Op-Ed: Who Was Least Wrong About COVID?

News

ZDoggMD and MedPage Today Editor-in-Chief Marty Makary, MD, MPH, give the COVID-19 pandemic and their pandemic predictions an examination with topics ranging from the lab-leak hypothesis, vaccine efficacy, and even a quick parody of Shaggy’s “It Wasn’t Me.”

Following is a rough transcript (note that errors are possible):

ZDoggMD: Z-Pac, Dr. Z, Dr. Marty Makary, you are professor of, what?

Makary: It doesn’t matter. It doesn’t matter.

ZDoggMD: Johns Hopkins, in the school of medicine, in the school of public health, in the school of business, you are a professor. Who does that? Only a gunner.

Makary: I brought you a little gift from the Johns Hopkins right there, in case you are concerned before your sixth booster.

ZDoggMD: You brought me a mask at the end of a pandemic.

Makary: I only give them to people with at least six boosters and two different vaccines.

ZDoggMD: Marty, I’ll have you know, I’ve gotten the Sinovac the Moderna, the Pfizer, the AstraZeneca, the Johnson & Johnson. I got Novavax, ’cause I was in their trial.

Sputnik?

I got Sputnik.

Makary: Sputnik.

I got all the versions.

All right, then you’re covered, then you’re covered, with the Sputnik. That clears out the last 2% of infections.

ZDoggMD: It kind of does, and I double mask, and I’m in a hermetically sealed bubble right now, that you can’t see. Thanks for the mask, dude. It’s funny, so you’ve been the pandemic superstar, as far as I’ve concerned, because you’ve been right about everything. We’re going to talk about that, but I always say this. Your book, “The Price we Pay,” which is a must read, you guys. We did a show about it when it came out in hardcover a couple of years back. It’s out in paperback, when? Shortly?

Yeah, June 8th. Yeah, it’s coming out June 8th in paperback, second edition. The last one was a year and a half ago. This has a COVID update and a followup in every section.

ZDoggMD: Okay, this book is about how we basically fix healthcare, period, end of story, full stop. It’s one of the most powerful… If you don’t read it and get super pissed, you’re not a human being, and you need to be excommunicated from this race of people, all right? That all being said, we got that out of the way, here’s the key thing. I hate you.

Makary: I’ve been wrong too, by the way.

ZDoggMD: Oh, come on, what, you pick the wrong socks one day? What have you been wrong about? Start with that, then we’ll say what you’ve been wrong about.

Makary: I thought I was the second most humble person in the world. It turns out I’m the most humble person.

ZDoggMD: You are such a surgeon and I love you, so okay–

Makary: I am a surgeon, but just before we get started, my preferred pronouns are supporter of the Z-Pac Tribe.

ZDoggMD: Those are the only pronouns I will allow you to list in your email and on Twitter. Oh my God, what a great idea. My pronouns are Z-Pac/Supporter.

Makary: Z-Pac, yes, member of the tribe.

ZDoggMD: Okay, I pitched your book and you pitched my supporter tribe. Let’s punch it out.

I’m a supporter. It’s real, man. You can check my subscription.

ZDoggMD: Check it before you wreck it. So Marty, here’s the thing. Okay, you’ve been all over the news. You write op-eds, you’ve been a major voice on the pandemic, and you’ve taken so many arrows for what ultimately turned out to be the correct advice. So let’s start at the beginning.

Makary: I like to push the field.

ZDoggMD: Yeah, you do, and it’s funny, because a lot of the times that you had come out with something, I would initially disagree and be like, “That’s not right,” and then I’m proven wrong.

Makary: And that’s good to have a healthy conversation. That’s how we used to do things before the political entrenchment.

ZDoggMD: Right, but I would never go, “Well, Marty’s an evil person for saying this,” but that’s what they do. So let’s see what you’re an evil person for saying that turned out to be right. In the early pandemic, you said, “Hey, this is a real pandemic, guys. “This is not a joke. “This is actually going to be bad,” and people were like, “Oh, you shut up, “you fear-mongering, Johns Hopkins epidemiology, “public policy guy.”

Makary: Yeah, took a lot of arrows in late February, early March. Scott Gottlieb and I went on a lot of networks, a lot of cable news networks, wrote a lot of pieces, wrote one in MedPage Today saying this, “We need to abandon the idea this is contained. “What happened in Italy is going to happen “in the United States, “and hundreds of thousands of people will die, “maybe more if we don’t take it seriously.”

ZDoggMD: And you know what’s crazy is at the time, I was like this feels like we’re over-blowing this. I kind of believe in CDC and WHO. They’re going to control this. Science will win. It’s okay. It’s probably just flu with a little extra mortality.

Makary: American exceptionalism.

Yes.

Yes.

Yes.

Our immune system is exceptional.

ZDoggMD: Ever since July 4th, 1776, we have more T cells and more B cells than the rest of the world combined.

Makary: And more obesity and more disabled, more medicated, more hospitalized people than any country in the world.

ZDoggMD: You just stop that right… You shut your mouth.

Makary: Exceptional.

ZDoggMD: Okay, you’ve come here from Egypt, and you tell me my country doesn’t have B cells, but no, no–

Makary: Have good memory.

ZDoggMD: You actually said at the time, “Listen, I think we should have universal masking,” and people like Michael Osterholm were saying masks were dumb. I was saying cloth masks are probably a bad idea, ’cause we’re gonna be touching our face, and the public is too dumb to figure out how to use masks correctly, and you were like, “No, universal masking, it’ll save lives.” In retrospect–

Makary: Yeah, I took a lot of heat for it. So that was a New York Times piece that went viral in mid spring, right when the pandemic was bad, and nobody was talking about masking in a universal way, so I wrote this piece in the Times, calling for universal masking, took a lot of criticism for it, even among doctors, a lot of physicians.

ZDoggMD: Yeah, because we were also like, “Hey, well, let’s stop instilling panic. “Patients are going to be wearing masks on their face “and wearing gloves to the supermarket. “What the heck?” And of course…

Makary: And when you put something out that radical, I’ve gotta be honest with you, you get a little nervous, maybe I’m wrong, because that was based on, not hard randomized trials, but the empirical observations of Chinese doctors. Johns Hopkins, the Infectious Diseases Department, several doctors had a conference call with doctors in Wuhan at the hospital, early in January, when they were going through their really bad thing, and those doctors had a very clear message to us, and that was please urge everyone to wear a mask, and so I followed and I called a lot of doctors over there and I was trying to understand it, and they were saying, look, pretty amazing, it was contained in Wuhan in a country of 1.2 billion. How did they do that? The whole country masked up and some other things, draconian lockdowns.

ZDoggMD: Major lockdowns, yeah.

Makary: Welding people in their rooms.

ZDoggMD: Hiding all the data, and all the other thing, yeah, yeah.

Makary: But it’s a small cost for a potentially big benefit, and Korea did it, and other countries that got burned with MERS.

ZDoggMD: Right, and you said it, actually. I remember in those op-eds, you said, “Could you actually listen to the Chinese doctors?” What is this weird xenophobia that we have about listening to our colleagues in a different country, that happens to have a different political system?

Makary: And it’s not a revelation. It’s not like the Jordan River parted. What happened was SARS-CoV-2, which is COVID-19, spreads exactly like SARS-CoV-1. Guess what? It’s not that big of a revelation, a aerosolized virus.

ZDoggMD: Right, well, that was a brave thing to do, and I think the truth is you can have dissent, you can say, “Oh, no, actually, that’s wrong, “and here’s why I think so, the lack of data,” and so on, and when you were saying the precautionary principle, our experience in China, and it turns out, I think, you were absolutely right in–

Makary: And that debate is good. We should be having that debate.

ZDoggMD: 1000%.

Makary: Not political entrenchment and battle.

ZDoggMD: And this is the thing, and then admitting when you were on the wrong end of the debate. Early on, I was like I think masks are a bad idea for the public. For hospitals, absolutely. We need to save it all for them. I was also concerned that all the masks are going to go to the Joe Blow who’s at low risk, and then our frontline health care staff are dying, and that was one of my concerns, but Monica Gandhi, on the show, convinced me. She was like, no, this inoculum theory is a real thing.

Makary: She’s terrific.

ZDoggMD: Yeah, so you’ve got to update your prior data set and then change your mind, and then you have to also own when and why you were incorrect. See, it’s not like a judgment thing, like, oh, man, I was wrong, I’m the worst, I’m a worthless piece of crap, so therefore I’m going to deny it and project confidence. No, you go, yeah, I was wrong, because science is hard.

Makary: Yeah, it’s not sports betting in Vegas. It’s not like you pick your team, you cheer them on, and then you trash talk the other team, and then you’re just a massive let down if you don’t win. We need to evolve our strategy and thinking when the data changes.

ZDoggMD: When the data changes, absolutely. So you did that. Then about summertime, you were like, “Hey, guys, just FYI, “winter’s going to suck, “because just looking at these numbers, “this is the calm before the storm.”

Makary: Yeah, a snowflake before the blizzard was the piece, yeah.

ZDoggMD: Snowflake before the blizzard, and when did you write that and what place did you write that?

Makary: I don’t remember, but I went on Cable News saying that repeatedly, basically, like let’s brace up. People were like, in the TV interviews, “Have we learned lessons?” This is right after the fall initial outbreak. “Have we learned lessons for future pandemics “in future years?” We haven’t even learned our lesson three months, can’t even remember for three months how bad… It’s like forget about future pandemics right now.

ZDoggMD: We’re not even through this one.

Makary: Yeah.

ZDoggMD: So what are the lessons for 2100?

Makary: Yeah, anti-microbial 2050, increase in AMR.

ZDoggMD: And you were saying things that were actually… It’s interesting, ’cause you’re on a lot of networks that span the political spectrum. So you go on Fox News and say, “You know what? “The winter’s going to be really hard. “You’d better mask up.” Did you get pushback on those kind of networks?

Makary: Oh, yeah, yeah, I’m used to it, but a lot of people wanted to speak up, I found out, so I talked to a lot of doctors around the country. They either didn’t have a vehicle to do it, or they were afraid, because it would be seen as they’re representing their institution’s position, so they would always tell me things like, “I agree with that, but I just can’t say anything, “because of my institution. “It’ll look like X University is saying this.” I’m like this is the problem, not just in the pandemic, in all of healthcare, people are afraid to speak up.

ZDoggMD: Terrified.

Makary: When you see something that seems wrong, that it’s gonna affect people, people are gonna die, you gotta speak up.

ZDoggMD: You gotta do something.

Makary: We need more of that.

ZDoggMD: I agree, I agree, and so you were willing and able to do that–

Makary: That’s why I’m a big fan of Z-Pac, by the way.

ZDoggMD: Hey, what can I say? Keep pitching that, and I’ll just be like… And, guys, by the way, “The Price we Pay,” coming out in paperback, June 8th.

Makary: Has anyone ever accused you of not speaking your mind?

ZDoggMD: No. No, that’s not true. The anti-vaxxers accused me of speaking Pharma’s mind and not my own mind, which secretly knows that these vaccines are toxic poisons.

Makary: I think you enjoy the anti-vaxxers writing you.

ZDoggMD: I love them. It’s kind of like a love, hate, love thing, ’cause I kind of like their style of questioning everything. Even though it’s delusional, it’s a good practice for skepticism. The problem is it’s delusional intransigent skepticism, that’s not convincible, but at least it challenges your ideas. Remember you said earlier, it was like, “Well, what if I could be wrong?” What does that feel like? Well, in a way, it should feel like, okay, good, I’m wrong. What can I learn from this? What am I going to do next? What other beliefs of mine are probably not serving me, that are incorrect? So you said, “Okay, the fall’s gonna be a surge,” and then when the fall surge happened and FDA was starting to say, okay, EOAs are starting to be processed for these vaccines, you went on the warpath again, with flapping your big old mouth hole, talking about FDA. What’d you say about FDA?

Makary: Yeah, so they get the Pfizer application and Moderna application, and they schedule a meeting of their experts. Three weeks later, it’s like, hello, 2000 Americans are dying a day, how about we move that up a little bit? And by the way, it’s not that complicated of an analysis. It’s 44,000 people in a database, where you basically have zero adverse events, and the FDA, contrary to what people think, they’re not looking under the microscope, they’re not interviewing volunteers from the phase three trial, they get an application and they read it. Can you read a little faster? Don’t cut any corners on your process, but scheduling that meeting three weeks out for such a simple analysis, it was like… I have insiders at the FDA and they tell me nothing’s happening. Basically it’s dark over Thanksgiving. They’re frustrated, they’re angry, so they’re giving me the information, as I’m getting frustrated, saying, “Look, I’m going to speak out about this. “Can you tell me anonymously “what’s going on behind the scenes?” So there are a lot of people who adamantly defended the FDA, who know nothing about the process, couldn’t even tell you how many pages the application is or what the application’s asking for.

ZDoggMD: And remember, this is not an academic exercise. Thousands of people are dying per day.

Makary: Right, and people are perceiving my criticism to say cut corners on the approval.

ZDoggMD: Oh, right, yeah, yeah, of course, yeah.

Makary: No, don’t cut corners. Do the same analysis. By the way, we’re analyzing data every day in my research team, and analysis like that, I can have four different statisticians do an independent review of that data set and get you a result within 48 hours.

ZDoggMD: With a medical student bringing you coffee Q2 hours, right? Easily, easily, and I’m just saying, there’s one role for medical students and that’s gopher. Go for some more coffee for me. No, it’s true, and so you were saying that, then when…?

Makary: So the experts meet, they approve unanimously. They’re like, “Okay, when are we going to vote? “Okay, finally, we get to vote, vote unanimously.” Then there’s two days that pass, and so the people defending the FDA say, “Oh, they have to take their time, “make sure it’s all, their safety.” What’s going on two days after the unanimous vote by the experts?

ZDoggMD: You have to get it notarized.

Makary: You have to get it notarized, find a stapler and give it to Betty. She passes it on to the department of plain English.

ZDoggMD: There’s a fax involved. Meanwhile, another 4,000 people are dead.

Makary: Yeah, 6,000. I calculated, in those two days, 6,000 Americans died, and so those who defend the FDA said, “Well, it’s just two days. “It’s just processing time.” How about making it now? How about a sense of urgency? And, by the way, a lot of people at the FDA were like, “Please keep pushing us,” ’cause they can’t speak up there.

ZDoggMD: Yeah, yeah, and then we got into a situation where there was another Marty special,

Makary: Marty special.

ZDoggMD: and this Marty special was, and I say this, because you were right, “Hey, why are we vaccinating young people, “who just happened to be healthcare administrators “or something, that don’t touch patients?”

Makary: Yeah, the first people to get the vaccine. How do you look at this and not say something? Some of the people to get it the first week it’s out there, a 25-year-old media relations hospital worker, who is working from home, accountants, spouses of hospital administrators, hospital board members, I’m on a hospital board myself, I was offered the vaccine as a part of that.

ZDoggMD: Did you take it?

Makary: No, no, I wrote a piece in MedPage titled

ZDoggMD: Yeah, I think I read that.

Makary: “Why I’m not Going to get Vaccinated Right Now.” After a whole summer of Black Lives Matter, all of a sudden here, people with wealth and influence and power insert themselves and cut themselves in line ahead of those who are at greatest risk, basically saying my life matters more.

– Are you an anti-vaxxer? Because that’s what it ******* feels like to me. You take your mask and you get out.

Makary: I love anti-vaxxers, but I disagree with them.

ZDoggMD: So you were advocating that we go on an age-based, which is risk-based thing, give it to the elders first. Now, who did that and it turned out to work out?

Makary: Well, a bunch of states did it.

ZDoggMD: And the Brits.

Makary: So the Brits said, “Look, let’s do the first dose first. “Let’s focus on first doses.”

ZDoggMD: Also, that was the other thing, just give that first dose. So you had a good analogy for this with life preservers or something, right?

Makary: Yeah, so look, if you’ve got 20 life preservers and 200 people swimming in the ocean, and you’ve got a case fatality rate of COVID, why give two life preservers to one person? You’ve got a scarce resource. In the science of rationing, which, by the way, the government knows nothing about…

ZDoggMD: Right, but the UK knows about it.

Makary: UK did it. They’re very familiar with rationing and they did it. Well, they did this. They delayed the second dose to 12 weeks, so as many people could get that incredible protection of the first dose, and it is incredible, and I don’t say that to downplay the second dose. 92% efficacy at four weeks, published in the New England Journal of Medicine, for the Pfizer and Moderna vaccines, at four weeks, just from the first dose. That’s pretty good. When people are dying left and right, let’s focus on first doses, and so why would you give two life preservers to one person at that time?

ZDoggMD: Well, because you go from 94 to 97.6.

Makary: Yeah, the efficacy goes from 92 to 95, so three bonus percentage points.

ZDoggMD: That’s right. Think of the buoyancy, the extra buoyancy in the ocean, of two life preservers. Come on, come on, Marty, get your head on right. First of all, and I’ve got to say this, by saying these anti-dogma kind of things, although even Osterholm was saying it at that time, right?

Makary: Osterholm, Mashesh Job, Bob Wachter, lots of us.

ZDoggMD: Mashesh Job, Wachter, yeah, first dosers, right. You guys are the first dose clan, although clan is a very triggering word. You guys are the first dose crew.

Makary: Trigger word.

ZDoggMD: With a K. Many people will brand you as a heretic. You’re not just a dissenting scientific opinion, you are a bad human being. That’s how we tribalize this stuff during the pandemic, which is a huge problem.

Makary: Yeah, everyone wants to size you up. Are you one of us, on our side? Are you a liberal or are you one of them, a conservative? And that’s not healthy, especially right now, and the reality is, I’m not a partisan, I’m independent.

ZDoggMD: Okay, you are the most alt middle person I know. In the beginning, you were taking stances that were pissing off the right. Wait, universal masking? Wait, this thing is not the flu? Wait, what? You’re going on Fox and saying that.

Makary: Yeah, I went on Fox, Sunday morning show in March, said, “Hundreds of thousands of Americans “will die from this.”

ZDoggMD: Yeah, and I’m sure Brit Hume and these guys were like, “Wait, what? “I’m sorry, Marty. “You mean hundreds of thousands of foreigners will die, “not us, right? “Can you repeat that?”

Makary: He was a little taken… Actually, he was taken back with my comment,

ZDoggMD: Oh, was he?

Makary: but he came around actually.

ZDoggMD: Ah, that’s good, but then, just to prove that you’re not some kind of left wing stooge, then you say things like, for example, just now, “Hey, we’re going to have herd immunity by the end of April, “and by the way, this pandemic’s going to be over, “because the vaccines are great, and by the way, “natural immunity is a thing.” And guess what? You were pretty much right about everything, ’cause cases have plummeted, natural immunity does contribute, and probably the left was like, “Oh, who is this fascist going on Fox News, “saying that this thing’s over?”

Makary: Well, it’s amazing. Ignoring natural immunity, which, oddly, our public health officials have done, and I think it’s more a function of the old school nature of those officials. “We don’t have data on natural immunity.” It’s like open your eyes. No one is getting reinfected at any appreciable degree–

ZDoggMD: With severity, with severity.

Makary: Yeah, when the reinfections occur, the Danish study less than six tenths of 1% of people who got reinfected, they’re mild when they happen, and the idea that, “Oh, re-infection could happen,” it’s been around 15 months, the virus, where are those reinfections? Where’s the death and disability from reinfections? It’s like Bigfoot.

ZDoggMD: Right, but variants, Marty, but variants.

Makary: Yeah, so the variants, we’ve had hundreds of variants, none of them have evaded the life-saving protection of the vaccines.

– Bingo.

– None of them.

ZDoggMD: Including a recent study of an Indian variant and Pfizer and AstraZeneca, both highly effective.

Makary: Absolutely, exactly, yeah.

ZDoggMD: And the Indian variant’s the ones that everybody’s wetting their pants about, because India’s doing so poorly, even though the Indian variant isn’t driving a lot of that poor outcome. It’s actually the UK variant initially.

Makary: So why are public health officials dangling variant fear so much, at a time when, honestly, people need hope.

ZDoggMD: They not only need… Hope is accurate. It’s not like we’re slinging a lie. It’s like, “You know what? “Hope. “Hope sells. “The Price we Pay,” why medical care in the US is garbage.” No, it’s true.

Makary: Rochelle Walensky.

ZDoggMD: Yes. Hallowed be her name.

Makary: I admire her. I just wish she would speak what I believe she knows to be true sometimes. Kids at summer camp have to be six feet apart with a mask outdoors. She knows better, okay? She’s a smart doctor. She was at Hopkins, well-respected, head of ID at MGH.

ZDoggMD: Harvard, yeah.

Makary: She knows better. She can’t go against the party line. There’s party line stuff. There’s stuff that the CDC career staff puts out, and she’s afraid of speaking her mind. I thought we were supposed to be listening to science right now.

ZDoggMD: No, no, no, no, no, we’re listening to the science, Marty,

Makary: Only one, one science.

ZDoggMD: the science is, whatever my tribe says, the science is. It’s dogma. It’s not a scientific process. So for example, National Nurses United or whatever the big nursing union, came out and they were like, um. All this time, they’ve been shouting about follow the science, stay home, mask up, which are all fine. Now, they’re like, “Well, we disagree with the CDC. “We think masks needs to continue. “Why, well, ’cause science.” Wait, where? You don’t think the CDC looked at science to make their decision? Now that they’re saying something you disagree with, it’s suddenly not science anymore.

Makary: What’s the name of that group again? The National Nurses–

ZDoggMD: National Nurses United, I think?

Makary: Nurses United.

ZDoggMD: Yes.

Makary: The most disunited ununited group, in terms of their support of that union. It’s a union, so the names are deceiving. So the unions in general want this pandemic to go forever. Okay, I’m just going to put that out there.

ZDoggMD: Yeah, teachers unions?

Makary: Yeah, teachers unions. That was a joke.

ZDoggMD: It’s criminal.

Makary: We abandoned America’s kids

ZDoggMD: Children, yeah.

Makary: ‘Cause they don’t vote and they don’t have a voice, and San Francisco, right here in San Francisco, today, we’ve got one 10th the numbers of a seasonal flu right now, in terms of daily new cases… The case fatality rate is now the same. In the past, comparisons to flu were atrocious, because COVID was far more dangerous than the flu. I made those arguments to people all the time last year. This is not the flu. That’s one of the reasons so many people hated me last year. This is not the flu, and now, the case fatality rate has changed. The case fatality rate has decreased, because it is now in younger people, healthier people, and the case fatality rate now is similar to flu, and I wrote a piece in the New York Post on this, and in terms of daily case numbers, we’re at about 18,000. About 18,000 yesterday. Now, some of that was weekend reporting.

ZDoggMD: Actually, 12,000 is last I saw from STAT News. Yeah, that’s ridiculously low.

Makary: Yeah, I saw that number. Yeah, so we can report… But in this ballpark right now, so guess how many daily new flu cases we have in the middle of a mild flu season? The most mild flu season in over the last eight years was 2015, 2016. That was the most mild flu season. In the middle of that flu season, guess how many daily flu cases we had?

ZDoggMD: It must’ve been in the thousands.

Makary: 450,000, almost half a million.

ZDoggMD: Per day?

Makary: Per day.

ZDoggMD: In a slow flu season?

Makary: In the mildest flu season in the last eight years. We are one 10th that number of daily cases right now. We’ve got in-person learning only two days a week in San Francisco School. San Francisco had 12 cases in the whole city on Wednesday. We’ve got only kids there are two days a week right now, today, and where are our public health officials speaking up on behalf of those kids? It’s a disgrace.

ZDoggMD: They’re scared of the unions. They’re scared of the unions. They’re scared of their own teachers in their own schools. Listen, I was asked to speak at my own school district as an expert on COVID.

Makary: They need you.

ZDoggMD: Well, this is the problem. If I do that, I was worried that my own children would be retributed against, because one of their teachers is the biggest advocate for keeping school offline.

Makary: They’re militant.

ZDoggMD: It’s terrifying, and my own daughter was like, “Please don’t do this. “Please don’t do this, daddy.” And I said, “Well, okay, well, I know who is doing it “and they’re going to advocate.” So that that’s what’s happened, when even I’m afraid for my own kids. If it was me, I’d be like, “Yeah, let me at ’em.” Are you kidding me? Vinod Prasad’s been pushing it.

Makary: A lot of people.

ZDoggMD: And the thing is doctors are afraid to stand up and say these things.

Makary: This is where we need to stand up as professionals. Our communities need us right now when we see this. Medicine has an incredible heritage of being a voice for the voiceless. You look at our ancestors in medicine. You look at our incredible track record. Look at the care of kids with polio in 1954. When that vaccine was created, Salk said he would give it as a gift to the world. He would never get a patent, so as many kids in the world can get it as possible. That is our great heritage, and now, we don’t want to say anything, ’cause we’re… This is an American disgrace right now. So I don’t think the unions represent their members, despite their name.

ZDoggMD: I think you’re right, and honestly, that’s why you wrote this book too, because here we are complicit in these financial crimes against our patients, surprise billing, out of network charges, air ambulance fees, non-transparent pricing, people going bankrupt, hospital systems suing their own patients, and the doctors don’t even know.

Makary: Complacent.

ZDoggMD: Complacent. If they know that to keep morally integritous, that’s not a word, they have to deny they even know about it.

Makary: As soon as we tell the doctors, hey, this is what your hospital is doing, we discovered these cases, guess what? They’re outraged. They think it should stop. There’s a social justice mission in medicine.

ZDoggMD: I want to show these guys this. So if you guys think advocacy doesn’t make a difference, if you think physicians speaking up doesn’t make a difference, it makes a difference, and this is why. Marty writes this book a few years back. Well, how long, when was it?

Makary: A year and a half ago.

ZDoggMD: A year and a half ago, you came on the show, we did a thing. I was passionate after reading it.

Makary: That was fun.

ZDoggMD: I was pissed off. I dropped so many F-bombs in that episode, that it made it unshakable, and I apologize for that.

Makary: I heard a lot about it. My friends told me.

ZDoggMD: Oh, gosh, yeah, ’cause you didn’t even watch it. You’re like too many F-bombs, and the book comes out, now you have the paperback edition that came out with a revised afterword, summing up COVID and other things, and this graph says it all. This, guys, is the number of lawsuits against patients pre-book, that’s this area. The book comes out and look what happened to the number of lawsuits against patients for not paying their bills. It plummets. What’s the inflection point? A physician and a team of physicians and a group of people speaking out and saying, “This is an outrage. “This is against our calling. “This is creating moral injury in us. “How can we allow it to happen?” It works. Thank you, Marty.

Makary: Our students, nurses, around the country, we told people, “Go talk to your medical facility “and ask them these basic questions. “How did they do on medical billing quality?” Financial toxicity is a medical complication, and medical quality encompasses billing quality. Billing quality is medical quality. So look, we shut it down. We shut it down in about 70% of the places where it was happening that we studied it, so the book has a follow up on each section, but this is the millennial, social justice, generational value that came out in my students to say, “Hey, we don’t want to tolerate this. “We want to go and shut this down.” We called CEOs and asked them, “Will you please stop suing patients?” “Who are you calling for? “What is this? “Are you calling from the media?” “No, we’re just asking you to stop.” “Is this on the record?” “No, we’re just asking you to stop. “Your hospital sued 25,000 people in their town.”

ZDoggMD: They’re not rich patients.

Makary: No, they’re Walmart workers, food service workers.

ZDoggMD: Who have no say in what the bill was gonna be, because there’s no disclosure of what the prices are. That’s the thing.

Makary: We published a paper in JAMA on the practice of hospitals suing patients. Most hospitals won’t do it. A third did, and so good stuff is happening.

ZDoggMD: I love it.

– Good stuff is happening.

– I love it. I don’t even like the term activism. This is just speaking up for what’s right when you know what’s right, and you’re in the industry, and so speaking of that, so again, you’ve been pretty right on a lot of things on the pandemic. I have to say this. It seems to me like we are in a phase now where this pandemic is finishing in the United States, because of vaccines and all the other things, and I know this for a fact, you know why? Because I went to a memorial service in Berkeley, Berkeley, the bastion of liberaldom on earth. I went there for an undergrad, and it actually made me more conservative, because I was like, “These people are crazy, “but yet I love them.” All people, they’re expressing what their moral pallet is in the world, and as long as they leave me alone, I’m fine with it. So I go back to Berkeley, because a real important mentor in my life had passed during the pandemic, and they were just catching up, having the memorial, and I went to this party, because they made it a party for this guy, who was just, again, I wouldn’t be who I am if it wasn’t for this guy really believing in me and saying, “You know what? “You can be a teacher and you can do this, “even though you feel like you can’t,” and I met his family and all his friends, and there were dozens, dozens, if not hundreds of people at this thing, indoor and outdoor. No one was wearing a mask. Everyone was vaccinated. People were hugging and shaking hands. These are strangers to each other.

Makary: Good, good.

ZDoggMD: It was so beautiful, and if that’s happening in a place whose tribal identity, if you’re a liberal, is to believe that this pandemic is never going to end, I don’t think it’s true, I think these guys were showing the truth, which is the pandemic is over, and it’s because of actual rational science and the like, so that’s it.

Makary: We’ve gotta re-establish a human connection again. Look at the power of the human touch, that we see as physicians at the bedside. It’s monumental, right? When you’re in that bed with abdominal pain in the emergency room, we put a hand on your shoulder and say, “We’re going to take good care of you,” it makes the biggest difference in the world. Society needs that right now. Loneliness was an epidemic before COVID and it’s been magnified. We’ve got to start rebuilding communities, and look, COVID is not eradicated. We’re not going to get to some… It’s going to circulate at levels of five to 10,000 cases a day, probably for a year or two, until we stop testing like crazy. The PCR tests will detect 10 molecules of viral particles.

ZDoggMD: Come on, yeah. So of course people who’ve been vaccinated are gonna test positive. Here’s how a vaccine works. The virus comes in. It starts replicating. The immune system revs up. In the time it’s replicating, you’re gonna test positive.

Makary: Right, there’s going to be some remnant particles there. You’re not a leper. So I think we’re going to hit this equilibrium, but we used to talk about herd immunity, and when I wrote the piece in the winter, saying that herd immunity will come in late spring and we’ll have a wonderful summer, the term quickly got politicized I learned.

ZDoggMD: Yeah, it did, yeah, it did, yeah, it did.

Makary: In part because there was the largest spending bill ever in the history of the United States on the floor of the Senate, days during the article came out, so for that week, until the vote, all of a sudden, it’s like, hey, we’re going to pass $3 trillion, largest spending bill ever, for longterm, for COVID, and some schmuck there at Johns Hopkins is saying–

ZDoggMD: Is saying it’s over.

Makary: Hey, we’re going to mostly be done with this thing in a couple of months.

ZDoggMD: I didn’t realize that. Of course, that makes sense.

Makary: That’s how it got so politicized. Members of Congress told me that.

ZDoggMD: Oh, is that right?

Makary: Members of Congress told me that, yeah.

ZDoggMD: ‘Cause you’re based in DC, so yeah, of course, yeah.

Makary: Yeah, I didn’t know what was happening on the floor, but the point was that we’ve–

ZDoggMD: Heaven forbid that you adjust our thinking about the science of it.

Makary: Yeah, I was doing my lot–

ZDoggMD: What vote’s going on, that doesn’t matter.

Makary: There’s probably a lot of infectious diseases doctors out there that might be watching this and said, “I remember he called me just before that article to talk about natural immunity. I’m a public policy guy, do public health research. I took epidemiology at the School of Public Health, but my focus has been the redesign of healthcare and research methods, I’ve done a lot of research.

ZDoggMD: And you’re a surgeon, which means you know nothing.

Makary: Some days I’m a plumber. So I talked to these docs, and basically it was like, “Don’t we have a lot of data on natural immunity? “It’s powerful,” and they were like, “Yeah, and here’s the estimate.” So it was a crap shoot what the prevalence was. It turns out the California seroprevalence studies confirmed it was about half the population of Los Angeles, back in March. A lot of cases since then, and those who have circulating antibodies, it’s not even the full story. It’s also those with activated T cells, so you can be antibody negative. So anyway, there’s a lot of it, there’s a lot of it, so now, today, 62% of the adult population has been vaccinated. Roughly half of those who have not been have natural immunity. That means today, 80 to 85% of adults in America have immunity. Makes it harder for the virus to jump around in a community. What do you call that?

ZDoggMD: Ah, dynamic equilibrium. I will not say herd immunity, Marty, because that will violate my badge of tribal identity.

Makary: Well, you may remember, New York Times had a little article, where they just interviewed four people, one of whom is an expert in evolution, and they declared that there will never be herd immunity.

ZDoggMD: I saw that.

Makary: And it’s like, herd immunity is not binary. It’s gradual slowing.

ZDoggMD: It’s like me, non-binary. Okay, my pronouns are Z-Pac slash supporter. Sorry.

Makary: My preferred pronoun is author of “The Price we Pay” and supporter of the Z-Pac.

ZDoggMD: This is his pronouns right here.

Makary: That’s my pronoun.

ZDoggMD: So by the way, my daughter told me that she was wondering why kids were putting their pronouns all over their Zoom online, she’s like nine. She was like, “Why are these kids putting…” I go, “Well, what are their names? “Maybe they’re ambiguous.” She goes, “Sally, Billy.” I’m like, “Pronouns?” And she goes, “Yeah, “I’m going to make my pronouns she, him.” I’m like, “Is that a thing? “You should do that.”

Makary: All of the above.

ZDoggMD: All of the above. Yeah, those?

Makary: Can we just have a default?

ZDoggMD: Oh, I like that, like you’re this until proven otherwise?

Makary: Yeah, do you need to tell me that you’re he? I’m going to get big trouble here, I’m sure.

ZDoggMD: Of course, we both are.

Makary: Yeah, but can we just have a default? Do we need to take up that much time–?

ZDoggMD: I like the default being this.

Makary: This.

ZDoggMD: Well, this here says it has no pronouns.

Makary: Here’s an honest thought for eight seconds of seriousness. Gender confusion is a normal part of child development, and if we immediately assign something to that, when there’s no biological, medical or otherwise support for it, don’t you think some people may be using that choice to maybe rebel against their parents, seek autonomy, independence? That’s where I’m concerned, because there are absolutely transgender people out there, and they’ve been under-recognized, underappreciated, misunderstood. We need to give them the independence and the dignity that they deserve, that’s real, that there are transgenders. No one should be a denier, but when you open the door to people with normal gender confusion, hey, come on over to this side, it’s different, when it’s normal confusion, I’m not sure that’s healthy.

ZDoggMD: That’s a beautiful insight actually, because it almost lessens the struggle of actually people who really have profound… I can’t really find the right word for it, is dysphoria or they’re like, “No, this is clear. “I am not this gender that was assigned at birth,” and it’s interesting, because I actually heard from somebody here, there’s a big private school in town, where a lot of the kids have very affluent parents, all the tech people and all that, and a quarter of this population in this school identifies as gender non determinant, and it’s like, wow. Is that just taking a cross section of that whole population and there is the normal confusion, like, “Well, I like to play with dolls, “but I also like to shoot things,” or like, what is it? Or is it again like a cultural thing? Like it’s kinda cool to say, “Hey, I’m non binary,” or whatever, and does that lessen the actual experience of… And I don’t know, I don’t know, but we can’t even talk about it. Both of us are looking at each other like, is this, even just bringing this up, gonna get us canceled? The truth is–

– Are we, right now, canceled on Facebook? Are people even listening to us right now?

ZDoggMD: We haven’t even released it yet, and we’re proactively canceled.

Makary: Amazon Web Services.

ZDoggMD: AWS is picking it up and they’re like, “Ah, I’m noticing gender talk and it’s not dogma.”

Makary: I figure it’s just me and you talking right now, ’cause we’ve been canceled.

ZDoggMD: We’ve been canceled. Yeah, in fact, right now, we can just say what we really think. Okay, this is the thing. I think Bob Dole should run again. What, Bob Dole’s dead? I’m sorry, never mind.

Makary: Yeah, right, yeah, we can say that.

ZDoggMD: It is interesting, and actually, let’s focus on kids for a second. So there’s another non dogma thing that I would like to talk about. Kids 12 to 15 or younger, once that gets EUA’d, getting vaccinated, what are your thoughts on that?

Makary: Yeah, so I wrote a piece in the Washington Post, basically making the case for child vaccination, and made it in a way that people may not be familiar with, and that is it’s not really going to save a kid’s life. The 230 deaths from COVID in kids under age 18, that’s a pretty broad definition of kids, by the way, since kids 12 to 15 are physiologically similar to a 16, 17-year-old, and younger kids–

ZDoggMD: I believe children are just little adults. That’s what my pediatrics rotation tell me.

Makary: Yeah, they love that. Oh, they love that, yes. Somebody’s gonna be knocking on this door pretty soon.

ZDoggMD: An angry pediatrician with a stethoscope with a couple of bunnies on it, ready to just clock you in the face.

Makary: Oh, mate, if you want to get a pediatrician fired up, just say, “I know you have a code “and we don’t have a pediatric code kit, “but would this adult kit work?” No, but the beautiful thing about pediatrics, in all seriousness, that infield is intrinsically a voice for the voiceless, which is the cool thing, and that’s why they spoke up about schools needing to be in person early.

ZDoggMD: Exactly, exactly, exactly, they took a very collective stance on that.

Makary: Yeah, they did great. So it’s not really to prevent death. So the 230 deaths in kids under age 18 to date have all been in kids that have a chronic condition or a pre-existing condition, to the best of our knowledge. In other words, there’s never been a documented case of an entirely healthy kid dying of COVID.

ZDoggMD: Is that right? I didn’t know that.

– That’s right, now, we did an analysis with FAIR Health, and it turns out that in looking at half of the nation’s health insurance state, there was not a single healthy kid who’d died. Now, I’m sure it’s out, I’m sure it’s happened, so if they have a chronic condition, for sure, get the vaccine once they can.

ZDoggMD: That makes sense, yeah.

Makary: Let’s say they’re healthy. People might appropriately say, “Hey, the risk of death is infinitesimally small. Do I really need to do this?” Legitimate question. It’s not necessarily to save their life with a vaccine. It is to prevent the inflammatory syndrome, the post–

ZDoggMD: MIS-C.

Makary: MIS-C, and by the way, we found about 10,000 cases, or rather, we extrapolated about 10,000 cases, based on the reported cases. We think there’s been about 10,000 cases

– Of MIS-C.

– of MIS-C in the United States during COVID, and as Paul often says, if you could see it up front and personal in the ICU, it’s brutal, it’s painful and it can have sequela, so it’s also to prevent that.

ZDoggMD: Right, and that makes a lot of sense. I guess one of the questions I would have is do we know, in that population at scale, is there adverse events, like a myocarditis or something, that we don’t think is vaccine induced, but that could emerge, that then would say, okay, tip the risk benefit balance? And I have to say this. I did a video on this, and I also said, “Okay, this is why I’m vaccinating my child,” and my reasons were I don’t want her being out of school for two weeks with COVID, I don’t think her chance of MIS-C are very high, I don’t think her chance of transmitting are very high, but I want to be able to travel confidently, without having to be quarantined, like very practical things, and my daughter wanted it, so we publicly vaccinated her, we’re using a video and everything, and she enjoyed it. She had a comment during it. She was wearing her mask and we were at Kaiser getting it done, ’cause they had this nice outdoor thing, and she’s wearing a mask, and I go, “What are you doing?” She goes, “Well, I like this mask, “because it covers my acne while causing it.” So a real chip off the old block, that child. Anyway, so you were going to say something.

Makary: Yeah, and so I think it makes sense for parents to get their kids vaccinated, to prevent that MIS-C, but we’ve got, in this country, to start respecting those who choose not to get the vaccine.

ZDoggMD: Hello, thank you, and I never thought I’d say that.

Makary: We need to stop shaming them. If we want to address vaccine hesitancy, it’s very simple. We don’t need a celebrity running a commercial or some senator from Mississippi singing a song.

ZDoggMD: That happened?

Makary: That happened, Senator Kennedy.

ZDoggMD: Oh my gosh.

Makary: I’m not against them doing that. ♪ Needles, needles, needles. Go and get your needles.

ZDoggMD: What was it?

Makary: It was even worse singing quality than that.

ZDoggMD: Cornier than that? I’m a trained professional.

Makary: You’re a professional. They’re welcome to do that. They’re all God’s children, but that’s not going to do it. Getting politicians up there to do commercials… Here’s what you do. It’s pretty simple. Stop shaming people. Respect their decision. Have easy walk-in clinics, where it’s just accessible in the normal points of routine life.

ZDoggMD: Bingo.

Makary: That’s how you increase vaccine adoption. Flip the clinics, so they don’t have to register online. You can walk out after you get your groceries bagged and stop by and somebody says, “Hey, do you have five minutes to get your COVID vaccine?”

ZDoggMD: Perfect, perfect.

Makary: That’s how you do it.

ZDoggMD: Make it easy, cheap, convenient, absolutely right. Yeah, and honestly, I’ve gotta give a shout out to Kaiser. They made it quite easy and we’re not even Kaiser patients. We’re like free agents, in other words, our children see no one, because they have two physician parents, who can mistreat their pediatric conditions. Oh, no, that’s not true, and I think the other, I think, interesting thing there is, getting them back connected with a primary doc or a pediatrician as an excuse to go get the vaccine means they can catch up with all the childhood vaccines they didn’t get during the pandemic. So that’s another benefit of vaccination for kids. Now, this myocarditis thing is interesting, I think it’s still early and it probably may not be in association with vaccine, but even if it is, I think the number of cases are quite small and you could still make a risk benefit argument and say, “Well, okay, now the parents have this information, “so let’s make a decision.” Kind of like with Johnson & Johnson vaccine. Do you think the pause of Johnson & Johnson was just the worst decision in the history of mankind or what do you think?

Makary: I think it was an average poor decision for the FDA.

ZDoggMD: So just average on the spectrum.

Makary: I’ll tell you what the worst decision was the FDA made. So there’s about half a dose in the vial after you aspirate the vaccine in, say, the Pfizer vile, there’s about half a dose. Doctors and nurses wanted to aspirate that half dose, and aspirate another half dose from another vial,

ZDoggMD: Combine them.

Makary: And you would increase the vaccine supply by 15% if you did that. The FDA had a warning official label. You cannot. You’re not allowed to do that.

ZDoggMD: Whoa.

Makary: So these big vaccine centers, do you think they’re going to break the FDA rule? No, they can’t.

ZDoggMD: No, they can’t, yeah.

Makary: It’s a policy. I know the Fairfax Hospital, including their CEO, made a very, very clear plea to the FDA. People are dying thousands a day. We know how to aspirate things with sterile technique. We’re not using the same needle on 50 people. We’re not idiots, and that’s why the FDA didn’t allow it, like, “Oh, there could be contamination.” You’re aspirating four different doses from the same vial anyway. You’re not using the same needle. You’re aspirating with a sterile needle. You’re injecting. You’re disposing of the needle, then you get another needle. FDA said no. Multiple times people were asking them, and you just want to be like, “Are you completely disconnected from reality?” We would have increased our vaccine supply by 15% if you would’ve just let that… Nova threw out thousands of doses in December, and tens of thousands of doses–

ZDoggMD: When people were desperate.

Makary: Yeah.

ZDoggMD: And people were dying and people were desperate, and look, this is the thing. All of that would have been fine and dandy if we would have look back and gone, oh, who cares, if the vaccines weren’t the most effective fricking thing, when we look at just Israel, and then they look at the Seychelles, just little islands in India, have you heard about this thing?

Makary: Yeah.

ZDoggMD: So yo, 60% vaccine penetrants and now they’re getting a surge, including some vaccinated people, plus or minus tourists and stuff, and it’s like, well, did you see what vaccines they used? They used the Chinese vaccine, which, in the best of circumstances, is like 40% efficacious, and then the B-list version of AstraZeneca, I actually don’t know if that’s true, but it was like AstraZeneca Light.

Makary: A quarter dose of Sputnik.

ZDoggMD: Throw a little Sputnik in. It’s like, “In Russia, all vaccine trials are placebo versus placebo.”

Makary: Now, is the FDA gonna come after me? Is this fortified in here?

ZDoggMD: Well, let’s just say Amazon Web Services already blocked us for the pronoun thing, so I think we’re probably good.

Makary: If I don’t show up one day to work, I want you to know all my passwords are ZDogg number one.

– You know what? That used to be my password 10 years ago, before I was famous. I was like, ZDogg1, who’s ever going to that in? You know what’s crazy is when you first came on my show about this book, I said, in all dead seriousness, I said, “Do you have body guards?” ‘Cause major, major institutions, legacy players, are threatened by this, ’cause they make money on the backs of suing poor patients for overinflated charges, that they’ve been playing money games, fighting insurance companies over time and jacking up prices, and guess who pays the rack rate? The uninsured person. It’s sick, dude.

Makary: Yeah, the medical establishment is losing big time right now to a group of forward-thinking docs and nurses and young students, who are saying we want to redesign healthcare. This system is broken. If somebody comes in and we tell them exercise more, eat better, and then come back in six weeks after you take this medicine every day, and they are non-compliant, they come back and we tell them, you bad, bad non-compliant pig, patients hate that, doctors hate it, nurses hate… Why are we doing it? It’s broken.

ZDoggMD: It’s dumb. It’s dumb.

Makary: And so we’re seeing a revolution right now, redesigning healthcare, and that’s the exciting thing.

ZDoggMD: I can’t wait, and one thing I’ve got to say this, I’ve had Robbie Pearl on the show, I’ve had you on the show, both of you guys put some provocative things out there about physician behavior, and not just specifically physician behavior, but systemic issues that happen to involve physician behavior or physician culture, et cetera. Now, this is what I found. This triggers doctors in a way, that they behave exactly as you would predict they would behave, based on what you say in the books. So Robbie’s like, “Well, there’s gonna be anger and denial and repression,” and they do all of that, because they don’t see that two things can be simultaneously true. They cannot hold any degree of paradox that the system is fundamentally broken, that it’s designed to basically not help us, but actually causes us harm as physicians, let’s say. Forget about patients. That’s already assumed it’s causing them harm. It’s causing us harm, but then, that is also true that our own culture of resisting change, not working in teams, wanting entirely 100% autonomy without obeying any guidelines that are shown by evidence to actually help, unexplained care variation, ridiculous billing practices, fee for services kind of thing, those can simultaneously be true, while still physicians being good people, and we can work on all of them at once.

Makary: What I found, in doing the research for that book, is that doctors want to get beyond the walls of their hospitals and deal with the underlying issues that bring people to care, but they don’t have any guidance or a path to do that. There’s no specialty for…

ZDoggMD: Social determinants of health.

Makary: Yeah, yeah, yeah, we throw out these buzzwords and everybody feels good, and we go to these conferences and these panels at the Ritz-Carlton, we need to address social determinants and I’m, oh my gosh, yes.

ZDoggMD: Atul Gawande and Eric Topol will be on a panel today, talking about the social determinants of health, with ZDoggMD moderating. That’s going to push the needle. It’s really going to push the needle. [Marty] Oh, yeah, that’s going to make a big difference, but what I found is there’s a group of enlightened disruptors, who were partnered often with entrepreneurs, who are saying, “Can we start talking about school lunch programs “instead of just talking about bariatric surgery? “Can we talk about food as medicine? “Can we talk about educating folks “and spending time with them and addressing sleep “when we see that their blood pressure’s high, “instead of just throwing meds at them? “Can we deal with diabetes by talking about cooking classes, “instead of just throwing insulin at people?”

ZDoggMD: These students message me all the time, these young doctors message me all the time. They’re saying exactly that. This is a fascinating–

Makary: It gets them excited.

ZDoggMD: Oh, they get so fired up. I had an Australian emergency physician send me a video, directed at me, just to hear, “I’ve got to say this to you, ZDogg. “I came from Australia. “Americans are amazing. “American physicians are amazing. “Why is it that we torture people until they die? “Why is it that we do so many unnecessary tests? “Why is it that physicians no longer have a contact point “with their patients, where they’re doing an act of service “directly for patients, “like drawing their blood or putting in an IV “or holding their hands? “We don’t do that, we’ve outsourced that to everybody else.” So all these really interesting observations, she’s like, “This is all I care about, ZDogg. “Can you talk about this?” I was like, “Woman, “I’ve been screaming about this for 10 years. “Come on, join me. “This is a thing.” It’s true.

Makary: And when you’re in med school or trying to figure a career path out, people are hungry for this stuff, but they’re told, anesthesiology if you like this, psychiatry if you like this, internal medicine if you like it. You know what? Maybe they are also interested in addressing the underlying things that bring people to the hospital, addressing the way we deliver healthcare, redesigning healthcare, looking holistically, addressing the environmental exposures that cause cancer, instead of just learning the chemo protocols. People are hungry for this stuff, and we’re starting to see healthcare get redesigned.

ZDoggMD: Real systems thinkers, real systems thinkers.

Makary: Yeah, systems thinkers.

ZDoggMD: Yeah, I talk about alt middle a lot, this idea of this perch of being able to critically think, see a little truth in partiality, notice that the human systems are complex systems, humans are complex, assume good intent, et cetera. The technological equivalent of that is systems thinking. It’s saying, oh, this is a web of interconnected stuff. Everything is whole and part of a whole in it

Products You May Like

Articles You May Like

New noninvasive biomarker can be used in the diagnosis of NAFLD
Another shipping crisis looms on Covid fears in southern China
FDA Approves Astepro Allergy (azelastine) Nasal Spray for Over-the-Counter Use
Biden says delta Covid variant is ‘particularly dangerous’ for young people
Elizabeth Holmes’ attorneys concerned about finding unbiased jurors

Leave a Reply

Your email address will not be published. Required fields are marked *