WEBVTT - Vaccines and New Treatments for COVID-19 0:00:15.396 --> 0:00:22.756 Pushkin from Pushkin Industries. This is Deep Background, the show 0:00:22.796 --> 0:00:25.956 where we explore the stories behind the stories in the news. 0:00:26.476 --> 0:00:31.756 I'm Noah Feldman. Research into the novel Coronavirus is happening 0:00:32.276 --> 0:00:37.436 and being published or sometimes just press released at breakneck speed. 0:00:38.116 --> 0:00:41.796 Every few weeks, we hear about a possible new breakthrough 0:00:41.916 --> 0:00:45.516 or a potentially interesting avenue of research. But often that 0:00:45.556 --> 0:00:47.836 breakthrough it turns out to be too good to be true, 0:00:48.316 --> 0:00:50.836 or to have less effect than we might have imagined. 0:00:51.476 --> 0:00:54.156 To help us make sense of the latest about the 0:00:54.196 --> 0:00:57.596 novel coronavirus, which studies to watch, which studies are too 0:00:57.596 --> 0:01:00.236 soon to interpret, and where we are in the progress 0:01:00.276 --> 0:01:04.996 towards a vaccine, We're joined by doctor Sad Omer. Doctor 0:01:04.996 --> 0:01:09.436 Omer is a professor of infectious disease and epidemiology at 0:01:09.436 --> 0:01:12.116 the Yale School of Medicine and at the Yale School 0:01:12.116 --> 0:01:15.836 of Public Health. He's also director of the Yale Institute 0:01:15.916 --> 0:01:19.476 for Global Health. In short, he's perfectly qualified to talk 0:01:19.476 --> 0:01:25.356 about these questions. So thank you so much for joining me. 0:01:25.396 --> 0:01:28.276 I'm very grateful. I wonder if we could begin with 0:01:28.356 --> 0:01:32.836 some of the latest publicized developments in therapy. There's a 0:01:32.916 --> 0:01:36.036 large randomized study out of the UK, which we only 0:01:36.076 --> 0:01:38.316 see in so far in press release form, although we're 0:01:38.316 --> 0:01:41.996 getting used to that, involving the use of the steroid dexamethasone. 0:01:42.676 --> 0:01:45.316 What is your takeaway from that study. It's a very 0:01:45.556 --> 0:01:50.276 encouraging study for several reasons. First of all, from the protocol, 0:01:50.756 --> 0:01:54.436 it seems that it was a well conducted study. They 0:01:54.556 --> 0:01:58.556 showed an impact on mortality, not on everyone, but those 0:01:58.596 --> 0:02:01.636 who were on vents. The third thing is that it's 0:02:01.676 --> 0:02:04.956 a widely available drug. So whenever you are dealing with 0:02:04.996 --> 0:02:10.196 these public health emergencies, one concern, one major n is equity. 0:02:10.876 --> 0:02:13.876 At least in the initial few months after a drug 0:02:13.956 --> 0:02:18.196 is evaluated successfully or it comes out, etc. You're really 0:02:18.236 --> 0:02:22.596 concerned about getting that to the most vulnerable. Since this 0:02:22.716 --> 0:02:28.316 is a widely used drug already, we have broader availability. 0:02:28.356 --> 0:02:32.356 So that's the good news. The caveat, as you pointed out, 0:02:32.676 --> 0:02:35.036 is that all we know at this point is a 0:02:35.076 --> 0:02:39.156 press release, a press release from a credible group. But look, 0:02:39.196 --> 0:02:43.396 I would like to see at least data, maybe not 0:02:44.076 --> 0:02:46.956 a full flash paper, but they worst probably somewhere some 0:02:47.116 --> 0:02:50.756 discussion at their data Safety Monitoring board or somewhere where 0:02:50.796 --> 0:02:54.396 they presented those slides. At least share those slides. Now. 0:02:54.476 --> 0:02:58.116 I understand that there's a lot of time pressure on investigators, 0:02:58.116 --> 0:03:00.476 but if the data are good enough to be shared 0:03:00.476 --> 0:03:03.116 publicly in a press release, they should be good enough 0:03:03.156 --> 0:03:07.156 to be shared more broadly. The effect on mortality on 0:03:07.276 --> 0:03:11.276 deaths reported in a press lease was a one third 0:03:11.356 --> 0:03:13.636 reduction for those people who were so sick that they 0:03:13.636 --> 0:03:16.716 were on ventilators, and I believe a one in five 0:03:16.916 --> 0:03:19.956 reduction in deaths for those who were sick enough to 0:03:19.996 --> 0:03:23.476 be on oxygen but not oxygen delivered via a ventilator. 0:03:24.116 --> 0:03:25.876 And then for those who were very sick and in 0:03:25.916 --> 0:03:30.476 the hospital but we're not on oxygen, they reported no effect. Obviously, 0:03:30.516 --> 0:03:32.676 I'm asking you to reconstruct something that's not so simple 0:03:32.676 --> 0:03:36.196 to reconstruct. But why would one have expected those sorts 0:03:36.236 --> 0:03:41.876 of results specifically from this treatment. Yeah. So, look, we 0:03:42.036 --> 0:03:45.836 are learning about the disease as we go along, and 0:03:45.916 --> 0:03:50.396 sometimes what works in terms of treatment tells you as 0:03:50.476 --> 0:03:52.276 much about the disease as it tells you about the 0:03:52.316 --> 0:03:56.036 intervention itself. But in this case, and you know, these 0:03:56.076 --> 0:04:01.716 results combined with our previous current understanding of what's happening 0:04:02.076 --> 0:04:05.036 with the patient with the individual after you get the disease, 0:04:05.996 --> 0:04:12.356 is that there is this maladaptation and then this exaggerated 0:04:12.476 --> 0:04:17.036 response of the immune system. And so the contrast is 0:04:17.156 --> 0:04:20.276 higher when you have an intervention that is attacking the 0:04:20.396 --> 0:04:26.396 condition by dampening broadly the immune response at a stage 0:04:26.396 --> 0:04:31.356 when it's exaggerated. So that contrast would be highlighted in 0:04:31.516 --> 0:04:35.436 more severe patients because, for example, the cytokine storm is 0:04:35.476 --> 0:04:38.036 happening in more severe patients, So if you're attacking that, 0:04:38.036 --> 0:04:40.276 that's where the contrast is. So that would be in 0:04:40.476 --> 0:04:45.756 line with these results, and that's because steroids are broadly 0:04:45.796 --> 0:04:50.436 speaking anti inflammatory, but maybe going on in these most 0:04:50.476 --> 0:04:54.596 sick patients is some kind of the cytokinde storm, which 0:04:54.636 --> 0:05:00.276 is a kind of exaggerated immune reaction, exaggerated maladaptive. So 0:05:00.356 --> 0:05:03.396 it's not just the quantity of the immune response, but 0:05:03.476 --> 0:05:07.876 the type of immune response. But but essentially focusing on 0:05:07.916 --> 0:05:11.076 the type of response and the quantity of response and 0:05:11.156 --> 0:05:15.036 sometimes dampening it broadly speaking can have these benefits. So 0:05:15.116 --> 0:05:17.876 that would explain it. So if I just to make 0:05:17.876 --> 0:05:21.956 sure I'm understanding you correctly, because the sicker patients actually 0:05:21.996 --> 0:05:27.876 benefited proportionally more from the steroidal intervention that provides some 0:05:27.916 --> 0:05:30.436 indication that at least in those very very sick patients, 0:05:30.756 --> 0:05:32.596 what's going on is the kind of thing that might 0:05:32.596 --> 0:05:37.156 be responsive to steroids and therefore fits the theory argued 0:05:37.156 --> 0:05:39.476 for by some of your colleagues at Yale and others 0:05:39.956 --> 0:05:43.916 of the cytokind storm. Yeah, exactly. Let me ask you 0:05:43.956 --> 0:05:49.156 about this large genome wide association study that's being reported 0:05:49.236 --> 0:05:51.516 on in Europe. Again, I think we don't have the 0:05:51.596 --> 0:05:55.636 full final paper yet in which an argument is being 0:05:55.676 --> 0:06:01.276 made for an association of blood type, surprisingly enough with 0:06:01.476 --> 0:06:05.276 probability of suffering from COVID, not exposure to the virus, 0:06:05.276 --> 0:06:07.956 but suffering from the disease if you are exposed to 0:06:07.956 --> 0:06:10.516 the virus. And then there's it's not the blood type itself, 0:06:10.596 --> 0:06:13.116 according to the theory, at least, it's a some set 0:06:13.116 --> 0:06:16.796 of genes that are associated with the same gene area 0:06:16.956 --> 0:06:19.476 as the blood type. If I'm getting it right, say 0:06:19.476 --> 0:06:22.356 a word about that place. From my perspective, it's too 0:06:22.436 --> 0:06:27.996 early to say anything definitive about this. It's a signal generation. 0:06:28.116 --> 0:06:30.036 I think there needs to be a lot more work 0:06:30.556 --> 0:06:33.076 to look at. First of all, if the signal is 0:06:33.116 --> 0:06:35.516 credible because a lot of times when you do these 0:06:35.516 --> 0:06:41.116 observational studies in sick patients, you're not able to match 0:06:41.396 --> 0:06:45.716 appropriately you control for underlying confounding and so therefore that's 0:06:45.756 --> 0:06:47.596 one of the reasons we would like to see more 0:06:47.636 --> 0:06:51.076 detailed data, etc. To figure that out. I think this 0:06:51.116 --> 0:06:54.316 one is too early to say anything definitively. I think 0:06:54.316 --> 0:06:57.756 it's certainly something that needs to be followed up that 0:06:57.876 --> 0:07:01.676 could have further implications. So I would put it in 0:07:01.716 --> 0:07:05.596 the bucket of signal generation more than or hypothesis generation 0:07:05.716 --> 0:07:08.836 more than anything beyond that. It was fascinating to me 0:07:08.876 --> 0:07:11.076 because it reminded me of some of the other high 0:07:11.156 --> 0:07:15.356 profile GA genome white association studies, where you know, the 0:07:15.436 --> 0:07:18.756 researchers look potentially at hundreds of thousands in some cases 0:07:19.156 --> 0:07:22.356 of people with some condition and then they just literally 0:07:22.436 --> 0:07:24.916 mind the data, which is what scientists we're supposed to 0:07:24.956 --> 0:07:26.636 not do in the bad old days or maybe the 0:07:26.636 --> 0:07:28.916 good old days, and they say, well, we're minding the data, 0:07:28.956 --> 0:07:30.756 and here's what we see. You know, these are these 0:07:30.796 --> 0:07:33.396 associations that we find in the data, and therefore they 0:07:33.476 --> 0:07:35.596 must have some effect, and now let's try to figure 0:07:35.596 --> 0:07:38.156 out what that effect is it's sort of the opposite 0:07:38.196 --> 0:07:39.676 of what we were all taught. The scientific method is 0:07:39.716 --> 0:07:42.716 supposed to be, and yet it has caught on as 0:07:42.716 --> 0:07:46.636 a real methodology, and it often yields fascinating things. But 0:07:46.636 --> 0:07:48.756 of course there's some statistical reason to think that some 0:07:48.876 --> 0:07:52.316 things should be yielded anyway. Yeah. No, So here's the 0:07:52.556 --> 0:07:58.596 interesting thing DWAs. And big data techniques, whether applied directly 0:07:58.596 --> 0:08:02.236 to biology, to or to other sources of data, give 0:08:02.236 --> 0:08:06.316 you great power and for a lack of bettle example, 0:08:06.516 --> 0:08:10.956 you know, i'd quote spider Man, power comes great responsibility. 0:08:11.196 --> 0:08:14.476 Actually Voltaire said it before, but you know, you know 0:08:14.556 --> 0:08:17.276 spider Man, or actually his uncle Ben said it with 0:08:17.436 --> 0:08:20.676 more flair. So with this kind of these kinds of tools, 0:08:20.836 --> 0:08:26.116 it's okay, it's reasonable to apply these tools, but a 0:08:26.156 --> 0:08:29.676 lot of it is in what you do when you 0:08:29.796 --> 0:08:33.116 find something. So if it's taken as a signal hypothesis 0:08:33.156 --> 0:08:37.316 generation exercise to then do a sort of a hypothesis 0:08:37.356 --> 0:08:40.276 testing set of studies, this kind of an approach can 0:08:40.316 --> 0:08:45.476 add value. But if it is taken as hypothesis testing exercise, 0:08:46.076 --> 0:08:48.516 then you get into some of those other issues that 0:08:48.596 --> 0:08:52.556 you mentioned a little bit earlier. Two vaccines are getting 0:08:52.676 --> 0:08:56.236 very close to trials that are going to tell us 0:08:56.236 --> 0:09:00.556 probably whether they work or not. The Maderna vaccine RNA 0:09:00.636 --> 0:09:03.716 based vaccine, and then the Oxford vaccine, which is a 0:09:03.796 --> 0:09:08.116 trojan horse vaccine. These are both brand new techniques, neither 0:09:08.156 --> 0:09:10.436 of which, according to guests I've had here before, has 0:09:10.436 --> 0:09:14.276 ever generated a successful vaccine that went to market. Yet nevertheless, 0:09:14.316 --> 0:09:18.716 we're all extremely excited and eagerly anticipating the results. Everyone 0:09:18.756 --> 0:09:21.196 has some instinct about this. You're in a position to 0:09:21.236 --> 0:09:24.716 actually have an intelligent instinct. What is your instinct about 0:09:24.716 --> 0:09:27.636 these possible vaccines? So first of all, I add in 0:09:27.676 --> 0:09:30.436 a little bit of nuance to these are two Western 0:09:30.556 --> 0:09:34.716 vaccines that are two of the more prominent ones. There 0:09:34.756 --> 0:09:37.676 are a couple of Chinese vaccines that we should keep 0:09:37.716 --> 0:09:40.956 an eye out for and we should track. So one 0:09:41.076 --> 0:09:44.836 is produced by the company's Signo vac and then the 0:09:44.956 --> 0:09:48.436 other one is can sign on. But coming to these vaccines, 0:09:48.916 --> 0:09:52.556 the Modern vaccine and the Oxford vaccine are some of 0:09:52.596 --> 0:09:56.236 the earliest vaccines that are being evaluated or likely to 0:09:56.276 --> 0:09:59.596 be evaluated in large trials. The Oxford vaccine has an 0:09:59.716 --> 0:10:02.996 innovative trial design where they had a rolling Phase two 0:10:03.196 --> 0:10:08.556 three trial where they have already enrolled a bunch of people, 0:10:09.356 --> 0:10:13.196 not they're not close to their final sample size. And 0:10:13.556 --> 0:10:15.716 one of the complications, one of the nuance that has 0:10:15.756 --> 0:10:19.236 been added is that some of the earlier projections of 0:10:19.276 --> 0:10:22.836 their timeline, as I understand, was based on the incidence 0:10:23.516 --> 0:10:28.156 in the UK because that's where the main core of 0:10:28.196 --> 0:10:32.476 the investigators is located. So that the disease incidence going 0:10:32.516 --> 0:10:35.636 down seems to have complicated things a little bit. And 0:10:35.676 --> 0:10:38.436 they are going to Brazil now to recruit, which is 0:10:39.036 --> 0:10:42.716 very reasonable and this is how it should be done 0:10:43.236 --> 0:10:48.796 in a pandemic. But the reason I'm highlighting this is, look, 0:10:49.396 --> 0:10:51.796 this is one of the reasons why we should stay 0:10:51.796 --> 0:10:56.876 away from predicting that the vaccine will be available in 0:10:57.036 --> 0:11:00.596 three months. You can say that it will be available 0:11:00.916 --> 0:11:04.996 in the near future or the prospects look good, because 0:11:04.996 --> 0:11:06.956 there are a lot of things that can slow down 0:11:07.036 --> 0:11:10.636 your development process. But coming back to your original questions, 0:11:10.636 --> 0:11:13.836 so the main question that these are a new approaches, 0:11:14.676 --> 0:11:18.756 I think they're based on pretty sound biology. Then there 0:11:18.836 --> 0:11:22.716 should be in the front line of things where the 0:11:22.716 --> 0:11:28.236 global community and national programs invest Having said that things 0:11:28.316 --> 0:11:33.236 can go sideways you can have unexpected things. So what 0:11:33.276 --> 0:11:35.196 do we do about that? A First of all, have 0:11:35.756 --> 0:11:40.676 realistic expectations about the timelines. If they go early, that's great, 0:11:40.756 --> 0:11:43.276 but we should all have a little bit of humility 0:11:43.316 --> 0:11:47.156 about our projections, especially for new products. The other thing 0:11:47.436 --> 0:11:50.436 is we should all hedge our bets. So it's a 0:11:50.476 --> 0:11:55.396 good approach to have a diversity of technologies, some new, 0:11:54.996 --> 0:11:59.276 some old. So having a couple of live attenuated products 0:11:59.356 --> 0:12:03.356 in the mix, having a couple of recombinant vaccines in 0:12:03.396 --> 0:12:08.036 the mix helps us even out that risk. And so 0:12:08.236 --> 0:12:13.276 these are the few implications of having a vaccine program 0:12:13.836 --> 0:12:17.716 or a vaccine development program that has a few new, novel, 0:12:17.836 --> 0:12:21.276 innovative products. Can you say something about the two Chinese 0:12:21.356 --> 0:12:23.276 vaccines that you mentioned, because those have not gotten the 0:12:23.276 --> 0:12:25.356 same amount of coverage in the US media. But my 0:12:25.436 --> 0:12:28.836 understanding is one of them is a live attenuated vaccine, 0:12:28.836 --> 0:12:32.156 good old fashioned vaccine. Yeah, exactly. You take the virus 0:12:32.276 --> 0:12:37.596 and you primarily through serial passage through culture, take away 0:12:37.916 --> 0:12:42.116 the disease potential, but ideally maintain the replication potentials. So 0:12:42.156 --> 0:12:45.956 that's the live attenuated vaccine. There's another vector vaccine that 0:12:46.116 --> 0:12:48.396 is also in more advanced stages. So these are the 0:12:48.436 --> 0:12:52.436 two vaccines that are ahead of the pack in China. 0:12:52.556 --> 0:12:56.516 They also seem to have issues in terms of Phase 0:12:56.596 --> 0:13:00.316 three trials because of the successful control they have achieved 0:13:00.796 --> 0:13:04.596 in reducing the incidence of the virus in their own population. 0:13:05.436 --> 0:13:07.116 One of the most important things I think that you 0:13:07.196 --> 0:13:10.636 just said is that we need to realize that even 0:13:10.756 --> 0:13:14.476 just running the trials can take longer than one expects. 0:13:14.516 --> 0:13:17.796 Even if these are great, the durational issue isn't easily 0:13:17.836 --> 0:13:20.596 manageable because these aren't challenge trials. No one is being 0:13:20.716 --> 0:13:25.076 at this point intentionally exposed to stars Covy two virus. 0:13:25.356 --> 0:13:27.916 There have been people who've talked about the value of 0:13:27.956 --> 0:13:30.956 doing that. Under the circumstances, I have actually been opened. 0:13:30.956 --> 0:13:33.316 I understand ethical challenges. I've been sort of opened to 0:13:33.356 --> 0:13:36.796 the ethical argument that when many people are dying and 0:13:36.876 --> 0:13:39.156 the economic effects are as great as they are, if 0:13:39.196 --> 0:13:41.996 there's ever a time for challenge trials where people are 0:13:41.996 --> 0:13:44.596 intentionally exposed, this is it. It sounds as though you're 0:13:44.636 --> 0:13:48.876 not convinced, well, I'm actually I haven't made up my 0:13:48.956 --> 0:13:52.356 mind in terms of specific challenge trials, And here's the 0:13:52.396 --> 0:13:56.036 reason why I think they're a legitimate policy option that 0:13:56.116 --> 0:14:00.116 should be explored. But in order to going forward with 0:14:00.276 --> 0:14:03.356 an actual challenge trial, I think we need a few 0:14:03.396 --> 0:14:06.836 more things, and I like the WHO approach, so they 0:14:07.036 --> 0:14:09.836 issued ethical guidance about if to do it, this is 0:14:09.836 --> 0:14:14.476 how you do it. It's not straightforward to do a 0:14:14.596 --> 0:14:17.756 challenge studies because you have to have a standardized challenge 0:14:17.796 --> 0:14:21.796 doors for humans, you have to have a more rigorous 0:14:22.036 --> 0:14:25.436 set of protocols facilities. The ability to do that and 0:14:25.516 --> 0:14:29.076 the ability to conduct challenge trials is actually way more 0:14:29.196 --> 0:14:33.356 limited than to do efficacy trials throughout the world. So 0:14:33.396 --> 0:14:36.036 there are fewer centers in the world that have done 0:14:36.116 --> 0:14:39.596 human challenge studies. So obviously animal challenge studies are different. 0:14:40.156 --> 0:14:44.156 And so one of the thinking that that is there, 0:14:44.356 --> 0:14:47.716 which is not discussed too much in the public discourse 0:14:47.796 --> 0:14:52.756 or discussion, is what is the added time gain if 0:14:52.836 --> 0:14:57.236 you have to take these several steps that require you know, 0:14:57.316 --> 0:15:00.756 some time to iron out. Having said that, you know, 0:15:00.876 --> 0:15:03.716 developing it as a parallel policy option is very reasonable, 0:15:04.116 --> 0:15:07.356 but it should be done with not just policy discussion, 0:15:07.796 --> 0:15:11.316 but detailed call discussion. I want to ask you about 0:15:11.516 --> 0:15:15.876 asymptomatic transmission as sort of our last topic of conversation. 0:15:16.356 --> 0:15:18.436 I guess the question that I'm really interested in is 0:15:18.836 --> 0:15:23.596 we all understand that there's droplet transmission from coughing sneezing. 0:15:24.076 --> 0:15:26.796 We also understand that there is presumably some sort of 0:15:26.836 --> 0:15:32.516 aerosolization transmission where the droplets are much much, much much tinier. 0:15:33.476 --> 0:15:35.116 I think a lot of people are trying to figure 0:15:35.116 --> 0:15:38.636 out how they should think about those two aspects of 0:15:38.636 --> 0:15:42.316 transmission and what it means for masks. So within the 0:15:42.436 --> 0:15:46.196 symptomatic they can be sort of different modes of transmission. 0:15:46.236 --> 0:15:49.076 It could be from surfaces or full mites, mediums, large 0:15:49.076 --> 0:15:54.196 sized droplets as well as small sort of aerosols. Although 0:15:54.196 --> 0:15:58.396 that the data are being generated, there's a few things 0:15:58.436 --> 0:16:01.756 to keep in mind. First of all, the classifying the 0:16:01.756 --> 0:16:06.236 type of the size of droplet and the probability of 0:16:06.356 --> 0:16:10.796 something being aerosolized versus not so. Hanging out in the 0:16:10.876 --> 0:16:13.716 air for some periods and sort of transmitting through air 0:16:13.796 --> 0:16:16.916 is different from aerosualization, which stays much longer in the air. 0:16:17.476 --> 0:16:20.996 We do know that the risk of aerosolization is way 0:16:21.076 --> 0:16:25.716 higher in some higher risk procedures such as intubation, enduring 0:16:25.796 --> 0:16:30.196 medical procedures, and even you know specimen taking is likely 0:16:30.236 --> 0:16:32.876 to be especially in Nize with angel swabs, etc. So 0:16:32.916 --> 0:16:36.636 therefore healthcare workers need to have PPE for some of 0:16:36.636 --> 0:16:39.876 that stuff. The good news is if you have good 0:16:39.916 --> 0:16:45.196 personal protective equipment in healthcare settings, even with aerosolization, we 0:16:45.316 --> 0:16:49.756 seem to have fairly low transmission wherever PPE was available, 0:16:49.916 --> 0:16:52.756 So that's setting that aside. So now for mass transmission, 0:16:53.156 --> 0:16:58.716 what you're dealing with is a surface paced versus you know, 0:16:58.756 --> 0:17:02.276 these droplet transmission, which is not quite a rasalized but 0:17:02.356 --> 0:17:06.516 these droplets can travel, you know, reasonably far beyond six 0:17:06.516 --> 0:17:11.836 feet sometimes, and those droplets there is evidence, or again 0:17:11.876 --> 0:17:14.996 it's not definitive evidence, that you decrease the probability of 0:17:15.036 --> 0:17:18.996 that spread if you are wearing masks, but the effect 0:17:19.076 --> 0:17:22.836 size on an individual level is relatively modest. So the 0:17:22.956 --> 0:17:26.996 thinking is because it's not a very intrusive intervention, if 0:17:27.036 --> 0:17:31.796 you have masks compliance with mask wearing, you decrease the 0:17:31.876 --> 0:17:34.876 probability to an extent that you can see a substantial 0:17:34.916 --> 0:17:39.876 population impact. That last point is fascinating and one that 0:17:40.316 --> 0:17:43.036 has not I think been fully stated, partly maybe because 0:17:43.036 --> 0:17:45.596 people in the public health space don't want to state 0:17:45.636 --> 0:17:47.436 it as explicitly as you just did. So let's just 0:17:47.476 --> 0:17:49.916 go over it for clarity. What I hear you to 0:17:49.956 --> 0:17:54.436 be saying is that although the data on masks, not 0:17:54.516 --> 0:17:57.396 in the hospital context but in the public context, are 0:17:57.436 --> 0:18:01.636 not necessarily that definitive, and although the effects actually might 0:18:01.676 --> 0:18:04.836 be relatively small, there's a kind of public health judgment 0:18:04.916 --> 0:18:07.476 that says, well, it's very low cost for everybody to 0:18:07.476 --> 0:18:11.756 wear masks, and let's insist that people wear them, in fact, 0:18:11.796 --> 0:18:15.116 regulated by law in many places, including where I live 0:18:15.116 --> 0:18:20.476 in Massachusetts. And then we think that cumulatively, that is 0:18:20.556 --> 0:18:24.156 likely to have a harm reducing effect, and the theory 0:18:24.236 --> 0:18:27.596 is sort of that there's not that much downside. If 0:18:27.636 --> 0:18:30.516 that's the case. I do think there's a little bit 0:18:30.516 --> 0:18:33.076 of subtlety there, because it involves a value judgment about 0:18:33.116 --> 0:18:35.596 how low cost it is to wear a mask, and 0:18:35.676 --> 0:18:38.316 I think that may vary from person to person, and 0:18:39.076 --> 0:18:41.556 there are regional variations and how people feel about it, 0:18:41.716 --> 0:18:45.596 There are cultural differences in different places. So I'm wondering 0:18:45.596 --> 0:18:48.156 if you could just say a little bit more on that. Yeah, no, 0:18:48.356 --> 0:18:50.116 I agree, And so that's one of the reasons why 0:18:50.476 --> 0:18:53.356 public health agencies have gone back and forth on this issue. 0:18:53.356 --> 0:18:55.796 It's not a clear good issue. So there's a nice 0:18:55.876 --> 0:19:00.916 review by Oxford that try to incorporate all of these things, 0:19:01.036 --> 0:19:05.076 and they did show that at really high compliance numbers 0:19:05.596 --> 0:19:10.596 you can have a pretty substantial population level impact. What 0:19:10.796 --> 0:19:13.636 level of impact is there? So, based on the fact 0:19:13.636 --> 0:19:16.596 that a lot of these are assessments from studies that 0:19:16.636 --> 0:19:19.476 are sort of still evolving in terms of the evidence 0:19:19.516 --> 0:19:23.276 is still evolving. Because of that, I don't think we 0:19:23.316 --> 0:19:26.476 can say what is the amount of impact, but there's 0:19:26.516 --> 0:19:29.436 likely to be some population level impact. But I think 0:19:29.436 --> 0:19:31.836 you're right, we need to have some nuance in the messaging. 0:19:32.436 --> 0:19:34.756 Thank you very much. I really appreciate your time, my pleasure, 0:19:34.756 --> 0:19:44.916 and these were great questions. Sud's analysis is crisp, clear 0:19:45.316 --> 0:19:49.156 and helpful. First, and most importantly, we should not assume 0:19:49.556 --> 0:19:52.916 any specific time when we will know if the existing 0:19:52.996 --> 0:19:56.676 vaccines that are being tested work. Challenges to the testing 0:19:56.716 --> 0:19:59.676 process are endemic at a time when the virus is 0:19:59.716 --> 0:20:03.116 itself being controlled in many places in the world, and 0:20:03.276 --> 0:20:06.476 resetting up a protocol in a place where the disease 0:20:06.556 --> 0:20:10.276 is spreading faster is actually time consuming in its own right. 0:20:10.756 --> 0:20:12.956 So the fact that it is possible to get trial 0:20:12.996 --> 0:20:16.516 results sometime in twenty twenty does not at all mean 0:20:16.556 --> 0:20:20.476 that we will get those results in twenty twenty. Next, 0:20:20.516 --> 0:20:23.396 when it comes to new therapies, we need to see 0:20:23.596 --> 0:20:27.516 more data. It's very promising that the steroidal treatment of 0:20:27.676 --> 0:20:31.836 dexamethasone is helping to reduce deaths. This is the first 0:20:31.876 --> 0:20:35.996 therapy we've seen that actually specifically does reduce deaths, because 0:20:36.036 --> 0:20:39.356 the rim desvere therapy reduced time in the hospital but 0:20:39.476 --> 0:20:43.396 was not shown statistically to reduce deaths. So that's promising. 0:20:43.516 --> 0:20:46.516 But we still do not have publicly released data. What 0:20:46.636 --> 0:20:49.916 we have rather is a press release from a reputable group, 0:20:50.116 --> 0:20:53.236 Sad says. Sad also reminds us to keep an eye 0:20:53.316 --> 0:20:55.876 on the vaccines that are coming out of China, including 0:20:55.876 --> 0:20:59.916 a traditional style vaccine with an attenuated form of the virus, 0:20:59.956 --> 0:21:04.036 a topic to which we may return in a future episode. Last, 0:21:04.076 --> 0:21:07.036 but not least, when it comes to masks again, Soad 0:21:07.156 --> 0:21:11.476 calls for nuance. He points out that some studies suggest 0:21:11.956 --> 0:21:15.356 mild benefits of mask wearing, which can be magnified through 0:21:15.356 --> 0:21:19.476 the population if there's very very broad compliance, and that 0:21:19.556 --> 0:21:22.756 public health officials think that is worth doing, in part 0:21:22.836 --> 0:21:25.276 because they judge that the wearing of masks is not, 0:21:25.556 --> 0:21:29.956 in fact a high cost public intervention that raises fascinating 0:21:29.956 --> 0:21:33.396 issues about the costs versus the benefits of mask wearing. 0:21:33.716 --> 0:21:36.196 I guarantee you we will return to that issue in 0:21:36.236 --> 0:21:39.396 the near future as well. We'll be back in a moment. 0:21:49.516 --> 0:21:51.676 During the intense last couple of months, we've been so 0:21:51.756 --> 0:21:55.076 focused on getting you COVID stories that we temporarily paused 0:21:55.116 --> 0:21:56.756 a segment that we used to have on the show 0:21:56.956 --> 0:21:59.676 called Playback, where I choose a moment in the news 0:21:59.876 --> 0:22:03.716 and play it back to you for further discussion. This week, 0:22:03.756 --> 0:22:07.116 we're bringing playback back, and in particular, we're going to 0:22:07.196 --> 0:22:09.716 turn our attention where it always goes at the end 0:22:09.756 --> 0:22:18.356 of June, to the Supreme Court of the United States. 0:22:20.916 --> 0:22:22.916 That's the sound of people celebrating in front of the 0:22:22.956 --> 0:22:26.796 Supreme Court last Thursday, after the Supreme Court ruled that 0:22:26.836 --> 0:22:30.236 the Trump administration had acted unlawfully when it tried to 0:22:30.276 --> 0:22:35.316 rescind DHAKA, the Deferred Action for Childhood Arrival's program designed 0:22:35.316 --> 0:22:39.836 to protect people known as dreamers. From a moral standpoint, 0:22:40.036 --> 0:22:44.116 this is a tremendously gratifying decision. Dreamers are about the 0:22:44.156 --> 0:22:47.476 most sympathetic people you could imagine, And the fact that 0:22:47.476 --> 0:22:51.876 the Trump administration sought their deportation was again, from a 0:22:51.916 --> 0:22:56.556 moral standpoint, horrendous. That said, the Supreme Court's decision was 0:22:56.636 --> 0:23:00.116 itself surprising on the law. The decision was written by 0:23:00.196 --> 0:23:04.276 Chief Justice John Roberts, who is ordinarily a staunch conservative, 0:23:04.836 --> 0:23:06.356 and as the fact that it was a five to 0:23:06.356 --> 0:23:10.356 four decision shows, there were grounds that a conservative justice 0:23:10.396 --> 0:23:13.876 like Roberts could have used had he wanted to decide 0:23:14.116 --> 0:23:17.716 that what Barack Obama put in place, namely the DOCCA program, 0:23:18.036 --> 0:23:22.156 Donald Trump could remove. Indeed, Roberts typically has a rather 0:23:22.316 --> 0:23:26.076 expansive conception of executive power. And although we can know 0:23:26.116 --> 0:23:28.716 with one hundred percent certainty, I would say there's ninety 0:23:28.756 --> 0:23:32.116 nine percent probability that several years ago Roberts was one 0:23:32.116 --> 0:23:35.636 of the justices who voted to strike down an Obama 0:23:35.676 --> 0:23:39.036 program that was similar to DOCA but aimed at parents. 0:23:39.596 --> 0:23:42.396 So what was going on here? Why did Chief Justice 0:23:42.436 --> 0:23:46.116 John Roberts choose to leave his conservative allies and join 0:23:46.196 --> 0:23:50.996 the liberals to keep DOCCA in place. Sometimes when Roberts 0:23:50.996 --> 0:23:53.876 issues an apparently liberal decision, it's clear that what he's 0:23:53.916 --> 0:23:56.636 doing is trying to preserve the appearance of legitimacy of 0:23:56.636 --> 0:23:59.716 the Supreme Court by avoiding a scenario where the public 0:23:59.796 --> 0:24:04.476 would think of the justices as basically partisan. Roberts understands 0:24:04.516 --> 0:24:06.596 that the public knows that the Supreme Court justices have 0:24:06.636 --> 0:24:09.836 different ideologies. What he doesn't want is for the public 0:24:09.876 --> 0:24:12.596 to think that the justices vote based on the party 0:24:12.596 --> 0:24:16.436 of the person who appointed them. That may explain Roberts's 0:24:16.516 --> 0:24:20.556 vote not to entirely strike down Obamacare, the Affordable Care 0:24:20.596 --> 0:24:24.836 Act some years ago. In the DACA case, however, Roberts's 0:24:24.916 --> 0:24:28.396 motivation seems to have been somewhat different. What seems to 0:24:28.396 --> 0:24:31.836 be motivating Roberts is a kind of disrespect for the 0:24:31.876 --> 0:24:36.476 Donald Trump administration's unwillingness to cross its tees, dot its eyes, 0:24:36.516 --> 0:24:38.836 and follow the rule of law when it comes to 0:24:38.916 --> 0:24:43.076 issuing important governmental decisions. We saw this a year ago 0:24:43.396 --> 0:24:47.316 when Roberts also provided the decisive fifth vote to reverse 0:24:47.316 --> 0:24:50.756 the Trump administration's plan to put a citizenship question on 0:24:50.796 --> 0:24:54.036 the twenty twenty census. In that case, as in the 0:24:54.116 --> 0:24:57.556 DACA case, Roberts relied on a law called the Administrative 0:24:57.596 --> 0:25:00.196 Procedure Act, which is the law that gives the federal 0:25:00.276 --> 0:25:04.716 courts the authority to oversee and review decisions of administrative 0:25:04.756 --> 0:25:08.476 bodies in order to determine whether they complied with the 0:25:08.596 --> 0:25:13.276