Pandemic: Coronavirus Edition

You had me at antigenic drift

June 03, 2020 Dr. Stephen Kissler, Dr. Mark Kissler and Matt Boettger Season 1 Episode 28
Pandemic: Coronavirus Edition
You had me at antigenic drift
Pandemic: Coronavirus Edition
You had me at antigenic drift
Jun 03, 2020 Season 1 Episode 28
Dr. Stephen Kissler, Dr. Mark Kissler and Matt Boettger

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Show Notes Transcript

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[00:00:00] Matt: [00:00:00] You're listening to the Pandemic podcast where we equip you to live the most real life possible and the face today's crises. My name is Matt Boettger. I'm joined with my two good friends, Dr. Steven Kissler an epidemiologists at the Harvard School of Public Health. And Dr. Mark Kissler who is a doctor at the University of Colorado Hospital.

[00:00:15] We're all back on. The band is back. How's it going, guys? How have you been? 

[00:00:19] Mark: [00:00:19] Good to see you. 

[00:00:19] Matt: [00:00:19] Good to see you. Good to see you guys. we, before we get going, I think we all come with heavy hearts right now. I know I've been really struggling with the whole George Floyd, gruesome death. And it's been hard. I mean, it's, it's hard in so many reasons.

[00:00:33] And my stomach is in knots mostly all the days, probably because I don't even know how to respond. I've I personally have learned a lot about myself, my own ignorance, and I'm taking this time to learn a lot. and it's that kind of thing where you want to do something, right. You really want to do something, but you just don't know what to do.

[00:00:48] So you feel in a sense helpless, because partly because of my utter ignorance. And, we'll talk about how that maybe makes sense a little bit more of there's a really good example of how I screw it up. [00:01:00] Already by yesterday by trying too hard. So, but,  I have a really strong pit in my stomach and it's been hard to focus, honestly, you guys even coming on as podcasts, like, coronavirus, whatever,  it's just hard, but nonetheless, it's still important.

[00:01:14] It's still important to talk about. There's still a lot of stuff in the news, and there's a lot of relationships between the whole craziness of the pandemic and what we're seeing now as a response. to the death of George Floyd. And I think we're to spend a little bit of time reflecting upon that, and I'm excited to be able to do that and hopefully provide some value before we get started.

[00:01:33]like always, we, we always really appreciate the reviews that come by. Here's one review I want to read. It's our last one. It's been great. This, this gentleman's named a DDA, John T so thank you. ddajohnt I don't know who you are. he says. I've listened to a lot of folks with political bias pontificate about this pandemic, but these guys want you to understand the science and his book.

[00:01:53] The great influenza John Barry wrote about the conflict between science and politics in 1918. These [00:02:00] guys remind Steven, this is like his like devotional every night.

[00:02:08] Yeah, totally. We'll we'll launch a Steven's book study next month and continuing the quote. These guys remind me of those voices in 1918, who tried to help people understand what was going on so that they could make wise decisions that would have saved lives. Do yourself a favor and listen to this podcast.

[00:02:25] They have a lot of solid information that can help us help as you try to navigate through this time. So thanks. DDA John T for that awesome review. And if anybody would like to continue, we'd love that again. We'd love financial support as well, just to help us pay for all the equipment that we're using, that we can do that through podcast.

[00:02:43] As little as $5 a month month can help a lot, even a one time payment through PayPal or Venmo. Just check in the show notes with links to do just that. And lastly, if you want to sign up for my living in the real podcast, go to live in I have a lot of information there just released a new one on finding margin or life, which I really think we need to have that space [00:03:00] to be able to reflect and be able to learn more about what's going on and be truly educated and make wise decisions.

[00:03:06] Okay. There's a lot in the news man. Now that we're doing this every week, I feel like I just have a laundry list of things I want to talk to you about, and we just don't have the time. So Sunday, we're going to do it all night or when we get older. and I retire, but until then, we're gonna kind of keep this a little bit shorter.

[00:03:22] That was the first thing I want to throw to you, Mark. So I read a few days ago that modern clinical trial just entered to phase two. So what does this mean? And I heard it's a record pace, like 63 days to make that. So, what does this mean? What does phase two mean? And what does this mean for us for the hope of the vaccine?

[00:03:39] Is it on track maybe for potential January 1st? Oh, a release or sometime in January. 

[00:03:45] Mark: [00:03:45] Yeah, I think, you know, we'll see. it's, it is super fast. again, we talked a little bit about how phase one is mostly is geared towards safety. phase two is starting to determine the drugs efficacy. and so this is, you know, we're on, on the way.

[00:03:59]and then [00:04:00] we get a little bit of a sense of sort of the short term. affects like the side effects that you might get or the risks associated with the treatment. and then it's phase three is usually a, an even bigger study, where you look sort of against the current standard of care, which in this case is no vaccine.

[00:04:15]and so there it's, it's a stepwise process and the idea is you're kind of a build out each time. and you get more information each time, but you get some preliminary. So we of. Move through the phase one trial onto the phase two, where we're now starting to look actually at outcomes and efficacy in addition to safety, it's a big deal.

[00:04:31] And I think, you know, we'll see, there's just, it feels like there's so much, that's waiting on a vaccine, you know, we can do a certain amount of reopening and, and, you know, have been. And, and it's important to do that. but it just feels like until we have a vaccine, some of these things are just never going to really.

[00:04:48] Be as open as we want them to be. And so it, we'll see. We'll see. Yeah. 

[00:04:52] Matt: [00:04:52] So can I, can I ask a follow up question that even access makes me want to throw up? And this is my question, Mark. This scares me. It's [00:05:00] really to scare me to get this answer. Yeah. So is it possible that we get a vaccine say record time, January, and it's like the flu vaccine.

[00:05:08] Hmm, where it has a 32% rate of, of actually working per year. I mean, is there, what's the chance of that, that actually being the case or is it a pretty strong chance that will, it would hopefully work completely 

[00:05:23] Mark: [00:05:23] well. So there's nuances with the flu vaccine, right? And there's reasons that the flu vaccine, gets modified every year.

[00:05:30] And Steven can speak to some of that as well. Cause epidemiologists are really involved in figuring out which strains are going to be predominant things you have to know. So typically on these viruses. So they're on these viruses, there are different proteins, right? That, affect the way that the virus interacts with host cells and gains entry and, and some of the viral characteristics and things like that.

[00:05:49] And our immune system also recognizes those proteins. and if you prime the immune system to recognize the correct, glycoproteins, then in theory, you get a. Clinical [00:06:00] response. And if you miss the target, then you get less of a response. and so it's even tough to say, you know, from year to year, what percentage efficacy of the flu vaccine has.

[00:06:10] And like, we can drill down into that data too. Cause just getting a single number of efficacy is actually potentially a little bit misleading in terms of like how it works from year to year and different strains and what is clinical efficacy and all of that. Big picture was, it's it in Steven, correct me if I'm wrong.

[00:06:26] What we're, what we're working on right now is a vaccine for a, you know, for the stars two coronavirus, we have a very good sense of what glucose proteins we're trying to target. this isn't something that's undergoing seasonal antigen shift, as happens in the flu, and, or antigen drift, I guess, would be the, the actual antigen drift from year to year.

[00:06:47]and so. All that is to say, I'm hopeful that when we have a vaccine that targets those, it's actually going to work, at a relatively high rates of efficacy. 

[00:06:57] Matt: [00:06:57] You, you had me at antigen drift [00:07:00] and antigen drafts. Steven, do you want to chime in 

[00:07:03] Stephen: [00:07:03] largely just to agree with that, you know, flu is, Flu is a strange pathogen man.

[00:07:08] It's it is a constantly moving target and it, it mutates like crazy, you know, it was, it was like made to do that. and you know, most viruses do mutate at some rate, but it doesn't seem like the Corona virus mutates at that level. and so the, it isn't as much of a moving target. Like Mark said, we have a much better sense of what we are trying to target on it on the, on the, on the virus surface.

[00:07:33]My concern, I think with the, with the vaccine is not so much that it, that the efficacy won't be very high, but that it just won't the, that the, you know, the effectiveness may not last for a very long time, so you might need to get repeated boosters or something like that. but that's, that's a much better scenario to be in than just a vaccine that doesn't work out.

[00:07:52] Right. So I'm also Oh, sure. 

[00:07:53] Matt: [00:07:53] Yeah. I would imagine again, this is my inner insight. When we think of boosters around thinking like, Oh crap, it could be a monthly [00:08:00] booster. We're thinking like, Oh, maybe an annual booster. Yeah. 

[00:08:03] Stephen: [00:08:03] Basically like flu vaccine in that sense 

[00:08:06] Mark: [00:08:06] they can do, maybe they can do like a ....

[00:08:08] You know, you get your flu and your coronavirus every year in the same, you know, vaccine pretty like this 

[00:08:16] Matt: [00:08:16] is great. There is a sale going on right now.

[00:08:24]another great piece of information that I, that I don't fully understand. first human trial of potential antibody treatment for COVID-19 begins. I mean, I, from what I read, this is different from the other suspend going on, Mark, do you want to chime in for a few minutes and Steven. 

[00:08:38] Mark: [00:08:38] So, you know, I can't comment specifically on the study itself, but I can talk a little bit about the difference between vaccines and antibody therapy.

[00:08:45] So, you know, the idea of a vaccine is it's a, it stimulates the body's immune response. So it stimulates the production of cells and antibodies against a pathogen, to help protect you from getting sick. When you do get exposed to that, [00:09:00] antibody therapy kind of skips a step in it. It delivers the antibodies directly to you.

[00:09:06]you know, that's one of the things that underlies the idea of giving convalescent plasma or plasma from individuals who have recovered from Corona virus to those who are still ill, that you're giving them sort of a load of these antibodies that then go and detect and attach to the viral cells and stimulate the immune response that way.

[00:09:23] Now there are ways of creating. Antibodies. So that's done by, you know, giving plasma from somebody so needs donation every time, from somebody that's recovered and a matching blood type, there are ways to isolate antibodies and eventually to produce them, and manufacture them in a lab. and so that's the, that's kind of the big differences that we're, they're looking at engineering ways of creating antibodies, which is part of the human immune response so that they can be delivered directly, and hopefully help.

[00:09:51] To mitigate some of the effects of infection. Okay. 

[00:09:55] Matt: [00:09:55] So this seems to be something that could be given it's more directly, maybe not effective, but more directly, [00:10:00] provided to those who have COVID then. and antiviral that's, that's like some kind of competition of a preexisting, 

[00:10:07] Mark: [00:10:07] right? Yeah. It operates in sort of in a completely different way.

[00:10:10] So an antiviral medication is going to, in various ways decrease the amount of viral replication that happens. and, but they don't necessarily stimulate or mimic the body's innate immune response. so all of these kinds of the way I think about it is you've got sort of an arsenal of things that.

[00:10:28] Could potentially be helpful. So you have, you know, vaccine, which I think is probably the most important thing. You have antibody therapies that, mimic the body's responsive antivirals. And there's also anti-inflammatories which, is yet another part of the immune response that can actually end up causing harm once the balance, you know, that we call it the home homeostasis, the homeostatic balance tips over too much, and you get too much inflammation.

[00:10:51] A little bit of inflammation is good. It helps your body fight infections. Yeah. Too much is where we start to see some of these, you know, lung damage and fibrosis and, and, and [00:11:00] other complications. And so, so I, you, I think, you know, when I look at the potential therapeutics and what we have, I think that each of those categories, has some viable contenders and we may have to have some answers in each of those categories to help so that we have as much as our disposal, therapeutically.

[00:11:17] Okay, 

[00:11:18] Matt: [00:11:18] great. I know thing I saw on here. Steven D anything to add on that? Nope. Great. Nothing I saw was at home testing, arrives, with accuracy and question. Any, any thoughts on this? Is this something that's smart to do? Or are we just, is this kind of like the, I don't know, like. False sense of security kind of.

[00:11:35] I 

[00:11:35] Mark: [00:11:35] mean, I mean, I think if accuracy is in question accuracy as the question, or that is the question, because what we want is, ideally, and, you know, I think what, where we want us to be able to glean really high resolution epidemiologic data from home testing, that would be the. The big picture win. Right?

[00:11:55] So not only does it allow you to make decisions about if it's safe to [00:12:00] see somebody who's in a vulnerable population, but it also helps us globally as a society to understand where the disease is, how it's spreading and how quickly. and so, you know, I don't, I don't have, I don't know what you think, Steven, I don't have any like ideological reservations or problems with, at-home testing.

[00:12:18] I, I. Tend to think that's a great next step. The caveat being that it's just important as with anything, including a test that you get in the hospital to understand such things, as you know, what's at sensitivity, what's it specificity? What does a negative test mean? You know, is that a true negative or a false negative?

[00:12:36] And just having like a working understanding of that. And that is a role of, You know, somewhat nuanced and targeted scientific communication. 

[00:12:44] Stephen: [00:12:44] Yeah. You know, you're right. It's, there's, there's a really interesting behavioral element here too, which, if, if you, like you said, if the test doesn't have perfect specificity and you end up with a false positive or vice versa, you might well change your behavior based on the outcome of the test.

[00:12:59] And that, that could [00:13:00] actually end up leading to, you know, riskier behaviors or, or the spread of disease in cases where, where it might've been prevented, if a person just didn't know what their test status was. So, yeah, I think there is something really important about, you know, the, the, the fact that the, the physician patient relationship is a relationship and that ideally the physician is there, you know, both to diagnose and to treat, but also to help the patients sort of understand what these things actually mean on a practical level.

[00:13:24]and being able to speak to the patients sort of on, on their level and in a context that, that, that makes sense. And so, I do have some reservations about home testing because, I think that it's, it's an important thing to do, but like, like Mark said, just the communication will have to be very, very clear and very nuanced.

[00:13:40]and, yeah, I could see it in certain cases, backfiring, but I do think that, that ultimately it will be a valuable thing and, and something that, you know, we're headed that way. Anyway. yeah. And we'll just have to find ways to make sure that it is as safe and as accurate as possible. 

[00:13:57] Matt: [00:13:57] Yeah. That even think about that.

[00:13:58] And I've just this idea of [00:14:00] another advancement of becoming your own doctor and right. The, the, the, the drawbacks to that. And I've witnessed that in our, on our own family when we're, trusting dr. Google. to, help us get through some crazy situations and it only makes it worse. So, having a professional to go to, is an important thing, especially now when it's much easier just to Google, actually have been forced to go to the doctor.

[00:14:21] It might be a helpful thing to discuss with a professional. 

[00:14:23] Mark: [00:14:23] Yeah. Yeah, it's a complex, it's a complex thing. And I think we'll talk about it too, as we get to our kind of deeper dive on some of the racial issues as well. And you know, we've talked about this, I think just as a place that I want to bring up some of the racial disparities that we've seen just in test administration and this recognition that yes, I think in the ideal case, this, clinician patient relationship, is it.

[00:14:46] He has a good relationship and, you know, benevolent one and one that provides guidance. and I think in the messy kind of everyday way that this gets enacted in the world, there are big gaps and we're far from an ideal [00:15:00] scenario in which, everybody who needs care gets the care that they need and deserve.

[00:15:04] And, and so I think it's, this is, yet another just example of the way that the pandemic, I think, highlights and brings. You know, visible things that are already present. and, and, you know, there's lots and lots of conversations we can have about, kind of democratizing medicine and certain diagnostics and therapeutics and stuff.

[00:15:22] And that's a whole other whole other thing. but it's, it's just so interesting to me. How much of this is intersecting with kind of our current moment? 

[00:15:31] Matt: [00:15:31] That is an important bookmark to put on because we'll be going back really soon, but just exactly how this pandemic has already, even before the George Floyd, tragedy happened was already percolating and festering within.

[00:15:42] And, and the pandemic was elevating this, racial disparity, a couple more things I wanted to chat with with Steven. New Zealand heard this. This is huge success. Fifth straight day of no confirmations. Can we learn anything from this? Or is this just something unique to New Zealand that I just need to [00:16:00] like take my family and move there?

[00:16:02] Stephen: [00:16:02] Well, New Zealand seems like a great place. I've never been it's beautiful. Yeah. 

[00:16:06] Matt: [00:16:06] Yeah, I don't know. I just have pictures. 

[00:16:09] Stephen: [00:16:09] I, one of my, one of my very good friends from when I was doing my PhD is from New Zealand. I don't know if Ali listens to this, but if so, you know, go all blacks, the rugby team is amazing.

[00:16:17]and, yeah, New Zealand, you know, I think it's worth pointing out the obvious first. Right? So New Zealand is an Island, 

[00:16:25]Mark: [00:16:25] and has a high sheep to person. Indeed. Observationally observationally. That is probably the factor. Yeah. 

[00:16:33] Stephen: [00:16:33] Well, yeah. And that does play a role. You know, it's a lot easier to keep building this out when, you know, you're more likely to interact with the sheets than you are with another human being and, you know, and you can sort 

[00:16:41] Mark: [00:16:41] of like close your borders a lot more

[00:16:47] Stephen: [00:16:47] easily. One is wonderful. so yeah, so I think that the New Zealand definitely has a couple of geographic and demographic. things going in its favor where, the, the sort of strategy that worked for New Zealand would not work for a [00:17:00] United States. And that's not to say that there's nothing to learn from them.

[00:17:03] I think that there is a lot to learn from them. They were incredibly proactive with their response. there was a lot of trust in the authorities and there was a lot of, clear communication from, you know, from, from the government about what was happening, what was going to happen, what their intention was, what their goals were.

[00:17:18]and so those things I think are very transferable and are things that I really admire about their response and, and, and you're right. You know, they're, they're reaping the benefits. It seems like right now of, of their early action and of their buy in, And in many ways, it's, it seems like, you know, it, they're, they're a bit of a success story at the moment.

[00:17:39] It's, it's too early to say anything final about any one, you know, like this, this, this whole situation is still shifting and there's, it could very well be the case that there are new introductions there. But, but you know, the fact is that they're, they've achieved, a huge deal of control over the outbreak.

[00:17:54] And it seems like a lot of their population is, is, seems to be very satisfied with. With the actions that the government [00:18:00] took and other freedoms that they can enjoy as a result. 

[00:18:03] Matt: [00:18:03] That's great. Yeah. I mean, it doesn't hurt that the, like you said, that there at least there was a unified plan and a leadership and a community willing to, go along with it and support it and to just congratulations to New Zealand and they're a great achievement and hopefully it continues to be that way.

[00:18:18]another thing I want to say before we get to the deep dive, this one was fascinating to me. It just came on my radar. I think yesterday. And it said top journal retracts study, claiming masks ineffective and preventing COVID-19 spread. And so it was on a website that I've never heard of. So I was a little suspicious, but it was grounded in a good, I think it was, it was good.

[00:18:37] And I wanted to pick your brain on this with Steven on two areas. Number one, this idea of masks, because you have the who saying one thing and the CDC saying one thing, but that's kind of a, kind of a sidebar to the main part of this I wanted to ask you about. And this was in with this quote. And it said the article joins our ever growing list of retracted COVID-19 studies, which I don't know much about that.

[00:18:59] It is a reminder that [00:19:00] for all of the alarm over public publicity of preprints because they are not peer reviewed peer reviewed studies also require caution. And then here's the key line, perhaps the real problem is speed. Not peer review status. If only someone had warned us, Steven thoughts on these.

[00:19:18] Stephen: [00:19:18] Yeah. It's so the first thing I'll say is that, you know, it's, it's good that we're bringing this to light and it's, it's definitely true. That just because something is published in a peer reviewed article doesn't mean that it's true. science, this is going to be a strange thing to say, but science doesn't operate in the realm of.

[00:19:37] Truth or have proof. I mean, it does, to some extent, like it's aiming towards the truth for sure. But there is no one study that conclusively, you know, the, the scientific process is not aimed at, you know, conclusively proving something, right. That's that's mathematics. And then there's a very small subset of things that mathematics can say is actually true.

[00:19:55]science is about. Gathering evidence and discussing that evidence and sharing it and [00:20:00] achieving a consensus, such that, you know, beyond reasonable doubt, we can believe something to be true. and so on the one hand, you know, a retraction sounds like this, this huge issue, right? Like I think we think of retractions as a failing of the scientific process, but it's quite the opposite.

[00:20:16] Yeah, retractions happen frequently. I chuckled a little bit, when you were saying that the list of retracted articles is ever growing well, sure. Not shrinking, right? It's not going to shit. Like 

[00:20:28] Matt: [00:20:28] it's not going to go down, like I'm 

[00:20:31] Stephen: [00:20:31] not getting any younger either, right? Like there's only one direction that can go right.

[00:20:34] Matt: [00:20:34] Yeah. And so, 

[00:20:36] Stephen: [00:20:36] so like that's fine. And, and, and we, the scientific journal is a forum for discussion and communication. and th and the peer review process is intended to make it harder to publish things that are not reproducible, and that are not. Accurate. but things are gonna slip through, right? When, when a peer reviewing means basically that an article is sent out to three or four colleagues, you know, and, these people are also pressed for time and [00:21:00] that, and we do our best, you know, we do our due diligence because of the health of our field.

[00:21:03] Depends on it to review these things well, but. Some things do slip through and some things need to be retracted. And that's, that's another, I think that's actually another sign of health of, of, of the scientific field as a whole. you know, we're, we're learning as we go and there is this there's this trade off, of course, between between speed and accuracy.

[00:21:21] To some extent, if we could think about a single problem for our entire lives, it would probably be more accurate than, Know, then, then some of the things that we're necessarily putting out at a rapid pace right now, but, but the pace right now is also important as, as the situation continues to develop.

[00:21:35] So, it's, it's not clear sort of what that optimal balance is, and there's no doubt that we're not getting it totally right. but, but you know, I think, I think. What I do think is that that quote is, does, does a very good job of pointing out that there is a trade off between between speed and, and you know, sometimes the quality of the findings, not necessarily, but, but you know, on the whole that's, that's true.

[00:21:59]and it, it really [00:22:00] does require us to really be thoughtful about the information that we're consuming. 

[00:22:04] Matt: [00:22:04] Yeah. Before I hand over to Mark, I just, it just reminds me of last week. You and I, Steven. Or just, I think, I think it was last week, maybe a couple weeks ago. I'm not sure, but we talked about how the pressure of the media upon the scientists.

[00:22:15] And I could only imagine that doesn't help anything for, I mean, I think there's a natural desire, desire to put speed to the research to help there's that that's the main impetus. but then also the media's desire for rapid like, you know, conclusions like, you know, exact numbers and knowing exact words is going right now, doesn't help the scientific community to stay steady and strong and its research and understand and follow its processes to, to a T.

[00:22:41] So, Mark. You 

[00:22:43] Mark: [00:22:43] yeah. Agreed. I mean, I think we had, one of the things we had circled around early on was just the, even, even the case of a global pandemic is not a reason for, to kind of cut corners, methodologically speaking, just to kind of echo what you were saying that it's still important to have that rigorous approach, [00:23:00] because that's what gives us the highest quality of evidence and sort of the highest fidelity, that we can achieve to, you know, what's really.

[00:23:06] Happening in the world. So the other thing that I was just thinking about as a practice, that's really common in medicine, which is journal club. and I used the word practice kind of intentionally because it's like, it's, it's a thing that we do, but it's also sort of a way of doing that thing. And there's its own sort of rules and traditions around that.

[00:23:23] But the idea is just that this is a way that. Young clinicians learn to critically appraise the evidence. So it's not enough for something to be published in a peer reviewed journal. And then for you to go to the abstract and change your clinical practice, based on the sort of the one line conclusion, you really do have to understand the nuances of the methods, the patient populations, for which this is applicable and not applicable the, you know, degree of importance.

[00:23:50] And it. Of the primary outcomes, you know, things like that. And so, yeah. It's not a big revelation that just that something is peer [00:24:00] reviewed means that it's needs further investigation. that's ideally the way that we approach anything that comes across our desk, especially anything that we're going to consider changing our practice as a result of 

[00:24:10] Matt: [00:24:10] you kind of already led us into this next Vic.

[00:24:13] Big deep dive of just talking about what's going on. I mean, we've know since our, since our last time together last week with Steven and I, he was really at the cusp of what was happening in the riots and, the George Floyd death had already happened, but the, the, the really the, the, the aftermath had not really picked up and now we're in this explosive environment right now.

[00:24:32] Where there are protests going all over the place, peaceful ones, there's riots, there's even death, you know, just an Omaha a couple of days ago, which is my hometown. so that's why I bring it up here. someone killing a black man and allegedly self-defense that we still don't know exactly. but a lot of this going on a lot of violence and in the midst of.

[00:24:54] This pandemic. And I want to frame this. I'm gonna throw it to just Mark and the Steven. I just want to talk about like, what [00:25:00] is going on. And for me it's been really revealing, how ignorant I have been, in my own misunderstanding of my own privilege. and I've read a couple articles and I think the greatest thing that has come from this for me is that for the first time I'm seeing this literature come in front of my eyes now through Facebook, which is out the great creative medium.

[00:25:20] But I'm reading them and from trusted friends and it's really changing so many things about how I see things, what I've taken for granted. And, and, and the systemic racial disparity and racial injustice. And I want to start with, we talked about a few weeks back and Mark wanted to talk kind of mentioned about talking about the, the racial disparity, even with, through the coronavirus and the susceptibility of the black community, and seeing this and then, and seeing that susceptibility.

[00:25:48] And now we're in this context of, we've been home for a lot about, for a long period of time. we have been many people have lost their jobs. The stress is, is, is, is astronomically more [00:26:00] intense. And now we see this explosion of violence and protests, and now I'm being awakened to all these things. And one of the articles I had I had seen is this idea of coronavirus in black people.

[00:26:12] We need to talk about medical racism, and again, another eyeopening. And I wanted to throw it to you, Mark. And. When I read this and I I've learned this for the first time, what has been your experience? What have you seen? and, and what can you share about the disparity in the medical system with how we treat, the black community?

[00:26:29] Mark: [00:26:29] You know, I think, first off, just wanting to go back to an earlier point in a word that you had used, which was kind of revelation or this idea that, you know, something is being revealed. And I think it's really important to linger there for a minute, because in a certain sense, You know, what's what has happened is it is exceptional.

[00:26:48]but it also really, in some ways it reveals something that's been there all along, you know, and that in a certain way, that it's, that it is out of a place of privilege [00:27:00] that we can even. Not ha not have noticed that it was happening long before last week, you know? And, and I think that all, you know, all of us to varying degrees have some degree of, you know, understanding that this is a deep seated and a systemic and like lungs, very long standing issue.

[00:27:19] But, W w I think one of the important things to reflect on in a moment like this, you know, is, is not, is similar to a lot of what we've experienced with the stresses, that this is uncovering some things that is there and has been there for a long, long, long time. and it's not new. and it's, and so that, and I think that I agree, I think that there's something necessarily humbling and, and kind of immediately calling us out of ourselves.

[00:27:44] Just by the fact that, it takes something like this to begin to see, see those into, to make this deeper dive. And, and I think we have to make use of that impulse, you know, as much as we can. So, I think that's, that's just super important to kind of, you know, reflective of what's going on. [00:28:00] You'd asked, you know, about.

[00:28:02]about kind of systemic racism and how it is manifested within medicine. we talked a little bit, a couple of weeks ago about how one of the wrong ways to think about that is that, for some reason that, you know, black or Brown bodies or bodies of marginalized communities or bodies of difference are more susceptible.

[00:28:20] To disease. and that, that, that kind of reintroduces this more kind of invidious, like, you know, thinking, thinking and thought about difference. That really, what we need to think about is how it's systemic factors and factors that are deeply, deeply ingrained in our systems and our practices that perpetuate.

[00:28:40] Circumstances in which the consequences are far more grave. and you know, I think it's, it's, it's tough. It's tough to engage on that level. and I think that, you know, not that that's some of the racism that we see is of the type that is very kind of bald and very much kind of [00:29:00] interpersonal and directed.

[00:29:01]but so much of the racism that we. Participate in, it is of this other type. and without really having a deep understanding of how that happens and how we can sort of work against that grain, and how just there's an inherent momentum to it. And if we just go along. W with life as usual, we're actually still kind of participating, not kind of, we're still participating in that systemic movement, towards injustices and that sort of thing.

[00:29:27]I think that's, to me, that's the first step. And so it's not so much seeing instances of racist, words or actions that are directly, kind of focused on an individual patient, but it's. Also kind of understanding the ways that the broader systems in which we participate have that kind of built in, in really, really tough ways to tease out, but it absolutely crucial ways to start to tease out 

[00:29:50] Matt: [00:29:50] Steven.

[00:29:51] Yeah. 

[00:29:51] Stephen: [00:29:51] I mean, so I think I may have shared a little bit about, This on a previous podcast, but I think I want to talk a little bit [00:30:00] more about, a, a project that I was involved in an incident more from the personal perspective. So just before the pandemic really started ramping up, I was thinking about antibiotic prescribing and we noticed we were just looking at Massachusetts and we noticed that antibiotic prescribing rates were a lot lower in Boston than in the rest of Massachusetts.

[00:30:18]And you, one of the big pushes behind antibiotic resistance is you want to reduce antibiotic prescribing because prescribing higher prescribing there's a higher resistance, et cetera. So of course, you know, I was sitting there with, my two advisors and we were, we were thinking about why this might be the case.

[00:30:34] And we assumed, we know surely it's because the doctors in Boston are better, right. They're doing a better job of prescribing they're fresh out of medical school. They know about antibiotic resistance. They're doing a better job. and we, we dug into the data more and we did some more analysis and the things just weren't matching up and weren't matching up.

[00:30:50] And finally we came across, was, I was just generating some maps with some census data and the, Ended up basically just getting like this almost perfect [00:31:00] correlation with, with socioeconomic status or, there's this, this index that we think about in public health called the social deprivation index, but it, it, it incorporates a lot of things to basically predict a person's inability to access medical care.

[00:31:12]and, and race was one of those factors and, and it matched perfectly where, where basically people in more impoverished areas. we're prescribed to your antibiotics. And it was because they couldn't take their kids to the doctor because they couldn't afford to take off of work. And there was this moment where I was sitting in the room with, with my advisors.

[00:31:28] Right. And there's just like this. Probably two minutes, we just sort of sat there in silence were just like, Oh my gosh. Like it was, it was the sense of participating in exactly what Mark was talking about. You know, there's, there's this overt racism that we think about, but there was also this, this implicit racism that I think in that moment we were, we were.

[00:31:47] Guilty of in a sense, because we couldn't cast our minds, to, you know, initially what, what the actual problem was, which was a problem of access to care. We, we assumed that it was just because, you know, the doctors in Boston are the best and the brightest, [00:32:00] right. And, and it's those sorts of small assumptions that, that perpetuate, that continued access to care because, because we're literally, the problem was we're literally blind to the problem, right?

[00:32:10] If we, if we can't, if we can't even see that, if we can't, even if that notion can't enter ourselves, Set of possibilities and it didn't for us then, then how can we possibly begin to speak about it, to address it, to think about it in a productive way. and so, yeah, so, and I think that also goes to show that, you know, these, these problems, like we said existed long before this pandemic, and this pandemic is exacerbating some and, and revealing some to those of us who, as Mark said, had the privilege of ignoring them before.

[00:32:39]but you know, now here we are, and we're starting to look them a little bit more squarely in the face. 

[00:32:43] Matt: [00:32:43] Mark you were, Oh, go ahead, Mark. If you wanna keep talking, but you were mentioning at the very beginning about home tests and you wanted to put a bookmark in light of this and access and accessibility.

[00:32:54]you want to mention anything more about that as 

[00:32:56] Mark: [00:32:56] well? I mean, I think that, that kind of covers it. The, this, that. [00:33:00] As, as we address epidemiologic questions, we just have to know that none of that exists in a vacuum, that there is no kind of pure epidemiologic space that doesn't intersect with all of these other social variables and factors.

[00:33:15] And I think, you know, to, to kind of the other, other points that we've been circling around is the, in this, this conversation, Is, you know, what do we do? Like where do we go from here? And I think, what I'd like to hear from you guys and, and to learn, is like, where do we go to hear these voices and these other voices that need to be heard, and making sure that those are being elevated appropriately.

[00:33:37]you know, I think that, Yeah, one of the things. So one thing that my wife just brought to my attention this morning was Colorado public radio posted an article where, they pulled, some of the black leaders in our local, Colorado community about what, what should people be reading right now? You know, what are things, what are recommended books or, you know, things that you recommend engaging with to [00:34:00] help broaden your understanding of these.

[00:34:02] Ingrained issues of race. And I think that I love that idea, this idea of kind of like how do we very intentionally step outside of our typical routine, whatever that is, and seek out these other perspectives, and really, really seek out voices of. Of individuals who are, dealing with this every day that we just have to listen and continue to listen more and continue to listen better.

[00:34:25]and just re I mean that, if there's one thing that I'm taking away from this as just like, maybe part of my role is to just, listen more. 

[00:34:33] Matt: [00:34:33] Yeah. Steven, you mentioned this about we're blind to the problem, and this may seem disconnected to the pandemic coronavirus, but I think it really is connected and we'll land it.

[00:34:42] In a particular way, but we, I can speak for myself only. I am blind to the, the more insidious problem, of racism. That, that seems more innocuous that you were alluding to Mark, not to overt like in your face, but the systemic problem. Well, how do we do what we see, but we have to listen. We have to have [00:35:00] ears to be able to listen.

[00:35:02] And, and who are the voices that we're going to listen to, or remind me of I'll post this article that I posted on Facebook, I'll put it in the show notes. And it was about this. This was white girl who was saying, look, you know, I'm being, I'm being called to having white privilege. I don't know what it means.

[00:35:16] I love everyone, but I'm still saying, this is my problem. Can someone help me understand where my white privilege is? And so this gentleman who was black, who was, must have been a friend. Just rift for like, I don't know, it was a few pages long before he could have dinner with his family of going in chronologically of, of the issues that he faced as a young black child, a black adolescent, all the way through to, he went to Harvard.

[00:35:41] And one thing that stood out to me was that he was a freshman at Harvard and they were, it was some intercultural class and they were going to read on Malcolm X and a few other books by African Americans. And one of the white students stood up on the first day and said, I tried reading. This makes no sense to me.

[00:35:56] Like, why are we, why, why am I reading this? Right. and just so woke to me. And [00:36:00] he kind of explained, like, he was just so irate. He's like, I've been doing this my entire life. Every, every sitcom, every movie, every book I read is through a white perspective. That makes little sense to me and you for one class, one class, one to listen to a different voice and you can't do it.

[00:36:17] And that just, that really provoked a lot in me, even like what my boys are watching on TV, what books we're reading to them and how narrow it is and their framework. And I'm not providing an Avenue for them to listen to a different narrative, a different story. So they can add that to their arsenal of understanding.

[00:36:33] Steven. 

[00:36:34] Stephen: [00:36:34] Yeah, I think that, you know, that's, those are some really great points. And, I did skim through the article that he had sent him and I was similarly struck by, by that man's points. yeah. It's You know, these, these issues are so complex. And I think that it's very easy to, to, in a way, throw up our hands.

[00:36:51] You know, we talk about systemic injustices and, I think one of my fears is that we will say that, Oh, because it is a problem for the system that no [00:37:00] individual, one of us has a responsibility for changing it or no individual. One of us can, Can begin to understand what the issues are well enough that we could even know what, what action to take.

[00:37:09] And, and, and I hope we don't fall into, into that kind of apathy. I think that's, that's my biggest concern to be clear. I do think that a lot of these issues of access to care are absolutely multifactorial. Right. we can never pin everything on any one thing. I think anyone who does claim to have the single explanation for all of the ills in the world, It's almost certainly laying.

[00:37:30] Right. But, but also as an epidemiologist, we sort of, you know, when, when you see, injustices that do fall along racial lines, you know, the really, the only conclusion is that that's, there, that these, that these, you know, the, these injustices exist that they're in play. And even if we can't necessarily observe them directly, we're certainly observing them.

[00:37:54]Yeah, indirectly from some perspectives and many other people are observing them [00:38:00] all too directly. and so I think, I think my hope is just that we can, we can really, as Mark said, just like, listen and think, and really use the resources at our disposal to, to, to figure out, to sort of. What's going on and, and to try to take whatever action we can 

[00:38:15] Matt: [00:38:15] yeah.

[00:38:15] To kind of begin to sum things up and land it. I think exactly what Mark was saying. That for me, what I've realized that I need to follow this three step process. I need to follow. Listen. Discover and then take action. I'll give the example that I shared with Mark and Steven the other day. So it was blackout Tuesday yesterday, and I didn't even know it was that.

[00:38:33] And I saw some posts and I really wanted to participate. So I'm like, Oh, I don't want to do so. I did my black image. And did you know black blackout and said a couple of statements that, how I'm, I'm learning a lot from this. And then I find out today I did the wrong thing like that, that the blackout Tuesday was not actually for, to like stop all voices.

[00:38:48] It was simply to mute the commerce and the husband, the buzz of other things, and allow the real voices to rise to the top. And instead we all posted black pictures and [00:39:00] it drowned out the voices yesterday that needed to be heard. It's like, ah, Crap. I was trying to do the right thing and I didn't. And so it's making me now trying to take a step back, right.

[00:39:09] To listen more, to really focus in discovering where I have been misunderstood, where I've done things that have just been inappropriate, participated in systemic. Problem of, of, of, of, of the, of this racial disparity. And so my encouragement to, to, to everyone is I think your, your mother-in-law Debra, wrote an email asking this question of like, what I get that you guys want to talk about helping the vulnerable, but you know, going to charity and giving to charity and talking to friends, it still doesn't solve the problem.

[00:39:39] Like. Can you talk about the hard situation of what should we do? This is before this all happened. She sent me this email and honestly, I don't have a solid answer except for what Mark and Steven was saying is like, I think right now for me is the biggest thing. I need to learn how to listen. A great book that changed kind of my life, like in a, in a habitual kind of day to day basis is called the coaching [00:40:00] habit by I'm probably going to butcher his name by Michael Bungay stainer.

[00:40:05] And, he also came with a new book called the advice trap, which I think has kind of like two parts of the same coin. And he talks about if you want to be a good coach and this, this is related that you've got to learn how to listen. And, you know, basically being a good coach is all about asking the right questions and really provoking to understand the person before you.

[00:40:22] And I think that's the biggest thing we need to learn right now as how to ask the right questions and to listen. And to understand, and then to take the action necessary because I think we're taking the action first and we're jumping, we're putting the cart before the horse and we're creating more problems, especially since this is so insidious.

[00:40:39] And so systemic, it's going to take a longer time to understand the problem so we can have our answer to. A better solution just in the same way. 

[00:40:48] Mark: [00:40:48] So, yeah, I agree. And I think I do, I wish that I had a better kind of packaged answer. it's in terms of like, what do we do? And, and I think there's this temptation to be like, where, you know, where do we put our [00:41:00] energies and our, our money and our time so that these.

[00:41:03] Things get fixed, but I do really think that the first step is one of, at least for me of kind of that personal transformation. and I did want to go, just kind of address something that I think is really, really important, Matt, that you've been saying too, is this feeling of, whether it's awkwardness or not doing it right.

[00:41:19]that. I think that's, I think that's okay. I think that there's a place for that. and a place for, for messing up with good intentions, you know, of course we don't want to mess up, but, there's a certain vulnerability that comes from just starting that process and like stepping outside of yourself into another experience and speaking into some of these issues.

[00:41:39]and I was reminded of an essay that I really love, by Audrey Lorde, who is a poet, And I came across her kind of in studies of illness narratives because she has this really incredible meditation called the cancer journals about her diagnosis of with breast cancer. But it's, it intersects with her work as an activist and as an [00:42:00] artist.

[00:42:00]and she has this really amazing. S a M called the transformation of silence into language and action. And I did want to just flesh or a cite a couple lines from that, where she talks about the process of, of moving from a place of silence, into a place of language and action. So she says, and of course I'm afraid because the transformation of silence and the language and action is an act of self revelation.

[00:42:23] And that always seems fraught with danger. She goes on to say in the cause of silence, each of us draws the face of her own fear, fear of contempt, of censure, of some judgment or recognition of challenge of annihilation. But most of all, I think we fear the visibility without which we cannot truly live.

[00:42:42] And that visibility, which makes us most vulnerable is that, which also is the source of our greatest strength. She speaking in that, you know, particularly too. Other members of the community of, communities of color, who need to be more visible. and, and I think one of the things that we can do is, you know, we speak out [00:43:00] of our silence and, and out of our humility and kind of trying to understand, but we also, try and elevate those voices or get out of the way of those voices that are trying to speak out of their silence and need to be visible.

[00:43:12]so kind of an abstract answer. and a difficult one, but those are some of the things that I've been thinking about and reading in the last couple of weeks. 

[00:43:19] Matt: [00:43:19] That's great. I was thinking something similar of. Yeah, absolutely. Like I feel so, like in a different situation, feel awkward, even doing this episode, it's just been hard for me to like, I don't want to say the wrong thing and I probably screwed up by saying the wrong words and, and I think there's a, there's, like you said, there's an okayness with this in the sense of where I had a friend who talked about who was working with someone and they were black and, and she was trying to like understand her, her world.

[00:43:44] And it kept getting the pushback, like, well, you don't understand, you don't understand. And it was starting to get frustrating. They couldn't quite. Even just understanding each other. And it's almost to the point where I feel like my response has to be at this point in time that, yeah, I don't understand.

[00:43:57] And you have to [00:44:00] understand that. I don't understand. And that's okay as well. Like I don't, I will never understand, and I'm going to try for the rest of my life to understand, but there are things by which I'll probably constantly screw up. Yeah. But the most important thing is to lean in, to listen and to, and to take some kind of action.

[00:44:17] That's require a deeper sense of vulnerability and not a script and not something that's succinct. It's not something that's social media driven, but tenderness and empathy. it just indigenous, it just reminded me of going back. It's all about listening to the qualified professionals and right now, It's those who have the voices who have experienced the, the, the, the judgment and, the racial disparity in the race and the racism, and to listen to these voices.

[00:44:41] So I'm trying to every day listening, understanding, and trying to take better action. And that's, that's how it all started with, with, with COVID. I'm like, I have no idea what's going on and I need to learn to what it means to listen to them. Qualified professionals and not just annoys and it's not easy.

[00:44:56] I was thankful that I had Mark and Steven right at my disposal to be able to do that. [00:45:00] And this is a bigger and difficult situation, but I have friends who, who, who are, I believe have that ability to do that for me. And I hope that's there for you as well. So I encourage you all to, to really take a strong moment to listen and to become aware and to discover and to take action.

[00:45:17] Okay, that ends it for this episode. Thank you so much for listening again. If you have a free moment, leave a rating or review on iTunes as well. If you can support this podcast to podcast or a onetime payment on PayPal or Venmo all in the show notes, you want to contact Steven S T EP H E N K I S S L E R on Twitter. If you want to reach out to me, you can do that at [email protected] about the podcasts, the episodes, or anything. Feel free to reach out to me. We'd love to hear from the people who listen to this podcast, to hear what's going on in your side of the world. Well, we thank you for listening and we will see you again next week.

[00:45:52] Take care. 

[00:45:52] Bye bye.