The Ricochet Podcast - Special Ricochet Podcast: Dr. George Savage

Episode Date: March 16, 2020

With the country on virtual lockdown and many, many unanswered questions about the Corona Virus, we thought it was a good idea to do a stand alone podcast with our good friend and the most knowledgeable medical person we know (and full disclosure: Ricochet Board Member), Dr. George Savage. Rob Long, and later, Peter Robinson ask the questions on this show, but later in the week, we’ll open to the... Source

Hello and welcome to the special Ricochet podcast. You know, we always number these podcasts, so I'm going to call this number one and hope that it doesn't, I don't come to you later with a number 575. We are going to talk mostly about, well, I think exclusively about the virus, about what's happening and what we can do and what we expect and how to protect ourselves and our loved ones. And we are joined, or I am joined, I should say, Peter Robinson has a dry cough. It's not true. Peter Robinson is not joining us today.

It's just me, Rob Long from Ricochet. And I'm joined by George Savage. And George Savage is, for long-time listeners will know George, Dr. George Savage. I guess the best thing I could call you, George, is that you are the chief medical officer of Ricochet.com. Is that fair? Yes. Well, thank you very much. It's a tremendous responsibility. It is. You're also the co-founder and chief medical officer of Proteus Digital Health, which is in the med tech space. But most importantly, you're a doctor and you're

a thoughtful doctor and you're a smart guy the smartest guy we know but i'm gonna ask a bunch of dumb questions and just tell us what you think so um we're this is serious what's happening right this is serious uh it is it is a serious public health challenge um again as i said on the podcast i think the flagship a couple of weeks ago, it's not the end of the world. Uh, it is a, uh, it's not even a financial crisis or any kind of, um, you know, war terrorist attack.

It is a public health threat and there have to be alterations in daily life to deal with it. So it's serious. So I, I walk around, I'm living in New York city and I walked around on Friday afternoon and sometime and a bit yesterday, took a long walk. And people were in restaurants and people were in bars. Were they morons? Well, that's a strong way to put it.

I certainly understand the impulse for doing that kind of thing. I think that kind of congregation is going to be curtailed, severely curtailed here in the coming weeks to try to crack this epidemic. And that's based on an analysis of what's worked. And right now, South Korea is the best example of a democracy's response that has appeared to be very effective in stopping the spread of this virus. And we really need to emulate what they've done successfully. And that would include curtailing those kinds of activities. Right. And you say South Korea as a democracy because Singapore, which was very successful, and a few other countries in that area, were not, they're not democracies? Well, I'm mainly thinking about China, where after a belated start, you know, initially sort of imprisoning the messengers and trying to clamp

down on knowledge and allowing coronavirus to get going everywhere in the world, they belatedly had a very authoritarian response to effectively locking people in their apartment buildings and stationing police outside and doing all kinds of things that would be unacceptable in a free society. And so you scratch your head and then say, is this inevitable, as Boris Johnson was musing about and the British government as recently as last week? Or could you follow something that's more of a moderate ground? And South Korea has done that, and I think it's working. Okay, so can we just talk a little bit about epidemics in general before we talk

about this one? So one of the things that's been postulated about some of the non or the sort of less democratic places is that they had experience with SARS. I guess this is a version of SARS. And H1N1, the avian flu. And so they already had two warning shots across the bow. And so they were prepared to take drastic action early on. Is that fair? I don't know. Certainly in the case of China, I don't think it's fair because the only reason, or certainly a key reason, this is a global problem at the rate it

was, was that for the first four to six weeks of the crisis, they hid the problem. And as I mentioned before, we're actually imprisoning and disappearing doctors who were chatting to one another, talking about a new kind of pneumonia they were seeing that they were very worried about and did not alert the World Health Organization until I think it was December 31st, at which point everything got going. But at that time, many people had already traveled all around the world. And it was, as it turned out, too late. So the first case, the first Chinese reported case was something like, I mean, working backwards, right, was something like early December. Because there's a difference between actual cases, meaning cases where the testing came

back positive for the coronavirus, and also people who are symptomatic and reporting symptoms way before that. Right. So that there's a there's a huge delay in solid numbers and then kind of conjectured numbers that. So I guess what I'm saying is there could be people who are who had who had the virus, who were symptomatic in early December, in late November. That's right. Yeah, I think that's very fair. And looking back on physicians beginning to report on a serious new kind of pneumonia in China, it does appear that late November, beginning of December, it was certainly a factor that had already been noticed, which would imply that given the incubation time and what we know about the history where it generally begins as a mild illness and for those patients who go on to experience severe illness, there's a delay of five to even nine days. You can extrapolate and say sometime in the middle of November, this was really kicking off. So it's possible. I mean, look, I'm just now speculating. It's possible that there are a lot of people have already had this. That's right. I mean, this was a very bad flu season this year. Is it possible that people have already had this and gotten over it maybe? Or I'm going to say got over, but this is

something that people have been living with, we have all been living with, for at least two months. It's true, but I do think that the rate of spread of this virus does indicate that this has not been circulating generally. So there may certainly be more acute infections than anyone really knows. South Korea, again, has done the most surveillance-style widespread testing for the virus. And interestingly enough, they're reporting a lower mortality rate, about 0.7 percent or thereabouts than many other places in the world, which could mean they have a less aggressive strain of the virus. But more likely, they're appropriately diagnosing minor cases that are missed elsewhere, where if, again, you're only testing the most serious cases, you would have a factitiously high mortality rate because you're not testing people with the sniffles who just assume they have a common cold. And so that is very gratifying that the mortality is lower than perhaps we initially thought. It still is much

higher than the flu, though, so there's reason to be concerned. But there's no evidence that there's general immunity amongst people who've maybe had this and recovered in the past. It does seem to be a brand new thing. And that's why the spread is so alarming, because every person the virus touches is likely to amplify the virus and go on and transmit it somewhere else. There's some things we do know about this virus. I think the Diamond Princess, the cruise ship that was quarantined off of Japan, that tells us a lot about the spread, right? Because it's almost a perfect experiment. You got a bunch of people

locked in a space and we can find out who gets it and how it's gotten, right, and what the rate is. And the rate here of infection is, I guess the number is called R and then a number, right? And it's great. Yeah, it's pronounced R-naught, which is R with a superscript or subscript zero. It's just the rate of reproduction of the virus. So R1 or R1.3 is the flu. You know, one person infects about one and a third people. This one is somewhere between two and three? I think so. Again, we don't know for sure until we're looking back at this after widespread screening is in place, but it certainly is transmitting more efficiently than the flu.

The Financial Times has an excellent graph showing the natural trajectory of this along a variety of different countries, and it's showing, to put it in terms more people The Financial Times has an excellent graph showing the natural trajectory of this along a variety of different countries. And it's showing, to put it in terms more people can understand, about 33% more cases every day than the day before. And of course, that's an exponential. And all the countries, including the US, are following this. China has managed to flatten that curve after an awful lot of cases. South Korea has

done the same thing. Hong Kong and Singapore also have flat curves. So does Japan. But people think that's perhaps because they're not doing enough testing. And so what we want to do is as quickly as we can get on the South Korea curve and get off the curve that unfortunately Iran and Italy are on right now. You know, we are actually suddenly I don't mean to interrupt you, but we are joined by, I guess, Peter Robinson has come out of his safe room, and he's unwrapped himself from his antibacterial latex covering that he normally wears. And he's joining us. Hello, Peter. I'm talking to Dr. Savage, who I introduced as the chief medical officer of Ricochet.com. Oh, that's a fair introduction. He is indeed our chief medical officer.

So we're talking about the rate of infection. And I guess one thing you said to me, Dr. Savage, which was a little startling, was that we're not going to know much until after it's over. Is that true? Well, we'll know more and more as time goes on. I think what we have right now is we have the upper bound on illness mortality, which it looks as though right now about 10% of cases become seriously ill based on the best available data. And the mortality rate is about 0.7%, primarily the very elderly, people with coexisting conditions and comorbidities, that kind of thing. One reason why we're trying to draw this out and limit interaction and lower the peak is given how infectious this is, the one way to make the mortality rate higher would be to saturate the medical system all at once, where too many people are sick all at once. The 10 percent

who are severe can't have access to hospital beds. Many healthcare workers, nurses, doctors, and others are also down with the illness, so they can't necessarily help. And you wind up in this sort of loop where it all becomes much more serious with worse outcomes than if it were drawn out over months. So some people have argued, and again, in the UK a week or so ago, that this was being bandied about, that if it's going to happen anyway and everyone's going to get the illness, why not just have it all happen at once? The reason you don't want it to happen at once is it will saturate medical capabilities,

and people who need care and would otherwise do well won't get the care. And then secondarily, the longer the virus goes on, the less potent it usually will be. A brand new virus tends to moderate over time, just given selection pressure, since less seriously ill people will wind up producing a lot more virus than people who get sick and die all at once. And so what you're describing is essentially Italy, right, which is a system in a country overwhelmed by cases and not enough, I mean, just not enough support, right? Just not enough beds in a way. That's exactly right. And that could happen here too in a couple of months if we stayed on the curve that we were on last week, which is why people are getting very

serious. And this is why this is serious. A lot of people will look and say 320 million people, you know, three or 4,000 cases. Why is this such a big deal? It's because our brains don't necessarily get exponential growth intuitively. You have to think about it and show what this adds up to over time. And it adds up to something bad unless we change it. The good news is we still can. And and so the draconian moves, George, may I have an interaction or good? Yeah. Rob, if you've got a line of questioning going here, I will withdraw. As best I can tell. All right. So we have the mortality rate is about 0.7%. That seems to be holding up in Italy as well. I've got two or three questions. It's just off the top of my head. How do we know that when testing or are we relying on figures in South Korea? Are we relying on figures from countries where we think testing is taking place quite thoroughly?

Because for sure, we don't know the numerator in this country. We don't know how many people have been infected. How do we establish a mortality rate when establishing the number of persons who have been infected is very hard? Right. Well, what we can say is the upper bound of mortality, meaning the number of people died versus the confirmed cases, that's about 5.7%. If you look at all patients for whom there's an outcome, meaning someone either got better or they unfortunately died, and many new cases are happening every day, but you don't count them because they haven't been sick long enough to either recover or unfortunately pass away. So that's as high as it could be. Then you look at the total number of cases and you get a lower number, 2% or 3%.

And then you look at the countries that have done the best job thus far of surveillance, South Korea being my favorite at the moment, where they're testing an awful lot of people. And there you're starting to converge on about 0.7%. And I think that means that you're now capturing more and more of those patients who they have a sore throat, they have a slight fever, not a big deal, but they're getting tested and you say, aha, you have coronavirus and they get appropriately added into the calculation. So the good news on mortality is that the more data we have, the more it tends to go down. However, even at the lower range, as best we understand,

the bad news is it's still six, seven, eight times as lethal as flu. Is that correct? That's correct. And another correlate here is that it's not just that seven-tenths of a percent unfortunately die, typically the elderly and what have you. But about 10 percent of cases get seriously sick. But of course, I see 90 percent of those cases will recover with the appropriate hospital care and supportive care and drugs and all the other things to get through the flu. And the thing the public health officials are most concerned about is that we don't let the virus rip through society at a very high rate of speed where it overwhelms the capacity of hospitals. Now, hospitals in my own area here are taking appropriate steps to eliminate elective surgeries and try to empty beds just to be prepared for the worst should it arrive while the public health people are trying to keep us

from infecting them. So the choke points or the bottlenecks or the limiting factors as i understand it are hospital beds of which there are about 900 000 i've seen estimates and of course i'm an expert on this because i've been watching cable news for all weekend but the estimates run from about 850 000 to 950 000 so i'm just going to split the difference and say we have about 900 000 hospital beds i am going to assume that hospital beds cannot be added to the system very quickly. But correct me if I'm wrong. If you could take football stadiums and put up tents and gymnasiums and put up tents, can you add to that? I don't know. And the other bottleneck is ventilators of which where this figure comes from, I don't know, but it was issuing from the mouth of every cable news commentator this weekend. There are 12,000 ventilators in this country.

The federal government is bad at all kinds of things, but it's really good at smothering problems with money. How hard is it to ramp up the production of ventilators? So the two bottlenecks, George, would you address those? Are those the two bottlenecks, and how quickly can you add capacity? Sure. The first bottleneck, I think the essential one isn't so much hospital beds per se as ICU beds, intensive care unit beds, which require a lot more staffing of specialized nurses and

doctors and have all the high-tech equipment, including respirators, ventilators. I think there are more than 12,000. That strikes me as a low number off by maybe an order of magnitude, but I'm guessing here I don't have the exact number in my head. But I believe from what I've been reading over the weekend that there's about 45,000 ICU beds in the U.S. right now. In a pinch, you could double that number pretty readily by converting other beds and adding capacity to the existing system. But if you run the math of infection and you assume, you know, 10% serious illness rate, again, you could see that becoming overwhelmed also. There have been some steps about how could you convert unused hotels or what have you for

this kind of thing. The problem with the mass stadium approach and the tents is that any kind of ward-like structure could accelerate infection because you don't have separations, especially of people being separated from one another, people who have the virus versus others who have other things. And the medical team would be less available to do protective measures to keep themselves from being infected. So in China, they did construct some emergency sort of hospitals. Hopefully it won't come to that. But that's really the worry the public health people are trying to make that scenario not come true. Rob has a question, but I just want to correct. I found something online while you were talking, George.

This is published by the National Institute of Health. Grandpa's gone on the Internet. I don't know what you're talking about. Exactly. Well, I think I've gone up a step from cable news. We estimate there are 52,000. They don't estimate. They get 52,118 full-feature mechanical ventilators

owned by respondent hospitals. That's a lot more than the 12,000. Where that figure came from, I don't know. Maybe I dreamt it. Anyhow, so it's closer to 52,000, apparently. Rob, over to you. That makes sense that you'd have one per ICU bed because a lot of intensive care patients need ventilation support. And this is for people, again, who have the worst outcome, which is this respiratory distress syndrome,

and where you'd want to support them through that so that they can recover. And again, that's a minority of cases. The overwhelming majority of people who get this disease, it won't be a big deal. But given how infectious it is, given the tendency to infect huge numbers of the population, given no immunity, that small percentage will work out to be, unfortunately, a large number of people unless we can slow the spread, which is why everyone are taking these extraordinary steps and why it makes sense, even though it's having a negative impact

on the economy, the stock market, and just people's state of mind. So let me see if I can just sum up where we are so far. So the additional problem for treatment is that people are still having heart attacks and still having, you know, you know, we're still going into the ICU. Still, there's still people are still, you know, getting in fires and they still have to go to the emergency room. So that stuff has continued, although maybe everybody stays home, there'll be less of that. Um, but it seems like what you're saying is that the, the, the fatality rate in countries where treatment is available is going to be much, much lower than countries that are overwhelmed. Is that fair? I think that's fair. I think that is very fair. And that's certainly the sense that we have. And that's, again, what all these measures are designed to deal with. So in addition to the people who are working feverishly for...

You may want to watch that. Working feverishly may not be the best construction. Working quickly and working overtime to find a vaccine. And in addition to the people who are trying to get tests in people's hands and trying to use LabCorp and Quest to administer these large-scale tests, in addition to that, if you are participating in any act that helps keep the medical system from becoming overwhelmed, you are also, in many ways, lowering the death rate. Is that a fair assessment? It is. And another point to mention is greater time will allow us to prove out potential therapies for those who are very seriously ill and allow vaccine efforts to come to fruition as well. And one example is this drug Gilead developed in an attempt to treat Ebola years ago called remdesivir. Seems to show efficacy.

How did you get that name? I'm sorry. Okay, well, I don't know. But it wasn't all that great for Ebola. It's been used in some very desperately ill patients who weren't expected to survive and shown positive results. Of course, in medicine, we have to be very careful to rule out the fact that that patient may have been about to recover on their own anyway. And so that's now in a very rapid clinical study, rapidly implemented, the first data, I think, will be available sometime in about a month or so to show whether this is wishful thinking or whether it really helps.

Hopefully, the latter, of course. And then it will be offered to more and more people, assuming that works. Vaccines will make progress and so on and so forth. So there's all kinds of good reasons to spend a couple of months, if we need to, limiting interactions, certainly a couple of weeks at least, so that we can have this number of new infections per day begin to shrink relative to the day before rather than increase it as it has been. Okay. So one more topic, and then I want to just talk a little bit about what you recommend we all do. But before we get there, I don't want to talk about politics because I feel like the, the political issues here will, there's a time and a place for them to be settled and that's

going to be November. So it's, it's the, why waste time? Um, but it does seem like there is a, you know, full disclosure, I am not in favor of Medicare for all. I'm not in favor of, uh, you know, British style single payer. But it does seem like there is a confusion here about the difference between health care and the health care system and the public health system. Good point. The public health system is how we as a society and how the government plans for these and plans for these eventualities and educates the public about what they need to expect and what they need to do and what their duties are.

And the health care system in general. It doesn't seem like the solution is to make sure that we have permanent capacity for something like this, does it? I mean, would you recommend that after this is over, we say, okay, well, we're going to build, you know, 70,000 more hospitals and we're just going to keep them empty until this happens again? And I guess what I'm, I know I should let you answer, but I guess what I'm suggesting is that we have really four kinds of patients here who should not be mixed. We have the people who are asymptomatic but have tested positive. We have those who are, I'm assuming everybody's been tested, right? People who are symptomatic, but, you know, it's a bad cold. They're not the code red. They're young or whatever it is,

whatever, the virus hits them in a certain way that it's not debilitating them, but they are going to, as they say, shed virus. They're contagious. And then we have people who are in a test group, I'm sorry, a risk group, who are symptomatic out of test positive, or they haven't. They're not symptomatic, but it's dangerous. And then we have people who have full-blown serious things and should be in an ICU and a ventilator.

And those are four populations that should not be all in one hospital, or am I wrong? I don't know that they need to be in a special hospital or you need to have a parallel medical system. I just don't think that would be economic. If you consider the last time we had an epidemic that really was progressing at this sort of rate and didn't peter out on its own, that was a century ago. And so waiting a century for this kind of thing. I think recognizing the potential quicker would be very useful. I mean, again, without getting political, all generals and presidents and what have you always have this problem of fighting the last war when conditions have changed and being slow on the uptake. And there are many examples through history on that. And people just aren't wired very well to grasp exponential

numeric growth. It's just not really in our experience. And so when you first hear, well, there are 20 cases in America, it's sort of like, well, why is this a big deal? You get that, right? And people are slow to react. Again, the CDC, you have all the problems of bureaucracy in the U.S. government as well, where the CDC apparently didn't want to use the World Health Organization test. They had a better test because, after all, they invented it. And then it turned out that had technical problems that set the U.S. back. Then we had the FDA responding with delay to many hospitals that were developing their own tests and different private companies by putting them on ice until a week ago, the administration and everyone got together and they now are approving things very rapidly.

They could have done that several weeks earlier. I don't think it's any ill intent. It's just the way bureaucracies are. You do what you do and you tend to underestimate whatever the problem is until, you know, you have the equivalent of getting knocked upside the head. Just over this weekend, a life has changed from me more or less going to the office and going about my life on Friday but trying not to shake hands and doing things like that to now seemingly everything is being canceled moment by moment. Right, right, right.

The world is all waking up, and that's almost inevitable. I just don't think one administration versus another or one form of healthcare versus another would do any better. Well, before we go to the other stuff, I just want to ask you this. So I live in New York City, and it seems to me that today, actually, over the weekend, from Sunday to today, there's less traffic, there's fewer people on the street, I can tell. But it seems like there should be a system where people in New York City who are testing positive or have mild symptoms could go to the New York City Hotel, which is the commandeered New York City Hilton. I mean, there are plenty of beds in the city and stay there and self-quarantine and be there on the city's dime or on the public health's dime for a while. And then when they're asymptomatic or they're, they don't, they test, they're not, they're both through it. They get to go home. And, and it does seem like we all need to sort of teach ourselves how to diagnose ourselves at the level we are.

As Americans, we are used to getting an enormous amount of high-priced, high-cost attention for something very small. And I guess I'm being inarticulate, but I'm often struck by the time I spend with a doctor who represents some million-dollar worth of social inputs to get to create a licensed medical doctor in this country. And he's taken a swab of my throat, you know? And I was like, couldn't that be, I don't know, why do we need it? Why do I have, why do you have to go to Stanford Medical School to take a swab of my throat or look at my ear or to diagnose an ear infection or to, I mean, you know, God forbid, give me a prostate exam.

You're putting your finger on something important, and I don't mean your prostate. I want to lighten the mood here. I don't want to. Yeah, go ahead. But one of the worst places you can be right now if you don't have coronavirus is to head into the hospital emergency room or a clinic because where is everyone who's not feeling well going to be going? That very same point. And now we have technologies progressively, more and more of them in this field called digital health, where you can leverage the smartphone that you and everyone else is

carrying around to do more on your own, do more remotely, do more telepresence and connections with the health system that do not increase the risk of infecting other people. And so more and more of those tools should be available. And frankly, part of the declaration of emergency in the press conference the president gave, I think it was Friday, but late last week, involved suspending and changing certain rules around payment for telemedicine and digital health services, because you can imagine for the longest time, CMS, the Center for Medicare and Medicaid Services and others have been reluctant to reimburse for these kinds of remote physician services because it's hard to audit, right?

If you as a physician or a medical practice, you can get paid for an email or for thinking about somebody. Well, OK, the bills could go out of control. Whereas you can audit the fact that the patient showed up at your waiting room and they were there and you can identify if there's any fraud going on. I think people are getting over that and understanding that they need to find a way to preserve integrity around billing and enable these new technologies to work. Otherwise, the current system is just going to breed more infection. May I pursue that a little bit along the lines that I've learned from, I've actually learned to think this way from my friend and colleague, Rob Long. So the good news here may be, a piece of good news here may be,

Walmart is permitting people, they're setting up drive-thru clinics. What was it? There were Walmart and Walgreens. I just got an email, CVreens. I just got an email. CVS, I just got an email from my own healthcare provider that if you think you have symptoms, you do this, that, or the other, you go through a checklist online, and then they're going to put you online streaming video with a doc or a nurse or somebody qualified who will just look you over and talk to you online and see whether you need to get the next level of care. So all this is the kind of stuff that we've been

saying for years should be happening in healthcare anyway. We have technology that enables us to, just as Rob said, to broaden the reach of each individual physician. Qualified nurses should be doing more anyway. And we also know that certain kinds of examinations can be routinized and you ought to be able to go through a drive-through clinic. This is terrific news, right? As far as it goes? Yeah, I think it is. And that is one of the crisis-related changes I think that would be good for the health system in general. If you look at labor productivity, one of the worst-performing sectors is health care, where you have seemingly endless supplies of people who earn six-figure incomes that are required to do anything. And if you compare that to the rest of your life and what you can now do for yourself on your cell phone, from entertainment to finance to, you know, you name it, you can do it. Transportation, it's all leveraged on your cell phone, which is making people more productive. Most of healthcare

has been very sticky where it's all in person and consuming actual time from a very expensive professional. And as Rob and you were just pointing out, that's not necessary all the time anymore. And so this may be a catalyst to change. George, you're an entrepreneur in the medical field. You've started one company after another, and I've known you for years. And one of your – I'll ask how are things going. And quite often the answer will be, well, they'd be going faster if it weren't for the FDA. Does it at some level please you that we're about to have, that we are now conducting a nationwide experiment at how quickly we can develop new techniques and new vaccines when the FDA says, yes, sir, let's move this along. Yes, yes, yes.

As quickly as possible instead of, oh, we'll get back to you in a year and a half. Yes, it's very, it's a good side effect to a bad event, which is, again, the bureaucracy is having to analyze, both at CDC and FDA, how they do things and how to do it more quickly. The nearest analogy I can think about is in the 80s and 90s, when the HIV epidemic was out of control and everyone was trying to get a handle on this illness, which at that time wasn't treatable effectively and was killing large numbers of people. And of course, it was hard to catch relative to this disease. So it wasn't quite the public health threat that this is, but it really captured everyone's attention. And

as a result, HIV has become just another chronic illness that you can manage successfully through medicine. So a huge success there and done pretty quickly. Hopefully we'll do the same here. Okay, George, I know you've got to go to cure diseases or whatever. But, you know, we have important work here too. We're doing podcasts. Let's just wrap it up just with a, with a one more time, but we, we, um, uh, I get, you know, all this stuff, wash your hands, right? 20 seconds.

The virus dies at above 75 degrees. So if you can stand the warmer water, do the warmer water. Stop me when I'm saying something stupid. Um, don't go out. If you can don't go to, if you're especially even a risk group, don't go to restaurants. Don't go to bars for a while. Anything else? What else? What can an ordinary person hearing this, put it this way, what can an ordinary person hearing this who lives maybe in a place where there aren't a lot of people around anyway, what can they do? What should they be doing? Pretty much what you suggested, just disinfecting

surfaces a lot, washing towels and things like that more frequently, because anything that you touch that could transfer virus from somebody else to you, so door handles, elevator buttons, car handles, steering wheels, if a vehicle is shared with people who aren't already in your household, disinfecting kitchen surfaces, bathroom surfaces. If somebody in your household is sick, having them use one bathroom if you have more than one alone, again, more frequent clothes washing, etc., etc., avoiding embracing and shaking hands and what have you. I understand in places like France, that particular requirement is causing a lot of psychic turmoil, but that can really help. Hey, George, what do we know, if I may? George and Rob, I guess this is not a medical question. What do we know about the integrity of the grocery supply chain. This didn't cross my mind.

Last week, it was everybody go to work, carry on your life as usual. Just don't shake hands and sneeze into somebody else's face. Fine, no problem. But now, don't go out. Well, the one reason for which we all still have to go out is to go get groceries. And we look, turn on television, and we see that there are runs on some things that make no sense. But there are runs on grocery stores. People are very nervous about this. A, how's the supply chain going to hold up if all kinds of employees, including presumably

people in meatpacking plants and food processing operations of all kinds, are under the same kind of strictures as the rest of us? And B, should we be double washing that head of lettuce when we get it home? Should we be restricting ourselves to canned foods? Or is this whole line of questioning just showing that it's gotten under my skin? Well, I think the wartime analogy works here. There are certain essential industries in which food is required. So I think that those are industries that have to keep going and people have to keep going to work while we deal with this external threat of a virus. Right now, there are some disruptions, I think, that are primarily related to panic buying and hoarding and stockpiling,

things like toilet paper. I was in my local market this morning to pick up some eggs. There are no eggs. You know, it's starting to look like patchwork Soviet Union in terms of depopulated meat counters and, you know, where you scratch your head because there was plenty Saturday and today there isn't. So I think this is hopefully a very temporary item here. And hopefully, I won't have to start eyeing the deer in my neighborhood as a food source. Rob, what are you encountering in New York? Same thing. I think there's a lot of people stocking up on fresh food, which seems either optimistic or crazy. Optimistic meaning, well, I'm going to be eating in for the next seven days. Also crazy because what you really need, if you, well, I'm going to be eating in for the next seven days.

Also crazy because what you really need, if you really think that we're going to be hunkering down, you need beans and dried food and stuff that lasts for a long time, stuff in cans. Eating canned sardines for a while, which actually is pretty healthy, so it's not a bad thing. That is definitely happening, although I go to the supermarket. But I'm aware when I'm walking home with my bags that I'm going to have to, you know, wipe myself clean when I come in and I'm going to wipe the doorknobs and wipe the handles of my shopping bags and all that stuff. I'm sort of aware of that.

I thought you were about to say I'm aware as I'm walking home with my grocery bags that I'm going to have to fight off a few looters. No, no, there's no. But I guess what I'd say is like after this is over, George, which will be how long, George? Yeah. Well, you know, it's always dangerous to make predictions, especially about the future. But I think this is likely to be a couple of months event. Hopefully we begin to turn the corner more quickly and we see a trend., and we're not on the same degree of lockdown for all that time. But I think this particular peak, it's likely to be a month at the inside, a couple of months sort of the outside.

But, of course, I could be wrong about that, and it could go on longer. It just depends how the public responds and what happens with the case growth that we're seeing. Right. And when it's over, how much of the stuff that we're doing now should we just learn to do all the time? Good question. Yeah. Yeah, that's a good question. Well, certainly, you know, cleanliness around the house in terms of disinfecting surfaces and washing your hands a lot. That just makes sense generally. I think once there's a general immunity to this particular disease, we wouldn't have to go with this cutting restaurant capacities in half and staying away from people and all that. These events are really tailored to a brand new

virus that has a zoonotic virus that has come from bats and is now for the first time infecting people. And there is no immunity. And so it spreads like wildfire. I think this is something of a one-off. But some of the habits are good to continue. So you don't, I mean, I've been saying on, I guess I should now, I'm opening myself up here. I've been saying over and over again that we might actually get out of this one okay, but there's another one coming. That this is just exactly, this is the way the world works, the way the world we live in. No putting the toothpaste back in the tube. We should just be prepared for more of these events in the future.

And are you you is that wrong no you're you're correct that we should be prepared and we should uh draw some learnings from this particularly around surveillance for new viruses and then how you jump on them to hopefully contain them better than this happened but again i want to point out the thing that uh really messed up the world response here was that the point of origination, the Chinese government didn't just not know about it. They knew about it and did their darndest to cover it up and keep the rest of the world from knowing for a solid month. And in the era of global travel at 600 miles an hour, well, that just let the toothpaste out of the tube. So having the

Chinese government behave more responsibly would be a great way to prevent this. Wow. Well, those are people. Can you handle that, Rob? Yeah, those are people we cannot, we aren't voting on in November. So that's even more worrisome. That's right. Hey, so are you absolutely certain you don't want to discuss the politics of this at all me yeah you oh uh no we can't i just want to make sure that it's you're driving the bus here i just i feel like sometimes people i mean it's a human tendency to um to see and not just to see the consequences of an event but to see the event and the facts through a political lens to look at the other end of the telescope. I mean, the virus doesn't care who the president is, doesn't care the Speaker of the House,

the virus doesn't care that the media is liberal. The virus doesn't care that CNN is insane. The virus doesn't care. It doesn't have any politics at all. And so all of the things we've discussed are true. And they are true if they are politically, uh, politically damaging to the sitting president. And they would be true if Barack Obama was in the white house. They are true. Right. Exactly. Right. So in my, I don't know whether I'm right or wrong about this,

but this is what occurs to me. We can abstract this entirely and say the incumbent and the challenger, because it really doesn't matter who would be in the White House. Trump has his own. There are all kinds of things that are specific to Trump, but not this, I don't think. The incumbent had going for him until a month ago, the argument that the economy was doing extremely well, unemployment rates were down, he was handling all kinds of foreign policy issues. People would disagree about this, but he at least had an argument to make that he was standing up to China in particular. And now all of that is gone. All of it is gone.

We're headed into, I guess the technical definition of a recession is two quarters of negative growth or two quarters of contraction. I hope we don't get a second quarter. But if the factory whistle blows and everybody knocks off work to go home, we don't get a second quarter, but if the factory whistle blows and everybody knocks off work to go home, you don't get products. And that's sort of what's happening right now. The factory whistle is being blown and people are being told to go home. So we're going to get a contraction in our economy. And the Chinese are saying, oh yeah, are you standing up to us? Where do your antibiotics come from, by the way? We're being reminded.

Right. Right. So every argument the incumbent had is gone. And the challenger, and I say we abstract this, we have a very peculiar incumbent and a really, very strange and weak challenger. But as of a month ago, it used to the case the challenge it was the incumbents to lose the i beg and the challenger have to the challenger had to make a very strong case and as far as i can tell this has simply flipped the political calculus so that the challenger can win by not being the incumbent that's all he has to do i to complete his sentences he doesn't have

to agree i don't disagree i don't disagree i i i but i would i would say this though that i i um in our our friday podcast which came in which we did friday morning which was a day and a half after what i what i could consider to be a disastrous presidential speech from the oval office in which to be even people who support our ardent Trump supporters. If Barack Obama had given that speech and then 20 minutes later had contradicted himself and clarified himself and basically said, I'm sorry, I was wrong here. Three more. I got to correct the record here. And three major policy points would be a six act play. We'd be screaming in confidence and we'd be correct. Right. To do That said, the president has a lot, a lot of failings, but stubbornness in being

consistent is not one of them. Friday afternoon, that was a presidential press conference he gave a presidential appearance. He looked like instead of looking like a class clown, he looked like the class president. And the problem with the problem that Trump has in general is that people like the class clown. He's funny. He is a funny, engaging, funny person.

And he's making the libs, you know, driving them crazy. And people on CNN, their steam's coming out. And that's what he's good at. And he knows that. And that's great. I love that.

I mean, I'm not a fan and I love that. I totally see the appeal. I get it. And as long as the judges are conservative and, like, he's doing the right kind of tax cuts and the economy's growing and unemployment's low, I'm like, well, I just look like, you know, this sort of prim and proper Victorian, you know, blue stocking because I can't get with the program. That's true. But at some point, the people don't want the class clown. They want the class president. And he whiffed it horribly on Wednesday. He pulled it back together on Friday. I actually think that as long as he treats this with respect, treats this virus with respect, which I think he does because he's a bully, basically, and the virus has punched him in the nose that you can't that's true you can't have a rally against the virus you get no funny nicknames for this virus he's going to respect it and he's going to treat it with the

you know with the right probably with the right blood latitude i'm not sure that this won't help him if he does it right it has been i was about to say a century since calvin coolidge became president on the death of warren hard. But Coolidge was an experienced figure by then. He'd been governor of Massachusetts. We may never have had in all our history a man assume the office of president who had so much to learn about how that office worked. At the same time, he's a very quick learner. I would agree with that. At the same time, he's a very quick learner. unprecedented, the odds are that the bureaucracy and the executive will take a little while to get up to speed. And particularly, again, on these exponential kind of effects where at first, okay, you have a dozen cases, why is that a big deal? And it only emerges later that this is much

more contagious than some of the prior threats we had like SARS and MERS. Yeah. Wait, did it just drop out am i here no no i i just fell silent because that's sort of the the um much more contagious that's that that's what we just keep coming back to this is sort of i mean rob you're a genius at keeping things light but george said earlier though what what was it ge George used this phrase. Yeah, well, of course, the fatality only strikes those who have to worry about fatality are only the very elderly and whatnot. And I thought to myself, wait a minute, Rob and I are a small number of younger people who get this as well. But if you're looking for silver linings or blessings here, one that we have over 1918 was then it was the reverse. Older people did just fine. And it was the 20-somethings and the people in the prime of their life who were being struck down by this. So that's something.

I like that better. Funny, my attitude on this has changed over the years. George, thank you for joining us. That's great. And can we call on you again as the crisis evolves? Can we call on you again? What our listeners don't know is how often Rob and I call on George is, hey, George, I've got a little problem with my lower back. That's funny.

Every board meeting, George, of course, is a treasured and valued board member of Ricochet. Every board meeting, there's at least one hour of the agenda is dedicated to like, so wait, does this look good to you? What does he think? What does this look right to you? It's a major part of my practice. Yeah, by all means, call me anytime. Thanks, George. Thank you.

Thanks.