Big Covid Questions, the Nursing Shortage Crisis and a Friend of Pivot on the upcoming Elizabeth Holmes Trial

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Kara Swisher: Hi, everyone. This is Pivot from New York Magazine and the Vox Media Podcast Network. I'm Kara Swisher. Scott Galloway is still out trying to get cast in The Bachelor. So I'm joined by my brother, Dr. Jeffrey Swisher, chair of the Department of Anesthesiology at California Pacific Medical Center. Jeff, how are you?

Dr. Jeffrey Swisher: I am great. How are you doing, Kara?

Kara Swisher: Good, good. We have a lot to talk about today. I'm bringing in my brother because many people on Twitter have called for it, really.

Dr. Jeffrey Swisher: I know. I want to thank all my fans on Twitter and Dr. Subramanian in particular. Several have asked for me to be here. So great.

Kara Swisher: Well, I am only here not because you're my brother, but because you have a lot of information I need. As you know, I'm stuck in a house with our mom because we got near my cousin's partner who had COVID and here I am. So I have a lot of questions. I kind of feel like what Donald Jr. must feel like, or Meghan McCain, as far as nepotism goes. But I'll take it.

Dr. Jeffrey Swisher: That's okay. You'll take it.

Kara Swisher: But here I am. You've got to get me out of this house with Lucky. Anyway, let's start. Before we get into the medical stuff, let's talk about a couple of things. There's an update on the story about Catholic priests. You and I are both lapsed Catholics. And Grindr. The conservative news blog The Pillar put out more reporting on cell phone data that seems to show priests using the gay hookup app. Not a surprise to either of us, of course. The first report led to the resignation of Monsignor Jeffrey Burrell in late July. There have been two reports since then. The latest reports didn't name names but claim more use of the app in the U.S. and at the Vatican. So what do you think about this? What is the bigger outrage: priests violating their celibacy or the privacy violation?

Dr. Jeffrey Swisher: Well, first off, I don't think you were ever confirmed. I don't believe you were.

Kara Swisher: Really? I don't remember. I think I remember. I was. Yes, I had a white dress. Yes.

Dr. Jeffrey Swisher: All right. That's fine. So Jeffrey Burrell, he was the guy, wasn't he the head of the U.S. Conference of Bishops? He's the guy who wanted to deny Joe Biden the ability to take communion. Isn't that correct? There is a hypocrisy going on, Jeffrey.

Kara Swisher: Yes, a great hypocrisy. He's also the person who was extraordinarily anti-LGBTQ rights. He wanted to deny them adoption rights. He wanted to do all kinds of pretty horrible things. This is often the case. Self-hating hypocrites.

Dr. Jeffrey Swisher: So he deserves it? He deserves privacy violations?

Kara Swisher: Well, no. Actually, there's all kinds of yuck here. The fact that Pillar, the organization which looked into him, was tracking his cell phone movements. They were tracking which sites he visited from, metadata and actual data itself. The fact that that's available should scare everybody. I don't think there are any winners here. I think it's gross on both sides. This group of people has an agenda. They're sort of attacking Pope Francis. There's a whole fight going on within the Vatican, the more liberal wing, just like there is in this country, like everywhere else. They are using this, which has been an issue for many years. In a lot of ways, it's not the same as the scandals around pedophilia, because these are presumably consenting adults.

Dr. Jeffrey Swisher: Correct.

Kara Swisher: And at the same time, they've made a vow of celibacy. So I think what's difficult here is that the people doing this, pretending they're trying to help morality in the church, are really just doing it for their creepy political agendas.

Dr. Jeffrey Swisher: Well, keep in mind that celibacy in the priesthood is actually a relatively modern thing. The Council of Trent in 1563—

Kara Swisher: You're going to the Council of Trent?

Dr. Jeffrey Swisher: Yes. Actually, it goes before that. It goes to the Lateran Council of 1139 where they did that.

Kara Swisher: Everybody, Jeff got into Stanford and I didn't, but go ahead.

Dr. Jeffrey Swisher: The Council of Nicaea, which was even before that, which was Constantine, they actually rejected the fact that priests should not be celibate. But the point is, it's not dogma. It is regulation. The Pope tomorrow could say priests could get married, and that would be fine. So the whole concept of celibacy is a very unusual one, I think. This catching stuff, I go on the privacy side. I don't care how hypocritical it is. I think the privacy issues are much more important here in terms of tracking people and being able to use these apps.

Kara Swisher: Let's differentiate between pedophilia and homosexuality. They're totally different things.

Dr. Jeffrey Swisher: Yes, absolutely. Totally. 100% different. Obviously. But this is a bigger, wider problem in the Catholic Church. But it seems like in this case, tracking these priests is as creepy as it is tracking anybody.

Kara Swisher: Absolutely. I'm not for outing people in any way, shape, or form. It's an interesting thing.

Kara Swisher: So let's talk about the big Jeopardy controversy. To bring everyone up to speed: Sony named the show's EP, Mike Richards, as the new host along with Mayim Bialik. Then a report came out in The Ringer about sexist and racist comments he'd made in the past, and he stepped down. I don't want to talk about it a lot. I know some of our relatives watch Jeopardy. Who are you for as the host?

Dr. Jeffrey Swisher: I love LeVar Burton. I really like him, and I think he would be great. I don't think his inner, his trial, was all that great. I think he stumbled a few times. He also wasn't given the full opportunity. I think he only had five shows versus the ten. But the fact that this guy Mike Richards was the executive producer and he's the one who chose the people, and he chose himself...

Kara Swisher: Well, they supposedly he put himself out of whatever. The point is that I think the whole controversy is kind of silly and overblown. But what's going to be the next Jeopardy category? "Mammary Glands: Silly Names for $100." I'll take that for $100.

Dr. Jeffrey Swisher: [Laughs] This is Jeff referring to a podcast this guy did, which was in plain sight. It's amazing Sony didn't check. Tony Vinciquerra, I know very well, the head of Sony. I'm shocked he didn't check.

Kara Swisher: Nonetheless, you want LeVar Burton and I want Ken Jennings, I think. I think he'd be good. I think it'd be nice to have a woman, and it'd be great to have a woman of color too. I think that'd be fantastic.

Dr. Jeffrey Swisher: Well, that is true. They have Mayim Bialik, who is going to be a host of specials or stuff like that.

Kara Swisher: Correct, special stuff. That's Blossom, of course, for those who don't know. She's fantastic.

Dr. Jeffrey Swisher: She is indeed.

Kara Swisher: So lastly, I want to talk mostly about medical stuff. Let's start. The White House is pushing Joe Biden's plan to lower the cost of prescription drugs, letting Medicare negotiate prices with drug makers. The administration is selling this as a winning issue for House Democrats. Is it a win for patients? What do you think about this?

Dr. Jeffrey Swisher: I do, actually. Medicare, as the rules exist, don't allow the government or people to negotiate for drug prices. But I don't know if you've looked into it. I'll be 65 in four years and ready for Medicare, and I'm going to start studying now. I mean, literally understanding how Medicare works between Part A, Part B, Part C, Part D. What you're talking about here is the Part D part of Medicare, which is the prescription drug coverage. It's very complex. Most people over age 65 are on medication. I'm on two at age 60, 61. The importance to the senior population can't be overstated. So bringing the prices down, absolutely. And they're a voting block. I think the Democrats can bring in that cohort by helping out their lives. It's insane what the prices of some drugs are. Take insulin, something that is needed by so many people. The prices have skyrocketed over the years. And that doesn't even count some of these other more expensive medications that many seniors are on.

Kara Swisher: You were talking about delays in getting them because of various things. There was a hurricane or something like that or a tsunami at one place where they were making... You're an anesthesiologist, so you use a lot of drugs.

Dr. Jeffrey Swisher: I do, but I use them in the operating room. I'm not a prescriber, actually. I have the ability to prescribe, but my drugs are given by me in the operating room to patients directly. But we have a shortage of drugs in the operating room. It's insane which drugs are always on shortage. I get a list every day of basic medications that I have to come up with alternatives for.

Kara Swisher: Will the ability to negotiate help that? Or is that just a function of manufacturing and supply?

Dr. Jeffrey Swisher: I don't know about drug shortages. That's more of a function of manufacturing and supply. But drug prices are something where you negotiate with different insurance companies for different prices. The same drug, depending on the insurer. There was an article in the New York Times yesterday about the price of an MRI. With the same MRI, different manufacturers, the price can change by 4X. That's not the price the patient pays necessarily, unless it's self-pay. But that being said, the system is crazy. It's a patchwork system.

Kara Swisher: So you're going to study for four years and you're a medical doctor before you figure it out?

Dr. Jeffrey Swisher: No, no. I don't know many medical doctors who understand Medicare or understand drug pricing. We hire people to do this for us to figure out our insurance.

Kara Swisher: Oh, dear.

Kara Swisher: Okay, Jeff, time for our first big story. The FDA has given full approval to Pfizer's COVID vaccine, which makes it the first COVID vaccine to go from emergency use authorization to full FDA approval. Explain it for the people in very pithy terms. Explain what that means.

Dr. Jeffrey Swisher: Okay. Let's start with FDA approval of a medication. Manufacturers apply to the FDA for approval of a drug, and they have to submit all kinds of data, patient trials, phase one trials, phase two trials. It's a huge amount of work and expense to get a drug approved through the FDA. In this particular case, the mRNAs were really, even though they've been worked on for many years for other indications—

Kara Swisher: Like 15 years.

Dr. Jeffrey Swisher: Yeah, for a long time. They really rushed, with a lot of data to back it up, the mRNA approval for the Pfizer vaccine. They got what's called emergency use authorization. Even before that, you can have what's known as compassionate use authorization. For instance, when President Trump got the antibody cocktail—this is not the Pfizer drug, but the antibody—he got that under compassionate use before it had the EUA. So Pfizer and all the other mRNA vaccines and the Johnson & Johnson, which is an adenovirus vaccine, have EUA right now, emergency use authority.

Kara Swisher: So what is the difference? Full approval makes people feel like it's real?

Dr. Jeffrey Swisher: I guess. I mean, I don't think most people—

Kara Swisher: Well, they've been using it to say, "I'm not going to get the vaccine." I understand. So does it make it easier for schools and workplaces to enforce vaccine requirements?

Dr. Jeffrey Swisher: Yes, I think that is important. It gives cover for people to basically say, "Yeah, we can enforce these vaccine mandates." My hospital has a vaccine mandate. As of September 20th, I believe you have to be vaccinated.

Kara Swisher: What about peace of mind? You were telling me about people that you were treating that didn't have the vaccine and what you're seeing in San Francisco.

Dr. Jeffrey Swisher: Not just people I was treating, but people I work with. I had a long and very heated conversation with one of the surgical techs the other day. He's not vaccinated. I asked him, "Why aren't you vaccinated?" He says, "Because it's not approved." I said, "It is approved under EUA. A lot of things that you do are not approved. There's a lot of off-label use of medications." Then he said, "I don't want to take it because they're making me." I said, "They make you take polio vaccine. They make you take measles, mumps, rubella. The list is enormous. If you join the military, it's like 15 vaccines you have to have." I don't really understand this argument. I think it's been played up.

Kara Swisher: So what did you tell him? You had a heated conversation? Did you kick him out?

Dr. Jeffrey Swisher: No. As of September 20th, he's not going to be able to work there. It's difficult to argue with people who've already made up their mind about something. Logic doesn't seem to work on them.

Kara Swisher: So what do you do? You're seeing most of the people hospitalized that you're seeing are unvaccinated, correct?

Dr. Jeffrey Swisher: Well, interesting. Israel is the great place to look at for that data because they have the longest history. And we're not talking that long. This isn't that old a virus. We're talking about early 2019. They got people vaccinated early. If you look at the Israeli data right now, it's actually about 50-50 unvaccinated versus vaccinated who are getting sick. But still, the vast majority of people hospitalized—

Kara Swisher: Hospitalized, that's what you're telling me.

Dr. Jeffrey Swisher: Hospitalized, not infected, but hospitalized are unvaccinated. I looked at the numbers from my hospital today, and about two-thirds are unvaccinated, one-third is fully vaccinated. I think as immunity wanes, that doesn't necessarily mean in the ICU, intubated or prone. Those are mostly unvaccinated.

Kara Swisher: Mostly unvaccinated.

Dr. Jeffrey Swisher: And then if you look at the death rates, the people who are dying as a result of COVID now, they are the vast majority. We're talking about fractions of percent who are unvaccinated. Most people who are dying are unvaccinated. Delta is a different beast, though. Some of the data coming out of Israel shows that the Delta virus, not only is it more infectious, but it potentially is more lethal as well.

Kara Swisher: More lethal. And I'm stuck. I am not joking. Someone in our family got COVID even though he had been vaccinated. We had lunch with him outside mostly. We were inside for a very short amount of time. We were sitting here trying to figure out just getting tested, because of the virulence of the infection here.

Kara Swisher: The administration is rolling out booster shots for many Americans starting September 20th, speaking of that date. First off, is there a difference between a booster and a third shot?

Dr. Jeffrey Swisher: No, it's the same thing. A booster, the whole point is to spike your immune system again. Immunology is really complex. When you talk about immune status, you're mostly talking about antibody levels, B cells. There's another set called T cells, which are T memory cells. The idea is to spike the immune system by activating T memory cells to produce more antibodies to build your antibody level.

Kara Swisher: That's what I talked about with Dr. Patrick Soon-Shiong. It's to spike the memory of the body. Like, "Oh yeah, I've seen this before." So you produce a lot more of these T cells.

Dr. Jeffrey Swisher: In addition, T-helper cells and all these other things. I'm not an immunologist, so I don't want to speak out of turn.

Kara Swisher: Do you think people are line jumping on these? People who just decided, "I'm just going to get one before there's a rush"?

Dr. Jeffrey Swisher: No. But what's interesting is if you look at Walgreens and other drug stores, I looked the other day, there are so many open appointments now for the booster shot. I was tempted. I had a break in the operating room to go down and get mine because I got vaccinated in December for my first shot and January for my second. Looking at the Israeli data, we're seeing that they have one of the highest rates now of Delta. I think it's like 650 per million population. And that is a population that is 80% vaccinated.

Kara Swisher: Right. But who have gone along and wear masks, et cetera.

Dr. Jeffrey Swisher: Correct. There are confounding variables, though. The people who were vaccinated first were the elderly, the immune compromised, et cetera. So we may see that as a confounding variable in why they're getting sick in Israel. But I would pay attention to the Israeli data. There are a few researchers. And get a booster shot. I would definitely get a booster shot when you are able to.

Kara Swisher: Yes.

Kara Swisher: There's so much stress going back to school now with Delta. I just interviewed the head of one of the teachers' unions, Randy Weingarten. Particularly in Florida, she was pointing out a surge in cases. Your wife is a schoolteacher. What kind of conversations are you having about this? Although schools have proven to be pretty safe in terms of transmission.

Dr. Jeffrey Swisher: That's correct. Not only my wife, but my daughter is a schoolteacher too. She is just starting teaching in Jackson, Wyoming. My wife teaches second grade and my daughter teaches preschool. In Marin County, where I live, we've had very good safety measures. In fact, Dana went back teaching in October of last year. She was one of the earliest districts to go back. They did it via cohorts and they had plexiglass barriers, which of course they found don't seem to help. In fact, they may hurt. All of the kids are wearing masks, every one of them. All of the teachers are wearing masks. They don't eat lunch together. They eat lunch separately. They put in basic safety protocols. Better ventilation, keeping the doors open. They try to do outdoor teaching as much as they can. My wife is a big garden advocate, and she is doing a lot of outdoor education about monarch butterflies and gardening. They're trying to integrate those kinds of things into the curriculum. But I have to say, I asked her this morning, she went off to work, she started last Wednesday. Every single teacher is completely thrilled that they're back in the classroom. Zoom teaching was very hard. I don't think it served children well.

Kara Swisher: No, it certainly didn't. I think a lot of teachers resigned or retired because of it.

Dr. Jeffrey Swisher: Yes. We'll be talking about the nursing shortage, but there's a teacher shortage too. It was a really stressful year for them.

Kara Swisher: So in terms of going back, you're not worried about that. Just take the booster and do the same kind of safety things.

Dr. Jeffrey Swisher: For teachers, obviously the children aren't vaccinated. There are no children under the age of 12 who are. What to do for parents? Just wear the masks. Practice. Don't send your child to school if he or she is sick. Remember that signs of COVID are very simple. It's a coronavirus. The four coronaviruses are the common cold virus. It mimics and looks like a coronavirus. Children, fortunately, don't seem to have suffered the consequences as much as adults have as far as morbidity and mortality. Delta may be changing things a bit, though. We're seeing more children hospitalized with coronavirus. And that will be into the fall.

Kara Swisher: Right. And the fall, it will get worse because more people are inside.

Dr. Jeffrey Swisher: Yeah, right. And we'll see.

Kara Swisher: On good news on that front, the Secretary of Education said that public schools who want to institute mask mandates can't be denied federal funds. Of course, there's a huge argument over mask mandates, people screaming back and forth, the science being thrown around. It's still confusing at best. No matter what the pressures are facing from the state government, Governor Greg Abbott of Texas lost the battle to ban mask mandates in the state Supreme Court. He just did. Let's talk about this guy. He tested positive. And then four days later, he posts this video. Let's run it.

[Audio clip plays]

Greg Abbott (in clip): I am now testing negative for COVID. I'm told that my infection was brief and mild because of the vaccination that I received. So I encourage others who have not yet received the vaccination to consider getting one. My wife also continues to test negative. I will continue to quarantine at the recommendation of doctors. During that time, however, I will continue to work on issues that are important to the state of Texas, including opening infusion centers for antibody therapy treatment across the entire state of Texas.

[Clip ends]

Kara Swisher: What's an infusion center? Boy, I'm glad I didn't see that before. I would have gotten nauseous. So infusion center. He gets this treatment of these antibodies. That's a great thing. Well, maybe.

Dr. Jeffrey Swisher: It's what Donald Trump got under compassionate use. The company Regeneron makes it, as well as other companies like Eli Lilly. But Regeneron is the one you hear most in the news. It's a company that makes an antibody cocktail that consists of two monoclonal antibodies that they package into one vial and inject into people. You have to go to an infusion center for an intravenous injection. People don't talk about that, but that's not cheap. Even though the drug might be supplied free of charge, going to an infusion center, getting an IV, sitting in a place for an hour and a half to monitor side effects... Better to take the free vaccine, correct?

Kara Swisher: That's really... Oh, yeah. It's like the whole cows leaving the barn thing. Just shut the door. What do you think? Why is he focused on the infusion centers versus... He did say to go get vaccinated.

Dr. Jeffrey Swisher: He certainly did. Which is good. Although he didn't used to say that.

Kara Swisher: Yeah. And neither did Trump initially. All these people, anti-vaxxers, they created doubt. This should not have been politicized ever. The same thing with mask wearing. It should not have been politicized, but it was. As a result, we have all these problems now because people are following their political...

Dr. Jeffrey Swisher: And they're focusing on these antibody treatments. Florida, Missouri, Texas are promising millions of dollars in antibody treatment.

Kara Swisher: Yeah, but these are expensive treatments.

Dr. Jeffrey Swisher: They are expensive treatments. The actual... Are they effective? They work 80% of the time if you get the antibody within 10 days of having the first infection, or knowing that you have an infection. You have to not be hospitalized pretty much when you get them, but before you're hospitalized. In fact, there's data that suggests that once you're hospitalized and on oxygen, they actually may be harmful.

Kara Swisher: So it's confusing.

Dr. Jeffrey Swisher: The idea is get a vaccine. It's a no-brainer and it's so much less expensive. Each of these antibody treatments can cost anywhere from... The actual true cost is about $5,000. Regeneron is a multi-billion dollar company. It's like doing diabetes treatment when you could start with "don't eat so much sugar" or don't have a bad diet.

Kara Swisher: For type 2 diabetes.

Dr. Jeffrey Swisher: Right, yeah. For type 2 diabetes. It's a thing that comes way too late. It's like having the cows leave the barn, gone in the fields, and then buying a whole bunch of Segways and riding around trying to round up the cows. It's silly.

Kara Swisher: All right, yes. Okay. So when you notice all this as a doctor—and I'm going to get to the nurse in the next story in a second—but the politicization, now medicine has been politicized over years in lots of different ways. What is this like as a doctor?

Dr. Jeffrey Swisher: Well, it's frustrating. When you're treating people who could have, with a lot of prevention, stuff that is treatable. Massively morbidly obese people who can't always help it, it can be an endocrine issue. A lot of things are frustrating. Smoking is a good example. Don't smoke. It's not good for you. But we treat these diseases as a result of not taking into account the value of prevention, exercise, the common sense things. In this case, it's vaccines. It's vaccines and social distancing and wearing a mask. Common sense things. Keep in mind that masks, especially surgical masks, not N95s, but surgical masks aren't that good for reception of viral particles because they've got holes in the sides. N95s are a lot better, obviously. But what you're doing is a reverse of the tragedy of the commons essentially. You're wearing a mask to protect other people from you. That's why we wear masks in surgery. I've been wearing a mask every day for the last 31 years as an anesthesiologist. We're trying to prevent my spit from getting into your wound. Not so much that I'm afraid that your bacteria is going to come into me. That is very important to keep in mind. You are basically doing things for the good, like wearing seatbelts. You're preventing accidents. It's so weird that it's gotten to be this way on something like masks.

Kara Swisher: By the way, I haven't gotten one cold in the past 18 months.

Dr. Jeffrey Swisher: Neither have I. Because again, people are wearing masks in areas. They do that in Japan and China. This is very common in Asian countries.

Kara Swisher: I'm going to be wearing masks a lot more. I think I look good.

Dr. Jeffrey Swisher: Yeah. I think even in counties that have removed the mask mandate, I'm not going to the grocery store without a mask. Or places like that. And we have to work in the hospital forever.

Kara Swisher: Forever?

Dr. Jeffrey Swisher: Well, that's a good question. When I came on Pivot last time, I had a quote that was in one of those little red rim things in New York magazine. I said, "COVID is going to be with us. 2021 is going to be the year of COVID."

Kara Swisher: Yeah, it's going to be here. And you said all year?

Dr. Jeffrey Swisher: And I said, yeah, all year. Well, I'm going to extend that into next year. This is going to last a couple of years. Endemic. The 1918 flu lasted until 1920. That killed a lot more people.

Kara Swisher: Well, Jeff, you're a bummer, okay?

Dr. Jeffrey Swisher: I know, I'm a bummer. Sorry.

Kara Swisher: All right, let's go on a quick break. When we come back, our second big story, and then we'll talk to a friend of Pivot, John Carreyrou, when we get back. How exciting.

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Kara Swisher: Jeff, we're back for our second big story, zeroing in on the many terrible side effects of the pandemic. A nursing crisis reported in stark detail in The New York Times over the weekend. One in five ICUs are at least 95% capacity, making it difficult to maintain standard of care. Nurses have already been in the trenches for 17 months and the work isn't letting up with the Delta variant. Nursing shortages were a problem long before the pandemic. As you know, you've talked about it with me, but now a lot of them are retiring, moving to non-emergency room jobs, or just getting out. They're also sick of people. You've seen all these amazing interviews with them where they just are so tired of treating people who won't be treated. I just want to play a quick clip from a video log of a Tennessee ICU nurse, Catherine Ivy Sherman.

Catherine Ivy Sherman [in clip]: Not everyone has the luxury of being able to stick their head in the sand and ignore the world around them. I am so tired of the people who are creating their own reality where COVID is not a problem and then they have the audacity to get mad at people like me when we try and show them that no, this is real. You are the one living in a delusion. You don't get to be mad at us for figuring out how to deal with the reality.

Kara Swisher: Yeah, it's heartbreaking. There's a lot of that, Jeff. I've seen so many stories. It's either stories of people who wish they had gotten the vaccine and are dying, or these healthcare people. So how are you and your colleagues seeing this play out in hospitals, especially with nurses who are so critical? You've always been a supporter of nurses compared to most doctors. They're the backbone of the hospital. Nurses and techs.

Dr. Jeffrey Swisher: I don't want to minimize. I want to give a shout out to the nurses that I work with. One of the nurses I work with, Cara, is a huge fan of yours, Katie Hacker, and I want to say hi to her. These people are tireless workers, and they deserve everything they get in terms of compensation and consideration from the hospital. The problem is there is a huge shortage of nursing, and some of it's retirement. Half a million retire. They were baby boomers. There's no short-term easy fix. Training is difficult. Nursing schools are struggling to train.

Kara Swisher: That's right. There's not enough faculty to teach nurses.

Dr. Jeffrey Swisher: For a long time, nurses were recruited from other countries, a lot of Filipino nurses in San Francisco, because there's a shortage of American nurses being trained. We're seeing that in our hospital. It directly impacts me in the sense that my surgical schedule has turned from a more horizontal schedule to a more vertical one. I'm routinely working late into the evening, nine, 10, 11 p.m. every night, just to get through the elective surgical schedule because we have to close down operating rooms because we can't staff them. This is true of hospital beds. Even though hospitals might not be full to capacity, they have to have nurses to staff the beds. This is a problem.

Kara Swisher: So what are the long-term options?

Dr. Jeffrey Swisher: We have to train more nurses. Maybe we can solve two problems and start recruiting Afghani nurses from Afghanistan as immigrants. It's a difficult problem because it takes years to train a nurse and even more years to train a specialist nurse. We're behind the eight ball for many, many years. I don't know the solution. Throwing money at the problem seems to be what they're doing right now. Traveling nurses who go from place to place work under contract rather than at a particular hospital.

Kara Swisher: That's correct. There are bidding wars for these travel nurses. I'm hearing numbers like $150 an hour and up for some of these nurses. That's crazy because the nurses who live and work and are permanent nurses don't get paid anywhere near that. So what they're doing is emptying out hospitals in places where you most need it. Underfunded areas.

Dr. Jeffrey Swisher: Right. Which are the hot spots.

Kara Swisher: Right. What if a Mississippi nurse or a nurse from Tennessee is looking at California and saying, I can make $150. I'm going to come to California. I've seen an influx of nurses from those states working as travelers. They're all wonderful people and they are very compassionate and caring, but there's a limit. So money is not necessarily a good option. It's a good thing to pay people more, but it creates all kinds of weird incentives.

Kara Swisher: Doctors are obviously affected by this. Is there anything particular that doctors can do or should be doing, or the federal government?

Dr. Jeffrey Swisher: Doctors can write letters to congressmen and to senators and get involved in local politics. We can support our nurses by not being jerks. That's one of the biggest things, just to respect them and create a collegial environment. The old school of doctors being the captains of the ship, that's gone. I have a great relationship with the nurses in my hospital because we all understand what our roles are and how we contribute. Nurses are an amazing bunch of people.

Kara Swisher: What would you say to someone who is thinking of doing this? What would be the pitch you would make to them besides more money?

Dr. Jeffrey Swisher: To be a nurse? I would say it's a people job. It's a job where you can use science and your skill, and you're the frontline person dealing with patients. You're a healer.

Kara Swisher: Although what do you say to that woman? She's had it. She's out of fucks, I would say.

Dr. Jeffrey Swisher: Yeah, she's out of it. I don't blame her. It's exhausting. I think we're in the middle of the crisis. There's going to be a lot of post-mortem analysis, not to use a medical pun, on this crisis when it's over.

Kara Swisher: Is that a medical pun? Well, kind of, post-mortem. Okay. All right, my last question here before we get to John. There was a doctor in Alabama who refused to treat people who were unvaccinated. What do you think about that?

Dr. Jeffrey Swisher: I had mixed feelings. I'm like, OK, that makes sense. I'm writing a piece right now on the misunderstanding of what the Hippocratic Oath is. As a physician, I didn't sign up to say I'll treat some people and not others. When I worked at SF General in the trauma unit, I routinely treated people with swastika tattoos and murderers. You can't look at that. You have to treat people as people. That's what we do.

Kara Swisher: Even when they're saying... What do you think of this doctor when he did this? He had a very cogent argument about why he didn't want to.

Dr. Jeffrey Swisher: He did. I understand his argument, but unvaccinated people are unvaccinated due to ignorance. They've been fed this ignorance by people who should know better. People like Ron DeSantis, Abbott, Trump, people in the administration. It's nakedly political, to generate votes among their coalition. I don't know what it's for.

Kara Swisher: Did you ever think as a doctor you'd be dealing with that kind of thing?

Dr. Jeffrey Swisher: No. I was in medical school during a lot of the early HIV/AIDS crisis. I came out then. To me, there was no question. There was no issue that you treated these people. Even though we didn't know a lot about HIV when it first came out, that didn't stop any physician I know from treating them.

Kara Swisher: So you still will, no matter what, treat everybody?

Dr. Jeffrey Swisher: Yeah, I will treat anybody, no matter what, whether they're vaccinated or unvaccinated, because that's what I do.

Kara Swisher: Okay. Let's bring our friend of Pivot, John Carreyrou. John is an award-winning investigative reporter and author of the bestselling book, *Bad Blood: Secrets and Lies in a Silicon Valley Startup*. He was the first to break the scandal of the blood testing company Theranos in 2015 in the *Wall Street Journal*. I've done a long podcast with him about it, but he's got a new podcast out this week called *Bad Blood: The Final Chapter* about the Elizabeth Holmes trial, which is about to start. In the years leading up to this trial, things have gotten complicated. The missing laboratory database. There are a lot of people who would do anything to destroy all that. Fractured relationships. The notion of being abused, perhaps mentally, by an older man. And total plot twist, obviously she was going to get pregnant. Holmes is accused of massive fraud and lies about the capabilities of her technology. John, it's good to have you back.

John Carreyrou: It's good to be here. Thanks for having me.

Kara Swisher: I brought a doctor. He's related to me, but I brought a doctor to help me. Hey, John, how you doing? This is my brother, Jeff, Dr. Swisher. So let's just start with, you've reported on the story from the beginning. What new information should we expect to see come to light in the podcast? Tell me about making this and where we are now. Set the table for us for Holmes and what's going to happen.

John Carreyrou: Right. We're on the eve of her trial, which starts next week, August 31st. Jury selection is August 31st. This is a trial that's been a long time coming. I first reported on this in late 2015, so it's been six years. The wheels of justice have turned especially slowly here. We're going to see Holmes walk into that courthouse in San Jose. One big question is whether she's going to be carrying her newborn in a baby Bjorn. She will. There has been a lot of cynicism about the timing of this pregnancy. We'll see if that theater plays a role in this trial. In terms of the podcast, yes, there is new material. I got my hands on a lot of new material since I wrote my book, which was published three years ago. I got my hands on almost every SEC case exhibit. As you know, the SEC did its separate civil investigation that resulted in a settlement with Holmes. But Balwani, her ex-boyfriend, never settled, so that case is still ongoing. The SEC case overlaps a lot with the criminal case, at least one aspect of it, which is the investor fraud charges. Those SEC case exhibits gave me a lot of insight into what's coming. One of the most fascinating parts is this file with thousands of text messages between Sunny and Elizabeth that span about five years. Some are redacted, but most are not. Those text messages, which are the subject of episode three of my podcast, give you insight into their relationship. As you know, their relationship is going to be front and center at this trial.

Kara Swisher: So let me ask Jeff a medical question in a minute, but from what we know, what will her defense look like? Is she going to testify?

John Carreyrou: We don't know yet, but from filings that have come out, it looks like a central part of her defense is going to be to allege that her ex-boyfriend, who was the number two of the company, Sunny Balwani, was her Svengali. That he had this psychological grip on her. They may even allege that he abused her physically. They are certainly going to allege that he had a hold on her psychologically, that she was in his thrall, and that as a result, she kind of lost sight of right and wrong.

Kara Swisher: He's not being tried now. This is not his case that's coming, correct?

John Carreyrou: They were charged together, but their cases were severed precisely because of this, because they've turned on each other. He's going to be tried after she's tried at the beginning of next year. It looks like she's going to try to shift a lot of the blame to Sunny. She'll have to testify; she can't just assert it. I would bet that she does testify because I think it's not going to be enough for a psychologist who examined Holmes to go on the stand and testify to the fact that Sunny allegedly abused her. I think the jury is going to want more than that. They're going to want to hear it from her. I think she is going to want to see her go on the stand and explain exactly what this abuse was all about and how it led her to participate in this alleged fraud.

Kara Swisher: Jeff, question?

Dr. Jeffrey Swisher: I'm just amazed that she doesn't go on the stand and basically try to say that she's insane by basis of sociopathy and severe personality disorder. I'm not a psychiatrist, and I have never examined her. So as a physician, it's unethical for me to say that. However, Kara, do you remember back at the All Things Digital D conference that she wanted to come? You asked me very early on about Theranos, and I just basically said it's insane. If you told me that an alien race from 10,000 years in the future came back and gave this technology, I would have believed that more than the technology that they presented. All right, ask a question of John, the expert. Why do you think that no scientist or no physician ever signed on with Theranos at the beginning and blew the whistle on it?

John Carreyrou: There were a lot of experienced scientists and PhDs who joined the company at various points. The reason there weren't any whistleblowers earlier is that the stakes were a lot lower when it was a company in stealth mode that hadn't gone live with its technology, hadn't gone to the marketplace, and wasn't offering its blood tests to consumers. That only happened in the fall of 2013. That's when the stakes got a lot higher, 10 years into the life of the company. Then it took about a year and a half, two years for one whistleblower in particular, the former lab director who had just left the company when I contacted him, to gather up their courage and blow the whistle. Why weren't there whistleblowers earlier? Litigation was always in the air at Theranos. Elizabeth had sued employees early on. Everyone knew that David Boies was the attorney for the company. She had also sued Richard Fuisz, a childhood neighbor, alleging that he had stolen a patent. Sunny, who was running the company day to day, was very aggressive, firing people all the time and screaming at people. It was a very toxic workplace. There was a lot of fear of retribution. I saw it firsthand when I was doing my first stories for the *Wall Street Journal*. When I went on book leave to report out the book, a lot of people were scared to speak to me because Holmes and Balwani had not been indicted yet. They worried that they might not be and that they'd come for them. I had to do a lot of handholding and convince a lot of people to become sources.

Kara Swisher: One of the things that was very... Jeff, we talk about this. I get blood tests all the time. They're very onerous. Where is the technology right now? Or have you continued, John, to follow where this tech is? Because there is no technology here, correct? There's nothing to say.

John Carreyrou: Right. To this day, no one has been able to do what she claimed she had achieved, which is to do hundreds of tests off a tiny pinprick of blood from a fingertip. There are two basic problems with that. One is that capillary blood, which is the medical term for blood you get from a finger, is less pure than blood you get from a vein in the arm with a syringe. It's polluted by tissue and cells, and those interfere with certain tests. The other issue is that there are basically four big types of blood tests. When you've used your tiny sample of blood to do a handful of blood tests from one of those four categories, you've exhausted your sample. There's no sample left to then use the completely different methods and laboratory instruments required by those three other classes of blood tests. No one has solved this issue to this day. 2021, she was making these claims in 2013, 2014. To this day, no one has solved this.

Dr. Jeffrey Swisher: John, that goes to my point. As a physician who uses, I'll just take one example, potassium. Potassium is an ion in the blood which is critical for cellular conduction, neurochemical conduction, cardiac conduction. If the potassium is off by one or two milliequivalents per deciliter, I cancel a case. The error bars in that are very small. If you dilute a sample out 50, 100 times, you have to increase the error bars by that same amount. We knew this was nonsense from the very beginning from a physician standpoint. You talk about ELISA tests, electrochemical tests, antibody tests. It's just not physics. It is impossible. There is no physics on the planet Earth that allows her to do what she said she could do. This was known at the beginning. My point is, why did no doctor come in and say, this is impossible?

John Carreyrou: Most of them tend to be very respectful and they wait for data before they start making public claims. Most of those people who were being quietly skeptical were waiting for some sort of study or some sort of data to come out before they said anything. When I started my investigation in early 2015, one of the first things I did was call the chairs of laboratory departments at big medical academic centers. UCSF was one of them. Those guys were telling me immediately that they didn't believe this was possible. In my first story that was published at the end of 2015, I had one of them expressing very strong doubts about the feasibility of the technology.

Kara Swisher: So what happens beyond Holmes herself? The reason we didn't cover it was one, Jeff warned me, and two, I didn't think it was technology and I didn't think I knew enough about it. But what will this mean for Silicon Valley's "fake it till you make it" culture? There are lots of people who have done things that are fraudulent, obviously not someone that has impact on people's health. What is the result of your book? What is the conclusion? Do you think your podcast and the book and this final chapter is going to make a difference if she's convicted or if she isn't? Whether this has an impact on the "fake it till you make it" culture of Silicon Valley is the central theme here. You asked me if I think she's convicted. I still think she's going to be convicted if I had to bet on it, because the prosecution has so much written evidence, documents, and tons of witnesses. There's a part of the case that's very hard to defend, which is the patients and the erroneous blood tests that they received. If she is convicted, then potentially this will be a wake-up call in Silicon Valley for venture capitalists and especially for young entrepreneurs that you can only push the envelope so much. If you hype and you exaggerate to the point that you're outright lying, then it becomes securities fraud. Especially if your product is not software, but a medical device where lives are in the balance. If, on the other hand, she's acquitted, which is certainly a possibility, then I think this culture is going to continue. There's not going to be a course correction. I think it's probably only going to get worse. You'll have a bunch of young entrepreneurs running around Silicon Valley saying, "I sort of pushed the envelope, but look at Elizabeth Holmes. Look at what she got away with. She ended up doing no prison time. And I'm not as bad as she is. I'm keeping things more under control than she is."

Kara Swisher: I have one more last quick question. Why her? There are so many people. Some of the stuff isn't illegal that some of these entrepreneurs do. I'm thinking of WeWork. Nothing illegal. He told them what he was doing. It was all out in the open, but it was a lot of P.T. Barnum kind of stuff. Why her, do you think?

John Carreyrou: The difference between WeWork and Theranos and all these other Silicon Valley companies where entrepreneurs also exaggerate is that this was a medical device. This was a company that was operating in the healthcare arena where the stakes are extremely high. It's not software. It's not a smartphone app. If you release a buggy version, you can't rely on the first people to use it to iron out the kinks. If you're putting out a blood test, a finger stick test with a device that doesn't work, then lives are being affected by that. Lives were affected by that. We're going to hear about that from about half a dozen patients at trial. One of whom was falsely diagnosed by Theranos with HIV when she was perfectly healthy. A couple of other patients had viable pregnancies and were told that they'd lost their babies. There are real, stark real-world consequences to adopting the software culture and applying it to medicine.

Kara Swisher: And there's more to that to come, by the way. Is that what you're working on?

John Carreyrou: I think there's more of that to come in the sense that Silicon Valley used to be the computer industry. Increasingly, we're seeing Silicon Valley set its sights on other arenas, such as self-driving, drones, smart homes, and medicine. If entrepreneurs from Silicon Valley keep applying the "fake it till you make it" software ethos to these new arenas where lives are actually at stake... If you think about that Uber car that ran over a woman a couple of years ago in Tempe, Arizona. There are very real-world consequences to some of the things that Silicon Valley is doing these days. It's no longer just software or computer hardware. I think that convergence of these other industries with Silicon Valley is going to continue. I think it's going to potentially create more of these situations, which is why I think it's important for there to be a guilty verdict in this case. Otherwise, this won't be a cautionary tale.

Kara Swisher: So we're going to watch this podcast. It's going to go on until the case is ended, correct? This *Bad Blood: The Final Chapter*.

John Carreyrou: Correct.

Kara Swisher: And where's the movie? There was a movie, Kate McKinnon. There was Jennifer. My book was optioned by Legendary Pictures and by Adam McKay. The movie is still in development. We have a screenplay that will probably get touched up by McKay based on what happens at the trial. Jennifer Lawrence is still attached to play Holmes. She's attached. It's still moving forward. McKay's production company and Jen Lawrence's production company will produce. The studio is Legendary. I'm actually expecting some news on that front in the next couple of weeks.

Kara Swisher: All right. Well, we will be listening to *Bad Blood: The Final Chapter*. People can't get enough of this story. She's become some sort of symbolic icon in a way that's really fascinating. Watching her walk into this courtroom, I think she hasn't changed one little bit, I suspect.

John Carreyrou: Yeah. That's my feeling.

Kara Swisher: Sorry, Jeff. Thanks for your book.

Dr. Jeffrey Swisher: Thank you so much. That was a fantastic book. It was very well researched and, from a medical standpoint, extraordinarily accurate. So thank you.

John Carreyrou: Thanks very much. That's great to hear.

Kara Swisher: All right. Thank you so much, John.

John Carreyrou: Thank you.

Kara Swisher: All right, Jeff. That was fascinating. God, I am such a huge fan of his. He did an amazing reporting job. He's a great reporter, no matter what he covers.

Dr. Jeffrey Swisher: Yeah.

Kara Swisher: One more quick break. We'll be back for wins and fails.

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Kara Swisher: Okay, Jeff, wins and fails. Wins and fails. What do you got?

Dr. Jeffrey Swisher: For wins, we already talked about two of them. I think the big winners are the teachers and the nurses. Near and dear to my heart because of my wife and daughter, but the teachers have really, I think, are the big heroes. I remember when we started with this COVID thing, there was the nightly howl for the doctors and the caretakers. I think we should reinstitute a nightly howl for teachers and for nurses because they need it. They need our support. They're my big win.

Kara Swisher: All right. And what's your fail?

Dr. Jeffrey Swisher: Oh, there's so many this past week. I wanted to say that the media, how they're portraying the Afghan withdrawal and trying to lay the blame on Biden, is a horrible fail.

Kara Swisher: Your mom is doing that, just so you know.

Dr. Jeffrey Swisher: Of course, I know she is. Remember in 1979 when the Soviets invaded Afghanistan, I was a sophomore in college. There was a history before that, obviously. Friends of mine who may or may not have worked for the CIA went in with the Mujahideen, who were freedom fighters, right?

Dr. Jeffrey Swisher: Well, that's the Taliban that we know today. This is such a complex history. And I think the media is not doing anybody any service. Yeah, there's a lot of visuals. Yeah. I mean, it's just heartbreaking what we're seeing. But that's the big fail: how they're basically simplifying it.

Dr. Jeffrey Swisher: Keep in mind, Trump made this deal in May of this past year with the Taliban. Biden was given a giant steaming cauldron of shit, and he said, "Don't drop this." Well, nobody could not have dropped this.

Kara Swisher: I'm not saying that. Well, I don't know if that's true.

Dr. Jeffrey Swisher: Well, listen, I think that certainly as president, he's responsible for what happens on his watch. And I think that some of the messaging coming out of the administration was not good. But the Afghan problem is very complex. And I think that the fail is of the media trying to portray it in a more simplified manner.

Dr. Jeffrey Swisher: The other fail is DeSantis and Abbott. I mean, those guys are just losers with a capital L.

Kara Swisher: Okay. All right. And I give my win is the FDA approval for the Pfizer-BioNTech coronavirus vaccine and the others to come. I got that vaccine. I actually interviewed the creators of it. And I actually emailed them to thank them for it when I got it. And I plan to get a booster and everything else. I think that's really the win. And I think I hope they get vaccines for young people, younger people. When is that coming for people who have children under 12, Jeff?

Dr. Jeffrey Swisher: I'm going to guess it's not going to be for a while because they have to get enough. Like I mentioned about FDA trials, it's not going to be for several months, if not longer, before we have an under 12. It'll be age 5 to 11. They do this in cohorts. So the next cohort is going to be 5 to 11-year-olds. But I wouldn't anticipate we're going to see it until late, maybe mid next year.

Kara Swisher: Oh, wow. That makes me worried. I have small children, as you know.

Dr. Jeffrey Swisher: Yeah, I know you do. She's gorgeous, by the way.

Kara Swisher: Yeah. So we'll see how that goes. Jeff, I really appreciate it. Thank you so much.

Dr. Jeffrey Swisher: I appreciate being here. I mean, hopefully I made some sense and I didn't confuse people.

Kara Swisher: Yes. And you also took the place of Andrew Ross Sorkin, whose power went out in the Henri. I think it's Henri.

Dr. Jeffrey Swisher: Yeah. What an august company. You've had some great guests. I do miss Scott, though. I think I really miss Scott.

Kara Swisher: Everybody does. But having Pete Bahara and having George Conway and all these people. We've got some more coming up. Rule, Ben Smith, and Baratunde. And you, my fine brother.

Dr. Jeffrey Swisher: Yes. Well, I'm always happy to come back, Kara.

Kara Swisher: All right, great. We'll be back on Friday, by the way, for more. I think Sorkin is probably coming back for that. Go to nymag.com slash pivot to submit your questions for the Pivot podcast. The link is in our show notes. Jeff, do you have the script and you can read us out?

Dr. Jeffrey Swisher: I do. So go ahead.

Kara Swisher: Go for it.

Dr. Jeffrey Swisher: I will. Today's show is produced by Lara Naiman, Camila Salazar, Evan Engel, and Taylor Griffin. Ernie Envradat engineered this episode. Make sure you're subscribed to the show on Apple Podcasts. If you're an Android user like I am, check us out on Spotify or frankly, wherever you listen to podcasts. And if you liked our show, recommend it to a friend. I know I'm going to recommend it to all my friends who are going to get sick of me telling them about it.

Dr. Jeffrey Swisher: Thanks for listening to Pivot from New York Magazine and Vox Media. We'll be back later this week for another breakdown of all things tech and business.

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