Dr. Ezekiel Emanuel on Vaccines, Healthcare and Living a Healthy Life

WALTER ISAACSON: Thank you, Christiane. And Zeke Emanuel, welcome to the show.

EZEKIEL EMANUEL: It’s my great honor, Walter, to be with you.

ISAACSON: You have a book now on health and wellness, “Eat Your Ice Cream,” and it has a wonderful line at the beginning of it that puzzled me, because most writers on this subject wouldn’t have written this. You say, “We’re all going to die. You can waste all your time trying to extend your life by a few minutes, or you can make the time you have healthier and more meaningful.” This sort of distinguishes your book. It’s not just about everything you can do to live a minute or two longer. It’s about living better.

EMANUEL: Yeah. Our goal shouldn’t be just living a long time. As a matter of fact, you’re a historian and study history. I went back and one of the things you see is in the early 19– 20th century, 1909, there’s a big headline in the St. Louis Post Dispatch: “Live – Scientist Say You Can Live to 150 or 200 Years,” and it’s like you read that headline and could be today because everyone wants to live that long. But I think the real thing we say to ourselves is, we want quality of life. Well, what’s quality of life mean? It means being healthy, not being obsessed about living every extra minute, if it’s gonna compromise your pleasure, your fulfillment, your contribution to other people. And that’s the psychology, that’s the underlying philosophy, if you will, of the book.

ISAACSON: When I was at Time Magazine and we weren’t having a good year for newsstand sales, we just put a nutrition cover on. And you could do it either way, because things kept changing. We could say, eggs, good for you. No, eggs bad for you. Or cholesterol, good or bad? Or butter versus margarine. One time butter would be better – why don’t we know more? Why is it such a random science?

EMANUEL: Well, diet is hard to study. For one thing, what you eat today and every day has an impact over years. Those kind of studies are hard to do. That’s the first thing. Second, on diet, it’s hard to randomize people and have them stick to the diet for five years while you’re gonna study that. That’s one of the complications. But I think we have made a lot of progress and we shouldn’t undermine it. The studies also need to be big, a hundred thousand people to really see the effects and, but, and then to also unravel what the biological mechanisms of those effects. 

But let’s just go through that. We know one, that almost every American gets enough protein, and that should not really be an obsession of people. Two, almost every American doesn’t get enough fiber. And that should be something that people work on by eating more vegetables, eating more fruits, eating nuts which have, are all high in protein. Number three we do know that dairy is probably net net not bad for you and probably positive for you. And so we should encourage that. We also know and have discovered fermented foods, really, really important. We don’t eat enough fermented foods, whether it’s yogurt or keefer or cheeses or kimchi or sauerkraut or what your favorite fermented food is. Those are good because of the microbiome. I like to tell people, and this I think always knocks people’s socks off. There are a hundred trillion bacteria in your gut, that’s more cells than than the rest of your body. They’re there for a reason. Evolution didn’t conserve them for no reason at all. And having a big diversity of bacteria in the microbiome, really, really important. So we need to eat fermented items, good for the microbiome. We also need to eat more fiber, good for those bacteria to grow. And that I think we, as we’re learning, has a huge impact on our body, on our mental function, on our behavior. And I think that’s gonna be one of the big stories for the next 10 or 15 years as we unravel a lot of the different bacteria that are affecting us.

ISAACSON: Lemme talk about cognitive health. Because so many people now, I guess especially my age, worried about dementia, losing a memory. And I’ve started doing things like I started learning French and suddenly my short-term memory is a whole lot better, I think. What does work in terms of keeping your short-term memory?

EMANUEL: There’s a very important pivot point around retirement, where you stop going into the office, you stop with the social engagement, the schedule kind of slips. You don’t have another purpose. And the cognitive decline seems to accelerate that, especially for white-collar workers. So you have to actually proactively go out and reestablish the schedule, your social interactions, the challenges that you might have faced at work now. And I recommend to people, as you’re gonna retire, plan it out. Think about where you’re gonna volunteer, how you’re gonna do more things, how you’re gonna interact with people. That’s very, very critical. I think your learning French, I totally endorse it. Very, very good idea because it involves so much of the language. It involves your  – not so much a language, so much of brain function. It involves, you know, learning new words. It involves seeing things and being able to read. It involves being able to pronounce words. And it involves talking to someone else, which again, another social interaction.

ISAACSON: Every now and then, I like to have a drink, a glass of bourbon. I like to do it with friends. Is drinking good for you or bad for you in the sense of what you are talking about, of leading the good life?

EMANUEL: That’s a complicated – so let’s just talk about the physical manifestations. And I think scientists have come to the position that alcohol, while 65 to 70% of Americans do drink, alcohol itself does have health risks. It has health risks as far as the liver, we’re well acquainted with that. It has health risks in terms of cancer and in terms of other conditions, it disrupt sleep cycles. So that’s the physical side. But then there is, as you point out, lots of other aspects to alcohol. Almost every culture alcohol has been used in lots of ceremonies, but also in routine eating for celebrations, to be with other people, to lubricate social interactions, because it also happens to taste good. And I think when you balance those things out, first of all, we’re not gonna get to everyone being a teetotaler, so we should be clear about it.

And the occasional drink is not going to disrupt, you know, your lifespan. But if it increases your social interaction, and the meaningful social interactions, it’s a net positive in my view. And I’m not a drinker. My wife likes to imbibe. She is actually very conscious of using it properly. But I think, you know, for most people it is a way of, it’s a focus and brings people together. And in that sense I think net net it’s probably a positive for most people. Now, there are things we shouldn’t do, right? Binge drinking, bad idea. Drinking alone, bad idea. Drinking to drown out our sorrows, or because we’re depressed, bad idea. Drinking with other people as a social engagement over dinner or at a club, probably a really good idea.

ISAACSON: When you talk about things like that, that it should be for interaction, it should be leading a fulfilling life, not just trying to win the gold medal for leaving the longest life. It actually goes back in history. It reminds me of Hippocrates, the you know, the first of your line and then Aristotle. Is this something that’s been known throughout history?

EMANUEL: So generally it is the fact that – I mean, the six things I point out, they’re not unique under the sun. We have known these for 2,500 years. We have a lot more science about them and how they actually help the body. And for example, how social interaction actually is good. Mentally, it affects the brain through oxytocin as well as dopamine and serotonin. It also affects by decreasing cholesterol and therefore stress the heart rate, blood pressure. So we know it has physiological interactions, but all of these things, whether social interaction, nutrition, exercise, sleep, they’ve been known throughout history. What we know more now is their scientific basis, how much you need to do of each of these things. And that is helpful. But again, we’ve known a lot about this, which is why there’s people who’ve been able to live long and healthy lives before the science.

ISAACSON: There are a lot of happiness gurus out there saying, here’s the seven ways to be happy, or giving your advice on happiness. Is happiness the ultimate goal?

EMANUEL: It depends what you mean by happiness. So happiness in those our sort of modern lingo is, you know, pleasures sitting on the beach and drinking pina coladas. But happiness in the old Greek and the sense that our four you know, the founding fathers understood happiness as a fulfilling –

ISAACSON: Like the pursuit of happiness, you mean.

EMANUEL: Yes, the fulfilling life. And, you know, I go back to Ben Franklin, one of your great heroes, and someone you know a lot better than I do. You know, Franklin had sort of three guiding principles, I would say, to his life. One was curiosity. He was endlessly curious about the world, people, social structures, et cetera. The second was moral growth. He was constantly trying to improve himself, recognizing his failures, trying to overcome them. He didn’t succeed always. He sort of jokes that he never mastered orderliness in his life, and there was always a mess on his desk, as it were. And his last one was be useful and by useful he meant try to improve the world. And this was the master of creating social organizations to improve his community. He created the University of Pennsylvania, my university. He created the first hospital in the United States. He created insurance companies, he created fire departments. He created lending libraries. He created learned societies all to help improve the world. And I think if you have those guiding principles, be curious, keep your mind active, grow, recognize your deficiencies, and try to improve constantly and be useful in terms of improving the world. That is the kind of happiness that I am sort of suggesting underlies these six behaviors.

ISAACSON: Your friend, the former surgeon General Vivek Murthy, wrote an important report about an epidemic of loneliness. Tell me how that plays into this.

EMANUEL: I actually think that’s one of the great reports. It goes along with the smoking report from 1964. It’ll be recognized as one of the transformative reports from a surgeon general. Smoking, smoking that’s – there is a correlation because in his report, he reports on the fact that a study from Brigham Young University showed that being lonely is the equivalent of smoking 15 cigarettes a day. And that being lonely is again, associated with about a 25 to 30% increase in mortality over the subsequent time. Also, increased risk of depression. And we are going in the wrong direction. Young people are not having as many intimate relationships with the opposite sex and their own sex. They’re dining alone. They don’t know how to navigate social situations. This is a very bad situation. And actually, when they do surveys, they report fewer close friends, fewer people they can call and talk to.

A large part of that is the cell phone and social media, but that’s not all of it. It predates the cell phone and social media. And I think we are not paying enough attention to facilitating social interaction. And part of it is we need deep relationships. We need really those intimate relationships with deep friends who we can reveal inner secrets to, but we also need much more casual relationships. And you notice if you walk around that fewer people are actually talking to other people. One of the contrasts I’ve noticed is if you go to Europe and you’re in a cafe, no one’s on their phone. They’re talking to each other. In the United States a lot of people – yes, they might be in a place with other people, but they’re not interacting. They’re not talking. And I think that’s something we have to put the phone down and engage with people near us.

ISAACSON: You say you’re worried about the approach to vaccines now. Drill down on that with Secretary of Health and Human Services, Robert Kennedy. What do you think of what’s being done to the vaccine protocols now? You are a doctor.

EMANUEL: Well, first of all, I think the worries that are being fomented and the uncertainty and the complications are not gonna help. Over the last 30 years we’ve saved at least 1.1 million lives in the United States through vaccination. Everything from measles and chickenpox, rotavirus, flu. And we should recognize their value. Overall – and I have actually a nice, I think, table in my book about how little the risks are of vaccines, especially when you compare ’em to things like peanut allergies. So we should take vaccines and we should have them. The cutting back of the vaccines to now 11 recommended vaccines, we are way on the outlier risk, as is Denmark. Most countries have between 13 and 16. Canada has, for example, 16, and we should be much closer there. Taking away things like the Hepatitis A vaccine from the recommend, from the mandatory list, not a good direction to go. So I am very, very concerned about that. And I don’t think the decisions are science-based. 

If you look at the overwhelming data, and there is overwhelming data, more than 1.25 million people tested for just autism issues. No evidence that that’s true. But we still get this fear, this uncertainty, this pressure and I think it’s gonna undercut the public. We’ve already seen a huge drop in the number of kids getting vaccinated. Two thirds of the counties in the United States now have less than 95% of the children vaccinated against MMR. That’s below the herd immunity level. That is not a good place to be if we wanna raise healthy kids, vaccinations is one of those steps.

ISAACSON: You were very involved with dealing with the Affordable Care Act, Obamacare, and just recently the enhanced subsidies expired. What are you worried that’s going to do? And more broadly, what can we do about healthcare costs and making sure that people have affordable access to healthcare?

EMANUEL: Walter, you’ve put your finger on the issue. It’s beyond the expanded subsidies. They’re a manifestation of the fact that healthcare is now unaffordable, that even insured people are worried about going to the emergency room or worrying about going to the doctor, that they can’t afford it. It has gotten way out of control. Every part of the healthcare system has a responsibility to reduce costs. We need to look at hospitals and reduce those costs. They’re way too high. We need to look at insurance companies and reduce their costs and overhead and gaming of the system. Drugs need to come down in price. Administrative bloat – 20% of what we spend on healthcare goes to administration. That is insane. And no one is gonna shed a tear if we cut that back. And, you know, McKinsey has a study that says we can cut that back by at least a quarter – $250 billion a year without serious effort.

And hopefully AI will help in that regard. I’m very optimistic about that. But the system has to incentivize people to make those cuts. And we have to say, we’re not going over 17% of GDP devoted to healthcare. That’s the first thing. So we’re gonna put a cap on it. Everyone is gonna cut back, and we’re actually gonna try to roll back. Just imagine if we cut back from 17% of GDP going to healthcare to a 16 or 15%, that’s $3,000 per family, right, in their pocket. That savings out of the healthcare system. That’s real money to Americans. That changes the affordability equation. And I think that’s very important to focus on. By the way, it also gives us money to spend on other things, whether it’s education, the environment, you know, our electrical grid, whatever you think our priorities ought to be. And that I think is important. We can’t overinvest in healthcare and the healthcare system, which is what we’re doing.

ISAACSON: Well, wait, you say you could cut $3,000 per family, maybe bring it down a bit. That can’t just be done with administrative costs.

EMANUEL: Let me just say the following, $250 billion is roughly $700 per person in America. A family of four, that’s $2,800. 

The amount we spend on healthcare is mind boggling. And you always have to add more zeros because it’s – even small changes in healthcare are big dollar amounts. And that’s what we have to focus on. And we have to do it relentlessly because it frees, I mean, if we, if every family in America had 3,000 extra dollars, that would really change the economic situation of a lot of people in this country. In the bottom half of the income bracket.

ISAACSON: Zeke Emanuel, thank you so much for joining us.

EMANUEL: Thank you, Walter. Been a great interview.