Good morning. Good morning, everyone. And thank you all for joining us. Thanks to those who are joining us virtually. We have folks doing that as well. And thanks to everybody in the room, and a special thanks to our guests, who I personally know how busy a director of NIH is. So thank you so much for joining us this morning, Dr. Bhattacharya.
I think most people know about your background. I'll say just a few things. The eighteenth director of the National Institutes of Health. Became that on April the first of this year. And a Stanford graduate who, I think, B.A., M.A., Ph.D., and M.D.—(laughter)—from Stanford in terms of a wide, wide range of degrees. And focused on issues from medicine to issues of public health to research to economics, and health economics. So a very wide range. Over 170 published papers. Has spent time at everywhere from RAND to the National Bureau of Economic Research, in terms of the economics part of this, as well as at Stanford. All of that before becoming the NIH director. And has spent time on population aging, issues of chronic disease, as well as with a focus on vulnerable populations. So a lot in a very broad range. Great for the NIH to have someone. Many of you all probably know about the Great Barrington Declaration. And that's where a lot of folks, I think, learned about you and your work. And we'll talk a little bit about that today in our session. Born in Kolkata, India. And with that, welcome so much. We're so glad to have you.
Thank you for having me, Sylvia. Thank you for this opportunity to talk to everybody.
I thought we would actually start with things that people generally—you know, you can't find on Wikipedia or anywhere else. And that's, how did you come to science and economics? How did you come to these topics, and a little bit about your journey? Because I think that's always informative to understanding how you lead and how you think about the issues.
I mean, I've loved math and science since I was little. I kind of always wanted to be a doctor, because I figured this is how you use math and science to—I mean, it's just really sounds cliché—but it's how you use math and science to help people. But I got to—I got to undergraduate and I took—because they forced you to take general ed requirements—I took an econ class. And I was amazed by the idea that you—I mean, as soon as I encountered it, I realized that the idea of these constraints, like, you have to have rigor in your statistical thinking, all of that is really, really important for medicine. It's probably even more important for medicine than it is for economics. And I met, I met a man named Alan Garber, who's the president of Harvard, when I was nineteen. And he had an M.D. and a Ph.D. in economics. He absolutely inspired me. And I did an honors thesis with him. I did a Ph.D. in economics. Actually, first I got to medical school and I realized I couldn't just do medicine. It was—I missed economics too much. So I did a Ph.D. also, and then I had to figure out what I'd need to do when I grew up finally. (Laughter.) So.
Well, one other question on this kind of history. Lifetime returns to specialization in medicine. That would be the title of Dr Bhattacharya's dissertation. So we're going back in time.
You're going back. You're going back.
I'm going back. I'm going back. I did I did my research.
Yeah, I can tell, Sylvia. (Laughter.)
That is who I am. I, like you, like research as well as other things. Tell us just a little bit about that dissertation.
So the question was, why do surgeons earn so much money? (Laughter.) And the basic framework was that you have a few explanations that make market sense, right? So, like, surgeons have to train a long time in order to get to where they are. So, like, you know, no one's going to do it unless they make more money than you'd expect. They work a lot of hours. Back then this was before the eighty hour work week for residents. They were, like, 120 hours. There's 168 hours in a week, you guys. So, you know, that's something, right? And so, like, those would be normal market explanations. Also, you might think that surgeons are, like—well, if you ask surgeons they say they're smarter than everybody else. But so maybe that's why. The dissertation asks, do those market explanations—are they sufficient to answer why they earn so much more money than internal medicine doctors? And the answer is, no. About half of what the difference between internal medicine doctors—the sort of the rate of return for internal medicine doctors—lifetime returns for internal medicine doctors versus surgeons can be explained by these market forces. And the rest is essentially market power, which is actually bad news for the American healthcare system. It means we spend a lot of money, probably a lot more money than if we just had a sort of a more competitive market for surgeons and for doctors just generally.
Boy, we could go a lot of different places. And we will come to affordability and healthcare a little later on in our conversation. It would be interesting if you did this work with nurses. You don't have the length of the education, but some of that I'd be—
That is a really interesting topic. And that's something—
That would be a fascinating topic.
That's something I want to start supporting research on at the NIH, because I think that is fundamental. Both the market for physicians and market for nurses are fundamentally important for the affordability of care.
Primary care physicians and nurses and people at top of license.
We're going to come to affordability.
As you can see, we probably could go deep in a lot of topics, but we want to cover a lot of ground. And one of the places to start, which I think so many people here are probably interested in and I know is a focus of yours, is biomedical innovation. And I thought we could start the conversation on biomedical innovation, on, everybody says—we can probably survey this entire room, and everybody's going to be for biomedical innovation. But I think the real question is, how do we define success in biomedical innovation, so we get on the right path in terms of, OK, if this is how you define success, how do you think you best get there? So I want to start with, like, you're head of NIH. We are successful in biomedical innovation. And everybody in this room knows that five years from now if, please fill in the sentence so we'll all know, did we get there or not?
Well, I mean, that's a great question. And in fact, that's the question I asked myself when I got tapped for this crazy job. The U.S.—
And I can confirm it is a crazy job.
I really miss—I miss being a professor. That was a really fun job. But whatever, this is important, right? So the U.S. has seen no increase in life expectancy in this—for people in the country since 2010. From 2010 to 2019, it's flat. Flat at, like, eighty-one years. And this is true for every single—especially for minority populations. Flat. For whites? Flat. For rich, poor? Flat. Now, of course, there's big differences in life expectancy based on these factors, but the trend is flat for every almost everybody. And, of course, the pandemic, there was a collapse in life expectancy, more than our peer nations. And it's only this year we're back to 2019 levels, which means 2010 levels. If you look at our peer nations, their life expectancy is continuing to go up. The mission of the NIH is to support research that advances the health and longevity of the American people, of humans. And I will not view myself as a success unless we—unless we can turn the investments that we make in biomedicine into better health for Americans. That's the fundamental—if you want to understand the moment, why we're here, why there's so much distrust in science and medicine and public health, there's a lot to do with COVID, but that fact—why does MAHA exist? Why is it such a potent political force? It's because of that fact, no translation from the real advances in fundamental biological knowledge to better health for Americans.
So as we get to those—like, get into measures—I like measures and numbers and things like that. I want to ask you to create an index between longevity and wellness. In other words, so—you know, is longevity exactly the right—how do we think about balancing those things? If you live a long, long time, but your quality of life is not such, or if you live a long time but, like, at forty you have heart disease and other things. So how do you think about—you know, longevity is easy to measure. We can, you know, measure that one. Get to the wellness.
No, that's—I mean, that's a great point, right? So, like, when I was a tiny person—so I was, like, really focused—I was focused on demography. And there's, you know, in the 1990s it was essentially a birthright. Like, people were living longer. And there was also this idea of compression of morbidity. The idea was that you would—you we're all human, and we're eventually going to get frail. But that frailty would happen at the very tail end of your life. And so you'd live most of your life healthy and then, you know, you fall off at the very end, right? And it looked like there was progress toward that. Sometime in the 2000s that turned around. The chronic disease crisis that you see now everywhere, it essentially meant that we were not going to have that promise of, like, compressed morbidity toward the end of your life, with longer and longer lives. Economists have, like, a ton of these measures. You know, I can go into some, like, geeky details, but it's not worth it. By almost every measure, not just longevity, Americans are not healthier than we were. And the promise for our kids that they will live longer, live healthier lives, is gone. I mean, and so—I mean, I don't want to, like, put too fine a point on it, but, like, the huge advances in biomedicine, if they don't translate over to solving that problem, the traditional, almost universal as you said, Sylvia, support for biomedical research, biomedical innovation, people will start to ask, what are we getting for our money?
And as we think about that, wellness. And you've worked on chronic diseases. You know, what are the three in terms of, like, what would be good measures? Because, you know, what gets measured gets done. And how you—how do you think about what are the three things?
(Laughs.) Three is tough on this, because health is—you know, like, what is it, the U.N. definition—or, the World Health Organization definition of health it's, like, it's not simply the absence of disease, but, like, I mean, it's an insane thing where, like, you know—
Yeah, you're not hungry, you're not—
Well, it's, like, essentially, like, fulfillment—the ability to live a fulfilling life, right? That's very difficult to measure, because it means different things for different people. But the very least we can look at, we can look at the absence of disease, right? Do we have type two diabetes? Have we addressed that? The obesity crisis, the cancer incidence—the increasing cancer incidence, the Alzheimer's disease, Parkinson's disease, child disease of kids. So, like, you know, the autism epidemic, one in thirty-one kids. You know, you can go on and on. These are all things that that that make the lives of people less fulfilling than they otherwise would be, if we had better ways to address them.
Would you put lonely—how would you deal with mental health?
Loneliness is really important. I mean, actually—
How would you deal with mental health in these measures?
I wrote a paper about loneliness, actually, with the folks at the AARP. Because it turns out that that lonelier older adults have higher Medicare costs.
Loneliness is—actually, in the U.K. I think they have a minister of loneliness, of all things. So just a—I don't know what they did during the lockdowns, but whatever. That's another—
Maybe we may look at the Bhutanese and gross national happiness in terms of what they measure. So let's maybe turn to many folks in this room probably know of you and your work in the COVID epidemic and pandemic. And wanted to start with how you think about COVID itself. It is a virus. And how you think about COVID itself, and then how you think about it and its relationship to public health. Eventually, would like to get to a little bit of a dialogue and conversation about preparing for pandemics, and how we think we should do that.
Right. So COVID is a viral respiratory disease, obviously. It has—respiratory in the sense of, like, how it's transmitted. It has other impacts on human health beyond just the respiratory acute phase, sometimes. There's still, obviously, long COVID. The virus itself, I believe, was the output of essentially lab experiments that the U.S. funded, that the Chinese, very sort of irresponsibly, invested in. The disease itself in its early phases had a mortality rate—an infection fatality rate of about somewhere between two in 1,000 and four in 1,000. I can give you lots of evidence for that. The most important epidemiological fact about it, beyond that mortality rate, is its steep age gradient in mortality. Where for every seven years of age the mortality risk doubles, right? So the sharpest risk, the greatest mortality risk, were for older populations. It's vanishingly low risk—not zero—but very low risk of acute infection, mortality for children, for instance. And then this sort of exponential increase in risk with age.
The disease is—it's an RNA virus. So it mutates very, very rapidly. And, you know, as a result it resists—it resists having vaccinations that actually can prevent it from spreading or getting infected. You know, the evolution of the virus has a tremendously important role in thinking about, like, treatments. Treatments that, you know, worked early won't necessarily work late, and so on. So there's a lot more we can talk about, but that's how I think about COVID.
And as you think about that, and that mortality rate, in the early days was that the mortality—the one thing that I think, as we start to talk about pandemics, is what's known and what's not known. And the importance of—you know, I think we in the health space, all of us, and I speak to Ebola too, we don't communicate enough about, in a pandemic it is an evolution of knowledge. It's so extremely important to say, here's what we know, here's what we don't know. Here's what we kind of know, in terms of this issue. And communicating constantly about the—because it is an evolution. That's why, you know, the evolution of things that you know at different points in time, and the public engagement in that. But that brings us to the engagement of this particular issue and public health, which you spent time on and wrote about. And do you want to talk a little bit about that? But this evolution, as you do talk about it, I would love to hear your thinking about the importance of recognizing that in a pandemic, just as the virus is evolving, so is our knowledge, understanding, tools, and the public's perception and understanding.
Think it was like 1994 or '(9)5, I was a third year med student. And I don't know who's been to med school, but, like, the third year is, like, the most frightening time for a medical student, because you've done two years of class work and you're going into the clinics, meeting patients for the first time. Just so, like, and you put on this white coat. And you look in a patient, and the patient looks at you, and they think you know everything because you have the white coat on. But you really don't know anything. Oh, Sheri Fink is in the room. She was about my medical school colleague, my med school classmate. So she remembers. And it's absolutely frightening, right? Because you're sitting there in front of the patient, the patient's, like, asking you all these questions, and you literally know nothing. You can tell them what the Krebs cycle is, but you can't, like, answer the question, right? Answer the basic question. So that's what happened to public health, collectively, right? Public health was put in a position where they were asked to answer questions that they did not have the answers to. The big sin you can make as a medical student is you can pretend knowledge you don't have, tell the patient things that you don't know to be true. It's fine to say I don't know. I'll go look. I'll go ask. I'll go do some research for you. I'll get back to you, right? That's fine. That's good, OK. But it's not OK to say, this is what's happening to you, and you must do X, Y, or Z, when you don't know that that's what's happening. You don't have the knowledge. Public health suffered this third year medical student crisis. And it failed during the pandemic. It pretended a knowledge it didn't have. And, worse, what it did is it delegitimized honest discussion and debate. And I can tell you that from firsthand experience. Essentially it used all the power it had to make sure that people who did not agree with the answers that are being put out—is the virus aerosolized, what is the infection fatality rate, what is the age gradient mortality risk, how harmful will closing schools be for people? All of that needed to be discussed upfront in March of 2020 when the lockdown decision was made. And you could not have that discussion. And it was—I mean, we can point fingers, but collectively that's the root of the crisis we currently face.
The honest engagement with the fact that public health failed at its critical moment to have an honest engagement and discussion about the crisis we were facing, it's led to the public—the collapse of public trust in public health. I saw a JAMA article last year, Sylvia, where 70 percent of patients don't trust their own doctor. And one in four Americans think that scientists don't have the best interest of Americans at heart. It's a total disaster. We have to figure out a way past that, but that's the—that was my—that was the problem I had during COVID. It's not that I had all the answers. It's just we needed to have an honest discussion.
And as we think about that going forward, and the questions, what are the ways that you can have that kind of—now, you're, in the jobs now. So you're at NIH. And, you know, tomorrow, you know, we find out that, like, you know, it's the new H1N1, it's the new COVID, it's—you know, we're just starting to see it. We can't tell. We don't know the answer, is it asymptomatically? We don't know, is it respiratory, you know, is it aerosolized, does it go through the air, in terms of—we don't know those answers. And the American people are looking to you, you're the head of NIH, to answer those questions. How do you think through what you do? Because one of the things about the time for the dialogue is we kind of got to act, because people are dying. How do you weigh that acting and the importance of creating space for dialogue? How do you—how do you actually do it, when push comes to shove, people are dying, hospitals are shutting down. You know, in Italy we saw what happened. In New York, we saw what was happening. How do you—how do you balance these two things?
Well, first, you don't panic. That's rule number one. You certainly don't abet panic. I mean, I think that—abetting panics came to be seen in March of 2020 as a virtue. Like, we need to make sure that people are adequately scared. That's a critical mistake in public health. You do not scare the population beyond what—you have honest answers. I am very comfortable telling people I don't know. I'm very comfortable people-telling I don't know publicly. I'm very comfortable saying that I'm wrong when I'm wrong. I think that kind of engagement is going to be—in that kind of crisis, is going to be very, very important. Actually, can we broaden it to, like, how you prepare for pandemics?
Yeah, then on preparation.
Because I think we've had the wrong model for pandemic preparation for a very long time. The idea—this goes back, I think, to, let's say, 2000. It goes back further than that, but, like, let's just start at 2001 and the SARS pandemic—the SARS epidemic, right? That scared the living daylights out of people. You have a naturally occurring virus in that populations that nobody knew about. We thought coronaviruses were just a common cold. And all of a sudden you got a disease—an infection that can, like, kill—that had a really high infection fatality rate, you know, like five, ten times more than what COVID had, even in the early days of March. And it luckily didn't seem to spread via aerosols, which is why it didn't cause the—but it came out of a natural—it came out of a bat, right? A bat in China. The Chinese hid the—hid its spread early on, which made the response a little more difficult. And in 2006 there's the avian flu, right, where—H5N1. It's it doesn't actually infect humans very easily. You have to have a lot of exposure to it in order for it to infect humans. And it's a high death rate if it does infect a human, but there's very little evidence of human-to-human spread, right? Which is why we're not all dead. And so, like, you have a—you have this, like, desire to be able to predict what the next pandemic is going to be. But there are, like, I don't know, round off error, a trillion viruses. I don't know, there's just a very large number of viruses out there. And we do not, as humans, have the capacity to go and, sort of like a butterfly, collect every single last one of them—characterize every one of them. But we picked—we chose that as our strategy for predicting and preventing that and dealing with the next pandemic. And so what we did is we sent—we had a research program where we send scientists into the remote places of the world, bat caves in China or something, and bring viruses and pathogens they find there into labs, often with inadequate biosecurity or biosafety protocols, make them more transmissible among humans, manipulate them using powerful tools and research, with the idea that if we can tell—if we—if the virus that we pulled out of the bat cave is close in evolutionary space to the viruses—to something that can actually infect humans, well, those of the trillion viruses out there, those are the ones we should prepare for. And then we prepare vaccines or other countermeasures for the virus that has never infected a human. In other words, you prepare vaccines and countermeasures on—essentially in theory that, never testing on humans, and get give, like, contracts to companies to, like, stockpile them at scale into perpetuity. When the virus actually does make the leap, it will not be the virus that we play with in the lab, because evolution is incredibly creative, right? It will be a very different virus. And the counter measures we have, that we assume will protect us, will not protect us, because it's never been tested on humans. That paradigm for pandemic preparedness is a failed paradigm. And especially since there's a risk of a lab leak when you pull the viruses out of the remote places and manipulate them.
So we can, in terms of the preparedness, I want to move—I want to move on, because, everyone, at the top of the hour we're going to open it up to questions, and want to make sure we're able to do that. Because as part of that, your theory of preparedness. So want to—
We haven't even talked about my theory. I'm just thinking—I just criticized the old theory.
Yeah, yeah. But in terms of the inclusion of preparedness, in terms of our ability to know and understand when something is happening somewhere, so surveillance. Capabilities of surveillance. Capabilities of developing testing capability quite quickly. You know, in terms of some of the things that, you know, that one could do, that we do do, you know, that was a portion of the strategy of preparedness. But another portion are some of those other elements. And maybe we'll come to that through some of the questions. But before we open up to questions I wanted to try and get two more in. And at the end of the week last week we heard a lot in the news about vaccinations, particularly Hep-B. And at HHS, you kind of have a troika of FDA, Food and Drug Administration, NIH, National Institutes of Health, and CDC, the Center for Disease Control. And those three working together is, like, quite an important thing to outcomes for both public health, and individual health for that matter. And so as we think about that, that they usually are working together. And wanted to kind of understand, how is that working now in terms of the relationships? And, you know, how were you all able to engage, or not, in those issues—the vaccination issues?
I mean, there's quite good relations between me, and Marty Makary, and Mehmet Oz, and Bobby. I mean, so in that sense at the top level there's a lot of, like, you know, sort of desire to coordinate. Of course, the NIH, the FDA, and the CDC have very, very different roles, right? So the NIH is a slow burn. Like, we invest in research and, Lord willing, three, five, ten years from now, there'll be some huge advance, someone will win Nobel Prize, and Americans be healthier, right? That's the NIH. The FDA, they're responsible for deciding whether to approve the vaccines, for instance, for use. You know, there's standards for that. And then they're also responsible for post-market surveillance, if there's safety signals to identify them and say that. And then CDC is the public health agency, like, primarily. So they make—they make recommendations about, well, should you vaccinate your kids? When should you vaccinate your kids, and so on. And those are three very, very distinct roles. We can talk about this, but, like, the science, medicine, and public health I think have very different—I mean, in this—while we're aligned in the sense of, like, the ultimate goal, which is better health for people, they have very different standards and norms, and are actually in tension with each with each other to some degree, right? Just take the Hep-B question, right? So the Hep-B, the issue there was—the issue there—the primary issue, the real—the point of the arrow there, as you say, was should parents and doctors together decide when to give—when to give a child a Hep-B vaccination, right? The whole controversy was over shared decision-making. Shared decision-making on timing, right? And so that is—you can ask about the FDA, the NIH, and the CDC, as, like, decision-makers that can help contribute to this discussion. But fundamentally that is a question for the public at large. And this has to do with, like, the role of public health versus the role of medicine versus the role of science, right? So let's just take public health and medicine. When you see a doctor, do you want that doctor to represent your interests or do you want that doctor to represent public interests? When you're sick, and you go to a doctor, whose interests do you want that doctor to represent? If there's a tension between the public interest and the interest of the patient, who should the doctor represent? So the real issue, the real substantive issue at stake with that Hep-B decision, was that. Like, who—should you have shared decision-making between the doctor and the patient in deciding the timing of the vaccines, or should you have public health considerations at play? And especially this is in light of, like, a vast collapse in the trust that Americans have in doctors and in vaccines right now, in ways that are, as a doctor, quite distressing. So, you know, I just—I think that's the real issue that really the press went crazy, but they—we didn't—we sort of didn't get to have a real discussion yet about the fundamental issue at stake.
However, I want to go back to your thesis—your dissertation. I want to take us back to your dissertation, where markets didn't work. We learned from your dissertation that markets didn't work and surgeons were paid disproportionately. And now my question actually applies to science and the individual's interest. And, you know, let's just use Alexis de Tocqueville, self-interest, well understood. So if I accept the premise of part of this conversation, which is that we want the doctor representing the individual—or, to what extent. That was—I think, let me frame the question that way. In a world where we know the facts. We know the facts around Hep-B and what happened before and after in terms of people's ability to make that decision, both at that time—twenty-nine hours of labor, I'm not sure how cogent I was at that point in time, in terms of making these decisions and that sort of thing, and ability to do that in terms of protecting the child. And so just in terms of—the reason that NIH is connected is because the science and the research that gives us information about, you know, when these things are—decisions that we see. If we move the decisions to one place, what results we get from a from a measurable place. And so just, you know, as you—that's the scientific connection—
Yeah, so let's—on that, it's still—to me, it's an open question, right? So, like, a lot of other countries do it very differently, right? So they don't recommend the birth dose of Hep-B. They recommend the dose at two months for patients who are—for patients who are—for moms who are Hep-B negative they recommend two months, right? And so, you know, a lot of countries do it differently. I think it's a legitimate, interesting scientific question, what that—what that impact? That's the kind of thing the science ought to be interested in. I'm quite interested in that. But it's not an open—it's not—it's not a closed question, in my view, right? So, actually, this relates to the tension between science and public health, right? The ethical norm in public health is unanimity, right? If I go around as NIH director saying that smoking is not that bad for you, might even be good for you—which is not. It's terrible for you. Don't smoke. (Laughter.)
You're clear on this? So no one walks out of this room. I want to be clear that he said the other part.
Yeah. But I will have committed a sin, right? I will have essentially violated sort of what my obligation as a someone in a position of authority and power in science to—in public health—to, like, encourage people to do something that I know is really the scientific evidence is bad for them. There's this, unanimity of messaging is an ethical norm in public health. In science, it's the opposite. As a scientist, you must question whether established knowledge is true or false—is true. If you're not doing that, you're not a good scientist, right? You are always probing. And no—and very few questions are off limits. Very few questions are off limits. And so you have a clash of norms that you saw play out during the pandemic, where scientists—dissident scientists were subject to devastating takedowns, were, essentially, silenced, marginalized, delegitimized, because they were asking scientific questions about the basis for the kinds of advice that were given during the pandemic. I mean, it's—this is a fundamental tension, right, both between medicine and public health and science and public health, right? So—
