Inspecting the Spread and Management of Infectious Diseases—Mark Lurie—Associate Professor of Epidemiology, Brown University

Richard: Hello, this is Richard Jacobs with the Finding Genius Podcast.  I have an associate professor Mark Lurie.  He’s an associate professor of epidemiology at Brown University and we’re going to talk about some about HIV, a bit about coronavirus and various infectious diseases.  So, Mark, thanks for coming.

Mark Lurie: Thanks for having me.

Richard: Tell me what got you into Epidemiology and how long have you been working on it first of all?

Mark Lurie: So, I started in Epidemiology in the early 90s.  It was not a direct [inaudible – 0:00:32.9] for me.  I had no idea of really even wat epidemiology or public health was.  I was raised by — my dad was a doctor and so I knew a medicine wise and I knew that I certainly wanted to avoid that in my life.  But I didn’t know public health was an option until I was doing a master’s degree in African history.  I’m from Africa so I had a lifelong kind of interest in Africa but particularly in South Africa and [inaudible – 0:00:58.2] and its sort of long-term legacy to this day.  What I came across is a historian was as fascinating a study that looked at the early spread of tuberculosis in southern Africa.  And to cut a long story short, essentially what happened was with the discovery of gold in the late 1800s, you had large numbers of young men congregating around the goldmines, obviously, the underground conditions were highly conducive to the spread of tuberculosis who are working in a hot, dusty environment with lots of silica dust, which weakens the lungs and makes you more susceptible to tuberculosis.  And above ground, the conditions are perfectly right for the spread of TB to other miners because people are living in very close social [inaudible – 0:01:53.2] quarters.

That, we could have all guessed but it went Randy Packard, the author of this book “White Plague, Black Labor” showed was that as a result of the patterns of migration that have been engrained in South Africa, the first spread of TB were in these urban hotspots oftentimes around the mines, and then through a very efficient system of migrant labor, that is sending those men back to rural areas at that point really once a year around Christmas time when they got a break was a very efficient means of spreading tuberculosis than to rural areas, which had never before seen TB and therefore had a devastating impact.  I came around in the early 1990s when HIV was already an issue in this country but not really yet established itself in here in Africa and it was clear to me having read Packard and understanding the history of tuberculosis that the very conditions that he described in the early 1900s were very much still in existence today, the long-term impact of a migrate labor system in South Africa meant that most of the people who — that there’s a large amount of migration from rural areas to urban areas and that much of it is temporary and much of it is amongst men seeking employment who then return home sort of later in life or multiple times throughout the year.

And it was clear to me that HIV was going to follow a very kind of similar spread that Packard had described because those conditions were so similar and still you had those hostels that were exacerbating or poor living conditions but in the case of HIV, around those hostels, you saw the development of that kind of industry to service those people both sexually and with alcohol and those things kind of fueled the spread of HIV first on the goldmines and those hotspots and then, once again, very efficiently distributed throughout southern Africa when men migrated back home.  So, that’s how I got into it.  And my early work was in the province of South Africa called Kwazulu Natal, which turns out to be literally the epicenter of the HIV epidemic, probably the place where we have measured the highest prevalence and incidents of HIV in the world.  Also, it turned out to be a place with a very high amount of migration to the mines and to other places and I don’t think those two things are coincidental.

When I went back in South Africa in the early 1990s or 1994, it was just after Mandela had been elected the first democratic opportunity for the majority of South Africans and at time of great hope and also at the time really at the beginning of the epidemic where some serious mistakes were made that exacerbated the epidemic later on and indeed, I’ve seen some similar kinds of mistakes that we’re making today with coronavirus.

Richard: So, you have very unique insights into what’s going on right now.  So, let me know what are your thoughts, you see it with practiced eyes, so what do you think that nations are doing right and doing wrong in regards to coronavirus?  What do you see is the path ahead?

Mark Lurie: So, thinking of just a little bit broader, the things that intersect — where my work intersects is around the issue of migration and human movement.  If we think of that kind of historically, it’s remarkable that three or four generations, a vast majority of people never strayed more than 5 or 10 miles from their house that they were born.  They kept a very, very limited geographical [inaudible – 0:06:00.2] footprints.  And over the course of a couple of generations, that has changed absolutely and completely in human existence and we’re all caught in a mobile interconnected world and of course, that’s how infectious diseases move around.  So, that’s sort of one lesson is the importance of the human movement of contact between people because, after all, the thing that infectious diseases have in common is they spread between people, and therefore, they’re going to follow the kind of physical, geographical movement of people.

Another thing that I think is really important and draws some parallels to the HIV epidemic is that infectious disease epidemics tend to unfold in very short periods of time, unlike cancers and things, which are 10 or 12 or 15-year trajectories.  Infectious diseases happen in a much more contracted period of time.  So, think of where we are today with COVID, we’ve got 8 million infections globally of a disease that 6 months nobody had ever heard of and probably never existed.  So, in a very short period of time, this disease has been able to propagate the globe very, very efficiently.  And a corollary to the rapidity with which these things happen is the importance of early intervention.  So, as you wait and delay to intervene, the kind of accumulation of cases that you miss prior to intervention makes it very difficult to intervene effectively, which is a complicated way of saying, “You get much more bang for the buck early in the epidemic when you intervene early than when you do later”.

And if you think about that, in the US now, we’ve got multiple tens of thousands of ongoing cases, so to trace all of those people and the contacts of all of those people, that’s a huge logistical undertaking that’s very, very difficult to do.  However, if we’ve done it effectively at the beginning of the epidemic when we only had a few hundred or a few thousand cases, we would have stemmed the flow of the epidemic, so the importance of intervening kind of early and effectively.  And then, of course, there is a broader and kind of global health message, which is about the importance of consistent and accurate health messages from trustworthy people and that’s clearly something that we’ve lacked in this country in relation to COVID.

In South Africa as well, early in the epidemic, we had a president who didn’t think that HIV caused aids and a Minister of Health who’d thought that antiretrovirals were no good but people instead should be eating beetroot and garlic.  So, we’ve had our fair share of misinformation, and those things, I think, are highly detrimental to controlling an epidemic because they lead to conspiracy theories, they lead to ignorance and they lead to confusion.  And those are all of the things that one really wants to avoid when you have a small amount of time to address a really, really major issue.

Richard: Well, I have even heard that there was a myth going around with HIV that if you sleep with a virgin, it’ll cure you and just all kinds of crazy stuff.

Mark Lurie: Indeed. I mean that was one of many early kinds of theories of sham cures and treatments for HIV that we have been hearing about for a very long time.  Another sort of pressing parallel something to think about is even though we’re 35, 40 years into the HIV epidemic, we don’t yet have an effective vaccine.  We’ve tried multiple vaccines in human populations and none of them have been anything more than remotely encouraging.  In the vaccine situation with COVID, we are trying to compress a timeline that usually is much, much longer into a very short period of time.  So, HIV, we’ve never even developed even though we’re 35 years into it and knowing about the vaccine, on average, it takes about four years to develop a vaccine and we’re helping to develop one with coronavirus in something around a year.  President will tell you it’s around the corner and it’s about to be available and it’s obvious that it’s quite a long way away.  And even a year is an incredibly optimistic prediction, which is not to say that there isn’t an unprecedented effort underway with the multiple vaccines being developed and some of them already in testing, even some factories being built to produce vaccines about whose efficacy we don’t even yet know.  So, they are trying to do things like that to compress the timeline so that if we do find a vaccine that we can rapidly scale up production because after all, it’s something that we’re going to want to get to a vast majority of the global population, which is somewhere around 8 billion people at this point.

Richard: So, with HIV, how many people a year does it kill nowadays?  And it’s been around since the 80s, it just seems like everyone’s gotten used to it and it’s no big deal even though it’s a huge deal.

Mark Lurie: That’s true and there’s no doubt that there have been huge successes in HIV even though we don’t have a vaccine, what we do have is very effective treatment so that people who get on treatment early and are able to remain on treatment can essentially have about the same life expectancy as people who are uninfected with HIV.  So, it is remarkable in the sense that we do have an effective treatment.  The problem is that, as is always the case, the wealthy are more likely to get access to those treatments and poorer countries, historically have struggled and there are still many people in Africa, which remains the epicenter, who are not yet on treatment and equally important is that every year, we’re getting tens of thousands of new infections, so we haven’t stemmed the flow of new infections and we continue to add to that.  But again, the biggest weapon that we have in our arsenal is treatment, which is fabulous if you’re infected and it can not only extend your lifespan and allow you to return to very much kind of normal, physical activity but it also lowers the probability that you will infect other people.  So, it has a kind of individual and population-level benefit.  And we’ve seen that in the countries that are most impacted by HIV over the last decade.  Those are the ones that have actually seen the largest reduction in the number of new infections.  So, they haven’t completely eliminated new infections but they’ve reduced the amount of new infection significantly.  And that’s sort of true pretty much across southern Africa, most of that I personally believe is due to the public health impact of large-scale up of antiretroviral therapy and so that’s where we stand with the epidemic today.  You are right that it’s been a long time since HIV was the kind of flavor of the month that we all talked about and raised money for and was very much on our front pages and that is obviously not the case today, which is not to say that the end of HIV is anywhere near inside.

Richard: What about the world’s reaction to coronavirus?  Do you think it’s — I mean I don’t know, besides the plagues of old, it doesn’t seem like there is this much of response not even close.  What’s your thought on it?

Mark Lurie: This is probably the largest public health intervention that’s ever occurred.  I can’t think of anything short of the roll-out of antiretroviral therapy, which has impacted tens of millions of people across the world.  But this is something that impacted certainly a much larger proportion of people and it’s also something that because of lockdowns or stay-at-home orders that were widespread across the globe that somewhere close to the majority of the global population actually changed the behavior at least for several months.  So, in that way, it’s unprecedented and I think it’s fair to say at least from the data that we have from the United States that the lockdowns or stay-at-home orders, whatever you want to call them, were largely effective and I think there is some data starting to show that including some of my own work that we just submitted for a peer review and hopefully for publication, fairly soon that’s looking at what we call doubling time, which is a kind of measure of how quickly the epidemic is spreading.

And we’ve found something quite interesting, which is that across the United States, the doubling time has increased significantly when you compare the pre-lockdown period to the lockdown period.  So that’s a good thing.  It means it’s taking significantly longer.  In fact, it’s taking us 80% longer for the number of cases to double during the lockdown period as compared to the pre-lockdown period.  So, things slowed down considerably across the US when we went into lockdown.

Richard: That was the message though is flatten the curve but now what?  I mean it caused untold damage to economies, other diseases were ignored as we talked about offline, cancer screenings weren’t done, a lot of regular medical care was labeled as elective, which is a false label I believe, and there’s just been mass suffering.  So, we’ve flattened that curve but what about everything else, and what from here?  I mean it’s not going to go away, it looks like, at all.  So, what do you do, just keep locking down people forever is not going to work, what’s the pathway?

Mark Lurie: No. I think all of those things are true and I think it is increasingly difficult to keep locking people down.  And I think now that we’ve lightened those restrictions, we’ve sort of given people the key to open their doors to the lockdown.  It’s going to be doubly difficult to lockdown people again after that and that’s my major concern.  I personally believe that right now, we’re producing about 20,000 new cases a day in the United States and that’s been the case for quite a long period of time.  It’s a very, very flat curve.  It is not a curve that is noticeably going down but if anything, it’s [inaudible – 0:17:54.4] and continues to produce roughly 20,000 cases a day.  So, that 20,000 cases a day is 600,000 cases a month.  That is an awful lot of cases and we got about 1,000 deaths a day, which is 30,000 deaths per month and by some current modeling estimates, by the end of this summer, we’re going to have another 100,000 deaths.

So, it’s true that we’ve ignored other things but the scale and scope of what the coronavirus presents us and what it would have looked like had we not intervened at least early and relatively effectively, I think it’s actually mindboggling and it’s easier to say look at all the bad side effects and the shutdown of the economy, the truth is that if we haven’t done that, the numbers that we were seeing would be truly catastrophic and unable to be understood or dealt with in any kind of meaningful way.  And I don’t think that’s what anybody wants.  What we’re looking for is the right balance where we can return to a kind of normalcy but we have to be able to do that safely.  I think what we’re getting into is a false sense of complacency and I see that going on for the next couple of months partly because summertime is here, the virus spreads slightly less efficiently in warm weather and also people will be outdoors a lot more and it spreads less efficiently outdoors.  So, there is going to be, I think, a kind of continuation of the numbers that we have been seeing over the last couple of months without a drastic reduction and come the fall and the winter, when flu season comes around, when people are forced to be indoors and when we’re no longer going to be wanting to pay serious attention to lockdown orders and other kind of public health initiatives.  Then, I think we are potentially in for something that is even worse than what we’ve already experienced.

Richard: So, even worse, I mean the mortality rate, again, the number is still bouncing around and I’ve heard 0.26%, the higher percentages I don’t know if they apply or not, I mean who knows but again, why is this happening when all these other diseases, it’s totally okay to die from them?  Why having to be lockdown because of driving cars or HIV or cancer or things like that?  It just seems like this disease is the only one that matters and other ones, it’s like, “Yep, people die, no problem, it’s fine”.  And I don’t see any calculus on “Sure, maybe the lockdowns have helped to stem the spread of coronavirus” but what have been the externalities, what have been the negative parts?  I don’t see any calculus of that and I don’t see any attention being paid to it and I also don’t see what’s the plan from here; it seems like there is no plan.  At least in the US, there are at least 50 different plans, if there are any, and if anyone even trying to make sense of this, are they allowed to say anything without being censored or is there anything in place at all?

Mark Lurie: I mean look, a couple of issues there are.  I think you make a valid point that we can’t simply shut down all healthcare and all our society because there is a virus.  It is different than car accidents and other things in that it is spread from humans to humans, so shutting down and limiting human contact is a kind of known effective intervention.  That doesn’t make any sense to lockdown, to shutdown car accidents unless you wanted to stop people from driving completely, which actually we’ve done in a way during this pandemic and no doubt later, we’ll see the positive impact on that, which is that there’ll be fewer traffic deaths.  You are right.  There are multiple negative impacts that are not being addressed.  I wouldn’t defend that for one second and I would hope that we could be an advanced enough country that we could do multiple things at once and not have to only address the coronavirus epidemic but also be able to what multiple other health issues that we’re facing.

I wouldn’t say it’s us who are thinking about some of the flipsides of the coin, some of the positive things that have come out of this and I know that’s not easy to do because we’re also sick of being locked down and worrying about our relatives and our own health but we have drastically reduced air pollution, we have drastically reduced fuel consumption, we have allowed at least temporarily some animals to kind of regain their habitat.  So, there are a few positive things that come out of it and not in any way do they undo the terrible horror that we’re seeing as a result of COVID and the many things that we aren’t seeing that you have well-pointed out are going and continue to go on in the background because people don’t stop dying from other things; they’re still dying from malaria and TB and tuberculosis and many other things.  So, that all remains true.

Richard: So, obviously there is no answer, me being in the US, obviously I’m US-centric but I don’t know, do you think the world is just waiting for the US to do something and everyone follows or do you see the dynamic of what’s going on with coronavirus in various countries in the world?  I don’t hear anything, I know there are hotspots, sure, but otherwise, I just hear nothing.  Is anyone even looking or listening and what are other countries doing?

Mark Lurie: I think let’s put it this way.  The countries that are succeeding are not waiting around for the United States lead.  If anything, we’re leading them to the bottom.  And the few places that are seeing the greatest surges right now, which I’ve pointed out, Brazil and Russia are both places that in a way have followed the USA’s lead with disinformation, with denial, with the disorganized response and that’s precisely why they are competing with us for the very bottom, which is to say for the great number of cases.  In a lot of countries, there have been almost as many variations of an effort to stem COVID as there are countries.  As you probably know, some Scandinavian countries took a very different approach, Sweden, in particular, made a decision that based on the understanding that older people are much more vulnerable to COVID that their lockdown would mostly involve older people and would allow younger people to continue to move around and even many places didn’t cancel school.  That’s one kind of extreme example of a different way of addressing COVID.

Other more authoritarian places like China obviously had a major lockdown where they really shut everything down in a way that I think makes what we did in the US looked kind of sad.  Sure, we had a major shut down but I think nothing in relation to the way that China and a few other places were able to shut down.  A few places are blessed by geography.  I mean if you’re a small island like New Zealand, then it’s easier to keep the virus out and to control it when it comes in.  I think though one thing that many countries that are succeeding have in common is that they are doing lots and lots of testing and that’s one of the things that truly scare me in the United States is that we are not testing anywhere near the number of people per day that we should.

Richard: If they test, what good is that?  So, you test people, that’s a snapshot that day, either they have it or they don’t have it.  Then what?

Mark Lurie: Testing is critical not only because it identifies people but because it allows you to isolate those people to make sure that they don’t infect anyone else and to find their contacts to make sure that their contacts either are themselves not infected or don’t infect other people.  So, testing is critically important and it’s part of the broadest strategy to isolate and to find contacts of those people so that you can stop the new spread of infection.

Richard: But you can’t stop it forever.  People have to live, so they’re going to come out sometime and then at some point, they’re going to get infected.  You can’t stop the — the virus is unstoppable.  So, a certain percentage will have to get it at some point.

Mark Lurie: I mean the strategy is that we try to minimize what proportion of people get it for now until we have a vaccine.  You’re right about that that the virus right now is unstoppable and without a vaccine unless it burns itself out, it’s likely to infect a very large proportion of us.

Richard: So, what if they did that with AIDS, would the whole world be locked down for 20 years until they found or no one is allowed to have sex for 20, 30 years and so they’ve found antivirals?  I mean if a vaccine is going to take years, who knows if it’s even possible?  It just makes no sense.

Mark Lurie: I’ll tell you one thing you won’t be able to control is other people’s sex lives.  I think I’ve learned that more than anything.  You can tell people not to have sex but that’s a sure way to fail.  But the broader point that how do we balance the immediate large crisis that is undeniable with the kind of background, other things that are going on and I certainly don’t have the answer to that.  I think if we have erred in the other direction, which is to say we had less lockdown and less restriction, I think we would be in terrible shape.  I personally think that a thousand deaths a day in the United States is a crime.  It doesn’t have to happen and it shouldn’t happen.  And we are the wealthiest country in the world, we should be able to avoid this.  So, yes, I think it raises and points to all kinds of problems that we have in our health system and throughout our society and these things are going to take a long time to heal but to look away and pretend that COVID is not there or to try to kind of simultaneously deal with it, I think it’s very, very difficult.

This is a highly infectious disease and having people in close contact with one another is the precise condition that the virus spread.  So, the only prevention method that we have right now because we don’t have a vaccine is to simply keep people apart and make sure that they have fewer contacts with one another.

Richard: Why the only vaccine, why not antivirals, why does there have to be a vaccine?  Why can’t there be a treatment for it so it’s not so bad and the death rate goes from 1% to one-tenth of 1%?  No one cares that the flu rate could be one-tenth of 1% but we’re totally cool with that and we don’t do anything.  And the US alone, CDC’s studied that 70,000 die each year, that’s no problem.  Everyone’s cool with that.

Mark Lurie: No, I think that’s an exaggeration.  I wouldn’t say everyone’s cool with that.  I think that that is something that occurs in this country that is multiple public health and medical officials are trying to reduce that number in a whole variety of ways every year.  I don’t think we just accept that that sort of happens at background noise.  I think that there is a real effort to try to eliminate that.  So, it’s not that we turned a blind eye to that.  But 70,000 deaths over one year for flu is significant, in the course of six months, we’ve seen one-and-a-half times that number already but COVID.  So, by that calculation, we should be turning a huge amount of attention to COVID.

Richard: I agree we should give it attention but I just don’t see anyone seeing — I think we’re going to have to get to the point where we’re going to say, “Look, there has to be this balance.  There is going to be a certain amount of deaths, no one wants that”.  Maybe they need to set parameters on — I mean maybe that’s what they’re doing, number of deaths as soon as they get to this level, then you have to implement some level of restriction and then when it eases off, you open up again and then you go down and up and down and up, I don’t know.

Mark Lurie: I mean that’s essentially the kinds of guidelines that the White House put out for reopening.  The problem is that nobody is following those at all.  Everybody has their own kind of formula and even they’re not really following.  But I want to get back to an interesting point that you raised about why only a vaccine, why not treatment.  And you’re right that treatment could have a major impact.  There’s no doubt about that.  It’s more likely to have an individual-level impact than a population-level impact, which is to say that unless you’re able to get people on treatment very, very early, you’re not likely — the treatment itself is not likely to slow the spread of new infections.  So, even if treatment just …

Richard: So, what is the goal?  Is the goal for people not to die or is the goal for people not to get infected?  What’s wrong with being infected?  I mean people get sick of all kinds of things, so it doesn’t make sense like again, it’s not going away, stopping someone from being infected, I don’t think that’s just really — I mean that’s just part of life.  Everybody gets sickness.  I don’t want someone to die or they start to grow old, I mean people are going to get infected by all kinds of things but if you can stop them from dying, that’s like a huge win.

Mark Lurie: No.  But I mean by that calculation, you’d say why to prevent anything, I mean everybody is going to die so why bother preventing anything and why not have unprotected sex with as many people as you want and come in close with people who have a [inaudible – 0:33:29.0], I mean that doesn’t make any sense.

Richard: Well, I’m just pointing out the two extremes.  I’m not saying go to that extreme but I think people are going to the other extreme.  We can’t let people get infected.  Why not?  What’s wrong with that if there is an antiviral if most people are going to be okay with it, maybe that’s the best you can do.

Mark Lurie: So, that maybe the next step, the next best step that we have that we find some treatment and in fact, just a few days ago, there is some news that maybe even two treatments amongst people who are very ill with COVID, this is not the average COVID infection but amongst the sickest people who end up in a hospital, looks like some new drugs can cut the death rate by about a third.  So, that’s very significant. But it’s not significant if you’re one of the other two-thirds where it doesn’t cut the death rate.  So, I think the kind of cavalier attitude about, “Oh, we’re all going to get infected, so let’s just do that and move on”, that means that you’re willing to accept about somewhere between a half of a percent and 1% of the entire US population dying.  And I don’t think we should be willing to accept that.  I think that’s an avoidable possibility that with decent public health and proper messaging and proper investment, we should be able to avoid that.  There is no reason why that should …

Richard: What does avoiding mean though?  Zero deaths from COVID or half-a-percent is okay versus 1%?  I mean that’s the problem.  I’m not asking you to answer it but I don’t see …

Mark Lurie: No, of course.  Nobody is going to quantify and say, “Okay, half-a-percentage of deaths is okay but 3 quarters of percent is not okay”.  I mean to me, any avoidable death is not okay.  So, we should be doing whatever we can to avoid any death whatsoever.  If we can …

Richard: But that’s not being done with …

Mark Lurie: … reduce the number, then that’s a huge advantage that we currently have.  For me as a public health person, what I am most interested in is of course I am worried about people dying and the terrible outcomes that occur from COVID but I am equally worried, if not more so, about the spread from one person to another.  And interestingly, with — so going back to HIV, we know that with antiretrovirals, getting people on antiretrovirals, as I was saying before, don’t have this positive individual impact but what it also does is lowers the amount of virus in that person’s body and therefore, it lowers the probability that they can transmit to other people.  So, it has both the individual level and the population-level impact.

Now, if we had a treatment of the kind that you are describing, that would not only impact people who are the sickest people from COVID but could potentially change the course of COVID for everybody who was infected and we were able to effectively identify enough people early on in the disease, then you could see how a treatment like that, which is going to render people less infectious and therefore, less likely to infect other people could have a kind of population-level impact.  And that’s what I would be looking for.  Sure, I want to reduce the proportion of people who die but I also want to reduce the number of new infections and for a treatment to be effective there, you would have to identify people very, very early on in the course of the disease.  We know that a certain amount of transmission happens even before people have symptoms, so to be effective, then you have to identify people who are infected prior to them actually having symptoms.  And that brings us [inaudible – 0:37:29.3] close circle back to the importance of testing because unless you’re testing people frequently and a large proportion of the population, you’re never going to be able to identify enough people who are current-spreaders before they developed symptoms of the disease and therefore before they spread the disease to other people.

Richard: I’m just glad that all the diseases aren’t treated like this because no one would be able to do anything.

Mark Lurie: And I see your frustration.  We’ve all been locked up and I think some of the ill-effects of that have started to leak out in the last couple of weeks in terms of the kind of pent-up frustration and understandable anger that many people in this country are feeling.  So, yes, I hate to be a doomsday but there are many things about the current handling of the COVID epidemic in this country that really leave a lot to be desired and are leaving us with many more infections in this country than we need to have.

Richard: What’s the best way for people to find out more about you?

Mark Lurie: I would say have a look at our website, the International Health Institute of Brown University where I am employed as a faculty member.

Richard: Any particular publications that you’ve come out with or about to come out with that you want to draw people’s attention to?

Mark Lurie: Sure.  So, the things that I talked about early on about migration and HIV, some of that early work was published in the early 2000s in the journal AIDS and Sexually Transmitted Diseases.  And I’m hoping that a paper I just submitted to the journal of infectious diseases about doubling time of COVID in the United States will successfully [inaudible – 0:39:26.7] through peer review and be published at some time in the not-to-distant future.

Richard: Okay, very good.  Lurie, thanks for coming on the podcast.  I really appreciate it.

Mark Lurie: Thanks for having me.