A rather "personal" appeal for men to wear masks...

Stephen, Mark, and Matt are back with a lot to chat about and apparently need to learn sign language for our supporters...

We offer transcription now! Caution, it is AI transcription so please excuse AI errors.

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Matt's Dropped a New Episode of Living the Real Featuring a Great Conversation with Mark Kissler on what "real" means to him, and how he tries to live it out in his professional and personal life:

• Subscribe/Listen to Matt's Living the Real Podcast: https://bit.ly/3fyPIlx
• Download Matt's visual map of his conversation with Mark here -  http://livingthereal.com/markkissler
• Listen to Matt's episode on building margin in your life here - https://bit.ly/2WIM4yr

Things Discussed on Episode:

• TWiV 640: Test often, fast turnaround, with Michael Mina - https://bit.ly/2De8vF9
• Why do we have different blood types — and do they make us more vulnerable to Covid-19? - https://cnn.it/3jU5tXt
• CDC: One-third of COVID-19 patients who aren't hospitalized have long-term illness - https://nbcnews.to/3geU3eG
• Testicles Can Suffer Damage From Coronavirus Without Actual Infection, Study Says - https://bit.ly/3gcu7Ag
• Why do so many COVID-19 patients lose their sense of smell? Scientists now know - https://bit.ly/3fb6Kpp
• The CDC Updated Its Guidelines for When People With COVID-19 Can Be in Public Again - https://bit.ly/3jLZ9Bf
• Hygiene Theater Is a Huge Waste of Time - https://bit.ly/2BGhfmZ
• Flower in the Crannied Wall Poem - https://bit.ly/2P6oyY3

Transcript

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[00:00:00] Matt Boettger: [00:00:00] You're listening to the pandemic podcast. We equip you to live the most real life possible in the face of these crises. My name is Matt  and I'm joined with my two good friends who all back, dr. Steven Kissler epidemiologists at the Harvard school of public health and dr. Mark Kissler. Who's a doctor at university of Colorado hospital.

[00:00:15] Hey guys, how's it going? 

[00:00:17]Mark Kissler: [00:00:17] Great. Good to see you, man. 

[00:00:18] Matt Boettger: [00:00:18] Wow. Great. For the, you were so excited. There was a, a two second delay, and since we are trying to go live and you could only hear me, I quickly gave a manual to Steven and Mark on how to use sign language. So we can go live and we're going to sign language this entire episode.

[00:00:36] So, Nope, we're not totally joke. Lame joke, dad joke. So it's good to see you guys. I'm glad we're all back. Mark, you've been going crazy at the hospital. See if you're just going crazy. Being a scientist or are you just going crazy? 

[00:00:51] Stephen Kissler: [00:00:51] Yeah, it doesn't need any more explanation. 

[00:00:53] Matt Boettger: [00:00:53] Yeah. It's awesome that, yeah, it's like the shiny, so a few things to get going.

[00:00:59] I always see [00:01:00] love the reviews. Thank you so much for them. We can always use more. We've tipped over 100. Thank you. I would love to grab over 200 relatively soon, as well as. What else? Oh, I did say something, but I forgot. Oh yes. We are almost at a hundred thousand downloads. So I'm guessing by this week, we'll tip over the edge.

[00:01:19] Thank you so much. We'll celebrate it with a kazoo, next week or something like that. we could always use more set forth. It does, it 

[00:01:28] Mark Kissler: [00:01:28] feels a little bit like this is a PBS pledge drive. Like I've just hear the numbers. It's just like, there's a little bit of that. It's like, you know, yeah. 

[00:01:37] Matt Boettger: [00:01:37] We shouldn't have an intermission where like a little dance it's like that high risk Irish dancing.

[00:01:41] So, that that'd be Fergal. For a, if you can provide an Ireland, 

[00:01:47] Mark Kissler: [00:01:47] actually Yani is on after, after us, we interrupted the alive. 

[00:01:53] Matt Boettger: [00:01:53] Oh man. Oh man. I've seen river dance. It's incredible. The nineties, I loved it. It was so good captivating [00:02:00] riveting. Okay. So we could always use more financial support. We love it had a lot stuff we're trying to get paid off your patron.com/pandemic podcast.

[00:02:08] So as little as $5 a month can go a long way or just a onetime donation, PayPal Venmo all in the show notes. And just this morning dropped into their episode, had a feature Mark on living the real. It was fun, man. It was a heartfelt. a conversation coming out of some pretty difficult, experiences and, 

[00:02:26] Mark Kissler: [00:02:26] It was wrong.

[00:02:27] Yeah. That was wrong. It was right. It'd be interesting to hear how it turned out. 

[00:02:31] Matt Boettger: [00:02:31] Yeah. So check it out, live in the real.com. you can subscribe there. I will have it in the show notes and same thing, mind map to a conversation with Mark found some things that really hit me and struck deeply. You can do that at if you want to see it.

[00:02:44] After the podcast go to  dot com slash market Kissler. It's a little difficult, cause there's two Ks in there right in the middle smashed sandwich. So yeah, MRO. K K I S S out Hellyar so check it out. Okay. Let's get going. We have lots to cover. First of all, last week it was [00:03:00] just Steven and I. Mark was, was just doing some intense work at the hospital.

[00:03:04] We brought up paper tests, right for COVID. And you said you're gonna do a little bit of digging. I came across that video. Hey Steven, have you seen this video? And of course, like usual, I know the dude, so, so it was a great video. I'll put in the show notes, but what did you come up with with this whole.

[00:03:20] Paper tests. Is it accessible? Can we get it going? What are the roadblocks? Right. 

[00:03:24] Stephen Kissler: [00:03:24] So, yeah, so the paper tests themselves exist. the issue is that their sensitivity and specificity is not at the level that the FDA basically wants in order to approve it. So they set the, basically the, the sensitivity and specificity of the tests relative to the PCR tests, which are the things that you normally get.

[00:03:43] You know, if you get the cotton swab stuck up your nose, that's, that's, that's, what's happening to you. and so, but that's, that's tricky because, so you can use tests for two different reasons. You know, one of them is for clinical decision making, where you really want a test. That's great. And that can really tell if you've [00:04:00] got any virus circulating in your body.

[00:04:01] You know, you need to know what, like, sort of what course of treatment you need, but you can also use tests for surveillance. And that's where these paper tests are really bad. And, and, and that's the issue is essentially that the FDA doesn't have a separate track for regulating, tests that are forced surveillance rather than for clinical use.

[00:04:18]

[00:04:18] Mark Kissler: [00:04:18] And so this is, this is really interesting, cause that's been one of the big issues even early in the pandemic was some of the logistical challenges with getting tests approved through the FDA. 

[00:04:30] Matt Boettger: [00:04:30] Right. 

[00:04:31] Stephen Kissler: [00:04:31] Right. Well, and there's, there's some history to this too, just in the course of the pandemic, because another one of the issues is that, there, there was this flurry of antibody tests that came through that the FDA.

[00:04:41] Gave emergency approval too. And a lot of them ended up not working very well. and so I think that to a certain extent, they're also kind of trying to save face from that. and to not have another scenario where they're drawing a lot of flack because they approved tests that, that don't don't work that well.

[00:04:56] But these, these are. Fundamentally different tests, they would be [00:05:00] used for a different purpose. They're used to tell if you're infectious, which is well useful thing to know, rather than if you've had the virus at any point. Yeah. Which is also useful to know, but it doesn't help you stop the spread of disease.

[00:05:10]So I, yeah, I can talk to Allie. I I've for the last week, you know, at various intervals, I've just been pacing around our living room, like talking about like, what can we do about this? Because it's, I think it's so important. I mean, it's, this is really, probably one of the. One of the things that I think is most likely to have a direct and immediate impact on reducing the spread of COVID like, it's, it's there, we have the technology.

[00:05:33]and it's really about sort of the regulation at this point. and so people are writing to various policymakers, lawmakers to try to figure out like what we can do. actually the, the hosts of the interview that Michael was on have started collecting, These letters that people have been writing to their senators, that you could use as templates to sort of write to your own to try to do something.

[00:05:52] But, but I think the problem is we don't really know how to access the people who are in charge of making these decisions. Totally. So, if anybody knows anybody who's working [00:06:00] high up in the FDA 

[00:06:02] Matt Boettger: [00:06:02] yeah, totally bring them on the 

[00:06:04] Mark Kissler: [00:06:04] show technology. That's what it is. Do you know, what's the sensitivity, specificity specs on these tests.

[00:06:12] I'm just curious if you know, 

[00:06:13] Stephen Kissler: [00:06:13] right. So, so the issue is that the sensitivity and specificity vary over the course of your infection based on how much virus you have in your body. Right? So it's, the sensitivity and specificity is pretty poor immediately, immediately after you've gotten infected. And then.

[00:06:28] Long after you've been infectious. So when you know, you carry a viral RNA in your body for probably weeks after, after you've gotten your illness and sensitivity and specificity are often measured based on that long tail after you're no longer infectious, but the tests are very sensitive and specific when you're in the period where you're.

[00:06:47] Cranking out virus, which is when you want to know when you're in fact affected anyway, because that lets you determine so 

[00:06:53] Mark Kissler: [00:06:53] incidentally, I mean there's no diff even are even the tests, the PCR tests are more [00:07:00] sensitive and specific. They have a higher, you know, reliability when you have more viral RNA circulating.

[00:07:06] So the same thing, you know, we've in the hospital we use, if we have a height. Concern that somebody is infected and they test negative with the initial PCR. we try to get a lower respiratory tract sample, like a sputum sample because the yield of that is a little bit higher, so it's harder to get.

[00:07:22] And so it, same, same principle applies that. and it's kind of an interaction between what your pretest probability is. And then these test and characteristics that gives you a sense, after the test about whether or not you're infected. 

[00:07:34] Matt Boettger: [00:07:34] Yup, 

[00:07:34] Stephen Kissler: [00:07:34] exactly. 

[00:07:35]Matt Boettger: [00:07:35] So what, what I mean. This is, this is mind boggling to me.

[00:07:39] Like, yeah. I mean the FDA, I'm pretty sure whoever they are. I'm sure they, they, they listen to things and I like they're, they're not just in this bunker by themselves making up decisions. I feel like this is all over the place. So it's, it's it's mind boggling me. That's something that hasn't been already, even publicly announced from either the white house or [00:08:00] someplace that this is a real possible hope that we're even looking into.

[00:08:04]Which I don't even think I hear that, which is just like, why is there so many roadblocks to having scientists and, and to, to policymakers to quick iterate on something that's and I guess it just as a just gear base. So you, I mean, I go, you don't have all the answers that it was crap. We really screwed up with the antibodies.

[00:08:23] Let's make sure we get this right. I get that. But the same time when so many people are kind of growing almost exponentially, like the virus clamoring for this opportunity, why isn't this beam? 

[00:08:35]Stephen Kissler: [00:08:35] Pardon it? I think that this comes down to, to some extent too. the difference between thinking as thinking clinically and to thinking from the public health perspective, in a way, and I, and, and the FDA really was developed to.

[00:08:49] Foster and to regulate clinical medicine to sort of, and, and I think it's really interesting because a lot of times clinical medicine and public health go hand in hand, but there are times when they do diverge or [00:09:00] defer to some extent or the emphases differ. and so, the benchmarks that you use to measure the effectiveness of something.

[00:09:07] In a clinical setting or just not necessarily the ones that are relevant in public health. And I think that that, that turns out to be just like that. That's a really large gap if you're, if you're really, used to making decisions based on their clinical efficacy, it's just really hard to start thinking in terms of populations, in terms of reducing spread in terms of allowing a lot of imprecision for the sake of the greater good.

[00:09:28]and I think it's, I think it actually probably, yeah, just has a lot to do with habits of thought and with traditions and these institutions, that are deeply, deeply ingrained. so yeah, I 

[00:09:38] Matt Boettger: [00:09:38] think there's a lot there. I mean, I think there's like two things that I feel like this, this pandemic is just going to expose so many opportunities for growth.

[00:09:45] Just like you said, early on Mark with the CDC and the over rigid, just legislative or just the regulations that prevented for us to iterate quickly. And then of course there was some moving around and changing and modifying and giving exceptions to bring things out quickly, a little late to the game.

[00:10:00] [00:10:00] I'm guessing we're at this other roadblock. It's another area by which we were being revealed the same problem, different manifestation of this, which is just okay. Great opportunity. And I'm just like, I don't know. I'm just mind boggled that we haven't done anything to, to, to, to move it forward. I had another thought I totally forgot about it.

[00:10:16]I'll bring it back in a second. It was, it was really good too, but I'm just, I'm just absolutely. I'm just speechless. I'm really speechless. Yeah. Oh yeah. I think the thing is I was gonna say, it's like, now you guys have to correct me on this one. I feel like this is like the inverse. We're talking about how clinical is so important.

[00:10:30] We were talking about the difference between anecdotal evidence and clinical and, and how they work. But I think it's almost tipping the scales, the other direction, this case it's like, maybe not maybe a bit, because it's still clinical. Cause you're still looking at it, but now it's like, well, the overarching.

[00:10:44] Result of this, the experience of this would be over every day would be beneficial, right? The experiential we'd beneficial that overweights the clinical diagnosis. Am I wrong to say it's kind of the other, other side? I think, 

[00:10:56] Mark Kissler: [00:10:56] well, I think that, there's a danger in conflating, the difference [00:11:00] between a public health frame and a clinical frame, and the difference between a scientific.

[00:11:06] A evidence-based frame and an anecdotal frame. So I think those are two they're two separate axes, because I think what we need to do or ask questions in a robust, scientific way, you know, that's evidence-based, but we may have different thresholds for acceptance of, for instance, of like sensitivity and specificity in, if we're using it in a public health way.

[00:11:28]and so it's one of those things that it's, you know, what are the, what's the question that we're asking first and then how do we. Make sure that our metrics adhere to the question, you know, how, how that's validity right. Is like, does it answer the question I'm asking? And I think what Steven's alluding to is that we're very used to asking questions about.

[00:11:47] The relevance within a healthcare setting for a patient who's infected for an individual patient. We're not very used to, asking these questions from an epidemiologic frame, which is sure, maybe the paper [00:12:00] test, isn't going to be all that useful, you know, for you, Matt, if you're feeling sick, but it's going to be tremendously useful for these other things.

[00:12:06] And so I think, I think that's where that comes from. 

[00:12:09] Matt Boettger: [00:12:09] Okay. Great. Thanks for the update. I'm still hopeful. Anybody in there works for the FDA listening to this podcast. I don't know. Talk to Steven and Mark. Get something done. Please 

[00:12:18] Mark Kissler: [00:12:18] stop listening to her podcast. 

[00:12:20] Matt Boettger: [00:12:20] Yeah, it's tough. Call Steven right now. His phone rings.

[00:12:24] We'll start this episode right now. We're gonna wait five seconds. Okay. Okay. So let's, let's continue on blood types in coronavirus. I've been waiting for this. I'm going to bring you on Mark's we, you weren't on last time. Is there, is there a relationship. Between these two or what's, 

[00:12:39] Mark Kissler: [00:12:39] it looks like the last, last word that I saw.

[00:12:43]so there was an article from, July 17th that at mass general hospital, which is the local little local hospital down the street from us. Yeah. Mass general. No, it's one of the, you know, it's one of the preeminent. hospitals in the, in the country and [00:13:00] they did a study and it looks like they didn't see a relationship between blood type and severity.

[00:13:05]and there'd been some question about if blood type a was more prone to severe disease is, and, I think they did see some signal in this about, testing so that, that there were certain blood types that were more. Likely to test positive than those that were not. I don't see a lot of clinical utility in this, to be honest with you.

[00:13:24]and just in terms of like how I treat patients and would I take their blood count into effect? I think there's other things that probably have a much higher fidelity, you know, a high, what I call it kind of a higher signal in terms of predicting disease severity. Then blood type, things like certain inflammatory markers that we're looking at.

[00:13:43]and really just the clinical characteristics, you know, I think, that's far more useful to me, as a clinician. So it's interesting. and I think, you know, like we said, anything, all of these studies contribute a little bit to our understanding of the disease and how it works. and some of it's going to be useful.

[00:13:59] In the short [00:14:00] term, some of it may be just helpful and the longterm, some of it's maybe more academic interest, so great. 

[00:14:06] Matt Boettger: [00:14:06] You know, you reminded me of what you said that this is kind of like a, maybe more of a marginals like results and where you were saying there's other things right now, kind of with that article that wasn't going to mention the men branch to cut the cutaways.

[00:14:18] Right. That 40% of Americans are at risk of severe. And I think that's what you're getting to. It's like the 40% is basically those people have diabetes, high blood pressure. 

[00:14:27] Mark Kissler: [00:14:27] I have an article that says, you know, the headline says 40% of us adults are at risk for severe COVID-19 complications. You gotta also write one that says 40% of us adults suffer from obesity, hypertension, and cardiovascular disease and diabetes, you know?

[00:14:41] And, but I don't know. I just, as, as we. Not to get too bogged down in this, but as we're in a time in which there's a lot of skepticism about the way that the media is covering COVID-19 from certain quarters, I think it's really ideally we would be [00:15:00] not creating more noise. You know, that that's, that just is what it is.

[00:15:05] I think just the, what are what's our goal, you know? And if our goal is to achieve a certain sense of solidarity and like, let's, let's talk reasonably about. kinda like what, you know, doctor Katz, we were talking about David Katz many, many weeks ago. I wonder what happened to him. but you know, he wrote that article that was very measured.

[00:15:26]that really took her of what I thought was a really good public health approach to this, you know, without downplaying the reality of what's going on. And I think that that sort of thing is a lot more helpful than this sort of thing. in terms of bringing people together and sparking reasonable conversation.

[00:15:43] Matt Boettger: [00:15:43] Yeah. Yeah. Where do you go? Well, which is which news outlet is he going to be in? Because either going to be on one extreme or the other, like I'm the middle guy. Nobody wants to, 

[00:15:53] Mark Kissler: [00:15:53] it gets it's reasonable. 

[00:15:55] Matt Boettger: [00:15:55] He makes sense. Nobody wants the rationality right now. 

[00:16:01] [00:16:00] Mark Kissler: [00:16:01] I'm just curious if he's written anything since then.

[00:16:03] Matt Boettger: [00:16:03] Yeah, yeah. Be great to follow up on him. Okay. So. vaccines. I want to throw it to you, Mark, because there's been two vaccines now that are, Steven's mentioned a number of things the past couple weeks, which have been great. we're seeing one vaccine coming in to the next stage trial is really two vaccines.

[00:16:17] And you were saying that there might be something coming your way too, in your hospital soon to participate in the trials. 

[00:16:23] Mark Kissler: [00:16:23] Yeah. So it's a we're enrolling patients, which is super exciting. so, yeah, news was breaking kind of earlier this month, that university of Colorado hospital is one of the sites that's going to be participating in the trial for the, modern vaccine.

[00:16:36] And this is the first line. So it looks like they're looking to recruit a thousand patients, and. Yeah, as we talked about clinical trials have different phases. and this is a little, both at safety and efficacy and it looks like they're gonna follow patients for about a year. and so, you know, we've, we've had lots of concurrent clinical trials going on throughout for therapeutics.

[00:16:56]but this is to my knowledge, the first one related to vaccine. [00:17:00] So that's pretty cool. 

[00:17:01] Matt Boettger: [00:17:01] That's great. And then now I saw this article again, we see this, I see it in my circles of my friends, who I see a lot of things in my circle of friends, but one such thing when it comes to the vaccine, just, you know, they're, they're minor side effects, but they could be pretty bad.

[00:17:15] I know one thing I want to throw to you, Steven, is I don't really know the extent of how a vaccine does. How do they, how they modify things, a lot of phases, you know, like I know that they're trying to look at. To what extent when you opened up to 30,000 people, does it remain healthy? How many side effects, but if there are more side effects, did they change them or did they just, I put that as their footnote of the increasing list of side effects.

[00:17:37] How does that work in this phase of the game? 

[00:17:39]Stephen Kissler: [00:17:39] Yeah. I mean, in this phase, if they were to actually change the composition of the vaccine itself, they have to go right back to square one. So, if, if anything about either the molecular compound or the things that are in the vaccine as well, so vaccines often include both, both the active thing that your body is mounting an immune response to, and something called an adjutant.

[00:17:58] Which basically [00:18:00] sparks your immune response a little bit more heavily, so it makes it more effective. Okay. And if you were to change either of those things, especially the vaccine component itself, you'd have to start back at phase one. So now they're looking at dosage and just trying to get a sense for the probabilities of these things.

[00:18:14] Okay. so, but fortunately, there, there are so many vaccines that are being, that are sort of in the pipeline. Yeah. That if, if some fail, there's still a lot of different, different possibilities that are coming through, so. Okay, great. 

[00:18:26]Matt Boettger: [00:18:26] you know, in light of COVID itself, I read an article about one third of COVID patients who are aren't are not hospitalized, have a longterm illness.

[00:18:34] I wanted to throw this past. You guys have you guys seen much about this? I wanted to throw this, this click bait headline for me, for all you men out there who don't want to wear masks. Here we go. testicles can suffer damage from coronavirus without actual infection study says science times. Alright.

[00:18:50] When to wear a mask, 

[00:18:51] Stephen Kissler: [00:18:51] when to think twice, man, 

[00:18:52] Matt Boettger: [00:18:52] where it met with were proudly, proudly. Keep your manhood on your face, though. Yes. [00:19:00] On your face. Keep your. So in light of this really big headline, that's going to shake the world, that, that w what, anything, anything new on this? Or is there, are we seeing anything about this, that even small, minor things have longterm?

[00:19:16] Impacts that could be pretty 

[00:19:18] Mark Kissler: [00:19:18] tough. Well, that's been one of the things that we've talked about, in just in a clinical setting is it does seem like there's certain symptoms that linger on and people feel pretty credited for quite a while after this. and I don't know if that's because it's a novel virus to our immune system or it's just the way it is with this.

[00:19:34]but that's definitely, you know, I've seen that and I, you know, other people don't have such lingering effects, either, but I think that that's something that's, that's real. 

[00:19:42]Matt Boettger: [00:19:42] Okay. 

[00:19:42] Stephen Kissler: [00:19:42] Yeah. Yeah. I was, I was looking at the statistic, I think before we got on and, If I, if we're reading the same article, it was talking about that, symptoms can last, like they said, like weeks up to months.

[00:19:53] And I think the average duration of a viral upper respiratory infection is on the order of two weeks. Anyway, like you're going to be feeling [00:20:00] kind of rough from that for a couple of weeks. So that depending on where they're cut off of longterm symptoms, where that, that could sort of inflate that. But that said, I've also been hearing a lot from, People in the hospitals and primary care settings who are really starting to focus more on these longterm effects that that do seem to actually, I think that is actually a feature of COVID that, that, that is distinct from other viruses as far as we can tell, but there's, there's still just like, We haven't run those studies yet.

[00:20:25] Matt Boettger: [00:20:25] Okay. And I, you know, it's not like I want to get these, these like headlines to kind of make people more afraid of the virus. My response is like, I just want people to look at it in a real sense. Like just last week, I'm talking, I'm hearing the stories about friends and families who are closed circles, which I think were a decent sample population.

[00:20:43] Yeah. Who, you know, who, who really believe it's still all conspiracy that even though the mortality rates are just make believe, does it get people to be afraid? I'm like, I just can't believe this. Right? So again, it's not trying to inculcate fear that there might be longterm effects, but just to hopefully take it, you know, Hey, my goal, our goal, take it moderately.

[00:21:00] [00:20:59] Seriously. It'd be a great first step. Right. 

[00:21:02] Mark Kissler: [00:21:02] I found the way that fear is mobilized in conversations about coronavirus to be interesting. lately, I've heard that. You know, from a lot of spheres and I think there's some valence to the language of like, don't be afraid and, you know, or like be not afraid.

[00:21:16] And there's some, it, it often that's even in, in kind of like religious context that I, you know, that you hear that because it's, and I've, it's just interesting to me because there's a discourse underneath that discourse about like, so the assumption there is being, what is it that. You know, one is afraid of when, you know, they're the, the, that the other person is afraid of when you're exhorting them to be not afraid.

[00:21:38] Like there's another discourse going on there. and, and often there's a fear. Yeah. There's a complimentary fear, whether it's about governmental control or conspiracy or about other things. And so you're out of, out of one fear into another or from, you know, and it's, it's complicated. Cause I, I really, that, that phrase to me, Personally means a lot.

[00:21:57] And I have a lot of, it, it, I really [00:22:00] like that. but I think that, when it means. Actually what it says, you know, which is, you know, don't, don't operate out of this place of fear and suspicion and anxiety, you know, but out of a place of abundance and, and trust and care and that sort of thing. And I think it's just funny, the way that that language can be mobilized, for these implicit meanings.

[00:22:23]I just find that that's, that's a personal note, you know? but I've heard it a lot. And I think it's just worth, you know, recognizing that sometime just what, what that means. And what's the valence behind that. And what's, you know, the, the many layers of, kind of implication that are, that are in that phrase.

[00:22:40] And, so I don't know, just cause you said that that came up in your family conversation and things like that. Yeah. 

[00:22:46] Matt Boettger: [00:22:46] No, that's, that's great. It's kind of the whole, you know, tolerance and intolerance and how we can use these things. So. Quickly to like, you know, declare someone to be intolerant and judge them in the fact that yourself, you have your own [00:23:00] intolerance and you advocate tolerance, but it's, it's idea that things are complex and not to reduce things to some kind of quick trait sentence to get your point across.

[00:23:08] But yeah, 

[00:23:09] Mark Kissler: [00:23:09] so, I mean, I think, you know, the, the implication being that if you're. if you're kind of falling more on the side of, certain prudent measures, like wearing a mask or, you know, continuing physical distancing, that that must come from a place of fear, as opposed to a place of, you know, wherever else it may be coming from.

[00:23:25]I think maybe that's, that's the assumption that is most troublesome to me is like, you know, don't, you know, don't assume that I'm acting out of fear. you know, we're, we're like, you know, it's not, it's not about fear, it's about other things, you know? 

[00:23:40] Matt Boettger: [00:23:40] So anyway, it goes back to, I think when you and I were chatting Mark yesterday on the, on the real podcast, I'm just like, just trying to uphold a less of a sense of determination.

[00:23:49] I determine who you are and what you're experiencing, and really try to entertain discovery instead of just trying to. Like, maybe even asking the question, you know, I'm just curious, why, why do you, and then, [00:24:00] and then allow that to inform like, Oh, because you have an elderly mother or, Oh, I get it. You know, if I constantly tried to understand how the person versus the pigeon hole them, right.

[00:24:08] We can learn a lot from that. And I think we could 

[00:24:10] Mark Kissler: [00:24:10] come together anyway, kind of a left turn, but the lane had a lot of paying attention to our language. So. Cool. Yeah. Let's keep rolling. 

[00:24:18] Matt Boettger: [00:24:18] Let's go with, the next one here. Scientists know why people lose sense? I've smelled. 

[00:24:23] Mark Kissler: [00:24:23] All right, Mark. Well, okay. This is good.

[00:24:25] My favorite, my favorite thing about this is that I learned about a new cell, today because of this article that I didn't know existed. so I'm stoked about that. and so I love, so histology is super cool. I dunno if you guys have ever in, in your past lives gotten to take a class on histology, but I had a legendary, histology professor at Baylor college of medicine.

[00:24:47]and, 

[00:24:48] Matt Boettger: [00:24:48] hold on, quick pause. No histology. It clearly for my sake is said, it's the study of what? The nose, the smell. 

[00:24:54] Mark Kissler: [00:24:54] That's great. No, it's about cells. So it's about cells. It's all about structure function. So it's about, [00:25:00] it's about the way that microscopic. Processes like the set, the way that cells and tissues are arranged, all is coordinated in the functioning of an organism.

[00:25:09]and so I love it because it's, it's one of the most, it's really, it's a place for just a huge amount of wonder and awe. so my histology professor, dr. Frank Kretser, who the late dr. Frank Kretser, he passed away actually, while we were down in Houston at med school. but he, he would begin our histology classes, a, Poem by Lord Tennyson.

[00:25:29] So it was cranny in the crannied wall. W we should attach this to the show notes, but essentially this is, you know, it's a Poe poem about plucking a flower growing out of a wall. Beholding the root of the flower and, you know, and he says that, Oh, I'll have to find it. we'll put it in the show notes, but it's essentially the sense that you can perceive the hole through the very particular and the tiny.

[00:25:53]and I just love it. And that's what histology is all about is like perceiving, you know, these glimmers of the whole organism and the function and, [00:26:00] you know, in the, in the little, and so. Anyway. the, if apparently, I was back in the room, 

[00:26:08] Matt Boettger: [00:26:08] it's riveting. 

[00:26:09] Mark Kissler: [00:26:09] We're learning about these sustentacular cells, which is like, it sounds to me like a combination of sustaining and spectacular.

[00:26:17] That's like, I don't know who who's. PhD candidate got to name those cells, right? Spending a 

[00:26:25] Stephen Kissler: [00:26:25] lot of time something your daughter 

[00:26:26] Mark Kissler: [00:26:26] sustentacular cells, which support olfactory neurons. So anyway, you smell because there's nerves in your nose and particles. Hit hit the nerves and it sends a signal to your brain.

[00:26:38]and apparently there are as with many neuron cells, there are cells that just support those. So they serve a supporting function. It looks like coronavirus actually attacks the sus sustaining cells, these system, tacular cells, rather than the neurons themselves. So there'd been a question about, is it a neuro you know, there's some viruses that actually attack nerve, and, it.

[00:26:59] It doesn't seem to [00:27:00] be the case. It seems to be that these it's the supporting cells. So interesting. And kind of geek out on that a little bit. it is what it is. 

[00:27:08] Matt Boettger: [00:27:08] That was great. Well, good. Well, good. Well, the good news is it's not permanent. 

[00:27:11] Mark Kissler: [00:27:11] That's right. It comes back. Temporary comes back. Yup. Comes back.

[00:27:14] Yeah. 

[00:27:15] Matt Boettger: [00:27:15] Great. Okay. So Steven you're way coronavirus. I just say this has to be quick because you've been saying this Mark has been saying this since March Racine it now coronavirus cases seem to be kind of ebbing a little bit in the round. The Sunbelt Washington post says, and we're starting to see a rise in the Midwest.

[00:27:31] Is that an accurate statement? I haven't been able to look, but we've seen this and this is kind of following what you were expecting. Okay. 

[00:27:37] Stephen Kissler: [00:27:37] Yeah, that seems to be the case for me. And it looks like, and I've been following Arizona, Florida. In Texas, some of the places that have been really rising in the Sunbelt, and it seems like both the number of cases and the positivity of those places.

[00:27:48]it seems to be leveling off. It's too soon to say if it's actually turning around, but I think that's good news. but you're right. A lot of other places are starting to rise and, and we were talking a while ago about how a lot of, [00:28:00] especially particularly infectious respiratory pathogens often just hit.

[00:28:03] Places that have high population density sooner than others. And so to some extent, you know, it's, it's so interesting. Like I've been getting pretty consistently calls from reporters asking, you know, sort of like what's happening. Why are cases rising in different places? Did we reopen too soon? Like, is it people going to bars?

[00:28:21] And it's like, well, yes, yes, absolutely. Those things are all playing into it, but there's also this, I think sometimes we try to attribute, what's happening a little bit too strongly with the actions that we've been taking. So absolutely, you know, like. Going to bars, whatever, interacting with people like that.

[00:28:35] That is how disease spreads it's a necessary condition for disease to spread. But I think also partly what we're seeing is just this diffusion process of contagion through the country that's following roughly around of, population density and just sort of where people are and where they travel to.

[00:28:49] So, it's this really mixture of different elements. that's contributing to why we're seeing rises in certain places at certain times. Yeah. 

[00:28:59] Matt Boettger: [00:28:59] Okay. Great. [00:29:00] next thing here, w CDC changed their policy a little bit on when you can go back, leave isolation. I clicked on it. I don't think I have it, but I knew it was three conditions, but the thing the ones has changed, what used to be 14 days from the onslaught of symptoms now reduced to 10 days.

[00:29:14] So it sounds like there's been a lot more research to say roughly about 10 days. you can go back. I'm curious. Just throw you guys. What do you do when like, cause we're dealing with our own, our own work. That it's one thing if you're sick, but if you have kids that are sick right at your home, you have a fever, you know, we're saying, okay, stay home then.

[00:29:30]and just, just to be on the safe side, which that's our policy. That's great. Totally. But my question is, would you have any idea of like how many days, like it's one thing, if you can, we got it. But if my son had had a fever last Monday, 102.8, when, when is it okay for maybe responsible for the parent to be okay.

[00:29:47] I think I passed the threshold.

[00:29:48]Yeah. Anybody ABA, anybody? Nope. 

[00:29:51]Stephen Kissler: [00:29:51] Mark here for sound. Mark. 

[00:29:53] Matt Boettger: [00:29:53] Lost your sound Mark. 

[00:29:54]Mark Kissler: [00:29:54] How's that better. 

[00:29:56] Matt Boettger: [00:29:56] There you are. 

[00:29:56] Mark Kissler: [00:29:56] Are you there? You're back up. This is definitely something that [00:30:00] we've been talking a lot about. both personally and my kids' school, as they're trying to figure out what to do when we go back.

[00:30:05] Cause how do you know? You know, there's a lot of things that cause fevers and kids. And so if you're going to be sort of, the most conservative route would be after every fever, do we quarantine that long? Well then who. Like who's ever going to be at school at that point. you know, and, and so I think this is, I don't, I don't have a great answer for this.

[00:30:24] I don't know if Steven, you know, he was shaking his head while my mic was muted. So I don't, I don't expect for him to having a great answer either. I think 

[00:30:32] Stephen Kissler: [00:30:32] that's why we need the paper test sets. 

[00:30:34] Mark Kissler: [00:30:34] That's exactly right. That's exactly right. Is that this is the scenario that widespread. Low cost testing could make a really big difference.

[00:30:42]so that we reduce the burden of missed days at school, miss days at work for parents who were taking care of kids who had a fever last week, you know, this and that. That's why it's so important. And I do think a lot of these, you know, we've had a lot of questions about schools and stuff. And I think Steven, correct me if I'm wrong, but there's a thought that this is going to have to [00:31:00] be sort of a local determination that you're going to have to enter in a conversation with the families and your institution with the local epidemiologists who know what the prevalence is, in your area and the, your ability, you know, based on your school environment to do certain physical distancing measures that may or may not be.

[00:31:18] More or less helpful and, and then kind of make a local determination about your policies, which is tough. It'd be nice to have kind of blanket guidelines for everybody. but as we've seen this virus just has, you know, everything, all these factors are pretty substantial in the actual spread.

[00:31:36]Stephen Kissler: [00:31:36] Yeah, totally. And I mean to sort of take that maybe one step more general. I think that, that there's been a really consistent element of this outbreak that has required us to reevaluate, systems and thresholds and things that we do to determine, you know, how much contagion is in a given place. Like, like there's, there's so much about.

[00:31:56]covert that is very local and very community based and varies [00:32:00] depending on the comorbidities in that community. And just what time of year it is and who's there and what the age distribution is and what the tolerance of risk is. And yeah. What sorts of jobs, people are working all of these different things and you can never, you can never create a set of guidelines that covers all of them.

[00:32:16] And I think there's a, there's a real desire in, in certain branches of public health to just sort of deal with every scenario so that you sort of have this set of guidelines that you just you're just following, just tack down, you know, but it really, I think it's, yeah, there's, there's a, there's a real difficulty because I don't see any other way of doing this other than.

[00:32:34] With your very local communities and having conversation about your levels of risk and your desires and what, you know, what, what you're after, what are the, what are the goods that you're after and what are the things that you feel you can risk to attain them? 

[00:32:46]Matt Boettger: [00:32:46] Man, you're tapping into the most vulnerable part of the American like soul.

[00:32:51] I feel like the, the idea of like, did the. I mean, I think other countries handle it differently, you know, better and worse than w however that be the [00:33:00] case. But, and even hearing you say that, like makes me feel so vulnerable and I'm, so, you know, this country is such a country that is. prides itself in control and self control.

[00:33:10] Maybe not necessarily self control since like ethics, but like control control.  hear that note. You want this to be like, I need a plan. I need a plan to be able to do this. You're telling me that talk to my local school for like, and talk about my desires. Well, what does that have to do anything with, like with COBIT, you know, and so, but it does, I mean, this is a big, this is the big problem.

[00:33:30] And it's opening, I think, a bigger door for authentic discussion. If we could actually get there about 

[00:33:34] Mark Kissler: [00:33:34] 10 via zoom with my kids' school yesterday. And that I think was a good exemplar of how this goes. Sort of thing can be handled well, you know, they've done a lot of kind of prudent consultation and then they turned outward to the community of families and have had a lot of opportunities for feedback and conversation.

[00:33:53] And, you know, similar to how I think for me, a lot of this, you know, these conversations have been really helpful in [00:34:00] terms of why there's evidence, right. But. A lot of what we encounter has to be kind of grappled with in conversation. and it's been, this has really driven that home for me again and again, you know, from March all the way until now, about how valuable, the kind of knowledge that you gain through nuanced conversation can be.

[00:34:18]and so I was just wanted to commend our, you know, our kids, school, it's a public, you know, public charter in DPS. And, they did a really good job. I think of handling this. 

[00:34:28]Matt Boettger: [00:34:28] Yeah, my mind is kind of going all over the place, but I have some clients and we talk about systems. Cause I love systems and make it feel like it's not relevant, but it's one thing that people have a strong aversion to systems.

[00:34:38] Some people do it. Some people love it. I love it. Because it feels like it imposes like a square onto some kind of thing. A cookie cutter that's forces, everyone to act the same way. And that's the real risk of systems, right? The Yetis we've seen this with the CDC, this isn't a place that was cookie cutter and it's ability to be, to be agile cause some significant, you know, backlash.

[00:34:58] And they realized that [00:35:00] they were learning, that systems are there to serve the public. Right. And so they need to be the, when we develop them, we need to develop them in with the framework of having agility built into them. Because if we don't, it actually destroys the very thing it's trying to obtain.

[00:35:16] Right. Order. Right assistance. Yeah. Right. Anyway, just my little at my soapbox. Okay. As we land the plane, a couple more things here, that I want to look at. Yeah. We looked at, You're going to figure, how do we get people to take covenant? Oh, I forgot that. The Scorge Oh, no. I went to talk briefly about face mask.

[00:35:33] Just bring it up. I, you know, there's more and more evidence about how useful face masks are. I found it just really, I didn't talk to you guys about this. I found it fascinating. There was an article that someone posted on Facebook that's from 2015 and they resurfaced it as somehow, like. A backhanded way to talk about how face masks are pointless by saying that the evidence shows that cloth and pastes master oftentimes more, more, efficacious than surgical face masks.

[00:35:56] And I'm like, I have never, I'm like, okay. I have no idea why [00:36:00] this is like some kind of slap against the face gets face mask, but I've seen growing evidence that cloth face, especially if they're multilayered, right, great job, or a good job help you prevent the airborne particles from leaving your face.

[00:36:12] But I have no idea how this is somehow an argument against face masks, but except for, 

[00:36:17] Mark Kissler: [00:36:17] Hey, I don't know. I mean, it seems like, it seems like it could be a stylish. Yeah. 

[00:36:22] Matt Boettger: [00:36:22] Yeah. I have no idea. So I want just read it up item. It's one of many things I'm fundamentally confused about when I, when I, when I, when I, when I look at Facebook and some of the people who are talking about stuff, Oh, this is what I want to talk about briefly.

[00:36:35] I got it from the Atlantic. Of course, I love the Atlantic, the scourge of hygiene theater. This was great. This whole case. Say back in March, we saw this really, we didn't know what the virus was. There was so many unknowns. We scrubbed everything, washed her groceries, all this stuff. We didn't know what, so the unknowns made us.

[00:36:50] Go all in. 

[00:36:51] Mark Kissler: [00:36:51] I think we had a whole episode about surface transmission or two or three. I feel like we talked about it all the time. 

[00:36:58] Matt Boettger: [00:36:58] Yeah, it is all the time. It's like, it's, [00:37:00] it's a big thing. And so now I've seen this really hit the news this past seven days, there've been three articles, at least on this saying that, look, we've now know enough to realize that cleaning your, your mail and your, and your, and your vegetables and your packages.

[00:37:14] Really is not necessary. They can, I love how they talked about how hygiene theater and they compare it to nine 11 when we had this terrible tragedy. And the response was higher level of security in our, in our airports makes sense. But when you're constantly patting down, grandma's 97 years old and putting her through all these screens, chances are, she's not the one who's going to blow up the plane.

[00:37:35] Right. It, they taught, it was more like theater to get the people to feel a sense and emotional sense. I, they feel safe, but it's not a real sense. Right. It's an emotional sense. And I loved, I just loved this article. So I want to really anybody who's struggling with spending time washing their groceries, their packages to read this, I'll put it in the show notes.

[00:37:54] It was really helpful for me. They gave the example of yes, there was a, there was an article from the Lancet that did a [00:38:00] study about how the Kobe can last on services, but they gave a great example of like, If you actually look at the study, the actual threshold, the amount of virus need detected beyond that, that surface to potentially to infect you.

[00:38:14] They said you would need a hundred people, the sneeze on the same area. Right. And then after a short period of time to come in contact with it, I mean, that's a, that would be conspiracy that's. Okay. Some, if there's a line of a hundred people with COVID sneezing magic, just running from that location, because there's something else 

[00:38:31] Stephen Kissler: [00:38:31] going on.

[00:38:33] Mark Kissler: [00:38:33] That's where the logistical challenge alone is just a, it's just mind boggling.

[00:38:38]Matt Boettger: [00:38:38] Yeah. And you know, and again, if you want evidence, I gave this example from a, from Seoul, South Korea, there was 11 four building that had an outbreak. I was a call center. So everybody's talking there, they're yelling. So there's a lot of airborne.

[00:38:50] And so there's like a thousand people got an infected, but over the entire building. Only 1%. So you have all these people going up and down the elevator touching service all over, and this gives you this, [00:39:00] this anecdotal evidence that, that okay. it's airborne take, take, take that. Reallocate that energy to something that's more.

[00:39:07] Yeah. Yeah. 

[00:39:08] Mark Kissler: [00:39:08] Fruitful. I love that. I love that. Cut down on the things that we don't have to do. and, and the things that are wasteful or that put up unnecessary barriers to getting back to life, and maintain the things that are actually helpful. I think this is great. 

[00:39:22] Matt Boettger: [00:39:22] Yep. Yeah. 

[00:39:23] Stephen Kissler: [00:39:23] I do want to insert just sort of one thing here that, that in addition to that, I, I would hope that people can be graceful with themselves and with others who have been wiping down groceries and things like this for, for a long period of time as well.

[00:39:34] Because I think that one of the things I've noticed, with, With a lot of those pens that, that there's, there's almost this economy of smugness where people want to be right in the absence of evidence. Right. And then when something comes out, it's like, ah, I told you so. Yeah. And it's like, like we didn't know.

[00:39:50] And like, some people will err on the side of caution for some period of time and that, and that's, that doesn't necessarily mean that you like. 

[00:39:56] Matt Boettger: [00:39:56] Do 

[00:39:56] Stephen Kissler: [00:39:56] better beforehand. It's just like, there's a, you know, it's again, [00:40:00] this sort of process of like, of like things changing. So, I think that, you know, there've been, there've been a lot of things, you know, I got fed up with wiping down groceries probably after two weeks of doing it.

[00:40:11]and haven't been doing it for a very long time, but I know other people who have been doing it. You know, cause it religiously up until now. and very, there are a lot of other things that I still probably do that aren't necessary, like washing my hands after touching any doorknob that's outside of my house, you know, but there's like, I think there's there's, there is a lot of, importance here as we're dealing with ourselves and with each other to recognize that like we're in this process of learning things together too.

[00:40:34] Yeah. And that, you know, it it's, it's not a, it's not a thing shame necessarily to have done those things, or even to continue doing those things. As long as they're not interfering with your ability to actually be safe and to actually sort of conduct your life. So. 

[00:40:46] Matt Boettger: [00:40:46] Oh, that's good. And okay. Two things we'll end on this.

[00:40:49] The, just the surface that you just said, Steven, the first thing is, Hey, total full disclosure. We still clean our groceries. So even though I'm saying this, we do everything. We are, we are Cray Cray over here. [00:41:00] So we, we are, we are scrubbing letting mail. We'll probably get to you to do that for a while. So, I, I say this, 

[00:41:07] Mark Kissler: [00:41:07] I know we're at the other end of this, the story 

[00:41:09] Matt Boettger: [00:41:09] here out of, out of concern.

[00:41:10] So. Yeah. Okay. You guys, you guys were like, you can tell 

[00:41:15] Mark Kissler: [00:41:15] we're like, we're, we're like trying to, you know, like still farming the two year old to keep him away from the cherries before it gets in the door. And like, it's like climbing up the, you know, it was just like, they're just though. Yeah. It's just, I don't know if we've ever been able to successfully do so 

[00:41:33] Matt Boettger: [00:41:33] we just lock our doors it in cages for 30 minutes and then we'll let them out with the groceries there.

[00:41:39]you know, and this is I'll draw I'll, I'll end on this drop of a bomb, or maybe this is going to fall flat. And this makes no sense out of my mind, but is there anything relational, like a relational to the idea that here we are people wearing masks and doing these things and there's this like growing divergence of like, Oh, you're that person.

[00:41:56] Right? Cause when I went to that, climate was only one wearing a mask. And I think at some, [00:42:00] sometimes people are thinking, Oh, you're that person, right. Is that kind of a microcosm of the entire, like. Racial injustice. Like, I mean, it's just like it's, it's it's Malcolm Gladwell's book. I think it was a good talking with stranger.

[00:42:12] If you ain't ready, you got to read it so great. But it's, you know, he was kind of proposing almost. Now, I don't know if he was, he was meaning this. So I I'm so sorry if this is not what he's saying. This is just me interpreting that not much so much of racial injustice in some areas as it is somebody who's different from me.

[00:42:28] And that it's the idea of difference that actually just resonates so violent with us. It's sometimes like you're just different. And I've seen this on a microcosm of like, when I'm now I'm acting differently because of certain particular precautions and I'm being treated differently now because I'm no longer one of them.

[00:42:44] Right. I'm that group. Now, now I set myself aside. So I feel like the microcosm of the bigger reality of our cultural. 

[00:42:51]Mark Kissler: [00:42:51] Yeah. Yeah, I think, I mean, I think, I also want to keep categories distinct, you know, as much as we can. Cause I think there's very, you know, hugely different things at play [00:43:00] in each of those things in each of those yeah.

[00:43:02] Particular issues. that being said, I think the human tendency towards. Categorization and making other people, or just the sense of difference and other, you know, is something that we're really kind of in the midst of grappling with, as a society on all sorts of different levels, with all sorts of different kind of factors in play.

[00:43:22]so I definitely that that part resonates for sure is the sense of like, and how do we deal? In a deal with the other is it's interesting to me, I think, I love the idea of hospitality as being the virtue that is complimentary to that tendency, or, you know, kind of see that a lot of our, you know, tendencies are countered by particular virtues and this one of, how do we encounter an other who's actually, other than us who's is I think I love the idea of hospitality being kind of a positive description of what we can do in the place of that.

[00:43:55]so yeah, 

[00:43:55]Matt Boettger: [00:43:55] lovely on that. So, What's your one thing you to do to be more [00:44:00] hospitable to those around you and to practice a greater sense of discovery. Okay. Okay. We're gonna end there again, if you want to reach out to me and the podcast, right. And matt@livingthereal.com. Love to hear what's going on in your world.

[00:44:12] Your country, love to hear updates. And what you think about the podcast when you get ahold of Steven S T E P H E N K I S S. Oh, you are on Twitter again, please leave a review. It's so helpful. And we always need financial support to pay off all the crazy stuff. We've got to bring this to you quickly so I can move on to other things, maybe not better, but just other things in my life that I have responsibility over.

[00:44:33] And anyway, other than that, and check out living real.com Mark and I's conversation just as wonderful as with Steven. Good, good brothers to chat with, check it out on living the world.com and subscribe to the podcast and download that visual conversation. We will see you guys. All next week and gals take care.

[00:44:51] Bye bye.