Why a data-driven, holistic, and nuanced approach to our COVID-19 response is long overdue.
Vinay Prasad MD MPH is a practicing hematologist-oncologist and Associate Professor of Medicine at the University of California San Francisco. He studies cancer drugs, health policy, and clinical trials and better decision making. He is author of these academic articles, and the books Ending Medical Reversal(2015), and Malignant(2020). He hosts the oncology podcast Plenary Session, and runs a YouTube Channel VinayPrasadMDMPH. He tweets @VPrasadMDMPH.
In this encore podcast we talk about the first presidential debate and the foibles thereof, the goals of healthcare reform and single payer upside vs. downside, why soundbite news and social media culture has failed us, why data and being able to change our minds matters, the dangers of ideological purity and not thinking for ourselves, mask mandates, weighing the life years saved in different covid response scenarios, why it’s imperative that we figure out how to open schools ASAP, social equity and our COVID response, safetyism and safety “creep,” the counterproductive role of the elite Zoomocracy during the pandemic, and much more.
Zubin: What’s up everyone. Dr. Z, welcome to The ZDoggMD Show. Today I have returning to the studio, Dr. Vinay Prasad. He is a hematologist oncologist professor at UCSF my alma mater. We talked hella smack last time. We’re gonna talk hella smack this time about COVID, science, Twitter, you name it. I don’t know what’s gonna happen. I just invited him down and he agreed to show up and I just need to see another human face to face, Vinay welcome back man.
Vinay: ZDogg, it’s pleasure to be here.
Zubin: Dude. Your your podcast Plenary Session, by the way, we’re going to record a thing for your fan-
Vinay: That’s right, hopefully we’re gonna do an exclusive ZDogg interview.
Zubin: That’s right.
Zubin: Everybody you got, and hopefully that brings new eyes to your podcast.
Vinay: That’d be great, yeah.
Zubin: The reason I love your podcast is you don’t, you are always authentic. You’re not afraid you say, you know what? This is the deal. Like these drugs don’t work. This is the bias in medicine. This is what’s going on with money in the cancer space. I mean, how, how did you even start doing that?
Vinay: Well, I say, don’t get me wrong. I’m also afraid to talk about many things. I’m also afraid, but.
Zubin: You will be.
Vinay: I will be, someday. You know, we’re all one tweet away from end of career-
Zubin: Ah yeah, cancellation.
Vinay: Yeah of course. But I, I guess I would say, you know, I got interested in medicine. I got interested in health policy really early in my career, probably when I was a intern fourth year medical student, I, it was just like many people, you know, I started seeing things and the clinical side that rubbed me the wrong way, didn’t make a lot of sense. And so I started digging and you know, when you’re a doctor and you want to understand why the hospital works the way it does. I promise you one thing, the moment you understand how money is flowing through the system, people will start to make a lot more sense. So why aren’t we paying for this? Why are we doing it this way? The moment you start to figure out where the dollar bills go, you’ll make sense of that. So that’s kind of what got me interested in health policy.
Zubin: And, you know, nothing has changed. That’s exactly how it is.
Vinay: That’s how it is.
Zubin: Man, so how, speaking of money, how painful was that debate last night?
Vinay: It was atrocious. I mean, it was painful from the point of view of someone who wants to watch people to get a sense of what they think and what they will do. If that was your goal, to learn information-
Vinay: Fail, total fail. If your goal was to see how people want to posture themselves and present themselves to the electorate, well, then you might be sated by that, that diet. Well, not dialogue, monologue really.
Zubin: Yeah, yeah, monologue. It was, you know, it made me think at some point I just said, you know, this is, these are our choices, you know, just terrible and terrible in a form that should never have happened with a moderator. That was, you know, well guys, guys, I mean, what’s even the point? And the thing is, this is what our discourse, it, it felt, you know, what it felt like? It felt like watching live action Twitter.
Vinay: To a large degree, it was.
Vinay: But I guess I would pose, I would put the choices as, as terrible and someone who I think is a pretty decent person, but that’s just me. I mean, I think he’s a decent person, would do a decent job, but I mean, I guess I think you’re asking a good question, which is even in the best of circumstances, a debate is theater. It’s always been theater. For somebody who really wants to know what will, let’s say. We had two traditional politicians who actually don’t step on each other’s words and let people talk. Even in those circumstances in 90 minutes, to get a sense of what someone’s going to do for broad policy, for a nation. I think it’s an untenable thing. You reduce complex policy decisions to just catch phrases that have been scripted and poll tested to connect with people, it’s always been disconnected. And the truth about policy is I think political leaders really just kind of point the ship where, where we’re gonna go. And then actual policy is a series of compromises. What can you achieve? What you wish you achieved? If you drive things in a direction too quickly, you’ll actually create a backlash. So you have to move the ship of a huge multi trillion dollar economy rather judiciously. And so I think for many people, we confuse the destination with how to get there. And that’s one of the greatest problems I think with politics.
Zubin: Yeah, and you know what, I think that’s where we get into health care, because that was brought up in the political spectrum. You know, it’s, it’s Trump, accusing Biden, of being a single payerist, Biden, accusing Trump of having done absolutely nothing. And this whole idea that it’s this polarity, like you’re either a single payer socialist or you’re a do nothing, let the system continue to rampage, you know, through America, which by the way is not a sustainable thing. Neither one may be sustainable, but what are your thoughts on this? Because I have a lot of feelings about again, destination and path.
Zubin: So we all agree. I think. I’m trying to find an American who thinks there shouldn’t be universal coverage.
Vinay: Yeah, I think a few.
Zubin: They’re a few. And they’re the ones that are more the Darwinian-
Vinay: They have a lot of money in the level-
Zubin: Poor people who can’t afford healthcare should die. That’s evolution.
Vinay: I think there’s some people who do hold that view, perhaps unfortunately, but I think you’re right, that a lot of us, the majority of us in poll after poll believe that people should have access to care, they can afford care that’s reliable that provides what we need, because we believe that medical care is a different than other commodities, it’s a commodity that we all ought to get together and make sure everyone has, it’s a human right many people believe. I believe that. And I’m on the, I’m a little strongly on the political left, but what I think the excess of the political left is, is to wed themselves so tightly to a single way of getting it done, which would be a single payer system, or, you know, beyond a single payer, even there’s a, there’s something even more left than that, which is actually the government owns the apparatus of healthcare, a truly social-
Zubin: Like England, yeah.
Vinay: England, a truly nationalistic system. And I guess I would say that once you decide on the destination, we want everyone to get access to healthcare, to be affordable it, to be fair, to be free of racial and socioeconomic bias. Then the policy question is what gets you there in a way that prevents a backlash that’s sustainable. And, and I’ll just point out one thing that I think people may miss, which is that no matter what healthcare system you have, there’s always gonna be some people who are not satisfied because the one thing in this life we’re not guaranteed is to live forever. We all are gonna die. We’re all gonna get sick. And people who get sick, some fraction of them is not gonna be satisfied with the care because they’re gonna keep getting sick. You and I both know that, we’re doctors, there’s some patients, there’s some people there’s nothing we can do to change the course of that ship. That’s just biology. And when you have that in a system, people will attribute those bad symptoms to the institution that is keeping them in that path. So if there’s a single payer system, there’s only one person to blame. So one of the beauties of a public option and private systems is they may all be not perfect, but you can keep switching, which will satisfy you in a certain level. So I think one of the things that people on the strong left mistake is that some of these things that sound like a perfect policy solution, Medicare, for all, for instance, it may lead to unintended back lashes that you don’t anticipate, which is a fraction of people will be deeply discontent and they will have no other place to switch to. And that’s something you want to avoid. So that’s why I think like if you’re a politician, the politician should run on the platform of what’s the destination and a bunch of thoughtful people in thousands of pages should try to craft what’s the best way to get there. I don’t think it’s a really a 30 second sound bite.
Zubin: Yeah, and that, and that’s it. And I think that’s been the problem too, with our discourse around health care reform in general, because it’s like, it’s either this soundbite on CNN or MSNBC or Fox or whatever, or it’s a 30 page brief that no one reads from some think tank that is never gonna get done. What we need is to have the agreement as a society that A, what’s our goal. We want no Americans to go bankrupt due to medical bills. Let’s say that’s it. Okay. Well then let’s craft different solutions that will give people choice and options to get to that point. One of my big concerns with say a Medicare for all, is that, are you codifying a broken system? Are you saying I’m gonna pay for procedures and options and things that already we know don’t work, but we do them because we get paid. So we got to start sorting that out. There’s care delivery, there’s outcomes, research, what actually works. There’s fixing clinical trials and understanding the biases there, which you’ve written books about malignant and ending medical reversal or books you’ve written about this, that if you do it, it’ll get you so pissed off that you realizing we’re paying for stuff that doesn’t work. It’s hurting people. So all those things have to be on the table. It’s not just black or white.
Vinay: Yeah, you’re right.
Zubin: And I think part of the problem, too, staying on that, it looked talking about COVID you can’t have an honest, open, rational discussion where you trust the other person, because all you’re seeing are these soundbites on TV where it’s so politicized.
Vinay: Well, first, I just, I just want to pick up on something you said that I think is, is super important to restate, which is that all of us who believe that universal health care is something beyond traditional commodities. Those of us who go so far as to say, it’s a right. And I’ll put myself in that camp, that it is a right, a human right. The right to healthcare is a right to health care that actually works. The healthcare that costs a lot of money that doesn’t make people better off that’s profit seeking by, by for-profit interests, by shareholders. What we have in healthcare, as we consider it is a mix of both things. We’ve got a lot of things that are transformational. Somebody comes in with acute heart attack, ST elevation MI, you open up that artery, we’re talking double digit mortality benefit in like, you know, a couple of days, massive benefit. And then we’ve got devices, surgeries, pills that we all know have very weak evidence-base or bad evidence-base. And one of the problems in this space is if you just pay for everything, you’re gonna be paying for a lot of things that really redistribute wealth in a bad way. It takes wealth from everybody and gives it to the hands of a few shareholders. It’s a regressive tax and it doesn’t, and it’s done in the name of health, but it doesn’t actually improve people’s health. So to your point, which is that we have to do both, which is expand healthcare and reform healthcare. I think it has to be together because the moral justification for universal healthcare is that it’s actually helping people. There’s no moral justification to pay for devices that don’t make people better, that just enriches shareholders.
Zubin: That is a brilliant point that nobody talks about that. If you, let’s say you have a universal cover system where the government is paying some of this and we actually kind of do it, it’s called Medicare.
Vinay: Right, right, we do.
Zubin: So what is Medicare doing? It’s taking the commons, our money.
Zubin: And it’s redistributing it hopefully to do social good, which is take care of elders who have illness or people on dialysis, whatever the exemptions are for Medicare. Well, what happens when you’re taking the common money and you’re giving it to companies and shareholders and for profit entities that are making money on a product that has been approved based on biased research, that’s money driven. That’s generating lots of profits, that is not actually helping people, but the worst part of it is people, patients think it’s helping them because they are conditioned by the same companies, whether it’s a pharma company doing a direct to consumer ad, whether it’s their own doctor being conditioned by the pharma, the medical device rep that, hey, this thing is actually going to help people. And then they believe it and they’re getting paid to do it. So there’s a moral conflict there where they, they feel like, well, if I just do this, I’m doing the right thing because I’m also getting paid. And that’s how humans work. And people don’t talk about that. Until you fix that, if you throw public money more public money at it, we’ve already thrown a ton. What, the government pays roughly 50% of healthcare. If you consider VA and Tricare and medicare.
Vinay: It’s a trillion plus in federal expenditure on healthcare, a trillion plus per annum. It’s tremendous investment we’re making. And I think you’ve, you’ve put it so well, which is the, this is, this is a sector in the marketplace where the person at the end, the consumer, the patient, they’re not always in the position to know which of these many services you’re giving me, which are the ones that are really helping me. And which are the ones that are just kind of writing, writing the other ones are doing. They don’t know. And the other thing is some of the doctors giving them are well intentioned and very smart, but they may not have the very rigorous training it sometimes takes to separate these two. And all of the for profit entities want you to think that everything they’re selling is, is the magic bean. You know, they think everything is magical. My product is good. Their product’s good. They’re both good products. One product actually works one doesn’t, you know, that’s a distinction lost on people. And what you create as a system where you can give a tax cut to billionaires, or you can take the money from everybody and give it to a bunch of for profit companies that make a product that doesn’t make people live longer, live better. It’s essentially the same thing, a regressive distribution of income. And that’s something that I think people like me as a progressive, I think we should be cautious about. I think even people on the other end of the political spectrum, they don’t want to tax people to pay for things that don’t work. That’s not in line with their philosophy either. So it’s something that I think we can all agree on, which is we cannot keep funding things that do not make people live longer or live better. We got to stop paying for this. If you want to pay for that with your own money, so be it. But we can’t tax everyone in the name of health and pay for these things that don’t work. And proof that that’s happening is just the enormous amount of GDP we spend in this country on healthcare. And that we don’t get what we ought to get for it. We’re spending 20% of GDP on healthcare and our life expectancy is on the way down and we’re shorter than other Western industrialized nations. So I think this is the key problem that’s so inextricably interlocked with universality. I think a lot of people believe that we should do universal coverage first, and then we can reform this problem later. To some degree, I do believe that I think that that is a plausible strategy because once we have, once we’re investing in healthcare, there’ll be more impetus to find these things, but I think you gotta do them together as much as you can. And that’s a big thrust of my work is research in this space, no value, low value practices.
Zubin: That’s key. And again, I cannot emphasize enough that that is such a crucial part of the discussion that we never had. We know when they rolled out Obamacare, that was part of the original plan was outcomes measures and things like that, it’s kind of hard to do. And it didn’t really happen for a variety of reasons.
Vinay: Yeah. Some of the reasons the teeth were taken out of the bill, so we can have a PCORI, we can have an HRQ. We can have these institutes that are tasked with doing comparative effectiveness, see which pill is better, but they can never do any studies if the only thing that separates the two pills is cost. Oh, that’s kind of a-
Zubin: Kind of the point.
Vinay: Kind of the point.
Vinay: It’s kind of the point, we want to know if the cheaper thing works as well as the expensive thing. And then the other thing that has to be stated is there’s such an imbalance in the, in the lobbying space, all the people who are profiting from these things that don’t work, they have lots of money on hand and they can pay for lobbyists to go and push Congress to do things that keep their monies coming in. All the people on the other side, who are hurt, they’re, all of us are hurt to a very small degree. We don’t get together. We don’t think about this. We often are blind to it. We don’t have the collective ability to lobby equally on the other side. So it’s a fundamental imbalance in lobbying. And so these systems that concentrate wealth in this way by offering service that has no value, it tends to perpetuate itself. It tends to drive itself and fuel itself.
Zubin: Yeah. And you know, what’s interesting, you see, you’re a progressive, I’m a moderate. These are the common ideas that progressives, moderates, and conservatives can share.
Vinay: I agree.
Zubin: The idea that you don’t throw good money after bad, and you don’t, you don’t waste money on things that don’t work. You can argue about different techniques to get. But I think we all kind of have a similar goal. Like you said, there’s a sub fraction of people who think sick people should just die, who are poor, but that’s, let’s all agree that that’s a tiny sub fraction. Most of us want a society where we’re doing the right thing, that you talk about healthcare as a right. I talk about it often as, as it’s not even the right question to ask, is it a right or a privilege or a whatever, it’s a question of what kind of society do we want to be? So do we want a society where people go bankrupt and die because they don’t have money? Or do we want to be a society where we have enough smartness, the right things that we do, wealth, that we can actually prevent that from happening for everybody, and I want to be in that society, you know? And then I don’t care whether it’s a right or a provision, the ethics of it, it’s more, hey, we live in a pretty good place. I think a lot of Europeans feel that way, but they’re not perfect, right? They’re wasting money on a ton of stuff. Their costs are going up. There’s political infighting. So I don’t know.
Vinay: You know, to some degree, the labels that we use to identify our camps, maybe these labels would be actually in need of revision. I mean, for those of us, I mean more than any sort of label the label you provide to me as I’m, I’m, I’m an empiricist, I’m data-driven. If you, no matter what I believe, if you show me good data, that what I believe is wrong, I will denounce my belief on the spot-
Zubin: On the spot.
Vinay: On the spot.
Vinay: There’s no belief I cling to more than the ability to be persuaded by data. I am a data analyst. I think about how data is misused and used. That’s the religion I subscribe to above all else, is the proper use of data. To some degree, some of the political positions we find ourselves in are people who believe that this will work in the absence of data. And, and so I want to say that I’m willing to, you know, when you call myself a, when I call myself a progressive that’s, because I think much of the data supports some of the ideas of the progressive platform. I think I generally am in line with the direction they want to go to provide these services, to handle these problems. And also I think progressive is they don’t take things off the table, prima facia. We’re not gonna say, well, governments can’t do this. And these institutions can’t do that. We’re gonna say, I’m willing to consider anyone doing anything in this space if it actually works to solve the problem. That’s why I put myself in that bucket. But perhaps I’m not truly in that bucket because I don’t believe in the solutions more than I believe in the evidence. If the, if the evidence goes the other way, and some of these solutions don’t accomplish the stated goals of improving population health and lowering GDP spending on healthcare, I’m not gonna support it. So, so I put myself in a different bucket and that’s why I, you know, I’m not a politician. I’m not.
Zubin: Exactly. And that, and see, so this is, and this is why you’re on my show because I have a group of people that I trust to care about the data who would change their mind in an instant, you know, Offit’s one of these guys, Paul Offit he just like, well, okay, I know I was wrong about this. This is the thing. And, and that I think is so important. And then, you know, it’s funny. ‘Cause before the show we were talking, we were looking at a Fauci clip from March on Twitter, where he was talking about masks. And he was saying on “60 Minutes”, he said, listen, I don’t think mass are useful for the public right now in America. You know, maybe it protects a droplet, but people are touching their face and all of this, which is, which is what I was saying at that time too. And then now there’s a 180. Now the way the public sees that is that’s chaos, like these guys don’t know what they’re talking about. I mean, how do you interpret this thing?
Vinay: That’s a good question. I mean-
Zubin: As an empiricist.
Vinay: As an empiricist, I guess I would say that first, I have a lot of respect for Tony Fauci, who I crossed paths with a couple of times when I was working at the NIH and-
Zubin: What a gunner. God. And I went out the back at the Institute, me and the boy.
Vinay: Well, you know, when I worked at NIH, it wasn’t the true heydays of the NIH. It was, it was not the way it was. I think in the ’60’s and ’70’s where it really was the pinnacle. But nonetheless, it was still a great place. But Tony Fauci, I think is a good person. He’s a public servant. He’s been doing it a long time. I do think that we can, no matter where you fall in this issue, you, we have to admit that there were sort of public bungling of the communication around this issue. The reason we looked at that clip was that it’s abundantly clear that that clip and then a clip from maybe six weeks later, the language used about masks is a true 180 and the data did not change as fast as the language. I think, no matter even people who believe that there’s been new data, it didn’t change that fast and not that dramatically. And what do I think? So what do I think? I’m not the expert on public communication. There’s a philosophical question I have, which is in the interest of getting people to do what you want, can you embellish your hand? As a data person, as a scientist, I believe the answer is never, I will never embellish what I, what I say in an effort to get you to change your behavior. I respect everyone too much to do that. And I respect myself too much to ever capitulate on that front. I don’t know if everyone in politics feels the same way. I think some people may disagree and they say, you may have to up play your hand now about what the data shows, and you may have to downplay the hand earlier to get people not to take them away from healthcare workers. That’s their logic. I believe we would have been in a better place. If at every point in time we inserted all the appropriate nuance and caveats. We say, we want you to do this. We didn’t want you to do it before for these reasons. We want you to do it now. And you know, there’s still some ambiguity here. The, the other truth of it is there are some nations in this world that are doing cluster, randomized control trials in masks. There’s a study being done in, in, in Denmark. We will learn more information. We could have done a little bit more of that on this front. We could have answered a few more questions, not just around masks, but other non-pharmacologic determinants of spread, such as availability of hand sanitizer, plexiglass, partitions, masks, face shields, and they can all be done in sort of a factorial design where you randomized people to some parts of this and not others. And see which parts of this giant apparatus have the proportionate benefit. You know, I’m reminded of something that some pandemic experts tell me, which is this won’t be the only pandemic. We’ve got to use this as an opportunity to learn for the next pandemic. And in some ways we miss that opportunity to learn. So going back to your point, I guess I would say that I am so committed to data that I believe every time there is uncertainty, it is an opportunity to run a study, to decide who’s right or wrong. And what I fear is that in an effort to get people, to do what you want them to do, we overplay our hand and that will one day, perhaps it’s already started to, bite us in the bite us in the ass.
Zubin: I think you and Monica Gandhi, who was on the show recently is coming back, agree. She’s in my cabal of people that I think are empiricists and care deeply about human suffering and want to alleviate it by actually understanding it. And, you know, we were talking about that the public health should it, should’ve been give, treat people as grownups, tell them what you know, and don’t know and let them make the decisions. Like, would you agree with a national mask mandate?
Vinay: I guess, I mean, I guess I would say that I would say if you wanted people to do it, then I think the question would be what’s the best way to do it? And I guess the first question I would have is, and I don’t know the answers here, so this is why I’m going to talk you through my reasoning. And I’m going to be able to answer the question. But one of the things I would say is in this particular moment in time, I worry that mandating anything like mandate, put that label on it. Like you gotta do this and where it’s gonna backfire on a lot of people-
Zubin: Yeah, I agree.
Vinay: They’re gonna thumb their nose at you just because they don’t want anybody telling them what to do, right? So that’s one question I have, I don’t know if that’s the most effective way. The other thing might be to say we recommend it, the other thing might be to say, you know, we’re uncertain and we recommend it. And I think these kinds of messaging can be really strategized. The next question I have for you is I’m not sure under what legal framework it could even be authorized at a federal level, and I mean, I just don’t know-
Zubin: Constitutionally, yeah.
Vinay: Constitutionally or within how many of these decisions have to be made at a local level, state level or national level. The other thing I would offer is whether it be masks or face masks or masks or face shields, or the available of hand sanitizer at different strategies at grocery stores, I would say in so far as, as possible, we gotta think of experiments we can do. Can we randomize counties to different strategies and track changes in viral spread just to get a sense of which of these things is the key? Can we randomize counties to different strategies? Like one it’s mandatory. And the other thing about mandates are what are you gonna do if somebody doesn’t do it, right? So we’ve all seen the videos of somebody going without a mask and people have escalate it. Those, that’s what makes the videos. Perhaps there are many situations where, you know, people look the other way, which is, I think what a lot of people do in real life. If you escalate it, you have to ask yourself the question in the process of escalating this, am I going to make it worse? By calling the police and you have to hold somebody down to put a cuffs on them, or is this person potentially armed? Is it gonna you just putting, you know, is this a pressure cooker about to explode? You have to ask that question. So mandates have to be tied to what are the carrots and what are the sticks? And every part of that I think requires empirical data. So, so I guess I would say that, you know-
Zubin: It’s complicated.
Vinay: It’s complicated, but I mean, I mean, I, I would say that if you put me in charge of that question, it would, I would get you a good answer in about a week. And I would assemble a lot of people to answer that question. And this ties to something that, you know, you and I were talking about earlier, which is Twitter absolutism.
Zubin: Yeah, yeah, yeah.
Vinay: This idea that we don’t always know the answer to even simple things, we have a little humility to say, yeah, I see some pluses to it. I see some downsides, maybe there’s ways to sort that out, that idea that you could have that humility that’s lost in the world of social media and it makes me scared. It’s I will have many more followers if I go and tweet things like anyone who doesn’t wear a mask is an idiot. You’re killing me. Some video of this person didn’t wear a mask and they died. That’s something people did. Similarly, just how absurd would it be if somebody posted a video of this doctor wore mask all the time and they still got sick and died, we would say, well, that doesn’t prove anything. That’s just an anecdote. And, you know, nobody said masks work a 100% percent. So think about it the other way around, right? So what if somebody showed the anecdote the other way. That scares me, that we live in a time where people who are supposed to put the caveats in, who are supposed to say, I’m not a 100% sure about a broad sweeping policy change, that’s never been done in the history of humanity that those people would rather instead be just damn sure they know the right answer and that everyone who disagrees is a moron or an idiot, or wants to kill people. If the world is full of people who agree with me and morons and idiots, that’s a bad way to dichotomize the world. It’s a way that’s not gonna win your friends and you’re not gonna win battles. And so I really worry about what has happened with social media on this.
Zubin: And we recently did a video on “The Social Dilemma”, the Netflix documentary, and really social media has weaponized polarity in a way that it rewards it. So you get more followers, like you said, you would have 10 X, the followers, if you took that polarizing route. And I said that in the video, and I actually cited some doctors on Twitter that have, one of them has half a million followers rhymes with Pooh and just, just by sewing, absolutism, division, whether it’s political or medical. And, and, and again, if you know, if you’re putting in your Twitter handle wear a damn mask, you know, McGee, you’re not, who are you convincing?
Vinay: That’s what I wonder. I struggle with that. I struggle with it on so many questions, which is some of these questions people have dug in they’re in the trench, they’re fighting on their side. How are you gonna get them out? How are you gonna make middle ground? I’m not sure you’re calling them an idiot or insulting them, or, or just shouting louder is gonna do it. The other point you make and you alluded to, I think some of people on Twitter, who, I think many of us who are doctors don’t have a lot of respect for, even though they may put MDs in their title. One of the unifying themes among those people is you can gain a lot of followers if you pair medicine with a very strong political stance. You’re always for, or against this president, you’re always for, or against some political party, you pair those two and you gain all the, the occasional medical followers, but you gain all the political followers and the political animal on Twitter is far bigger than the medical animal. I mean just more-
Zubin: Order of magnitude.
Vinay: Order of magnitude. And I think we have to be careful. I mean, I’m somebody who believes that medicine is to some degree, ultimately political. This is about what we’re doing with human beings, how we value life, value health, in those who have less, it’s about justice, it’s tied to all these things. At the same time on every issue you have to approach it with, without a preconceived bias, with as fresh eyes as you can, and try to see what things people might be offering that are right or wrong and not always be wedded to some party line. It’s important to separate the two. And so somebody can be political on Twitter. Someone can be too political. I think there is such a distinction to be made.
Zubin: Yeah, I think you’re right. Yeah. I think that’s what it is because politics again is the way humans sort out values around data.
Vinay: Yes, yes.
Zubin: We can be empiricists and look at data, and then, okay, so how important is that to us? For example, if you’re someone who believes that humans should be Darwinianly competing for resources, well, it doesn’t matter what the data says about what’s best for the flourishing of human populations. Your goal is we’ll just reward the people who have the most money. That’s a value thing. So you can argue those politics and say, well, politics about policy. What policies are we gonna put in place? And that’s why you argue. That’s why last night’s debate was useless-
Zubin: Had nothing to do with policy, had nothing to do. And you had no idea what these people would actually do in office. And so it’s a waste, it’s political grand standing. It is a, again, a, a live action, Twitter feud where it’s just, again, you score points by creating polarity by insulting, by throwing out homonyms by interrupting. And I saw actually both of them do it, although it was asymmetrical. And, and so in the end, I think what we need to do is look at it and go, okay, how do we start to bring people back? I have this term, the Alt Middle, and it’s, it’s less of a political thing than it’s a hey, can we have a rational conversation? It doesn’t matter what you’re probably. I hate this. And Jordan Peterson used this term. And just by saying Jordan Peterson, I know you brand him as some kind of Alt Right person. Ideological possession is a term that he uses and he complains that people are they’re ideologically possessed. So in other words, I will always click these boxes because the party that I’m purportedly supporting will always click these boxes. I don’t think for myself, I don’t let data change what I think, no person, no argument will change what I think I’m ideologically possessed, and he’s like, no, think for yourself. And, and I, and I a 100% agree with it.
Vinay: Yeah, I heard somebody say that if, if the views of your friends and your party are, are all the views you hold, they’re not your views, which is true. Because if you’re really thinking for yourself, you will inevitably disagree with somebody on some fraction of the issues. We can never agree a 100%. It’s okay not to agree a 100%. We can meet where we agree. I think the debate also reflects the continuation of a trend, which is the media has commoditized politics in a dangerous way. If you watch an hour of CNN on COVID, I don’t think I learned anything.
Vinay: I don’t think I learned anything. I learn the same things I knew when I started, a very superficial look at things. People saying things louder, saying somebody did something right or wrong, or somebody who’s bad, somebody good? I don’t learn anything. What has happened? Do people, do you actually know anybody in your life who watches an hour of CNN? I know very few people in my life anymore, watches an hour, CNN, people are moving to places like your podcast. Other podcasts, people are moving to forums where the host of the forum is willing to talk to somebody for two hours, three hours. I listened to a lot of those podcasts. I learned so much more than I would learn from the snippets. Academics always complain that they go on some TV show and they have to get their message in two minutes. And then they practice how to deliver it as best they can. I think to some degree, we have to rebel against that. Some messages are not conveyed in two minutes. They need more minutes. And so either going to do it justice, or just don’t talk about it.
Zubin: Man, absolutely. Absolutely. I think the long form needs to come back. You can play it at two X-
Vinay: Two X man.
Zubin: Or skip through or read the transcript, whatever-
Vinay: Yeah, whatever.
Zubin: But have the long conversation. Like those Sam Harris podcast, where he gets someone on, they drill deep into stuff. Those are transformative for your thinking. I mean, my mind was changed. I was introduced to people like John Height and these other thinkers that then you go deep in their catalogs.
Vinay: Yes, I agree.
Zubin: That’s how we ought to be. And the thing is, I think what you said about media commodifying this, it’s important because the big corporate media companies make money by scoring the same points that you score on Twitter.
Vinay: Yes, yes.
Zubin: The individual reporters, if you talk to them and I have, they are heartbroken, they’re morally injured, because they want to go deep in the nuance. They don’t want a click bait headline. They, and they always like, I’ll do an interview with somebody and then I’ll see it. And I’ll be like, what the kind of fucking headline is that? And then they go my editor put that in because he knows it’s gonna get more clicks. I know it kind of reduces the whole thing to this not true thing. And I’m like, yeah, it does. Why is it? Well they make more money and there’s more advertising. I’m like, well, there’s the problem. And again, you started this whole thing by saying, when you were young in medicine, you were saying, hey, if you follow where the money flows, everything starts to make sense.
Zubin: Yeah. And that’s what we’re seeing in the media.
Vinay: I think that’s what we’re seeing. And I think the rise of some politicians has been largely driven by the fact that their antics get views, get clicks in an ecosystem where media is under pressure to keep and stay relevant. It’s a huge disservice and the ability to talk about, I mean, what would a round table really look like around the healthcare system? And you could assemble a bunch of really good people and we could talk about it for an hour and two hours as to what are the pros and cons of the German model UK system, the Japan Japanese system, the US system, how can we move towards providing universal coverage, making sure it’s affordable, but also the budget standard control. It’s a nuanced and complex discussion. It doesn’t fall under one slogan to reduce it to, you know, single payer or, or, or, and or that, that socialist or-
Zubin: Medicare for all.
Vinay: Medical, it does a disservice. And I wonder the average person who hears that they’re they feel as if they’re voting with more information, but do they really know that much more than if they didn’t know the platform at all? Just to know this one slogan it’s either good or bad. I mean, I’m not sure about it.
Zubin: I don’t think so. And you know, what’s interesting is when I talk to just random people in my life, whether let’s say it’s my contractor or somebody, somebody who’s like not a scientist.
Zubin: But it’s not an idiot.
Zubin: And they’ll tell you, oh, this is my understanding of COVID right now, from everything I’ve seen on the news. And I’ll go, okay, well, how about we think about it like this? Have you thought about this and this and this, and over the course of 30 minutes of conversation, their eyes open wide, like, wait, what? I never thought of it that way. That’s because no one’s had a 30 minute conversation with you about the nuance and the different ideas of this. And we’re all in this group think on COVID. Either you’re like a pro mask, shut them down, catastrophist or you’re a, you know, denial, hoax, open everything up, this thing’s a lie. And that’s not the dichotomy that exists.
Vinay: And that’s the most poisonous dichotomy, is that what you’ve articulated that, that dichotomy that you’ve articulated I think is, is true. I observe it in other people. And on top of it, they have taken those that dichotomy and tied it to political party. And that is a poison because that ties it to, to identity, to assume somebody is, it makes them much less likely to change their opinion on this issue in a setting of massive uncertainty. And what we’re really talking about at the end of the day is there’s no perfect choice. There’s no perfect answer. Something bad is happening and bad things are gonna happen. And you know, I talk about it on my podcast a little bit. There’s an equation we’re trying to like solve and let me just kind of walk you through this equation. In world A we do X, Y, and Z, and there’s a certain number of years of life we are losing. We are gonna lose the years of life from certain amount of viral spread. We’re also going to have some countervailing effects on if we close schools, what will happen to kids, their longterm longevity, their socioeconomic status, are there gonna be more teen pregnancies? There’s going to be more violence. What’s gonna happen to society? Are we gonna have loss of understanding of civics? Are we gonna have a disrupted society? Are there any threats to potentially democracy? What does shutdown do for businesses for small business owners, for upward mobility in society? There are all these pieces of the puzzle. There’s no scientist who says I study all the things that COVID pertains to. There is no such person. It pertains to everything in life. And we have several scenarios. We can do XYZ, or we can do QRS. And we have to think, what will the cumulative life year change be in these worlds? Which path is the path where we lose the least life years, balancing all these different things and balancing some things that are not easily translatable to other things and to answer that question, so basically what I’m trying to say is that it’s not an easy question. It is the greatest policy challenge. And what it means is you need to assemble people who have diverse points of view. You need to hear what they say. You need to strive to persuade, to understand, to educate yourself. We all are biased to seeing the, seeing our world view as the most important view, I’m a doctor. So things that happen in the hospital takes on profound importance to me. I may forget what does it really mean when kids stay home for months on end and they’re being abused potentially by some older person at their house. And there’s no system to detect that they don’t have food, you know, which is a true problem that we’re facing. So what I want to suggest is these policy polls, they are not helping us. They’re preventing us from having a conversation. People are blocking people, you know, you’re on the other side, you’re on the other side. Oh, you think schools should be open. You think we’ll block, block, block. That’s not the way to do it. You, this is a time where we have to have the conversation. You have to listen to things that where people disagree with you. Learn something, potentially. Take it down a notch. Not everyone who disagrees with you is evil. They’re not all bad people wanting to do bad things. Some people they believe in the same things you believe in. They just think that the path you’re on is not gonna achieve those things. You have to allow them to speak and consider their view.
Zubin: That was a brilliant rant dude, that I, that that’s what I’ve been trying to say less articulately on my show from the beginning, which is we need to listen to all these viewpoints and not shut them down, but then criticize them when there’s mistakes in data analysis, you know, like, you know, you look at those Bakersfield doctors that-
Vinay: Bad, bad. = Bad data.
Zubin: Bad data.
Zubin: Maybe, maybe they have really good points. Like there are a lot of points that I sympathize with the shutting down schools, bad, quarantining healthy people, little bit weird. Let’s see the data on that. What’s going on? And there’s this idea that there’s also this interesting politicization of it. Like either you love America and you think we’re doing everything right, or you’re so upset with the current administration that you’re like, America’s a mess we’re doing, we’re the worst in the world at all this stuff. And it’s like, well, okay. The truth is probably somewhere in between. And there’s a lot that goes into COVID like we have this group think on COVID based on our politics.
Vinay: Yeah, I think so.
Zubin: So one of the things I’ve been thinking about lately is, well, maybe America’s having some trouble because I want to also get back to something you said, which is look at all these factors, like in quality life here saved in these different scenarios. If you had a super computer that was way smarter than us,
Vinay: Sure sure.
Zubin: And advanced general intelligence that could look at this. And Sam Harris has talked about this from a morality standpoint. If you had a perfect computer that could tell you how much suffering and how much wellbeing was generated by every action, you could have a perfect moral code, but unfortunately we don’t have that-
Vinay: Exactly right.
Zubin: And the same thing goes with COVID. If you had a perfect computer that could look at, so what do we do? We look at other country. We see what’s, which should be studying it prospectively. We’re not because we suck. So now we look back and we go, okay, what happened in Sweden? What happened in Japan? How do we interpret that data? Are we cherry picking? What are we doing? So the US well, we’re a slightly older population than say, Africa. Let’s look at Africa, nobody’s dying in Africa. I mean, and again, now I’m becoming very black and white, but let’s say, yeah, very low mortality rate.
Vinay: There are countries where the population is younger. And so the death rates are younger, but yeah.
Zubin: Younger, there’s a different culture. Maybe they’re packed in, they have more coronavirus exposure at baseline. They have more T-cell immunity, we don’t know, but we know there’s differences.
Zubin: Yes. So America is uniquely fat, chronic diseased, a little bit older, late to the party in terms of closing borders and stuff. So that it’s already widespread. So this is what happens. And the question is how much hubris do we have on how much we can control and how much is just nature doing its thing. And we need to understand how to mitigate harm.
Vinay: Yes, and let me, so you’ve done a great job of articulating I think one just domain of concerns, which is how might the biology of the virus be different in different places? Now, let me talk about the next domain, which is how my policy responses be different in different places, based on the types of people who live there. So we’re in a country that’s deeply politically divided where there’s some people distrustful of central government, distressful government altogether the same policy solution that may work in a country where people have strong faith in the government may not work in a country where people question the government or divided by the government. And then the other piece of it, that’s hard to articulate is we all approach this with our unique experiences and biases. People who do theoretical science, the world often fits the models quite well. It looks really good in certain types of theoretical science, And I don’t want to cast a broad aspersion, I think theoretical science is super valuable and super fascinating, it has an important role, even in this moment. Those of us who do clinical medicine, those of us who do field public health work. And I’ve talked to some people who will be coming on my podcast, soon field public health work and clinical medicine, we know that when the rubber meets the road, the best laid plans of mice and men off go astray, that there are things that sound good. They make a lot of sense, but you try to implement that on the ground, in the middle of a problematic situation, not even COVID-19, but a different sort of outbreak situation. They know that it’s not always easy. Fieldwork in public health is a fraught thing. You’re limited by serious constraints, financial, what the population will accept what people want, what they’re willing to sacrifice their values and preferences. And so those people may have different policy solutions than people who are more on the theoretical mathematical side of modeling outbreaks and what would work. We need to consider that policy is, is science plus values, plus what can actually be achieved in the real world. It’s all these buckets. And those of us who have had a lot of experience trying to do things like every doctor, there’s nothing. I sometimes tell people there’s no better preparation to know that your grandest ambitions often don’t go the way you want them being a doctor. How often, you know, have you been frustrated that you can’t get something done or, or somebody doesn’t do something you wanted them to do? And you learn to meet people where they are and not where you wish they were.
Zubin: That’s exactly it. Hey Monica, when she was on the show is talking about motivating, you know, gay men in an HIV epidemic to wear condoms. You don’t tell them, hey, wear a condom dummy or you’re gonna kill people. You don’t, that’s not how you, and they had to learn that. And this is it’s just harm reduction, one-oh-one, you know, really. And I think in COVID, we’ve lost the idea of harm reduction. We’ve inflicted a lot of damage to our societal fabric through the conflict and the polarization, and the fact that we just can’t have rational conversation. I get a lot of my fans will message me comments or messages saying, I don’t agree with everything you say, but I’m glad that you have this sort of openness to new ideas and things. That’s the best compliment you could possibly get because you go, okay, I like that you don’t agree because I’m not right about everything, and I don’t think I am. I want to be proven wrong about certain things like, you know, things like flu shot, you know, I’ll make a video saying, I think we should all get flu shot, but then, you know, if you really drill into the data on flu shot, well, what’s the marginal benefit. Well, it’s not huge, but the risk is small. So you’re trying to do the least damage as you can and do the most good, right? And that’s how I feel. But you have to look at that data.
Vinay: You have to. I think that the greatest example right now, where I think, you know, that this kind of thinking is really important is, is the issue of schools. And I think that’s more than other things because we, we can debate when, under what circumstances should you open up restaurants and shops and bars, and I understand people have different preferences, value things differently. I tend to think that those sorts of sorts of things that can, that can come next, but schools is something that everyone has always felt is so important. The data supports in so many studies, that it is a tremendously important thing, and it’s not equally important for everyone. It’s not that important for the kids of rich parents. It’s important for the poorest among us, for ethnic minorities, for racial minorities. They’re the ones that benefit the most. And if you were to stand back and look at this whole country and look at what private schools and what charter schools and what daycares are running and what public schools are closed and where they’re closed and to whom they serve, you will see inequality like you’ve never seen before in this country. It is almost a segregated system in the sense that rich affluent majority populations have much more access to schools right now, than poor, disadvantaged minority populations. That’s a policy choice we’re making, but I don’t think we’re fully aware of that, that we’re making it like that. And I don’t think we fully have thought about all the parts of that equation. Are there theory, is there a theoretical reason you would slow viral spread? Yes. Does the empirical data show that there’ll be a lot? I put a question mark there. I think the empirical data about whether or not kids look younger than the age of 16 spread this virus tremendously is quite debatable and weak. So there’s this theoretical potential slowing of the virus and what are the harms to the kids? What’s gonna happen to their income, their life expectancy? What’s gonna happen when they’re at home with no one to detect child abuse or sexual abuse? What’s gonna happen when they don’t have access to food? And so I think this is the policy question that you have to take those two guys were on the stage yesterday and put them out of your mind. It’s not about them. It’s not about any politician. It’s about how do you make this choice. Balance this choice, balance it in terms of equity and justice. And I fear that the choice we’re making now is, is not in accordance with what’s best for these kids.
Zubin: That is the conversation that progressives should be having publicly instead of tisk tisking people about, oh, you know, if you want to open school, you’re a, some kind of right wing lunatic. Because what you just said is something I’ve been saying on the show as somebody who, again, I have a ton of I, if we’re, if we’re just going on, you’re a data driven guy. I tend to be a little more emotionally driven. So let me retranslate what you said into pure emotion. The worst way to attain social justice of any kind is to shut down schools that preferentially target the most vulnerable members of our society, whose only route out of this was education, food through the school’s structure, getting out of an abusive neighborhood environment, father, whatever it is, where they can be seen by someone who cares about them, who shows them some degree of connection, where they can, then every story you hear about someone rising up and bootstrapping themselves in this country had to do with a teacher or an educator, something like that.
Vinay: Of course, every one, yeah.
Zubin: And we as a policy based on really poor-
Vinay: I think so.
Zubin: Data have decided to shut down our schools and are influenced by factors that have nothing to do with the wellbeing of the students themselves. So in a way it’s almost a generational war. The elders who are making the policy are saying, kids stay home because you might make us sick. Because if you look at the data, you don’t get that sick from this. So it really upsets me, man.
Vinay: I agree with, I mean, everything you’ve articulated, it troubles me so greatly that this is the way in which we are, we are making this choice. And I also want to point out, not all schools are closed, right? A lot of private schools are open.
Zubin: That’s right.
Vinay: This is a choice for poor kids. The kids who need it the most. And I think public health has never done something like this. I not to my knowledge has ever done something like this closing schools in, in this widespread fashion. People who have boots on the ground, public health experience tell me that sometimes you decide as a value that we’re gonna value that whatever, come, what may we’re going to do our absolute best to make schools happen. When you start with that as your premise, what will might you do? There’s a photo that circulates of what kids are doing in Thailand, they’ve got plexiglass around their desk. They’re wearing masks and face shields. They’re doing extra precautions. They’re putting money into schools to try to get this revamping ventilation systems, maybe having classes outside, teachers who are at high risk. Perhaps they get a pass, that’s acceptable.
Zubin: Yeah, absolutely.
Vinay: Yeah, that’s totally fine. They can get a pass. Maybe parents who make above a certain income threshold, maybe those kids they are, they’re asked to be on a sort of a tiered way, a tiered fashion, some of the hybrid models, I think, well, we could talk about it all day, but some of the hybrid models, I think I’ve introduced some other problems. Like by circulating people around so much, you might actually make the problem worse. But I, I actually, I was kind of reluctant that. I said that about sort of using income as a factor. I think it has to be considered, but also judiciously. I think there’s a downside as well.
Zubin: There’s always a downside, yeah.
Vinay: And the downside I want to articulate is that if you take the system, as it is, and you see private schools still open and public schools are closed, the rich parents may pull their kids out. And what you’re left with when in a year from now two years from now is a school system where you’ve lost a lot of the rich parents who are pushing to make that school good. And that school is gonna further do wrong. So I guess I misspoke a little bit. I’m sorry I said that, but I guess what I, what I want to say is we have to have a strong commitment to making sure these kids’ schools, poor kids, disadvantaged kids, they gotta run. And you gotta figure out risk mitigation, make them run, do the best you can around it. If you do not make them run, the number of years of life you’re losing for a generation is gonna be catastrophic. That what you’re doing to society’s fabric is gonna be catastrophic. You’re going to sow the seeds I think, for political discontent for decades to come, I think it is the greatest, I think one of the greatest missteps here is that the folks on the left who are progressive, who should value these things, they, I fear are doing this for two reasons. One in part, because this president says it, so it’s easy to do the opposite of what he says. Also in part, because when you are rich and comfortable and you’re getting your food through Uber Eats, and you’re sitting in your house and you can put your kids in the extra playroom that you can convert into a, a sort of a, a classroom, it doesn’t affect you the same way. And I think those are at least two factors. And the third factor is general fear that this could be worse, and I think that has to be considered. And that should be mitigated as much as possible. I think the empirical data do not suggest that that risk is enough to outweigh all the harm we’re doing to these kids.
Zubin: Oh man. That was really well articulated, man. I agree. I agree. And again, you can quibble over the details of how to do it. And you should, and you should, but the goal should be open the schools. Remember how, okay. Do you remember what it was like when they first told you that schools were gonna close? It was like a knife in the chest. People were like, wait, what? The very fabric of reality is bending and wait, how long? Couple of weeks, right? That’s it. Maybe? No, the rest of the school year.
Vinay: The whole year, poof yeah.
Zubin: Wait, and they’re not coming back in the fall. Wait, what? And we start, there’s like a safetyism creep like, oh, well, okay, well we did this one. Now we can just do this. Well now we’ll just keep them closed. Oh, now we’ll do a distance. Okay. And what you said, Jay said this on our show and you know, people will accuse, Oh, Jay, you know, Jay interned at the Hoover institution for a period. So he must be some, you know, Alt-Right lunatic. No, he’s a thoughtful data-driven thinker-
Vinay: No, yeah, no.
Zubin: Who cares about people. He said on the show, every single study has shown that wealth equals health. So why are we doing everything we can to damage the economy, damage schools, that’s going to affect the quality of life years saved. But again, we don’t have a super computer show us this. It doesn’t fit into a sound bite. And we can’t, even asking the question, get you canceled.
Vinay: I worry that people’s ability to listen and reconsider their views on this issue is deeply limited in this moment.
Zubin: It is yeah.
Vinay: And I think, you know, I’ve had a number of people coming on my podcast. They span the political spectrum from people who are a little bit, I think center right? To people who are the most left you’ll ever see these episodes should come out in the next, you know, as soon as we can edit them.
Zubin: The communist episode-
Vinay: That’s communist, that’s right. But the, these people are all articulating the same concern. When one reflects on the things we’ve done about this pandemic, they are all been interventions that penalize the rich people the least, and the poor people, the most. Closures penalize, like poor people the most. School closures, absolutely the most. I also want to pick up on one thing you said, which was the March to now discussion. I think in March, totally, I’m totally fine with that decision. We had no idea what was gonna happen. Especially March 1st, we had no idea what would come in two weeks will, would every hospital be drowning like New York city? We had no idea. It was absolutely unprecedented. It’s, it’s okay to use the precautionary principles. It’s gonna put a pause in this, and we’re going to see what, where we are in two weeks before-
Zubin: Yeah, I agree.
Vinay: Then we got into the whole year. Even that might’ve been acceptable, then we’re getting into the fall. And that’s when I think we’ve had accumulating evidence that that might be excessive, that the balance has shifted a little bit. We do understand a lot more than we did back then. And that’s what I think the error has been. And I think you’re right about safetyism.
Zubin: It’s a creep.
Vinay: It’s a creep. And Jonathan Haidt, of course has been, I think, very good about talking about it. It really is sort of an irrationality because you worry about risks that are close and visible, and you forget about the risks that are further away and not visible. And so I think he talks eloquently about all the things parents do, they kind of protect their kids, put them in bubble wrap. And his worry is that doing those things keeps the kids from developing resiliency, increases anxiety, suicidality, depression. What happened right now with COVID-19, I think it’s just another level. We’re doing all these things to protect ourselves from immediate viral spread. The things we’re missing are, is gonna be long lasting damage to a generation of kids in deep ways, both for their physical health, for their economic prosperity, for economic justice, for upward mobility, even for mental health and anxiety. I worry we’re going to have unintended consequences on so many domains.
Zubin: I actually think “The Coddling of the American Mind”, his book was a prophecy about what would happen in, in a situation like this, and it’s all come true.
Vinay: It’s all come true, yeah.
Zubin: Because everything that he said, we’ve created this fragile generation. That’s powered by social media, that’s over parented and over protected against risks. People can see an overestimate like kidnapping.
Vinay: Things that come on “Dateline”-
Vinay: Right, exactly.
Zubin: “Dateline”, “60 Minutes”. You’re just constantly reminded of these irrational fears. And you forget, the kids need to go and play and have normal experiences.
Vinay: Experience risk.
Vinay: Take risks. That’s what it means to be a human being. I, life is not a bubble wrap safety thing. It’s a choices we make in pursuit of, you know, some values and goals that we all share.
Zubin: Some values we care about. You could, reduce that into life is to be lived not to be fearing death every second. And I look, I struggle with it as a dad, both my kids are in this Ninja camp where they just get thrown into this thing with other kids, they’re filthy running around doing stuff. What are they doing? These obstacle courses like “American Gladiator”. My daughter who’s this tiny little nine year old, weighs like 40 pounds. Like little pipsqueak comes back. And she said, man, I really hurt my wrist doing this thing. And I’m like, this is just what I need is she’s gonna break her wrist in this thing. I’m gonna have to take her to the ER, you know, it’s gonna be a mess. I have this high deductible plan. What if we get COVID while we’re there, this is all going through my head and in an instant. And then I’m like looking at her and I’m like, so do you want to stop doing this? And she’s like, no, it’s awesome. Today I climbed a rope up to the top and I’m like, that’s it? That’s the decision. She’s taking risks. She’s becoming anti fragile. The little bit of injury she got has made her actually it’s not even resilience. It’s more adaptable to future injury. It’s not that she’s resisting change. She’s growing stronger to future challenges in a way that that Haidt talks about is anti fragility. And for me, you know, and something you said that I think I want to get back to real quick is Jay talked about this too. Rich people, people that are even you and me, do you consider yourself rich? I don’t, but you know.
Vinay: I’m headed that direction, but I’m not there yet.
Zubin: Exactly. Everyone thinks they’re middle-class right? So I have, this has been great. The kids are at home on Zoom. We have high speed internet. They each have their own room to do their stuff. I have an assistant to help out with my stuff. I get to do my thing remotely. Oh, it’s the best! I am an elite in the Zoom-ocracy.
Vinay: Yeah. I think Jay Bhattacharya has used that term. And I think he has a point, which is, and it’s related to the Twitter point, I think, which is that people who have had an oversized role in shaping the narrative and discussion of COVID-19 are people who are largely insulated from the challenges of COVID-19. We can do my, I can do most of my work by Zoom, but you know, I’m gonna leave here soon, I’m gonna go to clinic and actually I’m physically going in clinic, but that’s not true of many. Some doctors have actually converted all their clinics to Zoom, to further mitigate their risk. And in addition to that, people are at home doing their entire work from, electronically. The Bay Area has announced that some of these jobs are never gonna be in person again. You can work wherever you want. Housing value in the peninsula is exploding. And housing value in the city is plummeting. While people move to live more comfortably, Uber Eats is running. Amazon Prime is running. All of the services you need to buy whatever you want, get the food in your house. I see doctors posting long threads about how their Uber Eats from, I don’t know, some fancy restaurant was delayed. God, do you understand what’s going on? People are really suffering. They’re suffering because people live paycheck to paycheck. People who have to work in person, who’s gonna watch their kids wen they’re at home? Is their grandma gonna be brought in? I mean, you are pushing on society in a way that you have never pushed on before that people who are comfortable and have money and can avoid these challenges. They’re not paying much price at all. They may be not getting a haircut like me. You know, that’s the extent of my suffering, but people, there are people who are really suffering. They don’t know where the money is gonna come from. They there that stimulus paycheck was a pittance compared to what they really need. And, and the policies are gonna deprive their kids have an opportunity more than they’re gonna deprive the kids of academics. So I think it we, you know, somebody comes on my podcast in a future episode, I’m gonna steal a line he says, ’cause he said it best. He said, if you were to stand back and you were to ask, what’s the set of policies I should make for COVID-19 that will help poor and disadvantaged people who are dying predominantly the virus and what are the policies that will keep rich people comfortable and lower their risk of contracting the virus. He says, everything we’re doing now would be in that bucket of keeping rich people comfortable. They can be testing as long as I make sure my Uber Eats driver doesn’t have COVID so he doesn’t spread it to me, but we’re not gonna do the things to actually mitigate a risk for, for people who are vulnerable. And so, you know, that’s what he comes on and says, so I’m stealing his line, Steph Burrell, but you’ll enjoy his episode.
Zubin: That’s exciting.
Vinay: But yeah, I think there’s a lot of truth to that, that the people on social media and to make the final point, the people on social media, on Twitter, who are so easy to say, we ought to do X, Y, and Z. They may themselves be removed from the penalties of X, Y, and Z. And I think that’s a challenge.
Zubin: And you know what I think what I find is so interesting is the faction of the political spectrum that’s supposed to advocate for poor and justice are the ones that are loudly advocating the opposite in this case. And, and it’s the actually, and I actually think that people are so surprised when so-and-so gets elected well, when this is what’s happening on the ground level, and there’s a guy in the White House saying, you know what, this whole thing’s a hoax. Everything’s gonna be, open schools, do all that. What they’re hearing is, okay, this guy is actually hearing our struggle.
Vinay: And, and I think that that’s a dangerous thing in the sense that it’s a hoax and open the schools doesn’t have to be the same bucket.
Zubin: No, no, exactly.
Vinay: It’s a serious threat. It’s really doing damage, but it’s still on the balance better to open schools. No. Someone needs to say that, I guess, I guess we’re saying that right now.
Zubin: We’re saying it now. And it’s funny because I’ve been saying that, and this is what happens in comments when I say that. People are like, hell yeah, this thing’s a lie.
Vinay: I know , I know.
Zubin: Or they’re like you are gonna murder people. This thing is a catastrophe. How dare you, you’re gonna kill teachers, what about grandma? And it’s like, you have to make the Aaron Ben David said, on the show, you have to make value decisions every day we get in our car. There’s a risk.
Vinay: There’s a risk, yeah.
Zubin: But we know the reward of being in the car outweighs the risk, at least that’s our calculation. It may not always, right?
Vinay: Just disappear all transportation.
Vinay: I think you’re right, that, I mean, what you’re arguing is we have to seize the middle. We have to seize the middle. And the reason we have to seize the middle on this issue is that it is an issue that we all-
Zubin: We all agree.
Vinay: We all can agree on. And the worry is that I think the particular flavor of politician that sees the moment that as you point out, and I think I agree with you actually, you know, I grew up in Northwest Indiana. And so I have, I think, a tremendous affinity for Middle America and what, what it’s like in some of these communities. And I think people here that, that you hear it, you understand my struggles, you understand what I’m dealing with. They hear that. And this, and, you know, some politicians have taken advantage of that in the moment, but there will someday be a politician that’s worse than the politician we have now. I think many of us, 20 years ago, we thought we had, we had already seen some bad politicians, but we didn’t know what we were in for. 20 years from now, you may see politicians that make, make you wish you were living in 2020. And that’s what I fear more than anything else. Politicians who offer you false promises, demonize ethnic, and racial minorities, they triumph when people have been starved of capital, when their kids’ opportunity is taken away. When the week in the poorest are downtrodden, they thrive under those circumstances. And we, the progressive side, we are sowing the seeds for their triumph years from now, I’m deeply fearful of that potential longterm outcome. And I think we have to do everything we can. When when schools do reopen, we’ve got to get rid of the, get rid of the summer. The school day has gotta be the same day as your workday. We can’t, none of this school ends at two o’clock. We have to commit education. This is not an agrarian economy anymore. We don’t need these three months. So the kids can be in the fields working or whatever it was the initial impetus for it, it makes no sense. Schools is a public commodity to take children and give them options. It has to run year round, it has to be proper hours, and you got to pay for that. And we have to all pay for that. And so it, hopefully it’s an opportunity to take it and do something really good, but I worry that there’s some despot and some tyrant out there who will seize it to do something really bad.
Zubin: Ah, I can’t think of a better way to end the podcast. I mean, that was absolutely spot on inspiring. That’s how we should be talking about this stuff. Especially, you know, you know, especially in a time when we’re in a political season, it’s like, well, now let’s be honest. What do we all want? Forget about your politics here. What, what do we actually want? We want people to thrive as much as we can without a whole bunch of inequity.
Zubin: Because nobody likes it. Nobody even I think even the very rich, the least empathic, rich person, does not want-
Vinay: They don’t want that because-
Vinay: It’s a danger. it’s a threat to them, too. Yes, it can. It can it’ll break. The system will break. You can only push it so much and you can’t push it any further. But I don’t, I think they actually don’t want it. They want people to have opportunity to work and make money and have better lives for their kids. Even if, while people do, some people want to retain the capital that’s been given to them by their ancestors. And some of us, some of us, I think that some of the capital should be pushed away. So that’s a philosophical value disagreement. But I think we all agree. And I think you’re right. We have to seize the middle on this issue. There is a middle ground. You take COVID seriously. You value vaccines. You know it’s not a hoax. You also think that on balance, maybe the calculus says we’ve got to do the best we can to mitigate risk and get these schools going. And that’s a reasonable position that I think we have to come to.
Zubin: I call it the Alt-Middle.
Vinay: The Alt-Middle.
Zubin: Yeah, exactly. I’m gonna start a blog. You know, Darkbart. Man. Vinay Prasad. Dude, it’s always a joy. I’m so glad I just, I just hit you up. And I was like, hey, would you mind coming by? It’s just such a great discussion, man. You guys just share the thing. I have nothing else to say. If you want to become a supporter, we usually go deeper for supporters. You and me, we have these conversations. And the reason I talk about supporters actually is this thing where they subscribe, it’s like 4.99 on YouTube or Facebook, or you can PayPal. I don’t care. The reason it’s not that I’m pitching you for money. It’s that the fund we talked to, we started the podcast with the same fundamental problem with how we behave is our incentives are jacked up based on money. Social media incentives are generate advertising clicks. So whatever click bait headline I make, whatever controversy I want to stir up, I get more points, take a political stance, I get more points. But what if the formula was different where people are paying you for the content because they appreciate the content. Well, then you do the right thing for that’s authentic to you. And if they want to buy that, that’s great. Well, it turns out there’s a bunch of people who want to buy that. So let’s sell authenticity in ourselves instead of clicks to advertisers. So that’s my pitch. I love you guys. Thanks for Vinay and check out Plenary Session. That’s been Vinay’s podcast. I’m gonna be on that too. And he’s going to have great, he’s, it’s a great podcast. Definitely subscribe to it. And we out, peace.
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