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

00:00:00.000 Welcome to the Making Sense Podcast. This is Sam Harris.

00:00:04.120 Okay, this is my second podcast on coronavirus,

00:00:08.840 and it is very consciously a follow-up to the one I just dropped with Nicholas Christakis.

00:00:15.300 I've done this with Dr. Amish Adalja,

00:00:18.900 who's an infectious disease specialist affiliated with Johns Hopkins University.

00:00:23.380 As many of you know, the Johns Hopkins website has

00:00:26.240 become a resource for more or less everyone on the spread of coronavirus.

00:00:31.740 And Amish has a background in infectious disease,

00:00:36.680 and he's helped develop U.S. government guidelines

00:00:39.320 for the treatment of plague and botulism and anthrax.

00:00:44.080 He has edited the journal Health Security,

00:00:47.880 a volume on global catastrophic biological risks.

00:00:51.880 He's a contributing author to the Handbook of Bioterrorism and Disaster Medicine.

00:00:56.240 So the spread of an emerging pandemic is very much in his wheelhouse.

00:01:01.780 As you'll hear, he sounds less concerned than I do.

00:01:07.280 And the reasons for that become explicit at two points.

00:01:12.980 So I just want to flag that here so that you have an emotional barometer to the conversation.

00:01:18.640 The first is that his estimate for the case fatality rate for coronavirus,

00:01:25.580 worst case, puts it at 0.6%, which is six times worse than influenza,

00:01:33.980 but quite a bit better than the worst case scenarios being talked about elsewhere.

00:01:39.760 He definitely thinks that this is going to be considerably lower than 1% fatality.

00:01:46.700 So if true, that's obviously good news.

00:01:49.560 Six times worse than the flu would still be quite terrible when you run the numbers,

00:01:54.080 but it doesn't put this virus at 3% or 2% or even 1.5%,

00:02:00.700 which is a very common figure one sees at the moment.

00:02:04.800 So I don't know how accurate an estimate that will prove to be,

00:02:08.720 but that is one reason why he sounds more hopeful than I have been.

00:02:15.000 But there are two other reasons that don't become explicit until the end of our conversation.

00:02:20.400 And I want to preview them here so you have the appropriate frame coming in.

00:02:26.800 The first is that Amish is a man who spends a lot of time thinking about the worst case scenario. 0.91

00:02:32.500 And the worst case scenario is something like a bird flu that mutates and becomes highly infectious

00:02:41.660 among people and has something like a 60% mortality rate.

00:02:46.620 He is thinking about species annihilating plagues that we know are possible, right,

00:02:53.300 and that we need to prepare for.

00:02:55.040 So in light of that possibility, what we're experiencing now,

00:02:59.060 even the worst case scenario, is very much a dress rehearsal

00:03:04.420 for something much, much worse that could yet happen.

00:03:08.680 So that's worth understanding.

00:03:12.640 But the other piece here, which, again, we talk about only at the end,

00:03:17.220 is that his primary concern now is not to sow panic, right?

00:03:22.780 And my primary concern has been to spread not panic, but heightened concern.

00:03:30.220 Because I'm encountering people who think that this is no big deal, right?

00:03:36.200 And I'm encountering them disproportionately on the right side of the aisle politically.

00:03:40.700 But I've seen people with real reputations and considerable reach tell their fans that

00:03:47.280 this is just like the flu and 6,000 people die every year of diabetes and we don't freak out about it.

00:03:55.100 They're not even making contact with the dynamics of this thing that is unfolding in front of us.

00:04:01.100 And so where you come down on the need to mollify people's fears or amplify their concerns here,

00:04:09.820 I guess, is a matter of judgment.

00:04:12.400 And Amish and I are running in different circles and have calibrated that rather differently.

00:04:18.360 So please know that going in.

00:04:21.500 I see a society that still doesn't want to close its schools.

00:04:24.520 I know people who are still going to concerts.

00:04:27.780 I have people who seem surprised that I expect that their spring break plans are going to change.

00:04:34.920 I know people who don't seem to understand why conferences are getting canceled.

00:04:39.140 And there's a pervasive sense, again, especially on the right side of the political spectrum,

00:04:46.860 that the media is exaggerating the problem here, very likely for political and monetary gain.

00:04:56.460 And my concern is to break through that bubble.

00:05:02.540 And you'll hear in a few places where I attempt to do that without fully understanding Amish's concern not to so panic.

00:05:11.580 But we come to a full understanding by the end.

00:05:15.040 Anyway, I hope you find this useful.

00:05:17.600 Undoubtedly, this will not be the last conversation on this topic I have.

00:05:21.820 Amish has agreed to come back anytime there's new information that he thinks people should know.

00:05:27.160 And I will do my best to make myself useful during what I am confident will be a challenging time for all of us.

00:05:35.100 And now I bring you Amish Adalja.

00:05:40.780 I am here with Dr. Amish Adalja.

00:05:43.600 Amish, thanks for joining me.

00:05:45.300 Thanks for having me.

00:05:46.540 So this is the second podcast I have done on coronavirus in 48 hours.

00:05:53.100 And I just, I really want to cover this topic completely insofar as we understand it at the moment.

00:05:59.880 And you really seem to be the right person to speak with here.

00:06:03.920 Give us your background and why you have any expertise on this topic.

00:06:09.160 Sure.

00:06:10.520 So I'm an infectious disease, critical care, and emergency medicine physician that has focused,

00:06:15.880 like I focused my whole entire career basically on emerging infectious disease, pandemic preparedness,

00:06:20.960 how infectious diseases and national security intersect.

00:06:23.600 And that's basically where I've kind of niched myself.

00:06:26.520 And when these types of outbreaks occur, it often is something that I've been thinking about long before the outbreak occurred.

00:06:32.080 And that's sort of why the media sometimes turns to me during these incidents.

00:06:35.420 And I try to understand them, dissect them, predict what's going to happen, and even do this when there's not an outbreak.

00:06:42.080 And you're affiliated with Johns Hopkins, correct?

00:06:44.420 Right.

00:06:44.720 So I'm part of a think tank at Johns Hopkins called the Johns Hopkins Center for Health Security,

00:06:48.980 which is a think tank devoted to infectious disease emergencies.

00:06:52.420 And it was founded back in 1997 by the man who eradicated smallpox from the earth, D.A. Henderson.

00:06:58.700 And it was initially founded in response to bioterrorism, but has now really expanded to think about all infectious disease emergencies.

00:07:04.940 And we have a multidisciplinary team of epidemiologists, physicians, people with MPHs, lots of different types of people,

00:07:12.500 infectious disease modelers.

00:07:13.580 And we try to really keep on top of these issues and kind of be the leading voice on them.

00:07:17.460 And you do seem to be the leading voice because the Johns Hopkins dashboard seems to be the dashboard that everyone is using to track the spread of this disease.

00:07:28.040 Yeah, that was something that people put together rapidly.

00:07:30.280 It's not in our specific center.

00:07:32.600 That's actually, I think, from one of the engineering schools that's put that together.

00:07:35.380 But it's been really useful, and it's been refreshing to see the world using Johns Hopkins' talent to help understand what's going on.

00:07:42.140 Okay, so it's March 10th, the day we're recording this.

00:07:45.560 I think we'll probably release this on the 11th.

00:07:48.800 And at the moment, there are around 118,000 confirmed cases and a little over 4,000 deaths.

00:07:56.600 And I know we have a denominator problem still, so we don't actually know how many people have been infected.

00:08:02.180 So it still requires some guesswork to estimate the case fatality rate.

00:08:07.460 But what is your best estimate at this point?

00:08:10.180 So the best estimate, I think, is derived mostly from the South Korean data where there's been extensive testing, the most per capita testing that's been done in any country where they actually have drive-through testing centers.

00:08:20.840 There, you're seeing the case fatality rate at 0.6.

00:08:23.460 So that's now become my upper bound.

00:08:25.180 I do still think that there is probably a severity bias there because it still takes some effort to want to go get tested.

00:08:30.960 So we're still not fully getting capture of everybody that might have very mild or minimal symptoms that people don't even barely notice.

00:08:37.880 So I think 0.6 is the upper bound.

00:08:39.820 And I think the lower bound is going to be somewhere, I would say, a little bit above seasonal flu, which is 0.1%.

00:08:45.460 So it's somewhere in there, but it's still a lot of fluctuation and still a lot of uncertainty.

00:08:50.340 Okay, so that is actually quite a bit more sanguine than anything I had heard up until now.

00:08:57.180 I mean, you know, I recorded my previous podcast 48 hours ago, and there you have, I think it was the Lancet reporting 1.2% to 1.6% or somewhere in there.

00:09:08.760 I mean, something like, you know, half the rate of the most dire predictions of around 3%.

00:09:14.060 So you're reasonably confident that 0.6% is the upper bound, which now we're talking about six times more lethal than the seasonal flu.

00:09:23.120 0.6 seems to be the best way to look at this.

00:09:25.780 When you think about the fact that we've had major testing constraints in many countries, and South Korea has been very aggressive at testing, and that's where they're seeing their number.

00:09:33.260 So I think that that's the easiest parameter to try to put into this big world of unknown about this.

00:09:39.580 And I definitely think the 1%, 3% numbers are way off because of the severity bias.

00:09:44.360 It's important to remember that seasonal flu is 0.1%, so it's still a magnitude higher, and it will be more difficult than dealing with the seasonal flu to deal with this virus.

00:09:54.640 I want to talk about the comparison with flu with respect to both severity and contagiousness in a minute.

00:10:02.440 But I'm wondering, so have any of these ships that essentially have been rather unfortunate and accidental science experiments where you have people cooped up in a giant floating Petri dish with this virus, and then you just have them quarantined, and so we can see what happens.

00:10:20.640 Have any of these ships provided a clear picture of the case fatality rate here?

00:10:26.700 I mean, I am sure there's an age bias with respect to the cohorts who are on the ships, but why don't we have a clear picture based on what's happened in each of these cases?

00:10:35.740 I think you just answered your own question, that there is a severe age bias when you're on a cruise ship, because remember, those are going to be older people.

00:10:42.980 Those are going to be people with medical conditions that like to go on these trips.

00:10:46.280 It's not going to necessarily be the representative sample of the population that you need to actually calculate a proper case fatality ratio.

00:10:53.720 What the ships do offer us is some idea of the attack rate, even though that's also limited, because sometimes those ships were doing things in order to try and prevent spread, even though it wasn't very successful.

00:11:02.780 But we saw about 20% attacked in the Japanese cruise ship.

00:11:07.180 So I do think that they provide some information, but it wasn't quite the perfect experiment, and I think it ended up almost being torture for some of those humans that were left on board that ship.

00:11:17.040 And I wouldn't draw too much from it other than the fact that we know that this is contagious in those types of settings and that elderly people are disproportionately going to be impacted with severe illness if they are infected.

00:11:28.960 Okay, so let's deal with this, the comparison with flu, because many people have been drawing comfort from the idea that if you're a healthy non-smoker under 70, you basically have nothing to worry about.

00:11:44.500 It's more or less just like the flu, and most of us are going to get this, right?

00:11:49.260 In fact, I think I even saw you say more or less this in a talk you gave.

00:11:56.120 I watched a YouTube video of a lecture you were giving a couple weeks back.

00:11:59.700 So most people are going to get this, and if you're healthy and not too old, it's not likely to be a problem for you.

00:12:08.300 Another statistic that I've heard a lot is that 80% of cases are mild.

00:12:12.880 So what is a mild case, and what is actually rational to believe here?

00:12:18.300 And I say this, you know, knowing, personally knowing someone who is 50 and a, you know, an extreme skier, i.e. quite healthy, or was quite healthy until he caught coronavirus, a non-smoker, and he's now on a ventilator.

00:12:34.580 Obviously, this is an anecdote, this is not science, but I don't have similar stories to tell about flu.

00:12:41.840 So what's the picture in terms of comparing the severity of this generally to flu?

00:12:47.920 While it is true that most cases are going to be mild and indistinguishable from the cold and the flu, this does seem to have a higher case fatality ratio.

00:12:56.140 So you are more likely to see people die from this than from influenza.

00:13:00.560 It is true that the deaths cluster in those that are elderly, that have other medical conditions.

00:13:06.460 But it's important to know that just because something clusters there doesn't mean that other diseases, other deaths can't occur in other age groups.

00:13:12.360 So we are going to see healthy people that die from this.

00:13:15.420 It's not going to be the norm.

00:13:16.940 It's not going to be as common, but it is going to happen, and it's important to prepare for that.

00:13:21.620 So even we see that with influenza right now.

00:13:23.500 This year's flu season, to draw the comparison back to flu, has seen the most children die from influenza in recorded history, except for during the 2009 H1N1 pandemic.

00:13:32.160 So we don't often hear so much about the younger people that die from flu as well, but it is true that those deaths occur.

00:13:38.780 And because this has a higher case fatality ratio likely than seasonal flu, we will see deaths in other age groups, although they will be clustered in the highest age groups.

00:13:48.560 And in terms of the mildest cases, it's true to say that it would be possible for this to present as benignly as an ordinary cold.

00:13:57.940 There are people walking around with the sniffles who may in fact have coronavirus.

00:14:02.860 Right.

00:14:03.240 That's definitely true.

00:14:04.180 Because remember, coronaviruses are a family of viruses.

00:14:06.800 There are four of them that cause seasonal colds every year, and this is now basically becoming the fifth seasonal coronavirus.

00:14:14.760 And we are going to see this spectrum of illness where many people will just have the sniffles or just have a cough or a sore throat, and nothing really becomes of it.

00:14:22.240 It's just like a normal cold.

00:14:23.420 But then there are that group that have risk factors or, by luck of the draw, have a more severe case.

00:14:29.160 So that's kind of one of the things that this virus has used to transmit itself so well is the fact that you've got these mild cases walking around in the community that just look like a cold, but they can then yet transmit it to other people.

00:14:40.220 So that's really advantageous from an evolutionary standpoint for a virus to have this spectrum of illness with these mild cases out there that are really serving as vectors for the virus.

00:14:48.440 And what do you make of the fact that it seems to be systematically more benign in children?

00:14:56.180 So that's a really important question that we're all trying to answer and try to come up with hypotheses for.

00:15:01.340 There's a couple of them.

00:15:02.120 One is that children tend to have less robust immune responses, and maybe most of the symptoms that we're seeing, especially the severe ones, are triggered by an overabundant immune response that's more characteristic of adults than in children.

00:15:14.400 And we know that that's the case for many infectious diseases.

00:15:17.260 For example, chickenpox is much milder in a child than in an adult.

00:15:20.540 So that's one hypothesis.

00:15:21.420 The other is, going back to those four circulating coronaviruses that are around every year, children get a lot more colds than adults, and there might be some cross-immunity because they have many more exposures to coronavirus in their daily life than an adult might.

00:15:33.780 So that cross-immunity might be somewhat protective. 0.95

00:15:35.900 But this is one of the leading research questions we need to understand, especially as we're trying to figure out what the role of children are in transmission as you hear about school closures occurring around the country.

00:15:45.260 Would that cross-immunity suggest that parents who have young children who also seem to get exposed to more of these viruses than people who don't have kids, would we likely be able to detect a lesser severity in their case?

00:16:00.800 It's a logical conclusion.

00:16:02.180 I don't think that we've actually tested any of that.

00:16:04.000 But these are all important things we need to do when we get proper diagnostic testing available to do these types of studies.

00:16:09.240 But these are all important research questions that are going to help us kind of right-size this outbreak response.

00:16:14.360 So let's talk about the contagiousness of this.

00:16:18.780 In terms of the so-called R0 factor, how does this compare to flu?

00:16:24.840 It looks like it's about in the same category as flu.

00:16:28.140 And there's a lot of mysticism, what I call mysticism about the R0. 0.94

00:16:31.080 People think it's like something intrinsic.

00:16:32.980 It's an intrinsic feature, like horsepower on an engine in a car.

00:16:37.060 When it's not, it's really an average number.

00:16:39.220 And you can have varying R0s for the same infectious disease.

00:16:42.380 It just depends on what that person does and the environment they interact in.

00:16:45.260 So you can have someone like typhoid Mary, who has a very high R0 for salmonella typhi, which caused typhoid fever.

00:16:50.720 And you can have someone who doesn't have a high R0.

00:16:52.540 So it's not something that I spend much time trying to delineate if the R0 is 2.3, meaning it infects one person infects 2.3 other people.

00:17:01.060 Or if it's 2.8 or whatever it is, I kind of think of them in batches.

00:17:03.800 I think if the R0 is less than 1, meaning that most people are not going to infect anybody, it's not something to worry about.

00:17:09.940 Then I think of the other extreme.

00:17:11.000 The R0 is 15.

00:17:12.260 So that's something like measles or whooping cough.

00:17:14.240 That's going to be very hard to deal with because you're going to have lots of people infected and lots of exposures.

00:17:19.680 And then I think of that middle ground of like the R0s between like 2 to 4. 1.00

00:17:23.020 And I put flu and I put this virus in there.

00:17:24.900 And I think that's a better way to think about it than trying to look at it as some intrinsic feature that you're trying to compare between viruses.

00:17:31.100 I think that gets a little bit too, trying to put too much of a statistical flavor to something that really is not completely exact that way.

00:17:38.980 It's just, this is transmissible.

00:17:40.620 It's not as transmissible as measles.

00:17:42.360 It's more transmissible than tetanus, which is not transmissible between humans.

00:17:46.340 In terms of the mechanism of spread, what do we know about that?

00:17:50.120 This is a respiratory virus.

00:17:52.140 So the main way that it spreads from person to person is through the coughs and sneezes that people experience and the particles that emanate from their body.

00:17:59.820 These are large droplets that fall to the ground in about 6 feet because of the action of gravity.

00:18:04.520 And it can also be transmitted from the surfaces that people touch that may have those droplets on them.

00:18:09.360 But the main mechanism is this respiratory droplets, the coughs and sneezes.

00:18:12.800 Because you've got a lot of questions I get all the time about, if someone hands me a pen, can I get it from a pen?

00:18:17.440 Of course, the answer is theoretically yes, but really, that's not how this virus is transmitting.

00:18:21.620 It's mostly through coughs and sneezes from person to person.

00:18:24.400 We don't know that there's quote-unquote airborne spread.

00:18:26.700 Airborne spread is a, some people mix that up with respiratory spread.

00:18:29.640 Airborne spread refers to a virus or a pathogen that can stay in the air for a long period of time.

00:18:35.660 So if I got on an elevator and had measles, for example, and then you got on the elevator an hour later, that air would still be infectious.

00:18:41.660 That's not really what we're seeing.

00:18:43.180 There may be some component of airborne spread in hospitals when they're doing procedures on people and they're aerosolizing the virus.

00:18:49.120 Suppose they're putting a breathing tube in someone or looking down in their lungs with a telescope or giving them a treatment that requires a drug aerosol.

00:18:56.520 That can sometimes cause airborne transmission.

00:18:58.640 But the primary means is really these respiratory droplets.

00:19:01.940 So with respect to surfaces, how long do we think it can live on a surface?

00:19:05.960 If you go look in medical journals, you will find stories of coronaviruses living nine days, being viable for nine days on a surface.

00:19:14.240 But that's important.

00:19:15.140 That's hard to extrapolate to everyday life because there's certain environmental characteristics that are conducive to the virus and certain ones that are not.

00:19:21.700 So, for example, temperature, humidity, UV radiation, all of that affects the viability of a virus.

00:19:28.860 And this is not a very hardy virus.

00:19:30.360 It actually has this lipid envelope or this kind of fatty layer around it, which actually can dry out.

00:19:35.260 So when you talk about viruses and how well they survive in the environment, if it's an enveloped virus like the coronaviruses are, it doesn't usually last that long in the environment compared to something like the norovirus, which you might have heard of from cruise ship outbreaks.

00:19:47.480 That can be very difficult to get out of a off of a surface or in a in a structure that it might have been contaminated with it.

00:19:53.840 So what I would say to most people is this is probably hours to day, a day or so.

00:19:57.640 And it's not something that you have to worry too much about because this is a virus that's easily deactivated by your standard household cleaners that you use during cold and flu season anyway.

00:20:07.020 OK, so unfortunately, I just watched a press conference given by the mayor of New York City, Bill de Blasio, where he said that this virus degrades in only a matter of minutes if it's on a surface.

00:20:20.280 This is a direct quote. It's only a matter of minutes before the virus is rendered inactive in the open air.

00:20:27.520 And he was referencing subway poles and plastic chairs and tabletops.

00:20:33.720 And that seems to be misinformation.

00:20:37.040 Would you be confident touching a tabletop that someone had just sneezed on a few minutes later and not washing your hands?

00:20:43.120 No, I think that minutes is that's not scientifically accurate.

00:20:47.120 I if it was hours, I would agree with.

00:20:49.380 But I don't think minutes unless this surface is a special surface that's got special characteristics on it, like it's made of copper or something that's that that's bad for the virus.

00:20:57.720 But no, I don't think that minutes is correct.

00:21:00.120 OK, so if you're among the nearly one million people who have watched that press conference on Facebook, please be advised.

00:21:07.420 What about objects that you might have shipped to you in the mail?

00:21:12.520 So someone has ordered a computer from Apple that was just freshly minted in Shanghai and made the trip.

00:21:21.800 Let's say it took 10 days to get to their house.

00:21:24.500 Now they're opening it like it's a very large piece of medical waste.

00:21:28.620 What do you say about that moment?

00:21:31.580 I don't think there's a real risk there.

00:21:32.940 I wouldn't hesitate about opening opening a package from China unless somebody told me that they package sneezes in there for me. 0.99

00:21:39.380 Just special.

00:21:39.920 But no, I don't think that these types of ordinary products are going to be a risk for individuals to touch or open.

00:21:46.420 OK, so let's talk about flattening the curve.

00:21:50.640 This is a phrase that many of us have absorbed now.

00:21:54.600 What does it mean and why is it what we should be thinking about at the moment?

00:21:58.800 So what we're talking about is an epidemic curve and that's the number of cases that occur over time.

00:22:02.660 And what flattening the curve refers to is trying to not have this big initial spike of cases.

00:22:08.420 So you still have the same area under the curve, the same number of cases, but you spread them out over time.

00:22:13.300 And that's somewhat easier for communities to cope with, especially when you're talking about bed space at a hospital or or any kind of limited resource that might be that might come into short supply during a pandemic.

00:22:24.320 So that's why you see people talk about, for example, closing schools or limiting social gatherings or trying to do any kind of social distancing, just trying to decrease the intensity of spread, knowing that you're still going to have the same number of cases.

00:22:36.300 But they're going to be spread out and they're going to be spread out and they're more easy to deal with.

00:22:39.900 So after this last podcast I recorded with Nicholas Christakis and after absorbing the growing concern around the spread of this virus, the punchline I've come away with is that if you can work from home, you absolutely should.

00:22:57.960 And whatever non-essential social contact you have on the calendar should be canceled.

00:23:06.360 If you have tickets to the concert that you've been looking forward to for a month and that's rolling around this weekend, you shouldn't be going to that concert.

00:23:15.520 You should avoid eating in restaurants if you actually can avoid eating in restaurants.

00:23:23.100 Anyone who can pull back at this point should pull back.

00:23:26.840 Is that too alarmist or is that simply good advice at this point?

00:23:32.800 It's all going to depend on each individual's risk hierarchy and where it all fits.

00:23:36.480 If you're an elderly person or have medical problems or maybe you live with one, someone like that, and you want to decrease their exposure, it might be prudent when you have high intensity transmission in your community to take those types of actions.

00:23:47.980 I don't think that the whole world needs to take those actions.

00:23:50.680 I myself haven't done most of that.

00:23:52.740 But I think that you have to really look at each location that the virus is spreading in and make a distinction on whether or not you think that this social distancing is going to help or it's going to not have an impact.

00:24:05.500 Because if you have widespread community involvement with this virus already, social distancing is maybe going to decrease your individual risk, but then you have to put that into your own value hierarchy and decide, yes, this is really important to me, so I'm going to risk it and just be very meticulous with my hand hygiene and not touch my face.

00:24:21.420 Or this is something that I didn't really want to go to anyway and I'm not going to do it.

00:24:24.420 Once we get to a point where if there's high intensity transmission, then you might see more stricter recommendations coming out about that type of non-essential travel.

00:24:35.280 But I do think that you're going to see variations across the country and variations with each person's risk preference.

00:24:42.500 And we do know that social distancing can cause damage because it's going to cause economic disruption when that happens.

00:24:49.180 So there are some things that are easier to do, like telecommuting, but some things that might be a little bit harder to do.

00:24:54.620 And I think that it's going to be difficult.

00:24:56.240 And we didn't do so much of that during 2009 H1N1.

00:24:59.080 We had some school closures and people did some things, but not as aggressive as we're seeing now.

00:25:03.820 So it will be interesting to see how this actually plays in an American setting with people trying to adjust their daily life to this virus.

00:25:10.800 And I think eventually you're going to see people start to be able to cope with it a little more as this doesn't go away without a vaccine.

00:25:18.360 Right. So let me just push back on two points there.

00:25:21.420 So we know that we're not doing and have not been doing adequate testing.

00:25:26.260 So we really can't be confident that we know how fully it has spread in our community.

00:25:33.900 How can a person assess that it hasn't yet spread much in the community and they don't have to worry about going down to the local coffee shop?

00:25:41.340 And two, given that the primary vector of contagion is having someone cough or sneeze too close to you, even more than anything that you can control by assiduous handwashing,

00:25:57.140 going to the rock concert puts you shoulder to shoulder with people who at any moment might turn and cough and sneeze on you.

00:26:04.780 So I'm not quite sure how to be confident going into those spaces, given those two facts.

00:26:11.980 So you're not going to be able to completely avoid this virus in that type of a setting if you're in a concert or if you're at something where you're going to have multiple interactions with people that are not in a controlled manner.

00:26:21.720 And rock concerts are going to be very different than certain other activities like going to a restaurant or going to a coffee shop where you can have some distance between people.

00:26:31.680 And I do agree that we don't quite know how much this is transmitting in our communities.

00:26:35.340 But one indicator that you can use is looking at what hospitals are doing.

00:26:39.780 You're going to hear about, even if there is a small proportion that get critically ill and need ICUs, you're going to hear about that in your community.

00:26:47.080 So I think in most communities, we haven't heard about people in the ICUs.

00:26:51.420 There are definitely cases in ICUs, but we don't have large numbers of them, which may be an indicator that there's been less community transmission or maybe this is less severe than we thought because we're not seeing those ICU patients all across the United States.

00:27:03.100 So it does become difficult because of the testing problem.

00:27:06.120 And I do think that there is some level of community spread going on in every city in the United States.

00:27:12.360 But then what lesson should we draw from the experience in Italy right now?

00:27:17.380 I mean, it seems like there's no reason to think that we are different from Italy apart from the timing at which the virus first landed.

00:27:27.480 What's happening in Italy now that is basically forcing the whole country into lockdown and straining the health system to the breaking point?

00:27:35.800 And why wouldn't you expect that to happen here if we just carry on business as usual?

00:27:40.700 I do think that the experience in Italy and hearing about these ICU bed shortages is something that kind of hits home for America because the health systems are somewhat similar, not completely similar.

00:27:51.000 And it's unclear to me exactly what's driving the force of infection in Italy and how that might be different in the United States.

00:27:56.880 We do know they have an older population than the United States, so that may account for more severity than here, but it's not that much older.

00:28:04.200 I think that the Italian government is taking an approach where they want to try and flatten the curve in a very drastic manner, kind of following what China did.

00:28:11.820 And I think that paradoxically may make things worse because you're going to panic the population and you're going to inundate the hospital with scared individuals.

00:28:18.300 And other parts of the health care system are going to suffer, just like it did in China, where people with heart attacks and strokes had difficulty getting their way to a hospital.

00:28:25.200 I think that we have to really drill into the Italian numbers and understand how much testing they're doing, what is their real case fatality ratio there, and try and use that information the best we can to prepare our hospitals and our ICUs for what might be a very severe season.

00:28:41.560 I do think that some of those drastic social distancing measures may be necessary in certain situations, but I don't think that you can have a blanket lockdown and expect that to actually work or be effective and not have negative consequences that might outweigh any positive there.

00:28:56.820 But this is all very fluid and very hard to quite—these aren't easy decisions to make, and there's a lot of uncertainty here, and that makes it hard to make any kind of specific recommendation on what to do without having full data and knowing what's exactly going on in the ground in Italy.

00:29:13.460 To come back to my question, because I really do want to sharpen this up and have listeners come away with a clear plan of action, again, my heuristic here is that if you can work from home and if you can cut out social contacts—

00:29:31.460 there are people who can't, obviously, there are jobs that are synonymous with being in that particular store or restaurant or office—but if you can pull yourself out of society to whatever degree and thereby deny this virus a path through you and your life to others, that seems to me to be an intrinsically wise and ethical thing to do.

00:29:58.360 Apart from, again, there are economic consequences to doing that, which people who own restaurants and own retail stores are understandably worried about.

00:30:08.820 But if the goal were simply to stop this thing as fully as we can, which is to say flatten the curve as fully as we can and keep the health care system running, is there any argument against taking that advice?

00:30:23.440 No, I don't think there's any argument against taking that advice.

00:30:25.660 I think sometimes it becomes impractical for certain people to do, but it is technically what you should be doing even during flu season if you can.

00:30:32.640 And there are some things that are easier to do and some things that are harder to do.

00:30:36.340 I don't think we'll see full social distancing with every American, but I do think that there will be a large proportion that do do that, especially those with high-risk conditions that are worried for their own safety or if they have relatives or they live with people that have those types of conditions.

00:30:51.940 I think it's going to be hard for that to happen for everybody, and there's going to be limited social distancing in certain locales.

00:30:59.200 And I think there's going to be a hesitancy to go to complete social distancing as an ideal, although theoretically, yes.

00:31:04.720 I mean, if you look at the actual facts of it, yes, if everybody social distanced, you would be able to flatten the curve substantially.

00:31:12.220 And in terms of actually flattening the curve and even reducing mortality, as we're seeing in China now, I mean, that is being achieved in China by the most extreme and heavy-handed quarantining of the whole society that has ever occurred. 0.83

00:31:31.240 I saw at some point recently, I forget where, it probably was on social media, that South Korea seems to also be driving this contagion downward.

00:31:42.600 Is that true? Is there any place else that's having success the way China is?

00:31:47.180 We have seen, I guess, variations of the Chinese model in other countries with Singapore, with Hong Kong, as well as even Taiwan, where they have done some extreme social distancing. 0.98

00:31:56.580 We're even seeing it now being implemented in New York State and Westchester County.

00:32:01.700 China, I think, took a very authoritarian approach because they had that tool available to them and really went to an extreme level that we really haven't seen probably since medieval age to medieval time with basically locking down 60 million people, suppressing free speech in terms of what doctors were allowed to say, and making it very difficult to even leave that area using armed guards.

00:32:24.380 And that was something that we were very, you know, from a public health standpoint, most people were very kind of appalled by that type of a reaction.

00:32:33.740 And now you're seeing people say, maybe that flattened the curve there, maybe that bought the world some time.

00:32:38.740 And I don't know if that's the truth or not, because this spread very quickly.

00:32:42.260 And I wonder, you know, when I saw this virus emerge in late December, and we realized quickly that this was something that was spreading between human to human very efficiently and had been spreading at least since November, unbeknownst to anybody.

00:32:55.240 We knew that this wasn't going to be just a China problem, that it likely had left China.

00:33:00.300 And a lot of us really argued that this probably should have moved from containment at a very early stage to mitigation with less of that type of lockdown mentality and more with fortifying hospitals, vaccine development, antivirals, diagnostic testing, and really taking a different approach, more like the one we took during 2009 H1N1.

00:33:21.160 Right. But it's true that H1N1 is not as contagious, right?

00:33:24.040 I don't know if it's not as contagious. We know that H1N1 infected a billion people over six months.

00:33:29.860 So that's pretty contagious. And 61 million people were infected with H1N1.

00:33:33.600 So it wasn't something that was small. And I think that's the best model we have.

00:33:37.140 We don't know where this one's going to end. And I would say this is around the same contagiousness level of H1N1, maybe a little bit more because we don't have, in H1N1, we had certain age groups that were less likely to be infected because of prior immunity that they had.

00:33:49.940 And I think that the approach of containment probably wasn't the best one to take for this type of virus.

00:33:55.320 And it might have expended public health resources that could have been better spent fortifying hospitals.

00:34:00.900 And of course, the Chinese built new hospitals and did things during this outbreak.

00:34:04.620 And I think that some of that Chinese stuff is not replicable in other parts of the world because there are certain values in other countries that people do not want to transcend that China did.

00:34:16.800 And I think those are very good values. And I myself objected to what China did there because I do think that there's another cost that's not necessarily this disease that you have to kind of figure into what happened in China. 0.90

00:34:29.620 And especially the fact that this is now being held out as an example by by certain individuals, I think, really can put us in a domino effect of this kind of draconian response that may in the end, we might lose more than we gain from it.

00:34:41.820 Yeah, I mean, I think there's nothing to emulate in the Chinese model apart from drawing the conclusion that insofar as you can avoid social contact, that is the way to mitigate the spread of this thing. 1.00

00:34:56.980 And if you really manage to avoid it, if you could wave a magic wand and impart a new norm of social distancing to everyone, you know, not at the point of a rifle, but at the point of a bright idea, we could change the level of contagion a lot.

00:35:15.460 But it's just whether everyone can get the message all at once. And we have a kind of coordination problem and we have massive economic incentives pointing the other direction, which worries me.

00:35:27.720 Right. And you have to remember that, you know, people run businesses, people that that that if people can't work and they get then they eventually aren't going to be able to eat.

00:35:34.160 So there's going to have to be some tradeoff that you have there between social distancing and then being able to be productive and be able to flourish.

00:35:43.100 So how much does smoking play a variable here? I don't know the rates, the relative rates of smoking in China and in Italy compared to the U.S., but is there any reason to believe that smoking is part of the epidemiological picture here in terms of the severity of the disease?

00:36:01.340 We definitely have seen smokers get severe illness in China, but the number looking at some of the data, some of my colleagues are looking at that and at least the data that's been published, we haven't been able to see a major signal there.

00:36:10.640 But it is true from a physiological standpoint that smoking is something that is conducive to respiratory viruses being much worse in a smoker than in a nonsmoker because it does damage all of these airway protective mechanisms that you have and makes you more at risk for diseases like emphysema and bronchitis, which make you more likely to have a severe case.

00:36:29.440 So I do think smoking plays a role. How much of a role it's playing currently is hard to tell, but I do think all things being equal, a smoker is going to have a harder time with this virus than a nonsmoker.

00:36:39.220 And it may be responsible for some of the severe illness that we're seeing in certain countries where there are higher smoking prevalences.

00:36:44.340 So in addition to being old, the risk seems to go up with every decade here.

00:36:51.920 So, you know, in addition to being over 50 and being a smoker, the points a person might have against them include heart disease, lung disease, cancer, compromised immune systems, diabetes.

00:37:04.800 Is there anything to add to that list or is that comprehensive?

00:37:08.620 I think that's pretty comprehensive. I mean, obviously, you're going to need to get a lot of data on the severe cases to see if there's any other disease processes, but they all kind of fit into that cluster that you're mentioning there.

00:37:20.180 Obviously, I think people who are on dialysis, I might add as well, kidney disease is also a high risk for people to have a severe infection.

00:37:27.260 But it's really any of these chronic medical conditions that keep people going to the hospital, keep them having to take medications, especially ones that interfere with their immune system, as well as advancing age.

00:37:36.160 It also seems like being a man is a chronic medical condition here, perhaps on other fronts as well.

00:37:42.100 So do we still think that it's hitting men harder than women?

00:37:45.760 It does appear to be a signal that we're seeing in the data that males are disproportionately getting more sick with this than females are.

00:37:53.220 And I think we've seen that with other infectious diseases, even influenza is worse in males than females.

00:37:58.080 And that may have to do with some idiosyncrasies and the differences between the immune system in a male and a female in the influence of certain sex hormones like testosterone and estrogen on the way the immune system functions.

00:38:09.220 And maybe men have a more, actually, I think they have a more exuberant immune response, which is responsible for how sick you feel.

00:38:14.500 And that's likely what might be behind this, but it's something that needs to be investigated.

00:38:18.280 What about the idea that a higher exposure creates a more severe expression of the virus?

00:38:25.760 So I think this was alleged with respect to medical workers in China getting it, you know, some of them being quite young and dying.

00:38:33.540 Is it a story of you're exposed or not, or it really matters just how much a dose you got of the virus initially?

00:38:40.660 There definitely is a dose response because we do this in animal challenge models where when you're trying to look at a virus, you might give them a really, really high dose of something to see what the, how much, what the lethal dose is.

00:38:51.700 So there definitely is an inoculation effect.

00:38:54.180 So the more you're exposed to, the intensity of the exposure could give you an overwhelming infection that might be hard to recover from versus someone who gets a smaller exposure.

00:39:02.280 The kinetics of that haven't all been worked out, but we've seen that with many, many different pathogens, that the, that the load that you're exposed to does have an impact on the severity of symptoms and how quickly you become ill.

00:39:13.460 And what does recovery look like?

00:39:16.120 I've heard reports of lung damage in people who recover.

00:39:19.860 There's a giant green number on the Johns Hopkins website.

00:39:23.480 I think last I looked, it was, you know, 65,000 people had recovered.

00:39:27.640 How cheerful a picture is it to recover from this?

00:39:30.940 So I would look at that number that you've seen, the 65,000 number with a little bit of, put a little context to it.

00:39:37.380 When we use the word recovered in terms of this type of data, they're talking about officially recovered by those ministries of health in those countries.

00:39:44.160 And what they're using there is fever free for a certain number of days and two negative diagnostic tests.

00:39:49.800 That's not really what recovery means to an individual.

00:39:52.240 For me, what recovery means to an individual is that they're able to, to do their activities of daily living.

00:39:56.940 And so I think that many more people than that have actually recovered because that's more of a epidemiological distinction that they're trying to decide when can they discharge someone and not have them infect other people.

00:40:08.120 When are they clear of the virus, basically not clear of symptoms.

00:40:11.480 Recovery is going to depend upon how severe in general your, your infection was.

00:40:14.880 Obviously, if you just had a mild illness that was indistinguishable from the common cold, there really is no recovery period.

00:40:19.400 You're going to have about a week of illness and you're going to bounce back just fine.

00:40:21.680 So if you're in a hospital and suppose you have pneumonia or you end up on a mechanical ventilator or in respiratory failure, then that recovery is going to be months and months with lung damage, with taking you a while to get back your same exercise tolerance if you've actually had damage to your lungs from this.

00:40:36.320 So it's going to really depend on how severe the initial insult was from this virus.

00:40:40.320 And those that are in ICUs are going to have protracted, protracted recovery periods, just like with any other type of pneumonia.

00:40:46.340 So let's talk about what might be on the horizon with respect to treatment and prevention.

00:40:52.780 Let's talk about treatment first.

00:40:55.020 What do you think the plausible timeline is for developing an antiviral treatment?

00:41:00.360 So fortunately for us, we have this ability to repurpose antivirals that may have been used for other causes, other, for other reasons, and then, and then try them out on this virus.

00:41:09.200 And we've been doing that rapidly.

00:41:10.520 So for example, there is a product called Remdesivir, which was used in the Ebola trials in the Democratic Republic of the Congo and didn't do so well in those trials.

00:41:18.120 But it had activity against coronaviruses and actually animal studies against the Middle East Respiratory Syndrome coronavirus that look good.

00:41:24.620 So that's currently in phase two clinical trials right now.

00:41:27.280 And we are hoping to see results from that in a couple of weeks.

00:41:30.120 It's already been given to patients on compassionate use basis.

00:41:32.720 So there is a lot of hope that that antiviral will appear maybe in several months after we get data from the clinical trials.

00:41:39.960 There are a whole host of other things.

00:41:41.440 There's actually a malaria drug that they're repurposing that happens to have activity against this virus.

00:41:46.100 And that's already FDA approved.

00:41:48.120 So doctors can actually prescribe that in the United States off-label to their patients with that.

00:41:52.200 And then there's a bunch that are kind of earlier in the development stage.

00:41:55.300 So I do think we will see an antiviral much quicker than a vaccine, for example.

00:41:58.820 But it's still going to be several weeks before we get data on how effective they are.

00:42:03.480 What's the antimalarial?

00:42:04.600 Is that chloroquine or something else?

00:42:05.920 It's chloroquine, yes.

00:42:06.760 What's actually the belief now with respect to the efficacy of chloroquine as a treatment?

00:42:12.360 We haven't done human trials on it, but there is a lot of studies in vitro, even before the SARS and before all these other coronaviruses,

00:42:20.700 trying to use it against the other common cold-causing coronaviruses.

00:42:23.780 And it seems to exhibit an antiviral effect against the virus.

00:42:27.240 And that's why what people are trying to count on is, does this have activity against this specific coronavirus?

00:42:32.720 And what we're seeing is some anecdotal reports of people using it, but there has been some effort to try and study this in a randomized controlled trial

00:42:39.620 and see if what they've seen in a test tube actually works in humans.

00:42:42.580 Are any of these other countries who don't have the same requirements that the FDA imposes on us out ahead of us in testing remedies?

00:42:52.540 Do you know what China is doing with respect to antivirals?

00:42:55.920 I know China has multiple clinical trials going on, not just of these antivirals that we mentioned, but also of traditional Chinese medicine.

00:43:03.180 So there is basically, I think, hundreds of clinical trials have been registered in China regarding different antiviral compounds.

00:43:09.720 So that's where the most cases are, too.

00:43:11.820 So you have to remember that it's difficult to recruit patients for trials,

00:43:16.160 especially in an emerging infectious disease outbreak when there may not be that many patients out there to actually recruit to put into your clinical trials.

00:43:23.560 So you're going to see the vast majority of trials being done in China because that's where the bulk of patients are.

00:43:28.440 Okay, so what's the soonest?

00:43:30.820 Let's say some drug was showing promise in China.

00:43:34.280 What do you think the soonest it could be properly vetted and manufactured and made available in the U.S. or in any other Western country?

00:43:46.580 I would say it's going to be months.

00:43:47.720 I think the FDA is poised to work very quickly if they have a compound that works.

00:43:50.980 They have this mechanism called the emergency use authorization, which they used.

00:43:54.340 They exercised during the 2009 H1N1 pandemic to make an experimental intravenous antiviral against flu available.

00:44:01.000 But they can work fast.

00:44:01.920 You just have to have some amount of data to show them that this is safe and is likely going to be efficacious.

00:44:10.080 And that's a little bit of a risk-benefit type of nuance thing that they have to do with each different product.

00:44:15.500 But I do think it would be months before we would see an antiviral.

00:44:19.080 Some of them, like remdesivir, which is the one that's in the phase 2 clinical trial made by Gilead,

00:44:23.640 that one we may see faster because they've got a lot of safety data already from the Ebola trial,

00:44:28.800 so they can leverage that safety data to just really look at the phase 2 trial results.

00:44:33.120 And maybe you see a decrease in the virus count in people, and you could rapidly get it available.

00:44:37.400 And I know that I've been reading about the company being able to rapidly scale up production

00:44:41.780 and that they're investing a lot to be able to do this.

00:44:44.360 So that may be something that we see in the short term if it's effective in the phase 2 trial.

00:44:49.100 And when do you think the bottleneck around testing will be unblocked?

00:44:54.520 When will it be just straightforwardly easy to get a test?

00:44:58.740 If you have a fever and you call your doctor, and I got to imagine at some point we're going to have a test

00:45:06.280 that a person can take from home so that they're not going out there spreading this illness on the way to get tested,

00:45:13.020 when do we arrive at that happy time?

00:45:15.160 So the roadblocks to testing are rapidly disappearing, but there's still a lot of them that need to be removed.

00:45:23.420 Right now, we've moved from the CDC being the exclusive purveyor of tests to the state health labs,

00:45:27.520 and now we've got big companies like Quest and LabCorp that can test.

00:45:30.480 But these are all send-out tests that are not done in your hospital.

00:45:33.600 There may be some academic medical centers that have made their own tests,

00:45:36.420 but for most hospitals, they're having to send this out, and that's a burden

00:45:40.020 because there's paperwork, there's regulatory stuff at the hospital level

00:45:43.360 that the hospital administrators want you to do before you test somebody.

00:45:46.400 That needs to disappear, and we need to be able to do this just like an HIV test or a flu test.

00:45:50.540 And for that to happen, we have to have on-site testing.

00:45:53.440 So that means that the kits that people have for other respiratory viruses in their hospitals,

00:45:57.460 they need to add this novel coronavirus to it, or they have to be standalone kits.

00:46:00.820 And that's going to take probably several months.

00:46:02.840 There are some companies going through the FDA to get these types of kits approved,

00:46:06.020 but I do think it's going to be some time before we get to the ability to just test

00:46:09.920 or even have home testing.

00:46:11.000 And I know the Gates Foundation is investing in home testing,

00:46:13.060 and home testing is something that people have been trying for flu for some time,

00:46:15.900 and I've actually done a project on that.

00:46:19.280 That's really the goal is that you can test this at your home,

00:46:21.820 so that you know whether you have it or not,

00:46:23.640 because it's really going to take some time to get a lot of the difficulties with testing.

00:46:29.740 And I've been frustrated with it myself trying to figure out

00:46:33.220 how you're going to get these tests ordered,

00:46:34.960 because as soon as you order that test in the hospital,

00:46:36.880 all the hospital administrators will swoop on to you saying,

00:46:38.920 why are you doing this?

00:46:39.540 What's going on with this patient?

00:46:41.100 Is everybody protected?

00:46:42.200 Are they isolated properly?

00:46:43.280 All of that kind of stuff happens.

00:46:44.440 So it becomes a headache for a lot of doctors to go through that

00:46:47.300 when many of these cases are mild.

00:46:49.760 But I do think this has been one of the biggest,

00:46:52.000 I guess, learning points in this outbreak,

00:46:53.760 and it's been the biggest mismanagement of this outbreak,

00:46:55.780 has been this lack of diagnostic testing.

00:46:59.240 So what about a vaccine?

00:47:00.980 What's the most optimistic timeline?

00:47:02.700 12 to 18 months, probably closer to 18 months.

00:47:05.700 Vaccine development is usually measured in years.

00:47:08.180 This is something that takes a long time to do.

00:47:10.360 We are moving as quickly as possible and already have candidates

00:47:13.520 basically poised to enter phase one clinical trials

00:47:16.260 because we've got some new technology that can get you to a vaccine candidate very fast.

00:47:20.920 But you have to remember, when you give a vaccine,

00:47:22.600 you're giving that to a healthy person.

00:47:24.060 So there is this high burden of safety testing that you need to do

00:47:27.340 because the person is not sick and you're giving them some kind of medication.

00:47:30.040 So you want to make sure that there's not any side effect.

00:47:32.520 And because this vaccine is something that you're going to

00:47:34.680 feasibly vaccinate the world with, 0.97

00:47:37.000 you really have to do clinical trials that are going to show you side effects

00:47:39.640 that happen maybe in 1 in 10,000 or 1 in 100,000 people

00:47:43.500 so that you have some idea.

00:47:45.260 So you're going to have to do big clinical trials

00:47:46.980 to be able to come up with that proper risk-benefit analysis

00:47:50.120 because it may be that there are certain risk groups

00:47:52.380 that you don't want to give this to

00:47:53.560 and certain risk groups you do want to give it to.

00:47:55.000 And that's going to take some time to figure out with big clinical trials.

00:47:58.080 So I would not expect a vaccine at any time before 12 months.

00:48:03.400 And I think if everything goes perfectly,

00:48:05.720 hopefully by 18 months we have it.

00:48:07.160 And remember during H1N1, that vaccine,

00:48:09.420 even though we know how to make flu vaccines,

00:48:10.980 didn't appear until after the virus had actually peaked in the fall of 2009.

00:48:15.760 And once we get a vaccine,

00:48:17.420 would you expect it to be like the flu

00:48:19.880 where you need a new version of this every year?

00:48:21.960 No, I don't necessarily think that's the case.

00:48:24.120 It might be more like measles

00:48:25.160 where you just need to get one and maybe a booster.

00:48:27.800 The coronavirus is very different than flu in that sense.

00:48:30.080 The flu is kind of the trickiest virus to make a vaccine against

00:48:32.400 because of its genetics and its structure.

00:48:35.660 And that's why we have to update the flu vaccine every year

00:48:38.080 because we don't have a universal flu vaccine.

00:48:40.180 I do think it's feasible to have a universal coronavirus vaccine.

00:48:43.700 Well, that's one happy point here.

00:48:45.420 Okay, so give me your picture of the next 12 months.

00:48:49.560 So for the next year, we almost certainly don't have a vaccine.

00:48:54.540 We may or may not have effective antiviral treatment coming in some months.

00:49:00.760 That the possibility that we might have something to give you if you get sick

00:49:04.540 that radically diminishes the severity of the illness,

00:49:08.120 that certainly argues beyond just the necessity of not destroying our healthcare system.

00:49:13.860 That argues, you know, for the personal wisdom of flattening the curve.

00:49:17.900 I mean, if you're going to get sick with this, it sounds like it's much better to get sick

00:49:21.720 some months from now when there's a chance that we can give you a medication that helps you.

00:49:27.120 So what do you think, for instance, will happen during the summer months?

00:49:32.120 Is there any reason to believe that the spread will be diminished

00:49:35.980 or even halted during the summer or not?

00:49:38.680 The best evidence we have is from the other four coronaviruses that circulate every year.

00:49:43.160 And what they do is peak in the winter and spring,

00:49:45.780 and then their transmission decreases during the summer in temperate climates.

00:49:50.020 So that doesn't mean that they go completely away,

00:49:52.700 that they are there at a much lower level because transmission characteristics aren't favored.

00:49:57.720 We think this coronavirus may behave like that.

00:49:59.900 We don't know for sure.

00:50:00.740 I think there's good reason to extrapolate,

00:50:02.680 because virus families tend to do very similar things when it comes to seasonality.

00:50:06.560 But remember that there's also another half of the globe in the southern hemisphere

00:50:09.780 will be entering its winter months when we're entering our summer months.

00:50:12.820 So we may see increased intensity of spread in Australia and New Zealand, for example.

00:50:16.980 And then what may happen is in the fall, it will come back.

00:50:20.120 And that kind of follows the H1N1 flu pattern.

00:50:22.560 And I think that's the most likely scenario that we'll see some decreased transmission in the summer

00:50:26.360 and then increased transmission in the fall.

00:50:29.040 Now, is the seasonality entirely due to just how human beings behave differently in warm weather?

00:50:34.920 Or is there some intrinsic property of the virus itself that is interacting there?

00:50:40.100 I think it's both.

00:50:40.760 There definitely are changes behaviorally that humans do in summer versus winter.

00:50:44.660 But the virus also, viruses tend to have certain transmission characteristics

00:50:48.040 that are favored or unfavored by certain environmental parameters.

00:50:52.960 So, for example, the ambient temperature, the temperature in your nose, the humidity,

00:50:56.860 all of that does have an effect on how well the virus can transmit between people

00:51:01.560 and live on surface and remain viable on surfaces.

00:51:04.440 So there is, it's kind of a combination of both that we see with respiratory viruses

00:51:07.800 that have seasonality.

00:51:09.640 So, and I see we're getting to the end of our hour here.

00:51:12.840 What's your level of concern about this big picture?

00:51:17.700 I mean, like, do you think that this was the plague we've been waiting for in infectious disease?

00:51:24.060 And, you know, we're struggling to raise all the resources and make all the changes we need to respond to it?

00:51:32.000 Or are you cautiously optimistic that this is a mere dress rehearsal for the plague

00:51:37.520 that we will one day need to respond to better than we've been responding to this one?

00:51:42.480 I think it's a dress rehearsal for a major plague.

00:51:45.740 Because if you look, for example, at our avian flu viruses in China,

00:51:49.040 the mortality rates of some of those are 60%.

00:51:51.120 They don't transmit efficiently from human to human, but they are flu viruses.

00:51:55.120 And what if one of those reshuffled and was able to transmit efficiently from human to human?

00:51:59.480 That would be cataclysmic.

00:52:01.620 This, we're dealing with a mortality rate of less than 1%.

00:52:04.020 This is something that's going to be very difficult for hospitals and healthcare systems to cope with.

00:52:08.900 But it really shows you just what a virus that kills less than 1% can do to a world.

00:52:14.100 And I do think that this is a lesson, that we're not doing this perfectly.

00:52:18.580 And if we were to have an avian flu virus, have human to human transmissibility, all bets would be off.

00:52:24.360 Because if we're having this much trouble dealing with a 0.6% mortality,

00:52:28.800 imagine what would happen if there was a 60% mortality flu virus circulating around.

00:52:34.680 So I think it's a dress rehearsal.

00:52:36.900 This is going to be bad, though.

00:52:38.380 And I think that there are going to be a lot of disruptions that we're going to have to deal with.

00:52:44.600 And it's going to be probably somewhat worse than H1N1.

00:52:48.280 H1N1 was the closest that we came to this type of thing in the modern era.

00:52:51.120 And even though most people are going to have a mild case and recover just fine,

00:52:56.840 it is going to be a burden to work in hospitals.

00:52:59.820 And it's going to really hopefully get people to think about how important infectious disease preparation is,

00:53:06.520 even when there's not a pandemic.

00:53:07.740 Because some of this stuff could have been predicted back from 2003.

00:53:10.900 We had a SARS outbreak.

00:53:12.620 We saw what a coronavirus could do.

00:53:14.400 And people wanted to make a vaccine for that.

00:53:16.120 But really now, 17 years later, we have no coronavirus vaccines for humans.

00:53:19.840 We have no coronavirus antiviral.

00:53:21.480 So this shows you what happens when there's complacency with these threats,

00:53:24.460 even though everyone in my community had been sounding the alarm about coronaviruses since at least 2003,

00:53:29.380 and some people even before that.

00:53:30.540 So what specifically would you say that we, at the level of individuals and institutions and cultures,

00:53:38.660 what should we change emphatically?

00:53:41.820 Just take the emergence of novel viruses and other pathogens out of wild species into the human population.

00:53:51.500 I mean, is it safe to say that we should not have wild animal markets where you put a bat on top of a pangolin,

00:53:57.500 on top of a pig, on top of a monkey, and have people work in those kinds of environments?

00:54:03.180 What are the things you would just check off your list of things for people to never do again

00:54:08.900 to prevent the emergence of a truly killer plague?

00:54:12.900 So emerging infectious diseases all emanate from animals.

00:54:16.500 So we do need to get smarter about how we deal with animals.

00:54:19.700 And those live markets where multiple different animals are housed together

00:54:23.520 and their body fluids are mixed together when they're slaughtered

00:54:26.560 and people are doing all of that without appropriate personal protective equipment,

00:54:30.340 I mean, that's basically a powder keg for viruses to jump into humans.

00:54:34.520 And many of those viruses won't do anything. 0.93

00:54:36.020 They'll just be dead ends.

00:54:37.400 But there is the chance that you have a SARS or you have this novel coronavirus

00:54:40.820 or you have avian influenza that can actually take off.

00:54:43.920 So we do have to really be meticulous about how we deal with those animal markets.

00:54:48.840 And that might not mean necessarily banning them,

00:54:51.320 but there are safety procedures that you can put in place,

00:54:53.580 the same way that you do at a slaughterhouse to protect the workers

00:54:56.580 and protect individuals from being exposed.

00:54:58.720 I do think that that's one thing that really needs to happen.

00:55:01.860 I think we kind of have an idea of what viruses are likely to do this.

00:55:08.100 And we have to get better at surveillance for them all the time.

00:55:11.820 How many times have you been to an urgent care clinic

00:55:13.900 and the doctor says you've got some virus?

00:55:15.960 Sometimes that virus might be important because many of these infections,

00:55:18.820 just like this novel virus, might present with just mild symptoms,

00:55:21.740 and that's in you, but it could be the first sign of a pandemic.

00:55:25.260 And that's what happened during H1N1

00:55:26.820 when two little girls got sick with a flu virus that nobody had seen before.

00:55:29.960 They figured it out.

00:55:30.600 Those girls were fine, but that was the sign of a pandemic. 1.00

00:55:32.660 We don't do any of that surveillance regularly.

00:55:35.440 We don't diagnose things down to a specific level.

00:55:38.080 We don't have antivirals that are broad spectrum.

00:55:42.160 We're not really looking at that kind of thing all the time.

00:55:45.040 Only when there's an emergency do we start pushing for antivirals.

00:55:47.500 I think a lot of that is what's missing and why pandemic preparedness

00:55:51.860 is something that we're perpetually trying to emphasize in the media

00:55:55.060 or to politicians that this is something you need to do

00:55:57.560 and think of as a national security issue

00:55:58.900 because look at how many billions of dollars are being lost,

00:56:01.080 how many lives are going to be lost.

00:56:02.640 And I think it's because we don't really take these steps

00:56:05.580 that are very obvious steps to take

00:56:08.300 if you've studied infectious disease emergence.

00:56:10.360 You seem a little more sanguine about this than I was expecting,

00:56:16.720 although I guess I could have expected it based on your YouTube lecture.

00:56:20.780 I'm wondering if that is by reference to how bad it could be.

00:56:25.680 Obviously, if an avian flu ever became fully human transmissible

00:56:30.300 and 60% lethal, that's quite a comparison case.

00:56:34.940 But do you really not think that we could be in the territory

00:56:40.400 of something like the 1918 influenza

00:56:43.700 given the current dynamics of coronavirus?

00:56:47.400 No, I don't think so.

00:56:48.080 1918 killed 50 to 100 million people.

00:56:50.980 We didn't have antibiotics.

00:56:52.240 We didn't have antivirals.

00:56:53.280 We didn't have any kind of vaccine development.

00:56:55.360 We didn't have intensive care units.

00:56:57.240 I don't think that we're at a 1918 level with this.

00:56:59.820 I think this is, if you want to gauge it,

00:57:01.760 it's going to be something like 1957 or 1968

00:57:05.300 where we had influenza pandemics.

00:57:06.980 It's going to be more on that scale,

00:57:08.600 which were more severe pandemics,

00:57:10.020 but not quite at the 1918 level,

00:57:11.560 but more severe than 2009.

00:57:13.560 So I think that that's where I would place it in that level.

00:57:17.000 So if you were going to bet on the proportion of people in America

00:57:21.920 who are going to get this over the course of the next 18 months,

00:57:26.580 what would you think that number is?

00:57:28.800 Probably 30 to 50%.

00:57:30.400 So if we say 50% of, you know, 340 million people

00:57:35.820 and a mortality rate of, I mean, 1%,

00:57:41.420 that would put us at, you know, 1.7 million dead.

00:57:45.540 So if it was half of that,

00:57:47.200 it's still an enormous number of people dead from this virus.

00:57:52.820 Yeah, I think it is going to be more than people will imagine,

00:57:56.200 but will it be cataclysmic?

00:57:58.260 I don't think that's the case.

00:58:00.060 The highest flu death rate we have, I think,

00:58:02.560 outside of a pandemic is 80,000 in 2017 to 2018.

00:58:07.440 So this is a magnitude higher than that.

00:58:09.780 And I do think it's going to be disruptive and bad.

00:58:12.000 But I think that what I'm worried about is that people's actions and reactions

00:58:16.960 and panic will actually make things worse and really lead to this kind of cascading effect

00:58:24.960 where hospitals can't operate, where there is widespread social chaos going on.

00:58:31.020 And that's what really worries me more than the virus itself.

00:58:35.300 Right. So that's interesting.

00:58:36.520 So I'd like to include this part of the conversation, if that's okay,

00:58:40.100 because it just seems like we're unpacking some of the subtext here.

00:58:43.420 So you could well imagine that 800,000 people could die from this over the course of the next year

00:58:51.420 based on what we currently know about the severity and contagiousness of the virus.

00:58:56.400 That does not seem far-fetched.

00:58:58.380 No, I don't think it seems far-fetched.

00:59:00.440 And I think that that's kind of one of my scenarios that I've envisioned.

00:59:05.540 What I want to see is, you know, I have a hard time reading into the healthcare system in China

00:59:11.100 or even the healthcare system in Italy.

00:59:12.660 I'm much more comfortable talking about the British or the Canadian or the American healthcare system.

00:59:18.700 And I contend to know what goes on in intensive care units of those types of hospitals.

00:59:24.660 So that helps me.

00:59:25.680 When we get data from there, I think, you know, I may refine what I think.

00:59:29.600 Because I know, I think it's much easier when you know what happens in an ICU

00:59:33.340 when you're one of those types of doctors that deals with that,

00:59:35.540 that you have some idea of how sick these patients are.

00:59:37.540 And I really want, you know, if I had a colleague that would call me and tell me what this is like,

00:59:41.580 that's a very different story than me reading these raw statistics from China

00:59:45.520 and not knowing what's going on.

00:59:47.740 And I think I might get a better picture and have a more refined idea

00:59:52.700 of what I think the case fatality ratio might be

00:59:54.700 and how many deaths there would be once we start seeing more cases in the United States

00:59:57.940 and we can see what this virus looks like, you know,

01:00:00.440 faced with kind of the most advanced healthcare system

01:00:04.000 in terms of critical care interventions in the world.

01:00:07.000 I mean, that might sound like I'm trying to like cheer for, you know,

01:00:09.460 American exceptionalism, but I think it is true 1.00

01:00:12.580 when it comes to critical care and severe illness

01:00:14.380 that there is American exceptionalism.

01:00:16.620 And you can look at the H1N1 death numbers

01:00:18.420 and compare the United States to other places

01:00:19.820 and you do see, you know, disparities there.

01:00:21.680 We're very good at this.

01:00:22.940 And so I want to see what happens when we have severe cases in the United States.

01:00:27.520 We've had some deaths here in the United States,

01:00:28.940 but those are not really representative

01:00:30.300 because they're largely drawn from nursing home populations

01:00:33.340 or elderly populations.

01:00:34.320 And we know that these respiratory viruses are very different in that group

01:00:37.660 than they are in other age demographics.

01:00:40.860 Right. Although this is all assuming that we've sufficiently flattened the curve

01:00:44.120 and that you're not on a gurney in a parking lot when you have this thing.

01:00:47.520 I hear you about not wanting to spread panic.

01:00:50.620 I'm a little worried that apart from seeing videos of people

01:00:55.040 fighting over toilet paper in markets around the world,

01:00:58.880 I'm worried that people aren't concerned enough.

01:01:01.720 When I see the way this is interacting with politics,

01:01:04.820 you know, strangely, ironically,

01:01:07.560 this is a virus that seems engineered in the current information environment

01:01:11.760 to kill Trump supporters

01:01:13.620 because the stuff I'm seeing on Fox News 0.98

01:01:16.740 and the right side of the aisle politically in the U.S.

01:01:20.620 is just a denial of the severity of the problem at every level.

01:01:26.000 And so it seems like they could use a little more panic,

01:01:29.520 at least on that side of things.

01:01:30.720 I won't take offense that I've been on Fox a lot,

01:01:33.080 but I've been trying to...

01:01:35.520 I've been trying to...

01:01:36.880 It's a fine line between invoking panic

01:01:39.800 and getting people proactively prepared.

01:01:42.040 And I've been trying, at least in my media appearances on Fox

01:01:44.500 or wherever it might be,

01:01:45.440 I've been trying to walk that line as best I can

01:01:47.860 because I do really worry about public panic

01:01:51.600 making it very hard for public health professionals

01:01:55.120 and healthcare professionals to do their job

01:01:56.740 and actually prompting a politician

01:01:59.400 to make some kind of drastic decision

01:02:01.380 that will make things worse for everybody.

01:02:02.960 So it is very difficult to do that.

01:02:06.320 And you are seeing this be politicized on both sides.

01:02:09.740 And it's almost the opposite of the politicization

01:02:12.100 that we saw during the Ebola outbreak,

01:02:13.740 which is interesting.

01:02:14.420 So just to sharpen that up,

01:02:17.120 your concern is that people with ordinary flus,

01:02:22.080 people who just get a cold,

01:02:23.700 people who have a fever for some other reason,

01:02:26.160 panic and go rushing to the hospital.

01:02:29.100 And that makes whatever curve flattening

01:02:31.640 we've achieved less and less achievable.

01:02:35.740 So what do you recommend people do

01:02:38.800 if they're concerned that they might be sick with something?

01:02:44.400 The same things that you would do

01:02:45.660 for something like influenza.

01:02:47.360 If you are somebody that's a high risk group,

01:02:49.360 that you're older, you've got medical conditions,

01:02:50.880 you really have to have a lower threshold

01:02:52.200 to seek medical care.

01:02:53.560 But the vast majority of people who get this infection

01:02:55.680 are not going to need hospitalization

01:02:57.520 and can be managed at home

01:02:58.660 with over-the-counter types of remedies.

01:03:00.920 So we don't want all of those people

01:03:02.340 showing up in emergency departments,

01:03:03.960 urgent care centers,

01:03:04.720 at the doctor's offices,

01:03:06.040 spreading the virus

01:03:06.840 and making crowding even worse.

01:03:09.580 That's what we don't want to happen.

01:03:11.020 There are going to be certain people

01:03:12.080 that are going to do that anyway,

01:03:14.060 but we want to keep that to a minimum.

01:03:15.400 So we need to get clear on,

01:03:16.900 you know, who needs to go to the hospital

01:03:17.980 and who doesn't need to go to the hospital.

01:03:19.440 And that's what I'm really worried about

01:03:20.800 is that hospitals will not be able to cope with this.

01:03:23.180 And hospitals in the U.S.

01:03:24.040 kind of run at almost capacity all the time.

01:03:26.600 And even a severe flu season

01:03:27.860 can put a hospital into dire straits.

01:03:29.660 We saw that during the 2017-2018 flu season.

01:03:32.740 That's what I'm worried about happening

01:03:34.560 is that type of panic running to the hospitals,

01:03:37.720 just like the panic buying of surgical masks

01:03:40.220 all over the country

01:03:40.980 has led to possible shortages

01:03:42.900 of those surgical masks

01:03:43.760 that people may need in hospital settings.

01:03:45.680 That's what I'm kind of worried about,

01:03:46.800 these kind of disruptive events

01:03:48.500 that are on top of this big disruptive event,

01:03:50.220 which is the virus,

01:03:51.060 and that cascading,

01:03:52.440 and then politicians, you know,

01:03:53.860 nationalizing something to make masks

01:03:55.620 or doing something like that

01:03:56.680 that may end up having negative consequences

01:03:58.640 that we're stuck with for some time,

01:03:59.900 or closing borders,

01:04:00.620 or doing things

01:04:01.200 that may not necessarily be effective,

01:04:03.660 but are perceived by the general population

01:04:05.880 as this person's doing something,

01:04:08.080 even if it's not effective.

01:04:09.080 And we see that all the time with outbreaks.

01:04:11.780 So is there anything that we haven't covered

01:04:14.240 that you think we should hit?

01:04:16.120 Is there any advice you have

01:04:17.700 or any resources you want to direct people toward?

01:04:20.320 Because again,

01:04:20.860 we're having this conversation on March 10th.

01:04:23.280 I've learned that a week is a very long time

01:04:26.460 in this business.

01:04:28.020 The world, a month from now,

01:04:29.640 could look very different.

01:04:30.960 Where would you direct people

01:04:32.680 to get the best information on a daily basis?

01:04:36.520 I do think the Centers for Disease Control

01:04:37.940 does have a lot of good information there.

01:04:40.880 They do put out new fact sheets.

01:04:42.420 They do have press conferences.

01:04:43.700 I think those are really accessible

01:04:45.340 and have most of the up-to-date

01:04:47.400 American-centric information,

01:04:49.600 so what's going on in your country.

01:04:50.920 I think that the local health departments

01:04:52.940 in the municipalities that you may live in,

01:04:55.600 those are also good resources.

01:04:56.900 And I would advise people to look at those now

01:04:59.100 because if there are going to be measures taken,

01:05:02.560 it's going to appear there.

01:05:03.860 And you want to know

01:05:05.000 what local health departments are thinking about now

01:05:08.640 so that you have some outlet

01:05:10.480 and some way to give them feedback

01:05:12.880 and understand what's happening

01:05:13.900 in your local community.

01:05:15.100 I do think that the Center for Health Security website,

01:05:17.360 where I work, just to plug that,

01:05:18.800 it does have an extensive section

01:05:20.940 devoted to coronavirus,

01:05:22.000 and we're working basically around the clock

01:05:23.940 to keep up to date

01:05:24.680 and having multiple conference calls a day

01:05:26.100 to try and understand what's going on.

01:05:27.480 So I think I would recommend our website as well.

01:05:30.900 The WHO has a good website as well

01:05:32.760 that has some information there,

01:05:34.620 and I would also recommend that.

01:05:36.000 But it's going to be a media frenzy for some time,

01:05:39.660 and it's going to be hard

01:05:40.500 to sort out the disinformation.

01:05:41.860 So I do think that people should start looking

01:05:43.940 for trusted sources of information,

01:05:45.220 and that may be the CDC

01:05:46.860 and your local health departments,

01:05:48.060 as well as some of the academic websites

01:05:49.460 that are out there.

01:05:50.820 Also, you can sign up

01:05:51.540 for the various newsletters

01:05:52.880 that come out of Johns Hopkins on this topic.

01:05:54.820 They have one just devoted to COVID-19.

01:05:57.940 Right.

01:05:58.460 And then there's also a journalistic outlet

01:06:00.680 called Stat News,

01:06:02.360 which is owned by the Boston Globe.

01:06:04.340 That's probably the premier science reporting organization

01:06:07.520 in the world, I would say.

01:06:09.200 And then there's also the University of Minnesota

01:06:10.680 has something called CIDRAP,

01:06:11.980 C-I-D-R-A-P, 1.00

01:06:13.020 the Center for Infectious Disease Research and Policy.

01:06:14.940 They're also a very good source as well.

01:06:18.140 Amish, it's been an education.

01:06:19.440 Thanks so much for your time.

01:06:20.760 Thanks for having me.

Making Sense - Sam Harris - March 11, 2020

#191 — Early Thoughts on a Pandemic

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