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Aaron's back answering your submitted questions about things related to the COVID-19. If you'd like to submit a question for a future episode you can do so at healthcaretriage.info

00:22 MYTH: Vitamin D/vitamin C/Echinacea/essential oils can help
00:33 MYTH: Drinking TONS of water aids recovery because you pee more, which helps flush out the virus faster
00:44 Is steam cleaning an effective way to clean spaces we must share with my paramedic husband? Are products like dish soap, vinegar, rubbing alcohol, hydrogen peroxide effective?
1:36 When getting food take-out/delivery, what if the person preparing my food (especially non-cooked food like salads or breads) is sick?
2:56 If I have to go to the grocery store, what’s the safest way to go about it?
3:35 I have cerebral palsy and I don’t understand why the CDC says I’m at higher risk. Do you know why?
3:57 - I’m in an older age group (60+) but in excellent health, am I still at higher risk? What about people with conditions that are being managed, like BP well-controlled with medication?
4:34 - Can being well-rested have an impact on your risk of getting severely ill?
4:54 - Does smoking increase your risk of catching the virus or just how well you can fight it? Any evidence that it’s bad to smoke marijuana if you have covid symptoms?
5:32 - I’m taking walks outside and keeping my distance, but sometimes runners pass me - it’s quick but they’re breathing heavily less than 6 feet away - should I be concerned?
6:23 - When is someone with COVID-19 “sick enough to go to the ER”?
6:52 - “What if I do this or that event with my family/friends but we all promise to stay in our own bubbles, 6 feet apart, while we do it”
8:21 - Should I go somewhere like an urgent care if I have acute issues like UTI or sinus infection and don’t have a primary care doc to call?
8:43 - If you have no symptoms, is it safe/recommended to donate blood?
8:52 - Say I’ve got a cough and shortness of breath, but I also have asthma and allergies, and still feel good enough to exercise, can I go biking or walking outside?
9:17 - Is it possible that the spread of COVID-19 started happening before it gained prominence?
10:01 - Is there a difference between "incubation period" (how long symptoms take to show up) and when a test would be positive?
10:38 - Why does testing matter if treatment is the same for sick or nonsick?
11:54 - What is the timeline during which we can ramp up testing to make sure we can do the suppression you advocate?
12:38 - If I'm pretty sure I'm sick, but I'm self-isolating and managing mild symptoms, can I report that somewhere so it's included in the statistics?
12:54 - In a previous Q&A you said antibody tests would be low priority, why is that?
13:31 - Will I be informed if I have been exposed? How will that information be provided to me?
14:29 - In your first episode you said to prevent a catastrophic return of the virus in the fall we need to "keep this at bay." For the people in the back, what does that mean and how long do we need to do that for?
17:53 - Given your view on the virus returning in fall, can you discuss infectious disease expert Michael Osterholm’s opinion that Covid-19 won’t be affected by season changes based on past examples of SARS and MERS?
18:43 - Can UV light kill the virus?
19:12 - Isn’t fever part of the way your body fights infection? Shouldn’t we let the fever do its job rather than suppress it with medication like acetaminophen?
19:51 - What’s the deal with Azithromycin and hydroxychloriquine?
20:05 - Why can’t we use Tamiflu on high risk patients at the first signs of infection?
20:29 - Who can I call if I don’t have a primary care provider?
20:49 - Any advice for people close to the end of pregnancy?
21:17 - I live in NYC with my nine month old baby. Will months of isolation hurt his development?
21:40 - How am I supposed to know which experts to believe?

Related HCT episodes:
1. April 01, 2020 Q&A: https://youtu.be/s-UgauaPkLk
2. March 18, 2020 Q&A: https://youtu.be/YIrTMCPGFZs

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#healthcare #COVID #coronavirus

 (00:00) to (02:00)


We're still sheltering in place, and we're still answering your questions about Covid-19.  That's the topic of this weeks healthcare triage.
*intro music*
We start right off the bat by saying that while we appreciate your questions, we have to skip those that ask for direct medical advice. We just can't do that like this, you should talk to your own healthcare professional.  But let's go!
We're gonna start with more myths.  First of all, more than one person asked about whether vitamin D or vitamin C or echinacea or essential oils can help.  No.  There's no evidence for that at all.  Yeah, no.  Just gonna stop right there.
Drinking tons of water aids recovery because you pee more, which helps flush out the virus faster.  No.  No evidence for that at all.  In fact, no, no, you don't pee out this virus that's not how you beat it.
Some hygiene and risk questions; doing the best I can with a shortage of disinfectant- is steam cleaning an effective way to clean spaces we must share with my paramedic husband? Are products like dish soap, vinegar, rubbing alcohol, hydrogen peroxide effective?  You know, cleaning, cleaning with soap and water is going to do a fairly large amount.  Certantly disinfectant products will likely help.  I'm not sure about steam cleaning, I don't think that there's any proven to adding that on top.  If you're doing those other things, for the most part you should be fine.  But of course same rules we've always said; hand washing, hand washing, hand washing, don't touch your face, stay away from others who are sick as much as you can.  And I get the idea that in a house that's hard.  You know, stay away from others when you're sick, don't obviously cough into the air.  All of these things are helpful in the house.  If you are, you know, concerned further than that certainly wipe down surfaces, wash them as best you can.
When getting food take out/ delivery, what if the person preparing my food (especially non-cooked food like salads or breads) is sick?  I mean, always we are relying on those who prepare and serve our food to follow the correct rules; they should not be clearly going to work if they are sick, they should not be coughing on food- they should.  No.  No.  Don't go (make) food if you are sick.  Of course there's asymptomatic carriers, what can you do.

 (02:00) to (04:00)


Well, most food is being cooked, so unless they're literally breathing on it on it's way out the door you're, for the most part going to be fine.  Um, I wouldn't worry about the food.  Now, packaging, again, common sense stuff; if you bring it into the house usually what we do is if we are getting take out, we bring it in, we unpack everything, we put it on plates, we Wash Our Hands, after the unpacking, we wash our hands before we eat, we wash our hands after we eat.
With groceries, sometimes we'll bring them home, leave them for a while because stuff actually starts to degrade, remember the virus dosn't live forever outside of a human being.  Then same rules apply, wash our hands, put everything away, wash our hands again.  It's the best.
Some people are wiping down the stuff they bring into the house, that's an added step, I don't know that that's absolutely necessary if you're doing all these other things.  And again, the virus is not jumping off the packaging and into your mouth, it still has to get there by touching your face.  So, Wash Your Hands .  Wash your hands.  
Grocery stores don't seem like a safe place to be right now, but food delivery is taking over a week.  If I have to go to the store, what's the safest way to go about it?  
Ok, pick a time when other people won't be there, so as few people as possible, usually early in the morning or as late as you can.  Stay away from other people.  You know, wash your hands, wash your hands, wash your hands.  Some places are giving out disinfectant wipes or washing down the carts, but clearly you can do that also yourself. Wash your hands.  Don't touch your face.  Don't touch stuff then touch your face.  Keep touching to a limited amount.  Be careful not to touch yourself while you're there.  Stay away from other people, get home, get in the car. Wash your hands wash your hands wash your hands, follow all the other rules.  
I have cerebral palsy and I don't understand why the CDC says I'm at higher risk.  Do you know why?  
The CDC is basically trying to be careful and say that anyone with a chronic condition is higher risk.  We are not conducting studies at this time to see which chronic conditions place people at increased risk.  We're just going with broad blanket statements.  You know, protect yourself as much as possible and that's what we're doing. 

 (04:00) to (06:00)


[slide, continued] "- but in excellent health, am I still at higher risk? What about people with conditions that are being managed, like BP well-controlled with medication?"

These are excellent questions. We're not doing, again, studies to really differentiate which specific people are at higher risk or not. We can only do these broad-based things like age or chronic condition or immunocompromised; all of them look concerning, therefore, we're giving out these kinds of statements.

Bottom line is if in an ideal world, we would all be protecting ourselves to the maximal amount: social distancing, proper hand washing, hygiene techniques - do the best to keep yourself safe. Everybody.

[slide] "Can being well-rested have an impact on your risk of getting severely ill? 

Maybe? I would, again, these are the kinds of things like, always, you should try to be well-rested, not even at the time of this. Does it provide an added benefit if you're otherwise gonna expose yourself? There's probably no evidence for that, but no reason not to not be well-rested. Do the best you can.

[slide] "Does smoking increase your risk of catching the virus or just how well you can fight it? Any evidence that it’s bad to smoke marijuana if you have covid symptoms?"

There's a link between smoking and sort of worse outcomes if you do get sick; that's a broad-based link, we're not doing randomized controlled trials, we're not checking to see how much smoking or at what levels or what you're smoking. The bottom line is that chronic smoking - certainly chronic, but I'm not even trouble to keep what smoking - does some lung damage, it's associated with bad outcomes and respiratory viruses in general. This would be no different. So, just protect yourself. Again, everybody seems to be sort of-, just protect yourself as best you can.

[slide] "I’m taking walks outside and keeping my distance, but sometimes runners pass me - it’s quick but they’re breathing heavily less than 6 feet away - should I be concerned?"

I take a walk every morning, I see people run, usually I try to cross the street. Why? Just be careful. Like, I read an article where somebody likened it to somebody smoking a cigarette; if you see someone smoking, you try to avoid them, you don't want to walk through their smoke cloud. You can sort of think of this the same way.

Does that mean you're going to get infected 100%?

 (06:00) to (08:00)


Absolutely not. It's still reasonably minimal risk, especially as I think more and more runners are probably gonna start wearing masks. Again, we're all getting concerned about breathing this out, this becomes less of a risk, but still stay away six feet as much as you can. And so, if you see someone coming at you and they're running, get out of the way if you can, or the runner should get out of the way - that would be polite, too. But you know, we're all trying to keep distance from each other, let's all do the best we can.

[slide] "When is someone with COVID-19 'sick enough to go to the ER?'" 

If you have any concerns at all about the-, first of all, if you have ever concerns that you are in serious risk, you call 9-1-1. If you have concerns about whether you should go see a doctor, you should call your doctor. But certainly if you can't breathe and you think you're an emergency, don't waste time in phone, call 9-1-1. But that should be for an emergency. Otherwise, call and ask. We don't just want people showing up at that emergency room without having called and ask first unless they're an emergency.

These are some "can" or "should I" questions. So many questions along the lines of -

[slide] “What if I do this or that event with my family/friends but we all promise to stay in our own bubbles, 6 feet apart, while we do it?” 

These are so hard to answer because this is all about harm reduction, it's about reducing risk as much as possible. So, while we're in the early stages of this, and no one almost has been sheltering in place for two weeks, we should be staying away as much as humanly possible. As time goes on, if people have truly engaged in social distancing to the point like, I literally other than to take a walk don't think I've left the house in the last week and a half at least. If after a couple weeks of that and my family doing much the same thing, we can be reasonably assured that no one in the house has it. If another family was doing the exact same thing, they can be reasonably sure no one in the family has it. At that point, there's an argument to be made we probably could engage in safe socializing if we stuck by those strict rules.

The problem is not everyone is following those rules. They're like, "I'm still going to the supermarket and hanging out with people, I'm still going to the office, I'm still doing this, but you know, I'm being safe." That's not really social distancing.

 (08:00) to (10:00)


- not really social distancing. Then, if you're still expanding your circle to other families, then you're really not social distancing. So, in specific instances, there's arguments to be made that this would be okay, but I have yet to be approached by anyone who's truly doing it and truly engaging in social distancing to where I would say "go ahead and do it" yet.

Many people are concerned about whether they can or -

[slide] "Should I go somewhere like an urgent care if I have acute issues like UTI or sinus infection and don’t have a primary care doc to call?"

The best thing you can do still is call someone first even if you're calling an urgent care center, because you just want to keep this to a minimum. But of course, if you have no other outlet and have to go seek care, I would certainly not tell you not to go seek care.

[slide] "If you have no symptoms, is it safe/recommended to donate blood?"

Call your blood bank, but I believe the answer is yes. But definitely call your blood bank.

[slide] "Say I’ve got a cough and shortness of breath, but I also have asthma and allergies, and still feel good enough to exercise - If I maintain a 6 foot buffer, cough into my elbow, wash my hands regularly, can I go biking or walking outside?"

If you're talking about for exercise purposes and you're sick and coughing, do not go outside. That's literally like now you're saying, "I'm still, that's more important to me even if I'm putting other people at risk." As much as you possibly can NOT do that, do not do that.

Testing or tracing. [slide] "I work at a university with a high international student population and in mid-January, I experienced sudden fever, shivers, dizziness, sore throat, headache, loss of taste and dry heaving. I tested negative for flu and strep and it makes me wonder if I had COVID. Is it possible that the spread of COVID-19 started happening before it gained prominence?" 

Yes. Possible. Widespread likely? No. But if you literally can be like, "I might've had a contact with someone in Wuhan who left there in December and I was near them in January, it's possible. Unfortunately, until we do serologic testing - where we're testing for antibodies to know who has been infected and who has recovered - we won't know. At some point in the future, you probably can get that test, and then you'll have a better sense. So, we don't know yet; don't necessarily believe you did.

 (10:00) to (12:00)


- don't necessarily believe you did.

[slide] "Is there a difference between 'incubation period' (how long symptoms take to show up) and when a test would be positive?"

Yes! It is likely that a test would be positive before symptoms would show up in some people, I'd say that's probably most people. The incubation period is really along the lines of how much people might be around and actually infecting other people before they know that they are sick. But there are also false negatives, false positives and tests, and sometimes people have to be tested more than once to show up that they actually have the virus and are infected. So, none of these things are perfect.

[slide] "Why does testing matter if treatment is the same for sick or non-sick?"

So, there are variety of reasons why people need a test. One, healthcare workers need a test to know whether they really need to be pulled off the front line or not, because if they're infectious, we don't want them seeing tons of people. We need to know in hospitals for actually quarantine's sake, for knowing whether they need to be in isolation, who can care for them or not.

For people at home, it can be useful, especially if we were engaging in contact tracing and isolation, which we absolutely need to do in the future in order to prevent this from getting so bad again, that we have to do this kind of massive social distancing. So, being able to test everyone who's symptomatic in the future would be important. And also, at some point, we're gonna want to test people who are asymptomatic to get background surveillance rates. So, there are lots of reasons.

Now, we're rationing them at the moment, so that's why we're trying to keep them for the people that truly need it, which is mostly you're going to be hospitalized or you work in a healthcare setting with movement into the outpatient setting when more and more tests become available. But that's the rationale. So, technically, if you're at home and really not that sick, it's more about rationing them than the sense that we don't want to test you. We just don't have enough tests yet.

[slide] "What is the timeline during which we can ramp up testing to make sure we can do the suppression you advocate?

 (12:00) to (14:00)


Like, now! As fast as possible. Like, do it! [sighs] I've written more than one article on this, and I'm sure by the time this airs I might have written another. But the only way we get out of this is if we can do massive widespread testing of anyone who potentially could have the virus. A recent report estimated that once we've suppressed this, to know we can do that moving forward when the disease is not that common. So, this is a future where we've really suppressed it. We'd still need capacity for at least 750,000 tests a week in the country. Lots of other people say we're gonna need more, that's a massive amount of very quick testing. We do not have that yet, we absolutely need it. We gotta keep moving forward.

[slide] "If I'm pretty sure I'm sick, but I'm self-isolating and managing mild symptoms, can I report that somewhere so it's included in the statistics?"

You absolutely can call your doctor and discuss with them. Depending on the state of testing in your area, they might even test you. So, absolutely let a healthcare provider know.

[slide] "In a previous Q&A you said antibody tests would be low priority, why is that?"

Well, low priority right this second, but we need them. The world's on fire right now metaphorically. We're worried about overwhelming the healthcare system, so the number one priority - by far - is flatten the curve. We don't need antibody testing for that.

We do need antibody testing, however, for coming out of this and for future looks at who has been infected or not - that, we do. So, it's all relative how much we need it. I'm focused right now on the stuff that's right in front of me, but others should be working on the stuff down the line and that includes antibody tests.

[slide] "Will I be informed if I have been exposed? How will that information be provided to me?"

In an ideal future that protects us, yes. If what we need, again, massive contact tracing and isolation. If we're gonna set-, that's how Singapore's doing it, and South Korea's doing it, and China-, that's what these other countries do. We're gonna need that in the future. Right now, we're not doing that because at this point we're just assuming it's an outbreak and it's so common it's not worth doing that kind of contact -


 (14:00) to (16:00)


-doing that kind of contact - we can't even do it, it's too many people. 

So, we're suppressing, we're mitigating, we're telling everyone to shelter in place - most places - and waiting for this to burn itself out inside houses and without much exposure, it will be much reduced. But at some point in the future, we do need that kind of infrastructure to do contact tracing. And then you would be informed hopefully by some kind of public health official if someone you'd come into contact with had been found to be infected. At which point, you'd be told you need to quarantine and isolate and hopefully get tested as well.

Next set of questions is on the virus. [slide] "In your first episode you said to prevent a catastrophic return of the virus in the fall we need to 'keep this at bay.' For the people in the back, what does that mean and how long do we need to do that for?"

Okay. So, again - ideal world - we have suppressed, we have far fewer cases than we have. So, if I'm going off the rules of the recent report by Gottlieb et al. that was published by the American Enterprise Institute, that means we want to see at least 14 straight days in an area of reduced infections, and we need them down to a manageable amount that we believe we could track every single one down that's occurring.

Two, we need massive testing so that we can do that, so that we can test every person who's symptomatic, and immediately start tracking down all their contacts and everything else.

Three, we need an infrastructure in place to believe that we could do the contact tracing and isolation. That if someone is found to be infected, that we know we can then find all the people that they were exposed to, we can track them down, tell them to isolate and be safe or quarantine, and then start testing them, and if any of them are positive, do the same thing again. That's a massive infrastructure, and we have to believe that our healthcare system has calmed down to the point where we're no longer worried that it's possibly going to get overwhelmed. 

So, all of those things at a minimum have to happen for us to go back to normal society. We also need to be able at some point to do-, it'd be nice to do serologic testing to know who's immune, and also do surveillance - meaning we're even gonna test -

 (16:00) to (18:00)


- surveillance - meaning we're even gonna test asymptomatic people to make sure that it's not in the community and we're missing it, but eventually, that would be picked up by people becoming symptomatic. So, all of that.

Even with that in place, things may get out of control. Like Singapore, there was an article in the news today that in Singapore a woman sort of quasi-violated quarantine and has actually caused an outbreak that's caused them to re-shutdown the schools. They've been doing a great job, but now, they're concerned things are starting to get out of control, so before we even talk about going up the curve, they're like, "Shut it all down for a month, and we'll see if in a month things look better and we'll reopen everything else."

That may be our fault. Though that's not a nationwide edict; we can manage this in localities, or by state, or by a number of ways to say, "Okay, this area's flaring; you shut down the schools, and you go shelter in place and get the virus under control." Across the country, that might not be an issue. So, we're going to have to be nimble across that. But that possible flaring may occur - and will occur - until we have herd immunity, which will occur in one of two ways:

We will have all been doing this long enough that eventually enough people will have become infected and immune that we will have achieved herd immunity, which is the LESS preferable outcome, because that will mean a lot of people got sick, and a lot of people got hospitalized, and unfortunately a lot of people died. Or we develop a vaccine, in which case we can achieve herd immunity without having to infect a lot of people, and then we can approach a more normal semblance of life.

However, "normal" is going to be relative. We may change a lot of the ways we do things in the future because of this pandemic to make sure this doesn't happen again. So, I don't know. But again, to keep this at bay, which is what I said before, we need to have significant infrastructure in place to monitor and prevent outbreaks from occurring.

[slide] "Given your view on the virus returning in fall, can you discuss infectious disease expert Michael Osterholm’s opinion that Covid-19 -

 (18:00) to (20:00)


"- COVID-19 won’t be affected by season changes based on past examples of SARS and MERS?"

I don't know if it might go down in the summer because we will have just come out of this huge social distancing thing or whether it will be like other seasonal viruses and just naturally seem to go down. And so, we don't know. But I think it is very likely that come at least the beginning of the summer - if we've really engaged in two months of this - it will be less than it was, and there will maybe be areas in the country where we could start setting up infrastructure to keep this at bay. 

But no one should be under the false assumption that, "Oh, it's summer; let's just do whatever we want - we'll deal with this in the fall." There will always be a risk of infection and spread; it just might be slightly less.

[slide] "Can UV light kill the virus?"

So, ultraviolet light can kill it on objects, but of course, you can't kill it in people by UV light - that's not the way it works. So, yeah. I guess if you put objects under ultraviolet light or leave them out in the sun for a while, it's more likely to kill the virus, but the virus doesn't live outside of human beings forever. And so it is a way to kill it outside of it, but also just leaving stuff alone for a significant period of time will bring the virus' numbers down as well.

Treatments and vaccines. [slide] "Isn’t fever part of the way your body fights infection? Shouldn’t we let the fever do its job rather than suppress it with medication like acetaminophen?"

So, these kinds of studies get done all the time where people take fever aids and then see if they're sicker longer, and usually the amounts of differences are minimal. And so, we treat fevers because it's not as if this is what prevents it. Also, high fevers can be really debilitating, and you gotta question is being sick a tiny bit of extra - even if it's statistically insignificant amount - worse than really being with a high fever and being utterly miserable and incapacitated or even in trouble. So, most people treat fevers.

[slide] "What’s the deal with Azithromycin and hydroxychloroquine?"

We're doing studies; we do not know. We're doing studies, and until those studies -

 (20:00) to (22:00)


- and until those studies are done, these are not the kinds of things that people should probably be doing willy-nilly. Certainly talk to your healthcare provider.

[slide] "Why can’t we use Tamiflu on high risk patients at the first signs of infection?"

Because everything has side effects and problems, and we don't just throw drugs at people, and Tamiflu is only for influenza, and it's just not how we do treatments, because then again, you're getting all the potential harms including side effects, but potentially no benefits that we know of, and that's not how we treat things or do science and hopefully help.

General advice and/or your thoughts. [slide] "Who can I call if I don’t have a primary care provider?"

I would say call an urgent care center if they exist, and do that. The second thing is to try - I know, as hard as this is, and I'm sorry, but this is a good example - we need primary care providers, we need doctors, so as much as you can, try to get one.

[slide] "Any advice for people close to the end of pregnancy? I'm worried about giving birth in an overburdened hospital..."

You and everyone else, believe me. So, I would check in with your hospital, there's guidance that's shifting over time about still making sure that someone can be in there besides you, they're keeping the number of people a room to a minimum, they're doing absolutely their best to deliver, but we're not turning people away from the hospital if they have to give birth. Hospitals know about this, OB-GYNs are preparing for this, stay in touch with yours and talk to them.

[slide] "I live in NYC with my nine month old baby. Will months of isolation hurt his development?"

Not long term. Still interact. You're still the most important thing for your baby. Talk to your baby, sing to your baby, interact, play with your baby, love your baby, hold your baby - do whatever you would otherwise normally do, do with your baby. Give that baby plenty of attention.

[slide] "As a layperson, how am I supposed to know which experts to believe? I ask because legitimate experts like John Ioannidis are saying that social distancing and shutting down our society are extreme overreactions, and that the fatality rate might be low as 0.3%."

Okay. First of all, even if the fatality is point-three percent, if 40-70% or more -

 (22:00) to (24:00)


- 70% or more of the population got sick from this to achieve herd immunity, that's a LOT of people getting sick, and point-three percent is a LOT of people dying. That's a really bad thing. REALLY bad. And probably would have a MASSIVE, massive impact on our economy. In fact, there have been some studies that I've just seen recently that look economic impacts from the Spanish flu, and they found that the places that just let it burn actually wound up doing even worse economically than the places who took an economic hit. Clearly things have changed in a hundred years, but it is not clear that letting it burn would have less of an economic impact than what we've got right now.

The second thing is that John wanted us, you know, serves a purpose, and his purpose is he sticks to evidence, and he's constantly beating that drum, that is his drum. And he's not incorrect that we don't have a ton of evidence that we are absolutely, positively, 100% doing the right thing - we don't know a lot of the variables that are in here. And if those variables change - like infectivity, fatality rate, the number of asymptomatic carrier - all of those could change the outcome. 

The problem is that the worst-case scenario is SO bad that we're avoid it. The worst-case scenario being that this burns through - again, let's say 70% of the US population and 2 million+ people die in a month, that 55,000 people die in a day in June - that just seem TOO BAD to take a chance. And so, most people and most experts, I should say, are advocating that we should take the more conservative approach in this case, because that's what makes sense.

John Ioannidis is consistent in that he's saying that we don't necessarily have evidence for that, and we should question it and think about the alternatives, and I don't think that's 100% wrong, but I would differ from him in this respect in that I think the bad outcome is so bad, and that there's -

 (24:00) to (24:57)


- so bad, and that there's enough evidence to argue that the measure we're taking seem to be having an effect in other countries that this is the course of action that we should take.

[credit slide, outro music]

Hey, we really appreciate you sticking with us through this pandemic, and if you like this episode, it really helps if you like and subscribe down below and share it. We want as many people to have access to these kinds of answers as possible. You can also go click on this link [points] and watch other videos that we have made answering questions. And in this time, if you can - if you can - it helps if you go to patreon.com/healthcaretriage, support the show in any way possible. We're doing our best keeping this thing going in a pandemic, but it's harder than it used to be, and it's always been work, so anything you can do to help support the show, really, we appreciate it.

We'd especially like to think our research associate, Joe Sevits, and of course, our Surgeon Admiral, Sam.

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