Tuesday, August 4, 2020

Out of the Crisis #17: Max Henderson on Covid Act Now, exponential growth, and how to help

From the very start, the coronavirus has been a fast-moving target. The mechanisms of where and how it's moved through the country have made managing the spread challenging. Max Henderson founded Covid Act Now to help with that process by making data-driven recommendations for sheltering in place (and later, for reopening) combined with public advocacy guidance to get local government to pay attention to the real facts about spread and safety. As he told me, "The cognitive load of just understanding what the heck is going on and where we stand and what's coming next is extremely, extremely difficult." The work of Covid Act Now has made it the definitive resource for getting cities and states to take action against what he thinks of as our common enemy--the coronavirus.

As the son of immigrants from Cuba and Germany, Max has deep faith in the power of American ingenuity. All of his work is designed to help it thrive. "From the very beginning," he explained, "our goal has always been to, one, be extremely clear, two, be extremely action-oriented, and three, be additive."

We talked about contributing solutions as an antidote to despair, being the target of a disinformation campaign as a result of putting real numbers about exponential growth into the public sphere, collaborating with experts, and how not to lose sight of the big picture even when your head is in the details. 

You can listen to my conversation with Max Henderson on Apple, Google, or wherever you like to download podcasts.


In addition, there's a full transcript of the show below.

 Highlights from the show:

  • Max introduces himself (2:43)
  • Grieving during COVID-19 (3:59)
  • Feeling powerless to help others and what he did (5:18)
  • On how contributing eases despair (8:05)
  • How he started Covid Act Now (10:52)
  • Description of Covid Act Now (12:00)
  • The Covid Act Now origin story (13:00)
  • How Max modeled Covid in January (17:09)
  • The danger of not understanding exponential growth (17:47)
  • Motivated reasoning and stay at home fatigue (22:01)
  • On being the target of a disinformation campaign (24:21)
  • The power of making a personal connection over the facts (28:44)
  • How we know the models are accurate (29:45)
  • The original model showing the effects of shelter-in-place and New York as example (31:53) 
  • The difficulties of managing micro knowledge versus macro knowledge about the virus (34:30)
  • Why Max made advocacy and action part of his work from the start (37:30)
  • The importance of public opinion and political air cover (39:35)
  • Covid Act Now's Resistbot campaign (41:18)
  • On American ingenuity and being the child of Cuban and German immigrants (43:47)
  • On getting the model right and not crowding out experts (46:37)
  • Transitioning from models to metrics and what the data shows (50:26)
  • Sitting in the eye of the storm (52:40)
  • Management and moving forward (54:01)


Show-related resources:

Transcript for Out of the Crisis #16, Max Henderson and Covid Act Now

Eric Ries: This is Out of the Crisis. My name is Eric Ries. Are we really ready to reopen here in the U.S.? I don't think so. It's almost like we've forgotten how scary, dangerous, or impossible this all seemed in the early days.

One of the recurring themes in these conversations is that exponential growth is hard to understand. We're not hardwired for it as human beings. Remember when the numbers were small and people dismissed a threat? Remember how quickly things went from okay to catastrophic? We are making the same mistakes as before, looking at our lower numbers and concluding that the virus is gone and everything will be okay.

But it doesn't have to be this way. We made drastic and radical changes before and we could do it again. Remember when shelter-in-place seemed like an impossible or radical idea? Remember how quickly it went from inconceivable to inevitable?

Max Henderson is a technologist who founded a group called Covid Act Now. They had simple calculators so that anyone could see the humanitarian toll of even a single day of their life. As the name suggests, Covid Act Now is not just a model, it's not just about data. It's about the need for urgent action in an exponential crisis.

They had an incredibly effective pressure campaign that helped ordinary citizens write their Mayor, write their governor with simple metrics like, "If we don't shut down, this many people will die." They had calculators so you could see how every day of delay could cost lives. That pressure campaign was a necessary counterweight to the lobbying that many public officials were receiving about the need to keep the economy open because the economic costs were going to be high. But what Max and his team understood is that there is no economy if the people who power it are sick and dying.

Through public advocacy and an unyielding commitment to data-driven recommendations, Covid Act Now became the definitive resource for getting cities and states to shelter-in-place. Now, they're turning their attention to modeling the reopening. And what have they found? Check the data for yourself. We are not anywhere close to being ready.

Understanding exponential growth is hard, but we're going to all have to get good at it for all our sakes. Here is my conversation with Max Henderson.

Max Henderson: Hey, my name is Max Henderson and I'm the CEO and founder of Covid Act Now. Prior to Covid Act Now, I was at Google and Firebase as a senior data science and Go-To-Market leader.

Eric Ries: Max. I really want to thank you for taking time to come talk to us during what has been a really challenging time for so many people. Before we get to Covid Act Now and, of course, action has been your watchword through this whole crisis, how are you doing? How's your family? What's your quarantine setup like?

Max Henderson: Yeah, of course, thank you so much for having me, Eric. It's been an interesting time. I and my family are safe. Thank God. We are-

Eric Ries: Glad to hear that.

Max Henderson:... distributed around the country and the world. And so, I think what's missing the most is just not being able to be together during a hard time like this, and I know lots of people are going through the same thing. I actually had a death in my family during this period, and it really highlighted-

Eric Ries: Oh, I'm so sorry.

Max Henderson: Thank you. It really highlighted the fact that you can't even get together to mourn. And so, it's certainly been real. I thankfully have... Me and mine are safe, and we are certainly in a more privileged position than most. So, despite all that, I'm very thankful for the opportunity to be able to have what I have during this.

Eric Ries: Do you mind saying a little bit about how you've been managing that grieving process when we can't use the normal tools of grief and the normal rituals that help people get through a hard time?

Max Henderson: Yeah, of course. It feels post-apocalyptic, right? I lost my uncle. He died suddenly in Germany. And my family there had to essentially drive through a border control that technically wasn't letting anybody across state lines, right? So, my other aunt who lives in another place had to literally drive to a checkpoint and explain why she should be let through when the borders were closed, to be able to go and grieve. Most of us who are not within driving distance had no chance of being able to get there.

The process has been extremely challenging and interesting. You have conversations on the phone that you would want to have in person. You can't hug a person. There are no words. I'm so thankful for being able to contribute in some way because it does give me a sense of galvanization and a way of channeling that energy into trying to help others and just move the effort forward. I think if I had less to do and less ways of being additional or additive that it would have made the situation a lot harder.

Eric Ries: I want to dig into that. What's been the hardest thing for you while we've all been in quarantine during the shelter-in-place?

Max Henderson: Hardest thing? That's a great question. I think--I'm very blessed. I was able to bring some friends on quarantine with me and so, I've, at least, had some sense of community during this and-

Eric Ries: That's great.

Max Henderson:... being busy. My family and my significant other have had other folks to interact with so that they're effectively, to some degree, mourning the loss of me because I'm constantly working on other things and they support me a ton in that, so I'm very, very blessed.

I think the hardest thing has just been the desire to want to help others. I realized, this is a bit perhaps of a cop-out answer given the fact that I have found something to channel my energy into, to me being in control in a crisis-response situation has added so much psychological safety that the personal elements of being in quarantine have really fallen into the background compared to just the urgency of being able to execute on all these things we want to do.

And so, the reality is that, for me, and I don't know if this is a particularly satisfying answer to this question, but I've received so much from this opportunity to serve in the sense that it's allowed me to take the feelings that I feel and I'm sure everyone feels around lack of control, lack of clarity of the future, lack of an opportunity to participate and channel those into productive things. It's just helped my psychology so much compared to the way I know I would feel if I was just sitting on the couch wondering what's going on and what I can do and just feeling completely powerless.

Eric Ries: I'm glad you said that because it's actually a pretty consistent theme among the folks that I have talked to, who are in the fight trying to make a difference. And look, I've had my moments where I envy the people who were bored during the crisis and wonder what it would be like if I was running out of Netflix shows to watch. But actually, having now talked to a number of those people and convinced them to volunteer and to help out, it seems like it's paradoxical to me being busy and being exposed to these dark facts, especially with the work that you've been doing, having a real sense of the danger of the epidemic and the scale of it. I think there is a psychological security in it.

It's just one of those really clear moments where the people who are being the most of service, they're not actually... It's not an act of self-sacrifice. It's actually psychologically very healthy to feel like there's something you can do in a situation that for most people, there really isn't.

Max Henderson: Yeah, 100%. They say that depression is fundamentally the feeling of being unable to control your own destiny, right? And that feeling of despair is something that I certainly have had less of because I've been able to participate in this way. And to be clear, I mean, there are days where I wake up and I'm like, "Wow, another 18-hour day. I'm exhausted." The work is extremely galvanizing. And it's rare that there is an opportunity, there is something that is so pressing and emergent and relevant that is also so hard, so operationally hard, so difficult from a data perspective.

This is one of those things that no matter how deep you dig, it is truly like a problem unknowable by one person. It just grows fractally in complexity, like the data is bad, our understanding of the disease is bad, human psychology and our ability to stay in these really difficult interventions is a complex problem. And so, there's so much complexity here that you can really dive into it. And I think that has had an incredibly positive effect paradoxically, on my psyche, totally.

And it doesn't surprise me at all that other people have had the same experience. It's a lot like giving, where you think giving is going to be a thing that only benefits the receiver, but ultimately, it benefits the giver as much as the receiver.

Eric Ries: Or maybe even more.

Max Henderson: I had a very similar experience. Or maybe even more, yeah, that's right.

Eric Ries: Yeah, that's certainly been my experience. I'm incredibly grateful for the opportunities to serve even when they've been hard. And I know there's some people listening who are like, "Oh, come on," but just you'll have to take these... Here's two testimonials that that's been our experience during a time when I honestly think despair is the real enemy even more than the virus. Because we can outsmart the virus, we have the tools and the technology and the science.

But the question is, will we have the will? Will we have the ability, the social cohesion to actually take the actions that are needed? And that's what I really appreciated about Covid Act Now and the work that you've done, is you're fighting that. That's our real enemy.

Max Henderson: Yeah, that's right. I mean, people might say like, "Oh, gosh, get out of here. You're being so holier than now," but I really think it's a much more practical thing than that. I think understanding... I'm a person who has always felt an incredible need to wrap my head around problems and just understand them. And so, it's purely... In some way, it's selfish.

By way of working on this full time, I get to have a better understanding. This whole thing started with me just being like, "Wow, I don't understand this." And there's such an overwhelming amount of information on a context that I can't imagine that many people understand it either. I'm not special. So, if I don't get it, then probably most people don't get it. How can I take all this complexity and collapse it and just make it so easy? If we can't all get on the same page about what's happening, it's impossible for us to make decisions. Like a political decision maker will not be able to say, "Hey, I'm doing this for this reason because this information and mistrust will just overwhelm that person's political capacity to make our political capital to make the decision."

People will argue about what the right solution is instead of just focusing on the solution, and the timelines are too short for that. So, it felt like, for me, the starting point was I need to understand what's going on. And then, it quickly became, "Well, if I've understood what's going on in a way that's simple, then I have a responsibility to share that with other people." And that fundamental thread is ultimately what developed into Covid Act Now.

Eric Ries: Say a little bit about what Covid Act Now is for those that don't know.

Max Henderson: So, Covid Act Now is a tool that was trying to send one very specific message, and that is that immediate action is required in the face of exponential growth in order to prevent catastrophic outcomes, right? So, the disease grows exponentially, and human beings don't think in terms of exponentials. We think in terms of linear change, so one goes to two goes to three goes to four. The disease fundamentally doesn't work that way. The disease grows exponentially, so one goes to two goes to four goes to eight. And those numbers start small, but they eventually become extremely big.

And just being able to help people build the intuition to understand that if we don't act now, catastrophic outcomes might result was the original takeaway for me in my research, and the thing that I felt and the group of us that started this felt a calling to share with the American public.

Eric Ries: Tell us the origin. So, was there a moment for you when the gravity of the pandemic crystallized in your mind?

Max Henderson: Yeah, there was a moment. This was really interesting. There's that commencement speech by Steve Jobs where he says that you can really only connect the dots in retrospect, and that it sounds like a trope, but it's been so real for me in so many places in my life. I've always had an interest in medicine and was in EMS for a while.

Eric Ries: Explain what an EMS is for those that don't know.

Max Henderson: Oh, yeah, of course. So, EMS is emergency medical services. So, think, emergency medical technicians, ambulances. EMS folks deal with disorders and cardiovascular disorders on the regular, right? Most emergencies that people have are either breathing problems or heart problems, major injuries. And so, I've always had an interest in this sort of thing. I thought for a long time that I wanted to be a doctor, spend some time in the pharmaceutical industry as well, and got a degree in System Dynamics. I've always been interested in nonlinear systems. And so, this was a really interesting coming together of two areas of interest for me academically in an extremely morbid, but also extremely practical way.

And so, I was on sabbatical studying to get my EMS certification and came across COVID. And I remember being extremely fascinated by it from the very beginning. In January, I started building a model just to try to understand as it was starting to spread it in China, just understanding the nature of the spread. It was designed just to share with me and mine, right? It was focused on what might happen in the Bay Area where I live if it started to spread here.

And it was after some of the data started to roll in that I realized how quickly it was growing. I had this epiphany, that we were already starting to have a case or two in the Bay Area, just how quickly this thing could possibly grow, right? We're talking from the first reported case to potentially thousands of hospitalizations in only a couple weeks. I had an aha moment that this information needed to not just be kept amongst me and my community but needed to be shared as widely as possible.

Within a few days of me sharing my model out just to my network, I ended up having to create a newsletter because thousands of people had signed up for updates. And eventually, after about a week or so of sending updates, I got approached by some folks that I had never met before who said, "Hey, Max, there are lots of states that don't have an analysis like this." I mean, keep in mind, this is a spreadsheet, right? I mean, it's not some super complex... Certainly, the thing has evolved, but back then it was just one tab in a spreadsheet. "You need to make something like this for every state."

And so, I agreed that I would do that, and I partnered with my other founders, Zack, Igor, and Jonathan. We built a copy of the spreadsheet for every state in the union, and Igor built the website. We hooked it up as quickly as we could. And within 48 hours of launching the thing, nearly 10 million Americans have come to the website and seen our predictions. And from there, as these things go, every time more people saw our predictions or relied on our math, the more galvanized and the stronger of a calling I had to continue and elaborate it and make it more reliable and complex and feature-rich. And so, we've, from that early success, just continue to build.

Eric Ries: How did you make that original model? I think what's really interesting, you're talking about like it's no big deal. But most of us encountered that same set of information earlier this year, and very few of us had the insight that you did to say, "Hey, let's build a model and see what could happen in the Bay Area." But how did you actually do it? What does it mean to model a disease like this?

Max Henderson: Yeah, it's a great question. I mean, the thing is, you can always make models more complicated and all models are always going to be wrong, right? So, I had to start with that, you're never going to have a perfect model. And so, in some ways, simplicity is better because something that's simple is easier to understand.

And the reality is that the most important thing here is the nonlinear behavior of the disease. I mean, I'll start by saying that, like I said, I got a degree in System Dynamics, and so spreadsheets and models are my jam. I'm no world class nonlinear systems expert at this point.

Eric Ries: Well, but you were on sabbatical from Google.

Max Henderson: That's right. But I mean, I hadn't touched a nonlinear model probably since college, right? So, the key insight here is not some complex modeling insight, but rather that the numbers, whether it's hospitalizations, deaths, infections, etc., all double on some fixed period. So, the simplest possible analysis here really is just take one cell in a spreadsheet and then measure how many days all the systems... So, when a nonlinear system like this is in exponential growth, every single category, infections, deaths, hospitalizations, they all grow at the same rate. And that rate is some doubling period that you can measure from the empirical data.

So, if you've got a four-day doubling period, which is what it was in most places before interventions went in place, the most simple analysis here is just one column for deaths, one column for infections, one column for hospitalizations. And every four days, the number in each column doubles. And everything else is really refinements and simplifications.

Obviously, at some point, when everyone is infected, things are no longer growing exponentially so there are some... Obviously, it doesn't continue forever. But that's the fundamental analysis, and it's actually really, really simple. So, it doesn't take the... Oftentimes, I found in this and other things that I've worked on that the answer, and this is something we've tried to keep in Covid Act Now until this day, we're done when there's nothing left to take away and not when there's nothing left to add.

So, we can always make the thing more complex. And the model is now this complicated Python thing that takes a 96-core machine 12 hours to run, but the fundamental dynamics are very much the same. And that is the scary thing about the fall that we face, right? Especially now that we've delayed a potential spike here, I think we're forgetting the fundamental nonlinear dynamics at work. And if we forget that, it's going to be very much to our detriment.

Eric Ries: It's driving me crazy. I was just talking to a very smart person who is saying, "Well, because here in the Bay Area, we've got the disease under control. Therefore, hospitalizations are down. And just looking at the linear data, therefore, it will be safe to open back up and therefore, there won't be danger, exponential-type danger anymore. We're past that phase." And it was a completely reasonable inference. I completely understood where they were coming from, but it's dead wrong. And if people draw that conclusion from the fact that these early interventions worked, aren't we in a lot of danger?

Max Henderson: Absolutely. Yeah. I mean, I actually heard one of the leading epidemiologists in Germany call this the prevention paradox, and I loved it. The idea that because through positive action, you stopped the bad thing from happening. The bad thing either was never going to happen or has gone forever now and can never come back, right? And effectively what we've done is buy ourselves time. That's it.

Every person who hasn't yet been infected is a potential person who can be infected once non-linear growth comes back. And when it comes back, it'll start off slow. At first, it'll seem like everything is fine when we're past the worst of it. Because when that one goes to two, and two goes to four, and four goes to eight, the numbers are small. But when you're at 500 and it goes to 1,000 in four days, and then it goes to 2,000 in four more days, and then 4,000 in four more days like we saw in New York, that's when things really become completely insane. And the scary thing is we all have to check our bias on this all the time because it's just not a way... It's not intuitive. It's never going to be intuitive.

And so, you really do have to look past the intuition of this thing. And even I, looking at the math every day, sometimes I feel it. I feel the, "Oh gosh. We've been doing this for two months, and it doesn't feel like it can continue and nothing bad has happened. So, was this all maybe an overreaction?" I know for certain the answer is no, right? There's no question in my mind whatsoever. But I think feeling that and knowing that that emotion is there is a super powerful thing because we're all feeling it, right? Everyone's tired. Everyone is uncertain. And if we-

Eric Ries: And motivated reasoning starts to kick in.

Max Henderson: Yeah, that's right. Motivated reasoning starts to kick in. And it's so subtle, you don't even notice it's happening.

Eric Ries: I have friends who wanted to have a party, and they were trying to convince themselves that it was safe to have the party and they were going to socially distance at the party. They had a whole plan for why it was going to be safe. But I noticed in the planning of this party that not only were they trying to convince themselves that it was safe, but it started to spill over into them making justifications of the pandemic wasn't actually that dangerous.

I don't think they were consciously aware of the fact... The fact that they were just tired of being stuck at home and missed each other and wanted to have this party was starting to affect their ability to reason objectively about the data that they were seeing from the outside world, never mind the fact that the data is grim and it's hard to face it head on.

It's funny you talked about the paradox of prevention. I actually wrote a blog post called The Curse of Prevention, but not recently, back in 2009. I had to look it up. It's that old. Where I was grappling with this, because in engineering, this comes up all the time, because how do you know when it's worth it to pay the cost of a mitigation of something that may never appear? And there's this political, we should call it what it is, this political impulse to use the curse of prevention to attack something that you don't want to have happen. And you can use it both ways.

You can say, “You're alarmist." The thing wasn't really true that we had to do the lockdown and criticize that way. You can use it the other way. You can make up potential dangerous things that could force someone to do a prevention that they don't really want to do, which has been the criticism on the other side. You've had the distinction of even being called fake news, which is one of the highest honors you can achieve in our current crazy times.

Talk a little bit about what that's been like to be on the receiving end of this idea that you're somehow manipulating the data or trying to serve some... I'm not even sure what your secret nefarious agenda even would be, but whatever it is, how do we know that this data is accurate and what's it been like to be the subject of this disinformation campaign?

Max Henderson: Yeah, it's been surreal, right? Because never having been the subject of something like this before, you'd think, "Oh, well, maybe there's some nuance or confusion." Where is the line between stretching the truth and just making something up? I can confirm there are people out there who are just willing to make things up.

Eric Ries: Just arguing in bad faith.

Max Henderson: Yeah, yeah. Arguing totally in bad faith.

Eric Ries: 100%.

Max Henderson: It's really, really interesting. Gosh, how can I describe it? Yeah, surreal is probably the best way to describe it. I mean, the funny thing is that’s the one major piece that's ever gotten put out on us, and we certainly get a lot of hate mail and things like that and way more positive encouragement thankfully. Everyone gets their share of malicious actors or people acting in bad faith.

The one article that really got written that I think wasn't most in bad faith also contained something in it that was like, "And these guys are predicting 13,000 hospitalizations in New York in two weeks. Can you believe it? And the number ended up being like 19,000, so there's some... It didn't age very well.

Eric Ries: Yeah. And I'm sure they didn't print a retraction and apology.

Max Henderson: No.

Eric Ries: But they're just onto the next conspiracy theory.

Max Henderson: They certainly did not. Yeah, nobody ever went back and, in fact, check that. Honestly, I don't know what our nefarious ends would be. But more than anything, it makes me sad that we are... At least there are some portions of our national discourse that are so divorced from reality that we can't help. Almost my reaction to these things has been like, "Gosh. Well, I wish I could just sit down with you and show you that I'm a human and that we're the same," and just show you what I see. And rather than argue with you, just try to bring you in and show you like, "Well, here's the challenge that I see. Let's just logic through this together."

And how do you see us solving this problem? What is it here that you think is fake? What is it here that you think my motivation is? Or is it just because like I'm some faceless person somewhere on the internet that it feels like this is the right way to handle the situation?

Eric Ries: Believe me, having done that all with such people, I mean, write a book and they'll see this experience and see what it's like. I think I can safely predict that not a single one of those people would be willing to sit down with you precisely because I think, at some level, at some visceral level, they understand that it would work. This bad faith nonsense, it is only effective if you can hide behind a veil of pseudo anonymity and you can really other the person that you're talking to. And if we actually had the connection and trust and love, right, the fundamental human connection that is needed, it's not possible to sustain that kind of ideology. And therefore, those things are actually dangerous to it.

Max Henderson: Yeah, I try. I certainly don't have the time to do this with all of them, but I try as much as I can when people post a troll comment or something or send me like a really, totally, unacceptably vitriolic email like, "Hey, you guys are the worst. You're trying to destroy the country," or even worse things that I won't even mention.

Eric Ries: We will not be linking in the show notes, but people can find them if they would like.

Max Henderson: Yeah. A lot of them are coming privately directly to me, I try in almost every case to react with exactly the opposite. I mean, some of them, I just can't engage with, but I try to respond with exactly the opposite language and say like, "Hey, thank you for bringing this up. You're so right to be skeptical. There's so much bad information out there. Here's what I see. And really, I see this situation as a once in all of our lifetime opportunity to save lives.

I love this country as much as anybody else does, and I'm trying to do the right thing. These are the facts as I see them and I'm willing to have a debate with you about what you see as being problematic here." And 90% of the time, people don't take me up on it. But about 10% of the time people do actually like, "Wow, I never expected an answer to this email. I'm sorry. I see what you're talking about. I have these two other questions." And then, it ends up turning out to be a productive discussion.

Eric Ries: That's outstanding.

Max Henderson: Those things are making me, honestly, they make me happier than almost anything else when I can actually make a connection with a person who is coming from such a place of mistrust and, I mean, I don't want to use the word "ignorance" because it makes it sound like I am somehow the keeper of knowledge, but mistrust and negativity. They can turn around to something as positive as a real personal connection and an alignment on some kind of objective reality.

Eric Ries: So, how do we know the models are accurate?

Max Henderson: It's a good question. We're working. So, I think first of all, we have to really understand what accuracy in the context of modeling means, right? All models are wrong, some models are useful. And the goal of modeling really more than calling an exact number X number of days, weeks, months out is to understand the variety of positive outcomes, find the catastrophic ones and figure out how to prune those, figure out how to make sure that those catastrophic outcomes never happen, and build intuition for how our actions can change the future.

You don't have to be right on every single right layer. There's so many ways a model can be right or wrong. It can get the actual number of hospitalizations or deaths or infections wrong, or the relative ratios of those things to each other, or exactly when they happen or what the shape of the curve is exactly. So, there are just so many different ways that things can be wrong.

And then, there's also the fact that this is a system where our expectations of the future change the future, right? If I expect that a huge spike of infection is coming and we shut down, the huge spike of infections doesn't come or at least it gets delayed like the situation we're in now. And so, in a world like that, right and wrong are a little bit more complicated than just like, "Could you call the exact number?" So, we think about this in a couple different ways.

One is we think about getting the shape of the curve right and understanding how the scenarios differ relative to each other. So, if I do X versus doing Y, what is the difference that I can expect on average between those two different outcomes, even if the exact numbers are going to be slightly different? The second is how do my actions change reality? Our original tool showed you what happened if we went to shelter-in-place and what would happen if we didn't. Even if those curves don't perfectly mirror reality, the relative difference between them is incredibly important for building intuition.

Eric Ries: Actually, if you don't mind, talk about what the model said at that time, because I think many of us have gotten used to the idea that we're going to do shelter-in-place and we forget that it was like five minutes ago, in historical time, that that was an extremely controversial idea.

Max Henderson: Yeah, I mean, when we first started talking about shelter-in-place, it wasn't even clear that this was within the realm of possibility, right? I mean, when we put the tool up, again, we were not telling anyone to do anything necessarily. We were just pointing out the speed at which a decision needed to be made because these were the relative possible outcomes that we were dealing with. But I mean, we were talking, at that time, about hundreds of thousands of hospitalizations in just a few short weeks.

I mean, we saw New York was the last to act. And so, New York really provides one of the few real examples of how bad it could get, and given it's an urban area, but even in the state, how bad it can get, 0.1% of the entire population of New York state has died from COVID, not 0.1% of infected. It's literally 0.1% of the entire population of the state. And last we checked, the antibody testing to see how many people had been infected came out to somewhere between 10% and 20% depending on where you were in the state. So, you're talking... This could have been five times as bad at least.

And so, the models were showing something actually quite similar to that. It was basically somewhere around 1% to 3% fatality rate for anyone who is infected, and probably about 70% or so of people infected before herd immunity would be reached. And so, you're talking about 1% to 2% or so in that range of fatalities in this country. So, at a population of 300 and 30 million, you're talking about somewhere between 3 million and 6 million people.

We've learned a lot more about the disease since then, but the numbers actually have not shifted that much, right, now that more data has come in about infection rates and we actually have some antibody tests. Keep in mind, at this time, we didn't have any. So, we didn't know how many people were actually getting sick. We just knew how many people were getting sick enough to go to the hospital.

The numbers have come down a bit. Our estimates of death rate have been cut roughly by a factor of two. But I mean, even a 1% death rate or a half a percent death rate in the United States is still somewhere between 1.5 million and 3.5 million people.

Eric Ries: Still a catastrophic loss.

Max Henderson: Still a catastrophic outcome, and that hasn't changed. That is our latest thinking. That is our more optimistic thinking.

Eric Ries: It seems like that, in some ways, because we're having such a hard time forming a national consensus about the facts as we learn more about the microstructure of the epidemic and the disease, and the effects of vitamin D, and the antibody tests, and all this micro knowledge, we lose sight of the fact that the macro facts have been established and are pretty well understood and have been pretty stable through the whole thing, namely this is a highly deadly, highly contagious, exponentially growing epidemic. And nothing can or will change that until a vaccine is developed.

Max Henderson: That's right. That's right. This was one of the reasons that we created and continue to work on Covid Act Now is that the reality is that we are doing a really bad job of paying attention to the forest and not the trees, right? Our national discourse is largely occupied by either, "Here's the number of deaths there were yesterday, or here's the number of hospitalizations there were last week. Or hey, someone said that chloroquine is a great treatment for..." We're dominated either by facts out of context or anecdata, and so it becomes incredibly... The cognitive load of just understanding what the heck is going on and where we stand and what's coming next is extremely, extremely difficult.

Using a weather analogy, instead of saying like, "This is what the temperature is going to be. Oh, you should bring an umbrella because there's a 50% chance of rain," well, right now in terms of COVID communication is, "Well, it was 75 degrees three days ago at 5:00. It has rained at least three times this year," which is not at all useful for understanding what you actually have to do.

Eric Ries: And who could really trust those umbrella manufacturers anyway?

Max Henderson: Right. Exactly. Maybe, "I've never seen rain, so maybe rain is not a thing. And I don't even need an umbrella."

Eric Ries: Yeah, distraction, delay, obfuscations act as information.

Max Henderson: Exactly. And when you factor in the fact that there, obviously, massive economic, public health, and mental health concerns even to the extreme measures we're taking, it becomes a massively complicated thing to understand.

Eric Ries: I kept thinking about-- in the early days of the crisis, especially in that wave when shelter-in-place was coming into effect, I tried to imagine what life must be like for the principal policymakers, especially mayors and governors, who must have been hearing from endless business lobbyists. None of whom I'm sure were saying we need to shelter-in-place. I'm sure they were all saying, "I need you to understand the catastrophic impact, the actions you're talking about taking will have on my industry and you better believe will remember who blah, blah, blah." The usual lobbying, self-interested playbook, that must have been so loud in the ears of policymakers. And one of the very few counterweights to that was the campaign that you were running with Covid Act Now.

So, talk about why you decided to take action and advocacy orientation versus just having like a neutral model at the beginning. What did you do and why was it important to you that policymakers have somebody telling them the actions that they could and must take?

Max Henderson: Yeah, great question. So, first of all, let me say I have... I mean, mistakes have been made and will be made, but I have just an immense respect for every policymaker and decision-maker in this situation. I mean, talk about the worst possible situation you could possibly be in as a decision-maker, you are responsible for every life lost and you're responsible for every job lost. And no one is ever going to know how it would be if you had acted differently. And so, you are the risk vessel. You are the person responsible no matter what, and that's a lose-lose.

So, from the very beginning, our goal has always been to, one, be extremely clear, two, be extremely action-oriented, and three, be additive. So, the goal here is not to say you have to do X or you have to do Y, but rather provide information that allows decision-makers not just to... They're suffering from the same information overload all the rest of us are. So, distill the information down to something so clear that the action is obvious, right?

The next thing to do, forget 10 levels down the decision tree and all the detail, just look at the situation in its most basic clear form and make the decision that obviously needs to be made no matter how hard it is. That, in and of itself, is a difficult thing. It's a really, really hard thing to do and something that we've been focused on as being the primary difference between us and all the other models out there, right, because there are now dozens of them, and they all do great work. Some of them are private and some of them are public. But the reality is that we don't necessarily need more complexity. We need less complexity and more clarity.

The other thing that I would add here is for decision-makers specifically, I think we overlook how important public opinion and political air cover is to making the right choices. In this country, we believe in freedom. You mentioned like a shutdown would nearly have been unmentionable or wasn't unmentionable when we started this thing, and if you're willing to convince the American public that something like this is necessary, and I'm convinced it was and continues to be necessary, then you need to clearly explain why that's the case. And you can't just hand over a model that only a PhD expert can interpret and say, "Well, we're just doing this. You got to trust me." That's just not the level of national discourse in this country.

And so, we wanted to create a tool that wasn't just telling decision-makers how to act, but that was simple enough that the general public could see it, understand it, and provide air cover for their leaders to do what was required. And one of the things that worries me the most right now is that as we shift into this prevention paradox, "Oh, well, maybe this was all an overreaction, or even if it wasn't, we're past the worst and it's time to go back to normal."

If we don't have similarly clear graphics to explain why either we're not there yet or what it will take to get there, then we're going to lose control as a nation. We're going to lose control over our decision-making here because ultimately, we're going to go back to something much more reactionary and less first principles-driven because it's just impossible for everyone to agree. And so, what ends up happening is decision-makers are forced to just take the average of public opinion and do that, right?

Eric Ries: Talk about the campaign you did with Resistbot to have people write to policymakers and try to motivate them. I was really proud to see that come together.

Max Henderson: Yeah, of course. So, the campaign we put together is we essentially sent out text messages to several million people who were Resistbot members to essentially let them know, on a push basis, what was going on in their state to actually look at the numbers and to come to their own conclusions about what action needed to be taken, and then make it really easy for them to communicate with their electeds about what their opinion was, right?

So, essentially taking the website and instead of forcing you to find it, sending it to people and just laying the information out and saying, "Look, here's a couple different scenarios. You can interact with them and see what the outcomes would be. And if you're convinced that action is needed, you should let your electeds know." It's that kind of thing, and I'm super proud that we did this. That, I think, made probably a bigger difference than modeling, right?

The model is a tool. It's a tool to an end. And that end is ultimately to get us as a country to make faster and better decisions. We could create the fanciest model in the world and be extremely proud of it on an academic basis, but if it doesn't actually create change, then it's a waste of time, in my opinion.

Eric Ries: Quick shout out to Dustin Moskovitz who underwrote the cost of the Resistbot campaign at a critical time. What role do you think that campaign and Covid Act Now played in convincing policymakers to take that drastic action to save lives?

Max Henderson: Wow, what a question. I'd like to believe, I mean, having communicated directly with probably half the states in the union, either in the public health department or in the governor's office, my sense is I believe I played a non-trivial role. I mean, at the end of the day, I'm much less worried about the role that we individually play and more worried about us getting to the right answer.

And the only reason I even care about the role we play is purely just to make sure that we are adding to the signal and not adding to the noise. We're actually doing something that has any effect whatsoever and we're not making the situation worse in some way. Because it is possible to have negative impact, right? It's possible to-

Eric Ries: Absolutely.

Max Henderson: I like to stay curious about our impact, but the truth is we're all on the same team together, right? I mean, my view here is this is... Depending on how you look at it, this is the first time that we've had a real enemy on our soil, and the American ingenuity can overcome anything. I mean, I'm convinced of that through and through, right? I mean, I'm a first-generation immigrant. My parents came here for a reason. As long as we are all on the same page, we can do anything. And so, if I can help, if our organization can help get us all on the same page, even just a little bit, that is work worth doing.

Eric Ries: Where did your parents come from?

Max Henderson: My father is Cuban. He fled the Castro regime in the late 1950s, early 1960s, and actually fought in the Bay of Pigs invasion. So, he was part of the entire Cuban missile crisis. I wrote a book about it. Mom is German immigrant, and she also came over here around the same time in the '60s. They met in Miami which is, I guess, where a Cuban and a German would be.

Eric Ries: I guess that that makes a lot of sense. And I appreciate you--there's nothing... We often see that immigrants and the children of immigrants have the most optimistic view of what America is capable of. And I appreciate you tying it to that patriotic sensation that we all ought to have, that we have a common enemy. It's really, in some ways, our truly global enemy, and that coordination, cooperation, solidarity, those are going to be essential ingredients to combating.

Max Henderson: That's right. And that's why I see there being a real missed opportunity to come together here, right? And I realized that either out of ignorance or out of malice, there were those that want to divide us. But the reality is that this is a unique opportunity for all of us to come together across the world, but even more so inside this country to find something that all of us have a common stake in, right?

I mean, all of us have parents and grandparents and people we care about that we don't want to lose but more importantly, whether you care about National Defense, or whether you care about protecting this country and what it stands for, or whether you care about the public health outcome, the reality is that all roads lead to Rome here. And so, if you choose to see this thing as the first successful invasion of the United State by some foreign enemy, then feel free to see it that way. But when you... I can't see how anybody looks at this and says like, "Oh, it's not a big deal, or we should just ignore it." That, I really cannot understand.

Eric Ries: You talked about how important it is to make sure that you're adding to the signal and not the noise. Can you talk a little bit about some of the guardrails you've put in place as this has grown to make sure that the data is accurate, obviously, within the parameters you described, but also that you are integrated with the scientific and public health communities? And this is not just tech... I think of the caricature of ignorant tech people trying to metal in scientific matters we don't understand. Just talk a little bit about the seriousness with which you've taken the need to get the model right.

Max Henderson: There are two things here, one is getting the model right and the other is not crowding out. We're not adding so much, just adding so many more voices to the discussion that the true experts cannot be heard, right? And we think about them both separately.

So, getting the model right is actually almost, in some ways, the more straightforward thing because there's a lot of prior art in epidemiological models that we can reach into. So, our model, we ended up moving from a spreadsheet model to a model based on one created by Alison Hill at Harvard that is open source. We ended up taking that thing and modifying it to have a couple more features, but ultimately, fundamentally operate in the same way.

We've partnered with Stanford and Georgetown epidemiological and public health folks there as well as other advisors like Nirav Shah, who is ex-Health Commissioner in New York and also a lecturer at Stanford and ex COO at Kaiser Permanente, to help provide us the guidance to make sure that we're sending the right public health message, the model has the right inputs, the output is believable. And so, our approach there has really leverage existing well-respected prior art and bring advisors into the fold so that we have...

We're not making these decisions on our own, right? The value that we add is the engineering work, being able to scale the thing up, communicate it clearly, essentially taking this great academic work and turning it into a consumer product that is reminiscent of the best in class tech products out there. That is the value that we're adding, but the guts are all public health and epidemiological people. So, that part is pretty straightforward because it's just like, "Hey, let's go find the experts and let's just amplify their thing."

I think that the much harder thing here is figuring out if you’re additional. Are you crowding out the experts by just adding more noise? And are there others who are sending pathological messages that you have a responsibility to answer to or to amplify the right message in the face of? And this is a much more difficult question. I think we've ultimately come to the conclusion because we're working with experts who tell us, we rely on them to tell us whether they believe our message to be additional, and we ask the question, "Are we actually adding to the message here? Are we saying something that others aren't already saying? Or are we crowding them out?" And we've come to the conclusion that, again, where we really add the most value is making the message approachable.

And that is the thing that it seems nobody quite had the ability to do, and it's not because we're special, it's just the multi-disciplinary nature of our organization. We brought together epidemiological experts who really understand the science, public health experts who really understand what the public message for that science needs to be, and tech folks who understand how to take a message and make it super approachable, super easy to interact with, super polished, and just very confident and inspiring. It's that combination of things that has really made us additional. The mixture really is greater than the sum of its parts.

Eric Ries: So, Max, tell us what the models are saying now. Where are we in this crisis?

Max Henderson: It's a great question. So, we've recently transitioned much more from models to metrics. And the model was really, really useful when we were trying to understand how non-linear behavior like explosive exponential growth was going to impact us in the short term because it's so counterintuitive. Right now, we're in a state where we've at least delayed, not avoided, but delayed the worst.

We've transitioned to a much more of a metrics approach. The difference here being rather than trying to understand what the future is going to be like, I'm trying to set goals and I'm trying to manage against goals, right? So, in this case, reopening. When am I ready and what does a good reopening look like versus a bad reopening?

There are a couple things that are clear. We are still maintaining the models because once we get through reopening, there's obviously risk of a second spike. And so, having the models in order as well. So, there's a couple really clear takeaways here. The first is we have not prevented. We have delayed what is potentially the inevitable unless we work on a holistic containment strategy.

The second is that the lockdown containment strategy, although it is extremely effective, and the best thing about it is that you can do it really quickly, is I think we all know is fundamentally unsustainable and we need to transition out of it as soon as possible. Because unlike some of the criticisms that are levied, I think all of us are intimately acquainted with the economic and human cost of being on lockdown. Nobody thinks that this is a free lunch. So, we need to transition away from this as quickly as possible. And the way to do that is through some combination, a slow-controlled reopening where we carefully and conservatively test how much disease growth comes back as we introduce various different parts of the... Or reopen various different parts of the economy, coupled with testing and tracing, right? So, coupled with both the opportunity.

Essentially, we have to know where the disease is spreading and how fast it is spreading at all time. And the way that we do that is we test as many people as possible to understand where the disease is, and then we trace all of their contacts and we test them as well. And anybody who's positive, we isolate them such that they cannot re-infect people. This way, we keep each infection from infecting less than one other person and things start to trend to zero.

I think our biggest risk here is that we believe we're outside the storm, but we're really in the eye of the storm right now. I'm from Florida, so you're going to hear hurricane analogies for me a lot. We're in the eye of the storm. And if we lose, if we take our eye off the ball, we will have as big of a spike as what we were predicting before this whole thing started. But we will be coming at it from a much weaker economic position, a much weaker emotional position because I know we're all tired.

And so, the main thing to pay attention to here is we are not out of the woods. And if we're not careful when we drop the ball halfway, we are in for as bad or potentially even worse of an outcome than before. So, careful management here is key.

Eric Ries: Where do you think we go from here? How do we get out of the crisis?

Max Henderson: That is a great question. Nobody has a crystal ball, but my view here is that... So, containment actually worked a lot better than we originally anticipated. There was a question at the very beginning when we were building these models, "Well, what is social distancing really going to buy us? Is it going to slow the disease, but it'll stay growing exponentially? Is it going to flatten? Or are we actually going to be able to make the disease shrink just by social distancing?" And the reality is that... At least our team was surprised.

We essentially set up two confidence intervals for our model, best case and worst case. And we ended up basically right on the button for the best-case scenario. So, from our perspective, this lockdown, as extreme as it was, actually has been much more effective than it could have been based on the data we had when we started. And that, to me, is really encouraging.

So, I think it's completely achievable for some combination of policies, lightweight social distancing policies, policies like masks for all that are really focused on preventing transmission in close quarters, and a combination of testing and tracing to allow us to bring the economy back online while at the same time slowing or completely stopping disease spread. I think it is possible.

The thing that scares me the most is that rather than approach this the way that we have past crises as an American people to say like, "We can do anything. We're going to figure this out, right? There's no challenge too big," it seems like we're copping out to some degree and saying like, "Oh, well, that seems unachievable. We can't do that, so we're not even going to try," right? And so, that is the thing that gives me the most pause through all this.

The way that we choose to frame these problems are going to have such a huge impact on what we end up doing. So, we can think of this as unemployment and people losing their jobs and the economy collapsing or we can think about this as a national effort where these people are heroes for slowing the spread of a deadly pathogen and we're going to treat them as such, right?

Eric Ries: Like a 21st century WPA?

Max Henderson: Yeah, exactly. This can either be like an aspirational, "We are coming together," or it can be, "Oh, my God, things are falling apart." And the reality is that that framing is super, super important. Similarly, workers on the frontlines, they can either be people who are unfortunate enough to have to return to work or they can be the heroes going to battle for us that we take care of with free health care and free testing and hazard pay. We can do this, right?

Eric Ries: Protective equipment.

Max Henderson: Right, exactly. That framing is super, super important. Similarly, any national challenge is either an opportunity to come together and rise to the occasion or a cause for despair. And I think it is important for us to realize that we have control over these narratives and we have control over these outcomes.

Eric Ries: Max, thanks for taking time to share the story and thank you for your work as an antidote to despair in these really challenging times. It's meant a lot to me, and I know to millions of others.

Max Henderson: My pleasure, Eric. Thank you for having me. It's been great.

Eric Ries: This has been Out of the Crisis. I'm Eric Ries. Out of the Crisis is produced by Ben Ehrlich, edited by Jacob Tender and Shawn Maguire, music composed and performed by Cody Martin, hosted by Breaker. For more information on the COVID-19 crisis and ways you can help, visit helpwithcovid.com. If you are working on a project related to the pandemic, please reach out to me on Twitter. I'm @E-R-I-C-R-I-E-S. Thanks for listening.

Tuesday, July 28, 2020

Out of the Crisis #16: Robert Schooley on why we weren't prepared, long-term thinking, and how to make decisions for the greater good.

Dr. Robert Schooley began his career just as the HIV-AIDS pandemic was coming to the forefront. He's dedicated his life to infectious disease research even as funding for infrastructure and national attention to this area of medicine have declined. Now, he's temporarily slowed his work on phage therapy to combat multi-drug resistant bacterial infections in order to help lead the civic response to the CoV-SARS-2 pandemic. Though mistakes have been made in the way the U.S. has handled the virus, his perspective and experience make him confident we'll find our way out. "Humanity's been through these infectious crises before with plague and smallpox and influenza," he explained to me, "at times when we had many fewer tools and much less insight than we do now about what we were dealing with."

There's a lot of work to be done, though, including finding ways to separate public health efforts from both politics and profit. Currently, he says, "we're essentially letting capitalism kill capitalism by not coming up with a way as a society to figure out how to commoditize these tests, and have them become a public health tool."

He hopes one of the outcomes of this pandemic will be that it helps us on all fronts to "make decisions that are sounder in terms of greater good for more people over a longer period of time."

We talked about why America was so unprepared to fight the virus, focusing on the legacies we leave behind, his experiences during the HIV-AIDS crisis and much more. Ultimately, he hopes we'll all make decisions according to one simple question: "What would you want for the people that matter to you most? Think about that as we make policy for what affects everybody else in the world. Because every decision we make, in varying degrees, has an impact on more than just us."

You can listen to my conversation with Robert Schooley on Apple, Google, or wherever you like to download podcasts.


A full transcript of the show is below.

Highlights from the show:

  • Robert Schooley introduces himself and talks about his quarantine circumstances at work and home (2:36)
  • His perspective on the current state of the crisis (5:02)
  • How he got into infectious disease research as a medical student (7:53)
  • The early days of the HIV epidemic in 1979 (11:30)
  • Antiretroviral drugs and research on an AIDS vaccine (15:02)
  • The similarities and differences between COVID and other pandemics (21:17)
  • How the virus entered the US and how it has spread (22:47)
  • How science-driven policy and response could have affected the pandemic's trajectory (27:38)
  • The first community case transmission (29:09)
  • The missed opportunity to prevent deaths (32:13)
  • The marshmallow game (34:35)
  • Was this kind of pandemic inevitable? (37:00)
  • The failure to invest in public health resources that would have helped manage SARS CoV-2 (39:40)
  • The two most important lessons of the pandemic (40:59)
  • What the U.S.'s focus on the short-term has done to the country (43:32)
  • A legacy built on sustainable health, climate, education and economy (44:20)
  • The problem with having a short investment horizon for drug research (45:12)
  • What's happening at UCSD and in San Diego (48:44)
  • The testing plan and how it could be a model for other institutions (51:27)
  • What companies need to do to bring people back safely (55:48)
  • The problem of test scarcity (57:27)
  • How to lower the cost of testing (59:48)
  • Why separating politics from science is the key to moving forward (1:01:35)
  • Creating systems and structures for isolation cases without punitive measures (1:02:41)
  • Phage therapy and bacterial infections (1:05:07)
  • Making decisions for the greater good, for more people, over a longer time (1:09:21)
  • The roadmap for exiting the crisis (1:11:37)

Show-related resources:

Transcript for Out of the Crisis #16, Dr. Robert Schooley


Eric Ries: My name is Eric Ries, this is Out of the Crisis.

Why are we still not ready? Right at this very moment, a second wave of the pandemic is brewing, and we are repeating the same mistakes. If we don't learn the lessons of the pandemic, hundreds of thousands will die. We're still casting about for blame and looking backwards, as if this is over. But we have to learn from our mistakes to prevent an unimaginable tragedy.

I don't believe this is as straightforward as saying if only we had stopped traveling sooner or if we had more Purell on hand we would have been better off. Why weren't we ready? Why are we still not ready? These seem like complicated questions to answer, but it is not impossible. There is a science to this.

Dr. Robert Schooley is a genuine expert. He has seen this before. He started his career on the front line to the HIV AIDS epidemic. Since, he has dedicated his life to infectious disease research, despite seeing the decline of funding infrastructure and national attention to this area of medicine. Now he is on the leading edge of infectious disease research at the University of California, San Diego, and has been a leader in the civic response to the pandemic.

Dr. Schooley is a rare person who understands deeply the many ways we could have been better prepared to fight COVID and the consequences of our inaction. In our conversation, he detailed the many, many mistakes we made along the way and most critically, how we can avoid them next time. Because this is not over. Dr. Schooley is now leading the charge for the Herculean effort it will take to reopen the UCSD campus. If it works, it will be one of the most comprehensive testing programs in the country.

It will require frequent and convenient testing for all students and faculty, 10s of thousands of people. It will have huge implications for the rest of us, helping us understand what will be required to reopen and to live in the new normal. However, the part of the conversation that will stick with me the longest I think, was when I asked him of the more than 100,000 deaths we have seen in the pandemic so far. How many were preventable? His answer; pretty much all of them.

Here's my conversation with Dr. Robert Schooley.

Robert Schooley: I'm Robert Turner Schooley, professor of medicine at the University of California San Diego. I'm a biologist and a member of the infectious disease division here at UC San Diego and have been involved in viral research, particularly RNA viruses, since HIV came along in the 80s. And have gotten increasingly involved in our response to the Coronavirus.

Eric Ries: Well, Dr. Schooley, thank you so much for taking the time. I know this must be a very hectic and busy time in the university. First of all, how have you been doing? How are your colleagues holding up in these difficult times, how's your family, what's the quarantine and the crisis been like for you?

Robert Schooley: Well, the family is doing fine. They're all home as many of us are trying to work from home and keep things going. The university is right now on kind of a summer quasi-hiatus. I think what people don't realize sometimes about research universities is that we never really shut down because we have a research effort that goes on year round. Of course, our students are here for three quarters of the year and the outbreak, for the most part truncated the last part of our last quarter and the summer is usually quieter. So the university is kind of quiet like it normally is in the summer as far as the students are concerned, but this summer has been a bit different because much of the research effort has been shut down. And except for those of us who have been doing research on Coronavirus, the campus has been really pretty quiet.

The hospitals have been busy. We continue to see quite a few cases here in San Diego County. Our biggest cluster of cases comes from the south part of the county near the border with Mexico. We have a large number of American citizens, American green card holders who have gotten sick in Mexico and are coming back to the US for care. And that's causing a bit of a challenge for the hospitals in the southern part of the county and for our hospital in the southern part of San Diego. With quite a few new cases every day we see about 160 new cases in San Diego County daily and we're not that large a county.

Eric Ries: So from your perspective, just looking at the big picture, where are we in this crisis?

Robert Schooley: Well, until about three weeks ago, I was hoping that we were beginning to see the end of the tunnel. The overall number of new cases in the US had been decreasing. We were beginning to see some parts of the country where the virus had been totally out of control in the early part of March to early April. New York, New Jersey, beginning to really see the epidemic in the rear view mirror, and things are still looking reasonably good there. But what's happened since then is the epidemic has taken off in other parts of the country. Both in parts of the country where it's just beginning to get its foothold, in the Midwest. But more so in the southeast and the Southwest where as the people went back to work, they didn't understand that going back to work also means going back to work and realizing there's still a virus out there and wearing masks in public and being careful about socializing.

And what's happening now is in some states, we're seeing the kinds of expansions of new cases that we saw in the early part of March. And we've had over the course of the last two weeks, of course, a lot of activity around the demonstrations and all around the country where we've had large numbers people out many without masks, a lot of yelling, a lot of pepper spray, and we haven't yet begun to see what impact that might be having on the outbreak.

What we're seeing the last couple of weeks is what happened over Memorial Day weekend. And I'm really concerned that we're headed into a new wave of infection that is going to be just as bad as the first wave. We've had 110,000 deaths now. And by the end of the summer we could have a total of 200,000 deaths if the current trends continue.

Eric Ries: I've also heard some reports that the way that police and authorities have responded to the protests using tear gas, pepper spray, locking people up in confined spaces in the name of riot control, those seem like just the perfect conditions to maximize viral transmission.

Robert Schooley: Yeah, I think this is absolutely on the money. There's no better way to do that than to confine people in small places with no personal protective devices with coughing and sputtering from pepper spray and tear gas. So the response to these demonstrations has certainly not helped us with epidemiology, among other things.

Eric Ries: I really wanted to speak with you because this is not the first epidemic that you have lived through, and lead the charge in helping to understand and reverse. Talk a little bit about your career, how you got into infectious disease research, why that was interesting to you. And if you don't mind, maybe say a little bit about your work with HIV and some of the earlier research that you lead for prior epidemics.

Robert Schooley: Well, I got into infectious diseases as a medical student, because I found the combination of the diseases we dealt with, big ones that we ... for the most part had antibiotics for in those days, we focused mainly on bacterial infections. And when patients came in, we could make a diagnosis and do something for them. They got better quickly, most of the time. And we really could do a lot for them.

Also, it is a cluster of diseases that disproportionately affected people at the other end of the economic spectrum. And I was training in East Baltimore at the time and most of my patients were intercity members of the Baltimore community. And I felt that since most of their disease version, a lot of their disease burden was infectious disease related.

Getting involved in that area of medicine was really quite exciting and very rewarding seeing people being able to respond to the drugs we had at the time. I went to the National Institutes of Health for my infectious disease fellowship thinking that I would continue to work on bacterial disease. When I got there, there were very few people working on bacterial disease. Almost all of the work at NIH in the section I went to focused on immunology. But there was one guy who was working on virology named Ray Dolan who had just come back to the NIH, from his fellowship in Boston and was heading up a virology lab.

At the time, virology was not thought to be very interesting because we didn't have good ways to diagnose specific viral infections except antibody responses. And those don't happen until somebody is either better or has died. And we had no drugs for them and the party line with antiviral drugs was that we wouldn't have any because viruses used the machinery of the cell to replicate. There was no way to separate them from the cells in which they grew to have therapeutic agents drugs that would work.

And as I began to go into the lab and work on the immunology of Epstein-Barr virus, the virus that caused infectious mononucleosis working with Ray Dolan and Tony Fauci, who at the time was really quite young. I got interested in some of the new antiviral drugs that were just beginning to come along to treat some of the herpes virus infections, herpes zoster, herpes encephalitis, herpes simplex encephalitis, herpes neonatorum. Herpes simplex can be a devastating disease in children.

And the paradigm shift occurred, that began to occur, that many people didn't think would happen that we actually could separate the pathogen from the target with drugs for viral diseases. And so I got quite interested in a combination of viral immunology and viral therapeutics.

After finishing three years at the NIH, I went to Boston and worked at the Masters General Hospital as a fellow.

Eric Ries: And now it's the early days of HIV.

Robert Schooley: Yep, I arrived in 1979. And the week I finished my fellowship was the week that HIV appeared in MWR. And initially it was a disease that was thought to be rare, was going to be seen mainly in New York and San Francisco. And I remember the first grant that I wrote about it, the scientific critique was it's a very interesting grant, scientifically compelling, but we don't believe we can fund it because there will never be enough diseases in Boston to study. Not enough people with disease in Boston to study.

Eric Ries: Wow.

Robert Schooley: I think for a long time for the first year or so, people really thought that this was going to be a very rare disease that was interesting immunologically, but would not have much societal impact. I got very interested in it because I had been working on some of the immune modulatory changes that herpes viruses had in transplant recipients. And one thing that happened was patients who have been received kidney transplants or lung transplants or liver transplants, if they got severe herpes virus infections, their CD4 cells went down and CDA cells went up. The ability to measure CD4 and A cells was really just happening in the transplant group that I was working with was one of the first to do that.

They were interested in whether or not these changes we're seeing with rejection, of the kidney, of the organ. I became interested in whether or not these had anything to do with viral infections. We found that whenever anybody got one of these herpes virus infections, they had their T-cells, we call them invert. The so-called helper cells decreased as their suppressor cells went up, as we called them in those days. And when HIV came along, we didn't know what caused the disease. At the time we didn't know about HIV, but with age we saw the same immunologic changes. And as these helper cells went away, people got the same kinds of infections I’d been seeing in the transplant patients that I was seeing in the hospital as a consultant. And so it was a fairly easy scientific shift into this new disease, which began to be much more pressing and to be much more ... It was much more clear that it was not going to be a limited problem. I also became fascinated by the patient population. I'd grown up in Alabama and had really very little insight into the MSM population.

If you'd asked me growing up in Alabama about how many members of the MSM community there were in Alabama, I'd say there must be at least 100, I don't know. But when Aids came along, what it did was it forced the whole community. They've been working all along beside us and kind of suppressed because of the stigma.

And in those days of being in that population, this disease forced them out of the closet and into the hospitals. And they encountered the same thing in the hospitals that they did in life. Their doctors didn't want to take care of them for a while. We didn't have anything we could do for them specifically, beyond trying to treat their infections. Young people my age were dying. The average survival if you came with pneumocystis, the time was six months. And I'd been used to infectious diseases in my younger career as a specialty in which we had drugs we could treat people with and who got better quickly.

So with AIDS, it was a very different story. And having had the experience with any viral drugs with herpes viruses, when the first drugs that came along for HIV to be studied became available. I got involved in the early antiretroviral trials, with AZT and drugs after that, and began to see the pendulum swing from people always dying to people beginning to do a bit better. And at the same time, my lab was working on the immune modulatory changes that the virus HIV was causing, and began to develop assays to look at killer T-cells in the lab, directed in HIV.

That time the party line most of these did not exist because people weren't looking at them in the right way. A fellow at the time in my lab, Bruce Walker developed a very nice assay that very clearly demonstrated that these cells were both wildly present, HIV present in this chronic infection, probably more than any other viral infection discovered at the time. They played a major role in controlling viral replication in people who were infected and kept people healthy for a prolonged period of time before the virus ultimately overcame their immune response.

This became a focus of vaccine research. And I was kind of working in both areas simultaneously in the late 1980s, and began to see progress with drugs and realized even though the party line was there's going to be a vaccine just around the corner, that there were so many complexities with HIV vaccine development that was going to be years before that came along, and I decided that I would focus more on drugs and got involved, first with developing individual drugs and then later with working with the National Institutes of Health and its AIDS clinical trials group as we develop the principles for antiretroviral therapy.

I ran the group from 1995 through 2002, which was an incredibly exciting period of time, during which time the so-called cocktails developed. And we realized that this disease could be one that was no longer fatal, in fact people would live with it for years and years and go back to doing what they would have done, had this disease not come along.

As we began to get control of disease in the US, I became interested in rather than continuing to study the nuances of antiviral drugs, trying to figure out how to get them to other places. And I and my vice chair of this group at the time, Constance Benson, who became Chair of the group after me, worked with the NIH to develop the first therapeutic research centers in Africa and Latin America and Asia. These research centers run by local people, again, to provide antiretroviral therapy in places where needed most and change the way that NIH did research in those areas.

Instead of having US universities hire people to do the studies, the ACTG gave the grants to African investigators and South Latin American investigators, who ran the studies, ran their units and became part of the scientific community that began to solve this disease in those parts of the world as well.

So HIV is now a disease that we still have ways to go, we still don't have that vaccine. But we do have drugs that can cause people who are able to get access to them and to take them have a life expectancy not that different from people without the disease. We have been able to use the drugs in ways that we can prevent people from coming infected, just like a vaccine would. There now long acting drugs that we learned last month can be injected and work for several months and prevent infection during that period of time very much again, like a vaccine would. So with HIV, we've done with drugs, what people would have liked to have done with vaccines and still have not been able to accomplish and it's been quite a good ... it's been very gratifying to see that disease go from where it was in 1991, to where it is now.

Eric Ries: It's a remarkable turnaround. I really appreciate the work that you have invested in this over a career. As you tell the story, there's some overtones with what we're living through right now that strike me and I wonder if you wouldn't mind telling the story of what you've seen with the COVID pandemic, through that lens. I pick up on when you're talking about the neglect of the authorities and the powers that be not taking it seriously enough, not acting decisively when there might have been a chance to prevent transmission. That certainly has some relevance to today, I think also about the universal belief that only a vaccine could solve the problem and that vaccine is imminent, but the need for complementary therapies and strategies.

That sure does sound familiar and just so you know, we've had some conversations in this series with folks working on repurposing existing drugs, on building an mRNA vaccine, doing drug discovery for possible therapeutics. So we've been through the science of what's possible a little bit here and there. But I think you have a unique perspective and are able to kind of help us understand the big picture of what's this been like from your experience having seen epidemics before. Having had the experience of HIV which of course is a much different and seems like a more complex pathogen in the first place.

But tell us about what the COVID pandemic has been like. What's what struck you as typical of all epidemics and what's unique to the situation?

Robert Schooley: It's very much like deja vu all over again, as they say. This disease was first noted in China. And initially people said, "Well, that's too bad, big problem for China. Not going to happen here." And when HIV was first described in New York and San Francisco, as I said earlier, the reception was this was just a problem for those cities. And what we've seen is this virus spread around the world with remarkable speed held both by its very rapid generation time, but also by this web of travel that is unprecedented and which was certainly how HIV initially got out of its first ... tore holes into humans was as places when the virus in circulating began to be places of interchange in the rest the world, it found its way out.

SARS COVID-2 didn't need to wait, it was already on planes long before we even knew the virus existed. The disease existed and was already circulating in places that we're unaware were circulating, but really feeling pretty smug and safe because it was a problem somewhere else. We've seen repeatedly this concept that if you just stop travel, you can prevent the virus from getting here and therefore we didn't need to worry about it.

You may remember we tried to stop people coming into the US who were HIV infected back in the day in the Reagan administration, and that didn't turn out to work so well. We tried the same thing here. And when we did that we then rather than saying, but we also need to realize it might still get here. And in fact, it's probably already here and look forward, we basically went to sleep. And then waited until the virus was being transmitted within the population widely enough that it was virtually impossible to catch up with by the time people began to acknowledge it as a problem. The only reason it really came to our attention in the US was it finally found its way into a nursing home in Washington State where you had a cluster of people who were susceptible enough to disease as opposed to just infection and transmission to get infected in a rapid succession.

And people suddenly realized the virus had made it to the US. We then turned around and said, "Well, we'll close the door to China" and forgot we had a front door to Europe. And then remembered that and then started this idea that if we just closed that door within 48 hours, we'd be safe. That led to probably the biggest influx of virus into the US from the beginning when people who were infected, Americans who were infected, rushed to get on planes to get back before it was too late. They sat in airports for hours.

Eric Ries: I still remember those images of the people waiting in the holding areas in the airports those days. And after that, it just seemed like if you were once again trying to cook up the perfect vehicle for maximizing transmission, that's how you do it.

Robert Schooley: Right. I turned to my wife sitting on the couch watching that night and said here it is, it couldn't have been better. And that of course, took several weeks to percolate through the northeast and then you had New York and that was all seeded in part by that but also by the people coming back and forth before then. But under the radar, the virus was spreading rapidly in the community and causing what was likely mistaken by more people than not as flu. Because we're in the middle of flu season and a lot of the people who were out and about were young people and weren't getting that ill.

But it wasn't until it began to get into older populations, that the virus began to overwhelm the healthcare system and to take off up and down our northeast corridor. And we're kind of reliving that. As we speak, we know that we were able to take the top off the peak in the country as a whole by robbing the virus of the chance to be spread from person to person by doing by working at home, by wearing masks when we're out, by hand washing, social distancing, decreasing the number of human contacts. And we've got clear evidence that worked.

And we have clear evidence from before we were doing that what the virus was doing epidemiologically it was exploding. Everyone who was infected was infecting three or four more people. And when we go back to what we were doing back to work, back to school, if we do it in the same way we were doing it in March, we'll have that same three to four person rate of spread. And another explosion that we'll have to fight again to get control of with hospitals worried about who's going to get the last respirator and we've already begun to see that happen. Montgomery, Alabama was nearly out of respirators 10 days ago. Things are getting very tight in Arizona now, and Phoenix.

Eric Ries: I think I just read that they are at like 75% ICU utilization, right?

Robert Schooley: Exactly. And when you look at the epidemic curve in Arizona, it's unbelievably steep. These are new cases, you've got the governor saying nonsense like, oh, we're testing more people, less letting us know, we have more infection. We're going to get those tests out there. But what's being countered are cases not ... And people in the hospital, hospitalizations, those are things that happen whether or not you're testing. And what that's telling us is that this virus is having its way with Arizona. And right now there's no end in sight if this current plan that they have continues to be in place.

Eric Ries: So rewind the tape to the start of the pandemic. One of the recurring themes in these conversations is the need to have science-driven policy and leaders who are fluent in the science of the kinds of challenges we're going to face in the 21st century. So what would a science driven policy response to this have looked like? If we could rewind the tape and do it over again?

Robert Schooley: Well, the science driven response would have been to look at what happened in China in late December, early January, where it infected 80,000 people and at least 80,000 people, absolutely cases that were counted in a very rapid fashion. Now, you could argue we didn't know about that, but we actually did, our intelligence agencies knew about it. We would have known more about it if we hadn't pulled all the people from the US CDC who were working in China last June. Up until last June, we pulled all of them out in a spat about tariffs, and we would have had real time intelligence in addition to what the intelligence community was saying.

And we would have said, that virus is highly transmissible, it moved across China, no time flat. And what we need to do is to be ready for it, if it gets here. We need to have our hospitals ready. We need to make sure we have enough respirators, we need to have enough ... We need to develop a test kit quickly, we need to figure out ... so we know who has it. And when you do use that test kit in ways that the test kits we have don't constrain us from finding the disease.

The first community case transmission occurred here in California where a woman who hadn't traveled to China became ill in a local hospital. The doctors taking care of her said this is not a usual pneumonia she must have COVID and wanted to get her tested. When they asked to have her tested, the public health people, the CDC said, "No, no, no, she hadn't been to China, she's not eligible for testing. We don't have enough kits." So she then was transferred to the University of California Davis where the doctors there said, "This sure doesn't look like pneumonia to me, this looks like Coronavirus. Can we test her?" And it took them another two to three days to be willing to test her then. And it was all because they'd set up this concept that it couldn't be Coronavirus if you hadn't had contact with someone from Wuhan China.

And if we'd had widespread test kits available and had used them when people came in, and had done community testing around the nursing home outbreak, we would have known that this virus is here. And it would have redoubled our efforts to make sure that we had the masks and gowns and gloves needed in the hospital. We would have been really much better prepared for this. And we would have talked about it as a severe problem, a serious problem that we need to do something about. We'd have recognized that China stopped having people go home for 10 days, rather than continuing to act like nothing was happening and waiting until people who were watching what was happening to your hospitals realized there were going to be 10s of thousands of deaths and that finally got people's attention.

And that was a missed opportunity for us. It's not ... Can you blame China? Can you blame the WHO? There are things they could have done better. There's evidence now that this virus may have been circulating in China in October, and people either didn't recognize it, or the disease wasn't acknowledged. But we knew about it in December, and we didn't do anything about it.

The Chinese acknowledged it was present in December, and within a week, the sequence of the virus was ... by early January, the sequence of the viruses were already online, we could have started making test kits, then we didn't even have the virus in hand to start developing an assay for it. And when we started trying to make an assay, we should have said to all the scientific community in the US who want to try to develop an assay, "Please do we need to have this." And instead we tried to control it and have the only place that could legally do it be the CDC and they managed not to get it done and to use the FDA to prevent research by researchers in university hospitals from developing an assay that can be used to turn the lights on about where this epidemic was at a time when politicians were saying, not a problem. We don't see it.

So we made a large number of mistakes early on, and we still haven't caught up with that. And unfortunately, we're watching some of those same mistakes be made again.

Eric Ries: It's heartbreaking to think that we're now talking about 100,000 deaths or you're saying the possibility of 200,000 by the end of the summer. I think it's almost too monstrous for us to process that those were preventable deaths. Is that really true?

Robert Schooley: Yeah, I think most of them were preventable. By the time we recognized that, by the time things were really rolling in China, the virus was probably already here. We would have had some deaths but we could have prevented most of them if we'd been prepared to deal with it in a more aggressive way. If you look at the difference in what happened in epidemiology in New York, and in California it's very clear that had we acted a few weeks earlier we would have prevented 10s of thousands of deaths. And New York and California did their shutdowns only three days apart. The difference was that in New York, they were having about 5,000 cases a day and in California, the number of cases a day were less than ... were 200 to 400. And it wasn't the number of cases that was signifying, the difference was that those cases were just a very downstream indicator of all the virus that was already circulating in the community.

And so New York's epidemic, although only the intervention was only three days later, it was much more advanced than California's. And the places that this virus is getting now and the resurgence are beginning to unravel what was going on in New York before the shutdown was put in place.

And it takes a couple of weeks once you decide to do something definitive, to begin to see the peak, occur and go over the other end. And so I really do fear that by ignoring what's happening, we're going to give the virus another run at our population and make it a lot harder to get back to what we want to do.

It was a very, I thought, insightful column by Paul Krugman times earlier this week, the marshmallow game, in which he talked about a game that you play with children in which you put a marshmallow in front of them on a plate. And you say if you wait 15 minutes and don't eat this, I'll give you another. You can have two marshmallows. And New Zealand was smart enough to wait for that second marshmallow, they are waiting until they get control of the epidemic to go back to work. We ate that marshmallow as fast as it was on the plate. And I'm concerned that we are missing the chance to really get this virus under control where we can do contact tracing and look for clusters of cases and get people quarantined when they are sick so they don't infect other people. We're missing that chance by just trying to titrate what we do in a way that the number of deaths is "acceptable".

Well, we're not going to get on top of the epidemic by doing that. And that's ultimately what we want to do. It's not just the peak of the curve, it's the area under the curve. Allowing the area under the curve to continue to evolve by not being willing to take advantage of what would have been a peak going down to the other side of the peak, and just stepping on the virus's neck so it can't come back and cause trouble. We haven't had the political will to do that, and that's bad for us.

Eric Ries: It seems just heartbreaking to me not just the calamity of the deaths and the botched initial response, but then the fact that the time that we all bought with our shared sacrifice of the shutdown and the shelter in place, that that time was squandered. I think that's hard for people to accept.

Robert Schooley: I think it's very hard for people to accept and the counter narrative that you will hear is see we did all that and it didn't matter. We did all that-

Eric Ries: People aren't very good with exponential math. Yeah.

Robert Schooley: Yeah. They aren't very good at exponential math and the message is we did that and we know how that works. We didn't do it long enough. And this talk about well, it's behind us now, and all that wasn't worth it. “It just hurt the economy” is reconstructed history that is really destructive in terms of how to get this epidemic back under control.

Eric Ries: Yeah. So I know in epidemiological circles and public health circles, there's been talk of this kind of pandemic for a long time. Is it your view that a pandemic like this was inevitable, at some point something like this was going to happen?

Robert Schooley: Well, we've seen two of them already. There's the initial SARS outbreak, we were able to get control of that. We had two fortunate events with that one. The first is the biology of that virus is slightly different than this one. This virus, although highly similar, has a unique feature that K Y Yuen and his colleagues at Hong Kong University figured out and that is, rather than stimulating the innate immune response, the first arm in our immune defense, this virus subverts that immune response and it grows in lung tissue about three and a half times as fast as the original SARS virus did.At a time when it's silence their innate immune response, innate immune responses, in fact, how we know we're sick, that's where the what interferon is generated. Interferon is what makes us feel bad when we have the flu. So at the same time, the virus is replicating rapidly by being able to shut that immune response down, it's helping us work and stay in class feeling fine. And the virus then spills over into our nose and throat, on our vocal cords and titers are higher than when you're actually sick and spreads in people who don't have symptoms. That accounts in my view for up to half the spread maybe more.

And SARS, the first SARS outbreak didn't have that feature. So if you isolated sick people, put them in the hospital and got to their contacts quickly, you could stop the epidemic. And luckily for the world that happened in a place where people were willing to do that, China and Hong Kong, they put people in quarantine, who were contacts and they stopped the epidemic.

The same thing happened with MERS, the Middle East Respiratory Syndrome 10 years later that occurred initially in Saudi Arabia and spread to a little offshoot into Korea. But it was also stopped by vigorous isolation and classical public health in places who still had public health priorities and had people in health departments, who could do contact racing. We've left that all atrophy in the US and didn't have that at our disposal.

Eric Ries: Why do you think we've historically neglected these investments?

Robert Schooley: Well, we tend to make investments in things that are in front of us, and we aren't good at preparing for things that we know will occur but aren't there now. And a lot of that is trying to ... we have these short electoral cycles two years at a time. And politicians don't really care what happens in five years, they care what happens in 18 to 24 months. And it's very hard for them to say we need to raise taxes or decrease expenditures in this area to have a reserve of N95 masks because we might need those. It's very hard for them to say, Well, right now we're not having an epidemic, but there's a good chance we will so we need to have health departments, have people who are trained and ready to go out there and find cases and stop them.

So when something subsides, in our rear view mirror, we then invest in something else. And that leaves us always having to catch up when that inevitable thing comes along. This is not going to be the last outbreak of respiratory illness that we see go around the world. If we get control of this, vaccines, drugs, social distancing, I hope we take a careful stock of what we didn't have in place and what could have saved all these lives and made it a lot less devastating to people and families and economies and say, if this comes back again, when it comes back, we're going to be ready this time.

That's the most important long term lesson I think that we as a global society should take home. The other global lesson to be learned is that viruses and infectious pathogens don't have maps that have country borders on them. What they see is people they can infect and we are so heavily intertwined as a global population now, that borders are not going to keep the viruses from spreading when they come along. And we should, as a global community, when we see a problem anywhere, all the rest of us should jump on it and help wherever that is get control of it, because it will be to us later. And it will be much harder to control if it's allowed to continue to expand, evolve, diversify, and deplete resources.

So, I hope in the future that instead of saying, "Boy, that's a problem China's having." We say, "How can we help you control the virus? Do you need some PPE?" And when we need help, they'll say the same to us. We are all in this together. And if anything has shown us that it's this virus, just like HIV showed us 30 years ago.

Eric Ries: I think it's really interesting that so many of the lessons that we need to learn from this virus are not really about health, or science or epidemiology, but rather about the values of our battered liberal democracy and the need for international cooperation, the need for empathy and compassion and truth telling on the part of our leaders. And this really difficult thing to have the right people making the right long term investments even when the problem as you say, it's not right in front of our face.

Robert Schooley: Well, I think the long term investment issue is something that is true for politicians, also true for corporations, and for universities and for societies. We have lost sight of the fact that we're only here for a short period of time on the planet and if we can make changes that benefit people down the road just as much as they benefit us, we're going to be a credit to our species. But if we keep doing things that are easy for us now and you have to pay for later, we should really think hard about why we're here in the first place.

Eric Ries: And what kind of legacy do we want to leave behind?

Robert Schooley: What kind of legacy we want to leave behind in infectious disease legacy, climate legacy, economic, educational legacy. Those are all things that by investing in these areas more than we do and more sustainably than we do, we can make the world exponentially better place than if we continue to try to just get by doing not quite enough damage for it to be cataclysmic, but not really thinking about how to solve a problem.

Eric Ries: I'm glad that you included for profit corporations in your list of institutions that need that way of thinking. We've been talking a lot about this next generation of leaders and the obligations they have to face the challenges of the 21st century in a multi stakeholder long term way. And that epidemic has just driven that home.

Robert Schooley: Well, I think that's right. I think what happens is ... I'm just a country doctor, but I understand shareholder value. And one of the things that has happened is we've changed the horizon for when shareholder value counts, it used to be you'd invest in a company, and watch it evolve over time and watch it develop products and watch it have an impact on society. And you would expect your return to be several years down the road. And now what people want is they want a clinical trial to start in 10 days whether the drug is ready or not, and they want a new bit of software to be out there, whether it's ready to go or not. And the longer term impact of not having stability both causes us to miss a lot of potential opportunities.

A lot of the most exciting fundamental research used to go on within companies. And now what happens is the companies that kind of outsource that to the biotech industry and the biotech industries, in turn, outsource what they used to do to the venture capital, early clusters of small people and each higher layer then tries to gobble up something that looks like it might work. And if it doesn't work in the 10 months, that people are going to give it, then it gets cast away.

In older paradigms in which you had a larger company that could look across platforms, and see where one part of the company had technology might help the other part of the company and where there was a little more patience. Because the CEOs bonus wasn't going to be calculated on the basis of what the stock price was on such and such a date, some of the things would have been really good ideas that actually came to fruition.

And the flip side of that is, of course, if you have too much of that, too many layers of control and caution, you end up stifling out innovation. And we need to find a happy medium point between those two to be able to think longer term than we have.

Eric Ries: And no one could argue that our current capital market structure is optimized for that happy medium. we're way out of whack.

Robert Schooley: Exactly. So I think maybe this will give us a chance to reflect on that as well. But we don't learn from our mistakes and our successes, we're missing great opportunities.

Eric Ries: Well, when I think about the memorial that we will have to build to the preventable deaths that have happened as a result of the pandemic, all I can think about is we just ... it would be a disgrace to let their sacrifice be in vain. And so if we don't take this opportunity, if we don't learn those lessons, then shame on all of us.

Robert Schooley: Couldn't agree with you more.

Eric Ries: Talk a little bit maybe on a more positive note, talk a little bit about what the response has been like in San Diego and at UCSD and the steps that you've taken and as I understand you're also involved in the plan to potentially reopen the campus once you have sufficient testing. Talk a little bit about what that's been like on the ground.

Robert Schooley: Well, we think universities are important obviously, that's why we're here. And we have done the best we could in this last quarter trying to teach our students at home. I think the faculty, I have to give them credit, they within about a 10-day period of time went from all face to face teaching to teaching remotely and delivered a remarkable quarter. But what we don't have when you don't have people go, you just don't have people interacting with their peers, you don't have students engaged actively in research with their professors and learning how to inquire and learning how to question each other. You don't have a research enterprise acting at full potential. And so for us, we think it's very important to be able to have our community back together in the fall, but we all have come back together in a way that we're putting people at risk. So we've tried to put in place three major components.

One is, risk mitigation, which is to try to make it difficult to RSV spread from one person to the other. And by that I mean classroom size, dormitory density, masking, anything we can put on the tennis court, any folding chair to make it hard for the virus to get from one place to the other we want to do.

So we've gotten to a plan using mathematical modeling. I have a brilliant partner named Natasha Martin who doesn't actually use modeling. And she's modeled the impact of larger class sizes, smaller class sizes, double dorm rooms, single rooms, those sorts of things to understand how we can most likely operate.

We then put in place in addition to our risk mitigation component, a component of viral surveillance, and that includes wanting to make sure we know everything we can about anybody who is sick so that we can get them taken care of medically and get them isolated from others. We want to be able to look for virus actively with viral shedding and monitoring. Natasha has done a calculation of how many people we would have to monitor every month with viral shedding tools to be able to have a 90% chance of knowing when we have a cluster of less than 10 cases on campus. So they could really intervene with isolation, and quarantine.

And it turns out that if we were able to do a nasal swab, or an oral swab on everybody on campus once a month, and by that I mean faculty and staff and students, we would achieve that goal. And so we developed a testing plan that will do that. To do that, we knew that we couldn't have it done in the hospital because what that would mean, 60,000 people every month would have to traipse over to the hospital and wait for an hour to be called up to be given a lab slip. And another hour to wait for somebody to take the sample and blow two hours out of your day, and nobody would do that. So we developed a testing format in which we have test boxes kind of all around the campus that have a swab and some transport medium in it and the swab has a QR code on it. People have an app that can read the QR code and assign that swab to their medical record number. So all you have to do is go back pick up a swab, point the app at it, stick the swab in your nose, your mouth and then throw the swab in a box and go on about your work just like you've brushed your teeth. And then we pick them up every few hours and run at the hospital.

Anybody who's got virus that shows is then notified and we make sure they get the health care they need and also find out who they might have been in contact with and look to see if they also need to be tested. And we have room set aside for students where they can have a private bathroom and private bedroom. Meals are brought to them while they're infectious so that we can use the third component of this, which is kind of isolation and contact tracing to prevent ongoing spread of the virus.

And so that three component activity is how we're modeling how we want to operate the campus in the fall. And we hope that we're going to be able to do that a lot but it’ going to depend on what happens to the epidemic over the next couple of months. But if we're at a place where we were at the end of May, then I think we can do this, and keep everybody safe and have the university function in close to the way that it should be functioning with people doing community service and working on research projects and teaching in an integrated, highly efficient way.

Eric Ries: If this plan succeeds, as you hope, could it be a model for how we could reopen other institutions in society?

Robert Schooley: Well hundreds of other institutions and also society as a whole. We're trying to find simple ways to monitor viral activity. We're also, I didn't mention we're going to be looking for virus in wastewater in dormitories and things to identify where the virus is circulating. So all of this about controlling Coronavirus is knowing where the virus is. And to kind of use the Wayne Gretzky model about what made him the greatest hockey player, he said, it's because I don't skate to where the puck is, I skate to where it's going to be. And if you can track where the virus has been moving, you can project where it's going to be and you can put your resources in play to stop that.

And that's what we need to be doing in society. We need to be able to do that with much more watching by testing the public. We need to do that with ways for people who are infected to be protected from their families and others. We need to have a public health effort that helps us identify people who are infected and get them out of harm's way. And we need a very effective hospital system to be able to take care of people efficiently. And in the meantime, we need to be investing vigorously in drug and vaccine development.

Eric Ries: One of the things that strikes me about the UCSD plan is, it's very well thought out, there's a lot of components that the people who are involved in the community would have to know about, you have the testing boxes, you have the app, QR code, the lab capacity, the contact tracing, like it's an integrated plan, it has a coherence to it.

And so if someone is not at UCSD, if they're working in a corporation or in any kind of situation where they're being asked to go back to work, if they're not seeing those signs of preparation around them, would you say that it's not safe, they should demand more from their place of work?

Robert Schooley: Well, ... as you said, what's the one thing that matters the most, the thing that matters the most right now is masking. And I think that it's critical for people who are back at work to be wearing a mask everywhere they go. I think right now we should have companies think carefully about how many people they bring back to work at one time. We're doing that here and not bringing everybody back at once to do research, for example.

I think, thinking about issues like having sanitary wipes and having thoughtful approaches to how we interact socially like in coffee stands, and cafeterias and workplaces. We need to rethink that for now. And if companies aren't doing that then you need to talk to the people in the company about the only way your company is going to be able to continue to function is for your workers to be functional. And that's not going to happen if we don't work together to stop this virus.

Eric Ries: The lack of seriousness on the part of people who are rushing to reopen, I just find totally shocking. And not just federal leaders but local leaders in some places, governors in some places and corporate leaders in some places. When I was talking to this company called Curative, which is an LA based SARS COV-2 testing company, they took over a clear lab and built out this testing capacity to do hundreds of thousands of tests. And they're powering the drive through testing in Los Angeles and in a number of cities around the country.

The thing that just scandalized me, and I just wonder if this is consistent with your experience as well, I think many of us in the public just assume that the reason there's still even today insufficient testing of the virus is simply that we don't have the test. There's not enough testing capacity or the labs aren't ready or the tests aren't ready. There's been a lot of disinformation about that. But what they said to me is they have hundreds of thousands of tests ready to go, they could be setting up drive thru testing in any city in America and the limiting step though, the one thing they really need is more contacts with more mayors to set it up. And the idea that it's a lack of political will, not some kind of technical limitation that's preventing us from doing the testing that would be needed to control the virus and reopen safely, I find it almost unbelievable.

Robert Schooley: Well, I think a lot of places the mayors don't ... in our city, for example, the mayor doesn't have any health component. It's all a county health department. And they're so busy trying to figure out why they don't have the personnel to do what they need to do. It's been very hard for them to set up testing. They work for a board of supervisors that hasn't planned that well for this and that kind of strategic thinking is hard for me to get to.

The other thing that we also need to do is think about the cost of these tests. They don't cost $100 apiece. That's what is charged to do them. But we've allowed some of the large testing companies to get that price because they essentially blackmail the Trump administration into that. When the Trump administration needed to show that they were doing more testing, they threatened to say, "We're not going to do testing at all, if you don't give us that price."

And we need to find a way to move this from a medical platform in which you make a large profit on a small number of tests to a commodity platform, we get the same quality test, but done at a high volume. You can end up having a much bigger impact on health and society and still make money if you move to that. But if a test cost is $100 a test, it's going to be very hard to use those tests to control the virus in the community.

Eric Ries: Given what you know about the reagents involved and the logistics of actually doing the testing, what could it cost?

Robert Schooley: Right now the real cost is probably somewhere around $35 to $40, by the time you pay for reagents that as they're kind of provided by commercial vendors. But the real cost could be as low as $10 or less if people take it to scale, do pooling, use some of the more innovative technologies. And that ought to be where we go with this. We can't have it both ways, which is to try to maintain these high profit margins and at the same time, move it out, to make it available to the millions of people that need to have it available to really understand in the society, what we're doing.

When you think about companies who want to go back to work, by being held hostage by the companies that are keeping the prices of these tests so high, we're essentially letting capitalism kill capitalism by not coming up with a way as a society to figure out how to commoditize these tests, and have them become a public health tool. And really liberate us to go back to work.

Eric Ries: I've been thinking about the saying hindsight is 2020 it, it being 2020 now, but if you think about trying to take advantage of all the hindsight now that we have. So everything that we've seen and learned, all the mistakes that we made all the lessons we should have learned from those mistakes. What do we need to do right now, going forward differently, to beat the virus and to reopen our economy?

Robert Schooley: Well, we need to, first of all, separate the politics from the science. Science says that we can do a lot of things right now that we weren't doing in April safely if we wear masks and pay attention to distancing and density and all that stuff. And we shouldn't have wearing a mask be a signal of where you stand politically. In fact, if I were trying to open the country and put this behind me, the first thing I would do at every time I go to the microphone is I'd be there with a mask on and say, "It's important you wear this so we can get on with our business." Because we know what's going to happen when people go out without masking and do what was going on in March and April.

So the first thing we need to do is to be able to come to agreement that we know where to stop the virus so far, we know we can do it again. But people have to do it and stop making it into some sort of litmus test about where you stand politically about how you feel about masks.

We need to have people who might be sick, have no disincentive to telling their boss or their workplace that they're sick and be sent home with pay, so that they're out of the workplace for the 10 days instead of at the workplace. Because having them there coughing and with a fever and working because they're afraid they're going to lose pay or be fired if they're found to be infected is a short way to keep the virus going. So we need to remove any disincentive to people being tested and to being able to stay home if you're infected.

We need to make it easier for people who are infected, to stay home. Make sure they have ways to get food and make sure that if they're with older people, they get away from those older people. Put your grandmother in a hotel. With a lot of the outbreaks in the ... or go to a hotel yourself. A lot of the outbreaks that have occurred in China and Europe and other places are within families.

So when you know you have a family member who's infected, don't repeat that over and over again with everybody in the family, and certainly not if you have someone who's highly vulnerable to this virus. People who were older and obese and COPD, people with asthma, renal failure, cardiovascular disease, get them out of the way when you know the virus is around and the ... Be patient in terms of trying to get back to large events, we've seen the Memorial Day weekend price we paid, let's not be that place next Memorial Day weekend.

Let's have this ... if you look at New Zealand look where it is now, they can have a Memorial Day weekend, next year.

Eric Ries: The last reported case, as I recall, is done. New Zealand is Coronavirus free, right?.

Robert Schooley: Right. We're a more complex society but there's no reason not to set that as our goal. And we know we have to, to do it and we just need to have the will to do it.

Eric Ries: I feel like I'd be remiss to have you on and not ask you about phage therapy. Do you mind?

Robert Schooley: No.

Eric Ries: Just explain a little bit about what that ... that's a big part of your research so just explain a little bit about phage therapy.

Robert Schooley: Well, we, in addition to dealing with Coronavirus, we're dealing with a kind of a global explosion of bacterial infections that are resistant to most antibiotics, if not all of them that we have. A lot of it is because we've used antibiotics for a long time for good purposes. We also use them to fatten up chickens and bacteria on the planet are Darwinian and they see these antibiotics and they evolve to be able to grow in their presence, develop resistance. And so we're running out of drugs to treat these more severe infections.

Pharma is working on new drugs but their pipeline isn't keeping up with the evolution of the microbiome of the planet. Probably the most efficient Pharma that's been around for 300 million years is the bacteriophage industry. Bacteriophages are viruses that live within bacteria, prey on them, kill them and go on to kill the same bacteria next to them. They are literally eaters of bacteria. And they've been co-evolving with bacteria for 300 million years.

We now know how to isolate them from the environment, to purify them and to use them therapeutically, in people who have some of these multidrug resistant bacterial infections when we don't have antibiotics to use. And I think that as we develop technologically more efficient ways to do this, we will open new avenues of infectious disease, therapeutics that may help us with this MDR pandemic that we're having.

The other thing that these bacteriophages can do is they break through biofilms. Biofilms are films that form on foreign bodies when bacteria grow on them. And one of the reasons why it's very hard to sterilize say, a prosthetic knee or a prosthetic hip if it happens to get infected or a pacemaker. Bacteriophages can break through those biofilms and when used with antibiotics, we think that some of these infections that have to be treated by removing the joint or removing the pacemaker, we may be able to treat with antibiotics and bacteriophage without having to remove the prosthesis which would be a major advance and we think would be very helpful.

So there's a lot of things that I think are on tap that we should think about with bacteriophage research going forward. We've had to back off on some of that in the last couple months because of the COVID outbreak, but the antibiotic resistance challenge hasn't gone away. And I think this is one of the more hopeful ways to get back to business in dealing with these multidrug resistant bacterial pathogens.

Eric Ries: And thinking about the through line of many of the things that you've said, going back to your interest in neglected populations in the public and governmental response to HIV and the lessons that we could learn from that. Obviously, your work on the pandemic itself and preparing our economy to reopen when we can do it safely. And this recurring theme of needing to make the investments that lay the foundation for future prosperity, future progress. What do you really hope will be the lessons that we learn from this in the biggest picture. Of course, we're going to learn ... we've all learned the lesson of funding infectious disease research which we neglected before. I hope we all learn the lesson of science driven policy and, frankly, simple things like washing hands and wearing masks that that's pretty important.

But if you think about the structural changes to our society, our civic culture, the way that we as the public engage with these issues, what do you hope will change as we emerge into the new normal?

Robert Schooley: When we think about who we're kind of wired to care most about as humans. We care about our spouses, and we care about our children. And I think if we think that about everyone on the planet is being in one of those two categories, and what you would want to leave them as your legacy. It helps us make decisions that are sounder in terms of greater good for more people over a longer period of time.

And I wouldn't want to have my children be worried about going out of the house and having someone stop them because of a broken taillight and end up in jail about it. I wouldn't want to have my children get tuberculosis and not have someone in the public health department be able to contact people that my child have been to school with and prevent them from having the same problem. What would you want for the people that matter to you most? And think about that as we make policy for what affects everybody else in the world. Because every decision we make, in varying degrees, has an impact on more than just us.

And I think if we can recast how we think to include that, obviously we’ve got to continue to have individualism. I like things that feel good too, but not have that be the short term satisfactions of things that feel good for a short while be what dominate our thinking as individuals, as corporations, as educational institutions, and think about the longer frame of history.

Eric Ries: We always like to end these conversations with the same question simply. Where do we go from here? How do we get out of the crisis?

Robert Schooley: Well, I think we have a roadmap. We just have to have the patience to follow it. We need to look at states that are having explosions and send people home until the virus spread is quelled. And if they go home and stay home more vigorously than we did the last couple of months ... China didn't stay home for weeks, for months ... They stayed home for two weeks period, and that's because everybody stayed home.

And if we could do that in a really definitive way in these places where the virus is exploding and kind of reset the clock, and then start back, being mindful of what we know about how to stop transmission, we may be out of this, at least the acute crisis and be able to operate our institutions and our companies, and our economy in a way that is sustainable. And work back toward being able to do what we were doing a year ago. Working on vaccines and drugs that will allow us to do that and realize that humanity's been through these infectious crises before with plague and smallpox and influenza, at times when we had many fewer tools and much less insight, than we do now about what we were dealing with. People didn't even know some of these were caused by microbes. And they got out of it. But they got out of it by being attentive to things that worked and didn't work, and being rigorous about taking those lessons to heart.

And I think we should do that with this epidemic as well. And I think we do that we'll get out of this one, just like we have the others.

Eric Ries: Dr. Schooley, I really appreciate you taking the time out, to have this conversation. Thank you for your lifetime of service to the cause of human progress and science driven discovery, and of course, for your leadership during these really difficult times.

Robert Schooley: Thanks. It's been a pleasure talking to you and good luck.

Eric Ries: This has been Out of the Crisis. I'm Eric Ries. Out of the Crisis is produced by Ben Ehrlich, edited by Jacob Tender. Music composed and performed by Cody Martin, hosting is by Breaker. For more information on COVID-19 and ways you can help visit helpwithcovid.com. If you have feedback or you're working on a project related to the pandemic, please reach out to me on Twitter. I'm at E-R-I-C-R-I-E-S. Let's solve this together.