[Intro music] Skipper Chong Warson: Hi, my name is Skipper Chong Warson. I'm a design director in San Francisco, California. Welcome to the second season of How This Works. This is the show where I talk to people about topics that they know incredibly well. And to kick things off today, Dr. Peter Chin-Hong joins us again from UCSF to talk to us about his work as an infectious disease specialist and professor of medicine. We recorded this show in two parts and in places it's going to sound like that. Specifically, during this episode, we're going to talk about the coronavirus and COVID among other topics. Dr. Chin-Hong or PCH as you said last time you were on the show that your students call you -- thank you for making time. Dr. Peter Chin-Hong: My pleasure, Skipper, thanks for having me back on. Skipper: Yeah. So how have you been since we last talked, we last talked in December of 2020 -- how are you doing? Peter: Well, I'm still on the treadmill. And even though things are a little bit quieter now on the hospital side, I feel like after the last two years, I haven't recovered, sort of mentally and physically. I've started going back to the gym, I guess which is good. But my running tolerance is definitely at an all-time low just because I've just been tired and mentally tired. And I probably will need a few years to recover, to tell the truth. Skipper: Hmm. So -- are you, is that one of the things that you do for your aerobic activity, is run? Peter: Yes, I love running. In the old days, quote-unquote, meaning two or three years ago -- Skipper: Sure. Peter: I love going to different places whenever I visit and then running as a way to see the sights and not pretty much as running on the treadmill. Although, you know, I should try to sudden, or restart doing more outdoor running, I think it's just so good for the soul as well as for the body. Skipper: Yeah, running is one of the things that I do as well to kind of move my body in the world. And I think there's something wonderful about being able to sort of stretch and compete against yourself. Or maybe if you're running with someone or running with a group, there's something about that intersection of being outside, moving your body, but then also having all of this data and information coming at you in terms of the outside world, which I think is wonderful. Peter: Yes, it's definitely one way that you can soak in a lot of things that's going on around you, it's almost like you're in a movie in a certain way because you go from one scene to the other. And people's activities and lives play out around you, particularly if you have, you know, music going on, as well as the soundtrack to a movie. So it kind of goes multimodal in that way. Skipper: It's a good metaphor. Dr. Chin-Hong, let's get into the "this" part of the topic, right, we're meant to talk, I think a pretty good amount today around COVID. And lots has happened since 2020, right? Variants, vaccine boosters, and mask mandates being lifted, some are being put back into place in a few places -- but what's happening with COVID? Can you tell us what you're seeing? Peter: Yeah, so I think right now, in the big 30,000-foot view, what we're seeing is a decoupling as people say, so when you look at the community and the numbers, everybody gets frightened, because look, 200% increase in Washington DC, or 1,000% increase in Puerto Rico -- but the hospitals have remained pretty much intact. So that's very, very different from other stages where you see something in the community. And then two weeks later, you see everything in the hospital too. And that's really because of our immunity forcefield that we built up with successive waves of infection. And the other thing is, all of these waves currently that are happening. They're all flavors of Omicron. And from the body's perspective, it's the same thing, even though it's more transmissible. So I think, first of all, I'm very happy this is happening, because I think we want to protect ourselves so we can take care of people who don't have COVID. And also you don't just like to have a lot of sick people in the world in general. And then number two is I don't think this will necessarily be the case. If we get a new variant later on in the air like in the fall or winter -- I hope it is but we don't really know what to expect in the future. Skipper: Okay -- how is the, I mean, a lot of what we're seeing is the Omicron -- how is this variant that's more common these days? How is it different than previous variants? And I wonder about, one of the things that I've I've read is around some of the symptoms, like the loss of taste and smell don't seem to be as common. Peter: Yes, definitely. So I think that most commonly, people experience a scratchy throat, congestion, sneezing, sometimes sinus pain, and headache, almost very localized to the head and neck area rather than the whole body. Part of it is because of the nature of Omicron and the variant itself, which seems to produce a lot in the upper airways, but not in the meat of the lung because there's something about this variant that doesn't allow itself to enter the body through the lung, as opposed to other variants. And what it means is, in general, people have more cold-like symptoms and less whole body going into your lungs, causing you to have problems breathing. However, we've seen a ton of hospitalizations in January -- so because so many people were infected with Omicron. And beginning, even if a small proportion, go to the hospital. And you know, there are some numbers around that even like in, you know, I think it's something like you had a 5% chance of getting hospitalized overall if you had Delta, but maybe a 1% chance if you had Omicron. But since it's 1% of a large group of people, that still means that some people got sick. And when they got sick, it looks like the other variants, but for the vast majority of people got it -- the point is apart from vaccinations, we can predict with certainty who will get really, really sick and who wouldn't. I mean, there are some rules like older and 65, immune-compromised, et cetera. But for the most part, there are still a lot of those folks who didn't go to the hospital as well. Skipper: You said previously, something around future variants. And I think one of the lessons that I've learned over the last couple of years is that all viruses mutate, and COVID is no different in this way. And you know, Delta, Omicron -- so will the variants keep coming? Peter: That's a great question. I think the variants will continue as long as we have transmissions occurring. That's why, you know, pillar four, objective four of the Biden endemic plan talks about giving vaccines to the rest of the world -- and even though that's stalled in Congress, it is a really key point to prevent the creation of variance, which ultimately affects people living in the US. So it's not just about the US being generous to the world, which I completely endorse, it's also about protecting the US interests as well. So coming back to your question, yes, as long as they are transmissions and unprotected people in the US and around the world, they will continue to be variants unquestionably. And the reason why in COVID, there are variants is essentially when the virus SARS COVID 2 makes copies of itself, it's like you have a bad photocopy machine in the office, and it makes smudges and errors, and sometimes by chance, those bad copies evade the immune system. And that's what's happened with the successive variants. Skipper: I see. You said a word that I've I've heard a few times in various news reporting, this notion of an endemic versus a pandemic. I saw most recently there was a PBS clip where Dr. Anthony Fauci was speaking on this topic. Can you define those two terms, endemic and pandemic? And just tell us what they are? Peter: Yeah, so there are two things to think about to consider something an endemic, endemic just means that it's in the background and we accept it, we can deal with the amount of impact it has on society because we want to carry on with our regular lives. So the poster child for endemic of course that most people can get is influenza. So when once people can get that concept as influenza so influenza, we know when it comes it's the wintertime. We can prepare for it by getting vaccines and stocking up on drugs in case people get sick. We know what to expect because we saw what came the year before or in other people's wintertime, half a year ago. And we can expect that about 30,000 people will die in the United States every year from influenza, and society accepts that -- in a bad flu season and we have 60,000 people dying. So when you think about COVID, you know, we've had 60,000 more than 60,000 deaths in the country already and it's not even the end of the year. And so that's probably questionable, although it may get to that point if we continue to have low numbers like that -- like 300 a day instead of 3000. But the other point about endemicity is predictability. And the only thing predictable about COVID is that it's unpredictable. So we don't have that box checked off. So, you know, I can't really call it endemic. I think, Dr. Fauci revised his comments or focus on the transition to rather than the fact that we're in it or another state. And the road to endemicity is probably what we're on but we're not really at the destination yet. Skipper: I see. So it's transition transitioning to an endemic not arrived at an endemic. Peter: I guess it's probably easier to see what we're not in currently, and we're not in catastrophe. Skipper: Okay. Peter: And catastrophes when you don't have enough beds with people and not enough oxygen or ventilators. And you don't have options, folks before vaccines before drugs, before Paxlovid, before monoclonal antibodies. So we're not there but we're not in a flu, sort of predictable state, either. We may get there. But I'd love to see the rest of the year play out before making any pronouncements. Skipper: Got it, I had a question for you around many news outlets are still reporting on the number of cases. And I wondered, How accurate is this given that more and more home testing is available? Peter: Yeah, so that's a great question, Skipper. So it's not accurate at all. But what's accurate is people who are in the hospital with COVID. Much more accurate, of course, you can quibble about the exact number as well. But how do people deal with this uncertainty, well they can look at the shape of the graph, they can look for accelerations or decelerations, which will be similar, they can look at wastewater, which we started looking at, which by the way, is twice where it was in terms of the amount of COVID virus material compared to a month ago. So that's probably more unbiased but doesn't talk about in video lemurs, just a bunch of virus in poop, essentially. So you can just quantify it by amount. So all of those things make us think that we're -- and then anecdotally, you know, I'm sure you've heard multiple people with breakthrough COVID. Now, when previously, you didn't hear that much about other people you knew having had it. So all of that leads to the point that we do have a lot more COVID than we expect -- and what we expect from like just looking at the official numbers. Skipper: Yeah. Peter: And also people's testing behavior has changed. Some people are not even getting tested anymore. Skipper: Yeah. Peter: Because, you know, they're, they're worried what that might mean. Skipper: Yeah. I know there are people who aren't testing now, for whatever reason, even if they did before. Dr. Chin-Hong, let me ask you something. I've heard this idea from some people that you can't get COVID twice, or you can't get it if you have the vaccine, or if you have the vaccine plus booster. Can you break this apart for me? Is this true? This is false? Peter: Yes. So reinfections are definitely becoming more of a thing. In the old days before Omicron, you had COVID once -- naturally, it'd be very rare to get it although there was older data showing that if you got vaccinated, you decrease your risk by half of getting reinfection. In the new era of Omicron, the virus is mutating very, very quickly, but staying with the same sort of like Omicron structure, but the outside is looking very different to the body. So like with the case of B four and B five, we're finding more and more reinfections of people overall. But it's still, you know, not as likely to get reinfected very soon after either a vaccine or natural infection even in Omicron. And soon after means, I think you probably have a grace period -- maybe of two months. If there's another wave after two months, given the fact that the spike proteins are looking so different to the body. It doesn't guarantee that you won't get reinfected. In fact, some people now believe that if the vaccines don't change, we probably should be getting used to the idea of having three to four infections every year, like a cold, although with vaccines, you're not going to go to the hospital, get really ill, and you're not going to die. Skipper: So when you say the COVID vaccine needs to change, I think what you mean is similar to how the flu vaccine, for instance, gets reformulated every year? Peter: Yes. So the vaccine needs to be updated because vaccines, the old formula based on the original variant from Wuhan, but Omicron spike proteins look so different, that the front guards, which are the antibodies have a harder time recognizing it, and you need a lot more guards, which is why the guards decline over time, for the new version of variants. In the updated vaccine, they may take something more recent and included almost how we do it, flu vaccines, as a cocktail of different variants, doesn't predict what the future variants look like but at least it predicted, you know, the recent more, you know, breakthrough kinds of variants, which the vaccine isn't as great at stopping at the front gate, but they're certainly good at kicking the enemy out once it gets inside of the body. Skipper: Sure. And this might be on the same line of thought. I know, you look at the numbers, a lot of people have been vaccinated. Maybe they have the booster, maybe they don't. But if someone has tested positive for COVID, should they still get the next thing? Should they still get the booster? Should they still get the thing that they haven't gotten yet. Peter: So it depends on who that person is, how fast they should run out and get the booster after natural infection. Skipper: Okay. Peter: If they're older, like say older than 65, they're immune-compromised -- and maybe if they have other co-morbidities, but not older, they should probably get it sooner rather than later. But they don't have to get it immediately. And the reason why is because everybody probably sees a different virus load when they get a natural infection. And the vaccine is very standardized. So I know what response you're gonna get. Some people might have no symptoms, a lot of symptoms, a little bit of symptoms, they may have different inoculants. It's like getting a vaccine with different doses, whereas I know what I'm giving you with the regular vaccine versus relying on natural infection. So the older you are, the more I'd want to make sure I'm giving you the right thing. And that's why those people should prioritize -- for most people, though, getting a natural infection almost is like getting a booster. So that's the way to think about it. But again, people have also used the booster for strategic reasons to top off antibodies, even though they know they're not going to get really ill. So if you're preparing a trip abroad, or a big event, or sleep kids going to summer camp, I mean, those are reasons to strategically top off your antibodies to give you the best chance of protecting against break-through infection, even though you won't get seriously ill with what do you currently have. Skipper: Gotcha. I heard something that I'd like to run past you. And this is an account from a nearby elementary school. So a child had a cold, a young child had a cold and colder all over the place in schools, especially in the lower grades. And the parents tested their child and tested themselves for COVID for five days. And the results were negative, negative, negative, etc. for five days. And then on day six, the child tests positive. And the school, the school nurse, reported it to the county and the county's response was, Yes, we're beginning to see cases like this. Not statistically alarming. But we are beginning to see cases like this. Can you tell me what's happening here? Peter: No, I've definitely heard cases like that as well. I think for most people, what's happening is that if you've been vaccinated, you already have your immune system on the alert for any enemies. So even my little bit of enemy makes the immune system react and try to kick it out of the house even though it's getting into the front gate, which is breakthrough infection. Skipper: Okay. Peter: So that process of being activated, makes you feel ill before you actually turn positive on the test, because there's not enough time to make that viral load high enough to be detected on the test. Skipper: Okay. Peter: In the old days, when people didn't have any vaccines, you have to wait for enough virus to get into your body to turn positive. But that also takes a while for the immune system to get and have the quantity to make you feel sick too so it was more in sync. But now people are feeling sicker before the virus actually gets high enough in quantity to be detected by the test. So that's generally what's going on the bottom line is, I think we're actually missing people who thought they had colds because they checked and they were negative. And then they ended up having COVID. But maybe they didn't even know it. Because nobody continues to check all the time. Skipper: Yeah. Peter: But some people do. And that's the reason why, if you're really wanting to know, PCR is probably the way to go. For example, say you're living with an immune-compromised person, elderly parents, or grandparents, you might want to make sure that that cold that you have is not COVID. But for everybody else, it probably doesn't matter as much. Skipper: And talking about testing, can you tell us what's happening in an at-home test versus PCR test, and then talk about the efficacy in both of these constructs? Peter: Yeah, so in general, the PCR is better for diagnosing you because it's more sensitive. Skipper: Okay. Peter: But the PCR test is crummy at telling you if you're still infectious at the end of illness. In other words, to diagnose myself with COVID, I'd probably want a PCR test if I could or repeat the rapid tests multiple times if it was at first negative. But to exit isolation, or to give me information as to whether or not I'm still infectious, a PCR test is not as good because it's so sensitive, it picks up often dead pieces of genetic material that's not alive. So it may give you the wrong idea that you're still infectious when you're not actually infectious at that point. So but an overall PCR test is very sensitive, is just, you know, more expensive and more laborious, harder to get access to because you have to go out to a testing site to get it. But again, it still has a lot of value. In today's world, it also for some people can give you information about viral load, which the regular at-home antigen tests don't do. So, you know, we can get a give you a lot of information in the hospital, from PCR test. And we can do genetic sequencing at a population level to figure out variants, but you can't do all those things with an at-home test, but that at-home test isn't convenient. And it's better to get tested in general than to not get tested at all. Skipper: Sure. And there's also a timeframe right, the at-home test, you can get have results in 15 to 30 minutes, the going out to, you know, a clinic or you know, drugstore, whatever it is, that's going to take a couple of days maybe. Peter: And depending on the vendor, but some vendors, they've been trying to get it done faster, but it's not 15 minutes, that's for sure. Skipper: For sure. Peter: There are new things on the horizon that I'm really excited about but they haven't reached primetime yet, but like the breathalyzer, for COVID, you know, rapid screenings for large events. But at home PCR is also a thing that two companies at least now making that kind of molecular test, but they're kind of expensive right now. Skipper: And what do these tests check for? The PCR test, as you said, tests, pieces of the virus, and those can be dead or alive. And the at-home tests, what are they look for exactly? Peter: Yeah, so the at-home test checks for big pieces chunks of protein. Skipper: Okay. Peter: So to give you some idea, you probably need 10s of 1000s of virus to be present for at-home antigen tests to turn positive. Whereas you probably just need a couple of viruses to be present for PCR to be positive, because it amplifies the genetic material. So the way I think about it is you're in a field and you're in a hot air balloon looking down the field. And if you're a PCR looking for virus, even if the virus is a deflated balloon, you'd find it. But if you're an antigen test looking down, it has to be like a big balloon up helium balloon for you to find it. Skipper: I see. So it's a matter of scale. That's a really great visual. Thank you for that. Understanding that there's so much more detail that we could get into, is there anything else that you want to talk about in the realm of COVID and what's happening right now? Peter: Yeah, so I think a lot of people are probably swimming in alphabet or alphanumeric soup right now, because these are all flavors of Omicron so I think the latest thing is, you know, sure, we heard about BA.1, which is the original Omicron. In January, then there was BA.2, which everybody got worried about, because it came, and started rearing its ugly head in Europe, Denmark, the UK, etc. And then now there's BA2.12.1, which is this sub-lineage that started off in New York. And some people think that it probably might be more in the Bay Area. That's why the Bay Area actually has the highest number of cases per 100,000 in the state right now, for a variety of reasons. But maybe because there's more of that sub-lineage here. Now we hear about XE, which we don't have a lot of in the US, which is kind of the spawn of Omicron and Delta, who can then we most recently heard about BA.4 and BA.5 in South Africa, fueling another surge, but with every surge, what's been interesting with these Omicron flavors is that the hospitals have been okay. So that's the reassuring thing. But COVID, even though you don't land in the hospital, it's not a walk in the park for a lot of people. So it's still something that I would really encourage people not to want to get, if at all, but that doesn't mean you don't embrace life successfully. And don't stay home and shelter in place indefinitely because there are people who are doing that because they're worried, but do your best you can to reduce your risk rather than thinking your risk is going to go to zero and know what your options are. So that's one big thing going on right now. And I guess the other big thing is when on Earth are we going to get vaccines for kids under five and under? And that is something that we're swimming in right now. Skipper: Yeah. I know, at its height, COVID was clocking in at something like 800,000 cases in the US per day. And I know that it's dropped. And like you said, it's more about the numbers might not be exactly right, because of home testing, or maybe people not even testing at all. But you know, the, it seems to clock in and somewhere around like 55,000 cases a day. But you're saying that the hospitals, though, are not near when we talked in December 2020. We talked about this notion of hospitals being at capacity, are hospitals still in that place? Or does it feel like there's a little bit of bandwidth there? Peter: Oh, there's a lot of bandwidth in hospitals right now. But we're cautiously optimistic. And I think we'll probably see just a slight uptick in hospitalizations, they're already seeing a slight uptick in New York right now. And it's trying to maybe force the mayor's hand in terms of receding, restarting some of the masking in certain situations. I mean, the public transit in New York has already restarted masking, of course BART has and then L.A. also has as well, for that reason. And I guess the big point is, we're not really over the pandemic, from the virus perspective, even though from the human mental perspective, we want to be. We're over it. Skipper: Yeah, we're over it. Peter: But it's not going anywhere. It's not having a huge impact on hospitals. But it's certainly having an impact still in society with people taken out of work, Broadway shoes being canceled, you know, and so on. Skipper: Yeah. Speaking of alphabet soup COVID variants, the World Health Organization (WHO) recently mentioned, BA.4 and BA.5 as strains of concern, and these are some of the more recent Omicron variants, can you put that statement into context? What does that mean? Peter: So overall, my comment about BA.4 and BA.5 is that it's nothing for us to be too alarmed about except that it will likely cause reinfections, and people who've had Omicron, it is a flavor of Omicron, after all, but what we're learning from the South African experience so far, is that although 90% of their population has been exposed to some sort of COVID, most of them Omicron. Recently, they are seeing a surge from a few 100 cases a day to 1000s of people, and it's driven by BA.4 and BA.5. And what that suggests is that even though the hospitals aren't really seeing a flood of patients, it's causing a lot of reinfections and people who had COVID before. Skipper: Okay. Yeah, around the idea of reinfections. And I think we're repeating some information that we've talked about before, but we're seeing these repeat infections in people who've had COVID before or people who have been vaccinated or people who have been vaccinated plus boosted and or also had COVID. Peter: Yes. So you know, you, you're seeing a lot more what we used to call so-called, to some extent breakthrough infections that is in people who've had vaccines, and maybe they've even had boosters, and they're still getting COVID. But I guess, the silver lining in that is that in the old days, you'd expected a lot more people to go to the hospital with that. And we're seeing much lower hospitalization rates in general. And that's really from the power of vaccines. In fact, the Commonwealth Fund did a projection in the United States, and found that we probably saved 1 million lives already from just vaccinations alone, which is not too shabby at all. And California did its own analysis recently, which showed, you know, 10s of 1000s of lives saved. But again, those are conservative estimates, because studies have also shown that every person who dies in a family affects at least nine other people around them. And also you have to think about people taking time off work to care for people, taken out of the workforce so the impact on society is much larger, and you prevent that from getting vaccines. Skipper: That's interesting. That's an interesting notion of how many lives we've saved. Because I think we've heard a lot of the numbers around cases, hospitalizations, deaths, but we don't necessarily see the upside like, and I know we're not at a point necessarily, to pat ourselves on the back, because, like you said, we're not at the state of endemic yet. But I think that that's one thing that a lot of people aren't seeing. I mean, people are tired, right, they don't want to wear a mask. They don't you know, they don't want to inconvenience their lives. But at the same time, we don't see the side of what are we doing this for? Peter: Exactly. That's why prevention is never sexy, because you don't get it so if you don't get it, then you're like, huh, it's like, it's like "Waiting for Godot" or something -- you don't really know what you missed out on. Because you never got it. Or your neighbor never got it. So you say to yourself, well, well, what's the point of it anyway. But that's why people can understand treatment because you feel bad. And then you take something and then you feel better. But prevention is really tough. That's why it's really hard for people to wrap their heads around funding public health because public health is all about prevention of things that you don't get, but because you don't get it, you can't really quantify it. Skipper: Yeah. So what's the current guidance on the notion of prevention and what to do now, I know it's different in California than it is in other states. But you know, I'm thinking about some of the things around like exposure notifications on your phone, if you have a smartphone, how important is it to be tested? If you're not feeling well, I mean, colds and the flu still exist. They're very much in our day to day, what about social distancing? Are these things still important? Peter: I would say the most important thing is that the lowest hanging fruit is if you have symptoms get tested. And don't stop at a rapid test. If you see if you have symptoms, particularly if you know other people who have COVID, you go to a PCR or you repeat the rapid tests constantly, or option three is you combine a nose sample in the same swab with a throat sample, because Omicron starts off in the throat, and then moves up to the nose. So if you swab the nose early on, you may not find it. It's not written anywhere but certainly, it makes a lot of biologic sense. And some people have done that. So those are things that people can do. So that's the lowest hanging fruit, the second fruit would be if you're at a dinner and somebody is positive or your phone goes off. If you work in a high-risk situation, or you live with vulnerable people, you might want to be proactive and get tested days three to five. But if you still continue to have no symptoms, you know, I don't think you have to be super anxious and continue to test. So that's that next level. So that's kind of like using testing as prevention. Because if you're positive, you can tell the people you're with and then they could have the power to stay away from you because you're going to be isolating. The second prevention, of course, and probably more important is vaccines. I think we're debating now between a second booster and the first but there's still 10s of millions of Americans who haven't gotten the first booster and I would say, if you want to run out and get something, get that first booster, there's zillions of studies showing that it's really really important to get that first booster shot -- preventing hospitalizations really is that goal. And the second shot, we can debate about that. But it's essentially, the older you are, the more I'd recommend getting it. So if you think about what Europe is doing, they're like, you can get the shots, we think when you're over 80, and that'll be our priority population. So, you know, that's the way I think about getting that second booster. But the most important is that first booster, because just like many other vaccines that we have, and it will help probably give you longevity for protection for longer. And then in terms of other protection things, for people who don't respond to vaccines, there's Evusheld, which is a long-acting monoclonal antibody. It's like factory-made antibodies in case you can't make any of your own. And you get two shots, and it kind of gives you protection for six months. Skipper: Okay. That's good to know. I wonder, you know, in that same vein of saving a million lives that we mentioned before, that you mentioned before, have there been any positive effects from COVID do you think? And I ask that knowing that COVID has been reported as the third leading cause of death in the US last year. Peter: Yeah, it's really hard to think about the positives of the pandemic, except that -- Skipper: Sure. Peter: We came together, although we also came apart, depending on how you look at things. We developed science at a dizzying pace. So the developments in mRNA vaccines and the success of those kinds of vaccines are being spilled over to lots of other areas like rheumatologic conditions, like autoimmune diseases and cancer. So I think that's crazy, it's crazy that in a few hours, you can sequence the whole virus and then cut and paste the code that tells you this makes a spike protein and then put that code in a fatty bubble and, and it seems that the body responds, I'm making antibodies and keeps you away from the hospitals. So the science is crazily amazing -- and number three is I think it for all the problems, though, it still showed the people that public health is important. And coming back to making prevention sexy, again, I think, again, with projections, like you save a million lives. And, you know, just today, I was talking to a colleague who got vaccinated and boosted, has diabetes older, and is a little bit overweight, who would have definitely been hospitalized, and all these probably even died. But just having to just get a bad case of COVID, never gotten to the hospital. And that's like another, you know, life saved in my own experience, I think just be someone I know. So I think that's been good. But there have been so many shortcomings exposed by COVID, including a lack of alignment between politics and science, and the US beating like 50 different heart muscles, but no coordinated push, and all these kinds of things. But they've been really good things too. Skipper: Got it. What about the larger infectious disease landscape? You know, how does, how we've dealt with COVID play into that larger that bigger story, right? And I guess one way to distill down this question might be what's after COVID? Peter: Well, I think we've been seeing some footprints of what might be to come soon. It's kind of like footprints in the sand, and then the waves wash it over, and then you don't see the footprints, except that come back again. And that's avian flu. So I think avian flu even before COVID was something that people had worried about, because essentially, it's the same idea. You have this thing that birds get and sure some of them might die, but some of them do okay. But once it gets into humans, like they have, depending on the strain, sure, we've never seen this thing before. So all of a sudden, we go crazy, and our bodies can't handle it. And that's avian flu. And then there's just regular flu that could mutate at any point to be like the 1918 flu pandemic, to again, the same idea, something that the body has never seen before. And then it will be like COVID all over again. And then finally, there are diseases that we've been seeing creep up over the last few years and decades because we've been pushing ourselves into jungles to build new cities and towns and houses, like even in California, valley fever (coccidioidomycosis), you know, from the Central Valley, Arizona. As you build more and more I just saw a report in the LA Times saying that the new L.A. and San Francisco is actually, you know, in the Central Valley, because that's where people are moving to -- Skipper: Sure. Peter: But as you develop in areas that humans haven't been before, in large numbers, you're gonna get all these, what we call emerging infections. So not to be like a Debbie Downer, but what it means is that we need to be always on the alert, we need to develop sophisticated molecular techniques of disease detection. And, you know, I think we will continue on with life, but we can't defund public health. We can't dismantle a pandemic office just because you don't see something because remember, like, we start off saying, when you don't see something that's actually the success of the program, because it's prevention. Skipper: Sure, the absence. You know, in our conversation last December, or December two years ago, and our conversation today, we've talked so much about COVID. But you also have other things that you do in your own work, right, you work as a teacher, how has your work as a teacher been influenced in the last few years? Peter: I'm so glad you asked that question. Because a lot of the narrative has been focused on students and sure students are probably the ones who suffer the most in the educational space because they've not been educated. It's estimated that we lost billions and billions of dollars in terms of economic development, because of this disruption in students lives in these past few years. But the pandemic has also had a profound effect on educators as well, because I think a lot of the joy of education is that physicality that when you see somebody and you see the light bulb go off in a student's head, you're like, Wow, I did something. When you deconstruct that really crazy algorithm into something that they can understand, you even understand it better, you feel, My job is done. But in COVID, all you end up doing is looking at a bunch of squares on your computer. And if you have a small laptop, like me, the squares look even smaller. And over time, people turn off the video. So you can't even have that relationship. So I think from the teachers' perspective, the last few years have really been tough, apart from the idea of putting yourself at risk of going to school, etc. But I think beyond that, you lost the joy of work. And that although we also were flexible, and everybody was flexible, and that's another success story, even in medical education, where I work in that space, we thought about ways in which somebody is ready to be a doctor, instead of a time-based strategy -- you need X number of years, but some people are ready sooner than others. And in the beginning of the pandemic, many places graduated students early so they can contribute faster to the workforce at the time. Skipper: Yeah, I agree. I think engagement and learning, I think there are some things that we've come to realize around it that are not how we thought of it, let's say three or four years ago. Peter: Exactly just like healthcare with telemedicine, but there are limitations to telemedicine. Skipper: I don't know if this is gonna make the episode cut -- but I remember last year, I had to have my yearly primary care physician, and my PCP visit, and one of the things that they asked me on this video visit was, can I test my own blood pressure, and I so happened to have a blood pressure machine at home, and I was able to test it and give them the number. But it felt funny, and maybe funny isn't the right word, but it felt different for me to volunteer my number versus having my blood pressure tested in the office. Peter: Yeah, definitely. And, you know, I think maybe at the end of the day, we will learn that we can do a lot of things remotely, but there is a loss with that. There's a loss of relationships, there's loss of joy on either side. Even when you mentioned you're doing your own blood pressure and you seeing the healthcare provider as a two-dimensional person. It's different from just having that whole-body contact with someone in the same space and maybe talking about your favorite meal that you had recently. And just seeing the whole body react to that instead of like that random face on that screen that's two dimensional and for all your know that person as it's just a bobblehead on on a swivel chair because you can't see the whole person engaged with you. Skipper: That's true. I mean, it could be a deep fake doctor in the future. Let's hope not -- Peter: Exactly. Skipper: Yeah. Peter: Or AI or robot or something. Skipper: Exactly. Well, Dr. Chin-Hong, is there anything else that you want to talk about today? I know we only have a few minutes left in our time, but is there anything else that you want to bring to the forefront? Dr. Peter Chin-Hong: Well, I just wanted to say that we have a lot more options now for people. I think the few parting comments of things to do to prepare would be to watch the COVID numbers like the weather report, even though there are limitations in the absolute number but the shape of the curve is important -- Skipper: Sure. Dr. Peter Chin-Hong: -- including hospitalizations. Number two is prepare your medicine chest with decongestants and just like you do for the summer with insect repellent, except you're gonna do that for the next potential surge, including a pulse oximeter. You can get those cheaply at Costco and Walgreens now to check your oxygenation in case we get a new variant in the future. It's also good for other things, too -- Skipper: Yeah. Dr. Peter Chin-Hong: -- that are non-COVID. Number three, you want to be up to date on your vaccines and really getting that first booster shot, it means so much to the success of the vaccine overall so I can't overemphasize that. Number four, know about Paxlovid, it really is one of the successes of recent therapeutics. And if -- even unvaccinated people, especially in unvaccinated people, 80-90% prevention of hospitalization, if taken within the first three to three days, 80% if taken within five days. Definitely know how to get that, particularly if you live with people who are at risk for getting seriously ill, or if you're one of those populations. And then number five, don't forget your masks and your tests, keep them stocked. The testing is interesting because the FDA keeps on extending the expiration date. So before you throw away a test, go online and make sure the extension isn't there, because it's not that they are trying to reuse old stuff it's that for the COVID testing, the expiration date was based on real-time so the more time we have and the lab companies are continuing to test these kits, that's when you'd see the expiration date -- Skipper: Yeah. Dr. Peter Chin-Hong: -- extended. So those are some pearls for the future. Skipper: Okay. Where can people find out more about you? Or is there a best place to find you online? Peter: Well, if you Google my name, Peter Chin-Hong, you'd find this kind of nice interview that the partner of medicine did with me, that speaks to where I came from -- the Caribbean and my influences on my parents. But probably my favorite thing that I did during the pandemic was the last lecture. So if you Google my name and last lecture, you'd see this really nicely produced segment that the students asked me to do, pretending that it was the last lecture I'd ever give them. Maybe that was their desire. But actually, it was really fun to work on it. Because, you know, I brought in music and dancing and different segments. So it's really a statement about not just about me, but about, you know, how we all deal with where we come from, and how that influences how we deal with pandemics and catastrophes and novel situations. Skipper: Okay. We'll link to it in the show notes, so that way people can find it easier. Well, thank you, thank you for -- Peter: Thank you for having me on. Skipper: Yeah, thank you for making time, Peter. PCH. We appreciate your work. Peter: Thank you. And I appreciate you, Skipper. Thanks for having me on. Skipper: And thank you for listening to How This Works. We're glad to be back for a second season. Please subscribe and then rate and review us in your favorite podcast app. You can find How This Works online at howthisworks.show, that's four words, no dashes. Again, that’s howthisworks.show. We’re also active on social media. We hope that you got as much out of my conversation with Dr. Chin-Hong as we had in making it. We'll talk again soon. [Outro music] Skipper Even in cold and flu season or flu, like the flu, even if you get the vaccine, and I know there are lots of people who say the flu vaccine is garbage or whatever, and some years it's more effective than others. Peter: Yes. Skipper: There are some years. I feel like in the past, even when I have gotten the vaccine, I still might get the flu twice. Or what I think is literally, right, right. It's not an exact science Peter: There are different strains of flu floating around. It's not just one flu that comes in. Skipper: Right. Peter: There are different kinds of flu in one season. Skipper: Right. Peter: So your observation is correct. Skipper: Yeah. Peter: But still, you haven't been hospitalized. So that's good. Skipper: That's right. I've never been hospitalized for the flu and knock on wood -- and you know, when you start to break down the statistical numbers around, so today's flu is somehow linked back to the big flu pandemic in 1918 as you look at the cost year over a year, life, money to treat the flu, etc. The flu is really, really serious. Peter: Yeah, we downplayed flu. But I think actually what I thought about recently is that our knowledge of COVID Now it might make us be healthier, have a healthy outlook against preventing flu, you know, costs and mortality in the future because I think maybe at the end of it, at least in some areas, people will be more sensitive to wearing masks or not being around when they have symptoms. Skipper: Right.