Mini-Episode: Living Through Two Public Health Crises, with Dr. Leana Wen
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Today, Andy calls emergency room physician and public health expert, Dr. Leana Wen to get the best advice on how to manage their risk of contracting COVID-19, even while resuming some normal activities. But they start by talking about why racism and police violence is also a public health emergency.
Keep up with Andy on Twitter @ASlavitt and Instagram @andyslavitt, and find Dr. Leana Wen @DrLeanaWen on Twitter and Instagram.
In the Bubble is supported in part by listeners like you. You can become a member, get exclusive bonus content, ask Andy questions, and get discounted merch at http://lemonadamedia.com/inthebubble/
Teladoc is our show sponsor for this episode! Teladoc provides access to certified doctors from the comfort and safety of home. Register now at https://www.teladoc.com/
Here are some other resources from today’s show:
- Adverse Childhood Experiences (ACEs) have been linked to a variety of health concerns. You can learn more about the research from the CDC https://bit.ly/2BDuEvH and take a version of the assessment for yourself here: https://n.pr/2UhpH1U
- Check out Dr. Wen’s writing on topics including harm reduction, having a baby during a pandemic, and a public health perspective on the protests: https://www.washingtonpost.com/people/leana-s-wen/
- Dr. Wen also wrote a book! Get your copy of When Doctors Don’t Listen here: https://www.amazon.com/When-Doctors-Dont-Listen-Misdiagnoses/dp/1250048486
- And remember to follow #opensafely and brush up on recommendations for keeping yourself healthy in the months ahead at https://www.open-safely.us/
[00:43] Andy Slavitt: Welcome to In the Bubble. This is Andy Slavitt I hope everybody’s doing OK. It’s been a very traumatic couple of weeks and it’s certainly not over. We’re dealing with twin traumas in the country right now. We’re dealing with, of course, a public health crisis in coronavirus. And at the same time, I think this epidemic of racism, which we talked about last week with DeRay Mckesson, as we discussed police violence, is also a public health crisis. That’s why this week we have a great guest to talk about these twin public health crises and how they’re impacting our communities. And that is Leana Wen, who is an emergency room physician and the former Baltimore City health commissioner. Very prominent feature on cable TV. And we’re going to talk about a couple of things. First, in a very practical way, I want to make sure that Leana does talk about how we cope with reducing our risk as we all get back to normal, and get back to a normal life. That’s gonna be one of the main things we’re going to talk about. Strategies for how to get back to normal life without putting yourself at risk. But before we do that, we’re going to have to start by talking about the other epidemic in this country. That’s the epidemic that has been plaguing us for centuries, and that is racism. And that shows up in so many forms, including in the way Covid hits people, but also obviously in police violence and things like that. So I’m really looking forward to this. And here comes Leana Wen. Let’s give her a call.
[02:28] Leana Wen: Hey, Andy, how’s it going?
[02:29] Andy Slavitt: Hey, Leana. We’ve been aiming to do stuff for quite a while together. You’re a public health professional who I admire. We’ve got sympatico views. We’ve worked on a couple of letters together. I think we’ve wanted to do more. Maybe In the Bubble is our chance to do it.
[02:46] Leana Wen: I’m excited about this. And thank you for inviting me to take part of this conversation.
[02:51] Andy Slavitt: Unfortunately, there’s nothing going on in the world for us to talk about, though. So, you know, we just have to make do with many, many world events. Leana, before we get started, I want to go back and ask you about yourself personally in a second, but it’s hard not to begin by looking at what’s been going on across the country emanating out of Minnesota. We’re recording this the first of June, so we’re still in the middle of things. Do you think about racism and the riots as a public health matter?
[03:24] Leana Wen: Yes. And I’m glad that you framed it this way, because there can be no doubt that racism is a public health issue. That in fact, racism is a public health crisis and emergency. The same way that Covid-19 pandemic is a public health emergency, too. I live in Baltimore, as you said, and all I have to do is look out the window at my community and see that a child born today can expect to live 20 years, more or less, just depending on the zip code that he or she is born into. All I need to do is look at race, zip code, social economics. Everything is tied together. And in fact you can pick any issue, whether it’s drug overdose or cardiovascular disease or socioeconomic status or incarceration — it will all have the same correlations by race. It will have the same correlations by income. And that’s the society that we already live in. And so, of course, it’s not surprising, I think, to any of us in public health that you see these same disparities play out with Covid-19 outcomes. And of course, that’s also why when we think about why these protests are occurring, they are deeply tied to health inequities. And of course, the health inequities themselves are closely tied to the social determinants that then are fueled by racism inequities, too. And so it’s a terribly tragic time for our country in every way.
[04:53] Andy Slavitt: Right. What I hear you saying is in part due to racism, whether it’s structural or overt, that has a dramatic impact on life expectancy, 20 years possibly, although these factors all tend to meld together. It strikes me that we have every smart scientist in the country and the world working on a cure for Covid-19. And it’s a problem we’ve been dealing with for months. Racism feels like a problem we’ve been dealing with for centuries. And I have confidence that eventually these scientists are going to figure out Covid-19. I don’t have the same confidence that we are going to either put forward the effort, or even know how to go out and attack these other issues you’re talking about.
[05:43] Leana Wen: Wow, that’s a profound way of putting it. Because it’s true. I mean, I think things are changing. They’re slow, but they are changing. Look, I was the health commissioner in Baltimore in 2015 after the death of Freddie Gray, an African-American man killed while in police custody. Talking about racism as a public health issue then, and this was just five years ago, I don’t know that people were comfortable with that concept. And even my raising it and others raising it just drew a lot of questions like, well, how is that the case? Why should you be talking about this? How does this work in a public health context? I think there is at least much more recognition of it now. And that’s a start. But I think we need to then focus on the solutions because we spent a lot of time, I think on the problem. And sometimes you look at something as big as racism and you think, well, it’s such a big issue. And even if we talk about social determinants, if everything ties to one another, then I think sometimes people throw up their hands and say, well, then there’s nothing I can do because it’s too big of a problem. But maybe we need to also start addressing some of these things. I mean, even something as tangible as where is testing? Can testing be directed to communities most in need? To minority communities, to African-American communities, so that they’re free of charge? I mean, even things at that granular of a level is a start.
[07:10] Andy Slavitt: I think you’re right. I think it is the size of the problem. I also think we are in a good bit of denial. Everybody you know would answer the question, I’m not racist. Somehow, everybody I know isn’t racist, including me. And yet we live in a racist society. There’s some cognitive dissonance that certainly I’m no expert in. But we did name this podcast In the Bubble. So therefore, I feel like I’m an expert in bubbles, at least. And so we all know that we form these bubbles. And it’s an increasingly big challenge. As a health commissioner, and in other public roles you’ve had, you’ve had to communicate about all of these issues and you’re very good about understanding where public sensitivity is, where frame of mind is. Neither one of us is black, yet you’ve had to talk about these issues. What have you learned about in a city like Baltimore and other places you’ve been, how to talk about these issues in ways that’s productive?
[08:18] Leana Wen: You know, I think for public health, one of the tenets is that you have to meet people where they are. And if people are so angry about police brutality and structural racism, and that’s where their mind is, no other amount of public health messaging on anything is going to get through. And so I think it’s meeting people where they are in that moment. I mean, after the death of Freddie Gray, there weren’t a huge number of issues that we saw in the city that I actually don’t think that we could have predicted in advance. There aren’t studies done on what public health should be doing, the role of public health after the unrest. I couldn’t have anticipated, for example, that over a dozen of our pharmacies would be burned down, looted and closed, and people couldn’t get access to medications. That people needed access to something as basic as food. I mean, I had people calling who said that their local corner store was burned down and there was no way that they were in a wheelchair and dependent on oxygen, they didn’t know if the bus was even operating, but they certainly couldn’t take two buses to go buy groceries. For me, I think these types of issues are unmasked. But unless you can address these acute issues now, you’re not going to get to anything else either. And in the same way, I mean, we also uncovered all this trauma and mental health concerns. I mean, the fact that racism and police brutality occurred in Baltimore was not a surprise to anyone living in the city. But a lot of people had suppressed these things and kind of just internalized it is something that we had to live through. But then we began to open the gates and people told all these stories.
[10:00] Leana Wen: Young people. I mean, we’re talking to a group of eight, nine, 10 year olds who were talking about what it felt like to watch their fathers and uncles die in front of them. What it was like to be handcuffed in their lunch room in front of other classmates and thrown in the back of a police car. If you can’t meet people where they are with these experiences — for example, you’re not going to be talking about Covid-19. They don’t care about that other existential issue unless you can address the existential issue in front of them right now.
[10:27] Andy Slavitt: Yes. And I think one of the links between this conversation and Covid-19 is this basic notion of trauma and safety. And the experience of a community. And you might talk a little bit, if you would, about work around ACES. This idea of repeated childhood trauma. From living in a community where the trauma is not acknowledged, the trauma is a daily part of your life, and as a result, people don’t feel safe. I think the link that you point to, which is very wise, is that if people are walking around basically not feeling safe, not feeling safe from the police, not feeling safe from economic anxiety and feeling safe from whatever. It’s hard to function and live to potential. And Covid-19 is the first time for many Americans, I think, that they’ve felt unsafe and unsure in a similar feeling. I’m not saying it’s a similar experience, but this feeling of not feeling safe, and the sort of look to government authorities to say, can you help me?
[11:37] Leana Wen: That’s such an interesting way of putting it. Because it is true. I mean, our worlds are turned upside down as a result of the pandemic. We don’t know what to expect. We have some things that we take for granted, like our kids going to school, is suddenly not the case. And we don’t even know when that’s going to come back to normal. The idea of giving someone a hug during a time of great emotion — actually, I, um, just gave a talk to a group of emergency physicians. And one thing that people, one person after another said that just broke my heart so much is this new normal of holding up a phone for people who are dying to say goodbye to their loved ones. I mean, I can’t even imagine that. But that’s part of the reality that we’re living in and the uncertainty of the world that we live in. And I think you make another point, too, about how when you have nothing to lose, then you also don’t want to do these things that we’re saying should be good practice. When tomorrow is looking no better than today, then why should you be doing social distancing, or why shouldn’t you be taking opioids? I mean, that’s you know, why shouldn’t we be having addictive behaviors when we don’t see the future that’s bright in front of us? I just wanted to reflect also on what you said about ACES, these adverse childhood experiences.
[12:56] Leana Wen: I use an example to illustrate this. One of the most challenging things that I did in my job in Baltimore was to chair a committee called a Child Fatality Review Committee. This is a state-mandated committee where we had to review every case of children, infants and children, who died in our city. And we looked at every case. And it could be death from gunshot homicide. It could be child abuse. It could be sleep-related infant death. It could be any number of things that resulted in children dying. And every time we would ask — we had all these agencies at the table. So there was health that was chairing it. But also the police departments, attorney’s office. We had social services, schools, sitting around the table. It was heartbreaking for a number of reasons. One of them is that in almost every case, every agency was aware of that child and that family in some way. And yet, despite all the interventions that might have taken place, the child still fell through the cracks and still died. So obviously, that’s heartbreaking, and very challenging to see what is your responsibility in all of this. But the other heartbreaking thing is when you looked at the ACES, the adverse childhood experiences that these kids went through, you don’t even have to count to know that they went through every trauma that you could imagine. And not only that, when you looked at the trauma that their mom, their dad, even their grandparents went through, that it’s multigenerational.
[14:23] Andy Slavitt: Multigenerational. Yeah. I mean, well, we’ll post some of the research on ACES, but the sad part of it is that it’s highly predictive of much of the disease and interaction with the justice system and addiction and suicide. These first several years of someone’s life, depending on how many different adverse childhood events that they experience. So when we think about the various stages that we’re going through, you actually said I think in the exact perfect way, which is we don’t have context for this pandemic. None of us have been here before. So to some degree, there’s a stage we’re going through, we’re sort of clutching at what is this? Is it really bad? Is it really good? Is it really not as bad as people say? Am I gonna be OK? And how do you frame the stages of what we’re going through? Because you do it in a very straight, clear way without an agenda. I would love for people to hear your version of kind of where we are and where we go.
[15:32] Leana Wen: I mean, one thing that we’ve been seeing from the very beginning that still remains true is that this is evolving. And I think that needs to be stated over and over again because there is new research coming out all the time. There’s new information coming out. And that, yes, that introduces a lot of uncertainty. But I also think we need to emphasize that constant reevaluation is good. That that’s the bedrock of a strong public health response. I mean, I’m an emergency physician, and in the E.R., if a patient came in in extremis, we don’t have an option but to do something to try to help them. And then you evaluate based on what is that something? And then you also reevaluate based on other information that you’re gathering in the meantime. Initially, you may not even know this patient’s name. You don’t know if they took an overdose of something versus they were in a car accident. Maybe they’re having a heart attack or stroke. You don’t know, but you act initially and then you reevaluate accordingly. And I think that needs to be said. That just because it seems like our approach is changing, it doesn’t mean that we are inconsistent or don’t know what we’re doing. Now, hindsight is 20/20, of course, I believe, and I know you’ve written and spoken a lot about this, Andy, that there were mistakes that were made. The federal government could should have done a lot of things differently, including not paying attention to testing early on was a huge misstep. Are there things that we could have done differently? I’m not saying we did nothing wrong. But rather that in a crisis, in an emergency, you’re not going to know the perfect way to do things. This is a new virus. I think a lot of us forget that we don’t even know about this seven months ago, that this is something that’s new to the world.
[17:15] Leana Wen: And, of course, there is new information coming out about it all the time. But that’s why I do hope that the way that, for example, our federal government would approach this, is to have ideally a daily briefing where we state where is the outbreak, what is happening, what is happening around the country and the world? What do we pay attention to? What are the data points that we’re talking about? What’s the new research and what are the guidelines that are coming out that people should be aware of? How should this change our behavior? So I think that constant reevaluation is good. And the fact that we’ve changed our approach from initially saying, at the very beginning of this back in January and February, saying get your flu shot because the flu is more likely to affect you at the end of January. That is true. And it’s true that we did have to do aggressive social distancing later on because that aggressive social distancing was key to saving lives. And also, now that we have to reopen, we have to reopen safely in an effort that you led. And so I think that constant change is what is to be expected in this outbreak.
[18:20] Andy Slavitt: But you’re saying it’s unsettling the people in the sense that they want someone to say, here’s what’s going on. Do you think we know 50 percent of what we’re going to eventually know about Covid-19? Do we know 25 percent? Do we know 75 percent?
[18:36] Leana Wen: I’m reminded of that proverb of the blind man and the elephant, right. That, you know, if you do, you just don’t know if you touch the trunk or whatever, you don’t know what else is out there that you don’t know. And I actually think that that’s the problem. I have no idea what percentage we know because we simply don’t know where this is all going. I think part of the problem is that we don’t have leadership that’s explaining the why. Not just the what, but the why. Even the what isn’t really clear, because there’s often conflicting information, as you know, from politicians versus from health experts. And there just is a lot of misinformation. And of course, in the space where there isn’t a consistent messenger, people fill in that space, and it gets really messy. I mean, you’re right, there could be so much that will change. And I’m certain about uncertainty. I’m certain that in time to come, we’re going to find out things like, as an example, maybe we will find out in time that we didn’t need to close down schools at all. Maybe children weren’t going to be super spreaders and weren’t going to get that sick. And we didn’t have to do that at all. I mean, I don’t know that that’s the case. But I can imagine all kinds of blame and recrimination that’s going to come about if that ends up being the case. But I think that confusion is coming about because we didn’t explain at the outset about exactly why these measures were being imposed. With the understanding that we’re doing the best that we can with limited information. and that hindsight is 20/20. And so I think that part is what’s been missing all along.
[20:12] Andy Slavitt: And it’s hard to count the lives saved. It’s hard to count them in ways that people can relate to. There’s this sort of nebulous benefit to social distancing, and a very clear cost to seeing people’s small businesses close and so forth. And I have to keep reminding myself that, you know, I’m someone who knows several people who have been lost to Covid-19. And we have some savings. And so we’ve been relatively unharmed economically. And most of the people I know have been more physically harmed than economically harmed. But for a lot of people, it’s the exact opposite. Not only do they not know people who have died from Covid-19, there’s a lot of people still who don’t know anybody who has had Covid-19. And yet they know a lot of people harmed economically. And so their rational perspective is we’ve way oversteered. And I’m finding it a challenge, but very important to try to leave room for people to have those views, but allow them to coexist. In other words, not have them conflict. And that’s a hard thing to figure out.
[21:24] Leana Wen: That’s a very good way of putting it. My longtime mentor, someone that I miss every day, is Congressman Elijah Cummings, who often talked about how the cost of doing nothing isn’t nothing. That there is a real cost of inaction. But how do you see that cost? And in the same vein, the idea that public health saved your life today, you just don’t know it, that there is no face of public health until something terrible happens. And unfortunately, that’s part of the problem. I do think that people are seeing the impacts of Covid in another way, too. I think that it’s, again, a complex issue. But I think anyone who’s trying to seek health care, non-Covid health care during this period has experienced it in some way. I mean, I gave birth during this pandemic, so I experienced this.
[22:13] Andy Slavitt: And I was going to talk about that. I was going to talk about that. And a matter of fact, we had a baby in the year 2001, just two months after 9/11. In fact, here’s that baby now, you can see him. He’s our co-host. Zach was a November 2001 baby and now he’s a full-fledged podcast co-host and he’s off to college at some point. You had a baby in 2020, in April 2020. And I kind of think there is some similarity in the sense that Zach has grown up kind of a post-9/11 kid entirely. And that’s just sort of the world he knows. He never knew the world before it. Your baby is going to grow up a post-pandemic baby, and I don’t really know what that means. What do you think?
[23:10] Leana Wen: Yeah, I think there’s going to be a whole generation of kids who are experiencing life differently. I mean, Zach, too. But the idea that you don’t know when you’re going off to college, or what that’s going to look like, or graduations that aren’t happening in person. I mean, I have a son who’s almost three and, you know, he was in preschool. Now I have no idea when she’s going to go back to preschool. He had a concept of playing with other kids. I don’t even know what that’s going to look like when he goes back to preschool, that he’s going to be taught not to touch other kids. It’s a very strange concept, not just of schooling, but I think of human interaction. I mean, the postpartum period, for example, is one that is considered to be one of the most vulnerable in a person’s life. And it could be isolated at the best of times. But one thing that you normally associate is people come and help you and see the baby. No one has come. I mean, understandably so. No one has held the baby other than me and my husband, and that’s such a weird thing to have happen, that all of us, I think, are wrestling with. I’m doing fine. I think we are so privileged in a lot of ways. I mean, I have a job. I’m working. My husband has a startup, which is another story, because trying to start a new business at this time is probably not what he would have chosen had he known. I mean, we’re very fortunate. And, you know, everybody’s healthy. And this is also our second child. I think had this been our first, it might have been much more challenging.
[24:45] Andy Slavitt: Anybody who’s had two children knows that we’re much more careless with our second kids. The first kids — Zach’s older brother, every time he had a different change of expression, we thought that was either the most amazing or the most awful thing in the world. Zach got a little more independence because we knew he was going to be OK.
[25:05] Leana Wen: How are you coping?
[25:06] Andy Slavitt: Well, we have two seniors. A senior in college and a senior in high school. I think they are so conscious of the fact that their life disruption is minor compared to people who have had real trauma visited on them. Yet it doesn’t mean that things that they looked forward to their whole lives didn’t matter to them. I’m probably, for better or worse, a crisis junkie in that I’ve fought my way through crisis with the Obama administration. And I need purpose in my life. And I strive everyday for purpose in my life. And when the purpose is easy to find, the days aren’t hard. I’m a soft touch. I’m kind of a sap. So when I see something that affects somebody else and I can’t do anything about it, I’m sad and I’m hard on myself. But I only wish I could do more, because I feel like I’m one of these people who has been given the opportunity to do more and to help more people, and I would just constantly ask myself, am I doing everything I can for the moment? And, you know, for Lana and I, on the positive side, having your 18-year-old and 22-year-old to spend time with you is an amazingly wonderful thing. Not so much for them. You know, they’ve got a longer list of people they’d probably rather hang out with, but it’s nice to be able to do that. I’m going to ask Zach to speak for himself.
[26:29] Zach Slavitt: Yeah, I’m doing fine. I mean, a lot of people are doing worse than me, so I can’t really complain much more than anybody else.
[26:38] Andy Slavitt: That’s a long essay from Zach.
[26:40] Leana Wen: Thank you. I do think that recognizing our privilege now is important, because — we’ve talked about this, Andy, that social distancing is a privilege, that so many of the things that we recommend for people to do is a privilege that not everyone has. And I actually think that it’s more incumbent on those of us who have that privilege to do as much as we can. I do thank you for what you’re doing and elevating your voice at this time.
[29:16] Andy Slavitt: So you have introduced a way of thinking about how to get back to life in a way that I think is really, really helpful, and has probably not been heard by enough people yet. And it’s a concept that’s familiar in healthcare that you’ve introduced in a very clever way to Covid-19 called harm reduction. So can you talk about harm reduction and Covid-19? What it means and how we should be using it to live our lives specifically differently?
[29:48] Leana Wen: So as of the time that we’re speaking, but certainly as of the time that the podcast is going to be aired, all 50 states are in some state of reopening. And I think a lot of public health experts would argue that they are reopening too soon. Not all of them, but at least many of them have not reached the White House’s own criteria for reopening. And that we, in essence, wasted time. We could have developed much better capacity for testing, tracing, isolation, but didn’t use that time as much as we should have done and don’t have the capabilities in place. And the numbers still keep on climbing. And so we are going to see a resurgence in the number of cases as states are reopening. So that made me think about, well, in what other aspect of our work in public health is there a situation when we recognize that the behavior that we’re undertaking is not ideal, but if it’s going to happen anyway, there are ways to reduce that level of risk. And actually there are a lot of other examples from public health. Driving a motorcycle is not something that we would recommend as good practice, but wearing a helmet is something that you could do to reduce your risk of death. Needle exchange is the classic example, by having needle exchange programs, it’s not, as critics would argue, condoning or supporting drug use, but rather saying for individuals who are not ready yet to get treatment for their addiction, you can have needle exchange to reduce hepatitis and HIV transmission. Safe sex practices. I mean, there are many other examples of harm reduction practices. I think this is true on a societal level. It’s also true on an individual level. Because if people now have to go back to work for their livelihoods, it doesn’t mean that they now have to do everything and go back to everything as life was before. There’s still ways to reduce their level of risk. And I think that was what I was trying to convey, that not all of it is in our hands as individuals. Policymakers can do a lot. I mean, hospital administrators can do a lot. And, for example, preparing for a surge that could come, or having clear stop signs for when restrictions have to be reapplied. But individuals can also be thinking about their own level of risk, and how to reduce that risk as much as possible.
[32:00] Andy Slavitt: And we included these some of these ideas that you talked about, your suggestion with the help of others, with your leadership in the #OpenSafely work that we’ve done. Give us some examples of how — let’s say you’re talking to someone as an individual now. They gotta go back to work. They’ve got to use transportation to get there. They’ve got to be in an environment with other people, who they don’t know if they’re sick or not. They can’t universally take a test anytime they want. In addition to that, they have to visit, and they want to visit their mother or grandmother, because they haven’t seen them in a long time. And what would be a harm-reduction strategy for an individual in going about a life like that?
[32:42] Leana Wen: Yeah, I think we’re all in that state in some way. Because even the act of leaving our house to go grocery shopping, there’s still some risk associated, very low risk. But there are still things that we can do to reduce that risk. We can’t isolate ourselves from the rest of society for the next year and a half, or however long it might take for a vaccine to be developed. So we all have to be thinking, I think, in terms of that harm reduction approach. So I’m taking your specific example. The individual who is going back to work, should talk to their employer about what are the practices that are already being put in place. So is, for example, in some cases, telecommuting is still an option. That definitely reduces the risk substantially if you’re able to do that. Maybe there are staggered shifts that you now have. Maybe you can choose a shift where if you have to use public transportation, you can take a less crowded train or bus and take that staggered shift accordingly. There are things that you could do at work. If you are using a shared computer, for example, you can make sure that you’re wiping down that surface. You could space out your desk, if that’s something that’s not already done. Avoid common spaces like the lunchrooms, but those are the things that you could do at work.
[33:50] Leana Wen: Then there are also things that you could do in your social life. I think a lot of people, again, misunderstand reopening, and think, well, if I’m going to be exposed to risk at work, I might as well go about doing everything else, too. That’s not true. I mean, if you can walk or bike or drive to work, do that. If you can avoid going to the restaurant, you don’t have to go eat out now just because restaurants are open. Just because you can’t do something doesn’t mean that you should. If you are going to get your hair cut, don’t also go to the restaurant. You can reduce your cumulative risk. And then to your specific point about seeing the rest of your family, I think you have to weigh your own risk and their individual conditions and risk, too. So there are a couple things you could do. You can see them from a distance, not just FaceTime and Skype, but also go visit them, but stay six feet away and not share drinks or other things during that particular visit. Or I’ve also seen some families create their own bubble, if you will, to your question about bubbles, but create their own bubble in saying we are both low risk families and we will assume each other’s risk by seeing each other. But again, you are taking on the risk of the highest-risk individual in that group by doing so.
[35:02] Andy Slavitt: But here’s what I think is so important about what you’re saying. We do have to put our lives on hold during this virus. We can live our lives. We can live alongside the virus by creating habits that are new habits that reduce our risk. And if you think in terms of reducing your risk instead of one polar extreme or another, going all out or not, it’s a very helpful mindset that I think it introduces. So, two elements that tell me where they fit in terms of risk reduction and harm reduction. The first is masks. And the second is what it looks like we’re learning about super spreaders and super spreader events. There is some number between — could be as low as one to two percent of infected people, could be as high as 10 percent of infected people, that appear to be responsible for 80 percent of the spread of Covid-19. And there’s three different studies, each came to slightly different conclusions. But all of them suggested that very large events where one person who is highly infectious is in contact with many, many, many people drive a lot of the spread. So given those two things, masks and then super spreader events, attending large events, how do you think about those on that harm reduction scale?
[36:31] Leana Wen: Well, I think masks are a classic harm-reduction strategy, harm-reduction mechanism. And it’s now becoming clear that if everyone wears a mask, this policy of universal masking could substantially reduce the rate of Covid-19 transmission by as much as 50 to 90 percent, depending on the study that you’re looking into. Though I will say about the issue of masks, that’s another one where our recommendations have evolved along with the science. Initially, I and many others, the CDC included, were saying the average person doesn’t need to wear masks. That healthcare workers should be wearing masks, but everyday people should not be wearing masks. What changed was asymptomatic transmission. And these studies that looked at universal masks, including in other countries. And so it is important to communicate, yes, our guidance has changed, but they changed because of the research. And now we need to follow the science about masks being, again, a powerful harm-reduction strategy.
[37:26] Andy Slavitt: I thought some of that was also we had such a shortage of N95 masks that if we had come out with that, people would have been competing for N95 masks with people who were higher priority. Now, maybe I’m being cynical, but that’s kind of how I interpreted it. But anyway. Super spreaders.
[37:44] Leana Wen: So you’re right about the studies that are coming out about it. I think it illustrates a couple of points. One is that of this potential viral load, that maybe there’s certain individuals who carry a higher load than others. And certainly it applies the other way around. That healthcare workers who were exposed to many individuals who have a lot of viral load altogether are more likely to get ill. It also brings up the opportunity that it’s often in these events, too, it’s not just that a person is a super spreader by themselves. They have to be exposed to events like a choir practice, a funeral, a birthday party, a concert, a pool party where they have the opportunity. And so that, again, I think the other way round is if you’re an individual who wants to avoid the effect of a super spreader, try to not go to big events like that where you’re likely to be exposed.
[38:32] Leana Wen: And then the other element here that’s important, I think, for people to know is the element of time. That time of exposure matters a lot. And that’s why another concept in this harm reduction approach is if you can reduce the time that you’re in a particular setting, you’re also substantially reducing your risk. So if for whatever reason, you really have to get your hair done, get your hair cut ideally outside. But don’t go to the all-day treatments, I would advise Andy and everybody else.
[39:07] Andy Slavitt: Right. Right. So I’m worried about things like churches. I’m worried about social gatherings. I’m worried about this whole debate about what’s going to happen with the Republican National Convention in North Carolina. I’m worried about the casinos opening in Las Vegas, because we have people coming from all over, flying back all over to these types of events. And as people know, I’m not advocating that we don’t figure out how to lead our lives. But when I think about harm reduction, there are some things that to me feel like they’re just in the camp that ought to be avoided, at least as far as we know right now. And to me, those big events concern me. I want to finish where we started. The data that I’ve seen, you may have seen more up-to-date data, is that African-Americans have twice the prevalence of Covid as do whites, based upon the size of the population. Now we’re learning that there are certain conditions, high blood pressure and diabetes that are particularly bad preconditions for Covid-19. And I know that you are very focused on solving that problem. And what you said before, we’ve got to meet people where they are, it feels like there’s no situation that it could apply to more than how we don’t think about the average person getting Covid, but we think about different subsets of the population who are high at risk. So I’m wondering if you can offer your thoughts on what the right strategy is if you are someone who is black or you’re in some other subgroup, that puts you more at risk.
[40:47] Leana Wen: Well, I think there’s the individual and there’s the societal. I think individuals need to look at their own level of risk based on all of these different factors, their own level of exposure, their underlying health conditions, their age, etc. And race certainly is a component of this. Now, we have studies coming out showing that African-Americans in this country are nearly three times more likely to die from it than whites. I mean, that’s an important part of the statistic that people have to consider for themselves as they calibrate their own risk. Understanding again, that it may not be an option.
[41:22] Leana Wen: I mean, it may be an option for me to drive to work, it’s not an option for a lot of people to not take public transportation, or not go into workplaces where they have higher exposures. I think also there is a societal responsibility to it. And just taking this back to where we started about when you look at the problem and it seems so big, are there some specific things that you can do to make a difference as policymakers? And that could include the very basic, very obvious of bringing testing into communities. Having communities that are particularly underserved, knowing that if these are the areas where Covid could spread very quickly, where one case often means many, that you’re targeting these particular populations. And we are doing that to some extent with testing, for example, in nursing homes and incarcerated populations. But also we should be thinking about particular zip codes and communities and communities of color where there’s going to be a higher risk of severe effects. Can we do a better job of testing, compiling our resources when it comes to contact tracing, and other public health infrastructure in these areas. And then, of course, there are the medium-term issues that we also have to be looking at, including paid sick leave and something that another effort that you led about looking at how are people going to be quarantining exactly? Maybe we should be paying people, and setting up spaces for them to be quarantining and isolating. I think all of these issues, and of course, even the underlying issues behind that — food access, housing insecurity — those are also the issues that are tied to this, too. And I’m not saying that everything needs to be addressed overnight, but I think it’s recognizing these issues and biting off chunks where we can. That’s actually what’s going to make a difference while ultimately acknowledging that racism and structural inequities did get us to where we are today.
[43:13] Andy Slavitt: Wow. We’ve got a lot of work to do, Leana. I am counting on working side-by-side with you in this, and I hope you will consider coming back on In the Bubble, because I suspect that this was a conversation that in five different ways people were just itching to hear. And you provided it for them. You certainly did for me, as you usually do.
[43:39] Leana Wen: Well, thank you. I really enjoyed our conversation. Thank you for doing what you’re doing. I would love to come back on and engage you because this is not an issue, and all the issues that we talked about, are not going away anytime soon.
[43:50] Andy Slavitt: Thank you, Leana Wen. It was nice how she shared her expertise, and she really went to a broad range of places which I think tie together all the messy things going on right now. There’s very few people who could do that. And as you could tell, she’s terrific. I’ve admired her for a long time. On Wednesday, we have another podcast episode that we are planning to have focus on back-to-school plans and education with Arne Duncan, who was the Secretary of Education under President Obama. And we’re going to explore the question that many of you been asking, which is, should the schools open? And if so, how, and what accommodations should be made, and all those things. So we’re planning on talking about education, unless, of course, something disruptive happens and we have to flip things around. But that’s where we’re headed right now. Thank you all so much for listening. And we’ll talk to you soon.
[45:04] Andy Slavitt: In the Bubble is a production of Lemonada Media. Niccole Galteland is our producer and Ivan Kuraev is our editor. Music is by Dan Molad and Oliver Hill. Zach Slavitt is our co-producer and my co-host. You can find out more about our show on social media @LemonadaMedia. And you can find me on social media at @ASlavitt on Twitter, @AndySlavitt on Instagram. If you liked what you heard today, tell your family and friends, but tell them at a distance. For now, stay safe. Share some joy. We’ll get through this together. And #StayHome.