0:00

Hi everyone, I'm Katie Current and

0:02

welcome to Next Question. It's

0:06

a new day for us here at Next Question, as

0:08

I'm sure it is for all of you. The

0:10

rampant spread of the coronavirus

0:12

across this country, let alone

0:15

the rest of the world, has forced

0:17

most of us indoors for an unknown

0:19

period of time. The level

0:21

of restrictions on where you can go and what

0:24

you can do, the closure of schools,

0:26

restaurants, nightlife, the canceling of

0:28

sports and entertainment is

0:31

largely unprecedented, but it's

0:33

necessary for the health and safety

0:35

of this country. So if you're not

0:37

social distancing yet, please

0:40

do. But

0:42

it's a lot to deal with, and I

0:44

know right now it's all consuming

0:47

for all of us. It's what we're reading

0:49

about and what we're worried about. But

0:51

I'd really like to help to settle

0:53

into this new reality and perhaps

0:56

understand what all of this means

0:58

for us, which is why we're deaty kating

1:00

the rest of this season of Next Question, which

1:02

means four more episodes every

1:05

week and perhaps even more to

1:07

the coronavirus pandemic. For

1:10

day to day news on this ever changing

1:13

story, I do recommend you continue to

1:15

turn to your local government, the CDC,

1:17

and the World Health Organization for

1:20

the most up to date information. I'm

1:22

also providing updates on my Instagram

1:25

feed. As

1:27

for me, well, I'm hold up in my house,

1:30

which means I might sound a little

1:32

different to you. Social distancing

1:34

means I'm not going into our usual studio

1:37

and speaking into a fancy microphone.

1:39

Right now, I'm sitting in my home office

1:42

and I'm recording myself on my phone,

1:45

and instead of speaking to my guests in person,

1:48

we're connecting over our computers.

1:50

So bear with us, everyone, but

1:52

please keep listening for this critically

1:55

important information. So today,

1:57

my next question, how do

1:59

we manage this new normal and

2:01

coronavirus anxiety.

2:05

To answer that, I called up my friend

2:08

Laurie Gottlieb. Laurie Hi

2:11

by. Laurie Gottlieb

2:13

is a psychotherapist with a private practice

2:16

in Los Angeles, but she's also

2:18

a best selling author, a journalist, and

2:20

soon a podcaster too. But

2:22

today we're focused on the issue

2:24

at hand, So um,

2:27

let's talk about why people are.

2:29

You know, I think with good reason, people are feeling

2:31

a lot of anxiety. But I think it's interesting

2:34

that the unpredictability

2:36

of all of this, Lorie, is a perfect

2:38

recipe for high anxiety.

2:40

Can you explain that? Yeah,

2:43

you know, it makes sense that we have anxiety.

2:46

And I think there are two kinds of anxiety. There's

2:48

productive anxiety and there's unproductive

2:51

anxiety. And productive

2:53

anxiety is the kind of

2:55

anxiety that helps you to take action. So

2:57

that's why we're washing our hands all the time. That's

2:59

why we're social distancing. If we if we

3:01

were in denial, if we said, oh, this is no big deal,

3:03

we wouldn't be protecting ourselves and other people.

3:06

So that's that's good anxiety.

3:08

The kind of anxiety that gets us into trouble

3:10

is unproductive anxiety, which is when

3:12

we start just ruminating and we

3:14

start catastrophizing and futurizing,

3:17

like you know, those thoughts of oh my

3:19

god, I'm going to get this and I'm going to die,

3:21

or someone I love is going to get this and they're going to die,

3:24

and you know, just all the stories that were

3:26

kind of spinning in our heads, and and

3:28

that doesn't help us in any way. Well,

3:30

what makes us go as human beings

3:33

too? That dark place?

3:35

I know that in therapy, you're

3:38

you know, this better than I. But sometimes

3:40

people do say to patients, what's

3:42

the worst that could happen, as a

3:44

way for them to help kind of

3:46

conquer their fears. But

3:48

you believe in this case, that's not super

3:51

helpful. I don't

3:53

think that that's helpful. I think that one

3:56

of the things that can really help ground us is

3:58

instead of thinking about what might up and in

4:00

the future because it hasn't happened yet, is

4:02

to stay grounded in the present. So

4:05

one of the things that I think happens is that

4:07

when something extraordinary happens, we

4:10

long for the ordinary. We want

4:12

we want our routines back, We want all those

4:14

things that we complained about, you know, when when we

4:16

didn't have something, we weren't

4:18

in a heightened state like this. Um, we

4:21

want it back, and yet it's still right in front of

4:23

us. So UM. I like to talk

4:25

about the concept of both, and which

4:27

is, yes, something horrible

4:30

is happening, and we

4:32

can also enjoy certain

4:35

things like the ordinary. We can

4:37

enjoy the time that we're having

4:39

connecting with people that we normally

4:41

don't really pay attention to

4:43

in our daily lives. We can

4:46

enjoy cooking together. We can, you know,

4:48

in our own isolated family units,

4:50

um, we can enjoy

4:53

having the time to read a book or to think

4:55

our own thoughts, or to um,

4:57

you know, actually face time with one

5:00

and actually listen when

5:02

you ask how are you? I think

5:04

one of the one of the kind of nice

5:06

things to come out of horrible

5:09

experience like this is that people

5:11

are very kind. Kindness comes

5:14

out. There's sort of a resurgence of kindness

5:16

in this world where civility

5:18

has been lost, and so

5:20

I think that both at both can

5:22

exist, and if we can focus on,

5:25

you know, holding our fear and feeling our

5:27

feelings, not being in denial of our anxiety,

5:29

and not being in denial of what's going on around us,

5:32

but also really trying

5:34

to stay present in what's happening

5:36

in that moment. We have so many

5:39

questions. But before we get to some

5:41

questions from people who follow

5:43

me or listen to the podcast, Laurie, I'm

5:46

a fairly normal person in

5:48

that I don't have huge anxiety,

5:51

but I'm finding I'm

5:53

feeling a little neurotic about my

5:55

health. If I have a little bit of a sore

5:58

throat when I wake up in the morning, or

6:00

if I cough, then I start thinking,

6:02

oh, my god, am I sick? And

6:05

I'm sure I'm not alone in that because

6:07

it's part of catastrophizing. I'm sure,

6:11

what what is that about? How can

6:13

we kind of calm ourselves down? Well,

6:16

I think the first step is just realizing it that

6:18

it's human nature to do that. So

6:20

I remember when I was in medical school, we

6:23

we talked about sort of medical school disease,

6:25

which was every disease that we were reading about.

6:27

We all thought we had all of a sudden we felt

6:29

the symptoms of it. You know, it's like, oh, my

6:31

god, I have this now because my my gland

6:34

feels inflamed or whatever. Um

6:36

that now that we're reading all the time about

6:38

the symptoms of coronavirus, you know,

6:40

it's almost like the power of of

6:43

uh implanting

6:45

it into your suggestion. Right. So,

6:47

so I think just realized that the power of suggestion

6:50

is very powerful. And

6:52

and so when you notice that, of course

6:54

be aware if you are having symptoms, but

6:56

also take a breath. Um.

6:59

Part of part of the problem is that we're reading

7:01

about and I always tell people

7:03

that, yes, you need to get daily updates,

7:06

but you don't really need more than that. I

7:08

think that the more that we're just you know,

7:10

kind of it's kind of like we're binge,

7:12

like binge watching a television show, but it's kind

7:14

of like binge eating junk food. That

7:17

the more you sit there and click from this

7:19

article to that article to the other article, it

7:22

makes you sick. It does not fill you up,

7:24

It does not help you. It actually makes you psychologically

7:27

ill. How do you talk to

7:29

kids about this? I'm sure that a lot

7:31

of parents, you know, my

7:33

children are older. Your son is

7:35

in high school now, right, he's

7:37

in middle school, middle school, so

7:39

he's he's at home. Is he expressing

7:43

concern? And how do you suggest

7:45

people talk to their kids about this? I

7:48

think that the way that we model

7:51

our response to this is going to

7:53

impact the way that our kids handle

7:55

their anxiety around it. So it's

7:58

kind of like I think, you know, when when you're on an

8:00

airplane, they always say put on your oxygen mask first

8:02

before you put on your child. But I

8:04

think it goes beyond that. It's how does the pilot

8:07

handle it when there's a problem

8:09

and the pilot doesn't say, oh

8:11

my god, we're all gonna die, you know, if there's something

8:14

the pilot says very calmly, Hey,

8:16

we're gonna experience some turbulence coming

8:18

up. We want all of you to fasten your seatbelts

8:20

and please don't walk in the aisles right now. And

8:23

I think that's very calming. And I think that for

8:25

our kids, we need to say, yes, here are the rules,

8:27

here are the boundaries. You can't go and play basketball.

8:29

I say this to my kid, you can't go play basketball

8:31

with your friends right now because we're social distancing,

8:34

um, you know, and and we're gonna do

8:37

this instead. And and just to kind

8:39

of, you know, under help them understand.

8:41

I think giving them a sense of purpose to around this,

8:43

which is we're not just doing this for ourselves.

8:46

We're doing this for our community. We're

8:48

doing this for our neighbors, for

8:50

the elderly people that we know. Um,

8:53

we're doing this for people with compromised immune systems.

8:55

And I think that kids really engage

8:58

in that when they realize that it's bigger than them.

9:00

It's not just oh, this is a bummer. I'm stuck here

9:02

and I can't play with my friends, and I can't

9:04

do the normal things I like to do. Um.

9:07

There's there's something about being connected

9:10

to the larger community that really resonates

9:12

with with tweens and teens.

9:15

Well, let's play dear therapist Lorie, because

9:17

we've got so many questions and I don't want to

9:19

be sort of a pig

9:22

about just asking my own Rosanna

9:24

says, how much information should we deal

9:26

with on an everyday basis, especially

9:28

with the situation changing by the hour

9:31

or day. Do you have any suggestions

9:34

for what is a healthy media diet?

9:38

Yeah? I do. I think once a day is

9:40

plenty. And I think that's because we

9:42

all know what we're supposed to be doing,

9:45

regardless of how many new cases are reported,

9:47

regardless of whether they're saying

9:50

you can't go here, you can't go that. We know we're supposed

9:52

to be social isolating. We know we're supposed

9:54

to be washing our hands constantly.

9:57

Um, we know that we're supposed to be cleaning the

10:00

the all the handles and um,

10:02

you know, door knobs and things like that in our homes

10:04

and all the sort of high touch surfaces.

10:07

We know what we're supposed to be doing. Nothing is

10:09

changing in that regard. So

10:11

and we also know if you're having symptoms what you're

10:14

supposed to do. So there's

10:16

no information that's going to happen during

10:18

the day. That's going to change the basic facts

10:20

of what we need to do in our lives. And we really

10:23

need to protect our psychological immune

10:25

systems as much as we're protecting our physical

10:28

immune systems, and that means not

10:30

overloading ourselves with information.

10:33

Here's another question. What are some tools

10:35

new moms or expectant moms

10:37

like me, She said, uh, can

10:39

use to get through this uncertain time. Bringing

10:42

a new baby home is tough enough, but

10:44

limiting the village from visiting

10:46

and helping will put a strain on many

10:49

Thanks to you. Yeah,

10:52

um, you know, I think that it's really important

10:54

for parents to kind of trade

10:57

off time so that they get a

10:59

break. So I think that when you've

11:01

got a baby and you don't have your village around

11:03

you a lot of times, um,

11:05

you know, you need each other as adult as

11:07

a couple. But sometimes

11:10

you're gonna have to say, you know what, it's your

11:12

turn, and I'm going to go take a bath or

11:14

I need to go just um,

11:16

you know, I need to go take a walk whatever

11:19

it is, and and hand off to the other parents.

11:21

And you really have to work as a team.

11:23

So I think that's really important, you know,

11:25

if you're living in a multigenerational household

11:27

and you have, um, you know, other

11:29

people to help, that's great. I think it's also

11:32

important that you you connect again

11:34

for your own mental health, that you connect with your friends

11:37

through technology and you take some breaks and

11:39

you laugh about how hard it is, and you laugh about the dirty

11:41

diapers, and you laugh about the naps that are

11:43

not being taken and all of those things because you need

11:45

someone to vent too. Yeah, definitely,

11:48

and laughter is really helpful. Here's

11:50

a question, j P. As I'm

11:52

an addict in recovery, are twelve step

11:55

groups and meetings are shutting down.

11:57

What is the best advice to stay

12:00

out of your monkey and stay connected

12:02

even at a time of much needed social

12:04

distancing. So

12:06

if you have a sponsor that you can connect

12:09

with virtually, that would be really helpful.

12:11

If you have other people from

12:14

that you know, from the group that you can connect

12:16

with, that would be helpful. There are also so many

12:18

online resources, um that

12:20

you can listen to podcasts, um.

12:23

You know, uh M. I was gonna

12:25

say, there's groups online where

12:27

you can you know, write in real time and connect

12:30

like that. So I would really search the internet.

12:32

I think the internet is our friend right now, not

12:34

in a sense of getting an overload of COVID

12:37

information, but in a sense of how we can get

12:39

creative around connecting with other people when we

12:41

need it most. Vivian

12:43

says, how can I stop obsessing and stockpiling

12:46

groceries? I think that's such an interesting

12:49

sort of primitive instinct. People

12:51

are going and kind of

12:53

sometimes hoarding food. They're so worried

12:55

that the grocery stores are going to close and

12:58

that they're going to starve to death. You

13:00

saw that with the toilet paper shortage.

13:02

It's fascinating thing

13:05

to observe just from a human behavior

13:07

standpoint. Um, what

13:10

advice could you give Vivian and other people

13:12

who are feeling that way. There's

13:15

a difference between being prepared

13:18

and obsessing, and that

13:20

line is going to shift

13:22

the more that you kind of think about,

13:24

oh, what's going to happen in the future. I

13:27

think being prepared means that, yeah, you have

13:29

some provisions in the house, and you

13:31

you know, you you have things that that you're going to

13:34

need. But you know, when

13:36

you start getting to the point where you've already

13:38

gotten the provisions and you think, oh, I need more,

13:40

and then I need more and then I need more. Um,

13:43

that's when you need to step back and say, you know what,

13:46

I am prepared. I will be able

13:48

to get more later. But I have enough. I've

13:50

done my preparations and I've done what the recommendations

13:53

are. And then you really have to let go.

13:55

And that's again we're staying in the present. Helps

13:57

where instead of thinking about, um,

13:59

you know, do I have enough, and and you

14:01

know, spending your emotional real estate on that,

14:04

do something else. And I

14:06

know that sounds like I'm trivializing

14:08

this, but I'm not. Um, you know, go do

14:10

a puzzle, Go get those art those art

14:12

supplies out, Go read a book, Go take a walk,

14:15

Go call a friend. You have to take

14:17

breaks, you have to let go, and

14:20

you have to stay active. I think, even though

14:23

you know the whole it seems anathetical

14:25

with the idea of staying home. There ways

14:28

to stay active at home. Clean

14:30

out your closet, get rid of all

14:32

the clothes or put them aside that you

14:34

can give for dress to dress for success

14:36

or to the goodwill. You know, it is a

14:39

good time to do some serious spring cleaning,

14:41

open the windows and and

14:43

you know, get the winter winter

14:46

out of your house and out of your things

14:48

and maybe downsize a little bit. Andy

14:51

asked, I have a friend who suffers from anxiety.

14:53

This is kind of an obvious question, but it's a good

14:55

one. How can I best support them during

14:58

this time? How can you support

15:00

people who you know? What can

15:03

you do for them?

15:05

One of the things that happens with anxiety is logic

15:08

doesn't help. So you can't really

15:10

talk somebody out of their anxiety and

15:12

try to tell them that things are going to be

15:14

okay. What you can do is you can

15:16

connect with them, and that's that naturally

15:19

sues people. So why don't you say,

15:21

hey, let's do let's have a virtual

15:23

dinner together. Um, hey,

15:26

let's watch a movie together virtually? Um,

15:29

you know what, whatever it is that you can do. Um.

15:31

You know some people are exercising together and

15:34

virtually, which is fun, so,

15:37

you know, and just moving your body helps so much

15:39

with anxiety. So if you can somehow get

15:41

your friend to, you know, move

15:44

around, and you can do it with that person

15:46

virtually. You can support the person through

15:49

actions, as opposed to your words

15:51

will not really help them, but your

15:53

actions will avas

15:55

how to focus on work while acknowledging

15:57

that we're all scared. No, I

15:59

think you and I know

16:02

that when you are worried or

16:04

stressed out, it's hard to concentrate.

16:07

Actually, I know that from

16:09

when my husband was sick. I would read

16:11

the same paragraph over and

16:13

over again in a book and I

16:16

could not, for the life of me, concentrate.

16:18

So how can you How can you

16:21

fight that? Is there anything you can

16:23

do? I guess reducing the stress will

16:25

help you concentrate more. There's

16:27

also something you can do with your body, which is

16:29

that sometimes when we kind of leave the

16:31

present, we need to physically ground

16:33

ourselves. So what you do is you close your

16:36

eyes, and you start with your feet and

16:38

you say, I feel my feet on the floor, and

16:40

you feel them, and then you move up and you

16:42

say, okay, I feel put your knees together.

16:45

I feel my knees, and you move up and

16:47

you just keep and you feel your breath and you feel your

16:49

diaphragm, and you feel the different parts

16:51

of your body and it brings you back to the

16:53

present moment and you take some breaths,

16:56

and then you move on with your work. Kristen

16:58

wants to know how do you cope with the idea that we

17:00

don't know how if when this

17:03

is going to end. I think that's in

17:05

addition to the unpredictability

17:08

of this, This kind of not

17:10

knowing when life will resume,

17:13

I think adds to people's stress

17:16

levels. Right, I mean not just am

17:18

I going to get this and what's going to happen? But how

17:20

long is this going to have to be

17:22

the new normal? So how do you cope

17:25

with that? I think

17:27

we have to acknowledge that humans

17:29

don't do well with uncertainty,

17:31

and so this is a good opportunity

17:33

for us to build up some resilience

17:36

around uncertainty, which means

17:38

that we just instead of trying to figure

17:40

it out. You know, this news report says that, or

17:42

this physician says that, to

17:44

just say we don't know, and to try

17:47

to get comfortable with that and say, what can

17:49

I do in the meantime to have

17:52

as normal of a routine that I can possibly

17:55

have under these circumstances.

17:57

You know, I don't want to let you go before asking

18:00

you if someone is having real

18:03

trouble, you know, if the anxiety

18:05

reaches a point where it's untenable

18:08

or it's affecting someone's physical

18:11

health health, Um,

18:13

you know, I I don't want

18:15

to trivialize the seriousness

18:17

of this. So what can people do

18:20

if they really feel there at the breaking their

18:22

breaking point, Laurie, They should

18:24

absolutely reach out to a therapist.

18:27

And so many therapists are doing online

18:30

sessions specifically right now

18:33

for this, and they should reach out.

18:35

And this is not a time for shame or stigma

18:38

or you know, oh my problems aren't

18:40

that bad minimizing our problems.

18:43

Um, everybody else is going through this, So why why

18:45

why should I get help? You know, all those things we say

18:47

to ourselves that prevent us from reaching out. This

18:50

is a time to say, I need to prioritize

18:52

my emotional health just as I'm prioritizing

18:55

my physical health. And if

18:57

you need to talk to someone, you do not need

18:59

to be in a christ is. You can just be having

19:01

a moment. You can be feeling kind of

19:03

free floating anxiety, depression,

19:06

whatever it is, or you just want to connect

19:08

with someone because you feel like preventively

19:10

to kind of preserve your emotional health. Please

19:13

please please reach out. You can find

19:15

you can do a quick Google search and you will find somebody

19:18

who is available to do that for you. Well,

19:23

Lourie stays safe and call

19:25

me and maybe we'll have a virtual

19:28

glass of wine together a cup of tea.

19:30

I don't want to encourage people to drink during this

19:32

time, but a glass of wine isn't

19:34

going to hurt, right, That's right, that's

19:36

right. Thank you so much, Katie. Okay,

19:38

bye, Laurie, all right, take care or stay safe.

19:44

Laurie gott Lee's latest book is called

19:46

Maybe You Should Talk to Someone. She's also

19:48

coming out with a podcast called Appropriately

19:51

Dear Therapist, co hosted Buy

19:53

Another Therapist, Guy Wench. It's

19:56

due to come out from my Heart hopefully

19:59

this summer. You know, I really like what

20:01

Laurie said earlier about how kindness

20:03

tends to emerge out of times of crisis.

20:06

People are kinder to one another, they

20:08

want to help, And I'd like to know

20:10

the large or small ways you're

20:12

seeing kindness or promoting it

20:15

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20:50

next question coming

20:52

up, we're going to be checking in with the doctor who's

20:54

a friend of mine and one of the smartest people

20:56

I know, to get a better sense

20:58

of how the coronavis irs affects

21:01

our bodies and also our

21:04

health care system.

21:20

Dr Peter Atilla is a Stanford

21:22

and Johns Hopkins trained physician living

21:25

in San Diego. His clinical

21:27

focus has been on longevity,

21:29

how to live better and longer, but

21:32

since the outbreak of coronavirus

21:34

or COVID nineteen, he shifted

21:36

gears, focusing his research

21:39

towards understanding the current situation,

21:42

what we can do to protect ourselves, and

21:44

potentially the implication

21:46

of what's to come. And now

21:49

he's here to share some of that with us.

21:52

So where are we now understanding?

21:55

This story seems to

21:57

change on an hourly, if

21:59

not minute I minute basis. If

22:02

you had to assess the situation right

22:04

now for our listeners, what would you say,

22:06

Well, you know, I think of these things

22:09

through the lens of um.

22:12

Is the rate at which we are seeing infections

22:14

growing or shrinking? So you can think of

22:16

being on one side or another of that peak.

22:19

So, for example, if we look at mainland China,

22:22

we know that they're now on the tail

22:24

end of this response. Again, there's

22:26

always possibilities that there's another outbreak

22:29

as they go back to work and begin to mobilize

22:32

society again. But notwithstanding that,

22:34

it's clear that they're on the right side of

22:36

that curve. Both um,

22:38

you know, right and correct um,

22:41

we're still on the left side of that curve, which means

22:43

each and every day it appears

22:46

that we are seeing more and more people get infected,

22:48

or the rate at which the infections

22:50

are increasing is is still increasing.

22:54

Now the million dollar question for

22:56

which a lot of people, you know, really smart people,

22:58

epidemiologists and such, are trying to project

23:00

is where is that peak? Because

23:03

the peak is sort of what gives

23:05

us a sense of that maximum rate

23:07

of infection um, and that

23:10

is, once you know what that looks like, then

23:12

you kind of have a sense of what the overall

23:14

number of infected people will be, and

23:16

then you can extrapolate, hopefully

23:19

from the data we see in other countries, what the impact

23:21

is going to be on the health care system. And

23:23

of course the things that really matter, like how

23:25

many people are going to potentially die or

23:28

otherwise be debilitated by this. Why

23:31

was Italy so overrun

23:34

with this virus? What was the perfect

23:36

storm that made it go through

23:39

that country like wildfire? So

23:41

I think we can speculate on a couple of things. First

23:44

of all, I think part of it is bad luck. I mean,

23:46

it's it's important to understand that

23:49

if um, let's let's just make the math

23:51

simple and say, let's let's pretend there were a hundred

23:53

infected people in China as

23:56

where the epicenter was, and that you

23:58

know, ten of them got on a plane aine and happen

24:00

to travel and go someplace. Well, the ten places

24:03

that they land are going to have a head

24:06

start in terms of where this

24:08

virus is going to spread. And if one

24:10

of the places they landed was Italy and one

24:12

of the place that they landed was Iran, then

24:15

those places are going to have a bit of a head start.

24:17

So I think there's just a little bit

24:19

of a luck component, which is it probably

24:21

got an early start on

24:23

the virus reaching there other factors

24:26

that seem to matter seem to be the age of the

24:28

population. So Italy has

24:30

a relatively old population

24:32

compared to other countries in Europe

24:35

and relative to the United States, meaning

24:37

they have more people who are in that high

24:39

risk category based on age alone.

24:42

Furthermore, there seems to be a slightly higher

24:45

prevalence of smoking, and smoking is definitely

24:47

one of the major risk factors

24:49

for people who, if they're infected, are more

24:51

likely to get ill. And then

24:53

I think the other component is, you know,

24:56

some of the sort of just societal things

24:58

about the proximity that people are

25:00

to each other. So in other words, if

25:02

you look at the place like Wyoming,

25:04

if someone had landed, if one of the first

25:06

people infected had landed in Wyoming, it

25:09

still would have likely spread slower

25:11

than landing in a place like Italy, northern

25:14

Italy, where the population density is

25:16

such that there's more contact with

25:18

an infected person to another. And then

25:20

I think, finally, just at the policy level, they

25:22

were probably a little bit later to realize

25:25

what was happening an institute the measures

25:27

necessary to slow the rate of spread. You

25:31

have said it, Italy taught us

25:33

that it is the morbidity rate, not

25:35

the mortality rate of the disease

25:37

that is grave for us.

25:40

Non doctors who

25:43

may be listening, including myself.

25:45

What is the difference. So,

25:47

mortality is kind of a binary

25:50

variable. It's to live or to die, and

25:53

there's a lot of attention that is appropriately

25:55

being placed on the mortality

25:57

rate. It's often described

26:00

through a case fatality rate, which is another

26:02

way of saying how many people die

26:04

for a given number of people who have this

26:06

infection. And obviously that's very important,

26:09

but morbidity is more

26:12

about the you know, long

26:15

term impact on quality of life, an

26:17

illness that has suffered that does not ultimately

26:19

result in death. And I was reading a paper

26:21

this morning, UM that

26:24

did a ten year follow up on

26:26

people who were infected with the

26:28

first STARS virus that we talked about

26:31

stars covie one. This was the two thousand

26:33

three epidemic. This was a pretty

26:35

lethal virus, certainly appeared more

26:37

lethal than the current virus. About ten percent

26:40

of people infected with this virus died,

26:42

so that's a staggering amount. But

26:45

what this paper followed up on was what were

26:47

the long term consequences of the people

26:49

who were infected but survived. And

26:52

it was quite disheartening, frankly,

26:54

that you saw much higher incidence of

26:56

cardiovascular disease in those people,

26:59

much higher incidents of lung disease in those

27:01

people as the so so if they

27:03

didn't die from the disease, they were still somewhat

27:05

debilitated by it. And I think

27:07

that that's something that we're going to see a

27:09

lot more of, and I think the

27:11

consequences of that, you know, economically,

27:13

will be significant. There are going to be people I

27:16

suspect who won't be able to go back to work in the

27:18

same capacity a year from now when

27:20

all is said and done, And the people who are most susceptible

27:23

to that are obviously the people who come in

27:25

with the greatest amount of pre existing

27:28

medical conditions. So, for example, diabetes.

27:31

Why as diabetes a risk for

27:33

this? And I don't think we know entirely, but

27:35

one thing we know is that people with diabetes

27:37

might already have some underlying

27:39

degree of insult to their

27:41

kidneys, to their heart, and it

27:44

might be that they are less likely to

27:46

recover from this, even if they're fortunate enough

27:48

to not succumb to it. Yeah, I was

27:50

interested in the diabetes angle

27:53

because I would understand smoking

27:55

because correct me if I'm

27:57

wrong, Peter. But this virus

28:01

does create some kind of fibrosis

28:03

and the lungs. Is that right? Eventually,

28:06

Yes, this is a virus that has a kind

28:08

of unique pathology relative to

28:11

influenza, for example, which would be a

28:13

cousin of it um.

28:15

The virus gets Every

28:17

virus has to replicate by getting into

28:19

a cell within our body. So it's you know, maybe

28:21

we're taking a step back to understand what the heck of

28:23

virus is. A virus is not quite

28:26

like a bacteria. The bacteria is

28:28

totally self sufficient, meaning it has

28:30

all of the equipment inside

28:32

of its cell to fully replicate on its

28:34

own outside of the body. That

28:37

doesn't mean it won't in fact us, but a virus

28:39

is different. A virus doesn't actually

28:42

have much to it. It's a much much

28:44

simpler piece of you

28:46

know, biologic you know entity.

28:49

It has in this case just some RNA

28:52

and that's about it. And so for

28:54

it to replicate and survive, it must

28:57

get inside of a host, and in

28:59

this case, you have now become the host. Prior

29:01

to this, of course, animals were the host, and

29:04

it uses our DNA

29:06

replicating machinery to

29:09

replicate itself. So if

29:11

you were going to think about this sort of teleologically,

29:13

the virus really has no intention of hurting

29:15

us. That's just an unintended consequence.

29:17

What it wants to do is replicate. From an

29:20

evolutionary perspective, and the most

29:22

successful viruses, by the way, the

29:24

ones that can go on forever and ever, don't

29:26

hurt their host at all. It's

29:28

the viruses that destroy their host

29:31

that don't really survive, much like ebola.

29:33

Ebola didn't spread very much because it was so

29:35

devastating to its host. So

29:37

when this virus comes in, it has

29:39

to pick a cell that it targets, and

29:42

that just happens to come down to sort of the molecular

29:44

biology of how this virus works.

29:47

And this cell it targets most

29:49

commonly is a cell in the lung called

29:52

a pneuma site because of a certain

29:54

receptor that that cell has that allows this

29:56

virus to enter. When it gets

29:58

into that cell, it basically

30:00

hijacks it. It takes over and

30:03

uses the cell's ability to replicate

30:05

and says, hey, I'm going to take this over for myself

30:08

and replicate myself. And it

30:10

does that and it ends up destroying that

30:12

cell. And it turns out that in

30:14

this case, that's a really bad cell

30:16

to lose because that cell, called

30:19

a type to numa. Site makes

30:21

a chemical called surfactant, and

30:24

you've probably heard of surfact and it's like a detergent

30:27

that allows the air

30:29

sacks in our lungs to not collapse

30:31

on themselves because of the surface tension.

30:34

And so when we lose enough of those,

30:37

the lungs begin to collapse and

30:39

we aren't able to exchange

30:41

air, and ultimately that results

30:43

in a type of pneumonia, or

30:46

really something more severe than a pneumonia

30:48

called acute respiratory distress syndrome,

30:51

where a person can't exchange gas,

30:53

and ultimately that will result in potentially

30:56

fibrosis of the lung. It

30:58

turns out, by the way that that cell um

31:00

that that that the virus can also gain access

31:02

to um muscle cells

31:04

of the heart, and so we believe

31:07

that we're going to see sort of fibrosis

31:10

of the heart going forward. In fact, thirty

31:12

or forty percent of patients on

31:14

autopsy, people who have already died from

31:16

this virus are showing injury to their heart.

31:20

This sounds very, very bleak,

31:22

but that's one of the reasons smokers

31:25

are particularly susceptible

31:28

because they already have some

31:30

of the some damage to the cells that

31:33

you were discussing, yep,

31:35

and they just have less what we would

31:37

call pulmonary reserve. They

31:39

have less lung capacity in

31:41

excess. So you know, someone like you, Katie,

31:44

who's really healthy, you know you're not

31:46

utilizing your full lung capacity when

31:48

you're sitting here at rest right now. You're using

31:50

a fraction of it. But let's say

31:52

that you know you're using of your

31:54

lung capacity. Will imagine somebody who

31:57

has smoked for a long period of time. For

31:59

them sitting at as they might be relying

32:01

on six of their lung capacity,

32:03

so they just have less of a buffer. You

32:05

know. You can think of it as like how much does someone

32:08

have in their savings account? Well, the person who

32:10

has less in their savings account is going

32:12

to be more likely to suffer

32:14

the shock of not, you know, having

32:17

a job. Before we

32:19

talk about being better prepared,

32:21

and I know that you watched the Bill

32:23

Gates Ted Talk, which I thought was eerily

32:26

prescient in its message.

32:28

But let's talk just briefly, because

32:31

I think people are desperate for this kind of information

32:33

to Peter, and you have access to

32:36

the latest, most accurate

32:38

information in terms of protecting

32:41

yourself. Um, tell

32:43

me what you're doing in your home with

32:46

your kids and your wife.

32:49

Well, we we sort of probably

32:51

came across as a little bit crazy at the

32:53

outset. In mid February,

32:56

I sort of woke up to what was happening. I had

32:59

been largely and denial through

33:01

January, and UM,

33:04

I think had naively assumed that

33:06

this would be much more like the First

33:08

Stars outbreak, or like the Murs

33:10

outbreak, except less

33:12

deadly and less likely to spread. In

33:15

other words, I hadn't fully dug

33:17

into the properties of this virus

33:19

that make it a little more troublesome, which is

33:21

namely its capacity for spread. But

33:25

in mid February, when I sort of woke up to this,

33:27

UM, I started to think about, well, what

33:30

what could we do if we wanted to buy

33:32

more time? And so that basically

33:34

came down to much greater social distancing,

33:37

and UM that meant, you know, canceling

33:39

all travel plans. And then

33:41

eventually it just you know, came

33:43

down to making a decision that was difficult to make,

33:45

and not a decision that everybody has the luxury

33:47

of making, because many people don't have the luxury of

33:49

working from home. But it was a decision

33:52

to basically quarantine ourselves, UM,

33:54

and so that meant that, you know, we don't

33:57

leave the house and people don't come to us

33:59

in the house. And the thinking would be

34:01

that after two to three weeks

34:03

of that period of a quarantine, absent having

34:05

an accurate test to measure UM,

34:08

if you are infected, if you're completely asymptomatic,

34:10

you know, no temperature changes or anything like that, the likelihood

34:13

that you're infected is low. And now at

34:15

least you're in sort of a safe spot while you wait

34:17

for time to sort of play this out. And

34:19

time does a lot of things right. Time allows us

34:22

to potentially develop a vaccine. Although

34:24

I think that's a longer term strategy than most

34:26

people think, it certainly allows us

34:28

to repurpose existing drugs and that's

34:30

something I'm really excited about. So if we're going to

34:32

talk about optimism, I actually am quite

34:35

optimistic that there are a suite of drugs

34:37

that already exist that we're now learning

34:39

how can be repurposed for this And most

34:41

importantly, it's giving the hospital

34:44

system and the health care system a chance

34:46

to slowly expand

34:49

to meet the needs that are necessary. Because again

34:51

to your point about Italy, the

34:54

real problem in Italy is not the total

34:56

number of people that are infected, it's

34:58

the speed at which those people needed

35:01

medical care. And so you

35:03

can you've heard the term flattening the curve. Why

35:05

are people saying that. It's like saying if

35:07

a hundred thousand people are going to require

35:09

hospitalization, it's a big difference

35:11

if they required in one month or

35:14

one year. And so it's

35:16

not clear that we're going to reduce the number of

35:18

people that are ultimately going to be infected, but we

35:20

want to spread it out as much as possible. So

35:23

on a personal level, my view is what can

35:25

I do to make sure I don't need healthcare resources

35:27

anytime soon. I talked

35:30

to the director of an urgent care center,

35:32

Peter, and he

35:35

said, do not go to the doctors,

35:37

do not you know, try to seek

35:40

medical care unless it

35:42

gets bad. But I wondered, is there an

35:44

inflection point, because I

35:46

think people are so paranoid.

35:49

Every time I cough, I get neurotic

35:51

and uh and and when

35:54

is that point where you

35:56

should seek medical care or at least

35:58

talk to a healthcare provide because

36:01

we don't want to clog the system.

36:04

Listeners, I'm sure agree with this,

36:06

but we also don't want to ignore

36:08

an illness that could worsen if

36:11

we don't get it, if we don't get the proper

36:13

attention. Yeah, I mean,

36:15

that's such an important question, and truthfully,

36:18

it's one for which I think the answer is not entirely

36:20

clear. Um, we probably

36:22

do need to think a little bit about how to stratify.

36:25

So I would agree with the advice that

36:27

your colleague and friend gave you,

36:29

which is, we certainly

36:31

don't want everyone who,

36:34

um, you know, thinks that they have

36:36

a little sniffle or a sneeze or a sore throat

36:39

to then expose themselves to

36:41

an infection by going out and seeking

36:44

medical care, especially when

36:46

we don't have testing readily available yet. That's the

36:48

important thing to understand is what is it going

36:50

to accomplish to go and put yourself

36:52

in harm's way If we

36:54

don't even have a test yet that's viable, are going to

36:57

offer as much. So I think we have to stratify

36:59

patient. So, you know, the way we are looking

37:01

at it in our practice is we're taking

37:03

the patients who we think are at highest risk.

37:06

So these are people who are you know, sort

37:08

of in their sixties and older people

37:10

who have existing conditions like high blood

37:12

pressure or heart disease, atrial fibrillation,

37:15

these sorts of things, and we're saying

37:17

we're going to have a lower threshold

37:20

for getting them tested or

37:22

getting them in to see someone if we have any

37:25

concern. You know, my wife yesterday was called

37:27

by a friend of hers who lives

37:29

in Colorado now, and she has a lot

37:31

of underlying medical conditions, and you

37:33

know, it was really difficult to spend

37:36

the time on the phone with here today and triage. What I

37:38

couldn't fully understand was either a panic

37:40

attack or legitimately an illness,

37:43

and you know, we had to make a call, and in the

37:45

end we saw it. We decided after

37:47

an hour she probably did need to go into the emergency

37:50

room and get checked out because I just couldn't be

37:52

comfortable that this was just anxiety

37:54

and I and she has so many underlying medical

37:56

conditions that I was actually concerned

37:59

that. You know, she's the type of person who,

38:01

if infected, could very precipitously,

38:03

you know, fall off that proverbial cliff. And

38:06

what happened, Um, you

38:08

know, she we went there. I

38:10

It's it's still unclear because of course, the testing

38:13

takes days to get back. So, but now she

38:15

is at least, you know, her blood pressure is normalized,

38:18

her oxygen levels are normalized.

38:21

Um, the thing we are most sensitive

38:23

to is shortness of breath. That seems

38:25

to be the biggest single predictor of

38:27

people who do versus do not need

38:30

medical attention. So people who do

38:32

not develop shortness of breath at

38:34

any point in time are generally

38:36

going to recover in what we call a self

38:38

limited way. I hate to

38:40

ask you this, doctor a tea

38:43

of a what is how

38:45

do you know if you have shortness of breath? I know

38:47

that probably sounds like a dumb question, but

38:49

is there something you can do to

38:52

figure out? Is it

38:54

walking upstairs? I mean I

38:56

get sometime shortness of breath if

38:58

I try to run a mile. I mean when

39:00

when can you tell you have that? Actually,

39:03

Katie, that is not a stupid question at all, and we've

39:06

actually tried to explain that exactly to

39:08

our patients. So I'm glad you asked. Um.

39:11

We think one of the best litmus test is

39:13

for litmus tests for shortness of breath

39:16

is air hunger while speaking

39:18

in long sentences. So when

39:21

someone who could normally rattle off,

39:23

you know, three minutes of talking

39:25

with just the simple breath in between, all of

39:28

a sudden has to take longer pauses

39:30

to take breaths in between speaking

39:32

to me, that's true shortness of breath.

39:35

You use an example of walking up a flight of stairs.

39:38

I think, if somebody knows what they're you

39:40

know, normal exercise tolerance is

39:43

when that dramatically decreases.

39:45

So if a person you know lives in an apartment

39:47

where they have to go up and down a flight of stairs

39:49

and normally that poses no risk

39:52

to them, and all of a sudden, now

39:54

they think, oh my god, like I'm

39:56

really winded walking up this flight of stairs,

39:59

that that might all so constitute shortness of

40:01

breath. Um. The other thing to keep

40:03

in mind is shortness of breath by itself

40:06

probably doesn't show up without some other

40:08

symptoms, such as, um,

40:10

you know, a fever, which is the single most

40:13

common symptom we see in people who are infected.

40:15

But of course it's important to understand people

40:17

can develop fevers for any sort of you

40:19

know common you know, cold or anything like

40:21

that orl right, absolutely,

40:24

and so all of this I think points to something which

40:27

is, you know, do as much as you can

40:29

buy phone right, call your doctor, walk

40:31

through all of these things and

40:33

and let you let your doctor help you decide

40:36

if you actually need to take

40:38

the next step of getting tested, which

40:40

again we're currently in a testing

40:43

environment that is not adequate. So

40:45

the CDC guidelines on testing

40:48

are actually quite stringent compared to what

40:50

I think they should be due to these limitations.

40:53

So you know that that does

40:55

raise the question who should be tested

40:58

and who shouldn't and uh,

41:01

sort of thinking about the common good and

41:03

not just yourself in these situations.

41:06

But gosh, you know, we're talking about in some

41:08

cases life or death, peter and

41:10

so people I think,

41:13

you know, they have this primal survival

41:15

instinct. So uh,

41:18

in terms of testing, you have

41:20

to rely on your health care provider. But they're

41:23

making some tough decisions in Italy about

41:27

who who gets medical attention

41:30

and who doesn't because of

41:32

the crowded conditions of hospitals,

41:35

etcetera. I mean, it's it

41:37

really feels like the makings of a

41:39

of a sci fi movie. Yeah,

41:42

they are making these decisions

41:44

in Europe um already,

41:47

and it's not clear

41:49

if we're not going to be in the same position

41:51

in the next two to three weeks. UM

41:55

as far as testing goes at the time, at

41:57

right this moment, Katie, the CDC

42:00

sidelines are that testing should be reserved

42:02

for people who are symptomatic only.

42:05

Now, why do I think that that's insufficient?

42:08

Um? I think it. If you really want to

42:10

control the rate of spread, you should

42:12

also be testing people with known exposure,

42:15

even if they are asymptomatic. Because

42:18

this virus has such a long latency

42:20

period. Let's assume that

42:22

you know, you are around somebody

42:24

who then went on to test positive or frankly

42:27

even went on to be symptomatic. In

42:29

an ideal world, if we had

42:31

a sufficient number of tests and a sufficient

42:33

infrastructure for testing, it would actually

42:35

be important to know that you were negative before

42:39

you know, we told you, hey, it's you know. The fact

42:41

that you're not symptomatic means you're not at risk.

42:44

In other words, the thing that makes

42:46

this virus so particularly

42:48

troublesome is that people

42:50

who have no symptoms can spread the

42:53

virus, and they can do so for a long

42:55

period of time, for fourteen

42:58

days, right, I mean, isn't that the inky bastion

43:00

period and the fact that some people can

43:03

be vectors and yet never symptomatic

43:06

that makes it really freaky. Right,

43:09

Yeah, that's the that's the superpower

43:11

of this virus. So if you were gonna like

43:14

create a you know, a list

43:16

of all the things that make this virus

43:18

sort of troubling, that that would

43:20

be its superpower is that it has

43:22

this ability to very

43:25

subtly get you know, get

43:27

from one person to another, usually

43:30

without that person knowing it. And again

43:32

we'll use Ebola as a stark contrast.

43:35

Right, why was Ebola not really

43:37

a big issue once it got

43:39

into um the United

43:41

States? Because people were

43:44

so sick when they got it that there

43:46

was no ambiguity about whether

43:48

that person had it and it was only

43:50

during that period of extreme sickness

43:52

that they could go on and shed the virus. If

43:56

in fact, people are practicing

43:58

social distancing, now all

44:01

these cities are closing down,

44:03

I guess you know San Francisco

44:06

is a shelter in place city other cities

44:09

as well. Is that going

44:11

to ameliorate or mitigate

44:13

some of the conditions

44:16

that will be prime for spreading

44:18

this virus around or have we missed

44:21

that window of opportunity, Peter. It

44:24

will absolutely have an impact. I mean,

44:26

in an ideal circumstance, if we had a time

44:28

machine. I think we would have done this, we would

44:30

have taken these precautions a month sooner. But

44:33

I'm actually still optimistic. And you

44:35

know, we have a team of

44:37

analysts that are building forecast

44:40

models, reviewing every piece

44:42

of data that's available

44:44

and including data that aren't publicly available

44:46

by you know, you speaking

44:48

with people on the front lines to pressure test

44:51

assumptions. I don't think

44:53

that it's a foregone conclusion how this

44:55

ends. So um

44:58

you know, I can't even sit

45:00

here and project how many people are going to

45:02

be infected in the United States, although there are

45:04

lots of estimates, and some of them are quite scary.

45:07

You know, Mark Lipsitch at the Harvard School of

45:09

Public Health projects that you

45:11

know, more than the U. S population

45:14

will ultimately be infected by this, and that the

45:16

mortality rates we're seeing those are staggering

45:18

numbers. That that the implication of that, by the way

45:20

to put it in some numbers, is more

45:23

people would die from this virus in a

45:25

year in the next year than die

45:27

of all other things combined. I

45:30

mean that that's a staggering statistic.

45:33

Do I think that that is set in stone

45:36

yet, that that is our fate? I don't. And

45:38

I do think that the more aggressively

45:41

we can socially distance ourselves, the

45:43

more aggressively we can implement testing

45:46

which will enable this stratification

45:49

of distancing between people, and

45:51

the more readily available we can

45:53

be pressure testing existing

45:55

drugs to then bring on

45:57

treatments that can reduce the mortality

46:00

and morbidity. I think we still

46:02

have a chance to bend the curve of this thing. We're

46:06

going to take a break, but we'll be right

46:08

back with more critically important

46:10

information from Dr Peter

46:12

A Tilla. Hi,

46:23

everyone, I'm so happy we were able

46:26

to get in touch with Dr Peter

46:28

Attia and he was able to spend

46:30

a good hour talking to us about

46:33

this scary pandemic because

46:35

I think his knowledge, his experience,

46:38

and his connections are really

46:40

unparalleled. So let's get

46:42

back to that important conversation. Let's

46:45

say someone goes to the hospital, Peter,

46:47

and they have COVID nineteen.

46:52

I know that ventilators and respirators

46:54

to help with lung capacity, but

46:57

are there any medicines that these people

47:00

are keetting or are they just going

47:02

to the hospital? And uh,

47:05

I mean, how are the how are doctors fighting it

47:07

right now? It's varying

47:09

by hospital. So myself

47:12

and my team, we have enough

47:14

friends in hospitals that we're

47:16

hearing, you know, we're finding out this hospital

47:18

in Boston is using this protocol, this

47:20

hospital in New York is doing this, etcetera.

47:23

UM, So right now, I would say, Katie, it's

47:25

not standardized, but you're crazy.

47:29

I mean, that seems insane

47:31

to me. That it's not that it isn't

47:33

standardized, that it's sort of kind

47:36

of a piecemeal approach.

47:39

Well, the primary approach, as you said, is

47:41

supportive care. So the single most important

47:44

thing for a person once they're in the hospital

47:46

is maintaining sufficient respiration

47:49

because that's the thing that's going to put a person

47:51

in the hospital. So the most

47:53

common thing that people are presenting with his respiratory

47:55

failure as opposed to say cardiac

47:58

failure, renal failure, or other organ failure.

48:00

So you know, the first, second, and third line

48:02

of defense is through you

48:05

know, oxygen and supplemental respiratory

48:07

care, hopefully not requiring mechanical

48:09

ventilation, but obviously at some point

48:11

that's happening for enough people. That's

48:14

that's the sort of supportive side of things. UM.

48:17

And I think we are seeing more and

48:19

more patients being treated with um

48:22

chloroquin and then, of course if

48:24

the doctor's treating the patient have reason

48:26

to believe that they're now developing secondary

48:29

infections, then things like antibiotics

48:31

are coming on board. And if

48:33

it turns into pneumonia exactly

48:36

if it's a pneumonia that they believe is

48:38

an actual bacterial pneumonia versus

48:41

sort of a viral pneumonia for which the antibiotics

48:43

wouldn't provide any benefit. There's

48:45

also HIV drugs. There's

48:48

a drug that that is a

48:50

protease inhibitor that I think

48:52

is sort of weakly

48:55

um potentially helpful.

48:57

It's still too soon to say, but the of

49:00

using it seems relatively low, so it's

49:02

it's also being tested. UM

49:04

one drug that I think to three weeks

49:07

ago we thought might be valuable that

49:09

is looking less valuable as the common

49:11

anti flu drug called tama flu,

49:14

so I think

49:16

most hospitals are moving away from that

49:18

now. But again UM

49:20

it is unfortunately not a fully

49:22

standardized protocol because even though the CDC

49:25

will have a recommendation, ultimately

49:27

the physicians are the ones

49:30

at the bedside that are going to be able to make the decisions.

49:34

Can you reverse this? So let's

49:36

say someone goes to the hospital they're having

49:38

respiratory failure. Can

49:40

those individuals with you

49:42

know, breathing assistance, with the ventilator

49:45

a respirator, can they then,

49:48

um get the virus that,

49:50

as you said, was sort of taking over

49:53

the cells and their lungs. Can they

49:55

how do they get that? How do they get

49:57

it out of their lungs? I know this ounds

50:00

sort of elementary, but I'm just trying

50:02

to figure out, you know,

50:05

is that kind of support enough to eradicate

50:07

this virus? Um.

50:10

No, it's actually not an elementary question at all. It's a

50:12

very important question. What's actually happening

50:15

is there's a war going on between

50:17

the virus and the immune system,

50:20

and the whole purpose of supportive care

50:22

such as ventilation is to buy time

50:25

for the immune system to win that fight.

50:28

Now it becomes a bit complicated because

50:30

the immune system, in its best effort

50:32

to win that fight, can also cause a

50:34

lot of damage to the host. So

50:37

you think of it like a war going

50:39

on in a country. You have the good guys

50:41

the bad guys. At the risk of oversimplifying it,

50:44

well, both of those entities

50:47

when engaging in war caused collateral

50:49

damage, and so it's like immunotherapy

50:52

and cancer, it becomes too refed

50:54

up and that can create all kinds of

50:56

autoimmune issues. Correct. Absolutely,

50:59

So the you know, the checkpoint inhibitors,

51:02

which you know are probably the most exciting thing

51:04

in all of immuno oncology right now, um,

51:07

exactly have that as a side effect, which is

51:09

autoimmunity. The immune system goes a little

51:11

too far now in in this type

51:13

of response to the immune system. It's not so much

51:15

autoimmunity that we're seeing as the problem,

51:17

but it's the sort of um, what's called

51:20

systemic inflammatory response

51:22

syndrome or this cytokine storm

51:25

that is sort of you know, wreaking

51:27

havoc both to kill the viruses, but it's

51:30

also the thing that can you know, cause

51:32

capillary leaking in the lungs that can

51:34

lead to other things like edema,

51:37

and it can damage other parts of the body. So

51:40

basically what you're saying is that it's a delicate

51:43

balance between the immune system,

51:45

which can cause inflammation and damage

51:47

if it's overly compensating

51:50

for the virus and sort

51:53

of keeping the virus in check. YEP.

51:56

And we use supportive

51:58

measures like ventilation to base sally by

52:00

time to augment

52:02

what the lung needs to do to

52:04

to create that amount of time and space necessary

52:07

for the immune system to ultimately win that fight.

52:09

But winning the fight means that

52:11

the virus has gone, you know, winning

52:14

the fight means that the number of actual

52:16

copies of that virus goes down

52:18

to some insignificant level um

52:21

and you know, to you know, to contrast

52:24

that with other things, like when you look at the Spanish

52:26

flu, the one

52:28

and one pandemic, that was kind of

52:30

a different animal. You know, that was an animal

52:32

where so much of the damage actually

52:34

came from the hyperactive immune

52:37

response and then this immune

52:39

paralysis that followed it that led

52:41

to these secondary infections. So

52:44

you know, paradoxically, the people that were most

52:46

vulnerable to that flu were people

52:48

that had the most robust immune system

52:50

and therefore the strongest immune response.

52:53

We're not seeing that here, which

52:55

suggests again it's just a

52:57

suggestion that a hyper

53:00

active immune response is less of a problem

53:03

than the actual damage the virus

53:05

is causing to the cells. That's

53:08

fascinating. Um.

53:10

That raises a couple of questions

53:12

about ventilators

53:14

and respirators and I don't even know

53:17

the difference, and maybe you can explain that.

53:19

But uh, there's a real

53:21

shortage of medical equipment. How serious

53:23

a problem will it be if there

53:26

is a lack of ventilators or respirators

53:28

to buy the time these patients need

53:31

and what is being done about that? So

53:33

it's a huge problem. Let me answer your first

53:35

question. So, respirators

53:37

are non invasive. So um

53:40

for example, you've probably visited somebody

53:43

in the hospital and you see like a little oxygen

53:45

mask that they have on, or even something called

53:47

a nasal canyla where there's a little device

53:49

that goes under their nose that's just passively blowing

53:51

oxygen at them. So

53:54

you know, you can you can provide a

53:56

person with supplemental oxygen in

53:59

that sort of passive manner. But

54:02

when a person becomes really

54:04

dependent on oxygen, they require

54:06

something called mechanical ventilation,

54:09

and to do that you have to undergo

54:11

a procedure called intibation, which anybody

54:14

who has had surgery has has you know, under

54:16

general and aesthetic has had that. But that's where

54:18

a tube is actually placed

54:20

into the main airway called

54:23

the trachea. So it's called an endotracheal tube.

54:26

When a person is intibated,

54:28

they also have to be paralyzed and sedated.

54:30

It's not a comfortable thing. You You couldn't

54:33

be wide awake sitting there intibated um,

54:36

so you have to be sedating the patients

54:38

and paralyzing them. And the reason you have to

54:40

do that is that their own

54:42

voluntary muscular movements can't

54:44

fight the ventilator, so you

54:46

actually have to basically shut them down to

54:48

let the machine do the breathing. And

54:51

you're absolutely right that these ventilators

54:53

are very, very specific and specialized

54:56

pieces of medical equipment, and

54:58

at some point we will run out of them. In

55:00

fact, was just speaking to someone

55:03

today at a small hospital outside

55:05

of New York City and they are now they

55:08

have just used their last ventilator, and

55:10

they are now what's called double venting

55:12

patients, which means using one ventilator

55:15

to treat two patients, which you would normally

55:17

never do because of the contamination.

55:20

Those two patients are now fully

55:22

sharing all their respiratory

55:24

pathogens. But of course, you know, desperate

55:27

times call for desperate measures, and if these patients

55:29

both have the same virus and

55:31

they are both suffering from you know the COVID nineteen

55:34

disease, then we we you know, we'll do

55:36

what we have to do. And then technically a ventilator

55:38

can probably be split up to four ways.

55:41

But at some point soon and

55:43

it could be within two to three weeks, this

55:46

could become an enormous problem, and so

55:48

well can can can We are manufacturers

55:51

kind of speeding up the

55:54

production of these pieces of equipment.

55:58

They are, but is still another

56:01

bottleneck. And the one thing that we can't make

56:03

more of is doctors, nurses

56:05

and respiratory therapists, and

56:07

so these pieces of equipment can't

56:09

work on their own. You know, a doctor

56:12

is necessary to put the end of tracheal

56:14

tube in. Nurses and respiratory

56:16

therapists are necessary to actually run the

56:18

ventilators and manage the medications

56:20

on a minute to minute basis. And

56:23

so it can't

56:25

be overstated that a

56:28

really fundamental break point

56:30

in this system could occur when the

56:32

health care system, through its workers,

56:35

is so overwhelmed that we can't

56:37

actually have people on the front lines that are doing

56:39

this work. So how

56:42

do they protect themselves because obviously

56:45

we need them desperately to be treating

56:47

patients. We probably need to and

56:50

I know that a lot of retired medical

56:52

professionals are being called in UM.

56:56

Are are they getting sick? I know

56:58

that some are, and should

57:00

I mean, how worried are you about that?

57:03

I'm actually quite worried about it because

57:06

of some data that we're seeing from around

57:08

the world, including China and Italy,

57:11

which is that when healthcare workers get

57:13

it, they seem to get a worse version

57:15

of it, suggesting at least preliminarily,

57:18

that there might be something about the amount

57:20

of virus or the manner in which

57:22

they're exposed to it that is

57:25

otherwise making it worse

57:27

than if they just acquired this virus

57:29

out in the community. So that's the first thing that

57:31

has me somewhat concerned. So how do

57:33

you think they're getting it? UM?

57:36

Probably just through a greater concentration

57:38

of respiratory droplets, given

57:40

the you know, the proximity that they have to

57:43

people who are sick. And obviously,

57:45

if someone is sick and they're in respiratory

57:47

distress and you're intibating them, you're leaning

57:50

over a person, and you're just being

57:52

exposed to a much greater amount of virus

57:55

than say, if you bumped into somebody at the supermarket.

57:58

The other thing that is in short supply is

58:00

ppe. It's the protective

58:03

equipment that the doctor's, nurses,

58:05

respiray therapist, all the people in the hospital need

58:08

to protect themselves against

58:10

this virus. And so inasmuch

58:12

as we need to be making more ventilators, we also

58:15

need to really be ramping up on the production

58:17

of all of the protective equipment. And

58:19

the countries that have done this well, I mean China

58:22

did this very well in the second

58:24

wave. So in the second wave

58:26

after Wuhan, very

58:28

few of the healthcare workers

58:31

became infected. So once they dialed

58:33

in on how to protect their healthcare

58:35

workers, um, they were able to do this

58:37

in a much safer way. So you know,

58:39

if I could wave a magic wand we'd be

58:41

making more ventilators, we'd have more

58:43

actual beds and spaces in the hospital, we'd

58:45

have more protective equipment for the

58:47

healthcare workers, and obviously we'd have

58:50

more testing available so that we could more quickly

58:52

identify and stratify patients at risk.

58:55

Speaking of that, I know that a

58:57

one thousand bed naval hospital ship

58:59

is being dispatch to New York Harbor.

59:02

We may be seen some

59:04

of these medical ships that are often used

59:06

in times of war being

59:09

deployed in specific ports

59:12

all around the country. Yeah,

59:15

it's it's sort of hard to believe

59:18

how much has happened in one week. Um.

59:21

And and it's it speaks to the nature

59:24

of non linear exponential growth and

59:26

and and again. You know, the irony of

59:28

it is that which we're talking about today,

59:30

in a week or two weeks will seem pedestrian

59:33

in terms of what we will know because of

59:35

how quickly things are changing, including

59:38

you know, the rate at which you know hospitals are running

59:40

out of ventilators. We should

59:43

uh mention one thing, and

59:45

that is a failure

59:48

to comply with CDC guidelines.

59:52

I hope we're not seeing as many kids

59:54

in bars, and not just kids. You know.

59:56

My neighbor in New York

59:58

City who lives on the Upper Side said the

1:00:00

bar was packed for St. Patrick's

1:00:02

Day. And it's so infuriating.

1:00:05

But not only young people. I read an article this

1:00:07

morning about children of baby boomers

1:00:10

trying to get their parents in their

1:00:12

seventies to not travel, to

1:00:14

not go to casinos. Um.

1:00:17

It seems insane to me that

1:00:19

people are being uh

1:00:21

so stupid and in some cases so selfish

1:00:24

about this or ignorant what

1:00:27

is that about? It's it's so interesting

1:00:29

you say that because I have noticed

1:00:32

two extremes um and

1:00:34

again these are anecdotes, so I can't speak

1:00:36

to this from sort of real aggregated data.

1:00:38

But you're absolutely right. I have noticed

1:00:40

far more concern from my patients

1:00:43

about their parents than their kids.

1:00:46

First for starters, So the

1:00:49

you know, I just I could rattle off ten stories

1:00:52

about, you know, people

1:00:54

who are in their seventies who have decided, Yep,

1:00:56

we're gonna we're gonna to the casino this weekend

1:00:58

and we're gonna go do this, and we're gonna go and do that, and

1:01:01

none of this stuff matters, and we're going out and

1:01:03

you know, doing all those things. And again I have

1:01:05

no idea what it is that. You know, I could speculate and say,

1:01:08

look, people at that age have been through a lot

1:01:10

and they've decided, hey, if it hasn't got me,

1:01:12

now it's not going to. And there's sort of a false

1:01:14

sense of confidence. Potentially, I

1:01:17

think they survives the stars outbreak

1:01:19

and they've been there, done that. Yeah,

1:01:22

there's a little bit of that. Um, we certainly

1:01:24

saw a little bit of that Machismo in New York

1:01:26

two weeks ago, which I haven't seen.

1:01:28

I've seen it damned down a bit, which was, hey, look, we survived

1:01:31

nine eleven. This thing is not going to get us. Um.

1:01:33

Obviously that's apples and oranges. So it's sort

1:01:35

of a nonsensical comparison. Um.

1:01:38

But I do share your concern with the number

1:01:40

of people who aren't respecting these quarantines.

1:01:42

In fact, our nanny who's

1:01:45

in college, one of

1:01:47

her classmates was an exchange

1:01:49

student in Italy, so he had

1:01:51

to come back from Italy, and he tested positive

1:01:54

upon arrival, and so he was placed

1:01:56

in a quarantine, which he violated.

1:01:59

So he was seen out on social media

1:02:01

three days after testing positive and

1:02:03

being forced into a quarantine, out at a party,

1:02:06

and so, you know, that kind of stuff is really

1:02:09

upsetting, and I think it is a bit of a communication

1:02:12

breakdown because I don't think that these people

1:02:15

would really be doing this if they understood

1:02:17

the significance of what they're doing. I just don't think

1:02:19

people are that selfish or that evil if

1:02:21

they really understand the significance, which

1:02:23

is, hey, you can feel fine. You

1:02:25

know, you college student who's twenty years

1:02:28

old, who tested positive who you

1:02:30

know has a little bit of a sore throat. It's

1:02:32

not about you getting worse. It's

1:02:34

about what you could do to somebody

1:02:37

who could then go and do it to somebody else. Right,

1:02:39

It's like you infect another kid at that party, they

1:02:41

go home and infect their grandmother or something like

1:02:43

that. So, you know, my hope is that we're

1:02:46

just going to educate people a lot more about

1:02:48

why the stakes are high and

1:02:50

how we all kind of have

1:02:53

a responsibility here to not just

1:02:55

protect ourselves, but to then protect

1:02:57

others through that protection. I don't

1:03:00

want to play the blame game, but was

1:03:02

critical time lost

1:03:05

when this wasn't taken seriously

1:03:07

by the administration and frankly

1:03:10

by some in the news media.

1:03:14

How how much damage

1:03:17

was done by that two

1:03:19

or three week period where it

1:03:22

just wasn't treated as a serious

1:03:24

threat to public health? Well

1:03:26

you alluded to the the Ted

1:03:28

talk by Bill Gates, which is now five years

1:03:30

old, and he sort of predicted,

1:03:33

uh, in pretty

1:03:36

frightening um, you know,

1:03:38

reality, what was potentially going

1:03:40

to come if I were going to, you

1:03:43

know, really say, if if I could go

1:03:45

back in time and change one thing in the last three months,

1:03:47

what would it be. It's the following on

1:03:50

January, the

1:03:54

genome of this novel, coronaviruns

1:03:56

was sequenced and it was made public

1:04:00

another Chinese you got it.

1:04:02

So the Chinese immediately figured out

1:04:04

what this was, immediately confirmed

1:04:06

it was a novel, brand new, never

1:04:08

before seeing coronavirus, and

1:04:10

put that information out to the world, and

1:04:13

some companies immediately ran and

1:04:16

developed pcr kits. And

1:04:18

you know, one of those companies in China has basically

1:04:20

gone on to do over a million tests

1:04:23

already and have incredible

1:04:25

data with specificity and sensitivity.

1:04:27

They can do a four hour turnaround. In fact,

1:04:29

they've already built fifty laboratories

1:04:31

in China, each one capable of

1:04:34

doing fifty thousand to a hundred

1:04:36

thousand tests per day. What

1:04:38

we did, in my opinion, was

1:04:41

the biggest mistake, which was basically ignoring

1:04:43

that information, and then when push

1:04:46

came to shove sort of doing a botched

1:04:48

job, the CDC sort of put together

1:04:51

its own um set of primers

1:04:54

that ended up not working very well. And then eventually

1:04:56

we got around to potentially doing something

1:04:58

with a company called Row. And where

1:05:01

we are right now at the time of this discussion

1:05:03

is we still don't really have any viable

1:05:05

means of testing. We're probably

1:05:08

just a little bit over fifty thou people

1:05:10

have been tested in the United States, which is you

1:05:12

know, two log orders below where

1:05:14

we need to be. So if you can

1:05:16

we just use the testing that's being used in

1:05:19

other places like South Korea,

1:05:21

the one that was developed by the w h

1:05:23

O. Did the CDC simply

1:05:25

think that that test was inadequate? It seems

1:05:27

to me that was insane.

1:05:30

At least use them while we develop a

1:05:32

more specific test. Yeah,

1:05:35

that that is absolutely correct. So

1:05:37

we are now in a situation called emergency

1:05:39

use authorization where I think the CDC

1:05:42

has finally realized that

1:05:44

they're not going to be the ones to solve this problem,

1:05:46

and they're basically saying, you

1:05:49

know, so the Secretary of hss UM, the

1:05:51

Secretary of Health and Humans has has basically

1:05:54

said, you know, you can

1:05:56

go and do this test on your own. So

1:05:58

I think right now what we're going to see as

1:06:01

states making their own decision

1:06:03

on what to do, and in fact, we're working

1:06:05

with one state right now

1:06:07

to try to help them to actually just get

1:06:09

that test from China directly, because

1:06:12

in my opinion, not does that not seem

1:06:14

insane to you. I mean, does that not seem

1:06:17

a massive failure of the federal government.

1:06:21

Yeah. And again I'm not the conspiracy

1:06:23

guy, so I I attribute these things more

1:06:25

to just you know, negligence

1:06:27

than anything nefarious. And I've

1:06:30

certainly heard people speculating that,

1:06:32

you know, there's sort of you know, an anti

1:06:34

China bias and all of these things. But

1:06:36

but I have to be honest. I think China

1:06:38

has been very forthcoming here, and I think this demonization

1:06:41

of China UM, either

1:06:44

either you know, covert or you

1:06:46

know or sort of explicit or implicit, has

1:06:48

really hurt us. UM. I think

1:06:50

I think China has been very forthcoming with their data,

1:06:53

and for some reason, our decision

1:06:55

to not utilize exactly

1:06:57

what they offered us as far as testing has

1:07:00

set us back, put us on our heels. And

1:07:02

my hope is that in the next week the bell gets

1:07:05

rung pretty loud on that and we

1:07:07

you know, we we take on these tests because

1:07:09

again, it's not an economic question. The United States

1:07:11

is very fortunate we can afford to do the testing.

1:07:14

Um. It's really a question of deployment

1:07:17

and other things. You know, you asked questions about running

1:07:19

out of things, Well, we don't even have enough swabs right

1:07:21

now, so we're not just having to buy

1:07:23

the PCR test gets. We actually have to make sure we have

1:07:25

enough re agents to use them, enough swabs to actually

1:07:28

you know, test them on the people. Um.

1:07:30

And that's the stuff that really we should

1:07:32

be stockpiling that stuff, right and

1:07:35

and and we certainly in early January

1:07:37

should have been preparing for this to

1:07:39

spread. And again, I I

1:07:42

think Bill Gates spoke to all of

1:07:44

those things five years ago at the tail

1:07:47

end of the Ebola outbreak, when he

1:07:49

said, look, it's not a question of if, but when

1:07:51

this happens again. And yet

1:07:53

the group responsible for a pandemic

1:07:56

response, or the Pandemic Response

1:07:58

Team, was disbanded in two

1:08:00

THO. Yeah,

1:08:02

I mean Michael Lewis's book The Fifth

1:08:05

Risk, I think does a great job of

1:08:07

explaining all the non sexy parts

1:08:09

of government that we tend to

1:08:11

forget about until disaster hits

1:08:14

um And it's funny I read that book when it came

1:08:17

out, so I don't even remember if in the book

1:08:19

Michael Lewis talked about this particular

1:08:21

side of the government. But you're absolutely

1:08:24

right, this is this is a part of government

1:08:26

that when things are good, it's easy to

1:08:28

forget about It's easy to say, hey, we can,

1:08:30

we can, we can cut costs by getting rid

1:08:32

of them. Um. But but

1:08:35

you know, you think of this like you think of insurance,

1:08:37

right, You don't buy insurance for your home after it

1:08:39

burns down. You have the insurance in place

1:08:41

before there's a fire. Before

1:08:45

we go on, one last question, even though

1:08:47

I could talk to you for hours, Peter

1:08:49

um, and that is, is there any

1:08:52

evidence that once you get the

1:08:54

this pathogen or this virus,

1:08:57

you build some immunity

1:09:00

to getting it a second time? Or is that

1:09:02

just a complete unknown? I

1:09:05

think it's an unknown right now, Katie. There

1:09:07

are two issues at hand. The first

1:09:09

is is this going to be like influenza,

1:09:12

where if you get it in a given

1:09:15

season, you're not likely to get it again,

1:09:17

but you'll always be susceptible to it in

1:09:19

subsequent seasons because it has enough

1:09:22

genetic migration or drift

1:09:24

year upon year upon year. Or

1:09:27

is it something like you know, the measles

1:09:30

or polio, where once you are vaccinated

1:09:32

against it, once you know it doesn't

1:09:34

that the virus is not moving around genetically

1:09:37

very much. And you know, either getting

1:09:39

vaccinated against it, or in this case, if you

1:09:42

acquire the virus and recover, you're

1:09:44

fine. We certainly think in

1:09:46

the short term there is immunity,

1:09:48

and that's one of the other really exciting potential

1:09:52

therapies right now is something called convalescent

1:09:54

serum, where you actually take blood

1:09:56

from a person who has recovered, you

1:09:59

ident deify the you know, uh,

1:10:02

the sort of the antigens

1:10:04

and things that are in the blood, and you can then infuse

1:10:06

them into people who are sick as a form of

1:10:08

therapy at high doses or at

1:10:10

low doses to impart short

1:10:12

term immunity on people. So given

1:10:15

that we're seeing um reasonable

1:10:17

evidence of the efficacy of convalescence serum,

1:10:20

that tells us that there must be at least some immunity

1:10:22

that's acquired from this. Peter,

1:10:25

thank you very much for spending some time

1:10:27

with us talking about this very

1:10:30

scary situation. Well,

1:10:32

Katie, thank you for what you're doing. Your podcasts

1:10:34

on this topic have been fantastic, So

1:10:37

anything I can do to to help

1:10:39

you get this message out. It's an honor that

1:10:48

was Dr Peter Attia. You can

1:10:50

follow more of his coronavirus coverage

1:10:52

on his Twitter at Peter Attia

1:10:55

empty and on his podcast

1:10:57

which is called The Drive, and

1:11:07

that does it for this episode of Next

1:11:09

Question. A reminder to all of our

1:11:11

listeners are reported episodes

1:11:13

on topics like maternal mortality

1:11:15

and the environmental impact of meat

1:11:18

are still to come, but in the next

1:11:20

season coming out this summer. The

1:11:22

rest of this season, as we mentioned,

1:11:24

throughout March and into April, will

1:11:27

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1:11:30

You can also follow us on Instagram

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1:11:34

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1:11:37

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1:11:39

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1:11:41

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1:11:43

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1:11:46

And a quick reminder, if you want to share a story

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1:12:24

you all so much for listening, and until

1:12:26

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1:12:29

Katie Couric. Next

1:12:38

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