Coronavirus update: How can we cope with COVID-19 anxiety?

indoors for an unknown period of time. The level of restrictions on where you can go and what you can do, the closure of schools, restaurants, nightlife, the canceling of sports and entertainment is largely unprecedented, but it's necessary for the health and safety of this country. So if you're not social distancing yet, please do. But it's a lot to deal with, and I know right now it's all consuming for all of us. It's what we're reading about and

what we're worried about. But I'd really like to help to settle into this new reality and perhaps understand what all of this means for us, which is why we're deaty kating the rest of this season of Next Question, which means four more episodes every week and perhaps even more to the coronavirus pandemic. For day to day news on this ever changing story, I do recommend you continue to turn to your local government, the CDC, and the World Health Organization for the most up to date information.

I'm also providing updates on my Instagram feed. As for me, well, I'm hold up in my house, which means I might sound a little different to you. Social distancing means I'm not going into our usual studio and speaking into a fancy microphone. Right now, I'm sitting in my home office and I'm recording myself on my phone, and instead of speaking to my guests in person, we're connecting over our computers. So bear with us, everyone, but please keep listening for

this critically important information. So today, my next question, how do we manage this new normal and coronavirus anxiety. To answer that, I called up my friend Laurie Gottlieb. Laurie Hi by. Laurie Gottlieb is a psychotherapist with a private practice in Los Angeles, but she's also a best selling author, a journalist, and soon a podcaster too. But today we're focused on the issue at hand, So um, let's talk about why people are. You know, I think with good reason,

people are feeling a lot of anxiety. But I think it's interesting that the unpredictability of all of this, Lorie, is a perfect recipe for high anxiety. Can you explain that? Yeah, you know, it makes sense that we have anxiety. And I think there are two kinds of anxiety. There's productive anxiety and there's unproductive anxiety. And productive anxiety is the kind of anxiety that helps you to take action. So that's why we're washing our hands all the time. That's

why we're social distancing. If we if we were in denial, if we said, oh, this is no big deal, we wouldn't be protecting ourselves and other people. So that's that's

good anxiety. The kind of anxiety that gets us into trouble is unproductive anxiety, which is when we start just ruminating and we start catastrophizing and futurizing, like you know, those thoughts of oh my god, I'm going to get this and I'm going to die, or someone I love is going to get this and they're going to die, and you know, just all the stories that were kind of spinning in our heads, and and that doesn't help us in any way. Well, what makes us go as

human beings too? That dark place? I know that in therapy, you're you know, this better than I. But sometimes people do say to patients, what's the worst that could happen, as a way for them to help kind of conquer their fears. But you believe in this case, that's not super helpful. I don't think that that's helpful. I think that one of the things that can really help ground us is instead of thinking about what might up and in the future because it hasn't happened yet, is to

stay grounded in the present. So one of the things that I think happens is that when something extraordinary happens, we long for the ordinary. We want we want our routines back, We want all those things that we complained about, you know, when when we didn't have something, we weren't in a heightened state like this. Um, we want it back, and yet it's still right in front of us. So UM. I like to talk about the concept of both, and which is, yes, something horrible is happening, and we can

also enjoy certain things like the ordinary. We can enjoy the time that we're having connecting with people that we normally don't really pay attention to in our daily lives. We can enjoy cooking together. We can, you know, in our own isolated family units, um, we can enjoy having the time to read a book or to think our own thoughts, or to um, you know, actually face time with one and actually listen when you ask how are you?

I think one of the one of the kind of nice things to come out of horrible experience like this

is that people are very kind. Kindness comes out. There's sort of a resurgence of kindness in this world where civility has been lost, and so I think that both at both can exist, and if we can focus on, you know, holding our fear and feeling our feelings, not being in denial of our anxiety, and not being in denial of what's going on around us, but also really trying to stay present in what's happening in that moment.

We have so many questions. But before we get to some questions from people who follow me or listen to the podcast, Laurie, I'm a fairly normal person in that I don't have huge anxiety, but I'm finding I'm feeling a little neurotic about my health. If I have a little bit of a sore throat when I wake up in the morning, or if I cough, then I start thinking, oh, my god, am I sick? And I'm sure I'm not alone in that because it's part of catastrophizing. I'm sure,

what what is that about? How can we kind of calm ourselves down? Well, I think the first step is just realizing it that it's human nature to do that. So I remember when I was in medical school, we we talked about sort of medical school disease, which was every disease that we were reading about. We all thought we had all of a sudden we felt the symptoms of it. You know, it's like, oh, my god, I have this now because my my gland feels inflamed or whatever.

Um that now that we're reading all the time about the symptoms of coronavirus, you know, it's almost like the power of of uh implanting it into your suggestion. Right. So, so I think just realized that the power of suggestion is very powerful. And and so when you notice that, of course be aware if you are having symptoms, but also take a breath. Um. Part of part of the problem is that we're reading about and I always tell people that, yes, you need to get daily updates, but

you don't really need more than that. I think that the more that we're just you know, kind of it's kind of like we're binge, like binge watching a television show, but it's kind of like binge eating junk food. That the more you sit there and click from this article to that article to the other article, it makes you sick. It does not fill you up, It does not help you. It actually makes you psychologically ill. How do you talk to kids about this? I'm sure that a lot of parents,

you know, my children are older. Your son is in high school now, right, he's in middle school, middle school, so he's he's at home. Is he expressing concern? And how do you suggest people talk to their kids about this? I think that the way that we model our response to this is going to impact the way that our kids handle their anxiety around it. So it's kind of like I think, you know, when when you're on an airplane, they always say put on your oxygen mask first before

you put on your child. But I think it goes beyond that. It's how does the pilot handle it when there's a problem and the pilot doesn't say, oh my god, we're all gonna die, you know, if there's something the pilot says very calmly, Hey, we're gonna experience some turbulence coming up. We want all of you to fasten your seatbelts and please don't walk in the aisles right now. And I think that's very calming. And I think that for our kids, we need to say, yes, here are

the rules, here are the boundaries. You can't go and play basketball. I say this to my kid, you can't go play basketball with your friends right now because we're social distancing, um, you know, and and we're gonna do this instead. And and just to kind of, you know, under help them understand. I think giving them a sense of purpose to around this, which is we're not just doing this for ourselves. We're doing this for our community. We're doing this for our neighbors, for the elderly people

that we know. Um, we're doing this for people with compromised immune systems. And I think that kids really engage in that when they realize that it's bigger than them. It's not just oh, this is a bummer. I'm stuck here and I can't play with my friends, and I can't do the normal things I like to do. Um. There's there's something about being connected to the larger community

that really resonates with with tweens and teens. Well, let's play dear therapist Lorie, because we've got so many questions and I don't want to be sort of a pig about just asking my own Rosanna says, how much information should we deal with on an everyday basis, especially with the situation changing by the hour or day. Do you have any suggestions for what is a healthy media diet? Yeah?

I do. I think once a day is plenty. And I think that's because we all know what we're supposed to be doing, regardless of how many new cases are reported, regardless of whether they're saying you can't go here, you can't go that. We know we're supposed to be social isolating. We know we're supposed to be washing our hands constantly. Um, we know that we're supposed to be cleaning the the all the handles and um, you know, door knobs and things like that in our homes and all the sort

of high touch surfaces. We know what we're supposed to be doing. Nothing is changing in that regard. So and we also know if you're having symptoms what you're supposed to do. So there's no information that's going to happen during the day. That's going to change the basic facts of what we need to do in our lives. And we really need to protect our psychological immune systems as much as we're protecting our physical immune systems, and that

means not overloading ourselves with information. Here's another question. What are some tools new moms or expectant moms like me, She said, uh, can use to get through this uncertain time. Bringing a new baby home is tough enough, but limiting the village from visiting and helping will put a strain on many Thanks to you. Yeah, um, you know, I think that it's really important for parents to kind of

trade off time so that they get a break. So I think that when you've got a baby and you don't have your village around you a lot of times, um, you know, you need each other as adult as a couple. But sometimes you're gonna have to say, you know what, it's your turn, and I'm going to go take a bath or I need to go just um, you know, I need to go take a walk whatever it is, and and hand off to the other parents. And you

really have to work as a team. So I think that's really important, you know, if you're living in a multigenerational household and you have, um, you know, other people to help, that's great. I think it's also important that you you connect again for your own mental health, that you connect with your friends through technology and you take some breaks and you laugh about how hard it is, and you laugh about the dirty diapers, and you laugh about the naps that are not being taken and all

of those things because you need someone to vent too. Yeah, definitely, and laughter is really helpful. Here's a question, j P. As I'm an addict in recovery, are twelve step groups and meetings are shutting down. What is the best advice to stay out of your monkey and stay connected even at a time of much needed social distancing. So if you have a sponsor that you can connect with virtually, that would be really helpful. If you have other people from that you know, from the group that you can

connect with, that would be helpful. There are also so many online resources, um that you can listen to podcasts, um. You know, uh M. I was gonna say, there's groups online where you can you know, write in real time and connect like that. So I would really search the internet. I think the internet is our friend right now, not in a sense of getting an overload of COVID information, but in a sense of how we can get creative around connecting with other people when we need it most.

Vivian says, how can I stop obsessing and stockpiling groceries? I think that's such an interesting sort of primitive instinct. People are going and kind of sometimes hoarding food. They're so worried that the grocery stores are going to close and that they're going to starve to death. You saw that with the toilet paper shortage. It's fascinating thing to observe just from a human behavior standpoint. Um, what advice could you give Vivian and other people who are feeling

that way. There's a difference between being prepared and obsessing, and that line is going to shift the more that you kind of think about, oh, what's going to happen in the future. I think being prepared means that, yeah, you have some provisions in the house, and you you know, you you have things that that you're going to need. But you know, when you start getting to the point where you've already gotten the provisions and you think, oh, I need more, and then I need more and then

I need more. Um, that's when you need to step back and say, you know what, I am prepared. I will be able to get more later. But I have enough. I've done my preparations and I've done what the recommendations are. And then you really have to let go. And that's again we're staying in the present. Helps where instead of thinking about, um, you know, do I have enough, and and you know, spending your emotional real estate on that, do something else. And I know that sounds like I'm

trivializing this, but I'm not. Um, you know, go do a puzzle, Go get those art those art supplies out, Go read a book, Go take a walk, Go call a friend. You have to take breaks, you have to let go, and you have to stay active. I think, even though you know the whole it seems anathetical with the idea of staying home. There ways to stay active at home. Clean out your closet, get rid of all the clothes or put them aside that you can give for dress to dress for success or to the goodwill.

You know, it is a good time to do some serious spring cleaning, open the windows and and you know, get the winter winter out of your house and out of your things and maybe downsize a little bit. Andy asked, I have a friend who suffers from anxiety. This is kind of an obvious question, but it's a good one. How can I best support them during this time? How can you support people who you know? What can you do for them? One of the things that happens with

anxiety is logic doesn't help. So you can't really talk somebody out of their anxiety and try to tell them that things are going to be okay. What you can do is you can connect with them, and that's that naturally sues people. So why don't you say, hey, let's do let's have a virtual dinner together. Um, hey, let's watch a movie together virtually? Um, you know what, whatever

it is that you can do. Um. You know some people are exercising together and virtually, which is fun, so, you know, and just moving your body helps so much with anxiety. So if you can somehow get your friend to, you know, move around, and you can do it with that person virtually. You can support the person through actions, as opposed to your words will not really help them, but your actions will avas how to focus on work

while acknowledging that we're all scared. No, I think you and I know that when you are worried or stressed out, it's hard to concentrate. Actually, I know that from when my husband was sick. I would read the same paragraph over and over again in a book and I could not, for the life of me, concentrate. So how can you How can you fight that? Is there anything you can do? I guess reducing the stress will help you concentrate more.

There's also something you can do with your body, which is that sometimes when we kind of leave the present, we need to physically ground ourselves. So what you do is you close your eyes, and you start with your feet and you say, I feel my feet on the floor, and you feel them, and then you move up and

you say, okay, I feel put your knees together. I feel my knees, and you move up and you just keep and you feel your breath and you feel your diaphragm, and you feel the different parts of your body and it brings you back to the present moment and you take some breaths, and then you move on with your work. Kristen wants to know how do you cope with the idea that we don't know how if when this is

going to end. I think that's in addition to the unpredictability of this, This kind of not knowing when life will resume, I think adds to people's stress levels. Right, I mean not just am I going to get this and what's going to happen? But how long is this going to have to be the new normal? So how

do you cope with that? I think we have to acknowledge that humans don't do well with uncertainty, and so this is a good opportunity for us to build up some resilience around uncertainty, which means that we just instead of trying to figure it out. You know, this news report says that, or this physician says that, to just say we don't know, and to try to get comfortable with that and say, what can I do in the meantime to have as normal of a routine that I

can possibly have under these circumstances. You know, I don't want to let you go before asking you if someone is having real trouble, you know, if the anxiety reaches a point where it's untenable or it's affecting someone's physical health health, Um, you know, I I don't want to trivialize the seriousness of this. So what can people do if they really feel there at the breaking their breaking point, Laurie,

They should absolutely reach out to a therapist. And so many therapists are doing online sessions specifically right now for this, and they should reach out. And this is not a time for shame or stigma or you know, oh my problems aren't that bad minimizing our problems. Um, everybody else is going through this, So why why why should I get help? You know, all those things we say to ourselves that prevent us from reaching out. This is a time to say, I need to prioritize my emotional health

just as I'm prioritizing my physical health. And if you need to talk to someone, you do not need to be in a christ is. You can just be having a moment. You can be feeling kind of free floating anxiety, depression, whatever it is, or you just want to connect with someone because you feel like preventively to kind of preserve your emotional health. Please please please reach out. You can find you can do a quick Google search and you

will find somebody who is available to do that for you. Well, Lourie stays safe and call me and maybe we'll have a virtual glass of wine together a cup of tea. I don't want to encourage people to drink during this time, but a glass of wine isn't going to hurt, right, That's right, that's right. Thank you so much, Katie. Okay, bye, Laurie, all right, take care or stay safe. Laurie gott Lee's latest book is called Maybe You Should Talk to Someone.

She's also coming out with a podcast called Appropriately Dear Therapist, co hosted Buy Another Therapist, Guy Wench. It's due to come out from my Heart hopefully this summer. You know, I really like what Laurie said earlier about how kindness tends to emerge out of times of crisis. People are kinder to one another, they want to help, And I'd like to know the large or small ways you're seeing

kindness or promoting it in your own community. If you want to share your story, please call and leave your name and a detailed message for us at Next Question. The number is eight four four four seven nine seven eight eight three. That number once again is eight four four four seven nine seven eight eight three. You can also email me a voice memo or a written note at info at Katie currect dot com. Just put next question kindness in the subject line and you might hear

your story right here. On next question coming up, we're going to be checking in with the doctor who's a friend of mine and one of the smartest people I know, to get a better sense of how the coronavis irs affects our bodies and also our health care system. Dr Peter Atilla is a Stanford and Johns Hopkins trained physician

living in San Diego. His clinical focus has been on longevity, how to live better and longer, but since the outbreak of coronavirus or COVID nineteen, he shifted gears, focusing his research towards understanding the current situation, what we can do to protect ourselves, and potentially the implication of what's to come. And now he's here to share some of that with us. So where are we now understanding? This story seems to change on an hourly, if not minute I minute basis.

If you had to assess the situation right now for our listeners, what would you say, Well, you know, I think of these things through the lens of um. Is the rate at which we are seeing infections growing or shrinking? So you can think of being on one side or another of that peak. So, for example, if we look at mainland China, we know that they're now on the tail end of this response. Again, there's always possibilities that there's another outbreak as they go back to work and

begin to mobilize society again. But notwithstanding that, it's clear that they're on the right side of that curve. Both um, you know, right and correct um, we're still on the left side of that curve, which means each and every day it appears that we are seeing more and more people get infected, or the rate at which the infections

are increasing is is still increasing. Now the million dollar question for which a lot of people, you know, really smart people, epidemiologists and such, are trying to project is

where is that peak? Because the peak is sort of what gives us a sense of that maximum rate of infection um, and that is, once you know what that looks like, then you kind of have a sense of what the overall number of infected people will be, and then you can extrapolate, hopefully from the data we see in other countries, what the impact is going to be on the health care system. And of course the things that really matter, like how many people are going to

potentially die or otherwise be debilitated by this. Why was Italy so overrun with this virus? What was the perfect storm that made it go through that country like wildfire? So I think we can speculate on a couple of things. First of all, I think part of it is bad luck.

I mean, it's it's important to understand that if um, let's let's just make the math simple and say, let's let's pretend there were a hundred infected people in China as where the epicenter was, and that you know, ten of them got on a plane aine and happen to travel and go someplace. Well, the ten places that they land are going to have a head start in terms

of where this virus is going to spread. And if one of the places they landed was Italy and one of the place that they landed was Iran, then those places are going to have a bit of a head start. So I think there's just a little bit of a luck component, which is it probably got an early start on the virus reaching there other factors that seem to

matter seem to be the age of the population. So Italy has a relatively old population compared to other countries in Europe and relative to the United States, meaning they have more people who are in that high risk category based on age alone. Furthermore, there seems to be a slightly higher prevalence of smoking, and smoking is definitely one of the major risk factors for people who, if they're infected,

are more likely to get ill. And then I think the other component is, you know, some of the sort of just societal things about the proximity that people are to each other. So in other words, if you look at the place like Wyoming, if someone had landed, if one of the first people infected had landed in Wyoming, it still would have likely spread slower than landing in a place like Italy, northern Italy, where the population density is such that there's more contact with an infected person

to another. And then I think, finally, just at the policy level, they were probably a little bit later to realize what was happening an institute the measures necessary to slow the rate of spread. You have said it, Italy taught us that it is the morbidity rate, not the mortality rate of the disease that is grave for us. Non doctors who may be listening, including myself. What is the difference. So, mortality is kind of a binary variable.

It's to live or to die, and there's a lot of attention that is appropriately being placed on the mortality rate. It's often described through a case fatality rate, which is another way of saying how many people die for a given number of people who have this infection. And obviously that's very important, but morbidity is more about the you know, long term impact on quality of life, an illness that

has suffered that does not ultimately result in death. And I was reading a paper this morning, UM that did a ten year follow up on people who were infected with the first STARS virus that we talked about stars covie one. This was the two thousand three epidemic. This was a pretty lethal virus, certainly appeared more lethal than the current virus. About ten percent of people infected with

this virus died, so that's a staggering amount. But what this paper followed up on was what were the long term consequences of the people who were infected but survived. And it was quite disheartening, frankly, that you saw much higher incidence of cardiovascular disease in those people, much higher incidents of lung disease in those people as the so so if they didn't die from the disease, they were

still somewhat debilitated by it. And I think that that's something that we're going to see a lot more of, and I think the consequences of that, you know, economically, will be significant. There are going to be people I suspect who won't be able to go back to work in the same capacity a year from now when all is said and done, And the people who are most susceptible to that are obviously the people who come in with the greatest amount of pre existing medical conditions. So,

for example, diabetes. Why as diabetes a risk for this? And I don't think we know entirely, but one thing we know is that people with diabetes might already have some underlying degree of insult to their kidneys, to their heart, and it might be that they are less likely to recover from this, even if they're fortunate enough to not succumb to it. Yeah, I was interested in the diabetes angle because I would understand smoking because correct me if

I'm wrong, Peter. But this virus does create some kind of fibrosis and the lungs. Is that right? Eventually, Yes, this is a virus that has a kind of unique pathology relative to influenza, for example, which would be a cousin of it um. The virus gets Every virus has to replicate by getting into a cell within our body. So it's you know, maybe we're taking a step back to understand what the heck of virus is. A virus

is not quite like a bacteria. The bacteria is totally self sufficient, meaning it has all of the equipment inside of its cell to fully replicate on its own outside of the body. That doesn't mean it won't in fact us, but a virus is different. A virus doesn't actually have much to it. It's a much much simpler piece of you know, biologic you know entity. It has in this

case just some RNA and that's about it. And so for it to replicate and survive, it must get inside of a host, and in this case, you have now become the host. Prior to this, of course, animals were the host, and it uses our DNA replicating machinery to replicate itself. So if you were going to think about this sort of teleologically, the virus really has no intention of hurting us. That's just an unintended consequence. What it

wants to do is replicate. From an evolutionary perspective, and the most successful viruses, by the way, the ones that can go on forever and ever, don't hurt their host at all. It's the viruses that destroy their host that don't really survive, much like ebola. Ebola didn't spread very much because it was so devastating to its host. So when this virus comes in, it has to pick a cell that it targets, and that just happens to come down to sort of the molecular biology of how this

virus works. And this cell it targets most commonly is a cell in the lung called a pneuma site because of a certain receptor that that cell has that allows this virus to enter. When it gets into that cell, it basically hijacks it. It takes over and uses the cell's ability to replicate and says, hey, I'm going to take this over for myself and replicate myself. And it

does that and it ends up destroying that cell. And it turns out that in this case, that's a really bad cell to lose because that cell, called a type to numa. Site makes a chemical called surfactant, and you've probably heard of surfact and it's like a detergent that allows the air sacks in our lungs to not collapse

on themselves because of the surface tension. And so when we lose enough of those, the lungs begin to collapse and we aren't able to exchange air, and ultimately that results in a type of pneumonia, or really something more severe than a pneumonia called acute respiratory distress syndrome, where a person can't exchange gas, and ultimately that will result

in potentially fibrosis of the lung. It turns out, by the way that that cell um that that that the virus can also gain access to um muscle cells of the heart, and so we believe that we're going to see sort of fibrosis of the heart going forward. In fact, thirty or forty percent of patients on autopsy, people who have already died from this virus are showing injury to

their heart. This sounds very, very bleak, but that's one of the reasons smokers are particularly susceptible because they already have some of the some damage to the cells that you were discussing, yep, and they just have less what we would call pulmonary reserve. They have less lung capacity in excess. So you know, someone like you, Katie, who's really healthy, you know you're not utilizing your full lung capacity when you're sitting here at rest right now. You're

using a fraction of it. But let's say that you know you're using of your lung capacity. Will imagine somebody who has smoked for a long period of time. For them sitting at as they might be relying on six of their lung capacity, so they just have less of a buffer. You know. You can think of it as like how much does someone have in their savings account? Well, the person who has less in their savings account is going to be more likely to suffer the shock of not,

you know, having a job. Before we talk about being better prepared, and I know that you watched the Bill Gates Ted Talk, which I thought was eerily prescient in its message. But let's talk just briefly, because I think people are desperate for this kind of information to Peter, and you have access to the latest, most accurate information in terms of protecting yourself. Um, tell me what you're doing in your home with your kids and your wife. Well, we we sort of probably came across as a little

bit crazy at the outset. In mid February, I sort of woke up to what was happening. I had been largely and denial through January, and UM, I think had naively assumed that this would be much more like the First Stars outbreak, or like the Murs outbreak, except less deadly and less likely to spread. In other words, I hadn't fully dug into the properties of this virus that make it a little more troublesome, which is namely its

capacity for spread. But in mid February, when I sort of woke up to this, UM, I started to think about, well, what what could we do if we wanted to buy more time? And so that basically came down to much greater social distancing, and UM that meant, you know, canceling

all travel plans. And then eventually it just you know, came down to making a decision that was difficult to make, and not a decision that everybody has the luxury of making, because many people don't have the luxury of working from home. But it was a decision to basically quarantine ourselves, UM, and so that meant that, you know, we don't leave the house and people don't come to us in the house.

And the thinking would be that after two to three weeks of that period of a quarantine, absent having an accurate test to measure UM, if you are infected, if you're completely asymptomatic, you know, no temperature changes or anything like that, the likelihood that you're infected is low. And now at least you're in sort of a safe spot while you wait for time to sort of play this out. And time does a lot of things right. Time allows

us to potentially develop a vaccine. Although I think that's a longer term strategy than most people think, it certainly allows us to repurpose existing drugs and that's something I'm

really excited about. So if we're going to talk about optimism, I actually am quite optimistic that there are a suite of drugs that already exist that we're now learning how can be repurposed for this And most importantly, it's giving the hospital system and the health care system a chance to slowly expand to meet the needs that are necessary.

Because again to your point about Italy, the real problem in Italy is not the total number of people that are infected, it's the speed at which those people needed medical care. And so you can you've heard the term flattening the curve. Why are people saying that. It's like saying if a hundred thousand people are going to require hospitalization, it's a big difference if they required in one month

or one year. And so it's not clear that we're going to reduce the number of people that are ultimately going to be infected, but we want to spread it out as much as possible. So on a personal level, my view is what can I do to make sure I don't need healthcare resources anytime soon. I talked to the director of an urgent care center, Peter, and he said, do not go to the doctors, do not you know,

try to seek medical care unless it gets bad. But I wondered, is there an inflection point, because I think people are so paranoid. Every time I cough, I get neurotic and uh and and when is that point where you should seek medical care or at least talk to a healthcare provide because we don't want to clog the system. Listeners, I'm sure agree with this, but we also don't want to ignore an illness that could worsen if we don't

get it, if we don't get the proper attention. Yeah, I mean, that's such an important question, and truthfully, it's one for which I think the answer is not entirely clear. Um, we probably do need to think a little bit about

how to stratify. So I would agree with the advice that your colleague and friend gave you, which is, we certainly don't want everyone who, um, you know, thinks that they have a little sniffle or a sneeze or a sore throat to then expose themselves to an infection by going out and seeking medical care, especially when we don't

have testing readily available yet. That's the important thing to understand is what is it going to accomplish to go and put yourself in harm's way If we don't even have a test yet that's viable, are going to offer as much. So I think we have to stratify patient. So, you know, the way we are looking at it in our practice is we're taking the patients who we think

are at highest risk. So these are people who are you know, sort of in their sixties and older people who have existing conditions like high blood pressure or heart disease, atrial fibrillation, these sorts of things, and we're saying we're going to have a lower threshold for getting them tested or getting them in to see someone if we have

any concern. You know, my wife yesterday was called by a friend of hers who lives in Colorado now, and she has a lot of underlying medical conditions, and you know, it was really difficult to spend the time on the phone with here today and triage. What I couldn't fully understand was either a panic attack or legitimately an illness, and you know, we had to make a call, and

in the end we saw it. We decided after an hour she probably did need to go into the emergency room and get checked out because I just couldn't be comfortable that this was just anxiety and I and she has so many underlying medical conditions that I was actually concerned that. You know, she's the type of person who, if infected, could very precipitously, you know, fall off that proverbial cliff. And what happened, Um, you know, she we went there. I It's it's still unclear because of course,

the testing takes days to get back. So, but now she is at least, you know, her blood pressure is normalized, her oxygen levels are normalized. Um, the thing we are most sensitive to is shortness of breath. That seems to be the biggest single predictor of people who do versus do not need medical attention. So people who do not develop shortness of breath at any point in time are generally going to recover in what we call a self

limited way. I hate to ask you this, doctor a tea of a what is how do you know if you have shortness of breath? I know that probably sounds like a dumb question, but is there something you can do to figure out? Is it walking upstairs? I mean I get sometime shortness of breath if I try to run a mile. I mean when when can you tell you have that? Actually, Katie, that is not a stupid question at all, and we've actually tried to explain that

exactly to our patients. So I'm glad you asked. Um. We think one of the best litmus test is for litmus tests for shortness of breath is air hunger while speaking in long sentences. So when someone who could normally rattle off, you know, three minutes of talking with just the simple breath in between, all of a sudden has to take longer pauses to take breaths in between speaking to me, that's true shortness of breath. You use an

example of walking up a flight of stairs. I think, if somebody knows what they're you know, normal exercise tolerance is when that dramatically decreases. So if a person you know lives in an apartment where they have to go up and down a flight of stairs and normally that poses no risk to them, and all of a sudden, now they think, oh my god, like I'm really winded walking up this flight of stairs, that that might all

so constitute shortness of breath. Um. The other thing to keep in mind is shortness of breath by itself probably doesn't show up without some other symptoms, such as, um, you know, a fever, which is the single most common

symptom we see in people who are infected. But of course it's important to understand people can develop fevers for any sort of you know common you know, cold or anything like that orl right, absolutely, and so all of this I think points to something which is, you know, do as much as you can buy phone right, call your doctor, walk through all of these things and and let you let your doctor help you decide if you actually need to take the next step of getting tested,

which again we're currently in a testing environment that is not adequate. So the CDC guidelines on testing are actually quite stringent compared to what I think they should be due to these limitations. So you know that that does raise the question who should be tested and who shouldn't and uh, sort of thinking about the common good and not just yourself in these situations. But gosh, you know, we're talking about in some cases life or death, peter and so people I think, you know, they have this

primal survival instinct. So uh, in terms of testing, you have to rely on your health care provider. But they're making some tough decisions in Italy about who who gets medical attention and who doesn't because of the crowded conditions of hospitals, etcetera. I mean, it's it really feels like the makings of a of a sci fi movie. Yeah, they are making these decisions in Europe um already, and it's not clear if we're not going to be in the same position in the next two to three weeks.

UM as far as testing goes at the time, at right this moment, Katie, the CDC sidelines are that testing should be reserved for people who are symptomatic only. Now, why do I think that that's insufficient? Um? I think it. If you really want to control the rate of spread, you should also be testing people with known exposure, even if they are asymptomatic. Because this virus has such a long latency period. Let's assume that you know, you are around somebody who then went on to test positive or

frankly even went on to be symptomatic. In an ideal world, if we had a sufficient number of tests and a sufficient infrastructure for testing, it would actually be important to know that you were negative before you know, we told you, hey, it's you know. The fact that you're not symptomatic means

you're not at risk. In other words, the thing that makes this virus so particularly troublesome is that people who have no symptoms can spread the virus, and they can do so for a long period of time, for fourteen days, right, I mean, isn't that the inky bastion period and the fact that some people can be vectors and yet never symptomatic that makes it really freaky. Right, Yeah, that's the

that's the superpower of this virus. So if you were gonna like create a you know, a list of all the things that make this virus sort of troubling, that that would be its superpower is that it has this ability to very subtly get you know, get from one person to another, usually without that person knowing it. And again we'll use Ebola as a stark contrast. Right, why was Ebola not really a big issue once it got

into um the United States? Because people were so sick when they got it that there was no ambiguity about whether that person had it and it was only during that period of extreme sickness that they could go on and shed the virus. If in fact, people are practicing social distancing, now all these cities are closing down, I guess you know San Francisco is a shelter in place

city other cities as well. Is that going to ameliorate or mitigate some of the conditions that will be prime for spreading this virus around or have we missed that window of opportunity, Peter. It will absolutely have an impact. I mean, in an ideal circumstance, if we had a time machine. I think we would have done this, we would have taken these precautions a month sooner. But I'm

actually still optimistic. And you know, we have a team of analysts that are building forecast models, reviewing every piece of data that's available and including data that aren't publicly available by you know, you speaking with people on the front lines to pressure test assumptions. I don't think that

it's a foregone conclusion how this ends. So um you know, I can't even sit here and project how many people are going to be infected in the United States, although there are lots of estimates, and some of them are quite scary. You know, Mark Lipsitch at the Harvard School of Public Health projects that you know, more than the U. S population will ultimately be infected by this, and that

the mortality rates we're seeing those are staggering numbers. That that the implication of that, by the way to put it in some numbers, is more people would die from this virus in a year in the next year than die of all other things combined. I mean that that's a staggering statistic. Do I think that that is set in stone yet, that that is our fate? I don't.

And I do think that the more aggressively we can socially distance ourselves, the more aggressively we can implement testing which will enable this stratification of distancing between people, and the more readily available we can be pressure testing existing drugs to then bring on treatments that can reduce the mortality and morbidity. I think we still have a chance to bend the curve of this thing. We're going to take a break, but we'll be right back with more

critically important information from Dr Peter A Tilla. Hi, everyone, I'm so happy we were able to get in touch with Dr Peter Attia and he was able to spend a good hour talking to us about this scary pandemic because I think his knowledge, his experience, and his connections are really unparalleled. So let's get back to that important conversation. Let's say someone goes to the hospital, Peter, and they

have COVID nineteen. I know that ventilators and respirators to help with lung capacity, but are there any medicines that these people are keetting or are they just going to the hospital? And uh, I mean, how are the how are doctors fighting it right now? It's varying by hospital. So myself and my team, we have enough friends in hospitals that we're hearing, you know, we're finding out this hospital in Boston is using this protocol, this hospital in

New York is doing this, etcetera. UM, So right now, I would say, Katie, it's not standardized, but you're crazy. I mean, that seems insane to me. That it's not that it isn't standardized, that it's sort of kind of a piecemeal approach. Well, the primary approach, as you said, is supportive care. So the single most important thing for a person once they're in the hospital is maintaining sufficient respiration because that's the thing that's going to put a

person in the hospital. So the most common thing that people are presenting with his respiratory failure as opposed to say cardiac failure, renal failure, or other organ failure. So you know, the first, second, and third line of defense is through you know, oxygen and supplemental respiratory care, hopefully not requiring mechanical ventilation, but obviously at some point that's happening for enough people. That's that's the sort of supportive

side of things. UM. And I think we are seeing more and more patients being treated with um chloroquin and then, of course if the doctor's treating the patient have reason to believe that they're now developing secondary infections, then things like antibiotics are coming on board. And if it turns into pneumonia exactly if it's a pneumonia that they believe is an actual bacterial pneumonia versus sort of a viral pneumonia for which the antibiotics wouldn't provide any benefit. There's

also HIV drugs. There's a drug that that is a protease inhibitor that I think is sort of weakly um potentially helpful. It's still too soon to say, but the of using it seems relatively low, so it's it's also being tested. UM one drug that I think to three weeks ago we thought might be valuable that is looking less valuable as the common anti flu drug called tama flu, so I think most hospitals are moving away from that now.

But again UM it is unfortunately not a fully standardized protocol because even though the CDC will have a recommendation, ultimately the physicians are the ones at the bedside that are going to be able to make the decisions. Can you reverse this? So let's say someone goes to the hospital they're having respiratory failure. Can those individuals with you know, breathing assistance, with the ventilator a respirator, can they then, um get the virus that, as you said, was sort

of taking over the cells and their lungs. Can they how do they get that? How do they get it out of their lungs? I know this ounds sort of elementary, but I'm just trying to figure out, you know, is that kind of support enough to eradicate this virus? Um. No, it's actually not an elementary question at all. It's a

very important question. What's actually happening is there's a war going on between the virus and the immune system, and the whole purpose of supportive care such as ventilation is to buy time for the immune system to win that fight. Now it becomes a bit complicated because the immune system, in its best effort to win that fight, can also cause a lot of damage to the host. So you think of it like a war going on in a country.

You have the good guys the bad guys. At the risk of oversimplifying it, well, both of those entities when engaging in war caused collateral damage, and so it's like immunotherapy and cancer, it becomes too refed up and that can create all kinds of autoimmune issues. Correct. Absolutely, So the you know, the checkpoint inhibitors, which you know are probably the most exciting thing in all of immuno oncology right now, um, exactly have that as a side effect,

which is autoimmunity. The immune system goes a little too far now in in this type of response to the

immune system. It's not so much autoimmunity that we're seeing as the problem, but it's the sort of um, what's called systemic inflammatory response syndrome or this cytokine storm that is sort of you know, wreaking havoc both to kill the viruses, but it's also the thing that can you know, cause capillary leaking in the lungs that can lead to other things like edema, and it can damage other parts

of the body. So basically what you're saying is that it's a delicate balance between the immune system, which can cause inflammation and damage if it's overly compensating for the virus and sort of keeping the virus in check. YEP. And we use supportive measures like ventilation to base sally by time to augment what the lung needs to do to to create that amount of time and space necessary

for the immune system to ultimately win that fight. But winning the fight means that the virus has gone, you know, winning the fight means that the number of actual copies of that virus goes down to some insignificant level um and you know, to you know, to contrast that with other things, like when you look at the Spanish flu, the one and one pandemic, that was kind of a

different animal. You know, that was an animal where so much of the damage actually came from the hyperactive immune response and then this immune paralysis that followed it that led to these secondary infections. So you know, paradoxically, the people that were most vulnerable to that flu were people that had the most robust immune system and therefore the

strongest immune response. We're not seeing that here, which suggests again it's just a suggestion that a hyper active immune response is less of a problem than the actual damage the virus is causing to the cells. That's fascinating. Um. That raises a couple of questions about ventilators and respirators and I don't even know the difference, and maybe you can explain that. But uh, there's a real shortage of

medical equipment. How serious a problem will it be if there is a lack of ventilators or respirators to buy the time these patients need and what is being done about that? So it's a huge problem. Let me answer

your first question. So, respirators are non invasive. So um for example, you've probably visited somebody in the hospital and you see like a little oxygen mask that they have on, or even something called a nasal canyla where there's a little device that goes under their nose that's just passively blowing oxygen at them. So you know, you can you can provide a person with supplemental oxygen in that sort

of passive manner. But when a person becomes really dependent on oxygen, they require something called mechanical ventilation, and to do that you have to undergo a procedure called intibation, which anybody who has had surgery has has you know, under general and aesthetic has had that. But that's where a tube is actually placed into the main airway called the trachea. So it's called an endotracheal tube. When a person is intibated, they also have to be paralyzed and sedated.

It's not a comfortable thing. You You couldn't be wide awake sitting there intibated um, so you have to be sedating the patients and paralyzing them. And the reason you have to do that is that their own voluntary muscular movements can't fight the ventilator, so you actually have to basically shut them down to let the machine do the breathing. And you're absolutely right that these ventilators are very, very specific and specialized pieces of medical equipment, and at some

point we will run out of them. In fact, was just speaking to someone today at a small hospital outside of New York City and they are now they have just used their last ventilator, and they are now what's called double venting patients, which means using one ventilator to treat two patients, which you would normally never do because of the contamination. Those two patients are now fully sharing

all their respiratory pathogens. But of course, you know, desperate times call for desperate measures, and if these patients both have the same virus and they are both suffering from you know the COVID nineteen disease, then we we you know, we'll do what we have to do. And then technically a ventilator can probably be split up to four ways.

But at some point soon and it could be within two to three weeks, this could become an enormous problem, and so well can can can We are manufacturers kind of speeding up the production of these pieces of equipment. They are, but is still another bottleneck. And the one thing that we can't make more of is doctors, nurses and respiratory therapists, and so these pieces of equipment can't work on their own. You know, a doctor is necessary

to put the end of tracheal tube in. Nurses and respiratory therapists are necessary to actually run the ventilators and manage the medications on a minute to minute basis. And so it can't be overstated that a really fundamental break point in this system could occur when the health care system, through its workers, is so overwhelmed that we can't actually have people on the front lines that are doing this work. So how do they protect themselves because obviously we need

them desperately to be treating patients. We probably need to and I know that a lot of retired medical professionals are being called in UM. Are are they getting sick? I know that some are, and should I mean, how

worried are you about that? I'm actually quite worried about it because of some data that we're seeing from around the world, including China and Italy, which is that when healthcare workers get it, they seem to get a worse version of it, suggesting at least preliminarily, that there might be something about the amount of virus or the manner in which they're exposed to it that is otherwise making it worse than if they just acquired this virus out

in the community. So that's the first thing that has me somewhat concerned. So how do you think they're getting it? UM? Probably just through a greater concentration of respiratory droplets, given the you know, the proximity that they have to people who are sick. And obviously, if someone is sick and they're in respiratory distress and you're intibating them, you're leaning over a person, and you're just being exposed to a much greater amount of virus than say, if you bumped

into somebody at the supermarket. The other thing that is in short supply is ppe. It's the protective equipment that the doctor's, nurses, respiray therapist, all the people in the hospital need to protect themselves against this virus. And so inasmuch as we need to be making more ventilators, we also need to really be ramping up on the production of all of the protective equipment. And the countries that have done this well, I mean China did this very

well in the second wave. So in the second wave after Wuhan, very few of the healthcare workers became infected. So once they dialed in on how to protect their healthcare workers, um, they were able to do this in a much safer way. So you know, if I could wave a magic wand we'd be making more ventilators, we'd have more actual beds and spaces in the hospital, we'd have more protective equipment for the healthcare workers, and obviously we'd have more testing available so that we could more

quickly identify and stratify patients at risk. Speaking of that, I know that a one thousand bed naval hospital ship is being dispatch to New York Harbor. We may be seen some of these medical ships that are often used in times of war being deployed in specific ports all around the country. Yeah, it's it's sort of hard to believe how much has happened in one week. Um. And and it's it speaks to the nature of non linear

exponential growth and and and again. You know, the irony of it is that which we're talking about today, in a week or two weeks will seem pedestrian in terms of what we will know because of how quickly things are changing, including you know, the rate at which you know hospitals are running out of ventilators. We should uh mention one thing, and that is a failure to comply with CDC guidelines. I hope we're not seeing as many

kids in bars, and not just kids. You know. My neighbor in New York City who lives on the Upper Side said the bar was packed for St. Patrick's Day. And it's so infuriating. But not only young people. I read an article this morning about children of baby boomers trying to get their parents in their seventies to not travel, to not go to casinos. Um. It seems insane to me that people are being uh so stupid and in some cases so selfish about this or ignorant what is

that about? It's it's so interesting you say that because I have noticed two extremes um and again these are anecdotes, so I can't speak to this from sort of real aggregated data. But you're absolutely right. I have noticed far more concern from my patients about their parents than their kids.

First for starters, So the you know, I just I could rattle off ten stories about, you know, people who are in their seventies who have decided, Yep, we're gonna we're gonna to the casino this weekend and we're gonna go do this, and we're gonna go and do that, and none of this stuff matters, and we're going out and you know, doing all those things. And again I

have no idea what it is that. You know, I could speculate and say, look, people at that age have been through a lot and they've decided, hey, if it hasn't got me, now it's not going to. And there's sort of a false sense of confidence. Potentially, I think they survives the stars outbreak and they've been there, done that. Yeah, there's a little bit of that. Um, we certainly saw a little bit of that Machismo in New York two

weeks ago, which I haven't seen. I've seen it damned down a bit, which was, hey, look, we survived nine eleven. This thing is not going to get us. Um. Obviously that's apples and oranges. So it's sort of a nonsensical comparison. Um. But I do share your concern with the number of

people who aren't respecting these quarantines. In fact, our nanny who's in college, one of her classmates was an exchange student in Italy, so he had to come back from Italy, and he tested positive upon arrival, and so he was

placed in a quarantine, which he violated. So he was seen out on social media three days after testing positive and being forced into a quarantine, out at a party, and so, you know, that kind of stuff is really upsetting, and I think it is a bit of a communication breakdown because I don't think that these people would really be doing this if they understood the significance of what

they're doing. I just don't think people are that selfish or that evil if they really understand the significance, which is, hey, you can feel fine. You know, you college student who's twenty years old, who tested positive who you know has a little bit of a sore throat. It's not about you getting worse. It's about what you could do to somebody who could then go and do it to somebody else. Right, It's like you infect another kid at that party, they

go home and infect their grandmother or something like that. So, you know, my hope is that we're just going to educate people a lot more about why the stakes are high and how we all kind of have a responsibility here to not just protect ourselves, but to then protect others through that protection. I don't want to play the blame game, but was critical time lost when this wasn't taken seriously by the administration and frankly by some in

the news media. How how much damage was done by that two or three week period where it just wasn't treated as a serious threat to public health? Well you alluded to the the Ted talk by Bill Gates, which is now five years old, and he sort of predicted, uh, in pretty frightening um, you know, reality, what was potentially going to come if I were going to, you know, really say, if if I could go back in time and change one thing in the last three months, what

would it be. It's the following on January, the genome of this novel, coronaviruns was sequenced and it was made public another Chinese you got it. So the Chinese immediately figured out what this was, immediately confirmed it was a novel, brand new, never before seeing coronavirus, and put that information out to the world, and some companies immediately ran and

developed pcr kits. And you know, one of those companies in China has basically gone on to do over a million tests already and have incredible data with specificity and sensitivity. They can do a four hour turnaround. In fact, they've already built fifty laboratories in China, each one capable of doing fifty thousand to a hundred thousand tests per day.

What we did, in my opinion, was the biggest mistake, which was basically ignoring that information, and then when push came to shove sort of doing a botched job, the CDC sort of put together its own um set of primers that ended up not working very well. And then eventually we got around to potentially doing something with a company called Row. And where we are right now at the time of this discussion is we still don't really

have any viable means of testing. We're probably just a little bit over fifty thou people have been tested in the United States, which is you know, two log orders below where we need to be. So if you can we just use the testing that's being used in other places like South Korea, the one that was developed by the w h O. Did the CDC simply think that that test was inadequate? It seems to me that was insane. At least use them while we develop a more specific test. Yeah,

that that is absolutely correct. So we are now in a situation called emergency use authorization where I think the CDC has finally realized that they're not going to be the ones to solve this problem, and they're basically saying, you know, so the Secretary of hss UM, the Secretary of Health and Humans has has basically said, you know, you can go and do this test on your own.

So I think right now what we're going to see as states making their own decision on what to do, and in fact, we're working with one state right now to try to help them to actually just get that test from China directly, because in my opinion, not does that not seem insane to you. I mean, does that not seem a massive failure of the federal government. Yeah. And again I'm not the conspiracy guy, so I I attribute these things more to just you know, negligence than

anything nefarious. And I've certainly heard people speculating that, you know, there's sort of you know, an anti China bias and all of these things. But but I have to be honest. I think China has been very forthcoming here, and I think this demonization of China UM, either either you know, covert or you know or sort of explicit or implicit,

has really hurt us. UM. I think I think China has been very forthcoming with their data, and for some reason, our decision to not utilize exactly what they offered us as far as testing has set us back, put us on our heels. And my hope is that in the next week the bell gets rung pretty loud on that and we you know, we we take on these tests because again, it's not an economic question. The United States is very fortunate we can afford to do the testing. Um.

It's really a question of deployment and other things. You know, you asked questions about running out of things, Well, we don't even have enough swabs right now, so we're not just having to buy the PCR test gets. We actually have to make sure we have enough re agents to use them, enough swabs to actually you know, test them on the people. Um. And that's the stuff that really we should be stockpiling that stuff, right and and and we certainly in early January should have been preparing for

this to spread. And again, I I think Bill Gates spoke to all of those things five years ago at the tail end of the Ebola outbreak, when he said, look, it's not a question of if, but when this happens again. And yet the group responsible for a pandemic response, or

the Pandemic Response Team, was disbanded in two THO. Yeah, I mean Michael Lewis's book The Fifth Risk, I think does a great job of explaining all the non sexy parts of government that we tend to forget about until disaster hits um And it's funny I read that book when it came out, so I don't even remember if in the book Michael Lewis talked about this particular side

of the government. But you're absolutely right, this is this is a part of government that when things are good, it's easy to forget about It's easy to say, hey, we can, we can, we can cut costs by getting rid of them. Um. But but you know, you think of this like you think of insurance, right, You don't buy insurance for your home after it burns down. You

have the insurance in place before there's a fire. Before we go on, one last question, even though I could talk to you for hours, Peter um, and that is, is there any evidence that once you get the this pathogen or this virus, you build some immunity to getting it a second time? Or is that just a complete unknown? I think it's an unknown right now, Katie. There are

two issues at hand. The first is is this going to be like influenza, where if you get it in a given season, you're not likely to get it again, but you'll always be susceptible to it in subsequent seasons because it has enough genetic migration or drift year upon year upon year. Or is it something like you know, the measles or polio, where once you are vaccinated against it, once you know it doesn't that the virus is not

moving around genetically very much. And you know, either getting vaccinated against it, or in this case, if you acquire

the virus and recover, you're fine. We certainly think in the short term there is immunity, and that's one of the other really exciting potential therapies right now is something called convalescent serum, where you actually take blood from a person who has recovered, you ident deify the you know, uh, the sort of the antigens and things that are in the blood, and you can then infuse them into people who are sick as a form of therapy at high doses or at low doses to impart short term immunity

on people. So given that we're seeing um reasonable evidence of the efficacy of convalescence serum, that tells us that there must be at least some immunity that's acquired from this. Peter, thank you very much for spending some time with us talking about this very scary situation. Well, Katie, thank you for what you're doing. Your podcasts on this topic have been fantastic, So anything I can do to to help you get this message out. It's an honor that was

Dr Peter Attia. You can follow more of his coronavirus coverage on his Twitter at Peter Attia empty and on his podcast which is called The Drive, and that does it for this episode of Next Question. A reminder to all of our listeners are reported episodes on topics like maternal mortality and the environmental impact of meat are still to come, but in the next season coming out this summer. The rest of this season, as we mentioned, throughout March

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