Dr. Anne Rimoin, epidemiologist and Professor of Epidemiology at the UCLA

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I'm Guy Kawasaki and this is remarkable people have you ever been to a party and you meet a doctor? So you ask about every ache and pain and symptom that you have. Or you meet a lawyer, so you ask about prenuptial agreements and long term capital gains and divorce law. Or a social media influencer. So you ask how to optimize your Instagram posts, how many times you should tweet, and what link shortener you should use. I had such an experience recently. I spoke for a UCLA conference and one of the other speakers was Dr. Ann Ramoine. After listening to her for five minutes, I figured out that she is truly an expert in emerging infections, global health, and vaccination. Ann is a professor of epidemiology at the UCLA Fielding School of Public Health. She has published 70 research articles and book chapters. Her work has been featured in the New York Times, the Atlantic, the the Economist, the Wall Street Journal, the Washington Post, Wired, Discovery, Scientific American, Popular Science, Forbes, National Geographic, Nature, and Science. She was recently inducted as a Fellow of the American Society of Tropical Medicine and Hygiene. Speaking of hygiene, there's a part where her plumber's pump or something makes a cameo appearance in a pandemic. Not everyone has a sound studio, but I digress. I wasn't about to waste such an opportunity with Anne, so I gathered every question I could think of about coronavirus testing, vaccination, public policy, epidemiology, and press the record button. This is one of the most important episodes of Remarkable People because it could literally save your life. I beg you, do not make your Christmas plans until you listen to this entire episode. It's more than an hour long, but every minute counts. This episode of Remarkable People is brought to you by Remarkable the Paper Tablet company. Yes, you got that right. Remarkable is sponsored by Remarkable. I have version two in my hot little hands and it's so good. A very impressive upgrade. Here's how I use 1. Taking notes while I'm interviewing a podcast guest 2. Taking notes while being briefed about a speaking gig. 3. Drafting the structure of keynote speeches. 4. Storing manuals for all the gizmos that I buy. 5. Roughing out drawings for things like surfboards, surfboard sheds. 6. Wrapping my head around complex ideas with diagrams and flowcharts. This is a remarkably well thought out product. It doesn't try to be all things to all people, but it takes notes better than anything I've used. Check out the recent reviews of the latest version. Hi, I'm Guy Kawasaki and this is the remarkable Ann Ramoine. What do you do every day? I mean, you're obviously not in Africa fighting Ebola. So how does an epidemiologist function in a pandemic?

That's a really good question. Actually, epidemiologists do a lot of different things. If you're an epidemiologist working in a department of health, then you're going to do things like be trying to assimilate all the data that is coming in from all over the place, the testing data, the vaccination data for other diseases, trying to understand trends in the population. I mean, that's what epidemiology is. It's about the trends in populations and trying to understand risk factors for various outcomes. So that's what most epidemiologists do. Now what I do here in my little HQ that I'm in, which is my office, is I'm working on a variety of studies. And so I'm organizing the studies, I'm dreaming them up, coming up with ideas, and then we come up with a team of people to be able to execute it so well. My whole career I've been working on epidemics and emerging infectious diseases in places like the Democratic Republic of the Congo, where I've been working on things like Ebola, monkeypox, hemorrhagic fever, fevers, vaccine preventable diseases, looking for new viruses, crossing species between animals and humans. And so I have a team in Kinshasa that is working on those kinds of studies. I have people that are collecting samples from animals, collecting samples from humans, doing questionnaires, working with the Ministry of Health, analyzing data. But here in the United States, so I've been working on a study trying to understand asymptomatic infection and immunity. And in healthcare workers and first responders as it relates to Covid, we're also doing studies trying to understand things like vaccine hesitancy and who wants to get the COVID vaccine, who doesn't, why they might be hesitant to get it so that we can Help develop policy and programs to be able to get people to understand the benefit of vaccination. And all of the things that we're trying to make happen, those are the things I'm doing here. I'm also working on a study with veterinarians trying to understand occupational exposure to COVID 19 to the virus to SARS CoV2. So I'm thinking up questions about how is this virus spreading in the population and what can we do to stop.

It were it not for this pandemic. Are you usually in the Democratic Republic of Congo or is this unusual for you to be in LA doing this? Are you usually out in the field?

I spend a little bit of time doing both. So in the early days, in my youth, I spent a lot of time in the field, a significant amount of time in the Democratic Republic of the Congo. But as I've gotten older, as I've matured in my career, I've now trained people to do the work that I was doing there. And they frankly do it better than I ever did. So they need me less and less all the time. I'm the person that's now writing the grants, raising the money, making sure that the studies happen, and doing the supervising. So I go usually four or five times a year to drc. I would say I normally spend these days maybe a third of my time in Congo, but not since the. The pandemic started. In fact, the last trip I took was going to and coming back from the DRC in mid February, and we had the first cases of COVID diagnosed when we were there.

Aren't you afraid of going into DRC to investigate Ebola? I can't even wrap my mind around that. What's the mindset? Are you. Are you the Marines or the Navy deals of science?

That's really. That's really interesting that you say that. I would say no, we're not the Marines of scientists. We're the detectives of science. We're the people. We're disease detectives. And that's in fact, what people often call epidemiologists. But it's so interesting that you ask me that question because I recently gave the introduction for the presidential address for the American Society of Tropical Medicine and Hygiene. And in that. And the president is this really wonderful man named Joel Bremen. And Joel Bremen was one of the first people to investigate the very first Ebola outbreak. He was part of that very first group. And I asked Richard, I asked all of these people who wanted to their impressions of Joel. And Joel is one of these people that's so wonderful at describing things. He really just has a way with words. And Richard, Richard Preston, who wrote the Hot Zone and Demon in the Freezer, gave me. You know, this was, this was a quote straight from his notes. And I think that Joel put it perfectly. And I'm just going to tell you what this quote is. And it's, we epidemiologists are like, are the steeplejacks of medicine. We're the joiners. We're the people who pull together the steel girders of skyscrapers. Concentration is very important. You're focused on what you have to get done. We're like surgeons in the operating room. I just think that's an unforgettable phrase. The steeple jacks of medicine.

I won't even go into a restaurant and eat and you're going to the DRC just to give you. So can't an epidemiologist impact more people than a medical doctor?

Absolutely. I think that people often conflate epidemiology and medicine. And while there are epidemiologists who are physicians and there are physicians who are epidemiologists, they have different functions. So an epidemiologist is trying to understand patterns of disease and put this all together, understand risk of disease. And so we're doing this work before somebody gets sick, hopefully. We're trying to understand the patterns of illness and infection or any disease process, whereas a patient, physician is actually treating a person. So we're interested in populations as epidemiologists, while medicine, well, physicians, clinicians, are interested in individuals. So it's just there are different pieces of it.

What percentage of your time is spent writing up proposals and seeking funding?

A lot more of my time than I would. I would like to spend. But that's the bottom line. The bottom line here is that there's very little funding for epidemic epidemiologic research. And I think that people forget, you know, this is the thing about public health in general, is that when public health is working, people say, why do we need to worry about this? Why do we need to invest in this? And I've actually spent the vast majority of my career working on preventing pandemics before they start. That's been the tagline of the things that I've been doing. It's better to stay out of trouble than it is to get out of trouble.

Wait, did you hear that screaming somewhere?

I'm going to actually have to ask the. There's a plumber in the other room who's. Hold on a second. Let me see if I can get him to stop. Hold on a second. Sorry. No, it's not a problem. Hold on a second. I didn't understand. He was supposed to be here at 11 this morning. Hold on.

Tell him it's. Tell him it's Wolf Blitzer on with you right now.

That happens.

Or Sean Hannity, if it maybe.

Listen, Guy Kawasaki is just as important here, so. Just a second. I'm going to just hold on for one more second.

No problem.

Hold.

We were talking about how much time you spend applying for funding.

I spend so much time applying for funding. I spend more time applying for funding than I would really like. The bottom line is there isn't a lot of funding for epidemiologic research. I think this kind of comes back to this original issue, that is, if people aren't interested in paying for things that are not as sexy and as tangible, and when public health is working, people feel like they don't have to invest in it. And I think that's one of the things that we've found with this epidemic, this pandemic, is that we're realizing the lack of funding that has existed for so long. This is one of these things you have to think about in terms of. This is an issue of national security, this is an issue of public health. This is an issue of global security by function, of the importance of it. We should be spending so much more money and investing in this. I mean, you could say lessons learned from a terrible event like 911 is what we realized is that we didn't have organizations that were funded enough and that they weren't talking to each other. And I think that we're seeing the same thing here is we've learned that disease surveillance is so critically important in having information and people talking to each other from various agencies and ministries of health and governments all over the world as it relates to disease surveillance is so critical. The SARS CoV2 virus was circulating long before we knew it was a problem. And if we had an international ability to monitor it and to monitor disease, we would be doing much better. But instead, we have these very small little piecemeal projects that are here and there and wherever. If we were spending this kind of money that we spend on our national defense, on public health, we would be in a much better place. And not just in terms of the pandemic, but in terms of everything. This is about the foundation of health. And so funding is definitely something that is hard to come by, and we spend a lot of time looking for it to be able to do just the very basics.

You could easily make the case that if we took all the money that we have spent or plan to spend building a physical wall between America and Mexico and put that all into public health, a lot more Americans would be alive and secure.

You're right. Bill Gates said it very well. It's microbes, not missiles. And that's where we really need to be investing. If anybody has learned anything from this pandemic, that it's you got to make that investment because you're going to pay. If you don't pay now, you pay.

Later, like the fram filter guy. So I'm going to ask you a series of more or less factual questions. I'm going to just fire away. So, number one, do all viruses start with animals and then cross over, or can you start with a human?

Well, that's a good question. We think that at least 70% of viruses are actually from animals. There are most. The majority of new viruses that we've seen come from animals to humans.

Do you have a theory on how CV19 came to be?

This is a coronavirus, and coronaviruses are very common. And we also know that coronaviruses like this virus have existed in bats for a very long time. They exist in many, many animals. So I do believe that this virus was a natural spillover event. It. It makes sense based on the science and based on what we've seen from the, from the sequencing, of course, anything is possible. And I don't think we'll ever actually know for sure exactly how it came into existence, because if there ever was something like in a. An accidental escape, I'm sure that information is never going to be readily available. But it seems to be something that would have very reasonably come from an animal to a human.

Having said that, whatever the origin, it does not really matter, does it, at this point?

Nope. It doesn't matter where, because here we are and all we can do is learn from where we are and have better systems in place to be able to detect viruses and pandemic threats and be able to do something about them before they rage out of control. It's like a wildfire.

Do you think that CV19 is going to be an annual event like the flu and every year we take a newly configured vaccine?

I do. I think that's very likely. I'm not sure if it's going to be an annual vaccine or not, or how frequently we're going to need it, but I do think that it is something that will require regular vaccination.

Let's Say there's this magical world where our political leaders are, in fact, intelligent, and we convinced everybody to lock down for two or three months. Could we control coronavirus, flu, common cold? Could we just knock it out?

Absolutely. Absolutely. I think we've learned more than anything else here that there are things that are in our control. It's just a matter if we have the collective willingness to be able to do the right thing. We know that masks are very effective, that hand washing is effective, that social distancing is effective, and it's. But you have to have everybody on board and to do these kinds of things. So it's really important that everybody think about what their impact is and what they can do to prevent disease going forward. But we certainly have it in our ability to do that. I mean, I think seeing what's happening in places like Asia versus what's happening in the United States is, you know, makes it very clear that the public health measures that these blunt public health measures do work. You don't always have to have fancy science to be able to attack something. Sometimes something. These really blunt public health measures are much better.

What's an epidemiologist reaction when the governor of South Dakota tweets this? Unfortunately, the spread of COVID 19 is rising in nearly every state, regardless of if they have mass mandates in place. Here in South Dakota, we're focusing on solutions that do good, not on responses that feel good. What's an epidemiologist say to that?

I would say it would feel really good if we saw cases decreasing and we know what works. The science tells us what works. Wearing masks, social distancing and hand hygiene, they all work, they all make a difference. And avoiding gatherings and crowds, if you follow the science, you're going to always be on the right side.

What's an epidemiologist say when the governor of North Dakota tells asymptomatic medical personnel to go to work?

The problem was there aren't enough health care workers to be able to manage. And it would be one thing, you know, at the beginning of the pandemic in New York, we were able to pull healthcare workers from all over the country to be able to backstop the sheer numbers of cases. But now we have cases rising in everywhere in the United States. So we're now in a situation where we don't have as much of a choice as we did in the early days.

Now, just for clarity, asymptomatic is not the same thing as not contagious, right?

That's absolutely right. We know that approximately 40% of cases of COVID 19 people are asymptomatic, meaning they never had any signs or symptoms at all. They never feel that they had the virus. And those people. We do have evidence that people that are asymptomatic are able to transmit is definitely very worrisome. And it's very problematic when you hear that people who are asymptomatic are actually going to work. We hope that the wearing of masks and the social distancing and the hand hygiene and the PPE that they're wearing will make that difference, but it's definitely worrisome.

Now we do have something called the Public Health Service Commission Corps, and I think they're about 12,000 people. So can't those 12,000 people, led by the surgeon general, assuming he's not in jail in Hawaii, can't they go and supplement the North Dakota medical personnel?

There are always people who can come in from somewhere to help. There are many options out there, but we're really getting down to the bott. And the Public Health Service isn't all doctors and nurses. You have people who are non medical. And I think that the problem is everywhere. Healthcare workers are exhausted, they're overworked, and this has been going on for a long time now. The problem is that we just don't have very many places to draw from at this point. I mean, we might have to start getting creative and start doing things like they've done in places in Europe and license nurses early or other medical personnel early. But we're now getting into the weeds and we have a ways to go until we get a vaccine that's available to us.

Do you have any advice about how one should talk to a coronavirus denier?

That's a really good question. And I think that gets to the crux of everything here. How do you talk to somebody who doesn't believe the same thing that you believe? That's Public Health Communication 101, you know. And I think that we haven't done enough talking to people that don't sound just like us and believe the same things that we believe. It certainly isn't going to be by shaming somebody or trying to insult them for how they feel or what they think. It's a process of giving people information and facts that they can digest and then think about how it actually pertains to them. I think that's the first thing. But the other thing that's so important, and this is what we've done, I mean, with Ebola, with vaccine campaigns in the Past, you have to get to community leaders, to influencers, to people that actually hold sway with people who don't believe in coronavirus or think coronavirus. I mean, all of this disinformation has come from somewhere and often from very influential people. So what we need to be able to do is stop talking to the same people over and over again, but look to those who might be willing to listen and then get in. I mean, that's how we've done it with Ebola campaigns or with Ebola outbreaks all along. You have to talk to the militia, you have to talk to the religious leaders. You have to talk to people that actually influence what the average person is thinking. And I think we've just not been very good at doing that.

In this current situation. What is your most important tool?

Most important tool that we have right now is the Internet, honestly, is the connectivity that we have. Thank God for the connectivity that we have. Because if we weren't able to talk the way that we're talking right now, and in fact, I know on your podcast we're not going to be able to see it, but we can see each other, and it makes a really big difference. To be able to read people and to be able to talk to people, to be able to keep all of the work that we're doing going would have been. It would have been impossible in days prior to be able to keep so much international work ongoing. So I would say all of the connectivity that we have and the communication, it's totally changed how we're able to work. But it's not just even on the computer. It's WhatsApp, it's FaceTime, it's cell phones, it's Zoom. It's a constellation of technologies that we're using that are totally changing how we're able to work. And I can even talk about this, and I know this to be true because I'm still working in places where that connectivity doesn't exist. So the last couple of Ebola outbreaks that we've had in the drc, and frankly, most of the time that I've worked there, the vast majority of the country has no connectivity. So I'm used to working in places where you have no cell phone coverage, no WI FI coverage, you're using handheld radios to be able to connect with people. And I've also watched over the years in a place like Congo, watched when a community actually gets cell phone coverage and how it totally changes everything. It changes the culture, it changes how they. They think about things. It changes Everything. So I think most people take this for granted now, but it's changed everything.

Does it change things for the better or the worse?

I think it changes things for the better. It's never all good or all bad, right? Maybe it can be all bad. I take that back. Maybe it could be all bad, but it's never all good. There's usually some balance here. I mean, it's true. You're going to have people on their cell phones all the. Maybe more aware of what's going on in the world, for better or for worse. But I would say when you think about it at a really base level of when people actually get connectivity in a place like the Congo, there really is no downside. This allows people to be in touch with family members and friends and the outside world in a way that doesn't exist previously. And I think it's hard for us here to sit here and understand what that looks like. So for disease surveillance, which is what an epidemiologist like myself spends a lot of time doing, it's really hard to know what's going on if people can't communicate. If there are cases of Ebola, for example, or something, that's Ebola. Like, you know, there's a hemorrhagic fever, a case of something. It's really hard for somebody to be able to get that information from point A to point B. They're going to have to get on a bicycle and ride a bicycle for 100km and maybe walk through a swamp and maybe get on a dugout canoe to be able to get that information, information from point A to point B. So I think we forget from where we sit how difficult it is to be able to even understand what's going on in the ground without connectivity.

I don't know the total composition of the Biden task force, but it seems to me that they need social psychologists and influencers and persuaders. The research part is done, isn't it? Now we have to just get people to do that.

This is where the hard work starts. This is really where the hardest work starts. That's actually a lesson that we've learned. This is the thing about this is we've learned this, that we've learned this lesson over and over again from other. Other viruses, from other public health problems. We've learned this with Ebola. People were not showing up for vaccination. They were not listening to things like that. We needed. People need to bury their dead and that they can't bury their dead the way that they would normally. They're not able to have funerals, things that are very personally cultural to them. And so that's very hard to get people to change how they feel because they don't believe the thing that you might believe or that I might believe. Now, in places like the Congo, the day you die is the most important day of your whole life. And all of the rituals around it are very important, which include hugging the corpse and kissing the corpse and being in close proximity to it. And those are ancient, long standing, super ingrained cultural norms that people feel totally ripped out of their environment if they can't do. And we've been able to tackle those things dealing with cultures that are so foreign from our own own and belief systems that are so far from our own. And how do we do it? We do with sociologists, with anthropologists, with psychologists, with good public health messaging and finding the right people who can start bridging that gap. We have not been able to do that here in our own United States of America. And that's what we're supposed to be. This is the United States of America. We should be working together and finding ways to bridge this gap. And I that same concern. I think that the task force that they've put together, that the Biden team has put together is fantastic. They are all fabulous, just stellar scientists that have that no doubt will use great science, but they also need. This needs to be a bipartisan effort. It needs to be an effort that absolutely includes everybody in the country and not just one group in the country. This isn't a red or a blue task force committee. This should be a purple task force committee. It should be a committee that is able to tackle this from all sides. And that is the only way that any disease has ever been fought. This is the 40th anniversary of smallpox eradication. Right now we eradicated a virus from the planet and we didn't do it because we all believed in the same thing at the same time time. It's the same problem over and over again.

Tell us how you really feel, Ann. I mean, don't hold yourself back, okay? I say this for myself too. While Trump is in office, I don't know if I should believe the CDC or the fda.

I think that everybody has had that problem and I think it's the CDC and the FDA have taken real hits on their credibility during this pandemic. We all feel it. You're not alone in feeling that. I have many friends and colleagues who are at CDC who are at fda and it's been very, very disheartening and frustrating to these career scientists who have been there for many administrations. And this is the first time that the CDC has not been right out at the front where they should have been leading the disease prevention and control charge. And I think it's going to take a long time to that kind of trust back. Because even when we have a new administration in place on one side, we all think, okay, now the Biden administration is in, now we can all believe it. But don't forget, there's 70 million people that voted for Donald Trump and they are going to believe something else. And so we are so fractured as a country. This goes back to this, what I said from the beginning, which is it's going to have to be both sides coming together and saying, enough is enough. Enough with the toxic environment. We've got to find a middle ground. Everybody isn't, you know, it's not one way or the other. It's got to be in the middle.

Just as a real practical rule of thumb, would it be safe for me to say that if Tony Fauci, Vivek Murthy or Deborah Brooks says, take the vaccine, it's okay to take the vaccine.

It'S going to be great. When they all say take the vaccine, that's going to be fantastic and very important that we hear from everybody that it is important to take the vaccine. But that's not going to be enough. There's going to have to be enough transparency around this vaccine that everybody feels it. I've been running this study in healthcare workers and first responders in Los Angeles for COVID 19 and we actually just put up on preprint yesterday, a publication assessing vaccine acceptability or vaccine acceptance in healthcare workers. And we found that 66% of all the healthcare workers we surveyed, and this is a major medical center in Los Angeles, they had reservations about the vaccine. The vast majority were not people who had any kind of vaccine hesitancy in general, but they were hesitant about this vaccine. And when we asked them why, it had to do with the, the political climate, it had to do with the accelerated timeline for vaccine development and the lack of information, those are all legitimate things. I think that this is going to be a safe and effective vaccine. But I too, of course would love to see the data and have real information before this vaccine comes out. And this eway it has gone in. This emergency use authorization for Pfizer has gone in. We're going to see it from Moderna next. The clock is ticking. Where is all of the public health messaging and all of the information that's going to need to be available. Because healthcare workers are arbiters of science and good public health behavior. They are the linchpins of a public health response. And if we can't get all of our healthcare workers who are going to be first in line for this vaccine to be feeling good about it, we're going to have a real problem.

I feel like when you go to a party and you find out that the person you're sitting next to is a doctor, so you ask them all the medical questions you've been wondering, or it's a family law, so you ask them all the divorce questions, or it's a social media influencer, so you say, how do I use Instagram? So I feel like I just met an epidemiologist and holy shit, I can just do a core dump of all the questions I have. I find that number amazing that such a high percentage of medical workers are hesitant. Which brought me to a thought of. I read someplace that something like 3,000 Mayo Clinic employees have been infected. How is that possible? We're not talking about DRC in a jungle. This is the Mayo Clinic. How can that many people get infected?

This virus is contagious. It's contagious and it's not. And I would say, you know what's really important to remember? I don't know, I haven't seen this particular study. But my guess is most infections have occurred in the community because a lot of healthcare workers have a lot of access to ppe. Thank God, because in the very early days there just wasn't enough ppe. So you see all of these people getting infected. Well, that's because there was no ppe. Now, most infections in healthcare workers happen to be in the community because then you go home, your risk is related to who's around you.

What is your assessment of the current state of at home testing for asymptomatic people?

Well, it's terrible. That's the state of it. The state is there's no state, there's no state of good testing available for asymptomatic people right now, period. Actually, in general, as of where we stand right now, asymptomatic infection testing just still isn't as good as we'd like it to be. Most all of these tests were really designed to be able to catch people when they're symptomatic, not when they're asymptomatic. And that's one of the big problems with all of these tests. I mean, with the studies that I'm doing. We've seen it all over the place. I've also been spending a lot of time just helping people understand their testing results. And I get a lot of calls from people all over saying, well, I see people test positive and then they test negative, and they test negative and they test positive. The testing situation is very fraught. One of the reasons it is fraught is it's just not available to people. It's not very. Not very easily available. The second problem is that the accuracy of the tests still are just not ideal for PCR tests. Even on the best days to get tested between day five and day eight after your exposure, that's most likely when you're gonna have a positive test. There's still a 20% chance that it could be a false negative. And rapid tests, rapid tests are just not as sensitive, and they're really not good at detecting disease when you're asymptomatic. We just don't have a good answer.

Yet to circle back a little bit. Meanwhile, we're saying, people who are, quote, asymptomatic should go back to work in North Dakota. And you just basically ripped the test.

It's a crapshoot. So there's still a lot of. There are probably a lot of people who are positive and they don't know it. And that's why we always say everybody has to act like they have it. Everybody has to act like they have it.

Let's say today was 200,000 infections. Is it more or less accurate to say that 16 to 22 days from now, one and a half percent of 200,000 people are going to die? Is it just math at this point?

Unfortunately, it is. You're talking about different pieces of it here. A lot of people are going to die. We don't know exactly how many. And we're seeing all of these new therapeutics come into play. The monoclonals are now being released. Then, on the other hand, we have more data that remdesivir isn't working as well as we had anticipated that it was. The mortality rates have definitely come down, but in particular in certain age groups and people who have comorbidities, it's still high. And overall, it's still higher than influenza. So the fact of the matter is, a lot of people are going to die. And needlessly, none of these people have to die. None of these people have to get sick. If we all wore masks and we social distance and we did the right thing, we would reduce the number of cases and the Number of deaths significantly. It just. We don't have the political will to do it.

Do you think that the concept of quote, unquote, extra deaths is a better measure of the severity of the impact of this virus?

I do. I think that when you look at this excess death rate and you see that you have excess death deaths in all age groups, it really shows you the impact of this virus. One thing I would also say it's more XX deaths is not just about the virus. They're also the other effects of this virus. There are a lot of people are not getting treatment for things that they would have gotten otherwise. People have heart attacks or strokes, things that they might have gone to the doctor for earlier. We're certainly seeing some of that as well. But I do think that the excess death rate speaks volumes about what the impact of this virus is here in the United States.

Do you think that herd immunity without an effective vaccine is achievable and realistic?

No, I don't. I don't at all.

Is striving for herd immunity without treatment basically. Basically saying we're going to sacrifice lives, tough love?

Yes. Yes, it is. Yes, it is. Herd immunity without a vaccine means you're going to have not only just. It's not even just about the number of deaths, it's the fact that you're hot just from COVID but that the hospital system will be so overwhelmed that people will die from many other things, more than we're seeing right now with these excess deaths. Because if the hospital system is completely overwhelmed, even if you just say, okay, well it's only older people or people who already somehow or another immunocompromised compromise, let's not worry about them. Let's worry about the young people. We have so many people in these categories in the United States that what you're going to end up seeing is hospital, our health system completely collapsing. So if you have an appendicitis, if you have cancer, if you get into a car accident, if you have any health problem at all, there isn't going to be a healthcare worker or a bed for you. So herd immunity is just not a strategy that makes any sense whatsoever on any level. Level.

We're hearing a lot of information about these two tests and they're 95% effective. So can you help people understand what does that mean? How did we come up with that number?

There was these clinical trials. What they've done is they've had a clinical trial and what they do is they take 50% of the people who are enrolled and give them the actual vaccine. And then another 50% who get a placebo, usually like a salt water shot or something else. It's just something. But they don't know it. Nobody knows. The only people that know are the Data Safety and monitoring Board, at the end of the day, the data. So there's nobody that knows who's who. And then people get the vaccine or they get the vaccine or the placebo and then they go back and live their life the way that they would live it otherwise. And at a certain point, people getting Covid or not getting Covid and then seeing what the severity of that infection is. So what we saw in both of these trials was that there were very few cases of COVID in the vaccine arms of the trial. There were more statistically significant number more in the placebo arm. And in both of these trials you also saw severe disease really mostly in those people who got the placebo. I think it was the Pfizer trial, I can't remember which one. But one of them had only one person with severe disease and the other one had no people with severe disease versus the placebos. So this is really magnificent news. This shows that the vaccine is not only effective against symptomatic infection, but it's also helpful against severe disease. And that's fantastic. All of the news so far that we've seen from the press releases, we haven't seen all of the data yet, but from the press releases, it's really fantastic. It's far beyond what anybody ever anticipated.

What could go wrong in the next phase, that is deployment?

Well, there's a lot that could go wrong during deployment. The devil's in the details here. So what's going to happen is it's going to, it's now going to be under consideration at the fda and they're going to make a decision at the FDA based on all of the data and they will have all of the data. And that's going to be really interesting to see. See, once that data has been looked at, it's then going to go on to the cdc and the CDC advisory committee is going to review the data and then recommend the vaccine and decide which groups are going to get it first. Once they decide, what's going to happen is that the government has a plan that the moment that this is done, there's going to be a system where 24 hours later they're going to ship these to hospitals and, and health centers and then we're going to have it out to people right after that. And that all sounds well and good, but that means you have to have all the logistics in place. Pfizer vaccine requires -94 freezers. Those freezers aren't everywhere. I mean, I have them in my laboratories here in the United States and in the Congo and we even have some that we put in these little mobile ones that we put in mud huts when we do these crazy studies that we do. Those freezers are not easy to come by and to have them and to be able to, to have this for mass dissemination is no mean feat. Now the good news is with the Moderna vaccine, they actually can be stored in a regular freezer or refrigerator that you could find at a CVS or you know, in a doctor's office. That'll make it a little bit easier, but nonetheless, deploying this vaccine is going to be just a monumental feat. When you go back, do you think about things like smallpox eradication and what the logistics are for those kinds of vaccines or any of the other? You know, I work on polio eradication in places like drc. Just the logistics of getting these vaccines out. We spend a lot of time these days just talking about what it's going to be like here in the United States, but we're going to have to do this all over the world. I think people have to think about what it's going to be like to be able to get these vaccines out everywhere. And there are many places here in the United States that it ain't so easy to be able to get vaccines out. I mean, you have to think that there are a lot of rural areas where it's just not going to be so safe, simple.

And what about the long term effects of the vaccine? Because the long term today is 90 days, right? Do we know what's gonna, what the vaccine caused in me years from now?

We don't, but this technology has been very well studied and even though it's the first time it's being used or licensed for use, theoretically there should be no major side effects. And most side effects from vaccines happen very soon after being, after getting the injection. So I'm not particularly concern, concerned about long term effects of the vaccine. I just like to see the data.

Do you think we'll in the near future have the kind of test where we give people vaccines and we purposely expose them to coronavirus to see if it truly does prevent infection?

So those are challenge studies and those already exist for things like influenza, but given the high mortality rates, you have to have, have really no other choice for it than to do that they've been doing that in the uk But I think that we've just felt that we have so much coronavirus here. You don't have to. We have enough cases here. This is only in places where you don't have enough cases. I hate to break it to you, we got plenty of cases here. Not an issue.

Do we know if kids truly infect teachers and administrators or not so that it could be safe for kids to go back to school even in this kind of exploding infection?

Well, the data has been very surprising to see that there have been so few cases linked to schools. We've had some clusters, but by and large, not just here in the United States, but in Europe, we've seen very few cases. So I think that we need to start really looking at these data and thinking through what can we do to get kids back in school. The right answer is you need good. You need a low transmission rate in the community to do that. So you don't get to have bars open and have schools open. You gotta pick your poison. So I think that's one of the things that we've really had, we've really struggled with here in the United States, whereas Europe just shut down the bars and said, okay, that's it. You want kids in school, you're going to have to make some hard choices. And I think that's really been one of the bigger issues here. But I think that the evidence is mounting that schools are safer than we thought they were. But that's for younger children. Having older children and teenagers in particular are able to spread the virus just like adults. So it's still a little. And there's no zero risk scenario. There just isn't.

Lets assume that Joe Biden is president. Let's assume that nothing can change the minds of 30 or 40% of the US population. Let's assume that these vaccines prove safe and effective. Let's assume that there's a new Surgeon General. Let's assume that BIRX and Fauci are unleashed. Now walk me through what's going to happen starting on January 20th, 20th. Walk me through the fantasy of how this evolves and life returns. Maybe not to normal, but not to this kind of craziness.

Well, Guy, I have news for you. That's not a fantasy, that's reality, my friend. We are about to see a sea change here. So. So when Biden takes office, what's going to happen is that we're going to have a new administration in place that will be able to start moving now. It would make much more sense. And many lives would be saved. Many lives would be saved. If the transition team was able to start working as they have in previous administration change, our many lives could be saved, many jobs could be saved, many shutdowns could be avoided. If we could start this transition right now because we're losing daylight here, we're going to see, we're going to see significant death and significant disease. In the interim, we could see another 100 to 150,000 deaths. I think that was the IHME model just recently. By the time the inauguration takes place place, it's going to take some time, given that they've not had access to the White House, they've not had access to the things that they need to have access to going forward. And so they're not going to be able to hit the ground running the way they'd like to, or Jerry rigging it and trying to figure out how to do it. But it's just ridiculous. It makes no sense to me that you can't have this transition already en route. I have no idea why it's happening the way it's happening. It seems totally irresponsible to me. We should be seeing by now some movement in that direction so that if this administration has no interest in controlling the virus, that the new administration can actually start running right away. And in which case we're going to see vaccines deployed to the right populations first and we're going to see this rolled out. We're going to be able to see public health campaigns for improving vaccine acceptance. One of the things, and one of the things you're asking me, because I think one of your points is there are going to be people who are not going to want to get the vaccine. Whether they're the health workers that we're talking to or whether it's the general public. They're going to be people that are going to refuse the vaccine. Because we have not been spending months and months dealing with doing a campaign to get people in a place where they can see the science, they can see what's happening. But here's some good news. That vaccine is so effective, 94%, 95% effective, that you can actually have a lower rate of vaccine acceptance and still probably reach herd immunity, which is some great news. You know, problem is, we just don't know how long the immunity is going to last. We're still. These are still questions we don't know the answer to. So we're not going to be able to say, okay, no worries, let's not worry about everybody taking it. Everybody should get this vaccine. But I think we're going to have some wiggle room, considering how effective it is. And that means, short story long, that's how you're going to get back to normal is when you have the. The vast majority of the population vaccinated and we have some herd immunity, and then people can get back to the business of living their lives.

If I may intuit, with a lot of what we've discussed, what we should be doing now is social distancing. Washing our hands, wearing masks, doing all these kind of things in anticipation that the vaccine, vaccines, plural, will help us. But between now and then, when it's deployed on a massive scale, we still need to do the simple stuff like washing your hands, maintaining social distance, and wearing a mask.

You got it? Mask up, wash up, and stay away. Those are the things we all need to do right now. And they sound so simple, right? It seems so simple, but it turns out it's much more complicated than people really thought. Who would have ever thought masks, wearing a mask would be political?

Everybody puts their seatbelt on. I don't see anybody protesting seat belts. So.

But don't you remember that people did protest it? This is a perfect example. This is. Yes, seatbelt laws were. It was a long time. It took a long time to get people to agree to seatbelt laws. And I often liken this to smoke smoking laws. There have been a lot of pushback with the smoking laws. So smoking laws, seatbelt laws, and texting. Right, these are all things that protect you from other people. It should be no different with wearing a mask. It's the same concept.

This podcast will come out after Thanksgiving, and it's so close to Thanksgiving anyway that it's too late to impact people's Thanksgiving plans. But we will be able to get it out before Christmas. So let's suppose that it's mid December. There are now 500,000 new infections per day. Four or five thousand people are dying per day. What is your advice to people planning on Christmas vacations, Christmas travel, Christmas, anything? What would you tell America to do for Christmas?

Ixnay on the isthmus Cray is what I would say. I would say it's really time, you know, to. You have to. We have to all think about what our priorities are right now. And the priorities that we have should really be about protecting our families and our communities. That's what Thanksgiving is. You know, Thanksgiving and Christmas are community, about community and family and sharing and giving and doing the right thing for the people that you love, and the thing that you could do for people that you love is to stay away from them right now. And that's not an easy thing to say. I want to be with my family. I want to be with my friends. I miss having all of these great moments together. So I would say to people, focus your energy this year on planning a fabulous holiday next year, because next year, it's going to be fabulous. This year, not so much. But there are things that you can do. You know, you can focus your energy elsewhere if you need to fill your time because it's stressful, and it's going to be stressful. I mean, this is a stressful holiday season. It's not going to be like other holiday seasons. If you're feeling alone, reach out to people, have Zoom calls, have FaceTime calls, find a way to connect remotely, pick up the phone, do things to give back to your community. I say to people, you know, they're worried about Thanksgiving, but this will be the same advice for Christmas time. Cook for people around you and leave it at their houses. If you can find ways to do things that fill your time substantively and take your mind off what you're not able to do this year. And I say to people this about Thanksgiving, but all. It's, you know, Thanksgiving. I'm not the first person to say this, but I heard somebody say that a Zoom Thanksgiving is better than an ICU Christmas, right?

Oh, my God. We should get. There's got to be a movie with Macaulay Culkin in there. I see you alone or something, right?

That's really what you. That's the. That's the thing, right? You really have to make sure. And it's gonna be the same thing between Christmas and. It's like anything that we do now is going to have a ripple effect for months to come. You want the people that you love to be around for next Thanksgiving and next Christmas, so just forego the festivities this year. Now, for those people who are gonna ignore all of this advice, and I do think that's a problem with public health, we say just don't. And then people are trying to sneak around the edges and finding out what to do. So if you're going to ignore the I or there's a reason that you just. You. You have to see people. Here's what I say. Better outdoors than indoors. If you have to keep it as small as you can, and if you must be indoors, because half the country. More than half the country is going to. Is. Are in places that they can't. You can't stay inside or outside. Spread out. Stay as far apart from each other as you can. Don't have a communal dinner around a table. If you have people who are living with other people, their little family pods, eat in different rooms, open windows, open doors. Keep the ventilation as best you can. And if you're going to be drinking something, or if you're going to eat, you only take your masks off when you eat, and then when you drink something, take a straw and put it under your mask. And that's how you can drink. So you can drink all night with your mask and on, far apart from everybody else. But that's no substitute for staying at home only with your pod. This is still a risky proposition, but it will reduce risk in that scenario.

I don't want to be accused of skirting the edges here, but let me ask you. Let's say I know somebody who's going to take his current pod to an Airbnb in another city.

City.

Maintaining the same practices in that other city, Airbnb. So all they're doing is moving. They're not adding more people to the pod. Is that okay?

Where are we going? No. Yeah. The bottom line is you don't want to be increasing your risk by adding more people into your group or finding, you know, having exposures and then this pod gets exposed through other people and then brings it back. Hypothetically speaking, the answer would be if you're just taking a group of people going from point A to point B and they're not having any other exposures, that's in principle, that should be fine. If the issue is bringing people from outside of your household or your pod, whatever it is, the people that you've been quarantined with all along, that's the thing we're trying to avoid, bringing other people into the mix. And that's the problem with the holidays, is all of a sudden you're us bringing. That's the whole essence of the holidays for us. You people flying in from all over the place and coming in from all over the place and mixing households and bringing people together, and we just can't do it this year. But you can take your pod and take that pod, go somewhere else, as long as there's no additional contact with. With other people.

Let's say that the person is in a place where you can open windows and have fans. Invented ventilation. Is there any real reason to Go buy a $500 HEPA filter when you can open windows and turn on fans?

Well, it's all. So I'm not an industrial hygienist, so I'm going to give you my knuckle dragging epidemiology answer and it's not going to be perfect, but I'm going to give you the gist. There are people who really deal with airflow all day long and I only look at it in a general way. There are plenty of hills of air filters that are not the $500 ones you can get cheaper ones for sure, but the ventilation is really important. What I would say is you don't want to be blowing air in and across people, so you don't want to be blowing your droplets across to other people. So how you're doing it is really important. I think that's really critical is that the airflow needs to be very good. And of course air filters are helpful. But there's no one thing that's going to save you here. That's the problem. It's all just layered on. You do as much as you can, but there isn't one thing.

So let's suppose Joe Biden calls you up and asks you to be the Secretary of Epidemiology. Question number one. Would you take the job?

Absolutely. I don't think that Joe Biden has my phone number and I'm on that list. But I think that there's nothing more important than public service and finding ways to do the right, right thing for society. The more we're able to do, the better off we are. But there are lots of people that are in Joe Biden's circle that I'm sure will be called upon for providing great epidemiologic advice. But if I were on that list, of course I would do it.

Let's assume that you are confirmed by the Senate. What are the. I guess that matters in how Georgia goes, but let's assume that that. And now what are the first things that you would do as Secretary of Epidemiology?

Well, I would say that the most important thing is to have really good disease surveillance in this country when we're just talking about epidemiology here. Because epidemiology are your eyes on the ground. You have to have situational awareness of what's happening around you and to have really good data coming in so you can have good policies coming in out. That's really important. And the epidemiologist is just going to deal with all the data and kind of sorting out what's happening there. But if you're talking about somebody that's responsible for we're just going to make up all the other things that it comes around to. You know, you need better testing and we need to have testing accessible to everybody because that's going to give us the data we need for it to be able to make good policy, but also allows a person to have actionable information that they can do something with. But you need a test that's actionable, accurate and inexpensive and available to people. It has to be available. The other thing I would do is I would really focus on this issue of vaccine hesitancy. Vaccines are great and vaccines that are 95% effective and have no side effects are even greater. But the greatest thing is vaccination. And that means you've got to get that vaccine into people's arms. And so that is going to require fantastic leadership and good public health. Modeling this pandemic has unveiled our deficiencies in public health. Communication just, it laid it starkly out there. And so we need to be getting all of our allies and influencers in disease control strategies out there and really, really telling us, telling the population that this is going to be okay. But they're not going to just tell people it's okay. We have to have the data. We need information. The process needs to be wide open. And so successful rollout of a coronavirus vaccine is going to have to be built on trust and confidence in communities across the country. So I think that those are the key things that I would personally focus on on. Those are the short term things. On the other hand, there's the long term issue. We're going to get past this, we're going to get past this virus. We're going to move on to greener pastures. They are in our sights, they really are. But I think we have to remember, it's very important to remember that every day countless viruses are mutating and evolving and spilling over into human populations. And at any moment, one of them could spark a new disease outbreak that uncontained could spread like wildfire.

Just like that.

Just like that. Imagine I used to give this speech. This was my shtick. I give this speech when trying to raise money to do this disease surveillance work that I do looking for new viruses. I have given this speech over and over again, although everybody used to just pat me on the head, say, oh, isn't that, that's really great, awesome. We're gonna work on something else. Well, I'm telling you right now, we need to be working on this because infectious diseases nobody boundaries. They don't need visas and an infection even in the Most remote corner of the world can make its way to a major city right here, as it has. I used to say this all the time to people, but now we've seen it happen. But what I will say is that we don't know when the next infectious threat to humans is going to be. We just don't. But we do know this. It's not a matter of if. It's a matter of when it's coming. Or it may already be out there, and it might be out there spreading undetected. And that's not hypothetical. It could come in another form besides a respiratory virus. I will say. I'll just tell you. For example, it wasn't all that long ago that there was a virus that emerged from the forests of the Congo and made its way to the capital of Kinshasa and then spread through the world through travel and trade. And since that time, more than 70 million people have been infected and 35 million people have died from that disease. And that's HIV. We have to think about what could have happened if we could have stopped HIV before it spread beyond its rural birthplace in equatorial Africa. What if we had stopped this virus from spreading beforehand? How many lives could we have saved? It's not just about what's happening with coronavirus, but it's about all these other viruses that are out there. And that brings me back to what I said from the beginning, and that is that infectious disease outbreaks are really like wildfires, and you must stomp them out when they are small and containable. And that's never been more true than right now.

I never thought we'd get through all these questions.

This is.

I bet you're so used to being on CNN and you have two minutes to explain everything about vaccines.

This is a much better forum. I love it. It's much better. This wildfire analogy is so important because time is of the essence. You live in California, I live in California. We speak the language of wildfires. We know the devastation that they can cause and what you need. And this comes back to. I'm going to loop this back around to the whole EPI thing here. And that is that you need good public health response. Public health response are like firefighters in a wildfire. And you need firefighters or these disease detectives and these disease responders at the ready. You need them well trained. You need them familiar with the terrain. They need to be able to get on the ground quickly with the right tools, with equipment, with strategies, and they have to be able to extinguish this spark before it turns into a raging inferno, slash global pandemic. And we didn't even talk about some of these things too. I do want to just say a couple of things that I think are super important that just make me think about you and the tech world and just this marriage of public health and science and tech and how important this moment is. And we've been seeing it in the work that I do in the Congo all the time. And I'm just going to give you a perfect example that the Congo, it's a place that has, it's 2/3 the size of western.

What is that?

Oh, seriously? It's like everybody here today, there was a truck that was just backing up. So in the Congo there are no roads and it's a country that's 2/3 the size of western Europe. And there are also very few maps in this country. And so all of this technology, these technologies like Open street map and ESRI and some of these other ones, all of this mapping has totally changed things because we used to just have hand drawn maps in the Congo. That's what we've been using all along are these just little hand drawn Maslik treasure maps. And they're, they're not to scale and things are all wrong where they are, but it's the only thing that exists. And all of a sudden we started mapping things out. We found that things were totally not in the right place. They were the size, the boundaries, the where a river was, where something just were just completely wrong because they were driven, drawn by a health care worker just by hand on a piece of paper. And so the mapping has been key. The technology, the GPS stuff has been key. The technology for conversation, being able to talk to people and to be able to capture data has been key. And I just challenge the tech community to be able to continue to partner with global health and public health and epidemiologists and to be able to really come up with new exciting ways to be able to, to prevent pandemics before they start to detect disease early on and to make it possible to look in every corner of places like the Congo where there still are no roads and there still are no phones and there still are no maps. This is really where the sweet spot is and this is what's gonna make a huge difference in the world. And to take. I think that tech has, I think that we as epidemiologists have a lot to learn from the tech community. And we, and I've heard you speak before very recently and I so identified with it because I think that so many of the things that you say are so important. Things like we need to just take things and throw it at the wall and see what happens. That's how you're going to find new viruses. It's your whole idea of don't worry, be crappy. Now, I'm not saying don't do good science. We should all do good science. But sometimes you have to have crazy ideas and just throw them out there and have the capacity and the funding to be able to find the way to look at these things and try them out. The way the tech community has been able to do it and the epidemiology and public health community has not, because we don't have the funds to be able to do it. I think that people should be innovating in this space because now they realize how important it is. Even things that you think of public health might have sounded a little dusty and old and not as exciting. But I think that the tech community is going to be very excited about ways going forward, how we can really capture this and move forward forward. It is such a pleasure and an honor to be able to do this with you. So I saw you speak at the Innovate thing. We got to talk the other week. I just feel like your philosophy and the way that you do things has a role like you, you have a role in public health. You really do. I challenge you to have a role in public health and epidemiology. I don't know what it is is yet, but you are an evangelist.

Do you know the famous story about how Steve Jobs, when he was recruiting John Scully, John Scully was working at PepsiCo. He was chairman of PepsiCo. So he told John Scully something to the effect of, do you just want to sell sugared water the rest of your life? And that's what got John SCULLY to leave PepsiCo to come to Macintosh to dent the universe, change the world, increase people's creativity and productivity. You could ask Guy Kawasaki, do you want to do more than sell more phones and computers? And I do.

Well, I have some ideas for you because I think we should talk about it. Because I think that there are so many stories to be told about public health and global health, but it's all about how you tell them. You can't have dry discussion of this stuff. It just like people don't listen. But there's got to be a really important way to be able to do this. And that is about the sales and marketing that you are talking. It's really true. This is it. This is where you're actually able to make a big difference. So I think that there are multiple things. I think that in figuring out vaccine hesitancy, I think that's one place that I think that you could be very helpful in. It's all about sales and marketing.

Okay, I'm your man. You just tell me how I can help you.

Okay, I actually gotta think about that. And then I say that the second thing is figuring out other mediums to be able to tell some stories. Because we're talking about this story right now of COVID 19. But this is going to go on much longer. This is a much bigger story about preventing disease and preventing pandemics before they start. You have to be able to get out there and be able to identify where it's going to happen. So this will be one of many conversations. I don't know what exactly. This is a don't worry, be crappy story here. There's going to. We just have to throw those ideas at the wall.

As long as I don't have to go to Africa and live in a village and fight disease hand to hand.

Okay, listen, I was like a cheerleader from Palos Verdes that made it now working on Ebola. Anybody can do it, but I promise not to drag you to the Congo unless you really want to.

I have such respect and awe for people. I also interviewed Dion Cersei from the New York Times who invested the Boko Haram. And I asked her how, how like you go to Nigeria and you go investigate Boko Haram. Does that not sound dangerous?

Dangerous to you?

So I'm just a wimp, but I know I'm a wimp, which is half the battle.

Hardly. Everybody has different things that they can do. And by the way, it's not that I'm not scared. I get scared. I get terrified. I'm particularly terrified of flying on the small planes that I have to take these little single engine Cessnas. Literally. I can't sleep before I have to get on these planes. I'm sorry. Terrified.

Oh, maybe you have never heard of this, but this might be very helpful for you. So there is a company called what? Three words. Have you ever heard of this?

I've never heard of it.

You were talking about mapping. So this company, it has to, I think 20 square feet. It has assigned three words to every 20 square foot area on the planet. Let's say the usual kind of example is we're going to the 49er game and we want to meet. That's a big stadium. And so I'm going to tell you because it's mapped to the parking lot, the stadium. Every place is down to 20 square feet. I am going to to be at Blue Lamp Watch. And you in your phone, you go to Blue Lamp Watch and it takes you right to where that person is standing. That's the kind of millennial use case. Now you can say, we discovered this case of Ebola at Basket App camera. And that is a specific 20 square foot place in the DRC. It's that precise. They've mapped the entire world. You can literally tell people exactly where you are in the world that you discovered. This chimp with coronavirus.

I'm gonna look it up. I'm gonna look it up. But I think that this is really great. I just think. But this kind of conversation is exactly what needs to happen so much more often. And I think that having these kind of serendipitous meetings, like us meeting at this Innovate thing, this is how really cool, cool concepts come to the fore. And scientists and tech people don't meet often enough.

We talk about a lot of bad stuff, bad stuff that has happened, bad stuff that is happening, and bad stuff that might happen. But there is an underlying message of optimism and hope. We need to do some simple things in the near future. Wash hands, stay out of crowded areas, wear a mask. It's not rocket science. Vaccines are on the way. But until enough people are vaccinated, we still have to do all the simple things. I'm Guy Kawasaki and this is Remarkable People. My thanks to Jeff C. And Peg Fitzpatrick, who are my vaccination against lousy podcasts. My thanks to Thomas Phelps, who introduced me to Ann. This interview would not have happened without, without him. And please, please, please remember the words of Ann Ramoin. She said that a Zoom Thanksgiving is better than an ICU Christmas. Mahalo, aloha and melekalikimaka. This episode of Remarkable People is brought to you by Remarkable, the paper tablet company. This is remarkable people.