COVID really is over this time, right? Abdul reflects on the fact that public health is about what we do in the background when no one is paying attention–and how now is not the time for public health leaders to take a breather, but to get ahead of the next variant. Abdul sits down with Dr. Don Burke, a global infectious disease expert, to walk through various scenarios for where we go from here.

Transcript

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Dr. Abdul El-Sayed: The Biden administration released a new COVID strategy, empowering Americans to live with COVID while still preparing for future variants. The U.S. will share taxpayer-funded COVID vaccine technology with the World Health Organization. And in his State of the Union, President Biden announced a new approach to tackling mental health. This is America Dissected. I’m your host, Dr. Abdul El-Sayed. I want you to bear with me here. Imagine you were a California state fire marshal and you just finished battling the worst year of forest fires ever to hit your state. You’re tired. Morale is down, and you just need a rest. But there’s no time for vacation. You’ve only got a few short months until the fire season starts again. So what do you do? Well, first you’d want to make sure that you’re prepared for next season. Repair all of your broken down equipment, fill all those unfilled firefighter vacancies. That way, at least you’re ready to take on what comes right ahead. But after that, you want to review what happened last year. What did we do well, what did we do poorly? What new insights can we gain by analyzing last year, reviewing all the newest approaches to firefighting? And there’s something more. After all, the climate crisis is what’s making every year’s fire worse than the last year. You’d really want to do your part to explain to the public why fire are getting worse and what they can do to make them better. OK, so this metaphor may maybe getting a bit obvious. We’re not really talking about fires today, though forest fires may be a good topic for a future episode. We’re cutting back into the pandemic. Because today I want to sit down and reflect on where we’re at, because this moment finally feels a bit different. Cases are tumbling, and that’s an amazing thing. Hospitalizations and deaths to COVID thankfully are following suit. Americans are moving into a phase of life that has us accommodating the pandemic. Masks are starting to come off in schools, grocery stores, and concert venues. But that doesn’t mean that COVID itself is over. In fact, this is the time to prepare. Over two years of this pandemic, Americans have gotten used to public health doing what public health is actually least equipped to do, responding to a crisis in the moment. But public health is actually about preventing crises from ever happening in the first place. At its best, it operates in the background to keep us safe in ways we may not even know about. Right now, public health agencies around the country are like the fire marshal I just talked about: they’re tired, they’re worn out, morale is down, basic operations are haggard if functioning at all. This is actually the most important moment for public health to do what it does best. While every day Americans are adjusting to life after the pandemic, we have to demand that public health continue to press forward to make sure that we’re actually after the pandemic. This was President Biden last week in his State of the Union:

[clip of President Biden] We’ll continue to combat the virus as we do other diseases. And because this virus mutates and spreads, we have to stay on guard. Here are four common sense steps as we move forward safely, in my view.

Dr. Abdul El-Sayed: The Biden administration has learned from past mistakes. When Omicron hit, we were caught flat-footed without the tests or high-quality masks we needed to face it down. And though high-quality antiviral pills existed, they weren’t available when people needed the most. Rather than take our foot off the gas, public health needs to step on it. It means continuing to press vaccines. It means more research on the long-term consequences of COVID, and it means trying to understand where the pandemic is going and heading it off at the curb. When everyone else stops paying attention is when public health needs to redouble our attention. Toward that end, I’ve been thinking a lot about where the virus is going, how it will evolve, and how that could affect us. One of the more interesting pieces I’ve read recently laid out four potential directions that the virus could evolve. It was written by Dr. Don Burke, Dean Emeritus of the University Of Pittsburgh School Of Public Health, who spent his career thinking about infectious disease epidemics. He joins me to lay out and explain those four alternatives for what SARS-CoV-2 could do next. After this break.

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Dr. Abdul El-Sayed: All right, you guys hear me now.

Dr. Donald Burke: Yes, hear you well. Yep.

Dr. Abdul El-Sayed: Right, perfect. All right. Let’s get started. Can you introduce yourself for the tape?

Dr. Donald Burke: Hi, I’m Donald Burke. I’m a physician, and I was the Dean of the Graduate School of Public Health at the University of Pittsburgh. I’m now a emeritus dean.

Dr. Abdul El-Sayed, narrating: Professor Don Burke is the dean emeritus at the University Of Pittsburgh Graduate School of Public Health. Prior to his time in the academy, Dr. Burke served 23 years on active duty in the U.S. Army, leading military infectious disease research at the Walter Reed Army Institute of Research in Washington, D.C., and at the Armed Forces Research Institute of Medical Sciences in Bangkok, Thailand. He’s been thinking about global pandemics his entire career. He’s here to share his thoughts about where COVID goes from here.

Dr. Abdul El-Sayed: Dr. Burke, thank you so much for joining the show and you know, your work caught my attention when you wrote a really fantastic op-ed for Stat news in which you laid out a series of scenarios for the future of the pandemic. I wanted to step back before we talk about those scenarios, and it’s clear to me that the way that these novel viruses emerge is really quite critical to understanding where they might go. So can you walk us through how we get a novel virus like SARS-CoV-2?

Dr. Donald Burke: Viruses are in nature and essentially every animal species has almost all the same general types of viruses that we do, and they’re mutating and evolving over time in those animals. And occasionally one of these viruses will jump species. It will jump from the animal into humans and occasionally from humans into animals. And in the process, it may spread rapidly or it may do nothing. But when it spreads rapidly, it becomes an emerging disease and a pandemic. But there’s a huge reservoir of viruses out in nature that are all evolving, any one of which could jump at any time.

Dr. Abdul El-Sayed: And there’s something particular too about the ways that these viruses can sort of jump between species having to do with recombination, right? The fancy term for saying that basically you get different pieces of viral genetic material admixing inside cells. What is that and what role does that play in helping us to think about where this might go?

Dr. Donald Burke: Yeah, so all of the viruses that are particularly good at jumping species and that have caused epidemics in humans recently, like influenza and HIV and the coronaviruses, all of these viruses not only change by mutation, but they change by swapping genetic information. And the way that that happens, if a single human becomes infected with two different viruses and they infect the person cells, then inside the cells, the viruses essentially cross over and exchange genetic information. You end up with a virus that on the left half of the genetic code is from one of the virus strains and on the right hand side of the gene sequence, it’s from the other virus. It’s a hybrid or a chimera. And sometimes those chimeras are more transmissible or more lethal than either of their parents, and in which case that’s the one that will take off. So it isn’t, we talk about the mutations often, but we have this other method that the viruses used too that’s recombination. Sometimes it’s, the viruses like influenza, the genomes are already pre-chunked, they’re in a series of segments almost like little chromosomes. And that when a cell becomes infected with two different viruses, you can come up with any of those combinations of the chunks of genetic information. It’s a good way of swapping information. The viruses are essentially built to be able to do that, to not only mutate, but to swap genes on an efficient basis.

Dr. Abdul El-Sayed: So having laid out that context, you wrote this piece laying out these four different approaches. What prompted you to write this? And then, of course, what are the four different potential outcomes here that were worth thinking through?

Dr. Donald Burke: I’ve been working in emerging infectious diseases, global infectious disease my entire career. And so I have worked in the rice fields in Southeast Asia on encephalitis viruses, in the jungles of Cameroon on HIV-related strains, and so I’ve been studying how viruses evolve and emerge. And some time ago, I was worried about coronaviruses, and I wrote that, that that could be a concern. And as I’ve watched the corona virus evolve, it’s really moving pretty quickly—that we’re getting these new variants popping up, the Alpha and the Delta and the Omicron. But what particularly got me concerned was sort of the confluence of two things. One was the the sort of consensus belief that we were sliding toward the new normal of mutants that we could deal with. But it was also the realization that Omicron really was a pretty big jump. It was, you know, there were 60 new mutations all in one virus all of a sudden. It wasn’t just a derivative of Delta. So it just reminded me that these viruses can take some pretty big jumps when given the opportunity. So you put the two count together, that people believe that, you know, we’re on a sort of the path that’s going to be a smooth path, plus the sign that Omicron take a big jump, plus the fact that coronaviruses are notorious for their jumping and evolution, just that we need to be ready for something other than a slide toward the new normal.

Dr. Abdul El-Sayed: Hmm. So, you know, to put it succinctly, these viruses jump rather quickly. We got lucky that it jumped in this particular direction, but here are some other directions it could jump that may require us to fundamentally rethink this notion that that the pandemic is is somehow over.

Dr. Donald Burke: Yeah. So when you say we got lucky, I have to say we’re not lucky with this epidemic.

Dr. Abdul El-Sayed: Yeah, fair.

Dr. Donald Burke: But I did right after the SARs 1 epidemic in 2003, 2004. We were lucky then. There were only 8,000 cases at that point. And if the virus at that point had been a little more transmissible or had been a little less clinically obvious for every case, it would have been much harder. And I wrote that at the time. And in fact, this one, SARS, if you want to call it SARS 2, is worse. And so, but it has sort of settled into a pattern now, and I just don’t want us to be complacent. I think we need to be both—and make, think about and make preparations for things that could go south.

Dr. Abdul El-Sayed: Yeah. And I really appreciate that correction. Obviously, a virus that has killed millions of people around the world, there’s nothing lucky about that. What I meant was the emergence of Omicron as a less severe variant, that is something that happens by chance. That’s not a directed outcome of an evolutionary process. I want to, I want to ask you, can you lay out these four different scenarios for us?

Dr. Donald Burke: Yeah. So the first one is, and I do think the most likely thing is that we will not have a major new catastrophe. Let me say that from the beginning, but I’m not sure of that, given the history of these viruses. So the first and the most likely is that we will see other viruses that come along that are variations, mutants and they will be not more virulent and we will be able to live with them. Not unlike the, we already have four coronaviruses that circulate through the human population, the technical names. But you know, they’re for the most part, pretty mild and cause common colds. And we all get them. Everybody on the planet gets infected with four different coronaviruses, and we never even noticed. It was, you know, sometimes you’d get a cold and not be able to go to school or go to work, but it rarely ended in severe disease. And so the first possibility is that SARS-CoV-2 will do the same thing, that it will evolve and become a little less virulent to get to the point where that will be the fifth common cold corona virus. I think that’s the most likely thing that’s going to happen.

Dr. Abdul El-Sayed: That’s good news, and that’s certainly what we hope will happen. But you know, the other three are a little bit different.

Dr. Donald Burke: Yeah, yeah. So the next one is that the virus doesn’t make any major evolutionary jumps, but it changes the cells in which it infects. That is that it instead of infecting the cells of the lining of the lung, it changes to attack the heart more, or the brain more, or the kidney more. And the reason that I worry about this one is that happens in coronaviruses in animals. One of the reasons that we can make some informed guesses about what could happen is that these things have already happened in animal species. So, for instance, in a coronavirus of pigs, it went for years as only causes—only—but a severe diarrhea and intestinal problem. And then it mutated and became transmissible and became a lung disease. The same virus, with a few extra mutations changed from affecting one organ system to another. So that’s the kind of thing that you have to be ready for is that just because today’s SARS-CoV-2 looks like this, tomorrow’s might change. Again, I don’t want to overemphasize that this is going to happen, but these are the things we have to be thinking about and be ready if they do.

Dr. Abdul El-Sayed: And there’s evidence that Omicron made a jump from attacking the lung tissue to attacking tissue in the throat, which, you know, is some evidence for this happening.

Dr. Donald Burke: Yeah. So that’s the, that one’s a milder variation off of the theme of what I’m talking about is that it, it’s still in the respiratory tract, but in a different part of the respiratory tract. And what I’m referring to is more of a change of the organ that involved, not only the sub components. But your points a good one, is that the virus has already shown its ability to move around the body a little bit.

Dr. Abdul El-Sayed: And then there’s the other two scenarios are a little bit more, are a little bit scarier, and one of them involves the recombination that we talked about. Can you can you walk us through that scenario?

Dr. Donald Burke: Yeah. So again, because there are all of these coronaviruses in nature—and the only reason that we don’t know all of the coronaviruses is we haven’t tested all the animal species for coronaviruses, but it looks like essentially every mammalian and most vertebrates have coronaviruses that are adapted to those species. And we already know that sometimes these can jump. There have been dog coronavirus, many epidemics in Southeast Asia and in humans. And so if you have a person who’s co-infected with a, one virus that is a normal common cold coronavirus or SARS-CoV-2 or any other coronaviruses and you get a jump with the animal, you could end up with one of these recombinants that could have new properties. And just, and it also may be able to evade the normal immune response to the preexisting immune response to SARS-CoV-2.

Dr. Abdul El-Sayed: And what makes that a potentially possible scenario is that we are starting to see a lot of our SARS-CoV-2 in other animal species, whether you’re talking about, you know, evidence that it’s infected cats or dogs, substantial evidence that’s infected deer, evidence that’s infecting mink in mink farms. You know, as you think it through what would be the scenario, what kind of animal scenario would you be most worried about, this potential recombination occurring in and then spilling back into humans?

Dr. Donald Burke: Yeah, I don’t—you know, no crystal ball here—but you know, there are some general principles and general principles are, you know, the animals that are the most populous and the viruses that have the most common contact—or the animal species that have the most common contact with humans. And so some of the virus—the animal species with the most are the domesticated agricultural products. Pigs would be a prime concern. Chickens would be another. You know, even mice have the coronaviruses. In many parts of the world, rodents have intimate contact with humans in their homes. And so those would be the ones I’d be most suspicious. I don’t think it’ll be a while coronavirus, and I don’t think, but you know, I say that, you know, only said facetiously, but the point is coronaviruses are just about everywhere.

Dr. Abdul El-Sayed, narrating: We’ll be back with more with Dr. Don Burke after this break.

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Dr. Abdul El-Sayed, narrating: And we’re back with more of my conversation with Dr. Don Burke.

Dr. Abdul El-Sayed: And, you know, it’s it’s important because we see this principle playing out regularly when it comes to another virus, which is the flu, right? We’re always constantly on guard for either an avian flu or a swine flu. And that’s exactly this process that you’re talking about, where you end up getting co-infection between a human influenza that—you know, not to personify it—but knows how to bind to our cells and infect us, with one that is endemic in either chickens or in pigs, where then you end up having this recombination and you get a different capacity for virulence, coupled with the ability to infect human cells. And then you know that that potentially causes an outbreak or worse, an epidemic. And so I want folks to sort of understand that this kind of thing happens with other viruses all the time. It’s not—or not all the time—but it happens with other viruses in ways that we’ve had to pay attention to in the past, and it’s plausible that it could happen with COVID-19 as well. And then you lay out the truly, the truly scary scenario involving the ability of SARS-CoV-2 to actually leverage our own immune response. Can you walk us through how that works and what that would entail?

Dr. Donald Burke: When I lived in Bangkok for six years, I studied a disease called dengue, which is common in the tropics. And dengue has been found that that there are four types of dengue. And if you’re infected with one type, you’re immune to that type, but that’s set you up for more severe disease should you get infected with a different type later. And so we studied that and showed that was the case. And then that turned out to be important in vaccine development for dengue, is that the vaccines primed you, particularly people who had never seen a dengue before, for being more likely to be infected than not from a vaccine. It’s the only virus that does that that we know of right now, the dengue viruses. So but, you know, but it’s a concern. So there is a virus of cats called the feline infectious peritonitis virus that if you give kittens a immune serum before you inoculate them, they get more severe disease than if they never had a, if you gave normal serum or no serum. And so that means that the coronaviruses has already have sort of, not fully, but a similar sort of disease process. So that’s what makes me worried that maybe this could happen and we should keep our eyes out for that as a possibility.

Dr. Abdul El-Sayed: So this feline virus is a corona virus?

Dr. Donald Burke: Yes. Yeah. Yeah.

Dr. Abdul El-Sayed: So cats have a version of the corona virus that targets cats with an immune response, and that then suggests to us that it’s plausible that SARS-CoV-2 could either mutate to take this on or potentially recombine to take on this capacity.

Dr. Donald Burke: Yeah, you know, I don’t know how it would evolve to do that. In feline infectious peritonitis, it requires the virus not only to have encounters somebody, or encounter a cat with immunity, but then it has to mutate a little bit more to be able to take on this property of not only evading the immune response, but exploiting the immune response. And so I do think we need to at least think about that and think about if we saw that, how could we respond quickly? How could we stop it? What would be the right surveillance mechanism so if it were trending in that direction, how would we know it? What would be, are there some studies in the laboratory or in animals that we could make sure to know what the characteristics might look like? You know, this is in the realm of speculation. I don’t want to say this is going to happen, but I do think that we need to think about all of the bad things that can happen, as well as the easy one. You know, there’s the slide toward endemicity could happen, but these other things are possibilities that we need to be prepared for.

Dr. Abdul El-Sayed: Yeah. I mean, obviously, the scenario, that fourth scenario is a truly blood-curdling scenario because now you’re talking about SARS being able to deliberately attack folks with immune responses, which means everybody who’s been vaccinated and everybody who’s been infected, which is what’s currently, you know, creating such a barrier to the evolution of yet another potential variant. And I want to underline the fact that this is not a highly-likely scenario, but that it’s a plausible scenario. And you know, earlier in the episode, we talked about the critical role of public health to stay vigilant, specifically, when everyone else has moved on. And, you know, it’s sort of hard because for a lot of people out there in the world, their understanding of public health and what public health does has actually evolved in a moment when public health is actually on its back foot because traditionally what public health is doing is operating in the background to prevent something terrible from happening, rather than responding as something terrible is happening. And so for a lot of folks, they’re used to public health sort of working as terrible things are happening rather than working in the background, and sort of what your engagement with these potential scenarios lays out is just how critical this next phase of public health is going to be to prevent any of the latter three scenarios from occurring. And as you think about where we are now and where we’re headed, what would your advice be to both federal public health agencies, whether it’s the CDC or others, or state and local public health agencies, around how to stay vigilant, how to focus on what needs to be done to hold COVID at bay and really get us to the point where we can, you know, a year from now have declared victory on this?

Dr. Donald Burke: Yeah. So the first thing I’d do is I just make sure that the appropriate agencies had thought through the issues and said, here are some scenarios—I laid out three there, probably a few more—and question what could we do to minimize the damage if these occur? And it’s not just in the realm of treatment, it’s the realm of how do we do the right surveillance to see these quicker rather than later? How do we, do we have public communication about these? How do we ensure that we’ve got the right international collaborations in place? There’s lots of different dimensions of this problem, so that’s the first thing I do, is just make sure we’ve thought it through ahead of time. We can’t think of everything that could occur, but I’d like to make sure these kind of things are taken care of. The second thing is the realization that this is this could happen anywhere on the planet, that even though we have our own epidemic, we are still a minority of the total infections that are occurring at any given moment around the world, and so the more we can do to help other countries, that’s in our interest. It is not charity. It is, if this were a question of terrorism or warfare or anything else, we wouldn’t hesitate to protect Americans by working internationally with whatever resources it takes. So I want to just stress the fact that this is a global epidemic with global consequences for all of us. And so that’s the other thing is that I would do, I would redouble our international control efforts.

Dr. Abdul El-Sayed: Mm-Hmm. And we we’ve just heard from the Biden administration following up on the State of the Union on a new COVID plan. And, you know, in some respects, it engages with what needs to be done right now to allow us to quote unquote “live” with the virus and move toward an endemicity scenario. But it also lays out some of the things that need to be done to protect folks in the interim and also to engage with the potential that there’s new variant. And one of the things that came up earlier was genomic surveillance. Where are we when it comes to genomic surveillance right now with respect to the scenarios that you laid out in other scenarios, and where do we need to be to be as vigilant as we need to be in order to jump on, you know, newly-emergent variant that might have some of these characteristics so that we can squash it in ways that we just weren’t able to with any of the previous variants before it?

Dr. Donald Burke: Yeah, so part of that problem is that these, the scenarios that I talk about will probably manifest them first, themselves first in their phenotype, in how they behave, less in their—because we probably won’t see them right away, even if we had an enormous global genomic surveillance. So I don’t know that they’ll be picked up that way. They’ll probably be picked up by a more epidemiological type of surveillance. Having said that, that having a strong genomics that allows us to track them as these variants do appear, will be important in any coordinated international response. So it’s, I have to say of the things that have happened during this epidemic is that the amount of genomic sequencing and understanding the emergence of variants has just been spectacular. No epidemic in history have we been able to track, we would never, even 15 years ago, we wouldn’t have been able to to know that we did have variants that were, you know, Alpha and Delta and then Omicron, and that they had been, and that they had been just changing with lightning speed. You know, one replacing the other because of increased transmissibility. We may have seen, if it were 15 years ago, we would have seen spikes in cases and we wouldn’t have known why. We would have figured it out, but not nearly as quickly. So it’s already, the genomics have been a strong point in the overall national and international response, but we can help strengthen other countries and do a better job of global surveillance.

Dr. Abdul El-Sayed: Mm hmm. So we’ve laid out a couple of scenarios. We talked a bit about what, how public health agencies and the public health workforce should be thinking about them. But you know, most of the folks who listen to this podcast are not epidemiologists, they’re not working at a health agency. How should the public be thinking about the future? And you know, maybe a more pertinent question is how are you and your family thinking about things right now with respect to changing mask guidance, et cetera?

Dr. Donald Burke: I don’t think that the possibility of these scenarios changes our day-to-day life. We do have to change our routines and adapt to the virus as it’s adapting to us. And as I said, the likely scenarios are that none of these are going to happen. If that’s the case, then what I and my family do is that we follow the CDC guidance, we get our vaccines, when we go out into areas that are with lots of other people in indoor settings, we still wear our masks. And not until the cases drop a bit more will we be comfortable going maskless. But so it really hasn’t materially changed our, these—you know, my knowing about these risks has not materially changed how we approach the disease. My job is as an epidemiologist and a virologist to think about things and what we need to be prepared for, but that doesn’t mean it changes our day-to-day lives.

Dr. Abdul El-Sayed: Well, I appreciate that and I know that tens of thousands of people out there listening also appreciate that. I think, you know, it’s important to know what the potential risks are and live according to the risks as they bear out for you and your family. And I think one of the hard parts about COVID is that it has occupied so much of our mind space and played on so many of our anxieties that I think people hearing about the potential risks sort of see them as inevitable. And that’s just not the case. Is that, you know, in a lot of ways, our job is to stay vigilant, stay aware, do the things that we can do, try and live our lives independent of what is potential risk and more according to what the risk looks like right now. And right now, there’s good news on the horizon. Cases continue to drop, obviously, hospitalizations and deaths are, you know, two or four weeks behind. And like you said, the highest potential outcome here is that we do continue to move toward endemicity and we can look back at this and say, Wow, that really was awful. But we should be ready, and certainly the professionals who are out there staying vigilant need to be ready for these potential outcomes. I really appreciate you joining us to share some of your thinking and some of your insights from your past work and expertise. That was Dr. Don Burke. He is the Dean Emeritus at the University Of Pittsburgh Graduate School of Public Health, a virologist and epidemiologist. Dr. Burke, thank you so much for joining us today.

Dr. Donald Burke: Thanks for having me.

Dr. Abdul El-Sayed, narrating: As usual, here’s what I’m watching right now. After his State of the Union, President Biden’s administration released a new approach to COVID for this moment. It’s founded on four critical goals. The first is on fighting COVID where we find it. That means continuing to flood the space with testing and to offer antiviral pills for those who test positive. The “test to treat” program would allow folks to get tested at pharmacies and immediately get access to a course of antiviral pills for free. It also steps on the gas for vaccine manufacturing and coordinating vaccines for young children as soon as they’re available. The second is to step up the genomic surveillance abilities so that we can sequence viral samples from COVID tests to identify new variants earlier and better understand how they could behave. The third is to protect critical institutions, especially schools. That means investing in air filtration and ventilation, better articulating guidelines for isolation and quarantine, and supplying tests. The fourth, and to me, the most important, is vaccinating the world. The administration has committed to donating 1.2 billion vaccine doses and supplying other critical medical supplies, but more importantly, is empowering lower and middle-income countries to manufacture their own vaccines. One of the most important things that the administration is doing is to share government funded research with the WHO’s COVID-19 technology pool. That way, countries can leverage the tech both to build upon it, but also to manufacture critical vaccines and supplies at home, vastly increasing their supply. Finally, one of the worst consequences of the pandemic has been its impact on mental health. This was President Biden at the State of the Union:.

[clip of President Biden] And let’s get all Americans the mental health services they need. More people can turn for help and full parity between physical and mental health care if we treat it that way in our insurance.

Dr. Abdul El-Sayed: So what does that mean? Biden aims to expand the behavioral health workforce to address the fact that there just aren’t enough mental health providers. That also includes training people with mental illness to be peer specialists, a critical step toward empowering these communities. It also includes launching a 988 crisis response plan that people in crisis can call and receive mental health first aid. Right now, mental health just isn’t reimbursed the same way as physical health, which means that it’s not provided the same way. Biden put his full force behind addressing this, including a proposed requirement for health insurance companies to fund at least three behavioral health visits a year without any out-of-pocket costs. In addition, President Biden wants to put mental health everywhere, expanding online options, options at school and universities, options at primary care facilities, and so on. He’s also focused on vulnerable communities, expanding access to Black and brown communities, but also making sure high-risk groups like veterans and health care workers have access to quality services. And to top it off, the administration’s really thinking about preventing mental illness as well, with a particular focus on research to understand the role of social media, particularly for young users.

That’s all for today. On your way out can you do me a favor and just rate and review the show? It really does help. Also, if you love the show and really want to rep us, drop by the Crooked Media store for some American Dissected drip. We’ve got our logo mugs and T-shirts, our Science Always Wins t-shirts, sweatshirts and dad caps, and our Safe and Effective tees which are on sale for $10 off while supplies last.

Dr. Abdul El-Sayed: America Dissected is a product of Crooked Media. Our producer is Austin Fisher. Our associate producer is Olivia Martinez. Veronica Simonetti mixes and masters the show. Production support from Tara Terpstra, Lyra Smith, and Ari Schwartz. Our theme song is by Taka Yasuzawa and Alex Sugiura. Our executive producers are Sarah Geismer, Sandy Girard, Michael Martinez, and me, Dr. Abdul El-Sayed, your host. Thank you for listening.