Subscribe to Lemonada Premium for Bonus Content

Description

Dr. Bob calls up infectious disease epidemiologist Julia Marcus to discuss risk, a concept many of us thought more about in the past year than ever before. Julia, a Harvard professor and contributor to The Atlantic, talks about why people take risks, the danger in stigmatizing risk-taking, and how to weigh the benefits and costs surrounding risk during the pandemic. They also cover pandemic fatigue and how Julia envisions the return to a new normal. Plus, the first Andy update from Lana!

 

Follow Dr. Bob on Twitter @Bob_Wachter and check out In the Bubble’s new Twitter account @inthebubblepod.

 

Follow Julia Marcus on Twitter @JuliaLMarcus.

 

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

 

In the Bubble is supported in part by listeners like you. Become a member, get exclusive bonus content, ask Andy questions, and get discounted merch at https://lemonadamedia.com/inthebubble/

 

Support the show by checking out our sponsors!

 

• Click this link for a list of current sponsors and discount codes for this show and all Lemonada shows: https://drive.google.com/file/d/1NEJFhcReE4ejw2Kw7ba8DVJ1xQLogPwA/view

 

Check out these resources from today’s episode: 

 

• Read Julia’s latest article for The Atlantic, “Vaccinated People Are Going to Hug Each Other:”  https://www.theatlantic.com/ideas/archive/2021/01/giving-people-more-freedom-whole-point-vaccines/617829/
• Check out all of Julia’s COVID-19 Atlantic articles here: https://www.theatlantic.com/author/julia-marcus/
• Read what Bob and other experts have to say about what’s safe to do post-vaccine in this Washington Post article: https://www.washingtonpost.com/health/2021/02/01/vaccinated-people-precautions/
• Learn more about Julia’s work with Harvard Medical School’s Department of Population Medicine: https://www.populationmedicine.org/jmarcus
• Learn more about Dr. Bob Wachter and the UCSF Department of Medicine here: https://medicine.ucsf.edu/

 

To follow along with a transcript and/or take notes for friends and family, go to www.lemonadamedia.com/show/in-the-bubble shortly after the air date.

 

Stay up to date with us on Twitter, Facebook, and Instagram at @LemonadaMedia. For additional resources, information, and a transcript of the episode, visit lemonadamedia.com.

Transcript

SPEAKERS

Lana Slavitt, Dr. Bob Wachter, Dr. Julia Marcus

Lana Slavitt  00:00

The good news is even though I’m only talking to him a few minutes a week it seems, I get to see him on TV three times a week and I can like replay it if I get lonely or something so, and he shaved the beard, that was huge.

Dr. Bob Wachter 

Welcome to IN THE BUBBLE from the front lines. I’m your host, Bob Wachter. That was Lana Slavitt. As you know, this used to be Andy Slavitt show. And we’ll be again in four months, but Andy’s gone. It seems like he’s been gone for years, but it’s actually only been 10 days. It would be nice to talk to Andy. But he’s now working about 27 hours a day. So we couldn’t get him. But we’re lucky to have Lana join us for our first genuine Andy report. So let’s go ahead and ring up a Lana Slavitt.

Dr. Bob Wachter

Hi, Lana, it’s great to see you this is this thing called IN THE BUBBLE. It’s a podcast, we talk about COVID and some other things, have you heard of it?

Lana Slavitt

I think I’ve heard a little bit about it.

Dr. Bob Wachter 

Well, thank you for coming on. So we promised when Andy, Andy left to do his gig in the White House that we would bring you on periodically to tell us how he’s doing. And love to hear how he’s doing. I assume he packed his lunch pail to go off to this new job. How’s it been going for the last 10 days?

Lana Slavitt

I think it’s been going okay. I mean, he landed on the 15th, only to discover that he wouldn’t be able to get into his apartment because it was within the secure zone around the White House. He’s only about a block and a half away. So he ended up staying with friends in their son who’s at colleges at twin bed in Alexandria, with his three suitcases and that’s..

Dr. Bob Wachter 

Not a bunk bed, I wish I had a vision of him at the top of a bunk bed, but just a twin.

Lana Slavitt

Very close, I think. But you know, he was carrying suitcases and they weren’t allowing packages in or, you know, really people who didn’t need to be there. So he finally got to move into the apartment by that weekend, that first weekend. But he had already hit the ground the very next day. So he’s working pretty much like seven days a week, you know, all the time, close to 24 hours a day trying to get enough sleep and stay healthy and all of that. He said that, you know, I should tell you that he’s got five main priorities. And they are to number one, reestablish trust with the public. Number two, with regard to vaccines more better, faster, and that’s probably the vast majority of their time.

Lana Slavitt  02:38

Number three is improving the response on public health measures and masks, so that we can you know, increase compliance and people wanting to actually wear a mask to help us defeat this pandemic. His fourth is health equity. And the fifth is ramping up testing to open schools. So those are sort of the, you know, there’s lots of other things and obviously, he’s leading the three times weekly briefings, which brief on this as well as sort of everything else related to fighting the pandemic. So the good news is, even though I’m only talking to him a few minutes a week, it seems I get to see him on TV three times a week, and I can like replay it if I get lonely or something.

Dr. Bob Wachter 

That must be pretty gratifying.

Lana Slavitt 

Oh, yeah. And he shaved the beard. Well,

Dr. Bob Wachter 

Well, that’s the thing.

Lana Slavitt

That was huge.

Dr. Bob Wachter 

I think it was striking. He really cleaned himself up pretty good. I think it looks like the sweatshirt is gone. The shave, he looks like he was really ready for action.

Lana Slavitt 

Oh, yeah, he had definitely let himself go during the pandemic. I mean, I was begging for that beard to go for like, I don’t know, nine months. And suddenly it was like gone after a phone call.

Dr. Bob Wachter 

Yeah, that’s just shows how much influence you have, I guess that took this..

Lana Slavitt

Very little, apparently.

Dr. Bob Wachter

Has he described anything about anything, it’s been surprising to him in terms of what he found when he got there?

Lana Slavitt

You know, I think that he it’s been a little bit like old home week where you keep running into people that you know from before, and he’s been really gratified to see that people joining the administration, many of them are people who were in it before. And that you know, that has allowed people to hit the ground running and to really start, you know, putting in place all the different programs not just you know, with regard to the pandemic, but other things that had been neglected over the last four years or in some cases really hurt. So that’s, you know, he enjoys running into people in the White House that he knows from his prior time working in DC. You know, the Navy mess is only open for takeout. I think he misses eating there.

Lana Slavitt  04:37

The West Wing is really quiet because they are keeping numbers down. So they’re doing this kind of rotation where you have a couple of days of the week that you’re assigned to actually be either there or his office is in old executive and, you know, the same kind of program there. So things are much quieter than you would expect given the pace of activity that he knows is happening around him, just because there are so few people around at any given time, they’re really taking the mitigation measures quite seriously. What else did he tell me?

Lana Slavitt

He said, The first three days were tough to acclimate, just kind of felt like what am I supposed to do here? And then, you know, suddenly it was like he was in the groove. And he’s been working, you know, non-stop ever since to do that. He did mention that, like you he’s concerned about the mutations and, but is gratified that they have such a strong scientific team working on this and really thinking about, you know, how do they tweak vaccines. You know, what, what will it be the impact of a herd immunity level on these variants and the odds of them popping up and all of that, so he feels confident people are on it, but it is obviously still worrisome.

Dr. Bob Wachter 

Well, there’s a question that inquiring listeners want to know. Does Brody miss Andy is the question that everybody is asking.

Lana Slavitt 

I think definitely, actually, because Andy was like, much more willing to like jump out of bed and take the dog for a walk when it was 4:30 in the morning, whereas I’m like, you’ll survive, you’ll live, just roll over and unless like hysterical barking, you know, happens he’s gonna be fine if it was like a hysterical situation in the carpet might be at risk, I might jump out of bed to let him out. But, Andy was definitely much more Brody’s servant than I am. So I know that Brody misses that.

Dr. Bob Wachter  06:26

Well, thank you for the report. It’s wonderful to hear how he’s doing. And more importantly, for all of us to see what he’s doing. It’s he’s making a vast difference. And, and that’s why as hard as it was to lose him for the podcast for a little while, we all knew that it was the right thing for all of us and for the country and for the world. So it’s great that he’s doing that.

Lana Slavitt 

Well. Thank you so much for stepping into I know that Andy was thrilled when you said yes. And I’ve really enjoyed actually listening to the episodes too. And you know, you’ve got your own unique approach to it. And it’s just, it’s been great. So I’m excited for the next few months.

Dr. Bob Wachter 

Thanks so much, please send him our warmest regards.

Lana Slavitt  

I will. Thanks, everyone.

Dr. Bob Wachter 

That was Lana Slavitt, with our first Andy report. Glad to hear that Andy’s doing well and really grateful for all he’s doing for all of us. Well, it strikes me that life was hard a year ago. But the decisions were easy. If you recall what March and April felt like we were staying at home, we were keeping our distance, we were washing our hands. Hopefully we’re wearing a mask. Since then, life has gotten paradoxically easier in a way but yet infinitely harder, since we now are forced to make about a thousand decisions a day seeing family, but when and which ones and under what circumstances and with how much ventilation?

Dr. Bob Wachter 

Were a mess. Okay, but now which ones? And how many? And is it safe to travel? And if so, how and when, what should we do with the mail. Each of these decisions is incredibly challenging and fraught. And none of us were trained to be epidemiologists or people who assess risk for a living. We find ourselves now in February, with things getting even more complicated with all of these swirling forces at play. We have a new administration that’s giving us good guidance and some real plans that are moving us in the right direction, we have these remarkably effective vaccines that are rolling out after a bumpy start beginning to move and we have some new ones on the horizon.

Dr. Bob Wachter  08:32

Case counts are coming down. But at the same time, we hear about the challenges with the viral variants that are either over the horizon or maybe even a little closer than that. We have shortages of vaccines, the vaccines are not 100% protective, although they’re awfully good. So it is enough to make your head spin trying to figure out how to weigh all of these forces and risks and what we’re giving up and how to manage. And each of us is making all of these decisions every single day, under conditions of uncertainty and a little bit of fear and dread. It’s really tough to do. For the past year, I have depended for my decision making on Julia Marcus, who has been more thoughtful than anyone I know.

Dr. Bob Wachter 

And helping us understand the nature of these risks, how humans process risk, and how to thoughtfully weigh the tradeoffs. It’s not all about risk and all the bad stuff that can happen. There’s bad stuff that happens when you hide under a table. And you’re not seeing your friends and family and you’re not sending your kids to school. So how do we think through all these tradeoffs and make the best possible decisions? Julia Marcus is an infectious disease epidemiologist. She’s associate professor at Harvard Medical School and Harvard Pilgrim Healthcare Institute. Like lots of the guests on our show. She wasn’t studying COVID a year ago, nobody was, she was focusing on implementation of pre-exposure prophylaxis known as PREP, to prevent new HIV infections and promote sexual health in the United States.

Dr. Bob Wachter  10:07

And through that work, she’s really been thinking deeply about how we message preventing infections, how we think about risks, how we weigh risks and benefits. Over the past year, she has been continuing her research in that but also has been writing for the lay public, including a series of articles in the Atlantic, about the pandemic, that are just infused with wisdom and lots of lessons that she’s learned from her work with HIV. So we’re privileged to have Julia Marcus join us today to talk through some of these complex issues in weighing risks in COVID. So, let us ring up Julia Marcus.

Dr. Bob Wachter 

Julia, thanks so much for coming on.

Dr. Julia Marcus 

Thanks for having me.

Dr. Bob Wachter

Let’s talk about how humans think about risk. Are we good at it? Not so good at it? Because obviously, that color is all of the decisions that we’re all being forced to make these days.

Dr. Julia Marcus 

I think we are both good at it and not so good at it. I mean, we think about risk constantly, every day, every decision we’re making involves some risk, some benefit. But I think a lot of that is just kind of built into the fabric of our lives, and we’re not doing it consciously. And I think when things start to become complicated, is when you have a very salient risk and a novel risk, and especially when it’s scary, when there’s some really potentially bad outcome.

Dr. Julia Marcus

And that can make it really challenging to start to do this risk benefit calculus on an everyday basis. And I think, you know, there are a lot of studies on risk perception, and there’s a whole body of literature on that and on how people make decisions around risk. But certainly people digest information around risk in very different ways. And it can depend on how it’s presented. Is it relative risk? Is it absolute risk? And again, how scary is that potentially bad outcome?

Dr. Bob Wachter  12:04

So, before we drill into some of the specifics of COVID, I wanted to talk to you about some of the things that do color our perception of risk. And the way we talk about it and communicate about it. I think, you know, having read a lot of your work over the course of the last year, I’ve sort of learned a lot from that. One point you make is our puritanical roots in the US seem to color the way we think about risk and the messaging about risk? Could you explain what you mean by that?

Dr. Julia Marcus 

Yeah, I mean, I think during the pandemic, there has been a real push to try to eliminate risk wherever possible. And that makes a lot of sense, because we’re talking about potentially very bad outcomes. And we need to as a society, minimize risk as much as possible and then certainly for individuals as well. But I think what gets lost in that discussion is why people take risks, and many times that’s for, let’s say, an economic need. So I think at this point, it’s pretty clear that COVID is not exclusively, but certainly heavily an occupational disease. So people are getting, getting COVID at work and bringing it home, and, you know, bring it to their households. So when you start to ask, why are people taking risks, then it kind of opens up that vision of like, “oh, people are taking risks, because they have to go to work.”

Dr. Julia Marcus 

And then there are other reasons, people take risks. And sometimes it’s for social connection. And that I think, has been heavily stigmatized in the pandemic. And to some extent, that makes sense, right? We want to create social norms around what’s okay to do and what’s not okay to do right now and one thing that’s really not okay to do is, let’s say have a big indoor party in the middle of a pandemic. And those are things that we want, we want to help people avoid and draw people away from. But I think in doing so, we have also created messaging that has emphasized that if people take any risks at all, especially socially, it reflects bad character, it’s selfish, it’s reckless, those are words that we hear a lot.

Dr. Julia Marcus  14:05

And I worry about that, because I think, to some extent, at least, some risk taking in that regard is necessary. And the sense that, you know, we cannot as humans live in total isolation for a year and a half, right? That’s, at that point, we’ve sacrificed other aspects of our health. And so there has to be some balance, I think, to these discussions and kind of a bigger perspective on risks benefits and tradeoffs and all of these decisions.

Dr. Bob Wachter

And I think you’re implying this in terms of people labeling some of this as being selfish or reckless, but it seems like there’s another thread that there’s sort of as a need for blame that there’s sort of an instinct to finger pointing. First of all, do you feel like that’s right? And second of all, you can imagine a world where that’s okay for certain activities. It is reckless. We do want to finger point, that’s a really bad thing to do. But there’s got to be a line drawn there. So how do you process this, what seems to be I don’t know, if it’s a universal instinct or an American instinct to, to finger point.

Dr. Julia Marcus

I think the finger pointing is probably a natural instinct, especially in the context of a lot of fear and uncertainty. I think they’re; you know, this is a sort of beyond my expertise as an epidemiologist, but it seems to me that when there is a lot of fear, we want to find a locus of control somewhere. And it’s easy to put that locus of control, I think, on other individuals, and we’re hearing that messaging from the top from, sometimes from health professionals, but often also from elected officials saying, you know, this is your fault as the public and if you would all just behave better and be smarter, we wouldn’t be in this situation.

Dr. Julia Marcus 

And so, of course, we’re kind of turning against each other when it’s we’ve been told this is really on you as individuals and not on us as the government to take care of you. I do think, you know, yes, there are certain things that are reckless in a pandemic, of course, but I think we also have to ask, what is the approach that is going to have the outcome we want, if the outcome we want is to reduce infections, and actually probably a broader outcome is to maximize health, including both infection prevention and other aspects of health, we have to ask, is telling people they’re being reckless and selfish when they are doing something reckless, like having a party?

Dr. Julia Marcus  16:16

Is blaming them for that going to change their behavior? Or is it going to make them hide it better? And you know, if the answer is that it’s just going to make them hide it better than we’ve basically shot ourselves in the foot in terms of pandemic containment? So we have to really think about not just what our instinct is in terms of blaming people, but also what is it that’s going to achieve the outcome we want and really approach this pragmatically.

Dr. Bob Wachter 

And is that a theme from kind of pandemic epidemiology through the ages, that in instinct to blame people and stigmatize it might sound good at some level, but actually turns out to be counterproductive?

Dr. Julia Marcus

I mean, that’s certainly something we learned in the HIV epidemic, that blaming individuals for their behavior, it doesn’t just not deter their behavior that you’re trying to deter, it also deters them from engaging with public health. And here we are decades into the HIV epidemic and still struggling to undo a lot of the stigma that was perpetuated early on around people’s, you know, risky behavior, and now what patients feel reluctant to disclose to doctors or to other people in their networks. And that continues to be a major barrier to ending the HIV epidemic worldwide.

Dr. Bob Wachter 

You talk in some of your writings about risk compensation that if we do X to try to decrease risk, people will automatically therefore do why, I think I heard the term in the in the world of patient safety. Sometimes people talk about revenge effects, they tell people to or people wear seatbelts, they’ll drive faster. They’re these compensatory acts that they take to sort of keep their overall risk stable. So talk about that. And in the context of a pandemic, how you think about this notion of risk compensation.

Dr. Julia Marcus  18:07

Yeah, this is something that has come up a lot in my field of HIV prevention. And it’s a concern, as you said that, you know, if you give somebody a prevention tool, and they feel protected, and they feel less fear of a bad outcome, they’re going to compensate by increasing their risk behavior in other ways. It tends to come up a lot and in the context of stigmatized behaviors, so as you said, there’s a, you know, it’s come up around seatbelts, it’s come up around sunscreen use, but especially it comes up around sex and drug use. So this concern that if you give people pre-exposure prophylaxis for HIV, they’re going to use condoms less often, or a concern that if you give people clean syringes, they’re going to use drugs more.

Dr. Julia Marcus 

This is a concern that comes up a lot around harm reduction tools, where you’re not trying necessarily to eliminate risk, you are giving people tools to reduce risk. And there’s a concern that in fact, you’re promoting risk taking and doing so. But in general, I mean, people have done a lot of research on risk compensation in different fields. And, of course, there are individuals who are potentially going to compensate with their risk behavior to a degree that it may increase their risk. But on a population level, I can’t think of any examples where there has been a case of those changes in behavior, negating the benefits of the prevention tool on a population level.

Dr. Julia Marcus

And in fact, I think the way we frame them is often that people are being irrational, you know, we’re worried that they’re going to be irresponsible, irrational, reckless, but they’re actually just responding to a true reduction in risk. For the most part, you know, when we think about PREP, which is what I work on a daily pill to prevent HIV, we’re giving somebody a pill that reduces the risk of HIV acquisition by 99%. And so, you know, changing their behavior in other ways in response to that is quite rational. And I think we’ve come up; we’ve seen it come up and COVID are on masks even. It was actually one of the reasons why there was a hesitation from the federal government to recommend masks.

Dr. Julia Marcus 

There was a concern that it would give people a false sense of security, they would socially distance less, and engage in other risky behaviors. But actually, the research shows the opposite, that people who wear masks are more likely to engage in those other protective behaviors. And again, we’re seeing it now coming up around vaccines, this concern that people who get a vaccine and it may increase their risk and other ways. And I think it’s something that is worth considering and worth tracking in our research. But I think we have to be careful not to let it turn into this sort of hysteria around, you know, are people going to use this as a ticket to party?

Dr. Bob Wachter  20:38

I guess one other sort of dominant theme in this whole discussion about risk behavior is risk to whom. and there are lots of domains where we say, “that’s risky, but you know, go for it, if you want to, or you want to, you want to hang glide, terrific.” And you can generalize that and say, well, if the person, you know, slams into the cliff, their healthcare costs that are generalized, but by and large, we say that’s your call, you decide on the level of risk and the harm will accrue to you. COVID and I guess maybe infectious disease, or at least contagious infectious diseases.

Dr. Bob Wachter 

Are examples that get kind of tricky, because there’s risk to you. And then there’s risk to me. And I may not care that much about risk to you, I you know, personally I do, because I’m a nice person, but as a society, you can make a choice, but the risk to you is not confined to you. It’s also the risk to others. So how does that fact, which I guess is true in every infectious disease, or every contagious infectious disease? How does that affect change, thinking about risk?

Dr. Julia Marcus 

It complicates it, I mean, it’s much simpler, I think, for an individual to make decisions about risk when it’s confined to just themselves. And then as public health professionals, and policy makers, when we think about putting, let’s say, restrictions on public spaces, that has to factor in as well, it’s not just risks to the individual, it’s also risk to the people around them. And so if we take a grocery store, for example, for somebody who feels that wearing a mask is an infringement on their civil liberties, well, it’s also an infringement on the civil liberties of the person working in the grocery store, who may be put at risk by the person not wearing a mask.

Dr. Julia Marcus  22:19

And so we have to kind of take all this into consideration. And it means I think, finding this balance between protecting the public health while trying to protect people’s freedom as much as possible, and there will be some compromise between the two that is going to make some people unhappy on both sides, I think.

Dr. Bob Wachter 

What do we know about messaging risk when it comes to those issues of is it just a risk to you versus risk to others? It struck me that early in the mask debate, there was this sort of line of reasoning that it’s not helping you all that much, that turns out to be partly wrong, but that it’s mostly for others. And the same thing has come up in other risk discussions, you know, it’s one thing, okay, you smoke, you might get lung cancer, it was another then once we discover that secondhand smoke is risky to others. Does the risk to others change people’s behavior in ways that are different than if the risk is purely to the person engaging in the behavior,

Dr. Julia Marcus

Different messages work for different people. So I think that there are some people who will respond better to a message that, you know, the mask really protects you yourself. And they feel well, that’s where I want to get the benefit here. And then other people are going to respond more to a message about caring for others. And so I think both of those messages, to the extent that they’re accurate, are important. And I think what we want to avoid is the messaging that is kind of moralistic and around, you know, if you’re a good person, you’re going to do this, if you don’t do it, you’re being selfish, and you’re reckless and putting others at risk.

Dr. Julia Marcus

And I think focusing on the kind of positive messaging, protecting yourself, protecting your community, and making it easy for people too. I mean, I want to be clear that messaging is not enough, a good public health messaging is necessary, but it’s not sufficient. So we, you know, we still haven’t gotten, you know, I’d love to get a mask in the mail from the federal government with a message saying, “this is exactly the mask you should be using. It’s got, you know, X number of layers and a filter. And, this is what you should use, and here’s, you know, two for each person in your family.”

Dr. Julia Marcus  24:27

And that has yet to happen, I would love to see mask dispensers on the outside of grocery stores, or wherever it is that we want people to wear masks, trains, buses, so we have to go beyond just telling people what to do and actually make it really easy for them to do it.

Dr. Bob Wachter 

So far, our discussion is mostly been a bummer. We’re talking about all these bad things and risks and horrible, horrible things that might afflict you or others. Let’s talk about benefits because I think one of the points that you have made that’s been quite persuasive is we’ve framed so much of this about the bad stuff that can happen, and haven’t really thought deeply about the tradeoffs and some of the good stuff that you’re foregoing, which of course, you have to weigh if you’re going to make a rational choice. So take us through some of the benefits that you think are important for us to weigh. And maybe we haven’t been weighing enough in making these decisions.

Dr. Julia Marcus 

I think it goes back to that question about why do people take risks? And when we don’t ask that question, we miss all these opportunities to really address what’s going on for people. So when we just say, you know, stay home, wear a mask, you know, that kind of repeat the same messages over and over and get frustrated when people are not engaging in those. I think we miss out on what messages and interventions might actually work for people. So if we take a step back, and we say, why are people taking risks? Again, we might see, well, they need to go to work, or we might see they miss their loved ones we might see; you know, their kids are struggling and really need to see other kids.

Dr. Julia Marcus 

And so then we start to see a bigger picture about what it is that people need. And also yes, what they want. I mean, sometimes people want to enjoy their lives, they want to have fun, they want some sense of pleasure in their lives. And I think that’s where we’ve, what we’ve really written off as an essential. So if you think back to all the messaging in the summer, and the media stories and the pictures of beaches, right? And people having fun on beaches, and how terrible that was, and how you know, how shameful it was, when in fact, it was a fairly low risk way to socially connect with people, I think if we, if we took a step back and said, “Oh, actually, people are going to some extent to interact with each other. So let’s support them in lower risk ways of doing that. And let’s even create spaces for them to do it.”

Dr. Julia Marcus  26:39

So again, like how do we make this easy for people and there are places where fire pits have been set up in parks, and you know, tents, open air tents where people can spend time together outdoors, you know, that that kind of sort of visible message where we’re restructuring spaces to say, instead of saying, “look, you have to just stop doing this saying, look, we know you want and need to do certain things. And here’s how we’re going to support you in doing that more safely.”

Dr. Bob Wachter

Yeah, so hard in that. I think one of the aspects of COVID, that’s different than many other things, is that the risk of getting it wrong once, people sort of catastrophize. And that’s not completely irrational, I mean, that it’s a little bit like airport security in a way that if one gets through, then something very bad could happen, and particularly, obviously, modified by what your personal risk is, but you’re sort of weighing the, what is the joy I get from hugging my relative or hanging out with my pals?

Dr. Bob Wachter 

How often do I need to do that? Against the possibility that one time, if you get it wrong, something pretty dire could happen. So, how does that change things, you know, it feels like on the on the benefit side, it’s unlikely that it’s going to be one thing that’s so decisive, it’s sort of a cumulative, how do I live my life? On the risk side, it’s just you know, it, we may be overvaluing this one thing, but if it happens, you know, we could be pretty unhappy.

Dr. Julia Marcus  28:14

Yeah, and I think that’s, there’s no easy answer there, I think it becomes obvious to people individually when competing risks become too big to ignore. So I’ll even give an example from my own household, in the early months of the pandemic, my kids were not interacting with any other kids. And there was a real negative impact on my older kid, really was visible, you know, really struggling. And it became, it just got to a point where one day we said, this is unacceptable, the risk to us as adults no longer outweighs the risk to our kid. And it just was a moment where it became clear. And that may happen for people. And of course, going back to this question of, you know, it’s not just risk to you, it’s also risk to others and that factors in as well.

Dr. Julia Marcus 

But at some point, decisions have to be made. And at that point, we said, “he has to interact with other kids, he just has to so.” And now, you know, I think that’s to me, that feels like a very reasonable decision. Now, if we think back to April, May, I think there was a lot more uncertainty and fear. And so at the time, it felt much riskier than it does to me now. I think also, we can’t sustain the same amount of fear that we, you can’t sustain fear for that long. So I think that there was a lot of fear at the beginning, and also a lot of solidarity that I think got kind of both of those, I think waned over time as they just sort of naturally would.

Dr. Bob Wachter 

Yeah, and how are you drawing the lines with your kids right now in terms of what they do what they don’t do, and how has that evolved over the over the last year?

Dr. Julia Marcus

Well, my older kid is a first grader and he’s in a hybrid program at school and so he’s home some of the time at school some of the time in a childcare program at the school some of the time, which is always a little sort of Ben’s my mind a little that he’s in the school and his teacher is there, but she’s in a different room. And he’s remote learning from the childcare program. My daughter is in daycare, and in both cases, lots of risk mitigation strategies in place. But you know, of course, you never know what may happen, but we’ve been okay so far. And I think people have to make these decisions based on what is going to work for their family and hopefully for the others around them, especially those who are vulnerable.

Dr. Bob Wachter  30:35

The schools may be the most emotionally charged and maybe most complex piece of all of this. So as you look back on the past year, what are the lessons from the schools? What did we get wrong, that we now maybe are getting righter? How are you thinking about that?

Dr. Julia Marcus 

I have no succinct answer to any question about schools. So as you said, it’s so complex, and it’s so emotionally charged. And I also feel like I have a conflict of interest as a parent, I mean, because it’s so obvious to me and my household how my kids, especially one of them has suffered from school closure, it’s difficult for me to think about it in an unbiased way. But I don’t think there’s any absolute here, I you know, people sort of dichotomize into schools are safe, and kids don’t transmit the virus to schools are totally unsafe and must be closed. And I think that, as usual, the truth is somewhere in between, but kids do play some role in transmission, even if they are less susceptible to infection, which it does appear to be that way, from what I can tell.

Dr. Julia Marcus 

And it does seem like with risk mitigation strategies in place, you can really reduce school transmission quite a lot. But of course, there are questions around the methodology of those studies, kids are not being screened regularly, they’re less likely to have symptoms. And so there are real challenges there. And of course, there needs to be protections for teachers. And we need to consider families at home who may be more vulnerable. So there is no easy answer. But I think what I would have liked to have seen, you know, to try to at least give some answer is a prioritization of the youngest kids, getting the youngest kids back in school.

Dr. Julia Marcus  32:21

And being a bit more creative around the use of space, although, of course, that doesn’t address staffing issues, if you’re going to have smaller classes, but I think there have been some districts that have managed to bring the youngest kids back, full time with distancing while the older kids have more remote learning. And I don’t think that’s ideal either. But it does seem to me that the youngest kids are the ones who have the most challenges with learning virtually. So I think that could have been a good place to start.

Dr. Bob Wachter

Any other lessons that you’ve taken from the way things have gone over the past year that you know, now knowing what we know, now, if, God forbid, there was another pandemic, five years from now, we should definitely do it differently in terms of how we communicate risk, or how we manage risk?

Dr. Julia Marcus 

Oh, so many, I think it’s gonna take me years to digest all of this, but I think ideally, if, actually, when there is another pandemic, ideally, the CDC would play very..

Dr. Bob Wachter 

I like “if” better than “when”

Dr. Julia Marcus 

Realistically, realistically, hopefully not on the same scale. You know, the next time there’s an emerging pathogen that may has pandemic potential, I hope that the CDC will be playing a very different role than it was, you know, during the last administration, I think that the lack of a national unified public health voice and the kind of defaulting to politicians doing the public health messaging was so detrimental. And I think now, I really have a lot of hope in the new administration, seeing the CDC restored, and stronger public health messaging, but I think the fragmentation of public health messaging down to like, you know, random people on Twitter, maybe not random, you know, experts, but people who are not whose job is not to do science communication on social media.

Dr. Julia Marcus  34:17

Or on cable TV, I think that really shaped the messaging in some potentially, you know, suboptimal ways. I also think just in terms of policy, the federal government obviously kind of abdicated its responsibility to do much of anything around the pandemic and just with enormous harm, incalculable harm, and the fact that we’re now 10-11 months into this and we don’t have universal paid sick leave, we don’t have supported isolation policies, you know, sort of basic things that day one of a pandemic, you ensure that people can stay home when they’re sick, and even that has not happened.

Dr. Bob Wachter 

You wrote recently in the Atlantic about vaccines, it seems like every few months, we have kind of a new wrinkle that poses a version of the same kinds of questions. How do we approach it? What kind of language do we use? Is there stigma? How do we manage risk under a new circumstance? So talk us through what this particular new phase is like as it pertains to risk and communication.

Dr. Julia Marcus 

Yeah, I just was, I had been noticing a pattern that I think others had started to notice as well around how the new vaccines were being covered in the media, talked about by scientists and debated, starting to start to be very hotly debated on Twitter. Specifically around how people should or should not change their behavior after vaccination. And it just, I started to get text messages and emails from colleagues who work in the prep field who, like me, were at the FDA hearing for the advisory committee hearing for PREP in 2012, where..

Dr. Bob Wachter  36:13

Let’s just let our listeners know what PREP is.

Dr. Julia Marcus

Right. So pre-exposure prophylaxis for HIV, a pill to prevent HIV. And the controversy at the time when PREP was coming up for approval was really focused around risk compensation and this idea that people would increase their risk behavior. And it was the main, one of the main topics covered at the FDA hearing. And I started to get all these messages from colleagues who were like, it’s just like 2012. And still we, this is still, this concern around risk compensation is still a barrier to PREP uptake, to PREP prescribing in the US. And still we see limited population impacts of PREP, partly because of these concerns around risk compensation.

Dr. Julia Marcus 

So it’s really kind of was a red flag for me. And it felt like the debate again, was getting kind of falsely dichotomize between nothing can change after vaccination, and everything changes after vaccination, when in fact, as I wrote in that piece, I think it’s somewhere in between, I think. I mean, the piece was not intended to tell people what they should or shouldn’t do, but just to kind of unpack this debate. And I think there’s a strong case to be made that we really do need precautions and public spaces for quite some time until many more people are vaccinated and infections wane quite a lot. But I think it’s also not quite right to tell people that absolutely nothing changes for them after vaccination.

Dr. Julia Marcus

When they have a, they’ve now received an intervention, you know, let’s say somebody is fully vaccinated has waited two weeks after their second dose, they’ve received an intervention that’s incredibly effective at preventing disease for them. And it’s likely to prevent transmission to some extent, we don’t know how much and that the jury’s still out on that. But even just talking about that, that prevention of illness for that person, I think even that was being kind of downplayed, as well, it’s not 100% effective in preventing disease. And I felt concerned that focusing so much on the uncertainties and the potential, you know, the imperfections of these vaccines, was actually going to dissuade vaccine uptake, and I was starting to I was just sort of lurking on Twitter, watching people, you know, discuss this and felt like it was pretty clear that, that was already happening.

Dr. Julia Marcus  38:28

That people were saying, “why should I take any risk as a person who’s at low risk of a bad outcome from COVID? Why would I take a vaccine that could pose some risk to me if it’s going to change nothing about my life?” And it also sounded like, a lot of the questions that doctors were getting were from older people who have been isolated and waiting to meet their first grandchild, or whatever the case may be, and are asking, when can I hug my family? And I think simply telling them absolutely nothing can change for you is a bit disingenuous when in fact, there is a true reduction in risk.

Dr. Bob Wachter 

Yeah, and it sounds like from your experience with PREP0, that actually is a tangible impact on people doing the thing, if they are told that it’s not going to change your life at all, or won’t change it until, you know, everybody is using it. So there is a pragmatic concern here that people will choose not to be vaccinated if the message is you can’t change anything that you’re doing.

Dr. Julia Marcus

Yeah, I think we can’t definitively say what messaging is, you know, unless that’s actually a testable hypothesis that has not been tested. But I think it’s a hypothesis that if you tell people, nothing can change for you. And you actually, I think in some cases, the messaging has gotten so overstated, that there are now people who say the vaccines do not prevent transmission, they will not prevent transmission that’s unknown, when in fact, it’s an unknown.

Dr. Bob Wachter

Almost certainly they lower the probability quite a bit, even if they may not 100% prevented.

Dr. Julia Marcus

That’s right. But I think things get a bit distorted and it’s not, I don’t think, it’s I don’t mean to say that health professionals have been distorting the message. But I think just the way these conversations play out, certain things get emphasized, the media kind of runs with it, certain headlines, you know, give a certain impression and then you end up with narratives that are not quite actually based on evidence.

Dr. Bob Wachter  40:19

Talk about pandemic fatigue. And it seems like we’re at a place now we’re coming up on a year that we’ve all been at this, almost seems unimaginable. But we probably still have another six to nine months of some version of the same.

Dr. Julia Marcus 

Painful.

Dr. Bob Wachter 

It’s hard to imagine. But that’s sort of the prediction. And that’s because we’re lucky. And we found these vaccines much more quickly than anyone expected. So, are there analogies from other things that you’ve studied that kind of teach us what’s unique about this stage? What are the things that we need to be paying particular attention to now that maybe we wouldn’t have 9 or 10 months ago?

Dr. Julia Marcus 

I don’t think there are direct analogies, but I just throughout have felt like, the more that public health messaging and policies as well can acknowledge that people are struggling, the more that the public will trust those messages and policy. So I think when I first you know, I use the term quarantine fatigue. And the first article I wrote for the Atlantic in May, and I got a lot of messages at the time saying, this is the first time anybody has said anything about how this is hard. And that was so striking to me like that should be, that should be just front and center. We know this is hard, and we know what we’re asking is hard. And just that little bit of empathy, I think can help build some trust. And I think now it’s not any less hard than it was, right?

Dr. Julia Marcus

And we’re all I think, pretty darn sick of this. And of course, some people are just inconvenience. Some people have suffered real tragedy. And there’s a whole spectrum, but I think everybody shares the goal of wanting it to be over. And I think just trying to message from a place of compassion, recognizing that people are struggling and that comparative suffering is generally not helpful, you know, this person is suffering more than this person. No, everyone has their challenges, and seeing those can not only make us better at our messaging and in terms of being compassionate, but can also point to, you know, ways to solve those problems and ways to help people get their needs met, while keeping their risk as low as possible.

Dr. Bob Wachter 

Yeah, it strikes me that I probably have felt this every month, but for some reason now feels like the most complex time in terms of making these decisions, on the one hand cases coming down rapidly. On the other hand, the variants looming over the horizon, or maybe not completely over the horizon as this sort of almost feels like the Jaws music a little bit that there’s this threat out there, we don’t know how big it is or how big it will get. But it’s clearly there. We’re all tired of everything about this and want to let our guard down.

Dr. Bob Wachter 

On the other hand, if you’re not vaccinated yet, you probably will have the opportunity to be in the next few months, which makes it seem like it may be a particularly bad time to get infected. So I just don’t know how the, you know, you’re a world class epidemiologist, you probably have the tools to process all that and come out with a rational decision about how to spend your days, but how does the average person sort of not just be paralyzed by all of this?

Dr. Julia Marcus

I don’t know, I mean, I’m often paralyzed by all of it, frankly. I found it very hard to focus and be productive and, you know, feel like a fully functional person during this pandemic. And just to normalize that, I’m sure that’s the experience for many others, but it’s overwhelming. And I would add to everything you just described also, deep inequities in vaccine rollout that complicate all of the things that you just said that some people are gonna have protection before others.

Dr. Julia Marcus  44:08

And actually we are limiting the population impact of vaccines in the inequitable rollout, so it’s hurting everybody. So I think you know, every time you see a vaccine selfie on Twitter, it like brings up all these feelings around, you know, all of this stuff. It’s really complex. And I think it can be paralyzing, but I don’t have, should have a more hopeful answer there.

Dr. Bob Wachter 

It’s just hard, we did a thing like a couple weeks ago here where it was not it was sort of the moral equivalent of a vaccine selfie, it was my wife and I who I am vaccinated, and she’s not, and sort of what it’s like living into in that household where two people have very, very different risks and, you know, sort of the combination of I think she’s happy and on the other hand, I think she’s feeling badly that she’s not. And we have to kind of sort out how this changes all over all of our activities. It’s really tough.

Dr. Julia Marcus

Yeah, and we just had a big discussion about ethical, you know, the ethics of, you know, what if your place comes up in line and you don’t feel that you should be taking that spot, and that just came up for us, my husband’s a therapist, who works remotely and here in Massachusetts, therapists who work remotely, we’re in phase one. And in the fine print, it kind of suggests that if you work remotely, you are not eligible. And yet, many, many, you know, remote working healthcare, you know, people who are within the healthcare field, even if they are working remotely, have gotten a spot.

Dr. Julia Marcus

And so there was a big discussion about whether he should decline. And so these everyday decisions, as you said, they’re sort of becoming more complicated, because now there’s a vaccine that is adding layers of complexity in terms of ethics, risk navigation, everything.

Dr. Bob Wachter 

Yeah. Take us through what you think the end game of this will be Visa V, you know, the, quote, “return to normal” because it strikes me that we’re unlikely to be in a situation where there is no more COVID, it is gone, and we can return to normal. As if 2020 never happened, it’s more likely there is going to be some COVID, it will create some small, much smaller risks than we’ve been living with for the past year, but nonzero, maybe analogous to the vaccine that, you know, we reached a point where the risk is really, really quite low, but not zero.

Dr. Bob Wachter  46:37

And as a society, we’re gonna have to make some calls about do we open everything back up. And as individuals, we’re gonna have to make some calls about behaviors that we didn’t give second thought to, you know, 18 months ago, but now we will. So how do you think this looks, let’s say in October, November, assuming that the vaccines really get out there and work?

Dr. Julia Marcus 

Yeah, I mean, I know as much as the next person about this, but I imagine it will be a slow process, and that there are going to be difficult decisions that we’re going to have to make, I think, because even when everybody who wants a vaccine has gotten one, that is not going to be everyone, and it’s not going to be kids, at least not right away. And so there are going to continue to be pockets of people who are not protected by vaccines. And of course, it remains to be seen, you know, or is there going to be some variant, an immune escape and all that, but assuming that, that we continue to have vaccines that are protective, even then it’s not gonna, we’re not gonna have 100% of people vaccinated by any means.

Dr. Julia Marcus 

But I think, you know, I think there will probably be a sort of painful phase of slowly getting back to life, and that, then we will get back to life, I think there will be challenges psychologically, I would guess around going back to activities that are that for so long have been associated with risk and with the potential for illness and death, even something like you know, going to a crowded bar, I feel like I would have a visceral reaction to that right now, even if I were vaccinated. And even if I knew that most people there were vaccinated, it would still be kind of a tough sell. And it would, it’s going to take our bodies and our minds, I think some time to adjust to this sort of new reality, where risk really is lower.

Dr. Julia Marcus  48:27

But it will probably be a protracted enough process that we will adjust along the way. And I really, I think we will, as some people say, we’re never going back to normal, I think we’ll go back to normal in for better or worse, you know, and hopefully we can, we can make it a better normal. But I think that when people think about both the ugly and the beautiful parts of normalcy, I think all of that messiness is going to be with us again, hopefully, you know, hopefully this year.

Dr. Bob Wachter

Yeah. Well, I think that’s probably a good note to stop on. So thank you, Julia, I really appreciate you doing this and also your writing and I’ve learned a ton about thinking about these things in a more kind of rational and intentional way from hearing you and from reading you. So thanks for everything you’ve done.

Dr. Julia Marcus 

Thanks so much for having me. I really appreciate it.

Dr. Bob Wachter

Thanks to Julia Marcus for a really important and interesting discussion about risk. I think it helps ground us and in thinking through these issues and making these really complicated tradeoffs and not stigmatizing people, not finger pointing, but really understanding that we’re all in a terrible predicament and people have to do the best they can. So being a little bit more charitable and generous. I think that’s part of the message. We have some amazing episodes coming up soon on IN THE BUBBLE. We will talk to them Steve Hahn. Steve was commissioner of the Food and Drug Administration over the past year and had to deal with some of the almost unimaginable amounts of pressure as he thought through issues of drug approval for several drugs, but most importantly, ultimately for the vaccines.

Dr. Bob Wachter  50:16

Stephen is an old friend, he and I were chief residents together at UCSF, long ago and look forward to catching up with him and seeing what the experience was like and what his insights are for the future. Going to talk to another old friend, Captain Sully Sullenberger, Sully, of course, is the pilot who landed the plane on the Hudson, a true miracle. But Sully actually, prior to that He is an expert in safety and safe systems, and has thought deeply about that and also about leadership. So we’ll talk to Sully about keeping people safe. We’ll talk about leadership and we’ll also talk about the massive challenges for the aviation industry this year and probably going forward.

Dr. Bob Wachter

We’ll talk to Don Berwick, Don is too many of us, one of the founding fathers in the field of health care quality and safety. Don also ran the Center for Medicare and Medicaid Services. Same job Andy had, under the last administration, Don did that under President Obama, he was the person responsible for communicating about the Affordable Care Act. And Don has thought a lot about issues of health equity and how the health care system can be made to work better. And then finally, we’ll talk to Emily Oster. Emily is a professor of economics at Brown University, and may be the foremost expert in the country on the economic implications of the schools and keeping schools closed. She’s done some pioneering research that helps inform some of the really, really hard decision making we’re all trying to go through as we think about what to do with the schools. So I look forward to speaking to all these people and look forward to further episodes of IN THE BUBBLE. Until we meet next, please stay safe and look forward to talking with you soon.

CREDITS

We’re a production of Lemonada Media. Kryssy Pease and Alex McOwen produced our show. Our mix is by Ivan Kuraev. Jessica Cordova Kramer and Stephanie Wittels Wachs executive produced the show. Our theme was composed by Dan Molad and Oliver Hill and additional music by Ivan Kuraev. You can find out more about our show on social media at @InTheBubblePod. Until next time, stay safe and stay sane. Thanks so much for listening.