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TRANSCRIPT ONLY
Peter Robinson: Joining us today, Dr. Jay Bhattacharya. This is our third session during the plague with Dr. Bhattacharya. Early on, he told us what to expect. In our second session with him, he reported on a study that he had just conducted in Santa Clara County. Back with us today, by popular demand, you are, Jay, I have to say, one of our more popular guests. Yes, it beats me, too. Today, Jay's going to be telling us about a third study, and an especially interesting study, that he had conducted with the Major League Baseball organization. Dr. Jay Bhattacharya and the MLB on Uncommon Knowledge with Peter Robinson in this special plague time edition. Welcome, everybody, and Jay, thanks for making time once again.
Jay Bhattacharya: My pleasure, Peter.
Peter Robinson: Okay, you've conducted three studies. Let's start with the one that's just about to become public, your study of the Major League Baseball organization. How did this come about? How did you conduct it? Just give us a layman's overview of the study itself.
Jay Bhattacharya: Sure, so it's similar, in some sense, to the other studies in that I'm looking for antibody prevalence in a population. It just so happens that this population is a very unique population, it's the set of employees who work for Major League Baseball and the major league teams around the country. How did it come about? The way that the other studies came about, actually, was through, in some sense, indirectly through Major League Baseball. A gentleman named Dan Eichner reached out to me and he offered me and my colleagues 15,000 of these test kits to check for antibodies. He said, "Use them for population health." Just for free. I mean, just a very generous man. And he works very routinely with Major League Baseball on all kinds of other sort of lab-related things. And he introduced us to the major league, the folks in New York. And they basically, very readily agreed to let us run a study in all of their employees. Mostly not athletes, actually. It's just regular Major League Baseball employees and some of their family members.
Peter Robinson: So these are the people who handle the accounting, who handle the catering services, who handles press relations, figure out the television contracts, that sort of thing.
Jay Bhattacharya: Yeah.
Peter Robinson: The people who are in the stadium office not down on the field or in the dugout. Is that correct, overall?
Jay Bhattacharya: Yeah, I mean, I think there may be some coaches, but for the most part, it's exactly who you said. I mean, it's people who just, they work for an organization. Just so happens, it's Major League Baseball.
Peter Robinson: Right, and so, I want to distinguish between, you say you were looking for antibodies. And that is a different kind of test from the kinds of tests that we saw earlier on in the crisis which were exclusively PCR, polymerase chain reactions tests, which simply identify whether you were sick at that moment or not. Your serological tests which search for antibodies say whether you are sick at that moment or have been sick in the past. Excuse me, not even sick, but have contracted the virus in the past and perhaps, even cleared it, so you're no longer sick. Is that right?
Jay Bhattacharya: Have you been paying attention? Do you even know what's happening?
Peter Robinson: This is the third time we're discussing it on camera, Jay. And you've explained it to me over coffee about five times in addition, so. I finally have it, all right.
Jay Bhattacharya: Yeah, we're looking for antibodies and as you say, we're looking for evidence of current or past infection with the antibodies. If I use the PCR test, I would just get how many people currently have the virus right now which is interesting but not, it's not as, I mean, to me, it's more interesting to know how many people already had the virus so we can figure out how far along epidemic we are.
Peter Robinson: Right and the second aspect of this test, when you conducted your first serological test, here in Santa Clara County, as I understand it, it was either the first or one of the very first serological test. They took longer to develop than the PCR tests and now several dozens of these tests have been conducted here, there and everywhere, this MLB test is the first test that gets us pinpoints across the map. We get some kind of feel for what's taking place across the nation. Is that correct?
Jay Bhattacharya: Yeah, that's correct. I mean, I wouldn't say it's national representative, that's not right, because the MLB population, even their employees are a unique population. But it is a population of nation-wide scope. And it's a peek as you say, into what the disease is doing all across the country in one go.
Peter Robinson: All right, and you mentioned when we talked about this the other day, you wouldn't tell me much because you hadn't published the results yet. But you mentioned that you can consider it almost entirely bad news.
Jay Bhattacharya: Well--
Peter Robinson: So, give us results. And tell us why or were you just feeling blue at that moment?
Jay Bhattacharya: I am feeling blue. I mean, I'll tell you the results and you can decide if it's good or bad.
Peter Robinson: All right.
Jay Bhattacharya: So, the first main line result is that the prevalence is .7% of the population, of the MLB employees, .7, so seven in a thousand have had evidence of the virus, infected with the virus. Now that's much lower than we found in Santa Clara County which is about 3%.
Peter Robinson: Yes, yes.
Jay Bhattacharya: So, a thousand. And in LA County, about 4%, about 40 in a thousand. So, it very clearly indicates that this is a different population which has been exposed less to the virus than you know, the populations at large that we found in Santa Clara and LA. As you say, a lot of other studies actually now have been done in the United States and elsewhere, again, these serological studies, one in Miami-:. They found about 3% just like Santa Clara. Another in New York was found about 25%, New York City and 25%. Upstate New York, about 3%. Telluride, Colorado, about one or 2%. And around the world, they found numbers, you know, ranging from you know, two to 3%, to as high as 30%, I think.
Peter Robinson: So your numbers are low. The MLB study comes in with low numbers but in general, aside from New York, New York is an outlier. Everywhere else you test, you get 3%, 4%, 2%, low single digits. New York pops up to double digits.
Jay Bhattacharya: Italy also.
Peter Robinson: Sorry?
Jay Bhattacharya: The northern part of Italy also pops up higher.
Peter Robinson: Right, okay.
Jay Bhattacharya: Some parts of Germany. Yeah, a lot of places were getting, you know, single digits, exactly.
Peter Robinson: All right. So let me ask why would the MLB population be .7, when's in some cases, we have data on the surrounding population. New York, certainly. What, they're the Mets and Yankees and they're, what were those results?
Jay Bhattacharya: They were like 3% in the MLB population and 25% and surrounding. Now, I think and actually that's true in Santa Clara too, so, you know, the Giants were zero.
Peter Robinson: Were they really?
Jay Bhattacharya: Yeah, 0%. The Angels, I think, Los Angeles. were the highest about 3.3%, still lower than the surrounding LA county. And of course, they're not in LA County but the closest. Dodgers were also below LA County. I mean, I think, so that points to a couple of things that are, I think, really important. So first of all, this is a working age population and it's an organization that has implemented a lot of, very actively implemented, measures to try to control the spread of disease. They've promulgated hand-washing protocols. They put in place, they've complied with stay-at-home orders. They've put in their social distancing when they are, sort of have to be in a place where they're at work. They shut down spring training early. I mean, they've worked very hard to control the spread. In one sense, that means, that is good news, right? That's been very effective in controlling the spread in their population. The other, the second thing is that they, we saw this in Santa Clara and LA and I think we're starting to see this nationwide. There's a steep socioeconomic status gradient in who gets, who has been exposed to this disease.
Peter Robinson: Meaning?
Jay Bhattacharya: Meaning that poor people are much more likely to have had disease than people who are you know, who have jobs, who have regular employment. And so we're kind of seeing that in the MLB population. The MLB employee population, they have regular jobs. And their prevalence is lower.
Peter Robinson: So these, the people you tested, in the Yankees organization, the people you tested work in the office complex attached to the stadium and then, they get in their cars and they drive home to nice suburbs in New Jersey. And they don't go home to the Bronx, the surrounding population. As I recall, the Bronx is one of the highest, within New York, the Bronx is one of the more infected areas.
Jay Bhattacharya: Yeah.
Peter Robinson: So it's, these are pretty good jobs, and these would be middle class to upper middle class people you tested and it's good in a time of plague to be middle class or upper middle class.
Jay Bhattacharya: I mean, we did have a few like concession workers and poor people but it was a mixed success getting those kinds of folks in 'cause they tend to be part-time employees opposed to full time employees. But yeah, I think generally, what you said is exactly right. I mean, I think we're sort of, in the MLB population, we're seeing a peak at that socioeconomic status gradient that we saw very clearly in the Santa Clara numbers and the LA numbers.
Peter Robinson: So Jay, the one piece of bad news, one piece of bad news is almost ethical rather than medical meaning, poor people get hit harder. This is not something we like in America, but that just seems to be what your study is demonstrating. But another piece of bad news is medical, more than 99% of the MLB employees have not been infected by the virus yet.
Jay Bhattacharya: Yeah.
Peter Robinson: That means this virus has a long way to go. Here we are two months into this lockdown. Everybody's just had it. The economy is down, four or 5%. 14% of Americans are unemployed. People have had it! And if we end the lockdown, whether we end the lockdown or not, this virus has a long way to go. Is that true?
Jay Bhattacharya: That's absolutely true. I mean, the epidemic is very far from over. The lockdown, as I said, from the MLB evidence and other places, has successfully slowed the spread of it. But that means that once we lift it, it's going to spread. Now, people talk about second waves. I mean, we don't know if the virus is seasonal or not. Second wave is, the idea is premised on that, maybe it's seasonal. So in the summer, it'll slow down and then spread just by itself. But it might not. It might just start growing after we lift the lockdowns. That's that is I think the main argument in favor of a lockdown.
Peter Robinson: As I said, we've been locked down for a couple of months now. And in my own mind, I'm still unclear what our leaders, Donald Trump, Andrew Cuomo, our own Governor, Gavin Newsom, what the rationale for the lockdown was and what it is now. There seem to be two rationales. One is, we make sure that our medical facilities don't get overwhelmed, that is to say, this was the concern at the very beginning, that emergency rooms would be swamped. We've have people choking to death in hallways because there weren't enough ventilators and so forth. That's over. I think there may have been a couple of hospitals in New York, I believe the Bronx and the Queens, where for a while, but even then it only lasted a week or ten days. The medical facilities really were under pressure. But even in New York, they didn't use the overflow capacity in the Javits Center. The hospital ship wasn't used. So if the purpose was to, of the lockdown, was to make sure we didn't overwhelm our medical facilities, it's done. We succeeded, right?
Jay Bhattacharya: No, that is correct. In fact, we have quite the opposite problem now, that there are hospital systems around the country that are going bankrupt because they had to shut down elective surgeries, all kinds of other services that they normally provide. And in fact, a lot of the money or a large chunk of the money that's been on the bailout is going to hospital systems, actually, just to make sure that we still have hospitals left in this country after the lockdown.
Peter Robinson: All right, and the other rationale, which I guess the politicians who make this argument or imply this argument, just don't know any better. The other rationale is we're going to keep you all locked up until we get this thing licked. But I do think just in casual conversation, that's in the backs of people's minds. Once the lockdown ends, the lockdown will end when there's no more danger. But that's not possible, is what you seem to be saying.
Jay Bhattacharya: No, I mean, I think that what you, the way you formulated it is exactly right. I think in the back of people's heads is this idea that somehow we can eradicate the disease, if we just stay locked down. That is not possible, right? The serological evidence and even the MLB study, suggests this, that it is suggested that the epidemic is too wide-spread to eradicate. It spreads via asymptomatic contact like people who don't have very many symptoms, just mild cold symptoms can spread the thing. They're not going to show up for testing. They're not gonna show up in a hospital. They won't go to a doctor. You won't know they're spreading, spreading the disease. I mean, just you know, just in LA County alone, the number suggests 400,000 plus people have the disease. It's not possible to eradicate it with a lockdown. And so, I think we have to come to terms with that.
Peter Robinson: Can I, on this question of eradication, I just want to, the counterexample, the disease that we think we could eradicate for example, for example, I'm just asking if this is correct, if this is the right way to think about it. Ebola, you know who has Ebola because it's very dramatic. Bleeding from all sorts of orifices and just horrible. Also, not terribly infectious once people realize what's going on because it's so disgusting, people keep their distance automatically. And in each Ebola outbreak of which I guess, there have been several in the last decade or so, I think all limited to Africa. But you can count the number of victims. You can keep people away from them. And then you can just wait until those victims either die alas with Ebola, I think at least half of them did die or recover and then it's all over, correct, roughly?
Jay Bhattacharya: I mean, that's the strategy that works with diseases like that. It's called, you test, you contact trace. So you figure out who they were in touch with. You go test those people and until you've identified all the people in their social circle that have had the disease and you isolate them, you quarantine them so they don't infect anybody else. That works fine when you have a disease with a very limited number of people who've been affected and where you don't get a lot of spread via people who don't show them any symptom. Basically, if you the disease, it's very clearly evident that you have it. You're likely to seek medical attention for it. A disease like this where we've seen a very large number of the people don't have very many symptoms and yes, can spread it, this kind of strategy will not work. This strategy is doomed to fail. In fact, it's going to be counterproductive to do a strategy like this. I was just looking at the news from Ventura County. Apparently they decided to do contact tracing. I mean, Governor Newsom just announced he's going to raise, essentially, an army of contact tracers. If you're found positive, they'll quarantine you, forcefully quarantine you. Right, so what are the incentive in effect of this? People are going to say, I don't want to be tested. What if I end up positive?
Peter Robinson: Right, right. All right, we can't eradicate the disease. Can you just take me through then, two concepts, just explain the concepts and then if you would explain how they apply to the current position situation. I have to say, I've heard the phrase heard herd immunity more times in the last few weeks than ever before in my life. And I don't quite know what it means. It's talking about human beings as if they were sheep, I suppose. How many people have to get infected before you get herd immunity? And then the other thing is, this quote, you use the phrase yourself. Another phrase we've heard over and over is running its course. The virus will run its course, viruses do somehow or other. So, just explain those two concepts.
Jay Bhattacharya: Sure, so I want to be a little bit careful here because there's still an active debate among immunologists about the extent to which you get, actually get immunity after you, after you've been affected. How complete that immunity is and how long it lasts. So, there's still questions that's left to answered. But, let's just take a tip like just a virus not necessarily COVID-19. I mean, typically, what you get from a virus is immunity, right, from a viral infection. You get antibodies that protect you against future infections, right? So, that's in fact, that's the whole point of vaccines is to produce those antibodies without actually being infected with the virus. Now, if a sufficiently large fraction of the population has these antibodies where they're protected, well, okay, so just imagine two people interacting, randomly in a population. If most of the people have had these antibodies, then, for sure no matter what, you're not going to be able to, that random interaction isn't going to result in the virus spreading from one person to the next. So herd immunity is a theoretical idea that says, about a certain fraction of the population, it's very unlikely that you're gonna contract the virus from interactions with other people.
Peter Robinson: And is there is standard fraction that is used? Do we say, it's a rule of thumb, a simple heuristic, once you get to 30% or 40%, you're okay?
Jay Bhattacharya: I mean, it varies from virus the virus and it varies on how infectious the thing happens to be it. It actually, so there's a lot like variables that go into what fraction that is. I mean, like just if I had to pick a number, I'd say 70%, 80% of the population, but it could be more, it could be be more, it could be less, depending on a whole bunch of variables that we don't yet know in the case of SARS-CoV-2.
Peter Robinson: But whatever it is, whatever the herd, whatever that number is to achieve herd immunity, it is way more than the 20% we see even at the highest infection levels in New York and it is way, way more, than the seven tenths of 1% that your study has just picked up among the middle and upper middle class workers of the Major League Baseball Association.
Jay Bhattacharya: Yeah.
Peter Robinson: So we cannot eradicate this disease. It's way too late for that. And we are not even close to herd immunity, is that correct?
Jay Bhattacharya: That is correct.
Peter Robinson: Well, you're just full of good cheer today.
Jay Bhattacharya: I try. I told you, Peter, there was gonna be bad news. I mean, I think .7 is a success in one sense, right? I mean, we've paid cost for the lockdown and that lockdown has produced slow spread. In that sense, we've achieved what we set out to do with the lockdown.
Peter Robinson: Okay, hold on right there, Buster, because my question to you is, was it the lockdown that achieved slow spread? If it was the lockdown that achieved a slow spread, why is Sweden, which did not lockdown. Now, in fairness to the argument, Swedish people, they encouraged people to engage in social distancing. Apparently, hotel vacancy shot up. Sweden's stopped traveling on air. People voluntarily engaged in a lot of the measures that we engage in but the Swedes kept the economy open. They kept their school's open. It's just an astounding thing that in the United States and the United Kingdom, in particular, I've been following Britain a little bit, in the first and second world wars, second world war, this is staggering. The Germans were bombing Britain in the second world war and they kept the schools open. They kept the children in school. Now, they were shipped out of London, some of them, but they kept the schools open. In this crisis, schools have been shut down. So, are you sure it was the lockdown that slowed the spread?
Jay Bhattacharya: I mean, the lockdown almost certainly slowed the spread. I mean, even if Sweden--
Peter Robinson: That beautiful question, you're just going to bat it aside like that?
Jay Bhattacharya: I mean, it couldn't not slow the spread. Now, what you're saying is that their private efforts that also slow the spread in the absence of formal requirements to lockdown or close schools, and I completely agree with that. In fact that's one of the major problems with disease models is that, they pretend that if in the absence of formal lockdown that people wouldn't engage in social distancing or hand washing or whatnot. I mean, I think, so that means that they tend to overestimate the benefits of the lockdown. In that sense, I completely agree with you. But the marginal effect of locking down formally is to produce the social interactions that we normally would do, even when we face the threat of a disease like COVID-19. So I think, these legal impositions have their effect. And we have to give them their due, not as much as people think because as you say, the private efforts that would have happened anyways, but still they do have their effect. You can see it in Swedish numbers, right? It's gone, it has spread more within Sweden than it has in Norway. There's more deaths in Sweden to date from COVID-19 than in the Norway.
Peter Robinson: But do we know that the Swedes are not simply getting through it more quickly, that they--
Jay Bhattacharya: No they.
Peter Robinson: Well, will they just have the same death rate in the end?
Jay Bhattacharya: That's the thing. It's not that the lockdown, people look at the lockdowns and they're saying things like, okay, the death rates have to go down for, you know, 14 days in a row and then we can lift the lockdowns, right? But if I'm right, the lockdowns are effective, you lift the lockdown, then it just starts growing again. Right, so it's not that the lock, the lockdowns are not a mechanism for disease eradication.
Peter Robinson: All right.
Jay Bhattacharya: Not a mechanism for disease eradication. It will never eradicate a disease. It will only delay when the disease happens. Now or later. You pay the cost now or you pay it later.
Peter Robinson: Alright, so COVID is like Wimpy in Popeye? I will gladly pay you on Thursday for a hamburger today. All right.
Jay Bhattacharya: I thought it was Tuesday but.
Peter Robinson: Tuesday, could be, could be. There I won't quibble. There, I will defer to your superior learning. Jay, let me ask you two or three questions that are just, what do we know now questions. The weather. Here in Northern California, the last couple of days, it's been in the 80s. That's dramatically different from when the lockdown started. It was still gray, rainy, cold. What do we know about warming temperatures?
Jay Bhattacharya: We don't know, we don't know for sure. I mean, I think there's a hypothesis going around that like some other viruses, it seasonal. And so it'll become more dormant and spread will be slower during the summer.
Peter Robinson: But we don't know why? We don't have for certain that it's warmer temperatures that slow it?
Jay Bhattacharya: Yeah, I mean, why could be just the virus doesn't, you know, it's unstable in sunlight or there could be all kinds of reasons why but we don't know for certain, that's true in this case, yet. I mean now, there's some evidence from Australia, for instance, it hasn't spread as widely in Australia, I think as people thought because they were they were in their--
Peter Robinson: Their summer.
Jay Bhattacharya: Yeah, exactly. When it was spreading, so.
Peter Robinson: Jay, what do we know about transmission outdoors versus transmission indoors?
Jay Bhattacharya: Seems like indoors is where it's happening, where most of the transmissions happen. So for instance in New York, a lot of the spread was in nursing homes, nursing homes. In Wuhan and in Italy, in hospitals, actually Italy also in nursing homes. You need, it seems like you need to have some extended contact with people who are positive in a setting indoors for it to spread. Now, that's not to say it can't spread outdoors, but it looks like from the evidence that I've seen, mostly, it's indoor spread.
Peter Robinson: All right, transmission from children to others. We learned very quickly that children didn't seem to come down with, they didn't become symptomatic but is there beginning to be evidence now about transmission from children to others?
Jay Bhattacharya: So there's this absolutely fascinating study out of Iceland, this company, I think deCODE Genetics it's called, they sequenced every single virus they could find inside, among people in Iceland. I think Iceland, they've actually done PCR tests on 12 or almost 15% of their population. And every positive person they got, they took the virus and they sequenced it. And they looked for mutations. And from these mutation patterns, you can figure out who got the virus from what, from whom.
Peter Robinson: I see.
Jay Bhattacharya: So for instance, they figured out that a lot of the virus in Iceland came from the UK because that's where the maximum mutation patterns are in the UK. And I saw some from some like ski resort towns in Germany or Austria or something. Anyways, so one of the main things they found was that there wasn't a single instance where they can show that the virus had gone from a child to an adult. It was always the other way around.
Peter Robinson: Always the other way around?
Jay Bhattacharya: I guess, I should be careful. They said it was not from a from a child to a parent. No instances of that. It's always the other way around.
Peter Robinson: All right. What do we know about the death rates? We talked earlier when you were about to conduct your first test, here in Sana Clara County, that the fatality rate was almost meaningless because we didn't know anything about the denominator, how many people have been infected. But I've seen so many stories. Again, I'm just a layman, I'm reading the newspaper and I'm checking with a professional now. I've seen so many stories that death certificates, there's at least cause for concern that death certificates are over stating deaths from COVID-19. Do you know anything about that? Is it all purely anecdotal?
Jay Bhattacharya: I mean, I think that death certificate data, I mean, they're filled out by doctors who have to make a difficult call, right? So you have a patient, I'll just take an example, that had nothing to do with COVID-19, just to give you an example of the difficulties, right? So, you take a patient with diabetes. They have a heart attack. The heart attack causes, 'cause of the diabetes, they're arteries are clogged up in their heart. The heart attack causes their heart to fail which then causes their lungs to fill up with fluid. Then they get pneumonia and they die of the pneumonia.
Peter Robinson: Okay.
Jay Bhattacharya: What should I write down for the cause of death there? Diabetes, heart disease? You know, pneumonia? You know, I mean, it could be a lot of things I could write down on there. So people are making difficult calls when they fill out death certificates. I don't want to second-guess that. I'm much more interested in the denominator, right? Even with whatever is happening in the numerator, what we found in Santa Clara is that it was somewhere between .1 and .2%. One in a 100,000 or 200,000 risk of death. Same thing in LA county. Actually, they found the same thing in Miami-Dade. They found, I think in Germany, they found somewhere between 0.25 and .4%. Again, 200,000 to 400,0000. In New York City, they found about 500,000. So it's basically consistent worldwide. Somewhere between one in a thousand and five in a thousand. In all of these serological studies worldwide. And, by the MLB by the way, is zero. There was no deaths in the MLB population, despite the .7%, 0% mortality.
Peter Robinson: I see. Jay, another one of these questions, I'm just asking for a simple education. Distinguish if you would between a vaccine and therapies.
Jay Bhattacharya: Yeah, so a vaccine, what it does, is it puts, it injects in you certain parts of the virus that don't actually make you sick.
Peter Robinson: Right.
Jay Bhattacharya: And that induces your body to produce antibodies that then, if you're exposed to the virus, would be neutralized by the antibodies. Right, so you're just, your body has now produced its own, essentially defense system, in reaction to the thing that you injected with.
Peter Robinson: So, it is of the nature of the vaccine, this is the bit I care about, it's the nature of the vaccine that it very substantially just solves the problem.
Jay Bhattacharya: Yeah.
Peter Robinson: But those are hard to develop?
Jay Bhattacharya: Very difficult. There aren't any vaccines for human coronaviruses. So, you know, there's six, I think, I don't exactly. I think there's five or six coronaviruses that infect humans and we don't have a single vaccine for any of them.
Peter Robinson: Wow, so this notion, apart from anything else, the idea that we could continue the lockdown until a vaccine is developed is just ridiculous, that's preposterous.
Jay Bhattacharya: Well, I mean, I hope I'm wrong. I mean, maybe like there's a tremendous effort worldwide to try to develop a vaccine, for SARS-CoV-2. And I hope that it succeeds. Should we continue the lockdown until it succeeds? Well, I mean, we don't have a vaccine for HIV. We don't have a vaccine for any of the coronaviruses. I mean, it's a very difficult task to develop a vaccine. So a lot of very bright minds working on it, but do, should we basically stop our--
Peter Robinson: It's unpredictable? It's unpredictable. It's not like building a building where we've built a lot of buildings in downtown Manhattan, 60 stories, West Side, yeah, okay, here's the budget. Here's the time and within 10% of each, we'll bring it in. You can't do that with a vaccine. It's just utterly open-ended.
Jay Bhattacharya: Hmm hmm.
Peter Robinson: Is that the, all right? Do we have evidence now that we have any really, any truly useful therapies for treating the thing?
Jay Bhattacharya: Okay, so--
Peter Robinson: So the vaccine solves the problem and the therapy addresses the problem after you're already sick, right?
Jay Bhattacharya: Right, so one of the things we learned from the serologic studies is that there's a very wide range of presentations, right? So there's the mild illness that or almost no symptoms, looks like a cold kind of version of it, and then there's these like absolutely deadly viral pneumonia that we've been reading in papers about. The focus of therapeutic effort is to either A, prevent the, once you get infected, from people getting the very, very severe presentations or if you do get the severe presentations, to make sure you don't die from it. So you can get essentially, healed, despite having had the severe presentation. So, those are the two kinds of, it's kind of the distinctions I make for therapeutics. I mean, there's been some advances. So like, there's a company up the street called Gilead that's produced a drug. It's an older drug that they tried out here called Ren.
Peter Robinson: Remdesivir?
Jay Bhattacharya: Remdesivir, you got it. Peter, they should give you an MD. Okay, so that seems to have some effect on people who have these like severe pneumonias, but they haven't checked to see if it reduces mortality yet. And they've done some randomized studies. I mean, it looks promising but is it, I don't think anyone thinks of it as, it solved the problem, right, so.
Peter Robinson: So, Jay, Jay, so now, I'm going to play, some composite character. I'm going to be one part Gavin Newsom and one part Andrew Cuomo and heaven help me, one part Donald J. Trump. And I'm going to say, doctor, fat lot of use you've been to me so far. I've got this lockdown going on. Huge numbers of people are unemployed. Even those who can work at home successfully and who can work at home and continue to receive their paycheck have had it about up to here. Schools are closed. Goodness knows how kids who are high school juniors this year going to apply to colleges next year when their junior year grades are ambiguous and they're not taking the SAT. This is, it's going to take, if we ended the lockdown tomorrow, it would take months for us to recover and to get back to anything that feels like normal. And here's what you're telling me, doctor. You're telling me, that we still, we have no idea when or if a vaccine will be developed. You're telling me that we have only very preliminary information about any therapies that might prove truly useful. You're telling me that although the fatality runs in the range of one to five in a thousand which sounds pretty low. Well, you know, a community, again, I'm a working politician. And I know the way the network effect works among people. One to five in a thousand is enough that when one of those people dies, three, four hundred will have heard of it, will have known the person, will have known the person's family. That is plenty to scare people, really scare people and understandably so. And you're telling me, that once this lockdown ends, this virus is still just getting started infecting our people. What in the hell do you want me to do?
Jay Bhattacharya: What I tell you is there is no safe option.
Peter Robinson: Oh, thank you, all right. Go ahead.
Jay Bhattacharya: If you think that having a lockdown, it will provide you safety, you're mistaken, because the problem is that this lockdown has had enormous, negative effects on the health of people in the United States and worldwide. We talked about it the first time, I talked about it, the way I was talking about is lives for lives. I still believe that. There have been people who've delayed their chemotherapy as a result of the lockdown. They've had heart attacks and not gone to the doctor. I just saw a report that estimating, you know, nearly 75,000 people, additional will have committed suicide or as a result of the lockdown, these are deaths of despair.
Peter Robinson: Wait, wait, worldwide or?
Jay Bhattacharya: No, US.
Peter Robinson: So how many people have died of the coronavirus so far? What's the top estimate, 30,000?
Jay Bhattacharya: Oh I don't, I haven't looked at the number today. But I think 70,000, up to now.
Peter Robinson: 70,000, so as many people who've killed themselves as have died?
Jay Bhattacharya: Well, I mean, I think that's the forecast. So that's not--
Peter Robinson: I see. All right, all right, all right.
Jay Bhattacharya: But you get the point. I mean, that happened during the Great Recession. There was these depths of despair. That's going to come back in spades when we have a GDP collapse of the sort they were seeing. And an unemployment rate that we haven't seen since the Great Depression. And that's just the United States. Worldwide, there is already evidence of resurgence of diseases that we thought we'd had a handle on. You know, 1.4 million cases of tuberculosis, not treated in India, starvation of children.
Peter Robinson: Whoa, is that 1.4--
Jay Bhattacharya: Million.
Peter Robinson: Million cases of tuberculosis in India?
Jay Bhattacharya: Yeah.
Peter Robinson: As a result of COVID? As a result of the--
Jay Bhattacharya: As a result of the lockdowns. I mean, it's basically people sparing the hospital systems to try to be able to treat COVID patients. I mean you know and shut down orders that make it difficult for people to travel to doctor, to the clinics to get the, I mean, for tuberculosis, you need basically regular antibiotic treatment for a very, very long time or its--
Peter Robinson: So, in place such as India, you impose a lockdown, and you're pushing the entire population into a time machine. Their healthcare regresses a century.
Jay Bhattacharya: Yeah, I mean I think, that's not just true in India, that's true in every country on Earth, especially the poor people in every country on Earth will suffer from this global economic collapse that essentially we've caused. I mean partly, it's due to COVID but it's partly also the response of the governments around the world to shut down our economies. There is no safe option here. You either face the problems that have to do with lifting a lockdown on COVID or you face the problems having to do with the economic collapse that we caused as a result of trying to deal with COVID.
Peter Robinson: All right.
Jay Bhattacharya: No matter what choice you make, Peter, you are in some sense, going to be on the hook.
Peter Robinson: Okay, so again, I'm playing a composite of several politicians. And I'm working politician. Here's my calculation. I'm going to keep the shutdown going until I figure out a way whereby whatever happens next, I don't get blamed. Is that a good calculation? Is that useful?
Jay Bhattacharya: I mean, I understand the incentives. I think what I would like to see is actual leadership.
Peter Robinson: Okay, so enough of my playing Gavin Newsom and Andrew Cuomo and Donald Trump, you're the governor of California. You're the governor of New York. You're the president of the United States. What do you do? Do you peel up a corner of the lockdown? What do you do, Jay?
Jay Bhattacharya: Well, I think there's a lot that we've learned about the virus that can help here.
Peter Robinson: All right.
Jay Bhattacharya: So one is, I think we know for certain that there's certain groups that are very, very high at risk when they get the disease.
Peter Robinson: Old and sick.
Jay Bhattacharya: Yes. So we have to work very hard to protect people when we start lifting the lockdown who fit that description, especially the places where they live, right? The fact that such a large fraction of the deaths have occurred in nursing homes is a clue that that's where we basically should be taking action to protect people. Quarantining like basically making the nursing homes much safer is going to be a huge priority to be able to lift the lockdown up. I think, there's other kinds of things we've learned about, so we're much better with ventilator protocols than we were at the beginning of the crisis. I think, that's a concrete improvement that's already starting to happen around the country and around the world. So I think, there's a lot potentially we can do using the lessons we've learned over the last couple of months to improve things as we lift the lockdown.
Peter Robinson: Jay, if I. You and I are now, forget about democracy, you and I are now co-emperors.
Jay Bhattacharya: Peter, it's more and more uncomfortable. First, I'm governor, now, I'm emperor?
Peter Robinson: Now, you're emperor. Well, the meaning if we could get anything done we wanted to do, what would we do? So I'm the budget emperor and I'll let you be the guy who decides. You be the decision emperor. But the budget emperor says, well, you know, the Fed has already made available 2.2 trillion, who knows, at that stage, the numbers are almost meaningless, but it's made available over, well over two trillion dollars in new debt facilities. And Congress is already enacted 2.3 trillion in various forms of aid. 40% of it wasted is my view but still or maybe 60%, but still some of it goes for unemployment. All right. So what you're saying is if we, whatever we need to do to protect the people most at risk, is going to cost a tiny fraction of what we've already spent for this lockdown. By the way, on top of the money going out, you have to take into account, a what? A 17, 18 trillion dollar economy, which has shrunk 5% in the last couple of months. So that's some X trillion dollars. The sums are just vast. So I guess, what I'm saying is, take a hundred billion and do anything you want with it. Would that help? Could you fix things pretty substantially with a 100 billion? Nursing homes, older people?
Jay Bhattacharya: You know, I think, those things we could do for sure. I mean, I don't think it would cost a hundred billion. I don't know how much it would cost.
Peter Robinson: Well, okay, my point is, actually if we're being sensible, we can do stuff, it doesn't cost much. That's my point. Is that right?
Jay Bhattacharya: Yeah, that's right. The other thing is I think is, we actually need a better, we need to better understand who actually is at risk. I mean, it's not all old people that are at risk. That's not right. So like, I think again, for not that expensive, we can better learn who's at risk and then focus our attention on providing support for those folks, right? So I don't know exactly what that would look like, so I'm a little hesitant to answer those, Peter, because I don't, I mean, this is why I'm not an emperor, like you have to help actually operationalize that idea.
Peter Robinson: Okay. So here's a question I have for you then. Again, this is just a layman fumbling around but, it occurred to me to think of the COVID-19 as two viruses even as, back at the turn of the 20th century, physicists began to think of light as both waveform and discrete particles, two contradictory concepts and yet, it seems that both were true. And here's what I mean. In a large majority of cases, COVID-19 is a bad flu, maybe even not a bad flu. People, quite a few people are totally asymptomatic. But in some unknown number of cases, smaller, much smaller, but still significant, it is much worse than the flu. So we have an unusually vigorous 55-year-old who comes this close to losing his life and he's the prime minister of the United Kingdom. That's not the flu. And if we can figure out what it is about these special cases, those are the cases that scare everybody witless, understandably so, right? Now, is there, have I framed a question that's scientifically pursuable?
Jay Bhattacharya: Yeah, I mean, I think the way I would say that is I think we have to characterize who's most at risk, what clinical characteristics, what demographic characteristics, puts you at highest risk for the severe presentation of the virus. That's an answerable question. I mean, there may be things we don't know but we can take a good stab at it already, I think. I think that should be the first priority for epidemiologists and clinicians to try to figure out, who's at most risk. And then once we have that answer to that, we can do more than just protect the nursing homes, right? We can tell people, okay, you have a set of characteristics that puts you at risk if you were to get infected. You know you wear a mask. You work to protect yourself from exposure. Consider carefully about working from home. Whereas like, you know, Peter, you don't fit the profile, someone that's really, really high-risk. You still have some risk. I mean, no life without risk. But you're more likely to be down over here than over here if you get it. You make your decisions about how you want to live your life.
Peter Robinson: Okay, last couple of questions. What about testing? Some people, Paul Romer, Nobel Prize winner, former colleague here at Stanford, now at NYU, but he's calling for vast numbers of tests, tens of millions of tests, testing becoming a regular part of everyone's life. How do we do, is that reasonable? Would it be useful? Where do you stand? I mean you're pro-testing because you were talking about a new test that you've conducted.
Jay Bhattacharya: Well, I think the question is like, how do you use the test and what does it mean for your life as a result of having this? So, the test, I think that Paul Romer is calling for, are these PCR tests. They test whether you actively have the virus, as we've talked about several times. So, you have the virus, you don't have the virus now, Peter. I tested you today. You're free to come to work. Do I test you tomorrow because you might have gotten the virus between today and tomorrow? Do I test you the next day? I think in order to be effective, I mean, you don't have to do that frequently. Maybe do it once a week.
Peter Robinson: But it's a lot.
Jay Bhattacharya: Antibody positive. I mean, I think you could, you'd have to have it, it really would have to become a regular part of your life, not just to come to work but to go to anywhere, right? If you wanted to do that, it would be billions and billions of tests all the time. The other problem with a lot of those tests are most of them, most of the PCR tests take two days to come back. Now, there are these point-of-care ones, I mean, I think clever people have been working to build a testing regimen that minimizes the probability of you're being sick when you go to work or an environment that, where you won't to interact using a combination of antibody tests and PCR tests. I assume that clever people are going to be able to come up with that kind of regimen. The question to me is, I mean, we normally have thought that health privacy is a good idea. Your DNA now is in the hands of, you go to a restaurant, you do the swab, now the DNA that's at the restaurant now is your DNA.
Peter Robinson: Hmm.
Jay Bhattacharya: You go, basically, anywhere you go, you're gonna get tested? I mean, I think that's possible. Again, some very, very clever people have designed mechanisms do that. But I think that would result in a fundamental change in how we view, a fundamental change in American life. I mean, I guess, I'll just leave it at that. I personally don't want that but I can see why people might because they trade that for some safety.
Peter Robinson: All right, a couple of last questions. Jay, so you're in favor of lifting the lockdown. And you have to answer an accusation of callousness from a former Vice President of the United States now running for President, Joe Biden, quote. "No life is worth losing "to add one more point to the Dow". Close quote. You, Jay Bhattacharya, are willing to trade lives for dollars. How do you answer that?
Jay Bhattacharya: I mean, I have to be careful. I'm in favor of the lockdown, lockdowns being lifted where it makes sense to lift them, right? So, where we've learned the numbers and we say, okay, it's not gonna overwhelm the systems or whatnot. Let's take that as given, right? So we've run the numbers--
Peter Robinson: And you're reckoning, that's most of the United States now?
Jay Bhattacharya: That's probably most of the United States. But again, we should run the numbers first just to be sure it's safe. But we don't have serologic studies everywhere. So, I don't know what the numbers are in most of the country. Anyway, so let's take as given. that I'm in favor of the lockdown being lifted in certain areas, right? The way I would answer Mr. Biden is, I would say, look, you've mischaracterized the other side, right? Are you in favor of 75,000 people killing themselves, Extra as a result of lockdown, right? Are you in favor of starving tens of millions of children across the Earth? I don't think an accusation of callousness. I mean, there's morality on both sides of this argument is what I'm trying to say. And it's extremely misleading to say that only the people who want to lift lockdowns are people who are greedy, focused on money, that's just not right. The fact is that lives are going to be lost on both sides of that policy and both sets of lives count in the calculus.
Peter Robinson: All right, Jay, penultimate question and then we get to the last question. Here's the penultimate question. The second time we talked, you discussed your study in Santa Clara County and within 48 hours of your releasing that study, within certain niches of the internet, there was an explosion of statistical challenges, which I'm perfectly happy to admit, I couldn't even begin to follow. Miscalculation of false negatives or false positives, something like that. Can you just, you have explained all the, you've dealt with these arguments, but just for viewers who saw that and may be wondering what's going on, can you tell us where viewers can go and then we'll link to it when we put up the show.
Jay Bhattacharya: Sure, so we have an answer to all of, I mean, I guess I was a Twitter celebrity for a little while as these statistical Twitter mob came after--
Peter Robinson: The infamous, not famous, but infamous.
Jay Bhattacharya: Infamous, infamous.
Peter Robinson: Yeah.
Jay Bhattacharya: I've been told that by my kids. So, I think if you, so let me characterize the basic argument. We're using a test that has some rate of false positives, meaning that if you're truly antibody negative, some of the time, actually it turns out to be about 0.5% of the time, meaning--
Peter Robinson: One half of 1%. All right.
Jay Bhattacharya: Right. It'll still show up as positive.
Peter Robinson: Right.
Jay Bhattacharya: Okay, suppose that the prevalence, is actually in the population, .3%. Well, that means I can't, I can't rule out that all of those .3%'s were actually zero.
Peter Robinson: Right, right, okay.
Jay Bhattacharya: Right, so essentially, that was the argument they were making.
Peter Robinson: The test isn't fine-grained enough to pick it up with reliable, with certainty. All right.
Jay Bhattacharya: Correct. So, I think, that's in essence the kind of argument they were making. There was a variant of that because they're talking about standard errors and a whole bunch of other details that we covered in the response document, that are not so important. But that, in a nutshell, is the argument that people were making. The problem with that argument is that they just got it wrong. Like you can actually, first, the prevalence in Santa Clara turned out to be about 3%, way more than the .5% that we have.
Peter Robinson: I see.
Jay Bhattacharya: And even at the base of the stand, like even if you took the worst case of what you thought our test characteristics were, you still were above zero. So I think they just simply got the the statistics wrong. And it was just, I mean, a lot of noise. I think a lot of that, a lot of the, why am I Twitter, infamous on Twitter? I mean, I think, even though I'm actually not on Twitter and I think a lot of the Twitter critics, what they were arguing is that, look, the test kit that we're using is not accurate enough to pick up the prevalence numbers that we saw. In fact, all of the positives we had could be false positives, but that argument is actually just simply wrong. It's just not true, even at the bottom of the, even if you take the worst case for how accurate our test kit is, it's accurate enough to pick up the 3% prevalence we picked up in Santa Clara and it's accurate enough to pick up the 4% we picked up in Los Angeles, and actually, it turns out it's accurate enough to pick up even the .7% we picked up in the MLB study. And we make that case in the sort of an answer to the critics in that that pre-print server you can link to.
Peter Robinson: Okay, terrific. Jay, here's the last question. Should the MLB start the baseball season?
Jay Bhattacharya: I think they're thinking about how to do that safely. I don't think probably--
Peter Robinson: If there is a way to do so safely, you'd advise them, if you're careful, you can go ahead?
Jay Bhattacharya: I mean, no one's asked me that question from the MLB what, they're just, they're not going to because I'm not hired by them to answer that question. In fact, I didn't get paid by them at all for the study. I think, the kinds of thinking that, let's leave the MLB aside, that I've seen from other sports leagues around the world that are thinking about this, is let's do testing to verify the set of athletes and coaches and empires and whatnot that are there, that are are negative. Essentially, isolate them for the whole season while they play games with each other in front of nobody.
Peter Robinson: Oh really? Oh.
Jay Bhattacharya: Yeah. That's kind of reopening I think they're thinking about. I mean, I don't want to get, again, I can't speak for the MLB. I don't actually know what the MLB is doing along these lines, but this is what I've heard from other sports leagues.
Peter Robinson: Is that over-cautious or is that perfectly reasonable?
Jay Bhattacharya: I think that's reasonable. I mean, I don't think you want to expose fans to this. You don't want to expose the athletes to this. You're asking me, what would I do if I was governor, like, what would I do if I were the--
Peter Robinson: MLB commissioner.
Jay Bhattacharya: The MLB commissioner. I mean, I would be risk-averse about this, but I also would want to seek ways to open everything up.
Peter Robinson: Okay. It's not as much fun, you know, buy me some peanuts and Cracker Jacks, that sort of thing.
Jay Bhattacharya: You can watch it on TV, Peter.
Peter Robinson: All right. Dr. Jay Bhattacharya, Professor of Medicine here at Stanford. Thank you for joining us once again.
Jay Bhattacharya: My pleasure, thank you, Peter.
Peter Robinson: For the Hoover Institution, Uncommon Knowledge, and Fox Nation, I'm Peter Robinson.
