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.

Wednesday, July 22, 2020

Out of the Crisis #15: Lenore Estrada on her SF New Deal, serving the hungry, and civic engagement

"We knew that if we wanted immediate action, the only way to do that was with private money," Lenore Estrada explained to me as we talked about why she founded SF New Deal in the days after being forced to lay off most of the staff at her San Francisco bakery, Three Babes Bakeshop. SF New Deal partners with local restaurants to provide meals on a weekly basis to those who are the neediest among us. It's a genuine win-win: people need food, and we have massive unemployment at the same time.

When it became clear that waiting for government funding and support would take weeks, if not months, Lenore instead looked to her community for both, using her experience with the layoffs and her expertise as a small business owner to solve two of the massive problems crashing over our society. "Every week that we let go by, more people were closing their businesses sometimes permanently, more people were losing their job and becoming food insecure in a lot of cases." Like so many people have in recent months, instead of riding out the storm with her family--and in the middle of a pregnancy, no less--she simply stepped up to fill a need.

We talked about how her background has made her well-suited for this kind of civic engagement, her relationship to the tech world, how she scaled the organization so quickly and much more.

You can listen to our conversation on Apple, Google, or wherever you like to download podcasts.


A full transcript of the show follows the resources below.

Highlights from the show:

  • Lenore introduces herself and talks about her family. (3:07)
  • Layoffs and the earliest days of SF New Deal (4:08)
  • On the immense responsibility of taking care of people as an owner-founder (5:54)
  • Trying to fill the cracks in our social solidarity (9:57)
  • Lenore's background and how she ended up on the front lines of the crisis (13:00)
  • How Lenore started Three Babes (14:41)
  • How the mindset that helped her build the bakery came into play for SF New Deal (17:26)
  • How usual channels of public information were superseded by private channels connected to the tech world (19:47)
  • Funding SF New Deal (22:30)
  • The exponential growth in feeding people from week to week (24:55)
  • SF New Deal's community partnerships and the impact they create (26:25)
  • Why a private citizen entrepreneur is doing this work and how she's scaled it so fast (27:58)
  • The need for immediate action to address growing food insecurity in underserved parts of the city (31:41)
  • Helping to make staying at home to flatten the curve possible through food delivery (33:07)
  • Running SF New Deal with just two people--its co-founders (33:38)
  • What it's going to take to handle this humanitarian food crisis (35:58)
  • The problems with how it's handled even in non-pandemic times (38:13)
  • Ways to help, both locally and financially (40:25)
  • Why Lenore named the organization New Deal and how her experience helped her structure it (43:16)
  • The urgent need for civic engagement (49:49)
  • The importance of government support for community organizations (51:41)

Show-related resources:

Transcript for Out of the Crisis #15: SF New Deal

Eric Ries: This is Out of the Crisis, I'm Eric Ries. Look, I know it sounds cliché, but one person really can change the world. I have been the witness to it many times in my career because I work with startup founders. One visionary can fundamentally change their industry, build a new institution, change the fabric of our entire society. By no means am I saying that this is easy, or that anyone truly can do it alone, but it is possible. Now more than ever, we need people to step up and make a difference because the organizations and structures that were supposed to protect us, that were supposed to support all of our people, have in so many ways failed.

That means we have nowhere else to turn but to each other and there are people out there who are making a real difference. Lenore Estrada is one of those people. 2020 was shaping up to be a promising year for her bakery called Three Babes. They were growing, hiring new people, and breaking ground on a new location. However, like so many of us, her 2020 plans were put on hold due to the pandemic. She had to lay off most of her workforce and had to basically put her entire production on hold. She could've just buckled down and tried to wait out the storm, or even walked away from entrepreneurship all together, but she didn't.

She turned her experience with the layoffs and her expertise as a small business owner to solve two of the massive problems crashing over our society. There is a tsunami of hunger that is reverberating through our entire society more and more as the economic carnage is increased every day, and our small businesses, especially those in hospitality like restaurants, are struggling to make ends meet to stay in business to keep their people employed. So, Lenore started something called the SF New Deal. SF New Deal partners with local restaurants to provide meals on a weekly basis to those who are the neediest among us. It's a genuine win-win, people are in need, they need to eat, and we have massive unemployment at the same time.

This is just one example of the kind of thing we're going to have to get good at in the months ahead. We're going to have to find ways to put the unemployed back to work doing socially useful things, laying the foundations for future prosperity. We have to find idle restaurants and get them feeding Americans. We have to find idle factories and put them to work building PPE. We have to take college students and retirees and so many people who have nothing to do right now and get them tutoring our children who can't go to school. So, SF New Deal is important not just for the work it does directly, but as an archetype of the kind of leadership we are going to need to get out of the crisis. Here's my conversation with Lenore Estrada.

Lenore Estrada: Hi, my name is Lenore Estrada. I'm the founder and executive director of SF New Deal. We are paying small businesses to make and deliver meals to hungry people here in San Francisco during the COVID crisis. Prior to COVID, I was and still am the founder and owner of Three Babes Bakeshop, a small bakery business here in San Francisco.

Eric Ries: A delicious one at that.

Lenore Estrada: Thanks.

Eric Ries: First, in the interest of full disclosure, also a friend of my sister's.

Lenore Estrada: That's true, Nicole is a good friend of mine from college.

Eric Ries: We'll give her a shout-out here. She's awesome.

Lenore Estrada: I love Nicole.

Eric Ries: So, these have been difficult times. Let's start just with how are you doing? How are you coping? How's your team, how's your family?

Lenore Estrada: It's been a lot. In some ways it's been pretty stressful. I'm a mom of a 19-month old boy and also I am pregnant. I'm about halfway through my pregnancy.

Eric Ries: Oh my goodness, congratulations.

Lenore Estrada: Thank you.

Eric Ries: But, the stress I can imagine.

Lenore Estrada: It's been really inspirational in a lot of ways. We started SF New Deal at the end of March. At the beginning of March, I had to lay off 20 of 26 workers at my small bakery, which was pretty stressful and sad, really hard, and there was also a lot of flurry of activity around just shutting everything down. We're still operating delivering pies and doing some pickups at our kitchen, but our staff is greatly reduced. We also were on the cusp of opening a new retail space in San Francisco's Mission District and that construction site had to completely shut down, so here in San Francisco the shelter in place order was announced and it was announced at noon to begin at midnight. So, we actually had to rent a giant moving truck with a lift gate, move massive amounts of equipment with just the small staff we had left, more than one 900-pound oven for example.

So, that was pretty stressful, and then since then I've been volunteering with SF New Deal full time. We launched on March 23rd and it's been a lot of very long days and nights. I still own my small business, which is being run primarily by my director of operations, but I've been working a lot of times till two or three in the morning, so definitely a lot of late nights and a lot of just stress and urgency.

Eric Ries: Next time someone criticizes entrepreneurs for whatever perceived slight in our society, we'll all be thinking of this story.

Lenore Estrada: Thanks.

Eric Ries: And, just the herculean efforts that you have put in, not just to your own business, and to your own community, but obviously trying to take care of the whole city--we’re immensely grateful.

Lenore Estrada: That can be said for all of the people who are participating with us. We have 35 volunteers, many of whom are volunteering full time and are people who have become unemployed recently in the wake of COVID and people are devoting 40 to 60 hour workweeks in a lot of cases, and many of our chefs are not paying themselves just so that they can keep their staff employed and they're working really long days, but definitely it speaks to the care that people who employ others are feeling for the individuals that they're providing paychecks for. It's not just paychecks, there's actually a lot of care about people's well-being and their families' well-being.

Eric Ries: It's an immense responsibility, I know that. I think about it every day. It's right up there with the feeling that I have about my biological family, and I don't think there's been enough conversation about those bonds and the stress and the emotional connection that we all feel, even the discussions around layoffs and the need to cut costs and extend runway and all that has been very clinical. Just say a bit about what it was like to have to cut back your staff to such an extreme degree.

Lenore Estrada: It was terrible. Cutting back my staff was so difficult. Definitely, I would say the toughest week I've ever had as a business owner, tougher than the death of my own parents I would say. I cried at work many times. At first, I came up with a plan where I could just reduce hours by a third and lay off people who mostly still lived with their parents, or for whom this was a second or part-time job, and then it immediately became apparent when almost all of our customers called to cancel orders for the next one to three months, and now it's looking like until the end of the year. It just became immediately apparent that we were going to lose 80 to 90% of our revenue for a span of several months and there was just no way for us to keep most of our staff.

So, we quickly went from our plan A to our plan D and in some cases I had to have multiple conversations with the same people in the same week from reducing their hours to reducing their hours further to cutting them completely, and at some point I had to cut people who had benefits with me and were losing benefits. Some of them-

Eric Ries: That's the hardest always.

Lenore Estrada: Really hard, and people who had families to support, and some of our workers aren't able to apply for benefits because of their immigration status, and so it was really terrible and on top of that if you're cutting someone who's losing health benefits, for me I felt this tremendous weight because I was worried ... there are public programs people can apply for, but I was worried about some of my workers contracting COVID just going to SF General Hospital to apply for benefits.

So, we luckily have a few members of our staff who speak both Spanish and English and could assist people in applying for benefits and we've been providing some food assistance as well to our Spanish speaking staff, but definitely I was having to make really terrible choices about who was staying and who was going and then even of the people who stayed, many of my staff members, all of them immediately were cut to 60% of what their previous hours were and I made personal loans to some staff members who were supporting family members. I had one staffer in particular who usually works two jobs, and she helps support her mother who has chronic health conditions and she came into work in tears because she could no longer provide support for her mom to buy medication, worried she was going to end up in the hospital for something that could've been easily prevented. So in that case, I just offered her a personal loan, but I definitely feel a strong bond with all of my staff members and it was devastating for me to have to cut them.

Eric Ries: A very wise person said to me that just as the pandemic, which is COVID-19, is more dangerous to individuals that have a preexisting condition, the pandemic is also more dangerous to societies that have preexisting conditions, and so much of what you're describing, these are the cracks in our sense of social solidarity and the systems that keep our society running are now becoming full on ruptures and our ability to ignore them in the past is not going to be so true going forward. We're either going to heal or fall apart.

Lenore Estrada: I hope so. I think it's been interesting for me doing the work with SF New Deal of getting meals to people. The normal community that I'm accustomed to working with is the community of small business owners here in San Francisco and so I've built on that work that the people we are also serving, our hungry population is here in San Francisco and there definitely is a big divide in experience between people who have a job where they can continue to work from home and collect a paycheck and the hungry people who we are serving, and I think some of our community partners have had just a really tough time emotionally seeing these conversations about society opening back up when within their own networks, more and more people are getting sick and dying.

Eric Ries: It's unconscionable. Let's just cut right to the chase. The idea that we're going to prematurely open up, I think this is a hysteria bordering on mass delusion and extremely dangerous.

Lenore Estrada: And, I think it's tough because in some of the communities we're serving, the entire population, they're wage workers and they rely on income from going into work some place, but their experience of what the shutdown has been has just been so different from most of the people who are in my usual social circle who work as a lawyer or at a tech company. Most of those groups might know someone elderly who has passed away at this point, but in general nobody they know is getting sick. At our partner level, many people are getting sick or hospitalized, even some of the volunteers who are working with the churches for example. The communities where you're seeing a lot of infection and spread are these communities that have fewer resources, where people have to go to work, where people have food insecurity.

And so, for them it's very real because lots of people around them are getting sick or have died and then for a large portion of the population, they don't really know anybody who's gotten sick or died, so it's just been a big contrast.

Eric Ries:Those fault lines, the preexisting fault lines in our society now are so much more evident, and yet because we all live in our special filter bubble I do think it's unusual to have someone like you, who actually acts as a bridge passing across both of these worlds. Talk a little bit about your background. How is it that you came to be in a social circle with so many lawyers and tech workers and people like that while also running a bakery and being on the ground in a ... how'd you find yourself in a circumstance where you wound up on the front lines of this crisis?

Lenore Estrada: So, for me actually, I think my whole life I've just interacted with a wide range of people. I'm from Stockton, California. I'm from a very working class family and one of seven kids. We did not have very many resources at all and my dad was one of 13 children. My dad's family were migrant workers, they were sheep shearers. My mom was from a middle class military family from the South, and so luckily my parents cared a lot about education and I grew up around, unfortunately, a lot of poverty and violence and just seeing people whose options were really limited by the circumstances into which they were born and also feeling a strong commitment to trying to help my community and working really hard to change my personal set of circumstances.

So, I ended up going to college at Yale, that's where I met your sister Nicole, and so I would say most of my friends ended up in more white collar or professional jobs and also a lot of them ended up starting companies. I tried a bunch of different jobs after college and I ended up just trying entrepreneurship and something that seemed accessible to me was starting a bakery because I had enjoyed baking when I was a kid, and so it just so happened ... I think it's actually more strange that I ended up with a bakery business and that I have a personal circle that is made up of people who aren't like that, but I started this small business, I had no money.

So, we actually started with $10,000 we raised on Kickstarter in 2011 and because we had no resources, we just clawed our way up, and actually, this is funny, I remember reading The Lean Startup and just thinking, I should really keep my situation asset-light here.

Eric Ries: Oh, really?

Lenore Estrada: Yeah, seriously. I was super committed to just not really investing in anything at the beginning, and just figuring out how it would work. So, we had this $10,000, we rented a commercial kitchen for 600 bucks a month in South San Francisco and we did these pop-ups out of a shipping container. I thought, if we did a popup we can use the space that's fallow and for the owner of that space, any money they're making, it's just wasted space. So, we just went into this café and they had a shipping container outside that they were using for storage and we just sort of pitched them on using it during the weekends to make this mini pie shop and they let us do it, and so that's how we launched the company.

Eric Ries: What a great MVP.

Lenore Estrada: And so, it was very popular, we got a lot of love from the community. And so, we just built from there and over time I definitely have been able to interact with lots of different kinds of people, which has been really neat. I think as a small business owner you see problems and people at a bunch of different levels in society. So, the concerns of my workers become my concerns. Also, the concerns of my clients become my concerns, and so you're sort of exposed to all these different points of view and have a way to just understand the challenges that lots of different kinds of people are trying to deal with and that's been really interesting for me, so sorry, that was long-winded.

Eric Ries: No, don't apologize. This is a podcast, that's the whole point. The reason I wanted you to tell that story, and first of all, thank you for the kind words--that means a lot to me whenever The Lean Startup can be helpful to someone that's starting something.

Lenore Estrada: It's funny, I kind of forgot about it, and then we were telling the story, I was like, "Oh yeah, here we go."

Eric Ries: There you go, but the reason I think it's important for people to understand the mindset that you had in building this baking empire from scratch is because history repeated itself in kind of a funny way when you were forced into service through SF New Deal. So, talk about that transition. When did you first conceive the idea for SF New Deal and what were those early days like?

Lenore Estrada: So, for us at the beginning of March, we noticed that orders were really slowing down and I think because I had a personal network that included people who were tech CEOs, who were really the kinds of companies that were my customers, I had access to information about what was happening in a way that I wouldn't otherwise have had. So, what I'm asking the people who are personally ordering from our company, "Hey, what are you seeing on the horizon for the month of March?" Everyone's response was nothing has changed, it's the same as ever, but if you had access to a CEO, that person will tell you, "We're about to make everyone work from home." Or in some cases with Facebook, I had friends who had already been working from home since late February and so that gave me the information I needed to act.

Eric Ries: And, those companies were your corporate clients of the bakery, is that right?

Lenore Estrada: That's right, some of them. Facebook is not a client of mine, but I just happen to have a friend who works in IT there and told me that they had already been sheltering in place because they have a lot of workers in Seattle, but my friend Emmett is the CEO of Twitch. Twitch is a customer of ours and I saw him at a dinner and he specifically told me that they were about to be closed for a month. So, that was actually really helpful. I think the tendency from everyone is just to wait longer because cutting people from your team and making these big changes is extremely painful and there is some risk. If you cut too many people and then it turns out it's not as big of a deal, then that's also problematic.

So, I think the tendency is just to wait to do the painful thing, but since I had the information up front about how difficult the endlong, the period of time was going to be when we had reduced sales, I was able to act immediately.

Eric Ries: Can we just comment for a second on how weird it is that in the way that this pandemic unfolded and what an indictment it is of our usual channels of public information? Because I've heard versions of this story many times now, that people who had privileged access to the tech community or to tech companies were better informed about what was going to unfold than the public at large, and how interesting the tech companies in particular were the ones who had the early warning.

Lenore Estrada: I don't know if it's that they had an early warning, but they need an early decision. So, I do think the tech companies here certainly took leadership in just deciding this is good for public health. The right thing to do is to make people work from home.

Eric Ries: And, we've gotten used to it, what a bold choice.

Lenore Estrada: I don't think that it was because they had any kind of privileged information. I think they were just looking at the numbers of how a pandemic works and just made the scientific decision, hey, this needs to happen because this is for everyone's best interest, and they acted. I do think something I've seen is that private actors, in this case the tech companies are able to move more quickly and make decisions that affect huge groups of people. Tech companies are huge employers here in the Bay Area, and the fact that they took leadership in having people work from home before the shelter in place order made a huge difference here in the Bay Area in the rate of spread of the virus.

Eric Ries: And, they probably saved a lot of lives inside and outside the tech community.

Lenore Estrada: Definitely, so a definite yes there, and I think we were lucky here in the Bay Area that tech companies are big employers and as a result the decisions they were making had these massive effects on public health.

Eric Ries: And, they chose to put people first rather than in some other industries where that wasn't the first impulse.

Lenore Estrada: Right, and the other thing is tech companies were able to switch to a work from home model and be largely unimpacted, so a lot of other companies can't do that and still stay open.

Eric Ries: Or at least convince themselves that they couldn't, although we're seeing a lot of creativity now.

Lenore Estrada: Exactly, but I think it is easier. My husband has a company called PeerWell, they prepare people for surgery and help them recover from surgery and they were already a distributed team, so for them it was really no switch over cost. So, I do think tech companies have an easier way to switch over to a work from home model than many other companies do, which allowed them to more quickly transition over to that model.

Eric Ries: So, go back to that conversation with Emmett because as I understand, he was one of the early funders of SF New Deal as it turned out.

Lenore Estrada: Yeah, I would say Emmett is definitely one of the founders of SF New Deal. He had reached out a number of times before the shelter-in-place to see if there was any way that he could help my company, Three Babes, to weather the storm and I had been very busy just shutting down different parts of my company and laying people off and hadn't really followed up. So, I would say a few days after the shelter in place, he reached out and he and his father had this idea of getting direct support to small businesses by paying them in some way to keep working, so that they wouldn't just shut down before government aid could come through.

I had been looking for ways to find private money to pay for food just for my business to donate to hospitals or some place like that. So, I had already been having conversations with UCSF and some other people looking for potential recipients of food. So, when Emmett reached out, I realized that rather than trying to do it for Three Babes, I should just not include my company and that we could have a big impact on the small business community at large in San Francisco because he was willing to commit $1 million to this cause.

And so, I thought, okay if Emmett will commit this money, we can start right away and we can probably raise more money and just start getting resources to people and even after a few brief conversations with leaders here in San Francisco, it became apparent to me that no government aid would be coming for many weeks which was baffling to me back then, but now I guess it makes more and more sense now that I understand more about how just funding and politics work here in San Francisco specifically, but probably more broadly.

So, San Francisco had raised this Give to SF fund, but none of that money had been distributed, and most of it still hasn't been distributed to anybody so far. So, immediately we had this goal of just springing into action and starting to disperse this money to the small business community. And so, within five days of Emmett initially contacting me, we started serving meals. We started with 1,000 meals the first week delivered through one community partner to three sites and then by the next week we were doing 18,000 meals working with 23 restaurants and had expanded the number of sites and community partners to over two dozen and then at this point it's been eight weeks, we're in our eighth week now I guess, and we've delivered 137,000 meals, more than that and $1.4 million have been dispersed to our restaurants and we've had no turnover really. All the restaurants who signed up are still working with us.

Eric Ries: Of course, probably the easiest product you ever had to sell.

Lenore Estrada: That's right, there's no better product market fit than giving away free food in a pandemic.

Eric Ries: And, I don't mean to make light of it. It's just so rare that you have these opportunities to find a true win-win-win situation where here we have restaurants that want to be able to work and have a food supply chain that is in crisis while a massive tsunami of hunger is spilling over our society. So, to be able to take those two opportunities and merge them with philanthropy, it's a really brilliant model.

Lenore Estrada: Thanks, I think it's not a super creative model I would say, but it has allowed us to just build on the existing infrastructure of chefs who are able to make lots of meals, and then for us it's been really important to partner with media organizations who have deep knowledge of the people they're serving. The partners we're working with are ... we have 18 different partners, but we have this amazing group of black churches, their ministers and volunteers just have decades of experience getting resources out to their communities. Working with UCSF's psychiatry department, they have an army of over 100 case workers who go out into the city and provide medication and food to people who are living in SROs or in some cases are homeless.

We're working with people who have recently been released from detention centers and social workers who are here to help them, and so we're sort of just using those existing community partners' relationships to quickly be able to understand the need and reach the people who really have a lot of need for resources and aren't being served.

Eric Ries: I think it's going to be a surprise to some people listening why you, a seemingly random private citizen, are the one doing this and not our government. Just explain, why does it make sense to have an entrepreneur doing this and how have you been able to scale so quickly?

Lenore Estrada: Honestly, I'm kind of surprised that a random entrepreneur such as myself is the one doing this as well. I felt that by now the government-

Eric Ries: Join the club.

Lenore Estrada: I thought by now the government would have already ... I thought maybe we'd be doing two to three weeks of mass feeding and then after that transition to a longer term plan to support the small businesses. The crazy thing is, as I mentioned, we're into our eighth week of service. Each week since week two we've been providing between 18,000 and 30,000 meals a week and they're to people who are not otherwise being served, which is crazy.

A number of things, the city of San Francisco has a lot of stuff they're trying to do. So, not only did they have to shut down the schools and figure out how to distribute food through the school sites who really aren't equipped to provide the volume of meals that they're providing. They're trying to house people who are unhoused in congregate sites, in trailers, in hotel rooms, and they need to find out a way to feed them. And then, they've had all these people who are COVID positive who they need to help shelter in place.

And so, for the first I would say six weeks of the crisis, the San Francisco city government was only focused on feeding people who were already COVID positive, which is baffling, but I think also there's just at some point a lack of ... they didn't come in with really a lot of existing organization or execution knowledge on the many things that they're being asked to do. So, I think they were just triaging and then trying to deal with the first problem first.

The other thing is because the government has this responsibility for running a fair and transparent process, the process takes a long time. So, they put out this RFQ, I would say three weeks ago at this point, they put out two of them, a request for qualification where you could apply to be someone who's feeding these populations that need food and they have to have a waiting period while people apply and then they have a deliberation period, then they make preliminary assignments, and then they assign the contract.

And, when they assign a contract, they have to allow a period of protest where anyone can contest who has been assigned a contract. So, they have to provide this very transparent process, but unfortunately there's really no way to make that go faster it seems like. So, even in a pandemic, you had the process for assigning the paid responsibility for providing meals has taken over four weeks, and that's just for the first tranche of people they're feeding, which is people who were previously unhoused, who have been moved to hotel rooms, and congregate sites.

So, the government is just not going to act quickly. That's just what we knew coming in. I as a small business owner, I laid off a bunch of my staff and then the city announced this program to be able to pay 40 hours of sick time for any worker in San Francisco that works for a small business. So, I was thrilled because I thought, oh, maybe I can provide another week of pay, but it took three weeks for the application to even come out to apply for that money. I think I received the first amount of that money last week, which is eight weeks after I had laid off my staff members.

So, the speed at which they're able to deliver is very slow and so we knew that if we wanted immediate action, the only way to do that was with private money, that every week that we let go by, more people were closing their businesses sometimes permanently, more people were losing their job and becoming food insecure in a lot of cases, and the people who were losing their jobs were for the most part living in the areas where COVID was spreading the fastest, where there are the highest infection rates and the highest spread.

Eric Ries: At great cost to society in the end.

Lenore Estrada: Exactly and at great cost to just their own lives. The SF African American Faith-Based Coalition, which is the black churches that we're working with, they were one of the first partners we got connected with, but they were working with a great sense of urgency because if you are black and you end up in the hospital you are much more likely to die or have very serious health outcomes and those populations already have a number of preexisting conditions. They have very high rates of hypertension. A lot of the people who are living here in San Francisco are elderly and so they had no way of getting food, and how can you shelter employees if you have no way to get food? There's just no way.

Eric Ries: It's totally self-defeating to focus on one aspect of the response and neglect of these others. You wind up making the very problem you're trying to solve and another area of the response worse.

Lenore Estrada: Exactly, so for us it was just as staying home at the beginning was essential to flattening the curve of infection, so to was actually making the staying at home possible, and the fact that the city was only taking responsibility for feeding the people who are already COVID positive was crazy because there weren't even any tests available. So, how do they even know who's COVID positive until people actually end up in the hospital? It was definitely very intense the first couple of weeks, but actually the reality is my other co-founder is Jacob Bindman, he just graduated from college in 2019 and he's been running all of our service operations and so the first week Jacob and I were the only volunteers for SF New Deal and somehow we managed to get a bunch of other volunteers to step up, but in one week we were able to deliver 18,000 meals, went from zero to 18,000 and we're just two random people.

I have experience in food and I guess so does he, but he's been working for me since he was 15, but come on, the government can't do it? It just seemed crazy, but the reality is they didn't do it and it's taken them a while to ramp up and so in the interim, the people who we're feeding, we're delivering one substantial meal a day and that's the only meal that most of them are receiving. We're also working with a number of other organizations to make sure to understand the overlap and there's extremely little overlap between the meals that we are providing and any meals being provided by other service providers, so that just speaks to the extent of the need.

Eric Ries: I really appreciate the sense of urgency that you have brought to this and I've personally taken a lot of inspiration from the model that you've pioneered here and I know several organizations have, including one as we've discussed before, that I'm involved in that has been looking at this to try to figure out what we can learn from it, and yet I have this feeling like we're not even close to the scale that we're going to need to handle the tsunami of hunger that is coming. You've been talking about working with these existing service organizations and helping the city in its inability to serve the neediest among us, which I’ve got to say is just incredible work, so thank you for that, but what about the millions more newly food insecure people, some of whom thought of themselves as in a pretty secure financial situation practically five minutes ago, what is it going to take to handle that humanitarian need that is crashing all around us right now?

Lenore Estrada: Well it's, as you know, a complex situation. I do think, gosh ... I think technology can actually be quite helpful in understanding and helping to address the need. One thing that I've been surprised by is just the lack of overall information that the government has about who needs food and who specifically those people are and where to find them. So, we've been working with USDR, you and I have had conversations, but we've been working with a number of different parties who are working to build technical solutions to understand and track need, so you can understand just who you need to serve, who's not being served, and then of the people who are providing services, where those resources are going. I do think there is some amount of hoarding by some groups and then not enough food for other groups.

Eric Ries: Terrible.

Lenore Estrada: I also think that a lot of the people who have great need here and who until recently were supporting themselves don't necessarily know where to look for assistance.

Eric Ries: That's a huge problem.

Lenore Estrada: Here in California there are lots of programs like CalFresh for instance where we just have a very low uptake. We have a low sign up rate for that in the state of California because it's kind of complicated to sign up for.

Eric Ries: We'll put links in the show notes by the way if anyone knows someone who is food insecure and needs help. There actually are a remarkable, but labyrinthine patchwork quilt of services that are available, including a new one called Onward California, which we'll include a link to and CalFresh and some preexisting ones as well. There is help available, but it's so hard to access and it's infuriating to me that we put this cognitive tax on those who are least able to bear it to find support.

Lenore Estrada: Right.

Eric Ries: It just makes no sense.

Lenore Estrada: It doesn't make any sense because we're all worse off for it. So, I think just-

Eric Ries: And, especially in a pandemic, right?

Lenore Estrada: Yeah, of course, but even in normal times, there's just no reason not to have 100% subscription to CalFresh. Almost everyone has a cellphone, but you have to make solutions that are easy to sign up for, and we've found a lot of success just partnering with existing community organizations who have networks of trust because I do think we see especially in communities of color and even more specifically in the Latinx community, it's a very diverse group of people with different circumstances, but if you were not born in this country, a lot of times you just aren't hooked in to the network of support that you could be getting, and so for us, even our own Spanish-speaking workers who have been laid off, we are reaching out to them and we have a specific person working with them to help them sign up for benefits and get support.

This population is really hard to reach, and so it doesn't need to be that way, but I do think there has to be a lot of just working within communities to understand what the actual need is. I think waiting for a federal solution that's going to work for everyone is a fool's errand because I don't think that there is. There's not going to be a solution that works for everyone. I think it's finding local community solutions and making those really effective is our best way to get full penetration.

Eric Ries: Those of us who are on the sidelines right now waiting for this problem to be solved are going to feel a lot of shame in the weeks and months that come because it's going to be bad and we've made some bad choices as a society that are causing this problem not to be solved when maybe under other circumstances it could have been. So, for those that are hearing us now and want to get in the fight or are realizing that this is not a problem that just magically someone else is going to solve, what would you suggest to them if they want to be helpful?

Lenore Estrada: I would say that people are listening across the country, and so I would suggest trying to find ways to get involved in your local community and that might be different depending on where you live. If you want to come check out our website, it's sfnewdeal.org.

Eric Ries: And, if people want to donate, are there specific donation instructions?

Lenore Estrada: Yeah, they can just donate on the website, or they can write in if they want to give through a donor-advised fund or give a large amount, but-

Eric Ries: You have a fiscal sponsor?

Lenore Estrada: We do, yes. CUESA, which is the Center for Urban Education about Sustainable Agriculture, they support a lot of small farming here in San Francisco and education around the food system. They've been an incredible partner and are doing lots of great work to help support the network of farmers that are a very important part of our ecosystem here and across the United States, but we've actually done phone calls and advising for people looking to start versions of SF New Deal in their own communities. We've talked to people ... there's a New Deal Marin that's started, a group in Vancouver who's doing similar work.

So, we've been having a lot of conversations with people to just get something going in their own community, but I would just recommend looking for a local solution that is adjusting food insecurity or helping to support people who are vulnerable in your own community and looking to the people who are needing the support to understand what the actual need is, so just really centering the populations in need when designing a solution. I've talked to dozens of people who have some app that allows people to volunteer who put a bunch of work into something and then at the end are like, "Hey, I have these people who signed up to volunteer, but I don't know who the people are who need help and nobody is signing up from needing help group.

And, that is because you've designed a solution that works for you and your friends who are most often millennial people who are upper middle class and very tech-savvy and that solution is probably not going to work for someone who doesn't speak English, who may not even have a smartphone, or if they do have a smart phone they don't necessarily trust whatever site they're finding online, so you have to actually ... I would just recommend working directly with community organizations in your location where you live to understand what it is they need and help them provide that.

Eric Ries: You picked the name New Deal, which I think is so evocative, obviously a reference to FDR and in a different time. Talk a little bit about why you made that choice and why'd you choose to make it San Francisco specifically.

Lenore Estrada: So, I live here in San Francisco and Emmett, he also lives here. He's originally from Seattle, but this is his home, and so we wanted to be able ... the scope of the need is great, and so we wanted to be able to make a real difference here in the place where we live and so we decided to just narrow the focus to small businesses here in San Francisco. We would love actually to be able to longer term support other kinds of small businesses and when we're talking about our six months to two year trajectory, we're thinking about other ways to loop in other types of small businesses.

There's immediate need for food and immediate need for restaurants particularly because they employ so many people here to have help staying in business and employing people, so that their own workers would not also become food insecure. So, we just launched with this program to support small food businesses and the uptake was so huge both from the need side of the people who are hungry and also from restaurants who wanted to sign up.

So, we have many thousands of meals on our wait list each week and also hundreds of restaurants. We had to close the wait list because we were getting so many sign ups and we couldn't onboard people without knowing that we could provide financial support for them. So, I suppose some models are very broad in the number of restaurants they're supporting, but are giving less support or support on a less consistent basis. For me as a food business owner, I know that it does you no good to have one huge order and then no orders for three weeks, which was what was happening to these restaurants.

They were closed, they were doing very low volume in takeout, and then every once in a while someone would come and buy 300 meals from them. That makes it super difficult and I've been in the situation, you get a big order, you need the money, and so you pull multiple all-nighters yourself because you have no way to hire people in such a short timeframe and then you have no way to employ them longer term-

Eric Ries: It's a production process, you need production leveling.

Lenore Estrada: Exactly, so I guess one reason why I think I specifically had the ability to help with this problem is because pies are extremely seasonal. We some days of the year literally sell 3,000 pies in one day and then sometimes we sell 10 pies. And so, we had to figure out ways to meet the spikes and also to just build, over the long term, a business model that was more resilient and allowed us to actually have a good number of staff that we could guarantee work to throughout the year, but that takes time.

And so, similarly here, there's the immediate need of just meeting the spikes in food insecurity and in cash needs for businesses and then also the need to longer term find a different model for people to grow into that will allow them to exist long term and build something, so that's what we're trying to do here. We chose the name SF New Deal, yes, you got the reference to FDR, but I guess our goal was to put the population to work, harness our collective power to show that we don't have to settle for waiting 10 weeks for the government to get aid and just settle for what that does to our community. We actually can work together to invest in ourselves and build something and weather this together and overcome it. And so, I think that was the spirit behind the name. We wanted a name that had just a big vision built into it.

Eric Ries: I'm really glad that you mentioned that because I've been thinking a lot about the WPA and the specific programs of the Great Depression that took advantage of the fact that in a depression, in an economic reset like this, many of the input factors of production that we're used to thinking about particularly labor cost, in the boom times cost of capital gets cheaper, but everything else gets more expensive. Now, we're going to see the reverse, so all of a sudden it's difficult to raise money for things, but there's incredible amounts of labor and other input factors available and food in this case.

And so, we're going to have to find a way to repurpose all of our production facilities across many industries that are idle and build huge WPA style programs. There's really no other way, and so obviously in food we have seen this incredible boom or bust phenomenon in food where some farmers, some producers in the grocery supply chain have their inventory flying off the shelves, but if you serve convention centers or restaurants or other parts of the supply chain, we're seeing farmers bulldozing crops, so that's ridiculous. We have incredible skilled people in restaurants and cafeterias across the country with nothing to do, but we're seeing the same problem in PPE where we have idle manufacturing facilities that could be making masks and gowns right now, but are not for want of relatively modest investments and re-skilling and production changeover.

Think about all of the homeschoolers, the involuntary homeschoolers, hundreds of of millions of them who could use online tutoring and story time and all of the sanity producing outcomes that would come from that and all of the retired people and artists and college students who are sitting at home with nothing to do. I could do this all day. So, what do you think it's going to take? You've been on the front lines of actually building a WPA style program from scratch and I think one big change in 2020 versus the 1930s is that these programs are being built organically bottoms up rather than tops down because, well, for all the differences in leadership and economic circumstance between then and now. What do you think it's going to take for us to really build at the scale that is needed to address this crisis?

Lenore Estrada: I think that the thing that's really necessary is civic engagement from everyday people who have an understanding of their own problems and the problems in their community coming together to find solutions that are going to keep our economy going and be for the benefit of our society and I do think that longer term you do need government's involvement and money to help support that. So, here in San Francisco we have this commitment from Emmett for $1 million. That has already been spent. It was important that we do that.

Eric Ries: And, thankfully you spent it. That was the right thing to do unequivocally.

Lenore Estrada: Right, no one else was spending anything, and so people weren't getting food and also businesses were closing.

Eric Ries: And, kudos to him for just stepping up and writing the check at a time when others were not.

Lenore Estrada: That's right, so we are still in need of private donations. The government money is beginning to open up and in terms of funding a longer term solution, I do think that government support is really important because when we talk about businesses needing a longer time horizon, for us when our partners started with us we told them, "Hey, we'll be providing you with meals for 10 weeks." Or to businesses, "We'll be giving you orders that are stable for 10 weeks, so you can plan to keep people on staff until you get PPP money." Which--I think around 60% of them have gotten PPP at this point.

So, it was meant to be a bridge, but in terms of planning for long term business is going to be affected and employment is really going to be affected for a couple of years. So, now that we're seeing some of these government contracts start to open up I do think the government providing support to community organizations who are finding ways to keep people employed and keep resources flowing and doing that on a two-month, six-month, 18-month time horizon is what is necessary to bridge people through, so that they can build a sustainable business model that will allow them to be self-sufficient moving forward.

So, I think it takes a lot of cooperation and I think I'm seeing why the government is so slow at everything, and a big part of that is just the need to try to find ways to make sure that there's not abuse of the system or grift and unfortunately the way the government has of doing that is by making everything extremely bureaucratic and that means that only the biggest actors in general can apply for government money and also that they have these very onerous checks and balances that just take a long time and are complicated to navigate.

Eric Ries: I've worked with many governments during the boom times who wanted to do digital transformation and every one of those projects, procurement is where it goes to die, and I can't tell you how many executives and cabinet secretaries and leaders of various stripes, mayors, and governors, lieutenant governors, you name it, who had to make the choice of is it really worth tackling that problem or should we just punt that to the future, chose the punt and now those cities and the states are paying the price as you've really described.

Lenore Estrada: I think what we found is that we're able to move quickly because we're building on trusted relationships within communities. Vinny, who's our guy that heads up community, he's the community organizer by background, he always says we're moving at the speed of trust. And so, I do think in some ways technology can become a way that you are able to verify things or have an understanding of the whole picture in a way that's both low cost and fast. That takes time to build, but I guess for us the thing that's been so efficient has been just accessing the people who already have knowledge about what's going on.

So, just really getting more civic engagement, more people who truly care about solving a problem, engaged in helping solve it, and understanding where resources are going and identifying where the problems are. For us, those are the people who are going to make sure that the money is distributed in an efficient way because they actually care about the people that they're serving, and so I just think you need more engagement from everyone and that's how you get the accountability. The volunteers and the community partners we're working with truly care if food is wasted because they know that there are finite resources and that some people are still not getting fed.

And so, if they find out that one person is hoarding food, there's a true motivation to make sure that that doesn't happen because one person hoarding four people's meals means those other three people get nothing and that's a devastating outcome if you actually care about the people you're serving.

Eric Ries: I want to thank you so much for coming on and for talking about this. That's just such a perfect place to wrap because I think people need to really understand this problem is immense and the only solution is for ordinary people to step up and take a leadership role. The cavalry is not coming. There's no other solution to be had and we are the actors that we've read about in history books. We have to take inspiration from our grandparent's generation who did this once before and they couldn't wait. There wasn't somebody else magically going to solve the problem and we have the luxury of their example to inspire us and now thankfully your example.

Lenore Estrada: Thanks.

Eric Ries: I hope many people will hear this and take inspiration from it.

Lenore Estrada: I hope so too, thanks. I think for me it's been my honor to serve. I think I normally have my staff of 26 and work to invest in my team and help them see their own possibilities to achieve more and I've been really inspired by the group of volunteers and everyday San Francisco residents who have been giving money or volunteering to drive food or drive PPE to distribute to restaurants and just get involved to help support our own neighbors here and it's really been my honor to have the privilege of serving.

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.