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Nick Jikomes
Can you tell for people that don't don't know you already a little bit about your scientific background and what you do?
Jay Bhattacharya 6:21
Sure, I have an MD and a PhD in economics, that I have been a professor in the School of Medicine at Stanford for about a month since 2001. And before that, I was a site scientist at the RAND Corporation. I had been studying infectious disease epidemiology and policy. Since 1998. My first papers were on on HIV HIV policy. I worked on it, you know, h one n one published paper, peer reviewed papers, h one and one on antibiotic resistance, a whole bunch of papers, I now do a whole range of issues in addition to that, but that's been a major threat of my work for most of my professional life. I work also with the FDA on vaccine safety was one of the what helped set up their their system, this system called best to do epidemiologic surveillance studies of vaccine and biologic safety. So I had a lot of experience working in these areas for over the last the last couple of decades.
Nick Jikomes 7:28
Interesting. And you know, we're going to spend a lot of our time here talking about COVID related issues. And so, you've obviously thought a lot about this. And I want to kind of start out with some questions for people around what we know today, and how our knowledge evolved in the past two years around how infectious transmission transmissible and deadly COVID is across different cohorts of the population and based on immune status and things. So if we rewind the clock and go back to early pandemic days, 2020 2021 What did we know, at that time about how infectious transmissible and deadly this virus was? And how is our knowledge changed around that over the past couple of years?
Jay Bhattacharya 8:12
Sure. So why don't we take those in turn? So first, first with with transmissibility, like how is the virus transmitted? I think in the early days of the pandemic, I don't think people really had any firm idea about that. There are pieces of evidence that had come out very early on that should have given indications that the disease was airborne, and that it spread via aerosols. Do you remember those very early on a report from a thing was a Chinese restaurant, a restaurant in China, where one patron got it? At one end of the restaurant, there was a fan blowing or something and then some the some patron completely another party on the other side of the restaurant then got it also. So I mean, that should have indicated that this disease was airborne. I think part of what the thinking was happening back then was that SARS one probably was spread more by fomites. It wasn't fomites meaning you spread it by you. You touch a surface that has it off, has it on I spit, the things stops on the surface I touched, I touched my eyes. And now Now I've got it. SARS one wasn't particularly good at transmitting from human to human. So I think in the back of some people's heads, especially prominent, you know, probably from public health folks, in places like the World Health Organization, they thought this might be like SARS, one, that it didn't spread all that efficiently. And that and you looked at the Chinese example, in January 2020. They did a draconian lockdown Wuhan, but it looked like the disease went away. Well, if it's airborne, it just spreads by aerosols, I mean, how can that be it must be it must have been people thought so spread more by fomites or other droplets or some other less less, it highly infectious kind of mechanism. So the the who I think famously put out a statement saying it's not not airborne. It was remarkable, actually, because it wasn't at all clear back then, that that was the case. Okay, so transmissibility. What do we know? What do we know? Now we know it's airborne. We know we absolutely no 100% No, now that it is it is spread by by aerosols, aerosols, you're like clouds, they stay in the air, they like to fight. It seems like they defy physics, you're not thinking too carefully about the physics of it. They so you have a very, very yawns. It'll sit in the room. If I had COVID. And I'm sitting in this room with very poor ventilation. It'll sit in the room for a long time. And someone else could come in and get it.
Nick Jikomes 10:43
You breathe it in. Yeah.
Jay Bhattacharya 10:46
So I think that's the primary way it goes, it may still spread. I mean, it may have some spread by droplets and, and fomites. But I think that is not the primary motor transmission.
Nick Jikomes 10:55
And so what about infectivity, like how infectious is this respiratory virus compared to, you know, other respiratory viruses that people may be familiar with?
Jay Bhattacharya 11:05
So if you have an unvaccinated population with measles, it's incredibly infectious. Yeah, you're you're it's you are in the presence of someone with measles for a short short period of time, and you can get it pretty quickly. On the other hand, something like turns out like leprosy is not all that infectious. It you can be sitting in the same room with someone. I when I was a medical student I actually worked in in in rural India and is in his clinic with treating Hansen's Disease. They're dead, like, every month, they would come to the clinic. And they would they would they meaning the patients with Hansen's Disease, leprosy come to the clinic. And they will get this new whole slew of antibiotics that were provided by the World Health Organization. And what the doctors who were not my preceptors were telling me is that I could sit in that room, I was healthy, young, healthy, I'm not going to get it. They don't really know how it transmits. But it's it's you have to be in sustained contact in environments where it's not particularly sanitary for a long period of time or to transmit. This is somewhere between measles and that I'd say, you have my I got COVID in August of 2021. And my family, I didn't isolate with my family, my I didn't wear masks, I just slept on the same bed with a wife, my kids were all around me. And they didn't get COVID. I think that you can get you know, on the other hand, omicron seems to be much more infectious. So that less, less less time in the presence of breeding near someone with Omicron. He's more likely to transmit. There's there was some questions about like whether viral load of the nose correlates with transmissibility. And I think I think the it's complicated, right. So for for children, it seems like the literature suggests that if you have a high viral load in the nose, it's still children not particularly good at transmitting this disease. For reasons we don't at least I don't fully understand. I'm not even fully I just don't understand. Still children seem less. They're not they're not for the same viral load the same amount of time around the kid. There's they seem less likely to pass these on than an adult with it. There's so so trenchless transmissibility, I think has changed during the pandemic early on. Less transmissible now a lot more with with with the Omicron variant.
Nick Jikomes 13:36
So yeah, there's this interesting question around some age differences here. So there may be differences between the young and old in terms of how easily they're infected or transmit the disease. There's also as many people know, at this point, a huge difference in your susceptibility to getting severe COVID and dying from COVID, depending on your age. How early in the pandemic were we aware of that? That age dependent effect in terms of the deadly deadliness? Specifically,
Jay Bhattacharya 14:04
that was the deadliness of the disease at the age gradient and the deadliest disease was apparent from the very earliest days of the pandemic, if you looked at the Chinese data, it was older people that were dying if you looked at the Diamond Princess, you know, that cruise ship that went around with so many so many people infected? It was it was the oldest people that were that were dying. Oh, by the way, the dam for instance, was interesting, because there was no isolation possible and but only like 60 70% of the ship got got the disease. So it wasn't you know, it the transmission. There was a hint about transmissibility even there. But in terms of who's dying from it, it was all it was the oldest people it was always has always been that Martin corridor. fent famously wrote a piece in that he tried to get published, just documenting from the, I think the Chinese data, the age gradient and mortality and Couldn't get it published, he ended up putting it in his in his LinkedIn blog just to have a marker that people could tell from early on in the pandemic, that there was this age gradient. So we knew that from the early set the pandemic that that the highest risk, people were older, and the children were very, very, very low risk. It's not that children can't get it and die from it, that's obviously false. They can't they can, it's just that relative to other risks in their lives, including other respiratory virus risks. It's, it's, you know, on that on that same order or lower.
Nick Jikomes 15:34
And, you know, I recall fairly early on in the pandemic, there's a lot of uncertainty. Obviously, people were scared and anxious for all sorts of reasons. But there was some controversy around this thing called the IFR. And you know, how, you know, the infection fatality rate or ratio. And, you know, some people were saying it was known, and it was one thing some people were saying it was unknown, we don't know what it is yet. And there were a range of opinions from different people out there in different organizations. What did we know early on and what do we know today about what this number this IFR actually is for this virus?
Jay Bhattacharya 16:12
Okay, so I actually played a pretty, pretty prominent part role in that story. Because so So, in March of 2020, I wrote a piece in The Wall Street Journal's the first op ed I've wrote in my life. That was with an analysis of data from the Diamond Princess, and from the NDA of all places, it just just to give some sense of what are the range of estimates that are possible for the infection fatality rate. And so just the audience knows that there's two distinct ideas or measures of fatality risk in infectious disease epidemiology for this in this kind of context. One is the case fatality rate, CFR case fatality rate has and its denominator it has the number of people who are who are poor become cases or cases in this case means you showed up at the doctor and the doctor diagnosed you with the thing where you show up in hospitals or you somehow show up in the morgue even and they diagnosed you with the thing. And the numerator then is the number of people died among the among the among the cases the IFR is is has the same numerator, but it has the denominator it has all of the people that were infected whether or not they showed up at the doctor whether or not even they knew they had the disease. So the IFR the denominator is much larger or potentially much larger is larger than then the CFR. The CFR then will will be a high range estimate high estimate of the actual fatality risk. Because, you know, in order to show up in the CFR statistic, you have to still show up at the doctor if you don't have if you have a mild illness, you don't show up at the doctor, you don't get counted in the denominator. That's an overestimate of the risk for the typical person getting infected. In the early days of the pandemic, the CFR estimates the World Health Organization put out was something like three 4%. And I remember seeing those estimates, I thought to myself, because that those those have to be overestimates. This is very highly transmissible there. And if it's true that there are many people who get this that aren't, don't have very severe illness, if there's a range of clinical presentations, with the severe pneumonia being only the tip of the iceberg, then then we're really that's it that estimate is a bad over estimate of the actual risk. This happened by the way, it's not theoretical. It's just happened with h one n one. In the 2009 epidemic. The early estimates of the CFR were like very high three, four or 5%. And people people were very scared about that. What happened with h1? No one was there was a series of studies called Zero prevalence studies zero meaning blood prevalence, meaning how common it is in populations to check what fraction of the population in different countries and different locations had antibodies that are specific to the h1 in one virus flu virus and then measure that the infection fatality rate rather than the the case fatality rate. And in that case, what was what they found was that there were 100 or more times infections than cases. For every case that was identified. There are 100 people floating around that had had the disease and didn't know it. There was evidence of it because they had they had antibodies in their bloodstream. And so that CFR though was 345 percent early on. was actually the IFR turned out to be point oh 1% 99.9% survival rather than 97% survival an enormous difference and that basically defend the date when no one epidemic and went from this huge, huge thing that were everyone was like worried about all They've been locked down then too much less worrisome. And it's sort of it basically deepened, defang the worry around the pandemic. I had that same hypothesis. I thought hypothesis in the early days of the pandemic, what if this disease was more widespread than we knew? And so I wrote this op ed in the Wall Street Journal calling for a study a zero prevalence study to be done as rapidly as possible to measure the measure the IFR.
Nick Jikomes 20:29
how rapidly can those be done?
Jay Bhattacharya 20:33
We did it in three weeks. So I wrote that I wrote the study, I wrote the op ed in March of 20, I think it was March 2020, is 2020 20/24 2020. And by April 4, we were in the field measuring antibody rates in Santa Clara County, the week after that we were in the field, measuring antibody rates in LA County with a sister study. I actually was surprised that it felt to me and my groups to do this, I thought that the CDC would do these studies,
Nick Jikomes 21:05
just naturally, they would have been doing them already. Yeah. So that's
Jay Bhattacharya 21:09
one of the reasons I wrote that op ed is because I was surprised and CDC had not already done the study, we're in the middle of a lockdown. They've done this lockdown without knowing how widespread the disease was, it shocked me as a basic piece of information we needed to know to make good decisions. And it's not that complicated or hard to run these studies. So I encourage you once, especially if you have the resources of the CDC. So So I so why are you i we ran this study, and we found was that in, in Santa Clara County, there's something like 40 or 50 times more infections than cases that when you adjust for the fact that there's a lag in, like when you get the disease for when you die from it, that that infection fatality rate was actually something like point 2% 99.8% survival. Now we were doing this in the middle of a lockdown. So there were some limitations in the study. The most important one is that we weren't allowed to go measure seroprevalence in nursing homes. So we were doing a community study, not nursing homes, of course, nursing homes were where most of the deaths were. And so we didn't have visibility into that. So the point 2% is, the infection fatality rate in the community at large is likely higher in nursing homes. The second thing, that limitation is we the sampling scheme we use was a Facebook split sampling scheme, we contacted people randomly by Facebook and ask them to participate in the study. This bias the study toward people were in in the higher income places inside Santa Clara County, higher income places were better protected, because there's more laptop class folks, less exposure, lower income places like South San Jose, we have less, fewer people sign up. And so we were biased in the direction of finding people that were higher income, and thus lower infection fatality rate we bias toward if look because of that sampling bias. We did a we did an adjustment to try to fix that based on the demographics of where people signed signed up. So our estimate that point 2% is representative of the distribution of population within the county based on the demographics. But you know, it's never as good as if you actually have a representative sample directly.
Nick Jikomes 23:32
Well, so you know, anyways, you guys did that study at that time, and you get the number that you got? What how does that number compared to what we know today, the IFRS
Jay Bhattacharya 23:42
so there was no doubt 100 or more of the studies that were done especially in 2020 that were they seemed like we were doing all the time. The the median IFR worldwide, according to was a a meta analysis by Gianni needies is something very close to the number we found was like point two, seven, something like that. So point 2.3% which means 99.8 to 99.7% survival. Younger countries have lower IFR average, which is not surprising this disease is much more damaging to old people. You older people older countries have higher IFR some places have especially if they were hit early in 2020 had a higher IFR. So New York had a higher IFR than some other places. not representative of the world at large. But the median among the estimates was something like point 3% point 2% Just like just exactly what we found in the in that first study
Nick Jikomes 24:37
20 point 2.3% How does that compare to another virus that people are maybe familiar with, you know, like a flu virus on a typical year or something like that. So you
Jay Bhattacharya 24:49
know, we don't do have excellent IFR data for fluids because we don't do these kinds of Sarah Palin's as routinely but the estimate for the flu people would say was something like point 1% So it's two two times. But on the other hand, the what the one flew that we did have an excellent estimate for this h one n one flew. There was point o 1%. So maybe it's 20 times more. Maybe it's 20 times worse. Ebola? We don't have an IFR. But it would you know, 30 40% mean, very, very, very high infection fatality rate. I think. So, this is this is worse than the flu. Absolutely. But nowhere near in the range of something like
Nick Jikomes 25:28
Ebola. I see. Yeah. Okay. That's, that's a good way to think about it. I think. And, you know, another question here, around, you know, how serious the illness can be, is how bad it is as a function of your immune status. So there's been a lot of a lot of discussion and and back and forth on this. Can you talk a little bit about the difference between natural immunity and versus people who have mRNA vaccination, versus people that have both, you know, one, or both? Or neither of those? How do things like the deadliness and the transmissibility change as a function of your immune status?
Jay Bhattacharya 26:08
Okay, so first, first of all, I think the key thing is we don't have a we don't have great data on any of the mRNA vaccines regarding transmissibility and so on. That because the randomised trials were like a very short duration, maybe two or three months, and many of the end up for instance, the Pfizer trial didn't check for transmissibility, didn't check to see if it protecting its transmissibility. They had as as his endpoint, the prevention of symptomatic infection, which which didn't include for instance, people had asymptomatic infection, right. So that was the primary endpoint. The opposite. So most of what we know is based on both for by the way, this is also true for natural immunity, but based on epidemiologic data, where there's matched cohorts of people, the tracked over time, match meanings like people who had COVID and not had COVID tracked over time, people that have the vaccine didn't have the vaccine tracked over time. Observation not randomly assigned to each group. I don't know how you randomly assign COVID status. I have no idea. Okay, so So, based on that, based on the best studies of that coming out of places like Qatar, Sweden, Denmark, Kaiser, Northern California, a few other places. What what's very clear is that if you had the disease and recovered, Israel, if you had the disease and recovered, you have better protection against reinfection. Then, if you just have the vaccine, the vaccine the protection against infection lasts for a short period of time, maybe 234 months, after three or four months the vaccine efficacy against infection, especially in in the during the delta wave dropped pretty pretty precipitously. I think it's even worse during the during Omicron. And so that means that if you have the vaccine, it's very common to get reinfected to Egypt to be infected again, infected so I got the I was vaccinated in April 2021. got infected in August 2021. That is a very typical outcome four months after you get the vaccine, you can get your against this optimal infection. The mechanism is not clear. But it may be that there's there's the fewer antibodies, your antibody production wanes as over time and fairly rapidly. On the other hand, so not and if you look at data from places that track patients who were poor infected, over a long period of time, the reinfection rate seems to be about point 3.4% Is data out of is out of Italy, a whole bunch of places that have tracked people over time that are infected and recovered. So you have very strong reinfection protection, if you were infected and recovered. When there's a new variant, the variants evade the ability to protect against reinfection for both natural immunity and the vaccine. And so a lot of people who were infected recovered before Omicron got got infected again, during Omicron. Same thing with the vaccines, a lot of people who got the vaccines in April 2021, like me, could get Omicron second I in fact, I did I got Omicron Omicron in like, a few months, a couple months ago, after having had the sort of the Delta variant in in 2021, head Omicron 2020 to add the vaccine and read and reinfection and yet I still got Omicron right. So none of these mechanisms provide guarantee protection against reinfection, similar permanent protection against reinfection or infection at all. We do not have any mechanism to guarantee that it's like it's like the other coronaviruses you've got the other Coronavirus is when you were little, almost certainly. And then you've got it again and again and again. Just you can get reinfected especially As new variants pop up what we have seen though, and this is that's the bad news and the good news is the reinfection or infection after the first time you got your vaccinated is less likely to produce it's less likely produce death or hospitalizations than the first time you're infected or or if you are unvaccinated, and you get the disease. So the vaccines and infection and COVID recovery both provide protection against bad outcomes if you when you are reinfected. I see.
Nick Jikomes 30:32
So even if you get reinfected with a new variant, so the new variants can escape the immunity that you get from having a prior natural infection, or escape the immune modulations. You've gotten from getting an mRNA vaccine, so you can still get reinfected. But even if it's a reinfection with a new variant, your chances of getting severe illness that requires hospitalization is lower whether or not it's an mRNA vaccine induced or natural induced immunity.
Jay Bhattacharya 30:58
Yeah, that seems to be clear from the from the epidemiological data, not not so much from the randomized trials. Randomized trials actually didn't show that about the mRNA is the randomized trials actually had no statistically significant difference in the mortality risk from infection for the placebo versus the the vaccinated group. In fact, it was slightly higher in the vaccinated group for the all cause mortality. So yeah, but but I think that the data that came out of the the epidemiological studies afterwards, show exactly what you just said, Nick.
Nick Jikomes 31:30
And do we know? So let's say, you get reinfected, one person gets reinfected. And they have not had COVID, before they have had at least two doses of the mRNA vaccines, another set of people gets infected and they've had a natural infection previously, is the immune response from each group of people going to be comparable? Or is it going to differ in any way? Are there are is each grouping and produce produce a different set of antibodies and cellular immune responses? What do we know? And what do we expect there in terms of similarity and difference,
Jay Bhattacharya 32:06
so that literature is still developing so that the other it's sometimes goes under the name of original antigenic sin, or it's not exactly OAS. But like, that's what people sometimes call it. I mean, the or like, you're essentially the idea is that your immune system is trained by the initial exposure to the antigen that you see version, the edge. And you see, so if you saw Omicron, first, your immune system is sort of primed to deal with Omicron, like spike proteins or whatever, where, whereas if you saw the vaccine, the original vaccine, which is based, basically Wuhan, the Wuhan version of the spiked protein, then you're trained to deal with that. And there is some evidence that that's true. I haven't decided yet. I don't think that literature, at least, to my satisfaction is ripe enough to for me to say with any certainty one way or the other about that. And I do, I don't think I've seen the epidemiological data, anything that convinces me to worry so much about that, because people who'd had COVID before and recovered with Delta, they're less likely to die from Omicron than someone who was completely immune naive for holding other things fixed. Which means that the, and you had the vaccine, the, again, the Wuhan, a vaccine, essentially, the woman vaccine, the vaccine trained on the Wuhan spike very variant that seems to provide good protection against severe disease, even against other variants. So the key thing to me is not the, I mean, I think a lot of people get mixed up on this because they're like thinking about infection blocking. There may be OAS around infection blocking guy from fully decided this, but the key thing to me is does it provide protection does does provide prior immunity, either by the vaccine or by or by recover recovery provide current protection against severe disease even against new variants. Seems like it does. That may wane over time. I don't know. I don't I'm not certain I think the people who've had hybrid immunity, we'd had the vaccine and then recovered or vice versa or the other order, either way, seems to have pretty good protection against when they're reinfected severe disease. I mean, so like, you know, I think if I had to rank probably like, hybrid immunity, straight natural immunity from from COVID recovery and then straight vaccine immunity in terms of like, protection against severe disease, but as they're all really close. So the marginal benefit of say getting vaccinated after you've covered or covered is small relative yet the marginal benefit you're entirely immunized.
Nick Jikomes 34:59
And so How does so the fact of the mRNA vaccines they contain mRNA for the spike protein of the virus specifically? How does that start to factor into some of this in terms of the magnitude of the immune response that the vaccines are going to induce? And does this play into in any way, the evolution of new variants and how they evolve?
Jay Bhattacharya 35:21
Okay, so now we're getting an area that's outside of exactly my expertise saw the so please forgive if the audience is listening, please forgive me this is now my totally ignorant understanding of it. But I'll just get I'll suggest, I'll try to tell you what I think. So I think the, the spike protein, that's the that's the epitopes, that you get if you are vaccinated. Of course, the the virus itself has many other proteins, including this n protein, which is which is, which induces a response when you when you're when you're infected, there is some literature suggests that the the antibodies to the end protein, let's say you're vaccinated, and then you're infected, the antibody you get to the end protein and the immune training, you get to the end protein from that infection is less sort of imprinted than if you asked if you just got COVID. First, without the vaccine, you get COVID. First with a vaccine, you get a broad range of responses to the s protein, the N protein, a whole whole whole shebang, right. Whereas if you got the vaccine, first, just the spike protein protected, you know, you're primed for the spike protein, you get the whole vaccine, then you whole virus, then and the N protein response is less, less pronounced, if you if you if you if you have it in that order. I don't think that I think that's true. But I don't think that I've seen any evidence that's convinced me that that leads to the failure now a third and another infection, that you're going to be more likely to die if as a result of it, you still have protected pretty well against severe disease, even if you got the vaccine first than the disease. So I just I saw, I don't know the upshot of that, of that of that. epidemiologically, other than to say, I don't see anything that data particularly concerns me about it.
Nick Jikomes 37:21
I see. So So I guess to summarize this whole part, in your view, vaccine induced immunity and natural immunity are comparable, there might be minor differences, but they're comparable in terms of their ability to protect you against severe illness. But in either case, they're not they're probably not going to protect you against transmission in the future against a new variant.
Jay Bhattacharya 37:42
Correct. Now, you asked me what evolution now and now we're really far afield next. So just just just again, so like, again, this is i It's fun for me to think about stuff outside of my field. But I'm happy to be corrected on this. But let me just say, I think that we have a very different ecological environment for this virus now than we once did. In March of 2020. We now have a very large fraction of population that's been infected. There's a recent estimate out of out of Harvard and Stanford suggesting like 94% of the population has been infected recovering the United States. That's probably true in like, in India, I know that that was true very early, even early on others, like there were very large fraction by 2020 2021. Was was infected and recovered. So you have you have a very different environment, that is that virus is facing you and the now there's a mix of vaccine, folks who'd had the vaccine and also COVID recovered the virus, I think the evolutionary pressure then on the virus is has been to produce produce mutations that evade that immunity. The virus wants to replicate. It wants to like it wants to it wants to survive if it's if it's so in the way it can do so is by evading that immunity, it may evading the the the antibodies that neutralize it. And I think Omicron is an example of that. I think that activates evades that immunity provided by the vaccines, the one based spike vaccines and the prior prior immunity from the from COVID recovery. It doesn't seem to be evolving in a direction of producing more severe disease or in any case, our immune response to is such that that we remember how to cope with it. We don't and you know, it makes some sense, right because like I think a lot of the issues with clinically with the virus is that you overreact to it. A lot of the a lot of the worst outcomes, you know, the severe viral pneumonia was it was an immune overreaction. Now, there are some other other things that you can eat that can happen if you get the virus, you know, clotting issues. or you know sending out the vaccines you get you get myocarditis and other other things I don't think those are like I think those are just essentially like they're not they're not they're not they're not they're not actually helped the virus replicate they don't have a virus there's there's no pressure, evolutionary pressure to make the virus we react in that way. Just unfortunate thing that the virus does that to some people. I don't view that as like evolutionarily important in that in that sense. It's it's clinically important. The key evolutionary thing to me is the pressure to evade immunity because if the virus didn't do that didn't evolve in that way he would die out. In that sense, I think it's very similar to the other Coronavirus is the other Coronavirus is also have their mRNA viruses, I'm sorry, their RNA viruses, they they evolve, they mutate a lot. Unlike DNA viruses mutate less. And there's less error checking. There's just there's going to be a lot of mutation, as well as there is with the other other Coronavirus, Human coronaviruses and other coronaviruses that float around. The question is what is selected for I think what's selected for is and Univision not deadliness
Nick Jikomes 41:14
I see. So, you know, one of the things you know, I remember back when the mRNA vaccines were first coming out, you know, many people like me at that time, were really excited and impressed by this technology, in particular, around the programmability of mRNA vaccines, as opposed to traditional vaccines and their potential for, you know, rapid development and iteration of a new variant comes out or whatever, a new virus, you know, start spreading through the population, you can practically overnight go in and change the sequence in the mRNA contained within the vaccines. And you know that that was a very important strength of this new technology. And some of the initial clinical results were also seemed to be very compelling, at least what we thought they were. But, you know, in retrospect, they're some of it seemed a bit confusing. So, you know, early days, you know, people like Anthony Fauci were saying things like, you know, quote, when people are vaccinated, they're not going to get infected. And now sort of famous viral tweet from the CEO of Pfizer, you know, said, quote, excited to share the updated analysis from our phase three study with bio Entech also showed that our COVID 19 vaccine was 100% effective in preventing COVID-19 and South Africa 100% Exclamation point. So at that time, when those statements were being made, were they mistaken? Were they not thinking about new variants? What exactly were they measuring? You know, in the case of the Pfizer biontech studies, when when they were coming out with those statements, and and what was your reaction to them at the time and now,
Jay Bhattacharya 42:51
so, I mean, I paid very close attention to the trials that were published in like they were in journal and other places for for both Mulder and and Pfizer, focusing on advisor, in fact, both of it's true for Maderna to the primary endpoint was prevention of severe of symptomatic infection. And they tracked patients for two or three months. So in December of 2020, what we knew is that the vaccines after after, let's say, after two weeks after you're fully vaccinated, would protect very strongly against symptomatic infections for a short while, that we knew we there's What didn't we know what we didn't know? Would that protection lasts for long? We didn't know whether a protect against severe disease, as they said that all cause mortality actually, was those higher, ultimately in the, in the, in the the vaccine group than in the placebo group in the in the randomised trials for Pfizer? Not necess not the disease nificantly different just, I mean, there was like 15 verses there was no there's no convincing evidence that to protect against all cause mortality. It wasn't powered for that. So you know, that wasn't so worried about that. And then, and then we didn't know if it prevented infections and transmissions. Given all of that uncertainty, what I my reaction to this was, we should definitely be using the vaccines for focus protection of vulnerable older people, it seems likely if it protects against symptomatic disease, it probably also protected against death from COVID. And we knew that the mortality was so much higher in older people than in young people. And so it's vital to get the vaccines to older make it available to every old older person on the face of the earth. You could pick a cutoff date 6560 Whatever you like, but depending on the vaccine supply, but it was what was the vital thing was to make sure older people got it for younger people was much less much less important. Prevention of cinematic infection is not as not that important endpoint for For a disease that produces a very, very, very, very low infection fatality rate, which is true for young people. So I wrote an op ed with Senator Gupta and in December 2020, arguing for using the vaccines for focus protection of older people. The the the CDC, and people like Tony Fauci, they had a very different approach to this evidence. They they looked at his evidence, and they hoped that would stop transmission, not on the basis of what was there and the evidence, but on the basis of, of their hope. There was, I guess, I guess that what the Pfizer CEO was reacting to was a small study in South Africa that that looked at transmission goes again, it was a short period of time. And they want it to be and you could see it in the language they use, they will say, Look, we need to use this vaccine to stop transmission and achieve herd immunity. By that what they meant, was essentially permanent protection against getting and spreading the disease. But they didn't actually have evidence that that that could that the vaccines could do that, at that point. They just hope that it would. And so the strategy they adopted was essentially universal mass vaccination with the vaccine. Rather than using the vaccine for focus protection of older people. That then led to calls for vaccine mandates, pressure on people social ostracization, and people that chose not to get the vaccine, it led to a whole host of, I think, incredibly damaging policies, not based on hard scientific data, but rather than a hope that the vaccines would do something that it turned out, in retrospect, the vaccines didn't actually do
Nick Jikomes 46:47
it. And but it sounds like at the time, a lot of those statements were made. The evidence that we had what wasn't necessarily ruling out the vaccines could prevent transmission, but didn't demonstrate that. And we just hoped that was going to be true so much, that people just sort of ran with it.
Jay Bhattacharya 47:05
That's exactly what I think happened. Right, they thought that, that if it prevented symptomatic infections for nine for three months, or two months, that provides enough basis for sort of for saying very strongly, I think overstating really, that, that the vaccine would stop transmission. In fact, they blurred that distinction in the minds of the public.
Nick Jikomes 47:29
Interesting, and, you know, around the mRNA vaccines, you know, you know, especially because this is a new kind of technology, it's a different kind of vaccine than people have have used historically. They just they just work in a fundamentally different way. You know, there's questions about the potential long term consequences of these vaccines. You know, there's there's the question of how long does the immunity last? And we've already talked about that a little bit, then there's the question of Are there any, you know, big or little potential negative side effects of these things. And obviously, this has also been an area of controversy. You know, on the one hand, we had to move very, very fast early on. And you know, you don't have time to do a multi year long term study, in the midst of a rapidly evolving pandemic, like we've been living through. On the other hand, this is new technology, and some time has passed. So what do we know today about any potential negative side effects that might come from these vaccines? In particular? What do we know about that in terms of how it might vary across different age and sex cohorts?
Jay Bhattacharya 48:31
Okay, excellent. Can I take that into parts as your reference is super interesting, about about uncertainty, and what you do within the midst of a pandemic? I think that's a really important point to think about is and remind me if I don't get to the second because that's also very important. So the uncertainty, how do you manage that in the in the midst of a pandemic? We don't, you can't expect that, you know, it's funny, like what in in polio, for polio, in 1954, Jonas Salk, and the March of Dimes, folks ran a study of a randomized control study of 1.8 million children
in the middle of a deadly pandemic. And they waited and saw what the results were took them a year.
And that that led to the mass adoption of the Salk polio vaccine. Later, they were like, you know, the Sabin vaccine turned out to be better for some uses and so on. But like, the key thing is that they were very, very careful, even the middle of a pandemic, to try to get absolutely rock solid, solid clinical evidence about the vaccine that we're using both the safety profiles and the and the efficacy. In this pandemic, it seemed like we were more panic than we were during the polio pandemic. We now the data we had was not bad actually, in some sense, like this protection against against symptomatic infection is a pretty important endpoint. But I think it was irresponsible in December 2020, to try to think that it would stop transmission when we didn't know that it would. And that it's it was irresponsible in December 2020, because it was outside of what the scientific evidence said. But then it was really irresponsible by July of 2021, when it was abundantly clear that that there was that heavily vaccinated countries were seeing big outbreaks. It was too late at that point to take make that as a safe assumption, you could make it maybe you make a defensible assumption in December 2020. That but not by by July 2021. And we double down on vaccine mandates. We've doubled down on vaccine passports and vaccine vaccine pressure to vaccinate, which I think has had a really negative consequence on vaccine on the confidence that people haven't vaccines. Even though the scientific evidence by July of 2021, was so clear that they did not stop the vaccine doesn't stop transmission. And so so so I think that in terms of like the uncertainty, what you want to do is you want to you want, there's always a balancing act, right? You have this major danger, major, major danger. Now there's this danger of flooding, others of the disease floating around, but you also need to have some, some adherence to basic scientific principles, or else you're going to end up having the public stop trusting you. Because I think what's happened during the pandemic. As far as like what we learned about side effects, I think there's still more to learn, but that what we learn is already really interesting and important. So first of all, it's become very clear. Now it wasn't so clear in December 2020. But it's become very clear now. And certainly, I think by 2021, that this vaccine causes myocarditis in young men are the inflammation of heart muscle in young men 15 to 40, I don't know, you'd pick some reason lower than than higher than that. It also causes it in women, but at much lower rates. I don't fully understand the mechanism of it. It's it's probably the spike protein of soy protein fragments. But it seems to cause it at higher rates than COVID infection does. The same age groups. So if it says
Nick Jikomes 52:24
that's actually important, I just want to emphasize that so it's true. It's true, that in young men, at least the rates of myocarditis from the mRNA vaccines are higher than they are from getting COVID.
Jay Bhattacharya 52:39
Yes, yeah. And of course, it doesn't prevent you from getting COVID. So like people would say, like, try to compare those two as if they were really important. But the question is not actually the relative rates of those. You can't avoid getting COVID. But at least the vaccine doesn't stop you from avoiding getting COVID doesn't stop you from getting COVID. So the question is, should I get vaccinated to prevent myocarditis? If I'm a young man, the answer is, it doesn't do that. So now you're giving yourself to risks that the market is missing from the vaccine, the market is just some COVID. Doesn't doesn't protect you against that. So the overall risk of myocarditis if you're vaccinated, your Eman is higher than if you're not vaccinated. Interesting. So we've learned that we we've learned also there was just a study that was just published in early December, out of it and analysis done by the FDA with a group I actually have worked with in the past, called the FDA best. They what they do is they have data from Medicare and other healthcare claims records where they track people over time, over long periods of time, Medicare the whole rest of their life. They can match that historically, people who were vaccinated and unvaccinated and then look at various outcomes of concern. What they concluded was that there is a elevated risk of pulmonary embolism or elderly people who take the mRNA vaccine, published in vaccines published peer reviewed major peer reviewed paper out of the FDA. And this was just published in December 2021 to 2022. There's reports out of Israel that suggest is higher rates of of some of some some cardiac events. There was a very careful reanalysis of the of the randomized data, randomized studies by by a group that includes one of the senior editors of the BMJ Peter Doshi, and then this the bleed authentic news show Friday and what they what they did is they they looked at reports of severe adverse events in the in the in the in the mRNA trials. Based on the based on a list of that That was compiled by the WHO to say, Okay, this may be associated with vaccines, these vaccines. And then they, they, for each serious adverse event, they would look at the clinical context of this happening is the potential event happening, this event happening, and not knowing if the patient was in the placebo group or in the vaccine group, they would assign a jury of Doc's to look at that and say, Is this likely vaccine associated, and they would vote. Based on that analysis, they found that there was a one in 800 risk of serious adverse events with MRA vaccines. Now, the the problem was that they don't, they don't have like detailed patient information. So they don't have age they didn't, they're trying to, like based on they just to have it based on what Pfizer has publicly released about these patients and the vaccine trial. So they're what they would like to be able to answer is, is it is that risk higher for young people than for old people? You don't know that from the trial? Because that's not been that's something to analyze that I think that kind of methodology really, is really appropriate for, for asking these kinds of questions. And I think Pfizer should release those data so that people can do those reanalyses. So, so we've learned a lot the vaccines, the vaccines are not benign. And one, there's one possibility which may be it's I mean, you know, the way the mRNA technology works, if they just use straight on modified mRNA, you'd actually induce a pretty severe immune reaction, there's a there's a big technological advance that happened in order to for this mRNA technology to work, which is they replaced one of the base pairs of the of the mRNA. With this with this pseudo urethane, which reduces the immunogenicity of the the mRNA itself. I mean, I think that it's made it possible, I like he was quite excited by the mRNA vaccine technology when I first heard about it, because for exactly the same reasons, you just, you know, with Africa, delicates, maybe we could use it to like, get a vaccine against malaria against a whole host of diseases that we really have not made a ton of progress against. And we could experiment rapidly with just changing the sequence. But I think it's more complicated than that. And this is I'm not about again, I'm not gonna apologize again, for for talking outside my area, I just this is stuff I read not not not my training. But it seems to me that it's not simple, as simple as just programming computer, and you just you run it and you have hardware, there's some interesting and important interactions that we don't anticipate, like, I don't think anyone would have anticipated the high rates of mRNA. This, this mRNA vaccine causes myocarditis in young men. I don't know, I don't know why if hiring young men and young women, I mean, I'd be open to hearing suggestions and hypotheses. But that's something I didn't anticipate I'm only getting I saw, I didn't want to just be before they came out. There's some complications around this. Because we don't fully understand the biology around it. And just changing that the sequence that we put into the heart of the mRNA vaccine that we're using, may actually have other biological effects that we don't anticipate. The lipid nanoparticles can cause problems, they potentially can cause problems that the ones that they're in case them. And who knows, like there's, there's a lot of things that you can only learn, unfortunately, by doing clinical experiments on actual people. The issue is, should we should we put these these kinds of technologies out at scale, without having done smaller scale experiments? I think it's irresponsible, even in the midst of a pandemic. I mean, in the, in the context of the, of the polio pandemic in 1954, we we slowed down and ran a very large scale trial before we before we put it out to the all the world's kids. We have to be careful, we have to we don't we shouldn't just because we're we've had a lot of scientific success have any universe around us, we still have to do the work very carefully to make sure that we're there unanticipated things, we're CMV and take those things seriously. That's what vaccine safety work is about. Right is to is to try to find those things so so that we improve the safety vaccines that are out there. So I think it's it's again, I mean, it's the one level of scientific question, as long as it's a policy and philosophical question, how much risk are we willing to take at population scale?
Nick Jikomes 59:26
Yeah. What some, you know, what's your reaction to the fact that, you know, these vaccines were very rapidly produced and distributed initially. And, you know, in my mind, you know, one of the whole points of, you know, one of the whole potential upsides of using these so called Programmable mRNA vaccines is, as we mentioned before, the the ability for rapid iteration, you know, if a new variant comes out, you can update your sequence and get a new version that's specific to the new or emerging variant. And yet, as we've had variant after variant come out, they haven't come out with new versions of mRNA vaccines as fast as I would have expected. Is that surprising to you? Do you know why that is?
Jay Bhattacharya 1:00:08
I mean, I think the problem is like, you can't, like you still have to test it in humans, right. So like, you know, I saw the FDA approved, the BA for five vaccine. In in on the basis of mouse evidence, and with a with a surrogate endpoint of, of boosting antibody production. There's specific to be a four five,
Nick Jikomes 1:00:33
was this was the kind of infamous study that was in six mice.
Jay Bhattacharya 1:00:36
Yeah, I was like, what, eight mice or whatever, I mean, actually, 30 mice, but eight were assigned to that what I can there's the point is that there's no humans in this study. I mean, it's it is, it's, I think it's just irresponsible like you it's a new product, it's not, you know, with with the, with the flu vaccine, there are there is mouse studies to check for immune genericity. But we actually have correlated with those mouse studies, strong human evidence going back decades. And especially the safety profiles of those flu vaccines are pretty well understood. And they still we still track them to check for, you know, Ganbare syndrome or whatnot. And it's, it's, you know, it's relatively, it's really low. Here, you have a new technology where there's there are safety signals that are concerning, it's brand new, we don't really know if we replace the mRNA code with without what will it produce something different or not, will produce side effects or not, that we didn't expect? And so on? We don't we just can't assume that they don't behave just like we do with the flu vaccine, which is a very, very, very different platform and technology. So yeah, just I think, I think it's just, we just went too fast. With this. There's another aspect of this of this technology. I said, I was like us super excited about the the availability, this technology, it just never never, I'm gonna win. This is probably the biggest mistake I made the whole pandemic was in March of 2020. I thought there was no way we could get a vaccine in a year. That just seemed outlandish. And so I was really pleasantly surprised that we had it in nine months. The problem is another problem now. And this is this looking forward to other pen future pandemics. Now that we have this technology I think there's we found that there's no guarantee that we get updated rapidly, there's no guarantee that we'll have the properties we expected to have once we once we actually get it like for instance, we expect it to stop transmission and it doesn't. We don't have we don't have omniscience around it. We still have to do the experiments, right. But we but what happens now is that people have overestimated the capacity of this technology to produce perfect vaccines that at scale rapidly. The next time there's a pandemic, we'll say, Well, why don't we lock down we get the vaccine until we get the vaccine in three months. It will this availability, this technology will induce lock downs that will end up causing the same catastrophic harm that they've had to poor people and vault and other vulnerable people to children worldwide, in the hopes of getting a vaccine rapidly out that for which we have absolutely no guarantee that will perform in the way expected for him that that that would no guarantee they won't have side effects that we don't anticipate. This, this vaccine technology is is a real advance which be treated the same way we treat other other vaccine technologies. You need to have clinical data, high quality clinical data for at least some extended period of time before you can do it at scale. And it should not be an excuse to lock down until as you know I think a lot of people or some people at least thought about the availability of vaccines as a way out of the lockdowns and 2020. I think linking lockdowns to the ability of vaccines is an enormous mistake. I think it will end up making us think that lockdowns are less harmful than they actually are, are more wise than they actually are. And
Nick Jikomes 1:04:12
when you when we talk about the harm caused by the lockdown or the way that we are reacting from a public public policy perspective, to a pandemic like this, can you talk a little bit about how that's measured? And maybe the concept of excess mortality? Like how do we actually tell that something like a lockdown or some other policy is is causing harm?
Jay Bhattacharya 1:04:33
Well, so excess mortality is a is an indirect measure of this because there's lots of things that can cause so the way excess mortality is measured is you look at mortality rates for different age groups, for instance, in previous years, in this case before the pandemic so 2015 to 2019. And then you look at mortality rates now, and you compare them the next was more to it. Now you can do age adjustments or other like technical aspects to it. But like, that's the key idea. And if you see higher mortality now for any cause, versus this for the same age group in 20 2015, to 2019, or whatever, again, whatever time period you want, that suggests that something has gone on that has killed more people now than before. Now that's an ambiguous signal, it can the deaths from that can come from COVID. It can come from lockdowns, it could even come from vaccine injuries, it could come from other things that are happening have nothing to do with COVID. Right. So it's a signal that tells you something's wrong, but doesn't tell you exactly why that thing is wrong. So there's more direct things that you can look at. That provides some indication, although not a full accounting, right. So for instance, the World Bank and the World Food, food. What's it called? There's, there's a there's a group in the world that tracks hunger around the world. The World Bank suggested that the economic in early like April 2020, suggested the economic dislocation caused by lock downs. You know, supply chain disruptions, disruptions in economic activity would lead to 100 million people 100 and 30 million people being thrown into poverty worldwide. Less than $2 a day of income a more or less $2 of income or less as a consequence of lock downs. It turns out that that's something like 100 million people thrown into poverty. When you say supply chain disruptions, it's not benign, it means somebody at the bottom of the supply chain loses their job. And they can't feed their family, they might be in some poor country. They can't feed their family and their and their family stars. In March of 2021, the UN estimated that that 230,000 children had died in South Asia alone, as a consequence of the dislocation caused by the economic dislocations caused by the lock downs and also disruptions in the immediate in standard immunizations. And the the the lock downs prevented because we wanted to keep hospital systems open, we stopped people from getting basic screening measures, including basic cancer screening like like breast cancer, colon cancer, people delayed now men and women are showing up with late stage cancer that should have been picked up earlier. And they're going to die from it. Another another thing, which is less well, no, but it's really important. The social science literature before the pandemic very strongly documented the importance of schooling on the health of children after they after they after they graduate. Turns out that even small disruptions, short disruptions in schooling, a few months can have long term consequences on the health of because what happens is those kids are less well educated, they're poor, they are less healthy and they live less long, they live less long they otherwise would, just based on those disruptions alone. So in their like, there was a JAMA Pediatrics piece early in the pandemic that estimated the spring disruptions of schooling in the United States would cost American school kids five and a half million life years and expectation over the over their lifetime. So these are like pieces of the puzzle. The problem is like the lock downs, the the effects of them are so myriad, so multi-dimensional, that we're going to be counting the harms for a very long time. There's so much harm that's linked to them, it's almost impossible to catalog them in its hole. But the broad pictures are absolutely shocking, and absolutely overwhelming. I think every poor person on the face of this earth was harmed by these lockdowns in some way or other children, vulnerable people. And the effect will be not just in terms of the economic well being of them, although that was devastating enough, but also in terms of the health, psychological and physical of the entire population.
Nick Jikomes 1:09:22
Well, at this point in the conversation, you know, God help us I want to talk about masks. You know, everyone's favorite subject. You know, obviously, there's a wide range of opinions, expert opinions and non expert opinions about masks. Very early in the pandemic, you know, a lot of people have forgotten this, you know, initially here in the US, at least, you know, a lot of experts and public health institutions were initially telling us, actually, don't don't worry about maths, they're not that useful. But then, you know, overnight at some point, they said actually, they are helpful. We were just saying that so that we could conserve supplies for health care workers. And then of course, we went through various cycles of masking mandates and endless debates on masking. And, and all of that, you know? Now, you know a lot of people experienced a lot of whiplash and anxiety around masks for all sorts of different reasons. But today, what can we say with confidence about the effectiveness of masks and preventing the spread of COVID for both regular cloth versus n95? Masks?
Jay Bhattacharya 1:10:26
Okay, Nick, you want to get kicked off YouTube, I can tell. It's funny because like I, the the one time I was kicked off YouTube, it was a was a roundtable with the Florida Governor DeSantis, Governor DeSantis, where he asked me about the efficacy of child masking mandate child masking and preventing disease. And I told him a fact which is that there is no randomized evidence at all, zero randomized evidence that shows that they're done even conducted a randomized trial, plus a randomized trial of masking and children. And that that we had no low high quality of instead also just the masking would work to protect children. And that video, YouTube censored that video of a sitting governor asking scientific advisors about on a scientific question. So what Let's not do this with the aisle? I'll try not to get you to Nick. But but I will
Nick Jikomes 1:11:16
just, you know, say what, what you know, to be true.
Jay Bhattacharya 1:11:20
So I think the evidence on masking before the pandemic was overwhelming. A number of high quality randomized cluster studying cluster studies that that found that masking work was ineffective in protecting people against highly infectious respiratory diseases like the flu. And the settings were included, like hospital settings, and that included different types of masks. There's some evidence that again, 95 masks fitted, were bought and worn by trained professionals where they were like, you know, change, you know, when they got wet and things like that. That might work to some degree. But even those there was like mixed evidence. In Population settings, I don't think there was a single one that actually had it had a very substantial effect on transmission of the flu. This was the basis and these were randomized studies. Like yeah, like there was one study. I'm not even sure how they like manage this, but they they on the Muslim Hodge, they, the researchers randomize the tents that people stayed in on the oldest pilgrimage to Mecca, that people make they randomized tents will sometimes go off mass and other tent didn't get the mass. And there was no difference in the flu rates among the two tents. Now there the uptake was like 50%, or something in the in the rent, but it'd been you know, like you force people to get mass you all not necessarily get perfect uptake. So the point is that the evidence on mass didn't never show, but when we ended the pandemic that they worked in community settings, not cloth masks, not not surgical mask nothing. This was the basis for why masks were not recommended early intended for the population at large. Because that's what the pre existing high quality evidence showed. I don't know why public health made that switch. But sometime in March, April, April 2020. Public Health decided that mat mat masking in the general population was was the way to go. I think there was a mistake, partly based on the translate that how people thought transmission work, people thought transmission worked by droplets spread droplets, or like rain, aerosols or like are like clouds, right? So like, I think masks can actually block droplets, you've used to ease into a mask, there's gonna be many fewer droplets, they're going to come out. And then if you don't have a mask, and so people thought, Okay, well, physically, it should make some sense that it should work. Even though there was this long literature before the pandemic, there's just that they don't work very well even for the flu. And
Nick Jikomes 1:14:02
so to use your analogy, I like what you just said. So droplets are like rain. Aerosols are like clouds is the idea here that simply because we're talking about aerosolized particles as the mode of transmission hear that those aerosols literally just go through the mask, the holes are just not small enough to trap them?
Jay Bhattacharya 1:14:20
Yeah, that's right for even forget about the mask itself. When you wear a mask and your glasses get fogged up, that's aerosols escaping out the hole, the big fat hole that's right here, or on the side or underneath. You have to actually have in order to have blocked that is really hard. You have to shave. You can't have a beard and actually have a close fit. You can't you have to you have to leave a line is uncomfortable. Where if you're actually fitted wearing a fitted n95 respirator properly, and if it gets wet, then the the way the n95 respirators work. It's not actually the physical block used So of holes that it's there's an electrostatic charge, that reduces the transmission of even smaller, very small particles through it. But when it gets wet, that sort of that sort of like capacity to block, even small particles goes away. And so that's why it's replace it when it's wet. I mean, it's being trained to wear an n95 is like it's your gift, do you fit testing, it's a complicated thing, if you ever had to go through it, to tell the public at large to wear it without any of the fit testing. It's just means the aerosols are escaping out the sides. I see. So I just I think so this is vastly oversold, I think, at least initially on a mistaken belief that it was mostly droplets there spreading the disease. And then, then somehow, it just, it didn't matter what the evidence was, like, there was that there was that Danish study that looked at mask wearing in terms of protection of of yourself, right, they randomly assigned surgical masks to one group and no surgical masks and other group. And there was hardly any difference in the rates at which they that they got to COVID. I mean, that I think it was statistically I don't remember, I think it was like statistically significant and, and the actual, absolute risk reduction was almost nothing from wearing surgical masks. There was a Bangladesh maths study where they randomly assigned different villages. Now that study again, didn't know these studies had kids in it. So like masking childrens is based on no randomized evidence, but that study found is that the cloth masks had noted his nificant effect, and the effect size was tiny, the RET the the the surgical masks had a statistically significant effect. But the effect the effect size was like not 9% of efficacy. In the in terms of like the reduction of risks with a confidence interval from zero to 18. There have been some reanalysis of those data that suggest that even the significance was overstated. And then there's just a there's just a recent study out of where was it? Like going senile? Nick, I'm sorry. There was another recent randomized study where they compared and 95 masks to two surgical masks and found no difference in Clint in hospital settings for spreader COVID. So the pre existing mask literature, the randomized mass literature on the flu found no have no effect. The existing mass literature on COVID randomized wrestlers finds little to no effect, very little efficacy. Now, if you have a low efficacy thing, let's take it at face value, say it's nonzero, let's say so. The problem is recommending at scale is that you have this you have this like this danger that happens that when like let's say, let's say someone's high risk of dying, if they get COVID. They were a low efficacy device. And they take more risk than they otherwise would. So even though physically that mask is reducing, has some efficacy, that you increase the exposure time. Yeah. And so you actually made things worse.
Nick Jikomes 1:18:18
Yeah, it's sort of like, it reminds me of the phenomenon of, you know, people buy like, you know, big trucks or SUVs. But then they become riskier drivers, because they feel like they're safer in that kind of thing. It's the same psychologically, it's the same type of phenomenon, I guess.
Jay Bhattacharya 1:18:33
Exactly. And early early days, we said, wear a cloth mask, and go out. But in your I mean, your say like your mat, my mask protects you, your mask protects me, but really people felt safe wearing cloth mask. And so they went out. Sometimes some even some high risk people went out, nothing indicates the cloth mask works at all. We probably kill people with those recommendations. So you have like, I mean, just in now, if you look at like the mass mandates, you compare places that have them and don't have them. There are these like low quality observational studies that the CDC keeps publishing the show that that math mandates worked in some places. But then when you extend the period out outside of just the narrow window, the CDC looks at it in or you introduce a control group, or you or you or you like do a more systematic analysis of lots of lots of areas that someone which impose or didn't impose them. There's no evidence that I've seen that indicates those mandates did anything to actually fundamentally alter disease transmission, or Georgia or the path of the disease, the disease comes and goes as well. So I think masking has been a complete disaster for the public health and scientific community. We vastly overstated the data there are in many cases completely Not just overstated, but like completely, completely misrepresented the data that there are ignored high quality data emphasize low quality data. And as a result, and worse is it's created these weird political divisions, we've turned mask wearing into a signal of your how empathic you are, like we moralize this, this, this, this piece of cloth. You wear your good guy, your Delaware your bad guy. And then the reaction to it is like, you know, screw you I'm not going to follow your rules. It's it's essentially created this social division, moralization of this thing, which never should have happened for a low efficacy vote for for app for a device that has very low efficacy against thing we want to prevent, and may even cause more harm than good. It's shocking to watch to watch this happened
Nick Jikomes 1:20:54
in real time. Yeah, and all of this gets into, you know how all of this feeds into the crisis of trust, basically, that we're in with respect to the public, and our public health and our and our government institutions. And, you know, all the all of the big institutions of society, there's people who will, you know, believe what our public health institutions will say, without thinking there's people who will never believe anything, they say, without thinking and everything in between. There's sort of no solidarity, no good solidarity in the population, of you know, having sort of a healthy, reasonable relationship with our institutions and being able to trust what they're saying and why. And I guess I want to ask you about sort of expertise and credentials, and and public trust, and the relationship between the public and our community of experts in in, you know, various institutions. So you know, you're a professor at Stanford University, very famous university, you've got an MD, you've got a PhD, you've got all these credentials, you're officially an expert. In some in some fields, you know, given your status, and the credentials you have, given the way things have gone over the course of the pandemic, and just over the course of your life and career. How have you sort of seen the relationship between credentials and expertise? And how and why regular people trust or place trust and authority figures with those credentials? How has all of that evolved over time? And what are your thoughts on what's driving those changes?
Jay Bhattacharya 1:22:25
By I mean, personally, I don't I've never cared about my credentials all that much. Like if I if I have data and logic and reasoning, to persuade you, then that's one thing. The fact that I'm at Stanford, on top of that should add nothing as far as I'm trying to do that. But I mean, in what I've seen during the pandemic has just been this almost like this, like guru worship, right? You find your guru when you knew you listen to them, no matter what, even if it's, you know, someone who doesn't really presenting solid data. At the worst, I think, is the example this is Tony Fauci. He famously gave an interview where he said something very close to if you question me, you're not simply questioning a man, you're questioning science itself. If you think about what that means, he's essentially has created this like this idea of science as this like Clerici with with Tony Fauci is the high Pope. It's like an inversion of what happened in the in the, in the enlightenment, right? Where the whole purpose of the Enlightenment was to say, look, it doesn't matter what your credentials are, if you have, you see Jupiter move it moved. You know, so I just I just don't I mean, I think that this credential is not that that's not true that the enlightenment, you eradicate it Credentialism. And science itself is so large and complicated, that it, it always is going to depend on trust, it's to some extent, and markers of trust, just to some extent, you know, even this conversation, I've made some speculation areas, I don't have, like a very strong expertise, I think it's fine, because I'm the only one allowed to do that. It's fun. But I have told you a caveat based on like, you know, this is this is not an area where that's that's my directly mind. I think everyone should be able to participate in science. But also everyone should be checked. There is no high Pope of science, there is no clarity in science. And I think this move to like, make credentials as like your Yeah, to be like the whole thing, the whole pandemic, that thing you'd hear and when almost anyone would speak up, that wasn't an epidemiologist is are you an epidemiologist, as if somehow epidemiologist automatically have the credentials or the knowledge and the wisdom to order all of society. science involves involves even people who have no credentials, being able to say, look, this is wrong. And if they if they're right, this is wrong, then we should listen to them. I have to say like the wrote this document called the Great Barrington declaration where there was a you know, where we argued that because of this high steep gradient in the age age, from risk disease, do focus protection for older people. When we wrote that document, I signed it with Martin cold off of Harvard, and snatcher Gupta of Oxford. So Stanford, Harvard, Oxford, that got a lot of attention because of the Stanford Harvard Oxford, right. But the ideas itself is the thing that should have gotten caught attention to any of the ideas is the old pandemic plan. That's really the key thing is that it's a century of wisdom. distilled down to a page. Focus protection on vulnerable people don't do don't disrupt the lives of people that aren't vulnerable so much, because you'll end up causing more harm than good. That wisdom was a century of respiratory virus, pandemic management, successful respiratory virus, pandemic managed, somewhat successful respiratory virus, betemit pandemic management. Four days after he wrote it. Francis Collins, the head of the NIH, wrote to Tony Fauci calling the three of us fringe epidemiologists, which is a fantastic term that I'm going to go to put on my, my, my tombstone, and the call for devastating takedown. And rather than arguing against the facts that we were arguing for one scientific basis, maybe we're wrong, maybe we're right, but he wanted a personal attack on us. In fact, he attacked us personally fringe epidemiologists. He viewed the great branch declaration as a challenge to his authority, rather than the to his arguments. That's the reason for what he did, though he they want it he and Francis Collins and Tony Fauci wanted to create this illusion. There was a consensus of scientific consensus in favor of the lockdowns that they've been supporting. That wasn't true, then it wasn't it's not true now, either, but certainly wasn't true that it was an illusion of consensus they wanted to create because they wanted to act like hypothesis science. And the idea of the devastating takedown was, essentially to say, look, we have more authority than they do, even though they're Stanford, Harvard, Oxford, we're, we're the were they were they were the that we are the not the ones who know. That is not how science works, Nick.
Nick Jikomes 1:27:15
And this is I guess, this is the distinction between science as a process versus thus science with a capital S that people have been making recently.
Jay Bhattacharya 1:27:24
Yeah, exactly. Science is a human thing. It's a conversation between people. It, it's not infallible. What it is, is a fantastic the only sort of the best way we know as humans to, to learn about the material world where we check ourselves and you and you and I, we have some disagreement about some scientific idea. And it doesn't matter if you're, if you're, if you're a Stanford professor or not, you're the you run an experiment. It favors you, Nick, you're right, I'm wrong. That's the way it works. That's how that's how science works. And I'll buy you dinner. And then we'll have another argument. And then the next do the next experiment. Maybe I'll be right the next time. That's that's the right way to think about science. Unfortunately, I think the social, the social sort of, like significance of science has turned into this, like source of oracular truth during the pandemic, that is dangerous for science, it's dangerous for public health. And it's dangerous for, for, for, for, for public policy.
Nick Jikomes 1:28:28
And so I guess, on this general subject of, you know, being able to debate and talk about things openly and discuss things at the level of ideas, rather than just deferring to who said them, and you know, what official position they're in. I like what you said earlier on, you know, evaluating your ideas, rather than, you know, the fact that you're at Stanford that that should add nothing to the veracity of your claims. You know, something that you got a lot of attention for recently was you were named, you are in the so called Twitter files, one of the episodes of the Twitter files because, you know, for a period of time, I'll let you discuss how long this was and what exactly happened. I don't remember all the details, but your account specifically was suppressed on Twitter in different ways. So can you talk a little bit about what what was uncovered there recently, or made public at least? And you know, why was that happening? And what exactly how exactly was your account being suppressed?
Jay Bhattacharya 1:29:29
So, so Barry Weiss is that fantastic reporters, she got invited by Elon Musk to look into the Twitter files to Twitter's files regarding regard regarding its censorship efforts during the pandemic. And along with other topics, there's so what I what I learned Nick, is that at Twitter, there are various tools that you can use to like look to see if people have have had people Like the status that people have for their, for their files, for their for their for their account. So for instance, my account, if you look at my, the, the tool that they have, has a little yellow badge that says I'm on a trends blacklist trans blacklist, if you click into those things you can then I actually, Elon invited me to go to Twitter. So this is where I actually got to see my own thing. If you click in you can see the history of that trans blacklist. Now, what is a trans blacklist the trans blacklist is it says that, that my tweets by the can go and other people that follow me can see them. But they will never get on this like trending kind of status so that people outside of my, my, my own network and see, you'll never show up in other people's things saying, oh, a judge other people like like this kind of tweet, right or, or trending so that a very large fraction of the Twitter Twittersphere sees it.
Nick Jikomes 1:31:08
And what why were you designated as being blacklisted?
Jay Bhattacharya 1:31:13
So I don't know that for certain what I do know is two things. One is that is that I was put on that trans blacklist the day I joined Twitter in August of 2021. Which is which is interesting that day I published a link to the Great Barrington declaration. That was the most important thing I probably I put on Twitter that day. And then the second thing I know is that this is based on a lawsuit that I'm I'm a participant in against the Biden administration, by the Missouri and Louisiana Attorney General's Office and the new civil liberties Alliance. It's a First Amendment lawsuit. What we know from that lawsuit is that there were dozen federal agencies cooperating closely together with to provide instructions in regular contact with big tech, including Twitter. And the content of that those instructions included what to censor what ideas to censor and the name of censoring misinformation and who to censor. The in Twitter and the Twitter headquarters, what I could see in the tool was that there were multiple people that complained about me the day I joined Twitter. And that led to the trans blacklist. It didn't say who complained. It didn't exactly talk about the process that Twitter used to decide that I deserve to be on this trans blacklist, but it was it seems very likely just connecting the dots that that there were that there was a federal agencies, potentially even including the NIH, or the CDC, told Twitter about If not me, but in particular, the Great Barrington declaration, that idea focus protection or something like that. I also found I searched on Martin cool. Dorf is a Harvard professor that signed that great band or co authored great branch declaration. He was actually put on a trans blacklist for for a while in July of 2020. And when I asked him what was happening then, on Twitter, he said that he was he was posting links to some Swedish data that suggested that opening schools was not harmful to kids, or particularly to teachers either. Over and over and over again, he said he was most active that during that short those few short months in July 2020, that's when he's most active on Twitter, posting that because he wanted to tell people that the scientific evidence did not favor opening schools, and then he was put on a trans blacklist for that. He actually wasn't on the current trans blacklist. So they use three times in 2022 was put on a trans blacklist. I still don't know fully the process, but it seems really clear that Twitter could not have been doing this just simply on their own. They just don't have the expertise or the or the frankly the the the motive the reason they did this is because they were encouraged by the government to do so.
Nick Jikomes 1:34:01
And so how long are you at Twitter with with Elon and the employees there?
Jay Bhattacharya 1:34:07
Oh, that was fun. It was I was there. I like arrived at like 3pm And then I left around nine. I talked to a lawn for an hour. He was very generous with his time. And actually I talked with you to some Twitter employees many of several of whom were pulled over from Tesla they were there as like Saturday night they told me that they'd be there until three that Elon was it as your three and at night that that like it was it was just they were like little actually look they were having fun. It was like the big bit it's like you walk in there's just like five star hotel is like completely empty. There's just all these engineers huddled around trying to like fix things.
Nick Jikomes 1:34:47
Interesting. What? You know, you were only with him for an hour. It's not like you know the guy super well. But given the acquisition of Twitter and the changes that that have happened since Elon Musk took Over, given, you know what you discovered about yourself in the Twitter files release, given your short interaction with him there? What's your general impression of him? Is he you know what he is? He's similar to the persona that he puts out there. Is he actually sort of the Free Speech Crusader that he's at least marketing himself to be? Is there some kind of intergalactic five d chess going on where there's much more than meets the eye? Like, like, what did you make of him compared to his public persona?
Jay Bhattacharya 1:35:30
I mean, actually, at first, I was actually really impressed by him, Nick. I mean, you know, and I think he made a joke about, about you, he spent $44 billion to buy Twitter. And he made a joke, like I could have bought a, I could have bought a nice island for the same money. And the reason he bought Twitter, and he told me was because he is absolutely incensed by the censorship. And that he views that censorship by Twitter, as incredibly damaging for our civilization. That's what motivated, I was actually, I wanted to know if I could share the date, the information I've been getting from the Twitter engineers about my blacklist, and so on, who asked him if I could, and then pointed out that look, I'm not going to sue because I think I fully support what Twitter 2.0 is doing and revealing this information is very healthy for the public to know what happened. And so but, but there were there are a lot of things that potentially could lead to lawsuits. He said, Look at he hates the idea of wasting his time sitting in depositions. But if that's what it took to like, to restore free speech to the world, and it's worth it. I really think he's motivated by by these feet. Now. You know, there's been like complications with like, someone docks, docks, his, like, where his family was or something and then the whole bunch of journalists that he said that they suspended and look back on and so there's, there's like complications. Free speech doesn't mean to me, you let every single thing go if you're like, threatening somebody, obviously, that's not that's not free speech. That's like, that's a that's a direct threat or, but but, but as a broadly speaking, that's his goal. That's the goal. I thought he could, that he told me he had I believe him. You wanted to restore the ability for people to disagree with each other, even on positions where the government was saying this is misinformation. On Twitter, and I think that's exactly what he's done. And actually the other half of it is like, I think he actually is against lockdowns and has been for the whole pandemic. That that became clear when I when we talked about the harms of the lockdown some of the stuff we discussed, I told him as well, there. I mean, he I think he's sincerely offended by the idea that lockdowns have harmed so many people. And that if we'd had a free discussion, maybe they wouldn't have happened.
Nick Jikomes 1:37:51
In in the wake of the whole public health crisis that we've been living through, and the sort of socio cultural volatility that that we have right now around that, and how many mixed feelings there are in different people believing different things. And, you know, and with with people like Anthony Fauci retiring soon, sort of with all of that stuff swirling, what are your hopes and predictions about how public health governance in the US evolves in the coming years?
Jay Bhattacharya 1:38:22
Why is each one of two directions like right now, the public confidence in public health is as low as I've ever seen it? And partly, it partly is almost entirely the fault of public health. Public health has taken on positions that are against what the scientific evidence is saying that automatically is going to cause a lot of a lot of like, unhappy even if if the scientific evidence was saying in favor of what like, say mass mandates or, or vaccine mandates or whatever they weren't. But like if they were even then they would be controversial, right? Because you're asking Pete forcing people to do at risk of their jobs, things that they don't want to do, or that they view as potentially harmful to their kids or whatnot. So but but the fact that is based on on not on scientific evidence, but on like extrapolations on ideas that aren't particularly supportable, given the evidence that makes people really distrustful of science of both science scientists and as particularly public health. The other aspect of this is politicization. Right? So this is this fact, like 99% of public health practitioners and officials in the United States are on the left. A lot of people on the right feel like their their ideas are not represented, respected by public health professionals. Now, that may be just perception or fact I think it's fact but like that, but let's say even it's just perception. That's a disaster for public health. Public health is not political in the sense that of a politician wins 50% plus one and you and I are successful politician Public health has to win over 90 95% of the people, for it to be effective. If it only wins over 40% of the people, it's not effective. In fact, it's an abject failure, even if it wins 50 plus one, it's an abject failure, even when 60% is abject failure, public health has acted far outside of, of its highest ethical norms. And as a result, a very large number of people don't longer trust it. So in order to fix that, you can't just do band aids, you actually have to fundamentally transform public health. So that's a very different kind of, you have to reestablish it with a with a focus, and a mission statement that that has science at its core, the Ethical Treatment of people at its core, and then you have to have reforms that have structures that that put, you know, essentially like checks and balances. So this kind of thing doesn't happen again. It's not enough stuff, don't say sorry, you actually have to, like, get the get the the processes in place, so that so that, you know, if if, if people are going to propose, say go around saying I am the science, someone's else's there to check them. So whether it's public health can recover from this depends a lot on what public health does, if it just keeps going the way it has, pretending as if it did everything right during the pandemic, or only a minor minor problem here and there, it will never be effective again. And every time it makes tries to do something substantively opposed. On the other hand, if it if the leaders of public health, I think that leadership needs to change, but with the new leaders of public health, whoever they are, work to make sure that these are the processes and internal structures, public health reform, so the the better checks and balances that are grounding in ethics that are grounded in science, and then then show the public what those are, involve the public in those decisions, then we have some chance.
Nick Jikomes 1:42:02
When you say involve the public in those decisions, what exactly do you mean?
Jay Bhattacharya 1:42:06
I mean, like, for instance, public health, local public health directors, right. county directors have Trump turns out tremendous power in the United States to make decisions about the lives of people. They're unelected, maybe make those into elected bodies. Public Health, the CDC is it looks I mean, it's very, very opaque to people. It's creative, a citizen participation group or something, allow journalists in the to be embedded inside the CDC don't don't the the NIH, ostensibly should be it's a scientific agency should be very open to public but it Redax huge fractions of these FOIA documents are redacted, not national security, if they're redacted. You have to make the actions of public health agencies completely transparent to the public. I mean, for instance, it would make it make it so that you could never tell a noble lie again, you can't. You can't, as a public health agency, you say, Okay, well, I, I'm going to try to tell you this, I'll tell you this, just to trick you and do something I want you to do, even though it's not true. That destroys trust, if you have public, the public involved, so that those those kinds of actions are transparent, they would never do it. Public health has been entirely opaque, entirely resistant to to feedback from the public. We just I mean, it just it it's the public health doesn't involve the public is not going public isn't going to trust it. I would contrast that with for instance, Swedish public health. That's like 90% of trust of the public. And so they never needed mandates, they never never used mandates for the COVID vaccines got pretty high uptake despite that, because public health trusted your public public trust public health. So I just I think is one of these things where like, we're in a very bad place in American Public Health. The public doesn't trust us as it shouldn't because we fail so badly. And the leaders of public health are just doubling down saying that pretending as if nothing went wrong The only problem was like this horrible Republicans caused all these problems. You know, even though the those horrible Republicans as you very sweet people really do need to be able to trust public health, for public health to work. It needs to it's something very fundamental needs change in American political, the attitude of it is to imperious to to divorce from basic ethics and to divorce from the scientific data for it to be effective.
Nick Jikomes 1:44:40
And, you know, as far as I can tell, it's not like public health was up in that 90 plus percent range and then COVID happened to deteriorated it was already not there. Why do you think you know, even pre COVID It wasn't where it needs to be.
Jay Bhattacharya 1:44:57
I mean, I think there was all that I think that like A set of people that are in public health, my observation platform working in public health is that they've spent most of their lives frustrated that the good ideas they have don't seem to be accepted. You know, so like the obesity epidemic is a good, good, good example of this, right. So like eat well exercise, really strong messages. On the other hand, there were like big successes, it just took a very long time, like smoking rates in the United States have dropped very, very sharply over a very long period of time. It took a generation of public health efforts, slow, frustrating, public health efforts, but still effective, because they built trust, so that most people understand now that smoking is very, very bad for you. But those efforts are not things that generate very rapid, rapid change. Those efforts are like community efforts where you reach out to groups, you get that you're not you're not demonizing them, because they smoke you, you tell you're educating them, you build trust over a long period of time, it's not directly political. And, you know, even action against tobacco companies. That turned out to be a bipartisan effort in the in the 90s. So you just you just you have to build coalitions, it's a slow thing. I think a lot of the reasons why public health was not trusted in the United States before is because it was it was seen as overly political, and they were moving to more rapidly than they had before they built the the kinds of coalition's in the public that would that would support them. And that is that an example of this is soda taxes. You know, it turned out to be a partisan thing that a lot of people really didn't want. And suddenly good reason, because like, it's a very regressive tax ends up it's for people that will pay a higher fraction of their income paying for things like soda taxes, you have to build coalitions that have ideas that understand who the public health is for the people, if you're imperiously ruling over people, they're not going to like you, you have to like you have to be in partnership with them. I think American Public Health for too long has not seen itself as partners of the people, but rather over the people trying to like direct it. I think that's, that's, that's a, that's a fundamental problem that's led to the distress born before the pandemic, and during the pandemic has just accelerated.
Nick Jikomes 1:47:25
You know, in the wake of, you know, everything that we've lived through, seeing how you know, the US handled the pandemic, seeing how other countries handle the pandemic, you know, China, New Zealand, you mentioned Sweden, you know, the full spectrum of what different countries did over the past two years, when you have the benefit of hindsight to look back at all those things. You know, how have some of these different strategies played out? What are some of the can you do like a compare and contrast? So the major differences between some of the countries that handled this in different ways and what you think worked best?
Jay Bhattacharya 1:48:00
Sure. I mean, it's, it's complicated, because the I don't think any country did it perfectly. So for instance, Swedish response, which I admire many ways, very early in pandemic was a was actually a failure. Like, what happened was that they, they did not protect their nursing homes in Stockholm, especially very well, because they didn't employ the principle of focus protection. The idea would be to protect older people, right, that's who's who's most vulnerable. So they made the same mistake that Andrew Cole made in New York or in border, or we made in Michigan or Pennsylvania, we sent COVID infected patients back to nursing home because the idea was protecting hospital systems rather than them than people. On the other hand, the sweeter spawns generally has been quite good. Apart from that, that mistake, right? So for instance, in the there were some mass gathering limitations, but most of what happened was was voluntary. They would, they would, they would tell people, you know, here's who it's high risk. And so they organize these community responses where like people, neighbors would deliver groceries to older people living in their neighborhood. They involve the community in mitigating the risk as best much as possible. They asked people to stay if you can stay home from work fine. If you're not, if you have to go to work, you go to work. They didn't try to like, imperiously close, close, due to shelter in place orders, mandatory business closures, and they never close schools for kids at 15 and under, not once, and children during spring 2020. No one died, no children died, even though they didn't close schools during the height of the worst part of the pandemic. And the teachers actually had lower death rates than the average of other workers in the population. So it's just it's one of these things where like, the voluntary the way that they used public health was to was it was essentially like in cooperation with public They've all they asked for voluntary cooperation publicly got it, because they treat the public like adults. As another example of like, I think a much more reasonable Paul like South Korea was a little more reasonable. Or there's parts I didn't like I didn't like the overweening contact tracing applications, they there was too much emphasis on that. And, but like early in the pandemic, they didn't close businesses, they didn't close schools, they were they were much more reasonable. Again, trying to like, involve the public in their, in their, in their response more and more effectively. The the, the Florida response, I think was was was pretty good. I mean, the the, the key thing, there was focused protection of older people, because they have such a large fraction of older population, they did a lot to try to protect nursing homes. You know, not perfectly because it's, this is so highly infectious. It's hard to hard to keep things out. The especially but what I really liked was early when the vaccines came out in December 2020. Governor DeSantis called me and asked me for advice about who to vaccinate, and I suggested suggested, prioritize older people. And by the end of January 2021, every older every person in the nursing home in in Florida had had a vaccine offer to them. I think every person over the age of 65 and had a vaccine offer them very rapidly. My mom and living in LA didn't get her vaccine until like late March 2021. Whereas every person in Florida had one offer a older person who'd been offered a vaccine by, you know, January 2021. It's peaked out lower than I would have hoped. But it's it's still that that early vaccination effort focused on older people was the key thing was saved many lives, I think, I think generally, places that you know, Scandinavia generally had much less emphasis on school closures, Europe generally has much less episode school closures. The Chinese example is is just a tragic example. Right? This the zero COVID policy has devastated the lives of so many Chinese people with vast human with human rights abuses on a vast scale. And it failed, it failed to keep the disease out just as just as you predicted, it would fail to keep it sees out. So it's, I mean, we're still going to there's still a lot to learn from from the various countries. It may it's impossible in the short time to like cover cover it covered in any detail. And of course, there's there's particulars about every single country that that would you would leave it you know, like I could think about the the theoretical approach, how you would manage it. That's what the Great Barrington declaration was in such a short one page document. But the press, it's always going to be local, right? Focus protections would always be a local thing. So people that are sometimes it's table, how do you do focus protection? There's no one answer, it's gonna be very different in South Central LA than it will be in Billings, Montana, then it'll be in, in in Stockholm. The key thing is to focus on protecting the most vulnerable. That's that's the key idea, and then not harming the less vulnerable with draconian policies that don't actually stop the disease from spreading. I mean, those those would have been the two principles. And to the extent that countries follow those two principles, I think they did better.
Nick Jikomes 1:53:23
Let's say there's another pandemic of some kind. And I guess the question is, what would it look like in order to justify something like a full lockdown for some period of time, what would the infection fatality rate have to be what kind of bug would we be talking about? If it you know, if it justified in your mind something like a lockdown?
Jay Bhattacharya 1:53:46
I mean, I think the key thing is not the infection fatality rate, but the the predictors of of high risk and then our knowledge of transmission right. So if you have a this is the irony, right. So if if you have something is very, very highly transmissible lockdown is not ever going to work. This is just a useless, harmful thing. You can I can imagine something that has your transmitted by, by by fomites or something that hasn't had very strong person to person transmission, where local lockdowns might be useful. So for instance, like I think, in the polio epidemic, that'd be local closures of schools, when the disease has been worth it. Hi. Hi, let me be it'd be very short duration, right. So if that's focused, it's children that are high risk, you know, that that the disease being transmitted high rates at right now, they didn't fully understand that it was fecal oral transmission then, but they would close schools to reduce the amount of spread of it. I can imagine a justification around that. But the school closures are very short and short in duration. It wasn't yours. They didn't say certain even close schools in anticipation of a vaccine coming for years. So so the the it has to be, would have to be balanced, I can't imagine a situation where I would ever support a full lockdown for extended period of time. Because that would always lead to more harm than good. But if you have a high IFR disease, we're gonna, it's going to cause deaths. That's unfortunate, there's nothing in it, let's say we have no way of mitigating it right. You have to accept that that the fact the key thing is who's most vulnerable, even even with a higher IFRS. And you can still identify who's the most vulnerable, who's least vulnerable, and ask people who are least vulnerable to to keep society going. Because if you just shut them down, also, you'll end up causing more harm than good. I just don't I don't think a lockdown of the kind we use will should ever be used again, I frankly think it should be a dirty word. I think we should we should shutter and water. When you think about the the harms get the extent of harms it caused to the poor, the vulnerable in the world, I can't imagine a disease that can be mitigated by it. Where that whereby the marginal benefit from it would actually outweigh the marginal harm in terms of the lives lost from them.
Nick Jikomes 1:56:15
You know, given what we've been talking about, and how much of a bummer, some of the stuff can be, I want to ask you more more of a positive question, more of an open ended question. What are you most hopeful or optimistic about in terms of the future of our society? In general?
Jay Bhattacharya 1:56:32
You know, I, despite the problems that we've seen with with that, with the application of science, I actually think like, there are a lot of good things. It's amazing to me how the scientific community came together to try to address this problem. A lot of really talented people put their minds to this. And a lot of advances happen as a result, right? In the vaccines being one of them. Although they're I think they were misused and caused a lot of social harm. The bile, biologically, I think, is quite an achievement. So I do think that that I'm actually quite hopeful that if we can put the right structures in place, there's a lot of good that can come out of science. And we've seen that during the pandemic. So it's to me that's, that's, that's quite helpful. The other thing I think, has been healthy. Although it's been painful, I think for scientists, is people people now have a much better understanding of what science actually is. That really did. I think most people who have been thinking about things now understand that science aren't scientists aren't gurus are not omniscient. We don't know. What we are, are people that are just curious about how the material world functions, and we we do experiments to try to understand it. And it's slow and halting. The fact that people understand that science is this human thing. It's not this, like the Spock like thing and we like, you know, somehow learn about the world, just by just by our sheer intelligence, it's, it's and that it's inaccessible to everybody. Now, I think now people understand science affects them. And that people understand that, that they can understand science, at least at some level, and maybe even participate in it. I'm hoping that this out of this pandemic will come a generation of kids who are interested in science, and that science trans is transformed into something that's much less authoritarian and much more participatory, much more democratic much more, much more. You know, so back at the roots of the enlightenment where we're listening, like everyone, everyone on the face of the earth who wanted to participate in science could do so.
Nick Jikomes 1:58:38
All right, well, Dr. Jay Bhattacharya, thank you very much for your time. I know you've been busy recently. So I appreciate you sitting down with me. Are there any final thoughts you want to leave people with or anything you want to reiterate from our discussion?
Jay Bhattacharya 1:58:52
Nick, I really grateful to be able to talk with you I've been I've been looking forward to it for a long while and hope this doesn't take get taken down on YouTube. So YouTube folks, we're actually we're actually trying to be just do on a science here. Alright, thanks. Take care