Dr. James Hamblin: Should You Stop Washing?

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

Howard Forman: And I’m Howie Forman. We are physicians and professors at Yale University. We’re trying to get closer to the truth about health and healthcare. This week, we’ll be both speaking with Dr. James Hamblin. But first, we’d like to check in on current health news. Harlan, what’s got your attention?

Harlan Krumholz: Well, in the world of the pandemic, there still remains a lot of stuff going on, not to mention that we’ve got a second pandemic now going on. As you know, the World Health Organization took this amazing step over the weekend to declare monkeypox a public health emergency of international concern, a designation that is only now currently describing two other diseases, COVID-19 and you know what the other one is?

Howard Forman: I did read it. Now, I don’t even remember. It was a—

Harlan Krumholz: Polio. Polio. Polio.

Howard Forman: Polio, right. Yep.

Harlan Krumholz: Which is, of course, of also great interest because there’s now been a case of polio reported. How much more can we take as a society? The issue about the WHO’s declaration about monkeypox, again, only COVID and polio, so now monkeypox joins it as a public health emergency of international concern. Something like, I don’t know, 75 countries have reported almost 20,000 cases and we know that only probably a minority of the actual cases are being reported. People are now going to look at wastewater, and then there’s a lot of vague guidance. For example, you can get this from touching, and so what’s that mean? I think this is just freaking people out.

So I know in the outro, you’re going to be sharing a lot more of your views about this. All I’m telling people is, just take a deep breath, first of all. Information’s still coming in. We may have missed an opportunity to move more quickly, and I know you’re going to get into this, but I worry that this just adds to the anxiety in the ecosystem. And also, people just turn off after a while, because unless there’s clear guidance, it’s hard to follow. That’s one thing. I know, like I said, you’re going to follow up more.

Another thing that’s been coming out that people are talking about is Evusheld. This is this combination, a monoclonal antibody, and I thought I would just explain it to people, because there’s a lot of messaging that’s coming out that’s saying that it’s being underused. And people may be wondering, “Well, what’s all this about? What is this, exactly?”

So look, just to get really basic, SARS-CoV-2, as most people know by now, uses a spike protein. We talk about the spike because the vaccine creates antibodies to the spike. It creates a spike to attach itself and enter human cells, which is how it causes the infection. The monoclonal antibodies bind to this spike protein, and they prevent the virus from entering and infecting human cells. It’s sort of like, this is the roadway it takes, this is the lock and key, and we block it, so it can’t really connect with the human cells and enter it. And by the way, that is what happens with the vaccine, too. The vaccine creates our own antibodies. This Evusheld is a combination of antibodies that are being manufactured and what we can do is to deliver this combination medication to help prevent the infection.

Now, here’s a key. This combination is not a treatment for COVID-19, and it shouldn’t be given to patients who are already infected. It’s really about trying to prevent the infection itself. It’s targeted toward a certain group of people. Now, this was given emergency use authorization in December 2021 by the FDA, and they said that eligible patients could include adults and those people 12 and older who are at least 88 pounds and are moderately to severely immunocompromised due to medical condition or immunosuppressive medications and may have an inadequate immune response.

These are people who can’t mount a defense. This is who it should be given for. So when you’re reading to say, “Here’s an underutilized medication,” it is for a specific slice of the population. It’s not for everybody. It is shown to be pretty effective. It can substantially decrease the risk of developing symptomatic COVID-19 for actually up to six months after administration, so it’s pretty good like that.

There are some potential side effects, of course, just like everything. Allergic reactions where they inject it. It can cause local swelling or bruising. All the kind of usual stuff. But the main thing is that these are usually pretty effective, and people tolerate them well, but it’s only for a certain population. So I just wanted to introduce for people listening this issue, because they may have heard, you know, there was a lot of chatter about this being underutilized.

Howard Forman: No, I was just going to say that I think the most common vaccinated person I saw presenting with severe COVID during the Omicron surge was the patient with a transplant, with a renal transplant or sometimes a liver transplant. Evusheld is exactly for that patient, the patient who the vaccine is never going to work well enough because they’re on immunosuppressive therapy. So I couldn’t agree more, and it’s nice to see that the evidence continues to confirm that it works.

Harlan Krumholz: We want to just amplify that message for people to know who are fitting in that group. Thanks, Howie. So I’m eager to hear James. Let’s get going.

Howard Forman: I’m really delighted to introduce Dr. James Hamblin. Dr. Hamblin is a preventive medicine physician and lecturer in health policy at the Yale School of Public Health. He’s the author of If Our Bodies Could Talk and Clean, the latter of which was named an Editor’s Pick by The New York Times Book Review and listed among the 21 best books of 2020 by Vanity Fair. James previously served as a staff writer and senior editor at The Atlantic, where he also had a humorous, thoughtful, and wildly popular video series with the same title as his book: “If Our Bodies Could Talk.” His work has been featured in The New York Times, Politico, NPR, The Guardian, and more. He has appeared on CNN, NBC, The Late Show with Stephen Colbert, and more than that. He earned his bachelor’s at Wake Forest and attended medical school at Indiana University, which is when I first came to know him. He then trained at UCLA partially in radiology and then completed the residency in general preventive medicine and public health at Yale, where he earned an MPH from our school, and this is where we met yet again.

On February 24th [of 2020], he penned a piece for The Atlantic entitled, “You’re Likely to Get the Coronavirus.” Early on in the pandemic, this was occasionally mocked as being alarmist. And as with so much of his work, it turned out to be spot-on and prescient.

So first of all, James, thank you very much for joining us today. I want to just start off by asking, you are, if anything, one of the most expert generalists in the world on so many topics. You’ve written about topics like COVID where I’d be hard-pressed to find anyone who knows more about COVID than you do, but you know it as a generalist. You’re not a vaccinologist. You’re not a virologist. You know more about the skin biome than anybody I certainly know and yet, this is not your area of scholarly expertise. What draws you to a particular topic within healthcare or health and draws you in to want to learn so much about it?

James Hamblin: That’s a great question and thank you so much for having me on the podcast. I’m a big fan of both of you and a long-time listener, first-time caller.

Harlan Krumholz: Indeed. Love that.

James Hamblin: What I love about journalism is that you get to follow what you’re interested in, and you get to keep learning and challenging yourself, and then you have to quickly learn as much as you can, digest it, and then regurgitate it in a way that is ideally entertaining and informative to people. It’s a mix of what is interesting to me and what I think is important for people to know and would be of interest to them, and then also just because I’ve been doing this for 10 years, stuff that is new to me. I don’t want to just be repeating myself.

So yeah, I don’t have any area of expertise, and I lean away from trying to go too far down a hole. I’ve done a lot of reporting, say, on food and nutrition, the food system. But as you go further, you go deeper, you end up speaking only to people who are already expert in it. So if you want to continue to speak to a general-interest audience, then you have to keep pushing yourself into new areas so you don’t get too niche and you’re talking about just one aspect of one bill or one policy proposal that’s really not of interest to anyone who isn’t already actively following the subject.

Harlan Krumholz: So James, it’s great to have you on. Boy, we don’t often have someone who says “I’m not an expert at anything” on, but also someone who is accomplished. That’s great humility. By the way, the Indiana University connection. I spent summer in high school in Bloomington. Let’s just talk about that for a second. Isn’t that a great place?

James Hamblin: Oh, it’s wonderful. Yeah. Second only to New Haven, Connecticut.

Harlan Krumholz: That is the right answer. That’s the right answer. So I’ve read your stuff, and it is really enlightening. And let’s just talk about Clean, a book that you published just before the pandemic. And I just wanted to read a couple things from it to go through a few things for listeners. So it starts off by saying, “Five years ago, I stopped showering. At least, by most modern definitions of the word. I still get my hair wet occasionally, but I quit shampooing or conditioning, or using soap, except on my hands. I also gave up other personal care products—exfoliants and moisturizers and deodorants—that I had always associated with being clean.” And then you said, “Well, what’s the ROI on giving all these things up, maybe besides repelling some people that you don’t want to have close to you.” But you say if you spend 30 minutes per day showering and applying products over the course of a long life, let’s just say a hundred years for the purpose of optimism and ease of math, you’ll spend 18,250 hours washing. At that rate, not showering frees up more than two years of your life.

And you go on, I think, to make the case about a lot of these products and a lot of our habits. One thing that occurred to me reading your book—and I really recommend it. It’s a fun book, it’s an enlightening book, it’s got a lot of facts that many people may not be aware of. But one of the things that reminded me that there’s so much in our lives that we take for granted as being part of the human condition, how we sleep, how we eat, and, in this case of this book, how we clean ourselves.

Because, as you know, take breakfast for example, how embedded orange juice is or what Kellogg’s did to making us think about what sugary treats ought to be part of our menu in the morning. But you go into this whole thing about saying, the way we’re acting now isn’t the way humans have always acted and it’s not clear that it’s a positive evolution. And in large cases, it’s a response to industry, I’ll say it like this, manipulating our taste. So give a little background like, how did you get into this? What interested you in it? And are you still not taking a shower?

James Hamblin: I’ll start with the last one. I’m a minimalist in that way. And I’m not prescriptive about it for other people, but the whole journey of investigating this book and learning about the skin microbiome and the history of our beliefs about hygiene and cleanliness, it really changed my own habits, such that I only do things that I really find to be enjoyable or truly necessary in some medical sense, like brushing your teeth to prevent cavities and tooth decay. So, yeah, and this is something, Harlan, that you talk about on this podcast often, that our environments, that our day-to-day habits really form the foundations of our health. And a lot of it is shaped by our ecosystems, by our societies, by policies, but there’s some degree that is affected by our individual decisions and our habits and our beliefs and things that are within the realm of things that we could voluntarily change.

And so whether it’s sleep, relationships, physical activity, what we eat, how we clean ourselves, what we apply to ourselves, what we put on and in our bodies, all of that tends to be very interesting to me because that’s the sort of thing that you’re doing it every single day for years and years and years. And that is probably having, overall, a cumulative effect. And even if an individual, in a single day, it doesn’t especially seem like it would matter. So those habits and thinking about building lifelong, sustainable, healthy systems, habits, lifestyles—that’s all of interest to me.

Harlan Krumholz: One thing I want to just jump in on here though, and then I’ll yield to Howie again. So in the course of a public health pandemic, we’re trying desperately to modify people’s behaviors. We’re trying to get them to do very simple things that might slow the spread or mitigate the transmission of the virus and to improve outcomes. And even the most basic things, of having highly effective vaccines, we’re having trouble getting the penetration. Meanwhile, some of these things that have percolated throughout the entire society, seemingly in rapid progression to become embedded in our behaviors, like the use of soap and shampoo and the way in which we work. People may find this crazy, but as you describe, this isn’t something that was always part of it. And yet industry found a way to make it so that we can’t live without it.

I’m going to just pivot now to the moment which is, you talk about, for example, how soap, which was already starting to sell well, began to really take hold after the 1918 influenza pandemic. How are these companies so successful at molding these health behaviors, and public health officials are unable to do so? And then I have a second part of it, which is, what do you think is going to be the change in behavior that emerges out of this pandemic that’s going to be seized on by some of the same forces?

Well, yeah, those are huge questions. I think fundamentally there have been more than a hundred years of intense, competitive, high-dollar marketing that has gone into creating our beliefs about hygiene. And with that is a self-perpetuating cycle by which people form beliefs about themselves, about others and socially enforce these things, where we’ll say that people are “gross” or “disgusting” if they don’t, say, wash their hair or if they smell like a human body, like if you can detect any smell on a person other than like lavender, then they’re “gross” or “disgusting.” And it’s one of the few areas where even socially progressive people will still be very openly judgmental. Maybe in a former generation, people might have been that way about obesity or different sexual orientations that were less than mainstream.

And as society has progressed and people have become much more open-minded, accepting, and yet those same people will just be like, “Oh, you don’t use this, you didn’t shower, you don’t use deodorant—you’re gross, you’re disgusting.” So it’s one of the final barriers there that, I think it’s really only a matter of people not examining their beliefs and where they come from and still associating those products with disease, with contagion, partially because of how they’re marketed and how they’re sold. If you go into a Walgreens or CVS, you see two aisles of deodorants and shampoos, which are doing zero to prevent or treat any disease, but they’re right there next to all the medications that help you take care of your cold or prevent... or right next to the counter where you’re getting your prescription. So it’s all bundled in. And I think a lot of people just haven’t thought about what is the line between cosmetic and medical or health product. And that’s sort of what I’m interrogating in the book.

Howard Forman: So I first want to draw people’s attention also to the fact that you have a newsletter that you update on an irregular basis, but regularly irregular. And it’s called “The Body” and the address is body.bulletin.com but we’ll make sure that’s in the notes for the podcast, but I’m struck by just how much time you’ll put into a single newsletter. And I’m not referring to the one about peanut butter smores, which I think is also very important that we may get to, but most of the others are very lengthy investigations of specific topics.

And just to give people an idea of just how varied they can be, you have many on COVID, obviously, because that’s been a hot topic, but you’ve also talked about the biofilms on your teeth, the use of Juul and electronic cigarette and how can that be banned when cigarettes are not, you also talk about the health effects of lawns and so on. So you’re writing these long-form pieces, which by the way, you get a lot of comments from people and you’re able to get feedback on both Twitter and Facebook on them. How do you pick a topic? What strikes you? You’ve also written about abortion, by the way. You’ve done a great job on that.

James Hamblin: Yeah. Thank you. That has been a kind of casual project. I started off blogging, like a lot of people, about a decade ago. And during especially the pandemic, I felt like it was, of necessity, very high-stakes and very serious. And I wanted a platform where I could be a little more casual. Again, I don’t always want to be preaching to people. Sometimes I just want to be working things out on the page, which you used to be able to do on the internet a little bit more. My platform grew, and I’m fortunate for that, but I also kind of had to have a fully formed idea before I opened my mouth. And I wanted to go back to working things out on the page and having a dialogue with readers, so that’s what “The Body” is. Something will pop into my head, and I can quickly write it.

Harlan Krumholz: Body dot bulletin dot com. That’s great.

Howard Forman: James, did you come up with the title of the article, “You’re Likely to Get the Coronavirus,” or is that something an editor came up with?

James Hamblin: “You’re Likely to Get the Coronavirus”? Yeah, that was my idea for a headline on the morning that it published. I had been working on this story for like a week before, and that was in February. And then on the morning of, they always run the headlines by me and ask if I have any ideas or feedback on it, make sure I’m okay with it. And I was like, “Actually I think we could probably say at this point, you’re going to get it.” And that was radical. And we watched right away for responses to it to see if people were freaking out or if there were people who were like serious people taking issue with it and they weren’t, so we stuck with that.

Harlan Krumholz: So, Howie, I know we’re coming down to the end and I just have a couple quick things I want to ask James based on the stuff that I’ve read that he’s written. And one is, between the pandemic and now we’ve got monkeypox, which we’re all talking about. And by the way, the guidance on monkeypox is so vague, it’s like, well, you can get it from people touching you. So what’s that supposed to mean? And you wrote this piece in the book, in Clean, that I thought was really important, which is that the health benefits of touch itself, platonic touch devoid of any sort of relationship, is well documented. And then you talked about your interviewing one of the pioneers in the field, Tiffany Field, developmental psychologist, who founded this Touch Research Institute at the University of Miami.

And again, you wrote this book before the pandemic, but I just wonder if you have any reflections now on how we need to incorporate the whole spectrum of potential unintended, adverse consequences of going after one thing. So if we say, “We’re going to minimize spread of X,” which would be a good thing to do, but what else do we lose? Lots of people focused on the economic fallout from harsh constraints on society in order to slow the curve. And by the way, when the hospital’s overflowing, there’s no question, there was a need to do things. But as we start looking at this, do you think now that, or maybe you always have, that there’s a need for us to incorporate the full spectrum of impacts of all of our public health initiatives, because even something as simple as touching, as people are sequestered and isolated, we take that away from people.

James Hamblin: Yeah, no. I’m so glad you mentioned that because as you know, and I know Howie knows, that’s always been part of a public health calculus. And if I recall correctly from that piece I wrote back in February, at the end of it was—February 2020—the end of it was, we’re going to have to figure out how to open up and balance prevention of transmission with living with this. That was the point of it. And there was this sort of false narrative among some political opportunists, I think, who were saying, “Oh, the public health people just want you to shelter in place and lock down and don’t care about anything else. And haven’t considered the effects of closing schools,” but I don’t know anyone who... that was just not a thing. And so that’s the way I know that I and you and Howie and everyone else that’s been thinking about this as, “What’s the overall balance for the guidance for a healthier world?”

Harlan Krumholz: Yeah, we can’t ask people to give up their whole lives, but yeah, it’s the balance.

James Hamblin: No, and yeah. And I don’t know anyone who has honestly so, yeah, I think there are a lot of great debates to have over about how to strike that balance, but the idea that we need that balance, I don’t think is up for debate, and it’s frustrating to hear people—

Harlan Krumholz: Well, and I have one more from the book that I wanted to say that I thought was interesting, that people might find... just a useful fact. But one of the things that you wrote was that it wasn’t until 2013 that the FDA told producers of antibacterial soaps that they needed to substantiate claims that antimicrobial cleaners have any benefit at all. And I think here, by the way, you’re just talking about the effect on bacteria, not even effect on actually people’s lives and health, but whether or not people who are making these claims. And that’s only 2013, and before that people could be making a lot of different claims on these soaps that weren’t substantiated. Were you surprised to find that out, and what did you think about it?

James Hamblin: Yeah, I will never be surprised to learn that the FDA has not really regulated something in the supplement or personal care space and that extends to vitamins, supplements, dietary supplements as well. You can basically, and I do in the book, make my own skincare product and create my own line. And all you have to do is register an address with them and be like, “I’m selling this, just so you know,” and then you can make all these really interesting claims, innuendo-wise, as long as you’re not saying, “This cures skin cancer” or “This prevents cardiovascular disease.” You can say, “Oh, it is protective to the dermal layers,” or “It promotes cardiac wellness,” and anyone who’s worried about cardiac disease is going to read between the lines there. But I think that people don’t realize that space is kind of the Wild West of... pretty much anything can be in there.

Harlan Krumholz: So are you selling your stuff? It’s sort of the anti-soap, so your preparation, it could go wild. It’s like anti—

Howard Forman: You should do it now, James.

James Hamblin: Oh, oh yeah. No, I mean, I am doing really well on the supplement space right now. No. Actually, I created the site, and I charged $200 for a two-ounce bottle and some people really actually did want to get it and I couldn’t bring myself to actually go through it with selling it, but there are people out there selling creams and serums and skincare products—

Harlan Krumholz: By the way, the more expensive, sometimes the more customers you get.

James Hamblin: Exactly. Yeah. I think because of this lack of information for consumers, we don’t have a lot to go on. So if it’s more expensive, it that’s one of the few cues of, “Oh, it must be a better product.”

Howard Forman: I will say this, though, for a man who perpetually looks like he’s 20 years old, I don’t think he needs much more than to just show your picture on the label.

Harlan Krumholz: No, this is evidence it’s working, Howie, it’s working.

Howard Forman: I know, that’s what I’m saying. That’s what I’m saying, I think that’s all the marketing he needs to do.

Harlan Krumholz: Because he’s not scraping off the skin layers every day with all the washing.

James Hamblin: Yeah.

Harlan Krumholz: So anyway, James, I want to just thank you so much for spending the time with us. It’s been really enlightening, and you’re such a great communicator. I think it really.... Both your thinking and then your ability to express it to the public. It’s such a gift and we really appreciate you coming on with us and appreciate all the work that you’re doing.

James Hamblin: Well, it’s an honor to be here. Thank you.

Howard Forman: And thank you for everything you do for Yale University as well. You’ve been an amazing teacher of our students, a mentor and advisor, and we appreciate it very much.

James Hamblin: Well, thank you for the podcast. I will continue listening to it every Thursday, excitedly.

Howard Forman: We’re going to have you come back. We’re going to have you come back soon enough.

James Hamblin: All right. Happy.

Harlan Krumholz: Howie’s going to replace me with you soon, just so you know. So that was great, Howie. I think it’s a good time for us to pivot to the final section. And so what’s been on your mind this week?

Howard Forman: Yeah. So as you mentioned earlier, the monkeypox outbreak honestly has been a fiasco. And while I mostly kept my opinions to myself, I also admit to being misled and frankly wrong two months ago when this first started to be a concern. I was confident that we would see a lot more cases, but equally confident that we, at least in the United States, could and would contain this as opposed to merely mitigating the outbreak. After all, we had vaccines, therapeutics, testing, and knowledge from decades of global experience with what we have called monkeypox to this moment. When the early outbreaks were identified as being centered in predominantly gay groups of individuals, it was not clear that this was being predominantly spread through sexual contact. And in fact, it was almost misleading, what people were saying. It was mostly that they were talking about social contact. And the thinking was that this was much like some earlier outbreaks of COVID that occurred in settings such as a Jewish synagogue, gay bars, or church choirs.

The mechanism was likely person-to-person contact. It is becoming increasingly clear that there is non-sexual person-to-person transmission, but it is vastly outweighed by sexual transmission. Ninety-eight percent of cases so far in the United States involve men who have sex with men. And 95% of cases are traced to sexual transmission itself. We may not have understood this early on, but we need to get this message out now and take the appropriate actions to mitigate, even if we can no longer completely contain it. And that involves educating communities, providing testing as needed, and vaccinating both before, as well as after, exposure in order to minimize harm.

As you alluded to earlier, people are still talking a lot about “how do you get this” and concern that if you’re near someone with it, you might get it from them. I have little doubt, quite frankly, that people will soon express fear about being around gay men, much as they did in the 1980s and 1990s with HIV/AIDS. This will cause yet more harm than is necessary. But if we can do our best right now, we can mitigate that harm. We can reduce that harm. Our public health authorities have a lot of work to do, and a lot of mistakes have already been made, but it is never too late to start taking this as seriously as it requires.

Harlan Krumholz: Yeah. I’m really glad you said all these things. As we said at the top of the podcast, the WHO making this designation is not a trivial thing. I mean only two other conditions have it. And I think this issue around gay men, there’s also probably reporting bias. Once the word gets out, people are going to be seen. And then that stigmatization also leads other people not to be seen. It’s way too early. And there is potential great harm in making it seem like there’s one community that is spreading it, that’s affected. That stigmatization is awful. So I’m really glad you brought this up, and I couldn’t agree with you more.

Howard Forman: And, and by the way, it will spread. I have no doubt that it will spread beyond the gay community. How much, how wide, how bad, I don’t know, but it will spread. And the stigma is going to be that somehow gay people brought it in and gay people gave this to me. This is not the case. This is an infectious disease.

Harlan Krumholz: Given that there are only like a million and a half vaccines and they’re not spreading, people probably won’t take them anyway. Should James write a piece that says everybody’s going to get monkeypox?

Howard Forman: I didn’t want to ask him during our segment, but I do think that’s top of mind right now. I’m looking forward. He covers these things so well that I have no doubt that he’s going to cover this well in weeks ahead.

Harlan Krumholz: Yeah. Well, anyway, I can say at least that I know the administration is focused on this now, and we’ve lost some time, but let’s see what unfolds. But again, I keep telling people, “Don’t freak out. Don’t freak out.”

Howard Forman: That’s right. That’s right.

Harlan Krumholz: Okay. 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 find us on Twitter.

Harlan Krumholz: I’m @H-M-K-Y-A-L-E, that’s H-M-K-Yale.

Howard Forman: And I’m @theHowie. That’s @T-H-E-H-O-W-I-E. You can also email us at health.veritas@yale.edu, aside from Twitter and our podcast, I’m fortunate to be the faculty director of the healthcare track and founder of the MBA for Executives program at the Yale School of Management. Feel free to reach out via email for more information on our innovative programs, or you can check our website, som.yale.edu/emba.

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

Howard Forman: Thanks very much, Harlan. Talk to you soon.