Zeke Emanuel's Provocative Advice on Making Healthcare Better

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. And we’re trying to get closer to the truth about health and healthcare. Usually we start off by talking with each other about healthcare topics of interest. But since our special guest is a Renaissance man of sorts in this regard, we thought we would cede this space to him. While the segment turns out to be longer than usual, it certainly is worth it.

I’m excited to introduce Dr. Ezekiel Emanuel. Dr. Ezekiel Emanuel is a highly accomplished oncologist, bioethicist, policymaker, and author jointly appointed by the UPenn School of Medicine of Wharton School. Dr. Emanuel is the vice provost for Global Initiatives, a Diane and Robert Levy University professor, and chair of the Department of Medical Ethics and Health Policy at UPenn. He’s also a senior fellow at the Center for American Progress and was one of 16 members of Joe Biden’s COVID-19 Advisory Board. Previously, Dr. Emanuel served as chair—

Ezekiel Emanuel: All right. Let’s get to the facts!

Howard Forman: Previously, Dr. Emanuel served as chair of the Department of Bioethics at the National Institutes of Health and special advisor of the Office of Management and Budget in the Obama White House, playing a leading role in passing the ACA, or Obamacare. Drawing on his breadth of health expertise, Dr. Emanuel has published over 300 articles, authored or edited 15 books, and contributed to op-eds in the New York Times, The Atlantic, and the Washington Post. I could go on and on with how much his work in healthcare, finance, biomedical ethics, and global health has influenced our lives in positive ways. But I will start off by thanking you for joining us and asking you what non-COVID healthcare issue is top of mind for you these days?

Ezekiel Emanuel: Non-COVID but a healthcare issue, whether there’s anything we can do to actually fix the system. Every time we try to fix the system, either we slip back or we end up doing something—I mean, look, the Affordable Care Act has had a big impact, 25 to 30 million people with insurance, healthcare spending as a percent of GDP has been flat for a decade, only went up because of the need to spend on COVID. Those are pretty impressive results. But the system is still crappy. When someone gets sick, they have to call to make sure that everything’s smoothed out. There’s still a lot of junk in the system that we don’t seem to be able to eliminate, whether it’s administrative waste, unnecessary care, low value, inefficiently delivered care. It frustrates you. So that frustrates me a lot.

On the other hand, a lot of positive things that you would think we should be investigating, we tend to go slowly. And that frustrates me, that we can’t seem to make progress on.... I don’t know whether they’re true or not. Probiotics is a good example. We now know that for treating C. diff, putting bacteria back is probably going to be good. Well, what about inflammatory bowel disease? What about a lot of these is ... you know, gluten sensitivity? We should be doing these trials, and we should be pushing them out very rapidly, but it’s taken, who knows, forever.

Howard Forman: Let me ask you one area that Harlan and I talked about early on in the podcast was whether there was going to be a prescription drug bill passed by Congress and is enormously strong bipartisan support. So if you wanted to think about something that should be easier to pass, even if it was just insulin copays, for instance, you would think it would be that. Is that possible? Or is that just pie in the sky to believe that could happen?

Ezekiel Emanuel: No, it should happen. And everything we know about Washington tells you it should happen. For one thing, 90-plus percent of the American public is supportive of drug price regulation, both sides. This is a bipartisan issue. This isn’t a polarization issue. When you have the support that high, now, no doubt when you get to specifics, it’ll go down, but it shouldn’t go down to 50%. And that’s the thing that gets passed. And the fact that we can’t pass it, A, speaks to the power and the savvy of the pharma lobby in producing opposition. And it also speaks to the fact that in a polarized country, one or two votes in the Senate can make all the difference. It’s right. I mean, Kyrsten Sinema is sitting there. No one can figure out why she is opposed, but she’s opposed. And I wish in this case a little campaign finance, grease would help, but it’s really, it’s very bizarre.

Harlan Krumholz: I think one... First of all, let’s want to say, thanks for joining us. And people may not know in that introduction, one of the things you are is like an amazing friend. And you and I have known each other for a long time, but I think everyone—

Ezekiel Emanuel: Well, thank you.

Harlan Krumholz: …who is the fortunate enough to be friends with you knows how deeply committed you are to your friends and how well you treat them.

Ezekiel Emanuel: Well, thank you. Thank you.

Harlan Krumholz: What I wanted to ask you was, so let’s get back to this trial thing, for example. So your interests are quite broad-based. They’re about how do we improve research and how do we improve healthcare itself, but this frustration is one that I’ve shared too. You and I have talked a lot about, for example, PCORI [Patient-Centered Outcomes Research Institute], the offshoot of the Affordable Care Act that was given $3 billion to try to produce evidence that would help guide healthcare.

What’s hard is to get people to actually follow new models. And what I advocated when I was on the board was, let’s do 200 rapid trials in the next two years, short-term trials with outcomes that people experience—insomnia, pain, indigestion, chest pain, a whole range of things with continuous outcomes that is on a scale, people can tell you, do they feel better or worse? And that right now they’re trying a million different strategies in order to improve. And we can just drive that forward. We can be a pipeline to produce high-quality evidence.

And there was just a resistance because the organization I would say was risk-averse. They wanted to make sure that they were going to be refunded. They tacked towards looking like ARC [Administrative Resource Center] and NIH. And then they adopted a lot of those same propensities about the way that they approach research. As a result, their output can’t be differentiated from what comes out from ARC or NIH, for example. And it’s not to say that there aren’t some good things that come out, but they don’t really have a distinctive way of doing things. They weren’t able to experiment. And this was a situation where a federal funding went to an independent group that didn’t need to get authorized every year by Congress. The notion was, this would enable it to take risks. And even in that situation, we were unable to really crack the case on this.

Now, meanwhile, fast-forward to today, PCORI continues to go. They did. They were successful in getting more money, and they now look like ARC and NIH. But now we’ve got ARPA, which is Joe Biden’s pet project to say, “I’m going to try to do science a different way,” only a billion dollars, by the way. Not, that’s not nothing, but it’s small potatoes with regard to really making a big impact, and it’s couched within NIH, and they say it’s going to report to the secretary. So it’s got a little bit of independence. What’s your view on whether this has any prospect of truly being a difference maker? And what should they have done with ARPA to really ensure that if they want to try something new, it can work

Ezekiel Emanuel: Well, first, having been a key architect of PCORI in the bill, and extremely frustrated by it. And as you know, I’ve written several critiques of it and critiques of the exact projects it has taken on and not taken on. And I concur totally with you that it has been more of a disappointment, and it just hasn’t done, to the extent that it’s done anything. It’s emphasized the patient-centered. It hasn’t emphasized actually solving or getting data. You might not solve, but getting data rapidly on things people do care about and that influences their lives on a day-to-day basis like pain and insomnia, as you point out.

I think everything at ARPA-H depends upon the culture. Remember, it’s not supposed to do research in the usual sense. It’s supposed to be more like a venture capital, making bets on projects or companies that’s supposed to develop novel, whether it’s diagnostics or therapies. And so the culture has to be very different from the NIH. The NIH is peer-reviewed. It’s become extremely risk-averse. Getting the first RO1 [Research Project Grant] is now over 44 years old. So you’re getting people already past their productive—

Harlan Krumholz: Creative moments. Yeah.

Ezekiel Emanuel: ...or innovative—I wouldn’t say “productive”—creative moments, all the data. And so everything will depend upon the culture there. And I think, Harlan, you put your finger on something exceedingly important, which is failure. So if you are in the venture world, which I’ve been, I would say, fortunate enough to be in for the last five years, I’ve learned a lot.

And one of the things you learn is, no one wants to fail, but you also have a high tolerance for failure. Otherwise, you’re not taking enough risk. And this combination of if you’re going to take risk, you have to be willing to fail. You like to back smart people who lower their chance of failure, but even smart people fail. And that’s not something that the government is very hospitable to.

Now, some of your readers may remember a senator from Wisconsin called William Proxmire who otherwise was a fantastic senator, liberal Democrat, very smart guy, very interested in government programs, but he created this Golden Fleece Award where he would make fun of some government program. And about half of them were right. They were real fleeces. But some of them were actually really important programs that had a funny name and he could make fun of them, but we actually needed them. And if they didn’t work, that was okay. And if they did work, they were going to actually be big.

And I think unless ARPA-H has the right culture of being willing to fail, taking bets, scanning the horizon, it’s not going to have an impact. And I fear that structure precisely because it’s in the NIH, which is not... I worked at the NIH for 13, 14 years. It’s not a risky place. I was on the far end of willing to take a lot of risks, but it’s not a place that is hospitable to that for a whole variety of reasons because of congressional oversight, among other things.

Harlan Krumholz: Many people will find that surprising. So you say our National Institutes of Health, which is supposed to be driving innovation in scientific medical research, is not taking a lot of risks on the research bets that they’re making?

Ezekiel Emanuel: Yes. I think actually quite the contrary. Everything we know suggests that they’ve become more conservative rather than more innovative. And I think COVID is an excellent example where it’s hard to say that, point to something the NIH has done that has been transformative of how we manage COVID patients, how we understand COVID patients. Almost all that innovation has come from other places. And things the NIH should have done, it never took the initiative on, whether it’s getting the epidemiology and the prevalence of long COVID or trying to identify the optimal schedule for vaccination. They did a study on mix and match [booster shots]—458 patients. You got to be kidding me. And they didn’t even do the right mix and match doses and other things. It just was nothing short of terrible malpractice.

Harlan Krumholz: One more quick thing on the story, I go back to what Howie said, so do you have hopes right now the director of the NIH position is open? Francis Collins has stepped down. Of course, he’s joined the White House to help for an interim role. But do you have thoughts about this next director of the NIH? And do you have hopes that person can help change this? Or it’s just the way the place works?

Ezekiel Emanuel: I think it is possible to change it, but that person would have to be innovative him- or herself and pretty innovative. So if I were taking that job—my free advice to the incoming NIH director is—I would take money, a substantial amount of money, but under a billion dollars. So in a $50 billion organization, we’re talking about 1%. And I initially would devote it to young researchers, where young researchers are immediately after PhD, after one postdoc, no longer than five years, and give them a million dollars a year for seven years. And each year have a cohort of one thousand of those people to do whatever they’re going to do and find the best thousand by nomination, by hook or by crook.

And that would, I think, dramatically shift the landscape. For one thing, it would change what medical schools hire and academic health centers hire because these people would come in with a $7 million purse. So they would be very valuable and you would give them a very long runway to try new and innovative things. And yet you wouldn’t dent the big behemoth that keeps going and doing its stuff. And I think that would be breathe new life into the institution.

Howard Forman: So speaking of free advice, you recently led a large group of individuals, including Harlan and me, on trying to come up with a COVID roadmap that would inform the government and really also the private sector on what the next steps are, what we need to do to be prepared for continued endemicity for future pandemics and other respiratory illnesses. How do you feel like that’s been received to date, considering that we’re still quibbling over trying to get a $10 billion bill passed? And what do you think the hopes are for government doing the right thing in a situation like this?

Ezekiel Emanuel: Well, first of all, to the extent that government was our main target, I think the reception has been remarkable prior to the release of our document. We spent many hours with senior government officials giving them briefings and advice on how to they should be thinking about things.

Second, we have had continued, after they released their strategic plan and we released our roadmap, we’ve had continued interaction with various government agencies, whether it’s about communication, indoor ventilation, long COVID shaping government policy extensively. So from the policy roadmap strategic plan aspect, it’s been very influential. And I think it’s also helped shape, if I might be so bold, how the public looks at it filtered through the media and the reporters who’ve been covering COVID.

Now, the separate issue that you ask about is the money issue. I think that’s bundled up with politics, unfortunately, and then the negative sense, that politicization of the money. But more importantly, I think it’s also bundled up... I think we’ve just learned something at this very moment, which is, how long can people dramatically change their lives before they scream uncle and have had enough of it. And I think we have our answer. It’s exactly two years.

I don’t think it’s just the United States that you’re seeing this. We’re getting back to normal. I don’t care what the risk is. We’re just going back to normal. You see this in Taiwan, where they’re having a increase, they’re going back to normal. You see this in Israel, in UK, in the Scandinavian countries. So I don’t think it’s America-specific. Two years is what you can ask people to do. That’s crazy, short of, you know, it’s a shooting war and you just can’t go back to normal.

I think that’s something we got to study, which is, why is that the kind of limit that we can ask people to contort themselves on something that’s, I think, still pretty serious? But whether we get enough money to do the things that we put in, I’m a little skeptical we will, unless Build Back Better passes. And this is somehow folded into that legislation.

Harlan Krumholz: One of the things that’s come out is this issue around long COVID. And we had a chapter on that in The Next Normal [Getting to and Sustaining the Next Normal: A Roadmap for Living with COVID]. The Biden administration announced yesterday a large-scale government-wide initiatives to address long COVID. It was a great move, but many of us think underfunded, and there’s still a ways to go on it. We should give kudos to the administration for embracing the idea that the government needs to do something about long COVID and actually pursuing some actions. But you were quoted as having some reservations about it also. What is it that you think they should have done?

Ezekiel Emanuel: Look, I agree with you, Harlan, and I think I said it’s a good step forward, and I probably should have said it’s a great step forward. And I do.... It is probably a testament to my impatience here. I think we’ve been looking at long COVID now for 20, 22 months. We’ve known that it exists. And I think we should have done a lot more research, and we need to do research urgently.

So my view is: What would make me—and I think that there are tens of millions of Americans like me—what would make me say, “All right, we can live with COVID and the coronavirus”? I know that if you’ve got updated vaccinations, three shots and soon to be four for some people, your chance of dying are exceedingly low, one in 30,000, something in that range.

But I have no idea what the risk of long COVID is. If it’s 10%—one in 10—that would be outrageous. How long it would last, what I can do reduce that risk, what treatments might be available…. We don’t have the answers to any of those questions. And I think this is a national emergency, and we really need to have much more intense focus on this and much more rapid development of not only understanding but actually therapeutic intervention.

Harlan Krumholz: Yeah. And I think one of the things, again, I think we were happy that they signaled the need to strengthen support for these individuals’ hotlines, being able to get compensation for disability, putting all that, pushing that forward. But it does get back to this question we were asking before, which is, why can’t research go faster? Why can’t we galvanize the efforts? This $1.2 billion the NIH got, the efforts were started last fall, and we’re still not even being able to see all the materials that are being generated. For the study they’re going to launch, it’s having trouble enrolling.... And again, it’s not just them. In this country, we got to crack this where we can figure out how to be more efficient and more agile with regard to knowledge generation. Getting back to PCORI, it was like, who’s going to do the experiments about how research could be done better, faster, cheaper? And one of my views is, if we can do it in partnership with patients, if we really galvanize their interest in enthusiasm, they’ve got the most at stake of anyone.

Ezekiel Emanuel: Yeah, I absolutely agree with you. This is a case where people are desperate. They’re absolutely desperate. Okay. Hang out the shingle. We want to learn what your situation is, and we’re going to give you the option to enroll in a therapeutic prop. Do we have any idea if statins work, if SSRI inhibitors work? Take things off the shelf. Might some of them work? Yes. Might many of them fail? Yes. But at least we’re trying something and learning from them. As it stands, we don’t know. There’s evidence on all of these things, some evidence, preliminary, but the world is better if we know that ivermectin doesn’t work or hydroxychloroquine doesn’t work. People will stop taking it. They’ll stop. Look, it would be better if we learn, you know what, this immune modulator, this anti-IL-6, that really works.

Howard Forman: So along those lines, though, I’ve always felt like the National Health Service of England, or the UK, and for that matter, Israel should have been performing vastly better than we are. Or for that matter, Kaiser Permanente in the United States or the VA system in the United States should have been performing vastly better in terms of extracting that type of information and answering questions for us.

And we are. We’re two years and one month into the pandemic. And we’re still seeing the bigger trials coming out on ivermectin. There’s still a lot of things we have not been able to answer definitively. We’ve not been able to do different types of trials of mixing different vaccinations or using, for instance, Paxlovid in the setting of people with previous infection or people with previous vaccination. What do we have to do if it’s not a National Health Service that’s going to be able to solve that quickly? What do you think the incentives have to be in our system or changes to our structure that will allow us to get answers quicker?

Ezekiel Emanuel: So, two things. First of all, you and I may disagree a little bit, but recovery in England, they’ve produced a lot of randomized trials pretty.... They’re the best place to have produced it. And the steroids showing that hydroxychloroquine didn’t work, blah, blah, blah. The Israelis also ... very good data. You may not agree with their idea of going to the fourth dose, et cetera, the fourth vaccine. I do think there is a problem on the scheduling of vaccinations that no one’s actually done the right studies. I find this mind-numbing, and now it’s probably impossible to do, given the level of vaccination.

I have an idea. Again, free advice to the next director of the NIH, which is, one of our problems is getting big academic centers and hospitals to agree on a common protocol and enroll. So my quintessential example is the convalescent plasma study. We were never able to do a randomized control trial. Everybody did their own schmutz, and then we had to amalgamate lots of stuff and then come to a conclusion rather than everyone, “All right, here’s the protocol. Everyone’s going to do the same protocol, and we’re all going to put it into a database.” And we can do it quickly because each one of the places started up if we just centralize it.

So we need more... One of the problems we suffer in our country, and I think you were hinting at this, Howie, is, at least an NHS in Britain or Israel, they have less fragmentation, and they have more coordination across different parts of the system. So how do we get more coordination in the enrollment in clinical trials? Well, the best way to get the attention, as far as I can see, of academic centers and medical schools is, we’re taking 5% of your indirect costs and we’re going to link it to your participation in these clinical trials and your enrollment, meaning enrollment based upon the number of patients you see in these clinical trials. And you don’t meet that? You don’t quickly get these up and running and stuff? We’re taking 5% away.

That gets the attention of a lot of people when serious money is at stake for them. And I think it’s going to have to be something like that. We’ve got one review of multi-center trials. You don’t have to review it. You get it up and running, you enroll the patients, and all the data’s going into a common database that everyone can look at. And you come and you propose ideas for a trial. If they’re accepted, you run the trial. If someone else’s, you didn’t win, you’ve got to put patients onto their trial. So you make it a collaborative effort and you make everyone have a stake in it.

Harlan Krumholz: No, I think that’s great. Hey, let me pivot to something else I’m curious to get your thoughts on. So when I saw you tweeting recently, it’s almost like every time you come out and say something, there are these people or bots or something that follow you around about the piece that you wrote years ago about your preference for the kind of care you would like to get when you hit 75 years old. And it’s almost crazy. I don’t think they understand what you wrote, and they’re mischaracterizing what you said. But it’s like, yeah, I don’t know, you’ve got this following. But maybe you could explain to people what you wrote. And then are you still getting flack for because actually I thought it was a very important piece and very thought-provoking. But go ahead. Maybe you can just explain what you did.

Ezekiel Emanuel: So first of all, I view part of my role in life is to be provocative and to make people think. That’s part of the reason I’m a professor and I love to teach is, and I tell my students at the start of every semester, I don’t want you doing any social media about that because I’m going to ask some really off-the-wall questions because I want you to think.

So the main thing when I look at a life—not at a moment, but over the arc—that I worry about is, either just repeating the same thing over and over again and not being, thinking creatively and just slowing down and becoming infirm, mentally as well as physically, and becoming a burden in that way and also dominating how people remember me.

When you look at the data about people, what you find is a very, very, very consistent peak of innovation and productivity as we were talking about in the late 30s, early 40s. And then a sort of, it’s not quite that people fall off a cliff, but it is somewhere between 70 and 75, almost everyone stops working, being productive. And if they continue to publish in things, it tends to be rehash of what went before.

So one of the things I thought about for that article is, what happens to us? We lose our friends, they’re dying, we’re dying. We lose our curiosity. We’ve seen it all. We get cynical, blah, blah, blah. And I think that there’s a whole series of things that set in at 70, 75, and the data confirm it if you just look at productivity, you look at how sharp faculty are. I think Yale Med School did a study about people after 70 not being as keen. And so I’m worried about that for myself, and I don’t want to live like that, and I don’t want my children and my grandchildren to remember me as a doddering old, blah blah.

So what did I say? Did I want to die at 75? No. I said I will not take medication or medical intervention where the purpose is to prolong my life. Now, if I were on a ski slope and someone ran into me, like it happened to actually a friend of ours, broke my hip, I would get that fixed. That’s not about prolonging my... that’s about getting rid of the pain and being mobile. So it’s a very fine and important distinction that was, if you don’t read the article, you miss it. And even if you do read the article but you’re not a good reader, you’ll miss it. That’s my principle.

Howard Forman: And by the way—

Ezekiel Emanuel: And people do still harass me about it.

Howard Forman: Yeah. And by the way, you read the article, you say many, many times 75 years is all I want to live, but the editor chose to title the article “Why I Hope to Die at 75,” which just goes to show that if you’re looking for clicks and attention, editors will do what they have to do. So you have to actually read the article to know what you wrote, because the title does not convey it.

Harlan Krumholz: So I’ve got one question here at the end. I just want to get some enlightenment since we have your attention. So one of the things that has always impressed me about you is your ability to tell people hard truths but in some ways to maintain your relationships over time so that, you know, there’s a lot of challenge in saying uncomfortable truths to people and many people can get offended and angry and upset. But you seem able to navigate a way to be able to say the truth and yet still remain connected to folks and to have relationships and not have that undermine the connection that you have with you. How are you able to do that?

Ezekiel Emanuel: You asked me this question a while ago, and I’ve been thinking about it, how I live. So I’m going to give you my best answer to that. So one of the things I reflected after you asked me, I don’t know, a couple of months ago you asked me this question. And so as you know, I have very strong opinions, and I’m not shy about saying my strong opinions.

On the other hand, it’s not my way or the highway. So I reflected upon my daughters. I would tell them things, you ought to do this. They would say, “Thanks, Dad. I’m doing the other.” And it never ruptured our relationship. I never insisted, “You got to do what I said.” It’s your life. I’ve been offering you free advice. And I know that my advice isn’t always good for people. I’ve been wrong about things. And I was that way with my father, who gave me plenty of advice, and he was wrong, and I did my thing. But I never make it “it’s my way or the highway.”

And I think that’s one of the things which, I will tell you what I think, I’ll tell it to your face. I won’t stab you in the back. You’re never like, “Is he going to...?” No, I’ll tell it right to your face. But I also don’t make it, your taking my advice as critical to our relationship. I’m happy if you do something different. I’m happy if you have a different view than me. And as a matter of fact, I enjoy that with people around me because I know my view. I’ve had a lot of time to test it out. I want to hear what you think. And if you have a better view, I change my mind all the time. If you have a better view, great. Let’s discuss it, and you tell me how I should change my view.

And so I do think that issue of.... I don’t feel threatened by you having it going off somewhere else. It doesn’t bother me. As a matter of fact, I like it when people... I think diversity’s an important thing, and a genuine diversity. And I’m not one of these, “It’s diversity as long as you agree with me.” I like that.

Now, there is something I don’t like, and it will end my relationship with someone. And one is, telling me something and doing the opposite and concealing it for me. And the other is just stabbing me in the back with a smile on your face. Yeah, just punch me in the chest. I can take that. Stab me in the back where I have to figure out what... it’s like, just be a man about it. Or I guess that’s no longer an acceptable phrase, but just tell me what you think and why you are doing this. I can take it. As I like to say to people, I have two brothers. There’s nothing anyone has ever said in my life that my brothers haven’t said to me and worse. Disagreeing is not the problem. Just tell me what you think.

Harlan Krumholz: Well, and I think it’s just that you say, “I’ll tell you what I think to your face. And you tell me what you say your face. You’re not going to be surprised I said something different to someone behind your back.” I think that makes a big difference.

Howard Forman: Harlan and I usually like to wrap up talking about what inspires us or keeps us up at night in non-healthcare news and between the war in Ukraine, the dysfunction in Congress, climate change, and Will Smith’s slap heard around the world. There’s a lot to choose from. But wondering if there is something that is either inspiring you or worrying you in particular right now that our listeners might not be focused on.

Ezekiel Emanuel: I think the moment is alternating between depressing and optimistic. So I’m in general an optimistic person. I do think the threat to democracy is—and again, this is not domestic, it’s worldwide—and so I think we need A, to think about it in a way that we haven’t that is larger than America, than the United States. And I do think that is a serious, serious problem.

Democracy is inherently defective, as we’ve seen in many, many places like Hungary just most recently where you can honestly elect someone who can then corrupt the system, corrupt the judiciary, corrupt the administrative agencies, corrupt the media. And I think it’s a fragile thing.

Now, why do we get infatuated with these autocrats, I think is also, and I think we’re at a moment where everyone is anxious about the future. Part of that anxiety is a sort of existential threat from climate change. I’m actually not a climate pessimist. I’m a climate optimist because I do think there’s a technological—we have all the technologies we need. Maybe we need a little more for carbon sequestration. It’s a deployment problem.

And that goes back to something we said at the start about the healthcare system, which is, it’s hard in the modern world to do things. And that I think is what has people really anxious and depressed. We’ve got solutions here between renewable energy, electric cars, fixing our farming system. We have most of the solutions right here, and yet we can’t seem to deploy them. And the sacrifice needed, we don’t seem to be willing to take on. And this keeps me up at night to figure out, why is this moment, 2020, different from say the 1950s when it seemed possible, “Yeah, want to create a highway system, I don’t know whether it’s a good or bad thing, but want to create.” We created a highway system. We created a space endeavor.

We don’t seem to be able to do that the same way. And I do think that actually is a serious source of the anxiety that people are feeling and feeling like we’re trapped. And that leads, I think to, well, these autocrats who are appeal the strong man, they’re going to change things. Now, Putin’s doing a good job of trying to undermine that image. But I do think the threat to democracy and this pervasive social anxiety is, it keeps me up at night, and I don’t know that I have a solution.

Howard Forman: Well, certainly, all of us are children of immigrants, and we are a nation of mostly immigrants. And it is ironic that the immigration issue ends up being such a divisive one given that central theme.

Ezekiel Emanuel: And also given how important they are—not “have been,” forget “to have been,” yes, “have been”—but are at this moment to creating new startups, creating jobs, revitalizing the... we have a labor shortage. There’s a solution to a labor shortage. When lots of people are knocking at your door to come in, we have a solution and these are very hardworking people. It’s crazy.

Howard Forman: Well, look, I just want to thank you, Zeke. You have, as Harlan said, Harlan’s known you for longer because you were in med school with Harlan, but I’ve been fortunate to know you for 20 years now. You have been an amazing friend. You’re a great person to work with. And in sincerity, you are an absolute leader. No, you’re a real leader. You actually lead by intention. And as our friend Vivek Murthy says, you lead with love, and you’re a smart guy and one of the smartest people.

Harlan Krumholz: Well, now, it’s getting really sentimental here.

Ezekiel Emanuel: Well, I would say, Howie, one of the great things I do have actually are friends like you and Harlan who are great, brilliant. And one of the things I’ve learned about leadership is, it’s that easy. Hire people who are fantastically smart, get out of the way, and when they have good ideas, champion them. But I’ve been department chair, I’ve run administrative programs and the—easy, easy, easy to do. And the best thing is, just hire really smart people. A, it’s fun and B, it becomes enormously successful.

Howard Forman: Thank you.

Harlan Krumholz: Great. Thanks so much. Really super.

Ezekiel Emanuel: Great. This has been a pleasure.

Harlan Krumholz: All right. Talk to you soon.

Ezekiel Emanuel: All right. Take care.

Harlan Krumholz: Howie, that was amazing. We really enjoyed talking with Zeke, but we’ve taken more time than usual. So let’s just go to the end and thank everyone for listening. 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 this on Twitter.

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

Howard Forman: And I’m @theHowie. That’s at 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 very much, Harlan. Talk to you soon.