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September 26, 2023
America Dissected

In This Episode

How worried should you be about B.A.2.86? When is it time to get another COVID shot? Is there any future for Medicare for All? We asked for your most pressing public health questions on Twitter, Facebook, and Discord. From unique COVID situations to the future of healthcare in America, Abdul delivers answers to each and every one of your questions.




[AD BREAK] [music break]


Dr. Abdul El-Sayed: Should you be worried about the newest COVID variant? Should you get the latest booster shot? Yeah, you should. How can you make a living in public health? This is America Dissected. I’m your host, Dr. Abdul El-Sayed. And today I’m answering your questions. [music break] Hey, everyone. I’m out traveling this week, so rather than our regular episode, we thought we’d put together a special mailbag episode. We asked for your questions on social media and in the Friends of the Pod Discord. And well, there’s a lot to get through. Joining me for the mailbag today is longtime America Dissected associate producer, all around phenomenal human being and good friend, Tara Terpstra. Tara, welcome to the pod. 


Tara Terpstra: Longtime producer, first time interviewer. Thank you for letting me be your guide for these questions today. 


Dr. Abdul El-Sayed: I uh, I would want no better guide. I could not get through my life without the Tara Terpstra, so glad to have her on the pod. Looking forward to the better guide. I could not get through my life without the Tara Terpstra. So glad to have her on the pod. Looking forward to the conversation, Tara. Thank you so much for being here. 


Tara Terpstra: You’re very kind. Thank you. We will get into it. So the first question is AE. Strange asks, where can I find PCR tests these days? And what is the most up to date guidance for isolation and masking after a COVID exposure? 


Dr. Abdul El-Sayed: Well that’s a really good question because there was this massive shift away from PCR to antigen testing, and a lot of the argument for doing that was simply to be able to get test information faster. Of course, PCR has to be sent out to a lab. You don’t get immediate PCR results and so people have to wait oftentimes, you know, 1 to 3 days, sometimes five days, especially in the beginning of the pandemic for actionable information. And by then they won’t necessarily have changed their behavior. Whereas with rapid tests, you get that information in 15 minutes and you can make it actionable. The upside of PCR testing, though, is that those tests automatically uh get recorded and they go into the data that helps us to understand where the pandemic is headed. And today, if you really want PCR testing, the best way to do it is through your PCP. Um. Most of the places where people would have gone for PCR testing have largely decommissioned it, whether they were standalone testing sites, even many of the pharmacies that had offered them. You can also, of course, go to your local trusty health department. They can offer that as well. When it comes to isolation and masking after a COVID exposure. The recommendation is to do it, and that’s probably the most important thing. But what does that mean? That means keeping yourself away from others without wearing an N95 mask. The recommendation is five days for everyone and then for folks who have marginal or minimal symptoms, especially after five days. Then you can test. And if you test negative, then that isolation period can end. So long as you’re still testing positive or experiencing symptoms that recommendation is to go out to ten days of isolation. And, you know, remember, masks are a two way protection, not just protecting you but protecting others from you. So if you do have to go out into the world, it’s recommended that you wear one of those N95s to protect others from the virus that you may be shedding. 


Tara Terpstra: Great. Goganader asks. I caught COVID recently. The CDC guidelines say I should wait three months after COVID diagnosis for the newest vaccine booster. Why is that? And Sofia asks, When should I get my COVID booster if I had COVID recently? 


Dr. Abdul El-Sayed: So remember, this virus is constantly and consistently changing. And if you’ve been exposed, the high probability is that you’ve been exposed to the most recent variant, right? The variant that is the most dominant, which means that your immune system has just upgraded your level of immunity to what you might be exposed to. So if you think about it, whenever you get a COVID vaccine, it’s thought that that immunity starts to wane after three months. So if you just got a natural bump of immunity, then the idea here is that you can extend your immunity window for another three months after your exposure immunity window starts to wane. So you get your exposure right, you get sick. For three months after that, your immunity is really quite strong because you just fought off the virus and then you would take the vaccine to update your immunity yet again. So you’d have another three months of protection. And so you know it doesn’t necessarily make sense to get vaccinated immediately afterwards because you, in effect, naturally vaccinated by actually getting exposure to the vaccine. The second question was about getting a COVID booster if you had COVID recently. I think the same issue applies. I would sort of start counting three months from the date of your exposure, and then that would probably be the optimal time to get that booster. 


Tara Terpstra: Reston asked, what is the difference between the booster shots and this new COVID vaccine? 


Dr. Abdul El-Sayed: So the past booster that we were talking about was called a bivalent booster. And what that booster included was mRNA from both what we call Wildtype SARS-CoV-2, meaning the original strain of SARS-CoV-2, which emerged in Wuhan and caused the initial illness and COVID 19 spread back in in 2020 and then um in Omicron uh and mRNA to the Omicron strain. Since the emergence of Omicron back in the bad old days of ’21, the virus has mutated quite a bit. And so now what we’re dealing with are what we call Omicron subvariants. So think like distant, distant, distant cousins from the original Omicron. And so the Bivalent booster doesn’t have coverage for the sub variants that uh are spreading right now. And so this new vaccine is updated against what’s called XBB, which is one of those distant cousins of the original Omicron and a closer relative to the sub variants that are spreading today. So imagine it being like a virus that consistently changes its mask. And your vaccine is kind of like a be on the lookout call. In this case, you’ve got to be on the lookout for the most recent mask rather than a mask that the virus was wearing you know, two years ago. And that really is the main difference. But in terms of the technology, it’s about the same. We’re taping this on September 14th. And as of now, the FDA and the CDC have approved and recommended, respectively, both Pfizer Bio n’ tech’s and Moderna’s updated vaccines. And both of those vaccines continue to use the same mRNA platform. And just to remind you all, what mRNA vaccines do is rather than give you a live virus which has been you know beaten half to death or giving you a dead virus, as we used to do, or you know con– continue to do with with some vaccines. What we’re um giving folks is a piece of the virus’s genetic material that our cells will translate into proteins that are viral proteins. And the minute our immune system recognizes proteins that aren’t natural to us, they form an immune response to it. And the value of doing it this way is obviously it’s better to give people genetic material for a small piece of a virus than an actual virus and risk, you know, that virus potentially causing disease in folks who are immune suppressed and um that it uh leaves behind a lot less residue. Even when you give viral proteins, which is another platform, there’s a lot more that you have to give. In this case, you’re giving a small piece of genetic material. Your body will destroy that small piece of genetic material after it’s translated into protein, uh and then that protein gets destroyed in the end. So it’s just a much more efficient delivery mechanism. But there’s a third vaccine that hasn’t yet been approved, and that’s um a vaccine from Novavax, which isn’t built off of the mRNA platform. It’s a more traditional kind of vaccine. And so um in that case, this is going to be somewhat new. Many experts will argue that, you know, if you get the opportunity, if you’ve had only mRNA vaccines to get the Novavax, what you’re basically doing is the immunological equivalent of training your iPhone to your face. You know if you’ve ever had to train your iPhone, you kind of let it see different views of your face because, of course, your face looks different from different angles. And the idea here is that rather than showing the same exact view, meaning, you know, the same mRNA technology, you might get a different look on um what the virus could look like in real life when you’re exposed to it by um by using a different platform of vaccine. Now, in the end, the thing that matters the most is just go get vaccinated. That really is the most important thing. But, you know, just just so so you all understand sort of what what these differences are um that Novavax vaccine uses a different platform than the traditional mRNA, it’s weird to say traditional mRNA vaccines. But, you know, the one that we’ve we’ve all gotten accustomed to for the last uh three years here. 


Tara Terpstra: Yeah, I know I for one, am looking forward to getting the new booster when it becomes available. Dunphy asked, is this strain of COVID showing up on rapid tests? 


Dr. Abdul El-Sayed: Yes. Um. From what we understand. So when you say this strain, you know, there are several that are floating around. And let me be clear about what I think you mean by this strain Dunphy. Um I also loved you in Modern Family. Just wanted to put that out there. Um. Is uh there are two majors that you’ve been hearing about. There’s Eris or EG5, which is a uh Omicron sub variant, right? Very, very similar to a Omicron. But, you know, just the latest and hate to say greatest, but the latest and most efficient version uh that we’re dealing with, and that is the top of the heap right now, it’s the it’s the most common variant that is identified when we sequence. But the other that made a lot of news recently is one called Pirola and Pirola is by BA.2.86. And what’s interesting about Pirola is that Pirola is um far further evolutionarily from Omicron than a lot of these sub variants. In fact, the evolutionary distance between Pirola and Omicron is is larger than the distance between Omicron and the original um Sars-cov2 from 2020. And so it really is a great leap forward. What we’re finding, though, is that while we’ve identified it in wastewater means it’s meaning it’s spreading, there aren’t that many cases that have actually been identified and you know that that could be for two reasons. One is that it’s just not very efficient at attacking cells. And that’s what a lot of lab studies have started to demonstrate. The other is we may not be as good at picking it up, and it’s still just not making people all that sick. So, you know, the ability just to really identify the difference there is difficult because, of course, when you look at population level data, it’s both that people have to know they have it and then get tested and then it has to show up on the test. And um we actually don’t know what uh why the caseload for this um uh subvariant is so low uh relative to the number of of countries that that it’s been in. And so it’s either that it’s just um not very good at causing illness, meaning people get infected, but that they don’t get very ill or we’re just not very good at identifying it, even when it does cause illness. And so you can imagine somebody having nondescript symptoms, you know, given that COVID symptoms are relatively nondescript, they test themselves, they test negative, and they say, well, this isn’t COVID. It could potentially be that’s a possibility. Um. But uh to the best of our knowledge, in terms of lab studies, um this sub variant does show up on on on rapid tests. It’s just not very good at attacking cells. But at the population level, there’s still a lot more I think we need to understand about Pirola. What I will say is, you know, relative to how worried we were about two or three weeks ago, when folks are like, hey yo, there’s a really, really vastly evolved sub variant here. I think there’s just a lot less to be worried about considering the fact that it’s just not making that many people sick. 


Tara Terpstra: I remember when we were like, there’s a new variant. Oh no, is this going to be the, you know, the big one so? [?]


Dr. Abdul El-Sayed: And we’ve been saying that for a while. 


Tara Terpstra: Yup. 


Dr. Abdul El-Sayed: We’d been saying, you know, we feel pretty good given the fact that, you know, 97% of people have been exposed to this virus at this point, like literally almost everybody’s had it. And even if they tell you they haven’t had it, you know, statistics tell us that when we look at their antibodies, they’ve got antibodies against it, meaning they’ve had it. And um and so a lot of that immunity actually didn’t come in 2020, it came in 2021 with Omicron. And so we’d said that, you know, we’ve gotten to this point now where I don’t want to say we’ve got herd immunity, as in nobody’s going to get sick, but that the ability for the virus to get safety and quarter in people’s bodies is a lot lower given that almost everybody has some reactivity against it. But we’d always said that there was a big asterisk, which is so far everything’s been Omicron subvariants for which most of us have um some exposure and some immunity. But if there was some different leap or some different clade that all bets could be off. And that’s why scientists were so worried. But it just turns out that this you know, this this variant is just not very good at making people sick, which is you know great news. 


Tara Terpstra: Yes, definitely. And as a follow up question, Melody asks, when should I start to worry about BA .2.86? 


Dr. Abdul El-Sayed: Well, to um to borrow from my podcast uh brother Dan Pfeiffer, worry about everything, panic about nothing. Um. Look, at this point, there’s nothing in the laboratory evidence or the broader epidemiologic evidence to tell me that we should be so worried about this. That being said, um there’s still a lot we need to learn. And, uh you know, I don’t know where this is going to evolve to. So my answer to you would be, well, I wouldn’t be so worried um and I certainly wouldn’t be panicked about it, but um I would keep an eye out. And look, the thing about COVID is uh we all kind of know the ways we need to protect ourselves. And the bigger risk right now, just epidemiologically is Eris and other Omicron subvariants. So get your booster, you’re protected. Other good news is the booster does appear to have reactivity against BA.2.86. So there’s that. 


Tara Terpstra: Yeah, that’s great news. Um. Caroline asks, should I still be masking on airplanes? 


Dr. Abdul El-Sayed: I’ll tell you this if you’re someone um who uh for some reason may not have an immune system that responds in a way that could keep you safe? Yes, certainly. Um. And when I say masks, you know, those cloth masks that we were wearing in 2020, not really worth it. If you’re going to mask, wear an N95, that’s the mask that will really protect you. And, you know, if you’re somebody who uh is in a high risk category, so someone over the age of 65, um I think that’s also an advisable thing. But for other folks, it really is a choice. And I can tell you that I don’t mask on airplanes, just given that the risk of of COVID has been really quite low, um that I’ve, you know, um had multiple courses of vaccine and been infected now twice. Uh. And so to that end, I say, well, you know, given those risks, um I’m going to choose not to mask. But I also think that it’s important that we create space where people who do mask feel comfortable and confident doing that. Um. And so, you know, I think you know masks have been so politicized, and I don’t have to tell you all this, but they’ve been so politicized now that um there’s always this sort of broader question of like, what does this say about who I am and my values? And I just really think that at this point in the pandemic, right, COVID is still around us. And if you’re uncomfortable or less comfortable with those risks or for some reason those risks are substantially worse for you, masking is a great option to protect yourself. And certainly if you’ve been exposed, masking is a necessary option to protect others from you. Uh. But for others who say, listen, I’m a little bit more comfortable with these risks um than, you know, it’s a it’s a reasonable choice not to mask. Um. What is not a reasonable choice is not to get vaccinated. And I just want to you know be clear about that. Um. You know, a lot of folks will say, well, you know, I sort of think about this as the Swiss cheese model, etc.. Um. But when we collectively protect ourselves, there is a herd immunity effect that still does happen. Now, I think the way that we talked about herd immunity back in 2020 was this like all or nothing thing. It’s like once we achieve this magical threshold of herd immunity, then no one would get sick ever or ever, ever again. Um. That’s not how it works. But it does reduce the probability that COVID started bouncing around. And that’s a good thing for everybody, both for the folks who mask and the folks who don’t, for the folks who are more vulnerable and the folks who are not. Um. And so, you know, I think on that front, uh I think the most important thing you can do is, um you know, to protect yourself by by getting vaccinated. The other and you’ve heard me harp on this a bunch of times, if you listen to the show, uh is indoor um indoor air quality. And, you know, it’s a small thing, but like in the spaces where you spend most of your time investing in uh an indoor air purifier uh that can literally pull viron particles out of the air, that’s a good thing to do. And, you know, in our family, we’ve got them in all the rooms where people spend a significant amount of time together. Um. And that’s something that makes me feel really quite a bit more comfortable considering I have a five year old and I have an eight month old and both of them spend spend their days in places with other children where they could be contracting illnesses and then bringing them home. And I really don’t want them giving them to each other. So um so that investment to me was one that was a slam dunk, obvious one. And it’s something that I don’t think we pay enough attention to uh in the spaces in which we occupy. 


Tara Terpstra: Yeah, definitely. We have also a question from our friends of the Pod Discord. So shout out to our folks out there, dude guy pal asks, Has there been any research done about COVID and loss of a smell? My mother had COVID two years ago and still says she lost about 60 to 70% of her ability to smell. 


Dr. Abdul El-Sayed: Yeah, there is, you know, increasing research here. And that was a really common initial complaint from from folks that seems to persist for a lot of people. And our understanding of what happens really is about just remember your sense of smell is like really like just like a really, really long um nerve ending that that ends in your nose. And it’s actually a really interesting thing, the way that your brain processes smell. It bypasses a lot of the brain circuitry that processes your other sensations, touch, uh your sense of vision or hearing, and it goes right to your limbic system. And that’s why when you smell something, the first thing that you experience tends to be a feeling. Like my dad when I was young, used to wear a very particular cologne, and whenever I smell that cologne, I am immediately transported back to sitting in my dad’s 1996 blue [?] on the way to hockey practice like that was that was that smell right? And I can’t unsmell it. It’s just like it’s just that’s what that is. And I then have to think about what I’m smelling versus when you see something or hear something that gets processed immediately uh through the more thinking parts of your brain that help you to try and process it. Um. And it’s a really just fascinating thing. So the way that we think that um or at least that that the research is sort of leading us to, uh is that the infection, um you know, you think about the way that COVID enters your body, right, in your nasal pharynx, um that it it you know, the way that it infected um those olfactory neurons um could have led to, you know, for some folks, semi-permanent or long term um loss of sense of smell. And um there also has been some evidence that you can kind of regain your sense of smell. It’s sort of like a physical therapy for your nose. Um And uh and so I encourage um dude guy pal’s mom to to look into that. Um. You know we take our sense of smell for granted. It’s not really one that mediates a lot of our lives. But um you know, some of the best things uh are smells, right? I mean, you think about uh I happen to really love love coffee. And so much of the experience of drinking coffee is smelling coffee. And that’s you know, I as a matter of course, um unless I absolutely have to, because I don’t want to spill it on my shirt or something, I try not to drink coffee with a lid on. Right. And that’s because I want to be able to smell my coffee when I drink my coffee. You know, if you’ve ever had an onion, if you plug your nose and eat onion, it tastes like an apple. It’s a very, very weird thing. But the difference between apple and an onion is the smell. Um. And so, you know, that loss is a real thing and um it does rob people of a lot of joy. And so I hope that she regains that. That really sucks. 


Tara Terpstra: Yeah. Uh Emma asks, do you think our COVID 19 response has made us more prepared for future pandemics? 


Dr. Abdul El-Sayed: [laugh] I really I super wish it did. Uh. So, as many of you know, at my day job I run a large urban health department in Michigan. And part of the challenge with public health is it’s feast or famine all the time. We have a major public health catastrophe and then all kinds of resources rush in. But very specific to the catastrophe and then a lot of the long term investment that we would have wanted to made to be ready for the next one, that investment goes elsewhere. And there’s this perverse thing about the pandemic, which is that um, you know, in the words of my friend Katelyn Jetelina um we’ve been trying to revise history on this about like what really happened. And in the process of revision, there is no political incentive to remember. So if you’re a Republican, you want to deny the fact that the pandemic ever happened in the first place. And if you’re a Democrat, you want to be able to say, well, we did all the things we needed to do to end the pandemic and now we’re past it. But nobody really wants to go back and actually look into what should we have done. And the political environment is such that the collective emergent phenomenon of that conversation is that we’re just not investing in the singular, most important set of institutions that could have prevented the kind of catastrophic outcomes that we had, which are public health institutions. So when I talk to my colleagues across the country, almost everybody’s in the same position, which is let’s see how long we can make um these post-COVID resources last. And wow, I really wish that there was more attention paid to what we do. At the same time, though, and I got to be honest, you know, a big theme of our show is how public health sometimes fails to have a broader conversation with the public. And it’s the raison d’etre for the show. And part of it is that we’re all kind of I hate to say it, we’re all like, we want more resources, but I’m kind of glad that nobody’s paying attention anymore because that kind of sucked. And this is not the time to slink into the shadows. This is the time for us to go on offense and say public health doesn’t just show up when there’s a major pandemic. Public health is the community that’s out there fighting for your lungs. Uh. When some major polluter is uh pushing all kinds of nasty stuff out of their smokestack, public health is there when um you’ve got, uh you know, vaping companies uh creating a product that looks like a highlighter so kids can bring it into school um and exploiting our children. Right? Public health is there uh when your health care system uh is is actively discriminating. And we can build alternative means uh to keep people from getting sick in the first place. Like, this is the time when we need to go on offense, not the time when we need to to go on defense. And I get that folks need a breather. But I think we’ve had our breather and this is the opportunity for us to step up and remind folks that we’ve been here all along. And I think that’s some of the frustration that people had with us. They’re like, how come y’all only show up when right there’s this major catastrophe and now you want to give me some medicine that I don’t even know I need? Right I mean, this is the thing about it, and I’ve said this I don’t know how many times on the show, but when people know they need medicine and our health care system denies it to them, and then we show up and say, here’s a medicine that that has a higher proportion or probability of protecting you from a disease. For a lot of folks, that’s all kinds of messed up. And I get, you know, folks in the public health community say, well, we’re different from medicine. I get that. But for folks who are not part of this community, that’s a difference without a distinction. And we’ve got to show up to be better and to define ourselves in the moments when the stakes aren’t so high. So this is the time, I think, to step up. And so I hate to say it, but to answer Emma’s question, I don’t think it’s made us more prepared. I actually think it’s it’s actually made us less prepared. I think by almost every metric, when you look at the porousness of our public health institutions, when you look at the number of young people leaving uh the profession and trying to find alternative work, um when you look at the level of burnout, uh I think I think we are less prepared today for the next one than we were in 2019. And that is a pretty sad comment. 


Tara Terpstra: Yeah. And it’s also a little bit scary because we don’t know when the next one will be. We might get caught unprepared. 


Dr. Abdul El-Sayed: Yeah. [music break]




Dr. Abdul El-Sayed: And we’re back. Next question. 


Tara Terpstra: Um. We also had actually an anti-vaxxer write in with a question. So we’ll dive into that one. Explain to me how the mRNA vaccine actually fights COVID while it weakens the immune system?


Dr. Abdul El-Sayed: You know, I really appreciate this person asking this question. And what I’m trying to do here is model a level of appreciation for an open dialog. I do want to acknowledge that the the question is based in a premise of misinformation, which is the notion that mRNA vaccines weaken the immune system. Um. There’s absolutely zero evidence that mRNA vaccines weaken an immune system. You know what an mRNA vaccine is versus, let’s say, a protein vaccine, as we discussed earlier. All an mRNA vaccine does is give your body a piece of genetic material that will then be transcribed by your own cellular infrastructure into a protein uh that is a piece of that virus. Your body will then acknowledge that that protein is not part of it and then build an immune response against that thing, your immune system is trained to recognize anything that’s not part of you, right? Anything that’s not actually part of your own body infrastructure, it’s literally got a map of every single protein your body makes. And it knows that those proteins are part of you. But when you get something that’s not part of you, it’s going to respond. And so there’s no way that having a piece of mRNA, which, by the way, your body makes like huge amounts of all the time put into your body is somehow going to weaken your immune system. It’s just not it’s just not how these things work. There’s also this notion that, like your immune system can be overwhelmed, like your immune system has an almost infinite capacity to render a response to almost anything that it sees as not part of itself. And if anything, nowadays, our immune systems are probably underwhelmed because we live in such sterile societies. And you got to remember who our ancestors were and what they did all day. They literally like, you know, they were exposed to the elements all the time. And so the amount that uh that our our bodies are exposed to is just far lower um than a lot of our ancestors. And in some respects, a lot of folks have posited and there’s some relatively decent evidence to suggest that part of the reason that we have so many more allergies nowadays um than there had been in the past is is exactly that is that there’s like a hyper immunity because we’re our immune systems are just less primed uh to see the number of things that um that immune systems were were evolved to see. Uh. And so, you know, if anything, it’s not like we’re overwhelming our immune system. If anything like our immune systems are really underwhelmed. And so they’re like [laugh] it’s almost like, you know, you imagine and I hate to use this cop analogy here, but permit me because it helps. It’s like, you know, the one cop in the small town, you know, gets a 911 call and like oh, whoa, what is this? Right. And it’s a 911 call over somebody stealing, I don’t know, a shopping cart. Right. And like, they come in with the cavalry on the shopping cart. Like, that’s basically what an allergy is. Right. And it’s because our immune systems are relatively underwhelmed. Um. So this notion that somehow, like, we’re we’re overtaxing our immune system just makes zero sense scientifically. 


Tara Terpstra: Oh, I also see uh ads what not people posting on social media about how to boost your immune system. And also it just makes me think like you don’t actually want to do that. Right? 


Dr. Abdul El-Sayed: Yeah. You want your immune system to have the things it needs to to to fight uh anything that’s not part of you that is not a thing that it shouldn’t be immune to. Right. So like, you know, anybody who has an allergy, for example, I have a really a like weird allergy to eggplant. I don’t I don’t know why I have an allergy to eggplant. I really enjoy eggplant. I still eat eggplant. But every time I eat eggplant, the roof of my mouth, like, gets really, really inflamed. And I still eat it. I don’t know why because I like the taste of it, but I don’t like that feeling. And this is my body being like, Oh, my God, there’s that eggplant again. You’re like, Yo, it’s just an eggplant. No big deal, right? Um. But that’s what an allergy is. And so you’re right. Like, you know, the idea like we have to boost our immune system. No, you kind of just have to eat the nutrients that you need, and your immune system will construct itself in the way that you need it to. The other thing you need to do is sleep regularly and drink enough water. Right? It’s like just these basic things that um I think sometimes in our hyper capitalized world um we don’t give ourselves enough of the obvious things like sleep or nutrition, and then we try and make it up by buying a product that somebody tells us that is going to make up for the obvious gap that we are unwilling to fill. So like instead of taking–


Tara Terpstra: Yup. 


Dr. Abdul El-Sayed: –so and so supplement, just like sleep enough, drink enough water and have you know enough nutrition and you should be okay. Now, look, not everybody has access to doing that, but also it’s not like lower income Americans are the ones who are, you know, feeding the supplement industry. It’s usually um folks with means who uh are for whatever reason not sleeping enough, not getting enough exercise, not um eating a nutritious, balanced diet who are then trying to make up for it with supplements, energy drinks, etc., etc.. Um. So yeah, just do those basic things and and most of the time you probably end up okay. 


Tara Terpstra: Yeah, definitely. Switching gears a bit. Our next question comes from KChan1197 and they ask, How can a recent MPH grad find a role that earns a livable wage? 


Dr. Abdul El-Sayed: Well, um I hope that you’ll going to uh and take a look at the roles that we have open. Um. No I, I don’t mean to make light of that. I understand that we don’t invest nearly enough in the professionals who choose to um dedicate their skills and talents to public health. And um we’ve got to do so much better. Generally in public health. There are a couple of different um pathways that you can go. Uh. There is the public pathway, which is working at a local, state uh or or um federal health uh program. So whether it’s the CDC on down to your state health department, on down to your local health department, on down to the, you know, pretty robust nonprofit world, um you’re doing sort of public oriented public health. There’s the academic route. Um. So potentially thinking about working in a research group or potentially going on and and getting further education and becoming um a researcher. That’s another route. And then the third is uh the private route, and they’re um an increasing crop of public health consultancies who support health departments um around the country. And then, of course, a pretty thriving nonprofit sector uh that isn’t sort of more public oriented um uh public health, but sort of more more micro mission driven. And these are all um opportunities. And so I hope that you find the path that you’re looking for. And um we need you here in public health. Uh. If you’re sort of someone who’s thinking, I’d love to spend my life working to support folks um who need my help. Public health is a great field uh and um and I hope that you’ll pursue it. Uh. So I hope Kchan you find that right opportunity. And I hope that you go on over to and take a look. 


Tara Terpstra: And JordanH395 asks in the Friends of the Pod Discord. I currently have an MPH in behavioral health and I’m currently considering a PhD or a DRPH. If I don’t want to be stuck doing academic research. What would you recommend? 


Dr. Abdul El-Sayed: Yeah, I mean, look, there are a lot of rules for folks who um have Ph.D.s, you know, whether it’s in program evaluation or leadership, um you know, these are credentials that you can use certainly uh in um the government spaces and in private work. I think generally it’s a matter of um thinking about careers. I think we do a disservice by asking folks what they want to be when they grow up. I think the better question that we should be asking them is what they want to change when they want to grow up? And then from there it’s how do you want to change it? And I think if you can be doing work that makes your soul sing uh against the challenges that you want to change, I that that really is a fulfilling career. And so I would ask you to say, what are the skills that you want to get out of your Ph.D.? And are those the skills that you feel like you need to get some sort of job? Or are those the skills that you feel like uh will help you do that thing that makes your soul sing? And um and if the answer to the latter is yes, then I think it’s a great thing to do. Um. There are a lot of folks who say, listen, I love quantitative analytics and I just really, really want to understand how to make sense out of numbers. Awesome, there are folks who say I really I love you know making sense out of how a program or system works. Awesome, folks who say I just really love team leadership. I love public communication. Awesome. Those are all different ways to um to make a difference in public health and do some damage against the kinds of health inequities that we have in our society. And all of those skills can be used. But you know it’s important to know yourself and and ask what are the things that I really enjoy doing that I’m really good at um what are the skills I want to be using, and then how do I use those things uh to to make people healthier and um to invest in my community. So more power to you Jordan. And I hope that all that goes well. Best of luck. You don’t have to you know, there’s not one career path um should you get a PhD, but just make sure it’s a Ph.D. in something that you really enjoy doing. 


Tara Terpstra: Yeah, I really like that uh what do you want to change when you grow up? I think that’s a great, great question to ask. The next question comes from Ahmadad87. They ask, have you recently seen any positive ways that our health care infrastructure has adapted to meet our future public health challenges? 


Dr. Abdul El-Sayed: I think there has been a lot more effort to systematize communication across levels of our public health infrastructure. We will really only know about whether or not we succeed or we will have had the tenacity to keep going, even as so much of the post-COVID infrastructure is being dismantled when the next calamity hits. And but, you know, the real challenge right now is like we just don’t have really strong two way communication between levels of public health and we really need that. So that’s a potential positive that could have come out of this and we’ll see if it persists. 


Tara Terpstra: And joining with the next question, spunkyred79 asked, How can we raise awareness for infrastructure needs? 


Dr. Abdul El-Sayed: That’s a real hard question. I think a lot of this, unfortunately, is just not sexy. Like, we’re never going to see a politician winning elections on public health infrastructure. But what we can talk about are the consequences of the lack thereof and fit it within a broader question of whether or not government works. And an analogy I always try and use is like, nobody really likes to go to the DMV or what we call here in Michigan the secretary of state. And that is a piece of government infrastructure that really ought to work. You kind of know exactly what you need. So there are very far fewer degrees of freedom than you you have in a public health setting. And yet the experience sucks, right? It generally sucks. It sucks for everybody. Nobody likes it. Nobody is like, Hey, man, guess what? I get to go sit at the DMV today. It’s going to be amazing. And the reason it sucks is because you have a system of or a whole political party that has made dismantling basic government infrastructure part of its mantra for the past 40 years. It doesn’t have to suck. We just assent to it sucking. And then because it sucks, people point to it and say, see, government can’t do anything. And I just think it’s helpful for us to communicate, you know, broader government infrastructure in the context of some of these analogies that people have to deal with every day. Yes, nobody very few people, unless you work in public health, has to deal with public health infrastructure every day. But you know it when it doesn’t work. But everybody has to have an experience at the DMV. So the question becomes, well, what happens in a pandemic if we build the DMV equivalent of a public health system? Because that’s what we have right now. And like are we okay with that? Is that what we really want? And I think there’s a way for us to explain that to the to the broader public um in a way that that sort of ties these things together. And I think that’s probably the way to do it. 


Tara Terpstra: Switching gears a little bit about some general health questions, Tricia asks, People say that 35 is often a fertility cliff for women. Is there any research that actually backs that up? 


Dr. Abdul El-Sayed: Yeah. Thanks for the the question, Tricia. Um. I don’t think that the right way to call it is a fertility cliff. I think that what the evidence does demonstrate is that there’s tends to be a substantial increase in the number of complications and an increase in infertility at the age of 35. And it’s not like a cliff or anything like that. It’s just that the the rates of a lot of these things go up, whether you’re talking about preterm birth or you’re talking about um pregnancy complications or you’re talking about stillbirth. These these rates do start to increase. They don’t they don’t jump dramatically, but they they do start to increase faster um at 35. And so that’s I think, why that’s been labeled that way. I started my career as a perinatal epidemiologist, so really studying birth outcomes. Um. And the sort of curve is is is pretty replicable. And there’s something about that number at 35 that where we start to see it. That being said, you know, where there have been some pretty vast improvements um in perinatal medicine has been around the safety of pregnancy in um in later age right. So past 35 and um that that is a real credit to um a lot of the investment that has been made in understanding some of the causes and trying to mitigate them. And similarly with fertility, Right. Fertility medicine’s come a real long way in 20 years. And so I think, you know, when you look at these population level statistics, it’s difficult because you can’t necessarily extrapolate them to any one individual. Right? Every one individual has different outcomes and higher probabilities versus lower probabilities still imply that there are a lot of people on the other side of those probabilities. So um I would just say generally when you hear those kinds of statistics, they’re not that nobody is doomed or destined uh to a particular probability outcome. Um. It just reflects what tends to happen in a population. So um if you happen to be in a situation uh where you’re contemplating uh fertility at this age, you know, I hope that you get all the resources you need. And one point I’ll make here is that one of the biggest issues that we have in this country is that we treat A, pregnancy like a disease and B, um that we have not invested in the kind of circumstances in our society that empower um people to carry uh pregnancies and to care for young in a way that recognizes how fundamentally important that is to our society. And we make it harder um for for people to do this thing that is like fundamental to human existence. And that’s a damn shame, and that’s a function of public policy. The other point I want to make on this is just that for all of these questions they are substantially worse and substantially harder in a circumstance where racism tends to create more and more obstacles at every turn. And so you know you see Black maternal mortality differences or infant mortality differences that are really quite stark and profound, that um that that take the question that was asked and make it that much worse for a subset of our population. And that you know has to be something that we seek to root out and address. 


Tara Terpstra: Yeah. Next Toghani asks, Why is it so hard to find a primary care physician these days? 


Dr. Abdul El-Sayed: Because we don’t pay primary care physicians enough. You know, if you look at graduating medical students, you look at their earning potential across various specialties because we have a sick care system rather than a health care system. We value treatment more than prevention. And so you can make way more money as a orthopedic surgeon treating the consequences of years of arthritis than you can as a primary care physician, helping somebody to prevent the onset of arthritis, um which it doesn’t match the value set that most of us would have. Most of us would say, if you could choose between having a disease and getting cured versus never having had the disease at all, I think everybody would say I’d rather never have had the disease at all. Um. But we just don’t pay for that. 


Tara Terpstra: Yeah. 


Dr. Abdul El-Sayed: Instead, we pay for the treatment after the disease rather than paying for the prevention before the disease. And so because we don’t pay our primary care physicians as much as we pay quaternary and tertiary care specialty providers, people choose to become quaternary and tertiary care specialty providers. And so we have um more of those um than we proportionately would need uh versus primary care docs. And look, you know, the truth of the matter is we don’t have enough doctors to begin with. And that really is a function of, you know, the American Medical Association that has artificially reduced the supply of physicians. So we just don’t have enough who are graduating every year to provide the health care that we need. Um. And so, you know, in reality, we probably need more everybody. But, you know, what would that mean? That would mean reducing physician salaries across the board, right? You increase the supply of something uh and the price for that thing goes down. And so the big picture reason is we don’t pay primary care doctors enough relative to specialty care doctors. But the other big reason is that we don’t have enough doctors. And so we’ve artificially decreased the supply of physicians, um which means that, you know, those physicians who make the least are going to be the hardest to find. 


Tara Terpstra: Yeah, and Brian asked, I recently noticed that men in the gay/bi community are all taking their prep differently. Some are taking it every day, others only before a sexual encounter. One doctor friend told me that everyday use, which is what the prescription says, may actually have long term adverse health effects. 


Dr. Abdul El-Sayed: When it comes to prep, you know, Prep is um in effect a similar approach to thinking about so Prep stands for pre-exposure prophylaxis. It’s it’s almost like taking a vaccine in a pill form every single day. Like that’s the same logic. Um. And the most important thing about Prep, of course, is preventing HIV infection. And in that case, you do have to have, you know, enough of the medication on board um such that you are um you are uh killing the HIV virus if in fact, you are exposed. Right. The way Prep works is it’s basically um low dose um HIV medication. So not taking it as much as recommended may may actually sacrifice um or put you at risk of actually not achieving the broader point of um of of of prep itself um when it comes to adverse risk, every medication has potential adverse effects. Um. But what you’re doing is weighing that against the adverse effects of not taking the medication. And if you’re someone who’s at risk of contracting HIV, that long term risk, of course is HIV. And so um, you know, I think when when it comes to uh the decision to take prep, it’s pretty clear that the benefit vastly outweighs the risks. And I think the most important thing to do is, is to find a physician who you trust um and who you feel safe and secure with so that you can have these conversations and think through this with each other. But I do want to just, you know, paint the broader picture here, which is to say, you know, if you’re not taking enough, you may not have enough of the medication on board to actually do the job. Um. And, uh you know, and weighing that against the risk of of long term adverse effects is always important. But let’s not you know lose the baby with the bathwater, as they say. 


Tara Terpstra: Yeah. Our next question comes from Aviva, who asks, I recently read that Phenylephrine, which was once considered an active ingredient in painkillers and DayQuil was found to be ineffective by the FDA. How was it ever found effective? 


Dr. Abdul El-Sayed: You know, this gets back to a really hard question in epidemiology and I’m about to nerd out here on you all so um forgive me like fast forward– 


Tara Terpstra: Please do. 


Tara Terpstra: –a couple times, [laugh] it’s really hard to measure like objectively measure the symptoms that Phenylephrine in theory was supposed to prevent. So creating objective measures for um what it means to be congested is like really quite hard, right? Because congestion is a is a subjective experience and everybody’s nasal pharynx and anatomy is really quite different. So the amount of mucus you actually need in your nasal pharynx to cause quote, “congestion” is kind of hard to measure and not the same for everybody. Right? So a lot of these studies are about people’s subjective experiences. And yes, you want to try and blind people to the medication that they’re getting, um but oftentimes you get a lot of placebo effect in these kinds of studies. So it’s just really, really difficult to to create a real contrast to to try and actually get objective evidence about the effect of something like a um a congestion medication. And so you end up you know, the science is really hard to do. And um and so you end up just you know, the way science works is you you sort of start with one nucleus of evidence and then evidence starts to pile up and move in a certain direction. Um. And so, uh you know, part of what we have now versus what we hadn’t had in the past was actually objective means of measuring, right? You can use like real time MRI to actually look at, you know, what is happening in someone’s nasal pharynx. And so you can say like if you know, X proportion of their nasal pharynx is congested with mucus, we’re going to call that objective congestion. And so you can do far better studies now because of the kind of technology that we have today than you would have had in the past when the medication was approved. And so a lot of this just gets back to like very simple study design and whether or not you can you can create you can measure the variable you want to measure correctly um or at least consistently, and you can control against, you know, the things that pollute any study which, you know, which is one of the most important ones is the placebo effect. Um. And that probably explains why you know we ended up getting to where we got. 


Tara Terpstra: Yeah. Uh. Kitty asks, What are your thoughts on Mitt Romney retiring from politics, specifically his comments about not wanting to run again because he’d be in his mid eighties at the end of another term? 


Dr. Abdul El-Sayed: Yeah, so, you know, you’re asking a guy who ran for governor at like 32. Um. I think we need a new crop of leaders whose experiences and buy in into the future reflect the experiences that folks who are going to live in the future have actually faced. And one of the biggest challenges I think we have in our politics right now is that a lot of what was true for um politicians in their seventies and eighties has not been true for a very long time. Right. The your ability to go to a public university for 1500 bucks. You know, I met a gentleman when I was running who went to the University of Michigan, paid full tuition, and he told me he could raise enough you could make enough money scooping ice cream in the summers to afford his tuition, room and board and extra for beer. That’s what he said. Like the idea that you could do that– 


Tara Terpstra: Amazing. 


Dr. Abdul El-Sayed: –today. Right. Um. The idea that you could do that today is just nuts. And so you end up having folks whose experiences of college are just not consistent with young people’s experience of college, who then are looking back and saying, why are those kids so lazy nowadays? Well, they’re not lazy. It’s just that we’ve vastly expanded the administrative cost of college, which has raised tuition for everybody because uh we have undercut or disinvested in the kind of subsidies that a lot of those folks took advantage of, whether it was through, you know, the GI Bill or other means. And um and so you just need folks making public policy that is consistent with the lived experience of people uh who um, you know, who have experienced policy as it is, not as it was. Um. And so, you know, I think it’s a brave thing for somebody to unilaterally pull out of politics. Obviously, when it comes to Mitt Romney, it’s unclear whether or not he would have been elected anyway. Um. But I have to say, you know, whatever you feel about the man, he’s taken some courageous positions. And, you know, I don’t subscribe to the idea that because you disagree with somebody fundamentally on a number of issues, that you cannot give them credit for the good things that they’ve done. And, you know, I will say with Mitt Romney, I disagree deeply with his politics. You know, I probably don’t agree with almost anything, um but I do believe that he was willing to show courage when it came to some of the corruption of our democratic ideals by people of his party. And I um I think he’s also showing courage now to step in. I do want to say, though, right that given where we are right now in our politics, everything that I said about age is true and is a real fundamental challenge. But we’re also in a situation right now where we continue to face an existential threat regarding democracy itself because of one of the frontrunners for president. And when it comes to the other frontrunner for president, the current president of the United States, um this is someone who has soundly beaten the other guy before. This is someone who um, you know, has really surprised me with a lot of the policy he’s been able to push. And I understand, believe frankly, that he’s earned the right to finish the job. Right um. And so, you know, toward that end, I think the generality can be true, even if the specific case, um you know, may force you to actually contend with the realities on the ground. Um. But, look, I’d love to see our politics sort of move on. We do need folks with younger ideas and lived experience that’s more consistent with the lived experience of folks right now. Um. And, you know, I think that will come with more politicians showing courage. Just because you’ve accumulated enough power to be able to stay in office doesn’t necessarily mean that um you’re leveraging that office to the best effect. And, you know, it takes a lot of courage for a politician to say that about themselves. And so I really credit Mitt Romney for for doing that. 


Tara Terpstra: Riall asked, Do you think there’s any hope for Medicare for All in a future administration? 


Dr. Abdul El-Sayed: Yes, yes, absolutely. Look, um there was a really interesting I talked about this on the show a couple weeks ago. There was a really interesting poll commissioned by the American Association of Medical Colleges, and they polled young people ages 18 to 24, and they found that like more than two thirds of Gen Z Republicans believe that health care is a human right and the government has a responsibility to to to to offer it. So, like, I mean, just like at that point. 


Tara Terpstra: Wow. 


Dr. Abdul El-Sayed: Yeah, right. I mean, this is the point about like generational change. Um. This is just consensus among young people nowadays. And so, you know, our ability to to to make this the law of the land is going to come when we empower folks who’ve lived on the wrong side of an insurance system that for far too long has not insured anyone. When you actually think about the technical meaning of being sure about anything. And a lot of that actually comes with the fact that, you know, if you’re over 65 nowadays, obviously you’re on Medicare, but for most of your life, your private insurance was pretty good. You didn’t have an insane deductible. Your premiums weren’t like some a huge proportion of your of your take home pay. And what’s happened is that deductibles have skyrocketed. Premiums have skyrocketed, the cost of health care has skyrocketed. So today, insurance companies get away with this you know one neat trick of charging you a huge premium and then charging you a deductible on the back end, in effect, hitting you twice for the same cost. And so if you’re a young person who barely can afford health insurance at all, and you’ve watched your parents like struggle to pay their deductible every single year and you know, your family’s rushing to get all their medical needs met before the end of the year, before the deductible kicks in. You’re like, this system sucks. And it has sucked for a really long time. Even if most of our politicians have not experienced it sucking because it didn’t suck as bad in the past. And so I just think that this generational change is fundamentally going to change the way people think about this. And so I believe deeply that we’re going to get there. Now, look, it’s going to be fits and starts, um and it may not be the perfect system that, you know, I would love to see. I hope I can be a part of making it that perfect system. But, you know, I think it’s going to get a lot a lot better because unfortunately, it’s just getting a lot worse until it does. 


Tara Terpstra: And following up on that, TabbyCat is looking for good news in the Friends of the Pod Discord. They asked, are there any positives or wins that have recently happened or coming that would make health care more affordable, especially for folks with chronic health care needs? 


Dr. Abdul El-Sayed: Yeah, look, um you know, I’ve been a bit of a skeptic of the Inflation Reduction Act, Medicare price negotiation. But now that the first ten drugs have been announced and then there’s going to be another ten drugs next year and another ten after that and another ten after that. There’s a huge knock on effect in the pharmaceutical system, when Medicare posts its negotiated price it creates a benchmark for private insurers to pay that price as well. Right. They say Medicare is getting that rate. I want that rate, too. And so this really should over the next several years to decade. It really should make prescription drugs that much more affordable in this country. And that’s a really big deal. Now, a lot of folks would push back and say, well, you know, you’re going to negotiate these drugs, all the pharmaceutical companies are going to do is raise rates on other drugs. Well, they could, but there’s two things stopping them from doing that. Then it’s the risk of having those drugs that they raise rates on become the next negotiated drug. Or it’s the fact that the Inflation Reduction Act also limits price increases to inflation rates. And if not, there are rebates that get charged. And so there are some there’s some real help coming on the horizon. And that’s a big effing deal. Right. And um so that is really good news. And I think that’s just real cause to celebrate. I really wish and I hate to be one of those like, you know, Democrats should be better at messaging. I really wish we were better at explaining this because it really is a big deal. And folks need to go out there and say, hey, listen, like for the first time, your government is forcing those insurance companies to pay rates that are fair like every other country in the world gets to pay. Um. And that’s that’s pretty awesome. 


Tara Terpstra: Yes. Yes. And then Heather and Amy asked, Do you think you’ll ever run for office again? 


Dr. Abdul El-Sayed: Oh. Um. [laughter] I got two amazing, brilliant, loving, beautiful daughters. And one of them is about to turn six, and the other one is uh eight months. And the way I think about it is that my life is numbered in a number of big hugs that I get to get from those little girls when I get home from work. And I don’t want to miss out on any of them or at least the minimal possible. So to me, that question really is about how do I maximize the number of those hugs and then get to a point where, you know, you know, there’s going to come a point I know um where I walk into the door and nobody’s really there to hug me. And when that happens, I think I might start thinking about it again. Until then, um I just feel like, you know, a lot of people who can occupy a political office, but there’s nobody who’s going to be a dad to those those little girls. And I want to be the best that I can be. So, you know, for me that that really is um priority number one. And after that, we’ll see. Look, I, I, I wish I could tell you I was done with it because it you know is a headache, and especially given the fact that, like our politics have turned into perpetual silly season. Part of me just feels like, you know, once we can all grow up and have a like, meaningful discourse about how to make people’s lives better, I’d love to go back to it. But then part of me also says, you know, when you see a fire, you either want to run toward it or run away from it. And I would rather be the kind of person who’s willing to run toward it and trust me, our politics is on fire. So there’s a lot of competing interests. But for me, the biggest priority is recognizing that little girls are growing up. And I don’t want to miss that. 


Tara Terpstra: Yeah those hugs and cuddles from the littles, they’re just truly the best. 


Dr. Abdul El-Sayed: They are the resource of which life is made. 


Tara Terpstra: Agree. Agree. To round out our session today, Stephanie asks, Would you consider taking America Dissected on the road for a live show? 


Dr. Abdul El-Sayed: Yes. So, Stephanie, I hope you’ll join us for our live show on November 12th at the American Public Health Association meeting in Atlanta. Um. We’ve hosted a couple of these. Uh. We’re really excited uh to be hosting another one. We’ll be talking about public health and the Internet. Um. There’s a lot there. So I really, really hope that you’ll join us. 


Tara Terpstra: It’ll be fun. Come see us. That is everything we have for today. Thank you again for letting me field these questions with you. It’s been a lot of fun, and I hope we get to do it again soon. 


Dr. Abdul El-Sayed: Tara, it has been a privilege and an honor. Thank you for being an amazing co-captain in this and generally in all things that we’ve been able to do together. So I just really appreciate you. [music break] That’s it for today, on your way out don’t forget to rate and review. It really goes a long way. Also, if you love the show and want to rep us, do drop by the Crooked Store for some American Dissected merch. We’ve got our sick pod bro tanks available. They’re great if you happen to live in warm weather season and if not, they’re really lovely to sleep in. [music break] America Dissected is a product of Crooked Media. Our producer is Austin Fisher. Our associate producers are Tara Terpstra and Emma Illick-Frank. Vasilis Fotopoulos mixes and masters the show. Production support from Ari Schwartz. Our theme song is by Taka Yasuzawa and Alex Sugiura. Our executive producers are Leo Duran, Sarah Geismer, Michael Martinez, and me. Dr. Abdul, I’ll say your host. Thanks for listening. [music break] This show is for general information and entertainment purposes only. It’s not intended to provide specific health care or medical advice and should not be construed as providing health care or medical advice. Please consult your physician with any questions related to your own health. The views expressed in this podcast reflect those of the host and his guests and do not necessarily represent the views and opinions of Wayne County, Michigan, or its Department of Health, Human and Veterans Services.