Thứ Năm, 18 tháng 6, 2020

Coronavirus Q&A: Immunity Passports in Time of COVID-19

nice to be here thanks for making me come always so seek is the Diane s Levy and Robert M Levy University professor at University of Pennsylvania professor of 

healthcare management vice provost for global initiatives and chair of the department of medical ethics and health policy a lot of titles ich so we're gonna discuss two viewpoints but principally focusing on Zeke's viewpoint that he wrote with ghovat Prasad entitled the ethics of kovat nineteen immunity based licenses immunity passports which has been in the news more and more just the last few days and we'll return to that but seek before we start you write on ethics you write on health policy right in other areas pretty prominent in the media recently can you just tell people a little bit about your training background I don't think we've ever discussed that in our various podcasts ah well I did medical school and after three years of medical school I took off and I went and did a degree in political science at Harvard focusing on political theory but I had training in other areas of political science including international relations and American politics and constitutional law and then I did my internship year of residency and fellowship and then I began writing a lot in the bioethics world where my dissertation was and about I don't know 20 years into being a bioethicists I decided that I wanted to get more involved in health policy because a lot of the questions I was most interested in were butting up against universal health care coverage allocation of resources and things like that and so I began writing a lot more studying and writing a lot more in health policy and then because I fortunate enough to get a job in the White House during the Affordable Care Act got a first-hand look at both policymaking and trying to put ideas into action but I would you know if you're curious and and you can read the literature I think you know it's possible to come up with some ways of contributing so well you've been invaluable and I think I've mentioned to people before you're a member of our editorial board and you're just a fabulous contributor to JAMA in the Jama family so thank you so the ethics of Coppa 19 immunity based licenses could you say a little bit about your co-author I always make sure they get credit yeah so Govind is a former student of mine or a fellow of mine he worked with me at the NIH when I was head of the department of one of the most brilliant people I had trained for sure he's a law professor now at Denver University he's done a lot of bioethics he's also uniquely trained in heavy as a JD as well as a PhD in philosophy and we have collaborated a lot on the work related to allocating scarce medical resources and we've been working on the whole issue related to kovat we've actually just launched the big project trying to think through how you would distribute a vaccine among countries not with just within a country so over the weekend the United Kingdom announced that if you want to come and visit you get quarantined for two weeks one of the CEOs of one of the airline said well one of the things that may help airline travel is a so called you know Kovac passport this notion of an immunity immunity passport what's the science between a what's the science behind an immunity passport well at the moment there's no good science but I think that the presumption is the following that someone who gets infected with Koba 19 will have an immune response raised antibodies and other immune cells that can fight Koba 19 and that they will be immune from a reinfection and they want to also be shedding virus particles themselves and that that this will last for a period of time years hopefully and that would allow us to say they can't be infected by kovat 19 and most importantly they can't shed it and get other people infected by Kovac 19 and I think that would um you know make them able to do things that other people might not they might be people who well they can come into the country because they're not going to be carrying kovat for example into Britain or New Zealand or other places that you know may become covet free second you might actually want them for doing certain jobs where the risk of infection could have very devastating consequences like working in nursing homes or working in the supply chain of food production so I think the these immunity passports if we can guarantee the science that yes in fact these antibodies are neutralizing they last for a period of time a long time offers you know you have to have that science for the advantages but a lot of people think that science is likely but we need to confirm it I mean you know we just shouldn't say well it's likely people have anybody we need to show that that's true right so for the purposes of this discussion let's make the assumption that over the next three four or five months we will know if you could test someone if you know they've developed IgG and neutralizing antibodies and then over the subsequent six months or a year we will know how long it lasts because without the science this is an on discussion so let's say that let's assume that the science so let's start with something you and I already exchanged emails about Germany in World War two decided to put Jewish stars on the coats of Jewish people and it led to profound consequences so stigma and we're going to go through the different elements of the of the viewpoint but can you talk about stigma yeah so I think we have to recognize what the difference is between having a star because you're Jewish or your religion or you know one grandparent was Jewish and having a immunity passport because you've recovered from Koba at 19 and affection so the first is what the lawyers call an invidious category and invidious discrimination it's taking a totally irrelevant factor your religion or your grandparents religion and excluding you from all sorts of benefits and rights in society you can't be a member of a certain group you have to wear this star you're excluded from certain jobs and eventually you're put on train to concentration camp that is very different than an immunity passport that is based upon not an invidious category like race religion or gender but it's based upon your recovering from an infection and being immune so you can't pass it on let us remember we are already you know penalizing all sorts of people everyone in society in some ways that's the physically distance because of the threat of being a potential carrier of kovat 19 infection so I think they're very different kinds of categories would we stigmatize people who don't have an immunity passport I don't think it's a matter of stigmatization we would simply recognize that they're vulnerable to populate to infection and that they might have an infection being asymptomatic unless we test them so I think these are not analogous kind of experiences so let's talk about you break it up into Liberty immunity based licenses and the least restrictive alternative then you go on to immunity based licenses and ethical values and we'll walk through those and then practical challenges so let's talk about Liberty immunity based licenses and the least restrictive alternatives right so what is an immunity based license good for it's good for certifying that you have been infected and would allow you then to do certain things as you've already mentioned Howard travel maybe work in certain industries and perform certain functions or be admitted to a hospital for a loved one because you can't either catch or transmit the infection and that enhances your liberty if you're a person who has had cope it and we should remember that at the moment everyone is barred from you know they have to physically distance I can't do large gatherings they have to do all sorts of other restrictions quarantine in certain cases this actually enhances the liberty of the people who have been infected by Kovac now the least restrictive alternative is a principle that has been used in public health and in the law to say look when we're trying to affect a public health policy we have to use the least restrictive method we have to recognize that the policy might not apply to certain people or might not apply well to certain people and therefore we shouldn't apply it to them and so this is a case of the policy of physically distancing not being able to go into shops not being able to visit relatives in the hospital that is not relevant to people who are have experience kovin and are immune to it and so it's simply recognizing that principle in the case of kovat 19 and so we think it the immunity passport actually enhances the liberty of those people who've been exposed and recovered from koban 19 and does not then further diminish the liberty of those people who are naive to the coronavirus now Zeke you've seen a data we published quite a bit of it and we have two more pieces that just went up which is around healthcare disparities how do you layer the the concern that particularly african-american communities indigenous populations in the US have had a strikingly higher rate of disease how do you layer that on top of this notion of liberty and immunity based licenses so we should distinguish the disparities that we're seeing in here I'm in Washington DC at the moment and you know the african-american population is something like 45 to 50 percent of the city population but in terms of deaths it's somewhere around 80 percent of all deaths are among African Americans it's a horrible disparity but remember actually the immunity passport were then because it's so much more prevalent in the african-american community would then actually in title or entitled allow these african-americans who have been exposed to the virus to do the functions and participate in employment activities that I've mentioned so in some ways it you know I don't want to say you know makes it worthwhile or addresses the disparity but those are two different issues the disparity is you know relates to probably much more frequent comorbidities in that community much worse situations call it housing and other items that might expose them more frequently to the virus access to health care services and institutions lower and then disinformation that seems to have been targeted to the african-american community about their vulnerability those disparities are totally different than the immunity based passport and in some sense I think it's important there's no discrimination on the immunity based Passport it's whether you've recovered from covent or not right now you do talk about this analogy to drivers and pilot licenses could you just talk about that that's similarity yeah so you know why do we have the current situation with koban 19 because it's risky and because it poses you know potential lethal threat to yourself and others why do we have driver's license because driving an automobile poses lethal threat to yourself and others we test people we make distinctions in gradations so you can drive a passenger car but unless you're specially trained you can't drive a large motorcycle or a truck or a school bus and similarly with immunity passports you know you you get certified but you know it's time limited because we don't know how long you need to be alas it may entitle you to do certain things but not other things and they're very much the same and the main reason we're giving you this license is public safety we're protecting other people and we're allowing you to do something because you're safe you're not going to infect other people and you're not going to be infected yourself and I think there the analogy is actually quite good in point of fact now you then go into some ethical values and I will go through them one at a time there's four that you mentioned yeah the first immunity license could maximize benefits by safely in Haven enabling social and economic activities such as patronage of bars and restaurants yeah if you haven't if we have an immunity passport people might be able to then sit inside at bars and restaurants when we reopen they might be able to go to get their hair cut or dentist's office or other things that require close physical contact yeah as I've mentioned it also will permit people to visit relatives in the hospital or a nursing home and that might also be preference for hiring them because they're not going to transmit the virus from person to person to person if they work in a healthcare facility or in a nursing home or in other places prisons where transmission because of the tight concentration of people the inability to physically distance appropriately might make it problematic to have people who could transmit the virus if they were infected immunity license immunity likely and that God that would sorry that would be good for everyone right it would be good for for example relatives who are patients in the hospital would be good for the residents of nursing home and hospital patient hospitalized patients well when I envision in the future I can see how we can get to some places opening restaurants is not one I can really see that that's the hardest one and you and I both like going out to dinner second immunity licenses can be consistent with priority two the least advantaged could you explain what that term least advantage means yeah well one of the keye ethical principles that has been I think you know risen to prominence you might say over the last 50 years is that it's important to recognize who the lease advantage and most of us have an intuition that they should be given special attention because they have had multiple disadvantages in life I remember I think it was Franklin Roosevelt who wrote that you know the measure of society is not what we do for the well-off on what we do for the people with the least well-off and to make sure that you know they have an equal chance in life this certainly doesn't immunity based passport doesn't undermine those people who have been least advantage in life and it in some ways the people who've been disadvantaged by getting infection have a certain advantage in and having recovered from it so I think it's it's important I mean one of the things we've heard is that this somehow is discriminatory immunity based passport is a discrimination I will say it's got a differential impact on people right some people are gonna be allowed to do certain things that other people aren't the people who are Kovac recovered from Kovac can engage in certain activities that other people cannot I'm now a differential impact is not necessarily discriminatory if it doesn't rest on some artificial category that isn't relevant but being infected with Kovac is a relevant category to spreading infection and so we recognize that and it's important I think to distinguish differential impact from discrimination not every differential impact is a result of discrimination and ought to be quashed and I think that's a distinction that is often hard for people to understand and grasp now you then go into practical challenges we already talked about one which is that the science needs to work so let's do away with that the science needs to work yeah but some of the others are payment like you know this is going to be expensive nothing in the US healthcare system is inexpensive you and I've talked about that I want to make it expensive put it in the US healthcare system so how can you imagine payment would work or the like how would you get the license and maintain it well I think that actually is one of the bad parts of our current system which is we often charge people rich or poor the same amount of money for a license or a procedure things like that done by the government and I think that's quite bad I think that if we're gonna have immunity based passports they have to be free and now we have you know payment for the test so we should definitely ensure that if you've got a test you get a serology because you should not have to pay for the passport or the license in addition to that and and I think that's just a basic requirement it's I think of it kind of like a poll tax it should not be a poll tax and I think you know making people pay a lot for their driver's license there's also a surreptitious tax on the poor that is not really fair one of the other challenges you and I you know your dad was a pediatrician I'm a pediatrician we talked about the so called varicella parties of my youth and my children's youth so you convey you confer advantage on people and then they go you know I'm 25 I'm 30 my you know my two boys you know are 27 and 30 go get infected and you get your serology passport your immunity passport how do you prevent that I don't think you can fully prevent that you know we are a society of individual rights and we want people to be able to exercise their rights and make choices about their own life and how much risks that are gonna take we allow the you know people to do extreme sports we allow people to go skiing to bungee jump and all sorts of other things and have real risks we allow them to drive cars and they have real risks of that so we're not gonna get rid of it entirely on the other hand you don't want to incentivize behavior that does carry some serious complications and unfortunately you know even though they're low among people who are younger they're not zero as the latest round of Kawasaki cases or strokes in young people has alerted us to you know this isn't a totally benign disease in young people it is relatively benign and it's pretty low risk but it's not zero risk and so we should in think of ways of disincentivizing this these kind of parties like you I did have a varicella party for my children didn't work but we did try it and I do think that one of the ways we can think about it is maybe starting the immunity based licenses with health care workers nursing home workers who've already been exposed or people in the food service industry who have already been exposed so that these are people who are not likely to go out and expose themselves likely to be fully informed about the situation and and their passport in in the situation would be beneficial but we can think of other ways to kind of restriction and disincentivizing the behavior but as I said at the start I don't think there's any way we can 100% prevent it as long as we like people to have Liberty and structure their own lives and take some risks in how they pursue their lives I think it's inevitable that some people are gonna you know and probably already have gone out and gotten self infected well tens of millions went out to out this weekend as states opened up so it's clear that tens of millions of people are willing to take some risk um before we turn to other subjects and there's some questions some of which we've touched on I wouldn't say it's been a great three or four months for the FDA the CDC so who becomes a licensing body I think that's a really good question and you also want to create a license that is very hard to fabricate or Forge or counterfeit and so I do think you have to have some non hackable electronic certification probably the states are going to do it that's the way we do it in the United States you know we do it with driver's license that way the FAA does pilots license but I do think the states are probably in the end gonna have this responsibility do you think it's by the way I think this is coming yeah it's gonna say that was mine is it inevitable so you do you think this is inevitable I think it is inevitable and I'll tell you why I think what's inevitable about it is countries Chile Germany I've already said they're gonna probably use this if New Zealand becomes virus-free you can imagine that they're gonna want people to come in only you can demonstrate it in one way of demonstrating is either a 14-day quarantine or an immunity based license one way maybe of getting around the UK 14 day quarantine if you want to get there is an immunity based license so I think it's gonna be the travel that originally puts it out there and sort of forces the United States to adopt it I would also say I haven't heard a knock down argument against this and so I think there's gonna be pressure from people to begin developing it you know just imagine if you were a parent of a child going to school or you were hiring a nanny or something like that you would do your own you know immunity you might very well do your own immunity based passport kind of requirement and so I think if it starts out haphazard you know and we have it I think you're gonna get an organized system for it so I do think it's almost inevitable can you imagine one of the concerns that I've thought through you know you're at Penn and and let's say 10% of your workforce has been infected and you know you can test you know that they have serology whatever the last three months six months nine months you'd follow them and we'll know that will evolve as I said that you and I are more convinced that we'll get get it right on the science and we'll begin to know at three months ninety nine percent of people are still protected or whatever the timeline is and you'll have to be retested but can you imagine within a healthcare system you know you have you know 20% of your surgeons have been infected so so they they draw a different type of responsibility or duty or ICU Docs or IDI physicians and that they begin to object to that that you're putting your your your their always caring for the patients whom it's unknown if they have kovat 19 or they do have kovin 19 and so you begin to divide your workforce in a way that people may be uncomfortable with have you thought through like what it would mean in the healthcare system or a skilled nursing home yeah no I think you're right um you know if you had health care workers who work Ovid exposed and immune you might say it's better for you to work on the kovin floor and again we're all doing extraordinary things this is a crazy time requiring us to work in ways that we hadn't anticipated and haven't done I think as a doctor we have to remember our first obligation is the patients and if we have special talents and in this case having you know been infected with Kovac that allows us to care for patients more safely I think that's something that's really important for us to do and I think you know as I understand physician duties and health care worker duties nor this applies just as much to nurses and respiratory therapists you know our patient is our highest obligation and caring for them safely and is really important and yes this might put imposition on us and might create some challenges for us but I don't think we can say well it creates challenges for us but you know I don't want to do it we recognize that you have a higher duty as if you're a doctor and I think that's something you know I've been very very pleased that this generation of doctor seems to have recognized that right from the start of this pandemic and I think you know that just the ethos we have to make sure is prevalent throughout the profession well I don't I don't think there's been a time in my 40-year career I've been prouder of my profession and in the last three or four months I agree it's I ordinary commitment patient care in the face of numerous challenges that we've already gone over we're gonna turn on well and I think the fact that society this the fact that society is igniting it and using the language of heroes tells you how much you know the American public agrees with that and I think how much we really need heroes average people we're just gonna step up say this is my duty I accept my duty and I'm gonna do it so two viewpoints the we've been discussing zieks with kovat prasad the ethics of copán 19 immunity based licenses and also there was a an accompanying viewpoint by mark wall and david Studdard entitled privileges and immunity certification during the köppen 19 pandemic but I told seek at the beginning I wanted to do one or two other ethics and policy issues so human vaccine challenges I think all the rage three or four weeks ago but over the last week or two some issues have come up one isolating the virus not that easy secondly you truly are PD putting people at risk and we have no cure definitely no cure even some of the initial reports you know you're seeing a three or four percent benefit in terms of the Tao of fatality but these are not cures at all what's your sense of human challenges around vaccine Z well I think it's a it's an interesting question first of all your your listeners need to recognize we've done challenge studies and other infectious diseases this it wouldn't be the first you know I was party to talking about challenge subjects related to malaria when the military was trying various drugs and gonna give them to volunteers and then infect them with malaria now malaria is a little different we do have treatments for malaria although it is can be a fatal illness – this is different as you point out you know maybe the mortality rate is 1% but it isn't 0% maybe it's skewed to people over 65 so we don't enroll them only enroll younger people but it's not zero on the other hand it does seem to me that there's very very urgent public health I mean social value to this research and to getting a vaccine out quicker so I think a lot of the questions is are really you might say practical first of all is this actually gonna be faster or not faster right um it's unclear that this is actually you know the main justification for doing this is why wait for people to be exposed to covin and to see how many people can track over it just you know get this done faster it's not clear that this is going to be done faster for a variety of reasons second um there's a big question about generalizability right right one of the big issues here is well how generalizable will the challenge study on a thirty-year-old be to someone who say sixty-five or seventy where most of the mortality is and where we know the immunised getting immunity from a vaccine is not as common and so I think you know we might end up with a crazy situation of where you do a challenge study on thirty-year-old and yet the predominant people who you want to get the vaccine are people who are 70 and you don't know anything about it so it may not have as much social value as a regular study would be even if you would you know sort of dichotomize will try for safety reasons in under 65 first and then in over 65 so I'm I I think those two challenges not as fast and it may not be generalizable you may not get the kind of information the valid scientific information to make a judgement are really really important to answer before we went ahead with a challenge study I think in principle given a 1 or 1/2 a percent mortality rate and a very informed population it wouldn't be unethical in principle second sherry glide was on a live stream about ten days ago we talked about two issues small practices which are really struggling my lord they are really struggling in hospitals and sherry mentioned around hospitals she said look I more data to really understand what this year's gonna look like for hospitals you know some may not do as poorly they have a cash flow problem at the moment but if elective surgery comes back and they can make it up billing comes in for the intensive care patients they've taken care of you know if they have global payment contracts as an insurer as part of the hospital they may do okay she just said I don't know she needs more data she's more concerned about small practices but this weekend you you wrote a piece that there are some real winners and it's insurers could you elaborate a little bit about what you said in that piece I did read it and I know what you said but I think people would be anything because you think they need to share some of what could be some huge benefits like GEICO's given some of the car insurance places are given money back right right so because of the drop in elective surgery even the drop in hospital admissions for other things yeah Edie visitor plummeted exactly right Edie visits and you know where did all those myocardial infarctions go insurers are doing well now we should remember not all of that money is there you know if there's a self-insured employer my employer the University of Pennsylvania shell itself insured so it's not actually the insurance company that administers the contract that's actually saving money it's Penn that is and we could get to how employers should should handle this but it is the case that insurers are making money they're making money on Medicare Advantage they're making money on commercial the exchange patients and they there I think are doing some things we've heard of that of ones that have advanced money to practices and have made various policies that have helped the physicians as well as patients but we think they should be doing more many of them raised two objections to us our demand that they do more one objection is well the elective procedures will come roaring back hospitals want to make profits now I think that there are I think that is a worry it's a legitimate worry but I think it raises two issues for me one is why the hell are we paying so much for elective procedures shouldn't we redo our reimbursement system so that hospitals are not making their money on elective procedures like hip replacements and knee replacements and back surgeries that seems to me if this is how hospitals are making their money we ought to rethink what we're paying for those procedures and maybe lower if all the profit margin is there and raised payment for more necessary medical care but the second thing I would say is I'm not convinced not at all convinced that these elective procedures are going to come roaring back remember there is a supply problem a supply issue which is yes hospitals and surgeons and others may want to do these elective procedures but you got to have patients who are willing to get the elective procedures and I'm a little more skeptical that we're gonna have a lot of patients lining up to get those elective procedures for one thing you know a lot of people with back pain the teacher of time may take care of it and for another thing a lot of them I think this residual fear of going into the hospital may last a lot longer than insurers are recognizing and so there may be in fact it might not roll back at all and we might think of other other ways that we sort of put a pause on on these elective procedure you know I've been a big advocate of what's called shared decision-making that you really have to use a formal informed consent process where patients get the actual data on their procedure in general and the procedure at the particular institution before they will be if the institution will be reimbursed for it because we know if that's done well a lot of patients don't want those elective procedures nonetheless I do think insures need to make it easier and I agree with Jerry glede as you portrayed her which is that it's the independent small practices that need help yeah and I think there are a lot of things insurers can do we're working with a number of them to try to think about switching them to capitation yeah that's a good thing for the system why cake why just you know bail them out make we have a a structural transformative change everyone's been trying to get make sure we institutionalize telemedicine make sure we go to capitation so doctors have a different incentive structure when we come out of Kovac I think this would be a huge benefit to everyone and would use this moment of crisis for longer-term more sustained treatment but I think insurance companies need to be creative and they need to get into the dialogue I also have recommended you know there's a patient component here and one of the things insurers might do is rethink the deductible co-payments situation I think I've long advocated why are we charging co-pays and deductibles for primary care visits we want to encourage them and we should have no deductibles and no co-pays for those primary care visits and get patients to orient themselves and their care to primary care doctors similarly I think for generic medications I think those are relatively cheap to everyone and we should have no co-pays for those so I think there's a variety each category here the independent primary care doctors and and other specialists the hospitals and especially the patients insurers could be creative in helping out and I think we're probably gonna see a lot of action on that last question then I'll let you go Thanks see the presumptive Democratic nominee is Joe Biden and a few weeks ago you know someone said to me oh did you hear mr.

Biden's recommendation or suggestion or policy initiative of lowering the age of Medicare to 60 I go no I didn't and then I was reading about it and you know Medicare now is very different than Medicare ten years ago ten years ago was all government-run now it's 35 40 percent Medicare Advantage private insurers we've done quite well in that market the recommendation of lowering it to age 60 do you think this is feasible passable if he were to become president so let me say two things first I think coming out of Kovac even halfway through Kovac you're gonna see a huge for universal coverage not 90% that we have now but a huge push because I think the uncertainty and insecurity that is being created by COBIT people are going to demand on healthcare I need security and I do think there's gonna be a big push how you achieve that how do we get to universal coverage is the right answer to lower the Medicare age is the right answer to create Medicaid through all and say if you don't have Medicare you don't have employer-sponsored insurance you're on Medicaid and that's that and everyone's got it and we're gonna federalize it so we don't have the Texas and you know Alabama and Georgia and Florida saying no we're not going to expand the Medicaid covered I do think there's gonna be huge pressure and what exactly the resolution is I don't know and which approach we take I don't know but I would not be surprised if we end up in 2022 2023 with a much expanded health care covered I hope as we go there we make the system simpler because it's gotten so complex and you know figuring out what you're eligible for is is a real problem but I would also mention Howard you know it given 33 million Americans have lost their job a lot of them are going to be losing their employer-sponsored insurance even with employee insurance companies may be stepping up and and waiving premiums or giving premium holidays and stuff there is going to be a lot of people who are clock without insurance maybe they're in Texas they're unemployed they're not poor enough to get Medicaid but they're not eligible for the exchanges yeah it's gonna be a lot of people are gonna be demanding coverage and a system as we've known it is not going to be able to solve that problem and I think that creates a political pressure there's obviously got to be other things political pressure is not enough it's a necessary but not sufficient condition you're gonna need what's the plan and you're gonna need a change in the government so that the Senate would have to flip in the presidency would have to flip but neither of those are unimaginable going in to 2022 I do have to say I find it a little strange in this moment that President Trump has decided that it's his moment to declare we got to get rid of the ACA that just seems hard to understand as a response to a healthcare pandemic so it's interesting when I you know I spoke to Don Berwick we did a livestream last last week about you know just how medicine and society will change no one's a grander wiser thinker than Don and he said you know the the the 55 million people who feel most secure with their health insurance at the moment are the people on Medicare not Medicaid you have private insurance it was very interesting who feels most secure and it's someone who's 65 or older whether they're on private insurance or Medicare because if they lose their job they can get Medicare yeah and you thought that would have long-term implications about how people think about this from a pastry standpoint I think he's right I think the you know I learned this as a oncologist the most powerful not the most a extremely powerful sentiment emotion is uncertainty people hate it and I think right now there's a lot of uncertainty and uncertainty around health insurance and I think people are gonna try to I need security there I don't want this uncertainty anymore and if it could happen to me we've got to solve this problem I think you're gonna see something happen this is Howard Bochner editor-in-chief of Jong I've been talking to a really remarkable colleague and member of the Jama editorial board Zeke Emanuel Zeke's the Diane Levy and robertlevi University professor University of Pennsylvania vice provost of global initiatives and chair of the department of medical ethics and health policy Zeke as always thanks so much for joining me today you're you're just a pleasure to chat with Thank You Howard it's been a wonderful great questions be healthy be safe thank see take care all right you.

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