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Coronavirus Update With Nicholas Christakis

Yale Sterling Professor Nicholas A. Christakis, MD, PhD, MPH, returns to JAMA's Q&A series to discuss the surge in US cases and other recent pandemic developments. Dr Christakis is author of the recently published book 'Apollo's Arrow: The Profound and Enduring Impact of Coronavirus on the Way We Live.' Recorded November 23, 2020.

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>> Howard Bauchner: Hello and welcome to Conversations with Dr. Bauchner. Once again, it is Howard Bauchner, editor in chief of JAMA. And once again, I'm joined by Nicholas Christakis. Nicholas is a professor both of sociology and medicine. He's a Sterling professor of social and natural sciences, internal medicine, biomedical engineering at Yale, a very esteemed position at Yale. Not many Sterling professors. How many Sterling professors at Yale, Nicholas?

>> Nicholas Christakis: I don't know exactly. I think about 40 actually, you know, out of 700 faculty, something like that.

>> Howard Bauchner: Before we begin, I want to wish everyone a Happy Thanksgiving, and I say it to everyone in my emails, stay healthy and keep it small this year. So, Nicholas, we're going to talk a bit about what you've written in your book entitled Apollo's Arrow, but I have some questions as a lead-up to that. What's your impression, Nicholas, of the last couple weeks around COVID-19 in the United States, the numbers, the number of hospitalizations. What's your sense of this, Nicholas?

>> Well, first of all, I mean the remarkable news in the last two weeks is the release of the phase three results, the interim results, and now we're beginning to get the final results of the two vaccines, now the third vaccine AstraZeneca vaccine. So, and of course, the Sinovac vaccine, the Chinese vaccine, is in the background as well. I think, and I'll come back to what's happening in the tempo of the epidemic more generally, but just because you framed it in the last two weeks, and that is big news --

>> Howard Bauchner: Right. Those are the two, those are the good and the bad, the good, bad, and ugly, the numbers and then the vaccine news.

>> Nicholas Christakis: Yeah.

>> Howard Bauchner: But go ahead, Nicholas.

>> Nicholas Christakis: Well, I was just going to say, you know, one of the arguments that I had tried to make in Apollo's Arrow is that, you know, this way we are living right now seems so alien and unnatural to us, but it's really important for people to understand that plagues are not new to our species. They're just new to us. You know, we think this is such a crazy experience that we're having, but people have been struggling with plagues for thousands of years. The bible talks about plagues. Shakespeare talks about plagues. The Iliad opens with, you know, the plague on the Greeks, then Apollo rains down. But what's different, what is in fact different about our current experience is that we, we have in our time and the crucible happens to occur at a moment when we can invent a vaccine in real time. I mean the technological capacity that we have to actually in real time respond and within a year have completed phase three trials of active agents is mind boggling, and we are lucky, we are so lucky, that our moment facing this, you know, age-old threat is happening now. So, that's the good news, and that's a very big dramatic thing in the last two weeks that obviously everyone is paying attention to. There's more. I don't know whether you want to talk about it, there are, I don't want people to think the vaccines are a panacea, and I also don't want people to be overly optimistic or misinterpret what we still don't know about vaccines, the existing ones, which is still considerable. But on the bad news side, you know, I think our country we should be ashamed of how we've done. We have not adequately made efforts to control the epidemic. We are having, as everyone had expected, a second wave.

>> Howard Bauchner: Yeah.

>> Nicholas Christakis: The debate had been is how bad the second wave would be. I think when you and I last spoke, we talked about the fact that there would be waves.

>> Howard Bauchner: Right, right.

>> Nicholas Christakis: Every respiratory pandemic has these waves. There'll be another one in a year, whether we have a vaccine or not, there will be another wave in a year. The vaccine may tamp down the amplitude of that wave, but we'll see a boost again in a year. But I think this wave could be, will surely be as bad as the first wave and could be twice as bad, and of course, the 1918 pandemic, the second wave was four times as bad in terms of overall mortality in our country. So, you know, I'm very worried that we are just not, we're not doing the right things we need to do as a nation, and it's going to bad, get worse.

>> Howard Bauchner: Returning to the science, it's interesting, because Tony had written a viewpoint for us a few years ago about new vaccine platforms, and you know, he has a wonderful figure chart in it talking about the time to develop a vaccine. And I think in that, he talks about getting it down to 18 months. This was three or four years ago, and he talks about virus, adenovirus, mRNA and DNA. Unfortunately, we've had a test case, and we've gotten it down to under a year, substantially under a year. It is extraordinary. So, that portion of the science is extraordinary. There's been some concern that the clinical trial platforms in the U.S. have not been that robust. So, it's mixed from that standpoint.

>> Nicholas Christakis: Well, I want, yeah, and I also want, you know, as long as we're sort of hopscotching around already, which is one of the things I love about talking to you, but just to pursue for a moment the vaccine issue. So, I just want people to, most of the listeners here will understand, of course, that even from the moment we have the successful conduct of a phase three trial that shows that the drug or the vaccine is effective and that there's no significant safety problems, so far discerned, and even once we get approval, which is likely to be accelerated, as a nation we have a number of other problems still. We, first of all, have to manufacture millions of doses. We have to distribute them, and several of these vaccines require quite demanding cold chains, and we have to persuade the public to take the vaccines and get an acceptance. And if you do some basic calculations based on the R0 of this pathogen, the basic reproduction number, if you take as a benchmark that the R0 for this is about 3, the herd immunity threshold using the standard formula is R0 minus 1 divided by R0 or 3 minus 1 divided by 3 is 2/3, the herd immunity threshold is 67%; however, that makes the assumption that what is something known as the well mixed assumption, it assumes that everyone is equally likely to interact with everyone else, which of course is not true. There's a network structure to the human population. There's heterogeneous risk. And if you make some adjustments based on that, it brings the ultimate herd immunity threshold down to about 40 to 50%, let's say 50% of the people, if we did nothing, and the pathogen just kept working its way through our species, we would reach this milestone of 50%, and then the epidemic force of the pathogen would be diminished, the pathogen would still exist, circulate, it could still infect people, but we would no longer have an epidemic. So, if we did nothing, the target is 50%. Right now, our best estimates are about 12 percent of Americans are infected, so we're about a fourth of the way there. Now, on the other hand, if we develop this vaccine and we go through all these additional steps, which is that we, you know, we have to, now we've approved it, we have to manufacture it, distribute it, get people to accept it, that's going to take some time, maybe another year, I would say. Meanwhile, the germ is still spreading. So, from my perspective, either way, we're going to be living in a changed world through let's say early 2022, where we're wearing masks, we're physical distancing, we're closing schools periodically, and so, and then we will reach this important milestone, either naturally through the spread of the pathogen or artificially through the deployment of the vaccine. So, that's one line of ideas that I think it's important to keep in mind, and then, it's not like the world is going to magically return to normal because even though we will have let's say the epidemiological and biological impact of the pandemic before us, we still are going to have to cope then with the psychological, sociological, and economic implications. You know, our economy has been tanked and so on, and it's going to take a while for us to unwind that impact, plus the clinical impact, although I think in the end between at least half a million Americans will die of this condition, unfortunately, and maybe as many as a million. It will be in that range, we also have to remember something I know you know, which is that the disability of the germ as well. That is to say, even if the virus doesn't kill you, some significant fraction of Americans will have some medium to long-term disability from this. So, so it's a lot to endure still. The vaccine is not going to be panacea. You know, we're not suddenly returning to business as usual in a few months.

>> Howard Bauchner: Right. You know, I've gone over the numbers. It's always interesting, because the vaccine won't be available for 80 million people, children. So, you're going to take out 80 million. So, of the 330 million, the group that could potentially get it is 330 million minus the 80 million children that won't be initially eligible, and not likely eligible for quite a while, because there's no child studies yet planned. Just to go back to the distribution, we may end up being here for an hour, because we have a long way to go, I'm optimistic about the first 20 million doses.

>> Nicholas Christakis: Yes, me too.

>> Howard Bauchner: They're going to go to healthcare workers, and they're going to be hospital based, Nicholas. It's the next 100 million that --

>> Nicholas Christakis: Yes.

>> Howard Bauchner: And sadly, the Trump administration hasn't shared much information. It's going to get distributed at the state level. No one knows the arithmetic that's going to allow it to get distributed. And you know, it's nice to send Massachusetts or Connecticut or where you live currently, Vermont, two million doses, but what do they do with two million doses? So, is it your sense that we'll do well initially, but it'll be the next 100 million that will really be the struggle.

>> Nicholas Christakis: Yeah. I think that's exactly right. I think, and I'm sure the vaccine manufacturers have already been tooling up, have been, you know, which is also unprecedented, have been preparing to manufacture the vaccines in anticipation of a successful trial, spending hundreds of millions of dollars getting ready and manufacturing the doses, even not knowing that they're going to be, not knowing whether they would be successful or not. So, the first few doses will go to the placebo arm of the study, which is, of course, exactly right. Those volunteers took risks to help us discover that the vaccine worked, and they should have first dibs on doses. So, that's 20,000 people for each vaccine, roughly speaking. Then, of course, as you say, they will go to healthcare workers and first responders, which is very ethically unproblematic and uncontested. People that are putting their lives on the line and need to be immune in order to be able to do their jobs, and also, those are individuals who are at best able to judge the risks and are, as you said, a very easy to distribute to population and to discern. So, that's a few million people. And then after that, as you said, there is other groups of people that will need to be immunized and will be done fairly efficiently, but the next hundred million is going to take time, and it's going to require, I think, the next administration to stand up a public outreach, a public health communication campaign that is effective by people who are seen as credible, and here I even have in mind public figures like Tom Hanks or Dolly Parton, you know, who could talk about their experiences. Tom Hanks, of course, had the condition, or Tony Fauci, I think, has a lot of credibility. Our former surgeon generals. And we're going to have to cultivate confidence in the American people that we're not lying to them, that when we say something, we talk about our uncertainty. We talk about our confidence. We talk about the evidence for our claims, and then when we revise what we say, we explain why. We previously told you this because of this reason. Now, we're revising it for these other reasons. So, all of this is going to be a huge challenge, and that's why I think it's going to take some time and why, as I said, the virus, of course, is still spreading among us. So, one way or the other, we will reach this herd immunity threshold. But I also want to say --

>> Howard Bauchner: You comment about being, making sure we can correct ourselves or somehow communicating uncertainty. There's been an interesting discussion in social media. You know, medicine is used to uncertainty. We always say we think so, you know, there's rarely that definitive study.

>> Nicholas Christakis: Yes, most likely --

>> Howard Bauchner: Most likely, it's rarely that definitive trial. That doesn't play well in social media. It ends up creating an enormous amount of noise, and so, I think that's really been part of the struggle. We just received a viewpoint by Raina Merchant about how social media changes the way we have to communicate public health messages, and I think that uncertainty that medicine is used to just doesn't do that well in this case. Have you thought about that?

>> Nicholas Christakis: Yeah, I have, and I talk about it in Apollo's Arrow. I mean, first of all, I think one of the challenges is to begin to educate the American public about what science is and is not. So, science is a search for the truth. It's not, and it's often incorrect, but scientists don't mind the fact that it's incorrect because they see science as a self-correcting process.

>> Howard Bauchner: Right.

>> Nicholas Christakis: You know, I published a result. Here's my evidence for this result. I'm communicating it to my colleagues, and then someone else comes along and does another experiment and says, no, actually you were wrong about that. And the whole, it's a whole system of inquiry, of coming to understand the world, and as Tony Fauci said, like a couple of months ago he made this remark, he said, you know, the system tends to correct itself, which is one of the good things. Unlike ideology, which tends not to be self-correcting. Science does tend to be self-correcting over some period of time. And I think it's important for people to understand this so that the scientists are telling you today, here's our best guess as to what the truth is based on the data we have. Here's the things against this idea. Here are the things for this idea, and soon we'll know more. We may revise our opinion, but we're slowly getting closer and closer to the truth. This is the thing. And I think getting people to understand this is part of the challenge. And in a way, the virus struck us at a moment when our intellectual life in this country had been thinned out, when we were especially weak. There were a number of trends, macro trends in our society, which I think are harming us. The first is, as you suggested, the lack of kind of scientific, the lack of scientific understanding by the person on the street. You know, the kind of, the state of knowledge about science in the American public. Another, related to that, is a kind of anti-elitism, which manifests itself as a kind of anti-expertise. So, we think that, oh, what do the experts know? Like every person thinks that they're an expert, and maybe that's been abetted by social media as well, and this is a very odd kind of belief system in our society right now, because when you need a plumber to deal with a plumbing emergency in your house, you want an expert plumber, and you believe that the plumber is an expert compared to you. And same, for example, with the surgeon. You know, you want an expert surgeon or a car mechanic or whatever it is. And the same goes with a whole range of topics. People devote their lives to acquiring expertise. It's not a kind of elitism. It's a kind of devotion, and it should be seen as that. That's the second. So, first is science knowledge, lack of science knowledge. Second is an anti-expertise, which is a manifestation of this anti-elitism. The third is a kind of political polarization in our society, which has been well-documented to be at a great high, which is, which manifests itself across all kinds of topics, and people think things are, you know, like you're with me or you're against me. You know, that you're either, you know, on this side or on that side. Or masks, for example, became politicized as political symbols, mask wearing, which didn't happen in other countries, but in our country, they came to be seen as symbols of virtue or of liberty, for instance, which is nuts. They're just a tool to stop respiratory droplets, you know. And finally, there's a loss of nuance in our society where people seem to think that things are black or white about so many topics. You know, and we can't speak in terms of shades of gray. And so, to summarize, I think all of these things are in some sense a mark of immaturity right now in our society and that we need to, in some sense, grow up a little bit and begin to face squarely the reality of this virus and work together, and in some sense, I think, our leaders need to call us to sacrifice, to shared purpose, to kind of a commitment, to confront and repel this invader, and we need to quickly, you know, get our thinking more clear if we're going to do a good job of it. So, I think that's another problem, where the virus struck us when we were weak in these regards.

>> Howard Bauchner: I think what was so frustrating for Tony was trying to lead the national dialogue, and he kept trying to say, it's not close or open. It's not life or the economy. And he tried over six months to communicate we can do both simultaneously. Keep the economy partially open and save lives. And it ended up being polarized into it was either health or the economy. And he tried mightily to change that conversation, largely unsuccessfully. Now, we haven't touched on what our conversation was supposed to be today yet.

>> Nicholas Christakis: I want to, yeah, I know, and I want to come back to something we left standing with the vaccine, but before I come to that, I want to say something else, which is it's very important for listeners to understand, if they're willing or if, I know the people listening to this are mostly healthcare workers who are, you know, sophisticated, but they may have relatives or other people they're talking to, and I think people need to understand that the problems we're having with the economy in our society are not as a result of what the government is doing. There is a result of what the virus is doing. For thousands of years during times of plaque, economies have collapsed. Even when governments did nothing, right. If you look at, and as I discuss in the book, the slowing down of social interactions, the collapse of an economy, is a function of having a contagious, deadly disease. And in principle, when the government takes action, we do that to mitigate those consequences, both the health consequences and the economic consequences. So, my argument would be, is any actions the government has taken actually have put us in a better place than we otherwise would have been. We could have been much wiser in the actions we took as a nation, much, much wise, and we haven't yet talked about this, but you know, we have been, I'm ashamed at how incompetent we have been at coping. We could not have prevented all deaths. We could not have prevented all economic hardship, but we certainly could have done better than we're doing and than we're going to do, because we're already at 1400 deaths a day right now. Every day, 1400 Americans are dying, every day. And that's going to keep rising over the coming weeks. So, we're going to blow by half a million American excess deaths as part of this, at the ultimate, when this pandemic is over, and the history books are written, this will be the second worst respiratory pandemic we've had in 100 years, certainly almost as bad as, it won't be as bad as 1918, but it'll be much worse than 1957, which was the prior second worst respiratory pandemic.

>> Howard Bauchner: And Steve, Steve [inaudible] research letter, you know, he had talked about what was then, October 1, 225,000 deaths, and then we talk about excess deaths. And in our editorial we talked about 400,000. Then I was worried, was it really going to be 400,000 excess deaths. I think we're going to be past a half a million excess deaths by January 1.

>> Nicholas Christakis: Oh, for sure. Yes. Well, I don't know by January 1, but soon, yes. We're going to wind up being between half a million and a million deaths. This is even with a vaccine. And now, let me just return to the vaccine topic. So, this magnificent news that these trials are showing efficacy of these vaccines, but let's understand what the trials have shown so far. So, for example, in the Pfizer and BioNTech trial, they had 43,000 people. I don't know all the details of the trial, but for the sake of argument, let's assume they were half and half were assigned. Half got the vaccine, half did not. And then to simplify numbers, I'm going to make, I'm going to use some approximate numbers to what was found in the trials, not exactly right. So, let's say 20,000 people got the vaccine, 20,000 did not. And let's say among those who got the vaccine, they said, 10 got ill, and among those who did not get the vaccine, 100 got ill. It wasn't exactly those numbers, but approximately. So, that's a huge effect benefit in preventing illness. But we don't know if the vaccine trial prevents death. It could be that 1 out of the 20,000 on an average, 1 out of 20,000 people died in the treatment arm, and 1 out of 20,000 died in the placebo arm. And so, we may have a vaccine which prevents people from getting ill but has actually no effect on mortality. That's entire possible. We still don't know the answer to that question, first. Second, we also don't know if the vaccine prevents infectiousness. It may keep you from getting sick, but it may have not a big effect on whether you spread the germ to other people, which is a big unknown, which we'd like to know. Third, we don't know how safe this drug is, this vaccine is. So, [inaudible] 40,000, that is terrifically large for detecting many side effects and adverse consequences but not enough to detect let's say a 1 in 100,000 or 1 in 200,000 serious adverse event or death probability from the vaccine. And as you know, usually for vaccines, we benchmark at 1 in a million serious adverse effects or death or 1 in 10 million. Most of the vaccines we have are very safe, and we tolerate those levels of mortality because, of course, we save thousands of lives from the vaccine, so it's a no brainer. But if in fact these vaccines have a 1 in 100,000 let's say kill people or cause a serious problem, paralysis or something, we won't really know that until we start rolling it out. And then, I think, because everyone, the world's eyes are on this, we're going to have a serious public messaging problem again, especially if we haven't prepared people for this. So, these adverse events, though still rare, and while the vaccine might still be worthwhile to use, will be breathlessly reported and will sap interest in the vaccine. And last, now that we're talking, [inaudible] people aren't overly optimistic about the vaccine, we can't know if there are long-term adverse consequences from the vaccine, because it's just like we can't know about long-term adverse consequences of the virus, this is, we can predict based on other vaccines or other coronaviruses or known biology and known medicine, but there are some things we can't do experiments about. We just have to wait for time to go by. And so, so I'm enormously optimistic and proud of our science and our medicine and what our country has achieved in developing these vaccines, but I just want people not to think that, oh well, it's over. It's not.

>> Howard Bauchner: Length of immunity, I would add, to the unknown.

>> Nicholas Christakis: Yes.

>> Howard Bauchner: People know I'm going to be talking to Paul next week, Paul Offit, and people have already sent me questions, could you please ask, but I know length of immunity is the other one.

>> Nicholas Christakis: I think like the, I mean I'm optimistic about that for a variety of reasons, and I'm sure Paul will know vastly more about this obviously. And I also think we're going to have so many different types of vaccines coming out that although this is a complicated area of immunology too, whether you would or wouldn't want people to get different kinds of the vaccines, but I think we're going to see some good vaccines, you know, within a year or two --

>> Howard Bauchner: Right. Plus we'll be able to follow someone so we know if at six months 95% are still protected, then you'll wait a year, and then you'll have to reimmunize. So, that's knowable, at least. Some of the other things are not so instantly knowable. Nicholas, now I wanted to get to, and part why you're here, and so, you have mentioned some of the financial mental health clinical. Let's start with medicine. What's here to stay in medicine. What has fundamentally occurred that you think has staying power within medicine?

>> Nicholas Christakis: Well, one of the things I think both, you know, I think doctors and nurses and healthcare workers appreciate this on the delivery side, but it's especially powerful when we, like other human beings, need to get medical care. The idea that you have to go see your healthcare provider in order to get many routine things taken care of is enormously inefficient and inconvenient. You know, the idea of going to see the doctor to get a prescription refill is absurd, at least driven by, you know, insurance regulations and other kind of bureaucratic requirements. So, I think because so much of our healthcare moved online during the pandemic period, I think many of the kinds of changes in healthcare delivery and in reimbursement rightly are here to stay. And I know Zeke Emmanuel has also written effectively about this. I mean I think, you know, I think that many routine visits will now move online and I would hope and assume that they would be reimbursed, and as Zeke has argued, there should be no difference in the reimbursement to avoid doctor saying, oh come to see me for routine care because I get a little bit more money. You don't want that. You want to avoid that, right? You want [inaudible].

>> Howard Bauchner: Right. Or my institution would get more money.

>> Nicholas Christakis: Yes, yes, exactly. It's not all mercenary, right. But I mean my point is, you want to set the incentives up so that we optimize efficiency in the system and minimize needless, you know, like dead weight. You know, like having people filling up our hospitals to get stuff that they don't need to come in for. Or routine dermatologic evaluations, or I think we're also going to see a profusion of home-base sensors. You know, the Apple watch, for example, where you can, you know, get a decent trace, you know, of a rhythm, and hit a button and send it to your doctor, you know. Or home oximeters. Or, of course, glucometers, and tidal volume measures. There's just so many devices that I think will become more common at home and will allow doctors and nurses to like provide in-care home to larger numbers of people. So, I think, you know, and web-enabled devices too, even simple ones, like thermometers, for example. So, I think, I think a lot of those types of technological changes and organization changes are here to stay when it comes to medicine.

>> Howard Bauchner: Workplace.

>> Nicholas Christakis: Well, I mean I think everyone is observing about the whole work from home stuff is going to change and will stay. Many leading tech CEOs have said, I think Facebook said that all their workers can stay at home even afterwards. And Tata Consultancy Services, which is one of the world's leading consulting firms has also made statements like that, and Qualtrics, a whole bunch of, I mean these are anecdotes, but many big corporations have said this. And part of that will be driven by economics and employee satisfaction. So, while the pandemic has been awful, let's not forget millions of Americans are out of work, at least 30 million Americans. Many people have lost loved ones or, you know, have been sick and been disabled. Many people have long COVID. This is, you know, many businesses have bone out of business. People are staying at home. There are a lot of mental health consequences. However, many people are delighted not to be commuting. You know, anyone that didn't have a job requiring, you know, like if you were a so-called essential worker, and you had to be out driving a truck or doing your job away from home, if you could do your job at home and you were allowed to do your job at home, now you don't have to commute. Now, for some people, that was also not so great. They liked getting out, I mean most people liked getting out of the house. But anyway, the point is that many employees would appreciate not having to commute, and many employers will appreciate not having to provide office space. You know, they can remove all of that expense from having their workers, you know, having to heat and house and provide all that stuff for their workers. So, I think the economics of working from home are going to drive some persistent changes in this regard. Plus the technology. We'll all had a dry run of using technology that allows us to do this. So, that's going to stick around, I think.

>> Howard Bauchner: Yeah. We've been trying to figure it out within the editorial and publishing groups. Like our editorial assistants, our manuscript editors, are working incredibly well and efficiently from home. And in Chicago, for some of them, that was an hour commute in both directions. So, they're saving two hours. Nicolas, but if you're a city like Chicago, or a city like New York, and you take out a million commuters, that has enormous implications for mass transportation. And who's paying for it?

>> Nicholas Christakis: And for air pollution and climate change.

>> Howard Bauchner: Air pollution and real estate. So, you've affected the real estate market. You've affected mass transportation. So, if you're a mayor of a major city, and you've just eliminated, you will never gain back 30 to 40% of your workforce. They simply will not be commuters. What happens to that infrastructure?

>> Nicholas Christakis: Well, I'm not sure if -- yes and no. So, one of the things I discuss in Apollo's Arrow is the response to city living since time immemorial.

>> Howard Bauchner: Okay.

>> Nicholas Christakis: And since time immemorial, whenever there's a plague, people flee the cities, and they go to the countryside.

>> Howard Bauchner: Right, right.

>> Nicholas Christakis: And they have for thousands of years, and this is well understood. And they're doing that, and the same thing happened with this pandemic in this country. But the cities always come back, I think partly because the value proposition for living in the cities is so high. People like to live in cities. It's exciting. There are employment opportunities. So, I think the cities will come back. I think right now we're seeing a lot of anecdotal evidence that suburban real estate prices are going up. Rents in urban areas are declining. Rural areas are seeing heavy demand. You know, wealthier people with second homes are suddenly enrolling their kids in school districts, you know, in the hinterland. So, we're seeing a lot of anecdotes, and I think eventually we'll see robust data about all of this. And people are hollowing out the cities to some extent. There are, you know, fewer people. But I think that will reverse. Like in ten years, I think we'll be right back or five years, and I think there'll be a different kind of economy. There'll be different things that people are doing. But I don't think that will come back. Same with globalization, by the way. So, I think that people have seen the ways in which a global pandemic puts the global supply chain, you know, breaks it, and we don't want to be relying on foreign countries for our PPE and our drugs, you know. We're going to have shortage of crucial drugs because we get those from India, and shortages of crucial PPE because we get those from China right at the time we need them because they're keeping them for their own people or because shipping is shut down because of the pandemic. You know, there's going to be a lot of onshoring, but I think even that eventually will revert, because I think the economic arguments in favor of globalization are so high, just like for cities, I think these trends, while we will step back for a few years, eventually, I think, will return.

>> Howard Bauchner: So, we've had quite a few articles on mental health. We just posted an article about community dwelling adults, older adults, who have done actually quite well. Most of the surveys suggest community dwelling adults have done well, and it's been an interesting phenomena because that was not the impression of many people. Charlie Marmar wrote, you know, 500,000 Deaths, Every Person Knows Ten, that means 5 to 10 million people will be exposed directly to a death of a loved one, which would not have occurred last year, some of these people are elderly and would have died. What's your sense about the mental health of the country?

>> Nicholas Christakis: Well, I look at some surveys by Gallup, by NORK, by other survey firms, and it's worse. I mean if you compare it to a year ago, sadness, anger, fear, these are all up. You know, enjoyment is down, you know, by 10 percentage points, 15 percentage points, so I'm making up the numbers. I don't have them in front of me. But let's say in 2019, you know, 20% of Americans reported feeling angry every day. Now maybe 30% might. Or, you know, 20% of Americans reported feeling sad every day. Now, maybe 35% might. I'm making up the numbers. But, you know, order, something like that. We have seen some rises in intimate partner violence because people are cooped up at home. The suicide evidence is mixed, I think, as you said so far. I'd be surprised if it weren't worse, you know, we don't see a bump in suicides when the dust settles. But, you know, there's sort of mixed evidence, I think, that I'm aware of so far. So, I would have, and it's typically the case that during times of plague, people get depressed. I mean it is just a, it is thousands of years this has happened, and I think -- so, yes, I think the mental health of the country is suffering. And I think that's one of the things that pandemics do. And while middle-aged and older adults that are living at home probably have the tools to cope, you know, they have the life experience, the maturity, you know. They're able to put this in the perspective, you know, that this is something, you know, some of them may have remembered the Vietnam War or they may have remembered a major recession or they've had a divorce in their lives or maybe their house burned down or they've had some other calamities in their lives, and they can kind of say, okay, this is bad, but you know, it's not so bad. You know, I'm just going to live at home for a year, and it'll be over. But the children, you know, I'm very worried about. I'm very worried about the 50 or 70 million young people you mentioned earlier and the impact of this on them, on losing schooling opportunities, on losing opportunities to be socialized with friends. I forgot the precise numbers, they're in the book, but I think 40% of American children have some adverse childhood event, which might include being homeless or having a divorced parent or a parent dying or some kind of significant economic hardship or being abused. And now, with this pandemic, we're adding a lot of burden to young children in our society, and that can leave long marks, and this has been studied with previous, for example, 1918, we know that some of the people who were young during the 1918 pandemic, which of course was conflated with the first world war, so it's a bit complicated, but you know, that they had lifelong impact.

>> Howard Bauchner: People may recognize the last name, Christakis, your brother, Dimitri, and I are friends. He's editor in chief of JAMA Pediatrics. Like me, he's a pediatrician. And he and I have talked --

>> Nicholas Christakis: Yes, we're very proud, we're very proud of Dimitri and the family. My sister, Katrina, and my brother Qunyon [phonetic], are very proud of him. [laughter]

>> Howard Bauchner: Oh, God. I'm going to hear from Dimitri.

>> Nicholas Christakis: Yes, of course you will.

>> Howard Bauchner: We have talked, Dimitri and I, and now we've touched on it, the educational cost of this respiratory.

>> Nicholas Christakis: Yeah, yes.

>> Howard Bauchner: Kids in an out of school. Now God knows what's going to happen between now and Christmas. I expect very few schools are going to reopen in the major metropolitan areas for in-person learning until after Christmas. People will try to buy six or eight weeks. Will the children need to repeat school? Will they need to repeat a grade? Will we make it up in summer school? I mean, the early evidence is really enormously concerning. On one hand, we say children are resilient, but on the other hand, they're losing an enormous amount of educational time.

>> Nicholas Christakis: So, I have a slightly different opinion about some of these things than my brother, Dimitri, who you said is a well-known pediatrician, and also, then, my wife, Erika, who is a well-known early childhood expert who has also written about this topic. So, in the family, we have a range of opinions [inaudible].

>> Howard Bauchner: So, let's get, let's get the range.

>> Nicholas Christakis: Yeah, well, no, we could, that's why we're not meeting for Thanksgiving this year in fact. That's why we're all, that's the reason were [inaudible] Thanksgiving. But, here's what I think, first of all, let me just say a few things. I do not think the, and Dimitri would say the same thing and so would Erika, the impact of the loss of schooling is not the same for every child of every age, okay. So, for example, I think I'm much more concerned about elementary school kids missing school that I am about high school or even middle school kids missing. And I'm not even, and I'm not worried about nursery school and kindergarten so much. I think those kids probably didn't benefit much from school, on average, anyway. So, I'm most worried about one to six. And I think the focus should be on, you know, I think the argument is very compelling, as there's, there should be no community in this nation where the bars are open but the elementary schools are closed. I mean this is, you know, this is the wrong priorities. First point. Second point, school is not necessarily good for everybody. For example, kids that are bullied at school or kids with autism spectrum disorder or super bright kids that are bored by school. So, there are many people for whom school, the lack of school, going to school, actually is helping them. Maybe 20, I'm going to make up a percentage, maybe 20% of kids might actually be advantaged by the cancelling of school. Plus, there are a lot of kids whose parents, for better or worse, through different means, are able to provide adequately for them. Remember, lots of kids, learning is not just what happens in school. Something like only a tenth of a kid's time is actually spent at school anyway. Most of the things that children learn are learning at home or learned out and about in their neighborhoods or interacting with their peers. So, there are many reason for optimism in this regard, on the one hand, and many reasons for us to think more subtly, remember earlier we were talking about the lack of nuance, we don't want to see things as black and white. Either the school must continue or it must stop or everyone benefits or everyone, you know, is harmed. It's not that way. There's nuance. You know, we may want to prioritize kids with special needs getting school. Like if a local school district can't stay open, the kids that their parents, that need a lot of effort, that the state is rightly paying for, you know, maybe we should stay open for those kids, and the rest of the kids can go home, etc. So, that the first point the heterogeneity and response, the heterogeneity by age. Now, will the kids be able to catch up and what is the lifelong impact of that? It's hard to say what that is, but I don't think it's trivial, and I do think that we any kind of public health intervention, whether it's closing schools or closing businesses or closing borders or banning gatherings or wearing masks or whatever we're doing, unfortunately, in a time of plague, we need to adopt a very cold-hearted utilitarian calculus. And so, when it comes to school closures, which I am in favor of, in general, as a tool, it certainly was in favor with the first attack back in the spring, I thought, we should have proactive school closure. Now that the virus is loose in our communities, it's a bit more complicated a decision. At a minimum, we should very sober mindedly evaluate what's the downside? How are people harmed? We need to quantify the harm to children and put that in the hopper when we're making these decisions.

>> Howard Bauchner: Nicholas, when you, throughout the book, you talk about previous plaques, particularly the various waves from the 1918 flu, what are the, are there lessons, are there lessons from history that can help us now? And I don't mean to, not just about masking, but that could genuinely provide insight as we think of the next six months, year, two years, or three years.

>> Nicholas Christakis: I mean, I think if there was one lesson that I could extract is something we touched on earlier at the beginning of the conversation, which is that the fact that we have to appreciate, that we are not the first ones to be enduring a serious plague. In fact, this plague that is our turn to face isn't actually so bad. Bad as it is, and remember 1% of people, the best estimates of the infection fatality rate of this pathogen are between 0.5 and 0.8%, although there was a recent paper in Nature that put it as high as 1%, the case fatality rate is double that approximately, let's say about 1% of people with this condition who get symptoms die, that's a bad, serious disease. It's going to be a leading killer in our society, but it's not as bad a plagues could have been. Bubonic Plague would kill 50% of the people in a city within a couple of months. Ebola will kill 80% of the people it afflicts in an outbreak. Smallpox in Native American populations would kill 95% of the, they'd be annihilated, these populations. Even in the movie Contagion, I think the case fatality rate was like 30% in that movie, you know, one in three people died. There is no reason, there's no sort of God-given reason why this particular pathogen that we are facing isn't worse. It could have been so much worse. So, I think the thing I would like to frame is that what is being called from us is to accept and maturely deal with, as I said earlier, our time in the crucible. You know, we are facing a plague. We're not the first generation of humans to face a plague. We need to do our best and to accept this reality and to cope with it in the wisest way possible, taking advantage of all of the prior knowledge that our species has accumulated about how to deal with this.

>> Howard Bauchner: Last question. Vice President Biden, President-elect Biden will likely be inaugurated in January. He will have a full plate to deal with. There's some action he can take now, but it does not appear as though he can do very much now, because the reigns of government haven't yet been handed to him. What do you think his health priorities need to be, both related to COVID-19, I call it the great pandemic of 2020, the great pandemic of 2020, which will now go into 2021 and certainly linger into 2022, hopefully not beyond 2022. What do, what does, what are his priorities around the pandemic and then healthcare in general, Nicholas.

>> Nicholas Christakis: Well, I was, I was interviewed about the book by Vivek Murthy, one of his health advisors, like a couple of months ago, and so, I was speaking to him. I'm not privacy to the President-elects thinking. I know the President-elect is, of course, focused on effective vaccine strategies and vaccine distribution strategies. That's going to be a significant logistical challenge, and I think it's going to be a public health messaging challenge. I think, I would hope the President-elect would be thinking seriously about how to use the bully pulpit and how to get effective communication from all branches of government about the importance of vaccination and rolling it out. I think that, I think that the Coronavirus is going to be his number one priority. It has to be. We can't fix the economy unless we fight the virus, and I think a lot of the money that we're spending and the attention that we're devoting is a little bit misdirected right now. So, I think efforts to shore up ways, public health procedures, in addition to pubic health education that I just mentioned, are important. So, a lot of this is just bread and butter stuff. More masking and encouraging people to wear masks. Better distribution of effective masks. I mean some masks work better than others. Are we manufacturing enough? There had been a plan I read months ago from the United States Post Office to distribute masks to every household. That was scuttled for some reason, I think political reasons, I don't quite understand why. More PPE, I think, for our healthcare workers. Better thinking regarding physical distancing and gathering bans and other kinds of like blocking and tackling for public health that are going to required. So, I think all of these basics need to be emphasized and not seen as political liabilities. And with that, especially now, like in some ways the existence of these vaccines shows us that there's a light at the end of the tunnel. Like if we can just keep our act together, you know, for a year, we can greatly reduce the burden of mortality in our society, get to the point where we can have these vaccines available, and actually wind up with lower loss of life and a healthier economy. Because death is expensive, right. Like having a circulating deadly germ is not, you know, is harsh on the economy. So, I think there are ways, sort of EPI 101, basic public health investments in infrastructure, public health messaging, better coordination between the feds and the states, all of these things are things that are going to just need a, you know, tremendous amount of effort.

>> Howard Bauchner: And the healthcare system, beyond COVID, or is all the focus on COVID in the short run

>> Nicholas Christakis: No, I mean this is, another thing, there's all this deferred vaccination, deferred healthcare because the hospitals weren't, you know, doing colonoscopies and screening tests. People, you know, weren't getting the kind of routine healthcare they need, all of that needs attention. But that goes back to a little bit of something you asked me earlier that we didn't discuss, which is apparently, and you would know this better than I and many listeners will probably know this better than I, you know, many hospitals, even though they are providing a crucial service in the history of our nation, in taking care of people who are sick from a deadly contagion, lost money, and many hospitals were at the risk of going out of business, because, of course, the way reimbursement works is hospitals make money from, you know, from elective procedures and high value procedures, and apparently, taking care of people who are infected with a deadly virus is not very remunerative. This is no way to organize a healthcare system. I mean this makes absolutely no sense. So, I think this is likely to be revisited. How we reimburse for these services. How we equip ourselves, you know, in the coming years, to pay for the kind of care that we need of our healthcare system in a time of a deadly contagion.

>> Howard Bauchner: This Howard Bauchner, editor in chief of JAMA, it's been Conversations with Dr. Bauchner. Nicholas, you're always so engaging. I really have to comment. You have an incredible mind, and I really want people to know, you're not just a, you are a physician as well as a sociologist. Your new book is one of the first out. It's called Apollo's Arrow. When I heard that the new book was coming out, it made me think of all the people who've left the Trump White House and tried to get a book out first, but yours is much more, much more an important read for me than those books. I really want to --

>> Nicholas Christakis: I'm glad to hear that, and thank you, and actually we didn't talk about all the work in my laboratory. We published a whole bunch of papers in good journals about the science of Coronavirus, but I also want to mention one thing, I guess maybe in parting it's a little late.

>> Howard Bauchner: Sure.

>> Nicholas Christakis: But, you know, this is a door handling, a door, one more thing, doctor. [laughter] I didn't tell you about the chest pain.

>> Howard Bauchner: Right. My chest pain! Should I worry about my chest pain? [laughter]

>> Nicholas Christakis: Yes, exactly. I know I came here to talk to you about this little [inaudible] on my foot, but, you know, on the way out, so let like, so let me door handle you.

>> Howard Bauchner: Sure.

>> Nicholas Christakis: Let me door handle you, which is one of the things my laboratory released is an app called Hunala, H-U-N-A-L-A, Hunala, H-U-N-A-L-A. It's on the Apple app store. It's on Google Play. It's only available in the United States, so far, and you can read about it at Hunala, H-U-N-A-L-A dot el dot edu. But what this app is, it's totally different than anyone else's app. It's based on network science. It's not a contact tracing app. It's not a backward-looking app. It's a forward-looking app that works like ways for Coronavirus, like a traffic app. It crowd sources information from people about whether they have symptoms and anonymously collects that information and uses machine learning algorithms plus some publicly available data, and it says are you likely to come into contact with the virus in the future, just like if you're driving down the highway and people five miles ahead of you report that traffic is at a standstill.

>> Howard Bauchner: Right.

>> Nicholas Christakis: And you can veer off the highway because you know you're going to come in contract with a traffic jams.

>> Howard Bauchner: Waze turns red, or Google Maps turns red.

>> Nicholas Christakis: Exactly. This is how our app works, and it's based on who you know and where you live, and it can forecast your risk of getting the disease and allow you to take protective action before you're infected. It also has some features like a weather app, and allows you to monitor conditions in four other regions around the country where grandma lives, where your children live, or whatever. The app temporarily asks you, and you don't have to give it permission, to access your contacts, but it doesn't copy your contacts. It just does that locally in order to make it easier for you to indicate who you interact with. And then it collects this basic information from you, and then you can use it as often as you want, daily or less frequently, like, you know, to say, okay, what are the conditions, what are the conditions based on where I'm living, what's Coronavirus doing, and based on who I am and who I'm interacting with, what is my risk. And so, it's a wonderful tool. I'm proud if it, that the programmers in my lab developed, and we haven't talked about other stuff. We've done a whole bunch of big data projects on whether turning out to vote in the primaries affected the course of the epidemic. We had a paper in Nature on the big data, looking at the phone data on the movement of millions of people through China and how that forecast the risk of the timing, intensity, and location of the pandemic in the early days, many, many things. So, the lab, the book, of course, I'm proud of, and I think people should read, if they want, but the laboratory, the human nature lab that I direct that has 20 wonderful people in it has been killing themselves trying to make a contribution to help our country confront this threat.

>> Howard Bauchner: This is Howard Bauchner. I've been talking to Nicholas Christakis, the Sterling Professor of social and natural science, internal medicine, and biomedical engineering. Nicholas, stay health. Enjoy Thanksgiving. Not too many disagreements with my fellow pediatrician. Go easy on Dimitri. He's a good person. Take care Nicholas. Stay healthy.

>> Nicholas Christakis: Thank you so much. Bye, bye.


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