89. A Cross Between Sherlock Holmes and Indiana Jones

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My guest today, Charity Dean, is a physician and leading voice in the field of public health.

If policymakers had taken her early warnings about COVID-19 seriously, hundreds of thousands of lives would have been saved.

She's one of the heroes in Michael Lewis's book on the pandemic called A Premonition, but her work on COVID is just the tip of the iceberg.

The first thing I did in the morning when I would wake up is I would check my work phone email to see if I had any reports back from the state on the molecular mutations of my new tuberculosis cases.

That was the most exciting moment of the day.

Welcome to People I Mostly Admire with Steve Levitt.

Being completely honest, without really knowing all that much about it, I've always had a really low opinion of the field of public health.

It feels to me like there's a lack of rigor in what they do, quasi-science that tries to get passed off as real science.

I'd really like to be wrong about that, and I'm hoping that Charity Dean will change my opinion today.

So Charity, I've heard it said about you that when you were young and feeling kind of blue, you cheered yourself up by reading books about the bubonic plague.

Is that really true?

Yes, in fact, it's still true today.

The other day, I was trying to recall a number of obscure examples of a reverse cord insanitaire.

And so once again, I pulled up the bubonic plague and read about it.

It's quite grotesque.

But when I was little, those were the stories that I absolutely loved.

And what was it that drew you to infectious disease?

I really believed and still believe that every human is born for a life purpose, whether that's raising a healthy family, being a doctor, being a teacher, and that that purpose impacts the whole world, that we're all connected in one giant web, what I call today the force.

I'm a huge Star Wars fan.

And so, when I was little, I knew that my life purpose was to be a doctor and to make a huge impact in communicable disease, infectious disease, although I would not have described it that way.

I grew up in a very, very strict religious culture in my family of origin.

And when I was about seven, some missionaries came to church and were talking about their work in Africa and were talking about diseases.

And I think one of them was a nurse.

And on the drive home that night, I told my parents, I'm going to be a doctor and I'm going to study disease.

And I was so young at the time that I think they probably just blew it off.

But I never wavered from that throughout my childhood, but I did learn not to talk about it quite as much.

Now, the environment you grew up in in Junction City, Oregon, with parents who hadn't gone to college, they were devoutly religious.

The last thing anyone would have expected from you was that you would go after a medical degree, right?

Yes, that's true.

I had a really loving childhood.

However, the culture of the church environment I was raised in, and certainly the culture of a small town in rural Oregon did not have a reference point for girls going to college and becoming doctors.

I didn't know anyone with a four-year degree when I was a child, much less someone who had gone to medical school.

So it was a completely unknown aspiration for a young girl in that church culture to dream of going to a four-year college, much less a graduate degree.

That might be acceptable to become a teacher or a pastor's wife with maybe a degree in biblical studies, but not a degree in microbiology with a minor in chemistry and French and a master's in tropical medicine.

That was just insanity.

So I was certainly the black sheep and I learned to keep it quiet.

Because you were even pulled out of science class on the days evolution was taught, right?

That is true.

So in sixth grade, I was a smart kid and did really well in classes, but I was bored out of my mind because I read a lot and was self-taught in a lot of stuff.

And school was boring to me.

And my amazing parents figured out, we've got to figure out a way to challenge her.

And there were no advanced classes, no honors classes.

You get what you get in rural Oregon and public school.

So their only option was to skip me up a grade.

And I was all for it.

And they lobbied the school to get me skipped over seventh grade, which meant that I missed the year when they taught the foundation of world history and biology.

So that was a challenge, but that's okay.

I learned it on my own.

And then in eighth grade, of course, there were courses in biology around evolution and most of the kids that were part of that religious community were pulled out of that courses so it wasn't just me there was a whole group of us sitting twiddling our thumbs in the principal's office those days and that was fairly normal wow i can't imagine being a kid everybody telling you can't do something and still choosing to do it anyway I agree.

It's funny looking back because when I got to college, so off I go to Oregon State University, 17 years old because I'd skipped a grade, pre-med, and decided to major in microbiology.

And you can imagine my shock as I started to learn microbiology and went, wait a second, molecular evolution.

is happening every minute.

Evolution isn't a theory.

Molecular evolution is happening in these bacteria and viruses constantly.

And oh my gosh, it makes some of them more fit.

And those are the ones that survive.

And those are the ones that become more virulent.

It was a fascinating new world that opened up to me.

And I thought, what else did I learn along my life that became assumptions that I might need to question?

And bit by bit, my whole world was rocked as I started to question

everything and embrace this scientific career that was in front of me that I fell in love with.

It's funny.

So I asked you about being pulled out of evolution class, but implicit in my own mind is that, well, of course you understood that evolution was really happening and it was just this crazy church elders who were doing it.

But you're telling me you actually were taught and believed that evolution was not going on?

That's correct.

Interesting.

So interesting.

But looking at it from the larger picture, you can see how seductive very rigid belief systems are.

And I really understand and have a lot of empathy as someone that grew up in that.

That when I was taught that evolution was false, you know, that was the larger picture of humans did not evolve from apes and the historical evolutionary picture.

But the people teaching that didn't know anything about molecular biology or molecular evolution.

And so you can see how one very legalistic rule set in a belief system propagates throughout everything that child learns.

And so when I got to college and majored in microbiology and became obsessed with molecular biology and evolution is the cornerstone of creating more virulent pathogens that cause horrific things like bubonic plague.

I became fascinated with it because it was so exciting to me that the history of public health is the history of humanity.

And all of that was predicated upon organisms creating more fit versions of themselves through natural selection and evolution.

So it was all a very exciting journey and I'm so thankful for it.

But it is also a true statement that when I showed up pre-med at Oregon State University, I did not believe in any form of evolution at all and did not understand the concept.

Wow.

Okay.

So people hadn't been very encouraging of your seven-year-old dream to be a doctor, but now you've gone to college, you've been pre-med.

Do people jump on board?

Is the church excited about you going to med school?

I haven't had contact with a lot of those people in many years.

I'll be honest, it's a really painful part of my history that I'd rather not discuss.

I can only imagine.

But I can say, my parents are amazing.

So today they live here in Santa Barbara, three minutes down the road from me.

I'm a single mom and they're a huge part of our lives.

And it's remarkable to watch the transformation in them over the years as they watched and supported me overcome all of these hurdles.

They were my biggest supporters, my biggest fans.

And you can imagine imagine that inherent in that was their own internal conflict over what the church said girls were allowed to be and what they saw their daughter becoming.

So I wasn't the only one that underwent a transformation because of the path that I chose.

My parents have been along for the journey.

In fact, when I was appointed by Governor Brown for the California Department of Public Health, my parents sold the farm.

in Oregon in the small area they'd lived for 43 years.

They sold everything, packed up a truck and moved to Sacramento to support me.

And if they hadn't done that, I don't know that I would have been able to stay and become state health officer and then serve as number two and then have the impact in the pandemic and the position I was in when Michael Lewis eventually found me.

So it's truly been a family team effort, this journey, sometimes more, sometimes less, but they've undergone their own transformation.

That's amazing because I had expected you to say that I made these tough choices choices and I haven't talked to my parents in 25 years because of those tough choices.

Because when you made the choices, you probably considered that possibility that it would estrange you from your family.

I did.

It's amazing that it turned out with such a happy ending.

Yeah.

And I know not every child who balks a cult-like religious, strict culture of origin has that happy ending.

I do.

And I'm super lucky.

And the life that we have today is beautiful.

So you do go to med school and then you do your medical residency.

And right at the point where you're about to land a lucrative job in private practice, you do what would be absolutely unthinkable to the typical young doctor.

You jump off the regular track to become a local public health officer.

That's true.

Although I considered and toyed with the idea of joining one of the concierge private practice boutique medical practices in Santa Barbara, I knew all along I would end up with my people.

And I wouldn't have described it that way at the time, but in retrospect, I realized I chose to work for the county because those are my people.

The county clinic patients and the populations that public health protects are vulnerable, disadvantaged, have had all kinds of life hurdles to overcome.

Dealing with poverty and the safety net system, growing up on food stamps and not having any resources.

That's who I identified with because that's where I'd come from too.

And I knew it's where I could make an impact.

And the other perk of being in public health is you've got to keep on thinking about these infectious diseases that had intrigued you your whole life.

That was the kicker for taking the the job.

When the medical director came and found me in primary care clinic, I remember I was sitting in one of the back offices in this fairly humble/slash shabby county clinic.

And he sat down and he said, Hey, so I heard a rumor that you have a master's of public health and tropical medicine.

Tell me about it.

And I perked up because nobody ever asked about my master's in public health and tropical medicine.

And that was my favorite subject.

And he said, We need a deputy health officer who will also serve as the tuberculosis controller and the communicable disease controller.

Does that sound interesting to you?

And I think I said to him something like, sure, I'd be happy to learn more.

But inside, I was thinking, does that sound interesting to me?

This is what I was born to do.

So it was just a clear fit.

Now, if there's one piece of advice that I've given most consistently over the years to young people, it's this.

Find something that you love, but that nobody else loves.

and then figure out how to build your life around that thing.

And the example I often use is the biologist E.O.

Wilson.

His whole life, he just loved everything about ants, and he became the world's foremost expert on ants.

But I have to say, after talking with you, Charity, E.O.

Wilson is going to get demoted because you even more than him.

have built your life around something that only you love, which is these pandemics and plagues.

I do love pandemics and plagues, but I love them because it's the history of the world.

And I'm curious about you.

Would you say that is true for your career path as well?

So a lot of people might like economics.

I didn't even like economics.

But what I did do as I had a crisis of faith in my first year of grad school and discovered I wasn't very interested in most of the topics that were being taught is I just sat back and I said, well, what am I interested in?

And I thought, I really love watching the show Cops on TV.

And so I'm just going to start researching police and it was an odd thing to do for an economist there wasn't really anybody doing that like you i decided to study the things i liked and i got lucky it was a wide open field and that wide open field made it much much easier to have an impact so would you say that both for your path and for the people that you interview that it's always true that when someone follows their obsession and what makes their heart sparkle with joy, that leads to the career path that is right for them.

Or have you ever seen circumstances where that might be a horrible idea?

I get a very select example.

So of the people I interview, they mostly will say, oh yeah, I stepped off the beaten path.

I found what I loved in Trinidad.

Great.

I do suspect for every person like you and like me, there are probably 50 or 100 who tried the same thing.

They loved macrame more than anyone else in the world.

They love macrame.

But in the end, it didn't work out, and they ended up having to work at Amazon in the shipping department or something like that.

So, I can't say scientifically whether it's a good strategy, but I think it at least raises the possibility that really great right tail emerges in your life.

Yeah, whether on average it's a good strategy, I'm not so sure that resonates.

I would add to that from what I've experienced and from what I've seen in colleagues, the lucky ones are often the brave ones because it takes an enormous amount of courage to follow that passion and not be embarrassed about it.

It's massively vulnerable to go all in on that obsession.

And the times in my career where I've hesitated, what I was really hesitating about is, do I really let out the crazy?

Because if I go all in on this thing,

I'm going to look like a crazy person and normal people won't understand, but I just can't stand it.

I love it so much.

I want to hear about a couple examples of crazy.

So you get to be a public health officer in Santa Barbara, and pre-COVID, you worrying a lot about tuberculosis.

Was it easy to get other people excited about that topic?

No, it was not.

Most of society thought that tuberculosis was a disease that had been eradicated and was no longer around.

100 years ago, it was the number one killer, but today it doesn't even make the top 10.

Most people did not realize that it was wreaking havoc across many communities in the United States.

California is the number one state for tuberculosis.

And where I was the local health officer on the Central Coast, we had a pretty substantial problem and all was ranked in the top 10, sometimes the top three counties in the state for the case rate of tuberculosis.

And not just regular old vanilla tuberculosis, but multi-drug resistant TB with unusual mutations.

I'm grateful to those mutations because they taught me molecular epidemiology.

They taught me how to do it manually, and that became incredibly useful in tracking the outbreaks up and down the coast.

And that skill set of tracking the molecular mutations manually is what enabled me to identify them super fast in some of the little kiddos that had them.

And we were able to save limbs and save lives by finding them early.

So the secret, in quotes, to fighting infectious disease is to act early because outbreaks tend to grow exponentially.

So they're much easier to contain if they're addressed quickly.

Now, did you find it was easy or hard to get people to act aggressively on tuberculosis before it was widespread?

It was always difficult for

anyone outside of communicable disease control to understand the sense of urgency with which we have to move in the very early stages of an outbreak.

One case of multi-drug resistant TB is an all-hands on deck, high-threat situation that necessitates early intervention

because it's catastrophic, especially when it spreads to children.

So the nurses and this amazing staff in the public health department that worked in disease control with me, They understood exactly what Dr.

Dean was going to do when a new case of MDR-TB was identified.

They knew I'd go hunting for more cases.

They knew I would issue health officer orders enforceable by police powers and that if it wasn't working and some of the patients were unwilling or unable to isolate, that I would use the full extent of the law.

I really always kept in mind that my job was to use the least restrictive measure necessary in considering individual rights and freedoms versus protecting a population from a threat, which meant at times the balance was tricky.

There were times I absolutely used the sheriff's department and the police department and whatever law enforcement was necessary to contain a disease, which meant keeping someone in isolation.

And at times that meant having to, unfortunately, put people in jail.

That's not uncommon in disease control and tuberculosis control.

But the vast majority of the time, it was really just ensuring that someone was following isolation orders and then going hunting for their contacts and ensuring that their contacts were fully evaluated, were put on treatment treatment if they needed to be, following them obsessively for two years along with the staff, and following the molecular mutations.

The first thing I did in the morning when I would wake up is I would check my work phone email to see if I had any reports back from the state on the molecular mutations of my new tuberculosis cases.

That was the most exciting moment of the day.

And in the mornings when I've had those reports back, I couldn't wait to get into work to map them out against the other mutations that we had.

It's like fingerprinting for a crime.

Imagine trying to do that mystery crime work without fingerprints.

And then suddenly, when you get fingerprints, everything matches up.

You're listening to People I Mostly Admire with Steve Lovett and his conversation with public health champion Charity Dean.

After this short break, they'll return to talk about Charity's role in Michael Lewis's book about COVID-19.

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Hey, Steve.

Hey, Morgan, how are you?

I'm good, thanks.

How are you?

I'm doing great.

Sometimes we check in about emails that have come across our inbox.

Have you seen any lately that caught your eye?

The thing that really surprised me was after talked with Sale Khan about the new Khan World School, and I mentioned in that episode that my team at the University of Chicago was putting together these seminars, which focused on big issues and were going to be a really important part of the curriculum, that we had so many listeners write in and saying they wanted to see those seminars.

Maybe a dozen people wrote and said, how can I get access to those?

And we hadn't actually thought about how to make them available to the public, but in response to those emails, we built a webpage riskrisc.ushicago.edu slash seminar and there we've put up over 50 of these seminars and our hope is that people will use them in whatever way they see fit we'd love to see them in classrooms across the country they might be a good substitute for a book for a monthly book group or even just I don't know to spur dinner conversation if you've got a weird intellectual family.

But anyway, we would love feedback and we would love people to tell us how you're using them and how we can make them better.

How about you?

Did anything catch your eye recently in our email stream?

There was an email that I found pretty interesting.

Our listener, Antonio, rode in with a medical innovation he had thought of while visiting his grandmother in the hospital.

Oh, God, I absolutely loved Antonio's idea.

Me too.

I thought it was brilliant.

Let me give the listeners listeners a little background.

So Antonio was visiting his grandmother and she was in the hospital.

She was near the end of her life and she needed to wear a respirator mask.

It sealed over her mouth and nose.

This made conversing with her nearly impossible.

Antonio could barely hear her and he's in his 20s and his grandfather really couldn't hear her.

And you know, this was at the end of her life.

So communicating is really important at that time.

So Antonio was thinking about this this and he realized that if he took the mask home, he could buy a pretty cheap microphone and he could install it into the mask so that while she was wearing it, she would be speaking through a mic and her family could hear her a lot better.

Now, I thought this was a genius idea, and I can't believe it doesn't exist already.

Yeah, it's the best kind of idea because for me, there's almost nothing that is more valuable than figuring out how to bring dignity to the end of life.

And this just seems like a great step in that direction.

And it also shows that sometimes the most brilliant ideas are really simple and straightforward and quite frankly, obvious.

And then the thing that you're always left to ask yourself is, well, if it's so obvious, why hasn't someone done it?

And I wouldn't be surprised if it just comes down to economics and the way hospitals work in the sense that it's a really easy decision to make.

Should I buy a new MRI machine?

And if I can keep it 47.8% occupied, then I will make a positive profit on it.

And in that setting, it's really easy for hospitals to decide to adopt new technology.

What Antonio is talking about, it's just much more subtle.

It increases the quality of life, but will it improve or not improve the hospital bottom line?

It's not totally clear to me it will make the hospital better off financially, but it is just so valuable to society.

it should be done.

Steve, you're really touching on another thing that Antonio brought up in his email.

Often on this show, we have guests who talk about machine learning advancements in medicine, which are great, but are really a long way off and will be a big investment of money and technology.

Meanwhile, there's really straightforward and simple interventions that could make a difference in the medical field.

And Antonio was curious about why innovation tends to happen at the highest sense of the margin while seemingly simple and baseline issues are often left wanting.

Yeah, I think it comes down to the way hospitals work, the way organizations work.

In a world in which hospitals were just trying to do the right thing for people, for sure, you would redesign the respirator.

And so I would like to do whatever we can to bring Antonio's idea to fruition.

I think that would be fantastic.

Are you serious about helping Antonio make this invention become a reality?

I am.

Antonio, I'm going to write you an email and let's work together and figure out how to make this a reality.

So Antonio, thanks for writing and to all those curious about the Con World School seminar content, you can find the website in our show notes.

If you have a question or an idea to share with us, our email address is pima at freakonomics.com.

That's p-im-a at freakonomics.com.

It's an acronym for our show.

We read every email that's sent and we look forward to reading yours.

I keep thinking back to Charity Dean saying that the most exciting part of her day was waking up and checking your phone to see if the new tuberculosis mutation reports had arrived.

It reminds me a little bit of my own excitement when I'm about to dive into a new data set.

My heart beats a little faster, my palms sweat.

To me, that seems totally natural, but I imagine to an outsider, it must seem really strange.

Now, I want to turn our conversation to COVID-19.

Now, there are a few things I still just don't understand about the pandemic.

And if there's anyone who can make sense of it for me, it's Charity Dean.

Okay, so it's the very beginning of the pandemic, January and February of 2020, when there was very little public awareness and massive uncertainty about what COVID would turn into.

And you almost immediately became convinced that COVID would be the real deal without traditional data.

So what was it that you saw that made you so sure?

In January of 2020, really three things were happening at once in my head.

But I'm not alone in this.

There are very smart disease controllers out there who think the same way.

Number one, pattern recognition.

After doing public health for 24 years, I have a pattern recognition of situations, threats, and combinations of intelligence.

Number two is index of suspicion.

So pattern recognition is important, but it serves the purpose of elevating an index of suspicion.

But number three, that index of suspicion and pattern recognition are based on a collection of data points.

So it's elevating the signal from the noise, recognizing that elevated signal fits a certain pattern, and then converting that elevated signal into an index of suspicion.

That is what leads to a so what?

So what do we do?

So what are the different decisions or mitigation measures or risk management that we can put in place based on that?

So in January of 2020, I had a very keen sense that this fits a pattern recognition that I've seen before and that I know.

I had a very high index of suspicion, and I was looking at a number of different scattered and unreliable and frankly pretty sketchy data points.

What were those data points?

I'm so curious.

A lot of the social media feeds coming out of Wuhan, I would describe as sketchy and unreliable, but taken collectively are a signal amidst the noise.

One of them was the videos or personal anecdotes about the tent hospitals that Wuhan was putting up over a weekend.

Many of us saw these videos.

They were pictures of bulldozers putting up tent hospitals very quickly.

Some of the other videos were what the situation was on the ground, that people were being locked into buildings and the police were dragging people off into quarantine and isolation and dragging people off to the hospitals or special quarantine centers.

And so citizens would post these videos and then very quickly they'd be taken down.

So one data point in isolation, not that useful.

50 of them within a six-hour period, super useful.

So taken collectively, that was certainly a data point.

And then many of the local newspapers were reporting how many people from the cruise ships that were sick were being taken to hospitals, how many had died, really anecdotal reports.

I would also call that a low to moderate confidence, but a highly specific report because in there it was really helping me calculate what was the attack rate of this virus.

Because in the beginning of any outbreak, it's very quiet, sometimes because the government is sweeping it under the rug, you have to go looking for atypical sources.

You have to go looking for hints anywhere.

And that's why I've described my job as local health officer or even state health officer as a cross between Sherlock Holmes and Indiana Jones.

There was no formalized intelligence network.

I did this the old-fashioned way, the way I always had, but it really followed that algorithm.

If you collect a vast number of atypical data sources with variable reliability, you assimilate those together and you look for the signal and the noise, that meets a pattern recognition or it doesn't, which turns into an index of suspicion that I always assign a confidence and threat to simply because I can't.

I've been doing it for a while.

So, believe it or not, I had a trip to Hong Kong scheduled for January 10th, 2020.

And interestingly, my father, who's a doctor and I think a very good and intuitive one, he said, are you crazy?

You can't go to Hong Kong right now with whatever this disease is.

And I thought about his advice and I was looking pretty carefully at the various data sources I could see as well.

And I decided to go.

I just didn't think there was anything worrisome at all.

And in fact, I went to Hong Kong for a week or two.

I actually got really sick in Hong Kong.

I don't think it was COVID, but it was interesting.

So I was looking at signals and completely misread them in retrospect, which is why you're the public health expert and why I'm not insured.

No, but I love that story because decision makers do the same thing, whether it's a governor or a president or a secretary or an enterprise CEO.

Without that.

experience of pattern recognition and index of suspicion, how could you possibly read the tea leaves and know what is coming?

Today, we'd call that machine learning and artificial intelligence, that you can actually train the machines to do this over time, but all of it starts with decades of experience of seeing those patterns.

Similarly, you better believe I'm not going to pick up economic signals and patterns in macroeconomics and be able to predict what's coming, but you can because you've studied it your whole life.

No, no, I can't do that either.

None of the economists can do that.

I think that's part of what economists have decided: the macroeconomy is too complicated.

We're not good at predicting anything.

We avoid predicting.

I mean, that's your job.

You don't have a choice not to predict it because that's why you're there.

Yeah, well, it's the signals and the noise.

And that's why we collectively, as a society, until we develop a system to surface the signals and the noise that can turn into that index of suspicion, we are no better off than we were in January 2020.

Something implicit in Michael Lewis' book, Premonition, that confuses me, but that he and I never actually had a chance to talk about it.

He suggests that if California had heeded your warnings and mounted an immediate, thoughtful, coordinated response to COVID, then COVID-wise, things would have turned out great for California.

Isn't it basically true that as long as the rest of the country and the rest of the world are screwing up their COVID response, it almost doesn't matter for Californians what California does, especially because California has such porous borders with other U.S.

states.

It's not like California is New Zealand with the ability to lock people out.

Yeah.

So you're right.

The answer is somewhere in the middle.

I don't know that even the best executed plans in California would have been 100% successful.

I think maybe at best they would have been 20% successful because of that concept you talked about.

Communicable disease is communicable.

It spreads.

So California can get an A plus,

but if all the other states surrounding California are not doing the same, then the disease spreads no matter what California does.

And we know that from 1918 and bubonic plague.

And unfortunately, the only thing that can work in that situation is a cordon sanitaire or a reverse cordon sanitaire.

in fact there's a city in colorado that did a reverse cordon sanitaire where they locked themselves in and everyone out in the 1918 spanish flu and it was successful but it's only successful while you maintain it as soon as you let those walls down the disease comes back in what i saw in california was phenomenal leadership by governor newsom and his team but governor can only be as good as they're able the surrounding states and the rest of the country they also have to do the right thing thing or the disease spreads.

So I do agree that the whole country needed a plan and didn't have a plan.

And that's why Michael tells the story in the book when Todd Park said, go shut yourself in a room and write out the plan for California.

Because I had written a plan for California in January, a very clear mitigation plan and containment plan for California.

But by the time Todd asked me to do that, it was now early March.

And I said, well, I can't write a plan just for California.

Cats out of the bag.

This virus is everywhere.

The only plan that would work would be a plan for all the states, a plan for the United States of America.

And even then, it's going to have to be a mitigation plan because we've lost our shot at containment.

You know, what I learned in some of the volunteer work I had done in the past, whether it was on the ground in Africa or working on stuff here in the United States, is that a voluntary grassroots efforts by citizens who want to protect their community and neighbors is always more impactful than a top-down government mandate.

That's how we see effective change happen.

I don't know that we will ever see an effective uniform operational response when it's mandated by government top-down.

And this is coming from a former local health officer who used to mandate things top-down.

I was just looking at the COVID statistics at the New York Times website the other day, and I was looking at reported death rates cumulative from the start of the pandemic.

And the countries that were hit hardest were a bunch of Balkan countries, Bulgaria, Hungary, North Macedonia.

They had nearly 500 deaths per 100,000 people.

In the US, in the UK, Italy, Belgium, these places also got hit hard.

We had about 300 deaths per 100,000 people.

Now, Australia and New Zealand, who quite effectively closed their borders, they had about 50 deaths per 100,000, or one-sixth of the USA.

All that makes sense to me.

But here's the thing that I remain incredibly puzzled by.

If you look at Africa, most of Africa had levels that were far lower of reported death rates, many countries near zero.

So Nigeria reported two deaths per 100,000.

Tanzania, one death per 100,000.

Kenya is on the high side, 11 deaths per 100,000, but still one-fifth of Australia and New Zealand.

Does the public health community have a good explanation for that?

Is it younger populations underreporting something else?

I've read some summaries or analyses by really smart people about it with different hypotheses.

I think the answer is less sexy or glamorous than that.

It comes down to ascertainment.

The data, even the data looking at New York Times or any of these incredibly reputable sites reporting the data, they're only as good as the data that they get.

So if they're getting garbage data in, then it's garbage data out.

And that's always true in public health, that the reporting is only good as the cases you're detecting.

So if assertainment rate is low or the ability to actually detect a case and then report it, then you're only getting maybe 5% or 10% of the actual cases in those reported numbers.

And that goes back to January of 2020.

Of course, I didn't believe the data coming out of China and believe the assertainment rate was low.

I would guesstimate on average, case ascertainment for the United States has been somewhere between 10 and 15% overall, which means the cases that are reported are only 10 to 15 percent of the actual cases out there.

And there's no doubt in my mind that that is true for the continent of Africa as well.

Having worked and lived there in two or three different countries, the public health infrastructure is even less robust than it is in the United States.

So the ability to test, confirm, and report a case is challenged.

When I look at reported cases, whether it's for South Africa or Italy or the United States, the first thing I do is I go hunting for a source of truth.

And in the U.S., the truthiest truth is the reported deaths or the reported hospitalization.

And then you make some assumptions about case fatality rate or hospitalization rate.

And then you can actually back calculate what is the true number of cases right now.

And then that gives you the delta between the true number of cases and the reported cases.

So the same is true for Africa.

It's true for COVID.

It's true for tuberculosis.

HIV is a great analog.

So I lived in Zimbabwe for a time between 99 and 2000.

And at that point, government actually did not allow testing and diagnosis of HIV AIDS.

So you can imagine that the ascertainment rate was nearly 0%.

And yet every day I was watching patients die of HIV AIDS.

Well, that's too bad.

I thought there was going to be some silver lining around Africa that everyone could cheer about because usually it's places like Africa and Southeast Asia that get hit the hardest by adverse natural events.

And I thought maybe you bring some good cheer, but we'll wait for that good cheer for another time.

You were living a pretty anonymous life, extremely accomplished, but not a celebrity in any way.

And then the writer Michael Lewis made you one of the heroes of his best-selling book, Premonition, about the COVID crisis.

And I don't use the word hero lightly.

He paints a picture of you as a real-life superwoman.

I mean, you overcome impossible odds using a combination of brilliant, savvy, kicking butt when people get in your way.

What was it like to read about yourself?

It was a little bit weird.

And quite honestly, I didn't figure out until months into working with Michael that I was one of the main characters in the book.

I thought my job was to teach him public health and microbiology and disease control, which I did with enthusiasm.

And I knew I might have a few quotes in the book, but it wasn't until he went out to Colorado and spent time with my sister that I realized he might be telling more of my story.

So I'm thrilled that Michael learned the public health system because today he is the country's biggest advocate for the role of the local health officer.

Like Michael Lewis wrote about you, a long time ago, Stephen Dubner profiled me in the New York Times piece, and it fundamentally changed my life.

Publishers came asking me to write a popular book, which ended up being Freakonomics, which Dubner and I wrote together.

And then the floodgates opened, speaking in front of thousands of people, going on the daily show with Jon Strew, a freakonomics movie.

And I got to say, it wasn't who I was at all.

I was this quiet little professor who was at home with a pile of data or at a chalkboard.

Yes.

But I was lost as a celebrity or a public intellectual.

So the way I coped with it is that I learned how to act, essentially, to play the part of the Freakonomics guy.

It's essentially me, but bigger and better than the real me.

But I saw how well it worked for me.

And I ended up not really on purpose, just by accident, building all sorts of other personas.

I don't know, the empathetic Steve, the business consultant Steve.

And after a while, I couldn't really tell what was authentic and what was just acting.

And I honestly, I somehow lost myself, my core, and all of it.

So that's how celebrity affected me.

What's your experience been like?

Can I ask you a follow-up question before we talk about my?

Of course.

How did you find your way back to your core?

What did you do?

I more or less just had a meltdown.

I think I was depressed and unhappy.

And I just made big changes in my life.

It all happened so subtly, I didn't even recognize what was happening and just that awareness.

And I've spent a lot of the last few years trying to sort it out.

It's not easy.

And I can't say I'm all the way there, but

I think at least I'm able to look back and understand what happened, which in real time I couldn't see.

Yeah, I always love.

hearing from people, how did you get back to center or how do you stay in center?

Especially for us introverts.

You got this taste of celebrity.

I'm just wondering how you've experienced it.

I've largely ignored it and put my head down to build software.

I'm happy to do interviews or TV spots where it's furthering.

the visibility and discussion around the most important conversation the country needs to have, which I liken to a fourth step, which is what kind of mess are we in?

What was our role in getting there?

What is the reality of the public health system in the United States of America?

And what kind of system would need to exist to have a shot at containment to actually protect national security?

That's the conversation I'm always game to have.

So I am willing to do speaking events to talk about that.

But for any other part of celebrity, I've largely not participated and just put my head down and kept doing what I'm doing.

So I was fascinated to hear that after this life in public service, you jumped to the private sector, starting a company called the Public Health Company, which obviously is a reflection of the fact that you think that your services will be more powerful in the private sector.

So tell me about that.

Well, it was simply that this capability has to exist, a scalable

commercial grade software platform that can move at the speed and scale that it would have to to protect businesses, to protect all kinds of assets, not just within capitalism, but within governments.

It was so revealing to watch how businesses had nothing, had no tools.

They had been led to believe falsely that the CDC would save them.

And it's false because first, the layered jurisdictional authority for communicable disease in the United States, there is no part for the CDC enforcing anything.

The states and the counties are the ones with the jurisdictional authority.

So it was just shocking to watch how businesses and enterprises and these incredibly influential decision makers, CEOs, they were the ones people were looking to.

to say, what do we do?

And they didn't have any answers because no capability existed to surface that index of suspicion and pattern recognition and intelligence so that they had at their fingertips.

How do we manage this risk?

Jumping into Silicon Valley was like landing on a foreign Star Wars planet, whole different language, whole different culture.

Even the laws of gravity are different.

In the last two weeks, I've learned four new product platforms as, you know, de facto head of product.

I start whiteboarding out the software and turn that into more technical documents and work with my team to turn that into software.

And then I watch it come to life right in front of my eyes.

And really my goal is to make myself obsolete.

A system that relies on human vigilance will always fail.

So how do we create a system that does not rely on human vigilance, that has layers of redundancies, and machines can be taught to elevate the signal from the noise and to quantify and parameterize

the different sources of data and intelligence in a way that can do it way faster than a human.

The fact that capability could be built and had been built for other sectors, that's what gets me out of bed every morning.

I've worked a lot with big companies and I would not say that it was easy to convince them to make big investments to deal with uncertain calamities that will happen in the semi-distant future.

Have you had a different experience?

trying to sell this product to people.

We've been so overwhelmed with interest that we have a very long waiting list of companies that would like to come on board of the platform.

That's fantastic.

But it's early.

The mottos that we're building with is, you know, to build early versions, get it out there in front of customers, get their feedback, make it better really fast, even right there on the meetings with them, fix the code, rework the UI so that what, boop, that bug is fixed or that change is there, that feature is there.

Every day, pushing out new code, new features.

And so it's incredibly addicting for those of us who are adrenaline junkies and like to see immediate action.

Boy, there's nothing like building software because you watch it come to life right in front of your eyes.

We have seven to 10 countries on the platform right now and are scaling up quickly to get to 20, 30, 40 countries and adding additional threats.

Obviously, we started with COVID, already are adding monkeypox and doing deep work on influenza and then looking at environmental threats, heat index and AQ air quality index and natural disasters.

All of these things are not isolated.

Maybe 50 years ago they were, but the world we live in today,

the greatest risk, biosecurity risks, are at the intersect of disease, climate change, population behavior, political unrest.

You layer on disease, political unrest, infrastructure destruction, and climate events.

And that's when you get the trifecta of risks.

Now, hearing you talk.

with such joy in your voice about the private sector.

Do you have regrets that you didn't jump sooner?

No,

because I needed to learn the lessons I learned the hard way to deeply understand in my soul that capitalism could build the solution,

not government.

There's a really important role for government, and there's a really important role for capitalism.

And I needed to understand the difference down to my toes so that when I made the decision to jump to the private sector, I was 100% convinced this is where the solution has to come from.

There couldn't be any doubt in my mind.

I'm so glad to hear it's working out so well in the private sector because obviously you hear economists tout the private sector, but sometimes businesses are just as bad as the public sector at getting things done.

But it sounds like you're going 100 miles an hour and that's fantastic.

Well, you know what's funny, Steve, is it's all based on what I understand of evolution.

Those concepts about evolution, natural selection for the fittest based on the environment today, the same is true of startups.

Startups are the research lab of American capitalism.

So the startups that survive are selected for as being the ones best suited or best positioned for what the market wants to buy today.

So in that way, it takes the pressure off.

My job is simply to follow and listen closely to the market.

It's evolution.

I love it.

It's interesting to hear someone who spent her whole life thinking about plagues and viruses use the same model to describe how markets work.

Charity uses a slightly different vocabulary than an economist would, but the basic idea is the same.

Ironically though, having spent so much of my life studying markets, I have a lot less confidence in their smooth functioning than charity does.

I'll be watching a new company closely and rooting for her.

In case you know someone looking for a job, my center at the University of Chicago is hiring for the research analyst position.

It's typically been filled by people just graduating from college, but we'll give careful consideration to anyone who's interested.

For more details, check out our website, it's risk.ushicago.edu slash news.

That's risc.ushicago.edu slash news.

You can also find the link in our episode's show notes.

Applications are due October 15.

We'll be back in two weeks with a guest that more listeners have asked for than anyone else, renowned philosopher Peter Singer.

I think I enjoy arguing, and so I could have been a lawyer, and perhaps I could have been quite a good lawyer, but I think I found a field in which I can argue much more broadly, and I do think that I've had an impact on people.

Thanks for listening, and we'll see you in two weeks.

People I Mostly Admire is part of the Freakonomics Radio Network, which also includes Freakonomics Radio, No Stupid Questions, and Freakonomics MD.

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Our staff also includes Neil Carruth, Gabriel Roth, Greg Ripen, Rebecca Lee Douglas, Julie Canfor, Zach Lepinsky, Ryan Kelly, Catherine Moncure, Eleanor Osborne, Jeremy Johnston, Daria Clennert, Emma Terrell, Lyric Boudich, Jacob Clemente, Alina Coleman, and Stephen Dubner.

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We can be reached at Pima at freakonomics.com.

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Thanks for listening.

This is so funny.

I was as shocked as you were when I opened up the book, and chapter one was the story of the autopsy.

Freakonomics Radio Network, the hidden side of everything.

Stitcher.

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I'm always honored to meet fans out in the wild.

The honor is mine.

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Well, the Geico app is top-notch.

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Sign what?

The app?

Yeah, sure.

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Could you sign it again?

Anything to help, I suppose.

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Hi there, it's Andy Richter, and I'm here to tell you about my podcast, The Three Questions with Andy Richter.

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