Your television provider. Joining us from boston is dr. Jeremy faust. He is an Emergency Room Physician at Brigham Womens hospital. We thank you for being with us. We want to begin with your op ed in the Washington Post with this headline, the metric that could tell us when it is safe to reemerge. Dr. Faust, what is that metric . Ust the metric that has been discussed the least but matters the most is what is called excess mortality, or excess deaths. That is simply the number of people who are dying in comparison to the usual rates we know about. For over 100 years we have been really good about keeping track of how Many Americans die every week, every year, from all causes heart attacks, cancer, old age. The numbers are remarkably stable. We know that. It is a credit to the epidemiologists of the past and present that we know that. What has occurred in the past month is unprecedented in recent decades. We are seeing a gigantic spike in certain areas of the country in deaths total. We know the reason for that is covid19. The more important is the sheer numbers tells us this is having an outlandish effect compared to a bad flu season or something else. That is the point. If you track the complete number of deaths, you know how real that is. Once this goes away, we may have had a handle on that. Host here is how you frame the argument. Excess mortality does not depend on counting the number of covid19 deaths, which ultimately relies on the subjective opinion of physicians and medical examiners proffering on their best guess is. Guesses. Graphs that track the months and years, generations blend into the next. There is an unusual rise in deaths. It tapers off by the end of the century. Then there is a sudden spike in new york and new jersey in september 2001. Mostly the death count drones on with the march of time without much deviation and without fail. Was sittingeah, i at my laptop writing that. It occurred to me this is an important moment in the history of our species. We have to acknowledge that. Excess mortality is a terrifying opportunity for us to see that and respond accordingly. It is on one hand a scary moment, and on the other it is a lightbulb to say we can track safe,nd know if were when we are safe. At some point, if we have been safe for long enough, if we can relax. Host that seems to be this question the question at this phase of the pandemic. How do you strike the balance between public safety, personal safety, and beginning to reestablish an economy that has basically been shut for the last seven weeks with more than 30 million americans now out of work . Dr. Faust it is a very difficult problem our leaders face. Think would say is i historians will look back on this time and will wonder what we knew when we decided to proceed with reopening the economy in this particular moment. I imagine would like to know that we knew the extent of the excess mortality. Yes, we knew that. But it was determined that other things mattered more. What i am not really hearing and it could be the case is the argument citing if we stay closed saying if we stay closed for too long, it could cause starvation and deaths. Stay enclosed has caused a decrease in the normal care. There are fewer heart attacks being diagnosed. The number of deaths occurring because of that is a tiny fraction compared to covid. Reopeninge is we are the economy without really having done a very careful analysis in saying, well, what are we risking here . How many lives are going to be cost by this strategy . I think that is a hard balance to find. I dont have a sense that is the question anyone is seriously asking. Host what are you seeing as an er doctor . What is coming to the hospital today . Dr. Faust here in massachusetts, every day is a different day. It is so random. That is the life of an emergency dr. That is why i love my job. You never have the same day twice. There were days i did not love it as much because it was less reassurance and more trying to keep people alive. In the er we are proud that we save lives here and there. There were times we were seeing an extraordinary number of sick people. Overall our volumes were down because people were afraid to come in. That will crop up over time, the effect of that. I dont think we see that yet. The number of icu patients was off the charts for us. We were able to expand in time in massachusetts. We were way over our capacity in the intensive care unit, but fortunately developed good policy to expand in time. Now we are seeing a drop off in that, but it is so random because you could have a spike tomorrow. If it went through one or two Nursing Homes that hadnt been exposed yet, you could have a hundred more cases, and of those, 50 are in the icu and die, whereas a bunch of students get together and got it, you might have a few bad cases, but capacity would not feel it in the same way. It is beginning to feel right now like a lull, but i look at the numbers on paper and i know we are nowhere out of this. I cant say that with any confidence. Host i preface this question, you are a physician, not a hospital administrator. But how are hospitals dealing with this . They dont have elective surgery. They have patients who are quite ill, many who cant afford to pay the bills when they leave the hospital. Dr. Faust the hospital administrators we get daily updates. They know the number one thing that matters is getting through this crisis. I am sure in the back of someones mind is how we will stay in business. I have heard people, not locally, but nationally talk about what it would take to get the hospitals through this because of the revenue stream issues you brought up. My sense is they have been laser focused on the problems at hand. That said, we have to use this moment to take stock of how we do things. Ways em is in many not broken not adequate. We see this crisis affect the poor and minority communities. Why . Because they have undiagnosed medical conditions like diabetes and high blood pressure. This virus hurts them harder. We look at this problem and say how can we get through it . What can we learn about it . I dont want to be mr. Pessimistic the entire hour, but the one Silver Lining we will have to look for is what do we learn . What does this experience teach us about how we have done Public Health until now . If we look inward at that and learn about ourselves, that could save lives. It could be that, in the final analysis years from now, what we have done today could save more lives than we ever lost. That depends on how many lives we save now and how much we learn. Host in a recent oped, you say there is no way to compare covid19 to the seasonal flu. Two very different viruses. Coronavirus far more serious. Dr. Faust correct. The thought there was people, for whatever reason seasonal influenza is the benchmark. It is the baseline upon which we make comparisons for Infectious Diseases. It is something people have heard of. The problem is these statistics accepted by my fellow physicians and the public about how many deaths there are per year by influenza are estimates determined by complicated algorithms by the cdc. These methodologies have been used for years. They are accepted as dogma. The problem with it is it would seem to suggest that 60,000 or so deaths per year can be attributed to influenza. That is about the same number of deaths per year as opioids and and motorlence Vehicle Safety collisions. Hadalized i unfortunately to tell many families that their loved one had died because of those other things, but i couldnt remember any time where i did that with the flu. It was not just because i am an er dr. I get told that about any patient i have. It is that the cdc estimates seem to overstate the case. We are counting covid deaths by one by one. We are estimating flu deaths. We are seeing today those estimates may not have been as accurate as we were led to believe. Comparing pure counts, it seems coronavirus is killing, per week, 20 times more americans than seasonal flu does during its worst week of the year. Average, covidn is 20 times worse. When we get better data, it will be higher than that, but i can substantiate that. What i can say is 20 times worse does agree with what we are seeing on the ground. I dont remember seeing anything like this. I looked at elmhurst hospital in queens as a resident physician, the epicenter of this crisis in new york and therefore the country. None of us had seen that. For peopleberculosis coming from africa. The fact that people say it is the flu, similar death counts i found that rationale to be dangerous because it is falsely reassuring. Host dr. Jeremy faust is an Emergency Room Physician joining us on this thursday. You are on the air. Good evening. It takes a few weeks for a test to be counted, and it could be off by a couple thousands. How accurate are these death tolls . Host thank you. How accurate are these tests . Dr. Faust the death tolls do lag a bit. It depends statebystate. The cdc is the slowest, because they have the responsibility to aggregate everything. When we see, for example, the cdc will publish the provisional daily counts of coronavirus and say it is as of yesterday, what is remarkable is that is incomplete data. You will see yesterday the total number of deaths as of may 5 looks like it was lower than it was last year. Day we because after one only have a certain number of precincts reporting, so to speak. Even in that context we have a dozen states reporting excess mortality this early. In a week or two when the lag catches up, we will then see how many states report excess mortality. There is a bit of a lag, but not so much that we cant figure out where we are. If you find a one you are already over, you are in an unusual situation, which is where we find ourselves today in the country. Host the next caller is from oakland, california. We talk about it, we tend to say there are black and browns that are dying. There would be a different take if you say it the other way, deathsx out of 10 virus are white. It was considered something that if it was something that is considered attacking them, they would take it more serious as compared to minorities. That is not the issue. Americans are dying, but i think they would treat it more seriously if it were racialized the other way. Six out of 10 white people are dying. Host we will get a response. Dr. Faust i understand the callers point of view. It is unfortunate we live in a society where people care about which race dies more than the next. Inm sure that is true certain sections of the country. We have a historical legacy to deal with. I think people in general, in my experience, they identify with people that look like them and from their community. What concerns me is even though 70,000 people is an extraordinarily high number of deaths, it is not enough so that the average american knows one person who died of it. To get to that place, he would have to have you would have to have a half million deaths. To her point, how do you make it real . Unfortunately it is what the eye sees. People say i dont see anyone dying, it is not so bad outside the hot zones. Inside the hot zones they understand it. The socialeason is determinants of health is a major driver of these differences. It is not a genetic thing. It is nothrase is your genetic code that determines your outcome, it is your zip code. It is a call to action for all our communities. We have to have undiagnosed hypertension diagnosed so that when this happens, the same people that continuously get hit hardest are once again disproportionately impacted. Physician. Re an er you are a podcast host . Dr. Faust yeah, the past six or seven years i had a podcast i do with my colleagues and another er doctor. Ands for doctors and nurses other professionals. We try to bridge the old and the new. In the past months we went to all covid all the time. I started a blog about frontline workers and research experts. Our Research Director is a physician and lawyer. Our Research Editor is a Johns Hopkins resident physician, an unbelievably bright young doctor. We try to package the latest news from the perspective of a frontline dr. But make it readable for the public. We thought we would feel some fill some gaps. Host you are on with dr. Jeremy faust in boston tonight. Caller am i still protecting myself by staying in . I heard that in new york some of the people that died from covid19 stayed in. Governor as the the number Governor Cuomo said yesterday, people stayed home yet still contracted covid19. Dr. Faust it is a difficult question. I dont want to give advice on what the caller should do. Listen to Public Health advisors at the local level. There is a greater point to be drawn from the question. Different is very from any other virus we ever encountered, which is that it spreads even in patients who dont yet have symptoms, asymptomatic patients. That is an unusual circumstance. We get sick and we know it because of the cost and the fever. We feel crummy. We selfisolate all the time. We stay home from work. If you think of the evolution of that, i talked to a colleague of mine at yale. Not only are these immune responses sort of a crude immunological site fight, it has a population benefit. It tells the world, stay away from me, i am sick right now. This virus exploits that assumption because it doesnt make everybody feel sick, so people go out and spread it. That is what makes this virus different. Not many do that and also seem to kill 1 of the people it comes into contact with. That is what makes this virus a once in a century pathogen. Host why in so many cases severe chest pains, respiratory conditions with coronavirus . Dr. Faust we are trying to unpack a bigger question that relates, as far as the virus that causes covid19, is this particular virus special or different . Does it have something on a body physiology level that is truly different than the usual, or is it viral sepsis . That means the virus makes your body fight and fight and your own immune system turns on itself. You are causing organ damage to your own tissues. It is important to know. We have not experienced a viral pathogen like this in a long time to know what it looks like when a virus like this goes across a population who has never seen it before. Has seenely humanity this before. Virus camekind of across and it wreaks havoc. It is unclear if there is Something Special about this pathogen or whether it has been a long time since we have seen unbridled attack on a body that doesnt have any kind of immunity. We will in a few years. Host our guest is dr. Jeremy faust. He is on twitter. He is an er physician at Brigham Womens hospital, also an instructor at harvard medical center. Richard in washington. Good evening. Caller a few minutes ago dr. Faust was asked about reopening the economy and made the assumption that the economy should be reopened only if the excess deaths that would be c covid19 would be exceeded by the deaths avoided by reopening the economy. That assumes we have an absolute value to avoid death. Automobiles or motorcycles . Because of the pleasure or what it is. We trade off for death. We do it all the time. Smoking. Why should cigarettes even be produced . We make those tradeoffs all the time. Some people may want to watch professional sports even if there are excess deaths as a result of covid19. It isnt just a question of the deaths caused by shutting down the economy, it is also the pleasure forgot and how much forgone and how much people value that in comparison to death. Host what is your recommendation . How would you proceed . Aller dr. Faust was making wrong assumption. It isnt making the kind of tradeoff people make individually in terms of policy. That is not for me to choose, but that is the choice that has to be made. Host thanks for the call. Dr. Faust somebody has to make that choice. I think the caller makes a great point. It is not inconsistent with what i wrote in the Washington Post. It is part of that calculation. We didnt say excess death is the only thing, we said it has to be a big part of the conversation. It reminds me of an old saying, if you do everything doctors tell you to do, you will live a long life and it will feel like a long life. As the caller says, there is a role for just enjoying life. What i am getting at with this concept he is referring to is we make these determinations all the time. Whether we know it or not, we are deliberate about that. We decide to raise the speed limit 10 miles an hour for convenience or the economy or whatever reason. When we do that, there is a death cortland correlant to that. All kinds of decisions we make are constantly taking this into account. It is the way society works. I am writing about this concept too. I am thinking seriously about it. Need to be that we explicit about what our parameters are. Some people would say open up now because i dont care how many people die, i have to get back to life. Some would say, how dare you, if even one life is lost by wanting to just enjoy living, you are essentially infringing on my right to live. This is a complicated calculation that needs to be made. My assessment is very few people are thinking in those terms. In a couple minutes, we will talk to a George WashingtonUniversity Hospital dr. About the possibility of a second wave and what that would look like. With dr. Jeremy faust. Caller good evening. My concern is for the children that are having problems related to the coronavirus. Is could wondering this possibly be something to do with children being exposed to so many different kinds of cleaners and the protection things we are trying to use for this virus . They affect children differently. Along with other illnesses, it could be a reaction to these cleaners. Thank you. Thank you. Dr. Faust an important point is is the cure worse than the disease . I have not seen any evidence to suggest that is driving an uptick in pediatric mortality. The number of young people who died from this virus is thankfully very small and low. We are starting to understand more about why certain children do develop more seville air and is just more severe illness as we learn about why adults are becoming more ill. The ones who get sick, why . What is there risk for it . Their risk for it . We dont yet really know enough on the physiological side of the virus what is happening before you factor in these environmental things, which probably have some impact, but not a great one. I dont think we are dealing with a lead paint situation where that is driving serious disease in the kids. It could go in any which direction. For all we know, keeping kids from school could be hurting them, it could be