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In the Bubble with Andy Slavitt: Our Shot
All Podcasts What’s the COVID Risk Right Now? (with Bob Wachter)

What’s the COVID Risk Right Now? (with Bob Wachter)

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Description

Have we reached the so-called “new normal” people keep talking about? And if so, what does that mean for you? Andy reunites with former guest host Dr. Bob Wachter who has started to let his guard down in terms of risk tolerance. They discuss why Bob feels like the time is right for that, how to think about the things that can scare us back into a more vigilant state, and Bob’s thoughts for what COVID looks like long-term. This is a nuanced conversation on a complex topic that will help you navigate this uncertain time. Plus, Andy’s mom joins at the start to offer up some show ideas.

Keep up with Andy on Twitter @ASlavitt and Instagram @andyslavitt.

Follow Bob @Bob_Wachter on Twitter.

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Transcript

SPEAKERS

Andy Slavitt, Dr. Bob Wachter, Andy’s Mom

Andy Slavitt  00:18

Welcome to IN THE BUBBLE, this is your host, Andy Slavitt. How are we all feeling today? We have a great episode for you, you’ll have Bob Wachter and Andy Slavitt on the same show. I know it’ll seem strange. Bob is the great physician, the head of Internal Medicine at UCSF, he was my substitute host when I was at the White House, he’ll be joining us for the show in just a few minutes. But first, I want to talk to you, you and your treadmill, whatever you’re doing, hopefully not playing me on rapid speed. Otherwise, I talk really, really fast. But on a normal speed. So cases arising again in the US, one thing I’ve noticed, cases are always either rising or falling. Funny how that works. Sometimes they’re rising, sometimes they’re falling. And it’s interesting, because I think when cases are rising, like our blood pressure goes up at the same rate. And when cases are falling, it feels like our blood pressure might be going down at the same rate. Why is that? Is that a good thing? You know, that was natural, over the course of 2020 and early to 2021. But maybe just maybe going forward? And we’ll have a little bit of this conversation with Bob. Maybe it’s not so natural. I mean, maybe it’s not so necessary anymore, maybe, in fact, we’re going to see some ups and downs. And part of our job is to care the right amount. What do I mean by that? That means that we need to care enough to take precautions, but not care so much that it’s disrupts our lives.

Andy Slavitt  01:49

So I have a piece coming out of the Washington Post tomorrow, which is about that, in many respects. You know, it’s prompted by a tweet that I put out, which I said, you know, sorry, the pandemic isn’t over yet. But it really is also talking about, it’s not an entirely negative articles talking about how we’re really ushering in what I’m calling the tools era. That’s it the tools era, it’s got a catchy name, kind of like, you know, manifest destiny, we call it the tools era, but really saying is that we have many of the tools now, whether it’s indoor air filters, or vaccines, or soon to be antivirals, masks, and, and many other things that just help us keep ourselves safe, keep ourselves as safe as possible, and allow us to do many of the things that we hadn’t been able to do for the last year and a half. And that’s a good thing. Now there are some things that I would say we probably all would agree that are safer to do when you get lower levels of cases. And some that are safer to do. And you have higher levels of cases, but many, many, many things, including traveling, going to school, eating outdoors, all these things with the right precautions, I think are things that we can mostly move on with, now we can’t forget the fact that that the virus is more dangerous for some than others. And we’ve got to be conscious of that.

Andy Slavitt 

But that kind of weird state where it’s like as it goes up is going down, we’ve got the holidays coming up, how to handle it, that’s precisely what the conversation with Bob is going to be all about and he is great. So I think you’re gonna love it. It was a really, it was a really great conversation. And one of the things that as I think you know, if you’ve been listening to the show we’ve been trying to figure out is how in any way to change the show, going into 2022. Obviously, we’re going to continue to talk about the bubbles that we’ve created around the pandemic. But you may have noticed that we’ve had some shows recently on some slightly different topics related to other types of bubbles related to this idea of the bubbles created by social media, which we did with Kevin Swisher who’s just fabulous to conversation around climate and climate change and getting the real story and the real plan from insiders. And so I think I thought in order to further this conversation further my own thinking about what the show should be doing next I have one of our longtime listeners, one of our most loyal listener, someone who claims to listen to every single episode on the show to bounce around her ideas. And that person is my mom. Hi, Mom.

Andy’s Mom  04:13

Hi, how are you?

Andy Slavitt 

Good.

Andy’s Mom 

And it’s true. I have listened to every podcast and I’ve learned a lot.

Andy Slavitt 

Really? Okay well I’m gonna make you prove that because it’s quite a bold statement. What’s the episode you like that you listen to this year?

Andy’s Mom 

Oh, how can I pick just one I mean the one was Karen Swisher that was my the last one that I was like fascinated with in the climate change. Everyone you do, it’s my favorite.

Andy Slavitt 

I see. It’s like the Midas touch everything I’m touching just turning to gold.

Andy’s Mom 

Absolutely.

Andy Slavitt 

And you like my dad jokes?

Andy’s Mom 

Mostly.

Andy Slavitt 

Now you’ve gained back some credibility with the audience. Okay, so as you know,  we’ve been thinking about this you know, the show, which has largely developed around during the pandemic, we’ve done something like 150 shows, can you believe that’s where Kryssy’s hair is gonna eventually turn gray. And, you know, we’re asking the question of, you know, should we be covering more topics next year, So what do you think? Should we start to cover more topics?

Andy’s Mom 

Absolutely. I think you’re; you have such a good way of talking to people and getting information out of them. I think it’s very important to do, would you like some suggestions?

Andy Slavitt 

What I liked some suggestions. Well, look, you’ve been texting me suggestions, which I’ve been keeping track of. And I think some of them been quite interesting. Now, you don’t always tell me the topic. So sometimes you’re just like, say Supreme Court, like in the middle of the blue. And I’m like, we’re not even having a conversation about the show. We may be having a conversation about I don’t know, my sister, your daughter, or something else in the middle, you like Supreme Court. And I’m like, what about the Supreme Court? And then you’re like, for the show.

Andy’s Mom 

Actually. I’ll say let’s talk about the Supreme Court.

Andy Slavitt  06:01

Okay. Do you think I should have all nine members of the Supreme Court on?

Andy’s Mom 

Well, one of the questions I’m asking is, should it be expanded? And why haven’t we heard about that? Let’s find out exactly what their plan is, are they going to vote on Texas, the abortion law.

Andy Slavitt 

Good. That’s good topic,

Andy’s Mom 

I think you’re not going to get all the members or maybe you can get someone like Beto and someone who maybe have a discussion, someone who’s really against the law in Texas, and someone who’s really for, you know, what promoted these men to feel that they have a right to tell women how they should work, or their customers how they should live with their bodies. They should make decisions for women; we’re not making decisions for them. We’re not telling them that they affect amazed or not to get them.

Andy Slavitt

I think you’ve got an opinion on this issue. Okay, good. So that’s a topic, what other kinds of things that display specific shows. But what types of things should the show expand into? Not only, necessarily just ideas for a specific show? You’re welcome to give those as well.

Andy’s Mom

Well, I live in Chicago. So crime is a very big issue for me. I mean, how are we ever going to make headway? I know, there are little pockets and people are working. And people who are former gang members are trying to do their best. But it’s not enough. And it’s so swamped and out so slow moving. Okay, on to another topic. I hate to see people or think about people not having food to eat. It’s terrible. I try to donate food. But I don’t think there’s enough information about how we could all do this dysfunctions in our government. I don’t know if there’s an answer to that. But maybe, I thought maybe Al Franken could talk about was the Senate like this when he was in it? Are there any solutions to this? Probably, this is a circuitous argument. And maybe there just aren’t. And then something that’s, you know, one of the things that there’s so many things on my mind, what about the migrants, and all the separations are just so many things going on in this country that I don’t think all of us feel responsibility for. I will talk about global warming. I don’t think global warming is ever going to affect me in my life. But it’s certainly going to affect my children and my grandchildren. And I’m willing to sacrifice for that. But I hear people who voted for Trump say, I don’t want any part of this. This isn’t bothering me. I think we have to get into the minds of these people, and why they feel that way.

Andy Slavitt  08:32

Yeah, this sort of multi-generational battle that exists. Yeah, look, I think climate just feels like it’s getting wrapped into almost every other topic. It’s just a part of almost everything. We talk about housing, food, inequality, it’s just sort of seeping in.

Andy’s Mom 

And it’s just going to get worse and worse. And when I think about my, you know, my great grandchildren, who aren’t here yet, but still, I mean, I want this to be a good world for them. What about the investigations? How are they going into, at the January uprising? What’s happening? These people are not, they’re not cooperating the people that are being asked to communicate?

Andy Slavitt 

These are good suggestions. So they sound like, like the very topical things on people’s minds. You know, I’d like to think that if I were going to cover them, I would be able to provide some element of how to think about solutions or creative solutions or innovation, rather than just bemoaning the stuck, Congressman, in the fights that we’re having. So but you know, there’s finding those kinds of guests I think, is kind of what we tried to do in the show.

Andy’s Mom

I just think that’s really necessary. Yes, just discussing the topic and saying it’s there. There have to be solutions proposed. Things we could do, you know, layman could do.

Andy Slavitt

Gotcha. Well, I think that’s all great. I think we probably have to wrap up. If you got more ideas, you know, you know where to find me, mom. And if you’re listening and you’ve got ideas, we will welcome them to, you can send them to inthebubble@lemonadamedia.com You can also use that to say hi to my mom cuz I’m not going to give you her email address. Well, thanks for these. I love you, mom.

Andy’s Mom  10:12

I love you too. Maybe we’ll do it again

Andy Slavitt

And with that, I feel so sorry for Bob Wachter. Who’s got to follow my mom. Let’s bring him on.

Dr. Bob Wachter 

Hello, Andy, how are you?

Andy Slavitt 

I’m good. How are you?

Dr. Bob Wachter 

I’m great. Nice to see you.

Andy Slavitt 

I’m glad you’re back on in the bubble. Do you miss it?

Dr. Bob Wachter 

I do. I do. You are so much better at it than I was particularly the ad reading. You are just awesome at that. I have to say.

Andy Slavitt 

I loved the ad reading. I realized the trick to the ad rating is if you’re reading fast, then  no one’s going to be offended.

Dr. Bob Wachter 

But you do it with such passion. It’s really impressive. No, I miss it. It  was wonderful. What a chance to talk to incredible people and a great audience. So it was a joy. But it was nice to hand it back to you. I have to say when you came back on, I was wondering how much longer it would last because I thought COVID was going away. So that was not quite right.

Andy Slavitt 

You know, right before I came back, I stepped off in Minnesota and we were at our next-door neighbor’s house who were delightful people. And Julie listens to the show. Jeff doesn’t listen the show very often. But Julie loves the show. And as I was leaving Jeff, Julie’s husband said to me, you know, the show’s been great while you were gone. And I said I saw I said, oh, do you like Bob better than me? He goes, well a matter of fact, I do. I was like, okay, well, your score one, four, for honesty. But, you know, I think people, I’m sure it’s plenty people that miss your kind of right, academic kind of not such a great sense of humor.

Dr. Bob Wachter 

No dad jokes. I tried to parrot you every now and then it was literally a pale imitation. It was a lot of fun. And it was, I’m guessing for both of us, just keeping up on this thing is a really interesting and important thing to do. And then the chance to take in talk to these amazing folks and distill it and try to educate other people. It was just, it was an honor. So thank you for the opportunity.

Andy Slavitt  12:10

Well, people don’t also realize, at least for me how much therapy there is in doing the show every week, because it feels good to be engaging in it and having the conversation and I get a lot of sanity out of doing the show. So I’m actually grateful for people who listen.

Dr. Bob Wachter 

Yeah, no, it also just feels good to be useful. And everybody’s trying to be useful in different ways. And this is clearly one of them.

Andy Slavitt 

Some of us are doctors. So you’re actually […]

Dr. Bob Wachter 

There’s that. But I tell you, no, I’m a doctor about a month a year. And the rest of the time I’m mostly an administrator and writer and things like that. And I tell people, I’m a witch doctor, I tell people which doctor they should see. Because I get calls and emails constantly, you know, I’ve got this problem, who should I see? And luckily, I’m surrounded by great people. And I do a lot of that.

Andy Slavitt

So where are we now in the pandemic? Are we you know, if this were a baseball game, which I know is a passion of yours. Are we being we in the seventh eighth ninth innings? Are we kind of moving to a place where at least in pandemic part of this has an end in sight in your mind? Are we it’s a completely unknown? Are we earlier on still? What’s your sense?

Dr. Bob Wachter 

Yeah, about two or three weeks ago, I kind of came up with this metaphor in a way of painting the Golden Gate Bridge, which I live in San Francisco, and it’s front and center. When you think about metaphors, you know, the Golden Gate Bridge is enormous. It has to be painted with this beautiful reddish paint. And then the minute you’re done, you’ve got to start all over again. And the epiphany for me was we may be at some kind of level of a balancing point where the forces to make things better and the forces to make things worse, sort of cancel each other out. And the painting the Golden Gate Bridge metaphor comes in, in that the forces to make things better, which obviously are vaccinations and now boosters, and vaccinating more populations and mandates, which seemed to mostly be working, are all for the better and are pushing things in the right direction. And yet, the minute you get yourself in a better place, a bunch of bad things start happening. One is people become a little less careful, you know, which is understandable. The other is and sometimes they become less careful because they were careful and they just think things are safer. Sometimes they see it as an excuse to do things they never wanted to do like wear masks. And then the level of immunity that you have begins to wear off whether it was from your vaccines or from your infection. And so I have this and so you’ve got to start all over again. You got to re-vaccinate people, you got to reconvince people that that they need to get vaccinated in the first place and it has an effect feeling to me like we’re in this position where those forces kind of balance each other out. So in baseball metaphor, it feels like we’re in the seventh inning, but we’re in a tie game and one of those pitchers tools where it may go on for a very, very long time, which is kind of frustrating.

Andy Slavitt 

Groundhog’s Day.

Andy Slavitt 

So, is it another way of saying that that, you know, somewhere in the 1000 to 1500 deaths a day is kind of a place where we’re going to be stuck for the foreseeable future? Without kind of something jarring at loose?

Dr. Bob Wachter 

Yeah, I don’t think that I think the way I tend to think about this is that the deaths will come down because the vaccine rates are going up. And we’re vaccinating more populations, particularly kids and mandates are working reasonably well, better than I thought. So I think we are going to have more of a dissociation between cases and deaths. So that’s good news. These oral medications first, the Merck and now the Pfizer are very exciting, and particularly the Pfizer if that if those numbers hold up, in terms of game changer, I thought the vaccines were 11, you know, on a scale of 1 through 10, and I thought the Merck drug was a two or three and the Pfizer drug might be a five or a six. So it’s a pretty big deal. If people who begin to feel ill can get tested, can get a prescription can’t get on these medicines. And if in fact, it decreases their chance of getting super sick by 90%. That’s a big deal. So if both of those, if those medicines get approved, and they work as well as they appear to work in the trials, then you’ve done a lot to decrease the number of deaths.

Dr. Bob Wachter  17:04

But you’re still I think we’re stuck with still having a pretty good amount of COVID around. And, you know, maybe the cases come down by 20% or 30%, maybe the deaths come down by 40%, or 50%, or 60%, I don’t think they come down by 90. And they certainly don’t come down by 100%. So I think we’re stuck with a version of what we have now, for the foreseeable future better than what we have now. But then the Golden Gate Bridge thing kicks in in the people, you look at the south, now the South is doing great. South is doing great, mostly, because a lot of people have been infected, and they have some measure of immunity, but that will fade over time. And if they didn’t get vaccinated in the first place, they’re probably not going to get vaccinated again. So they’re set up to be slammed again. So it’s sort of all of that sort of has to it’s all these vectors sort of force facing in different directions. But I do think the oral antivirals do help a lot. And when we get them out there, if they turn out to be as good as they appear to be in the trials, that’s a really big thing.

Andy Slavitt  18:07

So if there’s a 40% to 50% reduction in deaths, we’re still talking about, you know, 200,000 to 250,000 deaths a year, which to put things in perspective, it’s in the opioid crisis, we lose about 70,000 people, about 40,000 people die from accidents, about 600,000 people die from cancer every year. So it just kind of fits into a periodic respiratory disease that unfortunately, is with us, and we have to be careful and kills people. Is that your sense of it?

Dr. Bob Wachter 

Well, I you know, I’m not. This is not what I’m rooting for.

Andy Slavitt 

No, of course, I think people know, I think people know that you’re a doctor and you’re waiting for zero deaths. I think we can stipulate that.

Dr. Bob Wachter 

Okay. Yeah, let’s stipulate that and I think the number of cases should come down some I think when you look at, I like one of the advantages I have, I get to live in San Francisco. And so I get to see what it looks like to have a highly vaccinated community. And we’re up to about 80% of the population, the entire population being vaccinated. Most of the teens have gotten vaccinated, I’m guessing that most of the little kids will get vaccinated. And we now have 50 cases a day in a city of 900,000 people. It’s not zero.

Andy Slavitt 

What’s the vaccination level in San Francisco?

Dr. Bob Wachter 

It’s in the high 70s of the entire population.

Andy Slavitt 

How do you interpret the data from Denmark where you’ve got over 70% of people vaccinated? And yet you got another wave?

Dr. Bob Wachter 

Yeah, I don’t know. My guess is I don’t know the timing. I think the waning of immunity is real. I think that if you start looking at populations that are highly vaccinated but not boosted who got their shots in January and February and March, you’re going to start seeing significant vulnerability. It’s pretty clear that 80% is not enough to get to herd immunity, it may be that 90% is not enough to get to herd immunity. So it’s not like you are, you have a magic shield at 80%. And I think when you see a place like San Francisco, San Francisco’s vaccine behavior is on the same gene. So it’s masking behavior. I go out on the streets today, there’s still a fair number of people wearing masks walking their dog, everybody’s wearing masks indoors, people are being very careful in that speak, the same thinking that leads them to take vaccines leads them to masks. So you can see, I don’t know Denmark very well, if places 80% vaccinated, but their vaccines were eight months ago, and they haven’t taken boosters. And B, they have used 80% as their trigger to take off the mass and go to 2019. I think they’re not; I don’t think they’ll have the kind of surge that we saw last year. But I don’t think they’re going to keep themselves at a you know, at a very low case rate. So I think you sort of have to do all of it, you have to hit the vaccine numbers, you have to then hit the booster numbers when people have had vaccines more than six months ago. And you have to not jettison the safe behaviors until you’re at a significantly higher vaccine and booster rate than we are now. What do you think, by the way?

Andy Slavitt

Well, I just keep saying the data for a second. Because I’m not I don’t think it’s so clear. I mean, in the last two weeks, the number of cases per day in San Francisco have doubled. Now, it’s still a low number. You know, we’re still talking about averaging under 100 cases a day. But it’s doubled in Los Angeles and throughout California. A few if you take California as a whole, it’s tripled in the last two weeks. Timing is not that dissimilar to last year, timing for when things hit the South is not that dissimilar to last year. So I think we’re probably premature in saying we kind of have an understanding of what’s going on here. And clearly there’s correlation between vaccination rates in location and the cases coming back. But I think your most important point that you said, I completely agree with is we’re sitting at a place where, sadly, this delta virus is less forgiving 70%, 80%, 90%, which would have been fine for the 2020 version of COVID. More than fine, and probably fine, even for Alpha, with Delta isn’t right. Yeah, we had Larry Brilliant on the show, not that long ago. And he said something which kind of I went to like the oh, wow, I didn’t totally get that, which is that this is actually the fastest spreading respiratory virus in recorded history.

Andy Slavitt  22:31

And I was thinking, well, isn’t it that the measles because measles spreads, you know, at about three times the R-naught, the rate of spread as COVID. And he said, yes. But it takes two weeks for a generation to occur and COVID spread incubation periods two days. So by the time you get to two weeks out, you’ve gotten way more spread of Delta, than you had in measles. And so it’s very unforgiving because it spreads so quickly, without people really knowing it or realizing it. And it doesn’t take. I mean, I’d venture to say that everybody has dropped their guard down at least a little bit. Maybe except people who know they’re sick. And I know they’re very at risk. And it’s just enough, it just happens to be that, that the threshold may be so high that any amount of wiggle room you give it whether it’s people vaccinated, or people just living their life, it’s gonna mean you’re gonna see a job in cases. And I take your point that let’s hope that that mean doesn’t necessarily mean we see a jump in death to the same degree. But I think we are, we are probably premature in declaring that we’ve got a handle on this thing, and there are going to be future waves.

Dr. Bob Wachter 

Yeah, no, I think there are going to be future waves. And I also think that, you know, when you look at a place like San Francisco, that’s almost 80% vaccinated. And then you look at parts of the south where it’s, I don’t know, 30 or 40. The total number of people that are immune, it have some level immunity may actually be similar. I mean, you have this sort of odd balance where if you didn’t get it by vaccine By now you’ve probably gotten it by delta. But then in both groups, you have waning and so in a place where most of the immunity is from natural infection, the waning is whatever happens to people with natural infection, which I think we don’t, we still don’t understand very well. You see studies saying the protection from natural infection is far lower and patchier then for vaccination. You see some studies disputing that I you know, I think the weight of the evidence says that the immunity you have for natural infection is not as good as vaccination is going to wane faster, but even if it’s about the same, the folks that got their vaccines I think are fairly likely to get boosted the folks that got infection and never got vaccines are fairly unlikely to get vaccinated. So you just see, you know, the minute you’re in decent shape, you become vulnerable again.

Dr. Bob Wachter

It’s a familiar feel to me, because a lot of my work in my professional life was in the field of patient safety. And which is sort of medical mistakes, how do medical mistakes work. And the most important thinker in that field is a psychologist from Manchester, England named Jim Reason and Reason used to say that, that sort of the minute that you feel safe is the minute you’re becoming unsafe again, it’s just it’s a natural phenomenon. Humans are busy, they tend to want to move on to the next thing. There’s a lot of stuff. That’s crossing our radar. And so as soon as we feel invulnerable, we let our guards down. It’s a natural phenomenon, then you become at risk again. So that’s why in terms of I think the issue of are we inappropriately or appropriately letting our guards down, I think is an interesting question. I have become a little bit less careful than I was, let’s say six months ago. And it’s not that I think I am being magical about the risk, I think I understand it pretty well. It’s that I think we’re in a world in which it’s probably not going to get that much safer than it is now for the foreseeable future.

Dr. Bob Wachter  26:14

So, in my decision making, weighing, you know, how well does the mask work and how risky is the activity and you know,  how much virus is there in my community, all those sort of things. I used to have another fudge factor and the factor was, and things are going to get better, because I will get vaccinated, the community will get vaccinated cases will go down. So if I can just hunker down and wait for the cavalry, then there will be a safer time and a safer place. And then we can go back to normal. I really don’t think that anymore, which is sad. And so I held a conference in San Francisco a month ago, where I did it in person at 300 people in person, had another 500 people watching, virtually fully masked. We checked vaccination status; it was about as safe as I think we could make it. But my rationale was partly this, was partly if I’m not doing it now, I’m sort of saying I may never do it. And is that the right call? And I felt like probably not.

Andy Slavitt 

So would you go to a Giants game? Do you go to a Giants game? Outdoor stadium? People sitting near one another? With or without a mask?

Dr. Bob Wachter 

I bring a mask with me. I don’t wear it in when I’m sitting outside. And I do wear it when I’m getting a hot dog.

Andy Slavitt 

And what about a Rangers game? And the reason I asked this is because in California, there’s some vaccination requirement and even in some locations where there’s not, there’s a high degree of vaccinations whereas Texas it’s obviously different. Would you go to an outdoor Texas Rangers game?

Dr. Bob Wachter 

You know what it depended more on the case rate. And so I think I haven’t checked Texas lately, but if the case rate was lower, yeah, I think I’d be I think I’d be relatively comfortable doing that. I went to a James Taylor concert last week and an indoor stadium.

Andy Slavitt 

Would you bring a gun?

Dr. Bob Wachter 

I did not bring a gun. James Taylor in San Francisco seemed fairly safe.

Andy Slavitt  28:06

I don’t know. To me, that seems the most dangerous of all, like, you could get all kinds of things there. Maybe not COVID. But maybe some other things.

Dr. Bob Wachter 

Well, the problem with it, of course, it was a James Taylor Jackson Browne concert. You know, Jackson Browne, who I remember being this incredibly dashing. Young guy now looks like me. I mean, it looks like an old geezer. The people I listened to I don’t know if this happened to you, the people I listened to or like all only people I listened to in college. It’s really pretty sad.

Andy Slavitt 

Did you hear in Nashville about these people were at a karaoke bar. Did you hear about this? They’re at a karaoke bar. And someone comes in and puts on Honky Tonk Woman, you know, the stone song, of course. And it was Mick Jagger. Yeah, he did. It was Mick Jagger. He did a he did a karaoke in this karaoke bar, like, just literally walked in and people were like, Oh my god. Can you imagine being in a bar and having literally Mick Jagger walk in, walk on stage and do Honky Tonk Woman on a karaoke machine?

Dr. Bob Wachter 

That’s pretty cool. It reminds me that I saw the Paul McCartney thing when he went back to Liverpool with James Corden and went into his old bar. And it’s just so magical.

Andy Slavitt 

Yeah, there’s an equivalent for you and me, but I don’t know what it is. We really probably have that experience all kinds of time. But yeah, I think those kinds of individual decisions, going to a Rangers game, going to a concert, etc. are in part a reflection of I think what you say which is very astute point, which is if not now, when? In part for a lot of people. They’re probably just done with it. You know?

Dr. Bob Wachter

What are you doing in your individual time.

Andy Slavitt 

It’s similar, but I will tell you this. I do have a colleague who is now in the hospital with COVID. And it’s pretty serious, I don’t know how it’s gonna turn out. And of course, I’m always, you know, worried about the worst. But even if the worst doesn’t happen, this is incredibly hard on him. And you know, just communicating with him is the little as I have what he’s going through, even if he recovers quickly, which I pray he does. It’s awful. Yeah, when he’s experiencing all of the symptoms he’s experiencing, and it’s scary. So I will say that, like, I probably like a lot of people in that I drift into slightly more relaxed habits. And then something will happen and remind me to bounce back and be more careful. Because, like you, I mean, I’ve been a very highly vaccinated county, right, like over 90%. And I’ve, you know, obviously been vaccinated, etc. So I feel probably really, really safe. Yet, I think about the fact that this virus travels very, very fast, and it can do a lot of damage. And I still think it’s worth remembering, if even for people in those situations, and then I know, there’s just a ton of people that unfortunately, aren’t in those situations, either because of where they live, or because they have cancer, or had cancer, or something. And that kind of reminds me that as a society, we’ve got to do as much as we can to stay together and support each other. And that’s got to play a role as well, right?

Dr. Bob Wachter  31:28

Yeah. I mean, that’s been, as you’ve said, many times, that’s been some ways, the most disappointing part of the past 18-20 months, it feels like it should have been an opportunity for us to come together and the fact that we’ve partisanized everything is ludicrous, and unbelievably disappointing. I you know, that seeing your friend in the hospital, and I am sorry about that, is, you know, is interesting to me as a physician, because, you know, I’ve taken care of hundreds of people that have died. And so, and there is this heuristic, there is a sort of thing that happens in our brains, when I see someone and take care of someone my age who had a heart attack, I bagged the Ben and Jerry’s that night, you know, for a few days, I start eating a little healthier, and I go to the gym, and then I revert back to my normal five-year-old diet, you know, eating like a teenager. And, you know, there, it’s natural to see that and your brain can’t help but weigh that quite heavily in your own personal decision making. But, you know, we all have a limit on how vigilant we can be, I guess that’s probably wrong, we can be vigilant forever. But it carries a cost. It comes at some cost in terms of things that we’re not doing and the joys we get in life. And so it’s important to weigh all these things. And when you see someone with a bad case of COVID, it’s going to sway you a little bit. But probably in a way inappropriately. And I don’t mean that at all pejoratively. It’s sort of we you know, when I take care of a patient, and they have given me an anticoagulant to prevent a stroke and they bleed from that anticoagulant. I’m now reluctant to give people anticoagulants for a while even though I know as a you know, risk versus benefit. The prevention of the stroke is more important, and I’m benefiting more people than harming. But when we see something in front of us, it will tend to sway our decision making that’s perfectly natural.

Andy Slavitt 

So we’re not all rational beings, right? We’ve got emotions.

Dr. Bob Wachter 

Yeah, when we’re all replaced by computers, this will be easier. But for now, where we have all that complexity, right?

Andy Slavitt 

It makes us beautiful creatures. It makes us interesting. I mean, it makes us all different. And you know, I think we should respect those much because sometimes those emotions have, you may not describe them as rational. But there’s some of our self-protective I mean, some are instincts, right? Some are things that we can’t, you know, nature has taught us that, you know, you see a lion eat a deer and you’re a deer, you’re like, yeah, not going to go to that spot again, even though lion may not be there. So I think we should embrace ourselves in all our messiness. Try hard not to take it all too seriously. And we cover one other topic with any response to that I want to give you..

Dr. Bob Wachter  34:18

I think that’s right. I think one of the great challenges with COVID and you’ve made this point before is it is so stealthy, it is so unseen, that you know, it’s easy to weigh the unpleasantness of wearing a mask and hard to weigh the possibility that you are taking it off and being exposed to this thing you can’t see. And I’ve said to folks that you know, COVID is a terrible teacher. A good teacher is my kitchen stove, you touch it and your fingers gonna hurt like hell and you will never do that again. COVID, whose risk is both unseen and probabilistic? You can engage in risky business for a while and get away with it. And you’ll never know when you got it, and you’ll never see the virus that may kill you. So it makes it very difficult to be fully rational. And it’s perfectly human, to see this sick person in front of you, and weigh that very heavily in your decision making. And on the other hand, if you’re not seeing those sick people in front of you to minimize what’s going on. So, yeah, we’re complex human beings. And we, you know, they’re the things that we see that have emotional valence play, play very heavily to in our thinking.

Andy Slavitt

We actually just spoke to exactly the question I was heading towards, which is that the things that you can’t observe with your naked eye or your own experience, we historically our answer to that has been to rely on science and expertise, because it’s an invisible virus. So we need an expert to tell us about it. The only problem is, we need to believe them. We’re at a place where I think, underlying so much of what we’ve been struggling with, I think a lot of it is that we have some portion of our population. Not unique to the US. But some of their specific strains of this new us that no longer really believe science and scientists, experts, expertise, the institutions that have sort of, quote unquote, gotten us here, got democracy here had gotten there. And I think this is something that is, I’ve said this on the show before. This is something that precedes the 2016 election. This is something that’s probably we’ve been experiencing, for various complex reasons for a couple of decades, and it’s growing worse. And Donald Trump rode some of that wave, I don’t think he created that. But I think what we’ve run into is, it’s worth just saying earlier, you know, if you get 70% of people to do almost anything, you win, right, 70% people to vote for a candidate 70% of people to, you know, believe a certain way. But when the virus became more unforgiving than that, and we realized you need to get virtually everybody, then you run into this wall, where the cost of leaving all these people behind outcall it relative to their connection with the belief in science and expertise became a huge cost. And because this is so endemic, I’m wondering, A, whether you see the same thing? Is there, this gulf? How did this and then how does gulf develop? And how do we get around? How do we get past it? Because it feels like if we could only ever get some of us on board and leave large numbers of the population, not on board. Where do we go from there?

Dr. Bob Wachter  38:14

Yeah, it’s immensely frustrating. I have to say, I mean, I live in an echo chamber I live in work at an academic health system in San Francisco where in general, people have believed the science and done and done the right thing. This is a time where relative political homogeneity has been helpful. It’s important to sort of say that COVID is tricky, and infectious diseases are tricky in terms of the science. I got a note the other day from someone who said, I got vaccinated, and I was diagnosed with a thyroid disease, graves disease a few weeks later, she was quite convinced that that is what caused her graves disease, it’s a perfectly rational thing to think it’s wrong. There’s absolutely no evidence that it’s true. And when you look at the number of cases of new diagnosis of graves disease in the country, I think it’s a couple 100,000 a year, there are going to be a fair number that are in people who have recently been vaccinated, but trying to convince someone that that’s not it, that’s an easier causal link, I got vaccinated. And two weeks later, I had a heart attack, two weeks later I was diagnosed with graves disease, that’s an easier causal link than, you know, I got infected from this person who felt perfectly well, who I was, you know, in contact with at a wedding a week ago.

Dr. Bob Wachter

And so some of it is a pretty tricky thing to explain. You also have to not only believe scientists, you have to believe the data you have to sort of have a level of numeracy, which is kind of tricky. I mean, I you know, went to school for 100 years to learn how to think about risks and benefits and weigh them and understand statistics. So it is kind of tricky, but I mean, your core point is absolutely right. We’re in this really difficult and sad time in our world, where there’s always been some level of anti-science and some level of anti-elitism that’s always been a thread in American culture. But the degree to which it’s been magnified by the media and by social media, and the degree to which there is a clear business case for it, you know, you might have thought the pushback from it is going to be people are going to see that if they follow this stuff, they’re going to get sick, and their family members are going to get sick, and they’re going to die and all that. But, you know, you can act badly with COVID. And the odds are you still going to probably do, okay. And the perpetrators of this, you know, get hits and get likes and get media share and get make money and for whatever their motivation is, it doesn’t seem like it doesn’t pay. And so I have no idea how we get out of this, this loop, but it’s really destructive.

Andy Slavitt 

it’s like, you just told me that I might get sick and I didn’t. So you’re a doomsayer, right? Therefore,

Dr. Bob Wachter 

I don’t believe anything you say, right, right.

Andy Slavitt

Now, that’s one way to look at it. Now, let me try to look at it from the other lens, though. Which is only fair, which is how much of this is our fault? I’ll say, yours and mine specifically, no, not yours. I’m not specifically but you and among many, many others, for the way we communicate with people, and make our points in here. And here’s kind of what I mean by that. Very hard to find a lot of examples of scientists in the public health officials saying, gee, I was really wrong. Now, what we hear a lot of is, those were the facts I knew at the time, and the facts change. And it’s a novel virus, and, you know, which could end up sounding like, you know, people in an ivory tower, with an excuse for everything and a lot of arrogance. I’m just wondering, if there’s a rethink, both at that level, as well as the level of, we never really do much of a good sales job during good times around what science is doing for people, what public health is doing for people, you know, reminding people of all the things we’ve gained. And so a combination of those factors, makes me wonder whether or not like over the last 20 months, we’ve actually made things worse, because this gulf existed, and we’ve done nothing, in some sense. But say, God, those people, they just are anti science, as opposed to looking at how we’re doing things and recognizing that some of it is reinforcing their view?

Dr. Bob Wachter  42:44

Yeah, I don’t know, I try to be charitable to all of the communities here. And I think to the scientific community, I guess, I think we’ve done a pretty good job of processing rapidly evolving facts, changing understandings in you know, a swirl of information and misinformation. The way science works, where we’ve done a terrible job is we’re just not good at communicating to I think we’re good at communicating to people like us. Yeah. And we sort of, you know, I mean, you’re talking about elites, you’re talking, you know, if you’re a scientist, you probably have four or eight or more years of post-secondary education. And you probably have migrated to living in certain parts of the community where you’re surrounded by people who are reasonably well to do and those are our communities. And we sort of know how they think and how they respond, right. And I don’t think we have the foggiest idea how to communicate to someone who with a GED or, you know, with a high school degree, who works in, you know, in using their hands, and we got to get better at that. There’s no question about it.

Dr. Bob Wachter

But the fact that we were not good at that, you know, is sort of understandable. In the same way, it’s sort of understandable that someone would look at you and me and say, what, what do they know about my life? And I think there’s a lot of that, that explains our politics. And there’s a lot of that that explains what we’ve seen in the past, in the past 18 months. So yeah, we have to get better at it. But I guess I don’t accept the idea that we should just beat ourselves up for being so bad at this. We were doing the best we could in an unprecedented situation. And yeah, we all got Delta wrong, because you know, there was a probability of a Delta, but maybe it was 1% or 2%. There’s certainly a higher probability that there would be a variant that would be worse, but that it would be twice as bad. Yeah, I think that’s a pretty that was a pretty low odds. So that when you came back to the show in May, I remember asking you, you know, what, are you going to do probably do this for a couple of months and then COVID will be gone, right? Was I wrong? Dead wrong. Was that in retrospect, could I have gotten it righter? I don’t think so.

Andy Slavitt  44:59

What you just said is, is I want to just fixate on what you said, what you said that you were wrong. And I’ve said I was wrong. before. We don’t hear that very often. You know, we hear the second part, we hear this is why I said what I said at the time and the defense. And I think if someone’s like, so people just re litigate a lot of that I’m not blaming scientists, but I am saying what you said is a really important point, which is that there are echo chambers, where people feel very disconnected from what scientists say. And feel like that’s not them that maybe they’re being talked down to. And look, it matters, this top conversation matters, because it turns out, we can’t afford to lose 20% to 25% of the public, and manage something like this. And I would also acknowledge you never get everybody. 75% is a lot. But it does cause us to examine kind of how folks are disconnected. It’s not that doesn’t it’s not that dissimilar from other situations where people were like, yes, they told me that trade was good. And my job went away, right? And they have no idea what it’s like to live in my town, see my job, go away, see all of my friends and family go job boy, and then have them go on TV and say how good this is.

Dr. Bob Wachter  46:19

Or they’re going to retrain me to be a computer programmer. It’s like, you got to be kidding.

Andy Slavitt 

I’ve stopped. I’ve stopped listening by that point. Right. Right, right. So we don’t understand each other as well as we once did. We live very separate lives, if you work by the hour, or if you’ve got a salary, if you live in a city, you live in the country, there’s a lot of differences. And then as you said, there’s a bit there’s a social media network that feeds each of those groups and things that they want to see.

Dr. Bob Wachter 

Well, I mean, it’s the choose your own adventure portion is maybe the most destructive of all, you know, you think about when we were kids, you know, there were three networks you got your news from. And, you know, I hear all the time, I’m sure you do to people saying how grateful they are for our tweets and explaining things in ways that are really accessible. But you know, the people that are reading my tweets, and your tweets are not the people that we’re trying to reach, they are already converted, they’re part of, I think, to a large part, they’re part of our echo chambers. And maybe at the margin, we change some minds. But I don’t think we’re reaching a different population. And I’m not sure it’s our language that’s going to make the difference. They’re tuning into other channels.

Andy Slavitt 

Well, it’s been great having you back on, you know, you’re in an odd way, we’ve sort of become family through this show. So I really appreciate you the time period you stepped in when I was out in Washington, and something to keep doing. Great conversation today. Very, very real conversation. And then one of those conversations where I actually did learn a great deal.

Dr. Bob Wachter

Well, thank you. Thanks. Thanks for having me. And thank you for the opportunity to be on the show for four months, I felt like I was doing my little bit for the country because it was part of what allowed you to go and save lives, which you absolutely did so. And I love the team and I have my I have my Lemonada Mug so it was nice, nice reconnecting with everybody.

Andy Slavitt  48:09

Yeah, I call them big podcast. We wary of big podcast with all their mugs and everything.

Dr. Bob Wachter 

Exactly. Alright, thanks. Good to see you.

Andy Slavitt

All right. Now, thank you to Bob Wachter, thank you to my mom, for, you know, everything, but also for being on the show. And I can’t just can’t say Bob doesn’t belong in the same breath with my mom. It’s just, it’s just not right. But thank you both. Coming up on the show Wednesday, how conservatives and liberals are facing off and talking to each other about COVID with Hugh Hewitt, noted conservative, I think you’re gonna want to listen to that show. That’s all I’m going to tell you. Suspend your, whatever you might be thinking if you have hesitation, I think you’re really gonna want to listen to the show. It’s a really good dialogue, safe or not safe holiday gatherings. We’re going to talk about how to make sure we keep our holiday safe. Then Regeneron, Leonard Schleifer, the CEO of Regeneron. We’re gonna talk about the monoclonal, the Regeneron monoclonal with the CEO, how they work, how to get them what they’re all about, and I think it will be a good show. Thanks, everybody. Talk to you Wednesday.

CREDITS

Thanks for listening to IN THE BUBBLE. Hope you rate us highly. We’re a production of Lemonada Media. Kryssy Pease and Alex McOwen produced the show. Our mix is by Ivan Kuraev and Veronica Rodriguez. Jessica Cordova Kramer and Stephanie Wittels Wachs are the executive producers of the show, we love them dearly. Our theme was composed by Dan Molad and Oliver Hill, and additional music by Ivan Kuraev. You can find out more about our show on social media at @LemonadaMedia. And you can find me at @ASlavitt on Twitter or at @AndySlavitt on Instagram. If you like what you heard today, please tell your friends and please stay safe, share some joy and we will definitely get through this together.

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