Lex Fridman PodcastMichael Mina: Rapid COVID Testing | Lex Fridman Podcast #235
EVERY SPOKEN WORD
150 min read · 30,010 words- 0:00 – 1:22
Introduction
- LFLex Fridman
The following is a conversation with Michael Mina, his second time on the podcast. He's a professor at Harvard doing research on infectious disease and immunology. In my view, the most powerful, doable, and obvious solution to COVID-19 from the very beginning is rapid at-home testing. This is what Michael has been talking about and writing about since the beginning of the pandemic. The accuracy of these tests is high for the task of detecting contagiousness, which is what matters. Hundreds of millions can be manufactured quickly and relatively cheaply, privacy and individual freedoms are preserved. I believe that if you give people the power of information, information about whether they are contagious or not, they will do the right thing, at scale, all while respecting their freedom and minimizing the destructive effects of the pandemic on our health and our economy. This solution was obvious in May of 2020. It was obvious when Michael and I spoke the first time a year ago, and it is obvious today. We talk about why it has not yet been done and how we can still do it. This is the Lex Fridman Podcast. To support it, please check out our sponsors in the description. And now, here's my conversation with Michael Mina.
- 1:22 – 11:25
At-home COVID-19 tests
- LFLex Fridman
We spoke a year ago about rapid at-home testing, and I think, you think, it should have been, still should be a big part of the solution to COVID. So let's recap. Where do things stand today in terms of rapid at-home testing?
- MMMichael Mina
Well, (laughs) it's, uh, it's certainly something that, uh, you're right. I do think we should have them today. We've now had almost 20 months of living in anxiety, uncertainty, uh, being afraid for our health, for our family's health, for our friends', you know, shutdowns, economic instability. Everything has been uncertain because of this virus. And then there's this little test, and it's the first time for many people that they are, they're using it and they're feeling empowered. They're feeling like they can control their little slice of this pandemic. So as these tests have come out and more and more and more Americans have had an opportunity to go and buy them from, you know, CVS or Walgreens or wherever they're at, I think that it's really shifting the tenor of the discussion. For a long time, all of 2020, it was like, I often felt like it was me and a few other people against the world, you know?
- LFLex Fridman
Mm-hmm.
- MMMichael Mina
These tests should be public health tools. These tests are infectiousness indicators. They shouldn't be compared to PCR. You know, all of the, these different things, and we could of course go through and recap (laughs) what those, what the benefits and the, and the, and the metrics are that we should be looking at. But the point is, last year and most of this year was about educating scientists, educating public health leaders, educating physicians to get them to understand that there is a different reason to test in a pandemic than purely diagnostics, and transmission blockade and severing transmission chain is the big one. So now I think we're at a point where people are now understanding. And they're understanding because they are feeling it, they're holding it, and they're doing it and they're seeing, they're feeling the delight of seeing a negative and saying, "I feel more comfortable. It's not perfect, but it's pretty darn close to perfect to allowing me to go and see my mom without mistakenly infecting her." You know, or whatever the story might be. And now that that's happening, I think all of a sudden we're seeing a massive change, uh, politically for these tests. Uh, Biden just came out with the COVID-19 action plan the other day, and one of the main pillars of it was testing, and in particular bringing rapid tests, uh, scaling them up. So on that front, I think finally there is success. People are actually understanding. And, you know, I haven't stopped beating this drum for far too long, and I, like, hate rapid tests now. (laughs)
- LFLex Fridman
(laughs) So maybe it's good to step back. Uh, would you say most Americans have not taken a rapid at-home test?
- MMMichael Mina
Absolutely. Most have definitely not taken a rapid test.
- LFLex Fridman
Yeah. So, like, many of them probably don't know. They kind of probably say testing, they have, like, memories of testing, like PCR testing, they have to go into somewhere and they have to, like a, a swab deep in their nose, and that's the experience. Or maybe when, if you have to travel, like Canada or something like that, you have to get tested, that kind of stuff.
- MMMichael Mina
Mm-hmm.
- LFLex Fridman
So what are rapid at-home tests?
- MMMichael Mina
Yeah, so, so the rapid at-home tests are, uh, I like to call them paper strip tests, simple. They're simple tests that, I wish I brought some today, but I didn't. Um, they're simple tests that, uh, you swab. Uh, at the moment most of them use a swab that you just swab the front of your nose. So it's not one of the deep, the deep swabs that, you know, goes into your brain.
- LFLex Fridman
(laughs)
- MMMichael Mina
And, uh, and so it's not very uncomfortable. It's just like picking your nose, if you will, you know, and, and you, you put that swab in-
- LFLex Fridman
I've never done it.
- MMMichael Mina
(laughs) Yeah. You put that swab into, uh, a little tube, and the tube has some liquid in it, and then you, um, pour, put a few drops of that liquid onto a paper strip or you drop the paper strip into the tube just like, uh, a, one of those, um, indicators for the pool. And if you, just like a pregnancy test then, if you get two lines you're positive, one line you're negative. It's super simple. It takes 30 seconds once you know how to do it of hands-on time, and you wait around 10 minutes, and then you read the result. They are extraordinarily effective to answer one question: Am I infectious?And that is the public health question that we need to answer and consistently ask during this pandemic: Are you infectious? Am I infectious? Because it's only when we know that we're infectious that we can be empowered to not mistakenly infect others. Um, the PCR test is a little different, and we can go into the pros and cons, but, uh, you know, one of the, the major differences is that a PCR test gets a lot of... A lot of people talking about the PCR test say it's much more sensitive.
- LFLex Fridman
Mm-hmm.
- MMMichael Mina
And at an analytical level, it is. It can detect one molecule instead of 100,000. But for public health, we don't want a test that can detect one molecule. In fact, that has created a net negative for public health. We just want to know, am I infectious? And to know that question, to know if I'm infectious, I only need a test that is going to be positive if I have a high viral load, like a million. And when you're... And the virus grows so fast, it will go from zero to a billion in a, in a day. So you don't really need, even on the front end of an infection, you don't need better sensitivity, uh, if the trade-off is that you don't get the results for one, two, or three days. You absolutely want a rapid result that can tell you, "Yes, you're infectious. You're transmitting to others right now, and I'm going to give you the result right now." So it is a much more effective tool because it's fast, because it's accessible. We can use them in the home, uh, and there's some issues with using them at home. We can talk a little bit about what those issues are, like reporting and how do you... Is everything on the honor system if you have a test that you're taking at home and you use it to go to work? But they can be ac- they can be accessible. PCR has to go into a lab. It takes a lot of time for somebody to get a PCR test. They either have to go online and order it. It takes the next day for it to come back.
- LFLex Fridman
Mm-hmm.
- MMMichael Mina
They swab themself, they ship it off the next day, and then they get a result two days later. That's four days minimum for the most part and, you know, yet that point, you're not even infectious even if you did happen to be infectious when you first ordered the test.
- LFLex Fridman
Right.
- MMMichael Mina
So it's really of the speed of these tests and the accessibility and distribution of them that makes them so immensely powerful.
- LFLex Fridman
So this, like, amazing graphic you tweeted, it's exactly what you're saying, which is a rapid antigen test answers the question, am I currently infectious? And you have, I think, a comparison of three diff- oh, sorry, seven different tests based on the viral load, and based on the viral load across these different tests, you look at the likelihood of infectiousness. So what does this graphic show? We can overlay that for people. It's just, I, I think it's just really nice and really clear.
- MMMichael Mina
Yeah, so what that's showing is that we can never ask what's the sensitivity of a test and just let, let that be the answer. That's what the FDA does currently.
- LFLex Fridman
Mm-hmm.
- MMMichael Mina
And that question doesn't mean anything. We have to say, "What is the sensitivity of the test to detect what?"
- LFLex Fridman
Right.
- MMMichael Mina
And so we can have different viral loads. For example, we can have, you can have a viral load of one or you can have a viral load of a trillion, and, uh, a PCR test will tell, tell you that you are positive regardless of whether it's one or a trillion. Now, so we can't ask the question, how sensitive is a rapid test compared to PCR? Because that covers the whole gamut. What we really want to say is, how sensitive is the rapid test to detect me if I am infectious?
- LFLex Fridman
Mm-hmm.
- MMMichael Mina
And that gets to about 97% or so sensitive. If the question is, how likely is it to detect me if I'm a super-spreader? That's a really important one to be able to detect. They're all about 100% sensitive. So if you have extraordinarily high viral loads to the point where you might be a super-spreader, these simple rapid tests will essentially always catch you and tell you you're positive. And then as you go down the line, if you're no longer infectious at all, then these rapid tests might have a 0% sensitivity compared to PCR, but that's actually a good thing. The FDA and others look at it as though it's a bad thing 'cause they average it all together and say, "Oh, this is only a 40% sensitive test compared to PCR." But that's not the right way to look at it. You want to say, "Well, out of all of the samples, how many of them were not transmissible? How many were mid, moderate, high, extremely high, super-spreader?" And you should, at the very least, create a weighted average based on transmissibility potential. We don't do that, you know, and that's why nobody in America has these tests because, or that's why they're very rare, 'cause we have slowed down their authorization because of that misunderstanding that they don't have to be 80 or 90% sensitive compared to any time PCR positivity. They need to be 80 or 90% or more if you're infectious. And for that question, they're like 95, up to 100% sensitive when you're most infectious.
- LFLex Fridman
So when you have a lot of virion particles in you, so it would mean, that's what it means when, when you say viral load, that means you're going to be very infectious. The more you have, the more infectious you are, and this test is basically very good at detecting when you're very infectious.
- 11:25 – 17:44
Medical devices and FDA classification
- LFLex Fridman
Why don't we have, uh, rapid at-home tests? So you said there's a bit of confusion. FDA is involved. You've talked about, you continue to talk about that, uh, th- these at-home tests are classified as, I guess, medical devices.
- MMMichael Mina
That's right.
- LFLex Fridman
And so because of that, FDA is looking at them differently than, uh, they probably should be looked at. So what, what's the problem here? Can you, can you sort of explain? What does it mean to be a medical device? Why is that an issue? Where is the FDA messing up?
- MMMichael Mina
When we declare something as a medical device and we evaluate it as a medical device, then it makes sense that the comparison, if you're trying to get a new one onto the market, that the comparison would be against a gold standard medical device for that purpose. So PCR is currently the gold standard, or at least i- in the, in the eyes of the FDA, the PCR test is the gold standard, uh, medical device. And as a physician, that's because it's so sensitive. As a physician, I have one patient in front of me at a time, and that patient comes to me and I don't have to care about the 99.9999% of people in the world who are not in front of me. I only care about that one patient. And so when I get a sample from that patient and that patient's saying, "Doc, you know, I don't feel well. I, I haven't been feeling well for the last few weeks. Do you think this is COVID?" Well, for that question, I want to have the absolute best sensitivity test regardless of what it means for transmissibility because my patient isn't sitting in my office saying, "Doc, do you think I'm infectious?" They're saying, "Doc, do you think I have recently been or am infected?" And these are totally different things. One is medicine, and if the patient's infected, you know, I, I, the time isn't of the essence 'cause they're sitting there in my office. I can say, "Look, I'm sorry you're not feeling well. Let's get a PCR test on you. We'll be able to tell you if you have any evidence that there has been recently an infection inside of you."
- LFLex Fridman
Mm-hmm.
- MMMichael Mina
"And you'll get the results in a couple of days. And it might be expensive, and so insurance is going to pay for it. And you're just one person, and so I don't really care how many resources it takes to get you this answer." On the other hand, there's rapid an- there's public health testing, and public health testing is, it has to account for all of the people you're not seeing as well as the person you're testing at the moment. So accessibility becomes a central theme. Frequency of tests, it has to account for all the days that you're not sitting there in front of your doctor's office getting a test as well as the one you are. So, it has to say how frequently. What if you're infected tomorrow but you were at the doctor's office today getting a negative COVID test? That PCR test done at the doctor's office today is going to do nothing to let you know that you get exposed and infected tomorrow. The only way to know that is to be testing yourself frequently. So, and the reason it matters is that these tests can be accessible if we are okay with saying the real purpose of a, of a public health test is to answer the question, "Am I infectious?" The reason we want to answer that is if you're infectious, that's when you isolate. We actually don't want to isolate positive PCR, PCR positive individuals who are no longer infectious. That's bad public health practice. Like, if I haven't been infectious for three weeks, I don't want to have somebody tell me that I need to go and isolate for 10 days just because I happened to use a PCR test-
- LFLex Fridman
Mm-hmm.
- MMMichael Mina
... today, three weeks after I was infectious. And furthermore, I definitely don't want the public health agency to come and, you know, round up all the people I was with last night and say, "You guys have to quarantine for 14 days-"
- LFLex Fridman
Right.
- MMMichael Mina
"... because you were with Michael who wasn't infectious yesterday." It's nonsensical to do that.
- LFLex Fridman
And it's a huge disincentive to actually get tested voluntarily.
- MMMichael Mina
That's exactly right, huge disincentive to get tested. People, you know, if it's too sensitive, especially with flights, things like that, like, we shouldn't be stopping people from taking a flight if they haven't been infectious for 60 days. And, and to be clear, people are only infectious for, I don't know, somewhere between three and seven days, but can be positive on a PCR test for 30 to 70 days. So I mean, it's, it's potentially a tenfold difference in terms of how long you're PCR positive versus how long you're infectious. So we don't want to be taking people during those 30 to 70 days and saying, "You need to isolate just because you go and get a swab," or, "You can't go on your trip just because you had COVID last month." That's not good use of a test. So the reason we don't have these tools right now is because when we evaluate a ant- a rapid test as a medical device, the FDA says, "Well, this has to achieve the properties that we expect from a medical device," which again, doesn't have to take time into account, doesn't really have to take cost or resources or scalability or access into account. It only takes sensitivity and specificity to catch molecules. And so just by definition, I mean, it is a mathematical fact (laughs) , you know, that, that if you have a perfect public health test for COVID, which means that it would be 100% sensitive and 100% specific for contagious people or for the infectious stage of an infection, then it literally can't. It- it is an impossibility for that test to achieve an 80% sensitivity at a population level against a medical device, which is what the FDA asks for, and that's because you're only infectious for maybe 20%. So theoretically, it should only have a 20% sensitivity-
- LFLex Fridman
(laughs) Right.
- MMMichael Mina
... against the PCR while still being a perfect medical, uh, a perfect public health test.
- LFLex Fridman
And the test is answering the question, "Am I infectious?" That's what you're testing for, not for the exact counting of the virion particles in your system.
- MMMichael Mina
That's, that's exactly right.
- 17:44 – 34:07
Rapid test availability
- LFLex Fridman
Okay, so wha- why are we still here?
- MMMichael Mina
Yeah.
- LFLex Fridman
So have you had conversations with folks? You said that there's a bunch of, um, leaders that are kind of starting to wake up to this idea, but why has this taken so long? Why don't we still have hundreds of millions of at-home tests?
- MMMichael Mina
The reason it's taking long, I think, is...... because every agency and government is generally deferential to the FDA. And in this context, I would argue that government hasn't been particularly creative. So for example, last year when Trump was still president, I would... Or, or in the transition, and I, I recall talking to the White House a number of times and saying, "Here's a plan to give us our lives back." I think that was actually (laughs) the title of The Atlantic article. You know, and this plan can stop shutdowns, it can, it can stop outbreaks, it can allow society to keep running, and could have prevented the outbreaks of last winter and, and fall and saved hundreds of thousands of lives. So when I bring that to the White House or to the government or federal government, whoever it might be, and I say, "Here's a plan like this. This would work," they say... You know, what I get back is, "This sounds really interesting, Michael. Uh, it looks like it checks out, but there's one problem. We don't have the test. There's no scale." And that's kind of where it all dropped. It's like this defeatist attitude of like, "Oop, don't have the test, so, so we can't act on it." But now what's really changing... Well, and so that's really where things have been, and so nobody's paid attention. It's always been this, like, esoteric thing that, yeah, maybe one day we'll get around to it, but really it's not that important and the pandemic's going away. But the pandemic-
- LFLex Fridman
And now-
- MMMichael Mina
... this was like 100% predictable, everything that's happening today. We predicted it last year. You know, it's not... This isn't like rocket science or anything.
- LFLex Fridman
The variants and all those kinds of things. And so the FDA, we can start to understand why, but also, like, one question I want to ask, is it possible to go around the FDA?
- MMMichael Mina
Yeah. So why has the FDA not changed, and why has nobody tried to push the FDA to change? Like, the... I think what the real reason is the FDA has one job around these tests, and it is to authorize them as medical devices. They haven't been charged with doing anything else. So in their eyes, they're doing exactly what they're supposed to do.
- LFLex Fridman
Mm-hmm.
- MMMichael Mina
They're evaluating these tests as medical devices, and they're telling company after company after company, "Sorry, you don't make the cut." And the only way to make the cut is really to kind of skew your clinical trials to favor, uh, the rapid test being positive, which isn't really good practice. We shouldn't be trying to skew clinical (laughs) trials. Um, but that's kind of what's happened. That's been... It's been forced upon, uh, the companies to do that. And so I think the FDA truly believes from the bottom of their heart that they are doing the right thing here, and I would argue that to an extent they are. I've been pretty hard on the FDA, but maybe the issue is a higher level issue like the, the In Vitro Diagnostics Division is they get applications and they evaluate them, and the applications are for medical claims. That's, however, because there's been a misunderstanding of these tests, and the companies only know to apply for these as medical claims because there is no... There's nothing else in this country to apply for except a medical claim.
- LFLex Fridman
Mm-hmm.
- MMMichael Mina
So we, we don't have a public health pathway to evaluate a test and authorize a test. It doesn't exist. We have defunded and devalued public health for so long that we literally don't have a language for it. We don't have laws, a language, words. Is it called a public health test? Is it called something else? I call it a public health test because I'm trying to create a new definition here. But that's why, that's why nobody's acted, 'cause no- 'cause everyone says, "Well, there's no other pathway, so the FDA In Vitro Medical Diagnostics Division is the only pathway." So what I am trying to do is to say, look, the FDA very clearly states that they do not authorize or review public health tools and not... And they don't authorize or review public health tests for p- for COVID. So what I want the President of the United States to do is to utilize executive powers and take an executive action that can simply state like one line. One line could potentially change all of this, and it's a pretty obvious and simple line, and it is that any tools used for public health testing during this public health emergency will be designated as public health tools. Like, it's obvious, like, it's a public health emergency, it's a tool used for public health, it should be designated as a public health tool. If we can do that, if we can get that language out there so that's, that's the president's decision, then all of a sudden the FDA is off the hook. They're not trying to, to cram a, a square peg through a round hole. They can say, "Look, the antigen tests are not on us anymore, at least if they're going to be used for public health, like when you test 1,000 people at a time or test a, a school, a school classroom if they've been exposed, this is public health." And so then the CDC could take it over. The CDC could say, "Okay, what are the metrics we are interested in?" And they could say, "We're interested in a test that can catch you if you're infectious, so you want high viral load detection that's fast, that's scalable. And hey, you know, if your test has been used in Europe for months and has performed extremely well, then, then we'll give you a certificate by right, you know, immediately." And that could actually get ho- hundreds of millions of additional tests into the United States tomorrow.
- LFLex Fridman
So you need some kind of classification from an FDA or from somebody to call it a public health tool in order for it to be manufactured? Is, is it possible to just go around all of this and just for somebody to manufacture a scale, uh, tests and then-
- MMMichael Mina
Well, you, if you did that and you just called them, you put a claim on them that called them public health tools-... the FDA has a very weird view of this and they will tell you that it's illegal, that it's a crime. Um-
- LFLex Fridman
L- is, is there a way to say like, uh, Elon Musk did with the flamethrower, "It's not a flamethrower"?
- MMMichael Mina
(laughs) Uh, believe me, I've tried, I've tried to think of all the different approaches. Um, you know, there's weird, there's like ver- there's major inconsistencies here. So it's not like we don't have a precedent for a public health test even during this pandemic, there is a very strong precedent. Uh, pooled testing, we have companies like Ginkgo, right, based out here in Cambridge, that are, uh, you know, working with 100 different labs around the country, so that might mean, like, not a ton of quality control over those labs-
- LFLex Fridman
Mm-hmm.
- MMMichael Mina
... doing, uh... I mean, I don't want to say that they don't, I'm just saying the reality is if you're working with that many labs, y- it's hard to say. They're running pooled testing of millions and millions and millions of kids. So here you have a company that's testing, in each pool, 5 to 25 kids at a time, millions of kids in a pretty distributed way across the country in all these different labs, and the FDA doesn't care at all. You don't need an EUA, it doesn't need a regulatory authority. It's collection on site, it's getting shipped to a lab. There is no oversight of it.
- LFLex Fridman
Mm-hmm.
- MMMichael Mina
So why does that have no oversight, but a rapid test for, for pub- for the exact same purpose, you're just giving people immediate results instead of two-day delayed pooled PCR results, so it's a much more effective tool, why is the rapid test used for the same purpose not designated as a public health tool but requiring FDA authorization? It's a ridiculous r- reason and it's because the FDA says that if a test, and this is actually CMS that says this and then t- the FDA adopts it, if a test alters your behavior, if you get a, a single result and it's going to alter your behavior, then that is a medical device. But (laughs) the thing that I find ridiculous is, like, okay, but you can give a pooled test that alters 25 people's behavior at once-
- LFLex Fridman
Mm-hmm.
- MMMichael Mina
... and that's not falling... Like, that's more risky. One person turns positive in the pool and 25 people have to be quarantined. Yeah, and it's-
- LFLex Fridman
And, and, uh, how do they evaluate the accuracy? So for people who don't know, a pooled test is you're testing a small fraction of the people and if one of them is positive, then you basically say, "We have to retest everybody in the pool." Or, like, you, you-
- MMMichael Mina
Yeah. So you take... Let's say you have a school a- and each classroom you might have 20 kids each swab their nose in a classroom and all those swabs go into a single tube and then you rinse that tube out with some saline and you run a PCR test on that tube-
- LFLex Fridman
Mm-hmm.
- MMMichael Mina
... of 25 samples, 20 samples. And so if that tube turns positive in the PCR test, then all 20 or 25 of those students are now having to quarantine.
- LFLex Fridman
Yeah.
- MMMichael Mina
And if there's no positive, then all 20 or 25 students are interpreting that their result is negative. You know, so it really is a ridiculous decision by the FDA to say that if the test itself only tests one sample at a time, it's medicine because it will tell y- one person at a time if you're positive or if you're negative, but if you do it as a pool and you, and you tell 25 people that your pool was negative, then that's somehow different, that's public health not medicine. It, it, it doesn't make... There's no logic there.
- LFLex Fridman
Was it just personalities and accidents of history or something like that? For example, you, you talk about the, uh, public health tools and CDC, you look at masks. So masks were decided to somehow be an effective tool to help with the pandemic. Like, so, I'm, I'm sure the evidence that was used there was probably not as strong as the evidence supporting antigen and rapid tests. I was very much reading a lot of research on masks. It's tricky. It's really tricky to show how well they stop the transmission of a virus, especially when you don't fully understand how the virus (laughs) is transmitted-
- MMMichael Mina
(laughs)
- 34:07 – 50:46
Who is in charge of public health?
- LFLex Fridman
Who's supposed to care about public health? Is it the FDA? Is there some other organization yet to be created? Is it like, uh, just like with the military, the reason we have civilian leadership when, when you talk about war, is it the president that's supposed to do, like, override FDA, override doctors, override... And basically politicians in representing the people in a state of emergency make big public health decisions? Like, who is supposed to do it? Besides you on Twitter.
- MMMichael Mina
(laughs)
- LFLex Fridman
It's like most people really thinking about solutions to COVID will mention you or will mention this idea of rapid at-home testing and it's, it's... You watch that happening, this discussion that this is an obvious part of the solution and the solution's not happening. So who is supposed to implement this idea?
- MMMichael Mina
I think the CDC, that it should start there.
- LFLex Fridman
Override the FDA?
- MMMichael Mina
Well, I don't even think it needs to override it, and that's why I think these should just be designated as a different tool so that the companies... It's not overriding, it's just saying, "Look, this isn't even, this isn't in your jurisdiction to the FDA. This is just a, a public health tool." But the problem is, the Centers for Medicaid & Medicare Services designates any tool, just like FDA, they designate these as medical devices purely because they could change somebody's behavior based on the result of one test. So, to change that, at this point, unless you can get CMS buy-in, you know, we don't have, there is no designation as a public health tool. But the president can just say, "These are public health tools. These are not to be regulated as medical devices if their goal is not medicine but public health." And if he does that, he does have the authority to do that as president and to say, "I'm tasking the CDC to certify these tests, uh, or, or authorize them for use in the United States." And, you know, he has to say something like that. He can't come out and say, "These are public health tools. Have free rein, just, you know, any company start, start shipping them in the US," 'cause that would create pandemonium and we'd have a lot of bad tests. But there's a lot of really good tests out there. We just are taking like six to 12 months to run trials, they're failing because they can't keep up with PCR.And if the president were to do this, then the CDC could take it over and they could say, "Okay, it's on us. We're going to decide." The UK actually did this. They, early on, they said, "Okay." They laid out a very clear regimen. They said, "This is how we are going to evaluate rapid antigen tests because they're public health tools." They did it in a, in a domain that was outside of their normal medical diagnostic regulatory agencies and they, they literally just had a very fast screening to say what are the best tests. They went through a huge number of different tests and they said, "Okay, these are the, this is the rank order of which tests are good, which are bad, which are scalable, which are not." And they were able to de- start deploying them in weeks, not years. So I think the CDC really needs to take charge. The problem is when it comes to, like, law, if, uh, everyone currently perceives this as, like, fully within the domain of the FDA and they've never heard of such an FT- uh, public health test idea enabling... But the, but the FDA itself has created the idea by saying, "We don't regulate public health tools." So the word is out there. The FDA has said, "Eh, we don't regulate them," so that gives the president an opportunity to say, "Okay, these are those." (laughs) You know? "These are public health tools by definition." And, and I do think that this is a kind of a crisis, and it's a crisis of testing but it's also a crisis of, like, "Really? We're going to go through this whole pandemic and never figure this thing out?" That's just really sad, you know, if we get through this (laughs) and don't figure out how to evaluate a damn rapid test.
- LFLex Fridman
So how do vaccines play with this? So one of the things that, uh, when people discuss solutions to COVID, there's a sense that, um, once you have a vaccine, COVID is solved. So how does that interplay... Like, why do we still need tests if we have vaccines?
- MMMichael Mina
Yeah, I, um, I actually wrote an op-ed in New York Times or Wall Street Journal or something (laughs) that was titled, "Why We Still Need Rapid Tests (laughs) With, With Vaccines." And the real reason is because we have evaluated our vaccines based on their ability to stop disease. In fact, most of the trials didn't evaluate them based on their ability to stop transmission. They didn't even evaluate that at all, no less put it as one of the metrics for authorization. And with a virus like this, it would be a bit naive to think that it's really going to stop transmission well. I think a lot of excitement happened right after the first clinical trials, and I'm sure we were talking about it when, when I was last here, I would imagine, given the timing. But those first clinical trials came out and everyone, you know, jumped for joy that these things were going to be the, the end to this pandemic. But we had really shortsighted vision there by not recognizing two main features. One is, uh, that they might not stop transmission. Another... I guess three. Another is that, uh, new variants might come around that will break through the vaccine protective immunity. And the third is that we were not... Uh, we were measuring the efficacy of these vaccines during the peak of their performance, in the first few months after people got vaccinated, and that gives a skewed view of just how effective these are going to be long term. So what happened with the vaccines is that everyone got very comfortable. The C- including the CDC, saying, "If you've been vaccinated, you know, this is the end of the pandemic for you, and let's keep it up." But then Delta comes along and waning immunity comes along, and both of these things compound exactly (laughs) as anticipated to get breakthrough cases. And unfortunately what we're seeing now is the CDC and the administration went so all in on saying that breakthrough cases are rare, that transmission doesn't really happen if you're vaccinated, without great data, especially with Delta, that once people started seeing breakthrough cases, they started interpreting that as a failure of the vaccine. The vaccines are still working to keep people out of the hospital for the most part, uh, but they're not working to stop transmission. And if our goal is to stop transmission, which until we decide as a society that we have different goals, like we're okay with people getting ill and letting transmission go w- because we don't want to worry about it anymore, we're not there yet. So until we decide that we're not going to stop transmission, we need other avenues besides the vaccine because it's, it's not doing it. It also means that herd immunity isn't going to happen. And unfortunately as long as we keep letting spread happen in the context of vaccinated people, we're kind of giving this virus a boot camp of exactly what it needs to do and mutate to get around our vaccine-derived antibodies, and that makes me very nervous. So the more we can do to stop spread in the unvaccinated, in the elderly vaccinated, and in other people, the better. We, we, we just should be focusing on, on that.
- LFLex Fridman
So, so in your eyes the solution would look like this. You would ha- make enough tests where every single person would get tested every single day?
- MMMichael Mina
I think that that would be... I don't want to do that actually. I want to do a, a variation on that. I think what we should do is have a dynamical testing program. It doesn't have to be complicated. It's every household has a box of tests in their cupboard and if you haven't seen any cases in your community for a long time, stop testing. Do wastewater testing to see if there's any RNA coming back.
- LFLex Fridman
Mm-hmm.
- MMMichael Mina
Um, if you start to see RNA in the wastewater that represents the virus and you're still wanting to stop outbreaks, you say, "Hey, uh, you know those tests that are in your cupboards, households in this county? Why don't... Why doesn't each household or each person in each household use one test per week?"... and-
- LFLex Fridman
Can you, uh, sorry to, uh, just pause on that idea. That's really cool though, the wastewater testing. That's the thing? So you can, you can get a sense of how prevalent the virus is in a particular community by testing the, uh, the wastewater?
- MMMichael Mina
That's exactly right. And so the viral load associated, uh, the viral load that you can find in the community represents the prevalence of the virus in the community, which is really quite nice.
- LFLex Fridman
That's really cool. That's ni- that's a nice way to paint like a map of the d- the intensity, uh, of the virus. Okay, so when it, when it goes above a certain level, you can start doing m- much higher frequency testing per house- uh, in each household.
- MMMichael Mina
That's right. So I don't want people to be in testing purgatory. Like that's not what I want. I just want us to get (laughs) through this damn pandemic. And, and so we can monitor the wastewater or, uh, any other methods. We can monitor the hospitals and the clinics and if somebody does come in with COVID-like symptoms and then a few other people come in, you realize, "Okay, we got spread happening in our community." Send out a text message, put it on the news, put it in the newspaper, whatever you need to do to help people and tell families, "Use your test." And if the cases get worse, 'cause you're just doing it once a week, that's not going to stop transmission, but it's going to enable you to identify where outbreaks are happening. If you start to find outbreaks in pockets, then the rule is simply, okay, let's squash the outbreak real fast.
- LFLex Fridman
Mm-hmm.
- MMMichael Mina
So everyone in that area, in a certain ZIP code or whatever it might be, test every two days, you know, for seven days. Or every day for seven days. And you'll get rid of the outbreak. We can do that. And if you've now gone, again, you know, a week or two with no cases, uh, identified, s- stop the testing again.
- LFLex Fridman
Mm-hmm.
- MMMichael Mina
That's the nice thing that everything changes when people have the tests in their home. It becomes dynamic. It can become easy. You send a text message, "Take your test today." If some people don't do it, that's fine. The only goal is to get R below 1.0 and you stop the outbreak. People think it has to be near perfect. I always hear people say, "Oh, what if somebody doesn't, doesn't use it?" Or, "What if somebody lies?" It's like, well, you, you have 98% of people testing or, or even 50%, that's a whole lot better.
- LFLex Fridman
Mm-hmm.
- MMMichael Mina
And, you know, the another big difference that people I think oftentimes have there- have a problem wrapping their head around, especially to an extent, um, physicians who are used to really, well, like, who are used to different kinds of metrics is that all we have to do to completely stop an outbreak from spreading in a community is to get, for every 100 infected people, to get them to go on and infect 95. Most people would say, "Oh my God, that's a horrible, you know, that's a horrible program. You're still letting 100 people go in and infect 95 people."
- LFLex Fridman
Mm-hmm.
- MMMichael Mina
But that's, for, for a virus like this, that's a massive public health win. If you can get 100 people to infect 90, most people, doctors I would say, like a lot of people would say that sounds like a failure, to be honest. But if you do that for multiple days in a row, then in a couple of weeks, you've gone from a big outbreak to a very, very small outbreak. And on the other hand, if you don't do that, if you allow 100 people to just infect 140 people, because you're not doing the testing, then instead of having 20 people at the end of those four weeks with the testing, you literally would have 600. It's massive differences here. And all, the only goal then is to get R below 1.0, have 100 people infect less than 100 and you stop the outbreaks and everyone stays safe.
- LFLex Fridman
From everything you've seen, how cheap can these things get? From like in the past year, in, in terms of the developments you've seen with the various test manufacturers, how cheap can it be to make a test, to manufacture a test?
- MMMichael Mina
So there's the manufacturing process, that could be 50 cents. Maybe less. It's hard to get, it's hard to really have eyeballs inside these companies, you know, in, in terms of where they're producing them in China, um, and Taiwan and a number of other places. Um, uh, some of them are produced here in the United States too, but 50 cents say was a very, very reasonable, generous number for how much it costs per test. Um, you look at a place with high market competition that has actually authorized a lot of these tests, like Germany. Germany has 60, 70 some odd different companies have high quality rapid tests authorized. You can go there and buy it for 80 cents. You know, that's, and they're still making a profit. (laughs) And so, uh, so it's extremely cheap. Market competition can drive these tests, uh, way down in terms of cost. I think one of the most important features of a rapid test program is what do you do with the result? Is it going to be used for you to gain entry to school or work?
- LFLex Fridman
Right.
- MMMichael Mina
Is it going to be reported to the public health agencies? You know, all of these, the primary mode should be just get people tests, but really if you're going to be using it for a workplace thing, like what Biden is now saying, "Vaccinate or test," which is going to lead to a crisis if we don't fix this soon, 'cause we're going to have massive demand for testing in the next couple weeks. Uh, but when he says that, that's essentially saying, "Okay, companies need to make sure that their people are testing." So are you going to base it on the honor system? I would say you probably would not base testing on the honor system if it's like to, uh, take somebody who would otherwise be quarantined from in school and say, "You can go to school as long as your test is negative." So Test to Stay program is a big thing that I've been pushing for and others have. Uh, businesses bringing people into work, who need to test, they need to have verification. But they don't want to like set up nursing stations in their lobbies or in the school parking lot or whatever. Like everyone's tired of that. We need to bring the testing to home, but that means we need the technology to enable it. And so I was at a c- a conference recently, do you know Mike Milken?
- LFLex Fridman
Mm-hmm.
- MMMichael Mina
... Milken Institute. He's a very wealthy billionaire, but he's done a lot of philanthropy and he hosts a conference to raise money for, uh, prostate cancer research. I was at this conference, uh, recently, Francis Collins, a number of other people were there. Um, and every morning, we all had to test in the morning, which I thought was a great idea, obviously, (laughs) before we walked into that conference. And, um, but you didn't have to test there and they didn't base it on the honor system. Every morning, I l- I scan, I scanned a QR code on the box and eMed, which is a service that provides, uh, test, uh, verification-
- 50:46 – 58:02
Testing privacy
- LFLex Fridman
any mechanism of verification that's controlled by government can lead to overreach by said government. So there's a concern of that. Do you s- see their way of achieving testing that's verified but does not violate people's privacy or sense of freedom?
- MMMichael Mina
Absolutely. I, I, I think so. The way that, um ... Right now in the United States, they're requesting that these tests get, that the results get delivered to public health agencies. But I've long held that while that's ideal, it should never be the thing that holds up somebody being allowed to know their own status.
- LFLex Fridman
Yeah.
- MMMichael Mina
But if you are going to work and you have to let your boss or your manager, whomever, know that you were negative that day, or if you're going to school, I think it's going to be hard to maintain complete privacy, uh, in that situation because they need to know your name. But sure, I mean, could you cut off the public health reporting? Yes, you could.
- LFLex Fridman
Right.
- MMMichael Mina
But I worry, I mean, can you opt out? Maybe you could opt out. That should be a feature. "I want to opt out of the public health reporting because ..." you know, for whatever reason, "otherwise I'm not going to do the test." And, but that means that, okay, then you're not going to go to work. So right now there's this, this serious tension and I am very uncomfortable with the idea that we force anyone to do anything, but there is a tension between these two things for sure, and how do you balance that during a public health emergency? I think first and foremost, let people, everyone has a right to know their status.
- LFLex Fridman
Right.
- MMMichael Mina
The fact that we have made it hard for people to know their status on their terms I think is a travesty. I mean, it's just so terrible that we have prioritized us knowing at the expense of uni- essentially what public health has long said during this pandemic is, "If I'm public health, it's if I can't know, then you can't know your status." Like, that's not the right way to look at public health. We need to engage the public. And if some of them don't want to participate in the public health part but want to know their status, by default they are participating in public health whether they know it or not, because they're not going to go get their mom sick by mistake.
- LFLex Fridman
Right.
- MMMichael Mina
At least most people wouldn't.
- LFLex Fridman
And then also you can create systems where you can, um, individuals can form relationships based on their status without ever reporting it to a centralized place. So y- you can go to, I don't know, a, a local business owner might require that you show that you're negative, but that doesn't require reporting it. You can ... Like there might be, um, basically like a, an ID-
- MMMichael Mina
Mm-hmm.
- LFLex Fridman
... that's only in possession, you are in the only person in possession of that so you literally show it.
- MMMichael Mina
Exactly.
- LFLex Fridman
Here's a test I took, it's negative.
- MMMichael Mina
So-
- LFLex Fridman
And nobody else knows about that test.
- MMMichael Mina
So that could very well be done, even through a company like eMed. I think I, and I might be wrong here, uh, I believe that they take the test result and because they are considered a CLIA-waived laboratory, like a digital laboratory, they report their results by law out to, uh, the public health agencies. But let's say they were something a little different. Let's say you were verifying an over-the-counter test, and it doesn't have to be a CLIA-waived 'cause it's over the counter. Then you're not bound by CLIA rules and you could create the same service but that just doesn't report out to the public health agencies.
- LFLex Fridman
Yeah.
- MMMichael Mina
It gives people the option to opt in or out of public health reporting, and, you know, uh, I know that public health people get a little queasy when I talk about this, but as a public health person myself, like yes, of course I would prefer that the data be available to evaluate to know where the cases are. But first and foremost, I want to make sure that the people using the test...... are, are going to use the test. And if that means that they're not reporting and if that's the only way that they will use it is if it's not reported, then that's better than no test.
- LFLex Fridman
Yeah.
- MMMichael Mina
And-
- LFLex Fridman
Especially given that the central to the v- vaccine hesitancy is a distrust of authority and a distrust of government. So you're asking, (laughs) you're asking people to get tested, uh, and report their status, uh, to a centralized authority when they're clearly do not trust that authority. It doesn't make any sense. It, it seems like a perfect solution to let people who are hesitant on a vaccine to, uh, get their own status and have full control of that information and opt in, provide that information if they wish to. But they have the full control of it and they have the freedom to do with that information w- what they want.
- MMMichael Mina
I fully agree with that. I, I really do. I think we can have the verified services and we could have the privacy if you want it. If you want, if you need to go into a restaurant and there's a rule that you have to be a negative test, have it on your phone and only your phone. And it's okay. It, like, emailed, emails you the, the lab report. You have it. Can say, "Look, that's my name. I used it this morning. Negative." And in that case, you'd want something that just is there and is not going anywhere else. And I think that those services, like, I think they can exist. And it's a struggle because for those companies, uh, they don't want to fall out of favor with the CDC or with the FDA. And so this is a big problem in our marketplace, in general, by having, by having private companies who want to m- be the, be the public health agents of this pandemic, we lose a lot of control because the companies ultimately have to do what's going to make them money so they survive and keep performing the service. It's really, it's really just such a hard, um, problem. And I, this is why last time I was here, I, I'm guessing I was probably really pushing for the government to be producing these tests.
- LFLex Fridman
Mm-hmm.
- MMMichael Mina
I think I would've still been pushing for that. You know, at this point, I've decided, okay, the government's (laughs) clearly not going to do that. I've been thinking I really want Elon Musk to produce the tests. Like-
- LFLex Fridman
Mm-hmm.
- MMMichael Mina
... I, I really am sort of serious that these tests are simple to make, but we've been using, like, machines to make them that have been around for a long time. Scale is an issue right now, kind of. Really, it's the e-way process in getting the companies to be allowed to market in the US that's the issue. But let's just say scale is the issue and one company wants to make 20 million tests a day. These aren't that hard. Like, we, we should be able to do that. We just need a faster machine, a better machine-
- LFLex Fridman
Yeah.
- MMMichael Mina
... and a quicker one. And I-
- 58:02 – 1:09:15
Biden's COVID-19 Action Plan
- LFLex Fridman
um, what about this Biden action plan? So it sounds like the guy, uh, agrees with you, vaccinate or test. So I think given that choice, a lot of people go test in, in America because there's, there's, like, a division it seems like. So what... Is this just a politics? Is, is this just words? Or do you think this is actually going to lead to something? And maybe c- can you explain what the action plan-
- MMMichael Mina
Sure.
- LFLex Fridman
... is?
- MMMichael Mina
So there's, there's a number of pillars to the action plan. Um, the two that I've been most focused on, I mean, some of them are we want to get everyone vaccinated, all these things. And one pillar is saying any company in the United States that has, uh, more than 100 employees, uh, is now required to, uh, ensure that any unvaccinated individuals in their workforce, uh, test weekly.
- LFLex Fridman
Yeah.
- MMMichael Mina
Uh, another pillar is that the president's going to reduce the cost of PCR tests by 35%, which is pretty moderate reduction, um, and, uh, is going to reduce the cost of antigen tests and scale them up and make 280 million tests, uh, and put $2 billion into it. So those are the two that I found most intriguing for the kind of mission that I've been on, which is to just educate people around, "Hey, we have really, really powerful public health tools we have yet to deploy." Um, the issue at hand though is that now that the president has said vaccinate or test-
- LFLex Fridman
Mm-hmm.
- MMMichael Mina
... there's a problem inherent in that. You know, it's essentially to coerce people who are unvaccinated to get vaccinated 'cause vaccinate or test doesn't make sense when the vaccinated people can transmit the virus just fine.
- LFLex Fridman
Right.
- MMMichael Mina
So-
- LFLex Fridman
It should be vaccinate and test.
- MMMichael Mina
Exactly. It's... The problem that I have with that vaccinate or test idea is it's great if you want to use it as a coercive, uh, e- effort to get people vaccinated. Like, I'm not going to wade into that argument, do I agree with it or not. I'm just not going to even put my-
- LFLex Fridman
I, I dis-
- MMMichael Mina
... words under.
- LFLex Fridman
I disagree with... Let me say that.
- MMMichael Mina
(laughs)
- LFLex Fridman
I disagree. As opposed to doing great-
- MMMichael Mina
Yes. (laughs)
- LFLex Fridman
... science communication, this weird... Like, people talking down to the populous as if they're children, trying to trick them, "Here, have some candy." Uh, this kind of... Like, everyone with common sense... Somebody told me, I was, I was having a conversation, like, if the government is going to give you money to take the vaccine, people that were already hesitant about the vaccine (laughs) -
- MMMichael Mina
Yeah.
- LFLex Fridman
... are not going to trust whatever the heck you're doing. So don't trick people into taking the vaccine. Be honest and communicate.... transparently, everything that's known about the vaccine, communicate the data, inspire people-
- MMMichael Mina
(laughs)
- LFLex Fridman
... with, uh, (sighs) with, uh, transparency and, like, real communication of all the uncertainty around it and all the difficult decisions of risk and all those kinds of things. And, as opposed to s- trying to trick them like children into taking the vaccine. Anyway.
- MMMichael Mina
(laughs)
- LFLex Fridman
Yes. But...
- MMMichael Mina
Okay. Well, I didn't have to say it. (laughs) So there we go. Um-
- LFLex Fridman
But you're saying it should not be a, a, like, vaccinate or test. This, this n- th- that trade-off does not make sense.
- MMMichael Mina
Exactly. Vaccinate... By saying vaccinate or test is absolutely confusing because it implies, for anyone who's thinking about it, it is implying... And, and I've seen this because I have business leaders (laughs) call me, Fortune 500 business leaders who call me and say, "What do I do?" Like, "I have 8,000 employees. Where am I going to get my tests?" You know, and a lot of people are saying... They're calling this a, a pandemic of the unvaccinated. These types of divisive l- this l- divisive language doesn't help. This isn't a pandemic of the unvaccinated. This is a pandemic of a fucking virus. You know? Like, don't ever put it on the unvaccinated who, frankly, are just scared. They don't know who to trust, and we haven't given them a lot of reason to trust public health, to be frank. Uh, so I agree. I mean, uh, now that you've opened the door, I'll, I'll just s- say my piece. Like, absolutely, we need to be the most honest we can with all of this. This, this is confusing language to say vaccinate or test. We need to say, we need to be very upfront that s- uh, and say, "Look, vaccines aren't, are- aren't stopping transmission very well." Unfortunately, this is the world we have. We have Delta. We're going to have new mutants. We have a vaccine that's, that w- wanes somewhat over time. You know, this is biology. I'm sorry. I'm, you know... This is just what it is. And then we say, "But the vaccines are really protective for your personal health. They're going to keep you out of the hospital. This is what you should care about as an individual." And as a population, we need to figure out, okay, we have to stop transmission if that's our goal. So we should use the tools that are going to stop transmission if that's our goal. And saying vaccinate or test, if our goal is to actually stop transmission, that's confusing 'cause vaccines are not stopping it. They're maybe mildly (laughs) lowering the risk of transmission. So I, I'm just not a fan of that language. I think we should be being very, very clear, like you said, and upfront about what are the limitations of the test, of the vaccine, uh, and of the test. And we should be very clear that like, you know, it can only help. The American public in aggregate is extremely intelligent to, you know, they will figure out when you say that vaccine breakthrough cases are rare and then they start seeing story after story of like whole parties of people who are vaccinated and have outbreaks and, and everyone knows more people now who are having breakthrough cases than they knew who had regular cases before the vaccine, people start to wonder, "Hmm. Well, this is weird. They say that the vaccines are working and breakthrough cases are rare. Maybe the whole vaccine program is failing entirely." And so it ends up shooting ourselves in the foot if we try to create false expectations because we think it's going to be beneficial, uh, for one thing when it's not for the other. And so the other... So to get back to the (laughs) action plan-
- LFLex Fridman
Sure. (laughs)
- MMMichael Mina
... vaccinate or test I think, and, and the r- and the increase in rapid tests, I do think it was a bold move. I think it, uh... I, I th- I would say that it was the most prominent sort of display, encouraging display of the fact that rapid tests are indeed, uh, effective public health tools. My real concern now with, with... is that 280 million tests, that's like less than one per person per year in the United States. So that's not... The way that he said and delivered it and what most people think of when they hear the word 280 million, you don't usually put a lot of thought into what does that number mean. It sounds a big number. Most people are now going to be expecting that these tests are actually going to be staying in stock on the, on the shelves at CVS and Walgreens and Amazon or whatever. So that's crisis number one is like now the expectation is set for having rapid tests, but they're not going to scale that well. We won't have them. And then there's vaccinate or test, and that's going to bring millions and millions of people t- who are not currently testing to have to start testing. So that's going to overwhelm our PCR labs, and it's going to create five-day delays again with PCR, if not longer, 'cause we'll have backlogs. And so the only real solution to this is to just scale up the tests that are actually scalable, and that's these simple rapid tests. And it's not even to scale them up through production and manufacturing here. It's to open the doors so that the companies (laughs) that already exist here and can scale are allowed to do it and to bring in the international market. Some of the biggest diagnostic companies in the world are not selling their millions and millions and millions of tests in the, billions of tests in the United States because they don't want to play the, the, the game that the FDA is currently requiring of them. So we have an opportunity, and I, I am, uh, very encouraged that the president actually did put these into the action plan. And I do want to say for the record that I'm supportive of it in principle, um, but I think now, now what we actually are in a, in like a, uh, the timer has been set and we have to deal with the crisis before it happens. Otherwise, there could be some real political points taken off. You know, I do worry that the president, if he doesn't pull through with this and really make the tests available and we end up getting into this other test crisis this fall, there could be political consequences to that. And the reason is, like, these rapid tests are so personal. They become emotional almost. They're so... They give people that empowerment that I was talking about earlier. And when people can't get that because the shelves are out of stock, they actually feel frustrated and then that converts into like anger, like, and the, and blame. And so I do think that we have to be really smart about making a policy like this and then ensuring that we can carry through with what the average American is actually expecting.
- 1:09:15 – 1:16:10
Uncertainty, fear, and COVID
- MMMichael Mina
could've done it.
- LFLex Fridman
The most unpleasant thing about COVID is the uncertainty, and that's what leads to fear on both the, um, uh, vaccine hesitant, the, it's the uncertainty about the vaccine, and, uh, people who are, have taken the vaccine, the uncertainty around like, "Am I in danger walking around? Can I go? Can I walk down the hall?" Like, this fear of the world around you. And I think testing allows you to, uh, remove a lot of that uncertainty. Like, you, you gain back confidence that you can operate in this world and not get infected. And you become like a nicer person.
- MMMichael Mina
Mm-hmm.
- LFLex Fridman
I, I find myself every time I get tested I become a nicer person to others 'cause I know I'm not-
- MMMichael Mina
Putting them in danger. (laughs)
- LFLex Fridman
... uh, I'm not putting people in danger.
- MMMichael Mina
It's a ha- it's a heavy burden to carry, to worry, "Am I infectious? Like, I was out last night, but I do want to go see my mom today."
- LFLex Fridman
Mm-hmm.
- MMMichael Mina
You know? Like, "Am I infectious? I don't know." And, and this has created massive anxiety, and I can't tell... I completely agree that it is, it's a relieving feeling. And, and it's an amazing feeling to be in a room when, and I did this in the middle of the pandemic when everyone was supposed to be wearing a mask indoors, I had everyone rapid test, you know? And I said, "Everyone should rapid test before you walk into this room." And it was a wonderful experiment because everyone was just so relaxed.
- LFLex Fridman
Yeah. (laughs)
- MMMichael Mina
You know, the other, the alternative is everyone, nobody tests and everyone wears a mask. You have a mask that maybe gives you 20%, maybe, protection during, if you're all in the same room together, if that. Or you have a rapid test program where everyone rapid tests before and that gives you, like, 95% to 100% protection, not 100% but close. And all of a sudden that allows everyone to take a big sigh and be like, "Wow, this is the first time I've seen people without masks indoors in a long time and I feel pretty good." And restaurants, like, restaurants are scary right now because you just don't know who might be infectious and nobody's masked, and, like, wouldn't it be great to just go into a restaurant where you know that everyone (laughs) just tested-
- LFLex Fridman
Yeah.
- MMMichael Mina
... negative that day? It just really reduces anxiety. It makes individuals feel empowered. And, I mean, at the end of the day, COVID and our response to COVID is a res- is a, it's truly an information problem.
- LFLex Fridman
Mm-hmm.
- MMMichael Mina
You know, we, why do we quarantine anyone? Why did we ever close anything down? We didn't close things down because everyone is positive, we closed things down because we didn't know if anyone was positive. We quarantine a whole classroom of kids not because they're all positive, but because we don't know if one of them are positive-
- LFLex Fridman
Mm-hmm.
- MMMichael Mina
... and so we just quarantine everyone when there's a positive in the case, in the, in the classroom, like, one day, we'll then ask the whole classroom not to come to school for 10 days. That's not a biological problem, that's an information problem. And the crazy thing is we have the tool to solve that information problem. It's literally our eyes on the virus, it's how we see this virus, and if everyone glowed green when they were infectious, we would've never had to close down anyone, any society, and we would've never had the outbreaks 'cause we would've been able to stay away from the green people.
- LFLex Fridman
(laughs)
- MMMichael Mina
You know? And-
- LFLex Fridman
Yeah. I like what you said that quarantine is an information problem. That's absolutely right. What, is there something you can say to what people can do, like listening to this, individuals, do you just complain, like loudly, like, "Why can't we do this?" Can you speak with your money somehow? What, what can people do to help?
- MMMichael Mina
(laughs) God, it's, it's amazing to think (laughs) you're asking me this question and this video will go out to, you know, the web and all the people that watch you. And, uh, last year in July maybe, something like that, June, I forget exactly when it was, I was on TWV, This Week In Virology, um-
- LFLex Fridman
Shout-out to TWV, those guys are awesome.
- MMMichael Mina
They are awesome. I love, I love TWV.... and they asked me the exact same question towards the end. They said, "This makes so much sense, you know. Why wouldn't we do this? What can people do?" (laughs) And so I said, "Oh, you know, just send me an email." Like, (laughs) "Write to me. I'm sure you could find my email somewhere online."
- LFLex Fridman
Mm-hmm.
- MMMichael Mina
"And, uh, and get in touch and I will, you know, and, and we can try to figure out how to, uh, make something happen."
- LFLex Fridman
Yeah, that was smart.
- MMMichael Mina
Bad idea. (laughs)
- LFLex Fridman
Very smart.
- MMMichael Mina
Way too many emails. I didn't, I feel bad 'cause I didn't end up getting back to anyone 'cause I just got inundated. But it did lead to the development of rapidtest.org where we did automate the process of writing letters to, um, congressional members and, and, uh, elected representatives. So that helped. Fast-forward to today. What can, what can people do? I honestly don't know. Like what can the average person at this point do? We have tried everything. The FDA is immutable on this. They will not change and we shouldn't ask them to change 'cause they have decided that this is how they regulate medical devices and they're going to stick to it. So what we need to do, and maybe this is something to do, is get, if you know people who have sway over politicians, lobbyists, whatever it might be, let people know to request that the President, literally the President of the United States uses executive powers to just do as simp- something as simple as designating these powerful public health tools as public health tools. Allow the CDC and the NIH or whomever it must be, or, or academic centers of eg- excellence designated by the CDC, to evaluate the tests in a very fast fashion with the appropriate metrics that these tests need to achieve for public health. And within two days, we can have 10 new tests authorized.
- LFLex Fridman
Mm-hmm.
- 1:16:10 – 1:24:50
Vaccines and herd immunity
- MMMichael Mina
- LFLex Fridman
Do you think it's possible to reopen fully without solving the testing problem completely? Like do you think this vaccine approach will get us to reopen fully?
- MMMichael Mina
Uh, I do, yeah. I think over time though. I mean, if we, a lot of people ask me like, "What's, what's like happening?" Like, "What's the end game here?"
- LFLex Fridman
(laughs)
- MMMichael Mina
Like, "Where does this end?" And, um, it's actually not a mystery. The end game is we will grow out of this virus. Um, and by that I mean you and I and most people who are watching this are adults, all right? Adults don't like to get infected with a virus for the very first time as adults.
- LFLex Fridman
Yeah.
- MMMichael Mina
Babies are okay with it. And so what we have to do to understand how we're getting out of this virus is to look at babies, like at newborns and say, "Okay, how does a baby get out of their high-risk time period?" They get exposed. They get like exposed multiple times, or vaccinated-
- LFLex Fridman
Mm-hmm.
- MMMichael Mina
... of course. And eventually, they get exposed enough that they build up this nice cushion of immunity that's sufficiently diverse that they can battle whatever gets thrown at them 'cause they've seen it all already.
- LFLex Fridman
Yeah.
- MMMichael Mina
But one exposure doesn't do it. I mean, over the course of a, the first few years of life, kids get exposed to coronaviruses tons of times, lots of different viruses they get. So unfortunately what's happening with us, why this is so bad for us is that as we're adults, we don't regenerate tissue very well. We have like overabundant inflammatory response. We have all these problems that when we get an infection for the first time, it sucks, it harms us, it causes us problems. But over time, just like a baby, we're going to start building up our immunity through vaccines and exposures. You know, I hate to say it, but tons of people are getting exposed to Delta right now who don't know it. Tons. And, uh, if you're vaccinated, you don't know it is my point there. And, you know, at the end of the day, this is actually a, I, I do not want this to be misconstrued as like saying go get infected. But the fact that people are getting infected, you know, will add to our level of protection later on. And so-
- LFLex Fridman
Yeah, but the question is how long that whole process takes.
- MMMichael Mina
I think, (sighs) you know, my guess is probably by the end of next year, early 2023, we will probably start looking at this as though it is not a particularly dangerous virus for most people. The elderly though, it will still be, but that's because their immunity like-
- LFLex Fridman
Yeah, but with variants and stuff.
- MMMichael Mina
Well, right, that's the-
- LFLex Fridman
And I've heard other people say this statement you just said a year ago about the spring, right?
- MMMichael Mina
Well, that probably was not wise. (laughs)
- LFLex Fridman
Well, I mean, it's 'cause you're, the intuition is like, okay, now that there's a vaccine, you're either going to take the vaccine or get infected and then there'll be herd immunity over, like it'll be very quick. So, you know, that-
- MMMichael Mina
Yeah.
- LFLex Fridman
... that's the intuition but it seems like that's not happening. It seems like we're in this constant state of, uh, fearmongering for different reasons. It's almost, uh-It's almost like the virus got deeply integrated not into just our biology, but in the game of politics and in the fearmongering around the news. Because the virus now started being, together with the vaccine and the masks, and it started getting, uh, integrated into, uh, the division that's so effective at, uh, monetizing social media, for example. And so it's like, all right, so how do you get out of that?
- MMMichael Mina
Mm-hmm.
- LFLex Fridman
Because you can always kind of present certain kinds of numbers about number of cases or (inhales sharply) how, uh, full hospitals are and, and s- start making claims about there were still, this is as bad as it's ever been, those kinds of statements. And so I'm, I'm not sure exactly what the way out is, except the same way out as it was originally, which is testing, is information.
- MMMichael Mina
Yeah.
- LFLex Fridman
Uh, it's information.
- MMMichael Mina
Yeah. And, and I think we can do that. We can keep outbreaks suppressed with testing because it's information. Like people keep thinking of tests as being medical things. They're not. They're information. It can allow us to control things, just like we drive down a road and w- we look at the cars and we don't hit other cars because we have the information (laughs) that they're in the lane next to us and they're moving over it. Like that's just information.
- LFLex Fridman
Like you said, glow green.
- MMMichael Mina
Yeah.
- LFLex Fridman
The problem with the virus, you don't have, you don't see. You're walking around and everybody is a potential, uh, l- like infectious creature.
- MMMichael Mina
Mm-hmm.
- LFLex Fridman
And so if you see the world as a potentia- potential for infection, you're going to be terrified out of that world.
Episode duration: 1:46:46
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