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Meus pensamentos sobre onde estamos agora e para onde estamos indo

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Neste episódio, discutimos:

  • A experiência de Will e formação em saúde
  • Os desafios políticos, culturais e psicológicos que estamos enfrentando com o COVID-19
  • Se estamos achatando a curva
  • A estratégia de testar, rastrear e isolar
  • Os tipos de teste disponíveis para COVID-19
  • O que sabemos sobre imunidade
  • Sinais e sintomas de COVID-19
  • O que determina seu risco de infecção
  • Nossa resposta emocional à pandemia
  • Avaliando seu nível de conforto de risco
  • Como a pandemia pode terminar

Mostrar notas:

Olá pessoal, Chris Kresser aqui. Bem-vindo a outro episódio da Revolution Health Radio. Vou fazer algo um pouco diferente no programa esta semana. Eu serei o convidado. Convidei Will Welch, treinador de saúde funcional certificado pela ADAPT e treinador de saúde certificado pelo Conselho Nacional com experiência em psicologia organizacional, para me entrevistar. Quero fazer algumas atualizações do COVID-19.

Estamos em cerca de três meses e acho que muitos de vocês ouviram o podcast e seguiram meus e-mails, e talvez algumas de minhas postagens nas redes sociais. Portanto, você pode estar ciente de algumas das minhas reflexões mais recentes sobre esse tópico. Mas eu queria aproveitar a oportunidade para juntar tudo isso e acrescentar algumas ideias novas com base em novas pesquisas que foram publicadas apenas nos últimos dias, para que tudo esteja em um só lugar. E aqueles de vocês que não acompanham diariamente ou semanalmente todos os emails [and] as coisas das mídias sociais podem ter uma ideia de onde eu estou pensando sobre essa pandemia, tanto em termos de como as coisas vão se desenrolar nas próximas semanas, meses e anos, como em como podemos pensar em nossa própria resposta pessoal para isso. Então, eu realmente gostei dessa conversa e espero que seja útil para você. Vamos mergulhar.

Chris Kresser: Will Welch, obrigado por convidar o show hoje.

Will Welch: Obrigado Chris. Que bom estar com você.

Experiência de Will e formação em saúde

Chris Kresser: Nós não fizemos isso antes. É algo que eu queria fazer há algum tempo. Definitivamente, gravei alguns podcasts a solo, onde apenas falo sobre coisas, mas acho que é sempre mais envolvente ter uma conversa e algumas idas e vindas. Estou realmente ansioso por isso, e por que você não conta a todos um pouco sobre quem você é e o que faz e por que está hospedando este podcast?

Will Welch: Certo. Obrigado. Bem, acima de tudo, eu sou [an] ADAPT programa de treinamento de treinador de saúde grad. Sou um treinador de saúde funcional certificado pela ADAPT e um treinador de saúde certificado pelo Conselho Nacional a partir de fevereiro.

Chris Kresser: Parabéns por isso de novo.

Will Welch: Obrigado, [I] aprecio isso. [The] programa foi uma configuração tão boa para passar isso. assim [I’m] realmente emocionado por ter sopa de letrinhas depois do meu nome agora e NBC-HWC e A-CFHC.

Chris Kresser: Sim. Muitas cartas.

Will Welch: Mas, na verdade, comecei minha pesquisa em psicologia da saúde. E assim, unir isso e minha carreira corporativa de recursos humanos me levou ao treinamento em saúde. E eu pensei que era uma ótima fusão de tudo que eu tinha feito até aquele momento. E foi então que eu encontrei o programa de treinamento de treinadores de saúde. E agora também sou o gerente de matrículas do Kresser Institute. assim [I’m] muito feliz por estar aqui com você e ter a oportunidade de fazer algumas perguntas sobre a COVID[-19].

Chris Kresser: Ótimo. Bem, vamos mergulhar.

Os desafios políticos, culturais e psicológicos que estamos enfrentando com o COVID-19

Will Welch: Ótimo. Então, estamos quase três meses na pandemia de COVID-19 no [United States]. Como você está pensando na próxima etapa?

Chris Kresser: Oh garoto, eu penso muito sobre isso. E é uma grande questão. E você pode pensar de várias maneiras diferentes e de muitas perspectivas diferentes. Então, acho que muitos dos obstáculos que estamos enfrentando agora são na verdade psicológicos, emocionais, comportamentais e até políticos e culturais, em vez de apenas técnicos e científicos. Certamente, temos os desafios técnicos e científicos que estamos enfrentando, como criar testes mais precisos e que possam ser implantados mais rapidamente. Criando tratamentos eficazes ou uma vacina. Criando estratégias e tecnologias de rastreamento de contato mais eficazes. Tudo isso é muito real. Quero dizer, estamos trabalhando nisso, [and] estamos progredindo. Mas quanto mais tempo isso acontece, mais vejo que os obstáculos psicológicos, emocionais, comportamentais e depois políticos e culturais podem ser ainda maiores e mais difíceis de superar.

Então, o que quero dizer com isso é que os psicólogos sabem há muitos anos que respondemos à nossa realidade com base em nossa situação, coisas como idade ou sexo, raça ou etnia, status socioeconômico, crenças, [and] nossa saúde. Tudo isso informa como reagimos aos estímulos e informações que estão chegando e que determinam nossa “realidade”. E na psicologia, existe um conceito chamado cognição desmotivada, que é o domínio psicológico que mostra como as pessoas geram informações e argumentos de maneiras que lhes dão as respostas que desejam. E o que isso significa é que sentimentos e reações tendem a dominar os fatos. E muitas vezes interpretamos os fatos de uma maneira que nos ajuda a nos sentir bem ou virtuosos ou como se estivéssemos fazendo a coisa certa. Estamos do lado certo. E isso já é conhecido há algum tempo.

Como na psicologia do risco e na tomada de decisões, os psicólogos que estudam esse campo [have] Já sabemos há algum tempo, como os economistas, que não tomamos decisões racionais simplesmente calculando custos e benefícios, como faria um programa de computador. É realmente mais do que nossos sentimentos, que geralmente são inconscientes, tendem a ser os principais motivadores. E acho que estamos vendo isso começar agora, ou [it] está em andamento há muitas semanas e provavelmente continuará a acontecer. O tipo mais recente de exemplo disso são as diferentes reações de como devemos nos aproximar da COVID[-19] agora. Há quem argumente a favor de reabrir o mais rápido possível. E há outros que estão discutindo por ficarem presos. E esses argumentos às vezes são informados por fatos e ciências e outras vezes são realmente muito mais motivados por fatores políticos, culturais ou psicológicos.

Will Welch: E eu imagino que quanto mais isso durar, e aqui estamos, mais ou menos na faixa dos três meses, mais não somos atores racionais se compõem e mais tudo se concentra em todos os fatores que você listou, tomando decisões ainda mais difícil.

Chris Kresser: Absolutamente, acho que é esse o caso. E acho que também é o caso de um país tão grande e heterogêneo quanto os Estados Unidos, onde não temos uma política federal coerente que norteie a tomada de decisões e, em vez disso, temos respostas que são divididas não apenas estado por estado , mas mesmo município por município. Como aqui em Utah, temos diferentes condados tomando decisões diferentes. E não estou dizendo que isso não seja apropriado. O surto impactou os municípios de maneira diferente.

Por exemplo, no Condado de Summit, onde moro, ainda estamos em um nível de ameaça mais alto, de acordo com esse esquema de código de cores que o governador está usando do que alguns outros municípios, porque o Condado de Summit teve um surto bastante significativo no início. De fato, tivemos o maior número de casos fora de qualquer município, exceto um em Nova York. E isso foi provavelmente por causa de [the] Sundance [Film] Festival, que atrai muito turismo internacional, e também apenas as estações de esqui daqui, que atraem visitantes internacionais. Então, sim, há alguma diversidade na resposta. Mas quanto mais isso durar, como você diz, e menos coerente for a resposta, mais chances você terá de que esses fatores sociais, culturais e políticos se tornem uma importante força motriz na maneira como as pessoas estão respondendo.

Estamos achatando a curva?

Will Welch: Sim. Então, enquanto você pensa na próxima etapa, muitas coisas foram levantadas nos últimos três meses. Coisas como achatar a curva e muitas coisas básicas. Como você está vendo isso? Estamos realmente achatando a curva?

Chris Kresser: Definitivamente, nivelamos a curva, e esse é um desenvolvimento muito positivo e esse foi o objetivo inicial disso. E como todo mundo sabe até agora, o objetivo de aplainar a curva era reduzir a pressão sobre o sistema de saúde. Não era para acabar com a pandemia. E sinto que houve alguns erros significativos cometidos pelas autoridades no início desta pandemia. E quando digo autoridades, não estou falando apenas de políticos; Estou falando de funcionários da saúde pública, praticamente qualquer pessoa em qualquer posição de autoridade. Eles não estavam se comunicando efetivamente sobre a pandemia e não estavam definindo as expectativas adequadamente. E eles cometeram muitos erros que acho que estão voltando para nos assombrar agora.

Existe uma organização chamada Centro de Pesquisa e Política de Doenças Infecciosas [CIDRAP]. Michael Osterholm está envolvido nisso. Ele foi entrevistado em[[A experiência de Joe Rogan]e vários meios de comunicação tradicionais. Especialista muito afiado no campo e acho que ele tem um histórico melhor do que praticamente qualquer um em termos de previsão de como isso se desenrolaria. Ele tem muita experiência com o Ebola e outras pandemias. E a CIDRAP, essa organização, publicou algumas diretrizes de comunicação que os líderes devem seguir durante uma pandemia. E se você ler as diretrizes, verá que no [United States] especialmente, praticamente todas essas diretrizes foram desrespeitadas e não seguidas. Vou apenas escolher três deles como exemplos.

Então o número um era não exagere na segurança. Portanto, não conte às pessoas mentiras basicamente. Não diga a eles que será melhor do que realmente é. Porque quando você faz isso, há uma tendência dos políticos quererem fazer isso, certo? Eles não querem, nenhum político quer dar más notícias, mesmo as autoridades de saúde pública realmente não querem dar más notícias. Mas acontece que, psicologicamente, se você tranquiliza as pessoas e diz que elas serão melhores do que são e, pior ainda, você perde a confiança. E acho que foi exatamente isso que aconteceu. O público em geral perdeu muita confiança nas instituições e líderes em que eles podem ter depositado mais confiança antes da COVID[-19] pandemia.

O segundo é proclamar incerteza. Portanto, isso é novamente algo que não foi realmente adotado pelos líderes desde o início e talvez ainda não seja adotado. Esta é a pior pandemia que [have] enfrentou, sem dúvida, desde a pandemia de gripe espanhola de 1918. E há muita coisa que não sabemos. E isso fica claro para quem acompanha isso. Primeiro não usava máscara, depois usava máscara. Primeiro, não houve transmissão por via aérea e depois transmissão por via aérea. E em um ambiente com esse tipo de incerteza, é realmente importante poder compartilhar essa incerteza com as pessoas e dizer: “Veja, estamos fazendo o melhor que podemos. Ainda há muita coisa que não entendemos. Manteremos você informado quando soubermos mais. ” Mas em vez disso, há [was] muitas declarações inequívocas feitas desde o início. E então, quando essas declarações se mostraram falsas, mais uma vez, o público perde a confiança nas instituições e nos líderes que as estão fazendo.

E o último, lá [are] na verdade seis princípios. Mas o último sobre o qual vou falar é dilemas compartilhados. Portanto, isso está relacionado, é claro, a não exagerar e proclamar incertezas, mas se você tiver uma situação em que não há uma opção vencedora clara e estiver realmente escolhendo entre duas opções não tão boas, é uma situação difícil de ser enfrentada. in. E, novamente, isso é uma espécie de cenário de pesadelo para um político. Direita? Queremos ter, como, uma ótima opção para escolher e oferecer [to] pessoas. Mas se as opções estão realmente entre, digamos, encerrar tudo e ter uma enorme interrupção econômica e também a morte e todos os tipos de outras consequências desse desligamento econômico, ou não, fechar e meio que [an] nível insondável de doença e morte como resultado de não desligar, esse é um grande dilema. Direita?

E acontece que ser honesto sobre esses dilemas e compartilhá-los abertamente é a melhor abordagem, em vez de envolvê-lo e fazê-lo soar como “Ei, se fizermos esse desligamento, as coisas vão ficar ótimas. Voltaremos ao normal na Páscoa ou no Memorial Day “ou o que for. Novamente, se você fizer isso, e isso não acontecer, você perde a confiança. Então, acho que esses são alguns dos problemas que ocorreram. E eu estava voltando à sua pergunta original. Sim, nivelamos a curva, mas deveria ter ficado claro desde o início em toda a comunicação que estava acontecendo e que era apenas o primeiro passo. Ou vamos pensar em um jogo de beisebol. Achatar a curva é como o primeiro turno. E agora estamos no final do primeiro turno, ou talvez estejamos entrando, estamos no segundo turno agora. E tem isso [Winston] A citação de Churchill foi compartilhada várias vezes em que ele disse: “Agora este não é o fim. Não é nem o começo do fim. Mas é, talvez, o fim do começo.” E acho que é exatamente onde estamos agora.

Will Welch: Sim, isso coloca em grande alívio o local onde estamos com relação à situação. E pensando nisso no contexto de apenas três meses, entrando no segundo turno. Eu acho que isso apresenta um cenário em que as pessoas podem não estar pensando.

Chris Kresser: Sim.

A estratégia de teste, rastreamento e isolamento

Will Welch: Sim. Você falou sobre o componente psicológico disso e apenas compartilhou algumas coisas sobre incerteza, excesso de segurança e confiança. Eu acho que informação tem muito a ver com isso. E muitos países tiveram mais sucesso com a COVID[-19] quando eles empregaram uma estratégia de teste, rastreamento e isolamento, que fornece informações sobre quem tem coronavírus e de onde veio. Quão viável você acha que está aqui no [United States]?

Chris Kresser: Bem, agora, não estamos nem perto. Vamos começar por aí. Ainda não estamos em um lugar onde possamos implementar efetivamente uma estratégia de TTI, testar, rastrear e isolar países como Taiwan, por várias razões. Então, novamente, isso se divide em desafios técnicos e científicos, e se divide em desafios sociais, culturais e políticos.

Então, começando com o técnico e científico, no momento, não temos a capacidade de testar um número grande e suficiente de pessoas para tornar o teste uma pedra angular de como passamos por isso. No momento, estamos fazendo cerca de 300.000 dos swabs de DNA nasofaríngeo, nos quais enfiam um swab no nariz e enrolam-no em torno de um monte, obtêm algum material e o enviam para um laboratório. Realizamos cerca de 300.000 por dia e nossa capacidade atual estimada pela maioria dos especialistas é de 500.000 por dia. Estamos quase chegando ao topo da nossa capacidade e isso nem chega perto do número suficiente de testes que teríamos que fazer para implementar efetivamente o TTI. O teste de anticorpos é outra questão.

Podemos voltar, vamos voltar a falar sobre testes com muito mais detalhes em alguns momentos. Mas eu só quero responder sua pergunta amplamente. Então esse é o desafio da parte de testes. Então, a parte de rastreamento e isolamento da equação, acho que é parte do desafio técnico e científico e parte cultural e política. Assim, muitos dos países que tiveram mais sucesso com essas abordagens de ITT foram países relativamente homogêneos; eles têm um alto nível de confiança no governo que os cidadãos do país, têm populações muito menores e são muito mais propensos a se submeter a medidas que podem levar a uma diminuição significativa de sua privacidade.

E nenhuma dessas coisas é verdadeira sobre o [United States]. Portanto, temos uma população enorme que é heterogênea; é politicamente diverso e problemático. A segurança é uma grande preocupação, como deveria acontecer no [United States]. E assim, mesmo se formos capazes de superar os obstáculos técnicos e científicos de uma estratégia eficaz de rastreamento de contatos, Não acho que tenhamos vontade política e social para implementar isso em larga escala aqui. E isso tem que ser feito em larga escala para que seja eficaz. Se isso for feito sem entusiasmo, podemos obter algum benefício e acho que obteremos algum benefício. Mas não será, não pode ser a pedra angular do que fazemos, como tem sido em alguns dos outros países.

E então isso nos leva ao isolamento. Isso só funciona se você souber quem isolar, certo? E só funciona se as pessoas concordarem em ficar isoladas. Então, novamente, essas coisas têm um aspecto técnico e científico e social, cultural e político. Então, eu poderia resumir dizendo que acho que o TTI será parte da solução; já é. Já estamos rastreando contatos de uma maneira bastante tecnológica agora. E será um dos elementos que nos ajudará a avançar nisso, mas não na medida em que levou a resultados realmente significativos em Taiwan e Hong Kong e Cingapura e lugares assim.

Will Welch: Sim. E olhando para esses países como exemplo, é realmente difícil fazer uma analogia aqui para nós no [United States]. O contexto é tão dramaticamente diferente por todos os motivos que você acabou de compartilhar.

Chris Kresser: Isso é verdade. E esse é um bom argumento que se aplica a muitas outras discussões que estão ocorrendo no momento. Como a Suécia, por exemplo, seguiu uma estratégia diferente. E mesmo se a estratégia que eles seguiram, que está tentando alcançar imunidade de rebanho ao permitir que pessoas mais jovens que não estejam em alto risco sejam infectadas, com a idéia de que, se atingirem uma certa porcentagem da taxa de infecção, o vírus desaparecerá por conta própria, o que você quiser dizer sobre essa estratégia, seja ela boa ou ruim , e há muita controvérsia sobre isso, podemos dizer inequivocamente que, mesmo que seja eficaz na Suécia, isso não significa que seria eficaz no [United States] ou na África ou em qualquer outro país ou região, para esse assunto. Porque [of] a demografia da população, novamente, seu nível de confiança no governo e vontade de seguir as recomendações. Sua UTI e capacidade de cuidados intensivos. Seu acesso ao EPI, equipamento de proteção individual. Tudo isso determina se essa é uma estratégia eficaz para um determinado país ou mesmo para um determinado estado ou município do país. [United States]. Portanto, sempre temos que ter isso em mente quando falamos sobre essas coisas.

Will Welch: Direita. Sim. E há esses microclimas novamente, como você estava mencionando. O município em que você está versus o município em que eu estou versus a cidade de Nova York. Temos muitas pequenas considerações para cada um desses lugares.

Chris Kresser: Absolutamente. Montana não está na cidade de Nova York.

Will Welch: Não.

Chris Kresser: Você poderia estar em Montana e realmente nem sabia que COVID[-19] está acontecendo, tipo, se você não estivesse acompanhando muito as mídias sociais e apenas andando por aí, não saberia. Mas na cidade de Nova York, não há como não saber. Sua vida inteira foi virada de cabeça para baixo. E acho que isso realmente faz parte do que impulsionou a polarização neste país em termos de como as pessoas estão respondendo a isso, não apenas em termos políticos, mas também em aspectos geográficos, sociais e culturais. Porque uma pessoa, sua experiência com COVID[-19], Will, é sem dúvida diferente da minha experiência, que por sua vez é diferente da de nosso colega de trabalho que vive na experiência de Nova York, que por sua vez é diferente da de meu amigo na experiência de Montana. Então, quando você tem esses níveis dramaticamente diferentes de experiência, sobre os quais falamos antes, nossa psicologia de risco e tomada de decisão é realmente altamente informada por nossa experiência, não apenas pelos fatos. Então isso faz uma grande diferença.

Will Welch: Sim absolutamente. Você falou anteriormente no teste, rastreamento, [isolate] estratégia querendo voltar para a peça de teste. Quais são seus pensamentos sobre isso?

Os tipos de teste disponíveis para COVID-19

Chris Kresser: Bem, existem dois tipos de teste, é claro. Um deles está testando a infecção ativa atual. E o outro está testando as pessoas para determinar se elas tiveram um COVID[-19] infecção no passado. Então, vamos dividi-los em duas categorias e falar sobre cada uma delas separadamente.

Então primeiro infecção recorrente. O teste mais comum é o swab nasofaríngeo. Mencionamos que anteriormente, é um cotonete nasal muito profundo. Portanto, eles não estão apenas esfregando-o na parte externa da sua narina; eles colocam lá em cima, rodopiam. Se você nunca teve um desses, é bastante desconfortável. Seus olhos lacrimejam e parece quase o momento em que você está prestes a espirrar, estendido por vários segundos. Portanto, não estou tentando dissuadir ninguém de fazer o teste. Então, o que eles estão fazendo com esse swab é coletar material genético e depois enviá-lo para um laboratório que procura COVID[-19] material genético e retorna os resultados em 24 a 48 horas. É possível que demore mais tempo em alguns lugares e seja bastante preciso. Nenhum teste é perfeito, mas há uma chance relativamente baixa de falso positivo ou falso negativo com esse teste.

O desafio é que demora muito tempo. Se quisermos chegar a um local em que os funcionários estejam aparecendo no local de trabalho e eles sejam testados para o COVID[-19] antes de entrarem no local de trabalho, não tem como. Eles não podem ficar sentados e esperar 24 horas ou 48 horas para que os resultados dos testes retornem. E assim, mesmo que esse seja um teste preciso, não será realmente suficiente, não é suficiente para nos aproximar da retomada do novo normal, pós-COVID[-19] novo normal. Portanto, com isso em mente, existem, é claro, muitas empresas que estão trabalhando em testes que podem retornar resultados mais rapidamente e informar se você tem uma infecção atual. Então, um é o kit Abbott ID NOW. Este é o kit que foi usado na Casa Branca. Portanto, é um ponto de atendimento [test]. Também é um teste genético, mas pode retornar resultados entre cinco e 13 minutos, em vez de 24 a 48 horas.

Agora, o problema disso é que alguns estudos mostraram taxas bastante altas de sensibilidade e especificidade, o que significa que a sensibilidade determina a chance de um resultado falso-negativo e a especificidade determina a chance de um resultado falso-positivo [result]. E assim, um estudo, por exemplo, descobriu que você [have] nenhuma chance de um falso positivo neste teste e apenas cerca de 8% de um falso negativo, o que é muito bom. Definitivamente utilizável em campo. Mas então houve um grande estudo feito pela NYU que mostrou resultados muito piores. A chance de um falso negativo era de quase 48%, o que não é realmente melhor do que um lançamento de moeda. Você tem cerca da metade de “Eu tenho? Eu não sei. Vamos jogar uma moeda e descobrir. ” A chance de um falso positivo ainda era muito boa. Não era 100%, ou não 0%, mas era sobre [a] 1,5% de chance de ter um falso positivo, que é totalmente utilizável. E isso levou os pesquisadores da NYU que fizeram o estudo e outros especialistas da área, como Peter Hotez, pedindo que o kit Abbott ID NOW não fosse usado e a Casa Branca deveria usar uma tecnologia melhor. Portanto, há muita controvérsia sobre isso.

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Há outro chamado Cepheid GeneXpert. Isso se baseia em uma plataforma de testes genéticos que já foi usada para detectar outros patógenos. Portanto, ele tem uma história e eles apenas o adaptaram para poder testar a SARS [severe acute respiratory syndrome] coronavírus-2. E é outro teste genético no ponto de atendimento que retorna resultados em cerca de 30 a 45 minutos. Portanto, não tão rápido quanto o Abbott ID NOW e talvez ainda não seja super prático para certas aplicações em que alguém está esperando por 45 minutos. Mas muito melhor do que dois a cinco dias, certo? Portanto, este é um teste preciso. A chance de [a] falso negativo é de cerca de 5%. Então, isso é 95% de sensibilidade. Não foi possível encontrar um número específico para a especificidade ou a chance de um falso positivo. Mas parece ser muito específico e preciso. Portanto, isso parece estar emergindo como talvez a melhor opção em termos de um teste genético de resposta rápida.

E então outra empresa chamada Quidel acabou de fazer um teste de antígeno que recebeu o FDA de emergência [U.S. Food and Drug Administration] aprovação, [which] retorna resultados em 15 minutos. E não está testando DNA como os outros dois, o Cepheid GeneXpert e o Abbott ID NOW. Na verdade, está procurando antígenos virais, que são proteínas, proteínas virais. Portanto, não o DNA, mas as proteínas. E esse teste, infelizmente, também tem alguns problemas em termos de precisão. A chance de um falso negativo é de cerca de 20%. Mas a chance de um falso positivo é muito, muito baixa. Portanto, algumas pessoas estão argumentando que a maneira pela qual esse teste pode ser usado é rastrear rapidamente um monte de pessoas. E se alguém tem um resultado negativo, mas apresenta sintomas altamente sugestivos de COVID[-19], poderíamos enviar a amostra para o teste de DNA mais preciso que leva de 24 a 48 horas para retornar os resultados.

Portanto, mesmo que esse teste não seja muito preciso, ele pode ser usado de maneira que, de maneira benéfica. E certamente, se encontrar alguém positivo, isso é útil porque a chance de [a] positivo falso é basicamente zero. Então, à medida que avançamos, veremos uma combinação desses diferentes tipos de plataformas de teste que são usadas de maneiras diferentes. E chegaremos lá. Estou otimista de que o teste irá melhorar.

Will Welch: Fico feliz em saber que você é otimista. E acho que ser criativo com essas estratégias e usar vários testes para determinar quando eles têm taxas de erro diferentes parece um bom passo na direção certa. Então, fico feliz em ouvir isso.

Chris Kresser: Absolutamente sim. Não podemos deixar o perfeito ser o inimigo do bem, certo? Precisamos trabalhar com as ferramentas que temos e usá-las da melhor maneira possível.

Isso nos leva ao segundo componente importante do teste, que é determinar se alguém já foi infectado pelo SARS coronavírus-2. Então isso seria o teste de anticorpos. E isso é exame de sangue. E, infelizmente, como escrevi em um e-mail recentemente, o teste de anticorpos que temos atualmente não é muito preciso para dizer o mínimo. E a boa notícia é que acho que isso mudará com o tempo. E mesmo em algumas configurações, provavelmente já é suficientemente preciso. Mas para a população em geral, não é preciso o suficiente. E vou compartilhar um pouco sobre o porquê. Então, vamos ver se eu posso explicar isso. É muito mais fácil falar sobre isso com recursos visuais ou escrever sobre isso por e-mail, porque fica muito complexo.

Mas falamos sobre a sensibilidade e a especificidade de um teste:

  • Sensibilidade é a capacidade de um teste para identificar corretamente aqueles que realmente foram [infected], tão verdadeiro infectado. Então o verdadeiros positivos.
  • Especificidade é a capacidade de identificar corretamente aqueles que não foram infectados. Verdadeiros negativos.

Portanto, em um mundo perfeito, todos os nossos testes seriam 100% sensíveis e 100% específicos, mas esse não é o caso. Existem realmente muito poucos testes, se houver, que eu sei que são 100% sensíveis e 100% específicos. Portanto, a complicação adicional é que, mesmo que um teste tenha especificidade relativamente alta, o que significa que é improvável que retorne [a] falso positivo, digamos que a especificidade seja de 95%, o que geralmente seria considerado muito bom no campo dos testes. Não é tão simples com o coronavírus. Como quando a porcentagem geral de pessoas expostas ao patógeno ainda é baixa, uma especificidade de 95% ainda pode levar a um teste muito impreciso.

Portanto, se imaginarmos um grupo hipotético de 500 pessoas, digamos que 5% da população tenha sido infectada, o que corresponde à taxa que a maioria dos especialistas está assumindo agora, para o [United States], como, em geral. Claro, é muito mais alto em alguns lugares como Nova York e Seattle. É muito menor em outros lugares como Montana e Wyoming. Mas vamos supor, por enquanto, que cerca de 5% da população geral dos EUA foi infectada. Portanto, são 25 das 500 pessoas realmente infectadas. Mas se o teste tiver apenas 95% de especificidade, isso significa que, no mesmo grupo de 500 pessoas, será [also] retornar 25 falsos positivos. Portanto, se você obtiver um resultado positivo com esse teste, há basicamente 50% de chance de que seja preciso. Mais uma vez, estamos em um sorteio. Então isso não ajuda muito.

Will Welch: Sim, e esse exemplo, eu acho, coloca em um contraste gritante. Noventa e cinco por cento parece um número realmente alto, mas quando você usa esse exemplo e diz que, basicamente, ele se torna o sorteio, sim, que mostra uma imagem diferente.

Chris Kresser: E é muito determinado pela taxa de infecção em segundo plano, como o exemplo indicado. Portanto, no Condado de Summit, onde moro, a taxa de infecção é estimada em 1 a 2%. Portanto, nesse cenário, o teste de anticorpos seria ainda mais impreciso em um exemplo que acabei de dar. Por outro lado, se houver um lugar como a cidade de Nova York em que a verdadeira taxa de infecção possa ser mais de 20%, então sua chance de [a] falso positivo diminui. Portanto, existem duas maneiras de sairmos disso. O número um é, e espero que seja assim que aconteça mais rapidamente, é que os laboratórios lançam testes ainda mais específicos, com uma especificidade maior. Por exemplo, na semana passada, mencionei isso no e-mail que escrevi, um laboratório alemão chamado Euroimmun AG introduziu um kit de teste que foi aprovado no [United States] isso tem 100% de especificidade. Então isso significa praticamente nenhuma chance de um falso positivo.

E se temos um kit como esse, é realmente útil. Porque se alguém, se você for positivo, sabe que é preciso. E você pode estar relativamente certo de que, pelo menos até onde sabemos, podemos falar mais sobre isso em um minuto, você está um pouco imune a [coronavirus] ou você tem uma chance maior de ser imune e não ser contagioso. E isso pode levar a mudanças realmente significativas em seu comportamento. Pode permitir que você volte ao trabalho; isso pode permitir certos comportamentos que você não faria se não soubesse que já tinha o vírus e que não era mais contagioso. Então, acho que precisamos que esse teste de anticorpos seja mais preciso antes que possamos começar a retomar as atividades, como reunir grupos maiores de pessoas e fazer coisas que dependeriam de saber qual COVID das pessoas[-19] status é.

Will Welch: Sim, especialmente no contexto dos desafios relacionados ao rastreamento que você criou antes.

Chris Kresser: Sim.

Enquanto a pandemia do COVID-19 continua, ainda aprendemos muito sobre sintomas, transmissão, imunidade e muito mais. Neste episódio do RHR, discuto os mais recentes desenvolvimentos em torno do COVID-19 com o técnico de saúde Will Welch. #coronavírus (COVID-19

O que sabemos sobre a imunidade a COVID-19

Will Welch: Eu acho que ter esses testes de anticorpos é enorme. Agora, isso implora que a questão de qualquer conversa sobre testes tenha que envolver essa discussão sobre imunidade. O que sabemos sobre imunidade a SARS-COVID-2 no momento?

Chris Kresser: Not enough, unfortunately. Sim. There’s some conflicting data so far. On the pro side, there was a study actually published in Ciência. And they found, the researchers found T cells in the lungs of people with COVID, and that typically bodes well for the development of long-term protective immunity against the pathogen. On the other hand, we have a disturbing number of reports coming out of South Korea and China and other places, even in the [United States], of some people seeming to get COVID[-19] duas vezes. People who tested positive for COVID[-19] were hospitalized, had a pretty serious case, then recovered, went home, and then ended up in the hospital again later only to test positive again with COVID[-19]. And so, some people believe that one or the other of the test results might have been wrong. So, as we’ve been talking about, there’s a chance of [a] false positive. So perhaps the first time they were sick, they actually had a flu and the second time was COVID[-19] or vice versa. Or some people are speculating that they never actually got cleared SARS coronavirus-2. And even though they became asymptomatic or had fewer symptoms, they were still struggling with it.

I think what’s clear at this point is, I’ve heard a number of virologists and epidemiologists express this, is that COVID-19 is one of the most diverse and I’ve heard words like “weird” and “bizarre” used to describe the virus and the disease that it causes. Because it really is a chameleon. It has so many features that we don’t even really yet understand. And I think this question of immunity and whether it’s lifelong, or whether it’s short-lived, or perhaps we get a sort of a certain amount of immunity to it, and we’re able to contract it again, but the second time it’s less severe. We don’t know the answer to these questions yet, and we really, we need to find out, because that, of course, the answer is going to drive many different decisions that we might make in terms of how to move forward in the safest way.

Will Welch: And to go back to your analogy of just entering the second inning, only being three months [in] here in the [United States]. But globally, maybe in the fourth quarter of 2019 is when it started to emerge, we’re still collecting data from a scientific standpoint. It’s hard to answer questions like this with just a handful of data points in some areas for certain questions.

Chris Kresser: Absolutamente. As you know, that’s not how, the scientific process doesn’t work well under pressure, generally. And to be methodical and accurate with these processes takes time. And it’s incredibly frustrating for everybody involved because we don’t, we feel like we don’t have a lot of time. We want the answers now and we want to be able to make informed choices based on those answers, but it takes time to collect all of these data and make sense of them and also for the peer review process to happen. I mean, that’s another thing that’s difficult about the research that’s being published right now is that a lot of it isn’t peer reviewed. Because we’re trying to get it out as quickly as possible, which I think is the right approach. But we’re sacrificing accuracy for speed. And we just have to be aware of that and we have to not get too attached or wedded to any particular result, especially when it hasn’t been extensively peer reviewed.

Will Welch: Yeah, you’re seeing a lot more preprints coming out of the non-reviewed journal articles. And I think we’re banking on widespread scientific literacy and understanding of the scientific process to accurately kind of contextualize that information. And I’m not sure we can do that.

Chris Kresser: Sim. It’s pretty clear that we can’t if history is any indication of the future. And we’ve already seen some pretty high-profile examples of where that can go wrong. The Santa Clara study was a seroprevalence antibody study that was done to try to estimate the rough prevalence of COVID[-19] infection or SARS coronavirus-2 infection in the population in Santa Clara. And I’m sure as many people recall, the study results came back suggesting a dramatically higher prevalence or incidence of COVID-19 in the population there. Something like 80-fold higher than was typically assumed.

And then those data that were published by the researchers who did that study have been roundly criticized and challenged by other researchers. But it made quite a big splash in the media at that time and it became even a rallying call for the group of people who believe that we’re overreacting to this virus and that really many more people are infected and don’t have any symptoms at all. And therefore, we should end the lockdown. So these are serious, these findings, and especially when, whether they’re right or wrong, they can lead to pretty significant policy implications.

Signs and Symptoms of COVID-19

Will Welch: Sim. Another area where things have shifted a bit is around our understanding of the signs and symptoms of COVID[-19]. And that seems to have been shifting recently. What have we learned about this?

Chris Kresser: Again, that it’s weird or bizarre. I mean.

Will Welch: Those are technical terms, right?

Chris Kresser: Those are technical terms. Sim. Like, it’s so heterogeneous and diverse. It really can present so differently in different people. I mean, starting with, for some people, zero symptoms. There are people who have tested positive who had absolutely no idea that they were infected by the virus. They had no clinical signs or symptoms of COVID-19 at all. Then on the other end of the spectrum, we’ve got very, very severe pneumonia and complications that lead to morte.

So that’s a pretty broad presentation and you’ve got kind of everything in between. You have different populations being affected in different ways. As everybody knows by now, those with preexisting conditions like diabetes and heart disease have roughly [a] three-fold higher risk of death. People with obesity, even without any other kind of issues, have a much higher risk of hospitalization and that for some reason appears to be happening more in young people who are obese. We have no idea why. You’ve got generally kids who are typically not very affected at all and thought to be maybe even less contagious than adults. They tend to develop a pretty mild illness if they develop any illness at all.

And then on the other hand, we’ve been hearing over the last two weeks about a very severe multisystem inflammatory disease that’s developing in a very small fraction, fortunately, of children. And inexplicably, they develop this weeks after they initially contract the virus. So they have maybe mild illness for the first couple of weeks during the period that most people would be sick. And then, for some reason that we don’t yet understand, two, three weeks after that, they develop a very severe and potentially life-threatening multisystem inflammatory disease.

So those are just a few of the examples of how diverse this is. But from all the data that have been collected, we can come to some conclusions about what the most common presenting symptoms are. So, perhaps somewhat surprisingly, the number one symptom in terms of the minimum percentage of people that experience it is loss of smell or taste. And this is one that only became apparent a few weeks into the virus. In fact, I [have] a family member who, when I wrote, I did an Instagram video with an update about this symptom, loss of smell or taste, [said] that was the only symptom she was experiencing. And so it led her to go and get tested, and sure enough, she tested positive for coronavirus.

So this can be one of the main symptoms and, perhaps in some cases, the only symptom. Number two is cough, which is of course more typical and expected. And number three is fever. And then beyond that, you have shortness of breath, other upper respiratory symptoms like sore throat and stuffy or runny nose, fatigue, fairly common, muscle aches, headache, confusion, and gastrointestinal symptoms are a little more common than with some other similar conditions, up to close to 20 percent in some studies. But notably with kids, gastrointestinal symptoms seem to be much more common than in adults. And again, we don’t know why that is.

So those are the main ones. There are other bizarre, less common symptoms that are popping up that are confusing people. But I think statistically speaking, those are the main ones. What I would say is if somebody develops any type of flu-like illness where any of these symptoms are present, then I think it makes sense to get tested given the diversity of how it can present. If you’re able to get tested in your area and you do develop any of these kinds of symptoms, I think it makes sense to go ahead and get that test.

Will Welch: Yeah, that does make a lot of sense. And I assume if you’re symptomatic to stay home. Like, that’s another good piece of advice, right?

Chris Kresser: Fique em casa. Yeah, I mean, [in] some places, people are kind of still required to stay home. But even if you’re not, it’s yes, definitely a good idea to limit your exposure to other people and even limit your exposure to family members when you’re at home. If you can kind of set up a little quarantine area for yourself at home, especially if you’re living with people who are at higher risk, I think that’s a wise thing to do.

What Determines Your Risk of Infection?

Will Welch: Sim. And so you said, in a lot of places, people are still required to stay home. But many states are ending their stay-at-home orders. How can people stay safe as they venture out into the world again?

Chris Kresser: Yeah, this is the million-dollar question right now.

Will Welch: So you’re going to answer it for a million dollars, right?

Chris Kresser: Well, we all want to know. And again, this is a difficult calculation to make and a difficult question to answer in a general way. Because the answer would be very different for someone who is 80 years old with diabetes and heart disease and who’s overweight than it would be for someone who’s 25 and healthy with no preexisting conditions. But in a general sense, I think we can break down the risk of acquiring SARS coronavirus-2 in a pretty simple formula. So the risk of infection is equal to the amount of exposure to the virus times time.

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So the greater your exposure to the virus, like the more viral particles that you are exposed to and the longer you’re exposed to those particles, the higher your risk of infection. And there is, I think, a physician who is an infectious disease expert, Dr. Erin Bromage wrote a great article summarizing all the research that’s been done to quantify the different types of behaviors like coughing, sneezing, breathing, and how many viral particles and respiratory droplets those behaviors can produce. And thus, that actually helps us to determine that first exposure part of the formula.

So sneezing is the worst. A sneeze releases about 30,000 respiratory droplets traveling at 200 miles per hour, which it’s just so fascinating to learn about this stuff, even though it’s a little bit morbid. And the droplets from a sneeze are small. So they can travel all the way across the room and they’re also more likely to linger in the air, which is, of course, not what we want. And coughing is not quite as bad. Significantly less respiratory droplets, but still plenty to get you sick. So a cough releases about 3,000 droplets traveling at 50 miles per hour. And while most droplets from a cough fall to the ground quickly, they’re larger. Some can linger in the air for a significant amount of time. And Dr. Bromage pointed out that if a person is infected, a single cough or sneeze can expel as many as 200 million viral particles.

Will Welch: Uau.

Chris Kresser: Now, to put that in perspective, most experts estimate that as few as 1,000 viral particles are needed for an infection to take hold. So talking is also potentially problematic, especially loud talking. One relatively new study, which I mentioned in an email I wrote recently, found that talking can release about 1,000 droplets, and those can linger in the air for about eight to 14 minutes. And then breathing can release anywhere from 50 to 5,000 droplets. Most of the droplets from breathing fall to the ground quickly. So even though a breath may contain enough droplets to infect someone, the risk is going to be lower because the droplets fall to the ground quickly.

Now, just a side note here on masks. There’s been a lot of discussion and controversy about  whether people should be wearing masks. But I think if you understand this research that we’ve just covered, it makes it very clear why wearing masks can be enormously helpful even if they’re not N95 respirators or medical grade masks. Because when someone’s wearing a mask, if they sneeze or cough or even if they’re talking, the droplets that contain the virus are not going to spread out into the room and linger in the air. So this is, it’s a pretty straightforward thing. Wearing a mask is not about protecting yourself from the virus, it’s about reducing the transmission of the virus from any breathing, coughing, or sneezing that you might do, whether you know you’re infected or not. So I think this research sheds some light on why face coverings can be helpful.

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Will Welch: Yeah, and you talked initially about the social and cultural implications in the virus spread, as well. And wearing a mask also signals to other people this is something important to do. So I think it serves another purpose, as well.

Chris Kresser: Yeah, it’s unfortunate that wearing, the decision about wearing a mask has become highly polarized and politicized. And we could look at it as we did, we looked at having a garden at home during World War II. There was this concept of victory gardens because there were food shortages. And people were encouraged to grow their own food in so-called victory gardens to support the war effort. We really came together as a nation. And women got jobs bolting airplanes together. There was a massive effort on a national scale, to fight a common enemy. In this case, it was the Germans in World War II.

And we could look at interventions like masks in the same way that it’s not about protecting yourself, although indirectly it becomes that. Because if you’re reducing the risk of infection and spreading, you are actually protecting yourself. But it’s really more about protecting each other, especially the most vulnerable among us. And it’s about fighting this common enemy of coronavirus. And that’s something that we could have potentially united around and done together. But now, the decision about whether to wear a mask is no longer one that’s made for social good, or to protect our health and the [health of the] people who we love. It’s really more of a political statement at this point. And I find that to be very, very sad.

Will Welch: Yeah, it really is unfortunate. So back to, again, you mentioned a second ago the time and exposure components of that equation that Dr. Bromage talked about. And coughing and sneezing and talking having a certain kind of exposure level right away. What’s the time component there?

Chris Kresser: So the time component is, well, let’s talk about time and even another aspect of exposure. So exposure also is determined by whether you’re indoors or outdoors. So you imagine kind of being stuck in an elevator that’s broken down with two other people with COVID[-19] for six hours. That’s kind of a worst-case scenario.

Will Welch: Recipe for disaster.

Chris Kresser: Yeah, you’re probably going to get COVID-19 or have coronavirus, rather. So on the other hand, if you’re outside and you’re taking a hike and somebody passes you, even if they have coronavirus, and even if they’re not wearing a mask, if they’re just breathing and walking, the risk, as far as we can understand, is relatively low in that outdoor setting. And there’s only, in fact, been a single outbreak of COVID-19 that’s been traced to an outdoor setting. So the good news in all of this, there’s always some silver lining, I think that means that taking walks or doing other outdoor exercise and even spending time with other people in small groups outside while maintaining appropriate social distance is likely to be pretty safe.

On the other hand, the highest risk of infection occurs when spending long periods of time with larger groups of people in enclosed spaces, and that’s particularly true when ventilation is poor. So indoor birthdays, parties, funerals, weddings, restaurants, offices and other indoor workplaces, conferences, churches, choirs, especially because when people are singing, [they] emit a lot of respiratory droplets and viral particles, and maybe theaters, these can all be sources and they have been of significant outbreaks. Then you have something that’s a little bit in between like brief trips to the grocery store, or other retail locations. So you’ve got a much larger space than an elevator, for example, or even a small office. And also, people aren’t spending as much time in a grocery store. So the amount of exposure is lower and the time is lower, and therefore, the risk of infection is lower. If you’re just going in there, doing some shopping, and coming out, especially if most shoppers are wearing masks, and you’re wearing a mask.

So then you think about things like should I go back to work, [and] should I go back to the gym? Those questions kind of depend. If your office is well-ventilated, adequate social distancing is maintained, people are wearing masks, and there are relatively few employees present, I think the risk is pretty low. But if ventilation is bad and there are lots of employees packed close together and masks are not being worn or required (so, for example, the recent outbreaks in meatpacking plants), then the risk is pretty high. With the gym, if the gym’s strictly limiting the number of people that are present and ventilation is good, and they and you are being vigilant about wiping down surfaces, the risk is pretty low, though higher than it would be with outdoor exercise. But other indoor activities where people are packed more closely together or you imagine something like jiu-jitsu, where you’re rolling around on the floor with someone, and then probably the risk is a little bit higher.

So I think if we take precautions, and we understand these data and the risks, then we can actually make informed choices that can allow us to at least resume some parts of our life. Today, for example, I went on a great mountain bike ride. And I view the risk of that as being extremely low. And it’s something that really supports me and makes me feel good and is a great self-care thing for me to do. So if you have access to that kind of thing, it’s great to be able to do that now. But I think it’s still too soon to do some other activities that we might love to do that pose a higher risk.

Our Emotional Responses to the Pandemic

Will Welch: Yeah, and I think a lot of people will be glad to hear that as we get into, the Northern Hemisphere, anyway, spring and summer and all the activities that come along with that. So we’ve talked about the different ways in which this pandemic is affecting people, including the psychological aspects. But what about our emotional responses?

Chris Kresser: Yeah, I mean, we’ve touched on this a little bit so far. But I think they’re really important. And as I said earlier, perhaps the most important factor here because they determine almost everything, at least on an individual level. How we approach risk, how we conceive of and contextualize this whole pandemic, what actions we’re likely to take or not take as a result of it. And then, of course, more day-to-day, personal responses to the pandemic. Like how well we’re able to cope with it or not and relate to the other people in our lives, our partners and kids and people we’re sheltering in place with or interacting with as we start to get back out in the world.

And one of the things that I’m noticing a lot as we go through this is that, I mean, we’ve been in a situation, Will, that you’re well aware of and we all are of increased polarization. And that doesn’t just apply to politics. It certainly does apply to politics, but it applies to many other areas of life. Health, certainly, you’ve got like the vegan versus meat eating debates that can become just absolutely vitriolic and vicious. You’ve got lots of discussion about gender and its place in society and how that’s approached, and that can become vitriolic and hateful.

You’ve got all kinds of topics where it’s difficult to hold a nuanced opinion, and certainly to express it without receiving a lot of negative feedback from both sides. And there just seems to be a lot of anger and rage in the social and political discourse of today. And there are a couple of social psychologists, I believe you know one of them, Will, Jennifer Lerner. And is it Dacher Keltner?

Will Welch: Dacher Keltner? Sim.

Chris Kresser: Dacher, yeah, that did some research, and found that anger is closely associated with increased feelings of certainty, control, and optimism, which seems strange that anger would be linked in some ways to optimism. But what they think is when we feel very uncertain, information that helps us to direct our negative emotions toward a specific target, whether that’s a person or an institution or an idea, is psychologically comforting. And that sense of powerlessness that we have in a really complex and overwhelming situation makes it feel good to blame something or someone else, institutions or people, because it increases our sense of control and optimism, even if that sense is an illusion of control. And I think that’s partly why the response has become so highly politicized to COVID[-19] is that when we’re dealing with an invisible enemy, a very complex and overwhelming one, and when we’re in a situation where we’re not dealing with win-win choices, we’re dealing with lose-lose choices, humans don’t function very well in that situation. And we do tend to start blaming other people or other groups or other institutions, because that helps us to kind of catalyze our energy and direct it somewhere else.

Will Welch: Yeah, that makes a lot of sense, and to be sitting with uncertainty, and you talk about nuance and vulnerability there, for now, we’re three months into this, that’s a long time to be sitting with so much uncertainty and vulnerability. And so it seems natural that people would gravitate toward a more optimistic state, and happiness is great when it’s associated with optimism. But you’re talking about the connection between anger and optimism here, and that’s created this situation, which is pretty combustible.

Chris Kresser: Pretty combustible is a great two-word summary of the situation that we’re in. And it’s really easy to understand why we would make choices like this whether they’re conscious or unconscious. Because uncertainty is one of the most difficult experiences, I think, for human beings to tolerate. It really triggers that fight-or-flight response and we feel vulnerable; we feel like we can’t really respond effectively. Like, if you study animals in nature, for example, if an animal is threatened by a predator, and then escapes that interaction, the animal, at least in that situation, can run or fight. Because the enemy there is visible; it’s present right then and it’s kind of an acute situation that comes and goes relatively quickly. That kind of stress is not harmful necessarily over the long term because it just has a short-term impact, and when we can mount an effective response through fighting or fleeing, it has far less of an impact on us.

But studies of chronic stress have found that when we can’t fight or flee, when we can’t mount an effective response, and we feel helpless or powerless, the impact of that stress on our bodies and our minds is far more significant. And I think this is the place that we all find ourselves in. And so I think it’s a kind of biologically hardwired response to seek a target, again, a person, an institution, or something outside of ourselves that we can then fight because that actually helps us to process the stress that we’re feeling.

Will Welch: Yeah, it takes all the uncertainty out of it [and] provides some clarity in the situation, as well.

Chris Kresser: Absolutamente. So it’s just something to be aware of, I think, for all of us and to guard against. And there are other ways of dealing with this kind of stress that are perhaps more productive, like getting support. We’ve talked a lot about mindfulness and meditation, gratitude journaling, all the tools we’ve discussed [and] I’ve talked about in webinars and emails and social media posts recently to build more resilience and grit. Because that’s what we need to get through the situation.

Will Welch: Yeah, yeah. And you mentioned optimism before and it’s a great asset for balancing out stress when it’s tied to positive feelings and happiness. And there are many things to be optimistic about. You’ve talked about [them] in a number of your emails and podcasts, as well.

Chris Kresser: Absolutamente.

Will Welch: So some things to be optimistic about might be travel and being able to see people again. So how should we be thinking about risk at a personal level when we consider things like travel, eating out, meeting up with friends, and maybe our summer plans?

Assessing Your Risk Comfort Level

Chris Kresser: Yeah, it’s a great question. I think it’s important to understand that risk tolerance is very much an individual calculation. So one person might be comfortable with taking certain steps and doing certain activities that another person would be absolutely uncomfortable with, even if their circumstances are the same. Maybe they’re the same age, they don’t have any preexisting conditions, but they just approach these kinds of situations differently. And I think as a kind of meta comment, before we dive into specifics, it’s really important to understand and accept your own level of risk tolerance. Because I think that if you go too far outside of your own comfort level with risk, that’s going to generate its own stress. And what we don’t need now is additional stress.

Will Welch: Sim. And we talk about in the health coaching program a lot, meet yourself where you are. And I think that would be really good advice paralleling what you’re saying.

Chris Kresser: Exatamente. So let’s even take a step further back and talk about ways to think about risk from a public health perspective or at a larger population level.

So one of the failures in communication that we talked about earlier in the podcast was over reassurance on the part of leaders and health authorities, and not making it clear to people that we’re kind of in this for the long haul. That it wasn’t going to be a brief lockdown, followed by a return to complete normalcy. And along with that, I think, there’s been a failure of communication about how to even think about risk. It’s pretty clear now, I think we can all agree that we can’t get, there’s no scenario here where we can get risk to zero of getting coronavirus.

Even if an effective vaccine is developed, and even if effective antivirals are developed, and even if we shelter in place, and everybody just stayed home, we couldn’t get that risk down to zero. And even if we could get the risk to zero by, let’s say, sheltering in place and everybody being on lockdown indefinitely, it’s pretty clear that that would lead to other very big risks of economic turmoil or full-on catastrophe if it continued in lockdown mode, which then leads to death and disease from other causes and increase in suicide and so many other impacts that are just as significant as impacts, if not more so, than the impacts from COVID[-19].

So I think we really need to start with the recognition that there’s always some trade-off when we’re talking about risk reduction. It’s foolish and even dangerous, I would argue, to assume that there’s always a win-win option where you take this action, and all the problems are magically solved. That’s just not happening here. And so I think the better way to think about this is using a harm reduction model.

So harm reduction is a concept that has been employed in public health policies and approach[es] to addiction and even things like speed limit, which I’ll come back to in a moment. So let’s talk about clean needle programs. This is an approach that’s been used for decades now. And it comes out of the recognition that heroin addiction is a very serious addiction. And despite best intentions with group and individual therapy and treatment programs, many people are going to continue to use heroin. And so if they can be provided with clean needles, you’re not going to reduce the risk of issues that arise from heroin use itself. But you can then reduce the risk of disease transmission and other problems that can happen from using needles that are not clean. So that’s an example of a harm reduction model where we’re saying, okay, we may not be able to get the risk to zero here or reduce or eliminate harm, but we can take steps to reduce it.

I think speed limits are an even better analogy for what we’re going through right now. There are about 38,000 traffic deaths a year in the [United States]. And I think it’s pretty clear that if we reduce the speed limit to one mile per hour, just do a thought experiment here.

Will Welch: That sounds fun.

Chris Kresser: Yeah, we would probably eliminate almost 100 percent of those deaths, right? It’s pretty hard to die in a traffic accident if you’re going one mile per hour. And I mean, it sounds kind of ridiculous, right? But the fact is, we have already made a calculation where we have collectively agreed as a society to set a speed limit that will certainly lead to thousands of deaths each year. But we have agreed as a society to do that, because we recognize that if the speed limit was significantly lower and low enough to prevent all deaths, that would lead to many other undesirable consequences. How would food get delivered to [the] supermarket? Imagine trucks on the highway going one mile per hour. By the time the food gets there, it’s rotten in the stores and it would lead to …

Will Welch: My nighttime food order would take till tomorrow to get there.

Chris Kresser: Está certo. No two-hour Amazon Prime food delivery. Try two weeks or more. So, yeah, I mean, this is something we don’t, I’m sure few of us ever think about when we’re out driving [and] we see a speed limit sign. That sign is essentially a compromise, where we’re saying we’re going to accept a certain number of deaths per year, so that we can have a functioning society.

And this is where we are with COVID[-19]. Where we, in this reopening, we are saying this is almost certainly going to increase the number of people with serious disease and deaths. But we’re doing this because we need to have a functioning society. And you can, the analogy is that some of the measures that we’re going to continue to take in terms of promoting social,  continuing to social distance and advising that people wear masks and all the other interventions that we’ve talked about, that’s sort of like where we’re setting the speed limit. Direita? And just as there’s a different speed limit on the freeway, as there is a different speed limit on a backcountry road or near a school, we’re going to have to set the speed limit to be different for reopening in different parts of the community, depending on what the level of risk is, and harm is in those communities.

Will Welch: Yeah, I know [we were] talking about nuance before. There’s a lot of nuance that goes into how do you set that in a way that’s both opening stuff up and you don’t risk too much from the economy, but you don’t close it down and risk too much from a health standpoint? That’s a tough point to set.

Chris Kresser: That’s the million-dollar question. With speed limit[s], we have at least research to guide us on where to set that speed limit to kind of maximize the social utility and minimize the deaths and accidents. But even that’s controversial, right? You have the Autobahn in Germany, [where] you’ve got an 80 mile per hour speed limit on some interstate highways, and then you’ve got [a] much lower speed limit in other states. And so I think we’re going to see a similar varied response in different states and in different places based on how they assign relative value to the social good of reopening versus the social, physical, and health harm of COVID[-19] cases and deaths. So there’s really no right or wrong answer here.

And what I wish is that just as I wish there was a more productive, constructive debate or discussion around nutrition choices, I wish there was a more productive and constructive discussion happening around this question, which I think is a very valid and interesting question that deserves real, kind of dispassionate discussion. But it’s turned into a very polarized and often political kind of statement rather than any true discussion. So that’s the 30,000-foot view at a population level in terms of thinking about risk and harm reduction.

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In terms of individual level, I think we need to apply those same principles. We first need to recognize that there’s no way to completely eliminate risk, short of going and living in a cave somewhere. But then again, you introduce other risks, which are significant and valid. And then assessing your own risk tolerance. Are you a person who generally has higher or lower risk tolerance? So you start there. And then, if you’re thinking about something like travel, it would be assessing your risk factors. Do you have a preexisting condition like diabetes or heart disease? Or are you obese? Do you have preexisting lung issues? If you do, that sort of pushes you a little further into the more cautious. We think about it as a spectrum where on the left, you’re going to be not cautious at all, [and] on the right, you’re going to be more cautious.

If you have risk factors, that pushes you a little further over to the right, or if you live with someone who has risk factors, that pushes you a little further to the right. Think about the importance of the trip. Are you going to be with a relative, like someone in your family because there’s been a death in the family? Funerals aren’t really happening that much right now. But let’s say there’s a death or there’s a birth of a new baby. That’s a much more important, perhaps, event than something that is work-related and not essential or even a vacation.

You have to evaluate your tolerance of risk, as I said, and also your tolerance of inconvenience. Because especially if you’re going to be traveling by air right now in places where that’s possible, from everybody that I’ve talked to [who] has traveled by airplane recently, it has not been a pleasant experience. So there are a lot of precautions that need to be taken when traveling. And it’s already, air travel, with all the procedures, checkpoints, and stuff, was somewhat unpleasant, but it’s become even more that way. You need to think about whether you can practice good hygiene and social distancing, both en route while you’re traveling and wherever you’re going to end up. So I think those are all considerations for travel.

I generally think car trips are safer than flights at this point. And so we’ll probably be seeing a lot more road trips during the summer. In terms of getting together with groups, in some places they’ve relaxed the restrictions on [that], or relaxed the sheltering in place order. So, in theory, it’s possible to go out and have dinner with some friends at their house or vice versa. I would apply the same kind of framework that I just mentioned. Assessing your risk factors, evaluating the importance of the gathering, evaluating your tolerance of risk. Can you practice good hygiene and social distancing in those situations? Are you potentially going to be exposing other people that are at higher risk?

So, for example, I’d really love to see my parents. Faz algum tempo. I’d love for them to see their granddaughter and they’ve got other grandchildren that they haven’t seen, and they’re really missing them. But so far, other than some distanced outside visits that they’ve had with my brothers and their kids who live close by, there has been very limited in-person interaction because we’re really wanting to protect their health. And we know that people who are asymptomatic can be carriers. So that’s something, too, that is difficult and sad. I feel sad about it. But I feel more strongly about protecting their health and well-being until we learn more about this virus.

Will Welch: Yeah, and I think you make a good point there about we’re not just making decisions for ourselves, we’re also making decisions for the people that we’re interacting with. And those can be the people that we care about the most who may have certain risk factors, like parents.

Chris Kresser: Yes, yes, certainly.

Will Welch: So we’ve talked about the million-dollar question. How about the five-million-dollar question? How do you see this pandemic ending?

How Might the Pandemic End?

Chris Kresser: Yes, that’s the five-trillion-dollar question, perhaps, or even more. Now we’re thinking in trillions for sure in terms of economic impact. So yeah, there are a lot of ways to think about this. And I mean, let me just say, I’ll start by saying, I don’t know. And I think anyone who claims to know with certainty how this is going to play out is not being totally honest. And I’m, of course, not an epidemiologist or a virologist or an infectious disease expert. So my opinion is just based on following this very closely and being connected to many of those types of professionals and having lots of conversations with them and following all the research and news as everybody else is.

But my sense of this question, I mean, there are many variables [that] will affect the answer to this question, of course. So one of those is whether immunity is permanent to SARS coronavirus-2. If it is, then we can see it coming to a kind of distinct end where it really just, the number of new infections just gradually drops to almost zero and it’s effectively over. If immunity is not permanent, then it’s unlikely to end per se so much as it, that it might kind of gradually peter out or gradually lose significance and end up, or even persist at a significant level, but hopefully with smaller waves over time and maybe less severe impacts. So there’s a scenario in which immunity might not be complete such that people who have been infected before don’t get infected again. But it may be that the second time that they get infected, the effects are less severe.

So those are some scenarios that depend on what happens with immunity. And there’s been some interesting recent news about this. We still don’t really have the answer to that question. But there were brand new data that came out from South Korea just this morning that showed that people who tested positive for a second time, [who] they’re calling re-positives, are only shedding dead viral particles and they’re not actually infectious. So that’s good news, because that suggests that an immunity may be longer lasting and people aren’t getting it twice.

There were also some new data published this morning, as well. I mean, this is how fast things are moving. I do some preparation for the episode and then literally 12 hours later, I have to add or change things based on new data. So survivors of SARS[CoV]-1 from 2003 were found to retain neutralizing antibodies, nine to 17 years later. So it’s possible that functional antibodies to coronavirus can persist for a lot longer than previously shown. Because the idea has been that antibodies to SARS and MERS [Middle East respiratory syndrome] are shorter term than for many other viruses. So those are some positive new data that have come out recently in favor of the idea that we might develop immunity.

Another really important thing to understand is that it may be a misconception that we have to get to 60 percent infection rate in a population to see benefits. And that’s commonly the threshold that is thrown out there for reaching so-called herd immunity, which is the point at which the virus stops spreading through the population because enough people are infected already. And describing this is pretty technical. And we’ve already been going for a while. So I think I’m going to skip the hardcore technical explanation. But essentially, there are two numbers that are important to understand, and I think they’re widely misunderstood and have even been misused in a lot of articles.

  • One is R, which is the expected number of people that one infected person will pass the virus on to.
  • The other is R0, sometimes called R naught, which is the expected number of people that one infected person will pass the virus on to in a population where everyone is susceptible.

So the only difference between those two numbers is that R refers to how transmissible a virus is in a population where some people already are infected and not susceptible, whereas R naught or R0 is how many other people you will infect in a population where everyone is susceptible. So R0 is mostly impacted by things like social distancing and contact tracing isolation, because those are the most effective measures when everybody is susceptible—when the virus first hit the scene back in January and February. But R actually depends on two things, the R0 value and the percentage of the population who are not susceptible.

So, as you can probably gather, as the number of people in a given population goes up, then R will decline, even with no changes in social distancing, masks, etc. So somebody did an analysis using both R and R naught, and they found if just 13 percent of the population becomes infected, assuming an initial R naught value of two, R would drop to 1.75 with no changes in social distancing or masks or anything. At a 25 percent infection rate, R drops to 1.5. So that’s a half point drop from the initial R naught value just from more people getting infected. And then, if you combine that drop in R with a drop in R naught because of the social distancing measures and masks and things like that, then it’s conceivable that you could get to an R less than one where the number of infections starts to decline rather than stay stable or increase quite a bit before the percentage of the population being infected gets to 60 percent.

So, for example, if R naught can be dropped to 1.5 through social distancing, and masks and other measures, then you could potentially get to an R below one or where the infection stops spreading at a 40 percent infection rate rather than 60 percent infection rate. So this is still not, these are models, [and] models are not perfect, as we’ve learned. But I think that’s somewhat encouraging news that hasn’t been widely understood.

Will Welch: Yeah, I think that’s helpful context that as more people get infected, things change. And as we do more behaviors, like wearing masks and staying home, things will also change. And scientists are out there collecting data to find out the impact of these different things. And as you’ve said, more and more is out there and being reported, and we have a better sense of what that impact actually is.

Chris Kresser: Absolutamente. And of course, in any discussion that we have about how this is going to end, we need to talk briefly about vaccines and antiviral medications. So there’s been some big news on the vaccine front this week.

One report from Moderna, which was just released yesterday, at the time of this recording showed positive phase one trial results in a very small sample size, eight people. Normally, data would never be announced for eight people. But these are the times we live in, right? And these eight people produced neutralizing antibodies to SARS coronavirus-2 that were similar to antibodies seen in the [patients with] COVID-19 [who] had already recovered. So that’s a very positive finding. Of course, this is only a phase one trial. There [are] lots more steps to go through. But it’s an encouraging result for sure.

On the other hand, we had results from the Oxford lab that suggested that their vaccine won’t fully protect against the disease, but just reduce its severity, which is similar to how the flu vaccine works. And the downside of that is that a vaccine that reduces symptoms rather than completely prevents infection takes a lot longer to develop than one that does prevent infection. And it also requires studying a lot more people. Because if 20 to 40 percent of infections are asymptomatic, assessing the reduction of disease severity as the primary endpoint rather than preventing infection requires much larger trials with more people and much longer study periods.

So that was kind of a bit of not so great news on the vaccine front. And then there are other significant challenges with vaccines. It’s not just a question of can we develop a vaccine and will it work and will it be safe? It’s also a question of can it be deployed at the scale that it needs to be deployed at in order to be effective and help get us to a herd immunity situation or to end this pandemic? And that depends on manufacturing capacity. And it’s not something that we can necessarily just throw money and resources at and get the outcome that we want because there is a shortage of certain supplies that are critical in the manufacture of some of these vaccines. And it seems almost silly in a way, but the glass vials that many vaccines are stored in require a certain type of sand that they’re made from that’s in short supply. And so that could be a bottleneck, pun intended.

Will Welch: And we’ve seen it with the PPE, with masks, with ventilators.

Chris Kresser: Of course.

Will Welch: All these supply chain issues are really coming to …

Chris Kresser: It’s so frustrating, right? Because you think, like, wait a second. We can’t just make more cotton swabs? Like, those are not, we’re not talking about high-tech gear here. Or a mask actually like an N95, it seems like when we just bought them in boxes before, they seemed pretty low-tech. But they’re actually quite difficult to manufacture and there are only a few companies that do it, and they can’t just ramp up capacity immediately. They have to build the equipment. So it’s the glass vials, the stoppers that you use to plug up the glass vials for certain vaccines. Certain materials are needed in those stoppers because they can, if you use the wrong material, it can interact adversely with the vaccine, and those are in short supply. Only a few companies make those. And so, again, these are sort of the not very sexy or glorious aspects of the process, but they might end up standing in the way of getting to the point where there’s not only a vaccine that’s effective, but there’s one that can be distributed widely.

And that’s the other challenge, or thing that’s worth pointing out, [is] just like with the flu vaccine, there’s probably not just going to be one vaccine. There’ll be multiple different vaccines, some of which might be more effective and safe for kids, and some of which are better for pregnant women, some of which are better for the elderly. And so we’re going to have, there’s probably going to be multiple vaccines, and then there’s going to have to be this effort to distribute them on a wide scale. So I have, I’m definitely not an expert in this area. But I think the idea that we would have, it’s at least possible that we could have an effective and safe vaccine in 12 months. But that would be if every single thing goes right in the process. But that’s different than saying, everybody listening to this show will have access to that vaccine in 12 months. I think that’s almost certainly not going to be the case. Because there’ll be a relatively long path from when the vaccine is ready to when billions of doses of it are available or even hundreds of millions for people in the [United States].

And then there’s, of course, just the question of safety that’s on everybody’s mind because previous vaccines for coronavirus have led to antibody-dependent enhancement, which actually can increase the severity of acquiring those coronaviruses. And that’s something that everyone’s going to be looking out for in the development of these vaccines. And I think, fortunately, in the Moderna case, and maybe also the Oxford case, there was no evidence of antibody-dependent enhancement. But these sample sizes are very small. So they need to have much larger sample sizes to be able to rule that out.

Will Welch: Sim. And you also talked about another strategy, which would be the antiviral drugs, as well. Did you want to touch on that?

Chris Kresser: Yeah, again, it’s not my area of expertise, but I’ve been following it pretty closely in talking with our infectious disease doctor on staff, Dr. Asfour, who’s been on the show a couple of times. And certainly, there are some drugs like remdesivir that have emerged that seemed to lessen the severity of COVID[-19]. And I think that’s a promising route for development. I was listening to a podcast with Marc Lipsitch, who’s an infectious disease specialist, [who] works a lot on vaccines, and I’m sure many people have read or heard something from him during this pandemic. He’s been pretty vocal. He was saying that one of the most promising areas for therapy is coming up with drugs that can be taken very early, that will slow or stop the progression of COVID[-19] to the point where it gets very severe. Somebody first starts to feel symptoms, they take this antiviral medication, and that significantly reduces the likelihood that they develop pneumonia.

If we had medications like that, rather than just relying on medications that people take when they get to the hospital, and they’ve already progressed to a serious point, that would be a huge step, because it would really dramatically reduce the burden on the healthcare system and lessen the severity of infections. And I think, arguably, that would be an easier goal to obtain is developing drugs like that. Because if you look at most antivirals that exist today, they do tend to be much more effective when they’re taken early on in the progression of the disease, and they become a lot less effective the later they’re taken. So I think that’s a fruitful avenue for exploration.

Will Welch: Sim. I’m hearing from you that there are lots of potential points of intervention and that this is going to be a multifaceted strategy of all these pieces of the puzzle coming together to slow this down to a point where the economy opens up, [and] we can all start to get back to some of the things that we enjoy. But it’s not going to just be a silver bullet. It’s a lot of things here in the mix.

Chris Kresser: Yeah, 100 percent. And I think it’s also important to understand that this is not going to be a linear progression. I think that’s another thing that the powers that be failed to communicate. There was this idea that we’d have an early spike and then it would just be all downhill from there. And I don’t think that’s going to be the case, at least in some places. It may be in certain areas, but it may not be. We’re probably going to see sporadic waves of outbreaks and spikes as we kind of resume more normal activity.

There may, unfortunately, even be additional times where we have to go back to shelter in place, at least in certain areas. Nobody knows how this will play out. But I think cultivating what we’ve talked about many times now, cultivating realistic optimism is the best approach where you pay attention to what some of the worst-case scenarios could be, or at least, not great scenarios. And you do your best to prepare for those so that you are prepared if they happen and you’re not caught totally off guard either practically or psychologically. While also making sure to spend an equal, at least an equal amount of time attending to opportunities and upsides and bright spots that come about from COVID-19 and our experience with this pandemic. So that’s definitely my approach and it’s the approach I continue to recommend for everybody.

Will Welch: Thanks, Chris. I think realistic optimism is probably a good note to end on. Thank you for all the information, [and] for breaking things down. I think it’s really helpful. It’s been a helpful context for me. So I appreciate it and appreciate the opportunity to get to ask you all these questions.

Chris Kresser: Well, Will, thank you so much. It was a pleasure to answer those questions. I think you did a phenomenal job and it was a great conversation, and I appreciate you being willing and game to jump in and do it on such late notice.

Will Welch: Happy to. [I] appreciate it.

Chris Kresser: Okay, everybody. [I] hope this was really helpful. Feel free to send it on to a friend or family member you think would benefit from it. I’m just really eager to get this information out to as many people as possible so that we can make our response to this.

Stay safe and healthy and sane, and really come together and support each other as we move through this. That’s my hope that over time, we can try to be a little more on the same team as we approach this because we really are all in this together. And I think that’s abundantly clear. We’re connected whether we want to be or not. So it’s a good idea for us to keep that in mind as we navigate this. Keep sending your questions in [to] ChrisKresser.com/podcastquestion and I look forward to talking to you soon.



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