– Welcome, everybody, to today’s Building My Legacy Podcast. I have with us again today, Dr. Turner Osler. He is a trauma surgeon. He is also an epidemiologist. He has published in over 300 refereed journal, articles and in books, which is incredible. It’s a lot of work to do that kind of publishing, so, congratulations to you.

– Well, I’ll just say I have hard working residents and medical students, you know, I just like keep them on track, making most of the real work.

– Okay. That’s good, but you have to be organized. So I’m sharing that because he comes with a perspective of medicine and of what’s going on right now with our adapting to COVID. So the question I had for him for today is we’re gonna look at two things today in our podcast. One is; what does he see happening with COVID? Explain that a little bit, in terms of the real uncertainty that we’ve all been dealing with, the frustration of that, what kind of course we might anticipate moving forward? And then I want to come back and talk about; what’s the future of medicine from his perspective. He’s an academic physician, he’s practicing medicine, so he has a perspective, I think that is important for us to hear today. So, Dr. Osler, let’s start with, we were talking a little bit before we began the podcast about the uniqueness of COVID-19 as a virus. So would you just explained that to our audience?

– Sure. I might start by saying; viruses are kind of unique. They’re an amazing and you almost have to stop and search for a word to describe what it even is, because it isn’t really alive, but it kind of behaves like it is. A virus can sit in a jar on the shelf for 10s of years, thousands of years, 10s of thousands of years, maybe because it isn’t really doing anything. It’s just a little packet of information with some delivery stuff attached to it. But once it gets into a host, it invades a cell and then it subverts the machinery of the cell not to do what the cell was doing, making muscle protein or digesting glucose. It’s the versa cell, so its sole purpose is to make more copies of the virus. And so, by stealing all of the machinery and commandeering the whole cell, the virus is able to reproduce itself and if it can then somehow get from one host to the next. It can really spread quite a long way. And of course the virus isn’t good or evil, it’s just information trying to reproduce itself through the world, using the hardware that it finds, which is the cells of some host. So, it’s a very interesting object. And it isn’t known even if viruses evolved into living organisms, or if they’re viruses kind of were Renegade cells that just took off and develop a whole new approach to how they were gonna make their way in the world. I mean, we can’t get to that kind of history because there are no fossils of viruses. Although there are a lot of human DNA is copies of old viruses that we’ve encountered over the last millions of years, and why we’re even storing that in our DNA is sort of a mystery. So the whole… I mean, virality is a fascinating topic. But even given that, COVID-19 is a fascinating virus among viruses. It’s a wholly new virus, one that we hadn’t seen before, which in large measure accounts for why we’ve had such a spotty track record dealing with it. When we first encountered COVID, we thought, well maybe it’s just comes from animals to people and won’t be a big problem as long as we stay away from pangolins. Well, turns out, it’s spread from person to person, well, it won’t be such a big problem if it’s just people touching each other. This spread with particulates, or people coughing or sneezing. Much bigger problem because now one person could infect many, many people. And now even more lately, we’re discovering it’s actually spread in aerosols, which can be quite tiny particles that can float around in a room for many hours. So a whole space can become seething with COVID-19 viruses and now, most recently, we’re discovering that oh you have to have much higher airflow is in the room and maybe ultraviolet light and perhaps you need to give the room a rest every hour or two to clear out all the virus that people may have been breathing or aerosolizing into the room. You don’t have to cough or sneeze to get COVID-19 virus into the air, something like speaking, especially if there are fricatives, where tiny bits of saliva are aerosolized and are projected into the room, perhaps only a few feet, but as the water evaporates, and these little notices become tinier and tinier and lighter and lighter, they walked around in air and can stay airborne for hours. And even if they fall out of there onto the floor, when people walk along on the floor, creating air currents, COVID virus can be resuspended in the air. So it’s a no keeping track of where these little buggers are is a big problem for us. So… The business of how we’re going to behave to keep ourselves safe gets pretty complicated because we can’t really make a space entirely safe since every person who is experiencing COVID virus can create high concentrations of the virus local to him. So people talk about the room and the plume is a viral plume when people speak or cough or sing, or yell, any of these things that can cause a small droplets to be expelled from respiratory tract. Even speaking, because the vocal cords when they vibrate against each other aerosolize moisture that’s on the vocal cords. So that’s the plume that comes out of the person and then that plume fills up the room and now you need architects and engineers to try and arrange for airflow that’s fast enough to keep the room scrubbed of high concentrations of COVID-19. It turns out just saying the sentence hello world, if you’re shedding COVID-19 virus can spread 30 virions out into the air around you. Oh 30 is probably not an effective dose. so who’s so worried if you keep talking and talking and talking, the concentration builds. So it’s a fascinating problem trying to keep people safe. And probably the way to do it is to control it at the source with a mask and give yourself some extra protection with a mask. And by having two masks between someone who’s shedding virus and someone who doesn’t wish to be infected, the masks aren’t additive, they’re multiplicative. So if 10% of the virus gets passed the speaker’s mask and 10% of the virus gets through the listener’s mask, then only 1% of the virus made it the whole trip. And that two orders of magnitude drop and viral concentration can be enough to make what would have been an infection, not a problem.

– When people are now going back to work, Dr. Osler, given the plume and the way it spreads in the air, what does that really mean? Masks is that alone sufficient? I know people are trying to create space, but nonetheless, when you have groups working together, there is you… You’re looking at a project, you’re looking at timesheets, you’re looking at reports, and you’re on top of each other before you realize it. So-

– It’s a big problem and I think reengineering workflow is gonna be a lot of it. As we are discovering at this moment, you can accomplish a lot being in different rooms. So the notion that we have to be in the same room to get work done needs closer examination. And it may turn out that what COVID-19 is gonna tell us is all that office space in New York City was corporate dollars wasted, everybody could have been sitting at home and we could not rent that building to some other company. So that’s the first thing is that by reengineering workflow, maybe we don’t need so many people so close together so much of the time. If you happen to have the need to have people in closer proximity, there are several things you can do. One is you can put a mask on everybody very cheaply, and it’s immensely effective. It’s one of the catastrophes of COVID-19 that early on and an attempt to save masks for healthcare workers who were the tip of the spear and in the belly of the beast and needed protection, the message that was passed around was most people don’t need them in order to preserve our meager supply of masks for healthcare providers. This was a catastrophic error in messaging, it’s never a good idea to lie to people. And it was understood that everybody should be wearing a mask, we were just trying to save mass for those who needed them more. What we should have said is everybody should be wearing a mask. Let’s save the fancy ones for people who are in the hospital and everybody else can make their own. And we said that earlier, I think we would have been much better off. But by now we’ve gotten to the point where pretty much everybody in the… Everybody agrees that masks are the cheapest, safest, most effective intervention available to us. And in some mathematical modeling, if everyone were to wear a mask, they are not the transmissibility the virus falls below one, which is like the crucial level. If the transmissibility can be driven down below a level of one, which means on average, a person gives the virus to one other person. If that’s less than one, if on average, a person gives the virus to a half a person, which is only half the time does a person give a the virus someone else, well, the virus will just peter out organically. And in some modeling, it suggests that if everybody wore masks group, you’ll think that would be enough to suppress the pandemic. So that’s the top of my list because it’s cheap and effective and basically, without any side effects. As soon as you vaccinate somebody or do something fancy, you can create a problem that you weren’t aware of, but there are basically no problems associated with mask wearing. So that’s the first thing. The second thing is to keep people as far apart as you can, if they can collaborate over the web, that’s perfect. If they need to be in the same room, you can have space in the room, or better if they can be out of doors. That almost completely solves the problem. And a large study out of Wuhan, China, they did careful contact tracing for 7000 cases of COVID-19. And only two cases apparently occurred out of doors. Almost every transmission of COVID-19 has occurred indoors. So in some sense, it’s not the virus, that’s the problem, it’s humans proclivity to put themselves in tiny boxes crowded with other people. This is a unusual behavior for our species, which for 3 million years were hunter gatherers that didn’t have any buildings and we’re out of doors all of the time. If we were out of doors, it wouldn’t be an issue for us, but because we’re in confined spaces it’s a much bigger problem. So, if we can get the number of people down, then we can also re engineer the space to have bigger airflow. If you can open a window, that’s terrific, if you can’t you need your building engineer to turn up the airflow so that the air in the room is swapped out, ideally, every few minutes. Typically, it’s once or twice an hour. So there’s room to run by just replacing the air in the room more frequently. And then the idea is that… And if you have a lot of people in the room, they should leave every hour or two and give the building circulation a chance to clear out whatever viral plume there might be. So there’s the plume of virus particles that come from someone speaking or coughing or laughing or shouting or singing and then as the water evaporates, these particles become water free, smaller and lighter and can walk around for hours in the air and then the whole room becomes contaminated. The very air in the room becomes contaminated with COVID-19. And this is a problem because COVID-19 is inhaled down through the mouth, down the trachea and into the lungs and settles in the alveoli, which is where the COVID pneumonia develops and creates such a catastrophe for people. If somebody… If you get COVID spittle on your forehead, you’re fine, it won’t get through your skin. But if you inhale covid 19 virus particles deep into your long interior alveoli, this can be a big problem.

– As you watch what’s happened, where do you see this moving during the fall and into the winter, which is usually our flu season? People are most vulnerable during this period of time. And what should we anticipate? What do we need to be prepared for? How do we need to think and approach this?

– Very smart people have said, “It’s very difficult to make predictions, especially about the future.” And COVID-19 is is a hard problem because it doesn’t just depend on the virus, it depends on what we do. And if we decide that we’re gonna stop going out to bars and stop singing, karaoke bars, and we’re gonna wear masks, the future is quite different than if we all go back to carousing at night, unmasked and in crowded spaces. So the question you’re asking is, really, how are we going to behave as a population? And the answer is, I don’t know. But as a Bayesian statistician, my first guess is pretty much we’re gonna behave the way we used to behave. And so you watch college kids and they pretty quickly devolve to maskless fun, because they’re kids, and likely they’ll be fine. That said, there have been deaths in that demographic. And they certainly aren’t invulnerable. And their behavior certainly puts older people at risk by spreading the virus to the population. So we prefer that everybody wear masks and so on. So, what is going to happen? I think that, well, it’s already happened, right? I mean, we’ve had colleges open and then slam shut as soon as they had the first 300 cases. Okay. So now colleges are trying to open in a little more controlled way, but the problem is their lead times involved. It takes a week to get sick and it takes another week to get sick enough to be hospitalized and takes a few weeks to die. So it’s a month that goes by before you see a spike in the deaths. And so it’s hard to keep track. However, the Urbana Campus of the University of Illinois, has put in place a testing regimen where they’re gonna test every kid on campus twice a week. And according to some mathematical models, if you can test every kid, two or three times a week, you can catch them before they spread very much virus very far. And that may be enough to suppress the virus. How’s that even possible? Well, you have to use a different kind of test. The PCR tests that we’ve been using are terrifically accurate, but they’re very expensive and sometimes they’re way over subscribed. So sometimes it can take a week or longer to get the result back at which point it’s sort of pointless. These more recent point of care tests that detect antigens produced by the coronavirus rather than its RNA are much cheaper and much quicker and can be done like a pregnancy test at home. And so if you can start testing kids like that, then it may be possible to get up and running and something that’s much more recognizable as America. That said, it hinges on having these tests widely available, cheap enough that people can afford to do it every day or maybe have your employer provide it or maybe have your university provide it. And we know that if you want people to do stuff, something that’s important, you need to make it very easy for them, ideally free and widely available. So it may just be that cheaper, faster testing will kind of provide enough of a bulwark against COVID-19 that along with social distancing and masks, can drive the virus down to the point where we stop talking about a pandemic and we just talk about how inconvenient it is. And rather than having, people dying at a rate of 1000 a day, we’ll have something that’s way less… 1000 people dying, that’s like three airplanes crashing. And three airplanes are crashing every day people be going crazy. I guess we’re going pretty crazy over COVID-19 too, but the immediacy of it is, that’s a lot of deaths. And that’s a way under estimate. We’re coming to understand that, as a doctor, when somebody dies, and you say, “Well, did they die of COVID?” “Well, they had COVID, but they also had an MI and it wasn’t so well to start with.” “What killed it?” When you fill out… I fill out many death certificates. It’s hard to know what killed somebody because usually there’s more than one thing wrong. So who gets credit for the kill? Is it heart attack, or was it the fact that… So in order to get better estimates of how many people COVID-19 is actually killing, the way a statistician would do it is we’d look at how many people died in August of 2019 and then we compare it to how many people died in August of 2020. And then the difference is due to COVID-19. That’s the thing that changed between 2019 and 2020. By doing these differences in overall mortality, you get a much more accurate measure of how many people overall were killed by COVID , that’s way over 200,000. These are just numbers, of course, but having accurate numbers is the first step to being able to do mathematical modeling and figuring out what’s important if you’re trying to stop an epidemic, and that’s the kind of mathematical modeling that interests me most. And that’s why I’m such a such a proponent of masks because when we put things like mask into a model, they really, really are powerful predictors of driving down COVID-19 rates of disease, hospitalization and death.

– The good news is they listen to you talking about that is wearing a mask is pretty simple. It’s incredibly-

– And safe and cheap. And actually we make our own here at home, we could take a shop towel you need a shop towel, six staples and two rubber bands and you can make a mask that’s really pretty effective in under 60 seconds.

– So, I would like you to just say a few words about the push towards vaccines and what you see with that, and the value of it. Now I’m one of those who has my flu shot every year, but I also know I still may sometimes get a mild flu episode. So if you would speak to that, please.

– So the business of making vaccines is extremely complex, especially the flu vaccine because there are different strains of the flu virus. And so every year the people who make the flu vaccine have to guess, months in advance which strain of the flu virus is going to be sweeping through this year, and so which which strain of the flu virus we need to target with our vaccine. And they can’t target more than two or three because it gets very complicated to make a vaccine that goes after more than one virus. So some years they get it right and it seems to work better and some years we’re protected against the wrong kind of flu. So there’s that whole thing. COVID-19 doesn’t have that problem, it’s a single virus, so that’s pretty straightforward. And there are over 120 different vaccines and various stages of development now. And the early signs are that COVID-19 has this big spike protein that is what you see on electron microscopy that makes it look like a crown, which is where corona Latin for crown comes from. It’s a coronavirus, if you look at it, I’m scanning in, it looks like a crown with the spikes sticking up. And the spikes are the things by which it attaches to a cell in order to get inside the cell and steal the machinery. And it turns out that we can make the vaccines that were are under development almost all of them target this single spike protein and they do so well and they make antibody that binds to it. And these early vaccine trials, show that it protects monkeys pretty well, and hamsters are another good model for testing this kind of stuff. And so… And in humans when we’ve given them some of these Moderna vaccine for example, out of Boston, people make a robust antibody response to the vaccine, which suggests it’s going to be quite protective against the virus. So, it’s very likely that we’ll be able to have a good vaccine pretty quickly, maybe by early next year. Well, that’d be the best vaccine? It might be that still better vaccines come along, but that’s really not a problem, we wanna have more than one vaccine in our arsenal. Also making 300 million doses of the vaccine is gonna require a lot of effort. And so the logistics of making enough vaccines so everybody can have some, is a complicated problem. And as you’re making vaccine, first you have some and then you have more but who gets the first doses of vaccine? I mean, you can easily imagine a food fight about who gets the vaccine. You know, ethicists and others have thought carefully about these problems and seems likely that the plan ought to be to give the vaccine first to the people are the tip of the spear health care providers who are in the thick of it, and then give the vaccine next to groups that are most at risk, which would be people who are working in slaughterhouses or nursing homes or prisons, where infections have been cataclysmic, and then have the vaccine filter out to other people as it becomes available. So these kinds of considerations are kind of being worked through now. You hope that you know that Congress doesn’t pass a law that they get vaccinated first, but you have the feeling that the rich and well connected are going to get vaccinated early, you just have that sense.

– Oh, yeah. You don’t know but it’s good news to know that you think that the vaccine because of the nature of the coronavirus can be targeted and can be effective. So I think that’s good news to align.

– And I gotta say that ordinarily, a vaccine takes five or 10 years. But when the virus was identified in Wuhan China, some enterprising Chinese scientist, put the complete description of the RNA which is like 30,000 base pairs up on the web for researchers. He was subsequently fired for doing that, little known fact. But the structure of the viral DNA was immediately available to researchers around the world. The people that Moderna had developed a vaccine platform where they just need to know what kind of RNA is involved, and they can immediately start making a vaccine. So these men and women at moderna, were making a vaccine within weeks of the virus being identified and sequenced. Unheard of It’s amazing. But they had built this platform because everybody knew that something was gonna come down the pike, they just didn’t know what it would be. So the idea was to have a platform that can handle any virus that came down the pike. Brilliant idea. The down side is this has actually never been done before. So far it’s working great, but we’ve never actually developed a vaccine based on this platform before. So it’ll be… It’s nice that we have other irons in the fire, but this is a great one. I just saw Grand Rounds here at the University of Vermont last Friday was on COVID-19 vaccine. So, lot to be said about it, but we don’t have nearly enough time.

– It gives hope, and that’s what I think people want right now more than anything is hope. Before we leave our discussion Dr. Osler, I do want to just briefly, from your perspective, talk about where do you see the future of medicine going because I hear so much discussion. I feel a lot of autonomy from physicians and disquiet about them. And so, from your perspective, you’ve been in the business, your wife is a physician, and a rheumatologist, a specialist. Where do you see medicine going? We need doctors, we clearly know that from having gone through COVID. So what do you see then?

– I have to say, I came to the halcyon days of medicine, I had a terrific career doing surgery, I just loved every minute of it, and training residents and medical students. But over time there were more and more requirements for filling out paperwork and fighting with insurance companies and getting certification for this and approval for that and one thing another got to be harder and harder to actually do the business of operating and taking care of patients because there were more and more demands that kinda were replaced on physicians. And I watch my colleagues kind of struggle under the burden of having to do more paperwork for every day and coming home later and later and going to work earlier and earlier. So that when our son was like, finishing with his Degree in Computational Biology at Cornell, and I said, well you gotta at least apply to some medical school because you did pretty well on the MCAT. But I didn’t really feel like I should try and sell the project to him because I don’t really know how medicine is gonna be in the next 20 or 50 years, I don’t know if it’s gonna be fun. I don’t know if it’s gonna be fulfilling. I do know that training a physician is expensive, estimates are one to $2 million to train a doctor. So you can’t push all that off on kids who are going to medical school, but they push a lot of it off on them. So these kids are getting out of medical school with hundreds of thousands of dollars of debt. And if you add to that their college debt, these kids, and then they started residency where they get paid nothing, so they aren’t actually able to start paying down their debt until they’re in their 30s. And then if they’re a family practitioner, they might be making 100 grand a year. So, it’s a… And then we wonder why aren’t any family practitioners. Well, these kids, they want to pay off their debt before they die. So the the picture is complicated, ’cause kids go into it because they wanna do the right thing. But by the time they get through four years of medical school and start looking at a residency, more and more of them are looking at residences that will allow them to start making money to pay off their debt. So all of a sudden kids who want to be family practitioners are much more interested in dermatology or orthopedic surgery, neurosurgery or… And I think this is a terrible precedent, to have kids career aspirations, so subject to financial constraints. Meanwhile, the United States continues to need a huge influx of physicians and we’ve discovered it’s much easier to let some person who trained in India who speaks great English and got good medical training into the United States, you stamp their visa and you have a doctor for well, zero dollars and zero cents instead of the $2 million it costs to train up a US citizen. But is that really how we want medicine to develop? Most of the fellows in the rheumatology department are here at the University of Vermont are FMG’s, Foreign Medical Graduates because rheumatology isn’t remunerative enough to attract students who’ve come to medical school in the United States. So it’s a very complicated picture, and as soon as you are ambivalent about recommending it to your kid, you have to think boy, what is the future gonna be like? And then there are these really big ideas like a radiologist, looks at an X-ray and then tells you about it. There are perfectly good radiologists in India, and they’re 12 timezones away, so you could just take all the X-rays from your hospital and send them to India and have the readings back on everybody’s desk the next day, and physicians in India work for a pittance compared to hiring a radiologist here in the United States. So there was a huge push to try and get all your X-rays read on another continent. As a surgeon was very helpful to be able to go down to the radiology department with some wet film and ask some radiologists to help me puzzle it out something you can’t do with somebody in India. But if it’s gonna be driven solely by financial considerations, outsourcing your X-rays to India makes perfect sense. And a pathologist just looks at a slide and says, “This is cancer, it isn’t.” This is just pattern recognition. There’s software to do that. So maybe pathologists will be replaced by really advanced pattern recognition software. It’s hard to see how it’s all gonna develop. But I think we’re still gonna need smart people to make it all work. So I happen to think it’s an exciting time to be in medicine, but you need to have really a broad view of image recognition and economics and then finally, how do you bring it all home so it actually helps people.

– I wanted to close with that because I am very concerned about as we have healthcare discussions as we look at things like COVID, and we feel so impacted many people feel like they’ve been out of control because it’s so amorphous and we keep getting information that changes. It’s what happens when something-

– Don’t wear a mask, wear a mask, I don’t know.

– The part of what we’ve also seen is the incredible need for wise people who have experience. So it’s not just looking at numbers, but it’s looking at that those numbers with a database in your head, that you can say, just a minute, my gut tells me this makes sense, that doesn’t make sense. And so we’re learning… We’re seeing the value of that, yet we’re not having, I think, a really important meaningful discussion in our country, about our physicians, and what do we want from physicians in the future? And I think it’s important. And so I just wanted to begin this discussion and perhaps we’ll have more of these discussions and they have people in various fields, participate in that ’cause I just think, if we don’t address it, things will happen and then you regret it later. So let’s start talking about what are the issues so we can be proactive.

– We’re certainly an exciting time and COVID-19 it’s really been helpful as a stressor to the system to find out what’s working, and especially what’s not. And as it happens, the mortality for COVID-19 is way under 1%. So, although 200,000 people at least and more yet will die in the United States, it’s nowhere near the pandemic of 1918. So in some sense it’s just a warning shot over about teaching us where our weaknesses are and what we need to improve on.

– Dr. Osler thank you so much. This has been such a wonderful discussion and I think people will find a great deal of value in it. And those of you who haven’t listened to our prior podcast, Dr. Osler has a marvelous product that helps prevent back pain. So go back, listen to that ’cause you don’t wanna miss it. Dr. Osler thank you so much and thank you all for listening to Building My Legacy podcast today.

– Thanks all.