Why a holistic public health approach driven by reducing TOTAL pandemic harm just makes sense.

David L. Katz, MD, MPH FACPM, FACP, FACLM (SO MANY LETTERS 🤯) is the founder and former director of Yale University’s Yale-Griffin Prevention Research Center (1998-2019); Past President of the American College of Lifestyle Medicine; President and Founder of the non-profit True Health Initiative; and Founder and CEO of Diet ID, Inc. He is a Fellow of the American College of Preventive Medicine; the American College of Physicians; the American College of Lifestyle Medicine; and Morse College, Yale University.

On the COVID pandemic, he has advocated consistently for a policy of total harm minimization by means of risk-stratified interdiction efforts.

See also our interview with Dr. Jay Bhattacharya.

Transcript Below!

– Hey, guys. Today, I’m talking to Dr. David Katz. He really doesn’t need any introduction, but because we have to introduce we’re gonna do it anyway. So I’m gonna have David introduce himself, David, welcome to the show.

– Zubin, Great to be with you. Thank you very much. And a quick shout out to our mutual friend, Dr. Tom Rifai who introduced us.

– Yes.

– Tom heads up Reality Meets Science, does a great public service there. And he actually is involved in the True Health Initiative, he writes a news of the day Colorado. It’s that for us who appreciate that very much, great guy. And I’ve admired your work for a long time. So it’s great to have the opportunity to chat. And when we were chatting about whether or not we were gonna chat and record, the conversation just flowed so easily. So yeah, it seemed like an excellent match. So really glad to be with you. By way of background and inevitably we’re gonna talk about the pandemic. So I trained in internal medicine and really, I think what is most relevant to this discussion is my native penchant for seeing the big picture. There’s the famous liability of missing the forest for the trees and funny enough as area died as they can be the world’s best scientists are very prone to that. Because one of the things that science tends to inculcate is reductionism staying in your lane, staying in your channel. And of course if that becomes a tunnel, you see everything through that tunnel, everything outside the tunnel you’re prone to miss. And in fact this is true of science in general, it’s true of medicine, where everything is so hyper specialized. So “No, I’m sorry, that’s your left knee. I specialize in the right knee. You have to go see my colleague,” that kind of thing. I’m the opposite of that. So when I was training in internal medicine, much as I appreciated the opportunity to be there in the moments of most urgent need and take care of people, which has incredible privilege, it doesn’t get the attention it deserves when we talk about medicine and burnout. Now, being the one that people turn to in their moments of greatest need in anguish is an incredible privilege.

– It’s like a sacred privilege, that space that you have together.

– It’s sacred absolutely. Yeah, it is. It’s sacred space, no question about it. And the most deeply gratifying experiences of my life has involved that. Nothing you can do in public health, nothing you can do at scale replaces the poignancy of that intimate connection with another person or a family, and being there in the moments of greatest need. So I really fully appreciated that, but I was also very much impressed with the big picture. And of course when you’re training in internal medicine, you’re in the hospital 100 hours a week. So you started soaking in the lore of the hospital and its particular epidemiology. And I was struck by the fact that easily eight out of 10 hospital beds were filled with people who had stuff they never needed to get.

– Yep.

– And that really troubled me. And I thought can I contentedly spend the rest of my career, dealing with all of this human misery that never needed to happen, when maybe I could play a role in actually preventing it from happening. So I started thinking there’s gotta be more to the story than this. I started shopping around and found the Preventive Medicine Residency Program at Yale. And so I did a second residency in preventive medicine public health, focused on chronic disease epidemiology, and the rest, as they say is history. My career clinical teaching research has been focused on adding years to life, adding life to years. Over recent years, it’s also been very much focused on the health of the planet. There are no healthy people on a ruined planet and seeing the big picture. My preferential focus, unlike some of my colleagues who have opined in prominent places about the pandemic has not been infectious disease per se, it’s been more chronic disease, but that’s a difference of degree not kind. I’m trained in outbreak investigation, I’m trained in epidemiology and this pandemic is about a whole lot more than just the virus. And that’s what drew me into it, commenting on that. There’s more going on. There’s more than one way for a pandemic to hurt people, it’s not just by infecting them. So here we are.

– And this is why I wanted you to do that intro, because all of what you just said becomes acutely relevant for the conversation we’re gonna have. Because there are a lot of people online that are opining about the pandemic in ways that are useful and un-useful. The armchair epidemiologist, et cetera, et cetera, et cetera. And you and I actually had a similar path in that we both got rather frustrated seeing those five to eight out of 10 people in those hospital beds that didn’t need to be there if they just had good outpatient, preventative, holistic care that took into account nutrition and exercise and social connection and spirituality, whatever it is. As in our training, when you said we kind of steep in this pool of reductionism, it’s kind of really very true. We’re kind of conditioned that way. And listen, there’s not anything in particular wrong with that. It’s just that if you never do get a more 30,000 foot holistic connected integral view of it, you’re not gonna be able to talk about it. So what you just said, establishes the fact that first of all, we’re both coming from the same place, but second of all, you have a unique vantage point to be able to talk about what we’re gonna talk about, which is all the effects of the pandemic and how to reduce the most harm for the most people at the least cost. And so that’s why I was really excited when we got connected by Tom to talk about this.

– Thank you, likewise. And the only question, of course, in terms of the practical utility of discussion, which we’re gonna thoroughly enjoy and ideally will benefit some people, at least in terms of inspiring some rumination is timing. I wonder if at this point in the pandemic, anything we say is going to change the inertia of it all. It really does seem like inertia, that Isaac Newton is driving the bus at this point.

– F=MA

– So in the early going, I thought, okay, we have the right conversations with the right people in the right places and enough people hear them it’ll make a difference. But we’re so polarized, we were so dysfunctional through all of the critical early going, because we didn’t have grownups running the country, which was I mean, it really, the tragic confluence of one of the greatest public health crises of all time and certainly the greatest in living memory conjoined to utterly inept, federal leadership in the United States, absolute disaster. I mean, we just reap the whirlwind.

– Yeah. And what’s interesting though, is I think even in the early days of this, you and I were both kind of out there speaking about what was considered a contrarian viewpoint, which is, hey, after the initial sort of fear induced, and also I think appropriate lockdown environment where we said, we don’t know this virus, we don’t know what’s going on, we don’t have good data out of China, we don’t have good data yet on anything. Let’s just take a pause and then learn as much as we can. So then we can spin up a response that’s actually awake instead of this unconscious reactive thing. But what ended up happening is, and I think a piece of it is that federal, this kind of tone where we’ve politicized everything. And I think actually the left and the right are both guilty of this. If you’re standing in a transpartisan viewpoint, looking at this, going, okay, these guys are catastrophizing, these guys are denying, nobody’s leading. And what ended up happening is everyone went with their moral palate. Like I believe in Liberty versus oppression, autonomy versus communion, I believe in care versus harm, fairness versus cheating. Well, those are gonna put you down a path. And you recently put an article out on LinkedIn that I thought was beautiful. These paths in the snow that were trodden. And you were like it’s really easy to take the path that’s already paved. And there’s two. So pick one, polarize, go down it and forget the nuance or the fact that sometimes it’s hard work trudging through the snow to find a truth that’s more complex than the black and white.

– Thank you. I was just about to mention that. Yeah, so we had a nor’easter, we had a foot and a half of snow. I hike routinely in the woods outside my home. And I have routes that I take, and of course there are blazed trails there, but you go left or right of a given tree. Those kinds of things, I have a preference. But when you got 18 inches of snow and somebody has gone before you and packed down the snow, you go, the snow is packed. It’s really hard work going through the deep snow. Exactly, I really do think ideology is like that. So I think everybody who isn’t absolutely in the middle leans a bit left, leans a bit right. And so choosing between the left or the right trail is easy, but you may not go all the way to the left or all the way to the right, if you have the option. But very early in the pandemic, we were left with no option. Because I think the left view, which was catastrophizing, but also moral preening if you don’t do everything to protect, every last person from SARS-CoV-2, you’re a genocidal maniac. The accusations and some of the comments were really just unbelievably harsh. We don’t do everything to protect every last person from car crashes or heart disease or… I mean, are we genocidal maniacs for letting our kids ride school buses? Some kids are hurt and killed in the commute to and from school. Is that crazy? Is that unconscionable? You can’t live a life with zero risk. The only thing required to be at some risk of dying today is living today. And we all accept that every day, there’s a risk crossing the street. There’s a risk getting in your car. There’s a risk with absolutely everything you do every day. But somehow with SARS-CoV-2 very early on, it was catastrophizing and the only acceptable risk is zero risk. I mean, that’s just unrealistic, but that was one of the trails in the snow. Pick that one, or liberate my state, the whole thing’s a hoax, get off my civil liberties that this virus isn’t serious, we don’t need to respect it. Everybody in the water nevermind the sharks and riptides, grandma will be fine which was equally extreme in the other direction. So yeah, I weighed in early and said not so. Here’s the other thing, Zubin, I think we, along with killing expertise, I mean, sort of the rejection of elitism, elitism has become a bad word. Unless you’re talking about elite forces in the military, that’s still good. But for the most part, elite is bad until you need it. If you’ve got a child who needs a brain tumor removed, you want the world’s most elite neurosurgeon. Elite is bad in principle, it’s good in practice. But in principle, elite is bad, expert is bad. The other thing that we seem to have killed off is nuance. We’re a clickbait soundbites society, so give it to me in the most dumbed down form and make it extremely yes or extremely no. Extremely right, extremely wrong. Extremely right, extremely left, no nuance. Well, actually managing one of the great public health crises of all time, absolutely ineluctably requires a nuance. You don’t have to like that, too damn bad, it’s just true. And so, no, it’s not all one way or the other. We’re not going to protect every last person from this virus no matter we do. We don’t protect every last person from any infectious disease. On the other hand, we do need to protect as many as we possibly can. We just wanna make sure we don’t hurt more people than we help with the policies we implement. So my position at the start and my position now, and some of the things that I’ve talked about, I got wrong, I don’t think there’s anybody who has opined about the pandemic, who has been right about everything. Mike Osterholm, one of the world’s greatest pandemic response experts was opposed to masks before he was for masks, kind of like the CDC. You talk to Paul Offit, who’s awesome, and Paul admitted, he was just way off about the mortality. And we’ve all been wrong. So I was wrong about when it was gonna end.

– Me too.

– I looked at what happened in New York City, what happened here in the Northeast and said, “Okay, if we extrapolate that we can hope that this will end early fall.”

– Yes.

– It didn’t, I was wrong.

– Me too.

– But the basic policy response, everything that’s happened since the beginning has simply reaffirmed to me. The goal should have been total harm minimization and the right way to do that is the way we do everything in public health. Risk stratification, we rarely do one size fits all. The things that we apply to adults and kids differ. The guidance that we provide to people with different health conditions differ. Whether or not it’s safe to drive depends on your age and your eyesight, and a number of factors. Well, whether or not it’s safe to navigate through this pandemic depends on your native health, depends on your age. And we could have, we absolutely did have the means to generate public health policy that was nuanced. And I completely agree with you by the way. And I wrote about this in the New York Times, and then this concept was further developed in a column that Tom Friedman wrote in followup to mine when we conferred, the idea that we probably no matter what needed to lock down for some defined period of time to do reconnaissance. Look, we’ve got data out of Wuhan, we’ve got data out of South Korea, we don’t yet know exactly how their experience will relate to the United States. We have a different epidemiology here. We have a lot more diabetes, we have a lot more obesity, things may be different. We need a little bit of time to figure out everything we know and everything we need to know about this virus. So we can appropriately aim at total harm minimization, minimize the harms of infection and minimize the harms of our policy responses to the threat of infection, namely what we’re doing to social determinants of health. And the best way to do that is to match the protection, match the remedies to the nature of the threat. The nature of the threat is gonna vary with risk factors. We have some inkling about that. It was pretty clear out of Korea, old age is a risk factor. So we’re gonna be really careful with old people. Old age and frailty is an extreme risk factor. We had caused to know very, very early on, we should’ve put firewalls around our nursing homes. 40% of the mortality in the US has been in nursing homes. That’s incredible.

– It’s nuts. I mean, just really think about that. If you had done one thing, half the mortality would be less. So this idea of risk stratification, but again, like again, in the polarized conversation that was happening, and I wanna add a point to this, which is our media and our social media, both which are now really conflated into one thing, are rewarded through polarization, through clickbait headlines, through fear, through all of this. And we’re being played by these algorithms that even the creators of the algorithms don’t understand. So it’s much easier to send an angry catastrophizing email look at everybody’s, there’s a kid who’s sick, we better shut down all the schools forgetting that there’s all this harm that happens with that. But look at the sick child, preying on empathy versus compassion. Compassion is broad, love in the face of suffering, empathy looking at one person, feeling their pain, reactively, responding in a way that can be actually counterproductive. So all of this, I think, early on squandered, that reset that we had in the initial pause of lockdown that you said…

– And some of this is new, as you say, some of this is social media and our propensity to react to drama. I think is being exploited in new and creative ways and has been amplified by our exposure to it. But some of this is as old as our interactions with storytelling. Think about Don Henley song, “Dirty Laundry”. The fact that you’re always going to lead with drama. My friend, John Tesh, whom you may know media personality, Intelligence For Your Life is his radio program, says if it bleeds, it leads.

– [Zubin] Yep.

– And I worked on air for Good Morning America for a couple of years ago. And hanging in the control room was a plaque, that said, “Comfort the afflicted and afflict the comfortable.” I mean, that’s just you rock people back and forth, and you keep them interested. So anytime we got comfortable with our understanding of the pandemic, it was time to rock us back on our heels with a new affliction. No, it’s not safe for kids. And the problem for me was that trained in epidemiology and public health, you don’t make it through week one of Epi 101, without learning to ask what’s the denominator. So, okay. one kid is terribly sick with the virus, it can hurt kids. First of all, what was that kid’s health status to begin with? And a lot of that was obscured by the way. The headlines would tell us a young person is sick, a young person has died, a young health professional has died. You have to read way toward the end, or maybe even never be told this person had severe obesity or had major chronic illness. But that was usually the case. Young, healthy people have a vanishingly low rate of really severe reactions to this virus. That was true in the beginning. It’s true even now, but that’s not dramatic, so we weren’t given that information. So this is always been a problem, for the public at the receiving end. It’s good news for the media. And that’s the other problem here Zubin, I mean, this has absolutely been a field day feeding frenzy for the media. If you work for the media, the idea that you can have an endless source of drama. And the other thing is, and this is a crucial. I actually did a peer review commentary on this facing the facelessness of public health. When you’re trying to save the most people and that really is the objective of public health, the most possible good for all of us, promise all of us is none of us, all of us has no face. You can’t love all of us, you can’t feel deep compassion and empathy for all of us. Give me one of us, give me your beautiful face. I can understand you, I can look into your eyes. You can tell me your story, I’m gonna care deeply, who the heck is all of us. So the public is impossible to love. The thing that we’ve done a really bad job at conveying to professionals so that they can convey to the public is there is no such thing as the public. That behind that veil of statistical anonymity, it’s you and me and everybody else and our families and the people we love. And until we pack that veil more effectively, we do a really horrible job of saying, “Okay, this is one tragic story and I really care about this person, but what’s happening to everybody else?” And will my reaction to help this one person hurt a thousand. Because if, so, those are a thousand people that also have faces and names and families.

– It’s really remarkable, David, ’cause we’ve never really connected until like the last week. Everything you just said is exactly what I’ve been saying when I talk about empathy versus compassion, affective empathy, feeling that one person’s pain, Suzanne Somers on a Telethon going that you could help this child in Africa for pennies a day, people cough up the pennies. Okay, here’s a tragedy in Darfur with thousands of people that are relatively faceless. “I don’t care about that, I can’t help, there’s nothing there.” And that is if we could really feel compassion, which is this slightly more intellectual detached, love and concern in the face of mass suffering, we would wanna help as many people as possible in the most effective way, but that’s not how we’re conditioned and it’s not how the media works with us. So your job as a public health person is to look at the world that way. But I think a lot of our public health people have not communicated in a way that I think is resonating with the public.

– I agree with you and we’re facing an uphill battle any time we are opposing the native currency of evolutionary biology. So my principal work over the past 30 years is related to nutrition. I latched onto that early as the signature means of adding years to life, adding life to years. I didn’t chose that because I care about food more than the next person, I chose that because I wanted the most expedient way to help improve the human condition. And I think it was a good choice, but my interest in the pandemic is much the same. But when you think about nutrition, why is it so hard for people to eat well in the modern world? It’s because the modern world makes it so easy to eat in ways that line up well with the inclinations endowed to us by evolutionary biology. We like salt because in a natural world, salt is hard to find. We like sweet because breast milk is sweet and mammals who don’t like breast milk, get a really bad start in life. But also because after that, the only sources of concentrated sugar in nature, fruits and honey, and they’re great sources of energy. We like fatty food because it’s a concentrated source of energy and energy was in short supply. And we liked variety because it was hard to get. So I mean, basically enter the world of the drive-through and all you can eat buffet and of course, everybody is obese. We’ve just made that the path of least resistance. Every effort to fix that at the level of the individual basically is opposing the themes laid down by evolutionary biology. That’s a tough fight. I think the same thing here. So when you’re trained formally in public health and taught epidemiology and think about what’s the denominator. If we do this for the one, what are we doing to the thousand or the 10,000 or the 100,000 or the million, or however many, it’s really hard to do because we are natively tribal, we are natively drawn to faces. And in a way you can almost say, thank goodness, Zubin that we can’t feel the pain of every individual in every mass tragedy the world has ever known. I wrote a poem some years ago, If Sorrow Were Of Stone, you think about all the suffering, humanity has endured over the ages, killing fields in every part of the world and that the horrible abuses we’ve imposed upon one another, if all of that just added up and added up and added up, and we all felt it. How would you make it through a day? So we are substantially immune to communal suffering that doesn’t directly involve our intimate circle.

– Yeah.

– So we need both. I think we need stories linked to context, and that’s where the media, I think have for the most part, there are rarefied exceptions that have been absolutely brilliant and I can’t help, but shout out my now friend at the New York Times, Tom Friedman, I think his reporting on the pandemic has been brilliant, even though it’s not really his wheelhouse his expertise is in socio politics. So he kind of parlayed that into discussion of policy response. But we really have a hard time finding the context on our own and the media have a responsibility to provide it. So a child got terribly sick with COVID, we’re telling you this because it’s important to know it can happen. However, we have evidence to suggest that thousands upon thousands of kids have been infected. And that suggests this is a very rare occurrence, the risk is very low and there’s reason to be concerned about other ways the pandemic could harm kids, such as by closing schools and causing educational gaps, which will particularly be problematic for those already disadvantaged. See our reporting on that topic, essentially connect the dots. The dots were never connected. As you said, at the beginning of this conversation, you had a choice. You can either read the article about the one kid and look at that face and the anguish family who had a horrible case of COVID, or you can read the articles about the devastating effects of closing the nation schools, but the two never connect. Pick your path in the snow, but the nuance in the middle forget.

– Exactly.

– It’s been horrible.

– And so you’re either a commentator for Fox News, or you’re a commentator for CNN. I think you’ve been on both. Like, you’re one of the few people who’s like transverses the political divide. Like most people it’s like I’m gonna pick, okay, I’ll tell you what, I’m gonna promote this. And it’s crazy because you’re absolutely right. Both are true and you have to make decisions that affect harm versus care for multiple people. Which again you’re right if we could feel everyone’s pain, we would be incapacitated. And as doctors we’re trained a little bit more in that cognitive empathy. Like we understand what they’re going through, but we’re not gonna feel it. ‘Cause if we feel it, we don’t function. And one thing you said, and you’ve said a couple of times now that I think is important is you can add years to your life, which is great, but you need to add life to the years. And what we’ve done with the pandemic in our absolutism, either one way or the other is we’ve said, “Listen, we’re gonna make old people die alone in nursing homes, isolated. We’re gonna let people die in hospitals, isolated with no visitors, because we’re afraid of infecting a family member or infecting staff, et cetera, because we’re afraid, afraid, afraid.” Well, now what you’ve done is you’ve given someone a fate that is worse than death. Because we’re so conditioned to fear death, we don’t even know what death is, but we do know what life is and we know how to screw that up. And we managed to do that when we take an absolute stance. So I’m curious because when you talk about total harm minimization, how much of that factoring we’re gonna get into the details of it? How much of that factoring is these intangibles of human suffering that we’ve created? That creates scars and lasting tracks in the sand.

– No, I think that’s huge. And I experienced that up close and personal. My mother is 81 and we had conversations about the fact that I’m frightened of this virus, I don’t wanna get it. I’m equally frightened of dying something else before I can hug my grandchildren again. So I mean, we really needed to think about the bigger picture right from the start, even the people who most needed protection. If you’re over 80, you’re in the highest risk group. So my parents are both there. But even they say, this is not our only concern. There are other ways this situation can hurt us. So that was a critical need, I think right at the start. And yeah, I mean, quality of life is huge. And interestingly the oldest people who are at the greatest risk of this have the least time left and therefore the quality of that time is most crucial. Now, that’s been my impression, whether it’s patients or loved ones, when time starts getting short, you really wanna squeeze every drop of value out of every day. And we took that away with these indiscriminate responses to the virus. And again, I think what we needed to do was talk about effective policies to mitigate risk. And then essentially look for ways to do that with policies potentially mandates, empower individuals to understand their risks, empower them to be part of the remedy in terms of managing. Most critically I think if we had managed the waves. We keep talking about waves of the pandemic. We’re standing on the shore and the waves are crashing into us and we get knocked over, we try to get up and we get knocked over against the waves. Well, no, I mean, you know what to do in a situation where the waves, get out of surfboard, take control, ride the waves. I mean, we should have been the waves. Beaten the waves or even been the waves. And what I mean by that is, okay, so actually the risk differentials here are large enough that young healthy people, people under 50, without a major chronic disease, certainly people in under 40 without major chronic disease, very low risk. What if we shield everybody at moderate risk or above, away from this virus and say, “Okay, now those of you in the low risk group are willing, let’s have you be back out in the world.” Now, let’s see how that goes. And if a month later, hardly anybody’s been hurt and viral transmission rates have fallen really low because a month later essentially I’m gonna say that heretical thing, herd immunity has developed in that low-risk group. Well, then there isn’t much virus circulating, we can have the next wave go out slightly higher risk. We could have managed the waves. Written the waves, managed the waves, been the waves, instead, we were just victims of the waves. And even the people that we most needed to protect suffered as a result of that. Because as you say, indiscriminate policies, nobody can be with anybody. And yeah, I mean, people didn’t just die, they die isolated from their families and loved ones who frankly in many instances were in much lower risk groups and okay, you’ll be exposed to the virus, but that can be managed and this person should not check out alone. I volunteered in New York at the peak of all this. As close to the peak, as I could manage, it took a while to go through the bureaucracy and get back into the system. I’m not unlicensed in Connecticut, but not New York, there’s a little bit of a rigmarole. But by the time I got deployed, my colleagues in the ER in the Bronx where I was working for a little bit, tell me, “Well, we wish we had you last week.” Last week was really-

– Missed it by a week.

– I missed it by a week, but I was there and I was managing this stuff. So I met a woman sort of questionable call, whether she’d need to stay in the hospital or not. She was COVID positive, but her O2 sats were good and looked like she might be okay to go home, but her son was incredibly anxious and it was out in the parking lot. So early in this dance, I got his cell phone number, so I’m taking care of her and calling him in our parking lot so he could stay informed about what was going on. You had to do stuff like that. There were whole new experiences in medicine when families could not be together as you’re working your way through a crisis like this, it’s weird.

– Yeah. ‘Cause this piece about total harm minimization and a more strategic surgical approach to this based on risk stratification. Now, the pushback, and this is fascinating because you you were one of the signatories on the Great Barrington Declaration, along with my friend, Jay Bhattacharya and Jay’s been on the show. And what I liked about that declaration is, again, it took this view that, hey, actually, there’s a way to look at this that’s still a harm reduction approach. It’s just not shut everything down and catastrophize. Now, the pushback to that and I did a piece saying, “I don’t even know why we need these declarations, we ought to feel like, this ought to just be a conversation that we have, it isn’t a these paths.” But what was interesting about it is the pushback was instant and intense from a lot of people in public health and some scientists saying, yeah, but this is completely unfeasible because half the US population has risk factors that put them at risk for COVID. Elderly people aren’t just in nursing homes, they’re mixed in with multi-generational families. How do you protect them if you’re letting kids go out and work and potentially get infected? This is gonna kill people and destroy lives. I mean, how do you parse that?

– Well, first of all, just to back up, Jay Bhattacharya is great thoughtful, compassionate, concerned, just been great public health, professional, and inevitably got sorta tarred with the brush that comes out when you say anything about herd immunity or risk tiers. But he’s been moderate, temperate, modest, thoughtful, provocative, but in very reasonable ways from very beginning. So I really appreciate his work and commentary. Just for a minute, it’s important to know my day job is all about nutrition, diet, and chronic disease. And by the way, colleagues and I published a couple of papers in the journal of emerging infectious disease on the prevalence of cardio-metabolic risk factors that massively increase the risk of bad COVID outcomes. And mostly they are lifestyle driven in particular, bad diet, lack of exercise, smoking to a lesser degree.

– Okay, can I interrupt for a second? Because do you think that’s why America has been particularly hard hit apart from policy…

– It’s one of the reasons. Yeah, I think we’ve got a bunch of reasons, including the unbelievable ineptitude of our management of this and our failure to protect the most vulnerable, but absolutely, if you match us to other populations that had same level of exposure. So for example, Sweden, which famously didn’t lock down at all, they have a relatively elderly population, but they’re healthier than the US and their death rate per million is considerably lower than ours. And I think that’s because our cardiometabolic health, obesity rates, diabetes rates, heart disease rates coming into this, were off the charts. So first, what I would say is, interestingly, and here’s a provocation. My usual tribe is to the left. They’ve been the ones who’ve been, I think, most inclined to burn me in effigy throughout-

– Because we’re the intellectual elite, we have to be lefties.

– I mean, my tribe is to the left, my tribe has turned against me, I got voted off the Island, but what I say to you, tribe members is, I mean it, in for a penny if for a pound, if you’re gonna moralize about, we need to save every last life from COVID. Well, okay, yes, it’s horrible. 330,000 of our fellow citizens have died of this virus. 500,000 people die of poor diet quality in the United States every year, 500,000. Op-ed in the New York Times of August 26, 2019, Dariush Mozaffarian, Dean of nutrition, Tufts, Dan Glickman, former Secretary of Agriculture in the United States, our food is killing too many of us. Yeah, 500,000 premature deaths every year due to poor diet. So where is your outrage there? Why aren’t you advocating junk food across the board needs to be banned. Junk can not be food, food cannot be junk. But again, I mean, our inconsistency is incredible. That’s been my life’s work is to try to mitigate that horrible toll, 500,000 every year, it’s like a pandemic that never ever ends. And because it’s in slow motion, nobody even pays any attention to it. So again, if we’re gonna be morally outraged, let’s at least be more outrage consistently and we’re not. And that always bothers me, that’s also part of the big picture. Our failure to take our ideology and our principles and apply them in a consistent manner. if you’re consistently look, anything that can harm people at scale, I oppose, I oppose adamantly I’m outraged, I want it banned, okay. I may not agree with you every time, maybe I think that’s too intrusive, but at least you’re consistent, but I’m not seeing that consistency, our tribe is horrendously inconsistent. Completely outraged about SARS-CoV-2 and completely contemptuous and neglectful of other things that actually kill more people. So I think Jay has been very reasonable. I think the idea that we wanna minimize total harm, we wanna minimize the harms of infection, minimize the harms of our interdiction policies. And then how do you get there from here? So what I argued and I wanna make clear Zubin, ’cause I think it’s only fair to say this. It is not your job and it is not my job. And quite frankly, it’s not the job of any one person to generate the umpteen page, let’s arbitrarily make it up and say 1500 page policy manual for the nation’s response to the COVID-19 pandemic, but it absolutely could be done. So just to make clear to people that I think this is a utterly plausible public health response. If I’d been in charge of anything I would’ve said, “While we determine the impact of this virus on the US population specifically, we will lock down for, and as quickly and expeditiously we can.” Because in public health, you invoke the precautionary principle, always move people away from the direction of probable greater risk. And until we knew that the exact magnitude of the threat this virus represented move people away from the virus. So we’re gonna put basically a dome, a protective force field around everybody, because we don’t have enough information. We’re then going to collect the information we need by doing representative random sampling. At one point during all of this, I testified to the Senate committee on Homeland Security. And one of the questions the senators were asking was about, “Well, how do we function when we don’t have the data we need? And the data we need is millions of tests and we don’t have the materials to do millions of tests.” I said, we don’t need millions of tests. Everything we think we know about dietary intake in the United States comes from representative random sampling in 20,000 people or less in the NHNES National Health Nutrition Examination Survey, everything we think we know about the most important behavioral determinants of health comes from representative random sampling and some number of thousands of extrapolated to 330 million through the BRFSS, Behavioral Risk Factor Surveillance System. We have SEER to track cancer related epidemiology. In every instance, it’s representative random sampling. And if you get the right distribution to represent the whole population, you can extrapolate and you’ve got error bars, but it’s a lot better than flying blind. We were flying blind. So lock down for as long as it takes to build a data pyramid. What is the distribution of this virus? Who’s been infected? Most critical thing to know is how often is this asymptomatic? I imagine people who tune into your podcast routinely are sophisticated on these topics and know that every epidemic is like an iceberg. You immediately see the most severe cases, the bulk of it is the less severe cases that you have to go looking for under the waterline. Same thing here, so when anytime you encounter a new infectious disease, you become aware of it because it’s bad. I mean, if a new infectious disease gave you an itch that you scratched and it went away, or you sneezed twice, who would care? It would be gone before we ever bothered to notice. No, it killed somebody, it made somebody’s eyeballs catch fire. Okay, that’s weird, we need to look into that. It turns out that one person’s eyeballs caught fire and 10,000 people had it, and it didn’t do much of anything, we had to go looking for those. Same thing with every outbreak. So it was very clear, we needed to go looking for asymptomatic cases, build the data pyramid. Who’s had this? Who’s developed antibodies, or is immune by some other means like memory T cells? Out of those who developed symptoms, out of those who sought medical care, out of those who wound up in the hospital, out of those who wound up in the ICU, out of those who wound up on the vent and out of those who died? And as soon as we have a critical mass, 10,000, 20,000, 30,000, 50,000, some number, but vastly smaller than the millions they were talking about, we can put error bars around our estimates and say, we’ve got a really good idea of who’s at how much risk. And now we convene a Camp David Summit, if we need to, we do it virtually, where we have world-leading experts in epidemiology, virology, immunology. And for that matter, economic, social determinants, ethics, gerontology, pediatrics, we all get together, we get all the best brains, we map out the full expanse of relevant considerations and say, where is the common ground to achieve total harm minimization? What are we trying to do? First you need the what? You need the destination. Once you have that, say, okay, we’re aiming to minimize the lockdown by doing a risk stratified approach in implementing policies with a goal of minimizing total harms to people via disruption of social determinants and infection. Now, we need to think about all of the nuanced permutations. That’s what you were just asking. So you’ve got a kid who needs to go to school, living with a parent, who’s got type 2 diabetes. The parents are healthy, but the grandparents live there and they’re 80 years old. Well, now you need an army of 300, 400, 500, let’s say, masters level people, each assigned to one specific scenario to kind of map out what is the best guidance that is, can coordinate with our objectives here for this particular scenario. Who has to wear a mask? Who has to socially distance? Who has to shelter in place? When do we recommend that a kid not go to school because of the level of risk in the household? And then ultimately the government takes this massive information, 1500 page policy manual, puts it on an interactive website, where every individual can log in find their risk tier. It can be a color coded risk tier based on your age, a few factors we need to know about your health. You could even quantify this, there are risk calculators. I have colleagues at a company called Everest Health. They have this very elegant COVID risk calculator. You can actually get specific percent probability of hospitalization, ICU, or death based on the details of your health and age. So every individual in the country should have had access to that information. And you should be able to get that information about other members of your household. And you enter that in and it drops you into, here are the recommendations for your family. This is the work. I mean, it does sound like a big project. This could have been built in two weeks and we’re talking, it’s sort of been done months and months and months ago. And everybody would have been benefiting from this information since last February, March.

– Okay, or David, you could go on YouTube and listen to PLanDEmIC23, who said the whole thing’s a hoax, or you could take the approach that the scientists took, that the public health officials who said, “No, actually that’s too much work. That’s too complicated. We don’t know how to deal with this nuance. So we’re just gonna do this,” which then has all this collateral damage, which they’re perfectly willing to suffer instead of doing what you said, which is taking expertise, weaponizing it through actual a little bit of hard work for short period of time using technology, which we’re pretty good at using to get people to click on ads. So I’m pretty sure we could get it to calculate risk for us in which case we could then answer the one question that no American can answer at this time, which is what is actually my risk of this thing hurting me?

– Right, it’s maddening. So imagine a scenario, ideally, and again, that’s why I love talking to you, the timing’s frustrating. I mean, this stuff we’re talking about needed to happen six months ago, eight months ago, and I’m not sure what good it can do now. But maybe it’s not too late. But imagine, first of all, I think it’s important to note in the realm of psychology, Zubin that, that the thing that most inevitably leads to despair, despondency, desperation, depression is helplessness, helplessness. When your self-esteem is in the tank, you feel overwhelmed, you feel undone, and you feel like the things that are existential threats are beyond your control. That’s when we fall apart. And it makes an enormous difference to give people some sense of power and control.

– Agency.

– And even if it isn’t legitimate, it matters, but when it is legitimate, it makes a huge difference. So imagine a scenario where absolutely from the early going everybody could have found out here is the best estimate of your risk for the bad outcomes none of us wants to have happen to us. You can get the same information about all the people you love and the people you live with. You can get specific recommendations about how to minimize that risk. And a couple of things are included there, one, the general concept of hierarchical responsibility. Just like I reject the extremes of left and right, I reject the extremes of personal responsibility and public responsibility. Frankly, sometimes we’re all in this together. And the only thing that will protect us is action at the level of the body politic. It’s just true. I mean, frankly every parent could be really vigilant at the beach, but we’ve decided as a society, we want lifeguards and pools should have fences around them and there’s stuff we do collective decision-making. So I reject the view that we have to choose between the two. So hierarchical responsibility says some of this must be mandated, it must be policy that shouldn’t be more than it needs to be, but it should not be less. The government needs to do its job. Part of its job is guiding other institutions with parameters and maybe they’ve got a Chinese menu and can do some shopping, but they have to stay within the line. So if you’re a school, if you’re a university, if you’re a business, if you’re an airline, you must comply with the government’s requirements. But the way you do that, you have some latitude to decide what best fits your particular industry or business or location. And then finally, what can be deferred to individuals should be deferred to individuals. We should empower people. And then when you get to that third level of hierarchical responsibility, it’s not just about telling people what to do, it’s empowering them with options and understanding. And so here’s how you can protect yourself and your loved ones based on your specific risk tiers. And by the way, we’ll contextualize those for you, so your risk of a bad outcome from SARS-CoV-2 is this. Your child’s risk is this. It’s not gonna be zero, maybe that’ll freak you out. But here’s the risk of your child being injured in a given year if they just commute to and from school in a carpooler school bus. And if the risk of being hurt by the virus is less than their risk of commuting to school, which you let them do every year, maybe you don’t need to freak out about the virus. You just need to be careful. It doesn’t get transmitted to a loved one at much higher risk. So help people really understand, not just with numbers, epidemiologists may understand what the numbers mean, but I think we needed to translate the numbers into a context that resonated with everybody. And then said, by the way, a huge part of our problem in this country, I mean, if you’re over 80 years old, you’re over 80 years old. Although, if I may digress for just a second invoke another friend of ours, Dan Buettner who gave us the Blue Zones. In the Blue Zones, I’ve had colleagues report back to me with some data that we’ve all managed to dig into. In the Blue Zones being 80 is not like being 80 anywhere else even during the pandemic. In the Blue Zones, 80 is like 60, their risk of bad COVID outcomes, much, much lower. And for those who don’t know, five places around the world where people most routinely live to be a hundred, don’t get chronic disease. Well, if you’re much healthier to a much older age than other populations around the world, it stands to reason that your COVID age is actually lower than your chronological age and that appears to be the case. The reverse is true in populations like ours, where we have epidemic obesity or hyper endemic obesity and diabetes and heart disease and so forth. So again, a colleague and I did a couple of papers, a shout out to Mary Adams and the others who did the heavy lifting there. And we found six in 10 Americans have at least one major cardiometabolic liability, massively increasing COVID risk, four in 10 of us have two or more. Meaning you can be 40 years old and you have the risk of an 85-year-old basically. Well, there’s never been a better time to address that, has there? I mean I’ve spent a career trying to talk people into addressing these chronic liabilities and nobody pays attention until after their first heart attack. We all know everybody in preventive medicine knows this.

– It’s the Dean Ornish experience, yeah.

– Everybody gets religion after the first calamity, not before. Well, everybody’s afraid of COVID hurting them immediately. And the timeline of that kind of activates the fight or flight response in ways that the threat of diabetes and heart disease don’t. Well, let’s take advantage of that. By the way, folks, all this stuff, which would have been good for you anyway, because vitality really is the gift that keeps on giving, will protect you acutely against COVID and the benefits of lifestyle as medicine begin immediately. And this gets really interesting, really fast Zubin because we can demonstrate in a couple of different ways that if you eat one high quality meal versus typical junkie meal, it starts to alter your immune system’s capacity to deal with the virus within hours, within hours, not even days. And you can measure that with endothelial function responses, so better vascular behavior, better blood flow. And with chemotaxis, you actually alter chemotaxis in the postprandial period. So the way white blood cells react to provocations like a virus differs markedly in the aftermath of a really bad meal or a really good meal. Now, of course the benefits accrue over time, the longer you eat well, the longer you’re active, the better the care you take of yourself, the more you start to really reverse the metabolic damage, the bigger, the difference your immune system, but the benefit begins immediately. We could have, and in my view should have been selling that from very early in the pandemic. There’s never been a better time for a national health promotion campaign. Folks, we are in this together, let us do everything we possibly can to support one another in an effort to make ourselves this nation healthier, because that will protect our loved ones and ourselves from this virus. And by the way, the benefits of it won’t go away afterwards. There will be less diabetes, there will be less heart disease. We’ll take advantage of the acute threat to pursue chronic health.

– Yeah, it’s almost as if this virus was a pointer to that. It’s like, okay, let’s design a virus to most exploit what we’re worst at, which is eating healthily, forming community connections, that lower stress and cortisol. Meditation which improves immune function and generally lowers cortisol and stress and all these things that we ought to have been doing, now comes this virus that’s like, “Okay, I’m gonna start to hurt people that haven’t been doing this.” And but this is the tragedy though, David, and you know this as a public health person. It’s not really the individual’s fault, if you’re gonna use that word fault, we’ve designed a system whereby it is the default to eat the standard American diet, which is a garbage diet for most humans. Most humans don’t tolerate that diet in a way that is healthy. There’s probably a small percentage that can eat anything, the standard American diet and they don’t die, but most people can’t. And so here’s a virus that says, “Wake up, wake up, wake up.” We did a show with Ron Sinha, who’s a doctor here an internist here, and that was this whole thing. Here’s how you can eat better, de-stress and he calls it training for the COVID marathon. If you’re gonna get infected, don’t you wanna be in the best possible shape to run that marathon?

– And I completely agree. And again, just like the themes of evolutionary biology matter for our dietary preferences, they matter in terms of the poignancy of one person’s face versus statistics about public health. They mattered here as well. Because our nervous systems were designed for survival on the savannah. And there were no threats on the savannah that came at us in years and decades. So we’re blind to that. Effectively we’re blind to those threats. We need threats that are measured in seconds and minutes. So COVID feels like that. It feels like I can I go outside and I could contract this. It’s waiting for me. That fear activates a response that chronic disease doesn’t. And I think it’s partly the native hard wiring of our nervous system. Again, endowed to us, by the exigencies of survival and natural selection. I think it’s partly the old adage, familiarity breeds contempt, or at least complacency. So we’ve always had high levels of obesity as far back as anybody can remember. And so that’s just the way it is. So we don’t have to get all upset about that, we’ve always had high levels of diabetes, that’s just the way it is, although that’s not really true. I think, I predate you a bit, and when I was in medical training, we talked about adult onset diabetes. Type 2 is adult onset ’cause kids didn’t get it then. And I watched it undergo this epidemiologic transformation first, where more and more kids were getting it. And then we super imposed a change in nomenclature to make it okay, let’s call it type two. Let’s not be age-specific, the disease no longer is. And I think we should have called it adult onset diabetes happening for unconscionable reasons in children.

– I agree, it’s a crime.

– It’s a mouthful, but that’s the reality.

– [Zubin] It’s what it is.

– We peddle junk food to our kids, we made them obese and consequently, a chronic disease of midlife afflicted them. And we did not see the outrage that we see about SARS-CoV-2, we certainly should have. But absolutely, I agree with you entirely. I see no place in any of this for blame or fault. People used to be lean routinely. Not because they had self-discipline or personal responsibility that we lack, but because they lacked multicolored marshmallows for breakfast that we have. I mean, we completely changed the defaults and society…America runs on Dunkin.

– Wait a minute, David, are you making fun of me Lucky Charms? Because they’re delicious and they’re also vegan.

– Yeah, right, so I’ve heard, I wouldn’t know from personal experience, but I have heard that. So yeah, so I mean, our culture is responsible. But you can’t count on your culture to save you. What I’ve written about in many of my books is the idea that what we ultimately do need is a cultural revolution. We want health to be a national priority, a family value. Something that we all think about, maybe just a bit more like wealth. Something we actively invest in, cultivate, wanna share with our loved ones, wanna pay forward to our children. Why not? If you don’t have your health, you don’t have anything, but do we invest in it? Do we nurture it? Do we incubate it? Do we try to grow it? Do we try to share it? Do we try to pay for it? No, ’cause our culture talks us out of all of that, because the status quo is fantastic for a lot of really powerful entities. Basically big food makes a fortune, making us fat and sick. Big pharma makes a fortune treating diseases we never needed to get. And we’re perfectly happy with the status quo. So we need enough outrage to overcome all of that. And no, this isn’t our fault. we’re victims of this, but oh, woe is me, I’m a helpless victim, isn’t gonna help anybody. So while we are working to transform our culture, so we are more of a Blue Zone culture where the native currents in our culture, we toward health rather than away from it, you’ve got to take matters into your own hands. So I’ve spent my career talking about skill power, and I think this pertains to COVID too. So I’ve talked about willpower, that’s where you’re interested enough to do the work of finding out what you need to know.

– Intentionality.

– Yeah, learning what you never knew you never knew. But then to do something with it requires skill power. So I could say, “Hey, I really am interested in flying the plane. What’s involved in flying a plane?” Wow, gee, those cockpits are pretty complicated. Well, but I really wanna fly a plane, so I’m just gonna fly a plane, I’m gonna crash. No, now I have to learn how, if my willpower is sufficient to engage, the next thing I need is skill power. I wanna learn, I’ll take lessons, be a pilot. And we’ve all done this at points in our lives. Everybody learned the alphabet, everybody learned read, it was hard back in the day. But it’s an incredible advantage to be able to do that for the rest of your life. Most of us learned to ride bikes, we fell off a few times, skinned our knees, we paid a price, but then had this lifelong skill. Healthy living takes skill too. And whether you apply it as defense against obesity, diabetes, heart disease, et cetera, or you apply it as defense against the acute threat of COVID and whatever the next pandemic agent will be. Either way you can get there from here, but you need to be empowered. You do need some degree of willpower to at least be interested in and respect the value proposition. But then you have to say, “Okay, I’m in, somebody help me. I wanna acquire the skills.” I went to kindergarten in first grade, that’s how I learned to read and count. Where do I go to get the skills for healthy living? Help me out. My home turf, the American college of lifestyle medicine is all about that, the True Health Initiative is all about that. You’re an important agent of that effort as well. And people have to find the credible voices they can count on to guide them, that should be a national priority.

– And I think I wanna put a particular spin on this, finding credible voices to guide you has been one of the great challenges of the internet era and of the pandemic. So I’m gonna say this with conviction, people whether they’re anti maskers or pro universal lock downers, or mask shamers or whatever you wanna label people.

– I feel like you’ve got a flag shop there, pick your flag.

– Yeah, pick your flag and stick it right. What tribe do you belong to? Okay, here are the flags you can choose from. Cause if you pick the wrong flag and you’re a leftie, yeah, you’re gonna be screwed. If you’re a righty and you pick the wrong flag, oh man. And so if right, but the truth is everybody who’s shopping for those flags is trying to be good based on what their particular flavor. We were talking off camera a while back about Jonathan Haidt and his book, “The Righteous Mind”, they’re all trying to find their moral taste buds, a perfect balance and a Liberty versus oppression moral taste bud is gonna say, you know what? I don’t know that I want people telling me to wear a mask and clothes, not go to my restaurant and so on. And I’m still a good person. I think that’s wrong for them to do that. And if you tar that person as some kind of grandma killing villain, you’re done, it’s just nothing good coming.

– You push them to a more extreme version of their native opinion. Exactly, right, that’s what we been putting on them.

– What happens is they go on YouTube and they find a video called Plandemic or America’s frontline doctors, hydroxychloroquine, whatever it is. And they go, you know what? I like those guys, ’cause they’re speaking to me. This does feel like it’s a conspiracy of elites who use big words, like David Katz, telling me what to do. And I’m like, I don’t have that vocabulary and I take offense. And also I feel that this is very wrong morally to me. So I think we have to respect that. That’s been a challenge for me because I, by nature, I’m very judgy and kind of an a-hole, when I had to open up and say-

– Jeez, that’s quite a confession.

– Yeah, right. My regular tribe knows this as a fact. And they’re like, “Oh yeah, he’s just mean.”

– But then they love you-

– Yeah, strangely. ‘Cause they’re probably this cut from the same cloth. But this idea that we have to communicate across these moral palates and that’s been a challenge, I think for many people. Because they stake their flag and they put, Twitter is a great example like there’s no better place to virtue signal what your tribe is than Twitter. It’s like, okay, to take an avatar picture of you in a mask, add “wear a damn mask” into your thing. And suddenly your tribal identity is established, but how are you gonna influence someone who is on the other side of that argument?

– Yeah. So whether someone is on your side or not on your side, I think the reliable indications of reasonable thought are much the same. Certainty is always a red flag for me. We are moving through an unprecedented public health crisis. I mean, the closest thing was a hundred years ago, that was different. We don’t know what’s around the next span and every expert has been wrong about something. So anybody who tells you anything with absolute certainty run like hell and the other direction.

– I agree.

– And I felt that way about every clinician I’ve ever met too. I mean, the scariest thing a doctor can tell you is I know for sure how to do this and what’s gonna happen. No, I want a doc says, “I don’t know, I have doubts, but here’s what makes sense in light of what we know and what we don’t.” So there’s uncertainty. Honest people acknowledge uncertainty.

– [Zubin] Yes.

– Hucksters do not. And so anybody who doesn’t acknowledge uncertainty is dangerous. And that’s absolutely true, whether they’re saying exactly what you wanna hear or the antithesis of what you wanna hear. It doesn’t make a difference. And then frankly expertise does matter. You want people who speak a language, you can understand, but somebody sent me a video I was watching earlier today about if you’ve got a complicated plumbing problem, you don’t want your neighbor who says, “Well, I’ve never fixed that before, but let me give it a shot.” You want a plumber. Who’s much more likely to get it right. And we want experts flying airplanes, particularly if they have to land them in the Hudson River and on and on it goes. I mean, it actually matters to be trained, to do a particular thing. Same is true of public health, same is true of medicine. So the combination of, I’m not sure, but I have expertise, let me tell you how I see the situation. I think that’s valuable. I also think context is crucial. Someone who here’s why you shouldn’t wear a mask or here’s why you should wear a mask, who says absolutely nothing about countervailing evidence. There’s always countervailing evidence. So you can easily find online now the arguments against mask wearing, because there’ve been RCTs, a famous Danish study that showed that it was not helpful for the person wearing the mask and therefore masks are useless, well, not so fast. First of all, really hard to study the effects of you wearing a mask on other people not getting an infection, really hard to do. You can’t study everything important with an RCT, you need that context. Fellow parents, what do you think about your kids running with scissors? Bad idea, right? Well, where’s the RCT that proves that? Where’s the metaanalysis that says kids should not run with scissors? Not everything important comes with an RCT or from an RCT. That’s part of the context. So I look for uncertainty, I look for balance, I look for context, I look for someone willing to acknowledge that here’s my point of view based on what we know, but there is evidence to the contrary as well. And I think I’m going to reject it because the evidence in favor of a, is greater than the evidence for b, but it doesn’t mean there’s nothing to say about b, that’s honest. Life is like that, but that now suddenly we’re in the realm of nuance, we’ve come outside of those lanes in the snow, we’ve laid down our opposing flags.

– And vastly more ATP is required to do that work.

– Yeah, exactly. Whether you’re trudging through deep snow, where there is no prior path or you’re seeking a balanced nuanced understanding of a complex situation that requires you to hear what they’re saying and what they’re saying and separate baby from bath water in both cases, you’re exactly right. A lot more ATP is required. Now, we’re back to the wisdom of the ages. Worthwhile things tend to take effort.

– [Zubin] Take effort.

– Same is true of understanding. If you don’t apply some effort to understanding, you’ll just be led into direction of least resistance. And ultimately you’ll wind up renouncing, both science and sense as a result of that.

– I think this is the standard to which I try to choose guests for the show is they have that capacity. You are definitely a shining example of that, David. I mean, I think it’s funny, because we share respect for people that have similar ways of looking at the world. Jay’s a good example. When I had Jay in here, he could easily take a very partisan divisive stance on what he’s saying. And he’s like, “No.” I said, “Isn’t it heartbreaking that this is happening?” He goes,” I’m heartbroken by all of this. The harm of closing the schools and the people that are dying.” So let’s figure out a way to, Monica Gandhi, who’s quite evangelical about masks, but she says, “Let’s say we’re wrong, which it’s possible, sure. Well, then what’s the harm that we’ve done? Well, we might’ve heard people who are hard of hearing, we might’ve cause some liberty versus oppression people to be upset, but on balance, I feel like.” So those kinds of conversations are the ones we need to have. And you talked about picking out credible people misinformation. If people are absolutists, just stop listening to them. If people are absolutely certain in this, like you said, it goes in medicine too. When you’re online, if people keep moving the goalpost, like you say, “Okay, well then here’s the evidence for that?” They go, “Well, actually, this then.” That’s a sign that this is probably somebody you’ll never gonna convince and it’s misinformation. The idea that they’re cherry picking data and being absolute about it. Like people are picking this data out of Wuhan saying, “Oh look, asymptomatic cases don’t transmit disease, I don’t know if you’ve seen this data.” Where they looked at a lot of people and they said, “Look, a lot of them that were asymptomatic by PCR, we test them, they’re positive for PCR.” In their households, there was no transmission. Well, okay. First of all, you got to ask these very difficult nuanced questions. Is that PCR test a false positive? Were they pre-symptomatic or truly asymptomatic? What was the followup? What was the nature of the tribe? I mean, there’s a million questions, but you’re just gonna cherry pick to support what you already believe, well, then that’s not a very helpful discussion.

– And the truth there is a perfect example of where there’s likely to be nuance. Many people who are asymptomatic probably have a lower viral load than people with severe infections.

– That’s right.

– Any reasons maybe related to their exposure, may be related to their health immune system response. But the lower your viral load, the less virus you have to share with the rest of the world, the less infectious you are. So it’s probably both true. So some asymptomatic people do transmit depending on the immune response of the people they’re with, the intensity of the exposure, the length of the exposure, but they’re probably less likely to transmit. It just makes sense. And that would be another thing I would argue for is, and I agree with everything you just said, you really don’t want to renounce science because it’s too pointy headed, it’s too erudite. I mean so much of the way the modern world works is based on science. So you cannot watch, you can’t listen to podcasts or log into the internet and oppose science.

– And look at what we’re doing now?

– Science doesn’t work. You’ve tweaked that. Okay, so you just organized electrons and sent them through this magical realm of cyberspace, because why? Scientists made it possible. You can beam your thoughts to one person on the far side of the globe instantaneously. Why? Because science works. The evidence that science works is all around us all the time, we’re soaking in it. So you can’t renounce science, but I think a lot of scientists renounce sense, and I’ve argued that science has the power of a freight train, to take us to places that are hard to reach, we wouldn’t otherwise ever reach, but sense lays the tracks. And neither one is worth much without the other. You drive a freight train without tracks, you get a train wreck. Sense is where you ask the right question, sense is where you think of all the, yeah, but, okay. So science might say, “I did a study that showed there wasn’t transmission in a household from asymptomatic people.” Sense says, “Well, yeah, but what about the fact that we don’t completely trust the test? And maybe the people in the household were the ones who already had the infection and that’s where this asymptomatic person got it in the first place.” What about, and what about, and what about, that’s sense actually.

– [Zubin] Yeah.

– The two are critically dependent on one another, and that would be the other thing I would look for. Somebody who speaks to you, if they have real expertise, they should be invoking science and make that clear. But if they renounced sense and just think that every answer, if you do the right kind of study, that is the one source of human understanding. Again, I’ve raised five kids to adulthood, always thought running with scissors was a bad idea, remain confident about that to this day, have yet to see the RCT on the topic. Sense matters too.

– By the way, can we do an RCT on closing outdoor dining in California? How is that? I mean, that’s neither sense nor science. Like that’s neither. At that point, public policy just gone off the rails.

– And this is why some of what the extreme moral preening of the left has precipitated the extreme rejectionism on the right. I mean, you’re basically trampling on civil liberties to no gain. There’s no evidence that this is helping anybody and it’s hurting people and restaurants are going out of business. And then those people wind up in desperate situations, their life’s work and dreams are being ruined and their health is being ruined as a by-product of that. What about them? Don’t they count? And again, total harm minimization says, “Yeah, they can’t do count.” Those are real people too. We talk about the economy in terms of numbers, but behind those numbers are real people real lives and that’s why total harm minimization matters.

– Can I say one other thing, we’re already running up. and I don’t know how long we’ve been talking, but I just got to ask this because this just relates to that. So I’m sure you heard about this whole Stanford brouhaha recently, where with the vaccine and how they were relying on an algorithm to distribute it. And the algorithm was probably smarter than some humans and also dumb. So it had no sense, but it had a lot of science. And the algorithm basically said, okay, let’s look at these different factors, like how old you are, what your risk factors are, what your exposures are, and do some math and say, okay, these are the people who should get it first. And it basically ignored all the resident physicians, because they were young and they didn’t have a specific location. They’re all over the hospital, but now these are people taking care of COVID patients. But what’s interesting is from a purely dispassionate harm minimization standpoint, that may well have been the correct answer because those residents who are in their early 20s without comorbidity say, assuming that that’s true and they’re wearing PPE are actually at relatively low risk, even compared to an older attending with one comorbidity who sees less patients, but it’s still in the hospital exposed to a lot of people who do see patients. So it’s really complicated to get these sort of calculations correct.

– An algorithm is only ever as good as what we put into it. And inevitably, there’s a lot of science, and it’s really hard to build sense into an algorithm, which is why artificial intelligence, as promising as it, is still quite immature. Essentially we want it to be wise, we want it to be sensible, and we’ve got a ways to go to get it there. So for now the combination of the artificial intelligence of an algorithm, plus the human intelligence that involves sense, make a powerful partnership. So consider the fact that there’s been a lot of debates even about the extent to which the vaccines are gonna prevent transmission.

– [Zubin] Right, we don’t know.

– If we look at the history of public health, I mean, if you can’t get the native infection. I mean, the vaccine doesn’t give you the virus. So if we’re confident that the vaccine prevents you from getting sick with the virus, then either you’re not getting the virus at all, because your immune system fought it off, or you’re processing a much lower viral load and you’re processing it much faster.

– [Zubin] Yeah.

– Well, all of that translates almost inevitably just mechanistically into a massive reduction in your transmission. The residents, yeah, I would agree. I mean, I’ve been reading about this issue and I sympathize with the residents. They’re afraid they’re on the front-lines. They’re working these very long hours. First of all, the sleep deprivation of residency may be a significant immunosuppressant. I think that’s an important concern, they’re very stressed. But I would say that the primary reason to put residents way up toward the top of the list is their level of contact with patients is generally much, much greater than the attendings who spend less time in the hospital-

– Fewer viral load, yeah.

– Yeah, I mean, again, and it’s become a heretical term. I think that’s silly it’s a lack of understanding. We are aiming at herd immunity. Whether you get there because everybody’s had the infection and everybody who could bear it has born it, or you are getting there with a vaccine, either way, when enough of us are immune to this damn thing and it stop circulating that’s when the pandemic ends, one way or another, this ends with herd immunity. So I would argue that if the residents have the potential to get this and transmit it to patients if we’re counting on PPE, PPE were perfectly protective and we had enough of it. Then why is any health professional at the front of the list?

– [Zubin] Yeah.

– Then basically we’re just worried about the people who can’t get it because they’ll get too sick. But I think the reason that frontline professionals are on list is we don’t think PPE is a perfect protection. If you’re exposed a lot, you may get it. Well, residents are exposed a lot. And if residents are exposed a lot may get it and they’re young and it’s not gonna kill them, at least not very often, okay, that may be reduces their place in the queue. But then again, if they can get it and they can get sick with it, they can transmit it. And they have intimate contact with patients all over the hospital every day. So I’m on their side. I think there are all sorts of reasons why the algorithm is a little bit inattentive to some relevant considerations. And again, I’ve been reading a lot about this issue as if we need to debate it, will the vaccines be effective at preventing transmission to others? Okay, we don’t have the studies to prove it because phase one, two, three trials that were intended to get this rapid warp speed authorization of vaccines did not address that issue. But the history of immunization tells us if a vaccine is effective at protecting an individual, it’s going to cut down that person’s transmission of the pathogen to anybody else, too.

– I agree a thousand percent. And in fact, communicating that and look at how much ATP it took, just to even explain what you just did about the residents.

– I’m exhausted .

– It’s so easy to just say, yeah, boom, or to go, “Okay, well, here are the considerations and this is why I actually think residents should get vaccinated.”

– It’s a lot of hard work.

– It’s a lot of hard work. But that’s the work you got to do. Now, here’s the thing. If people trust you, they could then go, “Well, David’s put in the hard work, I’m gonna listen to his explanation, he’s gonna give me pros and cons, and I’m gonna make an educated decision.” That’s how we ought to be making our decisions.

– By the way, my mother is all over that. I think she’s the only one, but I know for sure, yep, I trust it. You trust this guy.

– My parents who are the same age as your parents, are also, well, watch my show for their medical advice. And I’m like and then I get uncomfortable. Then I’m like, I know what I don’t know and actually I’m comfortable with uncertainty. So don’t take anything I say without a grain of salt. But the interesting thing about this vaccine transmission thing is this has come up a lot in a lot of my audience who are very liberty versus oppression kind of minded. And they say, “Well, I don’t understand it. We raced to get this vaccine. It’s a heroic efforts, science. And now they’re telling me I still need to wear a mask and social distance once I’ve gotten the vaccine?” And I’m like, I don’t know that that’s the best communication strategy. We ought to talk about why? How this thing work? Like what you just did, which is say, yeah, we haven’t studied it directly, but all historical vaccines have done this. And you create a herd immunity threshold by reducing targets for virus to infect, viral load is lower, you can be careful in the short run, but man, let’s put an end point on it because otherwise people are just, they’re gonna feel despair.

– Right, totally agree.

– Yeah, so that being said, I think we did a thing today too . It was really a joy. I just love talking to people like you, which are, unfortunately, it’s a rare conversation than is common these days, that can see these sides and communicate them articulately. You have the expertise and the experiences, particularly in communication, who have an adorable dog and an amazing handcrafted home office that they carpentered themselves.

– Seriously, yeah. Where do you find guys like that?

– You just can’t. I mean, I would ask Dr. Oz, but, no, he doesn’t build anything himself. So all that being said man, I really wanna thank you. Will you come back so we can go deeper on some of these things in some future shows?

– It’s been an absolute pleasure. I’m sure that the people who watch you routinely already know this, but you’re great, thoughtful. It’s not easy to lead a conversation like this, that flows so freely explore so many things. To contribute as much as you do, because I mean, your comments here have been as important as mine and yet you make your guests feel like they can say everything you need to say. So it’s really a pleasure chatting me, it really feels just like a conversation. It just so happens you’re recording, maybe other people are watching us. At least my dog, my mother will, your parents will, we’ve got an audience of four easily.

– Exactly . That’s all that matters.

– Yeah, let’s do a part two as soon as our schedules allow.

– That’s tremendously generous of you, thank you. And guys, Z-Pac, I really enjoyed this conversation. If you did, too just share it. If you wanna support the work we do, become a Supporter on any of the platforms, just go to zdoggmd.com/supporters. It keeps us basically commercial interest free, which is great, because that means we’re no one’s pocket, but yours, the only butt we need to kiss has your name on it, which is creepy and also probably inappropriate. So I love you until next time we are out. Thank you, David.

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