Dr. Albert Ko: A Wider View of COVID-19

Harlan Krumholz: Welcome to Health & Veritas. I’m Harlan Krumholz.

Howard Forman: And I’m Howie Forman. We’re physicians and professors at Yale University, and we’re trying to get closer to the truth about health and healthcare.

Harlan Krumholz: Today we’re going to be talking with Dr. Albert Ko, colleague and friend of ours at the Yale School of Public Health. First, we usually talk about something in the news that got our attention, but I think it’s inescapable here, Howie. We’ve got to focus a bit on what the whole nation is riveted on, which is the pandemic. What are you thinking about where we are at this point?

Howard Forman: Yeah, so, we’re finally getting. . . . You know, they originally said, “In two weeks we’ll have information.” Well, it’s about four weeks later now, and we’re just starting to get up more clarifying information, both from South Africa and from England and Denmark and a few other places. But just before we got on here today, I noticed that Florida is growing cases at such an extraordinary rate that they’re actually catching up to New York, which was way, way ahead of them just about a week ago. And this isn’t Florida’s fault. This is just that Florida had no Delta wave before. It was completely gone. And then you had Omicron come in there, and it just took off in huge numbers. And so this is an incredibly infectious variant. It does appear to be as infectious, maybe even more than measles, which is something that nobody ever even contemplated before. And we’re just starting to see, I think, that the outbreaks are a little bit milder, but we still don’t know if the variant itself is milder. What are your thoughts, Harlan?

Harlan Krumholz: Well, I’ll say one thing about Florida. I just came back from Florida. I haven’t visited my mom. I took advantage of what I thought was going to be a window here before things got a little bit crazier with the pandemic. At least to my eye, it’s an interesting thing, but the behaviors in Florida look very much like there’s no pandemic going on. I mean, whether you’re talking about being inside getting your hair cut or being in the gym or walking around any indoor venue, people are not wearing masks. They’re hugging and you know, to my eye, and again, I wasn’t necessarily represent a view, but I was able to go around to a few different places while I was there. I think it’s a setup. I think people are fatigued there, and many of them don’t believe that there is a dangerous pandemic going on. So all the conditions are set for rapid spread.

I will tell you what my hope is. Look, we’re coming into the holiday, and so I try to be hopeful. And maybe what I believe is that the testing doesn’t accurately convey what’s going on with cases. And that’s in part because I’m concerned that the testing isn’t as accurate for Omicron as it has been for some of the other variants. There’s some evidence to suggest that could be true, that people who are positive don’t always report it since we’re using a lot of home testing now, and that a lot of people who get sick and have been in a position where they figure they can get COVID, aren’t getting tested because they just assume they have it. So our denominators are off. We don’t really know what the case rates are.

What we can do is look at the hospitalizations. Because we’re in the winter, the hospitals in many parts of the country, particularly in our part, for example, are close to capacity. So it only takes a few extra cases, a few extra people that need to be hospitalized to really nudge us into crisis. And that’s my major concern, but there’s a chance that this ends up, particularly among those vaccinated or those previously infected, to be milder than what we’ve seen on prior variants and spread faster. And if we’re lucky, it ends up going through the population relatively rapidly with less harm than we might otherwise think it would’ve caused. But it still depends on vaccinations, and it’s still a lot of uncertainty around that. But I just have this little nugget of hope that I’m holding onto, that we can get through this and not have as much damage as we’ve seen previously, but for the places in the country and for the people who are still holding out on the vaccine, they’re just continuing to place themselves at risk, and a rapid variant going through the population could be quite harmful for them.

Howard Forman: Yeah. I will say, we never got quite up to 4,000 deaths a week in the United States, which is just an unfathomable number to begin with. We never got up to that number. Even if we got up to half that number this time for a period of time, we could be seeing an incredible number of lives lost. And it does still appear that the vast majority of deaths are occurring among the unvaccinated. So I just can only echo what you’ve said: Everybody should go out and get vaccinated. And if you’ve been vaccinated and you’re due for a booster, get the booster now. This is a great time to get it.

Harlan Krumholz: Yeah. Yeah. And the good news is that we’ve got Albert Ko coming on, as I mentioned, and in this next segment, we’ll learn a lot from Albert, one of really the world’s leading experts on epidemics and has really been deeply studying and working to help us fight the pandemic from the very beginning, so that’s great. So, welcome, Albert. So happy to have you here. And especially at this moment where the pandemic is taking a turn for you to give some guidance.

Albert Ko: Well, first of all, thank you, Howie and Harlan, for the invitation.

Harlan Krumholz: So, Albert, I prepared a question I was going to ask you at the end, but I just can’t help myself but to put it out in the beginning. So here it is: How does this end?

Albert Ko: Well, I think the first thing is, is that there’s a lot of uncertainty and stochasticity in how pandemics roll out, but I think we are still in control of our destiny. And I think one of the things that we do need to get out of is this reactive mode with each wave. And we have to think about right now at this point, looking beyond Omicron and really laying down the tracks for how we’re going to deal with this in the long run, but we certainly need to get out of this reactive mode. Society, our families, our patients—they’re all getting tired. And this is really the time to come up with some strategy rather than reactions.

Howard Forman: What do you think has been the biggest mistakes that have been made either by the public at large or by our leadership in government that we need to learn from?

Albert Ko: Well, I think there’re several levels to that, Howie, but one that strikes me, and I think this resonates with now Harlan’s experience certainly under the leadership of Indra Nooyi during the reopening of Connecticut, the Advisory Group, and really the leadership of Governor Lamont here in our state, but I think the places, the countries, the states, the cities that got it wrong were the ones that didn’t prioritize public health. And I’m not talking about just public health or medical outcomes, I’m talking about social outcomes. And we see this dramatically around the world, you know, if we compare countries, China in and of itself, Korea, New Zealand, many of these countries. And it’s really this sequential ordering of priorities and policies. First the importance of public health in terms, in social protections, and then working onto the economic priorities, the financial priorities that go down the line.

This is nothing new. This actually came out with the Brookings Institute, important piece came out in April or May of 2020 when we’re in the middle of our first wave, and laying out that how that sequencing is going to really determine not only our health outcomes but also our social and economic outcomes there. That sticks out to me clearly.

I think the second thing is, is that how we dealt with uncertainty. And one big pitfall for all of us is that we got complacent after the initial wave of vaccinations in 2021, thinking that we had declared independence from COVID. And history in itself has told us that that may not necessarily be the case. It’s really the prioritization of short-term rather than a long-term vision in this process. Those are two things that kind of strike out to me among the many others.

Obviously we have many other issues about the preparedness, public health preparedness, chronic lack of investment in human resources and infrastructure in our public health system. These are not problems that happen overnight with the COVID pandemic, but these are problems that have been accruing over 20 or 30 years of lack of attention and lack of investment. But those are some of the ones that I carry with, you know, to me now. And unless we get behind that, we’re going to be set up for continued loss of life. Let me just throw out one other thing that I think is really important. If there’s anything else that taught us about . . . that the COVID epidemic or pandemic has taught us is really the importance of equity. And equity at very different levels. Equity, whether we’re talking about New Haven or Connecticut or United States, but importantly, the world. And the Omicron, the emergence and spread of Omicron is really, is a stark reminder to us about that we can’t leave anyone behind here and that the externalities are going to be great, not only for people in wealthy countries but throughout the world.

Harlan Krumholz: I have a question for you about looking at a global health perspective. You think a lot about how the world reacts to these situations. There are a lot of what we call ecological analyses, analyses that are done within specific geographic regions, that make comparisons. I just wonder how much do you think we can learn from comparing and contrasting different countries? So for example, people have talked about Sweden versus Norway and Finland, and trying to look at the different policies they implemented, or trying to take a look at South Korea and Japan and understand, how were they able to avoid the kind of massive loss of life that we sustained? We’re seeing lots of different approaches. Obviously they have sort of common threads, but Sweden was one more of allowing people to get out in the world and yet they were able to avoid it. What do you think about what we can learn from comparing and contrasting the experience of different countries?

Albert Ko: Yeah. Certainly I think we have a lot to learn from that. But let me predicate that argument by what we need to do in order to learn from that. And I think if there’s anything else, anything that has come up in this, during the pandemic, it’s really how, of course the success of biomedical interventions, but the biomedical approach, the vaccines, development of vaccines and hopefully oral antiviral agents is a good example of that. But I think we have to go back to our past lessons about HIV and other pandemics that we’ve experienced in thinking about what we, particularly as academicians, have kind of let down our public health community. One is, is coming up with cutting-edge methodology to take observational data, not just to identify . . . just not to estimate vaccine effectiveness in the real world but exactly addressing the key issues that you’re raising, Harlan.

We have much to learn from our colleagues across the street at the School of Economics and School of Management in that it’s really our inability to work across those boundaries, to take methodologies and also that siloed approach in—I fault the biomedical model on this—to take those methodologies, to get those quick answers to those key issues of what worked in New Zealand and what worked in Korea and what worked in China that could help us. What worked in Brazil with vaccination. We have the vaccines, but we have 30% of our population haven’t even gotten primary vaccination in the United States. So what can we learn from other countries, particularly in Latin America, that did a much better job despite the fact that they’re in a situation of vaccine shortages in demand-side issues or supply-side issues. I’m sorry about that.

I think predicate about before, what we can learn from this country is I think we need the methodology. We need those tools, and we can learn a lot from outside of our own niche. And the second part is that, what can we learn? Well, certainly one good example is vaccination. And this goes back to the argument of laying down the tracks for the long term. There was 30, 40, 50 years of investment by PAHO [Pan American Health Organization] and local ministries of health to make robust vaccination programs throughout the Americas, the heroes, public health heroes, Ciro de Quadros, who was the director of immunization at PAHO, Jarbas Barbosa, who was the head of the CDC equivalent in Brazil, investing in manpower, investing in participation in vaccination programs, giving communities a voice, something that we sorely miss here in the United States. Brazil—

Harlan Krumholz: What is the vaccination rate in Brazil now?

Albert Ko: Vaccination rate in Brazil is about 75%.

Harlan Krumholz: Higher than we are.

Albert Ko: Higher than we are. A higher proportion of Brazilians are vaccinated. . .

Harlan Krumholz: I didn’t realize that.

Albert Ko: . . . compared to United States, and that’s given the fact that they had severe vaccine shortages until June, and then they were able to open up, much of their vaccines were coming from AstraZeneca and from China with the CoronaVac that they were able to open the spigot in June in a very short period of time. And what did that gain? Whereas we underwent a devastating Delta epidemic here in the United States, Brazil dodged it. It was widespread introduction of Delta, but we didn’t have the wave death.

Howard Forman: And by the way, they’re a younger-than-average country, median age compared with the United States. So it’s not just higher vaccination rates, but higher vaccination rates that if you have equated it with the United States, it would be even vaster difference. Yeah. I’m curious to know, you are a true global health leader. Two years ago, or more than that, we separated from the World Health Organization. Now we’re trying to reclaim our attachment with the World Health Organization. You’ve already mentioned that we domestically have not invested enough in public health infrastructure. How do we reestablish our world leadership and collaborative ability with the World Health Organization, with all of our other peer nations, rather than shutting down travel to South Africa, we famously shut down travel to Brazil at times when we in fact actually had higher prevalence of disease in parts of our country. What are the steps that need to be taken right now that could help bridge this gap and get us on the right track?

Albert Ko: Yeah, so I think there are two issues, and I would separate them into vision and infrastructure. That vision, I’m not going to say anything that’s new, and I’m not going to say anything or propose anything that’s new in relation to this pandemic, but also beforehand, but it’s really countries coming . . . having a joint vision. And that vision needs to be centered around health equity in social justice. If we look at the amazing gains that we made in HIV, I’m thinking about my friend and colleague, former student Jim Kim, and what he did in WHO in 2003 with the 3 by 5. I think we need to go back to those past lessons, and we need to create that vision. And that vision needs to be grounded.

Howard Forman: You want to just say what “3 by 5” is, just for people listening?

Albert Ko: Three by five. So that was providing treatment, highly active antiretroviral treatment to people infected with HIV. So 3 million people in five years, and that at that time was considered the highest bar that could be reached. And it actually turned out to be the lowest bar once political willpower including that by President [George W.] Bush with PEPFAR [President's Emergency Plan for AIDS Relief] was achieved. But I think we have to go back to that issue of making a . . . going back to the meat and potatoes of I think what all of us aspire to, and that’s really the health equity, coming up with a common vision that resonates with all countries about health equity and social justice. And HIV is a good example of that.

The second issue is of course infrastructure. And I think if there’s anything that we learn here, it’s that we have to have a multilateral, going back to Howie’s point, we have to have multilateral initiatives. We can’t do . . . we can’t go back to the days where you had in the 1960s and ’70s, you had twenty thousand doses of measles vaccine and you unloaded them in Dakar, Senegal, without cold-chain storage, the infrastructure, the human resources to deliver that. We’re doing that now. We have vaccines expiring in the United States. We dump them into other countries, and we make our feel ourselves feel good on that. We have to break that mentality, and that’s only going to be done if it’s done multilaterally, so strengthening organizations. WHO, COVAX [COVID-19 Vaccines Global Access]. And these are big lifts in terms of both vision and infrastructure, but we have to do it. I don’t think we have a choice.

Harlan Krumholz: Let me just pepper you with two quick practical questions. One is, Israel’s contemplating a fourth booster. There are many people in this country who are now six months out of their boost. What are you thinking about with regard to additional boosting, and what about on-the-horizon drugs that are specific to the new variants? I mean vaccines that are specific to the new variants.

Albert Ko: Yeah. So a couple things and at different levels. So first of all, we really are looking towards new evidence, and hopefully that evidence will be coming out places like South Africa, the UK, about what vaccine effectiveness is against the current primary vaccination regimen of two doses. Now, for example, Pfizer, Moderna, AstraZeneca, but also what’s going to happen with the boost. Certainly there’s preliminary modeling evidence, empirical evidence suggesting that, of course, that the boost will not only decrease the risk of infection but also will boost up the, what we care most about is saving lives and decrease the risk of severe outcomes, such as hospitalizations and deaths. That as a preface, I think it’s premature going to the fourth dose. And that comes to another issue is that we still have a lot to do to get vaccination, primary vaccination to most of the world.

And we still are not at the point where the supply-side issues are not relevant and important. And that, again, takes a vision beyond a single country. Israel giving a fourth dose to its population without evidence. And working beyond that, of course it sounds reasonable to give the fourth dose. We don’t have safety data. We don’t have efficacy data on that. But I think, again, I go back to the point that the best way we’re going to protect the world is increasing the breadth and the range of vaccination, rather than piling on more boosters to a small segment of the population.

With respect to other . . . do we need to have a new vaccine? Okay? And what that’s going to look like? Of course, what we are going to learn in the next two or three weeks are going to be critical. All the test-negative design studies coming out of England are going to be really key. The preliminary data is showing that you can use a homologous or a mix and match with current vaccines. I think the bigger question on the horizon is what do we have. . . . Where is the next variant going to come from? Is it going to come from Omicron? Is it going to be a new strain? Certainly that jump in mutations really was a cautionary statement to all of us both in the scientific world, as well as in terms of governments. The Omicron really has challenged our concept about how new variants may emerge and whether we really are going to exhaust the landscape of mutations, you know, that translate to public health impact. I’m not sure if you guys have talked about that.

Harlan Krumholz: Yeah. You mean the fact that this is so far from the others, the marked number of changes that sort of made a clade that went off on its own, that sort, when you look at the map, it’s not close to the others. Is that what you mean?

Albert Ko: That, and going a couple steps back in the thought, so what was our kind of paradigm that we’re going to have incremental mutations that accrue. And those mutations, they may give a selective advantage, but they’re also going to have a fitness cost. Right? And that you have a lot of mutations, you also increase the prospect that you’re going to have a fitness cost that’s going to happen. I think Omicron seriously challenges that on two levels. One is that Omicron came out of the blue. It didn’t come from. . . . We had thought it would come from Delta, right? And it came out from a completely different lineage, which really, how do I say it, emphasizes the importance of genomic surveillance, not just in the rich countries but worldwide.

The second is, is that just the number, it’s like 36 mutations in the spike protein alone compared to Gamma, which was a pretty nasty variant that we suffered from in Brazil, which had 11, that big leap tells us that there are a lot of different configurations of those mutations that may not give that fitness cost. And we were just hoping that sometimes the mutations would burn themselves out and there would be kind of a plateau, but Omicron kind of calls that into question.

Harlan Krumholz: But how does that happen if you think about it teleologically? I mean, you do think that there’s a constant competition. One gets a little bit better than the other, outcompetes the other, but this came from an entirely different lineage. How does that happen?

Albert Ko: I still think that the model, the conceptual model that if you have uncontrolled transmission, high levels of viral replication, that will lead to mutations and that would increase the risk of . . . new mutations that have a public health impact. I think that conceptually. I would certainly, and a great person to pick their brain and have on this podcast is Paul Turner, because there are a lot of issues that are coming up and a lot of unknowns. So one is, is that this issue is the paradigm that you’re going to exhaust the mutations or the profiles or the landscapes of mutations that are going to have an important public health impact. Is that going to happen? And people thought that that could happen, right? And at some point you’re going to just burn out. But I think this calls it into the question.

The second is, what is the role of selective pressure? There have been not comprehensive studies in South Africa, but there have been cohort studies that showed that 50% of South Africans have gotten infected once. In our, I just came back from Brazil, as you know, in our cohort of two thousand urban slum residents in the city of Salvador in Brazil, 75% were infected over the first two waves. So 50% in the first D614G wave, and in another of those 50% that were not infected, 25% more got infected. 50% more got infected with Gamma variant. So you’ve got selective pressure, but what role does that play?

And then the third question is competition. Do these variants really compete? Does Omicron outcompete Delta, did Delta outcompete Alpha, and what’s the biological and epidemiological basis for that competition? But those are really key questions that we need to answer and get right. We kind of let. . . . If you remember D614G, we just kind of blew. . . . It took four or five months before we understood that this variant or that mutation had spread throughout the world. This really kind of goes back to that earlier discussion we had is that I’m not an ecologist or an evolutionary biologist, but we do need to get our heads around those kind of issues if we’re going to think about how we’re going to prepare for that long run, in that, what you had mentioned, Harlan, what’s our end going to be, because I think we all agree, with this transmissibility rate, there’s not going to be an end, right? We’re going to have COVID with us, it’s going to be endemic, but what does that endemicy look like? And what are the kind of getting out. . . . You know, I just was astounded by the work done by my colleagues at the Oswaldo Cruz Foundation, which is the NIH equivalent of the Brazilian Ministry of Health. But it does appear that with each success of immunizing exposure, whether another infection or vaccination, hopefully we’re not going to get the antigenics in, right? We’re going to have broadening, not only quantitative increase in antibodies, but we’re going to have broadening of the response. And I think that’s what some of the booster story is telling us about Omicron. So I do hope that. . . . I do see those as kind of really key questions that we hear at Yale, but beyond have to kind of answer.

Howard Forman: We’ve had a segment on SalivaDirect, and we’ve talked about testing on this show several times, but we’re at a crisis again in testing in this country and it’s multifactorial, and I’m just wondering what your thoughts are and what the future of testing looks like. Are we finally going to get a breakthrough where we have antigen testing widely available? Are we going to ever have PCR testing that’s so accessible that we don’t have to watch lines on TV? What are your thoughts about that?

Albert Ko: Yeah. So let me, I’ll put a plug in for testing, and this goes back to really the contributions of Harlan in the Reopen Connecticut Advisory Group. I think we got it right. I think the group got it right. And this made sense to us as physicians of why testing is so important. Connecticut, we went from 400 tests a day to roughly 20,000 tests a day within about six months, wrapping up that infrastructure. And what happened during that? I think it’s really important to learn from what happened in the past. What happened in that first wave is that particularly in our vulnerable communities, people were told, “Don’t come to the hospital until you are really sick and have to.” Right? And what happened with that? Well, our mortality rate ratio for Black Americans, Black African American populations here in Connecticut were five to six times higher than that over White population. With testing and with all the social protections that were rolled out, that went down to, still unacceptable, but that went down to about two, that an African American had twice as much risk of dying from COVID than a White resident in Connecticut. Why did we get off the tracks? Well, it’s the reaction, we got into the reactionary mood. The curve is down; we pulled the brakes on testing. When the curve came back up, we did more testing. And I think the one part, and I would say my . . . I would not have absolved myself because I think many of us wouldn’t have thought we’d need to test as widely as we needed to keep our schools open and so forth.

But now I think we’ve learned those lessons. And so widespread access to testing is going to be key, and they’re going to have to be done where people live, not in centralized areas in hospitals in the healthcare systems. They’re going to have to be done in homes; they’re going to have to be done in schools, nursing homes, our correctional facilities. I think one shining light through this whole pandemic is what the Department of Corrections has done here in the state under the leadership of Bob Richeson and Byron Kennedy. They kept up the momentum of testing all of the inmates in the correctional facilities throughout the pandemic, through all the wave. They didn’t give up when the wave was down to keep that population safe. So I think that is a good example of what we need to do.

And obviously there have been visionaries, Michael Mina from Harvard, who’d been pushing this all along, but this kind of gets back to our core principles, both as physicians and public health, is that you have to decentralize testing if you’re going to make a difference.

Harlan Krumholz: Thank you so much for these insights. I always learn a lot listening to you. I have one final question as we come to the end, which is, lots of people are wondering, what should they be doing now? So maybe I’ll ask you, what are you telling your family? How are you going to spend the holidays? And are you making any changes in your usual patterns based on the fact that we’re just about to experience a marked inflection Omicron in cases within Connecticut?

Albert Ko: Yeah. So unfortunately we don’t really have clear guidances, because I can protect myself and I protect my family, but we need to protect all of ourselves together. At my own level, what do we do? We’re wearing face masks when we go out, we’re going to be certainly wearing face masks when we’re indoors in any congregate setting, whether it’s a shopping mall, whether it’s at Yale University, whether it’s in the hospital. We’re reducing the number of people who are coming over for Christmas, and we haven’t done this, but it does make a lot of sense that people who are having gatherings and coming from different areas, particularly hotspots like New England, people are doing rapid testing on the day of the gathering. Those are kind of like the ABCs of what we know work. The gathering size, you know, testing, the use of face masks and so forth, it certainly puts a damper on the holidays, but those are the things that our family is doing to keep ourselves and our friends and family members safe.

Harlan Krumholz: That’s great.

Howard Forman: Thanks very much, Albert, for coming and joining us, the Raj and Indra Nooyi Professor of Public Health at Yale University and our colleague, thank you for everything that you’ve done for the state, for the school, and for the advancement of our knowledge during this pandemic and before.

Harlan Krumholz: Yeah. Thanks for your friendship, Albert, and happy holidays.

Albert Ko: Happy holidays to all of you, the listeners. And really congratulations Howie and Harlan on this, really this marvelous podcast and its ability to get out knowledge and evidence to people.

Harlan Krumholz: Thanks so much.

Howard Forman: Thank you. So, Harlan, usually we use this time to talk about some non-healthcare item in the news, but since we’re right before Christmas, right before the holidays, I just wonder, what are you hoping for next year?

Harlan Krumholz: Well, I mean, again, I’m hoping that we can look at what’s going on in the world and recognize that for us to get through the many challenges in front of us requires us to pull together and find common ground. I feel that the pandemic, climate change, all these things are so important, but the biggest threat is our inability to get along with each other and the polarization that’s occurring in almost all countries in the world. And then on a personal level, of course, still continue to feel the loss of the time with family and friends and the personal, like I said, I hope that we can get to a point in the pandemic with advances in science and changing behaviors where we can get a little more normalcy back and that the kind of social exchange that’s so vital to a full life becomes a greater part of societal norms. But I think we have to hold tight here in the meantime. How about you?

Howard Forman: Yeah. I’ll echo your point that I would love to see us building bridges and bridging the gaps that exist between us, both domestically and globally. I was heartened to hear Albert Ko talk a bit about both of his global work as well as the work that we need to do globally to get out of this pandemic and prepare for future challenges. And in alignment with you as well, I’m much looking forward to times that we spend with one another, with our families in person again. I do believe that’s in the future. I don’t think this is never-ending, but I think each of us has hard work to do to contribute to get us in that place. So I’m wishing all of our viewers, all of the listeners, I should say, a very happy holiday season. Merry Christmas, Happy Festivus if you celebrate it, Happy Kwanzaa, and a very happy and healthy new year to all of you. And we look forward to speaking to you again in the new year.

Harlan Krumholz: And I’m grateful to you, Howie, you proposed this, that we thought it’d be fun to try this podcast. It’s been great for us to be able to be together. I hope the listeners have also enjoyed it, and I look forward to us continuing to improve the platform and to make it more useful in the future. So happy holidays to you and to the listeners. And thank you all. And we’ll see you in 2022.

You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.

Howard Forman: So how did we do? To give us your feedback or to keep the conversation going, you can reach us at Twitter.

Harlan Krumholz: I’m @hmkyale. That’s H-M-K-Y-A-L-E.

Howard Forman: And I’m @thehowie. That’s @thehowie, T-H-E-H-O-W-I-E.

Harlan Krumholz: Health & Veritas is produced with the Yale School of Management. Thanks to our researcher, Sherrie Wang, and to our producer, Miranda Shafer. Talk to you soon, Howie.

Howard Forman: Thanks, Harlan. Talk to you soon. And thanks to everybody. Happy New Year!