Dr. David Katz: The Choreography of Contagion Interdiction

The media fervor currently swirling the pandemic is a fever of conflicting data and performative politics. Black and white, it's either sequester ad infinitum or back to work now — a conversation devoid of nuance. How to discern fact from fiction? Separate opinion from data? Politics from perspective? Like me, I suspect you're frustrated — yearning for evidence-based answers over conjecture; considered strategy over confusion; and objectivity over punditry. I can’t tell you when this alternate reality (which has morphed into a distorted normality) will cease. What I can offer is the experience and perception of one of the best and brightest in public health and preventive medicine. Meet David L. Katz, MD, MPH FACPM, FACP, FACLM. A pioneering voice in functional lifestyle medicine, David is a graduate of Dartmouth, the Albert Einstein College of Medicine & Yale School of Public Health. In addition, he is the founding director of Yale University’s Yale-Griffen Prevention Research Center, a past-president of the American College of Lifestyle Medicine, and the founder & president of the True Health Initiative, a non-profit coalition of more than 500 world-renowned physicians, scientists, and nutrition experts (including myself, the least qualified member of this coalition) committed to establishing and communicating a growing scientific consensus on the optimal diet for human beings and the planet. The recipient of 3 honorary doctorates, David was also a James Beard Award nominee in 2019 for health journalism, has contributed countless articles to top medical journals along with op-eds in The New York Times and other magazines, and somehow found the time to write 17 books, including his latest, How To Eat, which he co-authored with the great Mark Bittman. Although David has been a prominent voice in nutrition science and lifestyle medicine for many years, the pandemic has suddenly foisted him into a very bright spotlight. Currently making the major media rounds, you might have caught one of his recent appearances on Real Time With Bill Maher, CNN or Fox News, where he's been advocating for a more data-driven, targeted public health response to coronavirus. It's a strategy he calls vertical interdiction. It's (strangely) controversial. And it's the focus of today’s conversation — a nuanced discourse on improving how we consider and navigate the landmines of this unique global predicament. I appreciate David's thoughtful perspective and his commitment to service (including treating COVID-19 patients on the outbreak frontlines in the Bronx). He’s eloquent and data-driven. Evidence-based and no-nonsense. And quite charming to boot. To anyone suffering from the virus or the effects of it, my heart goes out to you. This pandemic is hurting us all, some in more catastrophic ways than others. I hope Dr. Katz’s words bring you comfort — he gets as close as he can to providing us with the answers we are all so desperately seeking. The visually inclined can watch it go down on YouTube. And as always, the audio version streams wild and free on Apple Podcasts and Spotify. It’s an honor to share his perspective with all of you today. May you receive it with an open mind and heart. Peace + Plants, Rich Learn more about your ad choices. Visit podcastchoices.com/adchoices

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:00Rich Roll?

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• 0:44Rich Roll?

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• 1:05Speaker 01

  You know, it's not as if you're gonna take some number of supplements and it's going to make you bulletproof, but the idea that diet makes no difference to immunity is absurd. Every day, your body is replacing white blood cells and the construction material comes from your nutrition. And so whether or not those cell membranes are optimized, whether or not you're able to replenish the productive capacity of your bone marrow, absolutely dependent on every aspect of diet. It's not just one nutrient. Yes, zinc is important, vitamin D is important, all of that, but it's the full array of amino acids, it's the full array of fatty acids. A balanced diet is the source of construction material for the replenishable portion of your immunity. Think about antibodies. We talk about antibodies. Well, those are proteins. You have to build them.

• 1:50Speaker 01

  You need an optimal diet to build optimal materials. And then there's antioxidants. The key role of antioxidants is to defend your healthy cells. Your immune system is like an army. It's engaged in chemical warfare. There is the risk of collateral damage. And frankly, one of the reasons people get so sick with COVID is this cytokine storm, which is activation of the immune system to fight the virus, doing damage to your healthy tissues. Balancing your immune response, so it's not excessive, but it's also adequate, has a lot to do with balanced nutrition. Protecting your healthy cells has a lot to do with balanced nutrition. So enormously important, and it's immediately actionable.

• 2:32Rich Roll?

  That's Dr. David Katz, and this is the Rich Roll Podcast.

• 2:47Rich Roll?

  The Rich Roll Podcast. Hey, everybody. Your host, Rich Roll, checking in. This is my podcast. Grab a seat. Let's start by taking a deep breath. Let's fill up our lungs, expand your abdomen.

• 3:07Rich Roll?

  Hold it just a little bit longer. Now exhale.

• 3:15Rich Roll?

  How's that feel? It feels pretty damn good, right? I hope all of you are being gentle with yourselves. This is indeed a challenging moment. And the collective stress is heavy. It affects all of us, even subconsciously. I know, I feel it. I'm sure you feel it as well. So perhaps consider lifting your foot off the gas a bit, taking it just a little bit slower and trying to love yourself a little bit more. Today, today's show is another coronavirus-themed check-in, attempting to glean a bit more COVID clarity amidst the confusion. The current state of affairs encircling this pandemic is, in my opinion at least,

• 4:00Rich Roll?

  a little bit of a debacle of conflicting data and too many extremist views. There's a lot of black and white thinking out there and not a lot of nuance. And it's hard to discern fact from fiction or separate opinion from data and politics from perspective. It's really hard. It's frustrating. And I suspect, like me, you'd prefer answers and well-considered strategy over confusion and punditry. And while I can't tell you when this alternate reality, which is quickly morphing into some kind of distorted normality, well, sheesh, what I can offer you today

• 4:44Rich Roll?

  is the experience and perception of one of the best and brightest in preventive medicine and public health. That, my friends, is the great Dr. David Katz, one of the leading voices in functional lifestyle medicine, a brilliant clinician and academic, who recently returned from a stint volunteering on the front lines of the coronavirus outbreak at a hospital emergency department in the Bronx. As always, plenty more thoughts to share about Dr. Katz and the conversation to come. But first.

• 5:23Rich Roll?

  Okay, Dr. David Katz. A graduate of Dartmouth, the Albert Einstein College of Medicine and Yale School of Public Health, David is the founding director of Yale University's Yale Griffin Prevention Research Center. He's a past president of the American College of Lifestyle Medicine and the founder and president of the True Health Initiative, a nonprofit coalition of more than 500 world-renowned physicians, scientists, and nutrition experts, including myself, although I'm certain I'm the least qualified member of this coalition, all committed to establishing and communicating a growing scientific consensus on the optimal diet for human beings and the planet.

• 6:07Rich Roll?

  David is also a James Beard Award nominee in 2019 for health journalism. He's contributed countless articles to top medical journals, along with op-eds in The New York Times, and somehow, along the way, found the time to write 17 books, including his latest, How to Eat, which he co-authored with the great Mark Bittman. Although David has been a prominent voice in nutrition science and lifestyle medicine for many years, this pandemic has suddenly foisted him into a very bright spotlight. You might have caught him a week and a half ago on Real Time with Bill Maher, or on CNN, or Fox News.

• 6:50Rich Roll?

  He's been making the major media outlet rounds of late. Advocating for a more data-driven, targeted, public health response to coronavirus, a strategy he calls "vertical interdiction," which is the focus of today's conversation, a discourse on how we should be thinking about and navigating this unique global predicament. I appreciate the work this man is doing and his commitment to service. He's eloquent, he's data-driven, no-nonsense, also quite charming, so it's an honor to share his message with all of you today. To anyone suffering from the virus or the effects of it, my heart goes out to you.

• 7:35Rich Roll?

  This pandemic is hurting us all, some in more catastrophic ways than others, and I hope that Dr. Katz's words bring you some comfort. He gets as close as he can to providing us with the answers we are also desperately seeking. So, here we go. This is me and David Katz, M.D., M.P.H., F.A.C.P.M., F.A.C.L.M. That's a mouthful. Enjoy. Well, nice to see you, David. Welcome to the podcast. This is a long time coming. We have a bit of history. We've actually never met in person, but we've gone back and forth over the years, and I

• 8:20Rich Roll?

  feel very connected to you. I've wanted you to come on the show for many years. I think we've had some back and forth, and I could never make it up to Connecticut to make that happen. And I always imagined that our podcast would be all about nutrition and lifestyle, but here we are in a moment in which I'm seeking your wisdom and experience in all-together different matter, specifically how we should be thinking about and responding individually and as a society to this COVID-19 pandemic. But before we launch into that, perhaps you could provide us with a little bit of background

• 9:05Rich Roll?

  on your work. You've been a prominent voice in lifestyle medicine for many years, but... The pandemic has really placed you in the public spotlight in a very unique and different way. So I'm interested in how this has come to pass and how we've arrived at this moment.

• 9:23Speaker 01

  Yeah, so am I. I'm asking every day, Rich, what is going on?

• 9:28Rich Roll?

  Yeah.

• 9:29Speaker 01

  Yeah, well, first of all, thanks for the intro. I feel the same way. I feel like we've known one another for years. And it's always odd when when your work is so overlapping and your ambitions are so aligned to discover, actually, we haven't met in person.

• 9:45Rich Roll?

  I know.

• 9:46Speaker 01

  Right? It's just, at some point, it just becomes, that can't be true. Yeah, I guess it's true. That's weird. So it's great to join you. And I would argue, actually, that what we've always wanted to talk about, diet, lifestyle, is medicine, the value proposition there, how much good could be done by getting that formula right, and what we need to talk about in this moment with everybody fixated on COVID, actually overlapped tremendously. And I actually think, Rich, that's why I'm where I am. And, you know, I didn't choose a career focused on nutrition and lifestyle because I like food more than other people.

• 10:27Speaker 01

  I chose it because that's where the action was. You know, in the early going of my career, I trained in internal medicine. And, you know, during 110 hours a week in the hospital for several years, it was painfully clear to me that eight out of 10 people in hospital beds never needed to get that sick in the first place. And we were all the king's horses and all the king's men. You know, the best we were ever going to be able to do is sort of patch them up, but never make them whole, never make them vital, never unscramble the eggs. And so I went on to train in preventive medicine to address that part.

• 11:04Speaker 01

  And then I chose to focus on nutrition and lifestyle because it was becoming clear at the time that diet in America was a leading determinant of health outcomes. Vitality, longevity, years in life, life in years. That's why I chose it. And in fact, what we've realized in the years since is diet is number one. Single leading predictor variable for all-cause mortality in the United States. There was an op-ed in the New York Times, August 26th of 2019, by Darius Moza-Farian at Tufts and Dan Glickman, former Secretary of Agriculture. Our food is killing too many of us. And that's the argument they make. Number-one predictor variable. So that's what I do. You know, I kind of want to beware stuff's on fire and bring a bucket and try to help

• 11:49Speaker 01

  put it out. And it's the very same inclination that got me caught up in the COVID response. I was looking at the data from all around the world in the very early going, so out of Wuhan and out of South Korea. And people were starting to freak out over here. We weren't yet sure what was going to happen in the United States. And, you know, some people were dismissing it. I thought that was wrong. Some people were getting hysterical. I thought that was wrong. I said, you know, it looks to me like, essentially, this is two very different diseases. There's a relatively small portion of the population, very elderly people and people with serious chronic illness, for whom this is a really bad actor.

• 12:30Speaker 01

  And then there's a large segment of the population, 98% to 99% of everybody who gets this thing, who may not even know they've had it. And, you know, South Korea's consistently reported, out of more than 10,000 cases they detected, 98% were relatively mild, something close to that. High 90s, anyway. And the real burden of this, so the likelihood of hospitalization, ICU, or death...

• 12:59Speaker 01

  Was massively concentrated among people who were elderly and/or chronically ill. Same thing in Italy, actually. You know, we were all fixated on that terrible mortality toll in northern Italy. Mm-hmm. But I think it was only 2.1% of all the deaths occurred in people under age 70, and 1.2% of all the deaths occurred in people who were free of some major chronic disease. Most of the mortality toll was in older people with chronic disease. So I was looking at that, and I said, you know, we're talking about shutting down society, we're talking about, you know, closing down businesses. And as a public health person, I've always been very respectful of the social determinants of health.

• 13:43Speaker 01

  You know, poverty is a major determinant of health outcomes: food insecurity, desperation, destitution. So I wrote an op-ed, which the New York Times wound up publishing. They called it, you know, "Is the Cure Worse Than the Disease"? I had called it something differently. I was arguing, basically, for a more surgical strike. Look, this is not an equal-opportunity scourge. Some people are at high risk, some are at low risk. We should do different things for those two population groups. But it wound up being called "Is the Cure Worse Than Disease"? And really, the issue was, this pandemic can hurt people at least two different ways. It can hurt them by infecting them, and it can hurt them if our interdiction methods ruin livelihoods and lives.

• 14:28Speaker 01

  And both of those are bad. What we ought to be striving for is total harm minimization, where we minimize the harm of the infection and minimize the harm of the interdiction. And that led me in the direction of what I call "vertical" or "risk-based" interdiction. Let's protect the people who most need protection, let's not shut down more than we need to shut down. I wrote my op-ed, and then Tom Friedman, three-time Pulitzer Prize winner, longstanding columnist at the New York Times, called me on a Saturday night. Literally, out of the blue, my phone rings, it's a number from Bethesda I don't recognize. And I usually don't answer those calls. But I said, you know, "I just had a piece in the New York Times, who knows what this is about, let me check it out." It's Tom Friedman. Uh-huh.

• 15:11Speaker 01

  And, Rich, I mean, I ran around the house, basically saying, and forgive me for speaking blood, "Holy shit, you won't believe who called me." You know, Tom Friedman just called me, out of the blue. So Tom said, you know, he really liked this perspective and he wanted to build his column around it, which he did. And let's just say the rest is history. So now Tom channeled my thinking in a column he wrote, which ran it up a really high flagpole. And then all hell broke loose. You know, I got calls from the governor of New York and the governor of Florida legislators and testifying to the senate and all the media appearances and so forth. And is it valid? Yes. You asked me about my background. So

• 15:52Speaker 01

  just briefly, I'm board certified in preventive medicine, public health, formally trained in epidemiology, have co-authored multiple editions of a leading textbook on epidemiology, preventive medicine, public health and biostatistics, taught all of those courses at the Yale School of Medicine for well over a decade. So, you know, ordinarily, I focus on diet, lifestyle, because that's most important. But the training really is preventing disease, promoting health, patterns in populations, epidemiology, and an understanding, not just of infectious disease epidemiology, because I would defer to others there who know more than I do.

• 16:34Speaker 01

  I'm not a virologist, certainly. But I also know a lot about social determinants and how, you know, the way this reverberates through all aspects of society translates into public health matters of great importance. So I'm seeing the big picture and opining, and here we are.

• 16:51Rich Roll?

  Right. So this op-ed piece is published March 20th, I believe, right? And, and if memory serves me, there was a sort of 10-day gestation period from the date in which you originally wrote this, up until the date that it was actually published, correct?

• 17:10Speaker 01

  Exactly.

• 17:11Rich Roll?

  So I suspect you're writing this in the wake of hearing that the NBA has suspended its, its season and Tom and Rita Hanks have contracted the disease. This is, you know, at the very beginning, stages of trying to grapple with how to deal with all of this. Also in a period in which every- Every single day feels like a year in terms of how much change there is.

• 17:38Rich Roll?

  Clearly, we've adopted what you would call a horizontal interdiction approach to all of this. And your piece was really about adopting a more surgical approach. And so where are we, you know, now, here we are, May 5th. A lot has changed, has this, has the evolution of our approach and what you're sort of canvassing and seeing right now changed your perspective in that original op-ed piece, which we should also mention has become a little bit of a political flashpoint.

• 18:11Speaker 01

  Right, right. And yeah, as everything does, I mean, our society is so polarized. It doesn't really matter how moderate or centrist your point of view is, it gets distorted in both directions. So, you know, it's never liberal enough for people, you know, to the extreme left. It's never conservative enough for people on the extreme right. I mean, no matter what, you're, you're, you're a human pinata. But yeah, just as you say, Rich, so I actually wrote it originally 10 days before it ran in the New York Times. And at that time, the early stuff was happening, you know, we heard about Tom Hanks and, and his wife and all of that. But we had not yet made the fateful decision to close down all of the universities in the country and send those kids home.

• 18:53Speaker 01

  And, you know, I have, I have five adult children and three of them were in that population, that demographic. And I was thinking, hmm, you know, what we're seeing in South Korea and increasingly in other countries is that, you know, young, healthy people may have this and not even know. What if that's going on in the college campuses? So, you know, potentially, we're going to take a lot of young people, seemingly perfectly healthy, who have asymptomatic versions of, of COVID. We're going to send them home to their 50 something parents, who if they're typical Americans have, you know, at least one major chronic disease, at least hypertension or type 2 diabetes or coronary disease. And in a multi-generational home, they may have their 70 something grandparents living there too.

• 19:36Speaker 01

  It really looks like it's potentially a bad disease in the parents. It looks like it's a devastating disease for the grandparents. Maybe these kids are better off staying in college campuses and let's just, you know, kind of wait and see what happens. Because, you know, maybe they all get over it, develop immunity to it, and, you know, that's when we send them home. We didn't do that. But I, those were the thoughts I was having. Between the time I originally wrote this and the time it ran the gauntlet to get published in the New York Times, we sent the kids home. We shut down businesses in New York City. I had three of my own kids come back home to shelter in place here. But, okay, you know, the die is cast. Aliyaakta est. And I thought, okay, you know, it looks to me with the dithering and delay here, you

• 20:18Speaker 01

  know, we're probably going to close the barn doors after letting all the horses run loose. And I kind of think that's what we did and we're still watching how that plays out. You know, in terms of my own perspective, so it's been informed, obviously, by the flow of data ever since I first opined, but it was also very important to me not to sit this out on the sidelines. And so when the call went out for volunteers in New York City, I immediately signed up. It took a while to work through the bureaucracy, but eventually I got deployed in the Bronx. And I did several 12-hour shifts in an emergency department in the Bronx. So I got to see this up close and personal. You know, we admitted case after case of COVID. But actually, it reaffirmed my view. So I saw young, healthy people in

• 21:02Speaker 01

  the ER for other reasons who, oh, by the way, probably had COVID too, and they got sent home and they were almost certainly going to be fine. I saw the occasional person in the middle where, you know, it was a little dicey. We hope they get better. They might get worse. Most of the docs I was working with had had it and recovered from it. Some of them had been tested and had to quarantine, then came back to work. Some of them did this and said, I'm pretty sure I had it. I didn't tell anybody. I just worked straight through it. On the other hand, there was a bulletin board in the emergency room with a picture of a beautiful woman with a lovely smile. Rest in peace. It was one of the nurses who had contracted this and died, relatively young woman. So, you know, again, the minute you stop respecting this disease, it is going to kill somebody you love. And I never lost

• 21:46Speaker 01

  sight of that. But the patients that were most consistently being admitted. And that were destined to the ICU or that died in the emergency room before we could admit them, or were likely to die in the hospital, were mostly elderly, sick people sent from the nursing home. And, you know, in the early going of my career, I worked for five years, part-time as an ER doc. And it was exactly the pattern I saw then. There was one major difference. So, you know, you always see ambulance after ambulance from nursing homes. Is there frail people on any given day, MI, stroke, urosepsis, all these different things that happen. What was different was same demographic, more or less the same volume, but everybody had the same diagnosis. That's weird. Everybody had COVID. So, you

• 22:29Speaker 01

  know, no question, it was different. By the time I was serving in New York, it was already a little too late. My colleagues were saying, we really needed you a week ago. And I, you know, I said, I signed up right away. Took a while to get through the system. But my, my view actually remains the same as it was, that, you know, again, New York's done seroprevalence testing. It looks like 20% of the state may have had this. That's 4 million people. So, you know, the, the, the death toll in New York relative to a denominator of 4 million is a tiny fraction of a percent, highly concentrated in older, chronically ill people. That pattern is being repeated around the world. The Diamond Princess, you know, really a contained environment. Only 20% of the people on the ship got infected. And by the way, that's a pattern we've seen

• 23:14Speaker 01

  repeated too. I don't know what it means, Rich, but I'm wondering, you know, are 80% of people natively resistant to just, you know, to, to getting this infection? That, we actually have data out of Germany, out of Sweden, out of Iran, the Diamond Princess, the Navy ships, and some evidence out of California, and the New York seroprevalence test that suggests, in a population that's widely exposed to this, 8 out of 10 people don't even get the infection. And of those who do get it, most of them either don't know at all, have no symptoms, they have mild symptoms. But on the other hand, I have, I've looked the enemy in the eye, and it's a terrible, bizarre disease. And I'm aware that it has killed young health professionals. And so-

• 23:59Speaker 01

  I always respected the potential of this infection to hurt people. But you know, with a with a total mortality toll, even this many months into it, very close to seasonal flu in the United States. I mean, they're really right in the same ballpark. And thirty million people unemployed because of our societal response to this. You know, so that's five hundred people who've lost their job for every one person who has lost their life to this. Both are bad. So I continue to think we should shift now to risk-based interdiction. We need to protect nursing homes. We need to identify as artfully as we can all of those groups at elevated risk of severe infection. And I think we ought to double down in protecting them. And and this is what I hope some of our discussion will be about today.

• 24:43Speaker 01

  We also ought to, we need a national, let's get healthy now campaign. There's never been a better time to get people to care about their weight and their insulin resistance, their diabetes, their heart disease. Because, you know, whereas those were slow motion threats before, everybody's acutely concerned about COVID. COVID has turned chronic health liabilities into the kind of acute threat that tickles your adrenal gland and activates the fight or flight response. So we've got people's attention. So we should identify risk. We should modify risk. We should protect people at elevated risk. But I really do think a large segment of the population can return to normalcy. And and there's a reason that's important, Rich.

• 25:26Speaker 01

  If we don't get this, those of us who, you know, who can safely get this infection, get over it and make antibodies to it, we are waiting for a vaccine to get our lives back. And that may be a very long time away from now, right? I mean, coronaviruses are tricky bugs. It's been really hard to make vaccines to them. And, you know, eighteen months has been the optimistic timeline. If we hit snags, it could be three years, it could be five years. I mean, it's hard to imagine life like this. For five years, if we're hoping to get back any of what was here before.

• 26:00Rich Roll?

  Right. I think that irrespective of the importance of flattening the curve, and you point this out in the op ed and it came up in your in your segment with Bill Maher, flattening the curve doesn't obviate us from contracting the disease. It just pushes the timeline out, right? So at some point.

• 26:21Speaker 01

  Yeah, I want to credit someone for that, actually. So two colleagues and one of the beautiful things that happened from my point of view, Rich, because, you know, I'm not an expert in mathematical risk modeling. I am not an expert in virology. But after Tom Friedman, you know, gave me the exposure that his column gave me, a who's who in all of these different fields, social determinants of health, health economics, mathematical models, found me. On the one hand, it's been completely overwhelming trying to keep up. On the other, it's been an incredible privilege learning from all these people. So Maria Chikina at University of Pittsburgh and Wes Pedgen at Carnegie Mellon, they're a couple that does mathematical risk modeling.

• 27:06Speaker 01

  And they published a piece entitled something along the lines, A Call for Honesty in Pandemic Modeling. And they actually, they went into an online tool that had been featured in a New York Times column by Nick Kristof, whom I love. But Nick was talking about the importance of flattening the curve. And they showed how you flatten the curve and you don't get that huge spike in hospitalizations and deaths. And it's really important to avoid overwhelming the medical system. Maria and Wes didn't create a new tool. They went into that very tool and said, okay, if you look at what was published in the New York Times, it, you know, it looks like there's a slight uptick right where they cut off the curve.

• 27:49Speaker 01

  We're going to show you what happens if you release the clamp. And there was the same high spike in hospitalizations and deaths. They said, in other words, if all, if your entire plan is flattening the curve.

• 28:01Speaker 01

  You have to do it forever, or until there is a highly effective vaccine mass-produced and uniformly administered. Because the minute you let go, everything you thought you were preventing happens, all you've done is change the days. That was, that was an aha moment for me. I, it had occurred to me from the start that, you know, that we could, again, pivot to risk-based interdiction. I hadn't thought to say, you know, this actually can be configured directly into the risk model, so that, yes, you flatten the curve at first, you don't overwhelm hospital systems, that's obviously important. But you need something to transition to, unless you're just gonna hunker in a bunker and wait for a vaccine. But that could be a very long timeline, and an awful lot of life, as we knew it before,

• 28:46Speaker 01

  will be gone by the time we all come out from under our desks.

• 28:49Rich Roll?

  Yeah, I think that, that risk assessment ends up being motivated in part by an emotional response to what we're seeing, because there seems to be a great crevasse between some of the data that you cited, and the harrowing and sobering accounts that you'll find if you scroll through your Twitter feed, from ICU doctors, or people that have contracted the disease, who paint, you know, a very scary picture of what it's like to endure this, or to, you know, die in an ICU, unable to be surrounded by your loved ones.

• 29:32Speaker 01

  Totally agree.

• 29:33Rich Roll?

  And, and I think that we should all take those stories to heart, and, and certainly, this is, this is not to, you know, minimize the severity of what we're dealing with, but I don't think that it can get in the way of driving an objective, well-thought-out plan for how we're going to, you know, navigate and ultimately come out the other side here. And there is a difference between complete horizontal interdiction, where we're on complete lockdown, and the other extreme of just doing whatever you want.

• 30:09Speaker 01

  Everybody back to the world.

• 30:11Rich Roll?

  Yeah, and I suppose on some level, Sweden is the canary in the coalmine here, by taking a tack that is somewhere, you know, in the middle of that spectrum, or perhaps, you know, bent to the right in terms of allowing people to do what they want. And people have a lot of opinions about that and are drawing conclusions, but my sense is that it's way too early to assess the success or failure of what Sweden is attempting to do. I don't, I don't know that we can really objectively evaluate that for another 18 to 24 months, because of course, they're going to have higher contraction rates and death rates at this moment, but what does it look like when there's a second wave or

• 30:54Rich Roll?

  a year from now, when we're trying to resume life on some level of normalcy?

• 30:59Speaker 01

  Which personally, I hope we do sooner than a year from now. So yeah, a number of really good points. Let me start with this one. Many years ago, Rich, I wrote an article in the American Journal of Health Promotion, "Facing the Facelessness of Public Health." Because you know, I'm a physician, 30 years of clinical care, but my career really has been focused on public health. And it occurred to me many years ago that public health labors under a tremendous encumbrance, and that is, nobody cries for the public. Nobody hears statistics and, and you know, and has a tear in their eye. Nobody feels

• 31:40Speaker 01

  passion for the public. But the public is a fiction. There is no public. There's you and me and everybody else. And the problem with much of what you and I do all the time, you know, we talk about the value proposition of lifestyle. 80% of all chronic disease could go away. We don't make people cry. We don't make people feel passion, because 80% is a bland statistic. I've tried to fix that in talks I've given by asking my audiences, "How many of you love somebody who's had a heart attack? How many of you love somebody who's had a stroke, or dementia, or diabetes, or cancer?" Now, everybody who put your hand in the air, you know, try to remember the day you found out about that diagnosis and how you felt. And now imagine a world where eight times in 10, we don't put our hands

• 32:22Speaker 01

  up, because that's what an 80% reduction in chronic disease would feel like. It's not remote, it's not anonymous, it's not about some entity called the public that isn't about you or me. It's about you and me, and our families, and people we love. But it's a huge burden to overcome, and the way you overcome it is storytelling. You put a face in the newspaper and say, "This is what we mean." Now, here's the problem. The news media have fixated exclusively on COVID. They've been feeding our anxiety about COVID for weeks and weeks and weeks. And you could easily get the impression that nobody in America dies of anything else. The reality is, heart disease kills 1,800 people a day in our country and has been doing it forever.

• 33:05Speaker 01

  8,000 people die in the United States every day of miscellaneous causes. So you could pick any one of those causes. You could pick just heart disease. You could pick just cancer. You could pick just traffic accidents and say, "We're going to experiment." You know, all the different media outlets are just going to tell stories about this one condition all the time. And we're going to, we're going to talk about the epidemiology and the statistics and the population level risk. But we're also going to tell the human interest stories. And, you know, honestly, if we had done that, I think we would be much more concerned about heart disease than we seem to be. And maybe would have done something about it, since it's all preventable. But we have done exactly that with COVID. And so there are actually two implications. One, yeah, you're right to care as much as you do.

• 33:50Speaker 01

  These are real people and, and these are, you know, these are grieving families. And it's all compounded by the fact that you can't be together, you know, in those moments of acute need. And that's unique and it's terrible. But the other is massive, massive risk distortion. You know, the feeling that, you know, because, you know, you tell the story, for example, that a child, a seemingly healthy child dies of COVID. And every parent in the country thinks, "Well, you know, I'm never sending my kids back to school." But the reality is, every year in this country, some number of kids die because parents put them in the car to drive them to school. And that number is much bigger than COVID. Or they died because they were on a school bus. Or they died because they rode their bikes outside. Now, these are all tragedies.

• 34:33Speaker 01

  But we're fixating only on the one cause, and it is distorting our perception. So, yeah, I totally agree with you. The human interest component, absolutely important. But why is it unimportant if the cause of death is something other than COVID? Those are real people too. Those are real families too. So we, we need to reconcile those two views. We need to respect this disease. We need to care enormously about every individual, every family that is suffering the anguish of this.

• 35:04Speaker 01

  But we also need to recognize families were suffering loss and anguish in the United States before COVID. We'll be suffering after COVID. Diet alone, poor diet, the thing you and I devote all our efforts to, kills half a million people, 500,000. So thus far, almost 10 times as many people as the total death toll from COVID, that's to date, but almost 10 times as many every year, kills them prematurely, right? Where's the outrage? Where's the, where's the passion and the compassion about that? Well, we're not telling those stories. What if that was in the newspaper every day? Another person died of diseases related to diet in America. And yet another, and another, and another, and another. You

• 35:47Speaker 01

  know, we could tell all of those stories with, with faces and families, but we tend not to. So it's important, it's valid, it's also a distortion.

• 35:57Rich Roll?

  Yeah, I suppose the qualitative difference with respect to the heart disease or, or diabetes example, is that you're not going to contract one of those diseases by being in the proximity of somebody that, that has it.

• 36:12Speaker 01

  Yes and no. Yes and no. Again, it's valid. There are a number of important differences. I'm not going to argue against that. But the, the medium of transmission for COVID is droplets through the air. The medium of transmission for death by diet is culture. But yes, being in America plays you at risk. Being in this culture means it's likely to be transmitted to you. And by the way, if it's transmitted to you, it's likely to be transmitted to your children. And there's a pretty robust literature on social networks and the risk of obesity, diabetes, and heart disease. So you could argue, all that's really different is the timeline and the mechanism of transmission. But these are transmissible

• 36:55Speaker 01

  conditions, and they play out over longer timelines, but they ultimately affect a lot more people. And, you know, you could say because they happen slower, maybe that means COVID's worse. But you, you know, you could also argue the other way. Well, here's the thing about those chronic diseases. They beat you up for a long time before they kill you, you know, before they ever take years from your life. They take a lot of life out of your years. And they're affecting children routinely. So yes, again.

• 37:23Speaker 01

  You know, valid.

• 37:24Rich Roll?

  We create social norms around risk assessment all the time. I mean, it would, it's certainly possible that we could institute a federal law that says you can't drive your car more than 10 miles an hour. We could make auto travel far more safe than it is. There's plenty of things that we could do to minimize risk for public health and safety. But there's this valence, this, this spectrum that I think is calibrated in accordance with liberty and, and, and personal freedoms. So.

• 37:56Speaker 01

  There's an, I agree with you. Listen, you, you're a terrific interviewer. Really? I mean, just awful. No, seriously. I'm really enjoying this. Let me point something out, if I may, Rich. It's a totally different topic, but I think it does shine a light on this. We had a huge societal hullabaloo about legalizing medical marijuana, let alone recreational marijuana, but just medical marijuana was, there was a lot of controversy, right?

• 38:21Rich Roll?

  Mm-hmm.

• 38:22Speaker 01

  What the public didn't realize is that cocaine was legal all along. It's in every emergency room. I, I used it as an ER doc. We, we use a 7% solution of cocaine on a cot, on a cotton swab and shove it up your nose when you come in with bad epistaxis, basically hemorrhage from the nose. Nothing works better to, to cauterize the bleeding temporarily so we can look in there and see what's going on and fix it. So cocaine was legal. To say nothing of drugs like Dilaudid, which is a much more potent opioid than heroin, and benzodiazepines, which are, you know, really dangerous habit-forming drugs. So in other words, drugs off the charts more dangerous than marijuana were legal all the time. And since they were legal all the time, nobody even thought to question it.

• 39:05Rich Roll?

  Mm-hmm.

• 39:06Speaker 01

  For the simple reason that marijuana wasn't legal in the first place, there was this intense consternation about, oh my God, a drug, you know, should it be available? And I would argue there's a bit of that going on. So, yeah, you can have much greater risks to any segment of the population, including children, that nobody pays much attention to because they are already normalized. And even if the risks associated with COVID were much lower. You still have a hard time talking people into them because we had already decided COVID risk is unacceptable. And in some sense, it's a little bit like juxtaposing medical marijuana and medical cocaine. There are greater risks that hide in plain sight

• 39:51Speaker 01

  that we blithely accept because we're used to them. And simply because this is new and exotic and we decided it was unacceptable right at the beginning, it's going to be a hard time. Even when we tell people, yeah, you know, the risk to your child going to school in the era of COVID may be comparable to the risk of driving your child to school for three months. It's still going to be difficult to talk people into that. But I do think that's going to be part of the transition back.

• 40:18Rich Roll?

  Right.

• 40:27Rich Roll?

  So here we are, we're in around week eight, I believe, of this experiment.

• 40:33Speaker 01

  It feels like a lifetime.

• 40:34Rich Roll?

  I know, right? I can't, I don't even remember what it was like before. And now when I watch a movie and I see people hugging, I have this visceral reaction to it. It's very strange.

• 40:45Speaker 01

  I feel the same way.

• 40:47Rich Roll?

  But we've been pursuing this path for a while now. Do you think it's possible at this point to shift courses and adopt a more strategic, vertical interdiction approach? Or has the die been cast and this is what we're living with and we just have to, you know, continue to pursue this way of life? Like, how are you thinking about our current moment? And if we could pivot, setting aside politics, what would that look like?

• 41:20Speaker 01

  Yeah, I definitely think we can. I almost think it's inevitable that we will because, you know, we're seeing these tensions. And sadly, you know, as you point out, I mean, to me, it's really quite surprising that anything I said was very controversial. My objective, clearly stated from the very beginning, was total harm minimization. And by the way, for listeners, we've collated all of our materials on the website of the True Health Initiative, under that rubric, Total Harm Minimization. We have the risk models and the columns and the essays and the blogs and the articles. But that was the goal. We basically said this virus can kill people. Um, unemployment, food insecurity, hunger, desperation, domestic violence, suicide,

• 42:03Speaker 01

  addiction, that can kill people too. All of that's bad. We need to be looking across the full expanse of that and devising policies to minimize total harm. So sort of surprising that, I mean, what's the controversy really? And then you, you, you'd have to quickly append to that, well, you know, our efforts at minimizing total harm can only be as good as our data. We need to know what the harms are and who's vulnerable to what. And if we're going to protect people, we need to know where to direct those efforts. But what we're seeing, instead of, you know, a lot of activity in what I think is the sensible middle, we're seeing the polarization that, that we have sown in our society. So reaping what we've sown. And so you've got, you know, the, we need to keep everybody

• 42:46Speaker 01

  hunkering in their bunker until there's a vaccine camp. And you've got everybody, you know, back in the water now. Don't worry about grandma, she'll be fine. Never mind the riptides and the sharks. You know, I, I reject both of those. And, um, you could, you could argue the better way to find the middle path would actually be to all come together, link arms and, and, you know, walk the middle path. But those opposing tensions are going to achieve the same thing, you know? So essentially, each side is pushing back against the other. And, you know, the, the only way out of the impasse is to say, okay, so, you know, we've got to return to some degree of, of normalcy. And, um, and

• 43:27Speaker 01

  yet we still have to protect people. And that, that would be vertical interdiction. So I, I think inevitably that's going to happen. What do we need to make that happen? So we actually do it well? We need data. And, um, at, at the time we're having this conversation, I'm about to testify to the, the Senate Committee on Homeland Security. I mean, really, my, my world is such a weird place, right? Yeah. Well, that's what I said when these guys called me. Seriously? But that's happening. And I'm going to say, look, you know, we, we've sort of bogged down in this issue of we need millions of, of tests and we don't have the resources for millions of tests. So therefore we throw our hands in the air. No, absolutely not. CDC routinely. Tells us really big stuff like, you know,

• 44:11Speaker 01

  diet quality in America and trends in dietary intake and trends in chronic disease, not by testing everybody in the country, but doing surveys like the BRFSS, Behavioral Risk Factor Surveillance System, in representative random samples. We need a representative random sample. Give me, you know, 20,000 people, 30,000 people. We can extrapolate to a population of 325 million. We really can. We just need to make sure we've got urban, suburban, rural, all age groups, all zip codes, socioeconomics, different health status. But that's what we're talking about. So you really mean to tell me, and, you know, better than 20,000 would be 50,000, but it's a small number. You can't tell me the United States of America couldn't pull together the wherewithal to do a representative random sample

• 44:56Speaker 01

  where we know whether you're infected or not, whether you're immune or not, your health status and all the rest. It's the work of 72 hours. It really is. So I would argue, we can do better than Sweden. You know, Sweden basically guessed. And Sweden could have done better protecting their nursing homes, frankly. Sweden certainly didn't have the data they needed to know who in the general population is in the high-risk group. But, you know, I think we can have Swedish cake and eat it too. And what I mean is, let's get the data we need so we really can risk stratify. And then say, okay, you know, we've got quintiles of risk, or tertiles of risk, or whatever it is. I don't know whether it's two groups, three groups, five groups, seven groups that, you know, are highly differentiated. But, you know, the highest-risk groups,

• 45:40Speaker 01

  fully protected until we get to an all-clear. And the all-clear could be a vaccine, but it could be herd immunity achieved natively with exposure to the virus too. The lowest-risk group, for whom the risk of severe COVID infection is no greater than seasonal flu and maybe lower. Absolutely, back out into the world, back to work, back to school. Intermediate groups, intermittent, intermediate policies. So either phased back in after levels of viral transmission are lower, or back but with personal protective equipment. And, you know, frankly, if we do this data-driven risk stratification, I think we could do a better job of taking care of the people who need it most. My parents are 80. They're generally healthy. My mom's had some health issues.

• 46:24Speaker 01

  Um, you know, we've not hugged them since the start of this, you know, they're sheltering at their home. My mother is, and I've told this story in the media, but it's true, you know, she can't get through a conversation about without crying. Yeah, okay, yes, I don't want to get COVID and die, but I'm equally afraid of dying of something else while waiting to be able to hug my grandchildren again. You know, I mean, they're, they're sort of comparably terrible existential threats when you're 80 years old and you know, that you're looking at, at, at the horizon of, you know, your life coming to an end. So, you know, how does my mom get to hug her grandchildren? It's either a vaccine and we don't know what that timeline is.

• 47:03Speaker 01

  Or it's enough of us have had this gotten over it that, you know, we can no longer transmit it and we say, Mom, it's okay to come back to the world now. So, you know, we need to think about several components. We need to think about minimizing total harm. We need to think about risk tiers. But we also need to think how these things are configured into some version of an all clear. Because, you know, you and I, Rich, can talk about this going on for a year or two or three and it, you know, it's terrible. But we at least expect to still be here when it ends, right? But if you're 80 years old, this is not the way you want your life to close out. I mean, that's just, that's truly horrible. So, you know, there, there's a whole cohort that's wondering, do I ever get back to the world before I check out?

• 47:49Speaker 01

  And, and I want to fix that. You know, that, that's also part of the human interest story here.

• 47:53Rich Roll?

  Yeah, I, I think that we struggle in trying, on the subject of, of minimizing total harm, sort of grasping what that means and what the approach is when we're dealing with poverty, isolation, education, food insecurity. But they, they, they're abstractions when we're dealing with the, you know, very real and immediate threat of trying to prevent people from contracting a potentially fatal disease. And so they get, they get back Bernard as something to deal with later. Meanwhile-

• 48:29Speaker 01

  Which is why, yeah, but that's why those stories need to be told too, right? So, you know, again, they, they are abstractions unless you put a face to them and you start telling in your newspapers and on television. Those human interest stories. You know, we have, we have the option of telling the, the tale of COVID fallout more completely. But my mom is not an abstraction to me, you know, obviously. And, and, you know, so I'm looking into the, the weepy eyes of someone who's saying, I, you know, I'm desperate to know that there's a plan. I'm desperate to know that there's a path back to a world where I get to hug my grandchildren.

• 49:11Rich Roll?

  Right. There is a sense that, that maybe there really isn't a plan right now. I mean, we hear the, the, the mantra of testing, testing, testing. And yet, this world of testing seems to be rife with all manner of problems. When we think about the antibody test or the swab test, there's a high degree of false negatives. As far as I've been told, I have a friend who first tested positive, then tested negative, then tested positive, then tested negative again. He's pretty sure he had it, but then it, you know, then maybe he didn't. And that

• 49:52Rich Roll?

  foments a lot of confusion and fear. So when you're talking about establishing a cohort that you can then test and then extrapolate the data from, you know, where are we in terms of testing, testing accessibility and also testing veracity?

• 50:11Speaker 01

  Yeah, no, it's a really good point. And I can tell you that for whatever reason, the third of my three 12-hour shifts in the emergency room in the Bronx, we admitted that day 20 people with COVID. I forget whether it was 19 or 20 who tested negative with the nasal swabs. But I mean, there was no doubt they had it. You know, there's, there's now sort of a classic lab panel. There are liver function abnormalities, kidney function abnormalities, coagulation abnormalities. There's a, there's a classic panel. I mean, it just jumps off the page and screams COVID at you and they all had that. But their swab was negative. And so, you know, we knew for sure that it was a bad batch of swabs or who, what. Yeah.

• 50:52Speaker 01

  So we, we need test kits we can trust. And with all the different entities producing kits and competing for their kits to be used. You know, again, it's the work of a couple of days to say, okay, the most reliable test methods for infection are and for antibodies are. And perfect? Nah. But perfect's the enemy of good. We need good data. Good will do. So, you know, that needs to be done. It should be coordinated federally. You know, we should have the FDA, the CDC, Department of Health and Human Services collaborating to get that sorted out. The best available kit should be deployed. And yeah, we have the resources to do 50,000 tests. We absolutely do. We can't do 5 million. We certainly can't do 50 million, but we could do 50,000. And

• 51:35Speaker 01

  that's what we ought to do. But you're right. We need data we can trust. But it's interesting because as you say, it's the false negative error rate that appears to be high. And yet, with all of the population samples, what we're finding is a lot more people have had this thing than we knew about. So again, in New York, it looks like 20%. So if that's 20% at the level of state, that's 4 million people. And that translates the mortality toll in the hardest hit part of the hardest hit country to a very small fraction of a percent. Now, that doesn't make this any less tragic if you were one of those people or one of those people was a loved one. And, you know, I hasten to note that every time we're talking

• 52:16Speaker 01

  about real people, real families, real pain, real loss. But what it does change is the likelihood that you are going to get this and die. You know, if, if out of all the people who get this, you know, 0.2% or 0.1% die of it, then, you know, the likelihood of you dying of it, even if you get it, is that, you know, something like 0.1 or 0.2% unless you're in a very high risk group. In other words, 99.9% probable that if you get this, you'll recover from it. And if, and, you know, if you're in a low risk group, it's 99.999, you know, that sort of thing. So it does absolutely change the emotional

• 53:00Speaker 01

  reaction to all of this. So it's really important. So we need those data. We need those data so we know what to do. We need those data so we know who to protect. We need those data so individuals can make some judgment about their personal risk and process their fear. I'm actually working with colleagues on a personal risk calculator, which I, you know, I, I used it myself and think, well, this is great because I'm 57 years old.

• 53:27Speaker 01

  I can tell you that before I, you know, went off to, to work in a New York City Emergency Department, I had to overcome a lot of resistance in my family. Uh, my kids freaked out, my wife freaked out, my mother totally freaked out, you know, there was crying and, and it made it hard for me. And I, and they said, you know, you're doing so much to address the policy, just, you know, keep doing that, you don't need to be on the front lines, you're making your contribution. I said, yeah, it just doesn't feel right. I'm a clinician, I'm an internist, uh, I have the skill set, they need the help, how can I justify abdicating? But there, you know, there was a great deal of anguish. So, you know, 57, I'm in the margin, right? 60 and above, you're definitely at high risk, but I'm extremely healthy, I practice what

• 54:10Speaker 01

  we preach and, you know, I'm a beneficiary of it. So I, I put myself through this risk calculator that colleagues are working on, and it, it determined that my COVID risk age was 40, 17 years younger, you know, which drops me, you know, so I, I have the COVID related risk of a healthy 40-year-old.

• 54:29Rich Roll?

  Right.

• 54:30Speaker 01

  Which meant, you know, my risk of, of needing hospitalization, if I get infected is, you know, is a percent, my, my, my risk of the ICU is a fraction of a percent, and my risk of dying of this is a tiny fraction of a percent. And, you know, I think that's a, it's a useful reality check. Now, those models are only as good as the data flowing into them, and when we generate better data, the models will get better. But even so, you know, I think, I think qualitatively, that's right. My risk is comparable to a person much younger because of my health status, and I can look at that and say, oh, okay, you know, I, I feel pretty good about this. I mean, it's very unlikely that this disease is going to hurt me, so I can get out there on the front lines and help other people. And, you know, that reassured my family.

• 55:12Rich Roll?

  And you were doing that in the Bronx, correct? Was that at, uh, Robert Osfeld's Hospital, Montefiore? Or which hospital were you at?

• 55:22Speaker 01

  It's at Rob Osfeld's Hospital System, so it was Montefiore.

• 55:25Rich Roll?

  Okay.

• 55:26Speaker 01

  Uh, Montefiore has several campuses, Rob was in one of the other hospitals, so I didn't get to see Rob during this time, I was on the Wakefield campus. Yeah, so actually, the way this worked, interesting story in its own right, uh, New York City Health and Hospitals Corporation sent out a call for volunteers, I signed up. Uh, you know, I heard about this through Governor Cuomo. And then I got an email as an alum of the Albert Einstein College of Medicine, which is home to the Montefiore Medical System. So that's where I went to medical school. They sent out an email to all of the alums and said, "We need help." So I signed up there, too. I immediately heard back from New York City Health and Hospitals, "You've been assigned to a hospital in Brooklyn. But here are the multiple steps you need to go through to clear our bureaucracy." And it was hours, hours and hours of online training.

• 56:11Speaker 01

  You know, you had to complete quizzes. So I said, "Okay, you know, I'm up to my eyeballs in work, but I'll do this as quickly as I can." And I started working through it. And it took me over a week to fit in all of those hours of training, much of it, by the way, about stuff that was totally irrelevant, like billing, Medicare fraud. I was a volunteer. Nobody was paying me anything, but I had to go through a training module about Medicare fraud. By the time I was nine-tenths done with the onboarding for New York City Health and Hospitals, Einstein got back and said, "Oh, no, no, we're not doing any of that nonsense. We can assign you tomorrow." I said, "Okay." So I, you know, I basically wrote back to the folks at the mothership, you know, for the state and said, "Give my assignment in Brooklyn to somebody else.

• 56:54Speaker 01

  I'm going to the Bronx instead because they can deploy me immediately and I haven't quite made it through your bureaucracy yet." That's unfortunate because I think a lot of people were caught up in that logjam and wanted to be on the front lines and were trying to get through. And by the time all of us finally broke through, you know, I think we were a little late for the party. But in any event, I wound up going to an Einstein system and Monty is part of Einstein. So Rob and I were, you know, we were basically in the same medical system, but at different campuses.

• 57:26Rich Roll?

  We hear a lot about ventilators and, you know, we're getting these stories from the doctors on the front lines through social media. But what is, you know, how would you relate that experience of being in that environment and treating people firsthand? Like, what do people not fully understand about that experience and what that's like? And, you know, where are some of the, perhaps misinformation about that?

• 57:54Speaker 01

  All right, let me address that. But before I do, since we were just talking about our friend Rob Osfeld, I just want to give a shout out to the people who are there all the time. You know, I retired from clinical care after 30 years, a few years ago, to focus on public health and these other things I do. And I went and helped, but let's be clear, you know, I just chipped in a little. You know, Rob's been there from the beginning and will be there through the end and, you know, my, my colleagues who are clinicians full-time, you know, it's day after day after day. And you and I have been saying on, on, during this discussion, Rich, that every day feels like a month. Well, I can tell you that 12 hours in an emergency department, you know, with COVID case after COVID case, it felt like a year. And these guys, you know, Rob

• 58:39Speaker 01

  and all of our clinical colleagues, they're, they're doing this day after day after day. So I, I just can't say enough about the support they deserve and, and how hard this is. And I can tell you this, you try, you know, we, we made a big fuss about not having PPE and not having N95 masks. It's no walk in the park to have one either. You try wearing an N95 mask for 12 hours straight. Your nose is abraded at the end of the day, your head is hurting from the elastic, seriously. Um, I now couldn't believe how eager I was to get the damn thing off.

• 59:10Rich Roll?

  Our mutual friend, Danielle Bellardo, has been sharing voluminously on this and related subjects. I mean, she's really, you know, I, I'm like, I, I don't know how she has time to post everything that she's posting, given, you know, the circumstances that she finds herself in. But, you know, following her gave me a very, you know, profound kind of tactile connection to visceral experience of what that must be like.

• 59:38Speaker 01

  Yeah, yeah. So I was, I was really glad to, to try it on, but I can't say I'm sorry that, you know, my contribution was the equivalent of about one week of work and, you know, doing it week after week after week. Wow. You know, it's, it's a heavy load. So, so kudos to them and thank you. Um, and I don't want more credit than I deserve. I, you know, my thinking was I cannot advocate. They need help. I'm going to sign up. But my hope is, you know, 10,000 people like me sign up too, because, you know, I'm going to contribute a week. That doesn't make much difference. 10,000 weeks of work makes a huge difference. And so I should be part of an army. And I think I was. Anyway, back to ventilators. So fascinating.

• 1:00:19Speaker 01

  I have never seen clinical medicine evolve this rapidly. Uh, in a, in a 30-year clinical career, I've never seen anything that caused us to change fundamental norms of treatment as fast as COVID did. My colleagues in the ER were telling me. Last week, this time, we would have intubated all these patients. They would have gone on ventilators. And this week, we're not, because this is a different disease. What's been described for COVID is that its effect on the lung is a bit like altitude sickness,

• 1:00:52Speaker 01

  that the pressure from the ventilator actually takes uninjured parts of the lung and injures them, and causes them to undergo the viral-related damage, which is very different from typical pneumonia, either bacterial or viral. And what's been discovered, along with many other advances in treatment, and by the way, this is why, you know, these days that feel like months and weeks that feel like years are good just the same, because we're learning very, very fast. And even getting this disease now is much better than getting it a week ago, let alone a month ago, in terms of your likely outcome.

• 1:01:27Rich Roll?

  Because of what we've learned along the way?

• 1:01:31Speaker 01

  Yeah, about the pathophysiology, about the treatments, I mean, they've evolved remarkably. In terms of the ventilator, what's clear is, you put somebody in a ventilator if you have absolutely no choice. If they just, you cannot oxygenate them without a ventilator, you have to put them on a ventilator and then try to get them off. But if you've got, you know, even this much latitude, you don't put them on a ventilator, you give them oxygen, and you do simple things like reposition them. They're on their left side, they're on their right side, if you can manage it, they're over on their stomachs. And it makes a huge difference in oxygenation, just repositioning. So the protocol a week prior had been plummeting oxygen level, intubate them.

• 1:02:12Speaker 01

  Protocol when I was in the emergency room was, do everything possible to avoid intubating them, give them high flow O2, change their position frequently, and wait it out for an hour or two, see what's happening. And I watched patients get better in an hour that would have been intubated and shipped off to the ICU the week before. Amazing. And then similarly, rapid advances in the medical treatment. Almost everybody that we admitted.

• 1:02:37Speaker 01

  Had a coagulopathy. In other words, they were at risk of blood clot formation. And there's a specific test called the D-dimer test that you can do quite rapidly to see, is your coagulation system in overdrive? Everybody's was. So, everybody got an anticoagulant. And a lot of the adverse outcomes in people who had been admitted the month prior were related to blood clot formation. And, you know, we didn't know that that was happening, so they weren't routinely treated for it. Now they're treated preemptively for that. And a number of other medical advances too. And of course, you know, now there's a lot, there was interest in hydroxychloroquine. That interest has sort of moved on to a drug called remdesivir.

• 1:03:20Speaker 01

  But the simple fact is, you know, all around the world, there is real-time experimentation to figure out what works. You know, one of the great problems, we've not talked about it yet. It's incredible how bad it is to conjoin the greatest crisis in public health and living memory with an utterly inept federal government. But, you know, that combination is truly dreadful. And yet, you know, we really have a massive boondoggle in terms of, you know, the leadership of our country right now. It's been a huge problem throughout this crisis. And one of the things I've been inclined to say throughout is,

• 1:04:03Speaker 01

  if only grownups were in charge, right? I mean, we really, we had enlightened, compassionate leadership that respected science and listened to the right experts. So, you know, we ought to have, and should long since have had, at the federal level, a clearinghouse that everybody could access with promising innovations, best practices. And they should, you know, it should be transparent. There should be criteria, it should be screened and filtered daily by an army of, you know, 300 people trained in science and public. I mean, none of this is rocket science, none of this is a trip to Mars. There's some effort and there's some person-time involved. But in the absence of grownups running the country, there are thankfully grownups running hospitals and clinics and research labs.

• 1:04:48Speaker 01

  And there has been massive exchange of ideas. And little by little, the best practices are percolating to the top and everybody's adopting them. And then that becomes the new standard. And then there's another round of experimentation to see what is the best of that tier. So, yeah, everybody can take comfort in the fact that the clinical management of COVID-19 is advancing very rapidly.

• 1:05:23Rich Roll?

  Well, we could spend a lot of time deconstructing the federal government's approach, or lack thereof, to this pandemic. My hope, of course, is that this is a learning experience that will inform the creation of institutions and protocols that will help us manage these sorts of situations in the future. But you mentioned that you're going to be speaking to Homeland Security. I'm curious about your interface with the administration. Have you had an opportunity to communicate with Dr. Fauci or his team? Or what is your relationship to the administration?

• 1:06:06Rich Roll?

  And are you in a position where you're of counsel to what is happening? Or what does that look like right now?

• 1:06:14Speaker 01

  It's interesting. So, you know, you mentioned before how my piece in the New York Times became something of a lightning rod. I don't think that's because of what I wrote in the New York Times. I think it's because I wrote my op-ed, Tom Friedman wrote his, and then President Trump tweeted, "Let's not let the cure be worse than the disease." That was the title of my op-ed in the New York Times.

• 1:06:36Rich Roll?

  Right. It was an immediate response to having read that piece, of course. And it dovetails perfectly into, you know, his preferred approach.

• 1:06:45Speaker 01

  That's what it looked like, yeah, governance by tweet. And, you know, I mean nuanced.

• 1:06:52Speaker 01

  Policy responses to the most complicated public health crisis in living memory is not conducive to governance by tweet. But I, you know, I think what happened was people sort of blamed me for the presidential tweet, which I didn't sanction. You know, I, I never favored everybody back in the water, never mind riptides and the sharks. Um, you know, I talked about a data-driven, risk-stratified pivot from horizontal to vertical interdiction. So it's been sort of fraught because it, I think if this were a different administration, I would have actively campaigned to have access and, and, you know, I think they would have welcomed it. Uh, you know, it, you don't have to look very hard into my paper trail to see where I stand with regard to this administration.

• 1:07:37Speaker 01

  So I don't think, you know, they'd be very comfortable meeting with me directly. Um, you know, I, I think Fauci probably, you know, knows he has all the expertise he needs. His problem is his boss. So mostly it's been indirect channels. I've had some communication with, um, with Fauci's, um, associates and have had some communication with people, um, associated with, uh, Joe Biden and have spoken to several governors. But this opportunity to interact with a bipartisan committee of the Senate is probably the best opportunity to influence the administration in a way that actually means something because,

• 1:08:22Speaker 01

  you know, there'll be several witnesses will all get to make a, a statement for five minutes, then be subject to Q and A, and then all of that information will be available. And there'll be so much more substance to that than, you know, trying to influence a president who, again, uh, you know, views this as just another situation to either declare one extreme or the other. It's a hoax, it's a war, who can we blame for it? You know, so I, I really struggled with that. I, I've had colleagues ask me, you know, if you were asked to be on the coronavirus task force, would you do it? I, I don't know. I don't, I don't trust the person in charge of the information to do the right things with it. So I I've been looking for ways to influence the policy response.

• 1:09:06Speaker 01

  My working with people, I I felt would put information to good use. I've been very impressed with Governor Cuomo. We we've spoken and, you know, I I think um he got caught up for a while in the race to procure resources. So, you know, there there was a lot of focus on the nuances of policy. And then he disappeared for a while. And I think it was all because he wanted to make sure he had P P E for everybody who needed it and ventilators and hospital beds. But I think, you know, now he's he's sort of moving back and looking at how do we start to open up New York in a responsible way, minimize total harm. So I I, you know, I think I've had a real influence there. And I think there's real opportunity because the governors all talk to one another. They're looking for best practices.

• 1:09:49Speaker 01

  And even though, you know, they're varying perspectives, to some extent partisan, to some extent related to character, they are all looking carefully at one another to see who produces the best outcome. Uh, so my efforts are mostly focused there.

• 1:10:04Rich Roll?

  And where does Michael Osterholm fall along this spectrum of of influence and opinion?

• 1:10:11Speaker 01

  Yeah, so I, you know, I I consider Mike certainly way above my pay grade when it comes to pandemic response specifically. You know, I I think, obviously, I I know more about the social determinants than he does. Um, but I I think Mike is arguably, you know, the single leading expert on pandemic response in the country, widely viewed as such. So when I have questions, I ask him. Uh, and one of the questions I asked him just a couple of days ago was, should I shut up? Should I stop talking? And he said, no, don't, because, you know, you you you absolutely do have the big pick. Because I thought, you know, I'm getting all this attention. I thought it would stop. I thought I had fifteen minutes in in the spotlight and it would have gone away a long time ago and it just keeps going and going.

• 1:10:54Speaker 01

  And should I just say, you know, go talk to Mike? And he said, no. You know, I mean, first of all, it's really important to be able to speak clearly. It's really important to take complicated things and express them in a way that that, you know, the the lay public can understand. And you're absolutely right. There's more to this story than just the virus or virology or infection. You know, there are all these other things. No, you've got to, you've got to keep doing what you're doing. My, my wife was listening quietly in the background because I had just had a conversation with her saying, you know, I, I, I need my life back. I know the world wants their lives back, but I'm not just living through, you know, this surreal period, but I'm living through this surreal period drinking from a fire hose. I've never been busy. I'm hearing from family, you know, we're home twiddling our thumbs, you know,

• 1:11:37Speaker 01

  do you want to read poetry? I'm saying, are you kidding? I have, you know, 15 hour workdays. I'm happy if I can get a night's sleep. But Mike said, no, you gotta keep going. Um, and in terms of our points of view, very, very highly confluence, but with one important exception. Um, Mike says past pandemics have fooled us. And so he natively is much more concerned about a second wave than I have been. So I, you know, I've looked at the data and said, wow, you know, almost everywhere we look where they, they, we do have decent testing for a population, about 20% of people exposed get infected. And about, you know,

• 1:12:20Speaker 01

  98 to 99% of those who get infected have a relatively mild case. And that pattern just plays out again and again and again, all around the world. It looks to me like there's a lot of native resistance, that people who, you know, who get this mostly become immune and we're well on our way to herd immunity. And, and Mike says, not so fast. You know, we, we were starting to feel good about some of the past, um, bad flu years and they waned in one season, then came back in the fall. That happened with the, the famous pandemic of 1918 as well. I'm not convinced yet that we're through this. I'm not convinced there won't be subsequent waves. And he cites data about, you know, high rates of infection in one country and low rates in a neighboring country and no

• 1:13:05Speaker 01

  good reason to account for it. So I'm tempted to think a lot of that has to do with demographics, you know, differences in age distribution and, and baseline health and testing. So we know there's a lot of infection in countries that do a lot of testing. We think there's almost no infection in countries that do no testing, but that's not because they don't have the disease. It's because they haven't ascertained. But Mike is more nervous about a second wave. And when somebody like Mike talks about stuff like that, I shut up and listen. And so, you know, he's made me temper my views and think, this is what the data are saying. This is what I think. I'm reasonably optimistic,

• 1:13:46Speaker 01

  but I think we have to stay really well prepared because past pandemics have surprised us in unpleasant ways. So do we need a supply of PPE? Do we need surge capacity in our hospital system? Do we need a surge supply of ventilators just in case things get bad in the fall? Hell, yeah. And whatever we do in terms of policy, we have to do it nimbly. We have to be prepared at every step of the way for an empirical reality check. This made sense based on what we knew, but we didn't know enough to be sure. And, and, you know, this is something I will also tell the Senate Committee, and I've been saying this throughout as well. If anybody tells you they're absolutely sure what's the right

• 1:14:27Speaker 01

  thing to do in this situation, run like hell in the other direction because we just don't have enough data to know for sure what's around the next bend. So I've been very gratified when I can, you know, I can get Mike's attention so readily. I've taken advantage of that. We've spoken multiple times, exchanged information. If I have doubts about something, I share it with him. There are others too. And, you know, I'm really surrounded by a group that knows a lot. But I don't pretend to be an expert in all of this, and I happily learn from those who are. And Mike's point of view is encouraging up to a point, but having, you know, been up close and personal with prior pandemics, he says, you know, keep your powder dry.

• 1:15:08Rich Roll?

  Right. What is your sense of the value of contact tracking apps at this point? There's been a lot of discussion about that, leveraging technology to get better data and balancing that against privacy concerns?

• 1:15:28Speaker 01

  Yeah. So I've never really focused preferentially on that. I, you know, I think I would be happy to know. Right now, what is the estimated prevalence of infection in the United States? What is the estimated prevalence of immunity? And what I've advocated is to build a data pyramid. So I'd like, you know, I'd like to be able to extrapolate from a representative random sample, total number infected, total number immune. Out of that group, how many had any symptoms at all? Out of that group, how many sought medical attention at all? Out of that group, how many got hospitalized? Out of that group, how many needed the ICU? Out of that group, how many died?

• 1:16:10Speaker 01

  And then how does all of that relate to a range of age, BMI, health status? And that would be almost everything I need to know. And if that told you, okay, the disease is bad and we really need to interrupt spread pretty much anytime someone gets infected, contact tracing becomes crucial. If that pyramid tells us, you know, again, everything we thought we knew from other countries is true, 98 to 99% of all cases are mild. And if you talk about people under 50, free of major chronic disease, 99.999% of cases are mild.

• 1:16:50Speaker 01

  Is it really worth the effort to put privacy at risk, to do contact tracing in that group? I'd say what we really want to do is make sure we carefully shield the most vulnerable from exposure. And if we're going to do contact tracing, let's focus that to that population as well to make sure essentially we're identifying, have you had an exposure? Do we need to do pulse oximetry? Because, you know, if you are 72 years old and we think you've been exposed, we want to detect the slightest initial decline in your oxygenation level so we can pounce on it. We don't want, we don't want to wait until, you know, you've got high fever or racked with chills and your oxygen is dropping below 90.

• 1:17:34Speaker 01

  Because, you know, we've missed the opportunity to intervene early. So I would say selective. My impression is with, you know, with the right data pyramid to guide us, contact tracing could be directed to protecting the highly vulnerable. But, you know, I don't think we need to care what the level of exchange is among college students one to another. Almost overwhelmingly, they're going to have a mild or asymptomatic doubt of this. Why do we need to know everybody they've associated with? It's a huge amount of data to process to very little good. And, you know, I would say the effort that we invest in every aspect of interdiction

• 1:18:12Speaker 01

  here should be guided by the likelihood of it saving lives, preventing bad outcomes, and I would channel it accordingly. So I see some value in it, but I would tend to approach it selectively.

• 1:18:26Rich Roll?

  Where is your head in terms of optimism versus pessimism in terms of, you know, how we're approaching this as a society? Like forecasting weeks or perhaps several months into the future, what do you think is most, is our most likely approach to this? And where are we going to see ourselves and find ourselves come July, August, September?

• 1:18:53Speaker 01

  Again, I think if only because we have these opposing forces of lock it all down until there's a vaccine, everybody back out to the world right away. You know, I think it, almost the inevitable result of those tensions is okay, middle path. Now, just so happens that the middle path, I think, is a good idea anyway in terms of minimizing total harm. So I think, you know, we could have gotten there because of science and sense. We may get there because, you know, it's the only way out of an impasse that's so polarized. But I think we're headed toward that, where we phase back to the world. I think inevitably it will be somewhat data-driven because we have data and governors

• 1:19:37Speaker 01

  are looking at the data they have. I think it will be somewhat experimental because we have Republican governors and Democratic governors and they're inclined to do things differently. So Georgia, I think, bungled by opening everything up too soon. I think there may be states that stay locked down too long, but you know, to some extent, I think the governors will be looking for, okay, who passes the Goldilocks test? You're too locked down, you're too opened up, looks like you're having the best experience, I'll have, I'll have what she's having. Right. I think there'll be some of that. I hope that we do rally to a nationally representative random sample. Again, it's not a huge job, would make a huge difference. So, you know, I think maybe this testimony to the Senate will influence that. I think that could happen, I think it should happen.

• 1:20:22Speaker 01

  And then, you know, I, I think we will start to see things open in waves and it's a little bit like put your toe in the water, put your foot in the water, put your leg in the water and, you know, let, let's see what happens. So I, I think, I think at this point, we have propagated enough anxiety about this that even when things open up, there're gonna be a lot of people who are reticent about letting their families go out to the world. I do think there's an opportunity to supplant, or supplement, rather, policy responses with informed and empowered individual decision-making. So I think the deployment of tools that help you, you know, quantify your own risk for a severe outcome, I, I think those would be timely.

• 1:21:07Speaker 01

  I think there's a real opportunity for what you and I were doing before all this, where we tell people, look, you know, the stuff that, that was placing your health in peril before in slow motion is now an acute threat, do something about it. You know, I, I'd like to see a federally mediated, let's get healthy now campaign, but I think a lot of individuals are going to be saying, you know, I'd really like to do something about, you know, my, my hypertension, my diabetes, my weight, where can I get help? I think that may be part of this. There may really be an aha moment about health in America. I, you know, and, and then the question becomes what happens with...

• 1:21:47Speaker 01

  My parents, for example, you know, when do we give them the all clear? So, you know, my inclination would be we, we look at viral transmission. We continue to track it. We try to get better data about the, the prevalence of antibodies. And when it seems that we have a high level of immunity among at least whatever portion of the population tends to get this thing and near zero transmission of the virus, they get to come back out to the world and hug their grandchildren. Mike Osterholm's point of view and, and the point of view of others who are warning we may see waves of this is, is a precautionary tale though that says, you know, let's, let's

• 1:22:28Speaker 01

  be really careful about the potential need for sheltering vulnerable populations again at a later date if in fact we got a lull and then another surge. Again, that may be true. I, I cannot dismiss points of view from people as well informed as, as Mike, but it, I can't, I can't use the, the notion of waves to account for what's happening on Navy ships. I can't use the notion of waves to account for what happened on the Diamond Princess. Why is it that on a contained ship, only 20% of people got infected? They were all exposed to one degree or another, but you know, eight out of 10 people on the ship didn't get the bug, at least in, in terms of what our testing tells us.

• 1:23:11Speaker 01

  And most of those who did get infected got over it and, and are now immune so far as we know. To me, that's very encouraging. So I'm, you know, I, I look at South Korea, I look at Iceland, I look at Germany, I look at Sweden, I look at the Diamond Princess, I look at the Navy vessels and I say, you know, honestly, I'm pretty optimistic. I think, I think a lot of the population is mentally resistant just to get this thing, even if they're exposed. I think most people who get it, if, you know, if they're not very elderly or not seriously ill or both. Recover from it. We are getting better at treating it. I think we do need to shelter the vulnerable, both because it's not safe for them to get it, and because that's the best way to avoid overwhelming the medical system. But I think we can stop doing that

• 1:23:55Speaker 01

  when the rest of us have already been out in the world, tested the waters for them, and said viral transmission's near zero. And then we just stay light on our feet. So if it starts to recur, we have adaptive policies. But I think we get to something approximating life as we knew it before, within the next couple of months.

• 1:24:15Rich Roll?

  That's encouraging. It does appear to be a very strange and perhaps unique disease in the manner in which it afflicts people. You know, as you mentioned, there are at-risk groups, of course, but we're all hearing the stories of the robust 30-year-old, you know, jujitsu artist or, you know, athlete who suddenly contracts this and dies. And I would suspect those are outlier cases, but they're also alarming in that it doesn't appear to have a rhyme or reason in the manner in which it impacts people in this disparate way. And I think that creates a lot of fear and confusion among people. That makes it

• 1:25:00Rich Roll?

  more difficult to wrap your head around, like, what the best course of action is for yourself, right? Like, I feel like, you know, I'm 53, but I'm pretty healthy. I don't spend a lot of time thinking about what it would be like to become that ill or to contract this disease. But in the back of my mind, I'm aware of those stories, and it weighs on me. And I think about that when I venture out into the world. And I juxtapose that against, you know, I think that, you know, we've all been locked down for a period of time. And I don't know what the vibe is in Connecticut and New York at the moment, but I can tell you in California... There's a growing restlessness. I think human beings are only wired to be able to adhere

• 1:25:45Rich Roll?

  to this kind of thing for so long before they just start bursting at the seams and they're like, "Fuck it, I'm gonna go out into the world and roll the dice, I'll be safe, but you know, I'm just not gonna stay at home any longer." And I'm seeing that, you know, now. And so there's like kind of a leakage or a spillover effect that irrespective of what the government is telling us we should or shouldn't do, or can or can't do, people are still gonna do what they're gonna do.

• 1:26:10Speaker 01

  Exactly. It's all the more reason why we are going to move into a next phase of this soon, if only because human nature drives us there. But back to your other point, I totally agree, Rich, and you know, again, this issue of, you know, it kills young, healthy people, it kills young health professionals, it does. But you do not make it through week one of Epidemiology 101 without learning to ask always and every time, what is the denominator? So I had a beloved colleague, really a dear friend, it's hard for me to tell this story even these several years later and not choke up, but Athar Ali, we worked together clinically for 15 years, first naturopathic physician ever on the faculty at Yale, died at 42 of

• 1:26:54Speaker 01

  esophageal cancer. I have no goddamn idea why. He never smoked, ate optimally, practiced meditation daily, exercised routinely, beautiful wife, lovely children, gentle, kind, loving, thoughtful, purposeful, I mean, just beautiful, beautiful human being. You know, it makes me angry. What unkind fate. And then just recently, I have a friend where I ride my horse, she's in her 40s, pancreatic cancer, no risk factors, no reason. If we told every one of those stories with the commitment we have to telling every COVID story... You know, what's going on? Pancreatic cancer, esophageal cancer.

• 1:27:38Speaker 01

  And there are enough of them out. There's a critical mass of these stories. They could be in the news every day. And we would wind up thinking, my God, I'm 57, you're 53, I'm 42, I was healthy. I didn't think I had to be afraid for my life every day, but every day, there's another story of a person my age or younger, my health or better, getting some dreadful disease we thought only happened to people with risk factors. What's going on? Oh, my God, the sky is falling. It's human nature to want to know why. And in medicine, one of the things you have to reconcile yourself to over the years is you often have a notion of why and sometimes don't have a clue. And when enough people get COVID, if millions and millions, again,

• 1:28:20Speaker 01

  zero prevalence suggests four million people in New York State alone have had this. But when millions of people get something, some of them are going to have a really bad, bizarre outcome you can't account for based on their health or their age. And then, of course, with the healthcare professionals, they're still quite rare because most of the frontline people have been exposed, probably have had this and gotten over it. So it's probably a very tiny fraction of the health professional cohort that has a severe case. But it may have something to do with dose. Another thing you don't make it through your MPH degree without learning is that infectious disease is host-agent environment.

• 1:29:02Speaker 01

  The host is you and me, the agent in this case is SARS-CoV-2. And the environment is very different if you were in a room where somebody with COVID had been a couple hours ago. You were exposed to some small number of viral particles. You got a little bit sick and your immune system took care of it versus you were doing bronchoscopy in the ICU and were exposed to a massive dose of viral particles that overwhelmed your defenses. And there's an easy way for people to think of this. It's a pretty good analogy. You have a compound, you're defending your perimeter, and your defense is your immune system. And if there's an ambush by a relatively small number of the enemy, you can repel them.

• 1:29:45Speaker 01

  If that same enemy amounts of force that is 100 times bigger than your defense force, you get overwhelmed and really bad things happen. Viral infections like that. So the dose of exposure is basically the size of that ambush. It makes a huge difference in whether your immune system gets the upper hand early or whether it's completely overwhelmed. And I think that accounts for some of the health professionals. But, but again, some of this is, you're just right and it's scary. Some of this is, yeah, but it's because we're telling COVID stories in every news cycle. And comparably bad things for comparably bizarre reasons are happening to young people around the country every day. And we're not telling those stories.

• 1:30:28Speaker 01

  So it looks like COVID is the one and only risk and oh dear God, sky is falling. It's a distortion. It really is. The risk is small.

• 1:30:36Rich Roll?

  Well, you've been incredibly generous with your time and I want to be mindful of that and release you to your life in a minute. But before we, before we wrap this up, I, I think it would be good to, to end it with some thoughts on, on, you know, what we can do personally. We spoke earlier a little bit about immunity. Obviously we want to maximize and, and boost our, our bodies, you know, immune response. We want our immune system to be functioning at its peak. There are certain things that we can do, lifestyle practices and dietary protocols that can enhance that.

• 1:31:16Rich Roll?

  And I think this is a subject matter that we could talk about for hours, but is, I want to keep it brief, but it's, it's a, you know, it's kind of an underrepresented conversation in this dialogue around coronavirus. What we can do personally to make sure that we're as healthy as possible. So should we come into contact with the virus, we're in the best position to be able to confront it and overcome it.

• 1:31:44Speaker 01

  Absolutely. I think it's a huge issue. And interestingly, it's another one that we polarize. So you've got people sort of peddling nutrient supplements willy-nilly. And then you've got articles in the New York Times and elsewhere telling people diet, nutrition, nutrients don't make any difference. And both of those are silly. You know, it's not as if you're going to take some number of supplements and it's going to make you bulletproof. But the idea that diet makes no difference to immunity is absurd. Every day, your body is replacing white blood cells and the construction material comes from your nutrition. And so whether or not those cell membranes are optimized, whether or not you're able to replenish the productive capacity of your bone marrow,

• 1:32:27Speaker 01

  absolutely dependent on every aspect of diet. It's not just one nutrient. Yes, zinc is important, vitamin D is important, all of that. But it's the full array of amino acids, it's the full array of fatty acids. A balanced diet is the source of construction material for the replenishable portion of your immunity. Think about antibodies. We talk about antibodies. Well, those are proteins. You have to build them. You need, you know, an optimal diet to build optimal materials. And then there's antioxidants. The key role of antioxidants is to defend your healthy cells. Your immune system is like an army. It's engaged in chemical warfare. There is the risk of collateral damage. And frankly, one of the reasons people get so sick with COVID is this cytokine storm,

• 1:33:09Speaker 01

  which is activation of the immune system to fight the virus, doing damage to your healthy tissues. Balancing your immune response, so it's not excessive, but it's also adequate, has a lot to do with balanced nutrition. Protecting your healthy cells has a lot to do with balanced nutrition. So enormously important, and it's immediately actionable. You know, we've done studies over the years when I was directing the Prevention Center at Yale, looking at vascular function and, you know, key measures of homeostasis and health that change in response to a single meal. So people should not think, you know, I know diet and lifestyle are important, but they can't help me in time. They can help you in time. You can make a difference today.

• 1:33:53Speaker 01

  You can make a real big difference in the span of some days and you can make an enormous difference. You could pretty much do a 180 in the span of weeks and that's fast enough. So, you know, we're trying to do everything we can to help with this. Again, collaborating with colleagues on a personal risk calculator. As you know, Rich, I run a company now, Diet ID, where we can assess diet pattern, diet quality, nutrient intake level, and we're making that freely available, direct to consumer. We're a B2B business, but we're actually making this available to people so they can see whether or not their diet is a risk factor for COVID and do something about it immediately. And we help coach them to a more optimal diet. So you can learn more about that at

• 1:34:35Speaker 01

  dietid.com. But the big picture here is that, you know, stuff about diet, lifestyle, health that maybe didn't grab your attention before because, again, it didn't trigger a fight or flight response. Suddenly it does. Suddenly, you know, you're not thinking, "Yeah, yeah, you know, I know I'm at risk for heart disease or diabetes, but I could fix that tomorrow and tomorrow and tomorrow." And tomorrow never comes. But you're literally worried about COVID infection tomorrow and all of a sudden you're saying, "Help!" Well, good news. You really can do something about it. So, physical activity, really important. Enough sleep, really important. Obviously, all the stuff about personal hygiene, managing stress, all those key elements of lifestyle is medicine that were important before. If

• 1:35:18Speaker 01

  you smoke, there's never been a better time to quit. But there's also never been a better time to improve your diet. And there are some nutrients that probably are a good idea. Vitamin D is one. Zinc is another. Vitamin C may be a third. Maybe omega-3 to balance immune system response. But one of the best defenses against a bad outcome here would be to optimize your diet. I think people know what that looks like, but on the off chance they don't, you want to be eating lots of vegetables, fruits, whole grains, beans, lentils, nuts and seeds, plain water when thirsty. You know, the more you're eating whole plant foods, the better. In terms of all of these different elements and, and you know, if we took the hours you

• 1:36:00Speaker 01

  just mentioned, we really could talk through all the mechanistic pathways. How does that translate into antibody production? How does that translate into lymphocyte production and activity and neutrophil production activity? You know, there's a there there. This is not whifty. This is not, you know, trying to make the case that that is important. You've got whole textbooks on the, the linkages between dietary intake, endocrine balance, immune system function. It's fundamentally important. It can alter your risk in hours and certainly days and profoundly in weeks. So I would say, you know, there's never been

• 1:36:41Speaker 01

  a better time. Don't let another day go by where you don't at least try to leverage the power of diet to protect you against this bug.

• 1:36:49Rich Roll?

  Yeah, that's fantastic advice. Well, thank you, David. I hope to continue that aspect of the conversation at a future date and, and do a podcast the way that we originally conceptualized it where we can go deep on diet and lifestyle. For people that are listening, you did a great job on Danielle Bellardo's podcast a while back where you kind of laid out your whole perspective on nutrition and that's certainly valuable if people are watching or listening. I could point you to that, but hopefully I'll have an opportunity to sit down, meet you in person and, and we could talk more. I hope you'll come back on the show.

• 1:37:26Speaker 01

  I look forward to that, Rich. Thanks. Thanks very much.

• 1:37:29Rich Roll?

  And keep, keep being a, a voice out there. I don't, I don't envy your political hot potato status at the moment, but a voice of reason is much appreciated in this moment of calamity. And I appreciate the work that you do. I'm a proud supporter of True Health Initiative, which hopefully we can talk about more later. And you know, I've, I've, I've been an avid fan and follower of the work that you've been doing for a long time. And I just wish you well and, and I want you to keep doing what you're doing. So stay healthy.

• 1:38:01Speaker 01

  All right, that's the plan. Thank you so much. I'm going to spend the rest of the day packing up this microphone that you sent me.

• 1:38:07Rich Roll?

  Sorry.

• 1:38:08Speaker 01

  I gotta get the damn thing back in the box.

• 1:38:10Rich Roll?

  We tried to make it easy. I think it worked out fine. How do you feel?

• 1:38:14Speaker 01

  I think it did too. Yeah, pretty good.

• 1:38:16Rich Roll?

  This is my first, I've done a couple of remote podcasts, but this is the first time I've tried to do it on video, and I think it went pretty good.

• 1:38:23Speaker 01

  Yeah, I think so too.

• 1:38:25Rich Roll?

  You made it easy for me. If people want to learn more about you and your work, what's the best place to point them towards?

• 1:38:32Speaker 01

  My website links to Diet ID and True Health Initiative. It's probably the easiest place for one-stop shopping, davidkatzmd.com.

• 1:38:41Rich Roll?

  Right, and I'll put links up in the show notes. You also write quite frequently on LinkedIn where you put some longer thought pieces there, so I'll direct you to that as well.

• 1:38:51Speaker 01

  Yeah, the website links to that too. Yeah, thank you. And listen, I really appreciate what you do, so thank you so much.

• 1:38:58Rich Roll?

  Thank you. All right, well, until next time, David. Thanks so much.

• 1:39:01Speaker 01

  Take care. Stay safe.

• 1:39:03Rich Roll?

  Peace.

• 1:39:04Speaker 01

  Peace.

• 1:39:05Rich Roll?

  Lance. How was it? How'd that one go down for you? How are you feeling? There's a lot to digest there, I know. So, maybe just let it simmer for a bit. To learn more about David's work, check out the show notes on the episode page at ritual.com. I've got links there to all of his digital destinations, as well as many articles pertinent to today's discussion, including David and Tom Friedman's respective New York Times op-ed pieces. While you're at it, give David a follow on the socials. You can find him @DRDavidKatz on Twitter and @DrDavidKatz on Facebook, as well as LinkedIn, where, as I mentioned, he publishes

• 1:39:48Rich Roll?

  many notable long reads that are worthy of your attention. Finally, check out his latest book, How to Eat. It's a game changer. Down with Fake News and Fads, Up with Science People. If you'd like to support the work we do here on the show, subscribe, rate, and comment on it on Apple Podcasts, Spotify, and YouTube. Share the show or your favorite episodes with friends or on social media. And you can support us on Patreon at ritual.com/donate. I appreciate my team, who endeavored, who labored. Long and hard to put on today's show. Jason Camiolo for audio engineering, production, show notes and interstitial music. Blake Curtis for doing double duty, helping me with the Zoom video version of today's

• 1:40:29Rich Roll?

  podcast, which had its technical difficulties, but I think everything went fine. Jessica Miranda for graphics, Ally Rogers, who generally does portraits, but not when we're doing remote. DK for advertiser relationships. Georgia Whaley for copywriting and theme music, as always, by Anna LeMme. Thanks a lot, you guys. I appreciate you. I'm wishing you well. I hope to meet you on this path of life in good health at some point, and I will see you back here in a couple of days with another great episode. Until then, be well, take care of yourselves, love yourselves, love others. Try to be a little bit gentle with yourselves. All right. Peace. Plants. Namaste.