A Playbook for Beating the Next Pandemic

Bapu JENA: So your kids call you dad. You don’t ask them to call you Dr. Gottlieb in the house?

Scott GOTTLIEB:  No one calls me Dr. Gottlieb.

JENA: They don’t?  So that’s inappropriate for me to be asking my wife and kids to call me that at home? Okay.

GOTTLIEB:  And you can call me Scott. 

JENA: Okay, all right. We’ll call you Scott. And I’ll still tell my kids to call me Dr. Jena.

JENA: That’s Dr. Scott Gottlieb. He was commissioner of the Food and Drug Administration from 2017 to 2019. Now he’s on the board of Pfizer. He has had a courtside seat to our fight against Covid-19 since the start of the pandemic. And I have a lot of questions for him. From the Freakonomics Radio Network, welcome to Freakonomics, M.D.

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I’m Bapu Jena. I’m a medical doctor and an economist. And this is a show where we dissect fascinating questions at the sweet spot between health and economics. Today, we have a guest who turned two of the biggest questions I’ve been curious about in the last year into a new book. Questions I bet you have too. Scott Gottlieb’s new book is called Uncontrolled Spread: Why Covid-19 Crushed Us and How We Can Defeat the Next Pandemic.

I should mention that we recorded this conversation with Scott just a couple of weeks ago, but things move so fast these days, there have already been some major milestones in the pandemic that we didn’t get a chance to talk about. President Biden rolled out new vaccine mandates. Vaccine makers are seeking approval for doses that are designed for kids as young as 5. The Mu variant has now been found in all 50 states in the U.S.

But we’re taking a step back in this conversation to focus on the early days of the pandemic. Like: What happened during the initial response? And how can we learn from experience to handle public health crises better in the future?

Before we dig into those two million-dollar questions — they’re probably even multi-billion-dollar questions — I had just a few other questions about how this kid from New Jersey grew up to be the head of the F.D.A. The first step in that journey was becoming a doctor. So, when did that happen?

GOTTLIEB: I always thought I wanted to go into medicine. It was a profession where you would engage in lifelong learning. It was a profession where there was a sense of service.

JENA: You know, Scott, I’ve done some work looking at whether or not medicine runs in families. So, if I had to bet, I would guess that someone in your family was also a doctor.

GOTTLIEB: Yeah. That’s a good observation. My dad’s a doctor. And you’re right, it does run in families.

JENA: And what kind of doctor was he?

GOTTLIEB: He’s a psychiatrist.

JENA: I see. Okay, but you didn’t train in psychiatry, right?

GOTTLIEB: No, I did general internal medicine.

JENA: Were you a shy kid when you grew up or were you more outgoing?

GOTTLIEB: I was probably more on the shy end than the extrovert.

JENA: So you’re telling me that in your high school yearbook, you were not voted the most likely to lead the F.D.A. Is that correct?

GOTTLIEB: That’s definitely true. I don’t think that there were things that I was doing when I was growing up that really would have predicted this. I was doing a lot of writing about healthcare policy, and then I started to get called upon to talk about that writing. And the writing about healthcare policy is also what put me on the radar of policymakers in Washington, who ultimately put me in positions that allowed me to work into higher-level jobs and ultimately end up as commissioner of the F.D.A.

JENA: Obviously, the commissioner of the F.D.A., it’s a big and important job. But day-to-day, what did that job entail?

GOTTLIEB: First of all, no two days are alike. Every day there’s a crisis of the day that’s going to disrupt your game plan. And you need to be set up in a way that you can both deal with whatever the issue is that came up on that day and continue to drive forward your policy agenda. And that’s a very hard thing to do. In terms of what that job entailed, I would say it’s a very political job with a lowercase p. I don’t mean Democrat, Republican political. I mean that there’s a lot of issues that come before the F.D.A. where the F.D.A. has to assert its prerogatives, where it’s in the domain of significant interest to someone else. A lot of the F.D.A.’s jurisdiction encroaches other agencies’ jurisdiction. So you constantly have inter-agency, interdepartmental disputes about jurisdiction.

JENA: All right. Let’s dive into the book. It’s called Uncontrolled Spread: Why Covid-19 Crushed Us and How We Can Defeat the Next Pandemic. I want to dive into the first question that your book takes on, which is: Why is it that Covid-19 crushed us? And it probably feels like a blur, but let’s go back in time to the very end of 2019, early 2020. Where were you? What were you doing as the pandemic started to take hold?

GOTTLIEB: I first became very alarmed about what was going on in China the weekend of Martin Luther King Day. And what alarmed me that day was that overnight the cases that China was reporting had quadrupled. So it had gone from something like 50 to 200. If 200 people are in the hospital, severely ill with a new viral pneumonia, that is an indication that there’s probably hundreds, if not thousands of cases behind that, and you’re just seeing the very tip of a very big iceberg. So that was very concerning to me.

JENA: And what was the response at that early stage?

GOTTLIEB: One of the things that went wrong was that the agencies weren’t coordinating, that H.H.S. hadn’t brought together F.D.A. and C.D.C. to solve some of these challenges. You couldn’t just have each agency off working on its own thing. You had to have a coordinated response across the agencies, and that didn’t happen. It actually didn’t happen until they started to create Operation Warp Speed, recognizing that the only way you were going to get a vaccine in a very timely fashion was to bring coordination.

JENA: So, this might be a good time to do a quick 101 before we get much deeper into this issue. So, on paper, before the pandemic, what would you have described the role of the F.D.A., the role of the C.D.C., and the way they interact? And then the next question is, how did the pandemic change that, and how should it have changed that?

GOTTLIEB: I mean, one of the challenges with the way the government operates is these agencies operate independently, and they each have a domain, and sometimes they guard it pretty jealously. A strong secretary’s office could have brought the agencies together and had them collaborate and cooperate on some of the bigger challenges. And that played out most vividly with the efforts to try to get a diagnostic test where very clearly, you know, if F.D.A. and C.D.C. had been working more closely together, I think that would have been far more efficient. We would have had more diagnostic tests delivered more quickly, and that could have made a difference on at least the initial wave of infection.

South Korea and the U.S. detected their first Covid-19 case on the same day, January 20, 2020. But, each country took a different approach to testing. South Korea acted much faster in scaling up widespread testing. By mid-March of 2020, South Korea had tested more than a quarter-million people for Covid-19. The U.S., which has a much larger population, had tested fewer than 60,000 people.

At the same time, several other countries were also outpacing the U.S. in testing. New Zealand was carrying out 171 tests per confirmed case while the U.S. conducted only seven tests per case. So, why did the U.S. have so much trouble getting diagnostic testing up and going? Well, there were problems with production and decisions to limit testing.

GOTTLIEB: There was a perception in the secretary’s office. We’d have this sort of very sequential process where C.D.C. would develop a test, a proprietary test. At first, they’d run it, then they’d deliver it to the public health labs. They would start running the test. And then we would eventually work on developing an F.D.A.-cleared or F.D.A.-approved test that would be distributed to academic hospitals and then distributed to a broader set of labs around the country.

That sequential process is what we have done historically with outbreaks of new diseases. In the setting of a fast-moving crisis and a pandemic, that was never going to be sufficient. You needed to get to scale very quickly. And I don’t think that there was an earlier enough recognition of that. So we didn’t engage the commercial manufacturers and get them into the game early enough. And that hung us up for months.

Now, by comparison, South Korea, which ended up having a lot of diagnostic capacity early and a lot of testing capacity early, turned immediately to its commercial manufacturers. And they had put in place procedures for a very rapid handoff to their commercial manufacturers to scale up testing after their very devastating experience with MERS. They also ended up changing dramatically their own C.D.C. and their own C.D.C.’s role in an outbreak in a way that I think is going to be something that we end up emulating in many respects.

And just a final point on this, the lack of diagnostic testing, which was a root of many of our early problems— we couldn’t identify how spread was occurring, so we overestimated the role of contaminated surfaces; we didn’t recognize the asymptomatic transmission. C.D.C. ended up seeing all these settings where they couldn’t identify a sick contact, but they ended up having a very large outbreak, and they said, aha, people must be getting infected from contaminated surfaces, because they didn’t recognize the asymptomatic cases because they couldn’t get them diagnosed. When we started to implement the stay-at-home orders, we did it nationally. We early on didn’t need to do it nationally. There were parts of the country where this virus hadn’t traveled yet. There were clearly parts of the country that were engulfed in major epidemics, like the New York metropolitan area. We needed to implement the stay-at-home orders and shut down congregate settings because it was out of control. But we ended up having to do a simultaneous shutdown of 14 days to slow the spread across the whole country because we didn’t know where it was and wasn’t spreading.

So when the virus eventually spread to the Southwest or the South, people down there said, look, we already shut down, we’re not doing this again. Had we not shut down the Southwest early on, and we probably didn’t need to because it wasn’t spread there at the time, we would have preserved the political capital of political leaders to do it when the spread eventually emerged in those parts of the country.

JENA: Another issue that you talk about in the book is just sort of our general level of preparation. You use this term fragile response, and you wrote that many of the plans and preparations turned out to be a technocratic illusion. What do you mean by fragile response? And what were some of those technocratic illusions?

GOTTLIEB: I think that there was this belief that we had stockpiled what we needed for a pandemic. And we had stockpiled some of what we needed for a pandemic with flu. The pathogen that we always feared was a flu. We never anticipated that a coronavirus would cause a pandemic. Really we should have been focused on broad categories of disease. We stockpiled the wrong things. Even what we stockpiled wasn’t kept up to date. I mean, the best metaphor for that were the ventilators that didn’t work, or the N95 masks where the band broke when people put it on because it had become brittle, because it hadn’t been stored properly. And it was very old. And even if we had stockpiled the right things, what we really needed to be investing in wasn’t necessarily a stockpile of products, but the capacity to make products in a crisis and the capacity to source them domestically.

What we never anticipated was that if there was a global pandemic, there would be a global, simultaneous run on all the supplies that would be needed to combat the pandemic. It seems such an obvious point now, but it wasn’t a source of preoccupation in the way it should have been. We should have recognized that in a global pandemic, we won’t be able to source anything X-U.S. because every other country will be pulling on those global supply chains. We had seen with H1N1 for example, the swine flu, other countries nationalized some of the supplies that we needed to combat that pandemic.

So we had seen the behaviors before, but we didn’t learn the lesson. And so what does it mean going forward? It means we need to think about how do we build the domestic capacities we’re going to need in a public health crisis. How do we make sure we have enough biological manufacturing capacity so we can scale the production of monoclonal antibodies, because they’re likely to be the first therapeutics that become available in the setting of a new viral pathogen?

How do we make sure we have domestic capacity to produce vaccines? How do we make sure we have domestic capacity to produce something as simple as an N95 mask or personal protective equipment? There are ways to do that that I don’t think are going to be exceedingly expensive, but it’s going to take some deliberate policy to try to make sure that we have those domestic capacities.

JENA: I want to read to you something that you wrote that stuck with me in the book. You wrote, ‘I’m convinced that America’s failures and successes in this pandemic were not merely the function of any particular person’s or party’s ideology or behavior. Even with different leadership, many of the same system failures would have persisted. To help safeguard our public health we need to identify those more fundamental weaknesses, the root causes of our vulnerability, to make sure this doesn’t happen again.’ You’ve talked about the what. Like, so, what are all the different things that went wrong? Issues related to testing, issues related to the creation of an appropriate national stockpile, issues related to our understanding of how the disease spreads. Tell me about the why. So, what are the root causes of that vulnerability?

GOTTLIEB: There’s been a lot of focus and narrative on the political mistakes and the political shortcomings, and there were clearly political mistakes. There were clearly political shortcomings. There was clearly a lack of leadership at the White House, at H.H.S. over critical issues at various junctures in this response.

I think we’ve sort of focused on those and been preoccupied with those at the expense of thinking about what were the failings at an agency level, that I think were more fundamental. I think ultimately the failings at the agency level were more impactful in deriving this sort of corrosive response or this inadequate response than what was happening at a political level.

And there were a lot of information gaps early on, and it was sort of the fog of war. The other problem is that C.D.C. is not an operational organization. They’re not FEMA. They’re not the D.O.D. In fact, in 2015, during the Ebola crisis in West Africa, it wasn’t until the D.O.D. went in on the ground that you really started to mobilize a response.

When the C.D.C. was there, it wasn’t able to mobilize a response. It’s just not what they do. They’re not a heavy lift organization. They’re a high science organization. They do exquisite scientific studies and they handle small outbreaks. I think that there was this perception that C.D.C. has this, that they’re going to handle the national response. They’re going to mobilize a response. They’re going to set up the quarantines. They’re going to get the testing in place.

Now, it could have been created. If we had recognized the shortcoming we could have, from the very outset, created some kind of hybrid capacity to mobilize a response.

And this is where the political leadership comes in. You could have brought together early on FEMA., you know, the Department of Defense, C.D.C., in a coordinated fashion, and married this sort of heavy lift capacity of an agency like a FEMA or a D.O.D. with the scientific prowess of C.D.C., and have some overall leadership of that. That didn’t happen. And that was the critical political mistake. But then the functional mistake was, well, C.D.C. just couldn’t execute it. Maybe they should have raised their hand earlier and said, guys, we can’t do this. We don’t have this. It didn’t happen.

JENA: I think one of the key roles of the F.D.A. is to balance the speed and safety of drug and other approvals. So, for example, the approval of a drug could take longer and we’d be more certain about its safety and efficacy, but for some diseases like Covid, people’s lives might actually hang in the balance. And that’s the key trade-off. So, in general, where do you land on this balance?

GOTTLIEB: Look, I think that the F.D.A. has performed admirably in the crisis. Now, where I think from a policy standpoint, you could rethink how the agency approaches these kinds of public health challenges: The Emergency Use Authorization, which a lot of the products were made available initially under an emergency use authorization, including the vaccine is a very flexible framework that Congress— initially, they created it to address an act of bioterrorism. But it was broadened to address pandemic risks as well in the Pandemic All Hazards Preparedness Act. It’s a very flexible framework that gives the agency a lot of discretion in terms of how it makes products available in the setting of a public health emergency, the amount of data that it requires, and who it makes products available to. So, one of the things you could do under an E.U.A. is you could say, we have a vaccine. We’re going to initially make it available just for nursing home patients. After we get some data in two weeks, we’re going to broaden it to anyone over the age of 65. And then we’re going to broaden it beyond that. Because you know that half the deaths are occurring in nursing homes. You know people over the age of 60 or 65 are at significantly greater risk than younger people from Covid. Even early on we knew that. So you could have made the vaccine available in a more titrated fashion based on risk.

An E.U.A. or Emergency Use Authorization allows the F.D.A. to use real world data from a limited group to assess the efficacy and safety of the vaccine. Traditionally, the system relies on randomized controlled trials, but in the throes of a pandemic, this could have been an approach on getting the vaccine out more quickly. Scott thinks that was a missed opportunity.

GOTTLIEB: A couple of weeks after the interim data became available, after the agency had an opportunity to analyze it, you could have made the vaccine available under a limited E.U.A., just for certain settings, continued to let the clinical trial dataset mature, collect more data, and collect the real-world evidence from what was happening in nursing homes.

So I’m just saying, you know, if you’re thinking about what could we have done differently under the existing framework, you could have taken a more graduated approach to the introduction of some of these therapeutics. Now, that framework really didn’t exist. But I think if Congress is looking at this and they’re saying, “how could we reform the E.U.A. process?” giving the agency sort of explicit direction to think about how to use in a graduated fashion might be one way to do that, because clearly there’s going to be certain groups that are more at risk of a new pathogen than others.

JENA: I’m listening to you talk about these issues, obviously you’re very passionate about them, and you stepped down from the F.D.A. as commissioner, I think in 2019. Right? So not long, arguably, before one of the most important times in F.D.A. history. So just, as a personal matter, were you a little relieved that you weren’t in the job during the pandemic? Or did you ever wish you were back in the job?

GOTTLIEB: No, I regretted not being there, being there with my colleagues. Obviously it’s easy to say from the outside what you would have done differently if you were on the inside. But one thing I know I would have done during the first weeks of the outbreak was getting the commercial diagnostic manufacturers in the game early. There were times when I called C.E.O.s of companies, when we had a public health crisis or a public health challenge and we needed a company to do something, to try to address a shortage that was going to ensue. And I would call the head of the company and say, we need you to do this. We need your help on this. And I can’t remember a single time when we got turned down.

Coming up, more with Scott Gottlieb about how we can prepare for the next pandemic, and what it will take to make sure we can leave this one in the past.

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JENA: I want to talk a little bit more about the future, because you spend a lot of time in the book talking about how to defeat the next pandemic, which I’m sure we all hope never occurs, but let’s spend some time talking about that. First, I want to talk about vaccines. I think we’re all remarkably amazed by how well, and how quickly, the Covid-19 vaccines were developed and how well they work. Between your connections with the government and then later your role on Pfizer’s board, which you’re on now, I think you’ve had more or less a front row seat. Are there things that you hope that we can learn from the process of developing vaccines that we can bring to the next pandemic or other public health issues that aren’t as pressing as Covid-19 but still important in their own right?

GOTTLIEB: Well, I think from a science and technology standpoint, we’ve crossed a Rubicon. We’ve crossed into the age of fully synthetic drugs and vaccines. The reason why we were able to come up with these vaccine constructs so quickly was because they were synthetically derived from sequence data alone. Moderna, they talk about the fact that they never had the virus actually in their laboratories. If this was three years ago, we wouldn’t have been able to do that. And there’s other places where you can look at these synthetic approaches to develop oral drugs and other kinds of therapeutics. I think we need to be investing in all of them.

So that’s sort of one lesson learned. The other is that we didn’t have domestic manufacturing capacity for vaccines or biologics. And we need to create a framework where there’s some reserve capacity that’s kept domestic that could be available in the setting of a crisis. There’s ways where you could create a hot base of manufacturing capacity, not a warm base. The old notion was we’ll build a facility, we’ll partially mothball it, which didn’t work so well because what we found was that if you simply built a facility and you only partially operated it, you weren’t making the necessary investments in equipment, in people that would allow that facility to be scaled up very quickly in the setting of a crisis. In order for it to be available, it needs to be operating. There’s ways where you could build facilities, overbuild them a little bit, keep them fully functional, keep them hot, but have some residual capacity, some reserve capacity in those facilities to be available in a crisis.

JENA: In addition to this issue of making sure that we have a robust manufacturing capacity that will allow us essentially to turn a switch and produce the types of drugs or vaccines that we need when needed, what else can we do to prepare?

GOTTLIEB: We need a different clinical trial infrastructure that allows us to do practical clinical studies in the setting of a crisis. We can’t be doing, you know, placebo randomized trials in a setting of a crisis where we monitor a thousand different variables like we would for a normal drug approval. We need to keep it simple. And the British did that with their recovery study. And, in fact, all of the important answers, or most of the important answers we got about Covid therapeutics came from that single trial, which the U.S. didn’t even participate in because they deemed it insufficiently rigorous. We were doing very exquisite, randomized, placebo-controlled studies. And the British were doing the recovery study, where they were saying, let’s only track the 15 most important variables. So we need a different clinical trial infrastructure.

I talk a lot about looking at public health through the lens of national security, and that touches on all these domestic capacities that you want to build, but it also gets into issues of how we handle outbreaks and emerging infections overseas.

Traditionally, it’s been perceived that we will do all of our disease surveillance globally under the auspices of multilateral agreements with other countries, and it will be led by our public health agencies. C.D.C. is the tip of the spear in doing disease surveillance globally to try to spot emerging outbreaks that could become the next pandemic. That’s not sufficient. Because what we now know is, countries conceal information. Countries have not been forthcoming with information about outbreaks. They’ve tried to contain them quietly before they raise their hand. And so we cannot trust that through international agreements alone, everyone coming together at the World Health Assembly under the W.H.O. and holding hands and saying, we really promise this time that we’re going to share information.

JENA: So, if I could kind of summarize, first, you have to be able to have a framework to identify a pandemic and issues around surveillance, perhaps using clandestine activities, might be relevant. The second thing is to make sure that if a pandemic occurs, that you have the infrastructure in place to set up diagnostic testing, manufacturing of testing, manufacturing of vaccines, manufacturing of novel therapeutics, and then having a clinical trial infrastructure behind that allows you to get that high-quality information as quickly as possible. On this last point, I want to talk about the situation that we are in now, which is one in which we have a therapy, a vaccine, a Covid-19 vaccine that can help us out of this pandemic. And yet, we have a sizeable number of Americans who are not vaccinated by choice. What are your thoughts as a doctor, as a regulator? What are the root causes of that hesitancy, of people’s reluctance to take a vaccine that from the data we know works?

GOTTLIEB: Some people are reluctant to take a vaccine because they say, well, it’s novel and I’m young and healthy, or I’ve had Covid and so I don’t really need the vaccine. And so they’re making, within their construct, what could be argued as a rational decision. You know, they have a reason to be less fearful of Covid. It’s a novel vaccine. We’ve, you know— we only have experience with it for a year and a half. Now, I would argue we have more experience with this vaccine than we do most modern therapeutics given the fact that it’s been in, you know, a billion people globally, you know. 350 million doses have been administered in the U S. That is a decision based on someone’s sort of rational thought process. And I think that person ultimately may change his or her mind. And I think a physician and others can provide counsel that may move that person into the vaccinated bucket.

Then there are people who, you know, are sort of in a higher risk category, but they’re hesitant about new therapeutics generally. And you see this all the time practicing medicine, where people just are reluctant to take something that’s perceived as new. That again, you can counsel that patient. Some of them will move into the vaccinated category over time. For some of them, the F.D.A. approval was something that was a rubric that was important. Others, you know, I think providers will be able to get more of those people in that bucket vaccinated.

And then there are people that, for them, this has become sort of a political touchstone. And that’s the most perplexing category in my view. People who sort of see opposition to the vaccine as an exercise of their freedoms or their liberties.

And I think, you know, unfortunately, because you’ve seen the government try to promote and incentivize and in some cases mandate vaccination, it reflexively becomes something that a certain cohort of Americans is now against. Will that dissipate over time? I think it probably will. And when it becomes less a political issue, it’ll be an issue that people no longer need to try to take a position on to identify their political stripes. I’m hopeful that this will dissipate.

JENA: You describe yourself as politically conservative. So, what is it like to be a conservative and a scientist and a doctor at a time when science itself is really being cast as being increasingly partisan?

GOTTLIEB: Well, I don’t know that there is anything unique about being a conservative in this environment other than that I think that there’s elements in the conservative movement that don’t do public health well anymore. I think that there was a time when conservatives and Republicans did public health really well. And that’s in jeopardy now. I think you’re seeing elements in the conservative movement that are sort of anti-public health and fomenting opposition to some of the reasonable, thoughtful policy steps that we’ve tried to advance in the last couple of years to deal with Covid. Some of the policies that we’ve adopted to try to deal with Covid I think should be debated. And we should question them and evaluate them and see if these are things that we would do again in the future. We were sort of in the fog of viral war, and we were reaching for what we could to try to control the impact of a very devastating virus. But there are certain things we should agree on. And we’re not even agreeing on the easy stuff right now.

JENA: What concerns you most as we look just forward in the next few months?

GOTTLIEB: Well, I think that this Delta wave is going to coarse its way through the population. This variant has been highly efficient at finding pockets of susceptibility and the social and geographic compartments. After this Delta wave has finished coursing its way through the population, you’re going to have a very high rate of immunity in the population, either through vaccination or people who’ve been previously infected with the virus. And I think as we get into the late fall and the winter, you[‘re] still going to have reasonable prevalence of this virus because it’s, after all, the winter time. People are indoors. Prevalence is going to decline, and we’re going to be living society against the backdrop of some pervasive spread, but it’s not going to shut down society.

What worries me is the unknowns. Is a new variant going to emerge that’s going to partially pierce the immunity that we’ve acquired either through infection or through vaccination, and be able to start to spread? We should be in a better position now. We should be able to spot it. We’re sequencing more. We can refashion our therapeutics if we had to, but I also think that it’s going to be hard for this virus to pull off that feat. It’s, first of all, going to be hard to envision a variant that’s more contagious than Delta, now, at least that’s my sort of optimistic, hopeful, you know, scientific prediction about the trajectory of this.

Thanks to Scott Gottlieb for taking the time to talk. We recorded this conversation just a couple of weeks ago, and of course lots of things have already changed since then. Keeping up with all the pandemic news has been pretty exhausting, and it doesn’t seem to be letting up. But while we keep doing our best to get through each day, I think it’s important to carve out some space to try to learn from this recent past and to diagnose the problems in our systems — not just dwell on the politics — that we’re going to need to address the next crisis head on. The insights in Scott’s book can, I think, help us do this.

The book is called Uncontrolled Spread: Why Covid-19 Crushed Us and How We Can Defeat the Next Pandemic. It’s 512 pages. And I’ll tell you, it might’ve sold more copies if it was called Harry Potter and the Curse of the SARS-CoV-2 Spike Protein. But seriously, it’s an important read.

That’s it for this week’s episode of Freakonomics, M.D. Thanks for listening, and I hope you follow the show. I’d love to hear from you. If you have thoughts on this episode or ideas for the show, you can email me at bapu@freakonomics.com. 

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Freakonomics, M.D. is part of the Freakonomics Radio Network, which also includes Freakonomics Radio, No Stupid Questions, and People I (Mostly) Admire. This show is produced by Stitcher and Renbud Radio. You can find us on Twitter and Instagram at @drbapupod. Original music composed by Andrew Edwards. This episode was produced by Colleen Pellesier and mixed by Eleanor Osborne. We had help from Brent Katz and Adam Yoffe. Our staff also includes Alison Craiglow, Greg Rippin, Joel Meyer, Tricia Bobeda, Emma Tyrrell, Jasmin Klinger, Lyric Bowditch, Jacob Clemente and Stephen Dubner. If you like this show or any other show in the Freakonomics Radio Network, please recommend it to your family and friends. That’s the best way to support the podcasts you love. As always, thanks for listening.