, 20% will die. So why is the number that people keep talking about far less than that? Why is the reported number of people that get the virus who actually wind up dying, it's not 1%.

We're not seeing 1% nationwide in terms of people getting the virus and dying. No, we know the answer to that question. I don't think there's any ambiguity scientifically. So in order to really compute these numbers, it's not easy. You're right. We have to look at how many people, we have to have a way of ascertaining who's infected, and then we have to have a way of ascertaining of those how many die. And that's called the infection fatality rate. And there was just a recent meta-analysis looking at very good data from around the world, multiple studies using different approaches that estimated that the infection fatality rate is between 0.5 and 0.8 percent and there's something called the case fatality rate

is the fraction of people who have symptoms who go when infected who die and that number is about twice that so about half the people get the virus and have no symptoms at all. So if you get symptoms, you have a higher risk of death. And so you can double 0.5 to 0.8 becomes 1 to 1.6% of people who develop symptoms from the disease die. And there was another very good study that was just released a couple of weeks ago that estimated the infection fatality rate to be about 1%. So there's a lot of little numbers I've thrown out at you. Right, but this is people with symptoms. Yeah, but even without symptoms, the infection fatality rate

is certainly not less than half a percent and could be as high as 1%. I would say it's going to be in that range, the IFR, the infection fatality rate. Isn't there a large percentage of people that get it that don't have symptoms? Half, about half, we think. That's right. Okay. Of the that get it that don't have symptoms? Half, about half, we think. That's right.

Okay. Of the people who get it don't have symptoms. But you said 99 point something percent of people who get it survive. And that point something is important. So I would say that if you said 99.5% of the people who get infected survive, I would say, yeah, it could be. But it's somewhere in there. I don't think I gave a number i think i said 99 point something but the point point being that unfortunately a lot of people saying this vaccine is 94 effective or 90 effective yeah what that means is that

yeah yeah but that what that means is is that if you're uh if it reduces your risk of death by that fraction. So, for example, in the vaccine trial, in the Pfizer trial, these numbers are approximate. They had about 43,000 people in the trial. Half of them got the vaccine. Half of them did not. And in the people who got the vaccine, nine people up to nine, let's say nine or 10, got, even though they were vaccinated, still got coronavirus, still had the disease. The vaccine was not perfect.

And in the arm that did not get the vaccine, the other 20,000 people, let's say 90 people approximately, got coronavirus. So what the vaccine did is it reduced your probability of getting the disease from 90 out of 20,000 people over the time window of the study to 10 out of 20,000 people. So the point here is that the vaccine is reducing your risk of getting seriously ill if you're infected. And you're infected and um and it and and it's not and you're certainly better off in other words you would have had let's say a one percent chance of

dying uh before and now you have a 0.1 chance of dying 90 percent lower than that because we you know we've given you the vaccine i completely completely i understand exactly what you're saying what i'm trying to say is there's an unfortunate narrative where people are saying, I'm not going to take a vaccine because the human immune system is more effective than the vaccine. That's not true. That's what I wanted to get out of you. Yeah, yeah, yeah. That's not true. Yeah, go ahead. Well, no, I'm saying the vaccine, the whole way vaccines work is it enhances your performance.

You know, it's like it stimulates your immune system to make it even better at fighting the virus. There's no sense in which you could argue that an unchallenged immune system is superior to a challenged immune system, a system that has been, you know, been given a vaccine. system that has been you know been given a vaccine so um this is what's important to tell people right because this narrative of 99 of the people who get it 99 point whatever uh your immune system is effective in fighting off this disease whereas with the virus it's only 90 plus whatever percent effective in preventing the virus so this is not this, that's not a good narrative, correct? That's right. And the way to think about it is just to pick some round numbers, as you were saying, and like, and like, like me, you sometimes use the word virus when you mean vaccine and you

use the word vaccine when you mean virus. I'm sorry. I do that all the time. Yeah. I do that all the time. It's so annoying. Yeah. But anyway, let's say for the sake of argument, you have an unvaccinated, you have a 99% chance of surviving if you get infected.

Right. You have to add to that the benefit of the vaccine, which is a 90%, let's say, effectiveness. So it'll reduce your probability from 99% chance of surviving to 99.9% chance of surviving. Thank you. That's exactly what I wanted to get out of you to 99.9% chance of surviving. Yes. Thank you. That's exactly what I wanted to get out of you. When you talk about the people that took the vaccine, and we know you have the data between the difference of the vaccine, the people that got the placebo, the people that got the vaccine that still wound up getting COVID, did they do health screens on these people and find out what

comorbidity factors they may have had and see if there's anything that would indicate that there's particular risks? We don't know that yet. Those results haven't been released. And also what we don't know, so we don't know the answer to that, but we will know. And also what we don't know yet is we don't know how safe the vaccine is. So first of all, just to be very clear, both Pfizer and Moderna have released interim results. And we have every reason to believe that the final efficacy results will be about the same. So as they complete the trial in the coming month or two, and more people get sick in both arms, we don't expect suddenly the vaccine not to work. I mean, we've gotten to a point where we're pretty sure that the vaccine

will be effective. But we don't yet know the safety of the vaccine is another thing we don't know. And we also don't know something else. It's very important for people to understand, again, and since everyone needs to be an immunologist now, imagine that you're doing a trial and you're trying to see whether a vaccine works or not. You have to define what counts as works, what counts as an endpoint. So let me give you three possibilities. One possibility is we're going to measure, does the vaccine prevent you from even getting infected? Or does the vaccine say, or do we say, the vaccine is not going to be able to stop you from getting infected. The virus is going to take root in your body, but the vaccine is going to be able to stop you from getting infected. The virus is going to take root in your body, but the vaccine is going to prevent the virus from making you seriously ill.

Or do we say, actually, the outcome we really care about is death. Does the virus reduce your probability of death? So it's possible that the vaccine, for example, might, just to illustrate this point, prevent you from getting seriously ill, but not reduce the probability of death. In other words, in the Pfizer trial that I just described to you, in the vaccine arm, 10 people got sick, and in the placebo arm, 90 people got sick. What if in both arms, one person died? One out of the 10 in the vaccine arm died, and one out of the 90 in the other arm died, and one out of the 90 in the other arm died, we would say that the vaccine was effective at lowering your probability of getting ill,

which is great, but it had no effect on dying. That's possible. It's possible that the vaccine will work at different phases of the illness process. And so the Pfizer trial revealed that there was a greatly reduced probability of people getting infected. The Moderna trial actually showed that its vaccine reduced the probability of people getting seriously ill, which is great. But it might, in fact, have no effect on mortality still. We don't know. Furthermore, we also don't know

whether this vaccine, even if it works, reduces, even if it works to reduce your probability of getting sick or dying, whether it works to reduce your ability to infect other people. So maybe we've started vaccinating the population. We're reducing the individual recipient's probability of getting sick, but they still can spread the disease. So this is something else that's not known. So we don't know the safety. We don't know which outcomes are really being affected. And we don't know if it affects infectiousness.

And all of these things are things we will soon learn in the coming year, but we don't yet know them. So I just, it's fantastic news that we have a vaccine, but I just don't want people to get i just it's fantastic news that we have a vaccine but i just don't want people to get think it's a panacea is that god please go continue no no i'm just gonna say one more thing which is that um which is that uh is that um hold on let me just remember recover what i was about to say about uh the vaccine and um um i forgot what i was about to say about the vaccine. And I forgot what I was going to say, but go on, you were going to say something. Sorry. No, no, it's my fault. This is the problem with Skype calls. Well, no, it's not just that. It's just a complicated topic. And there's, you know,

all I've been thinking about is coronavirus for the last 10 months. I mean, there's just so much stuff in my mind about this thing that, I remember, cuz I thought I was wanting to talk to you about this. So I want people to also begin to think about who should we give the vaccine to? What are the ethical and public health issues associated with, as we start producing the vaccine, first we'll have a million doses. Well, who should get the first million doses? It's pretty ethically uncontroversial that the very first doses should go to the people in the placebo arm of the trial because those people took the risk of being experimental subjects

they were randomly assigned to the placebo arm uh they clearly should get first dibs on the actual effective drug that's now been shown to be effective because of their contributions okay great then pretty uncontroversial is that the next group of people to get it should be doctors nurses firemen policemen first responders ambulance drivers all of those people health care workers those people because they're putting themselves in harm's way during a contagious disease to protect the rest of us, they should be next. Okay, fine. But then who? Who's next after that? And here it gets very tricky, both ethically and from a public health point of view. And let me give you an example of this. So on the one hand, you might say, we should vaccinate, let's say, vulnerable elderly people or people with chronic illnesses.

They have the greatest chance of dying if they get infected. We should give the first 10 or 20 million doses should go to elderly people in nursing homes. And there's a lot of compelling reason to do that. But it turns out that such individuals, from a network science perspective, are at what's called the end of the transmission chain. It actually might make more sense and we might save more lives from a public health point of view if we vaccinated working age people, people who are out and about. you and I, by virtue of making you immune, stop you from transmitting the disease to other people since you're out and about and seeing lots of other people, I might actually wind up saving more lives, paradoxically, by vaccinating the people at lowest risk. How do you educate people on that? That seems like a complicated one to explain. Yes. And our nation is going to face

this dilemma very soon, in fact. Because when the the initial of course, if we had 300 million doses, we wouldn't have to make these choices. We just give everyone the shot or who wanted it. And incidentally, the cold chain requirements for this. This is another topic now, tangent on a tangent. But, you know, many rural parts of our country simply don't have the kind of refrigerators that are needed to stockpile and administer these vaccines. What kind of refrigerators are needed for these vaccines? Well, the Pfizer one needs a minus 80 refrigerator. These aren't common, like below dry ice cold. And so not every pharmacy, your local CVS or Walgreens doesn't have

And so not every pharmacy, you know, your local CVS or Walgreens doesn't have usually this type of refrigeration. And so you so you and plus all the trucks transporting it, like from the moment that the vaccine is manufactured till the moment it's injected. It has to be most many vaccines, not all vaccines have to be in what is known as the cold chain. They can never be defrosted. And building the logistics to distribute the vaccine is a big, big challenge. So not only do we have to invent a vaccine like we are, which is magnificent that our nation is able to do that, but we have to manufacture it, which is not easy. You know, we need little glass vials.

We need millions of them. And we need factories that can produce this particular kind of vaccine, et cetera. We need to distribute it like the cold chain, the refrigeration I mentioned. And most important, we need to persuade people to accept the vaccine. And this touches on what we were discussing earlier, whether people will believe that the vaccine is useful. And of course, we have an anti-vax population in our country and so on. So all of these challenges have to be overcome. So if we had 300 million doses of the vaccine, this would be less of a dilemma.

But initially, we're not going to have that. We're going to have some lower number of doses. And those doses will be more easily administered in metropolitan areas that have the right refrigerators. So we as a nation are going to need to begin to think about this, about how to choose or distribute the vaccine. That's very complicated. Now, the difference between the Pfizer and the Moderna vaccine is what? Well, as I'm told, and I'm no expert on this narrow topic, that the Moderna vaccine actually doesn't require as cold refrigeration for reasons that I don't understand. Since they're both RNA vaccines, they both are encased in lipids. One of them requires a much colder temperature for distribution than the other. So the Moderna one,

I'm pretty sure, is the one that doesn't require quite as cold a refrigeration, which makes the logistics of distribution much easier. Do we know? We don't have any idea why. I'm sure experts know that. I don't know the answer to that, why it does. Is there anyone who's tried both? Is there any benefit in getting vaccinated with both vaccines? vaccinated with both vaccines? I doubt that because they're very similar in approach, but I can imagine that the time will come when there might be some benefit in getting two complementary vaccines, when we have developed still more approaches, as we were talking about earlier, when you can get this and also that. Now, it's also possible, and I mean, we just don't know the answers to all these questions. It's also possible. So some significant fraction of people who die of coronavirus die because of their own

body over response to it. Their immune system is too dramatic, too dramatically responds. And it's possible that we may not want to give people multiple versions, different kinds of vaccines, because we might overexcite their immune system in a way that actually harms them in some way. So these things are all going to be sorted out in the coming year. I just don't want people to think it's all simple because it's not. Now, Donald Trump is 74. He's overweight and eats cheeseburgers every day. When a guy like that catches COVID and is fine in four days, people get very dismissive of it, unfortunately.

What did he receive? What kind of treatment did he receive? And how different is it than what the average person would receive if they got sick? So he faced a very significant risk of death, and I think he got lucky. So remember, his doctors put him on dexamethasone. So, so far, we only have one proven drug that lowers your risk of death if you're seriously ill from COVID, and that's a very simple steroid called dexamethasone. And remdesivir has not been shown to lower mortality. It has been shown to lower your length of hospital stay. So there's some benefit to it,

but it doesn't appear to lower your risk of death. What would be the difference between lowering your risk of hospital stay and lowering your risk of death? Why would they let you out of the hospital if you hadn't shown significant health improvements? And wouldn't significant health improvements wouldn't significant health improvements signify that your body's recovering better? Yeah, it's a mystery and it's confusing. And when the first remdesivir trial

was published a few months ago, it didn't show a benefit for mortality, but it showed a trend. It looked like it would help, and it made sense. Like if it's lowering your hospital duration, probably it's good for you, and it'll also lower your risk of death. But then another trial came out, a much bigger trial, as part of the – I think it was called the Solidarity Consortium. Either the Solidarity or the Recovery – I can't remember right now – Consortium out of England, which showed that actually remdesivir had no benefit for mortality.

Now, how can that be? Imagine that you have 100 people who are sick, and in the group that gets remdesivir, they only wind up spending an average of 10 days in the hospital, but 10 of the people die. And in the other study, the people that did not get remdesivir, 100 people get sick, and they spend an average of 12 days in the hospital, but again, 10 of them die. So the remdesivir has lowered the hospital duration from 12 to 10 days, but it hasn't affected the probability of people dying. That's entirely possible. And that is, in fact, what appears to have happened. And this was a study, you said, that was in England?

Yes, it was a large study that was, I think the subjects were not just in England. It was organized by a group of English scientists, either the Solidarity or the Recovery Consortium, and I just don't remember right now the name of it. But I want to go back to your question about the president. So the president was given dexamethasone. your question about the president. So the president was given dexamethasone. And when that happened, I stated publicly that either the president was sicker than they were telling us. So he was sufficiently sick that they wanted to give him dexamethasone. Because giving dexamethasone early in the course of the disease, before you're very sick, actually can harm you. So you don't want to give it to someone at the beginning of their disease.

You need to wait until they're sufficiently sick and then it helps you. So either he was sicker than they told us and so they were lying to us or he was really needed the dexamethasone, in which case he faced a significant risk of death. So people in the trials that showed that the dexamethasone worked, 74-year-old overweight people, men, and men are much greater risk of dying than women of this condition, who got the dexamethasone, they had about a 20% chance of death. So I think the president actually faced a 20% chance of death when he was at the hospital, which is a big risk of death. And I think he got lucky. He survived. He was also given this cocktail of artificial antibodies to the disease,

which I think is another promising approach to treating this condition. We don't yet have the results of those randomized controlled trials, but we'll also know soon if those drugs help. So this was an experimental treatment that they gave him? Yes, they gave him? Yes. They gave him not the dexamethasone. That was a well-documented treatment. Right. But the antibody cocktail was apparently the CEO of the company of Regeneron was his golfing

buddy or something. I'm not exactly sure. So whatever it was, it seemed to be very effective. And then immediately- No, I wouldn't conclude that. he went on a wild tweet storm it seemed like he had a lot of energy well the dexamethasone may have given him he had a steroid high i i wouldn't conclude that the antibody cocktail was necessarily effective no no no i didn't i didn't mean that i meant the treatment the overall treatment whatever they gave him

when he was in the hospital the response was for ayear-old guy to be back on the campaign trail with this rigorous campaign that he was doing four or five days later, pretty damn impressive. Yes, I did not expect that at all. And as I said, I think he got lucky. And I do think steroids can make you a little psychotic and a little manic actually. And I think – I mean you can't really know from a distance. But to me, he had – as a doctor, looking at him, I thought this man has a little bit of a manic feel to him. But then they tapered his steroids and that went away. Just from the Twitter feed?

Yeah. But isn't that how he always is? yeah i mean but isn't that how he always is well i'm not an expert on donald trump's tweets but if you just looked at some of the you're right maybe maybe he was always that way but if you look at if you look at um some of the things he did like i think the the little having the secret service drive him around the hospital was a bit you know was a bit manic you know that was like a very irresponsible thing to do. It exposed people to risk. It put his own health at risk.

I mean, you and I, if you and I were in the hospital with COVID and we told our doctors, you know, I just want to go for a drive around the block right now and let me go to the hospital. I mean, they would say no. That would not be an okay thing to do. He wanted to wave to people, right? Yes. Yeah, right? Yes.

Yeah, hilarious. Yes. I mean, I think one of the things, and I make this argument in Apollo's Arrow, one of the things that's very interesting to me about plagues, earlier you talked about how plagues were one of the four horsemen of the apocalypse, Earlier you talked about how plagues were one of the four horsemen of the apocalypse. Is that lies and denial are like the squire of the horsemen. They like follow right behind.

And in a way you would even say that lies and denial, since they've occurred for thousands of years, whenever there's an outbreak, people have always developed superstitions. They've wanted to deny what's happening. There's been a lot of lying. There's been a lot of snake oil salesmen. You know, there's just a lot of mendacity that follows the germ. So the germ is spreading through social connections and bullshit is spreading through social connections. And I think that we saw this even in the president where he was, you know, frankly misrepresenting what was happening. We now know that he was told that it was going to be a pandemic in December, but was saying, oh, it's just a flu. Nothing's going to happen. Nothing's going to happen. He was lying. And and his whole hydroxychloroquine story, there was no evidence that this drug would work.

But, you know, he was like a snake oil salesman selling it. And you could even make the argument that. that it is the perfection of our democracy. It's the fact that we have a democratic system that allows us the popular will to be reflected in the leaders that we elect so that if the people wish to be lied to, they will elect a liar. Can I pause you for a second there? They will elect a liar. Can I pause you for a second there? There was a lot of people that did believe that hydroxychloroquine at the time had some positive benefits, including my doctor, who is not a Donald Trump supporter. This was no evidence at all. There was some suggestion that based on in vitro studies that the drug might work.

It wasn't crazy to consider that it would work. I mean, it wasn't a crazy idea to say, maybe this drug works, but there was no clinical evidence that it worked. There was no randomized controlled trials that should have worked. Right. But isn't that also because there was no time for any randomized controlled trials, because this was the initial stages of the pandemic? Yeah. So I'm not saying that it wasn't crazy to think that it might work, but to say that it does work is a different statement. I agree with you wholeheartedly that his endorsing of it as being some sort of a miracle cure was irresponsible.

Yes. But that's also kind of what he does, right? Like when he was sitting next to – I'm sorry, what is her name? Birx? What was her name? Yes. Yeah. Yes. Yeah. And he was saying maybe we can use some sort of internal disinfectant on people and all that.

He's riffing. He's the guy that likes to have the answers when he's giving these speeches. Yeah. And he likes people to pay attention. these speeches and he likes people to pay attention and i think in that response he's it's that's that's how he usually is as a human being he gets to be 70 years old now all of a sudden he's the president of the united states and he's doing this now it becomes a problem yeah so this is what i would like to say so i i and i set it up by saying you know it's a it's a reflection of the perfection of our democracy that we are able to get the public will reflected in our leaders.

And if the public will is to, as I said, have someone who tells you only good news and doesn't tell you bad news, we're going to get that. But I don't think that lets the leaders off the hook. And actually, before I explain that, let me just go back and say it's also true that many other leaders in other European nations, like in Italy or in England, also flubbed this. So it's not the case that only Trump singularly botched the response. Now, there were leaders in South Korea, in New Zealand, even in Greece, you know, who had a successful response. But my point is we're the United States of America. I expect more of us. We have the CDC. We're the richest nation on earth. We have scientists and doctors. We spend 17.7% of our GDP on health care. We have the National Security Agency. We have everything you would need to do better. And I expect more from us. So I absolutely do fault him for flubbing this.

But I also think the American people need to take some responsibility and need to sort of man up, you know, and recognize that the world has changed. There's some serious stuff that's going on and we have to do better in how we confront this threat. We can't be like children pretending that it's not there or fantasizing that it'll just miraculously go away. That's not a mature response.

And we have, unfortunately, a long road ahead. And, you know, we are not at the beginning of the end of this pandemic. We are just at the end of the beginning. And just to set the stage a little bit, here's what I think

is going to happen. So it's great that the vaccine has been invented, and we'll have several of them. But as we've discussed, there are going to be some problems and challenges in manufacturing it

and distributing it and persuading large numbers of people to get it and so on. And that's going to take time, let's say a year. So let's say the vaccine is approved in a couple of months, the beginning of 2021. I think we're going to spend all of 2021 doing all that other stuff, distributing the vaccine and so on. Meanwhile, the virus is still spreading. And right now, probably about 12% of Americans have been infected with the virus. In the end, for various calculations and reasons, probably about 50% need to be infected. The final attack rate probably needs to be about 50% before we reach this threshold known as herd immunity. So we're about a quarter of the way there, let's say. So the virus is going to keep

spreading. And while we're doing all that other stuff, so either way, I think we get to 2022 before we've reached herd immunity, either naturally because the virus has finally attacked that many people or artificially because we immunize that many people. So at that point, just to be clear, the virus isn't gone. It's still in our world. It's still circulating, but its epidemic thrust, its epidemic capacity now has been neutered. And the virus will be so-called endemic

when we reach the herd immunity threshold, either by vaccines or naturally. That's 2022, let's say. But that's just then we've overcome the biological and epidemiological impact of the virus. And until that time, we're going to be wearing masks, there's going to be intermittent school closures, we're going to have to have physical distancing, there's going to be gathering bands, hospitals will be full periodically. This is going to be the world we're in for the next year or so. And then we'll get to the point where we have herd immunity one way or the other. But then you see we have to recover from the psychological,

social, and economic shock. Let's not forget tens of millions of Americans are out of work. Many small businesses have gone out of business. We have sort of a reshaping of our economy in all kinds of radical ways. And it's going to take a while for that to unwind. Also, a lot of people are going to be disabled by this condition. So far, we've been talking about death. Probably five times as many people will be disabled, will have some form of long-term disability, renal, cardiac, neurological, or pulmonary. So if we have, let's's say half a million Americans, for sure half a million Americans will die of this condition.

Maybe as many as a million. It's going to, in the end, by the time the pandemic is over, it's going to be a number in that range. Whatever that number is, about five times as many will be disabled. So let's say half a million Americans die. We're going to have two and a half million Americans with some form of disability. We're going to have to cope with that as well. So if you look at the history of epidemic disease, it's going to take a year or two

to recover from that. So I think it's 2024 before we really begin to enter the post-pandemic period when life will return approximately to normal with some persistent changes in our society. And I'll say one more thing and then I'll shut up. If you look at the history of previous pandemics, what typically happens is during the time of the germ hitting the society, people get more religious. They become more abstemious. They save money. They withdraw from social contact. They avoid risks. Risk aversion increases, risk-taking declines. All of these things happen. And then when finally the epidemic is over, all of those things reverse. People relentlessly seek out social interactions, sporting events and nightclubs and restaurants and political rallies.

Sexual licentiousness goes up. Spending, people start spending money. Risk-taking comes back. One person, Neil Ferguson, actually, who kindly reviewed the book in the Times Literary Supplement, when he read this description, he goes, here's hoping that this is what it'll be like. So I think come 2024, late 2023, that period, we're going to have like the roaring 20s again, when our society is going to really be unleashed from this shock that we are experiencing. Oh, I'm looking forward to that. One thing I got to urge you is please, every time you get excited and slap your table, we get a loud bang out of your microphone. Okay. Sorry. We talked about the economic issue. You briefly just touched on it. What do you think can be done to mitigate the economic impact? And what states do you think are doing it right versus what states you

think are doing it wrong it seems to me that one of the big problems that people are having with this pandemic is all of a sudden governors and mayors have these powers that they never had before and they don't seem to totally make sense like they're allowing people to have mass protests and they're actually encourage them encouraging them but they're not allowing people to have mass protests and they're actually encouraging them but they're not allowing people to go to the gym they're allowing people to do things like go to walmart or go to target but they don't want them going to restaurants california is particularly restrictive and just today entered into a they went back to phase purple whatever the fuck that means where they're shutting everything down and this is right after the governor got caught going to a restaurant with a bunch of other people

doing things that he specifically told people not to do um this is a problem that people have with the power that government has now assumed and the real concern that many people have myself included is that we're never going to see them give that up is that the power that they have now to tell people to stay home don't work shut down schools shut down gyms shut down restaurants that they're not going to let that go people enjoy using power and especially if they have a legitimate a legitimate good cause for it like we do here in the pandemic. So I share your concerns and I understand what you're saying.

And there are many components to what you just said. First of all, I want people to understand that even during the bubonic plague in England, when the government wasn't ordering restaurants to close, the economy still collapsed. So we have to draw a distinction between what the germ is doing to us and our economy and what it would have done, regardless of what government did, versus what we are doing to ourselves in order to fight the virus. So I don't want people to think that, oh, if the government was doing nothing, our economy would be going great. No, I don't agree with that either. I think the economy

would still be fucked, but it would be less fucked. California is more fucked than Austin, Texas is. That's a fact. All right. Well, I believe you on that. I don't know what's happening in Austin, but I don't think that the economy would necessarily be less fucked if the government took no action. In fact, the principle, the ideal principle at least, is that by the government acting, we can protect the economy. So, for example, if the government were able to effectively force people to wear masks and if everyone wore masks, we actually could maybe have a functioning economy. That seems to be the message that we should get out. And if everyone wore masks, we actually could maybe have a functioning economy. That seems to be the message that we should get out. Yeah.

So just to be clear, the ideal world, I'm not saying that's how government is working, but I'm just saying in an ideal world, we as a people band together and say we're facing a common threat. Look, if we had an enemy on our borders, if we were being invaded by an army, you grabbing your gun and going to the frontier, it's useless, right? You can't stop the army by yourself. It's solitary action. It's not adequate in this situation. Furthermore, everyone else on their own running to the frontier in a disorganized way also is not effective. You need leaders, you need structure, you need platoons, you need weapons, you need strategy, you need all that other stuff, that coordination to repel the invader. And it's the same with this. We save our

skins by working together to repulse the invader. And in an ideal world, that's what government would do for us. It is an expression of the collective will for collective self-preservation. So I just want to, first of all, draw the distinction between what the virus did to us versus what we're doing to ourselves, which we seem to agree on. Now, the hypocrisy of our leaders, and then I'll come to the power issue, the hypocrisy is really worrisome to me. And we talked about this earlier. I think public messaging is a crucial part of the battle we had ahead of us. So we have to have people be honest with us and we have to have them be consistent. We can't say, oh, this is what you need to do, but I'm going to the French laundry for dinner. That's not okay. Exactly. So I totally agree with that. And that's why I want

our leaders, for example, when they appear in public to wear masks. I don't think that a lot of the political politicians who are going to public events not wearing masks. Vice President Pence, for example, went to some event at the Mayo Clinic, everyone else was masked, he wasn't masked. That's not the right message, in fact. And here's the other thing just to be clear. I know what's happening in North and South Dakota right now, I've been following it a little bit. And also in Idaho and other parts of the northern part of our country right now. It's in the nature of exponential growth to be deceived. Exponential growth is not an intuitive concept.

So when experts say that shit is going to hit the fan in a few weeks or it's really bad right now, the man on the street goes out, or the woman on the street goes out and looks around and says, nothing is happening. It's not so bad right now. What are you talking about? And it seems like the expert is lying. But what happens with exponential growth is, one becomes two, becomes four, becomes eight, becomes 16.

It looks like nothing has happened. Becomes 32, becomes 64 cases or deaths. That's not so many deaths. It doesn't look so bad. But then it explodes, right? Exponential growth, as we all learned in high school algebra. And that's the problem. And by that time, by the time that explosion takes place, it's too late. And this is why leadership is so important and why we as a people need to try to elect or empower individuals who are honest with us,

who are not hypocrites, who act according to their prescriptions, and who tell us the plain truth of what it is that we're facing. Because we are going to have to work together to get the best of this virus. What is happening in South Dakota and North Dakota? I'm not aware. Their hospitals are at capacity and the per capita. I think North Dakota has the highest per capita death rate of any place in the world right now. But it's a rural and not a very populous state. They were also pretty wide open, right?

Like they really didn't enforce any restrictions at all. Correct. And on the one hand, I am not saying, and this is important, I'm not saying that every place, well, there are some things that I think we need a national strategy for. So, for example, inconsistent rules from place to place can harm us. It's like designating one part of the swimming pool for pissing and just hoping for the best. I mean, it doesn't work when there's a contagious disease. That's a great example. Yeah, I wish it were mine if someone else came up with this. But anyway, so that's not, you know, we need to have some kind of

national strategy. We need some consistency. We can't have every little town having, you know, this town is masked, the next door town is not masked. This town closes its schools. The other town doesn't close its schools. You know, this state bans gatherings, but the adjoining state does not ban gatherings. We need some consistency. Having said that, however, it is also the case that different states are different. You know, the population density in New York City is completely different than the population density in Vermont or in North Dakota. And I can understand why people that live in rural states might say, well, we have one advantage, which they do have, you know, being less dense, the population density being lower. But that doesn't mean you can just count on that advantage and do nothing else. one advantage, which they do have, you know, being less dense, the population density being lower.

But that doesn't mean you can just count on that advantage and do nothing else. And this is something I wrote about. It's called the Swiss cheese model of pandemic control. So imagine that every layer of defense is a piece of Swiss cheese, for example, school closures or physical distancing or wearing masks or banning gatherings or testing, for example. So each one of those is a layer of defense, but each of them is not perfect. They have little holes in them. You should have the intuition that if you have just one layer of defense, it's imperfect. They're holes. The virus can get through. But if you add another piece of Swiss cheese where the holes are randomly positioned, maybe there's only a couple of gaps left after that second piece of Swiss cheese where a couple of holes happen to line up. And then you add a third or a fourth slice.

And by the fourth line of defense, there are no holes left to penetrate all four layers of Swiss cheese. This is what we need to do as a nation. Any one layer of defense is not enough. We need multiple layers. But the good news is, first, if we have enough layers, we don't necessarily need any more after that. So for example, if let's say we wear masks, we physical distance, we ban gatherings, and we have testing, maybe that means we don't have to close schools because they don't add anything else. Adding another piece of cheese as the as the fifth layer is not necessary.

And furthermore, this is what happened at the White House. They relied on one layer, which was testing. They didn't have masking. They didn't have physical distancing. They thought, oh, we're just going to do testing. It's not enough. And this is also they, though, because I don't think they did. I don't think he was getting tested.

I don't think he was either, honestly, but I have no inside knowledge. Well, all I need to hear is when they asked him, when was the last time you had a negative test? You asked me, when was the last time you had a negative test? Yesterday. I get tested every day. So if they're not asking him, if he's not answering that question, there's only one reason because he doesn't want to lie, because he knows other people know.

So he knows he's got an inner circle that is a little chatty Cathy. Talk a little bit. And they're going to rat him out, especially if he doesn't win the election. Right? Yes. I think he wasn't getting tested. I think that's right. I think they probably had the idea that we'll test everyone else that comes in contact with the president.

Yes. And they also, by the idea that we'll test everyone else that comes in contact with the president. Yes. And they also – by the way, tests are also not perfect. Remember we said there's no life without risk. These are all probability distributions. So the tests are – some tests are exceptionally good, but they're not perfect. You get a false negative. Well, he's also using a rapid antigen test, correct? He's using the test where they're doing the nasal swab or the saliva test. I don't know exactly what testing methodology was in use at the White House, but what I suspect happened is he got infected from someone else. And then I think, and this is just rank speculation, I think he was the point source after that. Because if you look at the network pattern of who got the disease, including the person, the Coast Guard officer that was carrying the nuclear football who got infected. By the way, this is just to be clear, it's in my view, the height of irresponsibility to be so lax.

The fact that our leadership was infected, including even the person holding the nuclear football, this is irresponsible, right? I mean, we should do, I expect more from the White House. But anyway, the if you look at the pattern of people, if you map out the network of who got infected, I think he was the common denominator for a lot of the infections. And so I think he got it somehow. He wasn't being tested. I speculate this is speculation. And then he spread it to lots of other groups. So basically, the president is a super spreader. Say it. spread it to lots of other groups. So basically, the president is a super spreader. Say it.

Yes, I think the data fit with the claim that the president was a super spreader. Yes. Yeah. So clearly, that's a gigantic problem. Elon Musk apparently now has COVID. And one of the things that he was talking about is how two tests came back positive and two tests came back negative. And a lot of people are criticizing him about this on Twitter, complaining about it without researching the nature of these tests themselves. And that the issue being that these tests are not that effective if you have a very mild case of the virus or if you barely have any in your system and that they might show positive and negative in the same day. I don't know the details of Elon Musk's testing.

I have to imagine that Elon Musk has good testing. So I was surprised by his description. And I don't believe he released information on whether he was having a PCR test for the virus or antibody tests for immunity. He did. He released it that it's rapid antigen test. So he wasn't getting PCR tests for the virus? He didn't this particular time when he tested four times, two negative and two positive. He's pretty specific about it on Twitter. And that's when people were criticizing his response. And those were all antibody tests, Joe?

Yes, I believe. I'm 99% sure because he was actually then questioning the effectiveness of PCR. Now, here's something that I wanted to discuss with you because I got confused about it. Someone was saying that with PCR tests, when you get to a certain number of tests, then it becomes problematic. Correct? Like an individual, an individual having a certain number of PCR tests. There's no way I can think of that would be the case. I mean, what the difference is, the PCR test is a test of saliva or nasal secretions for the virus. And typically, after you recover, you don't shed the virus anymore. Now, you can test positive for a while afterwards because you might still have some RNA from the virus in your system, but you're not infectious. So you can test positive,

but you can't infect anyone else. But usually, you know, after a number of weeks, you no longer test positive and that's done with. The antibody test is a test of your body's response to the virus, the proteins that you produce to fight the virus. Usually you take that from blood, but people have now developed saliva antibody tests, which is much more convenient. And those will be positive for a number of weeks or months, as we were discussing earlier. And there are two different kinds of antibodies. Actually, there are more than two, but there's a so-called IgM and IgG.

The IgM spikes within two or three days, and some tests can detect that, very sensitive, and the IgG almost immediately afterwards. that very sensitive and the IgG almost immediately afterwards. And you can use antibody tests to detect as your body was fighting off the virus. These are two different kinds of tests. The saliva test, this is something that I've heard of, but I've never seen implemented. Is there a more effective version? Is saliva more effective than the nasal swab? Well, just to be clear, the saliva test could be the saliva test for the virus or saliva test for the antibodies. It's much easier to use. There's two different ones.

Yeah, they're different things and they're different tests. And the saliva is, of course, much easier for all of us than having blood drawn or having someone put a Q-tip in our nose. So people are scrambling and have developed saliva tests both for the virus and for the antibodies to the virus now, which is, again, great news. Incidentally, just to be clear to people, why did the nation make a sacrifice of flattening the curve? Like, why did we have the school closures and the lockdowns and all of that stuff back in the spring? The reason we did it was to stop the percussive force of the virus. Like, it's like a tidal wave was going to come ashore, and we built breakers offshore so that the amplitude of the wave would be reduced. Still, the water would

come ashore, but it would come ashore more slowly than this huge wave hitting us. And the reason we did that was so that we could have our health care system begin to function, develop, discover that dexamethasone works, invent vaccines, invent tests, improve the tests, make the tests easier for us to take. So all of these things have happened in the last nine months. This is why we did the sacrifices we did last spring. test easier for us to take. So all of these things have happened in the last nine months. This is why we did the sacrifices we did last spring. And incidentally, this is why further sacrifices might be called from us. If we continue to behave well, we might be able to spare a lot of deaths because then we'll have really good vaccines that have been shown to work we'll have more medicines to treat the sick people our hospitals won't be inundated doctors can take care of you better when the hospital is 60 full than when the hospital is 120 percent full uh

they're not as exhausted the doctors do you want an exhausted doctor or with lack of supplies that's worried that he or she is going to get sick? Or do you want a well-rested doctor with adequate supplies that is mentally fit and ready to care for you? So all of these are reasons we're flattening the curve back then and now. And so these tests, these miraculous tests that we have for saliva now, have all been invented in the last couple of months. Jamie, did you find anything on the PCR? Nothing? I mean, I'm looking.

Okay. I know I read something about it. Joe, I can't imagine a way that the testing itself could be worse for you. I mean, you might get a false sense of... No, no, no, no. No one's saying that. No, it was something saying that it becomes ineffective after a certain number of cycles. Here's another question. Why do we have these upswings and why do we have waves? Like, what is the cause of waves? Is it people relaxing? Is it people gathering, going to bars seems to be particularly problematic, right?

Like, what is causing these waves? Is it that people get relaxed? So it's a lot of different things are doing it. So the existence of a second wave right now is completely unsurprising to anyone that studies respiratory pandemics. I'm unfamiliar with a respiratory pandemic in the last hundred years that hasn't had multiple waves. Incidentally, I'm telling you now, maybe you'll have me back on the show in a year, there'll be a third wave. A year from now, there'll be a third wave and actually probably a

fourth wave too. The amplitude of that wave, if we have a vaccine, will be lower, but we'll still have a blip up in cases a year from now winter compared to eight months from now summer. So respiratory pandemics come in waves and they do that for a number of reasons. One has to do with social interactions, the pattern of how people interact. Schools are open. In the summertime, schools are closed. In the fall, the schools open. And schools are a place where lots of human beings mix. There are 50 million children in schools and three or 4 million adults, teachers and janitors and others and cafeteria workers that work in schools. And parents drop off their kids and pick them up and chat at the school. So there's just a lot of social mixing that takes place in schools.

In the wintertime, people live differently. They move indoors. They have more close contact with each other. It's easier for respiratory pathogens to spread indoors than outdoors, as everyone knows by now. So human behavior changes in the winter. And this is why, incidentally, the germ typically goes to the southern hemisphere for its winter while we're having summer and then comes back north when our winter comes. Furthermore, there's physical and physiologic reasons. So the dryness of the air and the coldness of the air may facilitate the

dispersion of the virus. And our bodies, our immune systems, as you were discussing earlier, may function differently in the summer and in the winter. So for a host of many reasons, it is very standard that respiratory diseases have this scalloping sinusoidal pattern higher in the winter and then lower in the summer. So there's nothing surprising about what's happening right now. The one big unknown is how bad will the pandemic be now? Will it be in the 1918 pandemic, the second wave was four times as deadly as the first wave. And the question in many experts' minds right now is, is this COVID-19 pandemic, this second wave that America is beginning to experience now, will it be as deadly as the first wave or

more deadly? And I fear that it will be more deadly. And over a thousand Americans are dying every day of this condition, every single day, day after day. And that number is likely to go up unless we really get our act together. And even when we do get our act together, it'll take about three weeks before we see the deaths plateauing and then beginning to decline. So we're going to have thousands and thousands of deaths, like a battleship turning. Even if we start to make the turn, it's going to take many miles before the battleship turns. Same is going to happen here. And so I think we're going to have, it's going to be bad, unfortunately. I think many, many Americans are going to die. And again, this is not diminishing the impact of the disease or

the fact that it's a dangerous disease, but one of the things that the CDC had said was that only 6% of the people who died from COVID-19 had only COVID-19 and that the rest had an average of 2.6 comorbidity factors. Yeah, but a little bit, let me ask you a question. If you have diabetes and you're driving down the highway and you're in a car accident, what do we say killed you? Car accident? Yeah, we say the car accident killed you. We don't say, well, you had diabetes, so we're not going to say the car killed you. So the fact that people – and in fact, we all ultimately are going to die. Right, but you know that people will reverse that, right? Like people will say that people with leukemia who also had COVID, they're listing that as a COVID death when they really had leukemia anyway and they were probably likely going to die.

Yeah, but the person with diabetes was probably going to die of their diabetes, but they got into a car accident. So my answer is that, I can answer this question. So my answer is that the usual way we think of things that kill people, we think of the proximate cause. You know, let's say I had a chronic obstructive pulmonary disease, or I had end-stage renal disease and someone shot me. Just because I was getting dialysis and someone shot me doesn't mean that I was going to die anyway of my renal disease. Therefore, I wasn't murdered. I was murdered.

That's what killed me. Right, but you're talking about violent actions versus diseases and comorbidity factors. I don't think that's a fair comparison. No, I think it is fair because let's say you have, it's the same exact situation. Let's say you have cancer and you're getting chemotherapy and you're being treated for the cancer. And then you get infected with a pneumonia and you die of the pneumonia. You wouldn't have died, but for the pneumonia in this case, the scenario I'm putting to you is now, if you're going to make the argument you're making, and I understand where it's coming from, I don't mean to dismiss it completely, you would also then have to

apportion all deaths to have a fraction due to different causes. So you would say this person had diabetes and they also got coronavirus. So we're going to say it's 50% of the death is due to diabetes and 50% is due to the coronavirus. And you could go then, if you wanted to do that, you could like, for all causes of death, you could apportion them. And that would result in, you know, rejiggering multiple things. But it's not fair to just pick on coronavirus and say, well, actually people would have died of something else, so we're not going to count those deaths. But that's not what we're saying. What people are saying is that the actual danger of the disease is greatly exacerbated by the poor health of America. That's true.

This is what I'm getting at. Yeah, yeah. That is true. That is 100% true. And the comorbidities greatly increase your risk of death. So that is true. And this is incidentally one of the reasons why – I mean, Sweden is having its own problems right now. But one of the reasons it wasn't really fair to hold up Sweden as a comparison for our strategy is that the Swedes are much healthier than we are.

Exactly. And they have a, you know, they're a completely different society. Yeah. You know, we're not unfortunately as healthy as the Swedes. completely different society. We're not, unfortunately, as healthy as the Swedes. Yeah, that is something that I feel like we could have gotten into people's heads eight months ago and perhaps made a dent in the impact of the virus. It's hard to tell people you have to be healthier. They don't want to listen. People have their habits, and they have their vices, and they have their behaviorices and they have their behavior

patterns that they're just accustomed to. And it's very difficult to break people out of them. But some people would have listened. Some people, especially terrified, faced with the possibility of either surviving a pandemic or not, may have done something differently. And it's one of the things that frustrates me so much about not just the government response but the media's response to this is that i don't see anybody out there saying you gotta get healthier and it's the one thing that might save you yes i mean i i agree completely with that and and there are anecdotal stories i i have some of them in in the book of elderly people who are who fear getting this and who are not only, let's say, withdrawing socially and limiting their contacts, but they're trying to get fitter. You know, they're exercising more and trying to prepare their bodies for the possibility that they might get an infection and try to optimize their chances.

So I totally agree with that. You know, but it's hard. It's hard to persuade people to behave in a healthy way. It's always hard, let alone – but you're saying, I think correctly, you're saying, look, it should be easier to motivate them to do it now. Well, it might be hard, but it's not impossible. And there's been zero effort, zero. It's almost like it's not going to work. Let's just not try that, and let's just shut down all the businesses. That seems to me to be asinine.

Like, let's say, I'm going to make this up, but let's say for the sake of argument, we were given a choice. Either every American can lose 10 pounds or every American that's overweight, which is like 66% of Americans are overweight, two-thirds of them or more are overweight. Every overweight American can lose 10 pounds or we're going to close the businesses in your community. Actually, you know, I mean, I haven't done the calculation. We'd have to do it. But you can imagine doing such a calculation and concluding that, you know, actually that would be equivalent. And so we should tell people, you know, this is your dilemma. You're being called to action.

You're not being drafted into a war, but you need to sacrifice. You need to do your part. And your part is, you know, this. So I agree with you, Joe. I mean, I think that's right. I don't even think you're going to get them to be motivated that way. Telling people they have to sacrifice and do your part. People are fucking selfish. Tell them, listen, this is going to save you. This is the thing that's going to make you healthier. This is the thing that's going to give you a better chance at surviving if you get infected. But what frustrates the shit

out of me, a person who's spent most of my life thinking about health and fitness and wellness, is that there's been zero impact. There's been zero by the government, zero impact on people's health in that regard. Zero discussion of strengthening your immune system. And strategies and having health experts talk about proven strategies for boosting your immune system. There's been none of that. Yes. I think that should be part of the messaging. And I actually know some people that I can relay that to

that may influence the national messaging on this topic, actually. So I made a note of this point, and I know someone I can communicate this communicate this to well there's plenty of peer-reviewed studies national policy oh well that would be wonderful because there's plenty of peer-reviewed studies on the impact of specific vitamins and nutrients on your immune system yeah what else do you think we need to do that we're not doing? I think we talked about some of that already. I mean, you know, I think we need to get much better with testing. We need to get better with masking.

We need to, unfortunately, avoid gatherings. We need to be better with public messaging. We need to prepare the nation a bit more to understand what we're facing. I think we do need more coordination. I don't think this kind of patchwork approach will work. So these are all the things I think we should be doing. And in that messaging, incidentally, I would second what you said, which is encouraging people to take better care of themselves, which is a good thing to do anyway. So I think that's already a pretty tall order, Joe. I mean, I don't know what more we can do.

We are making heavy investments in vaccine technology and in science, which I think we need to do. I think we do need to take our public health infrastructure a bit more seriously. It's sort of a very unsexy thing to spend money on public health departments, but we need them. When this pandemic struck, we didn't even have contact tracing capabilities at the level we needed. It's very sort of bread and butter kind of public health capabilities, but we, compared to Asian countries, we didn't have that. So there are a number of strategic investments as a nation we need to make, all of which, incidentally, are peanuts compared to what's happening to us. I mean, Larry Summers, a former Treasury Secretary,

a former colleague of mine from when I was at Harvard, now I'm at Yale, and a colleague of his, David Cutler, who's a health economist at Harvard, they published a paper about a month or two ago, which called the coronavirus the $16 trillion virus. $16 trillion. These are vast sums of money. And they estimated that the hit to our economy by the virus was $8 trillion, and that there was a further $8 trillion loss because of the deaths, illnesses, and disability from the virus.

because of the deaths, illnesses, and disability from the virus. So our nation has suffered, from the moment this virus took root in our society, it has suffered a $16 trillion loss. It's like having a big house that just is burnt to the ground. It's gone. You know, it's just a big loss. And that's what we're facing as a country, actually. And I just think we I mean, I'm repeating myself. I think we just need to confront that and deal with that as sensibly as we can. I think one of the more unique things about America is that we have all these different states and we get to see all the different responses that different states have.

And that's one of the more confounding things about California's draconian methods, because it hasn't really been effective. There's still massive infections and deaths, and it doesn't seem to have done that much, particularly right now with the giant wave that they're experiencing. Florida is weird, right? Because Florida's essentially said, fuck it. You can do whatever you want. Haven't they?

They've basically opened up everything, live sporting events, concerts, restaurants. I haven't tracked it at this level of detail, but I do want to emphasize that even if the government says you can have live sporting events, only certain many people still won't go. So there is still – Yeah, but you're talking about Florida. I bet they'll is still yeah but you're talking about florida i bet i said you're talking about florida i bet they'll go they're the test monkeys they're the test monkeys for america i mean people in florida are wild folk they'll do some wild stuff yeah i i'm out there wrestling alligators yeah i haven't i haven't tracked you know every state and what every state is doing uh i i don't track it at that level i i definitely have a and also

incidentally i also don't look at cases by testing i look at deaths right because deaths are much less ambiguous like testing numbers can go up and down because we – Test more. Yeah, we test more or less. But deaths are much harder to fudge. So I monitor deaths. I have a sense of how many Americans have died on any given day and the cumulative toll of death. But I don't – and occasionally I'm paying attention to different states. Like earlier we were talking about the Dakotas.

So I haven't paid close attention to Florida and California lately. Well, Florida, the governor had a press conference, this is why I'm bringing this up, where he was bringing up where he had different age groups, he had a chart, and he was showing that we have to protect the most vulnerable, which is people, particularly older folks and obese folks. But he was basically saying for everyone else, this is not nearly as dangerous. Now, a lot of people got angry at him for this and they said it was irresponsible the way he was describing it but i i'm pretty sure they're basically opening up most things i mean they have disney world is open in a limited capacity there whereas disneyland in california is completely shut down and has been since march yeah but i have to i have to make make a point here about this.

And this goes back to our issue of our conversation about risk. So it is the case that most young people, if infected with this disease, face a very small risk of death. Let's say if you're in your 20s, you have a 1 in 3,000 chance of dying if you get infected, on average. If you're sick or you have some other condition or whatever okay you're higher but the truth of the matter is that young people face a low risk of death of all causes like i have kids in their 20s i wouldn't want my kids to get sick if they did get sick i would i would take some solace in the fact that this particular pathogen seems to spare the young it needn't have been this way other pathogens kill the young and spare the young. It needn't have been this way. Other pathogens kill the young and

spare the old. Like Spanish flu. Yeah, like that's not the case here. So I do take as a parent some solace in the fact that my kids, if sick, would be very likely to survive. But I would not say, oh, never mind if you get sick. That's not true. Their risk of death is very low from all causes. So why you would willingly accept an extra cause of death, especially one that doesn't offer any benefits. It's not like you're driving a race car and risking death, but you're having fun driving the race car. I think Florida's explanation for that would be that they want to open up their economy because they think there's a danger in closing the economy that is not discussed as often as the danger like in terms of the risk to human life suicide drug addiction there's a lot of factors in a depressed economy yeah and poverty is deadly i mean people losing

their job a hundred percent i totally agree and this is why going back, I think first thing we have to do is we have to tell the difference between what part of the economic damage is just due to the virus and what part is something we can do, you know, like we're doing to ourselves so we can affect it. Because remember, people are going to stop going out and shop, shopping just because they know there's a deadly virus out. So let's say for the sake of argument, 50% of the circulation of human beings that is reduced, that is lost, is because people themselves are making these decisions. So the economy is going to tank just because people don't want to shop anymore. And that's been happening for hundreds of years with epidemics. So there's that part. And then there's the next part, which is things that we're doing by, you

know, banning gatherings or closing restaurants or whatever. And then now, if we're going to decide whether to do that or not, your argument begins to have traction because you can say, look, when we close down that part of the economy, we're contributing to poverty and suicide and drug use and depression and all these other adverse effects. And then we have to engage in the very difficult and transparent as a society utilitarian calculus of saying, are the lives we lose because of that more or less than the lives we save? And here I agree that I think that we do need to be very cold hearted about it and do these calculations and publicize them. So if the governor of Florida said, I have thought deeply about this and I've consulted experts and we've done the calculations and we've concluded that we're going to have an extra 100,000 deaths or 30,000 deaths in Florida.

Because we are not closing the economy due to COVID. Whereas if we had closed the economy, we would have saved those lives, but we would have lost some other number of lives. And here's what I'm doing. Furthermore, dear Floridians, because we're not slowing the spread of the virus, some of you will get sick, will go to your local hospitals, and will be turned away to die because our beds are full capacity. And I am making that decision that we're going to take those deaths and we're going to take

that awful outcome of people being turned away at the hospital door. And we're doing that because we don't want to, we want to avoid these other deaths. That would at least be honest. And, you know, I would respect that, but I don't see that that's what's happening. I don't think that deep thought is going into it. I don't think serious calculation is going into it. And I certainly don't see governors saying we're going to keep our economy open, but the price of that will be these deaths. And when X, Y, Z happens in a week or in a month, I eat it too. That is kind of political suicide, right? To say that, to say we're calculating that a lot of you are going to die because of this decision, but the economy is going to do better. No, we're going to say fewer of you will die. Yes, you could do that.

Or you might even do the calculation and say, look, actually, we've done the calculation and we would lose 40,000 people due to the economy being tanked versus 30,000 lives due to COVID. And so I had to make the difficult decision as your governor to not issue these stay-at-home orders because this will result in saving lives. Or not. Say, actually, if I issued stay-at-home orders, we would prevent 30,000 COVID deaths. And if I don't issue stay-at-home orders, we would pay those 30,000 deaths from COVID, but we would have 20,000 deaths from the economy.

I'm mixing it all up now because I'm moving too fast and I hope listeners get the gist of it. The point is that there are lives on both sides of the ledger. And if you tally up those lives and you decide this is what you're going to do when you're honest with people, I have less of a problem with that. Now, Nicholas, if I gave you a magic wand and I said, you're the king of the world, tell me what to do. If you could be the person, you've studied this obviously very deeply to write this book, probably more deeply than most.

What do you think should be done? What step-by-step strategy to both preserve the economy and preserve the maximum amount of people's health? I don't think we can fully preserve the economy, and I don't think we can prevent all deaths. So we have to accept that both are going to suffer. all deaths. So we have to accept that both are going to suffer. I think we can do better as a nation by jiggling and jostling to implement a variety of slices of Swiss cheese that we discussed earlier, that if we collectively implement, mean we can protect more businesses and protect our schools so our kids can go to school. I'm not saying that it's 100% sure that we can do that. We might still have to close schools and close businesses.

But if we did more testing, more masking, more physical distancing, if we limited gatherings, if we had better messaging so people said, you know what, if I don't have Thanksgiving gatherings, then I can keep the businesses open and I can keep the schools open. So I think it's just immature to think that we can just go about life as it was before, because our world has changed. It's just not the same. We have to accept this, at least for a while. If we do those things, I think we have better messaging from our leaders. I think we will emerge from this pandemic, as we will inevitably in a couple of years, because plagues always end.

We are going to see the other side of this. We will emerge with it relatively more unscathed. That is to say, with fewer deaths from the disease and less damage to our economy. But there's no way, unfortunately, to fully avoid death and of course of course there's no way to avoid that we're in it right so but would you institute a nationwide mask mandate i don't think legally that's allowed but i think if the nation were able to do that i think we would we would greatly uh reduce the transmission of this germ we would save lives and minimize the other hardships that we had to implement. Yes, I think masks is the simplest thing. I mean, look, I can just put on,

I can put on this mask, you know, and if I do that thing and we all do that thing, we don't have to do other more difficult things. Why wouldn't we? It's the simplest thing you can do is to put on a mask. And the second simplest thing you can do is minimize your social interactions. These are much easier, you know, and your distance that you keep from other people. You know, for example, in my household, we try to make a shopping list and we go out shopping once a week instead of twice a week. I mean, we're having our social interactions. We're thinning out the crowds at the grocery store. We still buy the same amount of groceries. We're just not buying it. We're not having as many crowds. There are many common sense, basic things that we can do as a nation, which if we did, would actually allow our grocery

stores and restaurants and other places to fare better. So, I mean, that's what I would recommend. Yes. One of the things that people are really terrified about, particularly my friends that live in New York City, is that it's never coming back. There's a lot of the things that people are really terrified about particularly my friends that live in new york city is that it's never coming back there's a lot of my friends that are experiencing so many of their friends moving out seeing so many businesses go under they're really terrified of that that new york city is so big and it's such a a massive machine that to take out a giant chunk of it due to the pandemic, to have all these businesses go under, to have all these apartments that are available for lease, all these businesses available for lease. I don't see any strategy on the table to bring that back. I don't see

that being discussed. Is this something you considered when you wrote the book? Yeah. No, I think those will come back. I mean, I think, first of all, we're seeing an exodus from cities to rural parts of the country that has been seen with every plague for thousands of years. There's nothing surprising about the fact that in times of plague, people flee the cities, but the cities always come back. So I have no doubt. If I were a very rich person and I would be buying Manhattan real estate in a year or two. Not now though? What? Not now?

In a year or two? Well, I think it's still going to go down for a while, right? I mean, people are still leaving the cities and it takes a while for the market to clear. I'm no expert on Manhattan real estate. I made up that example. I'm not exactly. I'm not giving this. But the gist is clearly our economy is reshaping and people are moving to more rural parts. Anecdotally, we see rising house prices in rural parts and in suburbs. Also, with the working from home, people are beginning to realize, you know, I can do my job from home. Why should I be in a two-bedroom apartment in Philadelphia when I can

just as soon live on a big farm in rural Pennsylvania and do my job from a distance, and I'll get much more space for myself and my family and so on. So I think we're seeing that. But I do think the cities will come back because the intrinsic appeal of cities is so great. And they have always come back in the past. So eventually, I think the cities will return. But a lot of businesses have gone out of business and will go out of business. And this is awful. And let's not forget, I forgot the unemployment figures.

Maybe Jamie can look up. I don't have them handy right now. But like 30 million Americans have lost their jobs. I mean, many people are unemployed, let alone the loss of life. And as I said, we're not through with this yet. So I think this is a big shock. The airline industry, the hospitality industry, you think Boeing is selling a lot of planes right now? The travel industry. And incidentally, the travel industry is going to take a while to recover because now all of us have realized that, hey, I don't have to fly. I mean, I think doing business face-to-face is not going to stop. I think there's something extremely important about face-to-face for business. you have me on the show, I'll come down to Austin and we'll see each other, have a drink. It'll be totally a nicer experience, although this is great as far as I'm concerned. But anyway,

but many, many cases on the margin, people will say, why should I fly across the country to sign this contract or have some kind of a routine meeting? Skip it. We'll just do it by Zoom. So I think that's going to be persistent and that's going to have an effect on our economy i do another thing that's going to change joe i think there's going to be a change in women in sort of gender some of the gender dynamics because so if you look at the typical like the stereotypical heterosexual couple in this in this country so there are of, of course, homosexual couples. There are single family, single head of household families, single moms, single dads, much less common, raising their children.

But most households are heterosexual couples. And furthermore, it's stereotypic still, typical, that men earn more than women in the labor market. Not always the case. So not all households are heterosexual. Not all households does the man earn more than women in the labor market. Not always the case. So not all households are heterosexual. Not all households does the man earn more than women. But the predominant, the modal, as we say, pattern is still that in our society. So when the market, when the economy is tanking as it is,

and schools are closing, many families sit around the kitchen table and they're deciding how to cope. And they say, well, the man is making more money. He should remain in the labor market. And someone needs to watch the kids. So the woman is going to quit her, let's say, job that wasn't paying as much as the husband. And anyway, women might have, on average, a preference for being with their kids compared to men.

So we should absolutely allow individual households and families to make their own decisions about how to manage their own lives. But when millions of families reach similar decisions, we might find that the labor market gains that women have made over the last 10 or 20 years might have been reversed by this pandemic. That is to say, a few years from now, when we look at the labor force participation of women, we might see a changed landscape as a result of this virus. So there are all kinds of things that will persist, you know, that the world will have changed in some ways. So working from home, women's labor market participation, the travel industry,

schooling, you know, colleges, for example. A lot of colleges now have gone to develop the infrastructure and the bureaucracy for online learning. And some colleges will say, you know, we can actually offer an online degree much more easily. We were forced to do it. Healthcare, insurance companies, insurance companies used to not pay for, you know, why did you have to go to your doctor to get a prescription refill? This is ridiculous.

It's just stupid. Well, now, you know, everyone moved. People didn't want, doctors didn't want to see patients for such silly things. And we didn't want patients coming to hospitals and getting infected or infecting others. So we made an exception and we said, oh, you can, doctors can refill prescriptions without physically seeing the patient. You think that's going to come back? I mean, people are going to, you know, for two years, they will have been easily getting the prescription refilled. And now no. So they're going to be persistent changes in our society from all of these things. One of the things that disturbs me is that the stimulus package, that check that people got, the $1,200 check was one check, and it never repeated, and that was it.

It was crazy. Like, it didn't make any sense. I can't imagine they thought that it really helped people, especially over the long term. What, if any, effort has been put to try to increase that and try to send more checks out? And this has got to be a part of the response that the government has. Like Andrew Yang's universal basic income idea really made so much sense during this pandemic.

Like this is a real example of when something like this is absolutely necessary. Yes. example of when something like this is absolutely necessary. Yes, I think another example, and then I'll come back to that, although I'm no expert in this topic, is why health insurance is tied to your employment in this country. And it makes no sense, right? I mean, I don't want, if you lose your job and you can't get health care for a contagious disease, you're going to be out and about spreading this contagious disease. Or why we don't have sick leave policy for hourly workers. That also doesn't make sense. In other words, many hourly workers kept going to work when they were sick,

spreading the virus. This doesn't make any sense. We don't want that. So I think there are going to be changes in how we couple insurance to employment and sick leave policies because having a contagious disease illustrates some of the demerits in the existing system now same goes with universal basic income now i'm not an expert in this area but i i think that the way the government handled the way it just pumped out money and i think there was also some corruption

and like who got the money. I didn't track all this in detail. You may know this more than I do. I think we're going to have to rethink that. And I don't think we're done, unfortunately, with restructuring and rethinking the unemployment benefits. I do think we're going to have to do more

to provide for people because all of that stuff is about to end. And I think people are – there's going to be a wave of mortgage foreclosures and other financial hardships that people are going to experience. Yeah. No, I agree with you. Listen, Nicholas, next time we do this, I do hope we do it in person. But please tell people – do you have a copy of your book so you can hold it up? I do have a copy of the book.

Hold on. I put on – I uh it it has this nice cover yeah i put on the mask because this was swag that my uh that my publisher sent me which i thought was really cool swag so i have a limited of five of those masks that i'm aware what is the name apollo's arrow it comes from it's a nice thing to finish on. Hold it up again so I can see the spelling of it. Apollo's arrow. Okay. Yes.

And it comes from a story at the beginning of the Iliad. So the Greeks – this was events 3,000 years ago. So the Iliad, which is a Homer's story about the Trojan War, describes events that took place 3,000 years ago. And the book begins with a plague. What happened is the Greeks were laying siege to Troy. And they were periodically going on raids and sacking vassal states of Troy. And they would kill all the men, take all the treasure, and enslave the women and children. And bring them back to

their camps, and divide up the booty. So they had sacked a nearby city, and there was a maiden girl by the name of Chryseis who was given to Agamemnon, the principal king of the Greeks, as his prize. And Chryseis' father, Chryseis, was a priest of Apollo. Apollo was the ancient Greek god of healing and also of illness and disease. And so Chryses comes to the Greek camp to ransom his daughter. He brings a big treasure and he goes to Agamemnon's tent, the king of all the Greeks, and he falls on his knees and he begs him. He says, please release my daughter. And not only does Agamemnon say he will not release the daughter, but he treats this man extremely rudely in front of the Greek army, treats this priest, this important

priest. And he says, away with you. Not only will I not give you my daughter, but she will grow old in my house, in my bed, basically working as a slave for me. And if I see you lingering around the ships, you know, I will kill you. And he just smacks the man and sends him away. So the priest goes back down to the shore and he says a prayer. He says to Apollo, if I have ever served you, if I've ever given you sacrifices that have honored you, hear me now and come and punish the Greeks.

And the prayer instantly goes to Mount Olympus and Apollo hears him. And Apollo is enraged. And he picks up his big, I know you like archery. He was also the god of archery, picks up his big silver bow. And he comes flying through the air down among the ships that were encircling, on the beachhead, encircling Troy. And he crouches among the ships. And the ancient Greeks thought of diseases as Apollo's arrows, you know, invisible, you were just stricken by an invisible arrow. And he crouches among the ships and the book goes, the story goes of Apollo's arrows at the

beginning of the Iliad goes, first he killed the running dogs and the horses, and then he began to kill the men. Nine days through the army go the arrows of the God, and the funeral piles burnt day and night from the dead, until finally Hera, the queen of the gods, took pity on the Greeks because she saw them perishing, and she whispered into Achilles' ear, Achilles was another great king and warrior, whispers into his ear, call the Greeks to muster, return the girl to the priest so that the plague will end. And it turns out that then Agamemnon was forced to return this girl back to her father, and he had to pay a ransom. But his pride was so wounded that he then set into motion other events that ultimately led the last year of the war on Troy.

Well, that makes a lot more sense because I was wondering. I thought it was one word, Apollo Zero. That's what I thought you were saying. So I was like, how is that spelled? So there we see, we see the book now it's on the screen. Nicholas, thank you very much. Good luck with the sales of your book. Thank you very much for writing it. Thank you very much for having such a reasonable and objective perspective on this. And I really appreciate you very much. Joe, thank you for everything you do. And thank you for having me back.

And I look forward to doing this in person in Austin in a year. Absolutely. Thank you. Take care. Ciao, brother.