News & Events COVID Conversation with Zeke Emanuel and Biddy Martin

Zeke Emmanuel (00:00:11):
Hello, everyone. Thank you for joining us. We're in for a treat today. We have an hour with Dr. Zeke Emmanuel. Zeke is an oncologist and a bioethicist. He's also a Vice-Provost at the University of Pennsylvania. He's one of the best known and most sought after public health experts in the country. Many of you know that he was one of the architects of the affordable care act during the Obama administration. He is a Senior Fellow at the Center for American Progress. He has many more gigs for tonight, but we have him for an hour and we're delighted. Welcome, Zeke. Thank you so much for doing this.

Zeke Emmanuel (00:00:56):
You didn't say that I was an Amherst class grad of ’79.

Zeke Emmanuel (00:00:59):
Well, I'm getting to that. Not only were you a graduate of the class of ’79, you were a chemistry major and then you went on to get a medical degree and a Ph.D. In political theory from Harvard and it shows in your work, I think, all of that. Zeke, I just want to start for a few minutes on a personal note. I took the opportunity to read your memoir, Brothers Emmanuel, and I thought I would start there. It's an extraordinary account of extraordinary lives and extraordinary parents and families. You said you attribute the success of you and your brothers in part to your parents' art of jazz parenting. And I thought I would just start by asking you to explain to our audience what the art of jazz parenting is.

Zeke Emmanuel (00:01:57):
I think my parents were quite creative. I would say, I think I went on to say my mother was the sort of opposite of a helicopter parent. From a very young age, she would shoo us out of the house and make us find our own way and allow us to explore the neighborhood and do our own thing and have a set time to come back. We lived about a block and a half from the beach in Chicago and a large part of our summer, she would take us to the beach, plop us down, with a lot of food, towels, and tell us when to come back home. No cell phones. We had to occupy ourselves and figure out how to get on in the world.

Zeke Emmanuel (00:02:52):
And it was kind of a great arrangement. They did have a very high standards for what we should do. Expected us to take initiative. They instilled in us a very strong sense of social justice. My mom was very, very early on, involved in the civil rights movement and before the rest of the country and the anit-Vietnam war movement. She was very, very, sometimes I say violently against the war, but she was very militantly against the war. My father was very committed to getting rid of lead paint because he was a pediatrician and saw the ravages of lead paint and led a lot of efforts. He was also strongly committed to universal healthcare coverage. He did not understand the American system of denying coverage to many people and, and resigned the AMA over their opposition to Medicare and Medicaid expansion of coverage in this country.

Zeke Emmanuel (00:03:53):
That was a theme that we understood and were basically communicated that we had to do. The other great thing I think they did for us as part of this jazz parenting is for a lot of the time it was the three brothers together. We spent a lot of time together. We played together. They took us on summer vacations. It was us. We slept in the same bedroom for many, many years. We had to negotiate our complex relationship and the power dynamics. Anyone who's had siblings understands the complex power dynamics between kids for recognition, for attention, for time. But that was very, very important. And it's one of the reasons that my brothers and I remained extremely close. We talk multiple times a week all together. I think this sort of free form was very important. I will say one other thing and to all the people who are either--my mom was a, this was the early sixties, actually, I was born in the late fifties. She was a big believer in Dr. Spock before it became popular. Even when it was despised, and I think many of his philosophies of expressing love and affection to kid, and providing them support without providing the, heavy-handed directing what they would do, was very important to our growing up.

Zeke Emmanuel (00:05:30):
Zeke, just for the benefit of our students. You also write in the book that when you went to Amherst you discovered you were an Emmanual and you had a friend named Andy at Amherst to help you understand what that meant. It is a transition, isn't it? We all in a way learn what it meant to be in our families once we make that transition. Are you still in touch with Andy?

Zeke Emmanuel (00:05:58):
I spoke to him yesterday.

Zeke Emmanuel (00:06:01):
Okay. So he's still helping out with the transition?

Zeke Emmanuel (00:06:04):
Very much so actually. He's been a figurative uncle, uncle to my daughters. He's very much still in our lives.

Biddy Martin (00:06:14):
Wonderful. All right, well let's switch to COVID because that's what everybody wants to hear you talk about. And so do I. The news changes every day, but the state of the knowledge of the virus, and where it's headed, also seems to change. It's a complex. Is it a complicated virus or is it just that we haven't yet figured out, we haven't had enough time yet to figure it out?

Zeke Emmanuel (00:06:42):
Actually I don't, I think by virus standards it's not that complicated. I think the uncertainty is how it interacts with the body. The kind of clinical conditions it produces is complicated. How we shed it, how it actually is producing the damage in the body. We understand that there's a hyper immune response, but exactly what the components of the immune system are going out of whack and seeming to produce all the complications we see, whether it's clots or the lung, acute respiratory distress syndrome or now the auto-immune syndromes that seem to be popping up, why it seems to have this a very strong age gradient such that it's people over 65 who 80% of the mortality is concentrated in that group, what kind of co-morbidities that are associated with the worst outcomes, whether they're diabetes or hypertension or obesity.

Zeke Emmanuel (00:07:45):
I think these are all mysteries because we have not had a COVID virus, a coronavirus, excuse me, that has really had this negative impact on so many people. A lot of Corona viruses we get are relatively benign. We often don't even know we have the virus. And then SARS came and infected a number of people and killed about 775 people, but then disappeared. So there was no real followup. I think its mystery is more that we just don't have enough experience, clinical or virological of this particular kind.

Biddy Martin (00:08:30):
Yeah. And we don't have reliable therapeutics. But the testing is getting better. Is that accurate?

Zeke Emmanuel (00:08:39):
Well, we're getting more testing. True. That is both necessary if we're going to get a handle on this and a good thing. I would say the serological testing certainly at this moment. So the serology testing is the testing that you do to see if someone's been exposed and has antibodies to COVID-19. Those tests are like the wild West out there and you have no idea whether what you're getting is any good. I think there were a couple of bad judgments by the FDA on sort of permitting the wild West as opposed to making sure that every test had a sensitivity and specificity that they've now put in place, and hopefully that marketplace will become more regulated and ordered over the next four weeks or so, so that you know the quality of the tests you're getting. And that if it says you don't have antibodies, you don't have antibodies. If it says you says you do have antibodies, you actually do have antibodies. I mean, we are getting some good news. There's a report out today that it does look like everyone who recovers from COVID-19 infection does develop antibodies. Even if some people are a little delayed in that process. How long they last, we still don't know, and how protective they are. We still don't know.

Biddy Martin (00:10:01):
Yeah. And the testing for the virus, you and I have been talking about whether it will be as widely available and as capacious as all of us need it to be to open up. What are, what are your thoughts now about how quickly we're ramping up in the testing for the virus?

Zeke Emmanuel (00:10:25):
We're doing better. I think we can say that. We're still not at the level that I'd say that almost all the experts agree--several to 5 million tests a day. To really be sure that people are infected and we need them in, if not in real time, at the point of care, the way the president has it, then at least in real time that you need the results in 24 hours, not seven days. Can we get there? Of course we can get there.

Zeke Emmanuel (00:10:55):
This is not trying to send a man to the moon kind of problem that'll take eight years to solve. But it has been a problem. Part of it is, again, a lot of the people who would normally get in and solve this problem are sitting on this, have been sitting on the sidelines because they're...why get revved up for something where the market's going to go away in a couple of years when we have a vaccine, and I've just spent all this capital investing in revving up for the agents, new machinery, et cetera. That makes no business sense. As an economist, a health economist friend of mine said, that's not a problem that can't be solved. We know how to solve it. It's called money. Guarantee them that we'll pay for the revving up and we'll pay for the revving down, and switching, the focus afterwards.

Zeke Emmanuel (00:11:50):
That's kind of necessary to get people to commit. And we need that commitment to actually get not only the machines in place, but the supply chains that we need in place to provide the reagents and all the other stuff around it. Actually, I think it was yesterday, I talked to venture capitalists out in California, got the entire process robotically done. 24 hours a day, I think he said, his machine, for a hundred thousand dollars, could could do 2,400 samples reliably. You know, if we had 1a thousand of those machines, we'd be well on our way to solving this problem. Doesn't really require any human input. I think that that's a money problem. That is a, you know, commit the capital and we could have it. I think Congress has been, for whatever reason, partially because there hasn't been the right leadership in the White House, hasn't, I mean we've allocated $33 billion to testing rather than say $250 billion, which would certainly have solved this problem.

Biddy Martin (00:12:58):
Well, that's interesting because I certainly, we hear a lot of criticism of the federal government and Congress for the delays. I hadn't really understood, I don't think until he just said it, that there are people on the sidelines who could have been doing more, but for the risk of investing in something that might go away, but that makes total sense. Are people now investing in it with the realization that it's wise, necessary, and also wise business?

Zeke Emmanuel (00:13:34):
I think a big capital investment for a two year time horizon is not a wise move for a lot of businesses and it's not necessarily good. I think they have become convinced, and understanding that that was the barrier, something that should have been done, and the task force should have had, and it should have been part of rescue bill two or three. There was $33 billion put in for testing, but that's a small amount of what we need. That's roughly a hundred dollars per American for the testing. That assumes one test per person, not multiple tests over time per person, which is very likely what we're going to need going forward. I do think the proper planning and the proper understanding of what the demands for this kind of pandemic were going to be just didn't seem to filter into the legislation.

Biddy Martin (00:14:33):
Zeke, do you have a view on whether it's even worthwhile to talk about whose fault all the delays are? Is it China, is it our administration? Is that an even even a worthwhile conversation? And if so, do you have a view of how one gets at that?

Zeke Emmanuel (00:14:54):
It is a worthwhile conversation to the extent, not for today necessarily, but to the extent that we want to learn from this episode for preparedness for the next episode. You've got to know what do we have to do, what mistakes did we make, why didn't we take this seriously enough? Or why did some people take it seriously, but not others? Because this isn't going to be the last viral or some other serious threat. It's just the latest. It may be that, you could say in 2019, Oh, 1918, 1919, that was then, we're safe from it. That obviously is a mistake. It may not be an influenza pandemic. It may not be a COVID pandemic. Who knows what the next one will be, but we can be pretty darn sure there's going to be a next something.

Zeke Emmanuel (00:15:51):
We had SARS in 2003. We have H1N1 in 2009, 2010, we had MERS Zika, Ebola, COVID. If you can't see the pattern there, maybe you're not looking hard enough. These things, yes, some of them get burned out, but they're pretty serious and we can't tell what the next one's going to be necessarily and how serious it is, how easily transmissible, how deadly it is and when, in the cycle of things, it's going to hit. So learning what those signs are, having early warning systems, knowing what does preparedness mean, what do we have to put in place? Which agency's responsible? How are we going to coordinate it from the White House? All of that is I think, a necessary post-mortem to be done here. We used to, when I was growing up, have these big problems and we appointed presidential commissions, whether it was the Warren Commission or the Kerner Commission on civil rights, to study these things and come back with recommendations, that's probably is a useful item to do here. I'm not sure in the midst of trying to fight this pandemic. That's necessarily the first place I would start, but we should not say that's just past history. Let's move on. I don't think now is the time to do that investigation, but we should not ignore that investigation.

Biddy Martin (00:17:20):
What about the ethical dilemmas that have arisen in the treatment of the virus and a range of other domains? You're a bioethicist. You're writing about these ethical dilemmas, or you've written about them obviously before. What do you think are the

Biddy Martin (00:17:41):
most compelling, the most important ethical dilemmas this COVID-19 pandemic has created for us?

Zeke Emmanuel (00:17:50):
I began writing on the ethical dilemmas on pandemics in 2005. My first publication was in 2006 because there was that year that I mentioned that Secretary Lovett had his pandemic planning commission. They came out with a preparedness plan. I heard about the plan, listen to it, and I realized that their philosophy or their approach to allocating scarce resources during an influenza pandemic, especially vaccines, therapeutics like Tamiflu, that was wrong. They had prioritized first responders. But then the next group was the elderly with comorbidities who would likely die from a influenza pandemic, would be the most likely to die. I said, hmm, that doesn't sound right to me. You probably want to be saving kids first, because they have more life years. So we wrote an article on it and then I spent the next 15 years both writing about how to think about allocation of scarce resources when you had to choose between patients, whether it was for organ transplantation or for people during a pandemic, a therapeutic among people or a vaccine among people.

Zeke Emmanuel (00:19:08):
I taught a course at the university of Pennsylvania on it, every year, called, Rationing and Resource Allocation. I've been wrestling with that problem. And interestingly, when this came up, we had a framework for applying to this problem. We wrote it up in the New England Journal and circulated it. And I think there's been, I won't say universal consensus, but a pretty widespread consensus about that kind of framework, who gets priority and who doesn't. Probably some people out there will be loathe when I say I think that ethical problem has been solved. That may be overstating it a bit. But I don't think that's the most pressing ethical issue going forward. The most pressing ethical issue going forward is one I'm working on now, which is we're not going to have an unlimited amount of vaccine when, if we've discovered a vaccine, that is effective.

Zeke Emmanuel (00:20:05):
We're going to have a limited amount of vaccine and there are big ethical problems there. Now some people may be thinking, oh well the big ethical problem is who gets it first? I think again, we've solved that. It's going to be first responders. And then we're going to look at people whose lives can be saved, and a variety of other criteria. But the big issue is going to be, well, you have a limited amount of vaccine. How do you distribute it among all the countries? Cause you're not going to be able to immunize 7.8 billion people right away. And it may actually take years to immunize 7.8 billion people. If you look at what the production capacity for various vaccines is. The question is, how do you distribute that vaccine? How do you make that decision? I'm a little less interested in how you make that decision. I'm more interested in the substantive principles of who's first on the priority list, who's second, who's third, who's fourth? Really hard problem because not only is it domestic justice and domestic ethics, but it's international global between nation States and that's even harder. We're trying to work on that problem.

Biddy Martin (00:21:17):
Yes. And speaking of what's just and fair and right, we've certainly seen a whole set of inequities in this country and internationally highlighted by the effects of this pandemic. How does that play into your thinking about resources and allocation?

Zeke Emmanuel (00:21:40):
Well, it is, I mean, one of the things this pandemic has done is to highlight the inequities, both the disease burden of the rest of society and also, health inequities in terms of coverage and the delivery system. Doctors and hospitals and access to care. I'm here in Washington, D.C., 45 to 49% of the population is African-Americans. 79% of the deaths are African American. That has stayed pretty stable. What causes that? Well, probably, let's be honest, we're not one hundred percent sure, but probably three or four things all coming together. One is the comorbidities which we know put people at higher risk. As I mentioned, diabetes, hypertension, obesity are more prevalent in the African American and other minority communities. That is playing into this, those are related to lots of inequities in diet in this country in ability to exercise, in educational attainment, and other things.

Zeke Emmanuel (00:22:51):
Serious problem playing itself out in the COVID context. There's inequities as we know in access to healthcare services, the distribution of hospitals, the distribution of physicians, the access to health insurance, that we've had for a long time in this country. That probably plays into this as well because many inner city hospitals are not as well as equipped. Patients don't have a primary care doctors and don't get the kind of care over time for their chronic conditions. Third, there's inequity around housing issues. There does appear to be a strong relationship between crowding and housing, close family gathering, arrangements and spread of COVID. And we know that the housing arrangements for minority communities and poor communities is much worse and probably lends itself more to a spread of the virus. And last, there's also this information absorption and trust in the whole society as well as specifically the healthcare system and the willingness to believe that physical distancing is important,

Zeke Emmanuel (00:24:06):
wearing a mask is important. So you take all four of these things, each one of them to some degree a result of the socioeconomic and racial disparities in this country. And they're all compounded in the COVID case to lead to much worse health outcomes. We can talk all about equalizing attention once you're in the hospital to treatment for COVID in terms of getting into the ICU and getting a respirator and if remdesivir actually works while getting remdesivir, but that's chicken feed compared to the underlying socioeconomic disparities that go to, in our society and for racial minorities. And that has to be addressed if we're actually going to get even more equalized, the health outcomes, both the COVID and [inaudible] to all the other conditions that people suffer from.

Biddy Martin (00:25:05):
Before I turn to questions from the audience of you, you've just given a good segue to healthcare reform and you've played a major role in the past. Where's your thinking now? Not about what could be done immediately, but what's your thinking now about healthcare systems?

Zeke Emmanuel (00:25:25):
It's ironic that we should be talking about that just after the president has called for getting rid of the affordable care act. You know, 22 million fewer people would have had health coverage in 36 States. People who've lost their job would not have access to Medicaid if we went to the pre-ACA days. One of the things that COVID has made clear, we've now have, whatever, 35 million plus people who've lost their jobs. Tying health insurance to employment, really crummy idea. We really should probably not be doing that. Or if we do it, we need a much better safety net so that if someone loses their employment, they instantaneously have very adequate health coverage. And unfortunately, we don't have that in this country yet. It's especially problematic in places that have not expanded Medicaid,

Zeke Emmanuel (00:26:29):
the 14 states like Texas and Georgia and Florida that haven't expanded Medicaid. But I don't think the American public has a tolerate any longer, not having universal coverage and a system that really works. And I do think that the employer-sponsored system will shrink. If we provide an adequate alternative, a lot more people are gonna find themselves in that adequate alternative. Bernie Sanders-style Medicare for all, I don't think is going to...it's too contentious. I don't think it's going to happen. We could go to some other kind of Medicare expansion like vice president Biden has talked about, decreasing the age. I think actually, allowing all sorts of competition, for private insurance or regular old Medicare, fee for service, traditional Medicare as we call it. I think that could be an alternative. We could have Medicaid for anyone who doesn't have either Medicare or employer sponsored insurance and just fold everything into that. I think we're going to have a serious need for some alternative that is comprehensive going forward. And I think there will be a big push from the American population for that, especially when you have these 35 million Americans who were working, who never imagined that they would be unemployed all of a sudden, literally overnight, finding themselves without a job and without, in many cases, without health insurance. I think that is going to force change in this country.

Biddy Martin (00:28:10):
That's an excellent point. Let's just talk for a minute. I'm told I have a few more minutes to ask questions. Given that there's not federal coordination, which States do you think are doing a good job of opening up or of declining to open up?

Zeke Emmanuel (00:28:24):
I think probably, one of the best certainly was, both getting on top of the virus, decreasing the actual impact and now looks to be having the best situation may be Washington State. Jay Inslee, the governor there listened to his epidemiology people right after they had that death. In quick succession they found that high school kid who was infected, with no known association to China, and then a death in the nursing home. They jumped on it. They asked Amazon and Microsoft and other companies to send workers home and have them work from home, impose physical distancing and what the public health officials call NPI-- nonpharmacological interventions. They have done a remarkably good job of skating through and having a limited number of, that's and a low number of new cases per million population.

Zeke Emmanuel (00:29:35):
If you had to pick out one where the response has been good and really does seem to have been pretty textbook as far as the country goes, Washington state is it. Two things seem to have characterized that, first they were, quote unquote, lucky in that they had an early case that was detected and they had an early death that I think shocked people and brought them into this is serious and let's do what's necessary. And they had a governor who listened to his public health community, and a public health community that was well-informed, well-trained, understood what was necessary, understood what the messages had to be, the importance of the consistency of the messages. I think Georgia is a textbook example of the opposite. You have a governor that doesn't seem to listen to public health people, even though the CDC is located in his state and Emory has a phenomenal school of public health.

Zeke Emmanuel (00:30:40):
He was shocked that people could be spreading the virus and be asymptomatic. I guess not paying attention. First thing he opens up our barbershops, tattoo parlors, beauty salons, places where you need close physical contact for over prolonged periods. Probably not a wise move. There are some parts of the academy that can be opened up. Probably his rate of infections was still going up as he was opening up the state something with even the president's plan for opening up the country did not recommend these. They recommended 14 days of decline. I don't think, I personally don't think that's an adequate standard, but even that minimal standard was not met in Georgia. So that's a model of how not to do it.

Biddy Martin (00:31:37):
Let me go to some of the questions from our viewers. One asks, how will our response be different if there is no vaccine? There is no vaccine, but I think if we have...

Zeke Emmanuel (00:31:54):
That is a very black day if we're not able to develop a vaccine relatively quickly. We will have prolonged, serious, adverse events for a long time because you're going to have to physically distance for a long time, or we're just going to have to let it run through the population, have very high mortality rate in the population. Then we have to assume that you have prolonged immunity. If you have short-lived immunity and it's constantly running through the population, that gets you more to a sequence like the black death where the plague went through and every few years you have these big eruptions, all very high death rates over centuries. That would be an incredibly awful situation. So let's best not think about that. Okay.

Biddy Martin (00:32:55):
Here's an interesting one. The World Health Organization says that those who are infected may not be immune. You addressed this a little bit earlier saying that there was an announcement today about antibodies, but not necessarily of immunity. Why would a vaccine provide better immunity?

Zeke Emmanuel (00:33:14):
I don't think the World Health Organization said that those who get infected and recover are not immune. I think what they said is we don't know. It's a very different. It's not that we're sure they get infected, they get antibodies, but they're not protective or they don't get antibodies and they're not immune. We don't have that the other link in a large cohort of people, which is you get infected, you generate antibodies, which does seem to occur. And yet that the antibodies in general are not protective. That would be, again, a very bad situation for us because it means that you're constantly under threat of dying from COVID, of getting infected and dying from COVID. That would be a disastrous situation for us actually. So one of the reasons we think of a vaccine is possible is that people do develop antibodies and we hypothesize that those antibodies are protective at least for a while.

Zeke Emmanuel (00:34:18):
We can give people a vaccine. They will develop protective antibodies. It may be that we have to re-immunize them periodically, maybe even as frequently as every year. But you know, that's uncharted territory and we have to see how long the immunity lasts and how frequently we'd have to immunize people. Let's just say if it's an annual immunization, it's going to be tough because we know from influenza about two thirds of kids get immunized every year, but only about 45% of adults get immunized every year. And that's too low for herd immunity, which was one of the reasons that on an annual basis we get somewhere between 30 and 60,000 deaths every year from influenza. It's not the only reason, but it's a contributing reason.

Biddy Martin (00:35:09):
Here's a question, Zeke, about the ethics of mandating vaccination. What are the ethics of mandating vaccinations?

Zeke Emmanuel (00:35:18):
We should do it. We certainly can. There's no two ways about the question that we can mandate it for kids, everyone up to 18. I think above 18 you could mandate it because from an ethical standpoint, you're being immunized is important for my health and your spreading it to me. And so I think we can, from an ethical standpoint, easily say that people need to get it to protect the wider community. I am not a lawyer. Sometimes I practice one on TV, and as I understand it, I think it's Prince versus Massachusetts, if I've got it right, from the turn of the 20th century that said, yes, you can require adults to get immunized for the protection of the wider community, for the public health. I don't think this is a hard one, frankly.

Zeke Emmanuel (00:36:16):
It's certainly not a hard one, ethically, in my opinion, and I don't think it's a hard one legally given that precedent, and I know that the anti-vaxxers are already out there. I've always wondered, you know, why do we let them do that and endanger us and then also demand resources from us to treat them when they're sick because of the exposure to a virus that they could have gotten a vaccine for. Part of the problem I think is, and one of the things COVID is curing, if I can put it that way, people who are slightly older than me experienced widespread serious illnesses that were life threatening or if not life threatening, like polio, very, very life-transforming, in a negative way. They understood the value of vaccines.

Zeke Emmanuel (00:37:19):
They got rid of this scourge. I know from when I was growing up how frightened parents were of polio. I was really a first generation of kids who got polio and my parents didn't have to worry about me in the summer. Parents, you know, the generation just older than me, it was a real worry. Every summer, vaccines were a godsend to those people. If you look at the lines of kids for the polio vaccine, getting it in school, I mean, people were just so thrilled that they could protect their kids. And then we became complacent. You know, childhood became very, very safe, not totally safe, but very safe. And people became complacent about the value of vaccines and the value of preventing things like measles, mumps, diptheria. That shows you what happens in human beings when these threats are taken away. We forget the value while they got taken away because we have vaccines and you no longer have to confront this terrible, horrible illness that's life threatening. So I think COVID, if anything, has probably convinced a lot of people were on the fence: mandatory vaccination, probably a really good idea.

Biddy Martin (00:38:37):
Zeke. Um, a related question. How, how do we protect ourselves from disinformation?

Zeke Emmanuel (00:38:51):
I'm a physician and a bioethicist. You're asking me about, you know, the scourge of the internet and every false statement out there and how easy it is to spread a false false statements. Not only how easy it is to spread false statements, but the fact that it's easier to spread false statements and hysterical statements than it is to spread the truth because it requires more understanding to reason through the truth. Look, I'm a guy who it doesn't do Facebook, doesn't do Twitter, doesn't do Instagram precisely because I'm fed up with all of the, and I've never done them by the way, but I'm fed up with all of the how easy they are to sow disinformation, how easy they are to be plagued by...how misinformation is much easier to travel and to be retweeted and recirculated. These are horrible, horrible problems from this technology. And I don't know that we have a solution to that problem, but get off the damn thing. It's also not good for your productivity or your concentration.

Biddy Martin (00:39:58):
All right. Dr. Emmanuel. Well said. By the way, should

Biddy Martin (00:40:03):
colleges and universities

Biddy Martin (00:40:05):
be using Apple and Google apps that allow tracking of contacts, is that a good idea?

Zeke Emmanuel (00:40:14):
I think you mentioned, Biddy, that I'm a Senior Fellow at the Center for American Progress. And we released a report, I think almost exactly a month ago, about how to do testing and contact tracing and how. We do need technology to help us with contact tracing. But we can't entrust it to Apple, Facebook, Google, we need to use the data and the capacities that they have, but we need a trusted intermediary who is using that data to help with contact tracing, that trusted intermediary. We've made a proposal that it should be, I think it's the American Society of State and Territorial Health Officers, or the Association of State and Territorial Health Officers. They would get the information, hey would destroy the information after 45 days when it was no longer relevant to contact tracing, they would pledge not to commercialize it, not to merge it with other data, to not to keep a shadow, a record once they destroyed the data. I think there are ways of doing this in an ethical manner. Giving Facebook and others the power, I don't think so.

Biddy Martin (00:41:35):
Zeke, here's a question from an alum who says, I am 72. This is my 50th reunion year. What do I need to do to remain safe?

Zeke Emmanuel (00:41:47):
To remain safe, stay at home.

Biddy Martin (00:41:48):
Stay at home. We cancelled reunion. Stay at home.

Zeke Emmanuel (00:41:53):
Stay at home, especially if you're over 65. I mean, can you go out? Yes, but you've got to make sure you're not near anyone else. You're wearing a mask. You wash your hands the moment you get back in. You know, I live in Washington D.C. and literally I'm blessed because right out my front door is a part of the National Park, Rock Creek Park. I can walk down there and avoid people. I can ride my bike and be away from people. You've got to find places you can go out and at times of days you can go out and really go out and exercise and get some fresh air. You also have to be aware of staying away. It does appear, let me just say, that the casual contact, walking past someone six feet away with both of you having masks, on probably no sharing of the virus. In closed spaces where you're with someone new for a prolonged period of time, those look to be the problem areas.

Zeke Emmanuel (00:43:01):
So I would expect that for restaurants to come back, one of the things that might be wise is for outdoor seating, widely spaced, everyone wearing a mask, except while you're eating, is probably going to be the necessary ingredient. Being indoors [in restuarants], probably not that smart of a thing.

Biddy Martin (00:43:21):
Here's an interesting question. What is the ethical framework for developing risk tolerance for opening up?

Zeke Emmanuel (00:43:30):
I don't know. I'm not sure there's an ethical framework for that. I do think what we need, and many of us are stumbling towards that, my group at Penn included. We've got some very smart people working on this. We need the right model that tells us how many deaths and hospitalizations and complications, how many people get unemployed? How much does the GDP go down. Based upon various measures that we put in place, where those measures, we can see if we tailor them to this age group or we tailor them to this group of people with comorbidities or we open the schools. What's the impact on health? What's the impact on economics, et cetera. That complex model is what we need. It is a matter that now people will have different risk tolerances. Some people are risk averse and they really want to reduce the risk as much as possible.

Zeke Emmanuel (00:44:29):
Most of us are not consistent in doing that. We do things that are much more risky than other things. For example, we drive cars even though that's a pretty risky activity. But we don't do other things, say fly, which is typically safer. At the other end, some people are more risk-tolerant. I'm probably at the risk tolerant end. I do a lot of things that most people probably wouldn't do. I don't know, I mean we have to make clear what that trade off between number of lives, hospitalization, economics, unemployment, and the level of imposition is. We're going to have to reason together. This isn't something for each individual. This was something as a society as a whole, when do we open up, under what conditions, how much pain in terms of economic dislocation is that going to cause?

Zeke Emmanuel (00:45:22):
That, I think is where it goes. I'm not sure that it's an ethical framework over risk tolerance. People do naturally diverge in their risk tolerances. And let's face it, in a free society, where we want people to live a life that they can choose, we want to recognize that. We want to embrace people. We want to allow them to have that kind of difference. We don't want them to impose the consequences of that on the rest of us in terms of infecting the rest of us with COVID. You know, they do have to pursue their own life in a responsible manner that is aware of how it might increase the risk for other people. I hope that's a coherent answer.

Biddy Martin (00:46:05):
I thought it was completely coherent. There's a question about protestors calling on governors to end lock downs. I guess I would ask, given what you've just said, I'll just make a statement and you see what you think. It's hard in this country for some people to combine individual freedom with a sense of responsibility. How does one think about the confusion that emerges when people believe freedom in this country should mean the right to do whatever one wants regardless of its impact on others. I mean...

Zeke Emmanuel (00:46:41):
Well, we know about that. We know that that phrase that you just said, Biddy, is false. Your freedom. You can do whatever the hell you want no matter what its impact on others. That is a false phrase and we ought to take it more seriously. That we want to embrace your freedom. We want to celebrate your freedom. We want to give you the opportunity to exercise your freedom, but it has to be done in a way that doesn't impose costs, unacceptable costs, on other people at all. And that, I think, we haven't done in a consistent way, but we definitely need to do it in a consistent way. Let me just say something about the people who are protesting in state houses and demanding things open up. Maybe I'll say two or three things about that. The first thing I want to say is all the data, and there's some recent economic models that have just been produced within the week, suggest that fully opening up,

Zeke Emmanuel (00:47:35):
it's actually not the most optimal situation from an economic standpoint. Forget from a public health mortality, health care standpoint, purely economically, it's not the optimal thing. Some lockdown, some shelter in place, some physical distancing, some prohibition on gatherings actually saves you more money. Why is that? This is my second point. All the data suggest that people are not going to participate in commercial activity. Businesses are not going to stay open if people are afraid of getting COVID, right? I ain't buying a new set of jeans if I'm risking dying. That's just not a calculation people are going to do. So we, by imposing some of the public health measures, we actually inspire confidence in people and allow them to engage in routine activities. So we do need some public health measures for maximal actually economic activity. That's what all the models suggest.

Zeke Emmanuel (00:48:45):
That's what behavior suggests. There's recent data out that shows that economic activity went way down before the shelter in place orders by states were issued, which means that the public behave, even if the government did issue the stay at home orders, because people were not going to risk their lives for economic activity, going to a restaurant, going to a bar. If you want to open those things up and stimulate economic activity, you need some public health measures and you need a degree of confidence that people aren't going to get infected. And that's, I think a point lost on those protesters. All of us want to open up the economy. The question is to do it in an intelligent manner that protects the particularly vulnerable, and opens up the activities that are least risky first and most risky at the end, when we're going to understand more and maybe we'll have a therapeutic and maybe a vaccine.

Biddy Martin (00:49:46):
Yes, which leads to a question that I'm afraid to have you answer, but I'm going to ask it anyway and you'll say whatever you want. What is your specific advice to the Amherst community and other colleges about reopening?

Zeke Emmanuel (00:50:02):
[laughter] Should we reveal our secret, Biddy?

Biddy Martin (00:50:05):
I mean, you I have agreed to be one of my advisors and you didn't agree to be an advisor to everyone on this call but you go for it.

Zeke Emmanuel (00:50:15):
So, there's a spectrum from we're going to come back in the fall. We're going to have full online classes, full in-person classes. The students are going to live in the dorms, to at the other end, we're not going to have in-person classes. We're going to do everything online. Let me say, I think the former--we're going to have in -on classes for a full semester in the usual manner--I don't think that's viable. Why don't I think it's viable? We are going to have a second wave, whether that second wave is in, call it: July, August, September. Who knows. If we do have a big second wave at that time that would mainly be caused by this premature opening before we have a suitable testing regime, before the number of cases have gone down.

Zeke Emmanuel (00:51:06):
If we don't have it, then we're likely to have it in early fall, October, November, December because it's fall and people are going to do more circulating. We're going to have a flu season that's going to compound the problem. I think, though, the fact that we're likely to have a second wave during this is going to make it unlikely that we're going to have a full semester. So that leads to either we do it all online or we try to have this controlled togetherness where there are lots of safeguards in place. What are those safeguards? Well, students who are at high risk because they have a comorbid condition, don't come back. Students are tested, are asked the quarantine for 14 days and tested when they come in. We do institute a physical distancing measure in terms of how we hold classes.

Zeke Emmanuel (00:52:02):
We put kids in pods and ask them to remain in pods. It's going to be a different in person experience. That experience, I would suggest the idea that you do it in September and it's going to carry all the way through, call it Thanksgiving or further. Pretty unlikely, in my humble opinion. And so I think you have a plan, ability to say, alright, after the three weeks you're going home, and we're going to then transition to online learning. And if at three weeks things are looking fine, we're not seeing any increase, we've had a few cases amongst students or staff of COVID, but nothing terrible. Then maybe you continue it for a few more weeks and you play it week to week and everyone understands the situation you're in and everyone's willing to be flexible.

Zeke Emmanuel (00:52:53):
I think that's a possibility. It does. Your risk tolerance and your ability to live with an ulcer has to be high to do that. But I think it has certain advantages. It also has certain risks. Completely online I think is a problem from a pedagogic standpoint. I think it's a problem from students' standpoint. I think that's the range in which our discussion and deliberation needs to go. Here we are, what is today, May 6th, seventh, eighth. I know I've lost time, but we're not making that decision today and you shouldn't make that decision today. It's a decision that you would only make further down the line when you understand a little bit more on modeling what the campus can tolerate in terms of physical distancing, what the food hall can tolerate in terms of shifts and things like that. I think there's a lot of things that need to be assessed before you can finish that evaluation and make a final determination. And from what I know, not just of Amherst and other small colleges, but the big university that I'm a part of, everyone is gathered in the information gathering mode and everyone is putting that decision down before making a lot more scenario planning and evaluation of where is the epidemiology over the next couple of months.

Biddy Martin (00:54:24):
Thank you. Now two more questions. First, one from our audience. How would you build trust or how can we go about building trust among disadvantaged groups, disabled people or fat people who are worried they'll be refused necessary care?

Zeke Emmanuel (00:54:44):
I don't think it's a matter of refused necessarily care. Look, in our personal lives, all of us understand that trust is built up over time. It's not a one and done kind of thing. Right? You blow trust, you create this trust once. Trust is something that has to be built up over time. You have to walk the walk and you have to do things consistent with what you say you're gonna do. And I think that is what we need to do for minority communities. Frankly, it's what we need to do for the population as a whole. We need to have leaders who say what they're going to do, do it and apply it, not just to them, the voters, but to to themselves. So I'll just give what I take to be a simple no brainer: wearing a mask.

Zeke Emmanuel (00:55:39):
We've got good evidence. The CDC recommended it, although its recommendation has been a little watered down. There's a good reason. Is it foolproof? No. Is it an element that can reduce risk to some degree? Yes, we ought to all be wearing masks when we go out. I just think that's a no brainer. Modeling good behavior is really important. Physical distancing. We talk about six feet apart when you have a meeting, have people six feet apart. I don't want to be partisan here, but contrast the president's coronavirus press conferences with governor Cuomo's press conferences. Look at the crowding onstage versus we have a table. Everyone is six feet apart at the table. Night and day.

Biddy Martin (00:56:35):
All right. I know you have to go soon. I promised one of our faculty members about whom you said some very nice things that I would ask the following question.

Zeke Emmanuel (00:56:45):
Oh. And I get to say nice things about him again?

Zeke Emmanuel (00:56:48):
If you want to, only if you want to., Zeke, you wrote a piece sometime ago in the Atlantic in which you said living to 75 would suffice for you. I think you stated it a little more strongly, but I'm putting it in a tender way. And you gave your reasons why you thought that would suffice. I think we need you around far beyond your 75th year. I'm asking you to rethink that proposition.

Zeke Emmanuel (00:57:19):
[laughter] First of all, that's Austin Sarat who I have to say, I learned a huge amount from Austin about how to teach and how to get students really engaged. Austin used to put his face about two inches from my face and scream at me. I don't do that, but I do remember he used to scream questions and push you to give good answers and defend your answers. I do do that. And as I say, he was a very big inspiration in helping me understand how I learned and how I could help students learn. And so I'm always indebted to him for that. The second thing is I'm not at 75 and don't count your chickens before they hatch. You have no idea what a blithering idiot I might be at 75. There are many people who think I'm a blithering idiot now.

Zeke Emmanuel (00:58:12):
But one of my worries, so the best argument I think you can give against me at this very moment in time is Tony Fauci. Tony Fauchi is 79 and talk about a guy who's completely copos mentis, contributing, coming up with new ideas, developing policies, being totally creative. That's the guy. And if I were that at 75, I probably wouldn't reconsider my position, but my position is about curative medical treatments if I had cancer or something like that. I think that's a little different circumstance. It's not about I'm not taking any medication. It's not about, I'm not taking any medical care. But it does give you a sense of trying to think through what in life is valuable, what in life is meaningful to you, what is the reason you want to live and continue to live?

Zeke Emmanuel (00:59:09):
And that gets into what I think and have seen a lot of, which is sort of narrowing or coning in on life so that your ability to do less and less and less, ability to have meaningful relationships, ability to meaningfully contribute, ability to engage in meaningful activities has, slimmed down and you have to, you know, because we always accommodate to our situation. You accommodate to that. I'm not willing to do that and I think, I want to be a contributor as long as I can, and as long as I can, if I were Tony Fauci and being as amazing as he is at that age, that's a completely different circumstance.

Biddy Martin (00:59:56):
Well, I think we can count on that then. I'm very optimistic based on that. By the way, at the end of your book, you said your parents gave you, all three boys, an incredible sense of purpose and that you have had a life of striving. And then you said, perhaps, ironically, that when you each realized that you were satisfied with what you had achieved, you would be true adults. So have you reached adulthood, Zeke? [shakes head] No. Okay. I haven't either. [laughter]

Zeke Emmanuel (01:00:34):
You can evaluate your life in retrospect. It's what keeps me going. There's always more to do, more to learn, more to experience. I hope I'm not satisfied prematurely.

Biddy Martin (01:00:52):
I don't think there's any, any risk of that. Zeke, thank you so much. I know you have to go to a show. I really big show now and I just want to thank you. You're terrific. And this was a lot of fun and very informative and thought provoking and thanks to the audience for being here with us. Be well.

Zeke Emmanuel (01:01:11):
Thank you. Stay safe. It was a lovely interview, Biddy. I really appreciate the questions.

Biddy Martin (01:01:17):
Thank you. Bye. Bye. Bye.

Zeke Emmanuel (01:01:28):
Bye.