In this episode, Dr. Amesh Adalja talks about his journey to becoming an infectious disease physician, how he got into infectious disease research, and what we can learn from the recent outbreak of the Ebola virus in the United States. Dr. Ajay is a cardiologist, infectious disease specialist, and infectious disease analyst at the Center for Health Security, a think tank affiliated with Johns Hopkins, and a fellow at the Johns Hopkins Center for Public Health Security. He is also a frequent public speaker and public speaker, and has been featured in the New York Times, CNN, NPR, CBS, and NPR. He is the author of the book, Pandemic Preparedness: A Guide to Preparing for the Next Pandemic, and the co-founder of The Center for Disease Control and Prevention (CDP) at Johns Hopkins University, where he focuses on infectious disease preparedness, prevention, and response to emerging infectious diseases. Dr. Adalaja has been a professor of infectious disease and public health, and is the Director of the Program for Emerging Infectious Disease and Public Policy at the Centre for Health and Security Studies at Hopkins, a non-profit focused on the intersection of public health and public policy and infectious diseases, and focuses on public policy, public engagement, and public engagement. He has been involved in public speaking, public relations, and media, and he is a regular contributor to the Huffington Post, The Huffington Post and The New York Magazine. and The Atlantic, among many other publications. Thank you for listening to this episode. It was produced by Dr. Jay Shekharper and Dr. Kelly. . I hope you enjoy this episode and share it with your friends, family, colleagues, and loved it on social media, friends, and social media! and let us know what you think about it! and tweet us what you thought of it on your thoughts and what you're looking forward to hearing about it in the next episode! in the comments section! Timestamps: 1:00 - What do you think of this episode? 3: 4:30 - What is your favorite part of the podcast? 5: 6:20 - What's your favorite infectious disease doctor? 7: What are you looking for? 8:00 9:40 - How do you feel about infectious disease? 11:30 12:00 | How infectious disease affects your life? 13:15 - Why infectious disease can engulf you? 14:30 | What is infectious disease really matters?
Transcript
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00:00:02.000So, one of the obstacles to self-confidence in this country is the rise of a new culture of fear in America.
00:00:31.000I think we see that anything in fear in our culture of free speech, to fear of losing your job for saying the wrong thing, but there's a different kind of fear that we experienced during the early days of our COVID-19 pandemic, a fear of the unknown.
00:00:46.000I think that's one of the things that allows the I think we went through a small version of that through the COVID-19 pandemic in dealing with an unknown, a new virus that was spreading across the United States.
00:01:16.000And about which we had very few facts, but had to make decisions even in the face of uncertainty.
00:01:21.000And I think that there's a lot that we, if we were to go through this again, would have done very differently.
00:01:26.000The question is, there's no point in making mistakes if you don't learn from them.
00:01:30.000And I think that's a big part of what I'm hoping to do today in the discussion that I'm having today with my guest, Dr. Amesh Adalja.
00:01:38.000And thanks for joining me on the podcast.
00:01:40.000And I'm looking forward to Diving into not only your work, but what we can learn from the last couple of years, as we hopefully, you know, never have to go through this again, but God forbid, even if we did, what we would do about it.
00:01:55.000So, you know, I know a little bit about your background, but it might just be helpful to hear in your own voice, you know, what it is you do, what's your core focus, you know, for a quarter of research at Hopkins and otherwise, and then we'll get right into it.
00:02:07.000Sure, so I'm an infectious disease critical care and emergency medicine physician.
00:02:11.000I practice in the Pittsburgh area and see patients, and that's about half of my time.
00:02:15.000The other half is spent at a think tank affiliated with Johns Hopkins called the Center for Health Security, where I work on pandemic preparedness policy, emerging infectious diseases, the intersection of infectious disease national security.
00:02:26.000A lot of the national policies that you see with infectious disease, I'm involved in.
00:02:30.000I do a lot of media as well and public speaking.
00:04:02.000I started when I was 17, but I started as a second semester sophomore at Carnegie Mellon because my high school had all of these advanced standing classes, and I took all of these AP classes, then I went in the summers.
00:04:11.000So you finished college in two years at Carnegie Mellon?
00:04:26.000I realized I wasn't really challenging myself and I knew that if I was going to become a doctor, I was going to become an infectious disease doctor because that's always something that detective work, the Sherlock Holmes aspect of it, the fact that infectious disease affects everything.
00:04:36.000The reason I'm sitting here across from you is because infectious diseases have a cascading impact on the entire world and every element of it when there's a pandemic, for example.
00:04:44.000Very different than if you were sitting across from a cardiologist where, you know, a heart attack is one person and a communicable infectious disease can engulf the world.
00:04:51.000So all of those problems together kind of made it kind of endlessly fascinating for me and something that I think is always going to be challenging and always going to have something new happening and that's kind of why I got into it all.
00:05:06.000What would you say is the culture of the profession a little bit, of the subsist specialty?
00:05:11.000I'll maybe Give you a bias that I have, but it's a hypothesis.
00:05:19.000And I kind of want to get a response from you on it, which is that I think a lot of people who go into – I'm going to go to a different area here and I'll come back to it.
00:05:29.000In the area of climate science, right?
00:05:33.000The people who enter climate science as an area of study or inquiry – People disproportionately have a hunger for cause and impact.
00:05:49.000They believe that they want to impact The effect of warming on the planet or whatever, but which closes the Overton window of what they're actually able – the questions they're able to ask.
00:06:00.000And then that becomes the people who sit on grantmaking committees who then become – you know, create an endless circular loop of the projects that get funded versus don't as areas of inquiry.
00:06:10.000But I think the question I had is in the pandemic preparedness world is – I think there are skeptics, I'm probably among them, who look at a lot of the people, you know, Anthony Fauci is in some ways the facial embodiment of this, who almost are Can be sort of giddy about the prospect of a pandemic in terms of what it offers for field of study and ability to have an impact.
00:06:35.000Do you think that there's a tinge of that in the field of pandemic preparedness, sort of a hunger for the relevance when a pandemic actually comes up?
00:06:44.000Do we see that in the COVID-19 case or do you think I'm just totally off base there?
00:06:47.000I sort of understand the point you're making, and I would probably draw a distinction between infectious disease physicians and public health.
00:06:55.000Yeah, so I think that there are a lot of people in public health that go into that to be activists.
00:06:59.000That's probably been going on since the progressive era in this country, that public health has a lot of There's activism in it to try and solve societal problems, whether that's sanitation, whether that's lead in paint that kids are eating, or whatever, or fluoride in water.
00:07:16.000And then I think many of the people in the field have been warning about how unprepared The U.S. was or how unprepared the world was for any kind of public health emergency in terms of the public health infrastructure in this country, in terms of the ability of politicians to listen or to prioritize those types of things.
00:07:33.000And when a pandemic occurs, there is a lot of this, I told you so, because we have been saying that.
00:07:38.000And I count myself as kind of in both camps.
00:07:41.000I'm an infectious disease doctor who takes care of individual patients, but because I'm an infectious disease, this is communicable disease.
00:07:46.000And it does have impacts that cascade.
00:07:49.000But I do think that in my field, there is a lot of activism that's kind of been melded into that and it's sometimes hard to separate.
00:07:57.000And there is often a prioritization of population health over individual health and also not allowing, you know, kind of a A calamity like COVID-19 to be wasted, meaning that there's lots of other things they want to do or points they want to make that COVID-19 allowed them to do.
00:08:16.000For example, you've seen that with Medicaid expansion, for example.
00:08:22.000Yeah, I guess you draw that distinction in the culture of infectious disease, which is about treating individual patients versus the culture of public health research.
00:08:30.000It's one thing if you want to be an activist, you can be an activist.
00:08:33.000But I think that the The research culture, I think one is that is a little bit tinged with the culture of activism just from the selection bias of people who are drawn to it, you would say.
00:08:43.000Well, it depends on what you mean by the research.
00:08:45.000If it's somebody who's working on this one protein in HIV or hepatitis C or whatever it might be.
00:08:50.000Yeah, but when you're talking about, you know, large scale population interventions, there's going to be that activist element that comes into that and I think, you know, there's this Almost like this technocracy that if you can show that this is the better way to do it, then that should be the law, that should be the regulation.
00:09:07.000And that there's a major tendency, I think, in public health, at least now in COVID-19, to act with government force and government regulation when historically it always been usually voluntary and everybody had said that that's how you should do it.
00:09:20.000But a lot of that research, when they've got a research question and they've got an answer, then that becomes, this is what we should do.
00:09:26.000We should follow the science, which means...
00:09:31.000And I think that's one of the problems that's created this breach in trust between the general public and experts in public health in infectious disease to the point where, you know, even I get death threats all the time.
00:09:42.000Anybody that's in the field gets this.
00:09:59.000I get it from the left and the right, which probably tells me that I'm correct in what I'm saying.
00:10:03.000During this pandemic, I've been on television a lot and I was on – and I made a very conscious choice to – To not sign an exclusive with MSNBC and Fox who both offered them to me.
00:10:13.000I said I want to be able to go on all three, CNN, Fox and MSNBC because I want to be saying the same thing on all three of those networks because this is already going to be so political and our country is so tribal that...
00:10:25.000I needed to have the ability to speak to everybody, or I wanted to speak to everybody, but that will engender people on the left to get mad at you and on the right to get mad at you, and they often disagree with some of my policy prescriptions, or they disagree with how I've interpreted something, or they are very anti the vaccine or anti a drug or pro a drug, all of that.
00:10:47.000Even people in my hometown sort of turned against me because of uncertain issues.
00:10:52.000But I tended to think, you know, I'm not going to be really pushed around by that.
00:10:56.000And I think that it's unfortunate that we've got this breach because now when the next infectious disease emergency, it's going to be so much harder to actually communicate to people about recommendations or risk calculation because this whole thing has just been completely destroyed, this relationship.
00:11:14.000Who do you think is most responsible for that, if you had to pick?
00:11:17.000It's probably not one person or one actor, but maybe it is.
00:11:21.000Who do you think is responsible for that loss of trust that we would have in a method of getting to truth?
00:11:29.000I think it's – if you look at COVID-19, this has been – what happened here in the United States and across the world is a failure of governments, failures of national governments, state governments, local governments, even school boards to be able to actually be proactive and take the requisite actions when there was the window to take them and then getting forced to take blunt actions that were not necessarily going to be accepted by the population.
00:11:51.000And what happened was the government actually didn't learn from it.
00:12:35.000So we knew in January of 2020 that there was an efficiently spreading respiratory virus In China that was of the coronavirus family that had a predilection to kill people if they were older or had comorbid conditions.
00:12:50.000At that point, with a virus like that, you know it's going to be a pandemic.
00:13:10.000It's very constrained in its ability to get from a person to a person.
00:13:14.000And did China really allow the level of transparency for us to be able to say we – did China allow the level of transparency that we really need in order for – The US to have concluded what you just said that we know it's going to be a pandemic.
00:13:28.000Because as I remember, China was very cagey about it.
00:13:30.000On one hand, they said it's no big deal.
00:13:32.000On the other hand, they had these like white trucks like pouring bleach all over the streets.
00:13:36.000I remember seeing that in January of 2020 and wondering what the heck that was about.
00:13:42.000At first, they were very non-transparent, but they got overcome by events.
00:13:46.000We knew by mid-January that there was person-to-person spread because even if you look at the first case reports, we were hearing about people who had never been to that market, which is where they had initially thought was a super-spreading event.
00:13:56.000So we knew that there was likely transmission going on and those reports were occurring.
00:14:00.000So I do think that there was enough transparency, even if it wasn't coming from China.
00:14:03.000Remember, Taiwan had figured this out December 31st, they already started preparing of 2019 because they had people on the ground in China and understood what was happening.
00:14:13.000So I do think that what we should have done was, this is going to come, we need to make sure we have enough personal protective equipment in our hospitals, that we have hospital capacity, that we fortify nursing homes, that we don't have bad policies that allow nursing home patients to get infected because they're likely to die.
00:14:28.000We have to just tell any manufacturer that can make tests, we need tests.
00:14:32.000We're going to have to test a lot of people very quickly, and we don't have time to go through.
00:14:38.000We need a public health emergency to get emergency use authorizations for as many tests as possible.
00:14:45.000Get enough healthcare providers have portability of licenses to go from state to state.
00:14:49.000All of that stuff could have been done in January and February.
00:14:51.000And yes, it would have been early, but there was enough information to know that stuff was happening.
00:14:55.000I mean, at the very, very least, it should have been, we need a testing policy and we need to fortify nursing homes.
00:14:59.000If you had done those two things, I think you would have had a very different trajectory of the pandemic.
00:15:04.000I think the first 100,000 people were likely to die irrespective of what we did.
00:15:08.000But we would have been able to stop that cascade that occurred because we would have had the ability to test people, to know who's infected, and then take targeted interventions, isolate those that are contagious, rather than what happens in March where they say every activity has to be stopped because we have no way to know who's infected and who's not.
00:15:25.000We were completely blind, but blind by choice because the testing was so constrained that it was only CDC kits that were going to health departments, state health departments, with very, very, very strict testing criteria.
00:15:37.000So you had to have been from China, and you had to have symptoms of lower respiratory tract infection.
00:15:42.000So if you just had a sore throat, you couldn't get tested.
00:15:45.000So you went on your way and infected other people.
00:15:48.000So what happened is you had this transmission occurring that was underground Not noticed because we had no ability to test.
00:15:55.000And then it bubbled over in places like New York and put their hospitals into crisis, which is exactly what you would expect to happen if you take a reactive approach and give a virus like this two and a half months to fester and do nothing.
00:16:07.000And when you do take actions, you take the wrong actions, like travel bans and quarantining people on Air Force bases when the virus was on both sides of those Air Force base fences that they were doing.
00:16:16.000So it was just kind of mistake after mistake after mistake.
00:16:24.000Who's accountable for making those decisions?
00:16:26.000Who ought to be accountable for having made those correct decisions in your perspective?
00:16:31.000I think it's the federal government in general.
00:16:34.000That's where this was happening, that there was this evasion of what this meant and an inability to actually take action quickly and fast.
00:16:43.000I think it goes to the president eventually because it has to ultimately stop with him when he was saying, you know, there's 14 cases here.
00:16:55.000Why do you want to do this many tests?
00:16:56.000We've had that kind of attitude at the top.
00:16:58.000It becomes very hard to actually do things.
00:17:00.000And then when he actually started taking action in March...
00:17:05.000It was already too late to use any of those targeted methods, at least from most governors' perspectives, and they were scared, and they didn't want to make the wrong decision, so they erred on the side of, you know, we're going to do the most restrictive.
00:17:16.000And in the end, that ended up causing its own problems, the cascading problems with childhood learning, all the other medical problems that happened, all of the psychosocial issues that happened, all of the damage to the economy, and the fact that it didn't teach the population how to risk calculate.
00:17:30.000We should have been doing harm reduction, saying, this is going to be with us, we need to learn how to live with it, And learn how to use tools that science and medicine give us to be able to live with it.
00:17:57.000Let's just go back to that first origin in China.
00:18:01.000If it's really certain that by January...
00:18:06.000You know that it's, as you put, efficient in its infection.
00:18:11.000It transmits easily from person to person.
00:18:14.000The characteristics of the virus suggest that it would be the stuff of a global pandemic.
00:18:22.000Why couldn't it have just been contained to China at that point in time, actually?
00:18:26.000Because China did constrain travel within China But international travel was allowed.
00:18:33.000I'm just, just, again, for the purpose of learning, let's say the next time on these same set of facts, if everyone's asking, acting with good intentions, are we sure that it couldn't have just remained in China the way the past SARS epidemics had, notwithstanding the greater transmissibility of it?
00:18:49.000Like, is that a node, a Pandora's box that you could have left closed?
00:19:17.000And it was a particularly brisk flu season.
00:19:19.000Most people who have respiratory illnesses and most people with COVID-19 have mild illness indistinguishable from flu, they don't get tested.
00:19:25.000So there's people walking around with respiratory viruses, even here in Columbus, that aren't getting tested.
00:19:33.000And COVID-19 started out like that, as a virus mixed in together with all the other respiratory viruses.
00:19:38.000And because it efficiently spread, it was getting more and more people.
00:19:41.000So by the time they actually noticed, when they started to see the sickest patients, and remember, the case fatality rate is probably around 0.5%, 0.6%.
00:19:48.000So it's only the tip of the iceberg when you see the hospitalized patients.
00:19:51.000When they saw those hospitalized patients, That meant that there were so many more people in China that were infected that had likely all traveled by the time you noticed it.
00:19:58.000This is exactly what happened in 2009 with the H1N1 pandemic.
00:20:02.000By the time we saw those cases in California, we knew that the cat was out of the bag and there was nothing you could do because it's a spectrum of illness and all those mild cases would have been missed and mixed in with all the other respiratory junk that goes around every day.
00:20:17.000So let's get to the point where Alright, we're now getting to mid-2020.
00:20:25.000Alright, as you put, to borrow your expression of resistance now, cat's also out of the bag in the United States.
00:20:33.000Okay, there's no way we're going to put that genie back in the bottle.
00:20:36.000What do you think would have been the right course of action then?
00:20:39.000Which is really different than saying, okay, well, maybe early on you could have, you know, had a national plan to prevent transmission and or to at least have the ability to diagnose quickly, do testing, act accordingly, risk stratify to make sure older people aren't disproportionately killed.
00:20:56.000Okay, we're now into mid 2020 here, summer 2020. What would you have done differently there?
00:21:03.000At that point, what you're trying to do is give people tools to be able to live with a virus that's not going away.
00:21:08.000This is already June, July of 2020. And I think by that point, it is accurate.
00:21:12.000I mean, we kind of knew this was here to stay.
00:21:15.000I wrote a blog post in January of 2020 saying this is going to be the fifth seasonal coronavirus, that this was not a radical, but people thought I was a little bit off, but I think- That this is not what you say?
00:21:24.000That this was not going to be eradicable.
00:22:16.000And that didn't make sense, because we, by that time, understood that indoor transmission was much, much more likely than outdoor transmission.
00:22:22.000So we could have shifted a lot of things outdoor.
00:22:25.000We still had schools closed that had really no ability to think about even opening in the fall.
00:22:33.000That could have all been going on at that point, and it wasn't.
00:22:37.000It was still just kind of hunkered down.
00:22:39.000And then they still didn't invest in public health infrastructure because over what?
00:22:44.000So one of the things that happens when people test positive, you can do contact tracing if you have enough information.
00:22:51.000If you have enough people to do the contact tracing, we never hired those contact tracers.
00:22:55.000Many people put estimates that we need contact tracers.
00:22:57.000What would that actually look like, though?
00:22:59.000I mean, that just sounds like it's like a fatally hubristic to think that that's something that you actually are going to You can do it if you have enough contact tracers and you're able to- What does that mean, the contact tracer?
00:23:48.000They figure out whose people the contacts were.
00:23:50.000So that's kind of the bread and butter of public health.
00:23:52.000We do it for many communicable diseases.
00:23:54.000It's harder to do with a respiratory infection, But countries that were successful, like Taiwan, with avoiding lockdowns, used contact tracing.
00:24:02.000Maybe that's a little bit unfair because Taiwan, you know, jumped into action on December 31st, 2019, as I said, so they were able to keep pace with it.
00:24:09.000But they also have, you know, a very strong interest in infectious disease resiliency.
00:24:13.000Their vice president had a PhD in epidemiology at the time.
00:24:20.000Well, I mean, I don't know how much having a PhD in epidemiology as a public official would or wouldn't have helped them individually take the right steps towards...
00:24:34.000Towards, you know, prevention of spread.
00:24:36.000But it's just about being proactive and actually having the ability to cope with the cases.
00:24:42.000It wasn't even there during the Omicron waves that we had a year later, over a year later, that we were still seeing hospitals running into problem.
00:24:50.000We were still worrying about personal protective equipment.
00:24:52.000We were shortages of tests that were still occurring as it turned 2022. Oh, no, you're talking about...
00:24:58.000Now it's like a year and a half later.
00:25:00.000Right, but we still couldn't test for Omicron.
00:25:12.000And then fast forward to a whole different disease, monkeypox.
00:25:15.000The same exact testing problems that we had with COVID were repeated with monkeypox.
00:25:19.000That you had the strict testing criteria, only the state health departments could test.
00:25:23.000All of that is just not the way you respond to an infectious disease emergency.
00:25:28.000And that made me question the whole ability of our system to be able to do this.
00:25:33.000Here's a separate question, actually, just as like a framework.
00:25:38.000You know, pointing out that problem and wishing a solution into existence does not guarantee that there's going to be a different solution that comes into existence.
00:25:46.000And even some of those solutions may have costs of their own, just as lockdowns have costs.
00:25:52.000You know, I think that there are – you know, contact tracing for a fast-spreading respiratory illness is, you know, easier said than done.
00:26:02.000Was there – might it have been the right decision in – You know, summer of 2020 to just take a very separate national response, which is to say, we're just going to let it spread, achieve national immunity, protect vulnerable populations, and that's it.
00:26:23.000Like, how much better off do you think we, or worse off, do you think we would be as a country if that had been the approach we took in the summer, right?
00:26:30.000Because there's a lot you could debate between January and June.
00:26:34.000But July of 2020, just say, hey, look, school season's coming up soon.
00:26:42.000And at that point, I think we had a reasonably high degree of confidence that kids – We're not at risk that people with healthy baseline risk factors had very low risk of hospitalization or death to say that, okay, we're just going to have a national strategy that's designed to protect spread to the elderly and maybe with other significant pre-existing risk factors.
00:27:08.000Would we be in a better place as a country today From a health perspective alone, the economic, from a health perspective alone.
00:27:16.000Or would we be in a worse place today if that had been the approach we took in mid-2020?
00:27:20.000I think by mid-2020, people were going to do what they were going to do.
00:27:23.000And even when you had those very strict policies in place in certain states like California, for example, it wasn't really – I don't know that it would have – I think we sort of de facto were doing what you were saying, even though that there was things on the books and people were fighting and yelling.
00:27:38.000Most people were not, there were people that were going about making their own risk calculations on their own already.
00:27:44.000I think that's what I would have, you know, ideally I would have said, this is an endemic respiratory virus.
00:27:48.000These are the risk factors for severe disease.
00:27:50.000You don't want to get, this is something you should avoid.
00:27:51.000If you are somebody that contracts it, recognize that you're contagious and be very wary about the contacts that you have with high-risk individuals.
00:27:59.000Use home tests if they were available and then really make sure that our hospitals had the capacity to deal with patients, had the capacity to have enough mechanical ventilators, staffing, personal protective equipment for healthcare workers.
00:28:21.000Surfaces, you don't need to be washing your mail.
00:28:24.000They should have done that type of thing, but they didn't do that.
00:28:28.000And then what you had is half of the country, the red states is what people would say, were mostly going about their business where the blue states were not.
00:28:36.000And so I don't know that we would have been better or worse.
00:28:39.000I think that we kind of got the worst of everything.
00:28:41.000But I do think that that honest communication and allowing people to risk calculate and really risk stratify where the issue was, nursing homes, high-risk populations of any age, And give people tools to be able to navigate that.
00:28:55.000That would have been much better, a much better approach that would have avoided all of the acrimony, all of the fighting that's happened.
00:29:02.000And I think we would have had a lot, I think, you know, an overall better outcome that's probably not much different than what, if you kind of say that this would have made it worse.
00:29:13.000I don't know how much worse you could have done than what we did.
00:29:16.000So I think that it's a preferable approach to use harm reduction rather than abstinence only.
00:29:22.000And that's what happened during this pandemic was all abstinence only.
00:29:31.000I think the harm reduction approach would have been the right framework, no doubt about it.
00:29:36.000You know, functionally, some people, but not all people, because half the states in the country are blue or purple states that took a different approach.
00:29:44.000I mean, I think that had we at that point said, all right, cat's out of the bag.
00:29:48.000And one way or another, we're going to, you know, live with this thing.
00:29:54.000Let's just protect the people who are most at risk.
00:29:58.000That probably would have been the single greatest path to overall human flourishing.
00:30:04.000You wouldn't have had a year of kids missing school when they could have actually been on a different educational trajectory.
00:30:11.000Maybe it would have reached natural immunity more quickly.
00:30:13.000I don't know what your perspective is on that, but if the general population that was at low risk Got to widespread levels or more widespread levels of natural immunity, would we have actually been in a better off place much sooner?
00:30:27.000That's a, you know, maybe a debatable question, but that's kind of my perspective on this.
00:30:32.000I think what constrained Omicron and all of these other variants from causing problems is the fact that there's so much immunity in the population.
00:30:39.000And with COVID, with a virus like this, it mutates.
00:30:42.000So you don't get natural immunity the way, in the sense, the same way that you do against measles where you become kind of impervious to infection.
00:30:49.000What you get become impervious to if you're- Severe infection.
00:30:52.000Yes, a severe infection, which is what matters in a respiratory disease most.
00:30:55.000And it's for those high-risk populations that need to be boosted and need to be much more careful even after they've gotten vaccinated or been infected.
00:31:02.000But in the low-risk population, that immunity, at least into the Omicron era, was very robust even against infection.
00:31:09.000And I think what we're trying to do was shift the spectrum of illness of COVID to the mild side.
00:31:43.000There was a mistake in the way the public was asked to blanket trust the vaccines in the way that they came out versus a way that could have been handled differently.
00:31:54.000I mean let's just talk about the vaccine fact that – I mean there was a cascading narrative of preventing spread.
00:32:02.000To preventing getting ill, to making it more mild, to reducing the risk of spread all the way to the end that sort of was a cycle of eroding trust in vaccines that were developed in record time, but without really Embracing the humility that may have come with vaccines that were developed as quickly as they were, if you were to rewrite history or had the ability to change history, what do you think we should have done differently with respect to the vaccine rollout?
00:32:32.000So I think the vaccines overall have been what have given us success over this virus, and I was one of the first people vaccinated back in December, and I think that— Let me just sort of double-click on that for a second, just to understand.
00:32:46.000Versus the alternative model of widespread natural immunity, save for severe populations in mid 2020 had we adopted that policy of just saying, no lockdowns, no anything, protect vulnerable populations only, but that's the only response.
00:33:05.000That that would have led to an overall less optimal outcome than actually even the approach we took with the vaccines.
00:33:14.000Yes, because milder illness is always better than severe, even, you know, even if you're not at risk for severe disease, if you have an attenuated illness because you've been vaccinated, that's a win.
00:33:25.000And I think when you're talking about a safe and effective vaccine, that makes sense.
00:33:27.000But let me get back to, you know, your original question is that I think that there could have been more nuanced communication.
00:33:36.000Up until around the Delta, the Omicron period was able to block transmission.
00:33:40.000It's when Omicron evolved, that transmission blockade basically...
00:34:24.000It may no longer be transmission blocking because people thought, you know, we know that coronaviruses do this.
00:34:30.000So I think they could have said that up front because now what you have is people kind of And being challenged on this, and I think it's because oftentimes in these types of emergencies, the government wants to give a one-size-fits-all simple message, like duck and cover.
00:34:44.000When you were a little kid, when you were thinking about a Soviet nuclear war, it was duck and cover.
00:34:49.000And it would do absolutely nothing in the case of a nuclear war.
00:34:51.000Right, but it was a simple thing that you could tell people.
00:34:54.000That's oftentimes what's prized in public health emergency communication, but what it's doing is eroding trust.
00:35:01.000So, for example, the other aspect is we knew that people that were infected were not necessarily going to benefit as much from the vaccine because they had a lot of immunity.
00:35:08.000So they could have been more nuanced, saying maybe a single dose of vaccine is what's necessary for someone with prior infection.
00:35:15.000but they didn't do even that and there was data to prove that and i think that created a lot of distrust as well because they were kind of ignoring the data that was coming out on prior infection what the value of the vaccine this is all pre-omicon it's very different after omicron but pre-omicon they didn't kind of leave room for that the same thing happened with the booster campaign that we're still in now is that there's not nuance based on risk stratification it's one size fits all that's what they want they want to keep it simple and that ends up
00:35:42.000i think in the end and hurting people in my field, because then people say, "Well, why are you ignoring all of this data That doesn't make sense.
00:35:52.000And I think that's what should have- Novak Djokovic,
00:36:12.000the best tennis player in the world, possibly in history, is unable to enter the United States because he's not vaccinated with a vaccine that was supposed to work against an older variant at best and someone who has actually since acquired and reacquired natural immunity twice against a backdrop where we'll allow, you know, 100,000 people to get in a football stadium.
00:36:39.000Without actually quibbling about vaccination status, like that's the kind of thing that reveals some sense of a farce to the whole thing.
00:36:49.000I mean, like, what is your reaction to that fact?
00:36:52.000Right now, the US government will not allow Novak Djokovic to come into the United States to play a tennis tournament because he's not vaccinated.
00:36:58.000Like, what's the public supposed to make of something like that when it comes to public trust in vaccination itself?
00:37:04.000No, I think it's a stupid policy that they put in place because if he was an American citizen and wasn't vaccinated, he could come.
00:37:12.000And if his tournament was May 12th, he would be able to come in.
00:37:16.000But if it was May 9th, he can't come in because that's when the public health emergency ends and then they're going to drop that requirement.
00:37:21.000- As of this year, you're saying? - Yeah, I think this was silly at this stage to make this type of requirement.
00:37:29.000And I don't think that there's any reason to say, this is a foreigner who's not vaccinated versus this is an American who's not vaccinated and treat them differently and made absolutely no sense.
00:37:37.000I think it was very performative and really just more emblematic of the way that there's not nuance, that people want rules and they're gonna stick to that rule, even if the rule doesn't make sense any longer.
00:37:51.000It's like when President Biden put travel bans on South Africa for Omicron, when we said that that's not going to do anything, this is already here, that's performative, but he still did it, even though one of his campaign promises was, I'm never going to put travel bans in place, but he did that anyway.
00:38:06.000So there's a lot of performative stuff that goes on for political reasons, and I think that this is probably just a bureaucracy not recognizing that Is this stupid?
00:39:00.000But it's also a relic of a government that believed that its own declarations, I think, were Worthy of greater respect than something that a thinking individual through the scientific method of inquiry would have come to on their own.
00:39:16.000And I just think that creates a new culture in our country that sows mistrust amongst the people who invoke science as a word.
00:39:24.000I think the next time around, I think the fact that Novak is not able to come to this country right now to play tennis tournament will impede the government's effectiveness in convincing someone to take any vaccine the next time around.
00:39:36.000And, you know, I think that it's not just an innocent bureaucratic mistake.
00:39:39.000I think it's an impact that it has on a national culture on the back of it.
00:39:43.000I don't know what your reaction to that is.
00:39:44.000Well, I do think that there is this danger that, you know, that science gets elevated to this kind of level of like philosopher kings where what they say becomes true no matter what and then that kind of gives policymakers a way out.
00:40:00.000When it's actually the role of a politician or an elected leader to take what scientists are saying and then weigh that against what's possible, what makes sense, what are the other competing values and that never happened.
00:40:11.000I think that falls at the feet of politicians.
00:40:13.000How much does that fall at the In the culture of the scientific community itself, in sort of taking on questions that are actually normative questions, right?
00:40:22.000Policy questions, but wrapping them in the veneer of science.
00:40:26.000I don't think that they should not necessarily do that unless they're being very explicit.
00:40:31.000So I can tell you, if you want to stop this virus from happening, make everybody go into their house and never come out for two weeks.
00:40:41.000We could induce a coma to everybody, cryo-freeze them, you wouldn't have the spread of the virus.
00:40:45.000Right, or you tell people you want to stop drunk driving deaths, just get rid of cars.
00:40:49.000Get rid of cars, no more drunk driving deaths.
00:40:51.000So you have to take, when you're making a policy statement, when you're jumping to the normative from that, you have to actually say that you're doing that.
00:40:58.000You have to say, this is the values that are operative here.
00:41:02.000As opposed to disguising the normative agenda and the veneer of science, which is what we saw happen over and over again.
00:41:09.000And they don't allow people to have differing value.
00:41:13.000Each person has a different value hierarchy.
00:41:15.000Certain things are going to be more important for someone to visit their grandmother than for another person.
00:41:19.000And they didn't allow any of that to – that whole – You know, when they say, you know, stay at home or do this, do this, do that, they didn't actually take into account what people's values were and how important it was for that individual person to avoid getting COVID. They didn't do that.
00:41:32.000I wrote a piece for the Washington Post about this kind of value hierarchies and looking through And how people have to kind of navigate them and that they're not going to be the same for each person.
00:41:42.000So what you do is you give people tools and say, if you want to do this, these are the facts that you have.
00:41:48.000These are the facts that are operative.
00:41:50.000These are the tools you can use to reduce your risk, but you have to choose to do that and fit it into your value hierarchy.
00:41:54.000It might not be worth it for you to do all of that because it's so important to see your 90-year-old grandmother that you're not so much worried about that.
00:42:03.000It was just science that said, this is what...
00:42:05.000This is what we know about transmission, so that translates into never do this.
00:42:09.000Again, this goes back to the abstinence-only approach, but I do think that scientists can sometimes—I think it's a concept called scientism, where that ability to take scientific knowledge and move it into the normative field happens kind of with a wave of the hand, without actually making the argument that that should be— The way that people should act.
00:42:32.000I do think that scientists kind of got sucked up into it.
00:42:36.000How do we solve that within the sciences itself?
00:42:40.000I mean, I do think that there's a bit of a fatal hubris in people who train with technical expertise who ought to have authority in their area of technical expertise.
00:42:51.000Sort of have a fatal, even subconscious flaw to think that that gives them greater standing on the policy question.
00:42:57.000I think that was the essence of – at the essence of the loss of public trust in science itself when in fact the scientists, many of them at least, wore the mantle of scientism without even recognizing it.
00:43:10.000I do put this back at the feet of the politicians because I think they have to be able to keep those people in their lane and be willing to make those decisions and not just defer.
00:43:18.000They're kicking the can over to the scientists.
00:43:20.000It's much easier for them to say, I just did what the scientists told me.
00:43:23.000That removes their ability to evaluate what's being said and then put it through You know, some kind of calculus about what other things are important.
00:43:33.000Schools, people's mental health, cancer screening, whatever it may be.
00:43:39.000They just looked at it very short range, and they basically outsourced that idea to scientists and scientists who were given the task of, we need to stop this from spreading.
00:43:47.000So they're going to give you this solution, and if you can just blame it on them, then I think that makes you a lot more safer, that you did everything you did.
00:43:56.000You did exactly what the scientists told you, so how can I be to blame?
00:43:58.000How much do you think the sort of erosion of free speech On the debates relating to COVID policy in the 2020-2021 timeframe, how much worse off were we in making decisions because of that?
00:44:17.000I'm referring to ideas like lockdown, anti-lockdown speech was often taken down by the likes of YouTube or Facebook or even Twitter.
00:44:25.000I think that there was a bias in terms of what could and couldn't get published in scientific journals, in mainstream press, in the op-ed pages of places even like the Washington Post.
00:44:36.000How much do you think that culture of What viewpoint censorship in the debates around COVID policy hurt us in the end?
00:44:45.000Well, I think the more debate that we had, and if there was, you know, there was lots of misinformation circulating, and I think there was people sensitive to that because people were making- Yeah, that exactly was the rationale for censorship.
00:44:55.000People were making bad decisions based on that misinformation, but I think that that misinformation can be so easily debunked, and I think that some of it was ridiculous, the things that were out there with microchips and 5G, that was- What was that?
00:45:36.000And I think that when you're someone at Twitter or YouTube or Facebook or whatever, you're not an expert.
00:45:42.000And sometimes they would take things down that didn't even need to be taken down that were part of a rational debate that was going on about natural immunity or about origins of the virus or about what the role of certain measures may or may not be.
00:45:56.000They were taking things down just because they thought that was kind of...
00:45:58.000You know, the virtuous thing to do, that they were sort of virtue signaling to do that.
00:46:01.000And I think what it did is it just got the misinformation people even more fired up and created more politicization of what shouldn't have been politicized.
00:46:11.000So I do think that they erred a lot with what they did.
00:46:15.000And I think that it made, you know, I think that they have the right to, I think that they should be able to content moderate, but I think what they did in the end ended up making it worse.
00:46:24.000It actually did not achieve what they wanted it to achieve.
00:46:26.000They actually made it I mean it's something that was even more partisan, more … No better way to spawn a conspiracy in some ways than to censor so-called conspiracy theories because I think censorship reflects a lack of insecurity to be able to – a lack of security to be able to debunk whatever is stated that's misinformation on the merits.
00:46:49.000It sort of smacks of an insecurity there.
00:46:51.000I think that's part of what sort of sowed further the seeds of public mistrust in the way we saw it, don't you think?
00:46:56.000It's more – I think that – I don't know if it was their insecurity or they were just trying to be, you know, quote unquote good citizens and they thought that was what – It comes across as insecure though to somebody who is, you know – Open to a possibility of even a wrong answer to say, well, but then why is it that you'll silence my ability to say it?
00:47:14.000I think that fosters some sense of – some perception that you're insecure about your actual belief system that you couldn't win through debate, that you really could only win through the use of force and censorship instead.
00:47:27.000I don't even know if they themselves even had a side.
00:47:29.000Some of it just strikes me that they were just trying to do that and they didn't because some of the stuff that does pass through their filters can be way worse than what they actually block.
00:47:40.000So it to me was a little bit arbitrary and didn't make sense and a lot of us were doing a lot of time, spending a lot of time debunking things and I think that was working fine.
00:47:49.000I don't think in the end We decrease the amount of misinformation or people's adherence to or belief systems or their ability to believe or their tendency to believe misinformation.
00:48:00.000I think it only made it worse because then they saw this is secret.
00:48:06.000Sort of an analogy between lockdown policy.
00:48:09.000Not really having the effect of, you know, preventing transmission when it was not really that people didn't have trust in lockdowns anymore than suppression of speech had the effect of debunking misinformation anymore than, you know, you would have just by actually letting information flow more freely.
00:48:26.000I don't think that the amount of misinformation that people believed changed as a function of trying to censor it.
00:48:33.000It might have made it worse for all we know.
00:48:35.000Yeah, I think it did, and I think it just added more politics into something where there should have just been no politics involved.
00:48:41.000It should have been something that was— What does no politics involved mean, though?
00:48:45.000Because a big part of what you said earlier is every decision we make is still a policy decision of trade-off.
00:48:53.000But by politics, I mean no partisanship.
00:48:55.000Meaning that it's not something where there's a Democrat version of this, a Republican version of this, a Green Party version of this.
00:49:01.000Yeah, I mean, that would be nice, but I just want to double-click on that— Because it is something you hear pretty often.
00:49:06.000But I mean, let's suppose there is a Republican worldview that tends to favor more human freedom even if that comes at greater risk that we take in virtue of human flourishing and prosperity versus a Democrat view that's more oriented towards risk mitigation even if that reduces the whole size of the pie of human flourishing and economic activity.
00:49:25.000That's a political distinction and you could have.
00:49:28.000And it would not be a totally undesirable society in which, okay, Republicans had one view of what COVID policy as it related to lockdowns and preventive behaviors would be and Democrats would have another.
00:49:49.000You can look at the same fact and make two different evaluations.
00:49:52.000But what was happening is that you could write off the way a person would What they thought were facts based on their political affiliation.
00:50:16.000Policy prescriptions if you're a Republican or a Democrat or an independent or whatever it might be, but the underlying data is still the same.
00:50:24.000I mean, I think that's – it's one reality and people are doing is forming a value structure off of that and that some people may tend to Republican, some may tend to Democrat.
00:50:33.000But I think it's still the same underlying reality and I think right now we're in this kind of postmodern world where people don't believe that there's one reality, that there's one fact.
00:50:41.000They only view them whether they're a Republican or a Democrat or what sociodemographic group they are in or what – how they identify themselves rather than actually saying this is one world here, one set of facts that we're dealing with.
00:50:54.000That's the problem that I – when I say politics, I mean that.
00:50:58.000It's people only looking at it through their tribal lens and saying, this is what my tribe thinks about this, so that's what I'm going to think about this irrespective of what's on the ground.
00:51:06.000And I think that happens on – and it happens on both sides.
00:51:08.000It's not that I'm picking on – Republicans are picking on Democrats.
00:51:36.000Just wear your common sense hat for a second.
00:51:40.000There's an origin of a pandemic from a city in China, where there's a bioterrorism lab, where they're conducting research on respiratory viruses.
00:51:53.000And yet, for a long time, it was uncouth in the United States.
00:51:58.000Really around the world to acknowledge that it likely originated in that lab.
00:52:04.000In fact, there was this Lancet organized group of authors, you might remember this, who signed a statement rejecting and condemning the lab leak hypothesis pretty early on before we could have any facts to contravene it.
00:52:16.000Even when even common sense would have pointed in a given direction, social media companies, YouTube, etc, censored speech that said this did originate in a Chinese lab.
00:52:24.000Now we know it originated in a Chinese lab.
00:52:27.000Perhaps we could have actually derived more information earlier on in the pandemic that would have allowed us to get to solutions sooner had China been transparent and had we had the transparency of flow of information to get China to be more transparent at that time.
00:52:41.000What's your take on the whole situation?
00:52:45.000Quiet evolution of the consensus around where the pandemic originated, whether that matters what's at stake for preventing future pandemics.
00:52:56.000I personally think that China still remains the number one source of global pandemics going forward.
00:53:01.000The fact that this originated in Chinese lab.
00:53:06.000But we weren't able to talk about it or weren't able to arrive at that conclusion until three years, even after it was first so obvious to a layperson in retrospect.
00:53:15.000What are some of the takeaways to you of that part of this experience?
00:53:19.000So I think, first off, that I think it's very important that we understand the origin.
00:53:22.000I think that it does have bearing on how we think about pandemics in the future.
00:53:27.000Because if this happened from a laboratory accident, we need to understand how that breach occurred, and we need to do that research safely.
00:53:34.000If it came from the animal market, we need to know what the intermediate animal was, so we change our interactions with that intermediate animal because there's wet markets all around the world.
00:53:42.000And I think that those are important questions to answer.
00:53:45.000I think what happened early on is that this idea of a lab leak got bundled together with, this was a biological weapon, this was intentional, and then it became taboo to talk about it.
00:53:54.000That got package deal together, and it took some time before people started to separate, okay, this wasn't bioterrorism, this wasn't deliberate.
00:54:04.000But could it have been a lab accident?
00:54:05.000Once those two things separated, that allowed people to actually talk about it.
00:54:09.000And the other thing is that because Donald Trump is such a figure that put people off right away when he says something, even if it could be correct or if it's not completely wrong, they're going to just oppose it because Donald Trump was saying it.
00:54:23.000And I think that was part of it, is that Donald Trump started talking about this and certain other individuals started talking about this in right-wing circles, and then that automatically made people react and say, this is just...
00:54:33.000Some conspiracy theory, rather than actually understanding that there was a process, at least in my field, that people were trying to understand what was going on in that lab and if this was a laboratory leak.
00:54:43.000And I would say right now that there is a consensus from in the general public that this came from a laboratory leak from the Department of Energy, from the FBI.
00:54:51.000But there's still some open questions.
00:54:52.000A new research came out in the last couple of days about, you know, some swabs with raccoon dogs that might have been the intermediate host.
00:54:59.000So I think that we're still – it's still unknown.
00:55:01.000It's still – I think that there's still life in both hypotheses.
00:55:06.000But I don't know, as you said, that we're going to get to the answer to this until you see transparency from the Chinese government because they are the only ones that actually know the answer to this.
00:55:14.000They know what viruses – if there were precursor viruses in that lab.
00:55:18.000They know if there were biosecurity breaches.
00:55:19.000They know if people from that lab got sick with pneumonia and were seen in the hospital.
00:55:24.000And they also know what animals were in that lab that they basically destroyed the lab, the market, the day or so after that outbreak was declared.
00:55:33.000And even just now with this other hypothesis, the animal hypothesis, they basically pulled all those sequences down after that European and American team found those raccoon dog sequences in the data from there.
00:55:47.000Chinese, they don't want to know either way, whether it was a lab or whether it was the animal market, because both of it makes them look bad.
00:55:54.000And they continue to say that this was a US biological weapon or that this came from frozen food from the United States.
00:55:59.000So I think it just really speaks to the Chinese government's authoritarian lack of transparency.
00:56:05.000And I don't know that we'll get to the bottom of this, but I'm glad that President Biden signed that law to declassify the intelligence community's assessment within 90 days.
00:56:13.000So hopefully we'll see what the intelligence— Should be very soon, actually.
00:56:39.000I think that's going to be influenza is the greatest pandemic risk and we know that China is a place where all of these viruses circulate in the waterfowl populations that they have wet markets and poultry markets.
00:56:48.000Why do you say an influenza virus different from seasonal influenza you're saying?
00:56:51.000Yes, something from birth, just like 1918.
00:56:55.000Yeah, an avian influenza, I think, is the greatest pandemic threat we face.
00:56:58.000And I do think that China has a special combination of people and certain animals that make it more likely to come from there.
00:57:06.000But I don't want to say that it's the only risk because we all thought that.
00:57:10.000And then in 2009, the H1N1 pandemic virus came from Mexico, from pigs, from pig farms in Mexico, which was completely different.
00:57:17.000So I think we have to prepare for pandemics coming from other places, but places where animals and various humans interact in close proximity, that's where the greatest pandemic risks are.
00:57:29.000And China does have a lot of that and has that recipe and has had it for a while.
00:57:33.000And do you think that a failure, now this is less of a scientific expert question and let's get in the practice of distinguishing this, more of a policy and normative question or predictive question at least.
00:57:44.000What's your view on the importance of actually delivering accountability to China for not only the origin of the pandemic, but the lies, the apparent lies, at least, about the origin of it?
00:57:56.000Deflecting saying this came from frozen fruits in the United States or whatever.
00:57:59.000How important is it for the US to actually recognize the mistakes that were made resulting in the origin of this pandemic in order to create the conditions to prevent a future one that comes from China?
00:58:11.000I think it is important that we have accountability and I think that when you think about the way China blocks Taiwan from being a member of the World Health Organization, where they bully people with their influence of the World Health Organization, I do think they need to be held accountable.
00:58:25.000Already for what they've done with the obfuscation from the very beginning about person-to-person transmission, and now the obfuscation where they've made it very hard to even look into origins there.
00:58:36.000And I think that this is something that they should be held accountable.
00:58:39.000And I've always advocated that they need to come clean with how they've handled this pandemic to their own people and to the world, because they did Cause a tremendous amount of suffering with their zero COVID policy in China, which eventually was overcome because of all of the protests that happened there.
00:58:58.000But I think that it is important that we understand the answer to this because this isn't the last infectious disease emergency that we're going to face.
00:59:05.000And the more cooperation and coordination there is around the world, the easier it is to deal with this.
00:59:09.000If we can deal with this proactively, we're not reacting.
00:59:12.000We're not waiting to see what trickles out of some other country.
00:59:14.000I mean, this is happening right now in Equatorial Guinea with the Marburg outbreak where we're not hearing...
00:59:19.000We're not hearing about the cases appropriately.
00:59:21.000That's not the way you want to handle an infectious disease emergency.
00:59:24.000And I think that coming to grips with what happened with COVID does set a national norm that you need to be transparent when you have an infectious disease emergency occurring in your borders.
00:59:36.000And do you see some accountability as well for the US side of this where, you know, as it relates to gain-of-function research?
00:59:42.000Suppose it was the lab leak and it was a result of gain-of-function research.
00:59:45.000Like, what do you think is the net takeaway from that, right?
00:59:49.000I mean, that was the form of pandemic preparedness research, really, is what gain-of-function research is all about.
00:59:53.000So I think there's a role for gain-of-function research, but it has to be done in a very transparent and safe way.
00:59:59.000Of course, people who were proponents of it before would have said it and it appears that that resulted or contributed to resulting in a global pandemic.
01:00:06.000So the allegations about gain-of-function research with the Wuhan Institute of Virology is that they were being done at a BSL, a biosafety level that was too low, where you would not do those types of – you shouldn't be doing those types of experiments with that little personal protective equipment.
01:00:20.000So when you're doing these types of things, they need to be very transparent.
01:00:22.000They need to be done in a way that there is – Very little to zero risk of any kind of spillover occurring and a lot of mitigation in place if you're going to do gain-of-function research because I do think that there are questions that can be answered through gain-of-function research but it shouldn't be done kind of Just to do them, they actually should have some impact on, to use your word, human flourishing.
01:00:46.000This should help us to make a better vaccine, a better antiviral, to understand resistance.
01:00:50.000It shouldn't just be done to do it if it's so dangerous, if it costs some threshold.
01:00:56.000And this is exactly the kind of question where that distinction becomes blurry again as to where's the policy question of understanding the risks and benefits.
01:01:43.000The question is, which kinds of risks do you want to take in service of mitigating which other kinds of risks?
01:01:50.000I think that's the heart of what this COVID debate was all about.
01:01:52.000In many ways, we're still living the after effects of a lot of the mistakes that were made.
01:01:58.000Even if I don't agree with everything you said, I actually appreciate your perspective and your ability to clear-headedly distinguish between what is science and what is policy.
01:02:09.000I think we need more people like you in public health research in particular who are able to clear-sightedly, clear-headedly Keep those distinctions in mind because they are two different questions and you do a great job of parsing them.