While back, along with these television companies, supports cspan2 as a public service. Dr. Offit, and happy to be talking with you today trantwo the pleasure y is mine, thanks very much. Obviously the themes in your book are very relevant for what were going through today in the pandemic. And i know you said you startedd writing the book around the time the pandemic began, but can yu tell us when the idea for the book came from and why this book now . I think the emotion for this book actually came from the fact that i am a child of the 50s and i remember the polio epidemics. What i rememberme from that is e how devastating that pandemic or that early epidemic was, how much it affected my mother. We were not allowed to go to swim and a public pool. Me and my cousins with swimmingn dysplastic pools and the back. And so jonas salk made a polio vaccine animated by taking the virus growing get pure find it and inactivating it with the chemical. So you were inoculated with whole killed poliovirus. He tested it in 700 children in the pittsburgh area and he found it to be safe and induced the immune response he felt comfortable would be and this is coming up now because im on the fda Vaccine Advisory Committeeva and were on tuesday going to consider a several thousand child study for the five to 11yearolds. Some getting to that in this context. So he was happy. He said this is it, ive got it, tells his wife eureka, got it. But nonetheless he wanted to do a big study and that broke us her perky did want to do that. He did want to inoculate children with the perceived vaccine during polio season but nonetheless that was what was done. He had 420,000 children got the vaccine. 200,000 children got placebo and the vaccine was declared a year later by the person who had that trial safe, potent and effective. Effective. Those three words run headline every newspaper in the United States. Church bells rang out, synagogues held special provisions. Departments stop s to announce that over the loudspeaker, it was over the voice of america to all of europe last polio can be conquered. How do we know it was effective . Because 16 16 children died f polio in that study, all of the placebo group. We know it was effective because 36 were paralyzed, 34 in the placebo group. Those were first and second graders in 1950s. I was a first and second grader in the 1950s but for the flip of the coin those children could have lived longg fulfilling livs but didnt. T. That something we dont ever realize which is a human price that is invariably paid for knowledge and is coming up now with regard to these vaccines will be considering next tuesday for the five to 11yearolds. Host i was reminded over and over again while reading your book just how grateful i am that im alive and raising kids now and not in the 50s or not in previous times where there were so many diseases that killed kids. In particular the story about diphtheria and out into strangled kids is very compelling. Are there any diseases of the past that you would compare to covid19 in children. Guest well, one would be polio. Polio, like sarscov2, is largely an asymptomatic infection. Most children with polio had a mild intestinal illness. It was a summer intestinal virus. Virus. Only about one of every 200 people infected with polio primarily children would develop paralysis. Thats why its a frightening. It was friday because you did know who we shedding the virus. Everybody therefore became a potential person from whom you could contract that virus. Thats similar to this virus what made sarscov2 different than say sars one which raises its head in 2002 or mers ten years later is those viruses when they affected you cause you to have pretty severe illness. You knew who was infected say could put a moat around those people quarantined e and effectively stop what was a potential pandemic. A not this virus. 50 who get affected with this virus typically catch it from someone who never had symptoms and that was polio, same thing. Host okay. You also give many examples in the book of how things went wrong and how in the development of vaccines and therapeutics, and how those tragedies gave rise to new policies and new organizations within the u. S. Government to ensure safety and efficacy of medical products. So where are we today, and trust with those institutions, and if wed gone awry, which i think many would argue that we have, there are many who mistrust these organizations to keep our best interests at the forefront. Where do we go in restoring trust . K we are a cynical and tedious sort of conspiracy theoryladen society. We dont trust. Im not sure where that came. My guess would be sometime around watergate when we realized that there were people saying things and doing things that werent necessarily in our best interest. There was a lossof intensity certainly for me of with watergate. But howdo you regain that . Look at the current situation. Lookat the pandemic. There was a vaccine. We isolated that virus in january 2000 and sequenced it so now you have a virus 11 months later you had two large Clinical Trials of the paul eleven months later there was two Clinical Trials and 30,000 people showing the vaccine was remarkably effective and 95 of that and remarkably safe but not absolutely effective and notim absolutely safe. Then things move forward; right. Thousands of people get these vaccines, hundreds of thousands, millions, hundreds of millions get the vaccine and find things out you wish you knew beforehand and find out the mrna vaccine is a rare cause of myocarditis and the Johnson Johnson vaccine is a veryn rare cause of something called thrombosis meaning blood clots including blood clotteds in the brain, that can be fatal and about a handful of people who have died as a consequence of the j j vaccine. Soth the point is is you have systems in place now that can detect events as rare as that blood clotting phenomena with the j j and myocar die disis one in myocarditis in the one in 50,000 so its extremely rare and allowed us to monitor vaccines in this case post approval. Youre reich we deal we normouse level of distrust and its remarkable that 65 million peopling in the United States continue to not get this vaccine despite the factn that the evidence itt can save your life couldnt be clearer. Emily as someone in the scientific medical, community, what do you think our role is in communicating to the public and what advice would you give too other researchers about what to play their part to promote trust in the system and make those systems trust worthy . Paul perhaps the purpose for me in writing this book, you let people know you learn as you go and at some level building an airport while its in the air and thats true now. That has to be understood but what happens, you can sort of read my book the other way, which is that heres a series of tragedies that resulted in enormous amount of harm. Therefore you cant trust science or cant trust medicine but that is the process of knowledge. Knowledge is always hard earned and invariably associated with the human price. That has tabuns. The goal is in a dispassional way as possible and informed way as possible choose the lesser risk. When people say i dont want to get a vaccine orissing getting a vaccine, thrilliestinging getting this disease. Over the next few years, you have a choice to get vaccinated or get nationally infected. Thats not the best choice. We learn something about going back to the meeting that im going to have with the fda Vaccine Advisory Committee next tuesday. Well consider a trial in childrenle 511 years of age ofa few thousand childrenwh and abot to make a recommendation for a few million children, tens of millions ofab children. When do you know everything . You never know. The question is when do you know know . The question is when doou you think you know enough to move farred and thats the history of medical advances and we live 30 years longer than 100 years ago and the nine medical advances they talk about in the book theyre hard earned and will always be hard earned. People make the idea let me wait till the learning curve is over but its really never other. Emily as you say in the book, were always, day in and day out making decisions in the face of uncertainty. Whether we acknowledge it or not. I really liked your analogy of the Three Bridges to talk about the context of Decision Making ort Decision Making in the context of uncertainties. Can you talk a little bit about the Three Bridges analogy. Paul i guess lets suppose you have a certain disorder and you want to try a therapy thats well tested. That you know that its well tested and so if youre willing then to walk over that bridge and its well tested and a sturdy bridge, youre good. Then you know youre invariably new and new biological and now do you want to do that and to the degree you want to do that is that youre being chased by a lion. If youre being chased by a lion and the first person to do a humann to human heart transplant said that and a man named lewis was in desperate need of a heart and willing to be the first person to receive a human heart to heart transplant because the decision is easier in that case and the 4,000 people waiting for a heart transplant today and 1300 of them will die waiting and you dont know if youre one of the 1300 and do you want to be one of theg first or the fit to try a pig heart where they can be genetically engineered so you wont reject the heart and immunosuppressed therapy and in the last 48 hours, a successful kidney transplant or the person receiving a transplant received it from a big kidney and it went well. Do you want to give that a shot. Try that. Or try the well warned bridge if you will of getting a heart transplant knowing youll live probably 15 years on average after that transplant or try the pig heart and scared youre maybe one of the 1300 drying while waiting. Its always at some level, youre always gambling and i just think what you said earlier was exactly right and dont think were ever dealing with uncertainty but we always are. Emily we always are and unfortunately our human brains arent well evolved to think about risk and that uncertainty. Before it gain, these examples you give of individuals making decisions about whether to take the pig heart or wait and see if you can get a human transplant. Earlier in the pandemic, we were making those decisions as more of a collective and a population. We needed to cross the bridge that maybe uncertain but there was a line chasing us. How do you compare that individual patient Decision Making on whether or not to take an intervention with the decisions we were facing as a humanity early in the pandemic . Paul thats a great question, perfect question. So for example last september october, the Kaiser Family foundation did a polling of the United States citizens or americans and asked the question would you get a covid19 vaccine . This was before the vaccine came out. 30 said yes, they would. If youd asked me that question, i probably would have said no. Let me wait p to see the data. Im a skeptic and think everyone arnold the data table is a skeptic. Now youve tested this and 40,000 adults have gotten the vaccine and 95 effective at preventing any illness, mild, moderate, or severe illness and 100 effective at preventing severe illness. That means 20,000 was a placebo controlled study and 20,000 got the vaccine. Do you want to be one of the first to get that vaccine or do you want to wait till a few million doses are out there . The truth is the father of modern vaccines who was the primary research or developer said it best. He said i never give the sigh ofve relief till the first 3 million doses are out there because sometimes you find out things you wish youd never earlier. So do you want to wait . In which case you risk getting an infection because its so common. This is what were about weve been there with the 1215yearold recommendation and now well have the 511yearold recommendation. Do you want to wait. Do you want to wait till a few million children haveno been vaccinated knowing that every week between 150,000 and 250,000 children arere infected with ths virus and children act r more than a quarter of infections and delta reached down into the susceptible age group and 2,000 children are hospitalized every week and about 600 children have died. I was on service last week in Childrens Hospital in s philadelphia, there were plenty of children in encinitas intensive care unit suffering from the illness. Do you want to wait or not . Wait till more of the population are vaccinated or get the vaccine like a few thousand people are tested. Emily theres some examples of particular treatment of covid19 receiving emergency use authorization early on and hydroxychloroquine and convalescent therapy were two examples used and now we know how critical we should be and how critical in that retrospective analysis knowing what we know today . Paul it was best at times and theyk really succumb to what ws a lot of arm twisting Body Administration and anti administration looking for magic medicine. The hydroxychloroquine was never shown to work to either treat or prevent thiso illness and convalescent plasma data was very weak and when the commissioner is standing up in front of the public saying 35 out of every 100 people infected by this virus will have their life saved by convalescent plasma because that wasnt the data that was available. That was awful and scared me. Dr. Ezekiel emmanuel is heading to the november 3 election last year, i was afraid the administration would reach its hand into operation warp speed and two months to have no safety problems and youll go two months after the last and itll take you beyond the election date. Emily you mention the encroachment of politics into medical science and medical health and clearly some negative examples. Can you think of good examine es of politics interferes and is there good examples out there. Paul what i would say, a good example is lets go back to the trump administration. I think the decision to put 24 billion into this effort, i think the name operation warp speed was not the best choice but it kind of scared the people. You know, that what they did there was they basically mass produced the vaccine and they didnt wait for the finishing of the third based retrail to see if the vaccine worked or was resafe. They built the building and mass produced the vaccine and if it didnt work, they would throw the vaccine away and when they say they were successful, you can rollex it off the shelf. That was government taking over a program that was great. On the other hand if you want to see the government on the other side that would be the swine flu vaccines in 1976. There was an outbreak of basically h1n1 inferoensoft ando called swine flu influenza and so called swine flu and this could be a pandemic but it wasnt. There was enough information that probably would be advisers that told president ford and the government paid for that vaccine and 40 Million People got that vaccine and found to have anld unfortunate side effect called guillain beret syndrome. That was a real thing and a program that was disastrous in many ways. Emily what do you think about the politics on an International Scale around the pandemic and particularly vaccines. What has worked in your opinion and what should we avoid next time. Paul russia has a vaccine similar to the astrazeneca and Johnson Johnson vaccine and so called vector virus vaccine and its two doses and thats what you get in russia. The astrazeneca was primarily in the United Kingdom and some other European Countries and here the Moderna Vaccine is the main one and the research for that vaccine was done at the National Institutes of health, modernas a u. S. Company and thats a u. S. Product. Its interesting how its played out and its a national thing and talking about anesthesia in chloroform was a european invented phenomena and it was much more dangerous than two other anesthetic agents and it was perpetuated in new york and there was this kind of nationalistic sense of pride for those vetted. Emily y wow, do you think that nationalists sense of pride is also driving vaccine use . I mean i would imagine so; right . Even though some of these vaccines work better than others and it seems that countrys who have developed vaccines are sticking with theirs. Paul it certainly seems that way. Yes, i completely its interesting. You would think it wouldnt necessarily be that way and vaccines of china, the whole inactivated vaccine were better when we use that vaccine to the exclusion of say the pfizer or moderna or Johnson Johnson vaccine. Its not better and hasnt happened and had it been that way, it would have been different and in china, the moderna and pfizer and vaccine in china, its better than that vaccine. Nonetheless theyre using their vaccine. Emily perhaps this stage in the game where vax seep supplies are fairly Vaccine Supplies are trained, theres not much choice but maybe things will shift once thats no longer an issue. Paul this virus will be with s for awhile and the new england journal of medicine this past few weeks has a nova vaccine and those who are over 65 years of age and well seeho how that pls out and over time, theres more and more experience with this vaccine and about a billion people have been vaccinated in this world m of 7 billion peopl. Find out there may be differences in the safety profiles and therell be differences in the capacity of these different vaccines to protect against different variants as more and more variants arise. There will be differences in the capacity of immunity. Immunity. Emily im sure well be learning a lot more. Theres no doubt. Talk ago complete the catch the vaccines and general population in lay terms and how well vaccines work and i dont measure whether or not vaccines mework, we measure efficacy, safety, effectiveness, does it prevent infection. Does the vaccine prevent infectiousness or hospitalization, any disease, doesve it prevent death . Does it prevent all these myriad of outcomes that we think about with vaccines yet it gets distilled into ail general conct of whether or not vaccines worka theres a nuance there and should we be concerned of the loss of nuance and if so, why . Paul interesting to see the way this was played and i wa