A Conversation With Jay Bhattacharya of the National Institutes of Health

Director of the National Institutes of Health Jay Bhattacharya discusses the latest developments in biomedical innovation and how they will shape the future of public health research.

BURWELL: Good morning. Good morning, everyone. And thank you all for joining us. Thanks to those who are joining us virtually. We have folks doing that as well. And thanks to everybody in the room, and a special thanks to our guests, who I personally know how busy a director of NIH is. So thank you so much for joining us this morning, Dr. Bhattacharya.

I think most people know about your background. I’ll say just a few things. The eighteenth director of the National Institutes of Health. Became that on April the first of this year. And a Stanford graduate who, I think, B.A., M.A., Ph.D., and M.D.—(laughter)—from Stanford in terms of a wide, wide range of degrees. And focused on issues from medicine to issues of public health to research to economics, and health economics. So a very wide range. Over 170 published papers. Has spent time at everywhere from RAND to the National Bureau of Economic Research, in terms of the economics part of this, as well as at Stanford. All of that before becoming the NIH director. And has spent time on population aging, issues of chronic disease, as well as with a focus on vulnerable populations. So a lot in a very broad range. Great for the NIH to have someone. Many of you all probably know about the Great Barrington Declaration. And that’s where a lot of folks, I think, learned about you and your work. And we’ll talk a little bit about that today in our session. Born in Kolkata, India.

And with that, welcome so much. We’re so glad to have you.

BHATTACHARYA: Thank you for having me, Sylvia. Thank you for this opportunity to talk to everybody.

BURWELL: I thought we would actually start with things that people generally—you know, you can’t find on Wikipedia or anywhere else. And that’s, how did you come to science and economics? How did you come to these topics, and a little bit about your journey? Because I think that’s always informative to understanding how you lead and how you think about the issues.

BHATTACHARYA: I mean, I’ve loved math and science since I was little. I kind of always wanted to be a doctor, because I figured this is how you use math and science to—I mean, it’s just really sounds cliché—but it’s how you use math and science to help people. But I got to—I got to undergraduate and I took—because they forced you to take general ed requirements—I took an econ class. And I was amazed by the idea that you—I mean, as soon as I encountered it, I realized that the idea of these constraints, like, you have to have rigor in your statistical thinking, all of that is really, really important for medicine. It’s probably even more important for medicine than it is for economics.

And I met, I met a man named Alan Garber, who’s the president of Harvard, when I was nineteen. And he had an M.D. and a Ph.D. in economics. He absolutely inspired me. And I did an honors thesis with him. I did a Ph.D. in economics. Actually, first I got to medical school and I realized I couldn’t just do medicine. It was—I missed economics too much. So I did a Ph.D. also, and then I had to figure out what I’d need to do when I grew up finally. (Laughter.) So.

BURWELL: Well, one other question on this kind of history. Lifetime returns to specialization in medicine. That would be the title of Dr Bhattacharya’s dissertation. So we’re going back in time.

BHATTACHARYA: You’re going back. You’re going back.

BURWELL: I’m going back. I’m going back. I did I did my research.

BHATTACHARYA: Yeah, I can tell, Sylvia. (Laughter.)

BURWELL: That is who I am. I, like you, like research as well as other things. Tell us just a little bit about that dissertation.

BHATTACHARYA: So the question was, why do surgeons earn so much money? (Laughter.) And the basic framework was that you have a few explanations that make market sense, right? So, like, surgeons have to train a long time in order to get to where they are. So, like, you know, no one’s going to do it unless they make more money than you’d expect. They work a lot of hours. Back then this was before the eighty hour work week for residents. They were, like, 120 hours. There’s 168 hours in a week, you guys. So, you know, that’s something, right? And so, like, those would be normal market explanations. Also, you might think that surgeons are, like—well, if you ask surgeons they say they’re smarter than everybody else. But so maybe that’s why.

The dissertation asks, do those market explanations—are they sufficient to answer why they earn so much more money than internal medicine doctors? And the answer is, no. About half of what the difference between internal medicine doctors—the sort of the rate of return for internal medicine doctors—lifetime returns for internal medicine doctors versus surgeons can be explained by these market forces. And the rest is essentially market power, which is actually bad news for the American healthcare system. It means we spend a lot of money, probably a lot more money than if we just had a sort of a more competitive market for surgeons and for doctors just generally.

BURWELL: Boy, we could go a lot of different places. And we will come to affordability and healthcare a little later on in our conversation. It would be interesting if you did this work with nurses. You don’t have the length of the education, but some of that I’d be—

BHATTACHARYA: That is a really interesting topic. And that’s something—

BURWELL: That would be a fascinating topic.

BHATTACHARYA: That’s something I want to start supporting research on at the NIH, because I think that is fundamental. Both the market for physicians and market for nurses are fundamentally important for the affordability of care.

BURWELL: Primary care physicians and nurses and people at top of license.

BHATTACHARYA: Access to care—

BURWELL: We’re going to come to affordability.

BHATTACHARYA: OK.

BURWELL: As you can see, we probably could go deep in a lot of topics, but we want to cover a lot of ground. And one of the places to start, which I think so many people here are probably interested in and I know is a focus of yours, is biomedical innovation. And I thought we could start the conversation on biomedical innovation, on, everybody says—we can probably survey this entire room, and everybody’s going to be for biomedical innovation. But I think the real question is, how do we define success in biomedical innovation, so we get on the right path in terms of, OK, if this is how you define success, how do you think you best get there? So I want to start with, like, you’re head of NIH. We are successful in biomedical innovation. And everybody in this room knows that five years from now if, please fill in the sentence so we’ll all know, did we get there or not?

BHATTACHARYA: Well, I mean, that’s a great question. And in fact, that’s the question I asked myself when I got tapped for this crazy job. The U.S.—

BURWELL: And I can confirm it is a crazy job.

BHATTACHARYA: It is an insane job.

BURWELL: I just want to confirm.

BHATTACHARYA: I really miss—I miss being a professor. That was a really fun job. But whatever, this is important, right? So the U.S. has seen no increase in life expectancy in this—for people in the country since 2010. From 2010 to 2019, it’s flat. Flat at, like, eighty-one years. And this is true for every single—especially for minority populations. Flat. For whites? Flat. For rich, poor? Flat. Now, of course, there’s big differences in life expectancy based on these factors, but the trend is flat for every almost everybody. And, of course, the pandemic, there was a collapse in life expectancy, more than our peer nations. And it’s only this year we’re back to 2019 levels, which means 2010 levels.

If you look at our peer nations, their life expectancy is continuing to go up. The mission of the NIH is to support research that advances the health and longevity of the American people, of humans. And I will not view myself as a success unless we—unless we can turn the investments that we make in biomedicine into better health for Americans. That’s the fundamental—if you want to understand the moment, why we’re here, why there’s so much distrust in science and medicine and public health, there’s a lot to do with COVID, but that fact—why does MAHA exist? Why is it such a potent political force? It’s because of that fact, no translation from the real advances in fundamental biological knowledge to better health for Americans.

BURWELL: So as we get to those—like, get into measures—I like measures and numbers and things like that. I want to ask you to create an index between longevity and wellness. In other words, so—you know, is longevity exactly the right—how do we think about balancing those things? If you live a long, long time, but your quality of life is not such, or if you live a long time but, like, at forty you have heart disease and other things. So how do you think about—you know, longevity is easy to measure. We can, you know, measure that one. Get to the wellness.

BHATTACHARYA: No, that’s—I mean, that’s a great point, right? So, like, when I was a tiny person—so I was, like, really focused—I was focused on demography. And there’s, you know, in the 1990s it was essentially a birthright. Like, people were living longer. And there was also this idea of compression of morbidity. The idea was that you would—you we’re all human, and we’re eventually going to get frail. But that frailty would happen at the very tail end of your life. And so you’d live most of your life healthy and then, you know, you fall off at the very end, right? And it looked like there was progress toward that. Sometime in the 2000s that turned around. The chronic disease crisis that you see now everywhere, it essentially meant that we were not going to have that promise of, like, compressed morbidity toward the end of your life, with longer and longer lives.

Economists have, like, a ton of these measures. You know, I can go into some, like, geeky details, but it’s not worth it. By almost every measure, not just longevity, Americans are not healthier than we were. And the promise for our kids that they will live longer, live healthier lives, is gone. I mean, and so—I mean, I don’t want to, like, put too fine a point on it, but, like, the huge advances in biomedicine, if they don’t translate over to solving that problem, the traditional, almost universal as you said, Sylvia, support for biomedical research, biomedical innovation, people will start to ask, what are we getting for our money?

BURWELL: And as we think about that, wellness. And you’ve worked on chronic diseases. You know, what are the three in terms of, like, what would be good measures? Because, you know, what gets measured gets done. And how you—how do you think about what are the three things?

BHATTACHARYA: (Laughs.) Three is tough on this, because health is—you know, like, what is it, the U.N. definition—or, the World Health Organization definition of health it’s, like, it’s not simply the absence of disease, but, like, I mean, it’s an insane thing where, like, you know—

BURWELL: Yeah, you’re not hungry, you’re not—

BHATTACHARYA: Well, it’s, like, essentially, like, fulfillment—the ability to live a fulfilling life, right? That’s very difficult to measure, because it means different things for different people. But the very least we can look at, we can look at the absence of disease, right? Do we have type two diabetes? Have we addressed that? The obesity crisis, the cancer incidence—the increasing cancer incidence, the Alzheimer’s disease, Parkinson’s disease, child disease of kids. So, like, you know, the autism epidemic, one in thirty-one kids. You know, you can go on and on. These are all things that that that make the lives of people less fulfilling than they otherwise would be, if we had better ways to address them.

BURWELL: Would you put lonely—how would you deal with mental health?

BHATTACHARYA: Loneliness is really important. I mean, actually—

BURWELL: How would you deal with mental health in these measures?

BHATTACHARYA: I wrote a paper about loneliness, actually, with the folks at the AARP. Because it turns out that that lonelier older adults have higher Medicare costs.

BURWELL: Oh, yeah.

BHATTACHARYA: Loneliness is—actually, in the U.K. I think they have a minister of loneliness, of all things. So just a—I don’t know what they did during the lockdowns, but whatever. That’s another—

BURWELL: Maybe we may look at the Bhutanese and gross national happiness in terms of what they measure. So let’s maybe turn to many folks in this room probably know of you and your work in the COVID epidemic and pandemic. And wanted to start with how you think about COVID itself. It is a virus. And how you think about COVID itself, and then how you think about it and its relationship to public health. Eventually, would like to get to a little bit of a dialogue and conversation about preparing for pandemics, and how we think we should do that.

BHATTACHARYA: Right. So COVID is a viral respiratory disease, obviously. It has—respiratory in the sense of, like, how it’s transmitted. It has other impacts on human health beyond just the respiratory acute phase, sometimes. There’s still, obviously, long COVID. The virus itself, I believe, was the output of essentially lab experiments that the U.S. funded, that the Chinese, very sort of irresponsibly, invested in. The disease itself in its early phases had a mortality rate—an infection fatality rate of about somewhere between two in 1,000 and four in 1,000. I can give you lots of evidence for that. The most important epidemiological fact about it, beyond that mortality rate, is its steep age gradient in mortality. Where for every seven years of age the mortality risk doubles, right? So the sharpest risk, the greatest mortality risk, were for older populations. It’s vanishingly low risk—not zero—but very low risk of acute infection, mortality for children, for instance. And then this sort of exponential increase in risk with age.

The disease is—it’s an RNA virus. So it mutates very, very rapidly. And, you know, as a result it resists—it resists having vaccinations that actually can prevent it from spreading or getting infected. You know, the evolution of the virus has a tremendously important role in thinking about, like, treatments. Treatments that, you know, worked early won’t necessarily work late, and so on. So there’s a lot more we can talk about, but that’s how I think about COVID.

BURWELL: And as you think about that, and that mortality rate, in the early days was that the mortality—the one thing that I think, as we start to talk about pandemics, is what’s known and what’s not known. And the importance of—you know, I think we in the health space, all of us, and I speak to Ebola too, we don’t communicate enough about, in a pandemic it is an evolution of knowledge. It’s so extremely important to say, here’s what we know, here’s what we don’t know. Here’s what we kind of know, in terms of this issue. And communicating constantly about the—because it is an evolution. That’s why, you know, the evolution of things that you know at different points in time, and the public engagement in that.

But that brings us to the engagement of this particular issue and public health, which you spent time on and wrote about. And do you want to talk a little bit about that? But this evolution, as you do talk about it, I would love to hear your thinking about the importance of recognizing that in a pandemic, just as the virus is evolving, so is our knowledge, understanding, tools, and the public’s perception and understanding.

BHATTACHARYA: Think it was like 1994 or ’(9)5, I was a third year med student. And I don’t know who’s been to med school, but, like, the third year is, like, the most frightening time for a medical student, because you’ve done two years of class work and you’re going into the clinics, meeting patients for the first time. Just so, like, and you put on this white coat. And you look in a patient, and the patient looks at you, and they think you know everything because you have the white coat on. But you really don’t know anything. Oh, Sheri Fink is in the room. She was about my medical school colleague, my med school classmate. So she remembers. And it’s absolutely frightening, right? Because you’re sitting there in front of the patient, the patient’s, like, asking you all these questions, and you literally know nothing. You can tell them what the Krebs cycle is, but you can’t, like, answer the question, right? Answer the basic question.

So that’s what happened to public health, collectively, right? Public health was put in a position where they were asked to answer questions that they did not have the answers to. The big sin you can make as a medical student is you can pretend knowledge you don’t have, tell the patient things that you don’t know to be true. It’s fine to say I don’t know. I’ll go look. I’ll go ask. I’ll go do some research for you. I’ll get back to you, right? That’s fine. That’s good, OK. But it’s not OK to say, this is what’s happening to you, and you must do X, Y, or Z, when you don’t know that that’s what’s happening. You don’t have the knowledge. Public health suffered this third year medical student crisis. And it failed during the pandemic.

It pretended a knowledge it didn’t have. And, worse, what it did is it delegitimized honest discussion and debate. And I can tell you that from firsthand experience. Essentially it used all the power it had to make sure that people who did not agree with the answers that are being put out—is the virus aerosolized, what is the infection fatality rate, what is the age gradient mortality risk, how harmful will closing schools be for people? All of that needed to be discussed upfront in March of 2020 when the lockdown decision was made. And you could not have that discussion. And it was—I mean, we can point fingers, but collectively that’s the root of the crisis we currently face.

The honest engagement with the fact that public health failed at its critical moment to have an honest engagement and discussion about the crisis we were facing, it’s led to the public—the collapse of public trust in public health. I saw a JAMA article last year, Sylvia, where 70 percent of patients don’t trust their own doctor. And one in four Americans think that scientists don’t have the best interest of Americans at heart. It’s a total disaster. We have to figure out a way past that, but that’s the—that was my—that was the problem I had during COVID. It’s not that I had all the answers. It’s just we needed to have an honest discussion.

BURWELL: And as we think about that going forward, and the questions, what are the ways that you can have that kind of—now, you’re, in the jobs now. So you’re at NIH. And, you know, tomorrow, you know, we find out that, like, you know, it’s the new H1N1, it’s the new COVID, it’s—you know, we’re just starting to see it. We can’t tell. We don’t know the answer, is it asymptomatically? We don’t know, is it respiratory, you know, is it aerosolized, does it go through the air, in terms of—we don’t know those answers.

And the American people are looking to you, you’re the head of NIH, to answer those questions. How do you think through what you do? Because one of the things about the time for the dialogue is we kind of got to act, because people are dying. How do you weigh that acting and the importance of creating space for dialogue? How do you—how do you actually do it, when push comes to shove, people are dying, hospitals are shutting down. You know, in Italy we saw what happened. In New York, we saw what was happening. How do you—how do you balance these two things?

BHATTACHARYA: Well, first, you don’t panic. That’s rule number one. You certainly don’t abet panic. I mean, I think that—abetting panics came to be seen in March of 2020 as a virtue. Like, we need to make sure that people are adequately scared. That’s a critical mistake in public health. You do not scare the population beyond what—you have honest answers. I am very comfortable telling people I don’t know. I’m very comfortable people-telling I don’t know publicly. I’m very comfortable saying that I’m wrong when I’m wrong. I think that kind of engagement is going to be—in that kind of crisis, is going to be very, very important.

Actually, can we broaden it to, like, how you prepare for pandemics?

BURWELL: Yeah, then on preparation.

BHATTACHARYA: Because I think we’ve had the wrong model for pandemic preparation for a very long time. The idea—this goes back, I think, to, let’s say, 2000. It goes back further than that, but, like, let’s just start at 2001 and the SARS pandemic—the SARS epidemic, right? That scared the living daylights out of people. You have a naturally occurring virus in that populations that nobody knew about. We thought coronaviruses were just a common cold. And all of a sudden you got a disease—an infection that can, like, kill—that had a really high infection fatality rate, you know, like five, ten times more than what COVID had, even in the early days of March.

And it luckily didn’t seem to spread via aerosols, which is why it didn’t cause the—but it came out of a natural—it came out of a bat, right? A bat in China. The Chinese hid the—hid its spread early on, which made the response a little more difficult. And in 2006 there’s the avian flu, right, where—H5N1. It’s it doesn’t actually infect humans very easily. You have to have a lot of exposure to it in order for it to infect humans. And it’s a high death rate if it does infect a human, but there’s very little evidence of human-to-human spread, right? Which is why we’re not all dead. And so, like, you have a—you have this, like, desire to be able to predict what the next pandemic is going to be. But there are, like, I don’t know, round off error, a trillion viruses. I don’t know, there’s just a very large number of viruses out there. And we do not, as humans, have the capacity to go and, sort of like a butterfly, collect every single last one of them—characterize every one of them.

But we picked—we chose that as our strategy for predicting and preventing that and dealing with the next pandemic. And so what we did is we sent—we had a research program where we send scientists into the remote places of the world, bat caves in China or something, and bring viruses and pathogens they find there into labs, often with inadequate biosecurity or biosafety protocols, make them more transmissible among humans, manipulate them using powerful tools and research, with the idea that if we can tell—if we—if the virus that we pulled out of the bat cave is close in evolutionary space to the viruses—to something that can actually infect humans, well, those of the trillion viruses out there, those are the ones we should prepare for.

And then we prepare vaccines or other countermeasures for the virus that has never infected a human. In other words, you prepare vaccines and countermeasures on—essentially in theory that, never testing on humans, and get give, like, contracts to companies to, like, stockpile them at scale into perpetuity. When the virus actually does make the leap, it will not be the virus that we play with in the lab, because evolution is incredibly creative, right? It will be a very different virus. And the counter measures we have, that we assume will protect us, will not protect us, because it’s never been tested on humans. That paradigm for pandemic preparedness is a failed paradigm. And especially since there’s a risk of a lab leak when you pull the viruses out of the remote places and manipulate them.

BURWELL: So we can, in terms of the preparedness, I want to move—I want to move on, because, everyone, at the top of the hour we’re going to open it up to questions, and want to make sure we’re able to do that. Because as part of that, your theory of preparedness. So want to—

BHATTACHARYA: We haven’t even talked about my theory. I’m just thinking—I just criticized the old theory.

BURWELL: Yeah, yeah. But in terms of the inclusion of preparedness, in terms of our ability to know and understand when something is happening somewhere, so surveillance. Capabilities of surveillance. Capabilities of developing testing capability quite quickly. You know, in terms of some of the things that, you know, that one could do, that we do do, you know, that was a portion of the strategy of preparedness. But another portion are some of those other elements. And maybe we’ll come to that through some of the questions.

But before we open up to questions I wanted to try and get two more in. And at the end of the week last week we heard a lot in the news about vaccinations, particularly Hep-B. And at HHS, you kind of have a troika of FDA, Food and Drug Administration, NIH, National Institutes of Health, and CDC, the Center for Disease Control. And those three working together is, like, quite an important thing to outcomes for both public health, and individual health for that matter. And so as we think about that, that they usually are working together. And wanted to kind of understand, how is that working now in terms of the relationships? And, you know, how were you all able to engage, or not, in those issues—the vaccination issues?

BHATTACHARYA: I mean, there’s quite good relations between me, and Marty Makary, and Mehmet Oz, and Bobby. I mean, so in that sense at the top level there’s a lot of, like, you know, sort of desire to coordinate. Of course, the NIH, the FDA, and the CDC have very, very different roles, right? So the NIH is a slow burn. Like, we invest in research and, Lord willing, three, five, ten years from now, there’ll be some huge advance, someone will win Nobel Prize, and Americans be healthier, right? That’s the NIH. The FDA, they’re responsible for deciding whether to approve the vaccines, for instance, for use. You know, there’s standards for that. And then they’re also responsible for post-market surveillance, if there’s safety signals to identify them and say that. And then CDC is the public health agency, like, primarily. So they make—they make recommendations about, well, should you vaccinate your kids? When should you vaccinate your kids, and so on.

And those are three very, very distinct roles. We can talk about this, but, like, the science, medicine, and public health I think have very different—I mean, in this—while we’re aligned in the sense of, like, the ultimate goal, which is better health for people, they have very different standards and norms, and are actually in tension with each with each other to some degree, right? Just take the Hep-B question, right? So the Hep-B, the issue there was—the issue there—the primary issue, the real—the point of the arrow there, as you say, was should parents and doctors together decide when to give—when to give a child a Hep-B vaccination, right? The whole controversy was over shared decision-making. Shared decision-making on timing, right?

And so that is—you can ask about the FDA, the NIH, and the CDC, as, like, decision-makers that can help contribute to this discussion. But fundamentally that is a question for the public at large. And this has to do with, like, the role of public health versus the role of medicine versus the role of science, right? So let’s just take public health and medicine. When you see a doctor, do you want that doctor to represent your interests or do you want that doctor to represent public interests? When you’re sick, and you go to a doctor, whose interests do you want that doctor to represent? If there’s a tension between the public interest and the interest of the patient, who should the doctor represent?

So the real issue, the real substantive issue at stake with that Hep-B decision, was that. Like, who—should you have shared decision-making between the doctor and the patient in deciding the timing of the vaccines, or should you have public health considerations at play? And especially this is in light of, like, a vast collapse in the trust that Americans have in doctors and in vaccines right now, in ways that are, as a doctor, quite distressing. So, you know, I just—I think that’s the real issue that really the press went crazy, but they—we didn’t—we sort of didn’t get to have a real discussion yet about the fundamental issue at stake.

BURWELL: However, I want to go back to your thesis—your dissertation. I want to take us back to your dissertation, where markets didn’t work. We learned from your dissertation that markets didn’t work and surgeons were paid disproportionately. And now my question actually applies to science and the individual’s interest. And, you know, let’s just use Alexis de Tocqueville, self-interest, well understood. So if I accept the premise of part of this conversation, which is that we want the doctor representing the individual—or, to what extent.

That was—I think, let me frame the question that way. In a world where we know the facts. We know the facts around Hep-B and what happened before and after in terms of people’s ability to make that decision, both at that time—twenty-nine hours of labor, I’m not sure how cogent I was at that point in time, in terms of making these decisions and that sort of thing, and ability to do that in terms of protecting the child. And so just in terms of—the reason that NIH is connected is because the science and the research that gives us information about, you know, when these things are—decisions that we see. If we move the decisions to one place, what results we get from a from a measurable place. And so just, you know, as you—that’s the scientific connection—

BHATTACHARYA: Yeah, so let’s—on that, it’s still—to me, it’s an open question, right? So, like, a lot of other countries do it very differently, right? So they don’t recommend the birth dose of Hep-B. They recommend the dose at two months for patients who are—for patients who are—for moms who are Hep-B negative they recommend two months, right? And so, you know, a lot of countries do it differently. I think it’s a legitimate, interesting scientific question, what that—what that impact? That’s the kind of thing the science ought to be interested in. I’m quite interested in that. But it’s not an open—it’s not—it’s not a closed question, in my view, right? So, actually, this relates to the tension between science and public health, right? The ethical norm in public health is unanimity, right? If I go around as NIH director saying that smoking is not that bad for you, might even be good for you—which is not. It’s terrible for you. Don’t smoke. (Laughter.)

BURWELL: You’re clear on this? So no one walks out of this room. I want to be clear that he said the other part.

BHATTACHARYA: Yeah. But I will have committed a sin, right? I will have essentially violated sort of what my obligation as a someone in a position of authority and power in science to—in public health—to, like, encourage people to do something that I know is really the scientific evidence is bad for them. There’s this, unanimity of messaging is an ethical norm in public health. In science, it’s the opposite. As a scientist, you must question whether established knowledge is true or false—is true. If you’re not doing that, you’re not a good scientist, right? You are always probing. And no—and very few questions are off limits. Very few questions are off limits.

And so you have a clash of norms that you saw play out during the pandemic, where scientists—dissident scientists were subject to devastating takedowns, were, essentially, silenced, marginalized, delegitimized, because they were asking scientific questions about the basis for the kinds of advice that were given during the pandemic. I mean, it’s—this is a fundamental tension, right, both between medicine and public health and science and public health, right? So—

BURWELL: We didn’t—we weren’t going to discuss this tension about public health, individual health, and get into this. We don’t—

BHATTACHARYA: Sorry for jumping—

BURWELL: No, no, no. I think we don’t have time, but one of the things I would just add is you can’t keep them separated, because you also have to add economics. And so let’s just do, who’s going to pay for mammograms, and when? You know, that’s the—one of the easiest examples. And to have a health system—and, you know, that’s why, you know, when you’re sitting in the seat I sat in one has to think about it from a systemic approach.

BHATTACHARYA: Oh, so I thought my job is hard. That is an impossible job. I know no idea you or Bobby or those others do it. It’s just—

BURWELL: No, it is the crossover.

BHATTACHARYA: I just have to do science. I mean, that’s—(laughter)—

BURWELL: No, I mean it is—but it is the—you know, when one thinks about all this, it is that ability to bring all those elements. And I see one of my colleagues from HHS here, Richard Frank, economist—a health economist. But it is bringing all of those pieces together, and making decisions, and trading off—trading off that individual advice of the doctor, trading off the insurance companies and payers—companies, individuals, the federal government, your tax dollars’ ability to create a system that works. And you got to bring it all together. And that’s where one’s willingness to gather the different pieces and then make judgments becomes so important. We weren’t going to go down that path. We talked a little bit before, but we don’t have time.

We figured out we could have—like, we could go for days. But we’re going to open it up instead, in the room. And if you wouldn’t mind just introducing yourself before you ask your question, that would be terrific. We’re going to start in the room, and then I’m going to make sure I turn and see if we have anything online. Let’s start right here. And then we’ll go here and here.

Q: Thank you. Earl Carr, representing CJPA Global Advisors. Thank you for a fascinating discussion.

I want to go back to your question about being honest with the public about not knowing. In the middle of a health crisis, if you were to tell the public “we don’t know,” would that not ostensibly cause more of a health crisis, because people are counting on you and experts in sciences to understand and diagnose what the problem is? I mean, we have it in hindsight—you know, hindsight is always 20/20—but I’m just wondering if that would have caused even more of an uproar if you were to be honest with the public.

BHATTACHARYA: Oh, I mean, thank you for that question. But I think the answer is, no. I think it’s—the public is much more sophisticated than we think. If I say I don’t know, and I follow it up with here’s what we’re doing to find out, I think the public will respect that much more than, here’s—I know this is true, trust me, and then ex-post it not true, right? I think that is a recipe for disaster. I mean, we did this. It’s the recipe we followed during the pandemic. If we had—and I think it’s not just the pandemic, right? On question after—like why are autism rates rising? Like, one in one in thirty-one now, and one in ten—what is it—10,000—I don’t know. Some numbers, much smaller before.

I have seen twenty-five different theories for why, including, you know, new diagnoses criteria, the economic incentives to have an autism diagnosis, to, like, more biological questions. And as a scientist, I don’t know the answer. And when I’ve been asked—I was asked this in front—by the Senate—by the Senate. Like, what’s—you know? And when I was testifying in front of the Senate. And the honest answer is, I don’t know. And what I want to do about it is I want to support research with a broad range of hypotheses so that we can get an answer, right? There are families with severely autistic kids that are suffering that deserve better answers for why their kids are suffering, and how we can alleviate that suffering, and how we can potentially prevent that suffering for future families.

I think if we talk to the public that way, just honestly, the same way we talk to each other when we’re, you know, in, you know, whatever faculty lounge or something, I think people respond much more to that honesty with trust than they would if you pretend to knowledge you don’t have.

BURWELL: How do you think about the next part of that? Which is, I don’t know? I don’t know if Tylenol—you know, I don’t know, but I’m going to put a warning.

BHATTACHARYA: OK. I don’t know whether sushi eating during pregnancy is bad for kids or bad for—I don’t know. I mean, I’ve looked at that. My wife made me look at the evidence because she had three kids. So yeah, so—actually, she looked at the evidence herself. But that’s another—but—

BURWELL: And she is a physician.

BHATTACHARYA: She’s a doctor, yes. So we have a fun time.

BURWELL: We would trust is my—

BHATTACHARYA: You should trust my wife more than actually—

BURWELL: I was going to say—that was the point I was making.

BHATTACHARYA: (Laughs.) Yes. I mean, I’ll tell you that, and she’ll tell you that, so it’s fine. (Laughter.) So, but, yeah. So I think the—so, like, there’s a lot in—especially around pregnancy—about, you know, exposures. We don’t know because it is very difficult, almost impossible, to run randomized trials with pregnant women as the—as the subjects, for reasons you can completely understand, right? And so that means we’re left with this evidence vacuum. And so then, then the public health space is very, very risk averse. And they say, OK, well, you know, there’s this idea in Judaism of running—putting a ring around the Torah, where you don’t want to violate God’s law, so you start not doing lots of things that’s not explicitly part of God’s law, right? So that’s what public health is like. Let’s put a ring around the uncertainty. And so you don’t eat sushi.

I had a health economist colleague of mine, Emily Oster, who wrote a book about light to moderate drinking during pregnancy. And she got all kinds of grief from, like, all the pediatricians. She pointed out there’s not very good evidence on this. That’s where we are, right? So in light of that fact, that we don’t have a lot of very good evidence, I believe very fundamentally in shared decision-making. I tell you, here’s what we know, here’s what we don’t know, at least far as I’m concerned. I might be wrong. You guys can disagree with me about how you value the evidence. But, like, I’ll tell you my honest assessment of the evidence.

And then—and say so, like, for instance, the Tylenol decision essentially was that there is some evidence. In fact, there was a 2021 consensus report from a whole bunch of scientists around the world that there was a correlation, from large studies—in large epidemiological studies between Tylenol use during pregnancy and subsequent autism diagnoses. There was a bunch of controversy over that, because if you find—if you look at the epidemiological studies, large-scale epidemiological studies, you find the correlation. But then when you do sibling studies—so discordant sibling studies, where the same mom, one kid got—one kid was exposed to Tylenol during pregnancy, one kid wasn’t, you tend to find no correlation. There are methodological issues I could go deep into with the sibling studies, but it’s not worth going into it. There’s uncertainty. There’s not randomized evidence where we’d clear up that uncertainty. So why not treat Tylenol the way we treat sushi and light alcohol drinking?

BURWELL: Well, there’s also the word “correlation.”

BHATTACHARYA: Same thing with sushi eating, same thing with light alcohol use, yes.

BURWELL: But across the board, the question of correlation. You know—

BHATTACHARYA: I mean, the big difference between sushi eating and light alcohol use is you have a pharmaceutical interest, a company, that has a very, very strong interest in not finding that. There was a—there was a there was a company that—you know, J&J had Tylenol. They sold the Tylenol interest to Kenvue when the first reports starting coming out about the link—potential link between Tylenol and autism, right? That was in 2021. So, you know, you got—there’s a—this is a matter of public health. I didn’t get to make that decision about how public is—you know, other agencies. I’m going to fund research on this. That’s the job of the NIH.

BURWELL: Let’s go to the next question.

Q: Hi. Thanks for holding this session. I’m Gigi Gronvall. I’m a professor at Johns Hopkins Bloomberg School of Public Health.

I have a question about mRNA vaccines. You stated that they failed to earn the public trust, and used that to justify deprioritizing them and investing instead in an antiquated influenza vaccine technology instead. What scientific rationale supports that decision? And what—especially given the evidence that mRNA vaccines are safe and effective and have a lot of future potential?

BHATTACHARYA: So, Gigi, I think you have a number of assertions you make that a lot of scientists would disagree with. So, first of all, on the platform, the loss of public trust in the platform, the CDC’s recommendation was that all six-month-olds in this country be vaccinated with mRNA vaccine for COVID. And, like, 10 percent of the parents actually followed that advice. The CDC’s advice was that, essentially, like, more or less universal repeat booster vaccinations using the MRA platform. Thirty percent of the American population actually followed that advice. You have—we’ve invested billions of dollars in a platform that the public health authority is saying you should use at scale for COVID vaccines, and most of the American public is not using it.

If we invest in a platform—let’s say you’re right—and I don’t agree with you if you’re right—but, like, let’s say you’re right about the scientific evidence about the efficacy and—safety and efficacy of the COVID vaccine. The fact is that the public does not actually believe you, doesn’t believe us. So why should we invest in a platform that does not—I, at NIH, we have a lot of investments in mRNA technology, for instance, in cancer vaccines I think are very promising. We’re still investing in those. We’re going to continue to invest in those. There, I don’t think the public trust has been lost. But the assertion, for instance, that the COVID vaccine prevents you from getting COVID, or prevents you from spreading COVID, which turned out to be false, then on top of that all of these, like, vaccine mandates related to the COVID vaccine, I can completely understand why there’s loss of public trust in vaccine—in the COVID vaccines. Actually, now more broadly in vaccines, which I have much more trouble with.

So, yeah, I think the issue here is one of, like, where should we put our investments if we want to improve public health? The mRNA vaccines, in that sense, have not—mRNA COVID vaccines have failed to, like, adequately protect us. As far as the flu vaccine, you know, the BPL technology is actually quite promising. I know scientists who will fundamentally disagree with you about what you just said, antiquated. And it seems like a safe technology. It’s certainly worth investing in the science for it. We have major flu problems in this country. We need better flu vaccines.

BURWELL: But, with regard to the numbers, you said only 30 percent of people were taking the mRNA—

BHATTACHARYA: COVID vaccine, yeah.

BURWELL: The COVID vaccine, I’m sorry. That’s the total for COVID?

BHATTACHARYA: Yeah.

BURWELL: Because, the question becomes, is it that they don’t believe in COVID vaccines, or they don’t believe in the mRNA vaccine, in terms of public’s perception of things? And I would also just say, like, there are many things that, as we know from a public health perspective, like, OK, everybody who’s over fifty, have you gotten your colonoscopy? Like, in terms of, like—

BHATTACHARYA: It’s not 30 percent compliance with that.

BURWELL: But my point exactly. And you—

BHATTACHARYA: It’s not. It’s much higher than that, right?

BURWELL: Well, but the question—

BHATTACHARYA: I mean, we’ve been pretty successful, until the lockdown.

BURWELL: But we have—it takes a lot of time. It takes a lot of time to get people to understand, like, how many of our kids now get, you know, the right vaccines when they turn twelve to prevent, you know, certain types of cancers. And so I just—the question of basing—I’m just wondering, basing things on where we think the public is versus what we actually believe is the effectiveness. That’s an argument. That’s—

BHATTACHARYA: Well, let’s just say, Sylvia, of course—like, Sylvia, you cannot ignore the public perceptions of the efficacy and safety of products in making public health decisions, where you’re essentially requiring or essentially recommending the public at scale to take it, right? And especially if we’re making billions of dollars of investment in this, of taxpayer money in it. You have to take into account where the public is. Now, if you want the public to change where they are in their perceptions of it, you have to work honestly with the public to do that, right? So you have to tell them—you have to—you have to make the case to the public in ways that are meaningful to the public. You can’t just assert, because I’m a scientist I know, and that’s good enough. I mean, that was the—that was the path we took during the pandemic, and it didn’t work. It’s led us to this place of loss of trust.

BURWELL: But smoking, we didn’t encourage people to smoke, you know, while we were getting them to understand that it was a bad idea. The public—

BHATTACHARYA: Well, we kind of did, actually, but that’s another thing. (Laughs.) I mean, there were, like, ads on TV. I mean, it took a long time, right?

BURWELL: But the public health, you know, in terms of—let’s keep moving. (Laughter.) Let’s keep moving.

Q: Mr. Director, thank you so much for coming today. My name is Mark Vlasic. I split time between teaching at Georgetown and I’m a TV producer and film producer in Hollywood.

But early in my life I started in the Army and also worked for Secretary of Defense Robert Gates. And it’s from that chapter I had some exposure to the challenges of mental health, PTSD issues from our soldiers and Marines, what have you. And, of course, the fact that we’ve lost more people to suicide than from those combat situations. I’d love to hear your thoughts, anything you’d like to share, on breakthrough treatments for PTSD. Where is that research going? And are you interested in advancing that?

BHATTACHARYA: I’m absolutely interested in advancing it. This is not my area, so I’m going to be a little—a little careful about, like, specific—I mean, I can tell you what I think, but it’s worth what you pay for it. (Laughter.) I don’t know if you pay for this. But I do think it’s a fundamentally important area. Of course, for soldiers, but more broadly. The paradigms we have been using for managing depression, anxiety, PTSD, all of these—I mean, I get emails from so many people telling me they’re not working. And I hear from lots and lots of scientists with different ideas, very different ideas, than the standard, you know, take an SSRI and go home. And I think we owe those patients an answer and a broader range of thinking about this.

I’m in the middle of selecting a new NIMH director. And one of my criteria for selecting that person will be, first, an absolute commitment to rigor and science, but also a broad range of—like, an open-mindedness to this. I mean, like, I’ve had people tell me that psilocybin is the way. I have no idea. I don’t know. I mean, I looked at the literature and I can’t tell if it’s the way or not. At the same time, I think a rigorous evaluation of it’s something we owe the public, right?

BURWELL: I think we have a question online. Going to turn to Sophia for that, and then we’ll come to this table right here, and then come back up here.

OPERATOR: We’ll take our next question from Robert Klitzman. Please accept the unmute now prompt.

Q: Yes. I’m Robert Klitzman. I’m a professor in the medical school and the School of Public Health at Columbia University. So thank you very much for speaking with us today.

You mentioned shared decision-making as being important in vaccines and vaccine policy, but one important aspect of taking a vaccine, or having a child take a vaccine, is that one is helping not only one’s own health but the health of the community, the health of family, the health of others. And given that a lot of the public has relatively low scientific literacy—one-quarter of people don’t understand—don’t know that the Earth goes around the sun, for instance—can we really leave it up to the public to make decisions about whether to get vaccines or not? Won’t that be sort of leading to problems for public health, rather than helping it?

BHATTACHARYA: Thank you for that question. I guess, we live in a republic where the premise is that people are, in a sense, sovereign. Treating people as if they don’t know or understand or somehow, like. are less is a recipe for making sure that people don’t trust you. On the question of vaccines specifically, well, you know, it’s actually a scientific question, like, what the transmission blocking properties of a vaccine are. I think MMR is fantastic at transmission blocking. You take it and you’re not going to get—you’re not going to get, you know, measles, like ever. It’s a fantastic vaccine for that. But there are other vaccines where there’s much less evidence of transmission blocking.

In health economics, or economics, we have this idea of externalities, right? So the question of what are the positive externalities generated by vaccines is a(n) empirical question. It’s not always the case that every single vaccine automatically, just because you call it a vaccine, blocks transmission. We found out during COVID that’s obviously not true for the for the covid vaccines. So, you know, I think—and then the question is, once you have a positive externality, you’ve established a positive externality, should you ignore the will or desires or thoughts of people and compel them to take something they don’t want to take if they don’t trust you? I mean, you know, we can have that debate. I’m pretty sure I know which way it’ll go.

And I think—I think the right approach—you can look at with Scandinavian countries. They do not mandate vaccines. The U.K. doesn’t mandate the childhood vaccines. And yet they have, in the Scandinavian countries, more than 95 percent uptake of the childhood vaccines. It’s because they have a public health infrastructure and structure that the public trusts. They don’t believe that they’re trying to snow them over. They don’t believe they’re trying to force them to do things. Establishing that trust is the essential aspect of public health. And if you think about people as somehow ignorant, or less, or, like, half the population is the basket of deplorables or whatever, you are guaranteed not to earn their trust.

BURWELL: Linda.

Q: Thank you so much for meeting with—thank you so much for meeting with us. Linda Lourie. For purpose of this, former OSTP White House, former DOD.

Being as we’re at the Council on Foreign Relations wanted to take us internationally, particularly to China. And there’s been a lot of examples—can go through them, but I’m sure you’re familiar and probably other people in the room are—of NIH and other U.S. government research that forms the basis for Chinese AI, computer vision, and other surveillance-enabling technologies that pose a risk to human rights and to national security in general, particularly through the mil-civ fusion policy. Can you share what NIH is doing to implement the National Security Presidential Memorandum 33 on research security, which was a Trump one policy that was implemented and enhanced by the Biden administration? And as well as ensuring that NIH funded research doesn’t find its way into Chinese research institutions and companies? Thank you.

BHATTACHARYA: OK. Thanks for that question. I don’t want to get too deep into, like, the specifics, because there’s still a lot of ongoing discussions in the administration and inside the NIH about exactly how we’re going to do this. I think, first, the NIH has to be part of a broader policy. Can’t just be us acting alone on China. But let me just—so let me just broaden it out for the discussion, right? And let me start with just the first fact, which is—and just, I think, buttresses the premise of your question. The United States has invested a tremendous amount of money in the biomedical research infrastructure of China. Almost every single biomedical scientist of note in China trained in the United States and has—and in some way or other has received support from the NIH or other scientific institutions. That’s fact one.

Fact two, the Chinese biomedical infrastructure—research infrastructure is not inferior to ours. It might even be better than ours. It’s fact two, right? And fact three, there are real national security threats, given those two facts. So, for instance, there are supply chains for essential medicines that run through China that can get turned off in the content of hostilities, or tension, or whatever. So these are like—I mean, it’s like a Sputnik moment, in some sense. OK. So what are the two—I see two possible paths forward. And I don’t know which—where we’re going to end up. Because I do also think that we have a scientific interest in collaborating with scientists around the world. Put my naïve hat on as a scientist, it’s good for science to talk with lots and lots—for scientists to talk to lots and lots of people, lots of ideas.

And international scientific exchange of ideas is, like, the hallmark of, like—you know, I grew up in a town with a lot of hippies. They were—like, they were all into, like, you know, you, like, eat carob chips and have scientists talk to each other to make peace with the Soviet Union or something, right? So you have—you have two possibilities, I see. And I don’t know which way we’re going to end up. One is a divorce with China, a scientific divorce with China. Kind of like what happened in 1948 with the USSR and the U.S. I think that would be a disaster in many, many, many, many ways. I would love to see ways to avoid that. On the other hand, we have a regulatory structure that better protects American intellectual property rights, that better establishes domestic supply chains, and reduces the reliance on Chinese, you know, biomedicine for American needs. That’s the best outcome. I think the only outcome.

The other outcome is we just keep doing what we’re doing. That’s not going to—that’s not going to work. I mean, it’s not an American interest. So I’m actually open to hearing how to do this. We’re actively talking inside the administration about these matters. And I’m thinking about it. So this is the Council on Foreign Relations, right? So you guys have more expertise than I do about this topic. (Laughter.)

BURWELL: Thank you. I think we have time for one more upfront here, and then we will wrap up.

Q: Good morning. Thank you. Good morning. Thank you so much for the opportunity to be here this morning. My name is Robie Kakonge, Uganda’s ambassador to the U.S.

One of the strongest relationships we have with the U.S. is in public health. How would you guide that we improve on this relationship, especially in communication and post-COVID?

BHATTACHARYA: Yeah. Thank you for that. I mean, I think a lot of—a lot of the countries in the world were poorly served by the WHO, I think, during COVID. A lot of bad advice, especially to poorer countries, that devastated, you know, so many—the lives of so many poor people around the world. The administration is pulling out of the WHO. But we don’t just want it—we’re not doing that in order to disengage from the world. We actively want to engage more constructively with the world on matters of public health. And so what the discussions are going on now is for how to—how to reach out to countries, to collaborate with countries that both are—but that—in ways that can actually advance the health interest of those countries, and collaborate the U.S. so that we can, you know, help each other on our health decisions, right?

So a lot of the fights have been over infectious disease. We talked about that. But in many, many poor countries, infectious disease is not the primary—is not the only health threat. You know, there are chronic diseases that are really important in so many countries that are ignored. There are existing health problems and infrastructure that’s not just focused on infectious disease. Now, of course, infectious disease is still a problem, but that’s—so I think it’s a work in progress. But the desire is there to collaborate together in a more—in a more cooperative way on public health. What I saw during the pandemic was essentially global public health spread advice to countries—and I’ll just talk about—talked to some folks in this room.

I saw firsthand in Sri Lanka, because I was in contact with a lot of them, advice that was guaranteed to harm the wellbeing of the poor in ways that are—I mean, was still recovered—just breaks my heart to think about. And because essentially the Western panic over COVID, the advice was to elevate COVID un a country where there’s very—a relatively small number of older people, and elevate that as the primary health concern, when, in fact, there’s so many other health concerns that are more important in the context of countries that are young—that have a younger population. And it’s true in Africa. All across Africa this was the case.

I don’t know, again, what the ultimate thing will be, but the desire of the United States is to is to help have a more collaborative relationship on public health with countries around the world, in ways that better serve their interests and ours. And the WHO has failed at that.

BURWELL: Thank you. I want to thank all those who joined us online today, as well as all of you all in the room. And I’d like to ask you all to thank our guest today, Dr. Jay Bhattacharya. (Applause.)

BHATTACHARYA: Thank you, Sylvia.

(END)

This is an uncorrected transcript.