 What's it like serving on the front lines of the response to the coronavirus pandemic? And what have the federal, state and local responses gotten right and wrong so far? To answer those and other questions, reason turned to Dr. Jeremy S. Faust of Harvard Medical School and Brigham and Women's Hospital in Boston, where he trains emergency room doctors and is pulling daily shifts treating patients who have COVID-19. Faust stresses that attempts to reopen businesses, schools and other parts of everyday life will need to be based on local conditions and that effective containment has to rely on the voluntary participation of people who are given reliable information rather than ones who are bullied by political and medical authorities. It's not a weather system that we contract beginning, middle and end says Faust. We make the weather. If people believe in what their participation is, he says it's a hell of a lot easier to achieve containment than through some sort of draconian enforcement. Faust also co-hosts the foam podcast about ER and coronavirus issues and writes for Brief 19, a daily review of COVID-19 research and policy. Jeremy, thanks for talking to reason. Glad to be here. Thanks for having me. So, you know, tell me a paint-up picture of what is going on in emergency rooms and ICU units or, you know, intensive care units across the country or at least MWARE your work. The number one thing that I could say is there's an incredible diversity of experience, whether you're in New York, where people are stretched to the very limits of what's possible and being thrust into situations that they never were prepared for, to places like where I am in Boston where it's really different than anything we've ever done before, but more or less it's so far has been doable in the sense that we can respond and be nimble to the threat and change the way we do things in order to keep everybody safe. So, I think the tremendous diversity of experience from city to city, state to state just reflects a few things, the resources that are available and the number of cases and really this is the important thing, who gets infected because that can change everything. So, let's start with that. What do you mean who gets infected? You know, everything that we read or most things that we read is it's overwhelmingly older people, you know, people over 65 or at the highest risk of dying from this and of having really bad reactions. Is that true or is that not quite nuanced enough? Broadly speaking that's that's accurate. I think the data has consistently shown that over 65 and especially over 80 you have a massive uptick in fatality from this disease. Now, what we think is so different though, and this is where I get into the sort of who gets it matters, by and large the way I would say it is this if you have a thousand people who get the virus and it was say at a college that hadn't shut down yet versus a thousand people who get it in a couple of nursing homes. A thousand cases in one place, a thousand cases in the other, I would expect very, very few fatalities in the younger folks and then a ton of fatalities in the older folks and the implications for that other than just statistics are actually really important because the hospital that's receiving these patients is going to have a very, very different experience. So, if I receive a thousand young people, I'm going to find a bunch of people in that group who need help, but I won't be stretched to the limit of my ICU capacity. I won't be having to choose which patient goes on a ventilator and which one has to just die in front of me. That would be a situation which you would have if this thing had a thousand cases at once in a nursing home or in a few nursing homes. So, that is when I look at these curves and these fatality numbers, it's always important to remember that the piece of data is a piece of data. The narrative is separate So, what are we getting right as a country about the response to coronavirus and where are we just either making it up as we go along or heading in the wrong direction? Well, one thing that I would say is that because of how contagious this virus turns out to be, which is far more contagious than the initial estimates that we were told, the need for this shelter in place and incredible degree of social distancing is far more evident than what was initially thought. Because if you had, even with the numbers that you saw, it was going to be scary, but it wasn't nearly as bad as I think that we see. And so, because of that, these shelter in places and these kind of extreme social distancing is quite necessary in certain areas. And since we, and this is the part we're not doing right, because we don't know enough about prevalence data all across the country, we can't be more nuanced. We can't guess. And so if we knew, okay, in this city it's so low that we can do some degree of social distancing and in this city it's so high that we have to just completely shut down because we don't have that information that the tie goes to the scarier scenario in order to save lives. So in this, as usual, more information would be better. So we would know what to do. And so what I would say we're doing well is that when you look around, especially where I live, people are abiding by this. I think that it's, I'm a little surprised and pleasantly surprised to see that people are staying home. There's no traffic. You hear these stories and, you know, spring breakers going and doing crazy things. But by and large, I think people get it. And that's been really encouraging. I think it shows that people are willing to participate in something that's not convenient if they think it's for the greater good. So that's the only thing we're doing well is that we're responding to what we see in a way that I think is, I hate to use the word patriotic, but almost humanistic is that look, even if I am not worried about getting the virus, I am worried that I'll give it to someone else. So that's what's going well. I think what's not going well is the testing, having a strategy for that. And I think that it's something that we could have prevented. There's very little I think we could have done that was that's practical without a hindsight being 2020. It's easy to point fingers, but we knew this virus was a threat. The sequence, the genomic sequence was available early January. And I think when the final analysis, the who knew what about our testing capacity, when will be the million dollar question in terms of like, how did this get screwed up so royally in terms of that part of it? But other things are I think are very hard to have predicted because of the contagion and other and of course the asymptomatic transmission that the symptom free people being able to spread it. I can't you can't point fingers at that. That's that's something that we didn't know. And I don't think was appreciated. And it's so unusual. So with the testing is the problem like we went from zero test to a million tests, I guess relatively quickly, even if it should have started earlier. What's going on now? Because it seems like that the number of tests has not grown particularly well. Do we need different tests or do we need more of the same or what what what would help resolve that? There's a couple of ways to answer that question. It's a little bit of both. So it's well stated. The the reason I think that there's a couple reasons why testing numbers are not increasing sufficiently. And one is actually a little bit of an unequal demand. So I think that we've heard even stories that some of the commercial laboratories are saying, hey, we can run more tests. Why aren't they why aren't we being sent more tests? And that could be because in certain areas there are there is an excessive test there actually like where I'm working right now, it's changed. A month ago, I had to beg the Department of Health for a test. And they would say no. And I was like, are you kidding me? Like I need to test this person. They got it or I think they do. Now I don't have any real careers for the most part in my emergency department if I want to test. So for me, I don't think that there's a bottom like in our area in that way. But I'm sure that I know across the country, our colleagues who still can't who can't do these. And so if you could wave a magic wand and have the test be where they're needed, that would be great. But I'm worried that the reason that the testing is increasing is that the places where it's needed most don't have enough tests. And I can't tell you why that is. But I do know that we seem to have enough in some areas and not enough in other areas. And again, that's where a surveillance from the CDC would have been helpful. They're just now doing that, but we don't have enough information to know that. Are you a strong critic of the way that the CDC and the FDA have kind of handled the oversight of the testing regime so far? Or is that something that's not worth discussing at this moment? What I would say is that I don't know enough to be able to make a really informed opinion on that. But my sense from people who do is that for whoever's fault it was, whether it's the CDC or external factors that affected the CDC, but the early testing problem sent it around them. And I don't know to the extent how the FDA would have played into that. I know that now the FDA is doing a better job in terms of fast tracking tests. I think the CDC is now doing a better job with surveillance. But so I wouldn't necessarily want to cast blame per se, but I do think that we had policies in place that didn't allow for a ramp up. And I think that that was unfortunately a life, a death inducing mistake, because we know, and I wrote about this almost a month ago now, it's time to kind of fly, but we know that if we can, if we could do all this testing thing, you can tell people who were young and healthy, hey, look, you got it, and you don't even realize it, or maybe you thought it's a mild thing or a flu. So don't give it to the nursing home. And so don't go to work because you're a healthcare worker or whatever it would be. So that to me is unfortunately where this all started. And to answer your question, I think it's how we get out of it too. Both with the kind of testing to ramp up and increase availability where it's needed. And of course, the next thing, two more things I would say, one is to start to figure out how to use antibody testing. Because right now we test for the virus's genomic material, genetic material. So we do, that's called a PCR test. And that's a pretty good way of knowing if a patient has the disease or not, although it's not perfect. And then the antibody tests, which are blood tests, tell you where you expose at any point, how immune are you, we're still working out all those details. But knowing how much there is in terms of antibody prevalence in communities will be very helpful. Because if I find out that, hey, look, my entire town seems to have had this already. And 90% of us have the antibodies that you could open right up, right? We just have to know both quantitatively and qualitatively where we're at with that. And then the final piece, and this is a really a little more of a nuanced argument in the, even in the absence of what I would fantasize about, which will be like just tons and tons of tests for everyone all the time, like, you know, just you want it, you got it, like, you know, a billion tests, three per person or 10 per person in the country. And anytime you get to find out that may not be practical. But you do start to be able to guess or make a good estimate of how things are going. If you have a pretty wide testing regime, and you start to say what your what your hit rate is. So right now, you see, like, if I test somebody, I feel like, I mean, I'm making this up, but more than half the people that I test will test positive. And that means we're not testing enough people, not enough people coming to the ER or wherever else. Whereas in New York, it's starting to fall. So when you when you get to a point where you're doing a random surveillance, and a very, very tiny fraction of people actually have it, then you can say, Okay, we're on the tail end of this thing. I'll give you an example. A study just came out in the New England Journal the other day. And every single expected mother who was getting admitted to a hospital in New York was discreet. Like, they had 200 and something women who were about to give birth, and they just said, We don't care if you have a symptom or not, we're going to check you out. And it turned out that not surprisingly, 15% or so actually had it, which is a crazy high number when you think about it. But given what we know about New York may not be so surprising. What was remarkable was that eight times more people had no symptoms than symptoms. And now that may not expand out to other populations. And we don't, these are people who've been interacting with the healthcare system. So they might have a higher likelihood than you and me or actually, I have the higher one. But all to say that when you start to see your batting average, your sort of hit percentage drop below 2%, 1% less than that, then you can say, Okay, look, these are needles and haystacks, not everywhere you were. So there's been a lot of discussion about the idea that the premise is that once you have the disease, you are immune to it, and you're not going to transmit it. And so you can go back out into the population. There are some questions about that. How serious do we need to be taking that? Yeah, that's a question that I have to watch with you as well in terms of the immunologists and the specialists on that particular issue. But the way I would summarize it for people who are trying to get their mind around it would be to, we all have the experience of having our vaccinations as kids or as adults. And then you might have to get your blood drawn once in a while to get what's called the titers. And this is to say, Okay, you had your measles, mumps and rubella when you were a child. Are you still immune or not? And the numbers depending on the virus are correlated to, Okay, if your numbers are at this level, we think you're good. And that's what we need to kind of tease out here, which is, so we'll get a yes, no, pretty quickly on the coming weeks and months about how many people were exposed and all of this. The question will be, is it if everyone who has the antibodies is immune for how long? What does that mean? That's going to have to be teased out by very rigorous studies. But these are studies that thankfully, we actually know how to do. Let's say we, I mean the system. Can you describe what do you do in an emergency room situation or in an intensive care unit? What are you doing for patients when they come in? So the number one thing that I can do as an emergency doctor, well, there's that there's so many different things. The first thing is any EM doctor, emergency medicine doctor is we save life, we save limbs, we save organs. And that's what we do. So regardless of whether it's COVID or whatever it else is, it's the first thing to do is to stabilize the dying or the nearly dying patient, if that's possible. And if that's consistent with what they want, some people, they are clear, they don't want to be put on machines. And they want a natural life and a natural death. So that's number one. And so when a patient comes in and they're having near they're about to die from a respiratory failure, then and they want to be, we assume that they all want to be saved. Although again, this is where goals of care and most forms and all this sort of things, advanced directives, living wills, then what I can do as an ER doctor is to stabilize them and give them increasing amounts of oxygen, whether it's do masks or or I can do what's called intubation, which is when we put a patient asleep very rapidly, we paralyze them temporarily, I put a breathing tube into their near their lungs into their air pipe, a windpipe and and get them the oxygen they need. So that's the so in terms of the critical, critical illness, it's it's an oxygen issue. It's an it's an oxygen delivery issue. And however we need to do that is there's the way to go. And there's other details of this disease, we're starting to see other more blood clots, do we need to be more aggressively treating that? Are there other infections simultaneously? So that's the that's the big thing that the next big thing is, essentially, it's a resource utilization in the sense of is the patient in front of me assuming they've got coronavirus, do they actually have disease that needs to be looked after in in the hospital in the clearly if they need to be put on a ventilator, that's a pretty easy decision. But the other ones, the ones who sort of look a little uncomfortable, they need some oxygen, they might need some other treatments, maybe their blood pressure is a little a little dicey. Yeah, can I turn them around and send them home or is like, Oh, no, I need to watch these for longer. So it's it's essentially it's a risk, we call it risk stratification. And to know, okay, who among the people I send home are going to do poorly, if I do that, who among the ones if I keep them could go the other way. And this is another thing I argued in another article, if we overdo it, we can harm people, right? So if I admit a patient today, who has a reasonable but low chance of having had a stroke in the past 24 hours, you know, a month ago, I would have admitted them no problem, even though maybe it was not the best, if you really did a risk benefit calculation, it was kind of on the borderline. But we have to be careful because of a lot of issues, including litigation and including standards of care. But today, that same patient, if I admit them to the hospital, I'm really, really saying, well, I think that whatever is going on with your possible stroke is more important than the risk of you getting coronavirus while you're here. And that is a very different calculation, which is why I say everything's different. We have to, we have to follow the data and be nimble of that. So a lot of the is a decision process as to who's served, where and, and the most safely. And we're getting more and more data on that. But it's still a lot of it's just a judgment call. Can you talk a bit about the case fatality rate? And yeah, because that was, I think, the first writing of yours that came to my attention. And you, I guess it was like it, you know, you say like a month ago or two months ago, that seems like 10 years ago at this point. But you were arguing in a paper and, you know, that the case fatality rate, the number of people who have the disease who die from it is almost always going to go down because in typical pandemics, as you do a fuller accounting, the numbers starts to go down. What, what is your best estimate at this point of what a case fatality rate for coronavirus in the US is? And is it going up? Is it going down? And does that matter at this point? Well, I, I'm a very data-driven kind of guy. It's hard for me to make a prediction. But what I would, I would, what I would like to do is to, to break this into two parts. And I think that we're going to, and I think people should watch this, that they should look at a case fatality rate for people who essentially, initially had very mild symptoms and may not have even been tested at first. So put it this way, the case fatality rate for people who don't even know they have it or just got sick at home and they think they had it, I'm sure it's almost going to be zero because that's why they never got tested and discovered. So there's this huge pool of people who have the disease that we don't even know about and none of them die, right? And then you take a couple of them out who, who progress and get worse and then they show up to the hospital. And then you look at that pool of people. That's the second pool of people who show up at the hospital. And among that group, you can start to look at these numbers again and say, okay, is it 1% is 2%, is it 0.1%, 0.2%. And again, you have to put both of those pools together in order to make an overall case fatality. So, so one way we could look at it would say, patients who are admitted to the hospital, what's their case fatality rate? Patients who were seen at the hospital and sent home, how did, how many of them came back or died at home? What's their case fatality? Obviously much, much lower. And then the third piece is people who never even knew they had it. We'll figure this out through antibody testing and through other ways. And then you put all of that together and my assessment is you're going to see something far under 1%. And, but still over 1% for that really sick group and older group, but for the most people, it'll be far, far under 1%, which leads to the, I think, the inevitable question. If it's 0.5%, 0.2%, 0.6%, whatever, anything under 1% is within order of magnitude, apparently, of seasonal flu, right? Because seasonal flu, they tell us it's 0.1%. So how can this thing, if it's 0.5%, how can this thing just be five times worse than flu when, and what we're seeing to our system is not five times worse, it's 100 times worse than anything we've ever seen before. And that's where, again, really good data matters. Unfortunately, the 0.1 seasonal influenza number that you hear is not accurate. It is a gross overestimation of influenza deaths. So what you're saying is that it's not necessarily that the novel coronavirus is that much worse than what we think, but it's that we have been overestimating what a typical flu season produces. Without a doubt, yes. And I'll be writing about that more in the coming days and weeks. I'm not going to skew myself too much on that, but what I will say is that's an area of actually massive importance, not just because of academic, like, oh, which is worse, which is better. But actually, it could, because people say things like, oh, it's 60,000 deaths is what the newer revised thing is, that's what killed flu last year. So it's just another flu. And people who aren't in the hospitals who aren't in high prevalent area sort of shrug it off as like maybe, oh, this is kind of hysteria or making a big deal out of nothing because they're not seeing what they're own eyes. And so that's an incorrect comparison because you have to actually compare, and this is what I'll say, you have to compare counted deaths to counted deaths. And the 60,000 deaths due to influenza are not counted. They're estimated. And they're based on many assumptions and coefficients and multipliers that are used by public health officials to make what they think is a good estimate, but I think is probably being shown not to be. And it's, but it's for a laudable goal. They want to get people vaccinated, they want to tell people the hygiene matters. And so over selling the flu over the years had a kind of a public health benefit, I would say. But today, you have the president out there, and even a month or two ago, we had the surgeon general who I think is a very intelligent and measured guy saying, oh, it's just as bad as the, you know, this will be no worse than the flu to the numbers. Well, no, they're, they're, they're, they're, they're wrong. And the implications are, are, are gigantic. If they, if people use that information to say, okay, well, it's just another flu, let's open the economy. And that would be devastating. So what, what do you think? And I realize this might be outside of your area of expertise or comfort, but where do we need to be before we can say, okay, let's open up the economy? Or is this also going back to your earlier statements? Is this really what we need as more regional or more location specific data? Because what's going on in Boston or the greater Boston area in New York? And I don't know, you know, some place in Kentucky, these are radically different environments and should be treated differently. That's, that's what I'm saying. Yes. And I will just use New York and Alaska, the two extremes, right? The Alaska is an important part of our economy. And the caseload is, is, is obviously much lower. And, and just in general, the, the risk of, of a rapid spread is lower because just, just the density. And so one of the problems with New York is it's such a vertical town and everyone lives in the same place. They touch the same elevator buttons. I mean, it's a recipe for disaster. So you can have, you need a much stricter and slower reopening in a place like New York than you do in Alaska, even if you could measure everything perfectly, which of course we can't do. So what I would advocate for is a slow reopening that state by state, region by region, and also situation by situation. And some of it's a matter of two, there's two things to think about. One is how, how, how, how necessary is the thing to reopen, right? You could make different arguments about what was considered necessary and what's not. So you can have a little bit of a higher risk threshold for some necessary things, or a lower threshold, I suppose, sooner to open. On the other hand, you could say, well, look, this is also a low risk situation, even if it's not that useful. I've been using a silly example, but like the Boston Zoo where a bunch of kids go, I don't necessarily see why they can't reopen relatively sooner knowing that you just say, okay, look, usually we allow 1000 people in per day. And this month we'll let 100 people in per day and everyone's going to stay apart. And, and we're going to watch it carefully because I believe that some reopening in this way would be really beneficial for the, well for the economy, but also just for our society. I do worry you see these protests like, you know, we want to be free, let us out of our quarantine. I think if you ask too much of people for too long, there's this rebound effect where they rebel. It's a, it's a, it's in our nature to not want to be, you know, quarantined. And so the sooner we can safely do these things, the better, but each situation is, is completely unique. Could you talk a bit about what you think the legacy of this? And obviously, I mean, we're still in the thick of it. So it's, it's a little bit forward to do that. But what is the effect going to be on patient autonomy? I mean, do you, do you think is this a place where the medical profession or the public health profession and political scenarios will say, you know what we need to do is to give patients more information to make individual decisions, whereas this going to have more of the effect of saying individuals are not the people who should be making the decision here. It should be a larger outcome. It's an important question. There's so many different nuances to that. For one, the big ticket item here with autonomy is going to come down to vaccinations is if we have a vaccine that works and there are people who are refusing it, what do we do? I think that's going to be a really important question. And it's, it's always been kind of a hypothetical in the sense of, oh, we're going to have a resurgence of these pediatric diseases. And we actually, and then in some cases, we've seen it for real, right? So we've had to go through and say, okay, our religious exception is enough. Nope, that's changed. So that needle moves. I'm very, as you are, Nick, I'm very interested in to see where that goes. Because again, I think that the right to your own autonomy as a person, as a patient does is pretty broad. But I don't think it goes so far that it means that you can put your neighbors at risk. If that risk is real, if that risk is real, you know, if it's like, you know, you're going to imagine an insane situation. If someone didn't understand HIV, and they said, Oh, I don't want to live next to that person in the next household, they have AIDS, and I don't want to get their AIDS. Like that would be very ignorant. But the point, and that would be an extreme example of that your autonomy is not so important. You know, like, if you're the neighbor who believes that, you know, you're going to get infected by the neighbor, whereas a very communicable disease, their point is, you know, then it's like, well, actually, sorry, we have to, we have to do this, you know, we have to say what is right and what is wrong. So that's the big thing. The next thing I would say in terms of the autonomy question, in terms of medical information, I think that in general, I think that we've been moving towards more medical information. So that's for the better. One thing I think that one of the legacies that I would turn to that we haven't really touched on, but I think it would be interesting to you. And I think this this this listenership and readership is the issue of medical science in general and research. And we're seeing this just an astronomical number of research papers coming out about coronavirus and COVID-19, which are not precisely the same thing, once the virus and once the syndrome. But and the peer review process is something that really needs to be looked at. I think we've had situations in which in the past, I'm sure you're familiar, where the system has been really effective. And in times where it's been hijacked by people who are trying to make money. And in this case, I think that what's the real concern I have is that even among my colleagues, my physician colleagues who are supposed to be like scientists, sort of a little bit of throwing the scientific method to the out and just saying, Oh, forget it. So the examples of, well, we need something. Let's just give these medications out. And that very worries me greatly that we are that we're on this situation is unmasking some degree of scientific illiteracy among some of my colleagues. And even in very intelligent places, because there's just this intense desire to do something good. But sometimes we have, and there's there's a bias that we carry that we think that we help more people than that we think that what we do is more beneficial than it might maybe is, even though I think there's benefit. And we think that the way we hurt people is less severe than it is. So, you know, we always, the lawyers chase us down when we didn't do enough. But they never chase us down when we did too much. And they should, they should chase us down for both. And in fact, I think that doing too much is probably way underreported. And doing too little is probably over exaggerated. I think that that's a big thing is to stick to the scientific method. I'm very, very worried that people are saying, Oh, I heard an anecdote about this drug or that drug, and we're going to give it out without any really good science. And that's the part where I'd like to see a course correction. As a final question, you've talked about the pressure on people when you ask them to do too much to stay quarantined, to stay locked down. And it has, you know, psychological effects on people. How are how are you and your colleagues, you know, who are dealing with us on a daily basis? How are you guys holding up? And is there is there a psychological strain that is that gets to be too much? Or, you know, how does that play out? The psychological strain that my colleagues I have is only related to safety at work. If there's not enough personal protective equipment, then people are really worried. The rest of it, I don't think we're worried about going in fact, I think I think we have it easy. Everyone else is stuck at home. I'm just going to work like normal. Do you have do you have the personal protective equipment that you need? And does that, you know, does that short of seem to have been taken care of or we're rationing like crazy. So I've not yet encountered a situation here where I felt unsafe. But I never thought I'd be rationing. So that's that's that's but we also and but we see in New York, there have been places where it is unsafe. So that's real. So in terms of the stress on us, I don't I don't feel stressed. I think it's easier for people like me because I just know what to do. I got to work and I just stay safe. It's much harder for my family, like sticking home. They're not directly part of this. And that's where people get antsy. When can this be over? When do I get to go outside? When can I be free? And I think that the the number one sort of thing I'm learning here is that the way to get people to to effectively participate in these strategies that we know to work is not to force them to do it. Although if necessary, I guess that was what you try to do. But because that's not going to work. The best way to get people to to participate in these strategies is to have them understand why they're doing it and have them want to do it. And so it's almost like the way the yes, we can sort of war effort, you know, like, you know, we didn't live in a time during World War II where people will remember like what it is to like conserve for a greater cause. But I think that there is a sense of the greater generation that they wanted to do that in order to help the war effort. And I sort of feel the same way here. It's like, even if you had enough police in the world to say to save one at home and do it, you know, authoritarian governments could maybe accomplish. I don't think that would work. I think the best way to do it is to basically appeal to people's sense of what reason and duty and that it's just a lot easier to do something difficult if you know why you're doing it. And you have a sense of your part of it. So I do try to actually kind of inspire people to think about that doing nothing is doing a lot. And it's very appreciated because it's not it's not a weather system that we can track beginning middle and end. We make the weather. And so I think if people believe in what their participation is, it's a hell of a lot easier to achieve that than at, you know, at some sort of draconian sort of enforcement. Dr. Faust, thanks for talking. Where's the best place for people to follow your your thoughts and actions on all this? So well, Twitter at Jeremy Faust, but the I have a daily blog with a bunch of ER doctors and policy wonks called brief 19. And that's brief 19.com and brief underscore 19 on Twitter. And what we do is we do a two day exact a two page executive summary of the research and policy currents that as we see them. And we try to put all those crazy papers that are coming out into context to say, Okay, hold your horses, like here's what it says, let's not get ahead of ourselves. And then in the policy side, try to track what what we think matters and what it means. So it's for doctors, so it's by doctors, but it's written in a way that we hope is not just for health care professionals, but also for the mainstream sort of to light bulb on viewer or reader. And and that's been really successful. So that's the best way. All right. Thank you again. We're going to leave it there. Dr. Jeremy Faust, thanks for what you're doing and for joining us today. Great to be with you. Thanks so much.