 Good morning, everyone. We're lucky to have Dr. Michael Oosterholm, who is one of the country's leading disease experts. We spoke to him about a month ago. And he had a lot of, I think, very illuminating, if somewhat depressing things to say about the coming crisis or the crisis that was developing then, and is obviously now fully blown now. Dr. Oosterholm is the author of a great book, Deadliest Enemy, Our War Against Killer Germs. He is the founding director of the Center for Infectious Disease Research and Policy at the University of Minnesota. And I'm going to turn the floor over to him to make some opening observations and then we'll engage him in the Q&A. So thank you very much, Dr. Oosterholm. I know you were very busy. Thanks for sharing your time this morning. Well, thank you very much, Peter, for having me again. And it's a real honor to be with you. I appreciate all that you have been doing on behalf of your organization and your work in the public to continue to disseminate really very timely and helpful information about this situation. You have a unique understanding on a global basis of what all of this means in terms of the impact of what's happening. Let's just take a step back and kind of just look at where we've been kind of through the rear view of Mirac very quickly and where we're going. For some of us who have been involved with this for the last four and a half months, it seems as if it's been a lifetime. There was a world before COVID and now this world and there will be a world after COVID. I'm confident of that, but we'll talk a little bit about how we're going to get there and what it's going to mean. First of all, let me just say that back on January 20th, our group published a document that we shared with the group that we advise that in fact, there would be a worldwide pandemic that the information that we were able to glean from what was happening in China surely supported influenza virus like transmission of this coronavirus and that everything that it was doing was acting as if it would transmit on a global basis. Several days later, we put out a document that said it would take a while for this to actually be seen throughout the rest of the world because of the fact that one, based on what we knew, the incubation time between being infected and being infectious was probably three to five days. Using five days as the time period and that the fact that most people appeared to transmit on average about two people, that great R not number we talked about. So we had to go from one to two to four to eight to 16 to 32, knowing that a large segment of these cases would be very mild if even showing any symptoms. Well, as you know, it did appear on a global basis in late February, early March, and it was evident that in many communities where it had been already circulating in that low level for the previous month, suddenly flared up when we started talking about doubling numbers like 1,000 to 2,000 to 4,000 to 8,000 every five days. So from that perspective, this virus is basically followed the roadmap that we would expect to see an influenza-like virus transmission model follow. And so I'm gonna conclude for today's conversation that we are dealing with an influenza pandemic caused by a coronavirus. The one exception may be the fact that when children we see transmission, but not as much clinical illness we would see. And one other one that may be ultimately a slight difference, and I'll share with you today, I think that we accumulate more and more information about the transmission of this virus. It's very clear that this is at least if not more infectious than even what we see in the historic pandemic flu models of 1918 and so forth of a R not of 1.8, meaning at least that we're probably seeing something now between two and three, which has real implications for the transmission. We also, I think, have come to the conclusion globally that in fact, aerosols play an important role here. These are the tiniest of particles and that therefore when we talk about protection, distancing becomes even more important because of the lack of highly efficient transmission or reduction with certain kinds of respiratory protection, devices, we'll talk a little bit about masks, I'm sure as we go through this. And just to get a sense of where we're at right now, I think this is the hard part for people to hear, but I along with a number of my colleagues are very, very convinced that this is following very much like a 1918 model. And while I don't expect it to be exactly like that, what that's really telling us is that this first wave of what we're seeing right now through most of the world after basically left Asia is in fact just the beginning of what could very easily be 16 to 18 months of substantial activity of this virus around the world coming and going, wave after wave. Will the next waves get bigger like they did in 1918 where you had a spring peak and a fall peak? I don't know that, but it surely is a virus that likely will have to infect at least 60 minimum to 70% of the population before you're gonna see a major reduction in this transmission, meaning that's how many would have to be people who were infected, hopefully developing a, least a middle ground kind of immunity to it, meaning that it's lasting for at least some months, doesn't have to be a lifetime, before we're gonna see this slow down. And I think what's hard about that is in realizing we're really in the first innings. And I've a quote that keeps coming back to me from Sir Winston Churchill who once said, now this is not the end. It is not even the beginning of the end, but it's perhaps the end of the beginning. And I think that's where we're at right now. We're kind of in the second inning of a night inning game and we've got to consider how we're gonna prepare ourselves with the possibility that some of the cities that have been so hard hit already will actually have peaks some months down the road that may even be much larger in case numbers than we're seeing right now. What it means for communities who have seen very little transmission and what that means. I just would conclude with one last piece before we get into the questions and answers is the fact that for several months people kept pointing to Asia and saying, if we just did it like the Chinese did it, if we just did it like they do in Singapore or they did in Japan, then we could bring this under control. And I think people are now realizing that at best, any of those very, but I consider comprehensive, some would consider them even extreme control measures that were used there are starting to show the breaks in those measures. Meaning that now as you know, Singapore since we last talked last week declared a national state of emergency with ongoing transmission occurring in the community. We've seen the same thing happen in Japan. We're seeing increased community transmission in areas in Seoul and in Hong Kong. And I think what's even more confusing is what's happening in China as the situation in Wuhan has changed and now individuals are going back to work. We're seeing large crowds again. It's interesting and curious that the Chinese have closed down theaters again last week. And also they're reporting out upwards over a hundred people a day who are asymptomatically infected meaning they're positive, but they're not reporting symptoms. But meanwhile they only report one or two cases were symptomatic. These are again among Chinese nationals not imported cases. That makes no sense whatsoever. And so many of us are very concerned if not greatly challenged by what the Chinese government is reporting for numbers right now. And the bottom line is that after four and a half months so that the most extreme population movement limitations ever put in place from a public health standpoint over modern history, we're still seeing transmission occurring inside of China. And as the Chinese government brings back so many of these people in the Hubei province back to work as we see now transmission in other provinces of China. I think even there we're gonna see a reigniting of activity, what I don't believe it'll ever be as bad as it was in Wuhan just because of the ability they have to basically confront this situation. But we can't use Asia any longer as the perfect answer for what is happening here. We really are going to be dealing with this on a global basis, trying our best to suppress it as much as we can and where we go from here. And I think in the questions and answers I'm sure we'll get into the issue of what is our strategy going forward? Because at this point, my biggest concern expressed in the call several weeks ago and now is we still don't have a national plan. I can't tell you what our long-term strategy is for trying to deal with this. And that's critical. We have to develop that. So with that you, Peter, I'll turn it back over to you and we can go from there. Well, what should that long-term strategy look like? Well, first of all, it has to acknowledge that there needs to be a long-term strategy. I think that we're so focused right now on this issue of just getting over this wave flattening this curve. And I agree with that. That is an immediate issue. And if you're in one of the places that's on fire right now like New York, Detroit, Chicago, New Orleans, I mean, go down the list of areas. You can look at other places in the world. Italy now is hopefully on the downward side of that. Spain may be, but other areas around the world I ran all have had these major episodes. But again, people have handled this like it's almost like if this were a hurricane and it's now made landfall and it's just moved past our communities and now we can get into remediation. We can get into recovery. And I think that people understand that, we just have had the first round. And if I tell you anything, understand what happened in 1918 and you might be understanding what we're in for here today with this particular virus. So the first thing is we need a plan. That's critical. The second thing is that we have really two choices and then somewhere in between. One choice is we try to walk down like they did in Wuhan but we keep that tight. And that is the assumption made in the model that came from the University of Washington. It's basically for the next four months we are in a type of Wuhan-like shutdown. I think many of us have come to understand that that's just not going to survive the future societies that will be there to say we can't do that. You're just destroying not only the economy and it's not a dollar and cents issue. It really is about the fact of just the essential services and all the things that we need every day to keep our world going. Plus the fact we have to think about what it's doing to so much of the population. So that one is one alternative. The other one is let it kind of go willy-nilly and basically just let it burn through and let's get it over with in the next few months. I caution that on two points. One is that first of all, that would mean we would experience literally potentially several million deaths here in the United States worldwide. It would be a dramatic. And it would bring down our healthcare system as we know it. And that has consequences not just because of the fact that it would mean a very limited and clearly compromised care for COVID-19 patients. It would also mean that anyone else who had a serious health issue such as a heart attack, acute asthma attack, cancer, unintentional injuries or intentional injuries, where are they gonna go to get care when you have the whole healthcare system basically in default position? And so that isn't acceptable. And we have to understand what the implications are there of doing that. And in addition to that, I think that when we look at bringing that kind of situation to the healthcare system, that is what's going to cause people, I think, to have what I consider to be the almost panic-like mode. Right now, I would say there is no evidence of panic I see in the population. Nobody is burning down buildings, riots in the street. Even I haven't even heard of a knife being pulled or a gun being pulled in a department store where somebody grabbed the last roll of toilet paper in front of me. But people are really afraid, they are afraid and they should be. And they are experiencing tremendous emotional stress if you're unemployed, still waiting to understand what you might get for unemployment basis in a worldwide how this plays out. So I don't think that that's an alternative either. So there's gotta be something in the middle. And I liken it to what I call threading the rope through the needle where we have to understand how do we open back up in a way that is very sensitive to one of these wave starts that we attempt to do it. Everything can with social distancing and that term which has come to be used so much, I find unfortunate. I'd like to think that it's physical distancing must never social distance. Let's try to today in our modern age of internet hopefully we can do a better job with that. But I mean, how do we in fact then get, for example, the younger population who we know will be at much lower risk of serious disease and death. Now that doesn't mean it won't happen. And I think that we can talk more about that in a moment. What are the risk factors for why people might die? But bringing a substantial number of these individuals back into society and trying to bubble if we can and we can talk more about that. How we take care of those who are at highest risk of having a severe outcome and getting them through the next 16 to 18 to 20 months till we get a vaccine, minimizing their potential to get infected, their likelihood of ending up in a hospital and dying. And so what we have to have first is recognition we need a long-term plan. This can't be these day-to-day press conferences. They can't be 30 day plans that somehow just say social or physical distance. They've got to really talk about how we're gonna get that. And they have to be realistic. I have had so many frustrating experiences with really, really smart people who I kind of look at like hello. Everybody wants to do testing today. Everybody wants to say, we'll test millions of people each week and then we'll know and then we'll follow up. Very few people realize that the testing community in this country is under attack in a major way and that attack is coming from inadequate supply chains. Right now in our own state, we can only test hundreds of people in a day if possible with our state health lab because what has happened is we've had this incredible drawdown of reagent availability. It doesn't matter what test it is. Think about this. Before Wuhan, the reagent capability, meaning those chemicals that are key for running many of these tests without regard to which platform you're using. Whether you're testing for virus or you're testing for antibody. And what's happened is that before Wuhan, they were filled more or less adequately by a garden hose. Then Wuhan came along and clearly the Asian community wanted a much, much enhanced testing situation which they surely needed. And it kind of turned into a fire hose kind of reagent situation which just was barely being met, but it was. And then the whole world caught on fire. And now there are eight billion people who one way or another, somebody wants to test them. And now what we have is really almost a demand what I'd call a canal, water canal of need for these reagents. And so although you hear about all this news about this particular test is coming online, at this point, a care is gonna be available. When you actually look at what can be delivered, it is minimal. And so again, I urge whatever we do going forward has to be based on reality. You're not gonna test your way out of this thing and you don't have tests. You can say, well, let's just start making reagents. Well, this is where it's really important to understand the fact that it takes time to build those kind of facilities. It doesn't happen overnight. And I think a quote that I often use when I talk about being in this battle is from former Secretary of Defense Rumsfeld who said at one time, when you go to war you don't get to go with what you want. You have to go with what you have. And then that very same press conference where he was talking about why some certain pieces of military equipment homebies were not adequately protected. He said, this is not about money, this is about physics. Meaning you just, we can't build them fast enough because we don't have the plans to build them and it takes them to do those. So we're gonna be in this reagent issue for some time to come. And that's why when we look at long-term plans and what we need to do, they also have to be based on reality. And I'd say the same thing about ventilators. I'd say the same thing about personal protective equipment. They have to be based on reality. So I hope Peter, that gives you a sense of what we are talking about when we're really begging for the global community to come together and develop this long-term plan that's based on reality, not based on a pipe room. What is the role of the reagents in these tests? Well, reagents in of themselves are the part of the test that in a sense are like the gasoline in the car. For example, if you're going to take a swab and you have to have the swab itself to either do the throat or the nose, then you have to basically take that material out of that swab and you have to extract the RNA or the genetic piece of that so it now can be presented in the test itself to determine is that RNA there? And so if you don't have that intermediate piece that is so critical, you can't run the test. You just can't have a swab and walk into a lab and say test this. So for each of these tests, they have types of chemicals that are part of it that are required for the test to actually run. And it varies by which kind of test you're talking about but that's the challenge we have right now. You mentioned 1918 and can you reflect on the differences and the similarities? Obviously, the famous cases of St. Louis versus Philadelphia and others. I mean, because when people here in 1918, they immediately think of 50 million, 60 million people dead. I presume that public health generally has improved but is this virus not susceptible to the public health improvements we've had? Well, again, I surely don't want to suggest that the exact numbers of people who died in 1918 are going to be the same here relative to population changes. Today, of course, we have a much larger population globally than we had back then. But I think that the epidemiology is following very much that with the exception of course 1918 killed more often in the younger adult age population than we're seeing here, which is mostly older. But in terms of waves, which people can identify with and I can actually even take it to 2009 with H1N1 where a virus that was much less likely to kill. But if you look at that, for example, when I talk about waves, remember that virus appeared in North America and then spread around the world in late March, early April of 2009. And it has been the case throughout time, if you look at influenza pandemics, about six months later is when you see the big peak or one of the larger peaks that would occur. That's what happened in 1918 and it's what happened in 2009. That peak that occurred here in North America was in mid-September to mid-October. And those were warm months. And I might add that if I could just one more reflection on that, if you look at the last 10 influenza pandemics that have occurred over the past 250 years, two started in the winter, three started in the spring, two started in the summer and three started in the fall of the Northern Hemisphere. And every one of them had their bigger peaks about six months later. And so from that perspective, when you look at this, it shouldn't be surprising when I say of 1918 it's just what people can remember. I think one of the issues that we aren't really clear on and this is a challenge is we don't have really any of the major public health tools except the distancing issue beyond that of having vaccine. Even if we get effective drugs which would surely be a God sent, that is not gonna stop transmission. That's only going to make less than the impact it has in terms of number of severe cases and deaths. Transmission will still continue because remember most transmission is occurring earlier in the illness year before you even started taking these drugs. So if you look at that, what can we do about this? And one of the humbling things is in 1918 or if any of the influenza pandemics including as recently as 2009, the peaks of these waves occurred without really much human intervention. Why did suddenly in the spring of 1918 or the spring of 2009, do we see these initial peaks that then basically decreased to almost limited activity of any and that surely was just placed in some places and then have them come back? Now I gave you two examples of situations that first occurred in the spring and you might be thinking, oh, this is gonna be a summertime seasonal issue. For those other nine pandemics I talked about or eight in the case of minus 18 in 2009, they again were six months offset from whenever it emerged and you may have been aware that this past week in the National Academy of Sciences came out with a statement indicating that there really was not convincing evidence at all that there might be a seasonality with this. This may just continue to, this virus, this coronavirus may just continue right on and that people who have been counting on the possibility of this whole situation being a summertime hiatus may in fact not be true at all or it could be true but not because of seasonality which is this whole six months, the first emergence and six months later. So what we're doing here is trying to limit people's contact without even knowing is it, would these peaks occur if we hadn't done anything? Now I wanna believe and do believe and we've had some impact in places like the Greater New York City Metropolitan Area, other areas of the world and Wuhan. You know what we did talk about with Asia, what we've talked about in Italy. I think these interventions did have impact but how much I don't know because I don't know this would have just run its normal course and that's also concerning because it says if it comes back and there's gonna be a big peak, how much impact can we have on that? So we have to continue to rely on distancing as the primary means. I would sure tell people, even if we don't have the data that says that's what does it, this thing's gonna run its course, whatever we do. I wanna believe absolutely that we have to and must continue to when we see these curves starting to slope up, we've got to as the only available public health measure we can is really emphasized the importance of distancing. You mentioned the University of Washington model, which obviously has been influential at the White House it seems. But I think this is kind of creating a set amount of confusion because, Maria Baza, who's the mayor of Washington DC is using different models than the University of Washington model and she said publicly that it'll peak in the DC on June 28th which is a very different conclusion than what the University of Washington model is suggesting with a peak in mid-April. And so that's, so I guess that's one question and then related to that, isn't it, shouldn't it be the CDC's job to come up with a nationally kind of agreed upon model rather than no matter how good these individual universities are, people essentially having to shop around for some model that ends up being very different from state to state or federal government to local government? Well, thank you. Let me take the second question first and I'll come back to that first one. CDC's absence in this pandemic in the United States has been, I think, a tragedy. Yes, we're all well aware of the fact that there were problems with early test rollout and one day we'll be able to go back and take a look at that. But there are some of the best minds in the whole area of preparedness and pandemic response at the CDC. And their absence in a public way of doing just what you just said, coordinating all of these different modeling activities in a way that can synthesize them and bring them together in a coherent manner is really unfortunate. If I could urge any one thing happen today in terms of the federal response is that they have to have a much more important role at the table than they do now. Right now on the coronavirus task force, there is no primary public health expert. I think Dr. Fauci has done an incredible job. I have the highest regard for him and thank God he's been there. But again, the issue of modeling and the issue of surveillance really are expert uses that fit best at CDC. I would say the same thing is true about Dr. Bricks. So we need them and they could bring more discipline to this whole area of modeling. Having said that, let me just briefly talk about modeling. I've had some 60 graduate hours of statistics courses and you'd think that I would have some primary understanding of things like modeling. I can tell you right now, modeling is often a black box institution to me too. And I can tell you a couple of things. Whatever the conditions are you put on that model are gonna have a big impact. So when the University of Washington model says that we're going to assume a total shutdown like Wuhan and that we're gonna do this for the next four months, those are really important conditions. I don't believe, first of all, we're gonna ever achieve a Wuhan-like shutdown in the United States. It's never gonna happen. So that leads someone to question its reliability. Second thing is I don't know how they're actually measuring when they keep saying that the efforts underway are actually suppressing this, that the distancing issue is there. I don't know how to measure distance. I can't tell you what they're doing. They can pick states where the governors have recommended, some states where they're not. I've also looked at the fact that when a governor recommends this or puts this into place, what does that really mean in terms of actual contact? So I don't think we have any real good empirical data that way to know what's going on there. But I can tell you that this is a much bigger issue than four months. This has to be looked at in the totality. So when you look at the Imperial College model or the Harvard model from Mark Lipschitz's group, they're actually talking about, through the duration of 16 to 18 months. And they're making different assumptions too on what impact this distancing will have, which none of us really know. We don't know that. So I look at this and say, okay, we've got all these different models out there. Well, how are we gonna interpret this? And I've come to the point of saying, let's throw out all the models, throw them out. They're not helpful because they're causing those who believe that this is an exercise to criticize the administration are over-inflating the numbers. Those who say the administration is trying to downplay this, you're under-reporting the numbers and nobody trusts anybody. So I just take a step back and say, you know, I'm from rural Iowa where a lot of very common sense smart people live. And I think to myself, if I were at the local cafe, how could I explain to people sitting at that table what's going on? And I say, well, let's just take the following simple numbers. There are 320 million people in the United States. If half of them get infected in the next six to 18 months, what does that mean? And well, you can say 50% probably get infected. That surely supports the kind of numbers that I think any of my colleagues and I have come up with as a likely number. So, okay, that's 50%. And if you don't like that number, we can take another one. If 50%, that's 160 million people. And based on what we know from Asia, from the European Union and from the United States, about 80% of these patients on average will have asymptomatic, mild, moderate illness, but not ever seeking healthcare with it. About 20% will seek medical care. Of those, about half or 10% will be hospitalized. Of those who are hospitalized, about half will actually require some form of critical care treatment. There'll be intensive care. If you look at that then and say, okay, of those there, about 1% will die. And that's the numbers we've been seeing. 1% of 160 million is 1.6 million people over the next weeks to months. And so to me, that's the number I'm kind of looking at and saying, that's a real possibility. And if you don't like the numbers I just used, they're all transparent. There's no black box here. You just go ahead and change them however you want. And so I think that that's the kind of situation right now we just need to give people the sense this is gonna be really, really bad. Right this week, it's a sad commentary to say this, but on a daily basis, on average, if you look at the number of people who die from heart disease, cancer, et cetera, on a daily basis and compare what's happened in a daily basis right now with COVID-19, it has now become the number one cause of death in the United States, on a daily basis, the number one cause. Six weeks ago, it wasn't even the top 60. And so I think what we're trying to do is understand to people when a model is a model is a model and we're putting way too much weight on them. What we need is a general sense. Is this a category two, a category five, or a brand new category called the category eight hurricane? What is it? And I think that what this is telling us is in the most basic back of the envelope estimate, this is a really bad one. And so we have to be prepared for that. And beyond that, I think the precision is just not gonna be there, it's just not. And anybody who tries to slice and dice it too much we're just gonna get into a debate about what it really means. What has surprised you about this virus and COVID-19? You know, Peter, that's a hard one because I surely don't wanna come off as if I know what's gonna happen here. I'm kind of guessing this all the time. You know, when I wrote chapter 19 in my book, Deadliest Enemies, I laid out what would be an influenza. This pandemic originated in China. And I mean, what I thought was gonna happen is been following it to a T with the exception it's a coronavirus causing it, not an influenza virus. And so, you know, for me, this really hasn't been a big surprise yet. It hasn't surprised me. I think it's doing what it was, you know, it's mother nature made purpose. And it's our battle against it. And so I think that that's why, again, I surely don't wanna have any confidence that I'm telling you exactly what's gonna happen. I'm giving you the options. But you know, back in January, when we said on January 20th, so this is gonna be a worldwide pandemic, it's played out exactly as we had laid it out back in January. Even to the extent of seeing the sporadic, major hotspots in countries around the world, you know, which cities get hit. You know, why did Northern Italy take such a hit and Southern Italy didn't? You know, what is it that, what is doing this? This is exactly what we would expect if we had looked at a 1918 like model. That's exactly what happened in the spring wave of 1918. It spared a lot of locations. Unfortunately, over time, everybody got to participate. And I think that's what's there now. I think that the one thing that I wouldn't say is a surprise, but I think that is an unfolding fact is what is it doing in terms of serious illness? And who are the people who are most likely to be impacted? And we've already heard in the past week about the issues around racial disparity and gender disparity in terms of the people who are getting sick and actually developing serious illness and dying. And even there, if you go back and look at the influenza model for dying from respiratory distress syndrome, or in some cases, even potentially just primary pneumonia without that, this is actually filing very closely to what we see with flu. You know, we also are realizing that you're gonna see a different presentation in different areas of the world by the underlying presence of comorbidities. In China, very, very few people over the age of 40 are obese. And in the United States, about 45% of those people over age 40 are obese. Men and women alike, that's a major risk factor in influenza for a bad outcome while we're seeing the same thing here. On the other hand, in China, men over age 65, about 70% of them smoke, only about 2% of women. So we had a big differential there, which initially we thought maybe could account in part for the serious outcomes of men more often than women. But now we see in other parts of the world where the smoking disparity is not so acute, nor is the obesity issue difference between the genders. It clearly is impacting more men than women, but we've seen that also with influenza. So I think that at this point, I can't say that there's anything that's really surprised us, but it's just reminding us that what we're learning about it has already been learned in many ways by understanding influenza. And we just have to keep thinking back without absolutely saying this is what it'll be, but saying this has a good possibility to be like this because this is what we've already learned about what influenza did. And I think that to me has been the, not the surprise, but it's been the enlightenment as this thing continues to go through the population as to what's happening. Let me turn to some questions from our 112 participants right now. Are we any closer to knowing why COVID-19 is asymptomatic in some and life-threatening in others even when there's no preexisting conditions? No, a simple answer, we don't. It's an important issue. It is one that I think, again, looking at influenza, this is slightly different than flu in terms of what appears to be the frequency of asymptomatic infection, but we don't understand that yet at all. And I think we do know that underlying risk factors we just talked about surely are important in considering this, but we don't understand the interaction at all yet. And so relatedly, there's no genetic predisposition of the most serious complications that we know of. You know, I wouldn't say that. You know, we've had evidence of that in the past. And again, this is just a reminder to people, we never understood why certain native communities in 1918, the, you know, the Inuit population of Northern Canada and Alaska, for example, had up to 50 to 60% case fatality rates when they were impacted by this virus. We don't understand that at all why that happened, but it surely did point out that there had to be something genetically related. We even saw this in 2009 with the same population of age one in which was often missed, was just the increased mortality in that population. So we know that indigenous populations in other parts of the world have also seen this situation. So there has to be some genetic component, but I'm not aware that anybody understands it. So it wouldn't surprise me that we would see some genetic component here that is at work and we don't know. One of the other areas that we've seen in the past and we are not seeing it as much here, but with flu is pregnancy and that the major increase in serious illness and increased deaths was not uncommon. And there it's a situation where the question has, was this just because of the added physiologic compromise in terms of being able to breathe because of the position of the baby and pressing against the lungs or is there something going on immunologically where your immune system as a pregnant woman carrying an unborn child is at a very unique state in the sense that part of you says, get rid of that, that's not me. And part of you says, this is the most important cargo you'll ever carry in your life protected. And we know that there's some very interesting immunologic interplay that occurs during pregnancy. When the flu virus got in the middle of that, surely it caused some very, very serious outcomes. We don't understand why yet. So I think that these are questions that are really important ones to understand, particularly as we're trying to give advice to people, you may be at increased risk or not of having a serious outcome that would help if we could be more specific and say, rather than just you have underlying health conditions, what does that mean? And I think we really must do a better job of trying to understand that so we can better advise people on who are the ones that need to take the extra efforts to protect themselves from becoming infected. Well, just a clarification then. So on the question of pregnancy, what's the advice that can be given right now? Thank you for, yeah. Way now, I have not seen any evidence that pregnancy in and of itself is an increased risk factor for a severe outcome. We surely have pregnant women who are infected who are very sick, but we're not seeing that as an increased risk factor, meaning that they're not protected against getting seriously ill, but they're not getting more, they're not getting a higher frequency getting serious ill. Is there a world in which we would all be issued nationally recognized kind of status as being immune that would allow us to go back to work and relatedly, would that be 100% if there are sort of faulty tests that we've seen and I think some faulty tests already? Yes, this is another one of those kind of really questions. I've seen this come out from a number of people in the last few days that we just need to have this kind of system where we test you to see if in fact you have been infected using serology antibody tests. Let me tell you right now, the testing in this country and in some other parts of the world there's nothing more than the wild, wild West. There are now over 70 companies who have received emergency authorization approval from the FDA or states to now bring serology tests forward. I chair a group here in Minnesota that is involved with the testing question, trying to look at this and what testing is available, what are the shortfalls, but also what are the limitations? And I can tell you right now that at least probably 35 of these 70 tests should not even ever be on the market. How they got licensed is just beyond me. I mean, how they got approved, I should say, not licensed. And so I think there's gonna be a lot of bad information out there for some time to come. And so before we can launch on any kind of a national program, we have to understand two things. One is when I get tested with whatever test is used, what does that result really mean? Do I really have antibody or not? And I think that's a big challenge. The second thing, if I do have antibody, what does it mean? Am I protected? It's just meant that I already had my scrape with the virus, but I could have it again. And I think that at this point we don't really understand that yet. These both to me are important moonshot issues we need to do right now. We need to bring clarity to the serology work. We need to really invest in trying to get as much infrastructure for reagents and testing in general. All the comments I made earlier about the compromise of testing, a whole truth for antibody detection, serology. And then second of all, we have to know what does it mean? Am I protected? Am I not? How are we gonna find that out? How long am I protected? What does it mean? So I think until we have that, Peter, I think it is a wild, wild west. And I worry about that. I look, for example, in trying to respond to this situation in terms of healthcare workers. I think there've been a number of healthcare workers who have been infected, who suspect they've been infected, were never tested at the time, there were adequate testing available. And today if they could know that they were antibody positive and that there was sufficient data to say likely were protected becoming infected again, that wow, think how that would change the game in healthcare if 20 or 30% of our current staff are already protected. That would give them an incredible peace of mind. It would help us relieve the pressure on PPE as we know it because you very easily could be in these wards with COVID-19 patients and not have to wear an N95 respirator and feel confident that you're still protected. So I think this is really important and it's a priority, I think again, we don't seem to have a national prioritization around this. Instead, what we're doing is prioritizing, getting more and more companies approved for their emergency authorization test, which may be nothing short of junk. Only question of PPE, why the failure there? You know, is a policy failure or is this something else? Well, I think it's a combination of several things, but most notably, creative imagination and then understanding what that is telling us. First of all, we did not anticipate this situation. And when you look at a strategic national stockpile that may have half a day's worth of respirators in it for the country, that's hardly a stockpile. That's not even a good late night stopover. Well, Dr. Osub, I want to pick up on that point because when you listen to the White House briefing, often Vice President Pence will sort of recite, we're gonna get a million masks here from there, but my impression is we need a billion masks. We need, I mean, give us a sense of the numbers we actually need. Right, and that's where I was gonna go. I think actually that's really the important point. What I was gonna say is that we keep hearing about two million of these respirators are gonna end up today here or there, but nobody talks about the fact of what the use is. And let me just give an example. 3M, a company here in Minnesota. So clearly, I know them well. Actually on January 20th, when I put out this statement that this would be a worldwide pandemic and that I laid out the reasons why I thought it would, I met with senior leadership at 3M that day and gave them the day to why. On the morning of January 21st, they put every machine they had on 24-7 production and they've been producing in 95s at the highest rate they possibly could since that date of January 21st. More than six weeks before the federal government came to them wanting to buy additional respirators. So again, even in the short term, we had to get better prepared. We weren't getting better prepared. The companies did it on their own. But to put that context there of what you just asked, Peter, about the number, 3M can basically produce about 35 million respirators a month if every machine is going full bore. And anybody thinks they can come in and suddenly produce in 95s. That's just crazy. You have no idea how complicated these respirators are. For example, that's not paper in front of you that you have. That's a matrix. It's a poured material that allows air to move through it while trapping virus. You know, you make cars, doesn't mean you can suddenly make those, okay? But the 35 million that they produce a month, a last month in February, before we actually had COVID really circulated in New York, one hospital in New York alone went through 2 million in 95s, just that one hospital. So you can see the shortfall is huge. So every time I hear about this many more respirators, it gets back to your point of how many do we need? So don't tell me, you know, you hid, you know, basically we got 2 million more when at that very point we need 50 million more. And there is no one number right now. You know, we've looked at numbers between 500 million to over a billion respirators could be used. Now I don't happen to agree with that because I think the number is lower because the other thing we haven't done is we haven't done any conservation of respirators, meaning that we should be able to be using these. We published a piece on our website earlier this week about how do you actually disinfect and refurbish in 95 so you can use it over and over again and still keep it's efficiency. What kind of engineering controls have been put in place in healthcare facilities? So that if you have instead of 15 rooms that each of them has a COVID patient and every time you go in and out you have to doff and don, meaning you put it on, take it off, throw it away, put all 15 of those people in one ward, make sure that the air exchanges are appropriate so that it's not blowing infectious air back into the hospital. And then once you have those 15 in one ward you're in there, you don't have to take your equipment on and off every time. And so we need to do things like that too that we don't hear much about. We believe that you could save a sufficient number of N95s for multiple use if you just took up some of these refurbishing programs. And again, we don't have a national prioritization of that. That to me would be huge in helping healthcare workers have adequate protection. So the number is Peter much, much larger than we ever hear from the White House. I wish just once we could hear at one of these press briefings, this is what we have, but this is what we need. This is the shortfall and what are we gonna do to try to deal with it? Never hear that. All we hear about is how many pieces of equipment are out there or being moved without any sense at all of what was needed. What kind of failure inside? Major, I mean, I think the whole logistic issue, you know, right now we've put 50 different governors kind of in charge of the country. And I think many of them have performed admirably, admirably. I mean, I have such respect for what they've done. They're trying to thread that rope for the needle and they all are kind of on their own. Now they're helping each other. I will say that. I think that there's been a kind of international collaboration, but there has been a failure of national leadership here that's clear and compelling. Logistically, why are we suddenly entering the private logistics market at the same time? We have FEMA and what has been an incident command system that was set up a long, long time ago and has really worked well. And what it would do is basically allow for an equitable and a timely way for all these different critical pieces of equipment to be allocated to the states. You know, as you've heard many times, we've basically turned the 50 states into almost like an eBay environment where everybody has to outbid everybody. That is crazy, just crazy how that's happened. And so what we need to do is have up with the standard. Who has the highest priority for ventilators? Who has the highest priority for PPE and why? And then we match up with that. And you know, if we don't have enough for that, then everybody knows why it didn't come to your place. It went to somebody else's place because it wasn't about who could pay the most or who happened to be savvy enough to have a relationship with a private sector company. But it was actually about somebody was really air traffic control. And right now I like in this situation, we got 50 pilots out there all landing their planes at the same time all by themselves. And only, only if they're about ready to have a head on collision with other planes, do they get the chance to call air traffic control tower. That's unacceptable. And that's what's happening. Yeah. Let me turn to a question about now that we know that the virus is to some extent aerosolized. What's the relative risk of going to grocery stores, pharmacies? Should we be doing delivery curbside pickup instead? If most people in the store are wearing masks, is it safe to go? What is the implications of all this? Yeah. And this is a huge challenge. I mean, clearly, I don't want people to think that because we're talking about aerosols, these very fine particles that sit in the air. And I mentioned before the kind that are, when you see the sunlight coming into your window, you see it floating there, these particles. That's an aerosol. But at the same time, we have to acknowledge that we have put far, far too much emphasis on hand washing and environmental control. Listen, I come from a world of infectious diseases where I've spent my whole life preaching the importance of hand washing. I would never want to change that. It is important. We have to be intellectually and scientifically honest with the public and say, you don't stop washing your hands, but don't think all of the self-emphasis is placed on decontaminated in the environment or that basically washing your hands is going to have a big impact because it's not. And even CDC on their website at one point says, we don't know if the environment plays much role, but likely doesn't in transmission of these kinds of viruses. And so again, keep the hand washing, but it's not an obsession where that's what's going to make the difference. It's in the air. It's the air we share and breathe. The more times you go into public spaces, the greater the likelihood you're going to swap some air with somebody who has the virus that doesn't even know it, meaning they're not even symptomatic. And we have to be honest about that. Does that mean if you want to go to the grocery store, can you? Well, I would say if you're a person at high risk right now for having an adverse outcome, let's do everything we can to find a way for you to get those groceries delivered to you, even left outside your front door where you can go pick them up and not have to have contact with someone. Or if you are someone who knows someone who's actually had COVID-19, likely now protected, they could bring them to you. But I wouldn't want those people going out in public places like this right now with the level of virus transmission we have. Now for others who say, well, you know what? I'm going to have a relatively low risk of getting a serious outcome if I do get infected. You know, I think we only have to look at that and say, well, we don't want you to transmit it to anybody else, but you make that decision whether you go out there or not. And so I think that we have to be more honest and just say that, yes, breathing someone else's air is going to put you at risk. On anyone given day, how big is that? I don't know. It's you see how this virus is moving. You know, how many people have been infected today? We don't know. Guestaments have come out 10% to 15% of a place like in New York City. That's a total guesstimate. But the chances are it's out there. So, but we can't stop living life. We have to move forward. So again, this is part of what I talked about earlier about threading the needle with the rope. How do we get people back into society in a way that is also conscious of and doing everything possible to make sure we don't get people really sick and we don't let them get into the hospital and subsequently die? That's a good segue to the question of opening up. We've heard a lot from President Trump and others about opening up maybe even next month. Is that sound strategy? Well, you know, I've said from the first day and I think I have said it on this particular session we had a month ago is, you know, if you're going to ring the bell, how do you unring it? And we've made a number of recommendations about pretty dramatic actions in our society without really understanding, well, how do you unring it? You know, I kind of liken it to what's the on and off ramps of a freeway. And right now we're all trying, I think, to work on that to say if we are at a certain level should we be enacting these kinds of very strict recommendations? And as you've seen across the country there's been a big diversity on this and some people don't believe that we should be doing anything. You know, I find that unacceptable in the sense that they're not just putting themselves at risk, but they're putting others at risk if they're infectious, particularly if they're in the hospital needing care, they're putting their healthcare workers at risk that are taking care of them. So, but at the same time, I understand the need to have an on and off ramp. So we're working right here in our state to say, okay, at this level, if we see influence like illness surveillance going up or if we see, you know, different kinds of measures changing, then we have according to that some kind of action that then we can explain to the public why should we be in a sense lockdown right now or some kind of partial impact in recommendation? And then how do we relieve it? How do we say it's not inevitable? It's not just we're gonna pick a date out of the blue and we'll get to that date and say we're done or we'll move it two more weeks. Why? I don't know, but I think we should. And we need a really objective way. And I think if we had that, all 50 states would welcome that because then it could give them the opportunity to say, you know, look at, we're on fire here right now. We're not gonna change recommendations, but others that say, you know, we aren't seeing that kind of same situation and they have the data to actually support that. It's not just that they're not thinking they're seeing it. You think there are many areas right now that are in this early amplification stage, I talked about at the beginning of this call where we had evidence that cases were circulating. It's just that they hadn't really raised their ugly head a high enough level to actually be detected. And so I think at this point, we need the on and off kind of ramp data and outcomes so that we know how to do this. And we don't have that right now, we just don't. So, you know, people pick a date out of the blue and it's all about flattening the curve, which again, I don't really know what that means in terms of if you flatten it, how do you know that anything you do or don't do is gonna keep it flat? And what are the criteria to look at that? So we need that badly. Well, just in our final two minutes, Dr. Ostern, you know, there was a question, a good question about Wuhan, you know, basically sort of saying why, you know, at least the official numbers of deaths are pretty small relative to the size of the population. Do you believe those numbers? What, I mean, there's obviously been a controversy around Chinese lack of transparency. What do you make of the official numbers coming out of China? Well, right now the official number coming out of China make no sense whatsoever. As I pointed out, how can you have a hundred or more asymptomatic infections detected today and you only have two symptomatic cases? No one I think would support that that large pool of asymptomatic people exist compared to actual cases. So right there, there's something that doesn't make sense. And if you have that many asymptomatic infections you're picking up, I know they're doing routine screening, but that also says, look at how much virus is still circulating out there, it's gotta be happening. And with that, that means that there has to be more breakthrough cases that are occurring that are just not getting reported. There was an excellent piece in the Wall Street Journal earlier this past week that really, you know, was on the ground in Wuhan that interviewed people who believe that there were cases that were not getting reported that were happening. I think the one thing is clear, it's not happening in Hubei province or Wuhan specifically like it was in January. That was a house on fire. But I think that as long as you have the ember still burning somewhere in your house that house could catch on fire again. And I think that's what we're concerned about is that even with the Chinese ability to enforce otherwise unprecedented kinds of population movement restrictions, they're still having a problem. And that just gives the rest of the world the sense that I don't think almost anyone can do it like China does it. And if they can't do it like that, then you have to understand that whatever programs we take on, we have to be realistic about what we can accomplish. And I've already laid out the testing issue is a huge issue, not gonna happen soon. And the ability of once you do test somebody in their phone positive, what do you do with them, how do you deal with it, we don't know that. That's what they're working out in Wuhan right now and I'm not sure that they have the evidence that they really have brought this under the level of control that many people report it to be. Well, Dr. Oster, on that silver ring note, thank you very much for your time and thank you to the 100 plus participants who and the people who send in questions, we all want to thank you. Thank you, thank you Peter for all you're doing. Appreciate it. Thank you, sir.