Former CDC Intel Officer Dr. Rishi Desai on Why It's Hard to Get a Grip on the Coronavirus Pandemic

cases in the hospital are a lagging indicator of reality and when you don't have accurate testing on the ground which we don't then all you really have to go on is cases and that leaves you blind for a few weeks as to the reality of what's happening everybody I hope you enjoyed this episode brought to you by our sponsors at whoop you can save 15% off your purchase when you go to whoop calm and use the code HT at checkout now enjoy the episode everybody welcome to hell theory today's guest is dr. Rishi Desai he's a pediatric infectious disease doctor who was also formerly a member of the CDC working in their viral disease division doing outbreak research additionally he's a chief medical officer at osmosis and has been a leading voice across pretty much all media types educating the public daily on the current state of Cova 19 dr. Desai welcome to hell theory they thought for having me you can call me reach me by my first name amazing man well thank you so much for joining me I'm really excited to get into the current state of this give us the most up-to-date on learnings and the things that I care most about are obviously what what is actually happening inside the body at the viral level is that obviously everything we do to protect ourselves the solutions to this are all gonna be predicated on us pinning that down yeah so let's get into that you know the virus enters your body typically you're gonna get it in through one of three passageways your eyes nose and mouth probably mostly your nose and mouth and once it hits the back your throat that's where it starts its journey it starts infecting cells and gets down into your lungs and that's been the story for most of this outbreak we've thought about it as a lung disease and talked about it as infecting you know the little alveoli and causing damage to the lungs and I think what we're learning now you asked me about kind of what's the bleeding edge I'll tell you it's the blood and so as you go across from the lungs into the blood vessels it's what's happening in the blood vessels and I think that's what we're starting to realize right now in the past few weeks we've seen more more studies talking about strokes and young folks and so so in your age shouldn't be getting a stroke you know you're a healthy person presumably and and now we're seeing strokes and people your age my age for sure and that's worrisome you know people have thought up until now to disease of old people and it's a disease of lungs and now you tell them well there's an actual increased stroke risk and that's because it causes endovascular damage it's literally infecting the cells that line the blood vessels and damaging them and what does that sound like that sounds like what sets up for a heart attack or a stroke and that's I think the increasing realization that people are having about stars co2 or the virus that causes coma 19 yeah that the the notion of what's going on in the blood to me is is really interesting it certainly points at things that we can do to ultimately defeat if I can use that word the virus but talk to me a little bit more about what's happening at a cellular level so the cool thing is I've really started to understand how viruses work to be honest like and in the beginning I always imagined like a cold virus being able to move that it had some sort of locomotion so beginning to understand that's not how it travels that it has like the spikes on the outside that it is basically has evolved to attack only a few type of cells for the sort of infection site which is why it goes for things that have a mucosal layer so your eyes your nose your throat and that it has to get on that but once it gets on that that the infection can what I'm told happens very quickly within seconds but getting into what's really going on in those cells that are lining the blood vessels what's actually happening what is the damage that it's doing so the first thing I'll say is that think of it as a numbers game right so you just mentioned a really classic example you think of it touching you and it getting in and in taking five seconds to do so that's not how I think of it I think of it as if there's a lot of it then yeah I'm in trouble if there's a little bit I'm not in trouble so there a number of innate immune defense systems you have in place and you know it's a little bit like think of another numbers game you know sperm creating fertilization you know there are a number of reasons why sperm wouldn't make it to an egg and it's only because we you know have millions and billions of them that you get one to survive it's a numbers game similarly the virus is trying to play a numbers game it's gonna get stuck by mucus we have little proteins defensins within that mucus that are going to deactivate or you know attached it to the virus we have new coastal antibodies we have local monocytes you have all sorts of things set up to allow for you to not get an infection and if you get overwhelmed if you get too much of iris then yeah maybe you'll get an infection maybe some cells will get hijacked even when they get hijacked there is a numbers game on the other side you know getting one cell infected technically you might think of that as an infection and maybe some would agree with you others would say well known infection is when you can detect it well what's a detectable threshold is it a single cell can we detect a single cell infected not really not that I've ever seen so you have to have enough of an infection to even detect infection to call it infection and again that's a numbers Dan tune and the reason this matters is take two scenarios I'm in a grocery store I grab an apple someone sneezed on it two days ago there was a tiny amount of virus on it two days ago that's been steadily decreasing as the ambient temperature and humidity in the grocery store is causing the virus to essentially die off and so the actual threat is pretty low it's a very very tiny amount of virus on an apple but comparing now that scenario to another scenario where you for your healthcare worker you've intubated a patient they coughed in your face they got a lot of inoculum then you move to patient two they coughed in your face patient three been in cough but they sneeze ten minutes before you walked in you're getting multiple large inoculum so virus when you go home at night you're dealing with a lot more than that person with the Apple so these are two different scenarios and so numbers matter and that's why we're seeing so many more health care workers that are in that setting get sick when they're healthy and otherwise kind of able-bodied when in other scenarios you don't see those same attack rates so that's the first point I want to make now the second point is what happens when a cell gets infected you correctly point out cells no viruses don't walk around in fact that's why isolation works they don't they don't cross highways or walk across the street they don't walk around your body either and so when a cell is infected that cell might lyse it might break and the stuff inside might come out where does it go goes to the immediate vicinity right goes right into that area now there is some aerosolization and things like that that we've we know and you make bio aerosols even when you speak and so it does actually make its way out into the environment through that mechanism but it itself is not moving it's hitching a ride on a little droplet of mucus and that's it's right that's its uber to get into your you know workspace yeah the idea of viral load I find really interesting in terms of trying to protect yourself so obviously being outside if if you have to come into contact with somebody for whatever reason being outside is going to be obviously much better and then also my understanding is that you have like a band of humidity which is problematic for the virus so if it's too low the virus thrives if it's too high I've heard that it thrives but somewhere in like the 40 to 50% range am I getting that roughly right that it struggles yeah a lot of the humidity studies and data we have are actually not even on star scope do we have some but a lot of it is based on other cousin viruses like MERS and stars from back in 2002 so we're extrapolating and saying hey you know this is another corona virus I'm sure it behaves similarly and so when we look at temperature humidity data much of it is from other virus in the same corona Barton's family you're right you know there are two silver linings around this virus one it's not that Hardy so it's it's in this fat bubble and it's got a little RNA in it and that fat bubble essentially you get a bit of a cocoon when you have a bit of I call it spittle but essentially the little bits of stuff that come out of my nose and mouth every time I spit that I can't even see technically they're called bio aerosols those land somewhere sometimes they float in the air and when they land or they're floating they're evaporating right so in every moment they're slowly evaporating in that surface to volume ratios is making it more and more likely to evaporate over time and remember that's the ride it's hitching so the more devourer hits the more that's kind of being smaller and smaller and therefore it's you know less prone to just falling on the ground and so then it really just diffuses in the air so let's talk about this as an outbreak so you were working at the CDC looking at literally what we're living through now one give me some context where do you see this going what kind of drop-off should we expect I've seen that some of the numbers are beginning to trail off in the US are we on the decline now are we not and then the thing I care most about is is this coming back in the fall right so let's go through those in order I think things are getting better in most parts of the country I think things are getting worse in some parts of the country I think things we're getting better in might get worse in some areas let me give you a concrete example Southern California things were doing pretty well and then everyone hits the beach this past weekend so much so that governor Newsom just said you know what closing the Orange County beaches now what we're possibly gonna see in ten days is all those people that were beach goers are gonna go home they're gonna have more disease overall than they did previously they're gonna spend time with their elderly parents their elderly in-laws those folks are gonna get sick maybe that'll be eight days from now and then those folks are gonna get really sick sick enough to go to the ER 18 to 21 days from now so maybe in three weeks we'll see a little uptick and we'll all scratch our heads think what what is this what happened it's from that Beach incident three weeks ago guys that's why you're seeing this now so we're gonna see blips and this is the challenge is that the cases that come into the hospital are a lagging indicator of what's actually happening an example is when you look out at the starry sky you see light on your iris right but that star may be gone you know it takes billions of years for that light to hit you so you're getting a lagging indicator of the reality of your solar system and in outer space cases in the hospital are a lagging indicator of reality and when you don't have accurate testing on the ground which we don't then all you really have to go on is cases and that leaves you blind for a few weeks as to the reality of what's happening so that's my sense on what our country is experiencing now all the models are based on continued social this thing that's falling apart right now state-by-state we're seeing people lift barriers and saying hey it's okay to do you know let's say outdoors activities or okay golf's courses are open now because they're outdoors you know yard works okay landscaping that industry is okay constructions okay as you start opening up industries you're gonna start seeing more and more chance of this sort of uptick now my hope is that we'll see a little uptick which I imagine will prolly see maybe regionally maybe even nationally but that what happens afterwards is the key are we going to close down again or are we gonna say well let's let it ride because when you let it ride you let it ride for three more weeks now you've got six weeks because it took three weeks to get that data and then you didn't do anything about it so now you got a few more weeks to let it ride and so we'll see what happens but whatever we do is is really it's a delayed effect and so if we see a surge it's because we don't have actual on the ground reconnaissance we're going by this really old three-week old data and we keep making mistakes and fumbling our way through so that's my challenge or that's the challenge that I see are we gonna see an uptick in fall there's a good chance because I think what will happen is we're gonna keep making these little fumbles along the way we're like open no close open no close and we're not actually closing it down for a significant period of time to really shut it down and at the same time we're just now getting contact tracing up and going we're just now getting testing to the levels where we needed to be meaning our average number of tests per day in the US and if you've seen it but it's about 200,000 where was it the first week of April 150 so gosh in the whole month of April we bumped it from 150 to 200 we need to get to 800 that's the goal what are we doing we're slow walking to the solution we're not running to a solution now what I want to know I don't even think about colds and flus say May through September right I don't even think about it the odds like I wash my hands like a psychopath from October through April normally just cuz I hate getting sick so much I can't even tell you but like I'm already a psycho and as a psycho I always let my guard down in the summer months so why is this one so virulent that we still have to be on guard even now as we approach may like it is hot as hell here in SoCal right now I'm just shocked that we that this one sort of defies the normal pattern yes I'll take a word you just said virulent and and hone in on it so there's contagiousness and there's virulence so there are some things that are super virulent let's say Ebola it's not that contagious what you're worried about is contagiousness why is it that people are getting it so much even in the summer months and what I think the answer is gonna be is that there's just so much disease out there and it's pretty darn good at getting across so that could be one because the viral load you generate is huge so maybe it's replicating like mad and so when you do COFF it's not just a little bit like 10 to the 6 maybe it's 10 to the 7 like who knows what the exact inoculum is that you're putting out there it could be effective at actually living in the environment maybe it's just a little bit more Hardy than I'm giving it credit for or maybe it lands on larger bio aerosols so it has a little bit more time before they dry up completely it could be that it's actually really darn good and this is actually where I'm putting my bet at getting attached to that ace to receptor in the cell that's the name of the receptor we have ace 2 receptors on different cells in our body maybe it doesn't need too many of those receptors to get an infection to go across maybe other viruses need maybe more kind of hits to hit that receptor and tag it this one just sticks like a like a lock and a key there's a really really nice fit and so it could be a number of those factors whatever it is I think you're right that in the summer months it's getting warmer warmer we're still seeing it we saw outbreaks in Singapore Singapore is you know along that tropical belt in many countries only that tropical belt it's exploding in India right now so we're seeing it in places where it is fairly humid fairly hot and it's still kind of causing a lot of disease I think resting on this idea that it's gonna just dry up in the environment or that the humidity will kind of get it is probably not realistic I think what's much more realistic is thinking about it from a person-to-person standpoint rather than an environmental foam light to a person standpoint some of that's probably happening there's probably much more this person-to-person so as you think about like protecting yourself and your Emily like the more that we understand what the virus is doing in fact I'd love to hear more about the ACE to receptor how that works and how that influences how you think about keeping yourself safe sure it's a couple of concrete things that I do so I try and I'm not perfect at this and I don't expect anyone to be but I try to batch my grocery shopping I try to batch my errands and say let me do one errand and hit up a few different spots and so I don't have to keep going back out again every time I leave the house that's a chance especially if I'm going to an enclosed space where there's not as much ventilation when you're outdoors I'm going to the park that's a different ball of wax and if I'm going to a store where the ventilation even though they of course have HVAC systems they're not ventilating nearly as well and effectively as an outdoors area with a breeze so it's all about dilution if you can dilute the virus whether you do that with water when you're washing your Apple whether you're doing that with air as you're going through an outdoor space whether you're rolling the windows down and uber if you're in an uber anything you're doing to dilute is stacking the deck in your favor that's the first thing minimizing the trips at tyrunt's locations high risk is anything that's enclosed so again like minimizing batching your trips that's the second the third thing is when you're in your home cohorting yourself to your home so it's just me my wife my son my dog right like that's our cohort we stay together and we don't you know our son isn't going off anywhere else we're staying as a unit and so that's the best you can do is kind of keep your unit safe if you guys get sick likely it's everyone in the house that's going to get sick so protect everyone and make sure everyone's making the same smart choices you're making you know masks and coverings there's a lot of data now on the fact that they're probably helpful and probably need to be mandated frankly especially indoor settings so that's another thing that people can do is just cover their mouth it protects the source so you're not spitting it out even if you're talking as I said you can get it out there it also protects you from inhaling it and there are maths that you can make at home that have pretty good effectiveness at getting viruses screened out believe it or not so we can talk about that as well and the one I'll just give you the answer there is polyester seen is pretty effective with kitchen inside that's a good strategy those are some concrete steps you can take to minimize your chances of getting sick so talk to me more about the ACE 2 receptor so what's going on there or why is your money on that yeah so when you look at the ACE to receptor it's a receptor that sits on the airways and we know that that's where the spike protein you alluded to it it's called coronavirus because it looks like it has a crown under our microscope and corona means crown so it looks like it's wearing a little crown well that crown is studded with little proteins those proteins that are studded in its crown are spike proteins so those are the proteins it's using to attach what is it attached to attaches to a receptor we call it the h2 receptor that receptor it's lining many cells it's lining the cells with Airways but also it's loaded in the blood vessel cells so those cells have a lot of h2 and as we're seeing more and more disease in the blood vessels one hypothesis is that that's how it's causing the disease you know we know it binds to h2 already no cells have it logical conclusion is probably what's happening and so my money is on that's where it's binding and that's why it causes a lot of disease now there are some ideas like what if you for example inject someone with soluble ace 2 you know where it's kind of free-floating that ace 2 could bind up the spike protein and and therefore the spike protein can't bind to your ace 2 as it's already bound to this soluble used to so there are ideas out there and these are more than just ideas these are actually some of these are in randomized controlled trials where they're trying to see if this is a strategy to try to minimize the infectivity of the virus so this is out there this is why I'm betting on it that's really interesting so talk to me about the comorbidities I know that everybody's on diabetes is wildly problematic and if you have underlying diabetes you were in real trouble if you get Koba 19 but I was talking to another researcher and they said that nothing had been officially done around obesity have they since then that was a few weeks ago it's a good question you know in the data that I've looked at they have talked about obesity is a risk factor but I can't say with confidence that I've actually reviewed the obesity substrata of patients and whether that was not confounded by other factors but you're right you know diabetes specifically unmanaged diabetes you know where you have a1 seeds that are really high you know that's where the risk is highest all these conditions or conditions that essentially plague America obesity diabetes and ones we haven't talked about you know coronary artery disease lung disease asthma and these are all problems that many Americans have and carry with them I think there are a couple of things to notice here one it's it's about function right so if you have let's say this is how I explained it to my to my son if you have function that's like this and you take a hit you're down to here maybe that's fine maybe you can kind of go on with your day doing your notice it but if your function is already like this and then you go down this you feel that you'll be short of breath you'll be really tired and you'll be admitted to the hospital that's one factor the other factor is the fact that not only are you just losing function but maybe you're actually hitting the same target so we know it's cardiovascular disease what's damage there the intimal lining of the blood vessels that's fancy talk for the inner lining of that of that vessel wall that's what's damaged what that that's really interesting I want to stop you there to make sure that I understand this because now pieces just click together from what you started so originally what I was hearing was part of the reason that diabetes was creating such a problem is you've got high h a1c levels the hemoglobin is getting all clumped up with the sugar and the bloodstream is making oxygen transport very difficult so you've got a disease that's already exacerbating or lowering your ability to get the oxygen coupled with another comorbidity that does the same thing and now you have this double whammy and you've got a real problem which explains why intubating people with the ventilators is working it's not a mechanical problem this is a in the bloodstream you're just not able to shuttle the oxygen properly when I think about heart disease and again I could not be more of a novice but when I think about heart disease and the way that it attacks the lining and I think what a lot of people misunderstand and correct me if I'm explaining this improperly is that when you get plaque buildup it's not like it's clumping together inside the normal transit part of the blood vessel it's actually in the lining of the blood vessel and so it creates like this bulge and so if that's a like inflammation issue with the epithelial lining I'm not mistaken and this is further inflaming that area then this makes sense as to why this would exacerbate the problem and just from the little bit that I know about the sort of physiological impact of obesity fat is a signaling organ which is crazy to think about but that is pro-inflammatory so if you you have all these crazy inflammatory markers and then that leads into the cytokine storm it's sort of all starting to make sense yeah that's that's exactly right you're right in describing it it's it's causing a bulge and it's in some cases obviously you'd have some breakage there in that lining or the covering of that bulge but the fact is you're right it's in the walls and it causes that thing to bulge out and when it bulges out if you damage the thing that's lining it then yeah now you've got all this fatty gooey mess that's gonna cause lots of inflammation and can cause heart attacks or strokes and things like that because that starts to break apart and create essentially a blood clot right there that's how strokes happen now in heart attacks now with Koba 19:00 you talked about the phrase cytokine storm and it's out there people talk about it there is a lot of increasing evidence that that's exactly right and it's specifically there's one called il-6 interviewed is what right for people exactly what a cytokine is it's because once I understand what it does I was like okay I get why this is a problem yeah totally let's say that I'm in a room full of other people and I'm a cell and I've got to communicate things to the people around me well I can't just like speak and is cells don't have voices they don't have you know the ability to just talk through words so they talked through molecules and these molecules they're not words they're cytokines and so cytokines and which cytokines you put together and the the number of cytokines I'll tell a story so if I'm screaming in other words if I'm letting out a lot of il-6 I'm telling a story to all the cells around me that like hey I'm dying I'm going down here and things aren't going well for me are they going well for you and and if all the cells are screaming and they're all letting out il-6 well now you can detect that in the blood and you can check someone's il-6 of it I call my god this is high the cells are screaming they're endangered and this isn't going well and so that's what it's icon is it's it's basically a way of a one-celled talking to its neighbors it's its words and we can detect them and we can put together a story based on what we think aisle 6 means in the context of the other words and that one I'm talking about a lot because we know that for example kids are doing better than the elderly with Kobe 19 and if you look at their cytokine profiles you see why they have lower levels of a lot of these cytokines specifically aisle 6 but also some other ones that may tell you that actually kids with a RDS are doing better because of these profiles looking better and maybe that cytokine storm is a warning from the cells that hey the ship is going down here correct me if this is inaccurate so to sort of use your analogy of the screaming that the cytokines are basically screaming saying or the words that they represent our dear immune system come and address this attack this thing I'm going down you need to get this thing and so the reason that the cytokine storm becomes a problem is you have every cell screaming out immune system come and like attack this and so now the immune system is going bananas and you actually get the immune system just attacking everything because it's on such high alert it's like shooting first and asking questions later and so the the body has essentially it's got this military that's now shooting everything in its sight and diving into sort of at a cellular level what's happening if your body is already you have diabetes you are obese you already have all this inflammation you already have cytokines saying yo we have a problem and now you throw this other thing in if you have a high viral load and just literally every cell is crying out that it has a problem you get how the immune system becomes trigger-happy and and just goes bananas exactly and by the way the immune system is also part of the problem right it's releasing some il-62 but what the immune system tries to do is say like hey we need to make the blood vessels here a little leaky so that our immune cells can get in and and deal with whatever the problem is whoa whoa I've never heard that before what do you mean leaky so when a blood vessel is passing by an airway normally it's not leaky meaning liquid can't get out of that blood vessel so it's nice and tight between cells lining that wall well when you have inflammation just think of when you've fallen and banged your knee you have inflammation there but get the puffy right immediately it kind of swells up what is swelling exactly well it's leakage of liquid out of the blood vessels and into the tissues oh so endothelial cells instead of being nice and tight like I'm showing you right here they become more like that and as a result stuff is getting through well some of the stuff is good right it's immune cells getting through that's great good job good on you for sending out the mean cells but it's also fluid and so that's what happens when you're banging your knee or banging anything it's kind of swollen and puffy that's fluid getting through right so your blood has things other than blood cells and white blood cells it also has serum right so the serum component has a lot of proteins so that's antibodies that's a big part of it and those antibodies are gonna be necessary to be part of this immune response so you want these proteins to get over there you also have albumin and other proteins too so they're getting across albumin either cost but the other cooking is due and the reason that this is important is that if you now have leakiness not just in one area but in all areas because you again you're screaming all over the body and you know the immune systems kind of like going bang bang bang all right we have to respond everywhere well what happens when you get it kind of diffuse leakiness well now you've got a lot of wetness you've got a lot of extra fluid that's sitting between the air space over here and the blood vessel before the blood vessel interspace are nice and tight now you're filling up with fluid because again the leaky right if who's got to go somewhere it's going in between and now you're asking oxygen to get all the way from here to here and it's got a lake to swim through now that it never used to have to swim through right what do you think that happens a lot less oxygen gets across and so you become hypoxic and so that hypoxemia that we're talking about you know with with this and the shortness of breath you get so that's in part due to this massive Lake you've created and you're creating it not just in one part of the lungs it's all over and so you've got all this fluid now that's preventing oxygen from getting to where it needs to go which is the blood vessels and that's a big part of what happens with with search or when you get a systemic inflammatory response syndrome and that's what happens is a or TS and diffused inflammation causes fluid to get everywhere in fact it also gets in your tissues it's a lot of these patients end up being super puffy but they just got fluid everywhere there's fluid on-boarded and their kidneys can't push it out because also autonomic kidneys are failing so you end up getting into a very positive fluid balance as a result and that's what happens not just in this disease but in a lot of diseases where the end state is this massive inflammatory State some ants oh my god very much so really being able to grasp what's going on is super powerful and I guess I'm now talking to the audience like this stuff begins to staff like since I started doing health theory it's like you know one person will say one thing and you kind of hold on to but you don't really understand like where that goes and then another person says something and you just begin to like put all of this stuff together to I guess get a deeper understanding of why it's so important to take care of your health and when I can imagine something when I can picture the state of my blood vessels like it actually gives me more motivation to do things I don't necessarily want to do I want to eat ice cream and play video games all day that's what I want to do but you know I work out I eat right and all that stuff and it it really really helps like to actually piece these things together speaking of the pieces that are coming together you mentioned serum and I want to talk about passive immunity what we're finding with blood plasma like what's the the state of that yeah great great question and thanks for breaking it down like that for audience I feel the same way that when I understand something I care about it if I don't understand it I don't care and if I care about it I'm much more inclined to do something about it because care includes motivation as far as serum goes in plasma let's be really clear we've done this man times before this is not new in fact for many viruses let's take a very classic virus measles you can today you can go in if you're a high-risk patient and if you in the setting of an outbreak of measles you would be given measles antibody that's a thing in fact if you have other conditions you might have heard of the phrase IVIG what is that that's intravenous in the vein AG in the globulin so this is extremely common and the new thing is we're trying with Cova 19 because we're saying hey we tried with all these other diseases maybe it works here too of course it works it makes sense it's logical what it is is let's say between you and I let's say that I get co19 and I do fairly well and I recover and in the weeks afterwards you check my blood and of course as you would predict I got an immune response and I have an antibody floating around I have a lot of it so you basically take that antibody and you purify it and then let's say you get co19 and unfortunately you don't do so well for whatever reason you end up in the hospital and you go to ICU and you're sick and you're on other medications you're on antivirals you know steroids and they're like yeah you know we don't know how he's gonna do we really hope for the best but who knows in that situation they would give you my antibody as long as other things are cleaned up about it and you wouldn't have a reaction they would give it to you and what we've seen is that generally speaking when it's done it works it seems to you know make people better now here's the catch I purposely mentioned you're on steroids and you're on antivirals well what made you better was it the passive immunity was it the other stuff you're on was it the fact that time pass your immune system kicked in who knows and the question is not does it work but how much does this work is this moving the needle a lot or is it like yeah it's good but you know that's not really what made him better so that's what we're trying to figure out is how much of a benefit you really get from this and in the coming days and weeks of course we're gonna start seeing plasma drives where you know you say hey you know if you've recovered go donate blood but also donate plasma to help those that are sicker than you this is a national effort this is gonna happen and so it's just a matter of kind of figuring out what levels we accept what levels we think are safe etc etc let me ask the obvious question how on earth would that not be a hundred percent effective yeah great question so the first thing is that I'm giving you an antibody but antibodies are proteins and proteins break down so it's a little bit like I'm giving you fish I didn't give you a fisherman so I didn't teach your cells how to make the antibody only only a vaccine can do that I just gave you that fish and that will turnover over time it'll degrade in fact in some cases a quick example of this is that many cases where you do need IVIG infusions what's the frequency of those infusions monthly so you might need a monthly infusion of ibhe well why because it breaks down and so the question is how do you respond with your immune system well a crash course in immunology here goes is you have your innate immunity we talked a little bit about that mucus you've got some cells that's all part of your innate immunity then you've got your adaptive immunity which is really characterized by a kind of two big categories of cells there's a third but mostly it's your B cells and your T cells those two categories of cells are doing different things they work together and so you want to be able to for example track down infected cells and destroy them this antibody do that it helps that's not the actual cell destroying the other cell so there are other parts of immune system that you need to fight this effectively an antibody helps a little bit you know it's like bringing the violins to the game you still need the whole Orchestra to make this sound right and that's just a part of it not all of it so yeah it helps it doesn't cure the infection completely you know I actually have a question I can't believe I've never asked anybody this why are vaccines so hard to create like if if you know this is one of the main strands of this virus slap it around or whatever people do to weaken it and inject it and obviously there's a reason that this it's hard so I'm not saying that like I've solved something I'm just curious what what is it that makes it hard yeah so it's I wouldn't say it's hard it's just time consuming so there's preclinical trials that's where you weaken the virus or do whatever you're gonna do to kind of figure this out that happens and happened on a course of a few weeks of FERC over 19 so vaccine manufacturers got their act together they worked hard on this because everyone obviously sees the need and over the of weeks let's say six to eight weeks for some of them they got the vaccine ready for phase one amazing that's pretty fast phase one is a safety study is it safe okay that makes sense that happens over a few weeks phase 2 is immunogenicity so if I give you the vaccine why don't I measure some stuff to see if did you mount an immune response I can they measure your antibody levels maybe I can look and see if your T cells are responding I can do these things to see if there was any sort of effect those things all happen relatively quickly now here's the kicker phase 3 phase 3 of these trials is where it takes forever and I'll tell you why basically what you're doing at that point is you're saying all right it's safe there's some sort of immune response does it work in a clinical trial setting and the key here is it's called vaccine efficacy not effectiveness efficacy so vaccine efficacy is in a controlled environment if I vaccinate a bunch of people and then I follow another group people that didn't get vaccine does the group that got back soon have a lower rate of disease well how are you gonna know that well you're gonna know if they catch the disease at a lower rate well if we're all isolating we're all kind of trying to keep ourselves protected and cocooned you're not gonna really see a difference in these two groups right it's gonna take a while to see a difference and so these trials can last like 12 months 18 months to really see a difference in efficacy between these two populations right that's statistically significant and it's a large group of people you got to get even do it to notice that tiny difference right so that's the phase three trial it takes forever phase 4 is vaccine effectiveness now you launch it in your country or your kingdom or whatever it is that you have and you say in real life are we seeing that and what is in real life people can get the vaccine because it's only given in one city and the people in the rural areas oh I couldn't get vaccinated I didn't you know I didn't decide to do it or you have people saying I don't want to get vaccinated I don't trust it it might have something in it that's dangerous or you have people say I can't give the vaccine here at my clinic we don't have a fridge and you told me it has to be within this certain temperature and we we just have power out so you know the vaccine went bad all sorts of logistical and practical and social issues that prevent you from getting the same effects that you got in the bactine efficacy trial we're literally population is not benefiting at all maybe even though technically they could that's the effectiveness see now here's the kicker have you heard of human challenge studies or is this something you're familiar with I have because I cheated and I've obviously done a lot of research yeah for this episode but please tell people what it is yeah I mean basically it's it's giving a person the virus and on the face of that sounds super unethical you're giving people the virus this this thing that we're all told to to wash our hands and wash your apples over it now you're doing it to people how could that be okay and I'm not here suggesting that it is okay all I'm going to tell you is that this is a thing the WHI is a whole written piece about it they do that it has been done and the idea is that there are ways to mitigate the risk you take low risk individuals that otherwise had a good chance of getting the natural virus you know from their community and then you make sure they get the best monitoring in the best care and that's your way of essentially saying all right this is our way of minimizing the harm and if you can get a handful of people that you can literally just let's say you spray them in the face like a clone bottle with the virus let it get into their eyes nose mouth you can a figure out what dose thing they need to even get sick so now we finally know the viral dose or not get what you need which right now we're sort of conjecturing about but then you would know and then you could say okay well given that dose the people I got vaccinated actually did quite well and the people that didn't didn't and so we think that this was very protective and you can do it in this small cohort of people because you're actually giving the virus rather than just like sitting back and waiting for things to naturally happen and that condenses the timeline and that's what the whole ethical argument is about is is a week saved on the vaccine trial presuming that it's a successful one you get the bactine out to people is that justifiably okay for then turning around doing something like giving people the real virus is that trade-off acceptable and people can debate that and should debate that but that's what human xiaolin studies are yeah talk to me a little bit about vitamin D how important is it if I'm not mistaken there's actually levels certainly that are too low to provide any real benefit but there's also levels that are too high which I had never heard that before yeah it's a good question so the there is like most things the more you dig the more the controversy there is vitamin D is no different so there is some controversy around it what I'll say is that the endocrine society put out levels that I personally think make the most sense they suggested something like 75 animals per liter as a target that's 75 animals per liter target in my personal opinion might even be a little higher it might be okay you know maybe a hundred or so so when you get up to those levels what they've said in the endocrine papers at least is that it really promotes bone health it promotes protection against viruses is one thing and in factions in general so a number of kind of categories of disease but among them was you just had me say Restaurant viruses and so another study said hey if you give people vitamin D do they get less restaurant virus illnesses and the answer was emphatically yes and in fact that was mostly people that were very vitamin D deficient so they said if you were less than 25 nanomoles per liter which is pretty low and then you've got a daily dose in that study they said you know about 5,000 per week then you stand to benefit them most in terms of having a reduction in the number of arrest rate illnesses you got that was a recommendation The Endocrine Society said well let's zoom out not just a restaurant veterans but let's like a bone health and these other kind of factors and say maybe the target should be your target level the other one didn't have a target level but your target level may ought to be around 75 and to get there you might need 2,000 units per day if an adult that was their recommendation the only reason I'm suggesting that maybe even a little bit higher might be okay is there were studies done looking at folks like lifeguards in the Midwest and folks living in Hawaii and East African tribes that that essentially are out in the Sun more and in those groups of three different groups the levels were much higher above 100 and so the question is perhaps a normal level for a human being is above 100 and not sure how much higher but let's say a hundred at least and perhaps the reason all of us are essentially much lower or many of us is because we're indoors were wearing a lot of clothes were hunkered behind your laptops like you and I are right now and this is our kind of new lifestyle right like even when we go out to to work out many of us go to the gym which is covered and you know you're not really getting the sunlight that human beings were it essentially evolved to develop and kind of live with and so we're all essentially pretty deficient and that may be in the absence of that we do need supplements to get us back to a normal healthy level to boost our immune health among other things and from the reading I've done it definitely seems beneficial to get more sunlight for most of us and there are certain groups that are high-risk so for example if your darker skin tone like no I'm darker than you for example if I'm out there and you're out there you're benefiting more than I am and so I'm at higher risk of developing deficiencies and we see this in terms of like the latitude bands as well so probably in certain groups there should be monitoring or routine surveillance of vitamin D levels the other thing is testing itself is not great so sometimes you can take the same sample of blood test at five different ways and maybe get kind of scattershot results and so that is a separate problem of you know testing reliability but on the vitamin D point I think generally what most people agree on is there is value to getting more Sun lights from the Sun there's more value I mean also psychological benefits as well which we need to talk about but there's also value of probably taking supplements if you're not able to do that and most people are probably deficient yeah vitamin D is is implicated in a lot of things that definitely seems like one that people should really be going out of their way it's my understanding though that if you're over whether you're supplementing or getting into the Sun it's my understanding at some point your body begins to break it down I don't think your body would let you go quote-unquote too high is that not true so the societies have put out thresholds and they say you know you should probably be careful of vitamin D toxicity above a certain level but like most things if we can chemically reduce it to a pill and if you let's say take 50 of those pills on a day probably you can overdose on vitamin D in a way that could potentially hurt you that there's probably clear evidence of that having said that I think that the pendulum clearly is swung in the area of deficiency not overdoses at the moment and so I think that doing it in a smart and kind of a stable way over time makes a lot of sense and that we probably should be advocating for more vitamin D for people in general Rishi where can people connect with you man you putting out so much rad information what is the best place to connect well thank you I love the word rad so it's nice to hear it I will say that you know we're we're basically putting out over 19 content on osmosis todrick sashko 19 so that's all free we even have CME courses for those of your audience members that need tme it's a free course so go check it out basically yeah yeah exactly so that's the acronym there and it's um you know it's aimed at health professionals but honestly it's I think it's just aimed at anybody that's motivated and interested I can follow it and so yeah go go check out that site again awesome so we're ecstatic over 19 - to get you know the latest information as we know it amazing well dude thank you so much one last question if you were gonna have people make a single change that you think will have the biggest impact on their health and preventing getting cope at 19 what change would you have them make you know I just did a video today about climate change and it's about climate change in Kobe 19 and I do think that we're very focused on Kobe 19 rightly so I think that when you're thinking about things that feel like future threats like climate change that feels a little bit more ffice as a human brain goes I think we have a hard time wrapping ourselves around that and for a climate change and for health and for a number of other reasons I personally would recommend going out and eating some vegetables today and I can't think of anything that's more important than the fiber you get the nutrients you get the the sense of fulfillment from healthy proteins you get from eating vegetables so that's what that's what I would recommend all right well thank you so much man and again guys the content that he's putting out truly is rad you will enjoy it he is putting out a lot there is a ton of content osmosis is putting out a lot of free stuff that's really amazing I encourage you guys to check it out if you haven't already speaking of things that if you haven't done you should do if you haven't already be sure to subscribe and until next time my friends be legendary take care everyone I want to tell you all about our sponsor whoop life can be stressful we're all impacted by stress differently though from what we do at work how we train and our lives at home work constantly exerting ourselves and oftentimes we only think about what we do to stay fit and how we eat but we overlook the importance of sleep in all of this tomorrow's best work though is done by night and our sponsor loop is a fitness tracker strap with an incredible app that helps monitor your sleep who provides the personalized insights to make smarter performance habits from your sleep loop tracks all things sleep from your sleep cycles stages disturbances and 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