Taboo Trades
Taboo Trades
Pandemics with Govind Persad
Co-hosts Samantha Spindler (UVA Law 2L), Madison White (UVA Law 3L), and I discuss pandemic responses with Govind Persad. Our focus is how to preserve personal choice in crisis response.
Persad is an Assistant Professor at the University of Denver Sturm college of law. Persad’s research interests center on the legal and ethical dimensions of health insurance, health care financing, and markets in health care services, as well as professional ethics and the regulation of medical research.
And the other issue is that actually the U.S. is a weird case because the U.S., despite being extremely rich, had such a poor COVID response that it's like per capita deaths were really high. So in some cases, there was like a good argument, I think, actually, for the U.S. to get almost as many vaccines as it got, even if maybe they should have been distributed a lot better, because the U.S. was like compared to countries like, say, you know, Norway was just a lot of people were dying here.
SPEAKER_02:Hey, hey, everybody. Welcome to the Taboo Trades podcast, a show about stuff we aren't supposed to sell, but do anyway. I'm your host, Kim Kravick. Today's guest is Govind Persad, Assistant Professor at the University of Denver Sturm College of Law. Persad's research interests center on the legal and ethical dimensions of health insurance, healthcare financing, and markets in healthcare services, as well as professional ethics and the regulation of medical research. I first noticed Govind through social media, where it seemed that many of the public health and bioethics folks liked to yell at him. This, of course, made me very interested in him, and I started to look more closely at his work, which is original, timely, and interesting. Well, so first of all, Govind, thank you so much for joining us. It's really nice to sort of meet you in person rather than just stalking you over social media, as I've been doing for about a year now, and first identified you as an interesting thinker and a person that I wanted to get to know better and whose work I wanted to get to know better.
SPEAKER_05:Well, thank you so much. I'm really... Glad to get a chance to meet. And also, it's always fun to get a chance to interact with students, especially at other places. With the pandemic, that's a group that I don't get to interact with quite as much as I did when I was giving more in-person talks. So it's really nice to be able to do this.
SPEAKER_02:Oh, great. Well, so along those lines, let me first introduce, let me allow Madison and Samantha, my co-hosts for today, to introduce themselves.
SPEAKER_09:Hi, I'm Madison White. I'm a 3L at Virginia Law, and thank you so much for coming today.
SPEAKER_03:Hi, I'm Samantha Spindler, and I'm a 2L at UVA Law, and I'm very excited for this podcast today.
SPEAKER_02:Great. So I wanted to begin with the discussion of the super interesting paper that you sent us, Preserving Choice in Crisis Response, which is forthcoming in Social Philosophy and Policy. It's a really interesting and timely piece. We really enjoyed reading it, and it generated of both discussion and ranting among our group, some of which we'll perhaps share with you today. But let me just start with sort of getting out some of the major themes of the article. One major theme is that COVID policy should seek to preserve the value of individual choice and avoid what you call symbolic solidarity that requires everyone to make the same choices or behave the same way in response. And one thing, so we might as well just have you discuss this right away because one of the questions that we kept circling back to, and that you do anticipate in the paper and discuss in the paper, is, of course, pandemic precautions are a collective measure and individual failures to take care and impose externalities on others. And so one of the sort of overarching things we were interested in is how you, do you have a broad approach to how we can reconcile the importance of individual choice with some of the external and sort of, by definition, collective nature of pandemic response?
SPEAKER_05:Yeah, so I think one of the ways of thinking about this for me has been to think about how we respond to other factors sort of social challenges and problems, um, that require people to, um, come together to help to alleviate or maybe even eliminate, um, the problem at issue. And so I was thinking about, you know, some of the big problems that we deal with obviously are things like, um, uh, uh, poverty, um, uh, environmental, um, challenges like climate change and pollution. I think challenges of war and violence are on everyone's mind a lot recently. And I think for a lot of these, you know, poverty, I think in some ways feels simpler to me because my background is, I have a JD and PhD and my dissertation was on social mobility and distributive justice. So I'm sort of used to thinking about, in some ways, distributing justice. the kinds of goods that political philosophers are interested in. So things like income and wealth. And typically when we're concerned about poverty and we're concerned that people don't have enough, we don't usually say, you know, everybody needs to take, maybe everybody outside of poverty needs to take the exact same action down to the details to remedy poverty. Instead, at the same time, we do sort of ask everybody to do something So, you know, one of the most common things that we might do is we might... have some degree of redistributive taxation. And that gives sort of, in some ways, reconciles the value of choice with the value of addressing this problem, because, you know, a certain, say, proportion of earnings is going to go into the public fist to be able to help solve these problems. But that doesn't mean that I have to, you know, work in a specific job, that I have to, say, work as a social worker instead of a law professor, or that other people have to work at all instead of, say, having one member of their household be doing unpaid care work within their home, if that's what they think is most important. So I think one desirable thing about that approach is that you're still trying to solve the problem. You're not just saying, you know, it's not a problem worth addressing for society, but you're giving people some leeway in determining how they meet their obligations. Now, there are going to be some contexts where everybody does have to do the same thing to some extent. So nobody's allowed to, for instance, destroy poor people's possessions or something like that. So there are some ways in which everybody's subject to the same requirements. But I think as a default, We should only sort of say, well, everybody has to do the same thing if that looks like it's the... most effective way at achieving what we're trying to achieve, where we also take into consideration the fact that sort of requiring everybody to do the same thing could be both sort of burdensome for them and maybe not actually as effective overall in addressing the problem we're trying to address. So similarly for like pollution, right? Sometimes we do say, we can talk more about this. Sometimes we do say, you know, you can't do this thing. You can't have a refrigerator with old Freon or something. But in other contexts, we say things like, well, you know, yeah, you can choose to have a car that is less fuel efficient and drive more, but that means that you'll end up paying more because we will have higher prices for carbon intensive fuels or something like that. So I think that there's some virtues of the latter approach because they do allow people sort of more options to choose choose how they help to work to meet the problem, or even for war and violence, right? We usually don't, even at times where we have conscripted people, we don't conscript everyone. Generally, people have different ways that they might contribute to helping to deal with a challenge.
SPEAKER_02:So by symbolic solidarity, did you just mean generally the sort of adopting an approach that everybody has to do the same thing? Or did you have particular practices in mind? Because the students had something to say about this.
SPEAKER_05:Let me just tell you. you know, teaching my course, I have a lot of leeway in determining how much I want to interact in person with people at all. So I rarely wear a mask. And that's not because I rarely wear a mask in public places. It's because I spend a lot of my time inside preparing my class, writing papers, providing childcare for my kids, you know, writing reviews for journals, things you do. And I think the experience of people who have less autonomy in their jobs You know, for instance, rules about, you know, can people eat in a study room by themselves was much more frustrating to the students in a way that I hadn't really thought about because, you know, I teach my class, I do office hours, I had breakfast with my students outside. But one way of thinking about it is that I guess I would say there are lots of measures that, you know, when you're asking people to do something, you want to think about, is this going to be the most effective way or possibly the most effective way of solving the problem that we have at hand? And symbolic solidarity to me is where sort of having everybody do the same thing starts to maybe turn into an independent end in itself or something like that, where unlike, you know, say with the question of, do you use, you know, say, carbon tax versus a command and control regulation, I don't think the command and control is symbolic solidarity if you can make the case that, look, maybe for reasons of political constraints or even it's financially preferable, it's sort of the best way of achieving the outcome of mitigating, say, high carbon emissions. But symbolic solidarity is where it doesn't even look like, sort of based on plausible assumptions, the rule or requirement would do that. But nevertheless, it's being sort of argued for, where the case starts to depend sort of less on the fact that the behavior helps to address the problem and more on sort of other considerations. But it'd be really interesting to hear, interested to hear the students' thoughts about this, because again, I feel like, you know, it's not that it's been easy having two kids in a pandemic at all, two young kids who are not eligible for vaccination, but my experience day-to-day has been very different, I think, from people in frontline work or who are learners who are in person for much of the day.
SPEAKER_02:Yeah, so I will, I will let them sort of speak for themselves about this issue as they sort of come up with their questions. But my sense from our prior discussion is that it's a lot of the things that you hit on and you guys again, you know, speak for yourselves about any of this. My sense is that first of all, they have less control in some ways than perhaps they don't have an office, you know, on campus, perhaps that they can just go to and take their mask off and kick back or whatever. whatever, that they feel that perhaps some of the rules are not supported by evidence, and they find that frustrating. And they are just at lower risk than some, right? And so, I mean, one of the things that's interesting about your paper and why it was helpful for us to talk about it is that, you know, they are at one end of the spectrum, right? Most of them are young and healthy and at low risk. And then you have, you We're immune compromised and sort of very risk averse in the pandemic. And so it's just a sort of a crucible for the different risk tolerance that we will have during the pandemic and how we sort of approach that. I'm going to get now into sort of more of the heart of your paper. You have three approaches that you discuss for accomplishing this objective. Market trades, policy compromises, and comprehensive priority settings. And all of that is informed by a fourth goal of information generation. And each of these, as you can imagine, generated a number of questions from the group, especially market trading, because that is an important focus of this course. And as you envision it, the market trading could take place at a variety of different levels, national, subnational, and individual. And just to get your theory out there, at the national level, the idea is that countries could trade their COVID-19 vaccines for something else that matters more to them, for example, malaria or HIV drugs or money to feed the poor. So following up on the more general question above about externalities, as you point out in the paper, we want the world to have vaccines, not just for humanitarian reasons, but for selfish ones as well, right? I mean, the pandemic doesn't end so long as much of the world remains unvaccinated and a friendly place for mutations. And so So you address this in the paper. Can you perhaps comment on that a little bit? Because I know that people who haven't seen the paper yet will, this will probably be the first question. What about the fact that, you know, we have other, we have selfish reasons as well for wanting people to get vaccinated? Yeah.
SPEAKER_05:So I think, yeah. it can be a really good reason to sometimes, you know, one question is basically, you know, there are a variety of different health problems, social problems that a policy might try to address. And is there something sort of special and unique about addressing COVID-19 as opposed to other problems? So what's different about addressing, you know, COVID versus something like malaria? And as you point to one difference might be, you know, this difference in the risk of mutations and having more severe variants. So yeah, I guess what I would say is that you'd want to include that sort of, as it were, positive externality for people, including people, say, in developed countries of getting more folks vaccinated in the developing world as one sort of input in thinking about sort of, you know, if you're allowing trading, What are the pros and cons? Are there... Are there reasons, for instance, to... You can have a trading system, say, coexist with structures that are fixed, that aren't tradable. So it could be that, for instance, you can trade some entitlements, but if you choose to use your sort of pick from the bucket, as it were, on vaccines, maybe you get a little extra boost to take account of that positive externality. There's a paper that I think will come out soon that... your students may find interesting, especially those with an economics background. This is by Scott Commoners at Harvard and other authors, Mohamed Akbarpour at Stanford and authors at Chicago and Northwestern, where they sort of talk about hybridizing a price-based and a sort of traditional public health priority setting approach to vaccine allocation, where you use both as inputs, both sort of, as it were, regulators set kind of command and control priorities and you have some degree of price inputs as well. And so I think something like that, where you may say, for instance, We want to encourage vaccination in developing countries, and we want to be able to properly encourage that in a way that takes into account these positive externalities for everybody. But that doesn't mean that sort of the fact of the positive externalities means that this goal can never be traded off against others. Sometimes other goals may be more important even in view of the positive externalities of one. So I think that's how I would start initially. about it.
SPEAKER_02:Okay, great. That's very helpful. And thank you for the additional reference. I'm going to turn to the students with some questions now. And for all of you, if anybody wants to address the invitation that Govind extended to discuss the symbolic and solidarity building measures that he argues that we have done too much of, please feel free to do that. And I'm sure that Virginia is going to fire me for inviting you to discuss these things on the air, but I'm willing to take that risk for you guys because I love you. Okay, so Neva, you had a question about country-level trades. So,
SPEAKER_08:hi, I'm Neva Jones. I am a 3L here at UVA, and I'm going to stay away from discussing the symbolic solidarity issues because I want to graduate in May. But I do have a question about the country-level trading that you mentioned. My mind immediately goes to issues with systemic racism, institutional racism, just greed, corruption, obliviousness. And I wonder how you account for those things when you allow countries the opportunity to trade away the health of their citizens. So as an example, should China be allowed to trade away the 12 million doses of COVID-19 vaccine that were supposed to go to its weaker population, you know, for anti-PB meds for its non-weaker population. I think you touched on this a little bit in your discussion of exploitation and mistaken decision-making, but it doesn't really go in depth.
SPEAKER_05:Great. Thank you. This is a really important question and one that I wrestled with in writing a paper about vaccine allocation with some co-authors that came out in Science in 2020, I think. So basically I think you're absolutely right to point at the problem of basically sort of unjust or systemically racist country governments. And I think the question for me is to think about, Would allowing trading, you know, one risk in giving more leeway to governments is that they might use it to further unjust or racist objectives. Now, of course, we also saw that in the status quo where we didn't, I think, really have widespread trading. So even if you say to China, you know, you have to take, and actually China is an interesting case because my impression is that they largely didn't take vaccines externally. So it's not clear how much this would have made a difference for them. But basically the challenge is that how much to condition external policies on sort of fair or just intra-country governance, which very few countries do perfectly. So for the science paper, we were thinking about, you know, COVAX, the international body that's allocating vaccines. They said, you know, we should just give the same number of population proportional number to every country, not taking into account their internal distribution. And since some of us were worried about the exact issue that you were worried about, which is what if some countries internally, even setting aside trading are distributing their vaccines in ways that reinforce systemic injustices so that they exclude, as you say, for instance, minority populations who are already discriminated against or treated even more horrifically in the country. And I think this is the same puzzle as with sanctions. It's a really hard puzzle because one thing where you could say is no vaccines for countries that are going to distribute them unjustly, internally, If they're just going to give them to one population and not others, they should go to countries that are going to distribute them justly. And the thought is this might incentivize sort of adopting internally just practices. Maybe to get vaccines, you have to accept some degree of internal monitoring. So similarly, I think you could put guardrails on. So the trading, I think, is just a special instance of this general question of how much as a sort of external vaccine allocator you should try to not only get vaccines to countries, but try to influence their internal allocation policies to avoid the exacerbation of systemic racism or injustice. And we're really torn about this because you don't want a situation where countries just say, okay, if you're going to make us change, basically the good outcome is they change and they adopt more internally just practices. The bad outcome is they say, you know, forget it. We're not going to deal with you. And I'm interested in those who have other, because I think this comes up for all sorts of organizations, the International Monetary Fund, organizations providing financial aid in all kinds of ways. And I think one possibility is to say, maybe you'll try to put some guardrails, sorry, my lighting is bad, guardrails on banks trading. So for instance, you're allowed to trade vaccines for something else, but no matter whether you trade or not, your receipt of aid from COVAX or from the WHO comes along with some conditionality or monitoring obligations where if it seems like the benefits, whether they're vaccines or whether they're money or something like that, are being distributed unjustly, we reserve the right to sort of exercise that conditionality and, you know, cut you off from further access or take, you know, take other steps. And I do agree with you that I think that the issue of cash, I think somebody else may have raised this question, allowing countries to take it in forms of cash rather than in kind benefits does increase the risk, I think, for certain forms of corruption. So I wonder whether, and I'm curious, one way of trying to mitigate the worry that you rightly raise is to look at, for instance, what are the health problems that are disproportionately harming disadvantaged or discriminated against groups in that society, and maybe to allow trades that are for resources that would benefit those groups. So for instance, I don't, I'm not familiar enough to know if there are specific medical or other challenges that are facing that population in China, but if you allow trades with respect to that specific population, maybe that is more, makes it less likely than something like saying, well, you could trade your vaccines for cash, which creates the greater corruption risk. But thank you so much.
SPEAKER_02:And just to follow up on that, I mean, I like your idea of the various types of guardrails, or at least thinking about them. Because as you know, this is not a problem that is unique to this setting, right? I mean, there are so many, you brought up the IMF, and that's the first thing that occurred to me, actually, are the numerous examples of countries receiving aid money or borrowing money, supposedly to be used for a particular humanitarian project or something to benefit the population. And then, of course, is used instead to just line someone's pocket. or in some cases to buy arms that are used to oppress the very groups that they're supposed to be helping. And so it seems to me that this is, you don't have to write on a clean slate in some ways with regard to this particular problem. It's pervasive.
SPEAKER_05:Can I say just super quickly, this actually came up in the U.S. to some extent. There are all sorts of problems. I've written about this in a piece in Illinois Law Review, sort of problems of racial injustice and the COVID response. And one thing that came up for monoclonals is that, you know, by administration, I think, admirably tried to create certain guidelines for getting monoclonal antibodies to populations that were more COVID impacted. And then you had some, but they were doing it through states, so sub-nationally. We had some of the same problems as what has just been identified, where Florida, for instance, gave a lot of them to concierge clinics who said, you know, quote, we're just going to do it first come, first serve. So I think at that point, it was sort of maybe politically or practically difficult for them to pull them back. Although I I think it seems in some ways like plausible to me that you would say, look, and this is not just from, I think it's justified both from a perspective of not exacerbating prior disadvantage. And then also from just a sort of very boring, a sort of old public health benefit maximizing perspective to say to Florida, look, if you're going to give monoclonals to like you know, rich, boosted middle-aged people instead of, you know, immunocompromised people or very, very old adults, you know, then, you know, this is taxpayer-funded monoclonals. They should be used to sort of realize greater benefits. And it doesn't look like what you're doing is actually serving that end.
SPEAKER_02:Yeah. I realize this was not the most important thing in what you just said, but I'm shocked that in this, you have already written about this and had it published in a law review during the short amount of time, if I understood you
SPEAKER_05:correctly. It really feels like it's been in some ways like 10 years. Forever, yeah. I'm with you. But more reviews also appear for the students. My sense from submitting something in this cycle that was a short piece for the forum, actually your journal very nicely wrote back and said that they hadn't started reviewing the short pieces yet. But I think journals are sick and tired of reading COVID pieces. So...
SPEAKER_02:Okay. So at the country level, this market trading discussion is related, as you have already alluded to, to vaccine equity, where the question arises, if something is the standard of care in developed countries, it should be the standard of care worldwide. And this generated a lot of questions from us. It relates to a paper that you wrote, I think it was in the Lancet in 2016 with Zeke Emanuel, really relating to HIV drugs. I'm going to turn this over to Madison to ask you a question about that.
SPEAKER_09:Yeah. Thank you so much. So my question kind of had to do with the balance between sort of realism and idealism. And so reading your paper, it seems like your position was sort of based in a realism of we need to be getting some treatment to people rather than holding off for the best treatment to get to everybody, because it's better to get an inferior treatment to more people than the best treatment to fewer people. I'm curious if you think that the goal should be that we should still be working toward getting the best treatment to everybody? Or if you think that the time and the resources we put toward making that goal happen, kind of in line with like WHO and stuff like that, is actually taking away and causing harm in the long run because we're taking away the ability to get that inferior treatment to more people?
SPEAKER_05:Yeah, so my flip answer, but I think it's sort of true, is in some ways what I would want to do first is sort of ask them. to the extent you can ask them, sort of ask the potential beneficiaries of the program, do you prefer maybe quicker and wider access to a less effective intervention? Or do you prefer maybe less broad or waiting longer to get something that's more effective? And this obviously comes up with vaccines as well. So do you prefer to get, for instance, AstraZeneca quicker access Or do you prefer to wait longer for maybe if there's a view that mRNA vaccines are going to be more optimal? So yeah, I would think that ideally, and I don't know to what extent say COVAX did this, one of the challenges that I feel like ended up happening was that vaccines ended up arriving in countries that didn't end up being able to deliver them quickly in part because it's not clear that they were locally acceptable vaccines. And so you wouldn't want to have vaccines that like theoretically you would say, sure, these less effective vaccines are, you can get them to more people. If nobody will take them, that also wouldn't be good. So I would say I would start with sort of ask the sort of potential beneficiaries of programs sort of what their preferences are between different options. There's a really interesting study by Marion Danis, my former colleague at the NIH when I was a fellow, and Susan Gould at Michigan about health plan choice called Choosing Health Plans Altogether. And this is at the individual rather than the national level. What they found in some different papers were things like when you polled Medicare beneficiaries about what benefits they wanted in their benefit package, a lot of them valued things that are not provided over, say, having the very most, quote, cutting edge or newest or most costly drugs or chemotherapies, say, for certain conditions. So I think they were looking at cancer patients with Medicare. Many of them would have preferred to have, for instance, home health nurses or even things like cash benefits rather than having... So I would love to have seen... And obviously, it becomes challenging for the reasons talked about previously to say what I see, you know, ask them, ask who, you know, populations are diverse within countries. But it would be really interesting, I think, for COVAX to almost run a chat. This is called Choosing Health and Health Together, the academic chat exercise with these countries that are in vaccine shortfall and ask them, you know, what are the things that are high priorities for you to be able to sort of optimize the distribution of the different types of vaccines in response? to what people want. It's almost these chat approaches are almost kind of like, I don't know how housing worked for many of you who were an undergrad, but often it's, you know, people select different options that they value more. And then there's a kind of algorithm run to try to make the preferences as compostable as you can. Samantha.
SPEAKER_03:So I know you don't currently believe that requiring the best available housing drug treatment for HIV is the right decision. But something that you brought up in the paper that I'd like to explore more is that requiring the best available treatment might reduce the cost of treatment. But I was wondering, couldn't this also have the opposite effect? Meaning if only one treatment's allowed, couldn't that end up causing a monopoly, allowing pharmaceutical companies to charge anything they want because the demand's inelastic? And I was thinking along those lines, by just looking at like insulin in America, for example, or where there are so few producers, so they get to charge a very high price. So I was wondering if you could explore that a little bit more.
SPEAKER_05:Yeah, so what you say seems right. And I have to go back and look at the paper. I thought that we were saying that requiring the best available treatment would not necessarily decrease prices. And it might've been the interlocutors
SPEAKER_02:who are saying- It was, I think it was. But we actually- maybe you can educate us about why they would even take that position.
SPEAKER_05:You know, I was so confused by this. Oh, good. I'm almost relieved. So this is an organization I think has done a lot of really important work, Doctors Without Borders or MSF. I can't pronounce the French well enough. And obviously, you know, Paul Farmer, some of the folks have thought about a lot recently, although I'm given to understand that apparently his commencement speech at Duke some time ago was considered to be like not his best work. Yeah. Oh, interesting. Okay. No, I just saw this because I was very honored to be on a panel with him at Harvard virtually. It was going to be in person, but the pandemic made that impossible. And now, obviously, I've Something I would have wanted to ask him about, I didn't get the chance, is why they in this letter thought this. Because it did seem to me, for the reasons that were offered before, implausible that requiring the best... One way that it could do that would be if there was a sort of economies of scale phenomenon where maybe having, I don't know... a large enough market guaranteed meant that you were able to eventually drive down the marginal cost of the last one more. But in general, it hasn't been the experience with other products that requiring the provision of only one option would have the effect of driving prices down. So what we say in the paper is that it's an empirical question, but there's not necessarily reason to think that that requirement would do that. I mean, I think that MSF is committed for sort of moral rather than sort of economic reasons to this idea that, I mean, this is what I talk about in the paper about sympathy and empathy and that I think there's a very seductive attraction to the idea that, look, if something is, it's a kind of virtue of magnanimity or something about this. The idea is, you know, if this thing is, you know, good enough for me, it should be, I should give it to everybody else. Like, it'd be weird for me to like, I don't know, invite students to my house and then give them, here's an example. I have whatever nice, I don't actually, but say that I did. I have nice, fancy wine and I give them wine from Trader Joe's, which is what I actually have, because I said, well, by having this Trader Joe's wine, I could have more people over, people get to sort of enjoy more wine. It seems like you sort of optimize outcomes. But people will say, you know, look, it just seems sort of offensive, like not magnanimous. It's certainly not magnanimous for me to be having this like nice wine and giving two-buck check to the students who came for the reception. And so in the same way, I think MSF sort of, it's almost like this virtue of magnanimity rather than sort of outcome optimization guiding things where they say something like, look, you know, if in the U.S. you have, you you know, five boosters and whatever, you know, it would be sort of churlish to say to developing countries, you know, Pax Levita should not be the highest priority for you. And so they're, you know, And I could see, you know, if what those countries really want is Pax Livid, that's one thing. My concern is that it may not actually be sort of what those countries want when you look again at some of these other exercises, like the chat example. I don't know if that's something I was rambling a little bit there, but I do think it's an interesting issue of like, almost when I talk about magnanimity, a kind of value that seems like it has a pull, but almost runs orthogonal. And I tend to care more, at least in the public health perspective, about, you know, wanting people's lives to go better, not wanting them to die, not wanting them to suffer pain and other kinds of harms, not wanting them to, you know, have poverty. So,
SPEAKER_02:yeah. No, it makes perfect sense. Don't know a lot about vaccine pricing and thought there must have been something we were missing in that conversation. So somewhat of a relief to hear that we didn't miss a lot. lot, perhaps.
SPEAKER_05:The paper with Zeke and the MSF responded to was not about vaccines. It was about...
SPEAKER_02:Oh, you're right. That was about HIV treatments, yeah.
SPEAKER_05:But I don't tend to think that there would be any difference. I mean, one thing you do want to have for vaccines is you sometimes want to have an advanced commitment to buy a certain amount to motivate R&D and to motivate...
SPEAKER_02:Which is what we did, though, without having to... Right, exactly. But we didn't mandate...
SPEAKER_05:Yeah, so I think... Anyway, sorry, go ahead. I think I see another question.
SPEAKER_02:No, I'm going to turn it over to Jackson now.
SPEAKER_00:Hi, I'm Jackson Bailey. I'm a 3L at UVA. And I found your discussion of why Western populations are drawn more to COVID equality rather than perhaps what are more pressing illnesses to those developing countries was very interesting. And I just wanted to know if the lack of empathy that you describe in your paper within Western countries for these other illnesses that don't affect Western lives as much as an impediment to the markets proposed for trading medical supplies and needs of developing nations.
SPEAKER_05:So actually, sometimes I think this might speak to a virtue of the market approach, because the idea is that if the allocator, if you think about it, the allocator is going to tend more often to be more privileged, more often be from Western countries. And we saw this even with COVAX, where I think the leaders, the voices you saw up front were largely, I think, Western. I think if you, in some ways, if you had the... developing countries sort of bracketing for the moment the worry about the developing country governments being unjust. I mean, all governments can be unjust, certainly. I don't think the U.S. government is perfectly just in the way it distributed vaccines or therapeutics, but... having those countries be able to say, look, we think internally our priority is actually, you know, we want to deal with COVID, but we also are really worried about messing up our malaria response. We're worried about the fact that childhood vaccinations may drop off if we move. There's a problem in global health of what's called, quote, vertical programs that tend to get created by what I talk about as this sort of problem of empathy versus sympathy, where what happens is basically this. Like, I say, you know, I as a wealthy person in America, you know, my grandma or my kid gets this really bad disease and they need some expensive treatment, like they need a heart transplant or they need something like that. And so then I think, you know, gosh, it was so awful when this happened to my kid or my grandma or what have you. It should be that kids and grandmas in other countries have access to what my kid or my grandma got that helped them. And so then I go into that country, I set up, you know, an NGO and I'm like, you know, heart transplants in developing countries are us. And the problem of these programs is that you start sucking away fungible things like health personnel, financing, other things from things that might be greater local priorities. And this is something that's sort of talked about quite a bit in global health where, you know, my vertical program that's focused on addressing a specific condition ends up uh creating trade-offs and harms to other programs that may be more urgent so allowing the country a virtue of a sort of market type approach might be that it would allow the country to be able to determine what it receives in light of what it perceives its own needs to be, as opposed to what is emotionally most compelling to people here. I mean, I think we even see this to some extent with COVID, where even though I think COVID is much more of a global problem, it's still true that there are people certainly, many more people here who've lost family, to COVID than that have lost family to things like malaria or any number of other conditions that are more locally specific, even things like sort of childhood malnutrition. And so I think there's reason to worry that a sort of top-down allocation approach driven by developed countries may... have these kinds of problems.
SPEAKER_02:So Govind, I completely agree with you that this is a virtue of the market approach. I suspect that Jackson's concern was that this same lack of empathy that you document is one impediment to having Western countries, developed countries agree that market trading is a good response, in part because they don't see the need for it because of these very blinders that you've just mentioned. In other words, that it's a practical impediment. It's not a theoretical impediment.
SPEAKER_05:Yeah, you know, actually, like to the extent that, you know, if this approach, and I think Kovacs actually talked about this to somebody, so I need to find the reference, was discussed, what the objections were. Because to me, the sort of most compelling objections come from the facts that we've talked about. Yeah. So Caitlin O'Malley.
SPEAKER_07:Hi, I'm Caitlin O'Malley. I'm a 3L here at UVA. So I had a question about vaccine trades, namely, do principles of equity dictate that COVID vaccine should be primarily distributed in places where citizens have the highest risk of death as a result of COVID, even though their risk of death from other illnesses might be even higher than the risk from COVID, particularly if those other illnesses don't pose a risk for countries like the US? Because in that case, a vaccine vaccine trading program would force a country to choose between relieving several risks, each of which is more threatening than any health risk faced by the U.S.?
SPEAKER_05:Yeah, so I'm trying to think if I'm understanding this question perfectly. So certainly, you know, I think one question here is, certainly it's a problem if countries can't meet all of their population's urgent health needs. But Is that problem because of the trading? Or is the problem because of like the background lack of resources? That is, the availability of the trading allows you to choose to make a hard choice where otherwise you couldn't have even made the choice. So the trade converts a sort of bad situation with no choice into a really unpleasant choice. And I think Kim had talked about this in the case of organs, but I think it's a sort of open question whether, I tend to think in general, this is defeasible, it's generally often gonna be better to at least allow a bad choice rather than say, you don't have a choice at all. But there are some situations where, you may have read my advisor at Stanford, Deborah Satz's work, there's some cases where offering people a choice could lead to their being pushed to choose in ways that actually make them worse off than if they had no choice at all. So some people argue this about, for instance, if you were allowed to choose to waive you are right to the minimum wage, that could end up being worse for you because then you could be kind of bargained down below. Having this guardrail can sometimes be helpful in negotiation as often as being an empirical question. Is this helpful or responsive to the question?
SPEAKER_07:Yeah, no, I think that is very helpful. I think it's largely having to do with whether we take those background conditions into account when distributing the vaccine and then say, you know, is it better for the vaccines to go to the U.S., even though our risk is lower than that in other countries? Or should we direct all the resources to where they would save the most lives regardless?
UNKNOWN:Right.
SPEAKER_05:Yeah, I think my inclination was the science paper that I mentioned earlier is more toward the second approach that you want to direct resources to where they can do the most good. A challenge is that because of countries' national partiality, it's hard to actually have that happen. And the other issue is that actually the U.S. is a weird case because the U.S., despite being extremely rich, had such a poor COVID response that it's like per capita deaths were really high. So in some cases, there was like a good argument, I think, actually, for the U.S. to get almost as many vaccines as it got, even if maybe they should have been distributed a lot better because the U.S. was like, Compared to countries like, say, Norway, a lot of people were dying here.
SPEAKER_01:Great. I'm going to turn it over to Tom. Hi, Gobind. I'm Tom. I'm a 3L at the law school. This is changing course a little bit. But in the article, a statement of those having an opposing viewpoint kind of stood out to me. And they said something to the effect of the provision of less effective treatment sort of conflicts with a medical professional's commitment to non-malfeasance. And I'm curious, perhaps based on discussions you've had, how far proponents take this view, or if you really had any thoughts generally. For instance, with those having this view claim that a practitioner choosing a next best alternative medication equates to doing harm, because this would kind of seem to define the concept of harm differently than some might conventionally think. And how, if at all, would this view extend beyond medications to the context of surgery? that not using the best surgeon in a particular specialty would constitute malfeasance. When it comes to specific medications, a particular pill is identical. It's fungible. with every other pill. They're easy to manufacture and widely distribute, but this view would kind of seem to break down when we try to extend it to the context of surgery.
SPEAKER_05:Yeah. So I agree with, I think, the thrust of the question. I tend to find the distinction between beneficence and non-malfeasance a little hard to pin down and in some ways a sort of poor guide ethically. But yeah, some of this depends on, and so there's a But a couple of philosophers, legal theorists, Shauna Shiffrin at UCLA works on this, who defend conceptions of harm that I tend to find not that compelling but interesting. Where they say things, basically, I tend to think of harm as being somewhat comparative. So you harm somebody if you worsen their status with respect to some baseline. They... put harm non-comparatively, where they say somebody can be harmed even if they're made better off than they were ex-ante or better off than they were with respect to some baseline. And some of these people would be willing to say something like, you know, the person was harmed, even though, you know, the surgery saved their lives and, um, it was done by the second best surgeon that maybe they were harmed, um, because, you know, it, they were left in a some, you know, there, it was painful or something like that. To me, that's not how I think about what harm means, but, um, yeah. So I think, um, I'm not totally sure what my interlocutors think there, but I think that they may have like some ways maybe having to do with views about professional ethics commitments. The view is something like, this is something that I've thought about writing about another context. I think some people take the view that like, if you want to do something, then you have to, you know, what's the aphorism? Like, you know, if it's worth doing, it's worth doing right or something like that. And I tend not to think this, and this comes up in all sorts of contexts, like around the house, I will, you know, when I'm on a call, like this, I'll be like sort of wiping the counters to get them a little cleaner from all the like jam that my three-year-old's getting on the counters. And there are other approaches that somebody might take, and they can be valued in the household to having a diversity of approaches, where other people will take the view that, no, don't do that. Wait, and then really put an hour in and scrub the counters right. And I tend to think that in a lot of cases, even if you can't optimize an outcome or get an ideal, there can be a real virtue in making somebody's life go better. So I tend to think that it's too demanding to say that basically you're not responsible if you don't do the surgery, but that if you do it, you have to get it, um, uh, sort of perfect. You have to have it done by the best person. I think that can be paralyzing to effective global health response.
SPEAKER_02:Great. So, so far we've been talking about sort of national level trading. You also mentioned that we could have subnational trading at the more local level in which states with a high vaccine demand could have received vaccines early from low demand states in exchange for assistance with other local problems, perhaps, for example, the opioid crisis. And I couldn't help but think that in some ways what actually happened is exactly what you would expect to happen when trading is constrained, right? Because instead we saw sort of, I'm going to put them in quotes, gray markets where many people traveled to different jurisdictions, to low demand jurisdictions in order to get vaccines because a lot of us live in high demand. We live in college towns or urban areas that are high demand jurisdictions. And I was going to turn it over to Madison, who I thought had a very funny anecdote about this. And I know you said you wanted to hear some of the student experiences. So I'll give it to her.
SPEAKER_09:Oh, yeah. So I think the University of Virginia had a very interesting couple of days last year. We were being told that vaccines weren't going to be available for students in Charlottesville for a very long time because we have a lot of health systems and those people were first priority. And we have a lot of older people in Charlottesville. So those people are also first priority. So there wasn't really an insight for the students as far as whenever we were going to get a vaccine. And one Monday morning, There goes like kind of a group text that goes out to a lot of the students that there is a abandoned JCPenney about three hours away where they have been given tons and tons of vaccines. And they are like begging people to come and get them because in the area where they are located, a lot of people aren't wanting to come in and get the vaccine. So, I mean... I texted Alex, who's also in this class, and was like, I'm coming to pick you up at this time. And he was like, I have class. And I was like, you're skipping it. Like pulled up to the school and basically dragged him out. And we all like load up a car and caravan down and I'll go get our vaccines. And then a couple of days later, the Blue Ridge Health District, which is where Charlottesville is located, finds out about this and is like very mad that all of the students are driving three hours away to get their vaccines. And they send out like this very... from our perspective, it felt very aggressive, um, kind of newsletter to us telling us that this was wrong and we shouldn't be doing this. And, um, they will not be supporting us getting our like second dose vaccines in the Charlottesville area. So we'll all have to travel back to Danville, which we were like, okay, whatever, like we'll do it. Um, but for, it felt very, Because at the where we all got the vaccines, the people working there were begging us to invite friends. They were like, we have so many vaccines. We're getting more every single day in than we're actually able to give out every day. So we just have so many and are like begging people to come and get these. Meanwhile, in Charlottesville, you can't find a vaccine. It's not there. And so from our perspective, it was like, okay, well, if you have such a surplus in one place and such a deficiency in another, why is there not some way to try and get the vaccines where people are wanting to get them or where people can take advantage of them? So reading the article where it was talking about sort of more subnational trading, I think for a lot of us that experienced this two-day free-for-all last year, we kind of were like, well, this makes a lot of sense. And it seems like this could have been very useful for our situation.
SPEAKER_05:Yeah, so we argued, co-authors and I argued for this over and over on a variety of venues and got no uptake either from the Trump administration or from Biden, where we said, look, you should allocate not just per capita, you should take into account local demand, and you should also be proactive using sort of active outreach rather than just passively sending vaccines to somebody and waiting for people to show up. So this is a problem of Blue Ridge District's own making. Like, why were those vaccines sitting there? It's because they didn't consider vaccine acceptability. And this actually happened at the international level as well, where like tons of vaccines that were like close to expiry or like not accepted but locally got sent to countries in Africa and then ended up getting like burned. And if this is, it's not that I think these countries are to blame. I think that COVAX and WHR are to blame because you need to understand not just, you know, what ideally would happen, but, you know, will these vaccines actually be able to be used expeditiously? So it's a real disappointment to me to see so many health systems. They would say things like, well, it's the simplest in Georgia. They knew that there was more demand in Atlanta and rural Georgia. And Brian Kemp told people in Atlanta to drive, take a vacation to get vaccines, where you know that that is going to exacerbate inequalities. And my solution wouldn't be to say, well, ban the people from Atlanta from going to rural Georgia. It's to say, you should send more vaccines to the places where there's higher initial demand. There's going to be more vaccines later. But I think people were very don't know if it's for political reasons or what, were very, I think they felt like they would be more responsible if they made what looked like a more intentional choice to consider demand. And I think they preferred to just blame people for seeking out vaccines rather than allocating them optimally.
SPEAKER_02:So I'm going to turn this over to Alex.
SPEAKER_04:Sure. Hi, Govind. I'm Alex. I'm another 3L here at UVA. And I really had a question about sort of the the way that the national and international narrative change our focus and how that plays into our ability to assess risk. So like studies have shown that people overestimate their risk to COVID often and underestimate their risk to other things. Like for instance, I'm at higher risk of dying in my car on the way to school than I am of dying from COVID that I contract at school just because of my, you know, I'm young and relatively healthy and all of that. So when we're talking about, you know, giving people more freedom at the individual level to do these market trades and whatnot, I mean, what, how big is the worry that people are just going to be really bad at assessing risk and, and then who, you know, who speaks for them?
SPEAKER_05:Is it great? I mean, this is a standard problem in any kind of, I mean, I think what questions is a lot of different approaches you can take all the way between being strict command and control and having more flexibility. So, you know, For instance, you might worry the same thing about programs like SNAP, where you give people a choice of which products to purchase with their food assistance. And people on the one hand are going to say, well, instead of having SNAP where people can choose what foods would best suit them, you should just make them get a box of healthy foods. Interestingly, both this very left-wing guy from Current Affairs and the Trump administration wanted to replace SNAP with Harvest boxes of only healthy foods. Then on the other hand, you get people who, you know, most economists may end up saying SNAP is too restrictive. It's too paternalistic to say people should have to only pick from foods that are SNAP approved. We should just give people money. That's what economists tend to say. And I think the response to that would be, as you say, you know, People may misestimate their own risks and what would be best for them if you give them that unrestricted choice. So I would say there are circumstances where I wouldn't necessarily think that it would make sense to have... especially sort of trades of the individual levels where I talked about people swapping places in line. But there might be other situations where it can make sense to allow it in some situations, even if not maybe for people who are at sort of very high personal risk. The other thing is I think there's really interesting work in risk regulation about how the weird thing with COVID is it almost seems to be like a highly dreaded risk by some populations where they think, it's the most important thing to not even get infected with COVID. And then I go out to rural areas where some of my in-laws live, and it's the opposite. It's like an anti-dreaded risk. People who actually are at high risk are a lot more worried about other stuff than about the actually serious danger of dying from COVID. So it's really interesting because it's like, maybe all risks are like this. I need to go back and read. I think Aaron Moldavsky is the classic on this, but it's interesting to me to see a risk that at the same time is like... really scary to some people and then really unscary
SPEAKER_02:to others. As I said, trading is, of course, a big theme in this course. I was very interested in your discussion of some of the objections to trading, many of which we see every week in this class because they come up across settings. As I mentioned to you in an email, one of the ones that I find particularly frustrating is the notion that trading sort of makes inequality very vivid. And this is a common one with pretty much all of the taboo trades that we discuss in this class, although it doesn't usually come up quite as explicitly as it did in your piece. But we actually had this discussion with Al Roth on the very first episode this season. And to me, it really just motivates so much of the antagonism to trading in a lot of these settings, which, as you say, it just highlights the inequality that we've discussed. And so this is more of a comment than a question to use the standard workshop lingo. But I couldn't waste this opportunity to get that rant in.
SPEAKER_05:Yeah, because I do think that there can be really good reasons against trades, but I do find this particular objection, and this is in keeping with some people that I have worked with as well, I think the objections about externalities, the concern about people being harmed by having a choice because it worsens their bargaining power, those are really legitimate and sort of interesting objections. But the fact that it just, I don't know, looks gross or grosses people out, I just don't think that can be a good... I think it would be interesting to have a psychologist on and ask about this because part of this is that I think if you did the, you know, these people, there are some people who are psychologists who believe that things like disgust are legitimate bases for regulation. And I think, no, I think disgust is just like a disaster as a basis for regulation. I think there's really good reason to believe that sort of legitimizing that kind of response and policy is what leads to all sorts of things like legitimizing certain anti-immigration policies legitimizing homophobic anti-trans policies all sorts of stuff so i just tend to think you know you know disgust seems to me a very you know matter of personal taste and people are disgusted by durian other people like it it's fine to have a personal taste and find things disgusting but i don't think i think it sort of can't be a legitimate base for policy and i almost feel like it's um I thought about writing something about this prior to the pandemic. It feels to me almost akin to animus in constitutional law, where I almost feel like there's this sort of crazy constitutional argument where like, if all you can say about something is that, well, it's gross or it's disgusting and we shouldn't have it, that's the sort of infirm basis for prohibiting a behavior or a form of conduct. Now, of course, you know, for a lot of the stuff, you know, unlike things like marriage, it's not a fundamental right. So legislators are allowed to be sort of silly, but I do find this sort of way of reasoning, I think, very frustrating.
SPEAKER_02:I'm going to turn to Samantha and Caitlin Stallings for our last two questions. And if you guys want to ask them one after the other, and then we'll ask Govan to respond, that might be a good way of approaching it.
SPEAKER_03:So something that you brought up in the paper was additional fees to offset micro-COVIDs. And I think that could also go back to the symbolic solidarity point where paying fees for riskier activities means people have different experiences and that they're not responding to the pandemic in the same way. But something I was wondering about these fees, do you think that they would look similar to COVID-19 surcharges that restaurants currently have? Because these costs are said to be used to fund higher cleanliness standards and other things that help reduce risk for other people. So I was just wondering how you think that these charges would look
SPEAKER_02:Caitlin, why don't you go ahead and then we'll get a response.
SPEAKER_06:Hi, I'm Caitlin Stallings. I'm a 3L here at the University of Virginia. I know we've made it this far and I didn't introduce myself yet. So my question was, it's sort of similar to charging things for COVID. Basically, you suggested that we could have some sort of tax on people that wanted to have or wanted to engage in risky activities. And I thought maybe it might be less, and you rightly pointed out in your paper that that would probably face criticism from both sides. And I thought maybe it would be something that faced a little less criticism if we actually incentivized quote, good behavior, people engaging in less risky activities, for example, giving tax breaks to restaurants that only open two days a week or something like that. And I wanted to hear your thoughts on that.
SPEAKER_05:Yeah, so I really liked, I'm taking them in order. I really liked this last point and I was sort of embarrassed not to have thought of it for my own paper. So I may mention it and thank you for this one because, yeah, it was absolutely sort of psychologically a matter of framing. People often respond more positively if you frame something as a benefit rather than a penalty, even though like economically, structurally, it could end up being the same. So, yeah, you could, as it were, instead of having a tax for risky activities, you could have a subsidy for sort of activities that help with the COVID response. And I was actually surprised at sort of how little this has been done. Like, in some ways, it seems like a middle ground between, you know, do you mandate behavior X and do you prohibit behavior or do you do nothing? Um, or do you prohibit versus do nothing as opposed to saying, you know, we're going to, you saw this a little bit with vaccines, with the vaccine lotteries and so on. And there was this like hot empirical debate about whether vaccines were, uh, whether the lotteries worked. It seems like in the end they did something in some places and less than others, but it was very hard to tease apart because this kind of analysis is very hard to do. Um, But it would have been interesting to see it applied to things that I think were less polarizing than vaccines. Where, yeah, like absolutely, it's interesting that like when we provided some of this aid to like in the PPP loans, we didn't have any conditionality. So you could have actually had PPP loans where you got like a... extra bonus maybe if you, say, improve the ventilation in your business. That would be really clever. Or if we, again, use some of this financial leverage to, in other ways, sort of encourage behaviors that would have helped to mitigate the impact of the pandemic without necessarily needing to take the sort of harder step of mandating or prohibiting certain conduct. For the first, I'm trying to remember now, this woman's taking two questions. The first question was also really good, was about how people would, thinking about the fees and how they were used at restaurants. I think one advantage of having them if you could have them managed by a sort of general regulator as opposed to restaurants is you could, in theory, have more transparency and accountability about where that money went. Like I just paid one of these, it said, you know, 5% extra PPE charge at a place that I went with my botanic garden with my kids on the weekend. And, you know, I didn't actually notice it until I paid. And I was like, you know, it's sort of weird because like, you know, at this point, a lot of people are not even wearing masks in the restaurant. Like I have no way of tracking whether this money went to PPE for these workers. So like, it's hard to really be that happy about this fee. I do think, so I think Kim asked a question in the email with me that I wanted to get to that I think relates to this, where she said, look, people might still be mad about having a tax on risky activities to fund things like, you know, improving ICU care, paying physicians more, giving them child care so they're not out of work. when they are patients in need. And she said, I think in some ways it seemed initially compelling, but I, then I had a response, which was, you know, on the other hand, like if your grandma dies because she got COVID in a way that's traceable to like this outdoor wedding, it won't matter to you that the wedding had to pay this Pigovian tax to find the COVID response. And what I would say in response to think about it more is actually like this ignores in a sense, the fact that, whether your grandma dies is dependent not just on are people having outdoor weddings, but on the other stuff that the Pigovian tax might help with. So for instance, if the Pigovian tax like bought more Pax Livid or if it led to hospitals not being overcrowded and sort of counterbalanced that, it could actually be that like, you know, It's hard to know that, say, this is the reason why some people's at-risk family ended up surviving, but that the tax actually could end up having benefits as well. I think the challenge is that in some ways, although it's hard with COVID because it's hard to know exactly where you got it, it can be easier to trace the harms from the outdoor wedding than the benefits from the Pigovian tax or the ventilation or whatever. Right.
SPEAKER_02:So just to be clear, I wasn't questioning the validity of the the validity or effectiveness of the approach so much as the ability of people to make this sort of calculus that you just made and therefore get social buy-in.
SPEAKER_05:The stuff in economics where people talk about sort of visible and invisible effects and The worry, and I think you raised it rightly, and feel free to cut this out also because I realized you emailed it to me, so feel free to cut this
SPEAKER_02:out. No, no, it's fine. I would have asked you if we had had more time, so it's fine.
SPEAKER_05:Yeah, is that... one of the challenges is that I think it's a lot, it feels a lot more visible. Some policies that are, and others feel less visible. So this actually comes up to me. One of my frustrations recently, I think it's been interesting for me to see like some of the litigation on this in Virginia is the extent to which like people have gotten really polarized around masks in particular. And again, so to the exclusion of other interventions that might actually both be like less controversial and potentially more beneficial. So masks and ventilation, for instance, and it's not that you couldn't do both, but an interesting phenomenon is I do think like when people see people around them, like wearing masks, they feel more like visibly protected in a way that they might not feel if they saw that, like, or if they like you, cause you don't always know that like this building has like, you know, 10 exchanges an hour with a really good, HEPA filter or something else like that. And so I do think that some interventions can be sort of easier for political reasons, easier to adopt because they look more visibly protective. You get more credit for them. Even if they might not actually be the most effective ones. Or again, if you say something like, we're going to close these big gatherings down. Maybe people feel more protected, even if I remember emailing with a colleague who also works in public health stuff about Lollapalooza, where people were like really mad in a way that almost like a moral panic about Lollapalooza, which is mostly outside and had a vaccine requirement. And in the end, like, I don't think it actually produced that many cases. People were like gathering outside, which was probably a lot better than marginally what they would have been doing instead if they were like hanging out inside with their friends, listening to music and, I was going to say on a CD player, but I'm from the 90s, whatever people listen to music on now. So I think there have been a variety of situations where the visibility of a response ended up driving policy as opposed to the effects.
UNKNOWN:Yeah.
SPEAKER_02:Makes sense. I'm going to thank you and let you go. We've kept you past the amount of time that I promised we would keep you. So, first of all, it was great to meet you, quote, unquote, in person. What passes for in person these days? And thank you for coming and sharing this paper with us.
SPEAKER_05:Great. Thank you all so much. And thanks especially to the students. I know it's been a lot, especially for people who are staying. You weren't obliged to stay over time, but it was really fun to get to talk with you and to get to hear your questions and your experiences.
SPEAKER_02:All right. It was good to see you.
SPEAKER_05:Great. Thank you all so much.
SPEAKER_02:Thank
SPEAKER_05:you. Bye-bye.
